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> 



THE 

DISEASES OF INFANCY 

■ 

AND CHILDHOOD 

FOR THE USE OF STUDENTS 



AND PRACTITIONERS OF MEDICINE 



BY 

L. EMMETT HOLT, M. D., Sc. D., LL. D. 

n 

PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS 
(COLUMBIA UNIVERSITY), NEW YORK; ATTENDING PHYSICIAN TO THE BABIES' 
AND FOUNDLING HOSPITALS, NEW YORK ; CONSULTING PHYSICIAN TO 
THE NEW YORK INFANT ASYLUM, LYING-IN HOSPITAL, ORTHO- 
PEDIC, AND HOSPITAL FOR THE RUPTURED AND CRIPPLED 



WITH TWO HUNDRED AND FORTY-ONE ILLUSTRATIONS 
INCLUDING EIGHT CO TOURED PLATES 



FOURTH EDITION 
REVISED AND ENLARGED 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1908 



^' : 



-$° ,\-% 



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HrtHARYnf CONGRESS' 
I wo Cuoles Received 

AUG 28 190^ 

CoDvncht Entry 
CLASS H XXc, No, 

copra. 



Copyright, 1897, 1902, 1905, 1907, 
By D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



V 



TO 
VIRGIL P. GIBNEY, M. D., LL. D., 

PROFESSOR OF ORTHOPAEDIC SURGERY IN THE cbLLEGE OF PHYSICIANS AND 

SURGEONS (COLUMBIA UNIVERSITY), NEW YORK ; SURGEON-IN-CHIEF 

TO THE HOSPITAL FOR THE RUPTURED AND CRIPPLED, 

THIS VOLUME IS INSCRIBED 

AS A TRIBUTE TO HIS PERSONAL WORTH AND HIGH PROFESSIONAL ATTAINMENTS, 
AND IN GRATEFUL REMEMBRANCE OF MANY ACTS OF KINDNESS, 

BY THE AUTHOR. 



PKEFACE TO THE FOURTH EDITION. 



In no part of Paediatrics are new knowledge and experience changing 
our views more rapidly than in matters concerning nutrition. 

It has therefore become necessary to make another general revision 
of this section of the book. These pages have been largely rewritten and 
considerable new material introduced. It is hoped that in both sim- 
plicity and clearness the chapters upon infant feeding have been im- 
proved, and their practical value for the student and practitioner thereby 
enhanced. 

The other sections have been changed but slightly from the Third 
Edition. 

The author desires to acknowledge the assistance rendered in this re- 
vision by his associate, Dr. John Howland. 

14 West Fifty-fifth Street, 
New York. 

iv 






PKEFACE TO THE THIKD EDITION. 



Frequent revisions of a text-book in paediatrics are necessary if 
it would adequately present to its readers existing knowledge in this 
department of medicine. The present revision has been made with- 
out any important changes in the general arrangement, and at the 
same time without materially increasing the size of the volume. Cer- 
tain chapters have been much abridged while others have been much 
expanded. 

The needs of the student and practitioner rather than those of the 
specialist have been constantly kept in mind. The purpose has been 
to restrict the book to its own field — now so constantly widening — 
omitting the discussion of subjects which are fully treated in works 
upon pathology, general medicine, and surgery. 

Convinced of the great value of good pictures, both of clinical and 
pathological conditions, especial pains have been taken in this revision 
with the illustrations. Many old ones have been replaced by better 
ones, and altogether twenty-five new illustrations have been introduced. 
For much assistance with these, the author desires to express his obli- 
gation to his associate, Dr. H. B. Wilcox, by whom many of the origi- 
nal photographs were taken. Credit is due to Dr. F. C. Wood for the 
color drawing of the blood. 

While alterations have been found necessary in almost every 
chapter, the principal changes have been made in the articles upon 
the following subjects : Examination of the Sick Child, Hypertrophic 
Stenosis of the Pylorus, Diarrhoea! Diseases and Dysentery, Vaginitis, 



vi PREFACE TO THE THIRD EDITION. 

Cerebro- Spinal Meningitis, Mental Defects, Chondro-Dystrophy., Status 
Lymphaticus, and Diphtheria. Most of these chapters have been entirely 
rewritten; some appear for the first time in this edition. 

14 West Fifty-fifth Street, 
New York. 



TABLE OF CONTENTS. 



PART I. 

CHAPTER PAGE 

I. — Hygiene and General Care of Infants and Young Children . . 1 
Care of the newly-born child; bathing; clothing; care of the eyes; care of 
the mouth and teeth ; care of the skin ; care of the genital organs ; vaccina- 
tion; training to proper con trol of rectum and bladder; general hygiene of 
the nervous system; sleep; exercise; airing; the nursery; the nurse; the 
amount of air space required by infants ; the care of premature and delicate 
infants; incubators; the feeding of the premature infant. 

II. — Growth and Development of the Body 15 

Weight ; height ; growth of extremities as compared with the trunk ; the 
head; the chest; the abdomen; muscular development; development of spe- 
cial senses ; speech ; dentition. 

III. — Peculiarities of Disease in Children 30 

Etiology; symptomatology and diagnosis; pathology; prognosis and infant 
mortality ; prophylaxis ; therapeutics. 



PART II. 

Section I.— Diseases of the Newly-Born. 

I. — Asphyxia 69 

II. — Congenital Atelectasis 74 

III. — Icterus 77 

IV. — The Acute Infectious Diseases of the Newly-Born .... 81 
The acute pyogenic diseases; ophthalmia; tetanus; epidemic hsemoglobinuria;. 
fatty degeneration of the newly-born; pemphigus. 

V. — HEMORRHAGES 95 

Traumatic or accidental haemorrhages ; spontaneous haemorrhages. 

VI. — Birth Paralyses 107 

Cerebral paralysis; facial paralysis; paralysis of the upper extremity. 

VII. — Tumours of the Umbilicus, etc 113 

Umbilical hernia; mastitis; intestinal obstruction; diaphragmatic hernia; 
sclerema ; oedema ; inanition fever. 

Section II.— Nutrition. 
I. — Introductory 124 

The food constituents and the purposes they subserve in nutrition. 

vii 



Vlii TABLE OF CONTENTS. 

CHAPTER PAGE 

II. — The Infant's Dietary ....... - « 129 

Woman's milk; cow's milk; condensed milk; kumyss ; matzoon ; junket, 
curds and whey; beef preparations ; cereals; infant foods. 
III. — Infant Feeding „ 168 

Choice of methods; breastfeeding"; maternal nursing ; wet-nursing; weaning; 
mixed feeding ; artificial feeding. 

IV. — Feeding after the First Year 219 

Healthy infants during the second year; difficult cases during the second 
year; feeding from the third to the sixth year; feeding during acute illness. 

V. — The Derangements of Nutrition 226 

Acute inanition ; malnutrition ; marasmus. 

VI. — Diseases Due to Faulty Nutrition 244 

Scorbutus ; rickets. 

Section III. — Diseases of the Digestive System. 

I. — Diseases of the Lips, Tongue, and Mouth 274 

Malformations ; diseases of the lips ; diseases of the tongue ; alveolar abscess ; 
difficult dentition; catarrhal stomatitis; herpetic stomatitis; ulcerative stoma- 
titis ; thrush; gonorrhoeal stomatitis; syphilitic stomatitis; diphtheritic stoma- 
titis ; gangrenous stomatitis. 

II. — Diseases of the Pharynx 293 

Acute pharyngitis; uvulitis; elongated uvula; retro-pharyngeal abscess; 
adenoid vegetations of the vault of the pharynx. 

III. — Diseases of the Tonsils 307 

Croupous tonsillitis; ulcero - membranous tonsillitis; follicular tonsillitis; 
phlegmonous tonsillitis; chronic hypertrophy of the tonsils. 

IV. — Diseases of the (Esophagus 314 

Malformations; acute oesophagitis; retro-cesophageal abscess. 

V. — Diseases of the Stomach 318 

Digestion in infancy; malformations and malpositions of the stomach ; hyper- 
trophic stenosis of the pylorus; vomiting; cyclic vomiting; gastralgia; acute 
gastric indigestion; acute gastritis; gastro-duodenitis; chronic gastric indiges- 
tion ; dilatation of the stomach ; ulcer of the stomach ; tumours of the stomach ; 
haemorrhage from the stomach. 

VI. — Diseases of the Intestines 352 

Malformations and malpositions; diarrhoea; acute intestinal indigestion. 

VII. — Diseases of the Intestines (continued) 364 

Acute gastro-enteric intoxication; cholera infantum. 

VIII. — Diseases of the Intestines (continued) 385 

Acute colitis and ileo-colitis ; chronic ileo-colitis ; amoebic colitis; amyloid 
degeneration of the intestines; tuberculosis of the intestines and mesenteric 
lymph nodes. 

IX. — Diseases of the Intestines (continued) 413 

Chronic intestinal indigestion; intestinal colic; chronic constipation; intus- 
susception. 

X. — Diseases of the Intestines (continued) 438 

Appendicitis ; intestinal worms. 

XI. — Diseases of the IIectum 452 

Prolapsus ani ; fissure of the anus; proctitis; ischio-rectal abscess; luemor- 
rhoids ; incontinence of faeces. 



TABLE OF CONTEXTS. i x 

CHAPTER PAGE 

XII. — Diseases of the Liver 458 

Icterus; functional disorders; new growths; acute yellow atrophy; conges- 
tion of the liver ; abscess of the liver; cirrhosis; amyloid degeneration; fatty 
liver; hydatids; biliary calculi. 

XIII. — Diseases of the Peritonaeum 465 

Acute peritonitis; chronic (non-tuberculous) peritonitis; tuberculous perito- 
nitis ; ascites ; subphrenic abscess. 

Section IV.— Diseases of the Respiratory System. 

I. — Nasal Cavities 478 

Acute nasal catarrh ; chronic nasal catarrh ; chronic rhinitis ; membranous 
rhinitis ; epistaxis. 

II. — Diseases of the Larynx . 489 

Catarrhal spasm of the larynx; acute catarrhal laryngitis; membranous laryn- 
gitis; intubation; submucous laryngitis; chronic laryngitis; new growths; 
foreign bodies in the larynx. 

III. — Diseases of the Lungs 509 

The peculiarities of the lungs in infancy and early childhood; acute catarrhal 
bronchitis; fibrinous bronchitis ; chronic bronchitis; reflex cough ; asthma. 

IV. — Diseases of the Lungs {continued) . . 527 

Pneumonia; acute broncho-pneumonia. 

V. — Diseases of the Lungs {continued) 562 

Lobar pneumonia; pleuro-pneumonia ; hypostatic pneumonia; chronic bron- 
cho-pneumonia; abscess of the lung; gangrene of the lung; acquired atelec- 
tasis ; emphysema. 

VI.— Pleurisy 591 

Dry pleurisy ; pleurisy with serous effusion ; empyema. 

Section V. — Diseases of the Circulatory System. 

I. — Peculiarities of the Heart and Circulation in Early Life . . 606 

II. — Congenital Anomalies of the Heart 610 

III. — Pericarditis 617 

Acute pericarditis; chronic pericarditis witli adhesions. 

IV — Endocarditis and Valvular Disease 622 

Acute simple endocarditis ; malignant endocarditis; chronic valvular disease ; 
myocarditis; anasmic murmurs; functional disorders of the heart; diseases of 
the blood-vessels. 

Section VI.— Diseases of the Uro-Genital System. 

I. — The Urine in Infancy and Childhood 642 

Functional or cyclic albuminuria; hematuria; hemoglobinuria ; glycosuria; 
pyuria; lithuria; indicanuria ; acetonuria — diaeetonuria ; anuria; diabetes 
insipidus. 

II. — Diseases of the Kidneys . . . 654 

Malformations and malpositions; uric-acid infarctions; acute congestion of 
the kidney; chronic congestion of the kidney ; acute degeneration of the kid- 
neys; acute diffuse nephritis ; chronic nephritis; tuberculosis of the kidney; 
malignant tumours of the kidney; pyelitis — pyelo-cystitis ; renal calculi; trau- 
matic hydronephrosis; perinephritis; general oedema not dependent on renal 
disease. 



X " TABLE OF CONTENTS. 

CHAPTER PAGE 

III. — Diseases of the Genital Organs 683 

Malformations ; diseases of the male genitals ; diseases of the female genitals. 

IV.— Enuresis 692 

Vesical spasm ; vesical calculi. 

Section VII. — Diseases of the Nervous System. 
I. — Introductory 699 

II. — General and Functional Nervous Diseases 701 

Convulsions ; epilepsy ; tetany ; laryngismus stridulus ; chorea ; other spas- 
modic affections ; hysteria; headaches; disorders of speech ; disorders of sleep; 
injurious habits of infancy and childhood. 

III. — Diseases of the Brain and Meninges 747 

Malformations; pachymeningitis; acute meningitis ; ccrebro-spinal meningitis; 
simple acute meningitis; tuberculous meningitis; chronic basilar meningitis in 
infants ; thrombosis of the sinuses of the dura mater ; cerebral abscess : cere- 
bral tumour; hydrocephalus; infantile cerebral paralysis; mental defects; 
chondro-dystrophy ; sporadic cretinism ; insanity ; the stigmata of degenera- 
tion ; deaf-mutism. 

IV. — Diseases of the Spinal Cord 820 

Malformations; spinal meningitis; myelitis; compression-myelitis; acute 
poliomyelitis ; tumours of the spinal cord ; syringo-myelia ; Friedreich's 
ataxia ; Landry's paralysis ; the muscular atrophies. 

V. — Diseases of the Peripheral Nerves . . . . . . 846 

Multiple neuritis ; diphtheritic paralysis ; facial paralysis. 

Section VIII. — Diseases of the Blood, Lymph Nodes, Bones, etc. 

I. — Diseases of the Blood 856 

Leucocytosis ; simple anaemia ; chlorosis ; pseudo-leukaemic anaemia of in- 
fancy ; pernicious anaemia ; leukaemia ; haemophilia ; purpura. 

II. — Diseases of the Lymph Nodes 877 

Status lymphaticus; simple acute adenitis; simple chronic adenitis; syphilitic 
adenitis ; tuberculous adenitis ; Hodgkin's disease. 
III. — Diseases of the Spleen . . . 896 

IV. — Diseases of the Bones and Joints 899 

Acute arthritis of infants; tuberculous diseases of the bones and joints; syph- 
ilitic diseases of bone. 

V. — Diseases of the Skin 922 

Congenital ichthyosis; miliaria; seborrhcea; eczema; furunculosis ; gangren- 
ous, dermatitis ; impetigo contagiosa ; urticaria; scabies; tinea tonsurans. 
VI. — Acute Otitis 943 

Section IX.— The Specific Infectious Diseases. 

L— Scarlet Fever 953 

II.— Measles 977 

III.— Rubella . . . 993 

IV.— Varicella .... 996 

V. — Vaccinia — Vaccination . ° 998 

VI.— Pertussis ••••••'. 1004 



TABLE OF CONTENTS. 



XI 



CHAPTER 








PAGE 


VII.— Mumps . 


. . . . . . 1016 


VIII. — Diphtheria and Pseudo-Diphtheria 






. 1019 


IX. — Typhoid Fever . 


. 






. 1062 


X. — Tuberculosis 









. 1070 


XI.— Syphilis 


...... 






. 1106 


XII. — Influenza 


. 






. 1123 


XIII.— Malaria 


....... 






. 1131 



Section X. — Other General Diseases. 

I. — Rheumatism 

II. — Diabetes Mellitus 



1141 
1147 



LIST OF ILLUSTEATIOISTS. 



PLATES. FACING 

PAGE 

I. Chart showing by months the mortality of New York city for the dif- 
ferent ages for three years . .43 

II. Meningeal hemorrhage in the newly born 108 

III. Chart showing composition of various infant foods compared with 

woman's milk . - 165 

IV. Bone in rickets 255 

V. Typical rickets 258 

VI. Deformity of the chest in severe rickets ....... 261 

VII. The stomach at the different periods of infancy . . . . . 319 

VIII. Extensive superficial ulceration of the colon 387 

IX. Deep follicular ulcers of the colon . . . „ . . . . 388 

X. Membranous inflammation of the ileum 392 

XI. Acute broncho-pneumonia ......... 534 

XII. Acute pleuro-pneumonia . 580 

XIII. Chronic broncho-pneumonia 583 

XIV. Acute meningitis, complicating pleuro-pneumonia ..... 768 
XV. The blood in leukaemia and pernicious anaemia, etc. . . , . . 857 

XVI. Eruption of measles 981 

XVII. The pathognomonic sign of measles (Koplik's spots) .... 989 

XVIII. The diphtheritic membrane 1031 

XIX. Diphtheria bacilli and their associates 1041 

XX. Tuberculosis of the tracheo-bronchial lymph nodes .... 1082 



ILLUSTRATIONS IN THE TEXT. 

FIGURE PAGE 

1. Incubator . 12 

2. Breck's feeding tube .13 

3. 4. Scales 15 

5. Weight curve for the first twenty days 16 

6. Weight curve for the first year 18 

7. Skull, showing premature ossification ........ 23 

8. Apparatus for albolene spray 57 

9. Nasal syringe ... 58 

10. Position for nasal syringing 59 

11. Croup kettle 60 

12. Vapourizer Gl 

13. Steam atomizer 61 

xiii 



xiv LIST OP ILLUSTRATIONS. 

FIGURE • * PAGE 

14. Oiled-silk jacket 01 

15. Apparatus for stomach-washing 62 

16. Position for stomach-washing ........... 63 

17. Kemp's tube 65 

18. Colon of a child six months old 66 

19. Ribemont's tube 73 

20. Pemphigus neonatorum 95 

21. Double cephalhematoma, infant seven days old 98 

22. Erb's paralysis 112 

23. Umbilical tumours 114 

24. Temperature chart in inanition fever 122 

25. Human milk: A, colostrum period ; B, later period 130 

26. Apparatus for examination of human milk 135 

27. A, Babcock tubes; B, Lewi's modification for human milk . . . . 136 

28. Feser's lactoscope 148 

29. Arnold sterilizer 155 

30. Freeman Pasteurizer 156 

31. Weight curve of nursing and artificial feeding compared .... 169 

32. Weight curve showing effect of bad nursing and good feeding . . . 177 

33. Chart showing effect of pregnancy on weight of nursing infant . . . 179 

34. Weight curve of infant properly weaned 180 

35. Percentage of fat in different layers of milk 192 

36. Chapin's dipper for removing upper layers of milk 193 

37. Weight curve of bottle-fed infant for first six months 197 

38. Weight curve of artificially fed infant, showing effect of beginning with too 

high percentages 198 

39. Weight chart showing the effect of intelligent care 207 

40. Weight curve showing the advantage of temporarily stopping milk . . 216 

41. Case of marasmus 240 

42. Normal bone 256 

43. Rachitic bone 257 

44. Rachitic skull, inside view 260 

45. Rachitic head .261 

46. Rachitic skull, external view . 262 

47. Rachitic thorax in outline 262 

48. Rachitic bow-legs 263 

49. Rachitic knock-knees 264 

50. Rachitic deformity of legs 265 

51. Rachitic bow-legs in outline 272 

52. Epithelial desquamation of the tongue 277 

53. Thrush 287 

54. Cancrum oris 292 

55. Adenoid vegetations, natural size 300 

56. Chest deformity from adenoid vegetations of the pharynx .... 302 

57. 58. Child with adenoid vegetations, before and after operation . . . 306 

59. Dilatation of the stomach . 348 

60. Malformations of the rectum , 352 

61. Chart showing mortality from diarrhoeal diseases in New York . . . 355 

62. Chart showing frequency of diarrhoeal diseases 355 

63. Weight curve showing effect of acute gastro-enteric intoxication during 

first year 369 



LIST OF ILLUSTRATIONS. xv 

FIGURE ^ PAGE 

64. Temperature chart of acute intestinal intoxication with fatal re-infection . 371 

65. Acute catarrhal ileo-colitis, superficial type 387 

66. Acute catarrhal ileo-colitis, severe form . 388 

67. Follicular ulceration of the colon, early stage 390 

68. Follicular ulceration of the colon, later stage . 391 

69. Membranous colitis 393 

70. Weight curve showing loss from ileo-colitis 395 

71. Temperature chart in ileo-colitis 397 

72. Temperature chart in membranous colitis 399 

73. Temperature chart in membranous colitis, long case . . , m . 400 

74. Chronic catarrhal inflammation of the ileum 405 

75. Chronic intestinal indigestion 417 

76. Ileo-caecal intussusception . 429 

77. Mechanism of intussusception . 430 

78. Taenia saginata .... 446 

79. Taenia solium 446 

80. Taenia cucumerina 447 

81. Bothriocephalus latus 447 

82. Ascaris lumbricoides 448 

83. Oxyuris vermicularis 450 

84. Prolapsus ani . 453 

85. O'Dwyer's intubation set 499 

86. An air vesicle in broncho-pneumonia 528 

87. An air vesicle in lobar pneumonia . . . 529 

88. Broncho-pneumonia with thickened bronchus 534 

89. Broncho-pneumonia, hemorrhagic form 536 

90. Broncho-pneumonia with emphysema 537 

91. Broncho-pneumonia, diffuse purulent infiltration 538 

92. Persistent broncho-pneumonia . 540 

93. Temperature chart in mild uncomplicated broncho-pneumonia . ( . . 545 

94. Temperature chart, prolonged course, broncho-pneumonia .... 546 

95. Temperature chart, relapsing broncho-pneumonia 546 

96. Temperature chart, rapidly fatal broncho-pneumonia ..... 546 
97-100. Physical signs in broncho-pneumonia 548 

101. Temperature chart, persistent broncho-pneumonia . . . . 551 

102. Temperature chart, broncho-pneumonia following pertussis .... 552 

103. Temperature chart, typical lobar pneumonia 568 

104. Temperature chart, remittent type, lobar pneumonia 568 

105. Temperature chart, lobar pneumonia, subnormal temperature after crisis . 569 

106. Temperature chart, abortive pneumonia 569 

107-109. Physical signs, lobar pneumonia 573 

110. Section of lung, showing distribution of fluid in chest 598 

111, 112. Empyema following pneumonia 599 

113. Deformity after old empyema 604 

114. Apparatus for inducing lung expansion after empyema .... 605 

115. Showing normal areas of cardiac dulness 609 

116. Congenital cardiac disease 611 

117. Clubbing of fingers in congenital cardiac disease 614 

118. Congenital malformations of the kidney and ureters 657 

119. 120. Sarcoma of the kidney before and after operation ..... 673 
121. Tetany 718 

2 



xvi LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

122. Spasmodic torticollis 731 

123. Meningocele 747 

124. Encephalocele 747 

125. Hydrencephalocele 747 

126. Meningocele , 747 

127. Frontal meningocele 748 

128. Naso-frontal meningocele 748 

129. Cerebro-spinal meningitis showing frequency 754 

130. Posture in cerebro-spinal meningitis 758 

131. Temperature chart, cerebro-spinal meningitis 761 

132. Tracing of respiration in tubercular meningitis 773 

133. Temperature chart in tubercular meningitis 773 

134. Chronic basilar meningitis 776 

135. Chronic basilar meningitis 777 

136. Section of the brain in internal hydrocephalus 791 

137. Brain in external hydrocephalus . . 792 

138. Head in chronic hydrocephalus 793 

139. Brain showing atrophy 797 

140. Convulsions in infantile cerebral paralysis 798 

141. Spastic paraplegia 800 

142. Infantile hemiplegia showing contractures 802 

143-148. Various types of mental defect 805 

149. Brain in idiocy 806 

150. Chondrodystrophy, radiograph of skull 810 

151. Chondro-dystrophy, long bones 811 

152. Chondro-dystrophy, infantile figure 811 

153. Chondro-dystrophy, trident hand 812 

154. Chondro-dystrophy, adult figure . . 812 

155. A typical cretin 813 

156-159. Cretins, showing effect of thyroid treatment 814 

160. Spina bifida, meningocele (partially diagrammatic) 821 

161. Spina bifida, meningocele, case of 821 

162. Spina bifida, meningo-myelocele (partially diagrammatic) .... 822 

163. Spina bifida, syringo-myelocele 823 

164. Spina bifida, sacral 823 

165. Spina bifida, section of cord in 824 

166. Infantile spinal paralysis of lower extremity 835 

167. Infantile spinal paralysis of shoulder 836 

168. Muscular pseudo-hypertrophy 845 

169. Alcoholic neuritis 848 

170. Diphtheritic paralysis 849 

171. Facial paralysis 854 

172. Enlarged thymus . 880 

173. Acute suppurative adenitis, cervical 885 

174. Acute suppurative adenitis, inguinal 885 

175. Chain of tuberculous lymph nodes (posterior cervical) . . . . 890 

176. Cicatrices following tuberculous adenitis 892 

177. Section of the spine in Pott's disease 903 

178. Hip-joint disease 909 

179. Tuberculous dactylitis 914 

180. Syphilitic disease of the radius and ulna ........ 916 



LIST OF ILLUSTRATIONS. xvii 

FIGURE PAGE 

181. Syphilitic disease of the tibia 918 

182. Syphilitic disease of both tibise 919 

183. Syphilitic necrosis of the tibia 920 

184. Syphilitic dactylitis 921 

185. Congenital ichthyosis 923 

186. Temperature chart, acute otitis following influenza 944 

187. Temperature chart, acute otitis, early paracentesis 945 

188. Mastoid abscess 947 

189. Temperature charts in scarlet fever, mild cases 959 

190. Temperature chart in scarlet fever, typical curve 960 

191. Temperature chart in severe uncomplicated scarlet fever .... 961 

192. Temperature chart in fatal septic scarlet fever 962 

193. Temperature chart in scarlet fever with late otitis 966 

194. Temperature chart in scarlet fever with late nephritis 967 

195. 196. Temperature charts in measles, typical curve 983 

197. Temperature chart in measles, occasional course 983 

198. Temperature chart in measles, prolonged course 984 

199. 200. Temperature charts in measles complicated by pneumonia . . . 985 

201. Table showing protective power of vaccination 999 

202. Vaccination vesicles 1001 

203. Temperature chart in pseudo-diphtheria 1059 

204. Temperature chart in typhoid fever, short course 1065 

205. Temperature chart in typhoid fever, with relapse . . . . .1066 

206. Tuberculous broncho-pneumonia, diffuse consolidation 1079 

207. Cavity from tuberculous broncho-pneumonia. 1079 

208. A tuberculous nodule 1080 

209. Tuberculous broncho-pneumonia, early stage 1081 

210. Tuberculous bronchial lymph nodes 1083 

211. Temperature chart of tuberculosis following measles 1092 

212. Temperature chart of tuberculous broncho-pneumonia, general tuberculosis 1093 

213. Temperature chart of tuberculous broncho-pneumonia with softening . . 1094 

214. Syphilitic scaling in an infant 1114 

215. Syphilitic notched teeth 1116 

216. Syphilitic teeth, variously deformed 1117 

217. Temperature chart of severe influenza in an infant 1125 

218. Temperature chart of acute broncho-pneumonia complicating influenza . . 1127 

219. Temperature chart, quotidian intermittent fever 1133 

220. Temperature chart, tertian intermittent fever 1134 

221. Temperature chart in malaria, irregular type 1135 



THE DISEASES OF INFANCY AND CHILDHOOD. 

PART I. 



CHAPTER I. 

HYGIENE AND GENERAL CARE OF INFANTS AND YOUNG 

CHILDREN. 

The physical development of the child is essentially the product of 
the three factors — inheritance, surroundings, and food. The first of these 
it is beyond the physician's power to alter ; the second is largely and the 
third almost entirely within his control, at least in the more intelligent 
classes of society. These two subjects, infant hygiene and infant feeding, 
are the most important departments of pediatrics. 

The Care of the Newly-Born Child. — After the ligature of the cord the 
child should be wrapped in a thick blanket and placed in a warm room. 
In hospital practice the eyes should be cleansed with absorbent cotton 
and water which has been boiled, and then two or three drops of a two- 
per-cent solution of nitrate of silver, after Crede's method, instilled into 
each eye by means of a glass rod or eye-dropper. In private practice a 
saturated solution of boric acid may be substituted, unless the mother has 
had a purulent vaginal discharge, in which case the silver solution should 
always be used. The bath should now be given in a warm room ; the 
body being first oiled thoroughly in order to remove the vernix caseosa 
and then washed in water at a temperature of 100° F. The mouth should 
be cleansed with plain tepid water and a soft cloth, and no violence em- 
ployed. The cord may be covered with salicylic acid one part and starch 
nineteen parts, or simply with subnitrate of bismuth, and wrapped in 
sterile gauze or surgeon's lint. The abdomen should now be enveloped 
in a flannel band, eight or ten inches wide, and pinned rather snugly. 
Before dressing is completed, the child should be submitted to a thorough 
examination for injuries received during delivery, congenital deformities, 
also as to the condition of the respiration, circulation, etc. 

After dressing, the child should be placed in its crib and covered with 
blankets, and if the feet are cold, or the fingers and lips a little blue, it 

1 



2 HYGIENE AND GENERAL CARE OF INFANTS. 

should be surrounded by hot-water bottles covered with flannels, and 
placed near, but not in contact with, the body. The crib should be placed 
in a quiet, darkened room. The young infant should not occupy the 
same bed as the mother, unless it greatly needs the warmth of her body, 
other means of artificial heat not being at hand. 

The cord should be kept dry and disturbed as little as possible until 
it falls off. Under ordinary circumstances the cord separates from the 
fourth to the seventh day, the average being the fifth day. The stump 
should then be covered with the salicylic acid and starch powder, and a pad 
of sterile gauze about one fourth of an inch thick and two inches square 
applied and secured in position by means of the abdominal band. The 
purpose of this is to prevent umbilical hernia. The pad should be con- 
tinued for the first month. The use of stronger antiseptic dressings than 
that recommended is somewhat objectionable, since it preserves the cord 
too long and delays separation. The full bath should not be given until 
the cord has separated. 

The physician should always see to it that the infant cries enough to 
keep the lungs properly expanded. 

The question of food for the newly-born infant is considered in the 
chapter upon infant feeding. 

Bathing. — For the first few months the bath should be given at 98° 
F. The room should be warm, preferably there should be an open fire. 
The bath should be short and the body dried quickly, without too vigor- 
ous rubbing. The addition of salt to the bath is an advantage where the 
skin is unusually delicate or excoriations are present. One large handful 
should be used to a gallon of water. By the sixth month the temperature 
of the bath for healthy infants may be lowered to 95° F., and by the end 
of the first year to 90° F. Older children who are healthy should be sponged 
or douched for a moment at the close of the tepid bath with water at 65° 
or 70° F. During childhood the warm bath is preferably given at night. 
In the morning a cold sponge bath is desirable. This should be given in 
a warm room and while the child stands in a tub partly filled with warm 
water. This cold sponge should last but half a minute, and be followed 
by a brisk rubbing of the entire body. 

In some young infants and even older children there is no proper 
reaction after the bath, even when given at the temperatures mentioned ; 
children being pale, slightly blue about the lips and under the eyes. All 
tub bathing, and especially all cold bathing, should then be stopped, since 
a continuance can only be a drain upon the child's vitality. 

Clothing. — The clothing of infants should be light, warm, non-irri- 
tating to the skin, and loose enough to allow free motion of the extremi- 
ties ; nor should bands be pinned so tightly about the trunk as to em- 
barrass the movements either of the chest or of the abdomen. The chest 
should be covered with a woollen shirt, high in the neck and with long 



BATHING— CLOTHING. 3 

sleeves. All petticoats should be supported from the shoulders and not 
from waistbands. Canton flannel and stockinet are both superior as 
absorbents to the more commonly used linen diapers. Stockinet has the 
advantage of being very soft and pliable. Care should be given that in in- 
fants the feet be kept warm. If the circulation is very poor, a bag of hot 
water should always be in the crib. Cold feet are responsible for many 
attacks of colic and indigestion. 

The abdominal band is usually worn during infancy. It cannot be 
considered in any sense a necessity after the first few months, excepting 
in cases of very thin infants whose supply of fat in the abdominal walls is 
an insufficient protection to the viscera. For the first few weeks a band of 
plain flannel is to be preferred ; later, a knitted band with shoulder-straps. 
The fashion of low neck and short sleeves for infants and very young 
children has fortunately passed away — let us hope, never to return. 

During the summer the outer clothing should be light and the under 
clothing of the thinnest flannel or gauze. The changes in the tempera- 
ture of morning and evening may be met by extra wraps. The custom of 
allowing young children to go with legs bare has many enthusiastic advo- 
cates ; while it may not be objectionable during the heat of summer, its 
advantages at any season are very questionable in a changeable climate 
like that of New York or the Atlantic coast. Many delicate children are 
certainly injured by such ill-advised attempts at hardening. 

The night clothing of infants should be similar to that worn during 
the day, but should be loose, the material being of the lightest flannel. 
The night clothing for older children should consist of a thin woollen 
shirt and a union suit with waist and trousers, and in some cases with 
feet, if there is a tendency to get outside the coverings. The common 
mistake is to overload all children, but especially infants, with covering at 
night. This is an explanation of much of the restless sleep which is seen 
particularly in delicate children. 

Care of the Eyes. — During the first few days at the daily bath, the 
eyes should be cleansed with a saturated solution of boric acid. They 
should be carefully protected from too strong light during early infancy. 
It is desirable that a child should always sleep in a darkened room. 

Care of the Mouth and Teeth. — The mouth of the newly-born infant 
should be gently cleansed at each morning bath with boiled water and 
a soft cloth. On the first appearance of thrush the mouth should be 
washed after every feeding with a solution of bicarbonate of soda or borax 
(twenty grains to the ounce). Harm is often done by the use of too much 
force in cleansing the mouth of a young infant. 

The primary teeth as well as those of the permanent set should receive 
daily attention. Too often they are neglected altogether. Dirty teeth 
are likely sooner or later to become carious ; and carious teeth, besides 
being a cause of bad breath and neuralgia, are a constant menace to the 



4: HYGIENE AND GENERAL CARE OP INFANTS. 

health of the child, since they may harbour infectious germs of all varie- 
ties. Such teeth should either be filled or removed. 

Care of the Skin. — The skin of a young infant is exceedingly deli- 
cate, and excoriations, intertrigo, and eczema are of very common occur- 
rence. These conditions are much easier of prevention than of cure. 
The first essential in the care of the skin is cleanliness, and this must be 
secured without the use of strong soaps or too much rubbing. Napkins 
must be removed as soon as soiled or wet. Some bland absorbent powder, 
like starch, talcum, or the stearate of zinc, should be used in all the folds 
of the skin, in the neck, in the axillae, groins, and about the genitals, and 
in the folds of the thighs, particularly in very fat infants. If plain water 
produces an undue amount of irritation, the salt or bran bath should be 
employed. 

Care of the Genital Organs. — The female genitals need but little 
attention in young children, excepting as to cleanliness. This is more 
often neglected in older children than in infants. Vulvo-vaginitis is very 
common among the children of the poorer classes where cleanliness is 
neglected. 

In males the prepuce should receive attention during the first few 
weeks of life. If the foreskin is long and the preputial orifice small, 
circumcision should invariably be done. If it is not long, but is only 
adherent, these adhesions should be broken up, the parts thoroughly 
cleansed and the foreskin retracted daily until there is no disposition to a 
recurrence of the adhesions. These operations will be discussed more at 
length in a subsequent chapter. The only thing to be emphasised in 
the present connection is that the prepuce should receive proper atten- 
tion in early infancy, since this can now be done with less pain and dis- 
comfort to the child, and at the same time better results are obtained. 
If this matter is neglected during infancy, it is apt to be overlooked until 
harm has been produced by local or reflex irritation which phimosis or 
adherent prepuce may have excited. 

Vaccination. — This, although considered elsewhere, should be men- 
tioned in this connection as among the things requiring the physician's 
attention during the first months of life. 

Training to Proper Control of Rectum and Bladder. — It is surpris- 
ing to see what can be accomplished by intelligent efforts at training 
in these particulars. An infant can often be trained at three months to 
have its movements from the bowels when placed upon a small cham- 
ber. This not only saves a great amount of washing of napkins, but 
there is soon formed a habit of having the bowels move at a regular time 
or times each day. The infant must be put upon the chamber soon after 
its feeding. The importance of training young children to regular habits 
regarding evacuations from the bowels can hardly be overestimated. It 
should be impressed upon every mother and nurse by the physician, and 



SLEEP. 5 

especially the necessity of beginning training during infancy. Much of 
course will depend upon the food and the digestion ; but habit is a very 
large factor in the case. 

The training of the bladder is not quite so important, but the proper 
education of this organ adds much to the comfort of the child and the ease 
with which it is cared for. Before the end of the first year most intelli- 
gent children can be trained to indicate a desire to empty the bladder. 
Many mothers and nurses succeed in training children so well that by the 
tenth or eleventh month napkins are dispensed with during the day. 
On the other hand, it is very common to see children of two and even two 
and a half years still wearing napkins because of the lack of proper train- 
ing. Before it has reached the latter age a healthy child should go from 
10 p. m. until morning without emptying the bladder. The annoyance 
and discomfort from the neglect of early training in this particular are 
very great. Night feeding is responsible for much of the difficulty expe- 
rienced in training children to hold the water during the night. 

General Hygiene of the Nervous System. — Great injury is done to 
the nervous system of children by the influences with which they are 
surrounded during infancy, -especially during the first year. The brain 
grows more during the first two years than in all the rest of life. Normal 
healthy development of the nervous centres demands quiet, rest, peaceful 
surroundings, and freedom from everything which causes excitement or 
undue stimulation. 

The steadily increasing frequency of functional nervous diseases among 
young children is one of the most powerful arguments for greater atten- 
tion by physicians to the subject of the hygiene of the nervous sys- 
tem during infancy. Most parents err through ignorance. Playing with 
young children, stimulating to laughter and exciting them by sights, 
sounds, or movements until they shriek with apparent delight, may be a 
source of amusement to fond parents and admiring spectators, but it is 
almost invariably an injury to the child. This is especially harmful when 
done in the evening. It is the plain duty of the physician to enlighten 
parents upon this point, and insist that the infant shall be kept quiet, and 
that all such playing and romping as has been referred to shall, during 
the first year at least, be absolutely prohibited. 

Sleep. — The sleep of the newly-born infant is profound for the first 
two or three days and under normal conditions almost continuous. In 
the case of prolonged or tedious labor, or where from any cause undue 
compression has been exerted upon the head, it may approach the con- 
dition of semi-coma for twenty-four or forty-eight hours. This may be so 
deep as to excite apprehensions of serious brain lesions. If, however, there 
are associated with it no convulsions and no rigidity, this early stupor 
usually passes away on the second or third day. 

The sleep of early infancy is quiet and peaceful, but not very deep after 



6 HYGIENE AND GENERAL CARE OP INFANTS. 

the first month. After the third year the heavy sleep of childhood is 
commonly seen. A healthy infant during the first few weeks sleeps from 
twenty to twenty-two hours out of the twenty-four, waking only from 
hunger, discomfort, or pain. During the first six months a healthy infant 
will usually sleep from sixteen to eighteen hours a day, the waking pe- 
riods being only from half an hour to two hours long. At the age of one 
year most infants sleep from fourteen to fifteen hours, viz., from eleven 
to twelve hours at night, and two or three hours during the day, usually 
in two naps. When two years old usually thirteen to fourteen hours' 
sleep are taken ; eleven or twelve hours at night and one or two hours 
during the day, generally in a single nap. At the age of four years chil- 
dren require from eleven to twelve hours' sleep. It is always desirable, 
and in most cases with regularity it is possible, to keep up the daily nap 
until children are four years old. From six to ten years the amount of 
sleep required is ten or eleven hours, and from ten to sixteen years nine 
hours should be the minimum. 

Training in proper habits of sleep should be begun at birth. From 
the outset an infant should be accustomed to being put into its crib while 
awake and to go to sleep of its own accord. Booking and all other habits 
of this sort are useless and may even be harmful. An infant should not 
be allowed to sleep on the breast of the nurse, nor with the nipple of the 
bottle in its mouth. Other devices for putting infants to sleep, such as 
allowing the child to suck a rubber nipple or anything else, are positively 
injurious. If such means of inducing sleep are resorted to the infant soon 
acquires the habit of not sleeping without them. I have known of one 
instance where the habit of rocking during sleep was continued until the 
child was two years old ; the moment the rocking was stopped the infant 
would wake, and in consequence this practice was continued by the de- 
voted but misguided parents. A quiet, darkened room, a warm and com- 
fortable bed, an appetite satisfied, and dry napkins are all that are needed 
to induce sleep in a healthy child. 

The periods of sleep in young infants are usually from two to three 
hours long, with the exception of once or twice in the twenty-four hours, 
when a long sleep of five or six hours occurs. The purpose of training 
is to have the child take this long sleep at night. The habit of regular 
sleep is best established by wakening the infant regularly every two or 
two and a half hours during the day for feeding, and allowing it to sleep 
as long as possible during the night. This training goes hand-in-hand 
with regular habits of feeding. Such habits are easily formed if the plan 
be systematically followed from the outset. 

By the fifth month all feeding between 10 P. m. and 7 A. m. should be 
discontinued. If this is done most infants can be trained by this time to 
sleep all night. If the room is lighted, and the child taken from the crib 
or rocked or fed as soon as it wakens at night, there is no such thing as 



EXERCISE. 7 

the formation of good habits of sleep. Kegularity in sleep and feeding 
not only make the care of young infants very much easier, but they are of 
a good deal of importance for the health of the child. 

The causes of disturbed or irregular sleep in young infants are mainly 
two — hunger and indigestion. In nursing infants it is usually the for- 
mer ; in those artificially fed usually the latter. Sleeplessness from hun- 
ger is often seen in children who are nursed thirty or forty minutes and 
then fall asleep^ but wake in fifteen or twenty minutes crying and fretful. 
After being quieted they may fall asleep again for half an hour, but wake 
at short intervals. The peaceful sleep of two or three hours which should 
follow a proper feeding is never seen. With this restlessness, in indiges- 
tion other signs are usually present, such as bad stools, stationary weight, 
etc. The disturbed sleep due to overfeeding shows itself by much the 
same symptoms, excepting that the first sleep after the meal is usually 
longer. 

Exercise. — This is no less important in infancy than in later child- 
hood. An infant gets its exercise in the lusty cry which follows the cool 
sponge of the bath, in kicking its -legs about, waving its arms, etc. By 
these means pulmonary expansion and muscular development are in- 
creased and the general nutrition promoted. An infant's clothing should 
be such as not to interfere with its exercise. Confinement of the legs 
should not be permitted. In hospital practice I have often had a chance 
to observe the bad results which follow when very young infants are 
allowed to lie in the cribs nearly all the time. Little by little the vital 
processes flag, the cry becomes feeble, the weight is first stationary, then 
there is a steady loss. The a])petite fails so that food is at first taken 
without relish, then at times altogether refused; later, vomiting ensues 
and other symptoms of indigestion. This, in many cases, is the begin- 
ning of a steady downward course which goes on until a condition of hope- 
less marasmus is reached. Such infants must be taken up every few 
hours and carried about the wards ; the position should be frequently 
changed, and general friction of the entire body employed at least twice a 
day. Every means must be made use of to stimulate the vital activity. 
The value of systematic attention to these matters cannot be overestimated 
in hospitals for infants. Infants who are old enough to creep or stand 
usually take sufficient exercise unless they are restrained. At this age 
they should be allowed to do what they are eager to do. Every facility 
should be afforded for using their muscles. Exercise may be encouraged 
by placing upon the floor in a warm room a mattress or a thick " com- 
fortable," and allowing the infant to roll and tumble upon it at will. A 
large bed may answer the same purpose. 

In older children every form of out-of-door exercise should be encour- 
aged — ball, tennis, and all running games, horseback riding, the bicycle, 
tricycle, swimming, coasting, and skating. Up to the eleventh year no 



8 HYGIENE AND GENERAL CARE OF INFANTS. 

difference need be made in the exercise of the two sexes. Companion- 
ship is a necessity. Children brought up alone are at a great disadvantage 
in this respect, and are not likely to get as much exercise as they require. 
The amount of exercise allowed delicate children should be regulated 
with some degree of care. It may be carried to the point of moderate 
muscular fatigue, but never to muscular exhaustion. The latter is partic- 
ularly likely to be the case in competitive games. 

Exercise should have reference to the symmetrical development of the 
whole body. In prescribing it the specific needs of the individual child 
should be considered. By carefully regulated exercises very much may be 
done to check such deformities as round shoulders and slight lateral cur- 
vature of the spine, and also to develop narrow chests and feeble thoracic 
muscles. For purposes like these, gymnastics are exceedingly valuable to 
supplement out-of-door exercise, but they can never take their place. 

There are two important points with reference to exercise indoors : 
First, the playroom should be cool — from 60° to 65° F. ; never above 
this point. Secondly, during all active exercise the clothing should be 
loose and light, so as to allow the freest possible motion of the body. 

Airing. — In summer there can be no possible objection to a young 
infant being allowed out of doors at the end of the first week. It should 
be kept in the open air as much as possible during the day. In the fall 
and spring this should not be permitted until the child is at least a month 
old, and then only when the out-of-door temperature is above 60° F. 
During its outing the head should be protected from the wind and the 
eyes from the sun. The duration of the outing at first should be only fif- 
teen or twenty minutes, the time being gradually lengthened to two or 
three hours. The child should be gradually accustomed to changes of 
temperature in the room by opening wide the windows for a few min- 
utes each day even before it is taken out of doors, the child being dressed 
meanwhile as for an outing. In the case of children born late in the 
fall or in the winter this means of giving fresh air may be advantageously 
begun at one month and followed throughout the first winter. It is only 
necessary in all such cases that the changes be made very gradually 
both as to the length of the airing and to the temperature. The great 
advantage of this plan over that more commonly followed of keeping 
young infants closely housed for the first six months in case they are born 
in the fall or early winter, I can positively affirm from quite a wide obser- 
vation of both methods. It is a matter of very serious importance that 
every infant be furnished an abundance of pure fresh air in winter as well 
as in summer. When the plan above outlined is carefully and judiciously 
followed, the tendency to catarrhal affections instead of being increased is 
thereby greatly lessened. 

When four or five months old, there is no reason why a healthy child 
should not go out of doors on pleasant days if the temperature is not 



NURSERY. 9 

below 20° F. While there is a prejudice on the part of many mothers 
and some physicians against a child's sleeping out of doors in cold 
weather, it is a practice which I have always urged upon mothers, and 
have never seen followed by any but the most beneficial results. The 
days of all others when infants and very young children should not be 
out of doors are when there are high winds, especially those from the 
northeast, an atmosphere of melting snow, and during severe storms. 
Delicate infants must of course be more carefully guarded during the 
cold season. With most of these the plan of house-airing is all that 
should be attempted. 

Nursery. — This should be the sunniest and best-ventilated room in 
the house. It is the physician's duty to see that proper attention is paid 
to the lrygiene of the room in which the child spends at least four-fifths 
of its time during the first year, and two-thirds of its time during the 
first two or three years of life. Sunlight is absolutely indispensable. 
Sunny rooms always contain less organic matter and less humidity, and 
hence a room upon the north side of the house should always be avoided, 
preferably one in the second story should be chosen. Nothing which can 
in any way contaminate the air of the room should be allowed. There 
should be no drying of clothes or of napkins, and no plumbing. No food 
should be allowed to stand about the room. The gas should not be 
allowed to burn at night ; a small wax night-light furnishes all that is 
needed in the nursery. If possible the heat should be from an open fire ; 
the next best thing is the Franklin radiator. Nothing in the room is 
worse than steam heat from a radiator unless it be a gas stove which 
under no circumstances should be allowed, excepting possibly for a few 
minutes each morning during the bath. 

The temperature of the room during the day should be 70° F., but 
better 68° than 72° F. It is important that every nursery should have a 
thermometer, and that this and not the sensations of the nurse should be 
the guide. It is almost invariably true that the nursery is overheated. 
Often no other explanation can be found for chronic indigestion and fall- 
ing weight excepting a nursery whose habitual temperature ranges from 
75° to 80° F. At night for the first few months the temperature should 
not be allowed to fall below 65° F. After the first year the night tem- 
perature may fall to 60° or even 50° F. 

Free ventilation without draughts is an absolute necessity. This is 
best accomplished by ventilators in the windows, of which there are many 
excellent devices sold in the shops. While the child is absent from the 
room the windows should be widely opened and free airing of the nursery 
accomplished. The room should always be thoroughly aired at night be- 
fore the child is put to bed. The window may be kept open even in the first 
year, unless the temperature out of doors is below 35° F. A tier the first 
year the window may be open, unless the outside temperature is as low as 



10 HYGIENE AND GENERAL CARE OF INFANTS. 

20° F. If the window is open the door of the nursery should be closed, 
that currents of air may be avoided. The ventilation by means of an open 
fire is the most efficient. 

The furniture of the nursery should be as simple as possible, heavy 
hangings should be positively forbidden, and upholstered furniture used 
only to a small extent. Floors covered by large rugs are much more clean- 
ly than carpets, and hence are to be preferred. 

The child, whenever it is possible, should have a separate bed ; and 
so should the newly-born infant, in order to prevent the danger of over- 
lying by the mother, which among the lower classes is a frequent cause of 
death, and also to avoid the danger of too frequent night nursing, which is 
injurious alike to mother and child. Separate beds for older children will 
prevent the spread of many forms of infection from the diseased child to 
the healthy. The cradle for infants should be one which does not rock, in 
order that this unnecessary and vicious practice should not be carried on. 
The mattress should be of hair and quite firm. The pillow should be 
small ; in the summer, hair pillows are an advantage but not a neces- 
sity. The position of the child during sleep should be changed from 
time to time from one side to the other and then to the back. Atten- 
tion to all these details should not be beneath the physician's notice, since 
the violation of these plain rules of hygiene is at the bottom of many 
of the milder disorders and even of some of the more serious diseases seen 
in infancy. 

The Nurse. — The nurse of a young child should be healthy, young 
or in middle life, free from tuberculous or syphilitic taint, and from ca- 
tarrhal affections of the nose and throat. She should be neat in habit, 
of quiet disposition, and, most of all, she should be a person of intelli- 
gence. 

The Amount of Air Space required by Infants. — The nursery should 
always be as large a room as possible. One of the reasons why young 
infants do so badly in institutions is because of overcrowding. In a 
well-ventilated ward there should be allowed to each infant at least 1,000 
cubic feet for the best results. Children over two years old are not so 
sensitive to their surroundings, and may thrive in wards where only 700 
or 800 cubic feet are allowed to each child. 



THE CARE OF PREMATURE AND DELICATE INFANTS. 

Infants born before term, and some exceedingly delicate ones which are 
born at full term, require very special and particular care. The vitality is 
so feeble in these children that if they are handled in the ordinary way 
they survive at most but a few weeks. The symptom which indicates that 
such special care is necessary is most of all the weight of the child. Either 
congenital feebleness or prematurity may be assumed in most of the chil- 



THE CARE OF PREMATURE AND DELICATE INFANTS. H 

dren weighing less than four pounds ; also if the length of the body is less 
than nineteen inches. In these children all the organs are likely to be 
imperfectly developed and they are not ready for their work. Especially 
is this true of the lungs and of the organs of digestion. 

The clinical picture presented by these cases is quite characteristic. 
The body is limp ; the skin very soft and delicate and almost transparent ; 
the cry, a low feeble whine not unlike the mew of a kitten ; the respira- 
tory movements, extremely irregular, sometimes scarcely perceptible for 
several seconds ; the movements of the extremities infrequent and never 
vigorous. The general appearance is one of torpor. The muscles of the 
mouth and cheek and tongue may lack the requisite force for sucking, 
so that this is practically impossible, and even deglutition is slow, difficult, 
and prolonged. It is difficult to maintain the normal body temperature ; 
unless closely watched this may fall far below the normal, and may rise 
quite as much above it with the use of too much artificial heat. I once 
saw a fluctuation of 13° F. occur in a few hours from such causes. All the 
symptoms mentioned vary much according to the degree of prematurity. 

In the management of these cases there are two problems to be solved : 
the first to maintain the animal heat, the second to nourish the infant. 
Difficult as it always is to rear a premature infant, these difficulties are 
much increased in cases where proper means are not adopted immediately 
after birth. The loss which these children sustain during the first few 
days is in very many cases so great that subsequent measures, however 
well carried out, are futile. The heat-producing power is so feeble that 
the body temperature quickly falls below normal unless artificial heat is 
constantly used. The effect of cold upon these delicate infants is very 
serious, and not only growth but even life depends upon maintaining the 
body temperature steadily and uniformly. Their extreme susceptibility 
is something which it is difficult for one to appreciate who has not had 
experience in these cases. 

One of the simplest means of maintaining the temperature is to oil 
the skin and then roll the entire body, including extremities, in cotton 
1 tatting; even the neck and cranium may be covered, leaving only the face 
exposed. The usual diaper may be replaced by a pad of gauze and 
absorbent cotton. The body is then wrapped in blankets, placed in a 
dot lies-basket or bassinet with protected sides, and surrounded by bottles 
or bags containing hot water. A blanket or sheet should partially cover 
the top of the basket, forming a sort of hood to protect the eyes from 
light and the face and head from draughts. \n using hot-water bags, 
some caution must be exercised or too much heat may be secured. I 
have seen the temperature of an infant raised six or seven degrees from 
this cause. The temperature of the child should at first be taken every 
few hours to make sure that a proper amount of external heal is sup- 
plied, but not too much. 

A much better means of furnishing artificial heal is the electric pad 



12 



HYGIENE AND GENERAL CA'rtE OP INFANTS. 



known also as the " electrotherm." * These small heaters are attached to 
an electric fixture like a drop-light. A convenient size is ten by fifteen, 
inches. It is placed between two or three thicknesses of blanket, upon 
which the infant* lies in its basket. Three grades of heat can be obtained, 
according to the amount of electricity turned on. 

This mode of handling premature infants has been given a thorough 
trial in the Babies' Hospital and has been found to fulfil the indications 
with children as small as three pounds and as young as seven months 
quite as well as the incubator, at the same time being free from its 
clangers. It has not even been necessary, though perhaps desirable, to 
raise the general temperature of the room. But these patients, when 
kept in the ward at ordinary temperature, have maintained an even 
body temperature much more uniformly than I have seen with any other 
method — the incubator included. 

Premature infants should be disturbed as little as possible. The body 
should be oiled, and fresh cotton applied about once in three days. The 
feeding may be done without removing the child from its bed. 

Incubators. — The essential things in an incubator are means of main- 
taining a uniform temperature and efficient ventilation; since the dan- 
gers of infection are great, absolute cleanliness is indispensable. The 
temperature for the youngest and most delicate infants should be from 
90° to 95° F. ; for those somewhat older and stronger, from 85° to 
90° F. Ventilation is much more easily secured 
when the air admitted to the incubator is con- 
siderably below these figures, or not above 60° 
or 65° F. The incubator should therefore stand 
in a large cool room or communicate with the 
outside air. A thermostat attachment is a great 
advantage, as is also filtration of the air through 
cotton. Metal construction allows greater clean- 
liness and more complete disinfection. The in- 
cubator of Lion (Nice) seems to fulfil all these 
requirements better than any other yet con- 
structed. A similar one is shown in the illus- 
tration. It is necessary to watch not only the 
temperature of the incubator, as registered by 
a thermometer beside the baby, but the rectal 
temperature should be taken every few hours; 
fluctuations between 97.5° and 100.5° F. are 
unimportant. If the variations are much wider, 
the temperature of the apparatus should be 
modified accordingly. On account of the difficulties and dangers inherent 
in small incubators, Escherich has devised an " incubator room " in 




Fig. 1. — Incubator. 



* Obtained of Simplex Electric Heating Co., 89 Cortlandt Street, New York. 



THE CARE OF PREMATURE AND DELICATE INFANTS. 



13 




which several infants can be accommodated. It is four by eight feet, 
and six feet high. The nurse can enter this, and thus the removal of the 
child for feeding or any other purpose is avoided. 

Every incubator baby requires close and constant attention, and re- 
sults depend upon nothing so much as the intelligence and watchfulness 
of the nurse. In hospitals with nurses skilled in this 
particular line of work, excellent results are obtained; 
but outside of such institutions, with the usual obstetric 
nurse, the chances of failure are many. The incubator 
requires practically the entire time of one person by 
night and by day. No matter how carefully constructed, 
perfect ventilation is difficult to maintain, and with 
the infant's imperfectly expanded lungs attacks of as- 
phyxia are very likely to occur. A cylinder of oxygen 
should be at hand for use in such emergencies. Taking 
everything into consideration, I am not inclined to rec- 
ommend the use of the incubator except in institutions. 
Elsewhere the difficulties and dangers are so many and 
so great that in the majority of cases I believe better 
results will be obtained with the other means mentioned 
of maintaining body heat, particularly the electric pad. 

Feeding. — The feeding of the premature infant is 
not less important than the maintenance of heat and 
proper ventilation. Infants at eight months and those 
weighing five pounds or thereabouts can usually be made 
to take the breast after the first few days. Few below 
this age or weight will do so. Some will suck from a 
bottle, but the majority must be fed by other means. 
A medicine dropper may be used, or the Breck feeder 
(Fig. 2) ; the smallest and feeblest, however, must be fed by gavage, 
using a funnel and small rubber catheter. The food should be slowly 
given ; if rapidly, some is liable to be regurgitated, and this may produce 
attacks of asphyxia or even an aspiration pneumonia. The quantity 
of food and frequency of feeding will depend upon the size and age of 
the child. A seven months' baby weighing three and a half pounds 
should have, for the first twenty-four to thirty-six hours, only water, 
one to three teaspoonfuls every hour. Then regular food, half an ounce 
every hour, gradually increased to an ounce every hour and a half at the 
end of two weeks, and an ounce and a half every two hours at the end 
of three or four weeks. Artificial feeding I have not found very success- 
ful with premature infants. With some of the larger and more vigorous, 
cow's milk modified according to the directions given in the chapter- 
on Infant Feeding gives good results. I have once succeeded with a 
child of three pounds two ounces. For most of them under four and a 
3 



Fig. 2.— Brack's 

feeding-tube. 



14 



HYGIENE AND GENERAL CARE OF INFANTS. 



half pounds, breast milk is essential. The mother may furnish milk in 
a few cases if the child is born near term, and occasionally at eight 
months, but seldom earlier, so that a wet nurse must usually be depended 
upon. If the mother's milk is to be used, unless the child is very vigor- 
ous, it is better to pump her breasts and feed the baby with the dropper, 
in order that one may know exactly how much the child is getting ; since 
acute inanition from nursing upon breasts which have little or no milk 
is not an uncommon experience. In choosing a wet nurse it is not 
necessary that her child be a very young one. Since the milk must 
always be diluted at first, that of a woman whose child is between two 
weeks and two months old may answer. The milk is at first diluted 
with an equal amount of a 5-per-cent solution of milk sugar. The 
milk of a wet nurse will usually diminish rapidly in amount, and often 
change in quality when her breasts are pumped continually; it is there- 
fore better in most cases to have her nurse her own child at the same 
time, either wholly or in part, for a few weeks, until the premature 
infant is able to take the breast. 

The results with premature babies will depend very much upon how 
soon after birth they receive proper care. If an incubator is to be 
used it should be in readiness, so that the child can be put into it 
as soon as it is breathing properly. If the incubator is not employed 
until the child is several days old and is losing rapidly, the chances 
are poor. The age and vigour of the infant are of the greatest impor- 
tance in estimating the chances of survival. The following table gives 
Tarnier's statistics, showing the percentage of premature infants saved 
during a period of five years without the incubator, and during the 
succeeding five years with the incubator; also the percentage saved at 
the Sloane Hospital (New York), as published by Voorhees:* 



Age. 


Tarnier saved 
without incu- 
bators. 


Tarnier saved 
with incubator. 


Voorhees 
saved with 
incubators. 


Voorhees saved 
excluding cases 

dying a few 
hours after birth. 


Born at 6 months 


o-o 

21-5 
39-0 
540 

78-0 
88-0 


16-0 
36-6 

49-8 
77-0 
88-8 
96-0 


22-0 
41 

75-0 
70-0 




" " 6i " 


660 


u « rv « 


71 


" " 7£ " , . . 


89*0 


(( M Q M 


91-0 


" " 8i " 









Eesults will improve with the experience of the physician in the feed- 
ing and care of these very sensitive patients. Much is yet to be learned 
about them. 



* Archives of Paediatrics, May, 1900. An excellent article on the Care of Prema- 
ture Babies in Incubators. 



CHAPTEE II. 
GROWTH AND DEVELOPMENT OF THE BODY. 

Observations upon growth and development are of the utmost im- 
portance during infancy and childhood. Only by this means are very 
many diseases detected in their incipiency. Early recognition carries 
with it in most cases the possibility of checking such pathological proc- 
esses as, if allowed to go on, may affect the health not only in infancy 
but even throughout life. 

By familiarity with what is normal, detection of the abnormal soon 
becomes easy. Investigation in regard to these subjects should be made 
a part of the physical examination of every child. 

WEIGHT. 

The weight of the infant is the best means we have to measure its 
nutrition. It is as valuable a guide to the physician in infant feeding as 
is the temperature in a case of continued fever. Although the weight is 
not to be taken as the only guide to the child's condition, it is of such 









Fig. 4. 

importance that we cannot afford to dispense with it during the first two 
years. It is a great advantage to keep up regular observations during 
childhood. 

Weekly weighings should be made for the first six months, bi-weekly 
for the rest of the first year, and monthly during the second year. Deli- 
cate children should be weighed even more frequently. Satisfactory 
scales of moderate price for domestic use are sold in most of the 
shops as "Infants' Scales" (Fig. 3). These weigh up to twenty-four 

15 



16 



GROWTH AND DEVELOPMENT. 



pounds and indicate ounces. For hospital use and for very fine observa- 
tions more accurate scales are needed. In Fig. 4 are shown the scales I 
employ ; they weigh up to sixty-one pounds and indicate half ounces.* 

Weight at Birth. — The following figures are taken consecutively in 
nearly equal proportion from the records of the Nursery and Child's 
Hospital, the Sloane Maternity, and the New York Infant Asylum, and 
include only full-term children : 

Average weight of 568 females 7*16 lbs. (3,260 grammes). 

" " 590 males 7'55 " (3,400 " ). 



1,158 infants 735 



(3,330 



). 



Weight Curve during the First Few Weeks. — The accompanying 
chart represents the variations in weight for the first twenty days. These 
observations were made upon one hundred healthy, nursing infants, fifty 

males and fifty fe- 
males,at the Nursery 
and Child's Hospi- 
tal. The children 
were weighed daily 
during the period 
of observation. The 
average weight at 
birth was 7'1 pounds. 
The curve shows a 
very marked loss of 
weight on the first 
day and a slight loss 
on the second day, 
the lowest point be- 
ing touched at the 
beginning of the 
third day ; but from 
this time there was 
a steady gain. The 
average initial loss 
in these cases was 



DAILY WEIGHT CHART. 
Name,....- Date of Birth,.... 189 


Gms. 


Lbs. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


1C 


17 


18 


19 


20 


4420 
4310 
4200 
4080 
3970 
3850 
3740 
3630 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 


9% 

9 

%% 

8M 
8 

7 
Z% 
&K 
6M 

6 
b% 

5X 








































































































































































































































































































































































■—< 






















































































































































































































































































1 



































































































































































Fig. 5. — Weight curve of the first twenty days. 



ten ounces, being in each sex exactly eleven per cent of the body weight. 
In eight hundred and thirty-five cases, however, including those above 
mentioned, the average loss was nine and a half ounces. The loss of the 
first days is chiefly due to the discharge of the meconium and urine, but is 
in part from the excess of tissue waste over the nutriment derived from 
the breasts. After the third day, coincident with an abundant secretion 



* These are made by the Howe Scale Company. 



WEIGHT CURVE OF THE FIRST YEAR. 17 

of milk, there is a steady,- daily increase in weight. If the milk is very 
scanty or is wanting altogether, the loss in weight continues. 

The birth-weight of nursing children who thrive normally is regained 
on the average on the tenth day. The most frequent deviation from the 
normal curve consists in a continued loss or stationary weight after the 
third day. This may be due to acute illness, such as bronchitis, diarrhoea, 
pyaemia, or haemorrhage, but in the majority of cases there is a disturbance 
of nutrition from improper or insufficient food. This is quite as likely to 
be the case in nursing infants as in those who are artificially fed. Under 
these circumstances the loss may continue indefinitely, and it may be slow 
or rapid according to the character of the nursing or feeding. 

The weight curve of infants who are artificially fed, even though they 
are strong and vigorous and the feeding properly done, rarely follows for 
the first month the same lines as that of nursing infants. We usually 
see an initial loss which is about the same as in nursing infants, then a 
period of nearly stationary weight lasting from one to two weeks. After 
this the steady regular gain begins, and is quite equal to that of nursing 
infants. This period of stationary weight is to be expected while the 
infant is becoming accustomed to his new food. The chief danger at this 
time is that the physician, because there is no gain, may be led to increase 
either the strength or the quantity of the food so rapidly as to upset the 
child's digestion. 

There are cases in which ail excessive loss of weight during the first 
three or four days is associated with an elevation of temperature, but 
without any other evident signs of disease. Both the fever and the rapid 
loss in weight are to be looked upon as due to the same cause — inani- 
tion. This will be more fully considered in the chapter devoted to that 
subject. 

Excessive loss in weight during the first few days from any cause 
whatsoever, seriously handicaps an infant during the first weeks of its 
life. The great importance of this has not been sufficiently appreciated. 
Loss in weight after the third day is an indication for food in addition 
to that derived from the breast. 

Weight Curve of the First Year. — The curve of the accompanying 
chart is made up from complete weight charts of one hundred healthy 
nursing infants who were thriving and weighed every week, and the in- 
complete charts of about three hundred other infants. There are repre- 
sented in round numbers about ten thousand observations on children 
under one year. The period of most rapid increase is during the first 
three months. It is slowest from the sixth to the ninth month. This curve 
is not to be regarded as a normal line, like the normal line of the tempera- 
ture chart, but as an average line. An infant who is at birth a pound 
above the average may keep this distance above the line for the whole 



18 



GROWTH AND DEVELOPMENT. 



year; another weighing one pound less than the average may be as far 
below it. Girls throughout the year are on the average half a pound 
lighter than boys. No single child exactly follows the line all the way, 
but it is surprising how close to it a very large number of the cases come. 
In artificially-fed infants — provided the feeding is properly done — the 
curve does not differ essentially from that of breast-fed infants, excepting 



Name, 


WEIGHT CHART. 
Date of Birth 


















tRq 












J » . 7 


CO 

£ 
CD 


CO 
XI 

_l 


MONTH OF AGE. 


12 3456 78 9 10 11 12 


10890 
10430 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


24 
23 
22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6 
5 
















































































































































































































































































































































































































































































































































































































































































































































































































































































































U 1 












































































































































































x 






















































































it 
























































































































































































































































































































































































































«*" 


-* 
























































































































































































































































, 


<-■* 




















































































X 




















































































s 


f 




















































































y 






















































































s 














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































k. 


/> 







































































































































































































































































































































































































































































































































































































































Fig. 6.* — The weight curve of the first year. 



in the slower gain of the first month, although this difference is usually 
made up before the sixth month is reached. 

At the end of the first year the average child weighs nearly three times 
as much as at birth. Perfect health during the first year is consistent 
only with a steady gain in weight. A child may not always gain rapidly, 
but it should gain steadily, and if it does not, something is wrong. All 
the conditions surrounding the infant should be investigated, but espe- 
cially the food. One should not be satisfied unless the average weekly 
gain during the first six months is at least four ounces. In the second 
six months it may be slightly less. As a rule a child who gains regularly 
in weight is thriving; an exception must, however, be made in the case 
of some infants who are fed chiefly upon carbohydrate foods. 

* Blank weight charts are made by Geo. L. Goodman & Co., Pearl Street, New York. 



THE WEIGHT OF OLDER CHILDREN. 



19 



Weight from the Second to the Fifth Year. — Comparatively few obser- 
vations have been published upon the weight during this period. From 
three hundred and seventy-two personal observations it appears that the 
gain is about six pounds during the second year, about four and a half 
during the third year, and about four pounds during the fourth year : the 
actual weights are given in the large table (page 20). During this period 
the gain is rarely steady even in the second year. With most children it 
is slowest or the weight is stationary in the summer months, while the 
most rapid increase is usually seen in autumn. Throughout this period 
the girls gain in about the same ratio as boys, but remain on the average 
nearly one pound lighter. During almost every illness, no matter of what 
character, the gain in weight ceases, and usually there is a loss, the rapid- 
ity and extent of which are somewhat proportionate to the severity of the 
attack ; but it is always much more rapid in diseases of the digestive tract 
than in any other form of illness. 

Weight' of Older Children. — The weights given in the table of children 
from five to fourteen years are from Bowditch. Observations were made 
upon children of American parentage in the public schools of Boston — 
upon 4,327 boys and 3,681 girls.* It is to be remembered that these 
weights include the ordinary clothing, while those below five years are 
without clothing, f 

The slowest gain is from the fifth to the eighth year, when it is about 
four pounds a year. From the eighth to the eleventh year it rises to about 
six pounds a year. Up to the eleventh year the two sexes gain in about 
the same ratio. From the eleventh to the thirteenth year the girls gain 



* W. T. Porter has published (1894) observations made upon 14,744 children of Amer- 
ican parentage in the public schools of St. Louis. His figures show quite a variation 
from those of Bowditch, and are as follows : 





BOYS' weight. 


girls' weight. 


Age. 


Kilos. 


Pounds. 


Kilos. 


Pounds. 


6 years 


19-66 
21-67 
23-91 
26-08 
28-49 
31-26 
33-45 
35-96 
40-34 
47-25 
52-10 


43-2 

47-7 
52-6 
57-4 
62-7 
68-8 
73-6 
79-1 
88-7 
103-9 
114-6 


18-76 
20-82 
22-71 
25-07 
27-43 
29-93 
33-17 
38-29 
43 12 
46-90 
50-06 


41-3 


7 « 


45-8 


8 " 


50-0 


9 " 


55-1 


10 " 


60-3 


11 " 


65-8 


12 " 


730 


13 " 


84-2 


14 " 


94-9 


15 " 


103-2 


16 " 


110-1 







f The average weight of the ordinary house clothing of school children, ^according 
to Bowditch, is at five years 2-8 pounds for both sexes ; at seven years, 35 for both 
sexes ; at ten years, 5-7 pounds for boys and 4*5 pounds for girls ; at thirteen years, 7*4 
pounds for boys and 5-6 pounds for girls ; at sixteen years, 9-7 pounds for boys and 8-1 
pounds for girls. This must be deducted from weights given to obtain the net weight. 



20 



GROWTH AND DEVELOPMENT. 



much more rapidly, passing the boys for the first time and maintaining 
this lead until the fifteenth year, when again the boys pass them. 

Table showing Weight, Height, and Circumference of the Head and 
Chest from Birth to the Sixteenth Year* 



Age. 



Birth 

6 months 

12 months 

18 months 

2 years 

3 years 

4 years 

5 years 

6 years 

7 years 

8 years 

9 years 

10 years 

11 years 

12 years 

13 years 

14 years 

15 years 

16 years 



Sex. 



Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 



Pounds. Kilos, 



755 

7-16 

160 

15-5 

20-5 

19-8 

22-8 
22-0 

26 5 

25-5 

312 

30-0 

350 

34-0 

41 2 

39-8 

45 1 

43-8 

495 

48-0 

545 

52-9 

60 

57-5 

666 

64-1 

72 4 

70-3 

79-8 
81-4 

88-3 
91-2 

993 

100-3 

1108 

108-4 

123-7 

113-0 



3 

3 

7 
7 

9 

8 

10 

9 

12 

11 

14 

13 

15 

15 

18 
18 

20 

19 

22 

21 

24 

24 

26 

26 

30 

29 

32 

31 

36 

36 

40 

41 

45 

45 

50 

49 

56 

51 



Inches. Cm 



20 

20 

25 

25 

29 

28 



29 

32 

32 

35 

35 



41 

41 

44 

43 

46 

45 

48 
48 

50 

49 

52 

51 

54 

53 

55 

57 

58 
58 

61 

60 

63 

61 

65 

61 



73 

76 

75 

82 



89 
89 

96 

96 

106 

105 

112 

110 

117 

116 

122 

122 

127 

126 

132 

131 

137 

136 

141 

145 

147 

149 

155 

153 

159 

155 

166 

156 



Inches. Cm. 



13 

13 

16 

16 

18 
17 

18 
18 

19 

18 

20 

19 

20 

20 

21 

21 

23 

22 

23 

23 

24 

23 

25 

24 

25 

24 

26 

25 

27 

26 

27 

28 

28 
29 

30 

30 

31 

30 



34.2 

33-2 

420 

41-0 

45-9 

44-4 

471 

45-9 

48 4 

47-0 

511 

50-5 

52-8 
52-2 

54-8 

53-5 

59 1 

58-3 

60-6 

595 

62-2 

60-8 

63 9 

62-5 

65 6 

63-0 

67 2 

65-8 

68-8 
68-3 

70 6 

71-3 

73 3 

74-1 

76 6 

76-8 

79-2 

78-8 



Inches. Cm 



13 9 

13-5 

170 

16-6 

180 

17-6 

18 5 

18-0 

18-9 

18-6 

19 3 

19-0 

19-7 

19-5 

20 5 

20-2 



210 

20-7 



21 8 

21-5 



35 5 

34-5 

43 5 

42-2 

45 9 

44-6 

471 

45-9 

48-2 
47-2 

490 

48.4 

50.3 

49.6 

52.2 

51.3 



53-5 

52-8 



55 5 

54-8 



* The observations of Boas (Science, April 12, 1895) upon 4,319 children over six 
years old show that first born exceed children born at a later period both in height 
and weight. 



GROWTH OF THE EXTREMITIES. 21 

HEIGHT. 

The figures showing the height at different ages are given in the fore- 
going table. The measurements of infants at birth are taken in about 
equal numbers from the records of the New York Infant Asylum and 
the Sloane Maternity Hospital. They were made upon full-term infants. 

Average length of 231 males 20*61 inches (52 -5 cm.) ; 

211 females 20-47 " (52-2 " ); 

442 infants 20-54 " (52-35"). 

The most rapid gain in length is in the first year. During this period 
the child grows on an average a little over eight inches (21 cm.). This 
gain is usually, but not always, proportionate to the increase in weight. 
During the second year the average increase is three and a half inches (9 
cm.). From this time on the rate of increase is quite uniform in both 
sexes until the eleventh year, it being between two and three inches a 
year. 

After the eleventh year in girls and the twelfth in boys the growth is 
much more rapid. In height the girls exceed the boys at the twelfth and 
thirteenth years for the only time in their growth. 

In the figures given in the preceding table those of five years and over 
are taken from Bowditch, the observations being made upon the same 
children as those whose weights were taken. The observations from six 
months to four years inclusive are from original sources, and are drawn 
from about five hundred cases. The height much more than the weight 
of children is modified by hereditary influences. 

Rachitic children during infancy and early childhood are, as a rule, 
shorter than others. I have frequently measured such children during 
the third year who were six inches below the average for that age. The 
effect of malnutrition upon the length of the body is much less than on 
the weight. 

GROWTH OF THE EXTREMITIES AS COMPARED WITH THE TRUNK. 

At birth the trunk is relatively long and the extremities short. Sub- 
sequently the growth of the extremities is much more rapid than that 
of the trunk. Thus I have found at birth the length of the lower ex- 
tremities (measuring from the anterior superior spine of the ilium to 
the sole of the foot) to be forty-three per cent of the length of the body ; 
at five years, fifty-four per cent, and at sixteen years sixty per cent. The 
above figures are from one hundred and fifty observations, which, although 
not numerous enough for exact percentages, are still sufficient to give a 
very good idea of the general relation of the length of the extremities to 
that of the body as a whole. 
4 



22 GROWTH AND DEVELOPMENT. 

THE HEAD. 

Circumference. — The average circumference of the head at birth in 
four hundred and forty-six full-term infants observed at the Sloane 
Maternity Hospital and New York Infant Asylum was as follows: 

Average circumference of the head, 231 males. . 13.90 inches (35.5 cm.); 
" " " " 215 females. 13.52 " (34.5 " ); 

Total 446 infants. 13.71 " (35.0 " ). 

The occipito-frontal measurement was the one taken. 

The growth of the head is most rapid during the first year, the in- 
crease being about four inches (10 cm.). During the second year the 
increase is about one inch (2.5 cm.). From the second to the fifth year 
the growth is slower, being only about one and a half inches (4 cm.) for 
the three years. After the fifth year the increase in the circumference 
of the head is very slow (see table). 

Closure of the Sutures. — The main sutures of the cranium are not 
commonly ossified before the end of the sixth month, and very frequently 
some mobility may be detected at the end of the ninth month. Distinct 
separation of the cranial bones after birth is abnormal. It is most fre- 
quently seen in premature and in syphilitic infants. 

Closure of the Fontanels. — The posterior fontanel is usually ob- 
literated by the end of the second month. The anterior fontanel un- 
der normal conditions closes on an average at about the eighteenth 
month. The usual variations are between the fourteenth and twenty- 
second months. At the end of the first year the fontanel is generally 
about one inch in diameter. An open fontanel at the end of the second 
year may be considered abnormal. The closure of the fontanel is not 
always early in well-nourished children, nor is it always delayed in those 
suffering from malnutrition. In very rare cases the anterior fontanel 
may either be closed at birth or may close during the first few weeks of 
life. Closure of the fontanel by the middle of the first year is often seen 
in cases of arrested cerebral development. This indicates a serious con- 
dition, usually microcephalus. Closure of the fontanel in the early 
months of the second year may be due to the slow growth of the brain 
in a child suffering from general malnutrition but otherwise normal. 

In children with very large heads who exhibit no sign of rickets the 
fontanel is occasionally found open beyond the age of two years. By 
far the most frequent cause of delayed closure of the fontanel is rickets, 
in which condition it may be open up to the end of the third year. A 
large fontanel is one of the striking features of cretinism, and in un- 
treated cases is often seen as late as the eighth year or later. In infancy 
an open fontanel with a marked enlargement of the head should at once 
suggest hydrocephalus. There is an hereditary condition in which the 
fontanel remains open even to adult life. Two such cases in father and 



^v 



SHAPE OF THE HEAD. 23 

son were shown me by Marie in Paris. In both there was also lack of 
union between the two portions of the clavicle. 

Shape of the Head. — The deformity which results from compression 
during labour usually disappears by the end of the first month. During 
the first year the head often becomes flattened at the occiput in conse- 
quence of the child's lying too much upon the back. This is easily 
remedied by changing its position. A slight obliquity of the head may 




Fig. 7.— Premature ossification of the sagittal suture. Death at six weeks. 

result from a habitual position during nursing or sleep. A marked de- 
gree of obliquity is sometimes congenital, but usually disappears by the 
fifth or sixth year. 

The other abnormities in the shape of the head are chiefly due to 
rickets and hydrocephalus, more rarely to congenital malformations of 
the brain. They will be considered in the chapter devoted to these topics. 

Premature ossification of the sutures of the cranium occasionally gives 
rise to a very striking deformity of the head. I have seen two cases 
of such deformity from premature ossification of the sagittal suture. 
The heads in both cases were very narrow and long in the anteroposte- 
rior diameter. The forehead was narrow, prominent, and slightly pro- 



24 GROWTH AND DEVELOPMENT. 

jecting. The illustration on the previous page shows the skull of one of 
these cases. There is a complete obliteration of the sagittal suture. In 
this case there was a wide separation of the sutures at the junction of 
the parietal and temporal bones. 

THE CHEST. 

The figures showing the circumference of the chest at the different 
periods of childhood are given on page 20. The measurements up to 
and including five years are from personal observations, those from the 
sixth to the sixteenth are taken from Porter, and are drawn from obser- 
vations on 31,371 school children. The measurement of the chest is that 
taken midway between full inspiration and expiration, and at the level of 
the nipples. 

In the newly-born child the antero-posterior and the transverse diame- 
ters of the chest are nearly the same. As age advances, the transverse 
diameter increases very much more rapidly, so that the outline of the 
chest gradually assumes an elliptical shape, which it maintains during 
childhood. 

At birth, the circumference of the chest is about one half inch less 
than that of the head, but throughout infancy the two measurements 
are nearly the same. It is not until the third year that the average cir- 
cumference of the chest exceeds that of the head. According to Uffel- 
mann, the circumference of the head and the chest are the same until 
the twenty-first month in a robust child, and until two and a half years 
in an average child. The chest measurement in infants is always much 
modified by the amount of fat ; but, after making due allowance for this, 
a large chest always indicates a robust child and a small chest a delicate 
one. If at any age the circumference of the child's chest is found to be 
below the average, means should be taken, by gymnastics and other- 
wise, to develop it. 

Deformities of the thorax result chiefly from rickets, sometimes from 
empyema, emphysema, and cardiac disease ; in older children, from lat- 
eral curvature of the spine, or from Pott's disease. A peculiar deformity, 
usually congenital, but sometimes rachitic, is the funnel-shaped chest, the 
Trichter-brust of the Germans. It consists in a deep pit-like central 
depression at the lower end of the sternum. It is usually permanent. 

THE ABDOMEN. 

Throughout infancy the circumference of the abdomen is, as a rule, 
about the same as that of the chest. At the end of the second year 
the measurements of the head, chest, and abdomen are very often identi- 
cal ; after this time the chest measurement increases much more rapidly 
than the other two. Marked enlargement of the abdomen is seen in 



DEVELOPMENT OF THE SPECIAL SENSES. 25 

many varieties of chronic intestinal disorders. It is, however, most 
marked in the tympanites which so constantly accompanies rickets. 

MUSCULAR DEVELOPMENT. 

The first voluntary movements are usually in the fourth month, when 
the infant deliberately attempts to grasp some object placed before it. 
During the fourth month, as a rule, the head can be held erect when the 
trunk is supported. In many infants this is possible in the early part 
of the third month. At seven months a healthy child is usually able to 
sit erect and support the trunk for several minutes. 

In the ninth or tenth month are usually seen the first attempts to bear 
the weight upon the feet. At ten or eleven months a child stands with 
slight assistance. The first attempts at walking are commonly seen in 
the twelfth or thirteenth month. The average age at which children 
walk freely alone has been, in my experience, the fourteenth or fifteenth 
month. Quite wide variations are seen in healthy children. Very much 
depends upon the surroundings. I have known infants to walk at ten 
months and many others not until seventeen or eighteen months, although 
showing no evidences of disease, and although their development had not 
been retarded by previous illness. A very marked difference is seen in 
different families of children with respect to the time of walking. 

The physician is often consulted because of backward muscular devel- 
opment, most frequently because the child is late in walking. General 
malnutrition, or any other severe or prolonged illness, may postpone for 
several months this or any of the other functions mentioned. When 
there is no such explanation of the backwardness, a child who does not 
hold up its head, sit alone, or make efforts to stand or walk at the proper 
time, should be submitted to a careful examination for a cerebral or spinal 
paralysis, but especially for rickets which is the most frequent explanation 
of the symptoms. 

Contrivances for teaching infants to walk are unnecessary, and their 
effect may even be injurious. An infant should be allowed the greatest 
possible freedom in the use of its limbs. It should not be restrained 
from walking when inclined to do so, nor continually urged to walk when 
no voluntary attempts are made. Nothing short of mechanical restraint 
will prevent a healthy child from walking or standing when it is strong 
enough to do so. 

DEVELOPMENT OF THE SPECIAL SENSES.* 

Sight. — The newly-born infant avoids the light. Its pupils contract 
in a light room, and if a bright light is brought before the eyes they 

* For many of the facts in this paragraph I am indebted to Preyer's The Senses 
and the Will, American edition, 1888, D. Appleton & Co. 



26 GROWTH AND DEVELOPMENT. 

close. During the first few weeks the infant indicates by every sign that 
excessive light is unpleasant. As early as the sixth day the eyes will 
sometimes follow a light in the room, and the child may even turn the 
head for this purpose. The muscles of the eyes of the newly-born infant 
act irregularly and not in harmony. Co-ordinate action for general pur- 
poses is not established until about the end of the third month. Even 
after this time inco-ordinate action is occasionally seen. The eyelids also 
move irregularly, and are often partly separated during sleep. The cornea 
is but slightly sensitive during the first weeks. In Preyer's child it was 
not until the third month that the lids closed when the water in the bath 
touched the lashes or the cornea. The recognition of objects seen is usu- 
ally evident in the sixth month. 

It is important that the room in which the newly-born child is placed 
should be darkened, and that for the first few weeks the eyes should be 
protected against strong light. 

Hearing. — For the first twenty-four hours after birth infants are 
deaf. This deafness sometimes persists for several days. It is believed 
to be due to absence of air from the middle ear and to swelling of the 
mucous membrane which lines the tympanum. With the movements of 
respiration, air gradually finds its way into the middle ear, and the swell- 
ing subsides during the first few days. After this the hearing gradually 
improves, and during the early months of life it is very acute. The child 
starts at the slamming of a door, and even moderately loud noises will 
waken it from sleep. By the end of the second month it will sometimes 
turn its head in the direction from which the sound comes, and by the 
end of the third month this will usually be done. Demme found, in 
observations upon one hundred and fifty infants, that the voices of parents 
were recognised on an average at three and a half months. 

Not only are the ears unusually sensitive to sound in infancy, but 
the impression produced upon the brain is often marked — very loud 
sounds causing great fright, and sometimes even, it is reported, convul- 
sions. 

Touch. — Tactile sensibility is present at birth, but is not highly devel- 
oped except in the lips and tongue, where it is very acute for the obvious 
necessity of sucking. After the third month it is fairly acute over the 
surface of the body generally. Two especially sensitive areas, according 
to Preyer, are the forehead and external auditory meatus. 

Sensibility to painful impressions is present in early infancy, but very 
dull as compared with later childhood. 

Temperature is also distinguished. This recognition is especially 
acute in the tongue. A young infant is often seen to refuse to take 
the bottle because the milk is only a few degrees too cold or too 
Warm. 

The localization of sensory impressions comes later, probably not much 



DENTITION. 27 

before the middle of the sixth month, and is very imperfect throughout 
the first year. 

Taste. — This is highly developed, even from birth. According to the 
experiments of Kussmaul, the ability to distinguish sweet, sour and bit- 
ter, exists in the newly-born child — sweet exciting sucking movements, 
and bitter, grimaces. A young infant detects with surprising accuracy 
the slightest variation in the taste of its food, and the smallest difference 
is often enough to cause it to refuse its bottle altogether. Sweet sub- 
stances are always easily administered, and in combination with sirups 
even very bitter substances can be given ; but to aromatic powders and 
elixirs he usually objects. 

Smell. — Observations upon the sense of smell in newly-born infants 
are few and not altogether conclusive. Kroner's experiments appear to 
show that smell is present in the newly born. It has been noted to be 
especially acute in infants born blind. The sense of smell is developed 
much later than the other senses. Detection of fine differences in odours 
is not acquired until quite late in childhood, 

SPEECH. 

There is a very wide variation in children with reference to the time 
of development of the function of speech. Girls, as a rule, talk from two 
to four months earlier than boys. Towards the end of the first year the 
average child begins with the words " papa," " mamma." By the end of 
the second year it is able to put words together in short sentences of two 
or three words. Progress in speech from this time is very rapid, each 
month showing great improvement. Names of persons are commonly first 
acquired, then the names of objects. Next to this the verbs are learned, 
and then adverbs and adjectives. Conjunctions, prepositions, and articles 
follow in order, and last of all the personal pronouns. 

If a child of two years makes no attempt to speak, some mental defect 
may usually be inferred. 

DENTITION. 

The teeth are enclosed at birth in dental sacs which are situated in 
the gums. Superficially they are covered by the submucous connective 
tissue and the mucous membrane; the dental sacs rest in depressions in 
the alveolar process of the jaw. The tooth grows in length mainly as the 
result of the calcification of its roots, and being thus fixed below, it pushes 
upward towards the mucous membrane. This growth undoubtedly goes 
on steadily from birth until the tooth pierces the gum. 

The deciduous or milk teeth are twenty in number. The time at 
which they appear is subject to considerable variation even under normal 
conditions. The following is the order and the average time of appear- 
ance of the different teeth: 



28 GROWTH AND DEVELOPMENT. 

(1) Two lower central incisors 6 to 9 months. 

(2) Four upper incisors 8 " 12 " 

(3) Two lower lateral incisors and four anterior molars. 12 " 15 " 

(4) Four canines 18 " 24 

(5) Four posterior molars 24 " 30 " 

At 1 year a child should have 6 teeth. 

At H ' " " " " 12 " 

At 2 years " " " 16 " 

At 2* " " " " 20 " 

Quite wide variations on both sides of the average are common, and 
are not always easy of explanation. In many cases it seems to be a family 
idiosyncrasy, since in the different members of a family the teeth are 
apt to appear at about the same time. I know one family in which no 
less than three members of three successive generations were born with 
teeth, and in most of the other members the first teeth appeared in the 
third or fourth month. The order in which the teeth appear is much 
more regular than the time of their appearance. Slight variations are 
exceedingly common, but marked irregularities in the order of the appear- 
ance of the teeth are the rule in idiotic children or those suffering from 
slighter mental defects. 

The teeth may pierce the gum without any local manifestations. Very 
frequently, however, just before a tooth comes through there is noticed a 
moderate swelling and redness of the mucous membrane of the gum over- 
lying it, and to a slight degree this may affect the general mucous mem- 
brane of the mouth. This condition may be accompanied by a little fret- 
fulness and increased salivation, or both of these may be entirely wanting. 
These symptoms usually disappear when the tooth has pierced the gum. 
The symptoms of difficult dentition will be discussed in connection with 
Diseases of the Mouth. 

Infants may be born with teeth ; this is, however, an exceedingly rare 
occurrence. It is almost invariably one of the lower central incisors that 
is present. In case this interferes with nursing, or if it is very loosely 
attached to the gum, it should be extracted, but under other circumstances 
it should be allowed to remain, since, if it is removed, a second tooth is 
not likely to appear in its place in the first set. It is not at all uncommon 
for the first teeth to appear in the fourth month. Such teeth, in my 
experience, do not usually differ in character from those appearing later, 
unless they are in children who are syphilitic. Syphilitic children are 
rather prone to early dentition, and under such circumstances rapid and 
early decay is likely to take place. Nursing infants are, as a rule, a little 
earlier in their dentition than those artificially fed. 

Delayed dentition is usually due to rickets. However, in many healthy 
infants no teeth appear before the tenth month ; and I have occasionally 
seen the first ones at thirteen months in those who seemed perfectly 
healthy and showed no other evidence of rickets. On the other hand, it 



DENTITION. 29 

is by no means invariable that dentition is late in rachitic children. 
The latest dentition is seen in cases of cretinism. In such children it 
is not rare for the first teeth to appear as late as the eighteenth month. 
I have seen one child two years old with but two teeth. As a rule, 
dentition and ossification of the bones of the head go on in a corre- 
sponding manner ; where one is early the other is likely to be rapid, and 
conversely. 

Provided an infant is well nourished and thrives properly for the first 
six or eight months, the eruption of the teeth is likely to go on steadily 
after this time, even though the child may later have chronic indigestion 
or suffer from extreme malnutrition from any cause excepting rickets. 
If, however, the symptoms of malnutrition date from birth, dentition is 
almost invariably delayed. It is often a matter of very great surprise to 
see children who are markedly emaciated as a result of chronic indiges- 
tion or ileo-colitis and yet go on cutting their teeth regularly. I once 
had under my care a delicate infant of sixteen months, whose body length 
was twenty-eight inches and whose weight was less than nineteen pounds 
— almost exactly what they had been eight months previously — and yet 
he had thirteen good teeth. 

Eruption of the Permanent Teeth. — The first to appear are the first 
molars, which usually come in the sixth year, and hence the name six- 
year-old molars, which is applied to them. These appear posterior to the 
second molars of the first set. The following table from Forchheimer 
gives the average time of the appearance of the second teeth : 

First molars 6 years. 

Incisors 7 to 8 " 

Bicuspids 9 " 10 " 

Canines 12 " 14 " 

Second molars 12 " 15 " 

Third molars 17 " 25 " 

The incisors and canines replace the corresponding teeth of the 
first set. The eight bicuspids take the place of the eight molars of the 
first set. The molars of the permanent set appear back of the bicuspids, 
room being made for them by the growth of the jaw. As they grow 
and push upward they cause atrophy of the roots of the first teeth, 
and gradually cut off their blood supply, so that they loosen and 
fall out. 

The place of dentition as an etiological factor in the diseases of in- 
fancy will be considered in the chapter on Difficult Dentition. 



CHAPTER III. 
PECULIARITIES OF DISEASE IN CHILDREN. 

In" many particulars disease in children differs from that of later life. 
These differences relate to etiology, pathology, symptomatology, diagno- 
sis, and prognosis. The greatest contrast to adult life is presented by in- 
fancy and early childhood. After seven years, children in their diseases 
resemble adults more than they do infants. 

ETIOLOGY. 

1. Inheritance is an important factor. The disease most frequently 
transmitted directly is syphilis. Occasionally tuberculosis and other in- 
fectious diseases have been conveyed directly from the mother to the 
child. In cases where no distinct disease is transmitted, children may 
inherit from parents constitutional tendencies, or a diathesis which may 
manifest itself in infancy, or in some cases not until later childhood. 
Under this head we may place the influence of rheumatism, gout, the 
various neuroses, and possibly alcoholism and insanity. In consequence 
of these conditions in parents, the child may inherit no definite disease, 
but simply a vitiated constitution. • 

2. Malformations must be considered, particularly in the first two 
years of life. The most important of these, from a medical standpoint, 
are those of the heart, brain, and kidney. The various malformations of 
the mouth, nose, bladder, rectum, and genital organs belong more particu- 
larly to the domain of surgery. 

3. The Diseases or Accidents Connected with Birth. — Some of these are 
distinctly traumatic, like the meningeal haemorrhages. A very large class 
are the infectious processes in the newly born. Infection usually takes 
place through the umbilical wound, more rarely through the skin or 
mucous membranes. This class includes pyaemia, with its varied lesions 
in the brain, lungs, and serous membranes, erysipelas, ophthalmia, and 
tetanus. In the class of infectious diseases may also be included many of 
the varieties of pulmonary and intestinal diseases in the newly born, and 
probably also some of the hemorrhagic affections. 

4. Conditions Interfering with Proper Growth and Development. — 
These are among the largest etiological factors in the diseases of infancy. 
They are improper food or feeding, unhygienic surroundings, and neglect. 

30 



SYMPTOMATOLOGY AND DIAGNOSIS. 31 

These may cause specific diseases, like rickets or scurvy, or may lead to a 
condition of general malnutrition or marasmus. In this way they become 
most important predisposing factors, in infancy, to the acute diseases of 
the gastro-enteric tract, and later in childhood, to functional nervous dis- 



5. Infection. — This has already been mentioned as an important factor 
in diseases of the newly born. The number of diseases in later life di- 
rectly traceable to this is very large, and is constantly increasing. Under 
this head should be included not only the well-known classes of infectious 
and contagious diseases, but also a very large number of varieties of infec- 
tion which as yet have not been differentiated, and the nature of which 
is but imperfectly understood. 

SYMPTOMATOLOGY AND DIAGNOSIS. 

In older children the symptoms of disease are very much the same as 
in adults, and similar methods of examination may be employed. What 
is really peculiar to children belongs especially to the first three years of 
life, before speech has developed. During this period the chief and al- 
most the sole reliance of the physician must be upon the objective signs 
of the disease. It is not so much that diseases in early life are peculiar, 
as that the patients themselves are peculiar. 

Two fundamental facts are always to be kept in mind : First, that the 
common pathological processes are comparatively few, being chiefly of 
the gastro-enteric tract, the lungs, and the brain, but that the variations 
in clinical types are almost endless; the second is, that in infants, on 
account of the susceptibility of the nervous system, functional derange- 
ments are often accompanied by very grave symptoms, and may even 
prove fatal in twelve or twenty-four hours, or there may be speedy and 
complete recovery after very alarming symptoms. In many of these 
cases the symptoms are so indefinite that an exact diagnosis is impossible 
during life, and even the autopsy may throw but little light upon them. 

At the bedside it is of great assistance to the physician if he can keep 
in mind the most frequent forms of acute disease that are likely to be 
met with. In the first group, including those which are very common, 
may be placed acute indigestion and ileo-colitis, bronchitis, pneumonia, 
pharyngitis, and tonsillitis; in the second group, including those which 
are not quite so common, may be placed otitis and the acute infectious 
diseases — measles, scarlet fever, diphtheria, influenza, and malaria; in 
the third group, including the rarer forms of acute disease — meningitis, 
tuberculosis, rheumatism, and diseases of the kidneys. Under all circum- 
stances, the season, and the nature of the prevailing epidemic, if one 
exists, are to be considered. 

In the examination of a sick infant quite a different method is to be 
followed from that pursued with adults. Much information is to be gained 



32 PECULIARITIES OF DISEASE IN CHILDREN. 

from a history carefully taken from an intelligent mother or nurse, and 
much more from a close observation of the child, whether asleep or 
awake, quiet or crying. 

The History. — In view of the fact that but little information can 
be had from the patient, none at all in most cases, it is important to 
obtain from the mother or nurse as full and complete information as 
possible. A good history carefully obtained from an intelligent mother 
or nurse, puts the physician in possession, of a fund of information 
about the patient which is of the greatest value, not only in arriving 
at a diagnosis in the illness for which he is consulted, but is exceed- 
ingly helpful in the future management of the child. He may thus 
know the individual peculiarities and special pathological tendencies. 
The laity attach great importance, and justly so, to advice from the 
physician who " knows the child's constitution." Such a history should 
be taken at the first opportunity after the physician is placed in charge 
of a child, and with note book in hand, or half its value will be lost. 

Family History. — This should begin with the parents, going farther 
back, if possible, in man}^ cases of hereditary disease. One must know 
regarding tuberculosis, syphilis, rheumatism, or alcoholism, the gen- 
eral vigour of constitution and physical condition of both father and 
mother. Health during pregnancy and previous miscarriages are im- 
portant facts in the mother's history. One should know the number 
of other children living and their general health, the number dead and 
from what causes. A knowledge of the surroundings in which the child 
has lived may be necessary to appreciate the chances of exposure to 
tuberculosis, malaria, and many other forms of infection. 

Patient's Previous History. — This should begin with birth. One 
should inquire whether the child was premature or born at term, regard- 
ing the character of the labour, whether natural or instrumental, tedious 
or complicated, the condition and vigour of the child at birth, primary 
respirations, early convulsions, and the nutrition during the early days. 
Next the methods of feeding should be taken up — how long entirely 
and how long partly breast fed, the date of weaning and the form of 
artificial feeding then employed. If the patient is an infant, and the 
problem presented is one of its nutrition, all the reliable data relating 
to the feeding should be obtained, even to the minutest detail. This 
may be wearisome and consume time, but in no other way can one appre- 
ciate the conditions present. The best idea of the child's growth and 
development may be obtained from a weight record if one has been 
kept. If not available, one must depend upon general statements as 
to how the child thrived at different periods. The date of the appear- 
ance of the first teeth and the time and the order in which the teeth 
came, are significant. The general muscular development may be best 
determined by learning when the child could first hold the head erect, 



HISTORY. 33 

sit alone upon the floor, bear the weight upon the feet, creep or walk 
alone; the mental development, by learning as to early recognition of 
mother or nurse, knowing the bottle, understanding the meaning of 
words, speaking in words or sentences. The muscular and mental devel- 
opment of a normal child during the first two years is a subject with 
which the physician should be familiar if he would detect early those 
differences, often slight at this age, in children whose development is 
backward owing to cerebral lesions. 

All previous attacks of acute illness of whatever character should be 
noted, particularly the infectious diseases — measles, scarlet fever, diph- 
theria, pertussis, and influenza — with dates and details as to duration, 
severity, and complications. One should learn whether the child is espe- 
cially prone to disorders of digestion or those of the respiratory system. 
Under the former head are included early difficulties in feeding, acute 
attacks of indigestion, diarrhoea, or dysentery, also chronic disturbances 
of the stomach or bowels ; under the latter head, frequent catarrhal colds, 
earache or otitis, catarrhal croup, bronchitis, pneumonia, or pleurisy. 
Other points to be investigated relate to attacks of tonsillitis, operations 
for the removal of hypertrophied tonsils or adenoids, and previous dis- 
orders of the nervous system. In infants, particularly important are 
extreme restlessness, insomnia, convulsions, attacks of night terrors; 
in those who are older, hysterical manifestations, epilepsy, or chorea. 
Finally, one should know the date of successful vaccination. Inquiry 
should also be made concerning any recent exposure to infection in the 
community, school, or home. 

Present Illness. — One should first note the chief complaints as stated 
by mother or nurse. It is important to obtain as definite statements as 
possible as to the time when the child was quite well, and whether the 
onset of the illness was abrupt or gradual, and with what particular 
symptoms. In all digestive disorders one should know exactly concerning 
the child's food at the time of the onset, its quantity, character, and 
preparation; also any recent change in diet, the presence or absence of 
vomiting, and the condition of the bowels, whether loose or constipated, 
the frequency and character of the stools. General questions as to 
whether the bowels are regular or the stools normal are of no value, since 
the informant often is not capable of judging correctly. 

Nervous symptoms, like the others, should be elicited in response to 
direct questions regarding sleep, restlessness, moaning, crying out, or 
other evidences of pain, excitement, delirium, or convulsions, or unnatu- 
ral drowsiness. In any acute illness other important symptoms arc fever, 
sweating, dyspnoea, cough, hoarseness, nasal discharge, and the anion v.\ 
and composition of the urine. 

The Examination. — With infants, quite a different method should be 
followed from that pursued with adults. It may well begin with : 



34 PECULIARITIES OF DISEASE IN CHILDREN. 

General Inspection. — What is learned in this way will depend almost 
entirely upon the acuteness of observation of the physician, but much 
that is of value can be ascertained before the clothing is removed for the 
physical examination by simply watching the patient, whether asleep or 
awake, for several minutes. In acute disease, the following points should 
be noted especially : 

1. Nutrition and general development: whether the child is well 
nourished or the features pinched and wasted. 

2. The facial expression: whether it is bright and intelligent or dull 
and stupid, peaceful or anxious, quiet or disturbed, and whether the 
features are contracted from time to time, as if from pain. 

3. The character of the respiration : whether it is rapid or slow, easy 
or difficult; whether there is nasal obstruction, as indicated by snoring 
and mouth-breathing, suggesting in infants acute rhinitis, syphilis, or 
retro-pharyngeal abscess; in older children, diphtheria, scarlet fever, or 
adenoids. Marked dyspnoea is usually accompanied by active dilatation 
of the alae nasi. 

4. The posture : whether the child lies upon the back, side, or face ; 
whether the head is drawn back with general flexion of the extremities 
as in meningitis. 

5. The nervous condition : whether the child is restless, excitable, or 
drowsy and apathetic; if asleep, the nature of the sleep should be 
observed. 

6. The color of the skin of the face: whether pale or cyanotic; and 
the lips, whether fissured or excoriated. 

7. The amount of prostration : a practised eye can usually tell with 
older children whether the condition is grave or not, but infants not 
infrequently deceive even the most experienced observer. 

8. The cry: in conditions of restlessness or irritability, much infor- 
mation may be obtained from its character. It is important, but not 
always easy, to determine whether a child cries from fright, as at the 
approach of a stranger, from nervousness or bad training, from gen- 
eral irritability which may come from any acute disease, or from actual 
pain. The cry of fright is usually evident, because it comes with the 
physician's approach and ceases when he goes away. Children of highly 
neurotic parents and those who have been much indulged and badly 
trained will often cry when anything out of the usual routine occurs. 
The cry of pain may be very distinctive; it may be sharp and acute and 
accompanied by some attempt at localization, as when a child puts his 
hand to an inflamed part, but in infancy the pain of acute inflammation 
is often indicated only by general restlessness and irritability. This is 
frequently true of acute otitis. The cry of pain is usually accompanied 
by contraction of the features and other evidences of distress. 

The cry of some diseases is quite characteristic, as the short, catchy 



PHYSICAL EXAMINATION. 35 

cry of acute pneumonia or bronchitis; the hoarse cry of laryngitis, 
whether catarrhal, membranous, or syphilitic; the feeble whine of ex- 
treme exhaustion or marasmus; the moaning cry of intestinal disease; 
and the sharp cry of a child with scurvy whenever its bed or body is 
touched. 

Measurements. — These, though of greatest value in chronic diseases, 
particularly disturbances of nutrition, may be of assistance also in acute 
conditions. The important measurements are the circumference of the 
head, chest, and body length. The circumference of the abdomen is at 
times important, but varies so much with the degree of distention that 
it is not significant as to the general development. The measurements 
and weight furnish reliable data which are not only of assistance in the 
diagnosis of existing disease, but if recorded are useful for future com- 
parison. 

In taking the circumference of the head the largest measurement 
(over the occipital and frontal eminences) is preferable. The measure- 
ment of the chest is usually taken over the nipples. The body length 
of infants is best taken with a tape as the child lies upon his back upon 
a table or a firm bed. For older children, a special measuring stick is 
convenient. 

To estimate properly the significance of measurements they should 
be compared with the normal averages and with each other. It should 
be remembered that the head is normally larger than the chest until near 
the end of the second year; after this time, with a normal development, 
the chest should be larger. Any great disproportion between the size 
of the head and chest is suggestive of disease. The large head and the 
small chest belong especially to rickets. The measurements form impor- 
tant means of recognizing early such abnormalities as cretinism and 
achondroplasia, the variations often being marked before the other symp- 
toms are prominent. One who forms the habit of taking regular meas- 
urements soon appreciates the variations from the normal, and gains 
great assistance from these data. Such a record made from year to 
year in children whose development is in any way abnormal is of great 
value in indicating what should be done in the way of exercise to correct 
faulty conditions. 

Vital Signs — pulse, respiration, and temperature. — The significance 
of these signs is not to be measured by adult standards, since the suscepti- 
ble nervous system of infants and very young children greatly exaggerates 
their reaction to all forms of acute infection. 

The rate, regularity, quality, and tension of the pulse should be noted. 
In young children, the rate of the pulse is of less importance than its 
force and quality. A slow, irregular pulse is always significant, and 
should suggest meningitis or brain tumor; an irregular pulse, when 
rapid, has no special significance. The pulse rate is much increased 



36 PECULIARITIES OF DISEASE IN CHILDREN. 

from slight disturbances; the approach of the stranger or the examina- 
tion by the physician may canse it to rise 20 or 30 beats. In acute 
disease, a pulse rate of 150 is common, and 170 or 180 is often seen 
where other symptoms are not particularly severe. 

The rate, depth, and rhythm of respiration should be noted. The 
last often cannot be determined except by attentively watching the child 
for several minutes. In premature and very young infants a rather 
marked irregularity may be seen, often approaching the Cheyne-Stokes 
type. It is not to be taken as indicating a cerebral lesion, but seems 
rather to be due to the fact that the respiratory centre is not yet fulty 
able to control the movements. Eespiration of this type is seen only 
during the first weeks of life. Irregularity of rhythm at other times 
should suggest cerebral disease, usually meningitis. The respiration rate 
is proportionately greater in infants than in adults. In acute diseases 
of the lungs it not infrequently rises to 70 or 80, and occasionally it may 
be over 100 a minute. The rate is generally in proportion to the extent 
of the pulmonary lesion. 

The temperature of infants and very young children should, be taken 
in the rectum, since groin or axillary temperatures are untrustworthy 
and those in the mouth difficult to obtain. Immediately after birth the 
temperature of the child is about the same as that of the mother, or a 
little higher. It falls from 1° to 3° F. in the course of the first few 
hours. Soon it again rises to 98.5° or 99° F. 

From a large number of personal observations upon healthy infants, 
I have found that the rectal temperature under normal conditions varies 
between 98° and 99.5° F. ; occasionally the range may be as wide as 
97.5° to 100.5° F. in apparently perfect health. The heat-regulating 
centre in the brain acts only imperfectly in the young infant, and slight 
causes are enough to disturb the temperature. 

The temperature in infants is always higher than from corresponding 
causes in adults. Moreover, very high temperatures may be met with in 
cases not serious, and not infrequently when no explanation can be 
found even after thorough examination. In such cases the temperature 
seldom remains at a high point for more than a few hours. It is a 
continuous high temperature rather than a single rise which is significant 
of disease in infancy. Nothing is more perplexing to the young practi- 
tioner than the frequency with which a high temperature is seen in 
infants in cases of comparatively mild illness. 

It is common in chronic wasting diseases, in delicate infants and in 
those prematurely born, to find the temperature one or two degrees below 
the normal; 95° and 96° F. are of almost daily occurrence in hospitals, 
and much lower ones are not rare. Daily observations should be made 
with the thermometer in such conditions, just as in fever. 

Puzzling and apparently alarming temperatures are seen in infants 



PHYSICAL EXAMINATION. 37 

as a result of the application of artificial heat. In one of my patients, 
an infant two days old, a temperature of 107° F. was caused by the 
close proximity of two large hot-water bags placed in the baby's basket. 
The 3'ounger and feebler the child the more readily are such temperatures 
produced. 

Muscular and Mental Development. — The general muscular develop- 
ment is determined by seeing how well the child can hold up its head, 
sit alone, stand, or walk; the mental development in young infants by 
the intelligence of expression, the manner in which they respond to 
stimuli, the recognition of objects, fright at strangers, etc. ; later in the 
first year, by the use of their hands, their understanding of speech, and 
their ability to pronounce words. 

Local Examination. — For the purpose of making a complete routine 
examination of an infant the entire clothing, with the exception of the 
napkin, should be removed, and the infant placed preferably upon the 
nurse's lap upon a blanket. With older children the clothing may be 
removed and the body examined, one part at a time, but with all children 
it is essential that the examination be complete. A warm room is indis- 
pensable, and a table covered with a blanket in many respects better 
than the nurse's lap, although the latter has usually to be employed. 
The local examination should be deliberate, the physician should pro- 
ceed cautiously, winning the child by gradual approaches, and avoiding 
excitement, force, or anything which may cause pain. 

Skin. — The skin should first be inspected for eruptions, and it is 
important that the entire eruption be examined in order that the distri- 
bution as well as the character of the lesion may be seen. It should 
be noted also whether the skin is dry or moist. Marked wrinkling or 
loss of elasticity of the skin is one of the best indications of loss in 
weight. Bedsores are more frequently seen over the occiput than over 
the sacrum, and any large veins should be noted. 

External glands should now be examined, especially the cervical, 
axillary, inguinal, and epitrochlear. The cause of a marked enlarge- 
ment of any of these groups should be sought in the skin or mucous 
membranes with which they are connected. Marked swelling of the 
cervical glands may indicate early diphtheria, scarlet fever, or a simple 
acute inflammation dependent upon a rhino-pharyngitis. Enlargement 
of the epitrochlear glands is especially significant of syphilis. General 
enlargement of all the glands to a slight degree is seen in most cases 
of malnutrition and in many acute infectious diseases. 

Head. — One should first note whether the sutures are ossified, un- 
naturally open, or separated: al<o whether the fontanel is closed or. if 
open, whether it is depressed or bulging. Prominence- of (lie frontal 
or parietal regions when symmetrical are indicative of rickets. Irregular 
prominences of a smaller size, when present, are usually syphilitic. In 



38 PECULIARITIES OF DISEASE IN CHILDREN. 

the newly born, a tumour on the head, if in the median line, may indicate 
an encephalocele ; if limited to either the parietal or occipital bone it is 
usually a cephalhematoma. 

Eyes. — The condition of the conjunctiva and lids should be noted, 
also the presence of ptosis, strabismus, or other paralysis, but particularly 
the condition of the pupils, whether contracted or dilated, and the nature 
of their response to light. One should look also for the presence of 
corneal ulcers or the interstitial keratitis so frequent in late hereditary 
syphilis. 

Ears. — The presence of a discharge may be recognised by sight or 
by the odour. In any acute febrile condition one should look for tender- 
ness or swelling over the ear or mastoid. 

Nose. — The presence of any nasal discharge should be noted and its 
character determined. An abundant discharge tinged with blood, in 
young infants, should suggest syphilis; in older children, diphtheria; a 
chronic discharge, adenoid growths; a purulent discharge of one side, 
a foreign body. 

Mouth. — The appearance of the mucous membrane of the mouth 
and gums as well as the teeth may often be ascertained by watching 
the child while it is crying. It should be noted whether the tongue is 
dry or moist, clean or coated; whether thrush is present or any other 
form of stomatitis. If the gums are congested, swollen, or hemorrhagic, 
they should suggest scurvy. The number, position, and character of 
the teeth are important. The general colour of the mucous membrane 
may be significant in cases of cyanosis in congenital cardiac disease, and 
extreme pallor of the mucous membrane in anaemia. On the mucous 
membrane of the hard palate may often be found the first local evidence 
of scarlet fever in the form of a minute punctate eruption, and on that 
portion of the cheeks opposite the molar teeth should be sought Koplik's 
sign, the earliest reliable symptom of measles. 

Throat. — A careful examination of the pharynx and tonsils should 
never, be omitted in any acute illness, no matter what other symptoms 
may be present. Not only tonsillitis, but often diphtheria is overlooked 
from a failure to observe this as an invariable rule. A good light is 
essential, and one must train himself to take in all the appearances at 
a single glance. Marked general redness of the pharynx may be asso- 
ciated with scarlet fever, influenza, or simple acute pharyngitis. If other 
symptoms are present pointing to chronic nasal obstruction or to a 
catarrhal process of the rhino-pharynx, a digital examination should be 
made to determine the presence of adenoids. Dyspnoea with mouth- 
breathing when associated with difficulty in swallowing should, in an 
infant, always suggest retropharyngeal abscess. The examination of the 
mouth and throat may wisely be made the last step, since it usually 
disturbs a child so as to embarrass further investigation. 



PHYSICAL EXAMINATION. 39 

Neck. — One should consider the position in which the head is held 
and the amount of rigidity of the cervical muscles. Opisthotonus may he 
associated with meningitis or old cerebral palsy. A marked rigidity may 
indicate cervical Pott's disease or, if accompanied by torticollis, may 
be of rheumatic origin. 

Chest. — In young children particular importance should be attached 
to the shape of the chest. Symmetrical deformities are usually due to 
rickets. Contraction of one side only is most frequently the result of 
an old empyema or an extensive interstitial pneumonia. Bulging of the 
precordial region is frequent in cardiac disease. One should notice also 
the recession of the soft parts — intercostal spaces, the suprasternal notch, 
or the epigastrium; the amount of this is usually the best means of 
judging the severity of obstructive dyspnoea. Details regarding the phys- 
ical examination of the lungs are discussed in the introductory chapter 
to pulmonary diseases. 

Heart. — It should be remembered that under two years old loud 
murmurs are almost invariably of congenital origin, that soft murmurs 
at the base are very frequently due to anaemia, and that acquired cardiac 
disease is rare until after three years. For further details in the exam- 
ination the reader is referred to the chapters upon diseases of the heart. 

Abdomen. — There should be noted the presence or absence of tym- 
panites or abdominal tenderness, whether general or localized, and the 
existence of retraction of the abdominal walls as in meningitis. The 
size and position of the liver and spleen are best determined by palpation. 
The lower border of the liver is usually slightly below the free border of 
the ribs. If the spleen can be easily felt below the ribs, it is, as a rule, 
enlarged. If it can not be felt in a satisfactory examination, it is not 
sufficiently enlarged to be of any diagnostic importance. In acute disease 
a large spleen suggests malaria, typhoid, or tuberculosis; in chronic dis- 
ease, malaria, syphilis, leukaemia, or anaemia. 

Spine. — The most frequent spinal curves seen in infancy are those 
due to muscular weakness. These disappear by placing the child in a 
prone position. Eachitic curves are of the same general character, but 
as they have usually lasted a longer time the spine is less flexible and the 
curve may not entirely disappear by change of posture. An angular 
deformity or even marked rigidity of the spine should suggest Pott's 
disease. 

Extremities. — The colour of the skin and the character of the periph- 
eral circulation should be noted especially in pneumonia, diphtheria, and 
other diseases attended by weakened heart. Clubbing of the fingers or 
toes may be due to congenital heart disease or to chronic disease of the 
lungs. Desquamation of the palms or soles may indicate hereditary 
syphilis or scarlet fever, even though no other evidence may be pres- 
ent. The finger-nails may give valuable information in hereditary 



40 PECULIARITIES OF DISEASE IN CHILDREN. 

syphilis. In examining the extremities one should note especially the 
presence of tenderness, flaccidity, or rigidity of muscles, whether the 
limbs are wasted or plump, and the degree of muscular power ; also any 
abnormal swelling on the shaft or near the extremities of the bones, and, 
finally, the function of the joints. A general relaxation of the liga- 
ments is common in rickets and paralytic conditions. Flabbiness of the 
muscles belongs to malnutrition and rickets; rigidity, if chronic, is usu- 
ally indicative of cerebral palsy. Weakness of special groups, with atro- 
phy and flaccid muscles, suggests poliomyelitis. Acute tenderness of the 
legs in infants should suggest scurvy. Eachitic deformities are almost in- 
variably bilateral. Tuberculous bone disease affects the epiphyses, while 
syphilis usually involves the shafts, the only exception to this being the 
epiphyseal separation which may occur in the first months of life. 

The reflexes may be somewhat difficult to obtain in infants and when 
exaggerated may indicate cerebral palsy, meningitis, or, as in tetany, only 
an extreme irritability of the nervous centres without organic disease. 
The plantar reflex of Babinski has little significance in infants, and in 
older children it is present in many conditions. Kernig's sign is a form 
of muscular spasm almost invariably present in cerebro-spinal meningitis, 
but often seen in other diseases. 

Genital Organs. — Male children should be examined to determine the 
presence of phimosis or of undescended testicles. Hydrocele of the cord 
is a frequent condition, and may be mistaken for hernia. Both inguinal 
and umbilical hernia are very common. In female children it should be 
remembered that preputial adhesions may be considered normal, and are 
seldom the cause of the nervous symptoms attributed to them. Every 
vaginal discharge is significant, and if purulent should be examined 
bacteriologically. The great frequency of gonococcus infections is not 
appreciated, and they may be found when least expected. 

The examination is not complete without the inspection of the stools, 
the chemical and microscopical examination of the urine, and an examina- 
tion of the olood. All are more fully considered in special chanters. 

PATHOLOGY. 

The pathological processes which result from intra-uterine disease and 
those which are connected with delivery are peculiar to early life. They 
have already been referred to in the section on etiology. Of the processes 
of early life which begin after birth, the first in frequency are those of 
the mucous membranes resulting from the various forms of infection. 
In summer, it is the stomach and intestines which suffer chiefly; in 
winter, the respiratory tract. 

The serous membranes are rarely the seat of primary inflammation. 
The pleura is seldom the seat of primary disease, but very often in- 



PATHOLOGY. 41 

volved secondarily to disease of the lung itself. Affections of the peri- 
cardium and peritonaeum are quite rare. Meningitis is fairly common 
both in the simple and the tuberculous form. 

Diseases of the lymph nodes (lymphatic glands) play an important 
part in connection with the acute diseases of the mucous membranes, with 
many affections of the skin and even of the viscera. Acute infection tends 
to excite suppurative inflammation, particularly in infants ; a less active 
process leads to chronic hyperplasia in the mesenteric, mediastinal, and 
cervical glands, in the tonsils, adenoid tissue of the pharynx, etc. The 
lymph nodes in the neck and thorax are frequently the earliest seat of 
tuberculous deposits, and in very many cases they are the foci from which 
secondary infection of the lungs, brain, or joints may occur. 

Of the visceral inflammations * those of the lungs are the most com- 

* The following table gives in a general way a very good idea of the relative fre- 
quency of diseases of the different organs in infancy. It is based upon seven hundred 
and twenty-six consecutive autopsies in the New York Infant Asylum, extending over 
a period of eight years during my connection with that institution. More than one half 
of the autopsies I made personally. Of these children seventy-two per cent were 
under one year, twenty-five per cent between one and two years, and only three per 
cent were over two years. The institution does not receive infants under one month, 
hence the absence of lesions peculiar to the newly born : 

Table showing principal lesions in seven hundred and twenty-six 
consecutive autopsies in the New York Infant Asylum. 
Lungs : 

Pneumonia — Primary 139 

Complicating other acute infectious diseases 112 

Complicating other conditions 71 

Noted to be present in 322 

Pleurisy — No case uncomplicated with disease of lungs. 

Empyema 5 

Serous pleurisy 1 

Dry pleurisy in nearly all the severe cases of pneu- 
monia. 

Atelectasis (congenital) 6 

Pulmonary abscess (always with pneumonia) 7 

Pulmonary gangrene (always with pneumonia) 2 

Pulmonary tuberculosis 56 

Mouth : 

Noma 1 

Peritonaum : 

Acute peritonitis (localized 2, with acute pneumonia and pleurisy 2). . 4 
Kidneys : 

Acute nephritis (complicating scarlet fever 4, diphtheria 1, pneumonia 
4, measles 1, pertussis 1, ileo-colitis 2, pyonephrosis 1, apparently 

primary 5) 19 

Malformations of the kidney 7 



4:2 PECULIARITIES OF DISEASE IN CHILDREN. 

mon, it being rare to find the lungs normal at autopsy after any acute 
infectious disease which has lasted a week. Up to the third or fourth 
year of life the heart usually escapes. In older children it may be 
involved, as in adults, in the rheumatic diseases. The liver and spleen 
are not often the seat of organic disease in early life, nor is serious disease 
of the kidney likely to be met with excepting in connection with scarlet 
fever. Organic disease of the brain itself is rare, as is also organic dis- 
ease of the spinal cord, with the exception of poliomyelitis. Chronic dis- 
eases of the different viscera are decidedly rare, except when resulting 
from acute processes. Diseases of the bones and joints are common, and 
of extreme importance. They are usually of tuberculous, less frequently of 
syphilitic, origin. Diseases of the blood are quite common, but as yet 
but little understood. New growths are rare. The parts most frequently 
the seat are the kidney and the bones. Disorders of nutrition are ex- 
tremely common and of great importance, particularly rickets and scurvy. 

PROGNOSIS AND INFANT MORTALITY. 

The younger the patient the worse the prognosis in all the diseases of 
childhood. This is in consequence of the feeble resistance of the infan- 
tile organism to all diseases, particularly those which are of an acute 
nature. On the other hand, the rapid metabolism of childhood makes 
it possible for many conditions of an organic nature to disappear with 
time, or, as the phrase is, to be " outgrown," provided the patient can 
be so placed that the general nutrition can be carried to the highest 
point. 

The accompanying chart (Plate I) shows the mortality of New York 
city by months during the three years from 1890 to 1892, inclusive, 

Stomach and Intestines : 

Acute ileocolitis, with or without gastritis 116 

Acute gastritis (without intestinal lesions) None 

Acute diarrhceal disease (without gross lesions) 72 

Intussusception 1 

Heart : 

Pericarditis (all with acute pneumonia) 3 

Congenital malformations 3 

Acute or chronic endocarditis None 

Brain : 

Acute, simple, or purulent meningitis (7 with pneumonia, 2 cerebro- 
spinal) 14 

Tuberculous meningitis 11 

Acute encephalitis 1 

Chronic pachymeningitis 5 

Chronic simple meningitis 1 

Chronic hydrocephalus 3 

There were twenty-six deaths from marasmus without gross lesions. 



PLATE I. 



1 — 




CHILDREN UNDER 1 YEAR 
" 1 TO 2 YEARS 
2 TO 5 YEARS. 
5 TO 15 YEARS 

Over 15 years. 


















































































































































JAN. 


Feb. 


Mar. 


Apr. 


May 


June 


July 


Aug. 


Sept. 


Oct. 


Nov: 


Dec. 

























































Chart showing by months the mortality of New York city for the different ages 
for three years. (Scale, 1 in. = 2,200 deaths.) 



THE MOST FREQUENT CAUSES OP DEATH. 



43 



representing a total mortality of 128,136. The following table gives for 
comparison similar figures for the years 1898 to 1900 : 

Deaths — New York City. 



1890-1892. 



1898-1900. 



Under 1 year 32,916 = 26 per cent. 

lto 2 years 10,547= 8 " 

2 " 5 " 9,794 = 7 " 

5 " 15 " 5,470 =5 " 

Over 15 years .. . 69,409 = 54 

Total 128,136 



29,326 = 24 per cent. 
9,012= 7 " 
7,292= 6 " 
6,922= 5 " 

71,024 = 58 " 



123,576 



Thus about one-fourth of all the deaths occur during the first year 
of life, and nearly one-third in the first two years. The only age in 
which the mortality is much increased in summer is the first year. 

The Most Frequent Causes of Death at Different Periods. — According 
to the statistics of Eross from sixteen Continental cities, nearly ten per 
cent of all infants die during the first month of life. At this time the 
most important factor is congenital debility ; other causes are asphyxia, 
infection, congenital malformations of the heart, intestine, or genito- 
urinary tract, haemorrhages, convulsions, acute diarrhceal diseases, and 
pneumonia, which occurs both as a primary and a secondary lesion. 

Statistics from New York and other large American cities show, for 
the past ten years, a gratifying reduction in infant mortality, both rela- 
tive and actual. The following figures for New York are most striking : 



Population, Deaths, and Death Rate under Five Years, New York City. 


Year. 


Population 
under 5 
years. 


Deaths 
under 5 
years. 


Rate per 
1,000. 


Year. 


Population 
under 5 
years. 


Deaths 
under 5 
years. 


Rate per 

1,000. 


1891.... 
1892 ... 
1893.... 
1894. . . . 
1895. . . . 


188,703 
194,214 
199,886 
205,723 
212,983 


18,224 
18,684 
17,865 
17,558 
18,221 


96-6 
962 

89-4 
85-3 
85-6 


1896 

1897 

1898 

1899.... 
1900 


216,728 
220,641 
224.736 
229,029 
233,537 


16,807 
15,395 
15,591 
14,391 
15,648 


77-5 
69-8 
69-3 
62-8 
67-0 



It will be noted that the actual number of deaths has decreased by 
1,500, while the population under five years has increased by 55,000, 
and the death rate has fallen 30 per 1,000. 

Several causes have united to bring about this result, among which 
may be mentioned : a wider diffusion of knowledge in the matter of infant 
feeding and hygiene ; the fact that a larger number of infants than ever 
before are now sent into the country in summer; that all infants are 
looked after with greater care during the summer, many agencies being 
at work to improve their condition. Not least important of these is a bet- 
tering of the milk supply and the furnishing of pure milk, gratis, from 



44 PECULIARITIES OF DISEASE IN CHILDREN. 

different centres, together with a general adoption during hot weather 
of some form of milk sterilization — a practice well-nigh universal in the 
tenement districts. Antitoxin has reduced the death rate among older 
children. We find among rich and poor alike the largest number of 
deaths in the first year from disease of the gastro-enteric tract and maras- 
mus. In the second rank are acute diseases of the respiratory tract. 
All other causes of mortality fall far below these two. Of the acute 
infectious diseases pertussis takes the first place, with measles second; 
while tuberculosis ranks first of the chronic infections. Although rarely 
the cause of death, rickets is a very important factor in increasing the 
mortality of other diseases. 

During the second year the diseases of the gastro-enteric tract are 
still a large factor in the death rate, also the acute diseases of the lungs 
and the acute infectious diseases, especially measles, diphtheria, and per- 
tussis. Deaths from scarlet fever are much less numerous. General 
tuberculosis and tuberculous meningitis are frequent. 

From the second to the fifth year the deaths are mainly from acute 
infectious diseases — chiefly diphtheria and scarlet fever — much less fre- 
quently from measles or pertussis. In the next group come the acute dis- 
eases of the lungs, general tuberculosis, and tuberculous meningitis. 

From the fifth to the fifteenth year the mortality in childhood is re- 
markably small, diphtheria and scarlet fever being still in the front rank 
in point of frequency. Next come the acute diseases of the lungs, simple 
as well as tuberculous meningitis, diseases of the bones, appendicitis, 
rheumatism, and cardiac disease. 

Sudden Death. — This is not a very uncommon occurrence in infants 
who are apparently healthy. They are sometimes found dead in bed 
under circumstances in which grave suspicion may unjustly rest upon 
the attendants. This usually happens with those who are delicate or 
suffering from malnutrition, especially in institutions where sudden death 
is by no means rare. The most frequent causes in infants are the fol- 
lowing : 

1. Malformations. — While in most cases, to be sure, malformations 
of a serious nature give rise to symptoms, they may be absent, or may be 
so slight as to be overlooked. Infants may succumb during the first few 
days of life from malformations of the heart, lungs, kidneys, stomach or 
intestines, and sometimes from diaphragmatic and umbilical hernia. 

2. Internal haemorrhage. — This is chiefly limited to the first two 
weeks of life. In the cases that have come to my notice the cause has 
been rupture of some subperitoneal haemorrhage into the general abdomi- 
nal cavity. Such cases are reported in the chapter upon Visceral Haem- 
orrhages in the Newly Born. Under these circumstances no symptoms 
may exist until the occurrence of collapse, with death in a few hours. 

3. Asphyxia from overlying. — This is not very common, excepting 



SUDDEN DEATH. 45 

among the lower classes, and is most frequently due to intoxication on 
the part of the mother. Such infants after death present the usual le- 
sions of death from asphyxia, but without any evidence of violence. A 
recent writer in the British Medical Journal states that one thousand 
infants die every year from this cause in the city of London alone. 

4. Asphyxia from aspiration of food into the larynx and trachea. — 
This may be due to vomiting or to the regurgitation of food during sleep ; 
in a very weak infant it may occur while awake. This is usually seen in 
infants who are less than a year old, and most of the reported cases have 
been under six months. Such children are usually delicate. There seems 
to be vomiting with an attempt at crying, during which the food is drawn 
into the air passages. In some cases, as that reported by Demme, a single 
large clot of milk has been found in the larynx. In others, food is found 
in the larynx, trachea, and large bronchi. Cases have also been reported 
by Partridge and Parrot, and I have myself met with at least three. The 
infants have generally been found dead in bed within a few hours after 
feeding. This accident is more likely to happen when an infant lies 
upon its back. 

5. Asphyxia associated with enlargement of the thymus. — Although 
these cases are very imperfectly understood, they are not rare. I see two 
or three each year. The condition is most frequent in infancy, but is not 
confined to this period. When the child is suffering from some minor 
illness, often bronchitis, severe attacks of asphyxia, sometimes with con- 
vulsions, may unexpectedly occur and death soon follow. Or the first 
attack may not be fatal, and they may recur at intervals of a few hours 
for two or three days before death. Sometimes sudden death follows the 
administration of an anaesthetic, particularly chloroform. In most cases 
there is found a general hyperplasia of the lymphatic tissues throughout 
the body known as status lymphaticus, more fully discussed elsewhere. 
The fatal asphyxia has been ascribed to the pressure of the enlarged 
thymus upon the pneumogastric nerve, the trachea, or the heart. 

6. Atelectasis. — In very young infants there may be no symptoms ex- 
cepting malnutrition until sudden death occurs, sometimes with convul- 
sions and sometimes without any such symptoms. (See Atelectasis.) 

7. Marasmus. — In this class of cases sudden death is of very common 
occurrence. These children are often as well two or three hours before 
death as for several weeks. Death frequently occurs at night, the chil- 
dren being found dead in bed in the morning. In some of the cases the 
exciting cause seems to be the lowering of the temperature, while in many 
no exciting cause can be found; the vital spark simply goes out after 
burning for some time with a feeble intensity. In some of these cases 
the autopsy reveals atelectasis, but in many cases nothing abnormal is 
found, death apparently resulting from heart failure. 

5 



46 PECULIARITIES OF DISEASE IN CHILDREN. 

8. Convulsions in children previously showing no signs of disease. — 
Most of these cases are seen in children who were previously rachitic. 
In them the autopsy shows no lesion except those commonly associated 
with death from convulsions. It is extremely rare for a cerebral lesion 
such as haemorrhage to produce death in this way. In some of these 
rachitic cases death is due to spasm of the glottis. 

9. Asphyxia in older infants and young children. — This may result 
from the pressure of a retropharyngeal abscess upon the larynx or 
trachea, or from the rupture of such an abscess during sleep and the 
entrance of pus into the air passages. "While in most such cases other 
symptoms have been present, they may be latent. A rare cause of sud- 
den asphyxia in children from eighteen months to five years is pressure 
upon the pneumogastric by tuberculous bronchial nodes, or by ab- 
scesses in the posterior mediastinum connected with caries of the spine. 
I have seen examples of both the latter. Gibney has reported a case of 
sudden death from dislocation of the upper cervical vertebrae consequent 
upon caries. 

Sudden asphyxia may follow the ulceration of tuberculous lymph 
nodes and the escape of cheesy masses into the trachea or primary 
bronchi. This usually occurs in children from two to five years old, and 
many cases have been reported. 

10. Death after a few hours' illness, in which the chief symptom is 
high temperature. — This is quite a common occurrence. Children who 
are apparently well may be taken with great prostration and a high tem- 
perature, which may rise rapidly to 106° or even 107° F., with death in 
from six to twelve hours, sometimes preceded by convulsions. In my 
hospital experience I have met with many such cases. In infants, the 
most frequent explanation of these symptoms, as shown by autopsy, is 
acute congestive pneumonia; in older children it may be due to malig- 
nant scarlet fever or epidemic meningitis ; however, unless these diseases 
are prevailing epidemically it is somewhat hazardous to make such a 
diagnosis. 

It does not fall within the scope of this chapter to consider cases of 
sudden death from heart failure after diphtheria, with pleurisy with 
effusion, or with myocarditis. These will be discussed elsewhere. 

PROPHYLAXIS. 

There is no more promising field in medicine than the prevention of 
disease in childhood. The majority of the ailments from which children 
die, it is within the power of man in great measure to prevent. Prophy- 
laxis should aim at the solution of two distinct problems: (1) The re- 
moval of the causes which interfere with the proper growth and develop- 
ment of children; (2) the prevention of infection. The former can 
come only through the education first of the profession and then the 



THERAPEUTICS. 47 

general public, in the fundamental principles of infant feeding and hy- 
giene. This is a department which has received altogether too small a 
place in medical education. The latter must come through the profession, 
and through legislation, the purpose of which shall be more rigid quaran- 
tine, more thorough disinfection, and improved sanitation in all its depart- 
ments. 

THERAPEUTICS. 

Treatment in the diseases of children, and particularly those of infants, 
is a difficult subject. Therapeutics in infancy consists in something more 
than a graduated dosage of drugs. Many therapeutic means which are 
valuable in adults are useless in children, and many others which are of 
little value in adults are extremely useful in children. There is no doubt 
of the truth of the statement that children in the past have suffered much 
from overzealous treatment, particularly from drug-giving. It should be 
a fundamental principle never to give a dose of medicine without a clear 
and definite indication. If this rule is followed, it is surprising to find 
how often medication can be dispensed with, and also, in many cases, how 
much better children do without drugs than with them. A second rule 
is equally important : never to give a nauseous dose when one that is 
palatable will answer the purpose equally well. This is no small matter, 
and one that is well worth the physician's careful attention, if he would 
succeed in the management of sick children. The simpler prescriptions 
are made, the better. As a rule, infants revolt against most of the highly 
seasoned sirups and elixirs which are used to disguise the taste of unpleas- 
ant doses. Bitter medicines when mixed with water, are frequently ad- 
ministered without the slightest difficulty. 

It is a common mistake to underestimate the importance of the hy- 
gienic surroundings of the patient, the value of good nursing, careful 
feeding, and judicious stimulation, just as it is to overestimate the bene- 
ficial effects of drugs. In the great majority of acute ailments not serious 
in character, for which a physician is called, the patient recovers quite as 
promptly without drugs as with them. This does not mean that such 
children require no treatment, but that the least important part of the 
treatment is drug-giving, while the most important part is attention to 
the hygienic matters just referred to. In cases of severe illness, in infants 
especially, we must avoid all unnecessary medication, in order that the 
stomach may not be disturbed and vomiting excited. Hence the impor- 
tance of relying as far as possible upon local measures of treatment. The 
tendency to recovery from all acute processes, while seen in adults, is even 
more striking in children, where, if we can but remove that which hampers 
the bodily functions, Nature will conduct the case to a satisfactory tor mi- 
nation. Thus, after an attack of ordinary bronchitis of no great severity, 
it is often seen that the disturbance of the stomach and intestines, which 



48 PECULIARITIES OF DISEASE IN CHILDREN. 

can be directly traced to the drugs employed, continues long after the 
original disease has subsided, and is very much more difficult to relieve. 
In diseases of the stomach and intestines especially there is a great amount 
of overmedication, very much to the detriment of the patient. In all 
chronic disturbances of nutrition — chronic indigestion, malnutrition, and 
anaemia — nothing is of so much value as change of air and surroundings. 
This is most striking in the case of city children. With them it is a fre- 
quent experience that tonics of every description are of little or no avail, 
and yet immediate and most marked improvement begins when the chil- 
dren are sent to the country. 

The tablet triturates have furnished us with a convenient method of 
administering many drugs to children. Those which are especially useful 
are: calomel, from one tenth to one half grain; gray powder in the same 
doses ; antimony and ipecac, one one-hundredth of a grain each ; phena- 
cetine, one to two grains ; arsenious acid, one one-hundredth of a grain ; 
paregoric, fT[v ; Dover's powder, one tenth of a grain ; atropine, one four- 
hundredth to one two-hundredth of a grain. This list might be very 
greatly extended. 

As to the method of administration, it is to be remembered that 
several small doses are more easily given and less likely to disturb the 
stomach than a few larger ones. This method of administering very 
many drugs to children will be found extremely satisfactory — e. g., 
sodium bromide, one half grain every fifteen minutes, is often better 
than five grains every two hours ; phenacetine, one half grain every half 
hour, is better than two grains every two hours ; calomel, one tenth of a 
grain every hour, is better for constipation than a single dose of two 
grains. 

Antipyretics. — The indications for the employment of antipyretics in 
children are somewhat different from those in adults. It is to be borne 
in mind that, where the cause is similar, all temperatures in children are 
higher than in adults. Thus a simple pharyngitis, which in an adult 
causes a rise of temperature only to 100° or 101° F., is in a child not in- 
frequently accompanied by a temperature of 104°, or even 105° F. The 
height of the temperature, as measured by the thermometer, is not to be 
taken as the only guide for the employment of antipyretics. In many 
cases the temperature is 104°, or even 105° F., and yet the child exhibits 
no signs of unusual discomfort. Such a temperature manifestly does not 
call for interference. Again, a temperature of 103° F. may be accom- 
panied by very marked restlessness and other signs of distress which 
may be relieved by employing some antipyretic measure. The number 
of cases seen in practice, of high temperature apparently from trivial 
causes, is very great. One must not be unduly alarmed even by a very 
high temperature if it is of short duration. It is the continuously high 
temperature which indicates serious illness. Whenever the temperature 



ANTIPYRETICS. 49 

is found to be much above the normal it should be carefully watched, 
but not interfered with until a diagnosis has been made, unless the 
symptoms urgently demand it ; otherwise the physician may lose one of 
the most valuable aids to diagnosis, since it is not the height of the 
temperature but its course which is significant. In many cases it is very 
important to know whether the temperature uninfluenced by drugs is 
remittent, intermittent, or steadily high, and hence the advantage of 
waiting until a diagnosis has been made before disturbing the tempera- 
ture curve. This is, of course, not admissible when the temperature is 
itself a source of real danger, which after all is seldom the case. Since 
the cause of a great many obscure temperatures is found in the stom- 
ach and intestines, it very often happens that a purgative, stomach- 
washing, or intestinal irrigation may be the most efficient antipyretic. In 
cases of moderate elevation of temperature we need go no further than 
cold sponging. 

The most reliable antipyretic measure for infants is the use of cold. 
This may be employed — 

(1) As an ice cap to the head. — In many cases of quite high tempera- 
ture and restlessness in infants this alone will reduce the temperature one 
or two degrees and allay the nervous symptoms. 

(2) Cold sponging. — For this purpose water about 80° to 85° F., 
equal parts of alcohol and water, or equal parts of vinegar and water may 
be employed. In the case of infants, all the clothing except the diaper 
should be removed and the child laid upon a blanket. The body should 
be sponged for from ten to twenty minutes, and then wrapped in a 
blanket without further dressing. Cold sponging must be very frequently 
employed in order to be efficient in reducing high temperature. Its great 
value in allaying nervous symptoms, even when the temperature is not 
very high, is not sufficiently appreciated. Its effect is often more satis- 
factory than an anodyne. 

(3) Cold pack. — This is one of the simplest and most efficient means 
of reducing temperature which can be employed. The child should be 
stripped and laid upon a blanket. The entire trunk should then be 
enveloped in a small sheet wrung from water at a temperature of 100° F. 
Upon the outside- of this, ice may now be rubbed over the entire trunk, 
first in front and then behind. By this method there is no shock and 
no fright, and any ordinary temperature can usually be readily reduced. 

The rubbing with ice should be repeated in from five to thirty minute's, 
according to circumstances, after which the child may be rolled in the 
blanket upon which he is lying without the removal of the wet pack. 
The head should be sponged with cold water while this is being carried 
on, and artificial heat, if necessary, should be applied to the feet. The 
pack is continued from one to twenty-four hours, according to circum- 
stances. 



50 PECULIARITIES OF DISEASE IN CHILDREN. 

(4) The cold bath. — The child is put into a bath at a temperature of 
100° F., the bath being gradually lowered by the addition of ice to 85° or 
80° F. The body should be well rubbed while the child is in the bath and 
water should also be applied to the head. On removal from the bath, the 
body should be quickly dried and rolled in a warm blanket. The bath is 
usually continued from five to ten minutes. 

(5) Evaporation baths. — The trunk is closely enveloped in two layers 
of surgeon's gauze, or some loosely woven equivalent, which is moistened 
from time to time with water at a temperature of 115° F., continuous 
evaporation being kept up by means of a hand, or better electric, fan. 
The evaporation bath would seem to possess some important advantages in 
the case of infants and young children, in that it is more efficient than 
sponging, involves little disturbance of the patient, and causes no shock or 
fright. Hot applications should constantly be made to the extremities. 

(6) Rectal irrigations. — These are easily given, disturb the patient 
very little, and are effective in reducing the temperature. A double tube 

(see Fig. 17), the in-and-out flow of which can be readily regulated, 
should be employed. It is best to use at first water at a temperature of 
90° F., and gradually reduce this to 70° F. The irrigation should be 
continued for ten to fifteen minutes, or even longer if the desired fall in 
temperature is not obtained, and may be repeated as often as every three 
hours. 

Antipyretic Drugs. — Except in cases of malaria, quinine should not 
be employed for the reduction of temperature in children. 

Of the many coal-tar derivatives employed, phenacetine has the ad- 
vantage for children of being tasteless and causing little depression, but 
the slight disadvantage of practical insolubility. None of the drugs of 
this group is, however, to be employed in large doses with the sole purpose 
of reducing the temperature. Their great value in paediatrics consists 
rather in allaying the nervous symptoms which accompany fever, and 
this purpose can be accomplished by the use of comparatively small 
doses. To an infant of one year, phenacetine or antipyrine can be given 
in one-grain doses every hour or two hours until the desired effect is 
produced. For a child of five years a dose of two grains may be given 
in the same manner. When used as indicated, these drugs are of very 
great value in making the patient more comfortable, in promoting sleep, 
and in allaying headache and general pains. In cases of hyperpyrexia 
they are, however, much less certain and less safe than the use of cold. 
In many cases of mild pyrexia the symptoms are relieved by the ad- 
ministration, either separately or in combination, of citrate of potas- 
sium, spiritus aetheris nitrosi, and liquor ammonii acetatis, in small fre- 
quent doses. 

Stimulants. — In spite of the many statements to the contrary, alco- 
holic stimulants are well tolerated even by very young infants. Propor- 



STIMULANTS. 51 

tionately larger doses of alcohol than of many drugs may be adminis- 
tered to infants; still, all stimulants, and alcohol in particular, are very 
greatly abused in the hands of many practitioners. 

The indications for the employment of stimulants are much the same 
in young children as in adults. They are to be used whenever the pulse 
is weak, soft, and compressible, and whenever the general powers of the 
patient are very greatly depressed. In most of the acute fevers they are 
not to be given early in the disease, and in many cases they are not re- 
quired at all. They must often be used very sparingly while the tem- 
perature is high, but given freely as soon as it falls. In many acute 
febrile diseases stimulants are not called for at any period. This is 
especially true of most cases of lobar pneumonia. The time, however, 
when they are most likely to be needed is at or just after the crisis of 
the disease, when for twenty-four hours they should be very freely given. 
In broncho-pneumonia they are more often required, and their use 
should be begun earlier. This is particularly true of the broncho-pneu- 
monia which develops secondarily to the infectious diseases. In all toxic 
diseases, such as diphtheria, alcohol should be begun as soon as depressing 
symptoms show themselves, and continued in doses regulated by the 
degree of prostration. In the acute gastro-enteric diseases the depletion 
is often great and there is little absorption of food; the patients may 
in certain cases be sustained by alcohol for several days. 

Alcohol is contra-indicated in all acute febrile processes where there 
is high temperature, dry skin, flushed face, and a full, strong pulse. In 
such conditions it is often injurious. 

The method of administering alcohol is of no little importance. 
Brandy and whisky are in most cases to be preferred to the wines, but 
not always. Champagne may be substituted when spirits are not well 
borne by the stomach. For infants under one year old, brandy should 
be diluted with at least eight parts of water. It is commonly given in 
too concentrated a form. Altogether the best method of administration 
is to determine the amount to be given in every twenty-four hours, have 
it diluted sufficiently, and then administer it in small doses at short 
intervals. In this way vomiting is rarely produced. The addition of 
brandy to the water required by the thirst makes it less likely to disturb 
the stomach. 

The quantity of alcohol will depend very much upon circumstances. 
An infant one year old, for whom alcohol is indicated, should not be 
given to begin with more than half an ounce of brandy or whisky during 
the twenty- four hours, and even in bad conditions it is rarely advisable 
to give more than 'twice this quantity, except for a very short period. 
In children four years old double the amount may be employed in the 
corresponding conditions. Too much can not be said against the prac- 
tice, unfortunately with many practitioners a common one, of the reck- 



52 PECULIARITIES OF DISEASE IN CHILDREN. 

less use of alcohol in large doses in young children. I refer to such 
amounts as six or eight ounces daily of brandy or whisky for children of 
two or three years in cases of pneumonia or diphtheria. Little good 
and much harm is likely to follow such therapeutics. 

" Tonics. — Cod-liver oil stands at the head of the list of tonics for young 
children. It is particularly in the convalescence after acute diseases of 
the respiratory tract that we see its most striking benefit. It is also of 
very great use in anaemia, and in a large number of children who are 
extremely delicate. In these patients it may be advantageously adminis- 
tered throughout the greater part of nearly every winter season. In con- 
valescence after attacks of gastro-enteric disease it is not nearly so useful, 
and often must be withheld for a long time. It is a mistake to give cod- 
liver oil at any time when the tongue is coated, the digestion poor, and the 
stomach easily disturbed. In the case of infants, as a rule, the pure oil 
is to be preferred to the emulsions, but this is not always the case. The 
administration of small doses — i. e., ten or twenty drops of the oil three 
times a day continued for a long period — is much better than the use of 
larger doses for a shorter time. 

A perfect preparation of iron for use in infancy has not yet been dis- 
covered. During the first few years all astringent preparations should be 
avoided. To be recommended are the various peptonates, the albumi- 
nate, bitter wine, sweet wine, saccharated carbonate, pomate, and malate. 
These are only slightly constipating, and most of them can be given with 
milk. For older children nothing is better than reduced iron or Blaud's 
pills. 

Arsenic is second only to iron in the treatment of the anaemia of chil- 
dren, and in very many cases it is to be preferred to iron. The tablet 
triturates of arsenious acid, one one-hundredth of a grain, may be given 
immediately after meals three times a day, or one or two drops of Fowler's 
solution largely diluted with water. 

Alcohol is of very great value as a tonic in combination with some of 
the bitters, either small doses of quinine, nux vomica, or the bitter wine 
of iron. Usually wines, especially sherry, are to be preferred to spirits, 
although some children take spirits better. When combined with a bitter 
there is little danger of the formation of the alcoholic habit, even though 
its use may be long continued. 

Of the bitter tonics, quinine and nux vomica are easily superior to all 
others. 

Opiates. — Strong objections have been urged by many against the 
employment of opium in the diseases of infancy. While opiates have 
no doubt been abused, the fact remains that opium is almost as valu- 
able a remedy in the treatment of disease during the first five years 
as at any other period of life. Infants are, however, peculiarly suscep- 
tible to the drug, and relatively much smaller doses are required than 



OPIATES— ANODYNES. 



53 



of most medicines. If the physician will accustom himself to the use 
of very small doses, he will be surprised to see how satisfactory are the 
effects produced. 

The most useful preparations for young children are paregoric, Dover's 
powder, the deodorized tincture, morphine, and codeine. The follow- 
ing table gives what may be considered safe initial doses at the different 
ages : 



Paregoric 

Deodorized tincture 

Dover's powder 

Morphine 

Codeine 



1 month. 


3 months. 


1 year. 


5 years. 


m i 

Gr. & 
Gr. toW 
Gr. ^o-Q- 


TTt ii 

*Ito 
Gr.rV 
Gr. ufor 
Gr. ^ho 


til vtox 

m i to£ 

Gr. i to i 
Gr. yuo 

Gr. -gV 


v\ xxx to xl 

Ttj, ii to iii 

Gr. ii to iii 

Gr. gL to yz 

Gr. f - to i 



Ordinarily doses like the above should not be repeated oftener than 
every two hours. In exceptional circumstances, as when very great pain 
is present, the dose may be given more frequently. In the hypodermic 
use of morphine it should be remembered that its effects are always more 
uniform and striking than when the drug is administered by the mouth, 
and the dose should therefore be smaller. In every instance where a full 
dose of opium has been given the physician should wait until the effects 
have subsided before the dose is repeated. 

Anodynes. — Chloral is usually well borne even by quite young infants. 
In them it should never be administered by the mouth, but, on account 
of its irritant properties, always by the rectum. After rectal administra- 
tion its effects are usually manifest in half an hour, and sometimes sooner. 
The rectal dose for an infant of one month is one grain ; three months, 
two grains ; one year, three to five grains. It may be repeated every two 
to four hours, according to indications. Other drugs may replace this 
in most diseases, but in the case of infantile convulsions nothing is so 
reliable as chloral. 

Belladonna is well borne by children, and in larger doses than most 
drugs. A tolerance is quite readily established. The eruption is more 
readily produced than the other physiological effects, and even quite small 
doses may be sufficient to bring out a very abundant blush. The parents 
should be advised of this fact, lest undue alarm be felt. 

The drugs classed as antipyretics — phenacetine, antipyrine, and anti- 
febrine — are exceedingly valuable in the treatment of many diseases of 
infancy where irritative nervous symptoms are prominent. In many cases 
they may advantageously take the place of opium, except where pain is 
the principal symptom, as in otitis or pleurisy. Tn all conditions where 
spasm is a prominent symptom, whether of the larynx or bronchi, or local 
or general convulsions, antipyrine is especially valuable. 



54 PECULIARITIES OP DISEASE IN CHILDREN. 

Drugs well borne by Children. — In this list might be mentioned 
belladonna, the bromides, the iodides, chloral, quinine, calomel — in fact, 
all mercurials — and alcohol. 

The drugs not well borne include particularly cocaine and all prepa- 
rations of opium. In the case of many others, while the constitutional 
effects are well tolerated, they must be given carefully to young infants, 
since they are irritants to the stomach. In this class may be mentioned 
the salicylates, salol, the astringent preparations of iron, and the acids. 

Counter-irritants. — These are of great value in a large variety of dis- 
eases. Blisters should never be employed in the case of infants, and very 
rarely, and never needlessly, in the case of older children. In the latter 
they may be required in inflammations of the ear, of the joints, or of the 
spine ; they should never be applied to the chest. 

The mustard paste is probably the most satisfactory means of pro- 
ducing quick counter-irritation over a large surface. To make a mustard 
paste : Take one part powdered mustard and six parts of wheat flour, mix 
with lukewarm water, and spread between two layers of muslin. This 
should be removed as soon as a thorough redness of the skin has been 
produced — in most cases from five to eight minutes, according to the 
strength of the mustard employed. This may be repeated as often as 
every three hours, and continued for a week if necessary, without pro- 
ducing excoriations of the skin. For older children the paste may 
be made one part mustard to four parts flour. In pulmonary diseases 
it should be large enough to surround the chest. When it is used 
to produce general reaction in heart failure it should cover the entire 
trunk. 

The mustard pack. — The child is stripped and laid upon a blanket, 
and the trunk is surrounded by a large towel or sheet saturated with 
mustard water. This is made as follows : One tablespoonful of mustard 
to one quart of tepid water. In this a towel is dipped, and while drip- 
ping wound around the entire body. The patient should then be rolled 
in the blanket. This pack may be continued for ten or fifteen minutes, 
at the end of which time there will usually be a very decided redness of 
the whole body. It may be repeated according to indications. Where it 
is desired to produce a general counter-irritation, the mustard pack is not 
quite as efficient as the mustard bath, but it has the advantage in causing 
much less disturbance to the patient. The mustard pack is useful in the 
condition of collapse or of great prostration from any cause whatever, in 
convulsions, and in cerebral or pulmonary congestion. 

The turpentine stupe is made by wringing a piece of flannel out of 
water as hot as can be borne by the hand. Upon this is sprinkled ten or 
fifteen drops of the spirits of turpentine. The stupe is then applied to 
the body and covered with oiled silk or dry flannel. It is useful chiefly 
in abdominal pains or inflammations, but in infancy must be carefully 



POULTICES. 55 

watched or vesication will be produced. For continuous use it is not so 
valuable as the mustard paste. 

Stimulating liniments containing turpentine and other irritants are 
useful in inflammations of the chest, although less reliable than the mus- 
tard paste. One of the mildest and most useful preparations is camphor- 
ated oil. Another is olive oil four parts and turpentine one part. These 
may either be rubbed upon the surface, or a piece of flannel may be satu- 
rated with them and then applied to the skin. The old-fashioned spice 
bag is useful in many cases where a very mild counter-irritant is desired 
over the abdomen. 

Local blood-letting. — Leeches are often useful in arresting acute in- 
flammations of the mastoid or middle ear. They may also be applied to 
the praecordium in acute pneumonia with signs of failure of the right 
heart, viz., great dyspnoea and cyanosis. In robust children even vene- 
section may be employed with advantage for the above indications. 

Dry cups are useful even in young infants, to relieve acute pulmon- 
ary congestion. From four to six cups may be applied, and the eflect 
may be continued by the application of the mustard paste. Wet cups 
should never be used for young children. 

Poultices are useful in local inflammations about the glands of the 
neck, the joints, and in cellulitis in various parts of the body. They 
are indicated in pulmonary diseases in which there is great pain, as in 
pleurisy or in pleuro-pneumonia. In bronchitis and in broncho-pneu- 
monia their prolonged use is objectionable on account of their weight. 
Better effects can generally be produced by hot fomentations and coun- 
ter-irritation. Ground flaxseed is the best material for poultices. This 
should be mixed with boiling water until the proper consistency is 
reached, when the poultice should be put into a bag of muslin. The 
poultice should be covered with oiled silk or flannel, so that it will retain 
its heat as long as possible. To be of value, poultices must be applied 
hot and changed frequently. 

Hot fomentations are more cleanly than poultices and much more 
easily changed. One of the best means of applying them is by a piece of 
spongio-piline wrung from water as hot as the hand can bear. Where 
this can not be obtained, a large piece of flannel may be used in the same 
way, covered with cotton batting, and then with oiled silk. This method 
of using hot fomentations is exceedingly satisfactory for applications to 
the extremities. 

Cold. — Cold is useful in all forms of inflammation of the eyes and 
brain. In inflammation of the cervical lymph glands and of the joints 
it is of undoubted value, but its advantage over heat is questionable. The 
efficiency of both cold and heat in these cases depends largely upon the 
method of application. Sometimes in pleurisy much greater relief is ob- 
tained from the use of an ice bag to the chest than from hot applications, 



56 PECULIARITIES OF DISEASE IN CHILDREN. 

but this is not the general experience. The treatment of pneumonia by 
the application of the ice bag to the chest has many advocates, although 
in my own hands it has not yielded the results claimed for it. It is 
admissible only in lobar pneumonia, and here chiefly in older and stronger 
children. The application of cold in young or very delicate children 
should be made with caution in all inflammations of the respiratory tract. 

Cold is best applied to the head by an ice cap made like a helmet ; an 
ordinary rubber or flannel bag filled with ice may answer the purpose. 
The rubber coil filled with ice water is also an excellent method. For 
inflamed glands or joints the ice bag should be used ; for the eyes cold 
compresses changed every minute. 

The Hot Pack. — All clothing is to be removed and the child's body 
covered with towels wrung from water at a temperature of from 100° to 
110° F., after which the body should be rolled in a thick blanket. These 
hot applications may be changed every twenty or thirty minutes until free 
perspiration is produced, which may be continued as long as necessary. 
This is mainly useful in uraemia. 

The Hot Bath, like the mustard pack or the mustard bath, may be 
used to promote reaction in cases of shock or collapse. The patient should 
be put into the bath at a temperature of 100° F., the water being gradu- 
ally raised to 105°, or even to 110°, but rarely above this point. The body 
should be well rubbed while the patient is in the bath. A thermometer 
should be kept in the water to see that the temperature does not go too 
high. During the bath, in most cases, cold should be applied to the head. 

The Hot-Air or Vapour Bath. — All the clothing should be removed 
and the patient laid upon the bed with the bedclothing raised above the 
body ten or twelve inches, and sustained by means of a wicker support. 
The bedclothing should be pinned tightly about the neck, so that only 
the head is outside. Beneath the bed clothing hot vapour is introduced 
from a croup kettle or a vapourizer. This will usually induce free per- 
spiration in fifteen or twenty minutes. It may be continued from twenty 
to thirty minutes at a time. Instead of vapour, hot air may be intro- 
duced in the same way. The air space about the body is indispensable. 
The vapour bath is applicable chiefly to cases of uraemia. 

The Mustard Bath. — Four or five tablespoonfuls of powdered mustard 
should be mixed for a few minutes with one gallon of tepid water. To 
this should be added four or five gallons of plain water at a temperature 
of 100° F. The temperature of the bath may be raised by the addition of 
hot water to 105° or 110° F. if desired. Nothing is more efficient than 
the hot mustard bath for a general derivative effect in bringing the blood 
to the surface in cases of shock, collapse, heart failure from any cause, or 
in sudden congestion of the lungs or brain. The bath should not usually 
be continued for more than ten minutes. If necessary, it may be repeated 
in an hour. 



NASAL SPRAY. 



57 



The Bran Bath. — Put one quart of ordinary wheat bran in a bag made 
of coarse muslin or cheese cloth and place this in four. or five gallons of 
water. The bran bag should be frequently squeezed and moved about 
until the bath water resembles a thin porridge. It may be of any tem- 
perature desired, but usually about 90° to 95° F. is best. A bran bath is 
of great value in cases of eczema, excoriations about the buttocks, or in 
other cases where the skin is very delicate, and plain water seems to irri- 
tate it. 

The Tepid Bath may be given at a temperature of 95° to 100° F. It is 
very useful in many conditions of excitement or extreme nervous irrita- 
bility. To induce sleep it is often more efficient than drugs. 

The Cold Sponge or Shower Bath should be given in the morning 
before breakfast, and in a warm room. The child should stand in a 
foot tub containing warm water enough to cover the feet, then a large 
sponge holding about a pint of water at a temperature of from 40° to 60° 
F. should be squeezed three or four times over the chest, shoulders, and 
spine of the child, the skin being rubbed meanwhile. The bath should 
not last more than half a minute. It should be followed by a brisk rub- 
bing until a thorough reaction is established. This is very useful at all 
ages, but a particularly valuable tonic in delicate children. It may be 
used in those only eighteen months old. Not the least of the beneficial 
results is the full expansion of the lungs from the strong cry which the 
bath usually excites. In younger infants a cold plunge may be sub- 
stituted. This should be merely a single dip of the entire body in 
water at a temperature of 50° to 60° F. In order that beneficial effects 
shall follow the cold plunge or cold sponging, a good reaction must be 
established. If children lack suffi- 
cient vitality to secure this, and if 
they remain pale, pinched, and blue 
for some time after the bath, it 
must be discontinued altogether, 
or water of a higher temperature 
used. 

Nasal Spray. — This may be either 
of an aqueous or oily solution. For 
the oil spray an atomizer similar to 
that shown in the accompanying 
cut should be employed. It is valu- 
able in cases of dry catarrh, where there is a formation of crusts in the 
nose. A variety of oils may be used in the spray, albolene being per- 
haps as satisfactory as any. Fig. 8 shows an efficient atomizer for 
albolene. 

There are a good many forms of hand atomizers to be found in the 
market for the production of an aqueous spray. For a cleansing nasal 





Fig. 8, 



' ■AK*' ■■■' 

Albolene atomizer. 



58 PECULIARITIES OF DISEASE IN CHILDREN. 

spray, DobelPs solution, Seller's solution, Listerine ten-per-cent solution, 
or a two-per-cent solution of boric acid may be used. 

Nasal Syringing. — In cases of considerable nasal obstruction and in 
the more serious affections of the rhino-pharynx, only the syringe can be 
considered an efficient means of cleansing the cavity. 

The fountain syringe has the advantage of being easily regulated 
as to the force employed, this being determined by the height at which 
the bag is suspended above the bed. For ordinary purposes an eleva- 
tion of one or two feet is sufficient, and rarely is a greater pressure 




Fig. 9. — Nasal syringe. 

than three feet advisable. The last is desirable when a thorough 
flushing of the rhino-pharynx is required. The position of the patient 
is the same as that shown in Fig. 10. The danger of forcing fluid 
into the middle ear is greatly lessened if the patient keeps the mouth 
wide open. 

Where a smaller amount of fluid is sufficient a piston syringe may 
be employed. This should be small enough to be easily worked with 
one hand. It should have a soft rubber tip, to prevent injuring the 
nasal mucous membrane, and the tip should be large enough to fill the 
nostril. The best piston syringe for nasal use is shown in Fig. 9. This 
is made either of glass or hard rubber, and fulfils all the conditions 
mentioned. It is easy of action, can be readily cleansed, and holds 
about half an ounce. The same syringe should not be used for more 
than one patient, unless it has been very thoroughly disinfected. In hos- 
pitals, and even in private practice, nasal syringes are frequent carriers 
of infection. 

Either of two positions may be used in nasal syringing. In diph- 
theria, scarlet fever, or any constitutional disease attended by great 
depression, the child should not be removed from the bed. The syring- 
ing may be done by a single nurse, who stands at the head of the 
bed, alternately syringing the right and left nostril, turning the head 
from side to side (see Fig. 10). The other method is to hold the child 
erect on the lap, with the head inclined somewhat forward, the syring- 
ing being done by a second person standing behind. In either position 
the childs arms and hands should be securely pinioned to the sides by 
a sheet. To make sure that the rhino-pharynx has been reached the 
water should return through the opposite nostril or the mouth. When 



NASAL SYRINGING. 



59 



properly done, no prostration and very little irritation are caused. The 
bulb (Davison) syringe should not be employed for nasal irrigation; as 
the pressure can not be satisfactorily regulated, fluids are likely to be 
forced into the Eustachian tubes. 

Syringing the mouth and pharynx is useful in many pathological 
conditions of these parts, particularly in children too young to gargle. 
Either the fountain, piston, or bulb (Davison) syringe may be used. 




-Method of syringing the nose. 



If the pharynx is to be reached, the nozzle is used as a tongue depressor! 
This should be placed at the angle of the mouth between the back teeth. 
The child should be held in the sitting posture, with the head inclined 
forward. Only bland solutions should be employed. 



60 



PECULIARITIES OP DISEASE IN CHILDREN. 



Inhalations. — These are of very great utility in all affections of the 
respiratory tract. To be efficient, the patient should be put under a tent. 
A satisfactory tent may be made by erecting a T-shaped piece of wood at 
the head and foot of the crib and throwing over this a large sheet folded 
and pinned at the corners. Another method is, to stretch a cord around 
the top of each of the four posts of the crib, or simply from the centre of 
the head piece to the centre of the foot piece ; the sheet should be used as 
in the first instance. A very good tent may be improvised by throwing a 
large sheet over an open umbrella. Instead of an ordinary cotton sheet 
one of rubber cloth may be used. For hospital use I have found it con- 
venient to have a rubber cover made to fit closely over the top of the crib 
to be used for inhalations. The better the tent the more satisfactory are 
the results from inhalations. 

Inhalations may be in the form of vapour or spray. The apparatus 
employed may be the croup kettle, the vapourizer, or the steam atomizer. 
As all of these are used with alcohol lamps, innumerable accidents from 
fire have occurred with them. Patients and nurses should always be cau- 
tioned regarding this. The ordinary croup kettle is a clumsy affair and 
especially likely to be the cause of accidents. In Fig. 11 is shown one 
of an improved pattern,* which possesses the advantages both of the ordi- 
nary croup kettle and of the 
vapourizer. The base has been 
weighted, to prevent the appa- 
ratus being easily upset. The 
pail is low, which fact also contributes 
to its stability. It is provided with a 
safety alcohol lamp, the flame of which 
can be regulated by a screw. The 
lamp holds enough alcohol to burn 
from five to six hours. This kettle 
may be used to produce simple vapour, 
or vapour from lime water, or a medi- 
cated vapour may be employed. If the 
latter is desired, the substance to be va- 
pourized is placed on a sponge held in 
the expansion of the spout. The kettle 
should be filled with hot water before 
using. It should be placed upon the 
floor or a low box beside the crib, so that the end of the spout is just in- 
side the tent at a level with the surface of the bed. 

The vapourizer \ (Fig. 12) is one of the most satisfactory means of 




Fig. 11. — The author's croup kettle. 



* Made by Lewis & Conger, 130 W. 42d St.. New York. 
f Made by Whitall & Tatum, New York and Philadelphia. 



OILED-SILK JACKET. 



61 



obtaining medicated inhalations. The boiler is half filled with water, and 
the substance to be vapourized is placed upon a sponge which lies on a per- 





Fig. 12. — Vapourizer. 



Fig. 13. — Steam atomizer. 



forated diaphragm placed at the top of the boiler, so that all the steam 
generated in the boiler passes through it. 

The steam atomizer is shown in Fig. 13. For this no tent is required. 
It should be placed about one and a half or two feet from the patient's 
face, and the clothing protected by a rubber sheet. This is very efficient 
where steam or vapour of lime water are used, but is not to be advised for 
carbolic acid, creosote, etc. 

Oiled-silk Jacket. — In all forms of acute pulmonary inflammation this 
form of local application has largely supplanted the time-honoured poul- 
tice, both in hospital and in private practice. It keeps the skin at a uni- 
form temperature, maintains a moderate degree of counter-irritation, and 
gives the patient a great deal of comfort. The jacket consists of three 
layers — an outer one of oiled 
silk, an inner one of cheese 
cloth or light flannel, and a 
middle one of cotton batting 
or wool. The middle layer 
should be half an inch in 
thickness. The purpose of 
the lining is to keep the cot- 
ton in position. Fig. 14 
shows the pattern of the 
jacket. It is generally made F.o. u.-Pattem for oiled-silk jacket 

in two pieces, each of which should be about twelve inches wide and twelve 
inches long for a child of one year. These are sewed together along one 
border and lapped at the other, where it is secured by safety pins. A 
properly made jacket will last two weeks. 




62 



PECULIARITIES OF DISEASE IN CHILDREN. 



A 



Stomach-Washing consists in the introduction of water into the stom- 
ach through a flexible catheter or stomach tube and then siphoning it 
out. It was introduced into general practice among infants by Epstein, 
of Prague. To Seibert (New York) is due the credit of bringing the 

subject prominently before the minds of 
the medical profession in America. It is 
one of the most valuable therapeutic 
measures we possess. Stomach-washing 
has been employed almost daily for the 
past twelve years in the hospitals with 
which I am connected, during which 
period the stomach has been washed 
many thousand times. No accident 
whatever has occurred, and the operation 
may be considered entirely free from 
danger; in fact, it is difficult to pass 
the tube anywhere else than into the 
^jlplly oesophagus. The amount of prostration 

^|Bf may be compared to that of an ordinary 

W^ attack of vomiting. 

I IJ The apparatus for stomach-washing 

1 m is very simple (Fig. 15). There is re- 

V^ Jf quired a soft-rubber catheter, size 16, 

^^iii ^r American scale (24 French) — one with a 

large eye is preferred; a glass funnel, 
holding four to six ounces ; two feet of 
rubber tubing, and a few inches of glass tubing to join this to the cathe- 
ter. The child should be held in a sitting posture (Fig. 16), the body 
well protected by a rubber sheet, with a large basin conveniently near. 
The catheter should be moistened. While the tongue is depressed with 
the forefinger of the left hand, the catheter is passed rapidly back into the 
pharynx and down the oesophagus. It is important that the first part 
of the introduction should be as rapid as possible, for if the child begins 
to gag from the pharyngeal irritation the introduction of the tube may 
be quite difficult. No resistance is ordinarily encountered after the tube 
reaches the oesophagus. About ten inches of the catheter should be passed 
beyond the lips. When it has reached the stomach the funnel should be 
raised as high as possible, to allow the escape of gases almost invariably 
present. It should then be lowered, in order to siphon out the fluid con- 
tents. If nothing escapes, the funnel is then to be raised and from two 
to six ounces of water poured into it from a pitcher ; the funnel is then 
lowered and the water siphoned out. This procedure is repeated from 
four to ten times, or until the fluid comes back perfectly clear. About a 
quart of water is ordinarily used. Various solutions have been advised 



Fig. 15. — Apparatus for stomach- 
washing. 



STOMACH- WASHING. 



63 



for stomach- washing, but nothing is better than boiled water, used at the 
temperature of from 100° to 110° F. — the higher temperature being em- 
ployed when the gastric irritation is very great. Through the tube are 
easily discharged mucus and small curds ; larger ones are gradually broken 
down by repeated washing. Vomiting may be induced by overdistending 
the stomach with water. If there is great thirst there is often an advan- 
tage in leaving one or two ounces of water in the stomach. To this water 
it is at times beneficial to add lime water. 

Stomach-washing in its application is practically limited to children 
under two and a half years. It is easiest in those under eighteen months. 




16. — Position for stomach- washing. 



Children of three years and over are usually so much alarmed and struggle 
bo violently as to make it difficult and undesirable. 

The indications for stomach-washing are : ( 1 ) Acute gastric indiges- 
tion, either with or without persistent vomiting. Here the purpose is 



64 PECULIARITIES OF DISEASE IN CHILDREN. 

simply to clear the stomach of its irritating contents, and a single wash- 
ing may be sufficient. (2) Chronic indigestion attended with great 
production of gastric mucus, and sometimes, though rarely, by dilatation 
of the stomach. In these cases daily washing is required for a consider- 
able period. (3) Poisoning. 

Gavage. — (ravage consists in the forcible introduction of food into the 
stomach by a tube passed through the mouth. The same apparatus is 
employed as in stomach-washing, and the method is similar, with the 
exception that for gavage the child should be placed flat upon the back, 
the head being steadied by an assistant. In older children a mouth-gag 
is often necessary. After the tube has entered the stomach the funnel 
should be raised to allow the gas to escape. The food is then poured 
into the funnel ; as soon as it has disappeared the tube is tightly pinched 
and quickly withdrawn, to prevent food from trickling into the pharynx, 
since this is often a cause of vomiting. In young infants, after remov- 
ing the tube, it is well to keep the jaws separated by the fingers for a few 
moments to prevent gagging. If the food is regurgitated this usually 
happens at once. It may then be introduced a second time. After feed- 
ing, the child should be kept absolutely quiet upon the back. 

In cases where all the food is given by gavage the interval between 
feedings must be considerably longer than under other circumstances. 
The food given should be either wholly or partly predigested, since diges- 
tion in these cases is usually feeble. The stomach should be washed 
before each feeding, in order to remove mucus and to be sure that it is 
empty before the meal is given. 

Gavage is valuable, as already indicated in connection with the incu- 
bator, in the management of premature infants and after certain opera- 
tions upon the mouth and neck. It is also useful, first, in the case of very 
young infants, who, suffering from severe malnutrition, can not be in- 
duced to take food enough to sustain life ; secondly, in many acute dis- 
eases, particularly in septic cases where the child will not readily take the 
necessary food, as in diphtheria, scarlet fever, typhoid, pneumonia, etc. ; 
thirdly, in many cases of cerebral disease where food is refused on account 
of delirium or coma; and, fourthly, in uncontrollable vomiting, as first 
suggested by Kerley. 

Gavage is a very simple procedure and one which a nurse can easily 
be taught. It is free from danger, and in a great majority of cases the 
food given is not regurgitated. In acute septic cases not only may food 
be given, but also such medicines and stimulants as may be required, 
with little or no trouble. The advantage of gavage over the continued 
coaxing or holding the nose and forcing the patient to swallow, will be 
at once apparent to one using it. 

Nasal Feeding. — The method is similar to gavage, the only difference 
being that the tube is passed through the nose, and consequently a much 



IRRIGATION OF THE COLON. 65 

smaller one is used. No. 10 American or No. 16 French scale is a proper 
size. Nasal feeding is applicable to children over two years old, in whom 
the tube can seldom be passed through the mouth without the use of a 
gag, and then only after much struggling. It is of value after intuba- 
tion, tracheotomy, and other operations about the throat, also in some 
cases of throat paralysis, especially after diphtheria. 

Irrigation of the Colon. — By irrigation of the colon is meant the 
flushing of the entire large intestine by fluids injected high up through 
a catheter or rectal tube. Very rarely indeed do the injected fluids pass 
beyond the ileo-caecal valve. 

The apparatus required for irrigating the colon is a fountain syringe, 
five or six feet of rubber tubing, and a flexible rectal tube or soft-rubber 
catheter — No. 26 or 27, French scale, being preferred. Kemp's double- 




Fm. 17.— Kemp's tube. 

current tube of hard or flexible rubber (Fig. 17) is of great advan- 
tage. The child is placed upon the back, with the thighs flexed and the 
buttocks brought to the edge of the bed or table. He should lie upon 
a Kelly pad or a rubber sheet so arranged as to form a trough empty- 
ing into a large basin or tub. The bag containing the water is hung 
four or five feet above the bed. If a catheter is used it is inserted 
just within the sphincter before the water is turned on. As it flows 
the catheter is gradually pushed upward to a distance of twelve or four- 
teen inches. The water distending the intestine in advance of the cathe- 
ter usually makes its introduction quite easy. If, however, the attempt 
is made to introduce the catheter before turning on the water, it almost 
invariably doubles upon itself. In Fig. 18 is shown the colon of an in- 
fant of six months in position. It is the peculiar curve and the great 
length of the sigmoid flexure that make the introduction of water difficult, 
unless the tube is passed quite to the descending colon. When this is 
done the remainder of the colon fills with ease ; but if the tube is intro- 
duced only three or four inches the irrigation is not likely to extend 
beyond the sigmoid flexure. 

Usually a pint, and often a quart, will be introduced before any water 
returns. This is an advantage, since one can then be reasonably sure that 



66 



PECULIARITIES OF DISEASE IN CHILDREN. 



the upper part of the colon has been reached. The water is passed from 
time to time alongside the catheter, often with considerable force. At 
least a gallon of water should be used for a single irrigation. The wash- 
ing should be continued until the water returns quite clean. Gentle 
kneading of the abdomen should be continued during the irrigation, par- 
ticularly the early part of it, to facilitate the passage of the water into the 




wssss®* 



Fig. 18. — Colon of a child six months old, in position. (From a photograph.) 



upper part of the colon. At the end of the irrigation the rubber tube is de- 
tached and the water allowed to escape through the catheter, which remains 
in situ. Sometimes as much as a pint of water remains in the intestine. 
This is usually passed within half an hour. As the irrigation of the colon 
almost invariably excites active peristalsis of the lower ileum, this part of 
the intestine is emptied as well. It is to be remembered that the colon 
of an infant six months old will hold one pint without distention, and at 
the age of two years from two to three pints. 

Irrigation of the colon is useful to clear this part of the intestine of 
mucus, faecal matter, undigested food, and the products of decomposition. 



ENEMATA. 67 

It may also be employed as a means of local medication in ileo-colitis. 
Where the object is simply to cleanse the intestine, a saline solution — a 
teaspoonful of common salt to a pint of water — is preferred. 

The temperature of the water used for irrigation may be varied ac- 
cording to the special indications. For ordinary purposes, where cleans- 
ing only is aimed at, a temperature of from 95° to 100° F. seems to be 
best. When the body temperature is high, or when there is much pain, 
tenesmus and straining, cold water has important advantages. In cases 
of collapse or great prostration hot injections may be employed; these 
should not be hotter than 110° F., but at this temperature they may be 
used with safety. 

Irrigation under most circumstances is required only once in twenty- 
four hours. When it is employed it is important to use a large quantity 
of water. It must be done thoroughly to be of value, and either by the 
physician himself or an experienced nurse. 

Enemata. — Simple enemata are useful in infants and older children 
for constipation. Where an immediate effect is desired the most efficient 
is one containing glycerine — e. g., for an infant, one teaspoonful to one 
ounce of water. Oil enemata are useful where the faecal mass is hard and 
dry and expelled with difficulty. Enemata should always be given with 
care, and preferably a rubber catheter should be attached to the nozzle 
of the syringe. 

Xutrient enemata have a limited application in infancy. The rectum 
soon becomes intolerant, and rarely can more than three or four injec- 
tions be given before they cease to be retained. The quantity injected 
should be small, rarely more than one or two ounces, and the interval 
between injections should be at least four hours. In older children they 
may be used as in adults. For this purpose either completely peptonized 
milk or some of the forms of beef peptones, like Mosquera's beef jelly, 
may be employed. In giving stimulants in enemata care should always 
be taken that they be well diluted. 

The administration of drugs per rectum is useful in certain cases 
where, on account of the unpleasant taste or vomiting, the administration 
by mouth is difficult — e. g., quinine and chloral. As a diluent, gruel is 
preferable to water. If quinine is used, the bisulphate is the best prepara- 
tion, but this must be well diluted. The temperature of enemata which 
are to be retained should be about 100° F. It is necessary in infancy to 
press the buttocks together for half an hour afterwards to prevent the 
expulsion of the injection. 

Hypodermic Medication. — This is not often used in childhood, but it 
must not be forgotten that it is at times of the greatest service even in 
infancy. The use of morphine hypodermic-ally in convulsions, of mor- 
phine and atropine in cholera infantum, of strychnine in heart failure, 
as in pneumonia, may be cited as examples. 



68 PECULIARITIES OF DISEASE IN CHILDREN. 

Massage. — In older children massage is useful for the same conditions 
as those for which it is employed in adults; the most important are 
anaemia, general malnutrition, chorea, and chronic constipation. It is 
necessary that in the beginning only the mildest movements of massage 
should be employed, and these but for a short time. 

In infancy massage has a limited application, and it is doubtful 
whether it really does more than can be accomplished by the general 
friction of the body. This rubbing, either with the bare hand or with 
cocoa butter, or with some form of fat, is useful in malnutrition, in 
rickets, and in wasting diseases where the circulation is feeble and the 
muscular tone low. Cocoa butter is cleanly and has a pleasant odour, and 
is, I think, quite as valuable as the more commonly employed cod-liver 
oil, which is exceedingly disagreeable. The inunctions should be given 
daily after the morning bath, before an open fire. The rubbing should 
be continued for fifteen to twenty minutes. 

Anaesthetics. — As a general anaesthetic for routine use, ether is to be 
recommended for children. Its disadvantages can largely be overcome 
by proper administration; in point of safety it is immeasurably superior 
to chloroform for the very young. The administration of ether to young 
children may be advantageously preceded by a few whiffs of nitrous 
oxide or ethyl chloride; both, however, are to be used with caution in 
infants. Ether should be given slowly, well diluted with air, and if used 
in this way its unpleasant features may be obviated. This can best be 
accomplished by the use of some special form of inhaler. Ether should 
not be selected as the anaesthetic for patients suffering from nephritis, 
bronchitis, pneumonia, pleurisy, or any other disease attended by ob- 
structed respiration. For all these conditions chloroform is much safer. 

The dangers from chloroform are greatest when it is given too rapidly 
or in too concentrated a form. Both are exceedingly likely to occur 
where it is administered to a struggling child. The greatest care and 
judgment should be exercised at such times, or disastrous consequences 
may follow. To produce and maintain the effect desired with the mini- 
mum amount of chloroform should always be the aim. All anaesthetics, 
but especially chloroform, are dangerous in children with the so-called 
lymphatic diathesis. For the removal of tonsils or adenoids, so often 
required in such children, chloroform should not be employed. 

Nitrous oxide, while very useful in older children, as in adults, for 
momentary operations, is not well borne by infants. It produces so early 
and so deep asphyxia that its prolonged use may be fraught with serious 
danger. 

Ethyl chloride is coming into use as a rapidly acting anaesthetic for 
momentary operations, or preliminary to the use of ether. It is power- 
ful, and acts so quickly that it must be used with great caution in young 
children. Only a small amount is required. 



PART II 



SECTION I. 
DISEASES OF THE NEWLY BORN. 

CHAPTER I. 

ASPHYXIA. 

The lungs in the full- term foetus are of a uniform dark red colour, and 
show very distinctly upon their surface the lobular divisions. They are 
firm and solid and readily sink in water. The connective tissue is very 
abundant, and forms distinct fibrous septa, which stretch through the 
lungs in every direction. 

Inflation of the lungs begins with the first cry uttered by the infant 
as it is born into the world. The parts first expanded are the anterior 
borders of the lungs, then the upper lobes, and finally the lower lobes 
posteriorly. The superficial lobules are nearly always expanded before 
those in the interior of the lung. The inflation is sometimes irregular, 
because of the accumulation of mucus in some of the bronchial tubes. 
The right lung is frequently stated to be expanded earlier than the left. 
Although this is often the case, there is no uniformity in this respect. 
The important point to be remembered is, that the parts last inflated are 
the posterior portions of the lower lobes. The expansion of the lungs is a 
gradual process, and in healthy infants it is probably not complete much 
before the end of the second day. In delicate children it may be post- 
poned for several days, or even weeks. The above statements are based 
upon post-mortem observations upon infants dying from various causes 
during the first weeks. It has often been a matter of great surprise to 
find at autopsy on an infant two or three days old, that less than one half 
of the lung tissue was expanded, although the child had breathed well 
and shown.no signs of atelectasis. Under normal conditions at full term 
inflation of the lung takes place very readily, but not so readily in pre- 
mature or delicate infants, on account of the feebleness of the respiratory 
muscles. The longer it is postponed after birth the more difficult does it 
become, on account of the changes which occur in the collapsed air vesi- 



YO DISEASES OF THE NEWLY BORN. 

cles. The condition of the child in utero may be described as -one of 
foetal apncea, its oxygen being received and its carbon dioxide discharged 
through the placenta, which is essentially the organ of respiration at this 
period. This condition is interrupted by cutting off the supply of oxygen 
and the accumulation of carbon dioxide in the blood. Which of these is 
the important factor in inducing pulmonary respiration has been much 
debated ; but the best experimental evidence seems to show that it is the 
want of oxygen which stimulates the respiratory centres. 

Under the term " asphyxia " may be included all cases in which pri- 
mary respiration is not spontaneously established with sufficient force to 
maintain life. Usually there is no attempt at pulmonary respiration until 
after the birth of the child, but it may occur in utero or at any stage of 
parturition. Asphyxia may be of intra-uterine or extra-uterine origin. 

Etiology. — 1. Intra-uterine asphyxia. The maternal causes include 
any disturbance of the placental circulation during labour — anything 
which prolongs the second stage of labour, convulsions, haemorrhage, the 
use of ergot in the second stage, or, finally, the death of the mother. The 
causes relating to the child are pressure upon the cord, multiple winding 
of the cord about the neck, early separation of the placenta, and pressure 
upon the brain. If the respiratory stimulus comes before the birth of 
the child, the effort at respiration may cause the entrance into the mouth 
and air passages of amniotic fluid, mucus, blood, meconium, etc. 

2. Extra-uterine asphyxia. This condition is a much less common 
one. It arises from causes quite apart from those above mentioned, and 
depends upon malformations or intra-uterine disease of the organs of 
respiration, circulation, or of the brain. It may be secondary to an injury 
of any of these organs received during parturition. It is also seen in pre- 
mature infants, where it depends upon the feeble development of the nerve 
centres and respiratory muscles and upon the soft, yielding chest walls. 

Lesions. — In infants dying of intra-uterine asphyxia there are seen 
the usual changes found in death from suffocation, together with the effects 
of attempts at breathing in utero. There is general congestion of all the 
viscera, particularly of the brain and its meninges, the liver, and the lungs. 
They may show small, punctate haemorrhages, and occasionally large ex- 
travasations. Blood or bloody serum may be found in any of the serous 
cavities. The right heart is overdistended with dark, soft clots, and the 
blood generally is more fluid than normal. The lungs may contain no 
air, but more frequently there are small, scattered areas in which lobular 
inflation has taken place. If the child has lived several hours there are 
larger areas of expanded lung, especially in the upper lobes,' and these 
may even be emphysematous, if artificial inflation has been employed. 
In the mouth, nose, larnyx, and even as far as the finest bronchi, there 
may be found aspirated materials — amniotic fluid, blood, mucus, or me- 
conium. In extra-uterine asphyxia there are organic changes in the vis- 



ASPHYXIA. 7! 

cera — malformations of the lungs or the heart, intra-uterine pneumonia 
or pleuritic effusion, malformation of the diaphragm and sometimes of 
the brain. 

Symptoms. — Under normal conditions the newly-born infant begins at 
once to scream and to use its limbs, the purplish colour of the skin giving 
place in a few moments to a rosy pink. In the first degree of asphyxia — 
asphyxia livida — the child is deeply cyanosed. Either no attempt what- 
ever is made at respiration, or it is superficial and repeated only at long 
intervals. The pulse is slow, full, and strong. The vessels of the cord 
are distended. Muscular tone is preserved, and also cutaneous irritability, 
so that with the application of almost any kind of external stimulus, respi- 
ration is excited and the symptoms disappear. 

In the second degree — asphyxia pallida — the picture is quite a different 
one. The face is pale and death-like, though the lips may still be blue. 
The heart's action is weak, and by palpation can rarely be felt at all. By 
auscultation the sounds are feeble, irregular, and usually slow. The cord 
is soft, pale, and flaccid, and its vessels nearly empty. The sphincters are 
relaxed, and meconium oozes from the anus. There is entire loss of tone 
in the voluntary muscles, so that the extremities and entire body seem 
perfectly limp. Cutaneous sensibility is abolished. The extremities are 
often cold. There may occur a few short, convulsive contractions of the 
respiratory muscles, but these are without effect and soon cease. Unless 
such cases receive the most prompt and efficient treatment, the heart's 
action becomes more and more feeble until it ceases and death occurs. 
Other cases are partly resuscitated and may survive for a few hours or 
days, when they gradually sink, respiration becoming more and more 
feeble in spite of all efforts to maintain it. Between these two extremes 
all degrees of severity are seen. 

In extra-uterine asphyxia there may be some attempts at voluntary 
respiration continuing for several hours, sometimes for a day or two, but 
this may be inadequate to sustain life. 

Diagnosis. — Almost the only condition with which asphyxia is likely 
to be confounded is cerebral compression from a meningeal haemorrhage. 
The difficulties in the case are much increased by the fact that the two 
conditions are not infrequently associated. It may then be impossible to 
tell that in addition to asphyxia, intracranial haemorrhage is present. If the 
haemorrhage is extensive and the asphyxia only moderate, a diagnosis is 
possible in most of the cases. In haemorrhage there is often a history of 
undue compression during delivery — sometimes the use of forceps. The 
fontanel is bulging ; there is coma, and there may be paralysis. The re- 
spiratory murmur may be quite strong for several hours, but it gradually 
fails as the child becomes completely comatose. Anaemia resulting from 
a large haemorrhage, like that due to rupture of the cord, may simulate the 
severe form of asphyxia. 



72 DISEASES OF THE NEWLY BORN. 

Prognosis. — This depends upon the grade of asphyxia and the treat- 
ment employed. There is but little tendency to spontaneous recovery in 
any form. In the milder cases recovery is almost invariable with any 
intelligent treatment. In the severest cases the outcome is always doubt- 
ful, although by persistent effort many that are apparently hopeless may be 
saved. In a prognosis as to the ultimate result, the frequent complica- 
tion of asphyxia with meningeal haemorrhage should always be kept in 
mind. Apart from this complication it is doubtful whether asphyxia has 
anything to do with the production of idiocy. 

Treatment. — In every case the first step is to clear the mouth and 
pharynx of mucus by means of the finger covered with absorbent cotton. 
In the milder forms respiration is usually excited either by spanking the 
child or the alternate use of hot and cold baths. If the hot bath is em- 
ployed, the water should be from 105° to 110° F. and always tested by a 
thermometer. After a few moments the child may be dipped into ice- 
water, or the body may be douched with it. In the livid cases relief is 
often afforded by allowing the cord to bleed for a few moments before liga- 
tion. The loss of half an ounce of blood is ordinarily sufficient. Simply 
swinging the child in the air is a powerful stimulus to respiration. The 
above means will suffice in the great majority of cases. In the more severe 
forms, however, these are inadequate. There is no response whatever to 
external stimulation, either by heat or mechanical irritatiou. In these 
cases two methods of resuscitation may be employed : artificial respiration 
and direct inflation of the lungs. 

One of the most widely employed methods of inducing artificial respi- 
ration is that of Schultze. The infant is grasped by both axillae in such 
a way that the thumbs of the physician rest upon the anterior surface of 
the chest, the index fingers in the axillae, and the remaining fingers extend- 
ing across the back. The child is thus suspended at arm's length between 
the knees of the physician, the feet downward and the face anterior. The 
body is now swung forward and upward, until the physician's arms are 
nearly horizontal. This produces the inspiratory effort. When this point 
is reached, an arrest in the swinging causes flexion of the trunk, the head 
now being directed downward, the lower extremities fall toward the phy- 
sician until the whole weight of the body rests upon the thumbs. In this 
way expiration is produced. Lusk cautions against the employment of 
this method if the heart's action is very feeble, as it may cause the heart 
to stop altogether. 

A method introduced by Dew has been extensively employed in New 
York. The infant is grasped in such a way that the neck rests between 
the thumb and forefinger of the left hand, the head being allowed to fall 
far backward, the upper portion of the back resting upon the palm of the 
hand ; with the right hand the knees are grasped between the thumb 
and fingers, the thighs resting against the palm of the hand. Inspiration 



ASPHYXIA. 73 

is produced by depressing the pelvis and lower extremities thus causing 
the abdominal organs to drag upon the diaphragm, and at the same time 
gently bending the dorsal region of the spine backward. In expiration 
the movement is reversed, the head being brought forward and flexed 
upon the thorax, while at the same time the thighs are flexed so as to 
bring them against the abdomen. The body is thus alternately folded 
upon itself and unfolded as the movements are carried on. If there is 
much mucus in the mouth, the movement of expiration should first be 
made with the body completely inverted. This method is simple, efficient, 
and much less fatiguing than that of Schultze when it is to be main- 
tained for a long time. It is also of great advantage in that it can be 
carried on while the child is in the hot bath, one of the greatest objec- 
tions to the method of Schultze being the loss of animal heat incident to 
its use. 

In all cases where artificial respiration is used the first movement 
should be that of expiration, to expel, so far as possible, foreign substances 
from the air passages. The movements should be made from eight to 
twelve times a minute, and not too forcibly, the child being kept in the 
hot bath between the movements, and as much as possible during them. 
As long as the heart beats resuscitation is possible, and the case should 
not be abandoned. 

Inflation of the lungs is not usually of so much general value, although 
it is sometimes successful when all other means have failed. It may be 
done by the mouth-to-mouth method, or by the introduction of a catheter 




Fig. 19. — Ribemont's laryngeal tube for inflating the lungs. 

into the larnyx. The former is much easier, but is much less certain, 
since the air is liable to pass into the stomach. If, however, the head be 
carried pretty well backward, compression made over the epigastrium, and 
the nose closed, this is less likely to occur. The introduction of a flexible 
catheter into the larynx is by no means an easy matter even with consid- 
erable practice. The use of a stiff catheter is not so difficult, but it is capa- 
ble of doing harm. A much better instrument is the laryngeal tube of 
Eibemont (Fig. 19). This is inserted like an intubation tube. By means 
of the rubber bag attached, air may be forced into the lung, or mucus 
aspirated from the trachea and bronchi as may be desired. In all these 
methods, but especially when the catheter is used, care is necessary not to 
employ too much force. It should always be remembered that the ca- 



74 DISEASES OF THE NEWLY BORN. 

pacity of the lungs of the child is much less than that of those of the 
physician. Like artificial respiration, inflation is to be used in connec- 
tion with the external application of heat, preferably the continuous hot 
bath. 

The method introduced by Laborde, of making rhythmical traction 
upon the tongue ten or twelve times a minute as a means of exciting res- 
piration, is one of the most efficient within our reach. It may be resorted 
to in conjunction with other methods, or used alternately with them. 

In cases of asphyxia it is not enough to make the child cry. The 
deep respirations must be made to continue, for very often it happens 
that resuscitation is only partial, and that the child after six or eight 
hours lapses into its previous condition. All severe cases require careful 
watching for the first twenty-four or thirty-six hours, as a repetition of 
the treatment is often required. 



CHAPTER II. 
CONGENITAL ATELECTASIS. 

This condition is one in which there is a persistence of the foetal state 
in the whole or in any part of the lung. 

Atelectasis -is the pathological condition with which asphyxia of the 
newly born is usually associated. In most of the cases the condition of 
atelectasis is completely overcome by the means employed in resuscitation ; 
in some, however, these means are only partially successful, so that a por- 
tion of lung of variable extent remains in the foetal condition. These are 
the circumstances in which most of the cases of atelectasis arise. But 
there are others in which there is no history of early asphyxia, where the 
primary respirations, although taking place spontaneously, have not been 
of sufficient force and depth to produce full pulmonary expansion. This 
usually occurs in feeble infants, or in those who are premature. The 
causes of congenital atelectasis are therefore, in the main, those mentioned 
as producing asphyxia. 

Lesions. — In cases where the child dies during the first few days the 
amount of expanded lung is often very small, frequently not more than 
one fourth of the pulmonary area. The expanded portion is usually the 
anterior borders of the upper lobes. This is often the seat of acute em- 
physema. The rest of the lung is still in the foetal state ; it is of a 
brownish-red colour, very vascular, does not crepitate, and shows the lobu- 
lar outlines both on the surface and on section. With a little force the 
atelectatic lung may be completely inflated. 

If children have lived several months, nearly the whole of the upper 



CONGENITAL ATELECTASIS. 75 

lobes and the anterior portion of the lower lobes are usually well inflated. 
These portions are either normal or slightly emphysematous. The pos- 
terior portion of the upper lobes and the lower lobes are almost invariably 
the seat of the atelectasis. On the surface even these portions may pre- 
sent quite a large area of expanded vesicles, but the lobe is solid to the 
touch, and crepitates but slightly. On section it is seen that only the 
most superficial part of the lung is inflated, often only to the depth of 
a line, while the interior of the lobe is unexpanded. Small haemorrhages 
are frequently seen beneath the pleura. 

It is usual for both lungs to be affected, and often, but by no means 
uniformly, to about the same degree. It is frequently a great surprise to 
discover that a child has lived two or three months without presenting 
any signs of cyanosis, using not more than one third of its pulmonary area. 
This variety of atelectasis closely resembles the hypostatic pneumonia of 
delicate infants, and very often the two conditions are associated. It may 
require the microscope to decide between them. If congenital atelectasis 
has existed for some months, there are usually found evidences of pneu- 
monia. Inflation is not so easy as in recent cases, but with force the 
greater part of the lung can usually be expanded. The heart commonly 
shows the right auricle and ventricle to be distended with dark clots, and 
there is occasionally found a patent foramen ovale or some other form of 
congenital lesion. The liver and spleen are in most cases congested, and 
the spleen may be considerably enlarged. The mucous membrane of the 
stomach and intestines is sometimes deeply congested. 

Symptoms. — In one group of cases the children are asphyxiated at 
birth, but the attempts at resuscitation have been only partially successful. 
Although the patients may live for a few days, there is cyanosis, which 
gradually deepens, and death takes place from asphyxia, exhaustion, or 
convulsions. 

In a second group of cases the infants have been asphyxiated at birth, 
and resuscitated perhaps with difficulty, but to all appearance completely. 
They do not thrive, however, remaining small and delicate, gaining very 
little or not at all in weight, and showing poor circulation, cold extremi- 
ties, and occasionally subnormal temperature. It is characteristic of these 
cases that the cry is never loud, strong, and lusty. Some of them will not 
cry at all. Such children may live several weeks, or even months. There 
may develop at any time, often quite suddenly and without assignable cause, 
attacks of cyanosis with prostration. Children may have several such at- 
tacks, which do not excite suspicion since they pass away spontaneously. 
In other cases the symptoms are so severe that they may result fatally in a 
few hours, death being frequently preceded by convulsions. If energetically 
treated the symptoms may pass away but, reappearing in a few hours, or 
again after a week or more, they gradually deepen in intensity until death 
occurs. 



76 DISEASES OF THE NEWLY BORN. 

Two cases coming under my observation in the New York Infant 
Asylum in 1890, illustrate this point. The infants were twins, ten weeks 
old and delicate. Suddenly at night one child was taken with convul- 
sions, became deeply cyanosed, and died in two and a half hours. It had 
been suffering from a slight attack of indigestion and diarrhoea for a week 
previous, but apparently was not seriously ill. The other twin had been 
on the previous day as well as for several weeks. Two hours after the 
death of the first child the second was taken with similar symptoms, dying 
in a few hours. At autopsy I found very extensive atelectasis involving 
the posterior part of the upper and the greater part of both lower lobes. 
The lesions were almost identical in the two cases. In both, the stomach 
was greatly distended with food and gas. I have repeatedly seen the 
effect of overdistentiou of the stomach in producing cyanosis in young 
children, and in this instance I believe it to have been the exciting cause 
of the final symptoms. It was subsequently learned that during the six 
weeks of observation the nurse had witnessed several slight attacks of cy- 
anosis in one of the infants. 

I have seen a number of such cases, in which there was nothing what- 
ever to attract attention to the lungs until the final attack of cyanosis 
occurred, the children showing only the signs of malnutrition. In not all 
of these cases is there a history of asphyxia at birth. Some are only puny, 
delicate or premature, exhibiting during the early weeks of life all the 
signs of feeble vitality. The subsequent course is the same as in those in 
which there is early asphyxia. The duration of life in these cases depends 
chiefly upon the extent of the atelectasis. 

It is not to be supposed that all cases of congenital atelectasis ter- 
minate fatally. Infants in whom there is every reason to believe that 
atelectasis exists, from the occasional attacks during the first few weeks of 
cyanosis, feeble cry, poor circulation, etc., may under favourable conditions 
recover completely, even though no special treatment is directed to the 
Jungs. 

Diagnosis. — For this the physical signs are of much less value than the 
symptoms. It should be remembered that the principal seat of the disease 
is the lower lobes posteriorly. Percussion usually gives resonance over the 
entire chest, although this may be somewhat diminished posteriorly. There 
is not, however, so much change as one would expect to find, for the col- 
lapsed areas are surrounded by others which are overdistended, and there 
are in the midst of the collapsed parts, especially upon the surface, lobules 
which are inflated. If the two sides are involved to about the same degree, 
as is often the case, we can get no difference in the percussion note over 
the two lungs, and the change from the normal may be so slight as not to 
be appreciable. Where only one lung is affected a difference can usually 
be made out. The respiratory murmur is rarely bronchial, but generally 
only feeble in its intensity, and rather ruder in quality than normal. As 



ICTERUS. 77 

in the case of percussion, if only one lung is affected this is of some value 
in diagnosis, but it is not sufficiently marked to be readily recognized 
when both sides are involved. Occasionally rales are present. 

Treatment. — In the newly-born child, whether asphyxiated or not, the 
physician should see to it that the infant not only cries, but does so 
loudly and strongly, and that this cry is repeated every day. If children 
do not cry naturally they must be made to do so by the alternate use of 
the hot and cold bath, as in cases of asphyxia, or by mechanical means, 
like spanking. This should be repeated at least twice a day, and con- 
tinued for from fifteen to thirty minutes. It may seem cruel, but it is 
often the only means of saving life. Expansion of the lungs is much 
more easily induced during the first few days of life, becoming more and 
more difficult the longer it is delayed. Provided the condition is recog- 
nized, treatment is fairly successful. In institutions where delicate infants 
spend most of the time in their cribs, atelectasis is likely to be found. 
An infant needs exercise, and this is often only to be obtained by taking 
the child from its crib several times a day, by general friction, massage, 
the stimulus of fresh air, etc. Nothing is more certain to perpetuate 
atelectasis than to allow the infant a life of feeble vegetative existence. 
Food and feeding must be carefully attended to, but even these are of less 
importance than the maintenance of the animal heat. The temperature 
is often subnormal, and should be closely watched. If there is difficulty 
in keeping the child warm it should be rolled in cotton and surrounded 
by hot bottles, or kept in an incubator during the first few weeks. (See 
page 10.) During attacks of cyanosis the same means are to be employed 
as in cases of asphyxia of the newly born — cutaneous stimulation and arti- 
ficial respiration — the administration of drugs being of little or no value. 



CHAPTER III. 
ICTERUS. 

Several varieties of icterus are met with in the newly born. 

1. It is often seen in the various forms of pyogenic infection. In 
such cases the icterus is usually mild. 

2. It may depend upon syphilitic hepatitis — a rare cause. 

3. It may be due to congenital malformations of the bile-ducts. 

4. The most frequent of all varieties is the so-called idiopathic icterus, 
sometimes spoken of as " physiological " icterus. 

In the cases included under the first and second heads icterus is a 
minor symptom. The other varieties are sufficiently important to require 
separate consideration. 
7 



78 DISEASES OF THE NEWLY BORN. 



MALFORMATIONS OF THE BILE-DUCTS. 

The common bile-duct is the most frequently affected. There may 
be atresia at the point where it opens into the intestine, the duct may 
be represented by a fibrous cord, or it may be absent altogether. In 
many cases this is the only lesion; in others it is associated with an im- 
pervious hepatic or cystic duct; in still others the common duct is nor- 
mal, but the cystic or hepatic ducts are impervious. 

At autopsy all the organs are usually found intensely jaundiced, par- 
ticularly the liver. In recent cases this is very much swollen, but pre- 
sents no marked organic changes. In cases which have lasted several 
months there is commonly found chronic intestinal hepatitis, sometimes 
to a very marked degree. This was present in nine of the fifty cases col- 
lected by Thomson.* The gall-bladder is usually small, and often rudi- 
mentary. In cases of atresia of the common duct it may be greatly dis- 
tended. 

The condition of the bile-ducts is ascribed to an error in development 
and subsequent catarrhal inflammation. There does not seem to be suf- 
ficient evidence to prove that hereditary syphilis is an etiological factor 
of much importance. This was present in but five of Thomson's 
cases. 

Symptoms. — The most striking symptom is jaundice, which is usually 
noticed a day or two after birth, and steadily increases until it becomes 
intense. The urine is colored a dark brown or bronze by bile pigment, 
and even the meconium stools may be white, except in cases where mal- 
formation is limited to the cystic duct. The liver as a rule is much en- 
larged. The spleen is often swollen. Haemorrhages beneath the skin or 
from any of the mucous membranes are quite common. Vomiting is 
usually absent. In most cases there is progressive wasting, and death 
within the first few weeks. Of Thomson's fifty cases, nine lived less 
than a month, and only eighteen over four months. Lotze has reported 
a case of a child living eight months with an impervious hepatic duct. 
A frequent cause of death in the rapid cases is. convulsions. 

These malformations cannot be influenced by any treatment. 

PHYSIOLOGICAL OR IDIOPATHIC ICTERUS. 

In 900 consecutive births at the Sloane Maternity Hospital icterus 
was noted in 300 cases. In 88 it was intense, in 212 it was mild. Ac- 
cording to the statistics of various lying-in hospitals of Germany, it was 
found in from 40 to 80 per cent, of all infants. In the 300 cases just 
referred to, icterus was noticed on the first day in 4, on the second day in 
19, on the third day in 72, on the fourth day in 86, on the fifth day in 67, 

* Edinburgh Medical Journal, 1892. 



ICTERUS. 79 

and on or after the sixth day in 44. From the second to the fifth day is 
therefore the usual period for its appearance. 

It usually increases in severity for one or two days and then slowly 
disappears. The average duration in the mild cases is three or four days ; 
in those of moderate severity about a week ; in the most severe cases it 
may last for two weeks. The icterus is first noticed in the skin of the 
face and chest, then in the conjunctivae, then in the extremities. The 
skin varies in colour from a pale to an intense yellow. The urine in most 
cases is normal. It sometimes is of a light brown colour, and only in the 
most severe cases does it contain bile pigment. According to Eunge, both 
urea and uric acid are produced in larger amounts than in children not 
icteric. The stools are unchanged, the normal yellow evacuations occur- 
ring in the icteric as early as in those not affected. 

According to some observers, in infants who are icteric the initial loss 
in weight is greater and the subsequent gain slower than in other children. 
This is not borne out by the Sloane statistics. Of the 300 icteric children, 
155 made satisfactory progress in every respect and gained rapidly. The 
progress in 106 cases was said to be "fair" — i. e., at the time of dis- 
charge, usually on the tenth day, a slight gain in weight was noted. 
The remaining 39 did badly, not gaining in weight and showing other 
symptoms of malnutrition. The proportion of icteric infants who did 
well, moderately, and badly, was practically the same as of the other 
children in the institution not suffering from icterus. Icterus occurs with 
equal frequency in both sexes. According to Kehrer, it is more frequent 
in first children than in later ones, and considerably more frequent in 
premature children than in those born at term. The presentation, the 
duration of labour and its character — whether natural or artificial — have 
no influence upon the production of icterus. As a rule icteric children 
appear in other respects healthy, but in those below the average size the 
icterus is apt to be more intense. 

Few subjects have given rise to wider speculation than this form of 
icterus. Its exact pathology is at present unknown. Of the many theo- 
ries advanced, that of Silbermann is perhaps the most satisfactory — viz., 
that the icterus is due to resorption, and is hepatogenous in its origin. 
With this view Frerichs and Schultze agree. Silbermann explains the 
resorption by the existence of stasis in the capillary bile-ducts which are 
compressed by the dilated branches of the portal vein and the blood capil- 
laries. The change in the circulation of the liver is one of the results of 
the change in the blood which- occurs soon after birth. This results from 
an extensive destruction of the red blood cells — a kind of blood fermenta- 
tion. The more feeble the child the more intense the icterus, because 
the blood changes are more intense. In consequence of this destruction 
of red blood cells abundant material for the formation of bile pigment 
exists and accumulates in the hepatic vessels. 



80 DISEASES OF THE NEWLY BORN. 

In jaundiced infants who have died from accident or other causes the 
skin and almost all the internal organs are found icteric. There is also 
staining of the internal coat of the arteries, the" endocardium, the peri- 
cardium, and the pericardial fluid. Sometimes the subcutaneous connect- 
ive tissue is yellow, also the brain and cord ; the spleen and kidneys only 
in the most severe cases. In the kidneys uric-acid infarctions are often 
found, and sometimes bile pigment. The liver is rarely discoloured. The 
bile-ducts are normal. In certain cases Birch-Hirschfeld has discovered 
bile pigment in the liver cells. 

This jaundice is never fatal, and is not serious. Other conditions, 
such as atelectasis, may coexist, which may make the case grave. The chief 
point in diagnosis is not to confound physiological icterus with that de- 
pending upon other more serious conditions, such as sepsis or congenital 
malformation of the bile-ducts. In sepsis other symptoms are present, 
usually an abnormal condition of the umbilicus, and the symptoms ap- 
pear at a later date. In malformation of the bile-ducts the jaundice 
is very intense, and is frequently accompanied by marked hepatic en- 
largement. 

Physiological icterus requires no treatment. 



THE ACUTE PYOGENIC DISEASES. 81 

CHAPTER IV. 
THE ACUTE INFECTIONS OF TEE NEWLY BORN. 

It is possible for the newly-born infant to suffer from almost all of the 
common infectious diseases. Smallpox probably has been most frequently 
observed. In rare instances measles, influenza, typhoid fever, malaria, 
and pneumonia have occurred in the first days of life. As the mothers 
in many instances were suffering from the diseases during or just prior to 
delivery, the infants appear to have been infected before birth through the 
circulation of the mother. In other cases, especially in pneumonia, in- 
fluenza, and gastro-enteritis, infection may take place soon after birth. 
The symptoms of these diseases in the newly born differ very little from 
those occurring in any other young infant. In addition to the diseases 
mentioned, there are other forms of infection which belong especially — 
some of them exclusively — to the newly born. 

THE ACUTE PYOGENIC DISEASES. 

Under this head are grouped various infections of the newly born, due 
to the entrance of the common pyogenic bacteria. They have been desig- 
nated as puerperal fever of the child, also as pycemia or septicemia, or 
simply as sepsis of the newly horn. A variety of pathological and clinical 
conditions are met with. In some cases there is only a localized external 
inflammation, often terminating in abscess formation; sometimes one or 
more of the internal organs is affected; occasionally a general blood in- 
fection — a true septicaemia — is seen without any noteworthy local lesion; 
finally, there are the cases attended by the production of multiple ab- 
scesses in the viscera, joints, or cellular tissue — a true pyaemia. For- 
merly infections of this class were very common, especially in large lying- 
in hospitals ; but, owing to the general adoption of the methods of aseptic 
midwifery, they have steadily diminished. 

Etiology. — The source of infection of the child may be the vaginal se- 
cretion of the mother or, in rare cases, the mother's milk. Although it has 
been shown that in a great proportion of the cases the milk of a woman 
suffering from mastitis or from septicaemia contains pyogenic germs, still 
the taking of these into the stomach is not likely to infect the infant. 
More frequently the child is infected by the nurse in the process of d r 
ing the cord, bathing, or cleansing the mouth or eyes, possibly after hav- 
ing attended to the needs of a septic mother or another child. In feci i<>n 
may be carried by the physician, by instruments, or by the dressing 1 1 i 
the cord. Infection through the atmospheric air, while possible, is not 
a frequent cause. 

Infection through the umbilicus may occur either before or after the 



32 DISEASES OF THE NEWLY BORN. 

separation of the cord. The poison may enter through the umbilicus, 
although this may give no external evidence of disease. This was true 
in a case studied by Van Gieson, in which the infant died of meningitis 
when eight days old. The cord had healed properly, and at the autopsy 
the navel appeared normal. But the umbilical vessels inside the body 
contained pus. From this the meningitis evidently arose, as the same 
bacteria were found by culture both there and in the brain. Entering 
through the mouth, bacteria may lead to infectious processes in the 
throat, they may involve the stomach and intestines, rapidly producing 
death; or the alimentary tract may be the focus from which infection 
of distant parts may arise. 

The micro-organisms chiefly concerned in these infections are -the 
common pyogenic bacteria, staphylococcus pyogenes aureus and the strep- 
tococcus. The next in importance is the gonococcus, the role of which, 
especially in cases accompanied by joint suppuration, has only recently 
been appreciated. In one case of meningitis of my own only the colon 
bacillus was found. Pneumococcus infections occasionally complicate 
the others mentioned. While streptococcus infections are in general more 
serious than those due to the staphylococcus, some of the most severe 
ones met with belong to the latter class. 

Clinical Varieties. — Omphalitis. — In this variety there is inflammation 
of the umbilicus, and cellulitis of the abdominal wall in the immediate 
neighbourhood. This results in the formation of an umbilical phlegmon. 
It may terminate in resolution, in abscess, or in gangrene. The usual 
termination is in abscess. These abscesses may be small and superficial, 
or they may be more deeply seated between the abdominal muscles and 
the peritonaeum. Omphalitis usually begins in the second or third week 
of life, before the umbilicus has cicatrized. Locally there are redness, 
swelling, and induration. The process may result in abscess, there may 
be diffuse inflammation of the abdominal walls of an erysipelatous char- 
acter with extensive sloughing, or the infection may spread to the peri- 
tonaeum. 

Inflammation of the umbilical vessels. — This is one of the most fre- 
quent primary processes in pyasmic infection. The umbilical arteries are 
more frequently involved than the vein. According to Runge, inflamma- 
tion of the vessels is always preceded by inflammation of the connective 
tissue which surrounds them, as the poison is taken up by the lymphat- 
ics and not by the blood-vessels. Omphalitis is frequently present, but in 
some cases the umbilicus shows nothing abnormal. 

In arteritis the vessels may be involved to any degree : sometimes 
only a short distance from the abdominal wall, sometimes quite to the 
bladder. They contain pus, and often septic thrombi. Saccular dilata- 
tion is frequently present at several points. Pus sometimes exudes from 
the umbilical stump on pressure. The other lesions accompanying arteritis 



THE ACUTE PYOGENIC DISEASES. 83 

are those of pyaemic infection, more or less widely distributed. There are 
frequently peritonitis, suppuration of the joints, erysipelas, multiple ab- 
scesses of the cellular tissue, sometimes suppurative parotitis. Atelectasis 
is common. Pneumonia was found in twenty-two of Eunge's fifty-five 
cases. 

In cases of phlebitis, the umbilical vein is usually involved for its entire 
length from the abdominal wall to the liver. This may lead to an acute 
interstitial hepatitis going on to suppuration, or to phlebitis of the portal 
vein and some of its branches. In either case there is more or less paren- 
chymatous hepatitis, and often multiple abscesses of the liver, most of the 
patients being jaundiced. Peritonitis also is a frequent complication. 

Peritonitis. — This is one of the most frequent pathological processes 
in pyaemic infection, and is very often the cause of death. It is generally 
associated with umbilical arteritis, and often with erysipelas. In a con- 
siderable number of cases it is the most important lesion found. It may 
be localized or general. Localized peritonitis is generally in the neigh- 
bourhood of the umbilicus or of the liver. It may result in adhesions, or 
in the formation of peritoneal abscesses. More frequently the peritonitis 
is general, and resembles the septic peritonitis of adults. There is a great 
outpouring of lymph coating the intestines and other viscera and the 
inner surface of the abdominal wall, causing adhesions between the ab- 
dominal contents. Collections of sero-pus are found in the pelvis and in 
various pockets formed by the adhesions. Sometimes blood is present in 
the exudation. 

The special symptoms which indicate peritonitis are vomiting, abdomi- 
nal tenderness and distention, and protrusion of the umbilicus. The ab- 
dominal enlargement is chiefly from gas, but may be partly from fluid. 
There are present thoracic respiration, dorsal decubitus, and flexion of 
the thighs as in all varieties of acute peritonitis. The temperature is 
usually hut not necessarily high. 

Pneumonia. — The most common form seen is pleuro-pneumonia. 
There is an abundant exudate of grayish-yellow lymph covering the 
lung. Occasionally collections of pus are found in the sacs formed by 
the adhesions. Serous effusions are rare. The pulmonary lesion con- 
sists usually in a broncho-pneumonia, with consolidation of larger or 
smaller areas in the lungs — more often in the upper than in the lower 
lobes. It is not uncommon for minute abscesses to be found in the lung 
at various points. There is a purulent bronchitis of the larger and 
smaller tubes. 

The symptoms are obscure and often indefinite. The only character- 
istic ones are cyanosis and rapid respiration, with recession of the chest 
walls on inspiration. The physical signs are inconstant and uncertain. 
Pneumonia cannot usually be diagnosticated during life. In most of the 
fatal cases of pyogenic infection, whatever its type, there is found some 



84 DISEASES OF THE NEWLY BORN. 

involvement of the lungs. The changes are most extensive in cases in 
which the serous membranes are involved. 

Pericarditis is rare and usually associated with pleurisy. Endocar- 
ditis is very rare. Hirst has, however, reported a case. 

Meningitis. — The pia mater is the least liable to be affected of all the 
serous membranes, with the possible exception of the pericardium. When 
meningitis is present it is usually associated with peritonitis or with 
pleurisy. The lesions are those of acute purulent meningitis with a 
copious exudation, sometimes associated with meningeal haemorrhages, 
or with acute encephalitis and the production of multiple minute ab- 
scesses in the cortex. The local symptoms are often not marked, and 
are sometimes very obscure. The most characteristic are stupor, dilated 
pupils, opisthotonus, bulging fontanel, general rigidity, convulsions, and 
occasionally localized paralyses. The temperature is generally high. 

Gastro-enteritis. — Diarrhoea is a frequent symptom in all septic cases, 
constipation being rarely present. In many instances vomiting is a 
prominent symptom. In a small proportion o,f cases the most important 
local lesions are in the intestines, generally in the nature of a superficial 
catarrhal inflammation. 

Pseudo-membranous inflammations of the throat. — These are rarely 
seen in the newly born. J. Lewis Smith has made a report on a group of 
five cases occurring as a small epidemic in the New York Infant Asylum. 
They were associated with other lesions, and all were fatal. In several 
cases there was omphalitis. One of these was studied bacteriologically by 
Prudden, who found no Loemer's bacilli, but streptococci both in the exu- 
dation in the throat and in the umbilical abscess. Such inflammations are 
to be regarded as one manifestation of a general streptococcus infection. 

Osteomyelitis. — Allard has reported a series of cases in which, after 
the general and local symptoms of pyogenic infection had existed for 
some time, suppuration occurred over various bones, especially the hu- 
merus, tibia, metatarsal bones, sacrum, etc. Trephining revealed the 
lesions of osteomyelitis. The abscesses usually made their appearance 
between the fourth and the sixth week. The most rapid case died on the 
fourteenth day, and none lasted more than two and a half months. 

Joint suppuration. — In certain pysemic cases, and in some in which 
there are no other symptoms, acute suppuration in the joints occurs. 
This may come on very acutely in the first or second week, or more 
slowly as late as the second or third month. In the acute cases it is 
exceptional to have but one joint involved; often there are four or 
five. The small joints are rather oftener affected than the large 
ones, but almost any articulation in the body may be involved. 
With multiple joint suppuration there are present the general symptoms 
of pyaemia — high temperature, marked prostration, wasting, and often 
secondary visceral inflammations develop. In those which occur late, 



THE ACUTE PYOGENIC DISEASES. 85 

fewer joints are involved, often but a single one, the febrile symptoms 
are less marked, and the duration may be much longer. In my own 
experience, the organism most frequently found in these cases is the 
gonococcus; next to this in importance is the streptococcus. The joint 
lesion is usually a superficial one, the bones often escaping. The gono- 
coccus cases probably occur most frequently as a complication of ophthal- 
mia; but I have seen several in which ophthalmia was not present and 
where the point of entry could not be determined. 

Abscesses in the cellular tissue. — These are quite frequent, and may 
occur with suppuration in the joints or internal organs, or they may exist 
as the only lesion. They are nearly always multiple and may be found 
in almost any location. They vary in size from that of a small pea to 
one containing half an ounce of pus. They are due to the introduction 
of pyogenic germs, usually staphylococci. Their course is benign, and 
they require no treatment except incision and cleanliness. Where there 
is a disposition to their continued formation, the skin should be washed 
with an antiseptic solution. 

Erysipelas. — This is seen especially during the first two weeks of life, 
and usually starts from the umbilicus or some abrasion of the skin, most 
frequently about the genitals, or the scalp. When originating at the 
umbilicus it is generally complicated by other lesions, such as peritonitis 
and umbilical phlebitis. If it starts from any other part of the body it 
may be uncomplicated. Erysipelas beginning at the umbilicus gives rise 
to an area of induration and a circumscribed blush. At first it may 
resemble a simple cellulitis; but the steadily increasing area of elevated 
induration and redness soon indicates the nature of the inflammation. 
From whatever point starting, the erysipelatous inflammation, owing to 
the feeble resistance of the tissues, in most cases spreads widely. The 
entire abdomen, chest, and back may be involved, and it may even spread 
to the extremities. It may extend so that nearly the whole trunk is 
affected in four or five days. It usually involves only the skin and super- 
ficial cellular tissue; but it may involve the deeper areolar planes and 
terminate in diffuse suppuration, or even in gangrene. 

The constitutional symptoms are severe: great prostration, continu- 
ously high temperature — 102° to 105° F. — rapid wasting, and often 
vomiting, diarrhoea, or convulsions are present. The disease is always 
serious, and usually fatal. It is often complicated by broncho-pneu- 
monia. 

Distribution of the Lesions. — The frequency of the different visceral 
lesions in eighty-seven autopsies published by Bednar was as follows : 
Peritonitis in twenty-nine, pneumonia in fifteen, pleurisy in ten, menin- 
gitis in nine, meningeal hemorrhage in eight, encephalitis in eight, cere- 
bral haemorrhage in four, entero-colitis in five, pericarditis in lour. In 
thirty-one cases there was umbilical arteritis, and in nine cases umbilical 
8 



86 DISEASES OF THE NEWLY BORN. 

phlebitis. There was one case each of pulmonary haemorrhage, pleural 
haemorrhage, acute hydrocephalus, acute bronchitis, and suppuration in 
the cellular tissue. Runge's later observations of thirty-six cases showed 
umbilical arteritis in thirty, umbilical phlebitis in three, and normal um- 
bilicus in three. He found pneumonia in twenty-two of fifty-five cases. 
Other lesions frequently associated are atelectasis, swelling and softening 
of the spleen, cloudy swelling of the liver and kidneys, occasionally with 
foci of suppuration in these organs. The blood is dark, and coagulates 
imperfectly. 

General Symptoms. — These may begin at any time during the first ten 
days — very rarely after the twelfth day. Fever is an exceedingly variable 
symptom — it may be very high ; it may be almost absent ; occasionally 
there is subnormal temperature. The course of the temperature is very 
irregular. Wasting is constant and quite rapid. It depends upon the 
inability to take and digest food, upon the intestinal complications, and 
upon infection. In quite a number of cases wasting is almost the only 
symptom. Icterus is exceedingly common ; in many of the worst cases 
it is intense. It is met with where the liver is the seat of an acute paren- 
chymatous or acute suppurative inflammation, and in many other cases 
where it depends apparently upon the blood changes. Haemorrhages are 
common, and may be the direct cause of death. They may come from 
the umbilicus, the intestine, or almost any mucous membrane. They are 
sometimes subcutaneous, causing a general haemorrhagic eruption. Nerv- 
ous symptoms are generally present, and are sometimes marked. They 
are restlessness, rolling of the head, a constant whining cry, twitchings 
of the muscles of the extremities or face, stiffening of the body, more 
rarely general convulsions. Late in the disease, dulness and stupor are 
present. The pulse is rapid and weak and the respirations are often 
irregular, even when there is no cerebral complication. Diarrhoea is 
frequent ; the stools are green, brown, sometimes black from the presence 
of blood, and are often very foul. Vomiting is less common. 

In addition to these there are symptoms due to the various forms of 
local inflammation — peritonitis, meningitis, pneumonia, subcutaneous 
suppuration and gangrene, these all being found in varying degrees and 
in various combinations. 

Prophylaxis. — Pyogenic infection of the child, like puerperal fever in 
the mother, may be considered a preventable disease. Its occurrence is 
usually due to a failure to carry out proper rules regarding cleanliness and 
asepsis in connection with delivery. The statistics of the Moscow Lying- 
in Asylum, published by Miller in 1888, show that previous to the general 
introduction of antiseptic methods, from six to eight per cent of all in- 
fants born in the institution died from some variety of infection. In 
twenty-three hundred successive labours at the Sloane Maternity Hos- 
pital, covering about eight years, not a single marked case occurred. 



OPHTHALMIA. 87 

From these figures it will be evident that in the vast majority of cases 
the occurrence of a case of infection of a serious nature is the fault of 
the physician or nurse in attendance. 

The umbilicus should be cleansed and treated like any other fresh 
wound. Dry dressing should invariably be employed, and sterilized 
gauze or salicylated cotton in preference to household linen. If suppu- 
ration occurs at the time the cord separates, the parts should be cleansed 
daily with a bichloride solution, and a wet dressing of the same applied. 
The ligatures and everything which comes in contact with the umbilical 
wound should be sterilized. Careful attention should be given to the 
mouth, genitals, and all the muco-cutaneous surfaces, to prevent excoria- 
tions and intertrigo. Finally, every septic case occurring in an insti- 
tution should be immediately isolated. A nurse in charge of a septic 
mother should not have the care of the infant. 

Prognosis. — Pyogenic infections in the newly born, even in their 
mildest forms, are serious, and in their most severe forms almost always 
fatal. Very few cases recover in which erysipelas or any important 
visceral inflammation is present. The resistance of these little patients 
is so feeble that the tendency of every inflammation is to spread, until 
the child dies of exhaustion. Only patients with localized inflammations, 
such as those of joints, skin, etc., are likely to get well. 

Treatment. — This practically resolves itself into the treatment of in- 
dividual symptoms as they arise. Wherever suppuration occurs, external 
abscesses should be evacuated and treated antiseptically. For the local 
inflammations of the lungs, peritonaeum, and brain, little or nothing can 
be done in the way of direct treatment. Such inflammations are to be 
prevented, but can seldom be cured. The general indications are to look 
closely to the child's general nutrition by careful attention to all do ("ails 
of nursing and feeding, using stimulants whenever required by the con- 
dition of the pulse. For a local application in erysipelas, nothing in 
my experience has proven better than ichthyol ointment, ten to twenty- 
five per cent strength. It should be applied daily, spread upon muslin, 
which is then covered by gutta-percha tissue to prevent drying. 

OPHTHALMIA. 

Ophthalmia of the newly born is to be classed among the pyogenic 
diseases. It usually consists in a purulent conjunctivitis. In the more 
severe cases there may be ulceration of the cornea, and even perforation 
into the anterior chamber of the eye. 

The highly infectious nature of this ophthalmia is established. In 
the most severe cases the micro-organism generally found has been the 
gonococcus ; but in the milder forms the gonococcus may be absent, and 
any of the common pyogenic germs may be found. In the gonococcus 
cases the infection occurs during labour, from the secretions of the mother, 



88 DISEASES OF THE NEWLY BORN. 

from the examining fingers of the physician, or from instruments ; or 
after birth from infected cloths and other materials which come in con- 
tact with the eye. Healthy lochia produce only a catarrhal inflammation. 
The infection occurring after birth may take place at any time. That 
due to gonorrheal infection from the mother is generally manifested on 
the third day, and is often violent from the outset. 

The symptoms are swelling of the lids, chemosis, copious purulent dis- 
charge, sometimes haemorrhages from the lids, ulceration and there may 
even be sloughing of the cornea. The course of the disease depends upon 
the cause and upon the treatment employed. In the cases not due to 
the gonococcus the course is generally benign, and with ordinary cleanli- 
ness usually results in recovery without any permanent damage to the 
sight. The gonorrheal cases, unless energetically treated from the outset, 
are very frequently followed by permanent loss of vision. The best sta- 
tistics upon the causes of blindness in adults show that from twenty-six 
to thirty per cent of such cases are due to ophthalmia in the newly born. 
This disease is occasionally complicated by other symptoms of gonococcus 
infection of a pyaemic nature. Many cases followed by acute articular 
symptoms have been observed. 

Prophylaxis is of the utmost importance. Orede's statistics show that 
in 1874 the frequency of ophthalmia in his lying-in hospital was 13*6 per 
cent. In the three years ending 1883, among 1,160 newly-born children 
only one or two cases occurred. The method of prophylaxis which he 
adopted consists in dropping into the eyes of every child, immediately after 
birth, one or two drops of a two-per-cent solution of nitrate of silver. 
The general adoption of Crede's method, or of some similar means of dis- 
infection, has resulted in a very great diminution in the frequency of oph- 
thalmia throughout the world. These prophylactic means should be 
obligatory in all institutions, and should be used in all cases in private 
practice wherever there is any possible suspicion of the existence of gon- 
orrhoea. In all other cases the eyes should be carefully cleansed with a 
saturated solution of boric acid. The use before delivery of an antiseptic 
vaginal douche is theoretically indicated, but practically it has been found 
to be inadequate to the prevention of the disease. 

Treatment. — Everything which comes in contact with the eyes should 
be carefully disinfected. All cloths, cotton, etc., used for cleansing should 
be immediately burned. The strictest antiseptic precautions should be in- 
sisted on to prevent the spread of the infection by nurses. In institutions 
containing infants, severe cases of ophthalmia should always be isolated. 
The most important thing is to keep the eyes clean. In severe cases they 
must be cleansed every twenty minutes, night and day. It may be done 
by irrigation, or by using an eye-dropper with a bulbous tip, inserted 
alternately at the inner and the outer angle of the eye, and the fluid in- 
jected with force sufficient to empty thoroughly the conjunctival sac. 



TETANUS. 



89 



Either a saturated solution of boric acid, or a l-to-5,000 solution of 
bichloride, may be used in this way. Once or twice in twenty-four hours 
two or three drops of a one-per-cent solution of protargol should be used 
in each eye after cleansing with sterile water; this preparation is alto- 
gether more efficient than the commonly employed silver nitrate. Next 
to these measures is the use of cold. It may be applied as ice compresses 
which are changed every minute or two from a block of ice to the eye. 
These may be continued one-fourth of the time in the milder cases; in 
the severe ones almost constantly. When the cornea is involved the 
pupil should be dilated by atropine. If only one eye is affected the 
sound one should be protected by covering it with a compress kept wet 
with an antiseptic solution. 

TETANUS. 

Tetanus is an acute infectious disease characterized by tonic muscular 
spasm, which increases in severity by paroxysms occurring at longer or 
shorter intervals. It may be limited to the muscles of the jaw (trismus), 
or may affect all the muscles of the trunk, extremities, and neck. 

Though many writers have sought to maintain a difference between 
tetanus of the newly born and tetanus of later life, whether traumatic or 
not, their identity has been admitted for at least a dozen years. The dis- 
covery of the exact cause of tetanus is due to the work of Nicolaier, who 
in 1884 found a bacillus in the soil, with which he produced the disease in 
animals. He demonstrated the presence of this bacillus in the wounds of 
tetanus patients. Nicolaier did not, however, obtain the germ in pure 
culture ; but this was done by Kitasato in 1889. The bacillus is generally 
known as Nicolaier's bacillus. Since that time the germ has been found 
in the wounds of numerous patients with tetanus, including newly-born 
infants. 

The rapidity with which the infection spreads from the point of inoc- 
ulation is very remarkable, as shown by Kitasato's experiments. Thus, if 
one hour elapsed after infection before cauterizing the inoculated wound, 
the animal succumbed to the disease. The bacilli are not found in the 
blood or internal organs. The symptoms of the disease have been shown 
to depend upon the absorption of a toxic product of the tetanus bacillus 
called tetano-toxine. 

The germ of tetanus usually gains access to the body of tbe infant 
through the umbilical wound. It exists in the soil, and the disease pre- 
vails endemically in certain localities. It is common in certain parts 
of Long Island and New Jersey. Among the negroes in some parts of 
the South it has for many years occurred with great frequency. It is 
stated that on one of the islands of the Hebrides every fourth or fifth 
child dies of tetanus. In a single house in Copenhagen eighteen cases 



90 DISEASES OP THE NEWLY BORN. 

were observed. Tetanus is rare except where dirt and filth prevail; but 
these alone are not sufficient to produce the disease. It is a very rare dis- 
ease in the tenements of New York. 

Lesions. — There are no essential lesions of tetanus. Those which have 
been found have been partly accidental and partly a result of the disease 
rather than its cause. In most of the cases intense hyperemia of the 
spinal cord and its membranes is found, and not infrequently small ex- 
travasations of blood. Such small haemorrhages are occasionally found in 
the meninges of the brain — more frequently at the base than at the con- 
vexity. In rare instances haemorrhages of considerable size have occurred 
into the brain itself. The lungs are generally congested, and the right 
side of the heart overdistended. In most of the cases the umbilicus has 
not healed, and it may present evidences of septic infection in varying 
degrees. 

Symptoms. — These, as a rule, begin on the fifth or sixth day, or at 
the time of the separation of the cord. The first symptoms may not 
appear until the tenth or twelfth day, but rarely later than this. Gen- 
erally the first thing noticed is difficulty in nursing, which, on examina- 
tion, is found to be due to rigidity of the jaws (trismus). Nursing may 
be impossible on this account. The muscles of the jaw feel hard, the lips 
pout and all the muscles of the face seem firm. Soon a slight stiffening 
of the body occurs, the child straightening the back as it lies upon the 
lap and continuing rigid for a moment or two. In the interval it is at 
first completely relaxed. These paroxysms soon increase in frequency 
until they may come on every few minutes, being excited by any move- 
ment of the body. The relaxation is then only partial, and the neck and 
extremities, sometimes nearly the whole body, become rigid and stiff as a 
piece of wood. The arms are extended, the thumbs adducted, and the 
hands clenched. The thighs and legs are extended, and no motion is pos- 
sible at the hip or knee. The jaws can be separated slightly or not at all. 
The firm contractions of the facial muscles give a peculiar expression to 
the features. There is a low, whining cry. Swallowing is difficult, some- 
times impossible. The pulse is rapid and soon becomes weak. The tem- 
perature at first is normal, but in the most acute cases rises rapidly to 104° 
or even 106° ; in the milder cases it does not go above 101° F. 

Death is due to exhaustion, to fixation of the respiratory muscles, or 
to spasm of the larynx. In the less severe cases all the symptoms are 
milder, and there may be intervals in which the rigidity is scarcely notice- 
able, so that respiration and deglutition may be carried on for some time. 
In cases which terminate in recovery the temperature is but slightly ele- 
vated. The tonic contractions gradually become less severe, and the 
paroxysms less frequent. The children usually suffer for several weeks 
from the general symptoms of malnutrition, which are proportionate to 
the severity of the attack. Of eighty-eight fatal cases which are reported 



TETANUS. 91 

by Stadtfeldt all but five died between the ages of six and ten days. The 
duration of the disease in the fatal cases is seldom more than forty-eight 
hours, often less than twenty-four hours ; in those terminating in recov- 
ery, between one and three weeks. 

Prognosis. — No disease of infancy is more fatal than tetanus. Where 
it prevails endemically it is regarded by the laity as so uniformly fatal that 
usually no physician is called. Scattered through medical literature are 
quite a large number of isolated cases in which recovery has occurred. At 
the present time the proportion of fatal cases is probably between ninety 
and ninety-five per cent. Sporadic cases more frequently recover than 
those occurring in districts where the disease is endemic. The later the 
development of the symptoms, the slower their course, and the lower the 
temperature the more likely is the case to recover. 

Prophylaxis. — A proper understanding of the nature of the disease has 
brought with it the means of rational prevention. The first essential is 
obstetrical cleanliness, which must include scissors, hands, dressings, liga- 
tures — in short, everything which comes in contact with the umbilical 
wound. In districts where tetanus is endemic, thorough antiseptic treat- 
ment of the umbilicus should be insisted upon, both at the first dressing 
and later, particularly at the time of the separation of the cord. 

Treatment. — All drugs whose physiological action is that of motor 
depressants of the spinal cord have a certain amount of value in tetanus. 
The most important ones are chloral, the bromides, and calabar bean. 
Nearly all the reported cures have been by one of these drugs or a com- 
bination of them. The mistake usually made is in using too small doses 
to be of any efficacy. Enough to produce the physiological effects of the 
drug must be given. The initial dose should not be large, but it should 
be repeated until the full effects are obtained. Of those mentioned, chloral 
has been the one most generally relied upon. An hourly dose of one or 
two grains is usually required. If no effect is visible in ten or twelve 
hours the dose may be further increased, as the patient is in much greater 
danger from the disease than he can possibly be from the drug. Chloral 
may be given by the mouth or by the rectum, but must always be well 
diluted. The single case of recovery which I have witnessed was one 
treated by the bromide of potassium. This infant took eight grains every 
two hours for three days, afterwards smaller doses. Calabar bean has the 
advantage in that its extract may be given hypodermically ; one tenth of 
a grain may be administered from three to ten times daily, according to 
the severity of the symptoms. Monti has reported two cases cured by 
its use. The child must at all times be kept as quiet as possible, without 
unnecessary handling or bathing. If nursing or feeding by the mouth is 
impossible, because the jaws cannot be separated, the child may be fed 
by a tube passed through the nose. This is greatly to be preferred to 
rectal alimentation. Drugs may be administered in the same way. 



92 DISEASES OF THE NEWLY BORN. 

The antitoxine treatment. — Behring and Kitasato, after a series of 
experiments upon animals, were the first to produce an antitoxine which 
has the power of neutralizing the tetanus poison. In animals immunity 
is produced by its injection. It is also curative in those cases where 
tetanus has been produced experimentally. Its value has now been dem- 
onstrated in quite a large number of cases of traumatic tetanus in adults. 
The practical obstacle to the success of the. antitoxine treatment is the 
rapid absorption of the tetanus poison from the wound'. To be efficient 
it must be used early. 

Cases of tetanus neonatorum successfully treated by antitoxine have 
been reported by Papiewski, Escherich, McCaw, and others; but the 
number of cases in which it has been used is as yet too small to admit of 
positive deductions. It should by all means be tried wherever practica- 
ble. The best method of administration is still under discussion. Koux's 
experiments appear to show that the antitoxine is more efficient when in- 
jected directly into the brain than when used subcutaneously. Fortu- 
nately in the newly-born child this adds no difficulty, since the needle can 
readily be introduced through the open sutures. It is hardly necessary 
to add that the strictest antiseptic precautions must be observed. Eeli- 
able tetanus antitoxine is now prepared by Behring, the New York Health 
Department, and Parke, Davis & Co. The question of dosage is still 
unsettled. 

EPIDEMIC HEMOGLOBINURIA (WINCKEL'S DISEASE). 

The essential features of this disease are hemoglobinuria with icterus 
and cyanosis, this combination giving the skin a deeply bronzed hue (mala- 
die bronzee). It is a rare disease, but has generally occurred epidemically 
in institutions. It is usually fatal. All the symptoms point to an acute, 
rapid disintegration of the red blood-cells — a sort of blood fermentation. 
It is, without doubt, infectious, but its cause has not been discovered. 
Although generally called by the name of Winckel,* who in 1879 made a 
report upon an epidemic of twenty-three cases, the disease was quite well 
described by Charrin in 1873, with a report of fourteen cases, and ob- 
served by Bigelow, in Boston, in 1875. All the cases included in Winck- 
el's report occurred in one institution, affecting one fourth of the children 
born during the period. 

There is cyanosis, with a more or less intense icterus of the skin and 
internal organs. The umbilical vessels are usually normal. The kidneys 
are swollen, show small haemorrhages into their substance, and under the 
microscope the straight tubes are seen to be filled with crystals of haemo- 
globin, but contain no blood-cells. The bladder frequently contains 

* Winckel, Veroflientlich. der padiatrischen Section der Gesellsch. f. Heilk., Berlin, 
April, 1879. 



FATTY DEGENERATION. 93 

brownish, smoky urine. The spleen is swollen and filled with blood_ pig- 
ment, which is diffused throughout the cells of the pulp, and free in the 
blood-vessels. Punctate haemorrhages are seen in most of the other 
viscera. 

This disease most frequently attacks those who have been previously 
healthy. The symptoms usually begin from the fourth to the eighth day 
after birth. They are intense and fulminating in character, seldom last- 
ing more than two days, and often only one. The early symptoms are 
general restlessness, rapid pulse and respiration, prostration, cyanosis of 
the face, and general icterus, which is at first slight, but steadily in- 
creases until it becomes intense, the skin resembling that of a mulatto. 
The temperature is normal or slightly elevated. There is rapid asthenia, 
often terminating in coma or convulsions. The most characteristic symp- 
toms are those connected with the urine. It is passed frequently, in small 
quantities, with pain and straining. It is of a brown, smoky colour, and 
under the microscope shows haemoglobin in considerable quantity, renal 
epithelium, and sometimes granular casts and blood-cells, but does not 
contain bile pigment. Albumin is sometimes present, but not in large 
quantity. Examination of the blood shows an increase of the white cells 
and many free granules. 

Treatment is of little avail, since all severe cases die. 



FATTY DEGENERATION OF THE NEWLY BORN (BUHL'S DISEASE). 

A disease has been described by the author whose name it bears, 
the essential nature and causation of which are unknown. It occurs as 
isolated cases and not in groups, and is characterized by inflammatory 
changes leading to fatty degeneration in the viscera, especially the heart, 
liver, and kidneys; it seldom lasts more than two weeks, and is almost 
invariably fatal. There may be haemorrhages in any of the viscera, into 
the serous cavities, or from any mucous membrane. In the lungs are 
found large or small haemorrhagic infarctions, and the bronchi contain 
blood and bloody mucus. The liver in recent cases is large and soft; 
in those of longer standing it is pale and jaundiced, and shows marked 
fatty degeneration. The spleen is large and soft. The epithelium of 
the tubules of the kidney is acutely degenerated. The heart muscle is 
pale, soft, and fatty. Many of the lesions are similar to the ordinary 
post-mortem changes, and when found they should not be interpreted 
as pathological unless the autopsy is made within at least twelve hours 
after death. 

The clinical features of this disease, as described, resemble those of 
pyogenic infection; and since the observations were made before modern 
methods of bacteriological study, it is highly probable that Buhl's disease 
is merely a form of pyogenic infection in the newly born. 



94 DISEASES OF THE NEWLY BORN. 



PEMPHIGUS NEONATORUM— BULLOUS IMPETIGO. 

Pemphigus is a term which designates a lesion rather than a disease. 
By it is meant an eruption of bullae occurring usually upon a red base, 
the contents being in most cases clear serum. A condition somewhat 
resembling pemphigus sometimes follows the use in the newly born of 
too hot baths. Again, bullae are seen as one of the lesions of congenital 
syphilis; they are then usually present at birth or appear soon after. 
They are most frequently seen upon the palms and soles. Infants so 
affected are generally in wretched condition, and soon die. 

The only condition to which the term pemphigus neonatorum should 
be applied is quite different from both the preceding, and it has nothing 
in common with the pemphigus of later life. The disease is of infec- 
tious origin ; it is somewhat contagious, and occasionally occurs in small 
epidemics in institutions. It differs from the common impetigo con- 
tagiosa seen in older children, chiefly in severity and its association with 
visceral infections. Most patients in whom the disease occurs are deli- 
cate, but not always. I have seen it even in robust infants. 

The greater number of cases studied thus far have shown the pres- 
ence in the blebs of the staphylococcus pyogenes aureus. This was true 
of three typical cases occurring in my own hospital service. In one of 
these which came to autopsy, a general staphylococcus septicaemia was 
present. It is, however, not impossible that the staphylococcus infection 
is a secondary condition, the primary one being as yet undetermined. 

The clinical picture presented by pemphigus neonatorum is so strik- 
ing that it can scarcely be mistaken. The symptoms begin in most 
cases between the fourth and tenth day of life. The bullae first appear- 
ing are scattered and often not larger than one fourth or one half inch 
in diameter. They may be seen upon any part of the body, but are 
especially frequent about the face, hands, and other exposed parts. They 
rupture or dry to form crusts without suppuration. The small bullae 
may gradually increase in size or several may coalesce until they cover 
an area two or three inches in diameter. As the disease progresses, new 
bullae come out over almost any part of the body. The skin at first 
appears slightly reddened, then an exudation of serum occurs beneath the 
epidermis which loosens and slides upon the true skin. After rupture 
of the large bullae, the epidermis at the margin forms a thin filmy bor- 
der or hangs in shreds easily detached. The base of the large vesicles 
is a moist bright red surface. When many have formed, the appearance 
closely resembles that seen after an extensive burn. (Fig. 20.) 

The course of the local symptoms is at first slow ; then the bullae may 
spread with great rapidity and death occur in from twenty-four to forty- 
eight hours. In less severe cases the course is more prolonged, the blebs 
are smaller, and recovery may take place. 



HEMORRHAGES. 



95 



The constitutional symptoms are at first wanting, but increase with 
the number and extent of the bullae. There may be a slight rise of 
temperature or it may be subnormal. There is progressive weakness 




Fig. 20. — Pemphigus neonatorum. Symptoms began on 13th day; death on 16th day of asthe- 
nia; temperature subnormal. The dark areas in the picture are entirely denuded of epi- 
dermis ; they were formed by the coalescence of large bullae. 

and great depression, much like that occurring after a burn, and death 
occurs from exhaustion or from some visceral inflammation such as 
pneumonia or meningitis. 

It is important to distinguish pemphigus neonatorum from con- 
genital syphilis. In syphilitic cases, the liver and spleen are usually 
markedly enlarged, and other characteristic changes may be present in 
the nails, mucous membranes, or elsewhere. 

Xo treatment is of any avail in the most severe cases, when the bullae 
cover a considerable part of the surface of the body. In all cases the 
indications are absolute cleanliness and the use of absorbent powders, 
such as equal parts of boric acid and starch, to dry up the eruption, or 
wet dressings of 1-10,000 bichloride or one-per-cent solution of ichthyol. 
On account of the contagious nature of the disease cases occurring in 
institutions should be isolated. 



CHAPTEE V. 
HEMORRHAGES. 



Hemorrhages are quite frequent during the first days of life, and 
are important not only from the fact that they are often the cause of 
death, but, when the brain is the seat, from their remote effects. There 
are several conditions in the newly born which predispose to bleeding — the 
extreme delicacy of the blood-vc— <-l-. and the great changes taking place 
in the blood itself and in the circulation in the transition from intra- 
uterine to extra-uterine life. Haemorrhages may complicate many of the 



96 DISEASES OF THE NEWLY BORN. 

diseases of the early days of life, such as syphilis or sepsis, or they may 
exist alone. 

The cases may be divided into two groups: (1) Traumatic or Acci- 
dental Haemorrhages, which depend upon causes connected with delivery ; 
(2) Spontaneous Haemorrhages, or The Haemorrhagic Disease of the 
Newly Born. 

TRAUMATIC OR ACCIDENTAL HEMORRHAGES. 

These are mainly due to pressure in natural labour, or to means em- 
ployed in artificial delivery, but some of them may possibly result from 
injuries received before birth. They are more frequent in large children, 
in difficult labours, and where from any cause the body of the child has 
been subjected to undue pressure. 

Hematoma of the Sterno-Mastoid. — Haematoma, or, as it is sometimes 
called, induration of the sterno-mastoid muscle, leads to the formation of 
a tumour in the belly of the muscle. It is a rare condition, usually no- 
ticed in the second or third week of life, and it disappears spontaneously, 
without causing any permanent deformity. The tumour varies from three 
quarters of an inch to one inch and a half in length, being about the size 
and shape of a pigeon's egg. It is movable, almost cartilaginous to the 
touch, and sometimes slightly tender. The situation of the tumour is 
usually about the centre of the muscle. There is no discoloration of the 
skin. 

In about two-thirds of the cases it occurs after breech presentations. 
It is much more frequent upon the right than upon the left side. In 
twenty-seven cases collected by Henoch the right side was involved in 
twenty-one and the left in only six cases. The explanation of this differ- 
ence is to be found in the obstetrical position. Rarely, both sides may 
be involved. The head is usually inclined towards the shoulder of the 
affected side and rotated towards the opposite side. The swelling slowly 
diminishes in size, and in most cases by the end of the third month has 
entirely disappeared. Occasionally a slight torticollis remains for a 
longer time, but in the majority of cases the recovery is perfect. Haema- 
toma of the sterno-mastoid is due to the twisting of the head during par- 
turition. It is not an evidence of the employment of any improper force 
in delivery. The twisting of the head produces laceration of some of 
the blood-vessels of the muscle, and in some cases there is doubtless rup- 
ture of some of the fibres of the muscle itself. Following this there oc- 
curs a certain amount of inflammation of the muscle and its sheath. 
The tumour is due partly to blood-extravasation and partly to inflamma- 
tory products. In one or two recent cases in which the sheath of the 
muscle has been opened it has been found filled with blood. 

The condition requires no treatment. Operative interference is posi- 
tively contra-indicated. 



CEPHALHEMATOMA. 97 

Cephalhematoma. — This is a tumour containing blood, situated upon 
the head, usually over one parietal bone, and tending to spontaneous dis- 
appearance by absorption. The source of the blood is the rupture of the 
small vessels of the pericranium. 

Etiology. — Cephalhematoma is sometimes due to a distinct trauma- 
tism like the application of forceps or to some other injury during labour. 
In the majority of cases, however, there is no evidence of such injury. 
Besides the conditions predisposing to all haemorrhages, there is the in- 
creased pressure in the blood-vessels of the head during delivery, espe- 
cially when labour is prolonged or difficult ; there may be changes in the 
bone, such as an imperfect development of the external table, which 
has been found in a few instances, and in consequence of which the peri- 
osteum readily separates when the head is subjected to the pressure of 
the pelvis ; and, finally, there may be changes in the blood itself. Cephal- 
hematoma is a comparatively rare condition, being present, accord- 
ing to the statistics of the Sloane Maternity Hospital, in 20 of 1,300 con- 
secutive births, or 1 -6 per cent. The condition is more common after 
first, or difficult labours, and in vertex presentations; occurring twice 
as often in males as in females, probably from the greater size of the 
head. 

Lesions. — In the 20 Sloane cases, the situation was over the right 
parietal bone in 12 ; over the left in 2 ; over both parietals in 4 ; over the 
occipital in 2. The location of the tumour seems to have a very close 
relation to the position of the head in the pelvis. In 8 of the right-sided 
cases the head was in the left occipito-anterior position ; in 3 it was in 
the right occipito-anterior ; in 1 case the position was unknown. Of the 
cases with occipital tumours, both were breech presentations. Of the 16 
cases with a single tumour the labour was natural in 10, tedious in 4, and 
in 2 forceps were used. Of the 4 double cases, 2 were forceps deliveries, 
1 a tedious labour, and but 1 was natural. 

In rare cases triple tumours are met with, one over each parietal arid 
one over the occipital bone. The attachment of the periosteum along the 
sutures, usually limits the tumour to the surface of one bone. It never ex- 
tends across the sutures or over the fontanel. In cases where there is a 
more definite injury, such as from forceps, the tumour may be present over 
any one of the cranial bones, but more frequently over the parietal. The 
seat of the hemorrhage is between the periosteum and the cranium. The 
scalp shows punctate hemorrhages and sometimes infiltration with blood. 
In recent cases the blood is fluid ; later it is coagulated. The amount of 
extravasated blood is usually from half an ounce to an ounce. In ex- 
treme cases it may be from four to six ounces. The cases following natu- 
ral delivery are generally uncomplicated. The traumatic cases may be 
complicated by extravasations between the bone and the dura (internal 
cephalhematoma), or by meningeal or cerebral hemorrhages. If there is 




Fig. 21. — Double cephalkamiatoma, infant seven days old. 



98 DISEASES OF THE NEWLY BORN. 

a wound, infection may be followed by purulent meningitis and even by 
cerebral abscess. 

Symptoms. — The tumour is usually noticed from the first to the 
fourth day after birth, appearing as a slight prominence in one of 
the positions mentioned (Fig. 21). Gradually increasing in size, it at- 

_ tains its maximum at 

the end of a week or 
ten days, and then 
slowly diminishes. In 
the average case the 
tumour is about the 
size of a hen's egg, 
and is oval in form. 
In marked cases it 
may be one-third the 
size of the child's 
head. To the touch 
it is soft, elastic, fluc- 
tuating, and irreduci- 
ble. It does not increase with the cry or cough. There is no extra heat 
and no signs of inflammation. Usually the tumour does not pulsate, 
although in rare instances pulsating cephalhaematomata have been seen. 
Very soon the tumour is surrounded by a marginal ridge. At first this is 
apparently from coagulation of blood, but later it may be bony. The 
prominent ridge with the soft centre gives a sensation somewhat like that 
of a depressed fracture. Sometimes on pressure there is obtained a sort 
of parchment-crackling. This is generally found as the swelling is sub- 
siding, and is sometimes clearly due to the formation of minute bony 
plates upon the inner surface of the periosteum. It may be found when 
there is nothing but thin coagula to explain it. In certain cases follow- 
ing severe traumatism, cephalhematoma may be complicated with 
wounds of the scalp, fracture of the skull, and even lacerations of the 
dura mater or the brain. In such cases the tumour may become inflamed, 
but in the spontaneous cases this is extremely rare. The usual signs of 
abscess develop, which may open externally or burrow. Fortunately this 
termination is seldom seen. 

As a rule, without any interference, the uncomplicated cases go on to 
recovery. The complete disappearance of the tumour may be expected in 
from six weeks to three months, depending on its size ; but a hard, uneven 
elevation may remain at its site for a longer time. The cases due to severe 
traumatism are more serious, the gravity depending not upon the cephal- 
hematoma but upon the complicating lesions. 

Diagnosis. — Cephalhematoma may be confounded with encephalocele. 
This, however, occurs along the line of the sutures or at the fontanels, is 



VISCERAL HEMORRHAGES. 99 

partly reducible, pressure causes cerebral symptoms, and frequently the 
tumour increases with respiratory movements. Hydrocephalus is distin- 
guished by the symmetrical enlargement of the head, the large frontanels, 
and the widely separated sutures. Caput succedaneum often appears in the 
same jjlace as a cephalhematoma and at the same time, but is an cedem- 
atous, not a fluctuating tumour, is not circumscribed, lacks the hard, 
marginal border, and begins to disappear by the second or third day. 
From a depressed fracture of the skull, it is differentiated by the fact that 
in cephalhematoma there is a tumour and not a depression ; the promi- 
nent margin which is raised above the contour of the skull, is not osseous 
and the skull can be felt at the bottom of the centre of the tumour. 

The treatment in the uncomplicated cases is simply protective, all 
such cases tending to spontaneous recovery. No local or general treat- 
ment to promote absorption is required. The child should be so placed 
and so handled that no injury may be done to the affected part. Com- 
presses are unnecessary. If complications exist, such as injury to the 
bones, dura, or brain, they are to be treated in accordance with general 
surgical principles. Operative interference is called for only when sup- 
puration has occurred, or when there are brain symptoms which point to 
the existence of internal as well as external cephalhematoma. 

Visceral Haemorrhages. — While these are most frequent in large chil- 
dren and following difficult labours, they may occur in small children and 
where the labour has been easy and normal — their occurrence here being 
due to the feeble resistance of the blood-vessels. From one hundred and 
thirty autopsies upon still-born children or those dying soon after birth, 
Spencer concludes that intracranial hemorrhages are more frequent in 
head-forceps than in breech cases, and more frequent in breech than in 
natural vertex deliveries. Other visceral hemorrhages are much more 
frequent in breech cases. 

Not all visceral hemorrhages are to be classed as traumatic. They are 
often seen with the spontaneous hemorrhages from the skin or mucous 
membranes. When, however, they are single, they seem to me of trau- 
matic rather than of pathological origin. 

The most important of the visceral hemorrhages are intracranial. 
These are discussed in the chapter devoted to Birth Paralyses. Karely 
there may be large hemorrhages into the lung. Here the blood fills the 
air vesicles, the small bronchi, and coagula may be found even in the 
larger bronchi. A large part of a lobe or an entire lobe may be involved. 
On section the condition resembles atelectasis, and it may give the physical 
signs of consolidation. 

The abdominal viscera suffer more than those of the thorax because 
less protected against pressure. Small hemorrhages are not uncommon 
upon the surface of any of the viscera covered by peritoneum. Intra- 
peritoneal hemorrhages are rare, but may be very extensive, amounting to 

t.ofe. 



100 DISEASES OF THE NEWLY BORN. 

one or two pints. Sometimes no ruptured vessel can be found. The 
haemorrhage may be primarily in the peritoneal cavity, or it may result 
from rupture of one of the viscera, especially the suprarenal capsule. It 
may be large enough to produce death from loss of blood. 

Small surface haemorrhages of the liver are not infrequent. Occa- 
sionally one of considerable size occurs separating the peritoneal covering 
and forming a tumour generally upon the superior surface. Such lacer- 
ation may be produced during labour, and a slow accumulation of blood 
may take place beneath the capsule, death resulting, as in the case re- 
ported by Mendelson (New York), from rupture into the peritoneal cavity 
on the third day. Steffen reports a case of laceration of the capsule of 
the liver in a still-born infant. Of the large haemorrhages, those into the 
suprarenal capsules are perhaps the most frequent. Two cases have re- 
cently occurred in the Sloane Maternity Hospital. In one of these, the 
specimen of which I examined, the capsule was distended nearly to the 
size of an orange, and the kidney surrounded by a mass of blood-clots. 
Blood was extravasated into the retroperitoneal connective tissue, and 
rupture had taken place into the peritoneal cavity, which contained half 
a pint of partly coagulated blood. The child died on the fifth day. This 
case has been reported in full by Tuley.* Ahlfeld has reported a case of 
haemorrhage into both suprarenals. 

Except in the intracranial variety, visceral haemorrhages cause few 
symptoms, and in the great majority of cases the diagnosis is not made. 
Intrapulmonary haemorrhages have given rise to the signs of consolida- 
tion of the lung and even to haemoptysis (Miram's case). The abdominal 
haemorrhages are the most obscure. There may be a general abdominal 
distention with the usual symptoms of loss of blood, or there may be a 
circumscribed swelling. In many cases nothing is noticed until a rupture 
of a subperitoneal haemorrhage takes place into the general peritoneal 
cavity, when there may be sudden collapse and death. 

The visceral haemorrhages are not amenable to treatment. The prog- 
nosis depends upon the size and position of the haemorrhage. In the cases 
of abdominal haemorrhage the diagnosis is extremely obscure and is rarely 
made during life. 

SPONTANEOUS HEMORRHAGES— THE HEMORRHAGIC DISEASE OP 

THE NEWLY BORN. 

A disposition to bleeding is seen with many diseases of the first few days 
of life, especially those of an infectious character, like syphilis and pyaemia. 
With most of these, however, the haemorrhages are small, and the condi- 
tion may be compared to the haemorrhagic tendency seen in certain forms 
of infection of later life, such as measles, smallpox, and malignant endo- 

* Archives of Paediatrics, November, 1892. 



THE HEMORRHAGIC DISEASE. 



101 



carditis. There is, however, a class of cases in which the haemorrhages are 
not associated with any other known process, and in which the escape of 
blood from the small blood-vessels is the chief or essential symptom. In 
these cases the bleeding is much more extensive than in the others men- 
tioned. These haemorrhages are characterized by the fact that they are 
spontaneous in origin, having no connection with delivery, they are mul- 
tiple in location, and, while little influenced by treatment, they tend to 
cease spontaneously after quite a limited time. They are most often from 
the umbilicus, the mucous membranes of the stomach and intestines, or 
beneath the skin, but they may be from almost any mucous surface or 
into any organ of the body. 

Etiology. — Exactly what causes these haemorrhages is as yet unknown, 
but it is something which produces changes in the blood or in the blood- 
vessels, or in both, whereby the vessels are no longer able to hold their 
contents. In this class, as well as in the traumatic haemorrhages, the 
predisposing causes of bleeding in early life must be emphasized — viz., the 
fragile condition of the blood-vessels and the great changes taking place 
soon after birth both in the circulation and in the blood itself. These 
haemorrhages are not common, and are met with much more often in in- 
stitutions than in private practice. In 5,225 births in the Boston Lying-in 
Asylum, Townsend reports 32 cases of haemorrhage, or 0*6 per cent. In 
the Lying-in Asylum of Prague, Eitter observed 190 cases in 13,000 births, 
or 1*4 per cent. In the Foundling Asylum of Prague, Epstein reports 
haemorrhages in 8 per cent of 740 infants. 

These cases, except in very rare instances, are not manifestations of 
haemophilia. Of 576 bleeders collected by Grandidier, only 12 had a his- 
tory of haemorrhage at the time of falling off of the cord, and symptoms 
very rarely appeared before the end of the first year. Haemorrhages in the 
newly born are only slightly more frequent in males, while in haemophilia 
they predominate 13 to 1. The haemorrhagic disease of the newly born is 
self -limited, and runs a definite course to recovery or death. The tendency 
to bleed does not extend beyond a few weeks, and often lasts but a few 
days ; those who survive, recover perfectly. Circumcision has been done 
within a few days after the cessation of the haemorrhages without any un- 
usual bleeding. In a case lately under observation with the most exten- 
sive subcutaneous haemorrhages I have ever seen, all tendency to bleed 
had ceased before the separation of the cord, although there had previous- 
ly been bleeding at the navel. A similar case is reported by Townsend. 
These cases are not associated with difficult delivery. In only G of Town- 
send's * 50 cases was the labour abnormal. This is borne out by my own 
experience. Many of the children who bleed have previously been anaemic 
and in poor general condition ; but, on the other hand, many have been 



Archives of Paediatrics, 1894, p. 559. 



102 DISEASES OF THE NEWLY BOKN. 

strong and given every indication of being well nourished. Hereditary 
syphilis is associated in a small proportion of the cases — from 2 to 6 per 
cent, according to the observations of Epstein, Eitter, and Townsend. 
In 132 cases of congenital syphilis observed by Mracek, 14 per cent suf- 
fered from haemorrhages. 

A more frequent association with sepsis (pyogenic infection) has been 
observed. Of the 61 cases observed by Epstein not less than 29, and of 
the 190 cases of Eitter,* 24 were associated with sepsis. During the year 
1895 there were no less than 8 marked cases of haemorrhage in the Nur- 
sery and Child's Hospital in about 225 deliveries. While it is true that 
more cases of sepsis (pyogenic infection) occurred among the children 
during this period than usual, it was striking that not one of these haem- 
orrhagic cases gave any evidence of sepsis, and that none of the septic 
cases had bleeding. An epidemic of 10 cases of haemorrhages among 
54 births at the Few York Infirmary for Women and Children was stud- 
ied in 1899 by Kilham and Mercelis.f These all occurred in the course 
of two months; the epidemic ceased as soon as the cases were properly 
isolated. 

From the foregoing facts it is quite evident that not all the cases of 
bleeding are due to the same cause, and that while this symptom occurs 
in some cases of pyogenic infection, the latter does not explain most of 
those seen. The circumstances in which the haemorrhagic disease occurs 
point strongly to an infectious origin, but with our present knowledge we 
can not believe this cause to be the same as in ordinary sepsis — viz., the 
entrance of common pyogenic bacteria. Quite a number of these cases 
have now been studied bacteriologically, but with no very uniform results. 
In two cases by Gaertner J there was found in the blood a short bacillus 
resembling in some respects the colon bacillus, which, injected into the 
peritoneal cavity in young animals, chiefly dogs a few days old, produced 
a disease accompanied by haemorrhages resembling that seen in the newly 
born. The bacillus was recovered from the blood and all the organs of 
these animals. Several observers have confirmed his findings. Other 
organisms that have been isolated are the streptococcus, staphylococcus, 
bacillus pyocyaneus, an organism closely resembling the pneumococcus, 
and several others; but no one of these is constantly present. It seems 
likely that the specific cause, whatever its nature, produces changes not 
so much in the blood as in the blood-vessels themselves. Its action seems 
to be similar to that of a constituent found by Flexner and Nagouchi 
in rattlesnake venom, which produces rapid destruction of the vascular 
endothelium, and which has been called by them hcemorrhagin. 

While these haemorrhages are not traumatic, bleeding is exceedingly 
prone to occur in the skin over pressure points such as the back, the 

* Oesterreiches Jahrbuch fur Padiatrik, 1871, 127. 

f Archives of Paediatrics, March, 1899. \ Archiv f iir Kinderheilkunde, 1895. 



THE HEMORRHAGIC DISEASE. 1Q3 

elbows, the occiput, and the sacrum. It is also common from the mucous 
membranes which are the seat of pathological processes, especially from 
the eyes, the nose, and the genitals. 

Lesions. — In very many of the cases the autopsy shows nothing except 
the haemorrhages in the various situations and the blanching of the organs 
due to the loss of blood. The haemorrhages of the brain are usually me- 
ningeal and diffuse. They are considered more at length in the chapter 
upon Birth Paralyses. The pulmonary haemorrhages are usually small 
and unimportant, amounting only to small extravasations into the sub- 
stance of the lung or ecchymoses of the mucous membrane of the bronchi. 
Ecchymoses may be seen upon the surface of the pleura, the pericardium, 
or the peritoneum, but large haemorrhages into the pleura or pericardium 
are very rare. The thymus gland is often the seat of small extravasa- 
tions. The stomach and intestines may contain considerable blood vari- 
ously disorganized in the' different parts of the canal, and there may be 
ecchymoses of the mucous membrane. In addition, ulcers may be found 
in the stomach and duodenum. In twenty-four autopsies upon cases 
with haemorrhage from the stomach and intestines collected by Dusser,* 
ulcers were found in the stomach in nine cases, and in the intestines in 
four. These ulcers are multiple and are small, resembling the follicular 
ulcers of the colon. They are usually superficial, but may extend to the 
muscular coat and may even perforate. I have myself found ulcers in the 
stomach in a single case. They were associated with a moderate amount 
of follicular gastritis. The intestinal ulcers are found only in the duode- 
num and resemble those of the stomach. The cause of these ulcers is 
somewhat obscure ; some of them are undoubtedly dependent upon in- 
flammatory changes probably of infectious origin ; others have been com- 
pared to the peptic ulcers of later life, and are attributed to thrombi in the 
blood-vessels of the mucous membrane. These ulcers are found in but a 
small proportion of the cases in which bleeding occurs from the alimen- 
tary tract, and they may be wanting even where it has been very profuse. 

Small extravasations may be seen upon the surface of the liver, the 
spleen, or the kidneys. They may also be found in the substance of these 
organs. The large haemorrhages upon the surface of the liver, into the 
suprarenal capsules and other subperitoneal extravasations have been in- 
cluded, improperly perhaps, in the group of traumatic haemorrhages dis- 
cussed in the preceding chapter. From a rupture of any of these there 
may be large extravasations into the peritoneal cavity. Microscopical ex- 
aminations of the blood-vessels have been made in but a small number of 
cases. Mracek claims to have found evidences of endarteritis in some of 
the syphilitic cases in which there was bleeding. The changes found 
in the blood have not been uniform and have as yet been only im- 

* These, Paris, 1889. 



104: DISEASES OF THE NEWLY BORN. 

perfectly studied. The associated lesions found are most frequently those 
due to sepsis. 

Symptoms. — The time of beginning is most frequently in the first 
week of life, rarely after the twelfth day, although it has been observed as 
late as the sixth week. As a rule, the haemorrhages from the stomach 
and intestines begin earlier than those from the navel or the skin. The 
location of the haemorrhage in Eitter's 190 cases was as follows: Um- 
bilicus, 138 (umbilicus alone, 97) ; intestines, 39 ; mouth, 28 ; stomach, 
20 ; conjunctivae, 20 ; ears, 9. In Townsend's 50 cases : Intestines, 20 ; 
stomach, 14 ; mouth, 14 ; nose, 12 ; umbilicus, 18 (umbilicus alone, 3) ; 
subcutaneous ecchymoses, 21 ; abrasion of skin, 1 ; meninges, 4 ; cephal- 
haematoma, 3 ; abdomen, 2 ; pleura, lungs, and thymus, 1 each. 

In many cases nothing is noticed until the haemorrhage begins. The 
child may be previously healthy or feeble. The first bleeding noticed may 
be from the stomach, intestines, or any of the mucous surfaces, beneath 
the skin, or from the umbilicus. The amount of blood lost in most cases 
is not great, but there is a continuous oozing. The total haemorrhage 
may be only one or two drachms or it may reach several ounces. The 
skin is usually pale, the pulse feeble, and the general condition one of con- 
siderable prostration, often from the outset. In all cases there is rapid 
loss of weight. The temperature may be high, low, or subnormal. A 
marked elevation of temperature may depend not upon the haemorrhage 
but upon associated conditions. Fluctuations in temperature during the 
first three days are so common from disturbances of nutrition, that I attach* 
much less importance than have some writers to this symptom. Icterus is 
not more frequent than among other infants. In a large number of the 
cases there is diarrhoea. Convulsions often occur at the close of the disease. 

The duration of the disease in cases which recover is usually but one 
or two days. In fatal cases it is rarely more than three days, and often 
less than one. Death more frequently results from the gradual failure of 
all the vital forces than from a rapid loss of blood. 

Umbilical hcemorrhage. — A slight oozing from the umbilicus not in- 
frequently occurs when the ligature has been improperly applied, or when 
there is so much shrinking of the cord that the ligature has loosened. 
Sometimes rough handling at the time of the separation of the cord may 
excite a little bleeding. All the above conditions, however, are usually of 
trivial importance and are readily controlled by simple measures. Spon- 
taneous haemorrhage is quite a different matter. It is rather later than 
bleeding from the mucous membranes, usually occurring between the 
fourth and the seventh day. There may be bleeding into the cord as well 
as from its free extremity before it separates ; after separation, from the 
stump. A slight stain upon the dressing is usually the first note of warn- 
ing, but in exceptional circumstances a gush of blood is the first symptom. 
The haemorrhage may be temporarily arrested by various means, but it 



THE HEMORRHAGIC DISEASE. 105 

shows a strong tendency to occur in spite of everything which is done. 
The general symptoms depend upon the amount of bleeding and the ra- 
pidity with which it occurs. It is the same as in other haemorrhages of 
the newly born. The usual duration is two or three days. It has been 
known, however, to persist for twelve or fourteen days, and it may be 
fatal in less than twenty-four hours from the time it is noticed. 

Hemorrhage from the stomach and intestines. — Bleeding occurs much 
less frequently from the stomach than from the intestines. The latter 
is called melaena. Grastro-enteric haemorrhages begin, in the great ma- 
jority of cases, during the first three days of life. Of Dusser's 75 cases, the 
haemorrhage began on the first day in 24 cases ; on the second day in 22 
cases ; on the third day in 9 cases ; in only 10 cases later than the ninth 
day, and in no instance later than the twelfth day. The appearance of 
the blood vomited depends upon the length of time it has remained in 
the stomach. Usually it is in dark brown masses, and not very abun- 
dant; more rarely bright red blood may be ejected. The quantity varies 
from one drachm to half an ounce. Vomiting is liable to be excited by 
nursing. The blood discharged from the bowels is always dark coloured, 
usually intimately mixed with the stool, very rarely in clots. If in doubt 
between blood and meconium, one should look for the corpuscles with the 
microscope. When this is not conclusive on account of the disorganiza- 
tion of the corpuscles, a chemical test for haemoglobin should be made. 
Concealed haemorrhage into the stomach may take place, which may even 
be sufficient to produce death, no blood being vomited or passed by the 
bowels. In such cases the autopsy may reveal quite a large quantity of 
blood, both in the stomach and intestines. 

Hemorrhage from the mouth. — The quantity of blood is rarely large ; 
but it is here that it is often first seen. Its source may be the mucous 
membrane of the mouth, pharynx, oesophagus, stomach, or bronchi. It 
may be associated with ulceration of the hard palate, with thrush, or with 
fissures of the lips. 

Hemorrhages from the nose are infrequent, and are more often due to 
syphilis than to other causes. These are rarely profuse, but are frequently 
repeated. 

Subcutaneous hemorrhages. — These may appear in places exposed to 
pressure, such as the sacrum, heels, occiput, or back ; or in others which 
are not so exposed, as the abdomen, axillae, or thighs. They may follow 
other lesions of the skin, such as pemphigus, eczema, or furunculosis. In 
some cases these haemorrhages are very extensive, as in one recently 
under observation, where nearly one third of the thorax was covered. 
The extravasations are surrounded by an indurated border. Where they 
occur alone or form the principal lesion, the prognosis is favourable. 

Hematuria. — The urine is not only stained with blood, but sometimes 
contains clots. This haemorrhage may have its origin in the bladder, ure- 



106 DISEASES OF THE NEWLY BORN. 

thra, or kidney. Blood coming from the kidney is sometimes due to the 
irritation of uric-acid infarctions, and may have nothing to do with the 
general haemorrhagic disease. 

Hemorrhage from the conjunctiva. — The blood usually comes in drops 
from between the eyelids, chiefly from the tarsal surface. It is generally 
preceded by conjunctivitis. 

Hcemorrhage from the ears may originate in the external meatus or 
the middle ear. It is generally preceded by otitis. 

Hcemorrhage from the female genitals. — This not infrequently occurs 
without haemorrhages elsewhere, and under such circumstances is rarely 
serious. Cullingsworth has collected thirty-two cases in children under 
six weeks of age — no case having resulted fatally. These are not to be re- 
garded as cases of precocious menstruation. They are frequently preceded 
by catarrhal inflammations of the vagina. 

Diagnosis. — This is generally easy, as the haemorrhages are usually 
multiple and some of them external. A slight haemorrhage from the 
intestine may be easily overlooked. Large haemorrhages into the internal 
organs also are obscure and not often recognised. Spurious haemorrhages 
from the stomach may occur, blood being vomited which has been swal- 
lowed during birth or nursing. The source of bleeding may also be the 
mouth, nose or pharynx, and sometimes blood is swallowed in large quan- 
tities and afterward vomited. These cavities should therefore always 
be examined, since local treatment may be efficacious. Syphilis should 
be suspected when the bleeding is chiefly nasal. 

Prognosis. — In all circumstances the haemorrhagic disease in the 
newly born has a bad prognosis. Of seven hundred and nine cases col- 
lected by Townsend, the mortality was seventy-nine per cent. No ob- 
server has seen more than one third of his cases recover. In any single 
case the prognosis depends upon the extent and severity of the haemor- 
rhage, upon the vigour of the child, and upon how well it can be nour- 
ished. No case should be looked upon as hopeless, for perfect recovery 
has repeatedly taken place where it seemed impossible. 

Treatment. — Thus far no treatment seems to have any decided influ- 
ence in controlling this disease. Adrenalin and the suprarenal extract 
appear to have some effect in bleeding from accessible mucous mem- 
branes, and should be applied if the haemorrhage is from the nose, mouth, 
or pharynx. For internal use the suprarenal extract is to be preferred. 
I have seen one case in which benefit seemed to follow its use in severe 
gastric haemorrhage, but in others it has failed entirely. It may be 
given up to two grains every two hours. The subcutaneous injection of 
a two-per-cent solution of gelatin, which has been sterilized several times, 
is advocated by many European writers ; 40 to 50 cc. may be administered 
two to three times daily. The general treatment should have reference 
to maintaining the nutrition by careful feeding, judicious stimulation, 
and attention to the circulation, the body temperature, and the general 



BIRTH PARALYSES. 107 

condition of the child. Bleeding points on the skin or mucous membranes 
within reach are best treated by the application of chromic acid fused 
on a probe, or of nitrate of silver. Umbilical haemorrhage is best con- 
trolled by covering the umbilicus with a small pad of sterile cotton, over 
which is folded from either side the skin of the abdominal wall. This is 
held in place by two strips of adhesive plaster crossing the umbilicus 
obliquely. Astringent injections for intestinal haemorrhages are prac- 
tically useless, as the blood is almost invariably either from the stomach 
or from the upper part of the small intestine. 

CHAPTER VI. 
BIRTH PARALYSES. 

Bikth paralyses are chiefly due either to pressure upon the child by 
the parts of the mother or to artificial means employed in delivery. They 
may be cerebral, spinal, or peripheral. 

Cerebral paralyses are in almost every instance due to meningeal haem- 
orrhage. Very infrequently they depend upon cerebral haemorrhage, 
laceration of the brain, or pressure from a depressed fracture. 

Spinal paralyses are extremely rare, and only a few examples are on 
record. They are due to laceration of, or haemorrhage into the cord or its 
membranes. These lesions produce paraplegia, the exact distribution of 
which depends upon the point at which the cord is injured. 

Peripheral paralyses usually affect the face or the upper extremity. 
Paralysis of the face is due in most cases to the application of the 
forceps. Paralysis of the upper extremity is most frequently of the 
"upper-arm type," and is known as Erb's paralysis. It usually follows 
extraction in breech presentations. Peripheral paralysis of the lower 
extremity is almost unknown. 

CEREBRAL PARALYSIS. 

-Cerebral paralysis is often used synonymously with meningeal haemor- 
rhage. This lesion is not infrequent, and is of great importance not only 
from its immediate effects, but because upon it depend many of the cere- 
bral paralyses seen in later life. According to Cruveilhier, at least one 
third of the deaths of infants which occur during parturition are due to 
this cause. 

Etiology. — The same predisposing causes exist in the cases of menin- 
geal haemorrhages as in others occurring at this time. A small number of 
cases are associated with syphilis ; others with pyogenic infection. In a 
few cases there is a history of an injury— usually a fall or blow upon the 
abdomen— during the last months of pregnancy. Meningeal haemorrhage 



108 DISEASES OF THE NEWLY BORN. 

may occur as one of the lesions in the hemorrhagic disease of the newly 
born. The most important causes, however, are connected with parturi- 
tion. These haemorrhages are essentially mechanical, and are favoured 
by everything which increases or prolongs pressure upon the head. The 
conditions with which they are associated are tedious labour, breech pres- 
entations with difficulty in extracting the head, instrumental deliveries, 
and premature births. The majority occur in first-born children. Certain 
cases are associated with cardiac malformations — according to Bednar, a 
small aorta with hypertrophied heart, or the transposition of the large 
blood-vessels. In many of the cases there is also a haemorrhage outside 
the skull. 

Lesions. — These haemorrhages are very much more common at the 
base than at the convexity, and at the posterior, than at the anterior part 
of the skull. They are most frequently found over the cerebellum and 
the occipital lobes of the cerebrum. The entire extravasation is often 
beneath the tentorium. The extent of the haemorrhage is exceedingly 
variable. There may be a single large clot at the convexity or at the base 
(Plate II), the haemorrhage may be limited to the convexity of one 
hemisphere, or it may cover nearly the entire surface of the brain. Dif- 
fuse haemorrhages are more common than a single circumscribed clot. 
Of the eleven cases collected by McNutt (New York), in seven cases 
with vertex presentations the lesion was principally at the base, and usu- 
ally limited to that region. In four breech cases, however, it was prin- 
cipally at the convexity. The source of the blood may be a laceration of 
one of the sinuses of the dura mater caused by the overlapping of the 
parietal bones. This was found in one of the cases of Hirst (Phila- 
delphia). Much more frequently the blood comes from one of the cere- 
bral veins, or from the capillary vessels of the pia mater. In thirty- 
seven of Bednar's fifty-two cases, the extravasation was beneath the pia 
mater. In the remainder it was between the pia mater and the dura — 
i. e., in the arachnoid cavity. Haemorrhages between the dura and the 
skull may be said never to occur except when associated with fracture. 
If the child is still-born, or if death has occurred on the first or second 
day, the blood is partly fluid and partly coagulated ; later it is entirely 
coagulated and may have undergone partial absorption. The amount of 
extravasated blood varies between one drachm and four ounces, the aver- 
age amount being about one ounce. The blood extends into the fissures 
between the convolutions and sometimes into the ventricles along the 
choroid plexus, although this is rare. In large haemorrhages the brain 
substance is softened and in places may be quite disintegrated ; but with 
small extravasations these changes are very slight. In cases which survive 
for two or three weeks there is usually a certain amount of meningitis. 
The later changes — those of arrested development of the cortex aud cere- 
bral sclerosis — will be considered in the chapter devoted to Cerebral Pa- 



PLATE II. 




Meningeal Hemorrhage in the Newly Born. 

From a patient in the Nursery and Child's Hospital, dying on the sixth day. 
Primary respirations poor; child very dull and apathetic, refused to nurse ; once vom- 
ited blood and had an ecchymosis of the right conjunctiva. On the last day. high 
temperature (105° F.) and general convulsions. Some changed blood found in the 
stomach and intestines at the autopsy; brain greatly congested, and at the b*se u;ls 
the clot shown in the picture. 



CEREBRAL PARALYSIS. 109 

ralyses in the section on Diseases of the Nervous System. Haemorrhages 
into the membranes of the upper part of the cord are found in a large 
proportion of the fatal cases. Associated haemorrhages of the lungs and 
other organs are not uncommon. 

Symptoms. — If the haemorrhage is large, the child is usually still-born, 
although its movements may have been active up to the commencement of 
labour. When the haemorrhage is not so large as to be immediately fatal, 
the child may show no symptoms except dulness or torpor, with feeble 
or irregular respiration, death following within the first twenty-four 
hours. A large proportion of the cases are born asphyxiated, and fre- 
quently they are resuscitated only after considerable effort. They nurse 
feebly, often with great difficulty. Convulsions are common in cases 
which last for four or five days, and more with haemorrhages at the con- 
vexity than with those at the base. Opisthotonus is often present, also 
general rigidity of the extremities, clenching of the hands, and increased 
knee-jerks. Rarely there is complete relaxation of all the muscles. Some- 
times there are automatic movements. The respiration is usually dis- 
turbed; in most cases it is slow and irregular. The pulse is feeble and 
slow. The pupils are more frequently contracted than dilated, and there 
may be oscillation of the e}~eballs. In large haemorrhages there is marked 
bulging of the fontanel, and often separation of the sutures. If the haem- 
orrhage covers one hemisphere, there is complete hemiplegia of the oppo- 
site side. Small localized cortical haemorrhages may cause paralysis of 
the face, arm, or leg, according to the position of the lesion, or localized 
convulsions. In large haemorrhages at the base convulsions are rare, and 
death occurs early, usually in the first two days. In extensive cortical 
haemorrhages convulsions and rigidity of the extremities are frequent, 
and life is prolonged indefinitely. 

The majority of the fatal cases die within the first four days. In 
those lasting a longer time the symptom is tonic spasm of the trunk, or 
of one or more of the extremities, with localized paralysis — monoplegia, 
diplegia, or hemiplegia, according to the lesion — and localized or general 
convulsions often continuing for two or three weeks and gradually sub- 
siding. In the mildest cases nothing abnormal may be noticed until the 
child is old enough to walk or talk. In those more severe there may be 
gradual and continuous improvement of the early symptoms, and the 
case may go on to apparent recovery, but usually there is some perma- 
nent damage to the brain. The following observation of McXuti illus- 
trates the course and termination of one of the severe cases of meningeal 
haemorrhage : 

Breech presentation, tedious labour, head delivered l>\ forceps, almosl 
continuous convulsions for the first nine days. After the convulsions 
there was complete paralysis of both sides of the body, doI involving Hie 
face. The child never walked or -poke; the physical developmenl was 
very backward; the limbs became contractured ; death occurred at two 
9 



HO DISEASES OF THE NEWLY BORN. 

and a half years, from pneumonia. The autopsy showed atrophy of the 
brain on both sides about the fissure of Eolando. 

. The main diagnostic symptoms in recent cases, are stupor, rigidity, 
increased reflexes, convulsions, paralysis, and opisthotonus. These vary 
with the extent and situation of the lesion. Other symptoms are changes 
in the pupils, oscillation of the eyes, and bulging fontanel. 

Prognosis. — A large haemorrhage at the base quickly causes death; 
if it is located at the convexity, although the child may survive, there is 
always serious damage to the brain. Even from small haemorrhages 
some permanent injury usually results, though the extent of this may 
not be evident for years. 

Treatment. — This is mainly prophylactic, the chief indication being 
to shorten tedious labours by the early use of the forceps. Where the 
haemorrhage has been attributed to the forceps, the damage has rather 
been the result of the long-continued pressure before they were used. 
Nothing can be done after delivery to limit the amount of the haemor- 
rhage, except to keep the child as quiet as possible. The removal of the 
clot by surgical operation has twice been successfully accomplished by 
Cushing (Baltimore). With more accurate diagnosis there seems to be 
no reason why a considerable number may not be saved. The hopeless 
outlook for such cases when not relieved, justifies the taking of great 
risks. 

FACIAL PARALYSIS. 

The usual cause of facial paralysis is the use of the forceps, but this 
does not explain all the cases. The etiology of those in which the forceps 
have not been used is still somewhat obscure. In peripheral facial palsy 
the nerve is pressed upon, either near its exit from the stylo-mastoid fora- 
men, or where it crosses the ramus of the jaw, at which point the parotid 
gland gives it but little protection in the newly born. If the lesion is 
in front of this point, any one of the terminal branches may be affected ; 
most frequently it is the temporo-facial branch. As only one blade of 
the forceps commonly touches the face in this region, the paralysis is, as 
a rule, unilateral. 

Roulland has reported several cases not due to the forceps. In these 
the pressure is believed to have been produced by the promontory of the 
sacrum at the superior strait, or by the ischium at the inferior strait, as 
paralysis followed when the head was long arrested at one of these points. 
It was not seen with face or breech presentations. When facial paralysis 
is of central origin it depends generally upon a meningeal haemorrhage, 
and the arm and leg of the same side as the face are involved. It is, 
however, possible for a very small cortical haemorrhage to produce paral- 
ysis of the face only. This occurred in a case reported by McNutt. 

In repose, the only symptom noticed may be that the eye remains open 
upon the affected side, owing to paralysis of the orbicularis palpebrarum. 



PARALYSIS OF THE UPPER EXTREMITY. Ill 

When the muscles are called into action, as in crying, the whole side of 
the face is seen to be affected. The paralyzed side is smooth, full, and 
often appears to be somewhat swollen. The mouth is drawn to the side 
not affected. In this paralysis, the tongue, of course, is not implicated. It 
is therefore rare that nursing is seriously interfered with.* If the pa- 
ralysis is of central origin, only the lower half of the face is involved, 
while in peripheral paralysis, as the trunk of the nerve is injured, the 
upper half of the face, including the orbicularis palpebrarum, is also 
affected. 

The paralysis is generally noticed on the first or second day of life, 
and does not increase in severity. Its course and termination depend 
upon the extent of the injury done to the nerve. Some idea of this may 
often be gained by the amount of injury to the soft parts, although this 
is not an infallible guide. In cases not due to the forceps, the paralysis is 
slight and disappears in a few days; the great majority of the forceps 
cases follow the same favourable course, the paralysis gradually disappear- 
ing without treatment in about two weeks. In more serious cases it may 
last for months, or it may even be permanent. The reaction of degenera- 
tion is present in these severe cases, and there may even be perceptible 
atrophy of the muscles. This symptom is fortunately extremely rare. 

Treatment. — Nothing should be done for the first ten days except to 
protect the eye and keep it clean. If improvement has begun by the end 
of this time, the probabilities are that the case will require no treatment. 
If no improvement has taken place by the end of the third or fourth week, 
electricity should be used regularly and systematically. If the muscles 
respond to it, the faradic current may be employed ; if not, galvanism 
should be used. The electrical treatment should be continued for several 
months, or until recovery has taken place. 

PARALYSIS OF THE UPPER EXTREMITY. 

When this is due to a peripheral lesion it probably never involves the 
entire arm, but affects only certain muscles or groups of muscles. Al- 
though commonly occurring after an artificial delivery, it may be seen in 
cases where the labour has terminated naturally. Roulland f has reported 
a case in which deltoid paralysis, occurring in a large child, was attributed 
to pressure upon the shoulder during labour. In vertex presentations, 
paralysis is most frequently due to the forceps where one of the blades 
has extended down upon the neck, injuring the lower cervical nerves. It 
may be produced by traction with the finger in the axilla. Roulland 
reports a unique case of paralysis of both extremities, apparently due to 

* In this connection it is to be remembered that the principal part in nursing is 
done by the tongue, and not by the lips, 
f Paralysies des nouveau-nes, Paris, 1887, 



112 



DISEASES OF THE NEWLY BORN. 



the cord being very tightly wound around the neck. The great propor- 
tion of all cases of paralysis of the upper extremity follow extraction in 
breech presentations. The injury is usually inflicted by traction upon the 
shoulder in the delivery of the head, or in bringing down the arms when 
they are above the head. In the latter case the paralysis may be double 
and associated with fracture of the clavicle or humerus. In shoulder 
presentations, paralysis may be produced by traction upon the arm itself. 

The most common form of peripheral paralysis is that known as the 
" upper-arm type," or Erb's paralysis, in which the injury is inflicted at 
the anterior border of the trapezius muscle at the lower part of the neck, 

usually in such a position 

. ..-- as to affect the fifth and 

/'•■ sixth cervical nerves. The 

jm muscles paralyzed are the 

deltoid, biceps, brachialis an- 

'" r> ~ ' Jtj ticus, supinator longus, and 

* ■ -k sometimes the supra- and in- 

fra-spinatus. All these mus- 
cles may be involved, or only 
part of them, and in varying 
degrees. In case the injury 
is slight, the paralysis may 
not be noticed for some 
weeks. If severe, it is evi- 
dent in the first few days. 
The arm hangs lifeless by 
the side ; it is rotated in- 
ward, the forearm pronated, 
the palm looking outward 
(Fig. 22). The forearm and 
\hand are not affected. In 
severe cases there may be 
anaesthesia of the outer surface of the arm, in the region supplied by 
the circumflex and external cutaneous nerves. This is rarely marked, 
and in its slighter degrees it is very difficult to determine. It is char- 
acteristic of this paralysis that the triceps is not affected, so that power 
to extend the forearm remains, although it cannot be flexed. Atrophy 
of the paralyzed muscles occurs after a few weeks, but the muscles are 
so small and so covered with fat that it is rarely noticeable before 
the second year. It is most conspicuous in the deltoid. In all severe 
cases the reaction of degeneration is present. In some of the cases of 
long standing there occurs a shortening of the tendon of the subscapu- 
laris muscle, often associated with subluxation of the humerus. The 
paralysis may be complicated with fracture of the clavicle, the neck of 




Fig. 22. — Erb's paralysis, infant two months old. 



TUMOURS OF THE UMBILICUS. 113 

the scapula, or the shaft of the humerus, or with epiphyseal separation of 
its head. 

The prognosis depends upon the severity of the injury and also upon 
the time when treatment is begun. The great majority of cases recover 
spontaneously in two or three months, improvement being observed within 
a few weeks, first in the biceps and last in the deltoid. Spontaneous re- 
covery is not to be looked for unless it occurs within the first three 
months. Not infrequently some degree of paralysis persists until the 
third or fourth year, and in some of the muscles, usually the deltoid, it 
may even be permanent. If the muscles res]3ond to faradism, rapid im- 
provement can generally be prophesied. If the reaction of degeneration 
is present, improvement will be slow and the paralysis may be permanent. 

The diagnosis is usually not difficult, since the great majority of cases 
are of the " upper-arm type " with classical symptoms. Peripheral palsy 
of the arm can scarcely be confounded with that of cerebral origin. If 
the lesion is central it is one of the rarest occurrences for the arm alone to 
be involved ; either the leg or face, or both, are generally likewise affected. 
If the case does not come under observation until the child is a year old, 
it may be difficult, or without a good history, it may be impossible to dis- 
tinguish peripheral paralysis from that due to polio-myelitis. The peculiar 
group of muscles involved in Erb's paralysis is the only diagnostic point. 

In recent cases the disability resulting from the tenderness or pain of 
syphilitic epiphysitis may simulate paralysis, but there is lacking the 
characteristic position of the arm, and a careful examination discloses the 
fact that the paralysis is only apparent. This may affect both sides. 
Fracture of the clavicle or epiphyseal separation of the head of .the hu- 
merus may also be mistaken for paralysis. In cases of long standing, 
paralysis of the deltoid may resemble dislocation of the humerus. The 
reaction of degeneration differentiates paralysis from surgical injuries 
with similar deformities. 

The treatment consists in the use of electricity, which should be begun 
at the end of the first month at the latest, and used regularly. If the mus- 
cles respond to faradism this may be employed, but in most severe cases 
they do not, and galvanism must be used, according to the rules laid down 
for facial paralysis. 



CHAPTER VII. 

TUMOURS OF Till'] UMBILICUS. 

Granuloma. — This is nothing more than a mass of exuberant granula- 
tions at the umbilical stump. The mass is generally about the size of a 

pea — sometimes larger — bleeds readily, and has a thin, purulent discharge. 



114 



DISEASES OF THE NEWLY BORN. 



It is promptly cured by the application of any simple astringent; pow- 
dered alum is probably the best. In case this is not successful, the granu- 
lations may be touched with nitrate of silver or snipped off with scissors. 
Adenoma, Mucous Polypus, or Diverticulum Tumour — Umbilical Fis- 
tula. — The first three terms are used synonymously to describe an um- 
bilical tumour covered with a mucous membrane which is similar in 
structure to that of the small intestine. It is usually associated with an 
umbilical fistula. This tumour is formed by a prolapse at the navel of 
the mucous membrane of Meckel's diverticulum. This diverticulum is the 
remains of the omphalo-mesenteric duct. When it is present in infants, 
it is found in various stages of development. Most frequently there is a 




ABC D 

Fig. 23. — Umbilical fistula and tumours produced by prolapse of Meckel's diverticulum. (Barth.) 

blind pouch a few inches long given off from the lower part of the ileum. 
In other cases it may remain patent quite to the umbilicus, causing a 
faecal fistula (Fig. 23, A). As the intestine below it is generally normal, 
this fistula may persist for months or even years, giving rise to no symp- 
toms except a slight faecal discharge from the umbilicus. In certain cases 
intestinal worms have been discharged through it. It may close sponta- 
neously or be closed by operation. 

A prolapse of the mucous membrane lining the diverticulum produces 
an umbilical tumour with a fistula at its summit (Fig. 23, B). This is 
the most common form. A cross-section shows under the microscope the 
structure of the intestinal mucous membrane both as an external covering 
and lining of the fistulous tract. The prolapse may involve not only the 
mucous membrane but the entire intestinal wall. There then exists a 
conical tumour with a fistula which has but one external opening, but at 
a short distance from the surface it bifurcates, one branch leading upward 
and one downward (Fig. 23, C). A continuation of the prolapse gives a 
broad pedunculated tumour (Fig. 23, D), which may reach the size of 
a man's fist. Its covering is the same as in the other forms. It may con- 
tain several coils of intestine. In this form there are usually two fistulous 
openings {a, b) which communicate with the intestine. 

In all of these cases the tumour is smooth, irreducible, of a rosy pink 



UMBILICAL HERNIA. 115 

colour, and from its surface there oozes a mucous discharge. Microscop- 
ical examination shows the external covering to be the same in structure 
as the intestinal mucous membrane. These tumours are generally small, 
varying in size from a pea to a small cherry, but they may be very much 
larger. A faecal fistula usually, but not invariably, coexists. In the con- 
dition represented in Fig. 23, B, it is easy to see how an obliteration of the 
fistula may occur. The small tumours are readily cured by the ligature. 
The larger ones are usually associated with other serious malformations 
of the intestines, which make the outlook bad in almost every instance. 

UMBILICAL HERNIA. 

Hernia into the umbilical cord is a rare congenital condition of a 
most serious nature. It is due to some foetal defect, and varies in size 
from a small protrusion to complete eventration in which nearly all the 
abdominal organs are outside the body. There is no hernial sac. The 
prognosis is very bad. 

The common umbilical hernia is quite a different condition, and 
while a source of much annoyance it is rarely serious. It is much more 
common in females than in males, and occurs especially in those who are 
poorly nourished and rachitic. The tumour is usually from one-fourth to 
one-half an inch in diameter ; it may, however, be very large, and may 
even become strangulated, when a surgical operation may become neces- 
sary. The ordinary cases, however, require only mechanical treatment. 
The most important thing is prevention. For this purpose it is neces- 
sary, after the cord has separated, to place a firm pad over the navel, and 
to use a snug abdominal band for the first two or three months. Aftei 
this period it is uncommon for hernia to develop. In cases coming undei 
observation after the third or fourth month, the pad and abdominal 
bandage are inadequate, and other means must be employed to retain 
the hernia. The best of these consists in the use of two adhesive strips 
applied obliquely over the abdomen, crossing at the umbilicus, the skin 
along- the median line being folded inward so as to overlap the tumour, 
this forming the retention pad. A simple method of retention is to place 
over the tumour a coin or button covered with kid and hold it in position 
by a strip of adhesive plaster ten or twelve inches long. If the skin is 
made absolutely clean and zinc-oxide plaster used, excoriations arc rare. 
The dressing should be changed every few days and worn for several 
months. After the first year all mechanical treatment is unsatisfactory. 
For the very small tumours it is really unnecessary to use any form of 
apparatus, since these cases ordinarily show little or no tendency to in- 
crease in size, and the retention apparatus causes more annoyance than 
the hernia. These small herniae seem to disappear spontaneously during 
childhood, as they certainly are not often seen in children over seven 
years of age. 



Hq DISEASES OF THE NEWLY BORN. 

MASTITIS. 

According to Guillot, a certain amount of secretion in the breasts of 
the newly born is physiological. It is certainly very common. It is most 
abundant between the eighth and fifteenth days, but may continue in 
small quantities as late as the third month. It is seen with equal fre- 
quency in both sexes. The quantity of the secretion amounts in most 
cases only to a few drops ; in some, however, as much as a drachm has 
been obtained. Chemical analysis has shown this secretion to be essen- 
tially the same as the adult milk — containing fat, sugar, proteids, and 
salts. In gross appearance it resembles colostrum. The researches of 
Sinety * have shown that the mammary gland of the newly born contains 
cul-de-sacs lined with secreting cells, resembling those of the adult. Dur- 
ing the period of secretion the gland is slightly reddened, its vessels turgid, 
and all the signs of functional activity are present. This condition in it- 
self is of no practical importance, and in most cases, if left alone, the 
secretion ceases spontaneously after a week or ten days. If abundant, it 
can usually be dried up by painting the gland with tincture of belladonna. 
It sometimes happens, however, that the presence of this secretion tempts 
the nurse or attendant to rub or squeeze the breast. Such manipulation 
occasionally leads to serious results by exciting a mastitis which may ter- 
minate in abscess. Mastitis is not a very rare condition, and although 
the inflammation is not usually severe, it' may be serious and even fatal. 
The predisposing cause is the congestion which accompanies functional 
'activity, usually in the second week. The exciting cause is most often 
some form of traumatism — undue pressure, the squeezing of the breasts, 
or rough handling by the nurse. Through abrasions or fissures thus pro- 
duced, micro-organisms find a ready entrance with the same result as in 
the adult. It seems possible that the germs may enter through the lactif- 
erous ducts without any abrasion of the skin. Want of cleanliness is al- 
ways a favourable condition for such infection. 

The symptoms of mastitis usually begin during the second week of 
life. There are redness, swelling, and the usual signs of inflammation, 
which may terminate in resolution or in suppuration. The process may 
be limited to the mammary region, or a diffuse phlegmonous inflammation 
may be set up, as in a case reported by Bush,f in which there was ex- 
tensive sloughing of the tissues of the whole of one side of the chest, with 
a fatal result. In the great majority of cases the process does not reach 
this degree of intensity, but suppuration with the formation of single or 
multiple abscesses is not uncommon. In the female it is possible for the 
cicatrization which follows such an inflammation to interfere with the sub- 

* Gazette Medicale, No. 17, 1885. 

f New York Medical Journal, March, 1881. 



INTESTINAL OBSTRUCTION. 117 

sequent development of the gland. The general symptoms are restlessness, 
loss of sleep, disinclination to nurse, and loss of weight. In cases of diffuse 
phlegmonous inflammation the general symptoms are those of pyogenic 
infection. Jourda * has collected fifteen cases of mammary abscess, twelve 
of which recovered. They began between the fourth and the forty- second 
days. In eleven cases, only one side was involved ; in four, both sides. 

Mastitis is usually due to want of cleanliness or to meddlesome inter- 
ference ; the parts should therefore be kept scrupulously clean, and on no 
account should squeezing of the breasts be permitted. They should be pro- 
tected by a simple cotton pad. If acute inflammation develops, it should be 
treated in the beginning by hot applications. Should pus form, early in- 
cision with free drainage and general tonic and stimulant treatment are 

indicated. 

INTESTINAL OBSTRUCTION. 

The most frequent causes of intestinal obstruction in the newly born 
are malformations of the intestine ; rarely it may be due to pressure from 
tumours, or from a persistent omphalo-mesenteric duct or artery. The vari- 
ous pathological conditions present in intestinal malformations are consid- 
ered in the chapter on Diseases of the Intestines. The most common seat 
of obstruction is at the anus, the bowel being normally formed through- 
out, lacking only the external orifice. The next most frequent condition 
is obstruction in the rectum, which may be due either to a membranous 
septum in the gut, or to obliteration of the tube for some distance. 
These rectal obstructions are readily recognised. By the examining finger 
or a bougie the lower limit of the obstruction can be made out, but there 
is no means by which the upper limit can be determined except by open- 
ing the abdomen. When the obstruction is above the rectum, localization 
is more difficult ; but the most frequent seat is the duodenum. Of 38 
cases collected by Gaertner, the seat of obstruction was the duodenum in 
19 cases, the jejunum in 3, the ileum in 11, the colon in C, the ileum and 
colon in 1. There is often obstruction at more than one point. 

The symptoms vary with the seat and the degree of the obstruction. 
In atresia of the anus or rectum there is at first simply an absence of all 
discharges from the bowel. Later there is abdominal distention from 
dilatation of the sigmoid flexure and colon. After several days vomiting 
begins. If there is atresia of the duodenum or any part of the small 
intestine, vomiting begins early — usually by the second day of life — and it 
is persistent. Nothing is passed from the bowels after the first dark dis- 
charge of the contents of the colon, which is chiefly mucus. There is 
rapid asthenia, and death from inanition usually occurs in four or live days. 
The higher the obstruction the shorter the duration of life. If the con- 
dition is one of stenosis only, the symptoms are similar to those described 

* These, Paris, 1889. 
10 



118 DISEASES OP THE NEWLY BORN. 

but less severe, and life may be prolonged for several weeks, or even 
months. The constipation in these cases is not absolute. When the 
cause of obstruction is external pressure, the symptoms do not always be- 
gin immediately after birth. I have recently seen a child in whom noth- 
ing abnormal was noticed for the first three weeks, but at the end of that 
time there developed all the signs of acute intestinal obstruction. Lapa- 
rotomy revealed a loop of intestine constricted by a tiny cord, which was 
probably the remains of the omphalo-mesenteric duct. 

Cases of imperforate anus and membranous septum in the rectum are 
readily relieved by proper surgical treatment. In the other varieties of 
obstruction, whether in the rectum, in the colon, or in the small intestine, 
although life may be prolonged by the formation of an artificial anus, the 
ultimate result is almost invariably fatal, death usually occurring from 
marasmus during the early weeks of life. 

DIAPHRAGMATIC HERNIA. 

This is due to a congenital deficiency in the diaphragm, which is usu- 
ally on the left side. Of 118 cases collected by Livingston, 83 were 
on the left side, 18 on the right, 4 were central, 2 were double, in 1 
the diaphragm was absent. With small openings only a single coil 
of intestine, with large ones a considerable part of the abdominal con- 
tents, may be found in the thorax. This causes displacement of the 
heart, usually to the right side, prevents the full expansion of the left 
lung, and if the deformity occurs early in intra-uterine life the lung may 
remain rudimentary. If a large deficiency exists, infants may live but 
a few hours ; with smaller ones, life may be prolonged indefinitely. Book- 
er's * patient lived two and a half months with nearly all the small intes- 
tine and omentum and the transverse colon in the thorax; and North- 
rup's f patient, who died at three years and a half of intercurrent disease, 
had several coils of the ileum, the caecum, and the appendix in the chest. 

The symptoms are in all cases obscure, the only frequent one being 
dyspnoea, sometimes constant, sometimes in severe paroxysms resembling 
asthma, these being apparently produced by an accumulation of gas in 
the thoracic part of the intestine. The physical signs are those of pneu- 
mothorax, generally on the left side, with displacement of the heart to 
the right. The condition is not amenable to treatment. 

SCLEREMA. 

Sclerema is a condition characterized by hardening of the skin and 
subcutaneous tissues. It may occur in circumscribed areas or extend over 
nearly the entire body. It affects infants who are very feeble and usually 
terminates fatally. Although sclerema is chiefly seen in the first days of 

* Archives of Paediatrics, vol. xiv, p. 649. f Ibid., vol. ix, p. 130. 



SCLEREMA. 119 

life, it is not limited to the newly born, but may occur at any time during 
the first few months. It is not to be confounded with oedema of the 
newly born, with which condition it is, however, sometimes associated. 
From published reports it appears to be of not very infrequent occur- 
rence in Europe, chiefly in large foundling asylums. In America, sclerema 
is an extremely rare disease. In a discussion in the American Pediatric 
Society, in 1889, following the report of a case by Northrup, scarcely a 
dozen cases could be recalled by the members present. I have seen but 
five cases. In the newly born, sclerema affects those who are premature 
or very feeble, sometimes those who are syphilitic. Later it may follow 
any condition leading to extreme exhaustion, especially the different forms 
of diarrhceal disease. 

The first thing to attract attention is usually the induration of the 
skin. It is often seen first in the calves or the dorsum of the feet, some- 
times first in the cheeks, but soon extends over the greater part of the 
body. It is especially marked in the cheeks, buttocks, thighs and back, 
and regions where adipose tissue is abundant. It may affect the body uni- 
formly or in circumscribed areas. The skin may be smooth or it may ap- 
pear somewhat lobulated. The colour is normal or slightly bluish, often 
tinged with yellow. The lips are blue, and the capillary circulation so 
feeble that after pressure upon the nails the blood returns slowly or not 
at all. The limbs are stiff and board-like. The skin is cold to the touch, 
and often the thermometer in the axilla will not rise above 90° F. In 
cases reported by Roger and Parrot, an axillary temperature of 71° F. was 
recorded. The general feeling of the body has been well likened by 
Northrup to that of a half-frozen cadaver. The tongue and the mucous 
membrane of the mouth are cold ; no radial pulse can be felt ; the respira- 
tion is slow, irregular, embarrassed, and at times the movements of the 
thorax are scarcely perceptible. The cry is a feeble whine, scarcely au- 
dible. The duration of the disease is usually from three to four days. 
Death occurs slowly and quietly. If recovery takes place there is gradual 
improvement in the circulation and nutrition, and, later, a disappearance 
of the areas of induration. 

The causes of sclerema are general, the most important factors being 
loss of fluids, great feebleness with lowering of the body temperature, and, 
in consequence, hardening of the subcutaneous fat. If it be true, as 
stated by Langer, that the fat of early infancy contains more palmitine 
and stearine than that of adults, it is easy to see how this may occur. 
There are no essential lesions in this disease. Atelectasis is often pres- 
ent, and may have something more than an accidental association, as 
incomplete aeration of the blood is no doubt a factor in the product ion 
of the symptoms. In Northrup's case, the skin after being injected was 
studied with great care microscopically, with absolutely negative results. 

The prognosis is very bad, because of the grave conditions of which it 



120 DISEASES OF THE NEWLY BORN. 

is the expression, but it is not invariably fatal. In its milder forms, 
where treatment is begun early, recovery may take place. The diagnosis 
is to be made from oedema by the fact that there is no pitting upon pres- 
sure, by the rigidity of the body, and by the great reduction in the tem- 
perature. The most important thing in treatment is artificial heat ; noth- 
ing but the incubator is efficient. In addition to this, care should be taken 
to promote the general nutrition by careful feeding and by all other 
means possible. 

(EDEMA. 

(Edema has often been confounded with sclerema, but, although they 
may sometimes exist together, the conditions are quite distinct. (Edema 
occurs in delicate infants, and is associated with a feeble heart, especially 
of the right side, in consequence of which there are insufficient aeration of 
the blood, overfilling of the veins, and often a lowering of the body tem- 
perature. It also depends upon poor blood states, like severe anaemia, and 
I have seen it occur after haemorrhages. The kidneys are unaffected. 

The swelling is first noticed in the eyelids, the dorsum of the feet, the 
hands, or in dependent parts of the body. It may come on quite sud- 
denly. In severe cases there may be general anasarca, but dropsy into the 
serous cavities is rare. Sometimes the first thing observed may be a sud- 
den increase in weight before the oedema of any part is striking enough 
to be noticed. The general condition is feeble ; the surface of the body 
cool ; the temperature often subnormal ; the cry weak ; the urine often 
scanty, but rarely albuminous. The diagnosis of oedema is quite easy, the 
parts having the same appearance as in older patients. They are soft and 
waxy-looking, and pit upon pressure. While in most cases the prognosis 
is unfavourable, the disease is not necessarily fatal, since some even of the 
severe cases recover. The usual duration is five or six days ; but there are 
frequently relapses. 

The object of treatment is first to promote the general nutrition by all 
available means, and then to improve the circulation by the administra- 
tion of heart stimulants, particularly digitalis and alcohol. In cases of 
extensive oedema, alkaline diuretics, like the citrate of potash, may be 
combined with digitalis. The body-temperature must be carefully main- 
tained by artificial heat. The principal complications are diseases of the 
lungs and of the intestines. 

INANITION FEVER. 

The term inanition fever is not altogether a satisfactory one ; but, 
until these cases are better understood, it is adopted because it empha- 
sizes the very close connection which exists between the rise of tem- 
perature and the condition of inanition or starvation. Under this head- 
ing are included cases seen during the first five days of life — generally 
from the second to the fourth day — in which there is an elevation of tern- 



INANITION FEVER. 121 

perature, apparently clue to the fact that the infant gets very little, fre- 
quently nothing at all from the breast at which it is being suckled. It 
is further characteristic of these cases that the temperature falls when the 
child is put upon a full breast, or when artificial feeding is begun, or even 
when water is administered, if freely given. Some have ascribed the 
symptoms to uric-acid infarction of the kidneys. 

So far as my knowledge goes, the first to call attention to this condi- 
tion was McLane (New York), who in 1890 reported to one of the med- 
ical societies an extraordinary case of hyperpyrexia in a newly-born child. 
The infant was found on the sixth day with a temperature of 106° F., 
near which point it had remained for three days. The child was being 
suckled at a breast which was found to be absolutely dry. A wet-nurse 
was procured, the temperature fell to normal in a few hours, and the child, 
which when first seen was apparently in a hopeless condition, was soon 
perfectly well. 

Since that time very extensive observations, extending to upward of 
three thousand cases, have been made at the Sloane Maternity and Nurs- 
ery and Child's Hospitals, which have established the fact that a rise of 
temperature to 102° or even 104° F. is quite common in newly-born in- 
fants during the first few days. This fever is accompanied by no evi- 
dences of local disease, and ceases in nursing infants with the establish- 
ment of the free secretion of milk. The fall in temperature is often 
rapid, dropping to the normal in a few hours after having continued for 
three or four days, and in a large number of cases it does not rise again. 

The following case is a fairly typical one of the more severe form : 
The patient was the second child, the first having died at the age of 
ten days, from no disease it was said, but simply from exhaustion. At 
birth the infant, a boy, weighed eight and a quarter pounds and was 
apparently vigorous. During the first forty-eight hours his loss in weight 
was five and a half ounces and his condition good. I saw him on the 
evening of the third day. In the preceding twenty-four hours he had lost 
eight ounces in weight, and the temperature had gradually risen, until 
at the time of my visit it was 102-8° F. The body was limp, the child 
making no resistance to examination. He cried with a feeble whine ; 
the restlessness of the early part of the day having given place to complete 
apathy. The lips and skin were very dry, the fontanel sunken, the pulse 
weak. As the father, a physician, expressed it, " he had been wilting 
through the day like a flower in the sun." Although put to the breast 
regularly, the child had apparently got very little. It was, in fact, impos- 
sible to squeeze any milk from the mother's breasts. Water was freely 
given and a wet-nurse secured in a few hours. The first milk was taken 
from the wet-nurse at 11 p. M., and the temperature, which fell gradually 
during the night, was normal the next morning and did not rise again. 
(See chart, Fig. 24). During the succeeding four days the child gained 



122 



DISEASES OF THE NEWLY BORN. 



eighteen ounces in weight, and at the end of a week was as well as an 
average infant of his age. 

The symptoms are so uniform and so characteristic that they make 
for these cases of fever a class by themselves. The frequency with which 
this is seen is shown by the following statistics : Among 200 infants taken 
successively at the Nursery and Child's Hospital, 20 had fever during the 
first five days, reaching 101° F. or over, which was not explained by 
ordinary causes and followed the course above described. In 500 suc- 
cessive children born at the Sloane Maternity Hospital, there were 135 
with a similar fever. It was seen in vigorous infants as well as in those 

who were delicate. The usual 
duration of the fever was three 
days, the temperature generally 
touching the highest point upon 
the third or fourth day of life. 
In about two thirds of the cases 
the temperature did not rise above 
102° F. ; in 9 it was 104° F. or 
over, the highest recorded being 
106° F. The fall was generally 
quite abrupt, although not always 
so. Daily weighings, which were 
made in these cases, showed that 
the infants continued to lose 
weight while the fever continued, 
and that the loss almost invariably 
exceeded by several ounces that of 
the children who had no fever. 
The maximum loss noted was 
twenty-eight ounces. In quite a large number of cases it exceeded 
twenty ounces. As a rule the infants began to gain in weight when the 
temperature remained at the normal point, but not until then. 

The symptoms presented by these infants were a hot, dry skin, marked 
restlessness, dry lips, and a disposition to suck vigorously anything within 
reach. With very high temperature there were considerable prostration 
and weakened pulse. In the less severe cases there were only crying and 
restlessness. The rapidity with which the symptoms disappeared when 
the children were wet-nursed or properly fed, was very striking. 

It is important that this fever should be recognised, because it gives at 
times the first warning of a condition which may prove fatal. The extra 
loss of ten or fifteen ounces in the first week, is a serious handicap to 
newly-born infants, the effect of which may last for several weeks. The 
temperature of every child should be taken during the first week. All the 
usual local causes of fever are first to be excluded by a physical examina- 



102' 



101' 



100 



12 3 4 5 6 7 8 






3 


i 


I 


_t 


§ : 


i : = 


X J - 


I :: 


I— 
, 




x 3 


^ 



Fiq. 24. — Temperature chart. Inanition fever. 



INANITION FEVER. 123 

tion. This fever can hardly be confounded with that due to pyogenic 
infection, which rarely begins before the fifth or sixth day. 

The treatment is simple — viz., to give water regularly every two hours, 
in quantities up to an ounce at a time if required by the thirst of the 
child. This should be done in every case where the temperature reaches 
101° F. When the temperature does not at once begin to fall, the infant 
should be put upon another breast or artificial feeding should be begun. 
Examination of the breasts from which the child has been nursing will 
usually reveal the fact that the secretion of milk is very scanty and often 
entirely absent. 

Such a fever I have occasionally seen in older infants, usually in those 
who are nursing dry breasts or where fluid food and water have been with- 
held because of some gastric disturbance. It yields as promptly to treat- 
ment as does the same condition in the newly born. 



SECTION II. 
NUTRITION. 

CHAPTEE I. 

" INTRODUCTORY. 

Nutrition in its broadest sense is the most important branch of 
paediatrics. Nowhere else and at no other time of life does prophylaxis 
give such results as in the conditions of nutrition in infancy. The larg- 
est part of the immense mortality of the first year is traceable directly 
to disorders of nutrition. The importance of correct ideas regarding 
this subject can hardly be overestimated. The problem is not simply to 
save life during the perilous first year, but to adopt those means which 
shall tend to healthy growth and normal development. The child must 
be fed so as to avoid not only the immediate dangers of acute indigestion, 
diarrhoea, and marasmus, but the more remote ones of chronic indiges- 
tion, rickets, scurvy, and general malnutrition, since these conditions 
are the most important predisposing causes of acute disease in early life. 

One of the difficulties has always been that temporary success may 
mean ultimate failure. If the injurious effects of improper feeding were 
immediately manifest, there would be very much less of it than exists 
at the present time. Many things are valuable as temporary foods, which 
when used permanently are injurious. No better illustration of this is 
seen than in the too exclusive use of the carbohydrate foods. Infants 
fed upon many of the proprietary foods often grow ven^ fat, and for the 
time appear to be properly nourished. The effect of the absence from 
the diet of some of those elements which are of vital importance may not 
be evident for months. The physiological laws regarding the require- 
ments of the growing organism can not be ignored without serious con- 
sequences, which will sooner or later be evident. Correct ideas of infant 
feeding are based upon a knowledge of these laws. An accurate under- 
standing of fundamental principles is essential to success and the vast 
majority of failures may be ascribed to ignorance or disregard of them. 

124 



THE FOOD CONSTITUENTS— PROTEIDS. I2i 



THE^ FOOD CONSTITUENTS AND THE PURPOSES THEY SUBSERVE 

IN NUTRITION. 

In infancy and childhood, as in adult life, the elements of the food 
are five in number : proteids, fats, carbohydrates, mineral salts, and water. 
The forms in which they must be furnished to the child, and the relative 
quantities in which they are demanded, are different from those required 
by the adult. One reason for this difference is the delicate structure of 
the organs of digestion in infancy, and their inability to assimilate cer- 
tain forms of food. Again, provision must be made not only for the 
natural waste of the body, but for its rapid growth, nearly trebling in 
size, as it does, during the first twelve months. 

Proteids. — The proteids are essential to life, since they are the only 
kind of food which is capable of replacing the continuous nitrogenous 
waste of the cells of the body, upon the healthy condition of which the 
digestion and assimilation of the other elements of the food depend. 
Without the aid either of the fats or the carbohydrates, the proteids may 
sustain life and may even prevent a loss of weight for a time ; but in so 
doing a great excess of such food is required, as twenty-two parts of pro- 
teid can do the work of only ten parts of fat. Such a diet taxes severely 
the digestive organs and the kidneys. When, however, fats and carbohy- 
drates are added to the food, only one-half or one-third as much proteid 
is required to replace the nitrogenous waste, as in the case of an exclusive 
proteid diet. 

Of all the forms in which proteid food may be furnished to the body, 
in proportion to its nitrogen content, milk requires for its digestion the 
smallest amount of gastric and pancreatic juice. This fact is of the 
greatest importance and indicates the superiority of milk as a food, 
not only for the first year but throughout childhood. The most easily 
digested proteids are those of woman's milk. The greatest difficulty in 
artificial feeding is to supply their place for the nutrition of young in- 
fants when woman's milk is not available. The proteids of cow's milk 
present marked differences which are not yet fully understood. 

Although the digestion of the proteids is begun in the stomach, it 
is principally carried on in the intestines. Disturbances of digestion due 
to the proteids are, therefore, attended by intestinal rather than gastric 
symptoms, an important point to be remembered both with nursing in- 
fants and with those who are taking cow's milk. 

The proteid molecule is a very complex one when compared with that 
of the fats or carbohydrates. Growing out of this complexity of struc- 
ture is the relative difficulty of digestion and the possibility of an im- 
mense number of side-products which may be formed by the splitting 
up of the proteid molecule by digestive ferments or by the numbers and 
varieties of bacteria found in the intestine. While the products of decom- 



126 NUTRITION. 

position of the carbohydrates are often very irritating, those formed from 
the proteids may be very toxic and may be the cause of obscure and 
severe clinical conditions. 

The prolonged use of a diet in which the proteids are insufficient in 
amount or are furnished in such form that they can not be digested or 
assimilated, produces a certain definite .group of symptoms which are not 
always referred to their proper cause. In infants the most striking are 
anaemia, poor circulation, fee]ble muscular power, disinclination to exer- 
tion, and various functional nervous disturbances. Such children are 
often very fat. 

The vegetable proteids can not permanently take the place of the ani- 
mal proteids in the food of young infants.. 

Fats. — The uses of the fats in nutrition are many and varied. 

They form the most important source of animal heat, their caloric 
value being a little more than twice as great as that of the carbohydrates 
or the proteids. 

They save nitrogenous waste. The fats should be supplied in the 
food in such amount that the entire energy of the proteids may be 
utilized for the growth and nutrition of the cells of the body without 
being drawn upon to furnish animal heat. The rapid growth of the 
body in early life makes such demands upon the proteids that it is desir- 
able that other elements of the food should do the work of the proteids 
whenever possible. 

The fats increase the body weight. The large amount of fat stored 
up in the subcutaneous tissues in infancy is one of the best evidences 
of health. 

The fats supply important elements needed for the normal develop- 
ment of the nervous system. This fact is probably connected with the 
large amount of fat of various forms which the nerve structures contain. 
It is a familiar clinical fact that functional nervous disorders are exceed- 
ingly common as a result of the long-continued use of foods low in fat. 
Many such disturbances commonly seen with rickets are regarded by 
some as a consequence of fat-starvation. 

In the growth of bone the fats play an important role. The fatty 
acids formed in the intestine by the splitting up of the neutral fats of 
the food, combine with the insoluble salts of lime and magnesium and 
in this way, chiefly, these substances necessary for the growth of the 
skeleton are absorbed. Normal bony development, therefore, suffers if 
-the food is low in fat. 

The unabsorbed fats have a distinct value in preserving the proper 
consistency of the fascal mass. While neither the proteids of milk nor 
the milk sugar appears as such in the stools of the nursing infant, fat is 
abundant. It forms normally from 10 to 15 per cent of the dry sub- 
stance of the stool. The amount furnished to the infant is, therefore, 



CARBOHYDRATES. 127 

considerably in excess of the needs of the bod}' for nutrition. The use 
of this excess seems to be to increase the volume of the stool and to keep 
the mass so soft as to be easily expelled. This is readily appreciated by 
comparing the stool of a healthy nursing infant receiving a food contain- 
ing 1 or 45 per cent fat with that of an infant fed upon diluted cow's 
milk containing 2 per cent fat. In a sense, therefore, fat may be re- 
garded as a natural laxative. 

The amount of fat required in infancy is relatively much greater than 
in adult life. A well-nourished nursing infant weighing 15 pounds 
actually receives about one-half as much fat as is allowed in a ration for 
an adult doing moderate work, who weighs ten times as much. 

"While it is evident from the foregoing that the fat requirements of 
the young child are great, it must also be remembered that in certain 
conditions even the normal amount of fat is badly borne and may do 
positive harm. Fats do not readily form products injurious to the econ- 
omy as a consequence of imperfect digestion, but the amount given should 
be very greatly reduced in the following circumstances: (1) All wasting 
conditions depending upon disorders of digestion, whether due to func- 
tional derangement of the stomach, intestine, liver, or pancreas, or to 
chronic catarrhal inflammations of the stomach or intestine; (2) all 
acute disorders of digestion or acute inflammations of the stomach or 
intestines; (3) all febrile conditions, no matter from what cause. A 
failure to regard these contraindications is a constant source of trouble 
in practice. 

In the conditions just enumerated the fats must largely be replaced 
by the carbohydrates, as these substances are capable for the time being 
of assuming the functions of the fats, and besides are easily digested and 
assimilated. Such substitution should not be continued too long, as 
serious results may follow. The importance of fats in nutrition does 
not end with the first year ; they should be supplied liberally throughout 
childhood in the form of cream, eggs, butter, and cod-liver oil. 

Carbohydrates. — Although these, like the fats, can not replace the 
nitrogenous waste of the body, they are important aids to the proteids, 
and in this respect they are even more valuable than the fats. The carbo- 
hydrates are partly converted into fats, and may thus increase the body- 
weight. They are capable of replacing the fat-waste of the bod} r . They 
are one of the- most important sources of animal heat. 

Carbohydrates are the most abundant of the solid elements of the 
food, although they form a smaller percentage of the entire quantity of 
food in infancy than in adult life. The soluble carbohydrates which are 
used as foods for children are milk sugar, cane sugar, and ma I 
Since all of these are converted by digestion into glucose they are to a 
certain degree interchangeable. In selecting milk sugar as the chiei 
carbohydrate for the first year, we arc following Nature, for this is what 



128 NUTRITION. 

is furnished in the milk of all mammals. Milk sugar has a decided ad- 
vantage in not fermenting with the common varieties of yeast present 
in the stomach, as do both maltose and cane sugar. Like the other 
sugars, however, milk sugar does readily undergo fermentation in the 
intestine by the action of bacteria. 

The ability of the young infant to digest starches is relatively feeble, 
although this power does exist to some degree even from birth; but the 
greater part of the carbohydrates required should be furnished in the 
form of sugars. To infants of six months and over, starches may advan- 
tageously be added to the diet, and after the first year the quantity may 
be considerably increased. But in whatever form or quantity used thor- 
ough cooking is indispensable. Insufficient cooking is responsible for 
much of the starch indigestion seen in young children. 

The advantages of the carbohydrates as foods depend upon their easy 
digestibility. The transformation of any of the sugars into glucose is a 
relatively slight chemical change, when compared with that which is 
necessary in the fats or proteids before they can be absorbed. 

The carbohydrates are at a great disadvantage on account of the readi- 
ness with which they undergo fermentation in different parts of the 
alimentary tract. To such fermentations are due many of the symptoms 
seen in the common functional disorders of digestion. 

A diet consisting too exclusively of carbohydrates leads often to a 
rapid increase in weight, but it is not accompanied by a proportionate 
increase in strength. Infants so fed have but little resistance, and many 
of them become rachitic. The easy digestion of a food consisting chiefly 
of soluble carbohydrates, and the rapidity with which children so fed 
gain in weight, lead to a great misapprehension in regard to their value 
as foods. The ultimate results of such one-sided feeding, if long con- 
tinued, are almost invariably disastrous. 

In building up the cells of the body the proteids are first in impor- 
tance, the carbohydrates second, and the fats third. In the production of 
animal heat the fats come first, the carbohydrates second ; practically the 
proteids should never be called upon for this purpose. In a proper diet, 
all of these elements are represented. 

Mineral Salts. — These are relatively of greater importance in infancy 
than in later life, because of the rapid development of the skeleton dur- 
ing infancy and early childhood. The most important for this purpose 
are the. phosphates of lime and magnesium. These are furnished in 
abundance both in woman's and cow's milk. These salts are also neces- 
sary for cell growth. Other inorganic salts furnish the elements from 
which the mineral constituents of the blood and digestive 'fluids are 
formed, and still others facilitate absorption, excretion, and secretion. 

Water. — The food of all young mammals consists of from eighty to 
ninety per cent of water. This is needed for the solution of certain parts 



WOMAN'S MILK. 129 

of the food, such as the sugar, the salts, and some of the proteids, and for 
the suspension of the other proteids and the emulsified fat. All the food 
is thus dissolved or very finely divided so as to be more readily acted upon 
by the feeble digestive organs of the infant. Water is needed also in 
large quantities for the ,rapid elimination of the waste of fhe body. In 
proportion to its weight, an average infant during the first year requires 
about five times as much water as an adult. During the time when the 
child is upon an entirely fluid diet, the addition of much water other than 
that supplied by the food is unnecessary; but when the number of feed- 
ings becomes less frequent, and solid food is given in larger quantities, 
water should be given freely between the feedings at all seasons, but 
especially in the summer. 

Caloric Values. — The different foodstuffs have different caloric values : 

One gram of fat yields 9 ' 3 calories. 

" " " carbohydrates < " 4'1 " 

" " " proteids " 4*1 " 

It is important that these caloric values should be considered in the 
dietarv. 



CHAPTER II. 
THE INFANTS DIETARY. 

WOMAN'S MILK. 

Woman's milk is the ideal infant-food. A thorough knowledge of 
its character, exact composition, and variations is indispensable, for upon 
this knowledge are based all our rules for the preparation of foods used 
as substitutes for woman's milk when this can not be obtained. 

Woman's milk is a secretion of the mammary glands and not a mere 
transudation from the blood-vessels ; although under abnormal conditions 
it may partake more of the character of a transudation than a secretion. 
A lew drops may be squeezed from the breasts before parturition; gen- 
erally speaking, however, it is only present after delivery. During the 
first two days the secretion is scanty. Usually upon the third or fourth 
day it becomes well established, although it may be delayed until the 
fifth or sixth day. During the period of lactation, milk is constantly 
formed in the mammary glands, hut the process is more active while the 
child is at the breast. 

Physical Characters. — Woman's milk is of a bluish-white colour ami 
quite sweet to the taste. When freshly drawn its reaction is ampho- 



130 



NUTRITION. 



terie to litmus, or slightly acid to phenolphthalein. The specific gravity 
varies between 1026 and 1-036, the average being 1031 at 60° F. On 
the addition of acetic acid only a slight coagulation is seen, this being 
in the form of small nocculi, and never in large masses as is the case in 
cow's milk. Microscopically, there are seen great numbers of fat-globules 
nearly uniform in size and some granular matter. Occasionally there 
are present epithelial cells from the milk-ducts or from the nipple. 

Colostrum. — The secretion of the first three or four days differs quite 
markedly from the later milk. To this the name colostrum has been 
given. It is of a deep yellow colour, which is chiefly due to the colostrum- 







Fig. 25, A.— Colostrum. (Funke.) 







Fig. 25, B. — Woman's milk at a late period. 
(Funke.) 



corpuscles. It is not so sweet as the later milk. It has a specific gravity 
of 1030 to 1*040, a strongly alkaline reaction, and is coagulated into 
solid masses by heat, and sometimes coagulates spontaneously. It is very 
rich in proteids and in salts. Microscopically the fat-globules are of 
unequal size, and there are present large numbers of granular bodies 
known as colostrum-corpuscles (Fig. 25, A). These are four or five 
times the size of the milk-globules (Fig. 25, B), and they are probably 
epithelial cells which have undergone fatty degeneration. 



Composition of Colostrum* 

Proteids 5 • 71 

Fat 2 • 04 

Sugar 3-74 

Salts 28 

Water 88 23 

100-00 



From five analyses by Pfeiffer of milk obtained during the firs-t three days. 



WOMAN'S MILK. 131 

The colostrum-corpuscles are very abundant during the first few days, 
but under normal conditions they are not found after the tenth or 
twelfth day. 

Daily Quantity. — Exact information upon this point is difficult to 
obtain. There are recorded, however, extended observations made with 
great care upon eight cases,* from which some deductions may safely be 
drawn. All were healthy infants, nursing exclusively and gaining stead- 
ily in weight. 

From these observations, and others less extended, the average daily 
quantity of milk secreted under normal conditions of health may be 
assumed to be pretty nearly as follows : 

Approximately. 

At the end of the first week 10 to 16 oz. (300 to 500 grm.). 

During the second week 13 to 18 oz. (400 to 550 grm.). 

During the third week 14 to 24 oz. (430 to 720 grm.). 

During the fourth week '. . 16 to 26 oz. (500 to 800 grm.). 

From the fifth to the thirteenth week. . . 20 to 34 oz. (600 to 1,030 grm.). 

From the fourth to the sixth month 24 to 38 oz. (720 to 1,150 grm.). 

From the sixth to the ninth month 30 to 40 oz. (900 to 1,220 grm.). 

It will be noted that the amount increases very rapidty up to about 
the eighth week, and after this much more slowly. The amount of milk 

* Haehner's cases (Jahrb. f. Kinderh., xv, 23; xxi, 314). Case I. Female; birth- 
weight 7 pounds 14 ounces (3,100 grammes). First week, lost 1£ ounce (45 grammes); 
after this gained steadily during the twenty-three weeks of observation ; from second 
to ninth week, average weekly gain 8 ounces (241 grammes); from tenth to eighteenth 
week, average gain 4J ounces (138 grammes) ; from nineteenth to twenty-third week, 
average gain 4 ounces (130 grammes); weight at the end of twenty-third week, 14| 
pounds (6,690 grammes). 

Case II. Male ; birth- weight 6| pounds (2,950 grammes). Loss, first week, 3 ounces 
(90 grammes) ; after this gained steadily during the eleven weeks of observation ; from 
second to eleventh week, average weekly gain 7^ ounces (214 grammes) ; weight at end 
of eleventh week, 11 pounds 2 ounces (5,045 grammes). 

Case III. Female; birth- weight 3 pounds 9 ounces (1,620 grammes). Gain, first 
week, 1| ounce (45 grammes) ; during the succeeding twenty-one weeks of observation, 
average weekly gain 5 ounces (141 grammes) ; weight at the end of twenty-second 
week, 10 pounds 3 ounces (4,620 grammes). 

Laure's case (These, Paris, 1889). Female ; birth-weight 8 pounds 13 ounces (4,000 
grammes); loss, first week, 8 ounces (225 grammes); after this gained steadily during 
the nine weeks of observation, on an average 9£ ounces (268 grammes) weekly; at the 
end of ninth week, weight 13 pounds 3-J ounces (6,000 grammes). 

Ahlfeld's case (Deutsch. Ztschr. f. Prakt. Med., 1878). Birth-weight 7 pounds 11 
ounces (3,100 grammes). Observations continued from fourth to thirtieth week. Dur- 
ing first ten weeks, average weekly gain 5£ ounces (161 grammes); from eleventh to 
twentieth week, 7£ ounces (214 grammes); from twenty-first to thirtieth week, 6 ounces 
(168 grammes); at the end of the thirtieth week, weight 18 pounds 9A ounces (8,435 
grammes). 

Feer (Jahrb. f. Kinderh., xlii, 195). Three cases. 

In all these cases the amount of milk was determined by weighing the infant both 



132 



NUTRITION. 



varies also with the demands of the child in a very striking way. The 
quantities mentioned can not be taken as an absolute guide as to the 
amount of food to be given to bottle-fed infants. Breast milk contains 
an average of twelve per cent solids; while the modification of cow's 
milk best suited to the early months contains only from nine to eleven 
per cent solids. ■ For this period, therefore, somewhat larger quantities 
are needed than of breast milk. 

A comparison of the daily amount of milk taken with the weight of 
the child at the different periods, showed that both during the early and 
the later periods the larger children took not only more milk, but con- 
siderably more in proportion to their body-weight than did the smaller 
ones. This harmonizes with the common observation that small children 
are much more likely to be overfed than large ones. 

The average quantity taken at one nursing by five of the children 
previously mentioned was as follows : 

Approximately. 

During the first week ■§■ to 1| oz. (18 to 45 grm.). 

During the second week 1 to 3 oz. (30 to 90 grm.). 

During the third week 1£ to 4 oz. (45 to 120 grm.). 

During the fourth week 1^ to 4^ oz. (45 to 140 grm.). 

From the fifth to the seventh week 2 to 5 oz. (64 to 150 grm.). 

From the eighth to the eleventh week. ... 2-J to 5-J oz. (75 to 160 grm.). 

During the fourth month 3 to 6 oz. (90 to 180 grm.). 

During the fifth month 3^ to 6^ oz. (110 to 200 grm.). 

During the sixth month 4 to 7 oz. (120 to 220 grm.). 

before and after every nursing during the entire period of observation. The following 
table gives in a condensed form the daily quantity of milk in these cases : 



Time. 



1st day 

2d day 

3d day 

4th day 

5th day 

6th day 

7th day 

Average 2d week 

Average 3d week 

Average 4th week 

Average 5th week 

Average 6th week 

Average 7th week 

Average 8th week 

Average 9th week. ........ 

Average 10th to 13th week 
Average 14th to 17th week 
Average 18th to 23d week.. 
Average 24th to 30th week 



Haehner's 


Haehner's 


Haehner's 


Laure's 


Ahlfeld's 


1st case. 


2d case. 


3d case. 


case. 


case. 


Grammes. 


Grammes. 


Grammes. 


Grammes. 


Grammei. 


20 


75 


20 






176 


135 


45 








265 


325 


70 


125 






420 


295 


99 


222 






360 


290 


124 


400 






374 


340 


136 


475 






423 


350 


156 


500 






497 


423 


229 


556 






550 


468 


314 


730 






594 


531 


379 


810 


576 


663 


561 


447 


944 


655 


740 


661 


472 


978 


791 


880 


681 


525 


1,038 


811 


835 


730 


568 


1,024 


845 


766 


665 


584 


1,085 


810 


796 




600 




869 


807 




673 




983 


870 




709 




1,029 
1,145 



Feer's 
3 cases. 
Average. 



Grammes. 



256 

(average 
1st week) 



610 
667 
753 
802 
815 
820 
795 
845 
919 
1,002 



WOMAN'S M ILK. 



133 



Between the limits mentioned the greater number of cases will un- 
doubtedly fall. The amount taken at one time is, however, modified 
by the frequency of nursing, and is therefore not so good a guide to the 
amount of food required, as is the quantity taken in twenty-four hours. 

Composition. — Many of the older analyses of milk gave erroneous re- 
sults because of imperfect methods of examination. According to the 
most recent analyses of Pfeiffer, Koenig, Leeds, Harrington, Adriance, 
and others, the composition of human milk is as follows : 





Normal average. 


Common healthy variations. 


Fat 


Per cent. 

4-00 
7-00 
1-50 
0-20 

87-30 


Per cent. 

3 00 to 5-00 


Sugar 


6 00 M 7*00 


Proteids 


1-00 " 2-25 


Salts 


018 " 0'25 


Water 


89-82 "85-50 




100-00 


100-00 100-00 



In the older analyses, the percentage of proteids is almost invariably 
too high and the sugar too low. 

The milk varies in composition somewhat with the period of lacta- 
tion. That of the colostrum period is high in proteids and salts and 
low in sugar. By the end of the second week all these elements have 
usually reached their normal averages. After this time until near the 
end of lactation the regular variations are slight. However, there is 
seen, according to Adriance, a slow but steady fall in the proteids and 
-alts and a very slight rise in the sugar, while the fat is scarcely affected 
at all. 

Proteids. — The proteids are as yet imperfectly understood. The 
important ones are casein and lactalbumin; others, lactoglobulin and 
lactoprotein, are also described. The casein is in suspension by virtue of 
the presence of lime phosphate in the milk, with which it is probably in 
combination. It coagulates only slightly with rennet, while acetic acid 
produces a loose flocculent precipitate. The lactalbumin resembles the 
scrum-albumin of the blood. Chemists are by no means agreed in regard 
to the proportion of the different proteids present in milk. Lactalbumin 
exists in woman's milk in much larger amount than in cow's milk, and 
it is more abundant than the casein, the proportion of the two being, 
according to Koenig, about as five to four. 

The total proteids of normal milk are usually from one to two per 
cent. In abnormal specimens the variations arc from 1 to K> per cent. 
The proteids are highest in the milk of the first few days ; after the first 
month they vary but little until toward the close of lactation, when the 
amount falls very markedly. 



134 NUTRITION. 

Fat. — This exists in the form of minute globules, which are held in 
a state of permanent emulsion by the albuminous solution in which they 
are suspended. The fat of woman's milk is chiefly made up of the neu- 
tral fats — palmitine, stearine, and oleine; there are also small quantities 
of the fatty acids, but these are much less than in cow's milk. Like the 
proteids, the proportion of fat is subject to wide variations, 4 per cent 
being taken as the normal average. In a series of thirty-four analyses 
made for me at the laboratory of the College of Physicians and Surgeons, 
the fat varied between 1-12 and 6-66 per cent. The highest percentage 
I have known was 10-91. In forty-three analyses by Leeds, the variations 
were between 2- 11 and 6-89 per cent. The proportion is very little 
affected by the period of lactation. 

Sugar. — The sugar is in complete solution. Its proportion is nearly 
constant, the average being seven per cent. The ordinary variations are 
usually within the limits of 6 and 7 per cent. The sugar being so im- 
portant as a heat-producing element, Nature has wisely provided that 
this shall be the most constant ingredient of the milk. The amount of 
sugar is smallest in the milk of the first week; after the first month, 
however, the variations are slight. 

Salts. — The average proportion of inorganic salts is 0-20 per cent, or 
a little more than one-fourth that of cow's milk. 

With the exception of calcium phosphate nearly all the salts are in 
solution. The milk of the first few days is very rich in salts ; after the 
first month the variations are slight but show a gradual fall in the quan- 
tity present.* 

The Examination of Milk. — The exact composition of human milk is 
to be determined only by a complete chemical analysis. There are, how- 
ever, many variations in composition which the physician may readily 
ascertain for himself by simple methods of examination. 

The quantity of milk secreted by the breasts may be estimated by the 
quantity which may be drawn by a breast-pump, although this is not a 
very reliable test. If the child nurses habitually forty or fifty minutes, 
the probabilities are very strong that the quantity of milk is small. If 
the breasts at nursing time are full, hard, and tense, the supply is prob- 
ably abundant. If the breasts are soft and flabby, and appear to fill only 
while the child is nursing, it is almost certain that the quantity is small. 
The most reliable of all tests is weighing the infant before and after 
nursing, upon an accurate pair of scales, sufficiently sensitive to indicate 
half-ounces. Two or three weighings will suffice to show conclusively 
whether an infant at three months, for instance, is getting habitually 
four or five, or only one or two ounces at a nursing. 

The reaction of woman's milk even when freshly drawn is rarely 



Bunge's analysis is given on page 150, 



WOMAN'S MILK. 





alkaline, being amphoteric to litmus, or slightly acid to more delicate 
tests ( phenolphthalein ) . 

The specific gravity may be taken with any small hydrometer gradu- 
ated from 1010 to 1-040 (Fig. 26, A). 
The specific gravity is lowered by the 
fat, but increased by the other solids. 
An ordinary urinometer will answer 
every purpose, the only difficulty be- 
ing the quantity which is required to 
float the instrument. 

Microscopical examination. — The 
microscope reveals the presence of fat 
globules, colostrum-corpuscles, blood, 
pus, epithelium, and granular mat- 
ter. Colostrum-corpuscles are abnor- 
mal after the twelfth day; pus and 
blood are always abnormal. The 
presence of any of these elements 
necessitates the suspension of nurs- 
ing, at least temporarily. But little 
importance can be attached to the size 
and appearance of the fat globules as 
affecting the nutritive properties of 
the milk. 

The determination of fat. — The 
simplest method is by the cream- 
gauge (Fig. 26, B). Its results are 
only approximate, but in most cases 
sufficiently accurate for clinical pur- 
poses. The tube is filled to the zero 
mark with fresh milk, which stands, corked, at a room temperature for 
twenty- four hours, when the percentage of cream is read off. The ratio 
of this to the fat is approximately five to three; thus 5 per cent cream 
indicates 3 per cent fat, etc. 

For an accurate determination the best ready method is the modifi- 
cation by Lewi* of the Leffman and Beam test for cow's milk. This 
is a centrifugal test requiring special tubes. 

Sugar. — The proportion of sugar is so nearly constant that it may be 
ignored in clinical examinations. 

Proteids. — Clinical methods for the estimation of the proteids arc not 
altogether satisfactory. The one giving the best results is that in which 



Fig. 26. — Apparatus for examination of 
woman's milk. 

The author's lactometer and cream-gauge. 



* Lewi's method is as follows : 

(1) Place in the milk flask 2 - 92 c.c. of woman's milk measured in a special graduated 



136 



NUTRITION. 



the proteids are precipitated by a solution of phosphotungstic and hydro- 
chloric acids in the Esbach tube, the percentages being read off after 
standing twenty-four hours.* We may also form an approximate idea 
of the proteids from a knowledge of the specific gravity and the per- 
centage of fat, if we regard the sugar and salts as constant, or so nearly 
so as not to affect the specific gravity. We may thus determine whether 
they are greatly in excess or very low, which, after all, is the important 
thing. The specific gravity will then vary directly with the proportion 
of proteids, and inversely with the proportion of fat — i. e., high proteids, 
high specific gravity; high fat, low specific gravity. The application of 
this principle will be seen by reference to the accompanying table, f 

Woman's Milk. 





Specific gravity 70° F. 


Cream — 24 hours. 


.Proteids (calculated). 


Average 


1-031 

1-028-1-029 

1-032 

Low (below 1-028). 
Low (below 1-028). 
High (above 1-032). 
High (above 1-032). 


7% 

8#-12# 

5%-6fc 
High(above 10$). 
Low (below 5%). 

High. 

Low. 


1*5* 


Normal variations . . . 
Normal variations. . . 
Abnormal variations. 
Abnormal variations. 
Abnormal variations . 
Abnormal variations. 


Normal (rich milk). 

Normal (fair milk). 

Normal or slightly below. 

Very low (very poor milk). 

Very high (very rich milk). 

Normal (or nearly so). 




no' 



Fig. 27. — Tubes for determini 
the fat in milk. A, Babcock's 
tube for cow's milk ; B, Lewi's 
modification for woman's milk. 
(See also page 147). 



Avenue, New York. 
March, 1893. 



pipette; (2) carefully rinse the pipette and add the 
same quantity of sulphuric acid C. P. of specific 
gravity 1 -830. The acid should be added slowly, and 
mixed with the milk by gently rotating the flask. 
The colour turns to a very dark brown from the 
oxidation of the sugar and proteids; (3) now add 
0-6 c.c. of a mixture of equal parts of fusel oil and 
strong hydrochloric acid ; (4) add sufficient of a 
mixture of the same sulphuric acid and water, 
equal parts, to bring the level of the fluid well up 
into the neck of the flask : (5) centrifuge for three 
or four minutes. The percentage of fat is now read 
off, each one-tenth gradation in the neck of the 
flask representing 0*3 per cent of fat in the speci- 
men of milk. 

This test has been modified by omitting the 
addition of strong sulphuric acid — the second step 
in the test — and in the third step, amyl alcohol 
is substituted for fusel oil. These reagents are 
much safer of manipulation and meet all the in- 
dications. 

* For description see Boggs, Johns Hopkins 
Hospital Bulletin, No. 187, October, 1906. 

f The author's apparatus may be obtained from 
Eimer & Amend, Eighteenth Street and Third 
For a fuller discussion of the subject, see Archives of Paediatrics, 




WOMAN'S MILK. 



137 



Any specimen taken for examination should be either the middle por- 
tion of the milk — i.e., after nursing two or three minutes — or, better, 
the entire quantity from one breast, since the composition of the milk 
will differ very much according to the time when it is drawn. The first 
milk is slightly richer in proteids and much poorer in fat. The last 
drawn from the breasts is low in proteids and high in fat. The following 
analyses from Forster illustrate these differences : 





First portion. 


Second portion. 


Third portion. 


Fat.. 


Per cent. 

1-71 
1-13 


Per cent. 

2-77 
0-94 


Per cent. 

551 


Proteids 


0*71 







Conditions Affecting the Composition of Woman's Milk. — The age of 
the nurse. — This has no constant influence. Other things being equal, 
the milk of very young women, and also of those over thirty-five years 
of age, is likely to be lower in fat than that of women between twenty 
and thirty-five years. 

Number of pregnancies. — Adriance found that the average milk of 
23 primiparae and 23 multipara?, both taken at the third month, showed 
the following differences: The milk of the primiparae was higher in fat 
(4-06 against 367) and in proteids (1-61 against 135), but a little 
lower in sugar (652 against 6 85). 

Acute illness. — In the majority of cases of acute illness of a minor 
character and of short duration there is no perceptible effect upon the 
milk. ' In the acute febrile diseases of a severe type the quantity of milk 
is reduced, the fat is low, and the proteids are apt to be high. In septic 
conditions bacteria may appear in the milk. 

Menstruation. — The effect of this is exceedingly variable, depending 
much upon the individual and the ease of menstruation. 

The nature of the changes in milk sometimes produced by menstrua- 
tion is illustrated by the following case taken from Rotch : 



■ 


Second day of men- 
struation. Bowels 
of child loose. 


Seven days after 
menstruation. 
Bowels regular. 


Forty days after men- 
struation. Child 
gaining rapidly. 


Fat 


Per cent. 

1-37 

610 

2-78 

0-15 

89-60 


Per cent. 

2-02 
6-55 
2-12 
015 
89 16 


Per cent. 

2-74 


Sugar 


635 


Proteids 


0-98 


Salts 


014 


Water 


89-79 







From observations upon 685 cases, Meyer noted disturbances in the 
child in over one-half the Dumber. My own experience accords rather 
will) thai of Pfeiffer and Schlichter, who consider it quite exceptional for 
the child to be visibly affected. Schlichter made observations upon 



138 



NUTRITION. 



infants during 233 menstrual days, noting the condition of the stools 
and digestion both before and after menstruation. In ninety per cent of 
the cases there was no perceptible influence. In only eight per cent 
were the stools bad, and in only three per cent was there disturbance 
of the stomach with vomiting. 

At the present time sufficient observations have not been made to show 
whether the differences noted in the case cited above — low fat and high 
proteids — are the rule where disturbances are produced during menstrua- 
tion. Monti's examinations lead him to the conclusion that the fat is 
not constantly affected. It is safe to say that the changes are not uni- 
form, and that in very many cases none of importance are produced by 
menstruation. 

Diet. — The fat and the proteids of the milk are much influenced by 
diet, the sugar but very little. The fat is increased by a diet made up 
largely of nitrogenous food, meat, eggs, animal broths, etc. ; it is reduced 
by stopping these articles and substituting vegetables and farinaceous 
food. The proteids are increased by overfeeding and also by too little 
exercise. Starvation lowers the fat and sometimes also the proteids; 
the latter may, however, be increased but altered in character. All fluids 
tend to increase the quantity of milk. Alcohol in the form of malted 
drinks, and malt extracts increase the quantity of milk and the amount 
of fat. The effect of alcohol upon the proteids is not constant, but they 
are usually increased. The following table gives the result of analyses 
of the milk of two women observed in the New York Infant Asylum 
before, while taking, and after taking an alcoholic extract of malt: 





I. 
Without malt. 


II. 

After taking 8 oz. malt 

daily for 10 days. 


III. 
No malt for 7 days. 


Case I: 
Fat 


Per cent. 

1-74 

1-93 
7-02 
0-20 

1-12 
1-57 
7-11 
019 


Per cent. 

3-83 
1-58 
7-43 
0-17 

2-75 
2-34 
677 
0-17 


Per cent. 

2-41 


Proteids 


2-95 


Sugar 


659 


Salts 


0-19 


Case II : 

Fat 


1-70 


Proteids 


1-26 


Sugar 

Salts 


6-04 
0-18 







The child of Case I gained one ounce and a half during the four days 
preceding the first analysis ; that of Case II did not gain at all. During 
the ten days while taking the malt, the first child gained twelve ounces, 
the second child eight ounces. During the seven days after the malt 
was discontinued, the first child gained eight ounces, the second child 
one ounce. There was a notable increase in the quantity of milk in both 
cases while taking the malt. 



WOMAN'S MILK. 139 

The nursing woman should have a generous diet of simple food, and 
should drink largely of milk or gruels made with milk. The diet should 
be a varied one, not excessive in nitrogenous food nor in vegetables. All 
salads and highly seasoned dishes should be avoided, not so much because 
they upset the child, although this may happen, as because they are likely 
to disturb the digestion of the nurse. Nearly all the common vegetables 
and fruits in season may be allowed in moderation. Strong tea and coffee 
should be prohibited, although weak tea or coffee may be allowed, each 
but once a day. Cocoa is less objectionable than either tea or coffee. In 
addition to her regular meals the nurse should have milk or gruel at bed- 
time. The diet should in all cases be adapted to her digestion. The 
bowels should move daity, by the use of laxatives if necessary. Great 
harm often results from overfeeding with its consequent indigestion. 
The regular use of alcoholic beverages should be forbidden. 

Drugs. — The elimination of drugs through the milk is somewhat un- 
certain and variable ; few of those popularly supposed to affect the child 
through the milk realty do so. Given in full doses, belladonna regularly 
appears in the milk. Opium does not do so constantly; but when the 
milk is poor, enough may be excreted to produce serious symptoms, and, 
in infants a few days old, even to cause death. The iodides and bromides 
when long administered may be eliminated in sufficient quantity to pro- 
duce their constitutional effects in the child. Mercury does not appear 
regularly, but only after prolonged use, and then in variable quantity. 
Most of the saline cathartics, arsenic, and the salic}dates are occasionally 
found in the milk. Alcohol may seriously disturb the child if taken in 
considerable quantities by a nurse, although its elimination through the 
milk is doubtful. 

Pregnancy. — The milk of pregnant women is generally small in quan- 
tity and poor in quality, especially in fat, (See Weaning.) 

Bacteria. — Under normal conditions woman's milk may contain a few 
bacteria. They are chiefly cocci derived from the external milk ducts 
and are of no importance. In suppurative inflammation of the mam- 
mary gland, numerous bacteria may be found in the milk ; also in some 
cases of puerperal sepsis. Tubercle bacilli have been demonstrated by 
Roger and Gamier in the milk of a woman with advanced tuberculosis, 
but ordinarily they are not present unless the gland is the seat of the 
disease. 

The elimination of antitoxin and other protective substances by the 
milk. — The immunity of nursing infants to most of the contagious dis- 
eases has long been noted, but until recently little understood. Roger 
has published (Revue de Med., May, 1900) a striking instance in point. 
In a single year there were admitted to a hospital 3G nursing mothers 
suffering from contagious diseases: 15 had measles; 19 scarlet fever; 
1 diphtheria; 1 mumps. In no case did an infant contract the disease 



140 NUTRITION. 

of its mother, although nursing was continued. Animal experiments 
have demonstrated the constant presence of diphtheria antitoxin in the 
milk of immunized animals. The Widal reaction has been obtained with 
the milk of mothers suffering from typhoid and with the blood of their 
healthy nursing infants. Clinical observations like that of Eoger would 
seem to admit of no other explanation than that these infants did not 
take the disease of the mothers because something was conveyed to them 
through the milk, which rendered them immune. 

Nervous impressions. — The effect of the nervous condition of a 
woman upon her milk secretion is very striking. Both the quantity and 
the composition of the milk are markedly changed by many different 
nervous impressions. Fright, grief, passion or any great excitement may 
entirely arrest the secretion, or if not arrested the milk may be so altered 
in composition as to make the child acutely ill. Worry, anxiety, fatigue, 
or prolonged nervous strain may so alter the milk as to cause it to disagree 
with a child who had previously thrived well upon it. It is the nervous 
condition of the mother more than anything else which determines her 
success or failure as a nurse. The nervous factor is of far greater impor- 
tance than the diet. If a mother would nurse successfully, she must 
have plenty of rest and sleep, keep her mind free from unnecessary 
worries, avoid social engagements, and lead a simple, regular, natural life. 
Unless she can and will do this successful nursing can hardly be expected. 

The nature of the changes produced in milk by nervous disturbances 
in the mother are as yet little understood. Some infants are so pro- 
foundly affected as to suggest the development of toxic substances in the 
milk. The milk of the tired and worried mother is nearly always low 
in fat while the proteids are usually high, possibly at the same time 
altered in their composition. 

COW'S MILK. 

The only one of the lower animals whose milk is practically available 
for infant feeding is the cow. Cow's milk being our main reliance in 
the artificial feeding of infants and the staple food of nearly all young 
children, it follows that everything relating to its production and han- 
dling is important. The practising physician should therefore famil- 
iarize himself with the main facts regarding the production and handling 
of milk according to modern methods, since no one can do more than 
he to educate public opinion in these matters, and so to improve the 
milk supply of the community. Only an outline of the subject can be 
presented here. For more minute knowledge the reader is referred to 
special works upon the subject.* 

* Convenient works for a physician's use are Richmond's Dairy Chemistry; Conn's 
Bacteria in Milk and its Products; Aikman's Milk, Its Nature and Composition, Block, 
London, 1899; Russell's Outlines of Dairy Bacteriology, 1899; and Belcher's Clean 
Milk, Hardy Publishing Co., New York. 



COWS MILK. 141 

The essential conditions to be fulfilled in cow's milk which is to 
be used as a food for infants and young children are: (1) Freshness; 
(2) it should contain no preservatives; (3) it should be from healtlry 
animals, free from tuberculosis or other taint; (4) it should be clean; 
(5) it should not be skimmed or otherwise falsified; (6) it should con- 
tain no pathogenic organisms ; ( 7) the number of other organisms should 
not be excessive. It is also desirable for purposes of infant feeding that 
the composition of the milk, particularly the percentage of fat, should be 
known, and that the milk should be as nearly uniform as possible from 
day to day and at different seasons of the year. Mixed or herd milk is 
therefore to be preferred to that from a single animal, since it is subject 
to fewer variations. The common varieties or " grade cows " should be 
chosen rather than highly bred animals, if for no other reason, because 
they are more hardy, less subject to disease, and less susceptible to other 
influences which might affect the milk. 

As ordinarily handled, milk should be used before it is twenty-four 
hours old; after this time fermentative changes occur very rapidly, and 
such milk can not in summer be used with safety for young children. 
Milk may be safe when more than twenty-four hours old provided 
special precautions are taken regarding cleanliness in producing and 
handling it, and special care in keeping it constantly at a temperature 
below 50° F. 

Preservatives are very often added, particularly in hot weather, by 
unscrupulous dealers to retard the souring of milk, in order thereby to 
avoid the necessity and expense of proper icing. Formerly boric or sali- 
cylic acid were, and recently formaldehyd has been largely employed for 
this purpose. 

Micro-organisms in Milk. — Most of the common bacteria grow read- 
ily in milk, and the conditions under which it is produced and handled 
render it liable to contamination in many ways. 

1. Disease in the cow. — From disease of the udder streptococci or 
other pyogenic germs may enter the milk in such numbers as to excite 
acute gastro-enteritis in a child. Other diseases which may possibly be 
communicated from the cow are anthrax, the " foot-and-mouth " disease, 
and tuberculosis. In the State of New York it is estimated that 7 per 
cent of the cows are tuberculous. Pearson and Ravenel estimate tin 1 
proportion in Pennsylvania at 2 or 3 per cent, while Marshall state- 
that from 10 to 25 per cent of the Eastern dairy cattle are tuberculous. 
The best veterinarians regard tuberculosis as steadily increasing among 
cattle in the United States, particularly in the Eastern Stales. 01' the 
cattle slaughtered in London, 25 per cent are stated to be tuberculous. 
Unless the process is advanced or the udder is the seal of disease, wtv 
many tuberculous cows do not have tubercle bacilli in their milk. One 
English writer (Eastes) found tubercle bacilli in 11 of 18(5 miscella- 
11 



142 NUTRITION. 

neous specimens of milk examined. For reasons given elsewhere (vide 
Tuberculosis), I can not believe the danger of acquiring tuberculosis 
through milk as great as some have represented. We need further data 
before we can say positively how often human tuberculosis is acquired 
from cows ; absolute proof being almost impossible and the reported cases 
in which such transmission seemed highly probable being still few. For 
the present milk must be regarded as one of the possible sources of tuber- 
culous infection. The sale of milk from cows showing evidence of tuber- 
culosis upon physical examination, and from those having tuberculosis 
of the udder should not be permitted. Whether we should go further and 
exclude also the milk of every cow which reacts to the tuberculin test 
is still an open question. 

2. Specific pathogenic organisms accidentally gaining access to milk. 
— The role of milk in the spread of infectious disease may be appreciated 
by the fact that in 1900 Kober collected records of 330 outbreaks 
which were traced to it. The most important disease communicated in 
this way is typhoid fever. In the reports of 195 epidemics collected, 
typhoid existed at the dairy in 148 instances; in 67 the milk was diluted 
with infected well-water ; in 7 the cows probably waded in polluted water ; 
in 24 cases the employees acted as nurses, and in 10 they continued at 
work, although themselves suffering from the disease ; in one case it was 
found that the milk-pans were washed with cloths used about patients. 

Next to typhoid the disease most often spread through milk is scarlet 
fever. A very small percentage of the cases of scarlet fever, however, 
can be traced to contaminated milk; but the sudden and simultaneous 
development of a considerable number of cases of this disease in a com- 
munity, should lead one to consider the milk supply as a possible cause. 
Of 99 epidemics of scarlet fever, there was disease at the farm or dairy 
in 68; in 17, employees were themselves affected, and in 10 they acted 
as nurses ; in 6, persons connected with the dairy either lodged in or had 
visited infected houses; in 2 infection was brought by cans or bottles 
from the houses of patients ; in 3 the milk was stored near or in the sick- 
room; in one case milk-utensils were wiped with an infected cloth. 

Very infrequently diphtheria has been spread through milk. Of 36 
outbreaks of diphtheria collected, there was disease at the farm or dairy 
in 13 ; in 3, employees themselves were ill. Twelve of the outbreaks 
included in this series, however, were of very doubtful character. Besides 
these diseases mentioned, cholera, dysentery, and certain forms of diar- 
rhoeal diseases may probably be spread by milk. 

3. Otlier bacteria found in milk. — These are chiefly derived from the 
air of the stable, the hands and clothing of the milker, and from the 
dirt which falls from the udder, belly, and tail of the cow into the pail 
during milking; very many come from the cow's excreta. Freeman 
exposed a Petri gelatin-plate beneath a cow's udder for one minute dur- 



COW'S MILK. 143 

ing milking and obtained 4,450 colonies. The varieties of bacteria found 
in fresh milk are many and vary with locality. Toward the souring 
point the great majority are of two or three varieties only; fully 95 
per cent at that time belong to the lactic-acid-producing group. They 
cause the ordinary souring of milk by acting upon the milk sugar. Colon 
bacilli are very common. Other bacteria act upon the milk proteids, 
inducing various fermentative or putrefactive changes; and still others 
have a peptonizing power. Of 15 varieties frequently present which were 
studied by Kussell, 3 belonged to the lactic-acid group, 5 were peptoniz- 
ing bacteria, while 7 had no recognizable effect upon milk. 

Many of the bacteria are no doubt harmless. None have been shown 
to be beneficial. Others, while not strictly speaking pathogenic, when 
present in large numbers induce changes in milk that so impair its 
nutritive properties as to render it unfit for food, and in susceptible 
infants may cause serious illness. The effects of bacterial contamina- 
tion of milk are considered in the introductory chapter upon Diarrhceal 
Diseases. 

The number of bacteria in milk. — This depends upon three condi- 
tions: (1) Cleanliness in handling; (2) temperature; (3) age of the 
milk. Hence the bacterial count becomes of the greatest value in fur- 
nishing information as to these matters, although of less importance in 
regard to the production of disease than the nature of the organisms 
present. The influence of the different factors may be illustrated by 
the following experiments made at the laboratory of the New York 
Health Department: A sample of milk taken under good conditions 
contained immediately after milking 300 bacteria in each drop. It was 
cooled to 45° F., and kept at this temperature. After twenty- four hours 
it contained in each drop only 200 bacteria; after forty-eight hours, 900; 
and after seven ty-two hours, 150,000. The milk curdled on the sixth 
day. Another sample, taken in a dirty barn, cooled and kept at 52° F., 
contained at first 2,000 bacteria in each drop; in twenty-four hours, 
6,000; in forty-eight hours, 245,000; in seventy-two hours, 16,500,000. 
The milk curdled on the fourth day. The influence of temperature alone 
upon the multiplication of bacteria in milk is well shown by the follow- 
ing experiment: Four samples of the same milk were kept at different 
temperatures for twenty-four hours and equal quantities were then 
plated; No. I was kept at 60° F. and showed 134,340 colonies; No. II 
was kept at 55° F. and showed 67,170; No. Ill was kept at 50° V. and 
showed 1,362; No. IV was kepi at 45° F. and showed 1 IS. 

The ability of milk to resist the growth of bacteria for a certain time 
is indicated by these and many other experiments. Exactly to whal this 
is due is not quite clear. There seems, however, to be I it lie doubl thai 
milk, in common with other animal fluids, possesses certain bactericidal 
properties which render it stable for a limited time, which are soon ex- 



144 NUTRITION. 

hausted if the temperature is allowed to rise, but which assist materially 
in its preservation during the first twenty-four hours. 

The number of bacteria in cream is nearly always far greater than 
in milk. Cream is usually much older than milk at the time of delivery. 
Huddleston's investigations of the cream supplied to New York City led 
him to the conclusion that most of the cream was seventy-two hours old 
when it reached the consumer. The consistency of much of the heavy 
cream so popular with many is obtained with age and is largely the result 
of bacterial growth. Freeman's experiments with gravity cream showed 
that the bacteria were 300 times as numerous in the cream as in the 
milk left behind, the bacteria being apparently carried up with the fat 
globules. Both these facts emphasize the necessity of the greatest care 
with reference to cream and indicate one great advantage of centrifugal 
cream, that it can be marketed at least twenty-four hours earlier than 
gravity cream. 

A bacteriological standard for pure milk. — Much discussion has arisen 
of late, especially among different milk commissions of physicians, re- 
garding the possibility of establishing some such standard. One com- 
mission requires that the milk shall not have more than 10,000 bacteria 
in each cubic centimetre ; another fixes the limit at 30,000. Methods of 
cultivating and counting the bacteria of milk are by no means uniform, 
and it is often quite impossible to compare the figures of different ob- 
servers, because not all the conditions were the same. We are not yet 
ready to fix a standard. For milk sold in cans 100,000 to the cubic 
centimetre may be considered good; for bottled milk anything under 
30,000 is good, and an average under 10,000 is exceedingly good; the 
count in all cases being made at the time the milk is offered for sale. 

The reports made by the bacteriologist of one of the New York milk 
commissions show that by the most careful handling the number of bac- 
teria * may be kept at an average of a little more than 5,000 bacteria in 
each cubic centimetre at the time when it is delivered to customers. The 
bottled milk from single high-class dairies usually ranges from 10,000 
to 100,000 under the same conditions. Milk from mixed dairies deliv- 
ered in cans ranges from 100,000 to 40,000,000, the latter being often 
reached in very hot summer weather. 

* To accomplish such a result certain special precautions were observed ; the most 
important were the following : The stables had cement floors to admit of ready flushing 
with a hose ; no hay, straw, or fodder were kept in the stables ; shavings were used for 
bedding ; the cows were carefully groomed every day and not fed until after they were 
milked ; a few minutes before milking the loose dirt was removed from the udders 
with a damp cloth. The milkers wore sterilized coats and caps, and washed their 
hands before milking each cow: all bottles, pails, etc., were sterilized with live steam, 
the pails just before using. The milk was immediately removed to the milk-house, 
where it was strained, mixed, cooled to 38° F., bottled and sealed — all within twenty 
minutes from the time it left the cows. 



COW'S MILK. 145 

The means of excluding pathogenic bacteria, and of checking the 
spread of contagious diseases through milk. — Rules are readily deducible 
from a study of the records of how milk has usually been infected. 

1. Xo person suffering from, or in contact with a person suffering 
from, a contagious disease should enter a dairy building or in any way 
come in contact with the milk or milk-utensils; especially should this 
rule be enforced in the case of diphtheria, scarlet and typhoid fevers. 

2. Milk should not be handled in or near dwellings, privies, or sta- 
bles; cans and pails should be washed only at the dairy, and after ordi- 
nary cleansing they should be washed in boiling water or sterilized with 
live steam. Especial attention should be given to milk-bottles which 
have been in infected rooms. The hands of the milker should invariably 
be carefully washed just before milking. 

3. Dairies should be subject to regular city or state inspection. Milk 
from cows showing physical evidence of tuberculosis should be excluded; 
also that from animals which are in any way sick or are suffering from 
disease of the udder should not be used. 

4. In all epidemics of contagious disease, both large and small, the 
milk supply should be carefully investigated; and all cases of such dis- 
eases in the families of those who produce or handle the milk should be 
immediately reported and closely followed up by the authorities. 

Means of reducing the number and lessening the growth of bacteria 
in milk. — A marked diminution in the number of germs present in milk, 
as it is now handled, may be brought about by attention to two condi- 
tions — cleanliness and temperature — and the results will be directly in 
proportion to the care bestowed upon them. 

Cleanliness must have reference, in the first place, to the cows them- 
selves. Since most of the germs in milk come from the cows, it is impor- 
tant that the belly, udder, and tail should be cleansed before milking, to 
prevent droppings into the pail. The parts should be wiped with a dry or 
damp cloth. Milking should be done out of doors or in a clean, special 
shed ; if in the stable, this should be clean. Xo dry fodder should be fed 
and no sweeping done, nor anything else to raise a dust, just before milk- 
ing. The milker's hands should be carefully washed and dry, not moist- 
ened with milk, as is sometimes done. Milk pails and cans should be 
washed, as stated above, and always dried upside down, remaining in this 
position until used. Pails with a small opening partially protected by 
a hood should be used to lessen the contamination with dirt from the 
cows during milking. All sieves and straining cloths should be ster- 
ilized before each using. Milk should be bottled at the dairy, and so 
transported. When this is not done the milk, after cooling. Bhould be 
put into the vessel from which it is delivered; every lime the milk is 
handled, poured from one vessel into another, or in any way manipu- 
lated, the danger of contamination is increased. 



146 



NUTRITION. 



As to temperature, no point in the care of milk is more important 
than the rapid first cooling; as soon as possible after being drawn it 
should be cooled to at least 50° F. Unless the milk is taken at once to 
a milk-house and some of the special forms of cooling apparatus em- 
ployed, the cans should be immersed in spring water having a tempera- 
ture below 50° F., or in ice- water, anjd remain at least one hour. If a 
temperature of 50° F. is maintained during transportation, which is 
quite possible if cans and bottles are properly iced, and during subse- 
quent storage, the growth of bacteria may be so retarded that milk may 
be a safe food even when forty-eight hours old. If the temperature is 
not kept as low as 50° F. this result can not be depended upon, and with 
every degree above that point the increase in bacterial growth is very 
marked. Since the number of bacteria increases so rapidly with the age 
of the milk after the first twenty-four hours, it is of the utmost impor- 
tance that milk be shipped as quickly as possible after it is collected. 

A provision of the Sanitary Code of New York city requires that no 
milk shall be sold having a temperature above 50° F. This ordinance 
has done more than anything else to improve the milk supply of the city, 
especially to insure proper icing during transportation. 

The desirable results indicated above are to be secured, in the first 
place, by educating the public to appreciate, and dealers to produce, a 
better and cleaner milk; secondly, by giving to the health authorities 
of city and state greater power than heretofore in the matter of milk 
inspection; thirdly, by the formation of milk commissions,* through 
which the physicians of a town or city may co-operate to secure adequate 
supervision of at least a portion of the milk supply. 

Composition of Cow's Milk. — Except in the percentage of fat, the 
composition of mixed or herd milk varies but little, whatever the breed. 
The fat is lowest in the Holsteins, and highest in the Jerseys. 

Composition of Cow's Milk. 





Jerseys. 


Holsteins. 


Average good 
herd milk. 


Fat 


561 
5-15 
3-91 
0-74 
84-59 


3-46 

4-84 
3-39 
0-74 

87-57 


400 


Sugar 


4-50 


Proteids 


3 50 


Salts 


0-75 


Water . 


87-25 






Total 


100-00 


100-00 


100-00 







In the table the figures for Jersey and ITolstein herds are the averages given by the 
New York State Experiment Station. The legal requirements in New York and 
most of the States are, fat, 3 per cent ; solids not fat, 9 per cent. 



* The first such commission in the United States was organized in Newark, N. J., in 
1893, largely through the efforts of Dr. H. L. Coit. It entered into a contract with a 



COW'S MILK. 147 

The figures given for herd milk are a little lower for the proteids 
and a little higher for the sugar than the older analyses. It is with 
milk of such proportions that the average physician has to do in infant 
feeding. In a poor milk the only important difference to be considered 
is that the fat is from 05 to 1 per cent lower than the averages given. 
In a rich Jersey milk the chief difference is that the fat is 1 to 15 per 
cent higher than the averages; there is also an increase in the proteids 
and sugar which is less important, but should not be ignored. The vari- 
ations in the fat content of milk are those which are of most practical 
importance to the physician. As to the relative advantages of the dif- 
ferent breeds for this purpose, the difference does not seem great, pro- 
vided all are equally healthy. Jerseys and all highly bred animals are 
more prone to serious disease and minor disturbances than the hardier 
common breeds. 

The Examination of Cow's Milk. — The application of heat often 
causes coagulation in milk which is near the souring point, and also 
in colostrum milk. Both are unfit for use. The normal inaction of 
cow's milk is amphoteric or slightly acid. If strongly acid it should 
not be used; if alkaline, it is pretty certain that something has been 
added to it. 

The specific gravity is from 1-028 to 1-033. If the milk has been 
falsified by the removal of cream, the specific gravity is raised; if adul- 
terated by the addition of water, the specific gravity is lowered. 

The best of all ready methods of determining fat are by the Leffman 
and Beam and the Babcock tests.* By both the fat is brought to the 
surface by the centrifuge after the addition of sulphuric acid and other 
reagents. These tests are similar, but differ in the reagents used. When 
carefully made they are very accurate. For institutions such an appa- 
ratus is indispensable; and the composition of the milk and the cream 
used can be determined each day. The optical test by means of Feser's 

dairyman, the terms of which were that the selection of the cows, the details regarding 
their food and care, and the handling of the milk, should be under the supervision of 
the Medical Commission. All these matters were to be carried out according to the 
most improved methods. The animals were to be subjected to a regular inspection by 
a competent veterinary surgeon ; a chemist and bacteriologist to be employed to see 
that the milk was kept up to the standard both as regards composition and purity. In 
return, the milk, which was to be delivered only in bottles, was stamped with the 
approval of the commission as " certified milk," and sold at a slightly higher price 
than ordinary milk. This plan has proved eminently successful both from a medical 
and commercial standpoint, and has, with some minor modifications, been imitated in 
several other cities with equally satisfactory results. (See Archives of Pediatrics, 
1897, p. 824; also Philadelphia Medical Journal, October 20, 1900.) 

* The apparatus can be obtained of D. H. Burrell & Co., Little Palls, N. Y. 
The one sold as the "Facile Junior" may be used for woman's milk, mine, and 
other fluids as well as for cow's milk, and is very convenient for physicians' use, 
Price, $10, 



148 



NUTRITION. 



Fat: 

7 



— 4 cc. 



lactoscope (Fig. 28) is a good one, and with a little experience in the 
use of the instrument is quite accurate.* 

The cream-gauge may be used as for woman's milk, but it is not to 
be relied upon unless the milk is put into the cylinder soon after it is 
drawn and cooled rapidly by being placed in ice-water. Under these 
conditions, if the reading is made at the end of eight or ten hours the 
percentage of cream to that of fat is about three to one. If the milk 
has been first cooled and afterward handled two 
or three times before the test is made, the cream 
does not rise regularly, and the above ratio is not 
maintained. 

A microscopical examination of milk is of con- 
siderable importance, and in cases where the char- 
acter of the supply is questionable it may give 
valuable information. Both the cream and the 
sediment should be examined. Not much can be 
learned from a study of the fat globules, but 
among them may be found colostrum corpuscles, 
which are usually present for nearly a week after 
calving. The sediment is best studied after cen- 
trifuging. It should be examined for pus cells 
and blood, and stained for bacteria. A few leuco- 
cytes are almost invariably found in normal milk. 
Stokes and Wegefarth consider that an average of 
more than five in each field examined with an oil- 
immersion lens should be regarded as abnormal, 
and such milk excluded. The most frequent source 
of pus cells in numbers is inflammation of the 
udder. Pus cells may be associated with a stringy 
mucus as muco-pus. Blood may also result from 
inflammation of the udder, sometimes from trau- 
matism. 

Where pus cells are present the specimen should 
be examined for bacteria. Any of the ordinary 
pyogenic cocci may be found. Streptococci were found by Eastes in 
75 per cent of 186 specimens examined, although in most of these the 
number was so small that no symptoms were produced. He cites one 
instance where symptoms were caused. Woodward has reported a strik- 
ing example where a family of five children were all made seriously ill 
with vomiting and collapse after taking milk which was found by him 
to contain large numbers of streptococci. These cases are probably not 



Fig. 28.— Feser's lacto- 
scope. 



very rare. 



In staining milk for tubercle bacilli it should be remem- 



* Obtained of Eimer & Amend, Eighteenth Street and Third Avenue, New York. 



COW'S MILK. 149 

bered that the bacilli found are, as a ride, shorter than those found in 
human sputum. 

At the present time it is impossible to lay down definite rules as to 
what microscopical findings justify one in condemning a sample of milk ; 
but whenever pus cells, muco-pus, blood, or streptococci are at all nu- 
merous, the milk should be regarded as unfit for food and a thorough 
inspection of the herd should be made. 

The Differences between Cow's Milk and Woman's Milk. — Cow's 
milk is more opaque than woman's milk, although the latter may contain 
the larger proportion of fat. This opacity is due to the large proportion 
of calcium phosphate with which the casein is combined. 

The reaction of cow's milk soon after it is drawn becomes acid. It 
is almost invariably found so unless some alkali has been added. Wom- 
an's milk is distinctly less acid. 

The specific gravity and total solids in the two milks are about the 
same. 

The sugar of both cow's and woman's milk is identical in composi- 
tion; it is lactose in solution. The difference in amount is considerable. 
Cow's milk usually has 45 per cent, while woman's milk usually has 
from 6 to 7 per cent. 

The greater part of the fat of cow's milk is neutral fat, as in woman's 
milk; cow's milk, however, contains in addition much larger quantities 
of the volatile fatty acids than does woman's milk. 

The proteids of cow's milk are not only two and a half times as 
abundant as those of woman's milk, but they show marked differences 
in character. 

Our knowledge of the proteids both of cow's milk and woman's milk 
is still very imperfect. The separation of the different proteids is diffi- 
cult, and for this reason chemists are by no means agreed as to the pro- 
portions in which the different ones are present. It is well established that 
in woman's milk the soluble proteids, lactalbumin, etc., are in excess of 
the insoluble casein, Koenig giving the proportion as 5 to 4; in cow's 
milk, on the other hand, the proportion of the soluble proteids is much 
smaller than the insoluble, the latest writers giving the proportion as 
1 to 3. 

The casein* of cow's milk is readily coagulated by rennet, acids, 
and many metallic salts. The curd formed by the gastric juice is tough 



* By Haliburton and some other chemists the term casemogm is given to tins 
proteid as it exists in milk. When this is acted upon by rennet, it splits up into two 
substances: One, the firm, insoluble coagulum to which only tin; term casein is 
applied; the other, a soluble proteid which is known as whey-proteid ; this is pres- 
ent in but small amount. Those who use the term casein to designate the proteid 
as it exists in milk refer to the curd formed by the action of rennet in the stomach 
as paracasein. 
12 



150 



NUTRITION. 



and firm and dissolves slowly by the action of the digestive fluids. The 
casein of woman's milk is not regularly coagulated by rennet, and only 
slightly and with difficulty by acids and metallic salts. The curd formed 
by the gastric juice is loose and flocculent, and is readily and completely 
dissolved. It is this difference in the proteids which presents the greatest 
difficulty in the use of cow's milk for infant feeding. 

The inorganic salts in cow's milk are a little more than three times 
as abundant as in woman's milk. The most important differences in 
the composition of these salts are shown in the following analyses : 

Ash in 100 Parts of Milk (Bunge). 





Woman's. 


Cow's. 


Potassium oxide. 


•0703 

•0257 
0343 

•0065 
0006 
0469 

•0445 


•1760 


Sodium oxide 


•1110 


Calcium oxide 


• 1590 


Magnesium oxide 


0210 


Ferric oxide 


•0003 


Phosphoric acid 


•1970 


Chlorine. . .' 


•1690 






Total. 


•2288 


•7970 







It will be noted that cow's milk contains relatively a much larger 
amount of calcium phosphate and a smaller amount of potassium salts 
and of iron oxide. The ash does not accurately represent the mineral 
constituents of milk. About 8 per cent of the phosphoric acid of the ash, 
according to .Richmond, is derived from the phosphorus of the casein; 
while the traces of sulphuric and carbonic acid found are not true min- 
eral constituents of milk. Most of the more recent analyses show the 
presence of citric acid in both woman's and cow's milk. 

Cow's milk always contains a large number of bacteria, which increase 
in proportion to the age of the milk; woman's milk is either sterile or 
contains but a few cocci from the milk ducts- 
Cream. — A great misapprehension exists as to its composition. It is 
often spoken of as if it were entirely different from milk. It should 
rather be regarded as milk which contains an excess of fat. 

Cream is obtained either by skimming — the gravity process — or by 
the use of a centrifugal machine known as a separator. The latter pro- 
cess has the advantage in point of time, as centrifugal cream can be put 
upon the market from twenty-four to thirty-six hours earlier than grav- 
ity cream. It is, however, attended by a slight disadvantage, as it may 
break up mechanically some of the fat-globules, so that after heating they 
may form a thin oily layer at the top of the bottle. 

The following table gives the composition of an average milk and of 
centrifugal cream of different densities removed from the same milk: 



COW'S MILK. 



151 





Whole 
milk. 






Cream. 








I. 


II. 


III. 


IV. 


V. 


Fat 


4-00 
4-50 
3-50 
0-75 


800 
4-50 
3-40 
0-70 


12 00 
4-20 
330 
0'65 


16-00 
4-05 
320 
060 


20-00 
3 -90 
3-05 
0-55 


40-00 


Sugar 


3 00 


Proteids 


2 20 


Salts 


0-45 







These will be spoken of hereafter as 8-per-cent cream, 12-per-cent cream. 
16-per-cent cream, etc., as indicating the amount of fat which they 
contain. 

The percentages of proteids and sugar in the 8- and 12-per-cent 
creams are but little lower than in milk; in the very rich creams they 
are reduced by about one-third. 

It is unfortunate that no standard exists as to what shall be sold as 
cream. In Xew York, cream sold may contain anywhere between 8 and 
40 per cent fat. The very rich, centrifugal cream has from 35 to 40 
per cent fat; the ordinary centrifugal cream has about 18 to 20 per 
cent. Most of the gravity cream sold has from 1G to 20 per cent fat. 
It is possible to obtain from the milk laboratory cream of any desired 
percentage. 

Xone of the methods for determining the fat in milk is applicable 
to cream, except the Babcock or Leffman and Beam test. 

Top-Milk. — To secure a milk for infant feeding which is fresh and 
at the same time one which contains an extra amount of fat, the prac- 
tice has come largely into vogue of using the upper portion — a third, 
fourth, or fifth from milk purchased and delivered in bottles — after it 
has stood only a few hours. To this the term " top-milk " or " upper- 
milk " has been given. Different percentages of fat may be obtained by 
varying the amount removed and the length of time the milk has been 
allowed to stand. Top-milk and thin cream are practically identical in 
composition, although they may differ in freshness. 

If cow's milk from a mixed herd is put into bottles soon after it is 
drawn and rapidly cooled, it will be found that after four hours the 
upper fourth will contain nearly all the fat that will rise as cream, ami 
that the upper layers will have nearly the same percentage of fat whether 
the milk has stood for four hours, for eight hours, or over night. This 
has been demonstrated in a series of experiments made for me by Messrs. 
Upton & JefFers, at the Walker-Cordon Farm at Plainsboro. After the 
milk had been standing under the conditions mentioned, fat-tests were 
made will) the Babcock apparatus of the different four-ounce Layers of 
bottled milk which contained originally 1 per cenl of t'ai. The dif- 
ferent layers were carefully removed with a siphon, with the following 
results : 



152 



NUTRITION. 



Percentage of fat in- 


After four 
hours. 


After eight 
hours. 


Over night. 


Upper 4 oz 


20-50 
6-00 
1-50 
1-20 
1-00 


21-25 
6-50 
1-40 
1-00 
1-00 


22-00 


Second 4 oz 


6 50 


Third 4 oz 


1-00 


Fourth 4 oz 


30 


Fifth 4 oz 


0-20 







Each of these percentages represents the averages, each test having 
been repeated many times, 110 different tests in all having been made. 
It will be seen that after four hours the composition of the separate 
layers does not change very much with the period of standing. With 
this knowledge, it becomes a comparatively simple matter to secure almost 
any desired percentage of fat by simply varying the number of ounces 
removed from the upper part of the quart.* 

% This will of course not be the same with all milks, but will vary con- 
siderably according as the supply is from a good herd of selected cattle 
of mixed breeds (average 4 per cent fat), a Jersey or Alderney herd 
(5-25 to 5 -50 fat), or from widely scattered farms such as make up the 
general supply of any large town or city (3-25 to 350 fat). It is there- 
fore absolutely necessary for the physician to know with which one of 
these he is dealing, if the milk for infant feeding is to be modified at 
home from the different layers of top-milk. More mistakes are made 
just here than at any other step in this method of feeding. 

The tables given below are sufficiently accurate for home modifica- 
tion, provided the fat percentage of the whole milk is known. 

From 4 per cent Milk. 

To secure approximately a 10$ fat, remove the upper 11 oz., or about one third. 
" " " 7% " "16 " " one half. 



From 5'25 to 5-50 per cent {Jersey) Milk. 
To secure approximately a 10$ fat, remove the upper 15 oz., or nearly one half. 



u u 



24 



" three fourths. 



From 3-25 to 3-50 per cent Milk. 
To secure approximately a 10$ fat, remove the upper 8 oz., or about one fourth. 
" 7% " " " 11 " " one third. 



a u 



* A similar plan on a large scale may be followed in institutions by using an 
apparatus known as the " Cooley creamer." This consists of a wooden tank lined with 
metal, made of different sizes, holding two, four, or more cans of milk. The cans hold 
eighteen quarts, and are so covered that they can be submerged. The bottom of the 
can is inclined, and at the lowest point is placed a faucet. In the side is a glass 
window, so that the cream level can be distinctly seen. The cans are filled and 
placed in a tank of ice- water ; after six or twelve hours the lower portion is drawn off 
and the upper creamy layer left behind. In this way a cream of 7 or 10 per cent may 
be obtained. The Cooley creamer may be obtained at Bellows Falls, Vt. 



MILK STERILIZATION. 153 

The physician should make or have made with the Babeock apparatus 
several fat tests of a given milk supply in order to obtain a basis upon 
which to make his calculations, and also of his top-milk to control his 
results. In general it is wise for one who has much to do with infant 
feeding to have his patients take milk from the same supply to secure 
uniformity in his results. 

In or near large cities it is possible to obtain from the milk labora- 
tories milk with any desired percentage of fat. This of course greatly 
simplifies the whole matter. How top-milk of different percentages is 
used will be considered under The Home Modification of Milk. 

Milk Sterilizatiox. — The term sterilization is widely and rather 
loosely used to signify the heating of milk for the destruction of germs. 
It should, however, be borne in mind that none of the methods commonly 
employed renders milk sterile in the bacteriological sense of the word. 
What is accomplished is the destruction of such pathogenic germs as may 
be present, and from 95 to 99 per cent of the other bacteria, so as to 
retard for a considerable time the ordinary fermentative changes. The 
preservation of milk for infant feedings by boiling it in small bottles, 
was advocated by Jacobi many }-ears ago. 

The advantages of sterilizing milk are obvious. When we consider 
the enormous number of bacteria present in cow's milk with the usual 
methods of handling, and that none of these, so far as is now known, 
are advantageous, but that they are frequently the cause of disease, it is 
not strange that after its introduction by Soxhlet in 1886 the practice 
of heating milk used for infant feeding was rapidly adopted all over the 
world. Following him, the earlier experiments in sterilization were made 
at 212° F., usually continued for an hour and a half, and this tempera- 
ture is still largely employed on the Continent of Europe. Even this 
does not render milk safe for very long. Spores are not destroyed, and 
at ordinary room temperatures spore-bearing bacteria may soon develop 
in such numbers as to make the milk dangerous. Since some of these 
bacteria act upon the milk-proteids and not upon the sugar, such milk 
may not be sour, and hence its danger may not be recognised. 

There are disadvantages in heating milk. The change in taste and 
the constipating effects of sterilized milk were soon noticed ; other altera- 
tions were not so evident and have more recently come to be appreciated. 
although many of these are not yet fully explained. Some of the lactose 
is converted into caramel, causing a slight change in colour; the lactal- 
bumin is partially coagulated, this beginning at 100° F. (70° C.) ; the 
casein is rendered less coagulable by rennet, and appears to he acted upon 
more slowly both by pepsin and trypsin; Rettger lias shown thai when 
milk is heated above l-s.*) F. (85° C.) a volatile sulphide is Liberated, 
conclusive evidence of a change in the proteids; the organic phosphorus 
is changed into an inorganic phosphate; citric acid is partially preeipi- 



154: NUTRITION. 

tated as calcium citrate, and some lime salts, which are usually soluble, 
are converted into insoluble compounds. Some changes also occur in the 
fat. Moreover, certain natural ferments in fresh milk, believed to be of 
value in digestion, are destroyed by heat. 

Many of these changes are but imperfectly understood, and some of 
them are doubtless without any injurious effect upon nutrition. There 
is, however, one important clinical reason for believing that the nutritive 
properties of milk are impaired by heating to 212° F. — viz., the occur- 
rence of scurvy in infants who are fed upon such milk for a long time. 
Of 379 cases of infantile scurvy brought together in the Eeport of the 
American Pediatric Society in 1898, sterilized milk was the previous 
diet in 107. At least a score such cases have come under my own notice. 
Again and again cases of scurvy have been cured by simply ceasing to 
sterilize the milk. 

Sterilizing at Lower Temperatures. — Pasteurizing Milk. — To obviate 
the disadvantages above referred to, the practice has come largely into 
use in America of employing much lower temperatures for milk steriliza- 
tion, owing chiefly to the work of Freeman (New York) and Eussell 
(Wisconsin). 

At first 167° F. (75° C.) was used; subsequently, however, a lower 
temperature was found sufficient, and 150° to 155° F. (65° to 68° C.) 
are the temperatures which are now generally employed. These tempera- 
tures are maintained from twenty to thirty minutes. This is sufficient 
to kill the bacilli of tuberculosis, diphtheria, and typhoid fever, and 
from 98 to 99 8 per cent of all the other bacteria in milk. Most of 
the objectionable changes produced in sterilized milk are avoided when 
the temperature is raised only to 155° F. (68° C), while it accomplishes 
the purpose for which milk is heated. The advantages of this form of 
sterilization are therefore obvious. But spores are not destroyed, and 
such milk requires special handling. It should always be rapidly cooled 
and kept at a low temperature. Pasteurized milk should be used within 
a few hours after heating; no attempt should be made to keep it more 
than twenty-four hours, even upon ice.* 

Pasteurization vs. High-temperature Sterilization. — From what has 
already been said it would appear that the argument is altogether in 

* Quite distinct from the process just described is that known as commercial 
pasteurization. In this, by passing milk through hot pipes, it is heated to temperatures 
ranging from 140° F. for several minutes to 160° F. for a very brief period, usually for 
5 to 30 seconds. Such heating destroys from 90 to 99 per cent of the bacteria ordi- 
narily found in milk. According to the experiments made in the laboratory of the 
New York Health Department, a temperature of 160° F. maintained for 30 seconds 
under usual conditions kills typhoid, diphtheria, and colon bacilli. In a small per- 
centage of experiments about 1 in 100,000 of these bacteria withstood this exposure. 

By this treatment (160° for 30 seconds) the great majority of tubercle bacilli, which 
are the most resistent of the bacteria exciting disease that are found in milk, are either 



MILK STERILIZATION. 



155 



favour of pasteurization. The lowest temperature and the shortest time 
that will surely destroy the objectionable bacteria in milk would seem 
to merit general adoption. Pasteurization, however, requires consider- 
able care, intelligence, and special apparatus; if not properly done it 
may be worse than nothing. Moreover, pasteurized milk can not, in very 
hot weather, be kept without ice as long as 
it may be necessary to keep milk. Steril- 
ization at 212° F. (100° C.) is much 
simpler ; it may be done with many sim- 
ple and inexpensive forms of apparatus 
or even without any special apparatus. 
Where no ice is available, it is certainly 
safer in hot weather than pasteurization. 
Among the poor of our large cities, in 
summer, heating to 212° for an hour is 
to be advised as the most satisfactory, 
and indeed the only efficient, method of 
sterilization. It should not be forgotten 
that the use of such milk as the sole diet 
for a long time is attended with a certain 
amount of risk; and one should always 
be on the .watch for the soreness of the 
legs and the spongy gums that indicate 
the beginning of scurvy, as well as for 
the more general symptoms of malnutri- 
tion. Heating to 212° F. on two or three 
successive days is also to be recommended 
one or two weeks, as upon ocean journeys. 

Methods of Sterilization. — Milk should be sterilized preferably in 
small bottles, each one of which contains a sufficient quantity for one 




Fig. 29. — The Arnold sterilizer. 



milk must be kept for 



killed or so injured that they cannot infect. On the average about -fa of 1 per cent 
survive; 160° for one minute usually kills all. 

The pasteurized milk of commerce which is extensively sold in many large cit ies is 
chiefly milk that has been heated for from 5 to 30 seconds in the manner described. 
Such a destruction of bacteria as is accomplished makes it possible to keep milk in 
warm weather a much longer time before souring occurs. It is therefore a greal 
advantage to the dealer and he is likely to depend upon it rather than upon adequate 
icing and cleanliness in handling his milk. There are some serious objections to 
commercial pasteurization. Milk so heated should be quickly cooled, should be 
received into sterilized vessels and kept at a low temperature (below 50 P.). 1 1' t hese 
precautions are not taken bacteria develop rapidly and the milk may after 24 hours 
be more dangerous than if it had not been heated at all; since, unlike raw milk, it does 
not usually sour and reveal its contaminated condition. Commercial pasteurization 
should be permitted only under the most careful restrictions, and the can or bottle con- 
taining pasteurized milk should indicate the degree and time of heating. Its prac- 
tical advantages have as yet not been fully demonstrated. 



156 



NUTRITION. 



feeding. These bottles may be plugged with cotton or corks, or special 
rubber stoppers may be used. If the latter, they should be loosely in- 
serted during the process and pressed tightly home at its completion. 
Soxhlet's apparatus may be employed, or Arnold's (Fig. 29), or any 
one of a half dozen others sold in the shops. All that is really necessary 
is to expose the bottles on all sides to live steam in a closed vessel. It 
can be done effectively in any tin vessel which has a closely fitting cover 
and a perforated bottom, and which can be placed over a pot of boiling 
water. Sterilization at 212° is usually continued for one hour. The 





Fig. 30.— Freeman's pasteurizer. A, bottles in position for heating ; B, method of cooling. 

bottles should then be cooled in water as quickly as possible and placed 
upon ice or in the coolest place available. 

A simple apparatus for pasteurizing milk has been devised by Free- 
man (Fig. 30). In this the temperature is raised to 155° F. (68° C.) 
by hot water, while cold water is used as a conducting medium.* Another 
useful form of apparatus is that of the Walker-Gordon Laboratory Com- 
pany, which contains a thermometer so that any desired temperature can 



* Freeman's apparatus is used as follows : The pail is filled to the groove with 
water, which is then raised to the boiling point. The bottles of milk are dropped into 
their places in the cylindrical cups, sufficient water being poured into each cup to 
surround the bottle, this water acting as the conductor of heat. The pail is now 
removed from the stove and placed upon a board or other non-conductor, and the 
receptacle containing the bottles of milk is set inside and the cover replaced. The 
volumes of milk and water have been so calculated that in ten minutes they are both 
at a temperature of 155° F. The water contains heat enough to maintain this, with 
very slight variations, for twenty minutes. In half an hour the bottles of milk are 
removed and cooled rapidly by being placed in a water-bath, the water being changed 
once or twice ; or, better, by setting the pail in a sink and allowing the cold water to 
run from a faucet through a piece of rubber pipe into the pail, overflowing into the 
sink. This rapid cooling is very important. The bottles are then put in the refrigera- 
tor. This apparatus may be obtained from James Dougherty, 411 West Fifty-ninth 
Street, New York. (See Archives of Pediatrics, August, 1896.) 



MILK STERILIZATION. 157 

be secured. An essential step in pasteurizing milk is rapid cooling. 
After forty-five minutes the bottles should be removed from the pas- 
teurizer and placed in tepid water and afterward in ice-water, where 
they should remain half an hour before being placed in the cold room 
or ice chest. 

Limitations of Milk Sterilization. — While pasteurizing or sterilizing 
milk kills nearly all the living organisms, it destroys few of the spores, 
and probably but a small proportion, if any, of the toxins. Before sterili- 
zation milk may contain the products of bacterial growth in such quan- 
tity and of such a character as to render it unfit for food. Even though 
just sterilized, it may be poisonous to an infant. It is therefore impor- 
that sterilization be done at the earliest possible moment. 

Again, the fewer the spores and spore-bearing bacteria which the 
milk contains, the more effective the sterilization. Both these have a 
very close relation to the amount of dirt contained in the milk. Hence 
the cleaner the milk the better will be the result. 

The opinion has gained a certain amount of currenc}^ that, if milk 
lias only been " sterilized," it may be fed to a young infant without 
further modification; but it should be distinctly understood that ster- 
ilized milk requires the same modification for infant feeding as raw 
milk. There is no evidence to show that its digestibility is in any way 
enhanced by the process of heating. 

The sterilization of milk is chiefly valuable by enabling us to feed 
with safety milk in which, though it may be forty-eight hours old, no 
important fermentative changes have occurred, because the great pro- 
portion of the common bacteria have been destroyed as well as any 
pathogenic organisms present. As a therapeutic measure sterilized milk 
is useful in various forms of gastric or intestinal infection such as 
typhoid fever, dysentery, diarrhoea, etc. In certain of these conditions 
no milk is admissible; at other times sterilized milk may be given when 
raw milk would be harmful. 

Shall all Milk used for Infant-feeding' be Sterilized? — Only the 
cleanest milk can safely be used in summer without heating. So long as 
milk is produced and handled as the bulk of it is at present, not being 
delivered in large cities until it is considerably over twenty-four hours 
old, and not consumed until over forty-eight hours old, heating should 
invariably be practised in hot weather; also, where there is any doubt 
about the dairy hygiene or the health of the cows; and finally, during 
epidemics of typhoid fever, diphtheria, and scarlel fever. 

It is quite possible to produce milk which docs not need sterilization ; 
the conditions to be fulfilled have been already detailed. 'There are 
special dairies supplying such milk to many of our large cities, and their 
number may be very greatly increased if the medical profession will use 
its influence in this direction. M\ personal preference for routine use 



158 NUTRITION. 

in infant-feeding is for a milk so clean and fresh that it may be safely 
given without heating, feeling as I do that all forms of sterilization 
do impair, though possibly only to a slight degree, its nutritive proper- 
ties. It should, however, be borne in mind that there are some delicate 
infants with feeble digestion who thrive better upon sterilized milk than 
upon raw milk in which the bacterial content is quite low; for, even 
though not numerous, bacteria may yet do harm to such children. 
Healthy infants with good digestion may do well upon raw milk even 
though the number of bacteria is quite large — i. e., 100,000-1,000,000 
per c. c. ; while delicate infants or those with digestive disturbances may 
be seriously affected by such milk. In the country where milk is obtained 
fresh and used before it is twenty-four hours old, sterilizing is usually 
unnecessary if the cows are healthy and the milk properly handled. 

Peptonized Milk. — Milk is peptonized through the agency of a sub- 
stance derived from the pancreas, usually that of the pig. This is known 
in the market as " extractum pancreatis," the active ferment being the 
trypsin. As this acts only in an alkaline medium, bicarbonate of soda 
should first be added to the milk. The purpose of peptonizing is to 
secure a partial digestion of the casein of milk before feeding. 

Partially Peptonized Milk. — The process is as follows : * One pint of 
fresh cow's milk and four ounces of water are put into a bottle, and a 
powder added containing five grains of extractum pancreatis and fifteen 
grains of bicarbonate of soda. This is kept at a temperature of 105° to 
115° F., or about as warm as the hand can bear comfortably, best by 
placing the bottle in warm water. It should be shaken from time to time. 
For partial peptonization, the process is continued for from six to twenty 
minutes. The peptonizing powder is sold in glass tubes and in tablets. 
The tubes are to be preferred, as being less liable to deteriorate with age. 
Milk which has been peptonized ten minutes is not altered in taste; if, 
however, the process is continued for twenty minutes, a slightly bitter 
taste is noticed from the formation of peptones. This increases with 
the duration of the process of artificial digestion. If it is desired to 
arrest this after ten minutes, the milk may be raised to the boiling point, 
which destroys the ferment, or its activity may be stopped by placing 
the milk upon ice. If the milk is to be fed at once, neither of these 
procedures is necessary. If it is to be kept for several hours, scalding is 
more certain to arrest the change than lowering the temperature. 

Completely Peptonized Milk. — The process is exactly the same as 
the above, except that it is continued for two hours, which is generally 
required for the conversion of all the proteids into peptones. The addi- 
tion of acetic acid to such milk produces no coagulation. Although 
completely peptonized milk is quite bitter, this is not an obstacle to its 

* Fairchild's process. 



CONDENSED MILK. 



159 



use for young infants, who after the first or second bottle do not usually 
object to its taste. For those who are a little older, the bitter taste may 
be covered by lemon-juice and sugar — one even teaspoonful of cane sugar 
and two teaspoonfuls of lemon-juice being added to each four ounces of 
the milk. 

Peptonized milk is to be modified according to the age of the child 
and the condition of his digestion. Peptonized milk is a valuable re- 
source in chronic cases where there is feeble proteid digestion, and dur- 
ing attacks of acute indigestion in infancy. In acute attacks, completely 
peptonized milk is usually preferable to that which has been partially 
peptonized. It is not advisable to continue its use indefinitely, for in 
this case the stomach gradually becomes less and less able to do its work. 
At most, peptonization should be used only for a month or two at a time ; 
as the child improves the amount of the powder used is gradually dimin- 
ished and the time of peptonizing shortened. 

Condensed Milk. — This is prepared by heating fresh, cow's milk to 
212° F. to destroy the bacteria and then evaporating in vacuo at a low 
temperature to a little less than one-fourth its volume.* It is preserved 
in tin cans, usually with the addition of cane sugar in the proportion of 
about six ounces to a pint. The changes, therefore, to which the milk 
has been subjected are : evaporation of a part of the water, sterilization, 
and the addition of cane sugar. Fresh condensed milk to which no sugar 
has been added is to be obtained in many large cities. 

The composition of condensed milk is shown in the following table; 
also the results obtained when it is diluted with six, twelve, and eighteen 
parts of water, as usually fed: 





Condensed 
milk.t 


With 6 parts 

of water 

added. 


With 12 parts 
of water. 


With 18 parts 
of water. 


Fat 


Per cent. 

694 

8-43 

50-69 

1-39 
31-30 


Per cent. 

099 
120 

7-23 

0-17 
90-49 


Per cent. 

0-53 
0-G5 

3-90 

o-io 

94-82 


Per cent. 

36 


Proteids 


0-44 


G ( Cane, 40 44 / 

Salts 


267 
007 


Water 


90 46 







The dilution with twelve parts of water is that most frequently em- 
ployed, although eighteen is often used for very young infants. 

The reasons both for the success and for the failure of condense. I 
milk as an infant-food, are apparent from a study of its composition as 
it is ordinarily \\>i'<\. As a temporary food it is often useful, firsi because 



* Process followed by the Borden Condensed Milk Company. 

f Analysis of Borden's Eagle-brand condensed milk made for the author by 
E. E. Smith, Ph.D.,M.D. 



160 NUTRITION. 

it has been sterilized, but chiefly because both the fats and the proteids 
of cow's milk have been reduced by the usual dilution to a point at 
which an infant with a very weak digestion can manage them, while 
it furnishes an abundance of sugar, the easiest thing for an infant to 
digest. During the first few months of life it is often apparently very 
successful for these reasons, but it should not be continued indefinitely. 
It is rare to see an infant fed exclusively upon it who does not show 
more or less evidence of rickets. Condensed milk fails as a permanent 
food because it consists too largely of carbohydrates, and is lacking in 
fat. It is admissible for temporary use during attacks of indigestion, 
for infants with feeble digestion, especially in summer, for very young 
infants during the first two or three months, or among the very poor, 
where the cow's milk which is available is still more objectionable. It 
should not be continued as a permanent food where good, fresh cow's 
milk can be obtained. In travelling it is often the most convenient 
as well as the safest food to use. It should be diluted twelve times 
for an infant under one month, and from six to ten times for those 
who are older. 

The fresh condensed milk has not the disadvantage of the addition of 
a large amount of cane sugar, and requires essentially the same modifi- 
cation as ordinary cow's milk. For the poor in cities it is sometimes the 
best infant-food available. For routine use it should be diluted with 
from eight to twelve parts of water, and sugar added. 

Kumyss. — The original kumyss made by the Tartars was fermented 
mare's milk. In this country it is made from cow's milk. The ferment 
used by the Tartars was kefir grains, consisting of two forms of the ordi- 
nary yeast plant and great numbers of lactic-acid bacilli. Kumyss is 
sometimes made from skimmed milk, but 'usually from the whole milk, 
with the addition of cane sugar and a small proportion (about one-six- 
teenth) of water. The process now most commonly employed is started 
with ordinary yeast, causing a vinous fermentation. The best results 
are obtained when this is carried on at a temperature of from 60° to 
70° F. in corked bottles. It requires a week or ten days.* 

Kumyss contains alcohol, carbon dioxide, lactic acid, and traces of 
butyric and acetic acids. The casein is first coagulated, and then broken 
up into minute particles by agitation. Some of it is probably converted 
into albumoses. Kumyss has an acid reaction and a taste somewhat 
resembling buttermilk; at first it is often disagreeable, but a fondness 
for it is soon acquired. 

*The following is perhaps the best formula for the domestic manufacture of 
kumyss: One quart of fresh milk, half an ounce of sugar, two ounces of water, a piece 
of fresh yeast cake half an inch square; put into wired bottles, keep at a temperature 
between 60° and 70° F. for one week, or 85° to 95° F. for twenty-four hours, shaking 
five or six times a day, and then put upon ice. 



MATZOON. 



161 



Kumyss. 





Made from 

mare's milk 

(Koenig). 


Made from 
cow's milk 
(Koenig). 


Made from 

skimmed milk 

(Koenig). 


Brush's kumyss 
(Doremus). 


Fat 

Proteids . . . 


1-46 
2-24 
1-47 
1-91 
0-91 

6 : 42 
91-29 


1-83 
2-66 
4-09 
1-14 
0-55 

6 : 43 
89-30 


0-88 
2-89 
3-95 
1-38 
0-82 

6 : 53 
89-55 


1-'91 

2-04 


Sugar 


3-26 


Alcohol 


062 


Lactic acid. 




Acid 


0-30 


Carbon dioxide 

Salts 


0-44 
0-44 


Water 


90-99 







The advantages of kumyss are due to the alcohol, carbon dioxide, and 
lactic acid, and to the changes which have taken place in the casein of 
the milk. It is more useful for older children than for infants. It is a 
valuable resource in many forms of indigestion, both of the gastric and 
intestinal varieties. 

For infants, kumyss should be diluted, generally with an equal quan- 
tity of water. Many take it better if the gas has been allowed to escape 
by standing a few minutes. It is important that it be reasonably fresh. 

Matzoon. — Matzoon, or Zoolak, is a form of fermented milk first 
used in Asia Minor. The process of manufacture is given by Dadirrian 
as follows: The milk is first sterilized by boiling; a ferment is then 
added which is probably some form of yeast. The fermentation is begun 
at a temperature of about 105° F. and continued in an open vessel for 
twelve hours, the temperature being gradually reduced to about 70° F., 
after which it is cooled, bottled, and kept on ice. A slow fermentation 
continues after bottling, so that the older matzoon contains a little carbon 
dioxide and is more sour than the fresh. It keeps on ice for two or 
three weeks. It is a thick fluid with a taste resembling sour cream. For 
infant-feeding it should be diluted with water and fed with a spoon, as 
it is too thick to be drawn through a nipple. 

Matzoon, or Zoolak {Leeds). 

Proteids 3'48 

Fat 3-49 

. Milk sugar 3 • 68 

Lactic acid 0*90 

Alcohol and other products of fermentation 0-13 

Mineral salts 69 

Water < s ~ ' G3 

LOO -00 
By the process there is a decomposition of (lie milk sugar into alco- 
hol, lactic and carbonic acids. The changes in the proteids are similar 
to those in kumyss. It is used in the same conditions. 



162 * NUTRITION. 

Buttermilk. — When made from fresh cream this differs but little 
from skimmed milk, or milk from which the fat has been removed by 
a separator. Usually, however, as the churned cream is slightly sour, 
buttermilk contains an appreciable amount of lactic acid. To this chiefly 
its peculiar taste is due. The proportion of lactic acid depends upon the 
degree to which the souring process has been allowed to go. 

Buttermilk (Vieth). 

Fat 0-50 

Milk sugar 4*06 

Lactic acid • 80 

Proteids 3-60 

Inorganic salts 0'75 

Water 9039 



100 



00 



It is a valuable form of food in chronic intestinal indigestion and in 
diarrhceal disease. The value of buttermilk in infant-feeding depends 
upon its low fat, possibly also upon the lactic acid present, and upon 
some slight change in the milk proteids from the agitation. 

A good formula is, buttermilk, one quart ; barley flour, two even table- 
spoonfuls; water, four ounces. Cook slowly, constantly stirring, for 
twenty minutes ; then add two teaspoonf uls of cane sugar, or, better, one 
tablespoonful of milk sugar. 

Junket, Curds and Whey. — Junket is made as follows: To one 
pint of fresh lukewarm cow's milk are added two teaspoonfuls of essence 
of pepsin, liquid rennet, or a junket tablet. It is stirred for a moment 
and then allowed to stand until firmly coagulated. It is given cold. The 
only change which has taken place is the coagulation of the casein — such 
as occurs in the stomach as the first step in digestion. Junket is useful 
in the feeding of older children, but should not be given to infants. 

Whey. — The milk is coagulated with rennet as above, the curd is 
then broken up, and the whey strained off through muslin. The compo- 
sition of whey varies somewhat, depending upon the way in which it is 
prepared. If it is desired to have as little fat as possible, skimmed milk 
should be used, and the whey should be strained through fine muslin 
without pressure. If it is desired to retain some of the fat, whole milk 
may be used, coarser muslin, and more pressure. The proteids of whey 
are chiefly lactalbumin with a small amount of lactoprotein and lacto- 
globulin. 

Whey used alone is valuable in the acute indigestion of infants. It 
is the basis of the milk modifications, the purpose of which is to give a 
larger proportion of lactalbumin and a smaller proportion of casein than 
exist in any dilution of cow's milk. Such modifications of milk have a 
wide application and form a valuable addition to our means of infant- 



BEEP PREPARATIONS. 



103 



feeding. Wine whey may be made by adding sherry, usually in the pro- 
portion of one part to sixteen of whey. 



Whey. 





Average 

46 analyses 

(Koenig). 


From 
whole milk 
(Adriance). 


From 

fat-free milk 

(Adriance). 


Proteids . . 


0-86 
0-32 
4-79 
0-65 
93-38 


0-94 
0-90 
5-49 
0-48 
92-13 


1-17 


Fat 


004 


Sugar '. 


5-36 


Salts 


52 


Water. 


92-91 






Total 


100-00 


100-00 


100 00 







BEEP PREPARATIONS. 

The nutrient properties of these preparations are to be measured by 
the amount of albumin they contain, their stimulant properties by the 
proportion of extractives. 

Beef Juice. — Expressed beef juice is made as follows : A piece of lean 
steak is slightly broiled, and the juice pressed out by a meat-press or a 
lemon-squeezer. Two or three ounces can ordinarily be obtained from 
one pound of steak. This is seasoned with salt and given cold or warm, 
but not heated sufficiently to coagulate the albumin in solution. 

Another excellent method of making beef juice without cooking, is 
by taking one pound of finely-chopped lean beef and eight ounces of 
water and allowing this to stand in a covered jar upon ice from six to 
twelve hours. The juice is then squeezed out by twisting the meat in 
coarse muslin. It is seasoned with salt and given as above. This is not 
quite so palatable as that obtained by the first method, because it con- 
tains a smaller proportion of extractives. It can be made so, however, 
by the addition of sherry wine or celery salt. If the raw juice is added 
to milk in the proportion of two or three teaspoon fuls to each feeding, 
Ihe taste will not be noticed. The milk should not be warmed above 
100° F. before the addition of the juice. 

The composition of the two products is shown in the table on the 
following page. 

The only difference in the two preparations is that the first contains 
about twice as much of the extractives. The second process is much 
more economical, as more than three; times as much juice can be obtained 
from a given quantity of beef. If a stronger juice is desired, the amounl 
of proteids may be doubled by using only four ounces of water. This is 
preferable for all except young infants. 

Beef extracts are not to be considered in any sense as food-. Kem- 



164 



NUTRITION. 



merich has shown that animals receiving nothing else died of starvation, 
and sooner even than when everything was withheld. According to Chit- 
tenden, they contain no nitrogen in the form of proteids, but only in 
combination with the soluble extractives. They are stimulants, and as 
such are often useful. 

Beef Juice* 





I. 

Expressed juice 
from 1 lb., warm 
process ; quan- 
tity, 2^ oz. 


II. 

Cold process, 

1 lb. beef, 8 oz. 

water; quan^ 

tity, 8K oz. 


Proteids 


2-90 
0-60 
3-40 
0-20 
92*90 


3-00 


Fat. 




Extractives 


1-90 


Salts 


0-20 


Water 


04-90 








100-00 


100-00 



Of the preparations of beef in the market probably the best are Mos- 
quera's beef jelly, Armour's beef juice, Wyeth's beef juice, and Valen- 
tine's beef extract. Man}^ products sold as beef preparations, such as 
liquid peptonoids, panopeptone and others, contain from 15 to 20 per 
cent of alcohol, and should, therefore, be classed as stimulants rather 
than as nutrients. For infants they must be well diluted. Beef prepa- 
rations are valuable for older children in many cases of general mal- 
nutrition. 

Eaw scraped beef, or that which has been slightly cooked, is easily 
digested by most young children. There are many conditions in which 
other forms of proteid, particularly casein, are not well borne, and in- 
deed can not be taken at all, where children even as young as twelve 
months appear to digest this beef -pulp without any difficulty. It should 
be made from very rare or raw steak, finely scraped and well salted. A 
tablespoonful may be given at one feeding to a child of eighteen months. 
In nutrient properties this far exceeds most of the beef preparations in 
the market. The alleged danger of tapeworm from the use of raw meat 
is in this country so slight that it may be disregarded. 

Broths. — Animal broths may be made from mutton, veal, chicken, or 
beef. A good formula for general use is the following: One pound of 
lean meat, one pint of water ; stand for two hours, then cook over a slow 
fire for two hours down to half a pint. After it has cooled, skim off the 
fat and strain through a cloth. The composition of a broth so made is 
given by Cheadle as follows : 



* Analysis made for the author by E. E. Smith, Ph.D., M.D. 



PLATE III. 



WOMAN'S MILK. 



COW'S MILK. 

5^ 



Proteids 

Fat 

Soluble Carbohydrates (sugar) 

Salts 

Insoluble Carbohydrates (starch) 



CANNED CONDENSED MILK. 



MELLIN'S FOOD. 



MALTED MILK. 



P 



NESTLE'S FOOD. 



CARNRICK'S SOLUBLE FOOD 



P 



IMPERIAL GRANUM. 



Chart showing the solid ingredients of various infant foods 
as compared with those of woman's milk 



CEREALS. 105 



Beef Broth. 

Proteids 1 02 

Extractives 1-82 

Fat 

Salts ■...'.. 0-88 

Water 96"28 



100-00 



From their composition it will be seen that broths are not very nutri- 
tious ; they are, however, quite stimulating, and are at times useful, par- 
ticularly where milk must be temporarily withheld. They are, however, 
not adapted to prolonged use alone. Broths which have been thickened 
with either barley or rice flour are useful for children in the second and 
third years. 

CEREALS. 

Barley Water. — This may be made either from the grains or from 
the barley flour. When the grains are used, the following is the formula 
which I have been accustomed to employ : To two tablespoonfuls of pearl 
barley, add one quart of water, and boil continuously for six hours, keep- 
ing the quantity up to a quart by the addition of water; strain through 
coarse muslin. It is an advantage to soak the barley for a few hours, or 
even over-night, before cooking. The water in which it is soaked is not 
used. When cold this makes a rather thin jelly. Its composition by 
analysis is as follows : 

Barley Water. 

Starch 1 63 

Fat • 05 

Proteids ■ 09 

Inorganic Salts 003 

Water 9820 

100-00 

Almost an identical product may be obtained in an easier way by 
using either the prepared barley flour of the Health Food Company, 
Xew York, or Robinson's barley, two drachms — one even tablespoonful — 
to each twelve ounces of water, and cooking for twenty minutes. 

Rice Water, Oatmeal Water, etc. — These may be made in the same 
manner as the barley water, using the same proportions either of the 
flour or the grains. These are useful as additions to milk for healthy 
infants who have reached the age of seven or eight months ; they may 
also be given in many cases of acute or chronic indigestion where milk 
must be omitted or given in small quantities. When there is a tendency 
to constipation oatmeal is preferred : when to looseness, barley or rice 
water. The digestibility of cereals is greatly increased by the addition 



166 NUTRITION. 

of diastase; such preparations as Forbes's diastase, maltzyrne, Trom- 
mer's extract of malt, taka-diastase, cereo, etc., may be employed. 

INFANT-FOODS. 
It is not possible, nor even desirable, for a physician to know all about 
the infant-foods with which the market is flooded. He should, however, 
know at least that they are not perfect substitutes for breast-milk, that 
as permanent foods they are greatly inferior to properly modified cow's 
milk, and that as often used by the laity, and even by the medical pro- 
fession, they are capable of doing and have done much positive harm. 
Eickets and scurvy have so frequently followed their prolonged use, espe- 
cially when given without the addition of fresh milk, that there can be 
no escaping the conclusion that they were the active cause. The almost 
unanimous verdict of intelligent physicians is against their use as per- 
manent foods. On the other hand, there are times when some of these 
preparations may be of considerable value, but chiefly for temporary use 
in pathological conditions. Here they are to be prescribed like drugs, 
but only with a very definite knowledge of exactly what they do and what 
they do not contain. The most commonly used infant-foods may be 
grouped as follows: 

1. The Milk Foods. — Nestle* s food is perhaps the most widely known. 
The others closely resembling it in composition are the Anglo- Swiss, the 
Franco- Swiss, the American- Swiss, and Gerber's food. These foods are 
essentially sweetened condensed milk evaporated to dryness, with the 
addition of some form of flour which has been dextrinized; they all 

' contain a large proportion of unchanged starch. 

2. The Liebig or Malted Foods. — Mellin's food may be taken as a type 
> of the class. Others whic^i resemble it more or less closely are Liebig's, 

Horlick's food, Hawley's food, malted milk, and cereal milk. Mellin's 
food is composed principally (80 per cent) of soluble carbohydrates. 
They are derived from malted wheat and barley flour, and are composed 
chiefly of a mixture of dextrins, dextrose, and maltose. 

3. The Farinaceous Foods. — These are imperial granum, Kidge's 
food, HubbelPs prepared wheat, and Eobinson's patent barley. The first 
consists of wheat flour previously prepared by baking, by which a small 
proportion of the starch — from one to six per cent — has been converted 
into sugar. In chemical composition these four foods are very similar 
to each other, consisting mainly of unchanged starch which forms from 
seventy-five to eighty per cent of their solid constituents. 

4. Miscellaneous Foods. — Under this head may be mentioned Carn- 
rick's soluble food and Eskay's food. The composition of these is given 
in the table on the opposite page. 

A better idea of the composition of these foods can be obtained by 
a study of the accompanying chart (Plate III), which shows their solid 



INFAXT-FOODS. 



167 



The Composition of Infant-Foods* 



, Nestle 's 
food. 


Mellin's 
food. 


Eskay's 
food. 


Malted 
milk. 


Ridge's 
food. 


Imperial 
granum. 


Carn- 
rick's 
food. 


Fat 


Per cent. 

5-50 
14-34 
25-00 


Per cent. 

024 
11-50 

60 : 80 
19-20 

80-00 

*3 : 59 
4-73 


Per cent. 

1-16 

5-82 

}53'46f 

14 : 35 

67-81 

21-21 
1-30 
2-70 


Per cent. 

8-78 
16 35 

J49-15J 
18-80 

67-95 

'3 : 86 
3-06 


Per cent. 
1-11 

11-81 
'6 : 52 

*i : 28 

1-80 

76-21 
0-49 

8-58 


Per cent. 

1-04 
14-00 

: 42 

Y-38 

1-80 

73-54 
0-39 
9-23 


Per cent. 

7-45 


Proteids 


10-25 


Cane sugar 




Dextrose 




Lactose (milk sugar) 

Maltose . . 


657 

}27-36 

58-93 

15-39 
2-03 
3-81 




Dextrins 




Total soluble carbohy- 
drates 


27.08 


Insoluble carbohydrates 
(Starch) 


37-37 


Inorganic salts. . ... 


442 


Moisture 


3-42 



constituents as compared with those of woman's milk. The essential 
features of the foods are seen at a glance — i. e., they are all composed 
principally of carbohydrates and are lacking in fat. Some of them con- 
tain a large proportion of unchanged starch. Furthermore, their pro- 
teids, though often sufficient in amount, are chiefly vegetable, not animal 
proteids. jSTo one of them can be regarded in any sense as a proper 
substitute for breast-milk. 

Some of these foods — ISTestle's and other milk foods, malted milk, 
cereal milk, and Carnrick's food, and even some of the farinaceous foods, 
like imperial granum — are advertised as substitutes for breast-milk 
and recommended for use alone. Others, such as Mellin's, Liebig's, and 
Eskay's foods, are intended to be used with milk. The use of any of 
the commercial foods alone is admissible only for short periods during 
derangements of digestion, when we wish to withhold for the time all 
fat and milk proteids. Their prolonged use almost invariably produces 
some grave disorder of nutrition, most frequently rickets or scurvy. 
Those foods which require in their preparation the addition of milk 
are open to less serious objections. They should not be used with con- 
densed milk. When added to fresh milk they may serve a useful purpose 
in furnishing the additional carbohydrates required by an infant fed 
upon a diluted cow's milk. In such a case they take the place of milk 
sugar or cane sugar in the milk modification. That they themselves 
exert an important modifying influence upon cow's milk so as to increase 
its digestibility is certainly to be doubted. The group classed as farina- 
ceous foods, since they furnish starch in a convenient and palatable form, 
may often be advantageously used as an addition to milk after the seventh 
or eighth month and during the second year. 

* With the exception of Nestle's food and Carnrick's soluble food, these analyses 
were made for the author by E. P". Smith, Ph.D., M.D., of samples purchased in the 

open market, 1901. f Chiefly lactose. \ Largely mall 



1G8 NUTRITION. 

CHAPTER III. 
INFANT-FEEDING. 

CHOICE OF METHODS OF FEEDING. 

The different methods of feeding which are available are: 

1. Breast-feeding, either by the mother or by a wet-nurse. 

2. Mixed feeding, or a combination of nursing and artificial feeding. 

3. Artificial feeding exclusively. 

In deciding by which one of these methods a child shall be fed, many 
circumstances must be taken into consideration : the vigour of the child, 
the health of the mother, and especially the surroundings, since these 
determine very largely the success or failure of any method employed. 

Maternal Nursing. — This is the natural and the ideal method of 
infant-feeding. Every mother should nurse her infant unless there are 
some very weighty reasons to the contrary. The physician should do all 
in his power to encourage maternal nursing and to promote its success. 
This may be furthered by proper care of the nipples before delivery; by 
attention to them during the early days of nursing to prevent fissures 
and mastitis, which so often interrupt successful nursing; by careful 
regulation of the diet and habits of the nursing mother, and by impress- 
ing upon her the necessity of leading a simple, natural life. 

In spite of all efforts to the contrary, it is nevertheless a fact that 
the capacity for maternal nursing is steadily diminishing in this country, 
chiefly in the cities, but to a considerable degree in the rural districts 
as well. Among the well-to-do classes in New York and its suburbs, 
of those who have earnestly and intelligently attempted to nurse, less 
than 25 per cent, in my experience, have been able to continue satis- 
factorily for as long as three months. An intellectual city mother 
who is able to nurse her child successfully for the entire first year is 
almost a phenomenon. Among the poorer classes in our cities a marked 
decline in nursing ability is also seen, although not yet to the same 
degree as in the higher social scale. These are facts that must be taken 
into account in deciding the question of feeding. While nothing is so 
good as good maternal nursing, no method of feeding gives much worse 
results than poor nursing. Among the classes of society where most 
of the maternal nursing is very poor, but where every facility can be 
afforded for the best artificial feeding, one should not be slow to adopt 
the latter in cases of doubt. Among the poor and ignorant, however, 
where artificial feeding can not be carried on with anything like the 
same chances of success, one should persist in maternal nursing so long 
as there is any possibility of success. 



MATERNAL NURSING. 



169 



When maternal nursing should not be attempted. — (1) Xo mother 
who is the subject of tuberculosis in any form, whether latent or active, 
should nurse her infant; it can only hasten the progress of the disease 
in herself, while at the same time it exposes the infant to the danger of 
infection. (2) Nursing should seldom be allowed where serious com- 
plications have been connected with parturition, such as severe hsemor- 



WEEK OF 

AGE 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 


22 
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Fig. 31. — Weight curve of nursing and artificial feeding compared. 

Both infants were strong, well nourished, and in good surroundings. The bottle-fed infant 
was never once put to the breast; fed from the milk laboratory. First formula: Fat 1 per 
cent, sugar 5 per cent, proteids 0-5 per cent. At six weeks taking: Fat 3 per cent, sugar 7 per 
cent, proteids 1'25 per cent. It will be observed that the nursing infant made more rapid 
progress during the first few weeks, while the bottle-fed infant more than made up for this 
between the fifth and ninth month, for weaning became necessary in the other child owing to 
the gradual failure of the mother's milk. The stationary weight was the result of this condi- 
tion, and the irregular subsequent gain was incident to the change of food. 



rhage, puerperal convulsions, nephritis, or puerperal septicaemia. (3) II" 
the mother is choreic or epileptic. (4) If the mother is suffering from 
any serious chronic disease or is very delicate, since ureal harm may be 
done to her without any corresponding benefii to the child. (5) Where 
experience on two previous occasions under favourable conditions has 
shown her inability to nurse* her child. ((>) When no milk is secreted. 
With reference to the fourth and fifth conditions, an absolute opinion 
can not always be given at the outset. My own inclination as a result 



170 NUTRITION. 

of increasing experience is not to allow nursing in either of these con- 
ditions, provided the means for proper artificial feeding can be com- 
manded. The chances of success are so small and the difficulties are so 
increased by even a few weeks of bad nursing that I prefer not to put 
the child to the breast at all, even for the first two or three days. The 
breasts are bound up at once and kept bandaged. The theoretical objec- 
tion that uterine contractions are not likely to be sufficient under these 
circumstances does not hold in practice. When one begins with healthy 
digestive organs, artificial feeding is very simple and almost invariably 
successful; how simple and how successful, one who is in the habit of 
allowing all children to nurse until they are manifestly upset by it, can 
hardly appreciate. (See Fig. 31.) 

Artificial Feeding vs. Wet-Nursing. — When maternal nursing is im- 
possible or undesirable, the milk of another woman would seem to be 
the most natural and best substitute. While this is theoretically true, 
the practical obstacles are so many as to put wet-nursing out of the 
question as a general method of feeding. We have in America no peasant 
class like that of Europe to draw upon ; and in the class which furnishes 
most of our wet-nurses the capacity to nurse has steadily diminished. 
The expense of a wet-nurse — twenty-five to thirty-five dollars a month 
in New York — the danger of transmitting contagious disease, and the 
difficulty of obtaining proper care for her own infant, are all very serious 
objections to wet-nursing. The recent advances in artificial feeding have 
placed it now on quite a different footing from that which it formerly 
occupied. While it is true that good breast-milk is unquestionably the 
best food, it is equally true that properly modified cow's milk is a far 
better food than the milk of many wet-nurses who are employed. These 
facts added to the constantly increasing difficulty of obtaining good 
ones have caused wet-nurses to be pretty generally discarded, even in 
our large cities, where formerly no other substitute for maternal nursing 
was considered. 

There are, however, some conditions in which they are necessary, 
even indispensable. Some infants, usually those who have been badly 
started, can not be made to thrive upon any form of artificial feeding. 
There are also many premature infants and some very delicate ones 
whose powers of assimilation are so feeble that they are reared under 
any circumstances only with the greatest difficulty, but whose chances of 
life are much increased by a good wet-nurse. Again, in young infants 
who have been suffering for some time from chronic indigestion and 
failing nutrition, the symptoms of acute inanition sometimes develop 
with great rapidity and severity. From such a condition, apparently 
hopeless, infants may sometimes be rescued by the timely assistance of 
a good wet-nurse. 

The difficulties in the way of successful infant-feeding in foundling 



BREAST-FEEDING. 171 

asylums and other institutions for young infants are such that in them 
wet-nursing should be employed whenever possible. 

Mixed Feeding. — Mixed feeding, or a combination of nursing and 
artificial feeding, may be employed whenever the supply of the nurse is 
insufficient, also to relieve the mother from the strain of nursing entirely, 
and, during the later months, for the purpose of gradual weaning. 



BREAST-FEEDING. 

Care of the Breasts during Lactation. — For the safety of both mother 
and child it is essential that the most scrupulous attention be given to 
cleanliness. The nipples, and the breasts as well, should always be care- 
fully washed after each nursing. Usually plain water is sufficient, or a 
weak boric-acid solution may be employed. 

Nursing during the First Days of Life. — This is necessary, to accus- 
tom the child and the mother to the procedure, and to empty the breasts 
of the colostrum ; it also promotes uterine contractions. All these results 
can be attained by putting the child to the breast on the first day once 
in six hours, on the second day once in four hours. The child gets from 
the breast only from four to six ounces a day during the first two days. 
Did it require more nourishment before the milk-flow is usually estab- 
lished, we may be sure that Mature would not have been so late with 
her supply. The common practice of administering to an infant a few 
hours old all sorts of decoctions, with the idea that because it cries it 
is suffering from colic, can not be too strongly condemned. A certain 
amount of crying is necessary. In exceptional circumstances, when an 
infant is unusually large and strong and cries excessively, it may be 
necessary to give food even on the first day ; but this is not to be the rule. 
A little warm water, or a five-per-cent solution of milk sugar, should first 
be given; from two to four teaspoonfuls at a time are sufficient. If this 
does not satisfy the child, regular feeding should be begun on the sec- 
ond day. Should the milk be delayed beyond the second day, artificial 
feeding should then be begun at regular intervals. 

Nursing Habits. — Good habits of nursing and sleep are almost as 
easily formed as bad ones, provided one begins at the outset. A vast deal 
of the wear and tear incident to the nursing period may be avoided if 
the child is trained to regular habits. Attention to these minor points 
often makes all the difference between successful and unsuccessful nurs- 
ing. The physician must have a very clear notion of how often nursing 
is necessary, must give very explicit directions, and see that they are 
carried out. After the third day, for the first month, ten nursings in the 
twenty-four hours are quite sufficient, and no more should be allowed. 
An infant at this age can usually be depended upon to take at leasl one 
long sleep of from four to five hours in the course of the twenty-four. 



172 



NUTRITION. 



For the rest of the day the child should be awakened, if necessary, at 
the regular nursing time, and put to the breast; this plan being con- 
tinued until nine o'clock at night. It should then be allowed to sleep as 
long as it will, and but two nursings given between this hour and seven 
in the morning. In the course of two or three weeks a healthy infant 
can usually be trained to nurse and sleep with almost perfect regularity, 
frequently, when a month old, going six hours regularly at night without 
feeding. A trained nurse of my acquaintance states that out of thirty- 
three infants of which she had the care from birth, thirty-one were 
trained without difficulty in the manner stated. Of course, success in 
training must rest almost entirely with the nurse; but the physician 
should at least appreciate the importance of proper training and lend it 
his support. The great gain to the mother is, that she is enabled to have 
a quiet, undisturbed night. This has more to do with a good milk sup- 
ply than any other single thing in connection with the mother's habits. 
So far as the child is concerned, regular habits of feeding and sleep, and 
regular evacuations from the bowels, which nearly always go with them, 
are most important factors in infant hygiene. 

Schedule for Br east- Feeding. 



Age. 



Number of 

nursings in 

24 hours. 



Interval 

during the 

day. 



Night nursings 

between 
9 p.m. and 7 a.m. 



First day 

Second day 

Third to twentieth day 
Third to ninth week. . . 
Third to fifth month... 
Fifth to twelfth month 



4 
6 

10 

8 
7 
6 



Hours. 

6 

4 
2 

2* 

3 
3 



These rules can be carried into effect with but little difficulty, and 
with great benefit to both mother and child. It is to be remembered that 
we are here speaking only of healthy children. The possibility of train- 
ing children to eat and sleep in the manner described will be doubted 
only by one who has not made a careful trial of it. Relieving the mother 
of night-nursing after the child is five months old is of the greatest value, 
and will often enable her to continue lactation, when otherwise it would 
be brought to an abrupt termination. On no account should the child 
be allowed to sleep upon the mother's breast, nor in the same bed with 
the mother. The temptation to frequent nursing is thus largely removed. 
No mere sentiment in regard to these matters should be allowed to inter- 
fere with the plain dictates of reason and experience. 

Symptoms of Unsuccessful Nursing during the Early Weeks. — At- 
tempts at maternal nursing so often result in failure, jeopardizing the 
health, and even endangering the life of the child, that it becomes a 



BREAST-FEEDING. 173 

matter of the greatest importance to decide this question of nursing 
aright, and as early as possible. On the one hand, one should not hastily 
wean a child on account of symptoms which may have no connection 
with the food, nor should one advise weaning when the indigestion from 
which the infant is suffering is due to causes which are temporary and 
remediable. On the other hand, nursing should not be continued simply 
because a conscientious mother desires it, when every indication points to 
failure. If artificial feeding is to be employed the difficulties are fewer 
when it is begun early than after the digestive organs have been deranged 
by several weeks of poor nursing. These cases form a very large group 
and present peculiar difficulties in practice. While a decision is being- 
reached as to the ability of the mother to nurse, there is required close 
observation and a careful study of all the conditions, and even then the 
physician is liable to make mistakes in judgment the results of which 
may be serious. 

The bod} r -weight gives valuable information. The child does not gain 
or continues to lose after the usual initial loss of the first three or four 
days. Observations on the weight at least twice a week are necessary, and 
in cases presenting special difficulties the weight should be taken daily. 

At times there may be no vomiting, diarrhoea, or even severe colic, 
yet the child may fret and worry continually, sleep but little, and show 
a general discomfort. In other cases definite symptoms of gastric indi- 
gestion may be present, usually vomiting or frequent regurgitation of 
small amounts of undigested milk, later mixed with mucus; eructations 
of gas with or without vomiting may occur, and distention of the stom- 
ach with gas and gastric colic may follow. 

More often the symptoms of indigestion are intestinal. Occasionally 
there is constipation, but as a rule the stools are frequent, thin and 
green, containing flaky masses of undigested milk, and, after a short 
time, mucus which is frequently in large amount. The odour of the 
discharges may be slightly sour or there may be none at all. At times 
there is much gas and the stools are sour and irritating. If constipation 
is present there is apt to be severe colic and abdominal distention. The 
almost uniform absence of any elevation of temperature in these cases 
points strongly against the existence of an intestinal infection, which is 
further indicated by the prompt recovery under appropriate treatment. 
The condition seems to be one of indigestion with a secondary catarrh, 
which may affect either the stomach or the intestines, or both. In the 
cases in which the gastric symptoms predominate, the trouble seems pri- 
marily due to the fats. When the intestinal symptoms are most marked, 
it appears to be the proteids which are primarily at fault, but soon Inl- 
and sugars also disagree. 

Before considering the case one of inadequate nursing, or simple indi- 
gestion in a nursing infant, one should be careful to exclude organic 



174 



NUTRITION. 



conditions in the child, particularly hypertrophic stenosis of the pylorus. 
The diagnosis of unsuccessful nursing should include the changes in the 
milk and if possible the causes of these changes. 

As the first step one should endeavour to gain some idea as to the 
quantity of milk secreted. During the first week, particularly from the 
second to the fourth day, the temperature may he elevated quite apart 
from septic or inflammatory conditions or even evidences of indigestion. 
This is particularly seen where the breasts secrete almost nothing (see 
Inanition Fever). Often when the milk is very scanty something may 
be learned from the manner in which the child takes the breast. Where 
the milk is abundant, five or six minutes are often sufficient. If the milk 
is very scanty, an infant will frequently nurse half or three-quarters of 
an hour and then stop, more because it is exhausted than because it is 
satisfied. Sometimes, when the breasts are practically empty, the child 
will seize the nipple and nurse vigorously for a few moments, then drop 
it in apparent disgust and refuse to make any further efforts. The only 
satisfactory way of determining the quantity of milk secreted is to weigh 
the infant before and after each nursing. If the milk is merely scanty, 
but not otherwise abnormal, the infant does not gain, but shows no symp- 
toms of indigestion, such as vomiting, colic, or undigested stools, and 
he frets and cries from hunger only. 

An excessively rich milk is usually found under the following con- 
ditions : The mother is in good health, has large breasts which are full 
and tense at nursing time. In most cases she is upon a very abundant 
diet, getting little or no exercise, and frequently taking some alcoholic 
beverage with the notion that because the child is not thriving the milk 
is poor. The child may be colicky, sleepless, and uncomfortable, may 
vomit, may have frequent stools containing much undigested food, and 
may be losing in weight. A similar condition is often seen when a wet- 
nurse makes a change from the simple life and habits of her own home 
to the more luxurious life and diet of the family to which she goes. 
The milk then has usually a high specific gravity, is high in fat and high 
in proteids. The following analyses from Rotch illustrate the point: 
No. I shows milk of a healthy but under-fed wet-nurse two days before 
change of food; II, the milk of the same nurse after one month of rich 
food with very little exercise; III, milk of the same nurse, the food and 
exercise being regulated. The effect of the exercise and the change in 
diet is seen in a very marked reduction in the proteids. 





I. 


II. 


III. 


Fat 


Per cent. 

0-72 
675 
253 
0-22 


Per cent. 

544 
625 
461 
0-20 


Per cent. 

5-50 


Sugar 


6-60 


Proteids 


2-90 


Salts 


014 







BREAST-FEEDING. I75 

A scanty milk of a poor quality is most often seen where the mother 
is delicate or anaemic, or perhaps has had a difficult or complicated 
labour, and who besides. is anxious and careworn. It is often with the 
greatest difficulty that one can secure the necessary half ounce required 
for examination. The milk is usually low in total solids and very low- 
in fat. The specific gravity may be only 1024 to 1027, and the fat 
only one per cent or less. 

A disturbed or disordered milk secretion is sometimes seen when the 
milk is scanty, often when it is very abundant. Like the group of cases 
just mentioned this is frequently met with when the mother's general 
health is below the normal, but particularly is it influenced by her ner- 
vous condition. It is the highly nervous, emotional, worried woman 
whose milk we are now considering. During the first week or two the 
secretion may be excessive and then rapidly diminish; or, though the 
milk continues abundant, the infant shows no improvement. It is most 
frequently found on examination that the milk is low in fat (050 to 
1 per cent), while it is high in proteids (1-75 to 3-50 per cent). The 
child's symptoms are usually those of intestinal indigestion — severe colic, 
flatulence, and frequent, green, undigested stools. 

Management. — The cause of the symptoms being in the food and not 
in the child, the futility of all medicinal treatment will be at once appar- 
ent. He who expects to relieve the symptoms of indigestion by the use of 
digestive ferments, by giving something before the nursing to dilute the 
milk, or to check frequent intestinal discharges by opium or astringents, 
will be disappointed. Temporary benefit often follows a dose of castor 
oil, but unless the milk can be materially changed in composition no 
permanent improvement in the child is to be looked for. The question 
usually to be decided relates to the continuance of nursing. We have a 
choice of four courses: (1) To continue nursing, endeavouring to correcl 
the milk through treatment of the mother; (2) to partly nurse and 
partly feed 'from the bottle; (3) to stop all nursing temporarily, pump- 
ing the breasts meanwhile to keep up the secretion while we attempt to 
improve its character; (4) to wean at once and entirely. In deciding 
which of these courses is to be adopted we must take into consideration 
the condition of the child, the severity and duration of its symptoms, the 
findings of the milk examination, and the condition of the mother. 

While the analysis of the milk is of some value in determining the 
course to bo pursued, and should, if possible, bo made, it is of much le>< 
importance than the child's symptoms. Wo must be guided not by what 
the milk contains, but by how seriously it disagrees. The chemical ex- 
amination may show the milk to be of norma] average iu the proportion 
of its different ingredients and yet the child he seriously upset by il : 
on the other hand, a child may be doing admirably upon a milk which 
Bhows proportions which differ very greatly from the normal average. 
13 



176 NUTRITION. 

The question always concerns the effect of the particular milk upon the 
particular child. 

When the symptoms of indigestion are severe or have been prolonged 
it is usually a mistake to attempt to relieve the condition by simply 
substituting some other food for part of the nursings. This seldom leads 
to any material improvement in the symptoms, while it does confuse the 
result, since we can not now tell whether it is the breast or the bottle 
feeding which disagrees. A better plan is to stop nursing entirely for 
a time and try the bottle alone. If the symptoms are at once relieved 
the weaning should be permanent. 

When symptoms point to a scanty milk, but of fair quality — i. e., 
infant not gaining but without any particular symptoms of indigestion — 
one is often able to overcome the difficulties and continue the nursing to 
advantage. Until a decided increase in the milk has occurred the child 
should have supplementary feedings from the bottle in sufficient number 
to insure its being properly nourished. Only one or two a day may be 
required, or it may be desirable to nurse and give the bottle alternately. 
If the latter plan is followed, both breasts should be given at each nursing 
period for the stimulating effect upon the secretion. 

In the treatment of the mother the first thing is to secure for her an 
undisturbed rest at night. If possible, she should be entirely relieved of 
the care of the infant at this time, and if feeding is necessary the bottle 
should be given. She should have a certain amount of fresh air every 
day, driving if possible, or walking as soon as she is able to take more 
active exercise. Gentle massage of the breasts is often useful in stimu- 
lating secretion. It should be done with care and with every precaution 
against infection, and may be repeated two or three times a day for ten 
minutes. The diet should be abundant, with a large allowance of milk 
and meat, especially beef. If there is anoemia, iron should be given. 
Some of the alcoholic extracts of malt are useful (page 138). Every 
means should be taken to improve the general nutrition, for whatever 
benefits this improves the milk. If the conditions present are incident 
to the confinement or the convalescence, the prognosis is good; and in 
the course of a week or two very marked improvement may be evident, 
and lactation may be successfully continued. If, however, the conditions 
depend upon constitutional debility, the prognosis is much worse. Tem- 
porary improvement may take place, but it soon becomes evident that 
the nursing is a failure. 

When the symptoms are found to be associated with an over-rich 
milk the prospects for continuing nursing are much better than when 
the milk is poor. Unless the infant's digestion is very feeble or has been 
seriously upset either with vomiting or diarrhoea, one can usually so 
alter the milk by treating the mother as to make it possible to keep the 
baby at the breast. Alcohol should be prohibited; the diet, especially 



BREAST-FEEDING. 



177 



the amount of meat, should be reduced, and the mother required to take 
daily exercise in the open air, particularly by walking. The intervals 
between nursing should be lengthened, usually to three hours. In many 
cases there is an advantage in diluting the milk by allowing the child 
to take water before putting it to the breast. The improvement follow- 
ing such a change in regimen is often immediate, and with increasing 
age and weight the child gradually becomes accustomed to and is able 
to digest the rich milk. If, however, the child's symptoms of indiges- 



OF AGE 2 4 6 8 10 12 14 16 1 8 20 22 24 26 


19 
18 

17 

16 

15 

14 
CO 

QI3 

z 

D 

OI2 

Q. 

1 1 

10 

9 

8 

7 
6 




























































































































































































































































































































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/ 


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Fig. 32. — Weight curve showing the effect of bad nursing and good feeding. Maternal nursing 
for seven weeks; continued symptoms of indigestion; colic, frequent green passages, con- 
stant discomfort, etc.; other treatment without avail. Immediate improvement when 
weaned and put on modified milk from the laboratory. Formula : Fat 1-5 per cent, BUgar 
6 per cent, proteids 0-75 per cent. All symptoms of indigestion rapidly disappeared, the 
percentages were gradually increased, and steady gain in weight followed. 



tion are of an aggravated type, whether gastric or intestinal, i( will be 
necessary, even though the weight is increasing normally, to slop nurs- 
ing entirely for a time. The breasts should be pumped at regular inter- 
vals and the child placed upon some other food until the symptoms are 
relieved, and then brought back gradually to breast feeding. Should the 
infant's digestion be upsel a second time as soon as the brefesl is resumed, 
the child should be weaned. 

If the examination shows the milk to be of ven poor quality (i. e., 
low in fat, low in total solids), whether scanty or abundant, the outlook 



178 NUTRITION. 

is not good. It is seldom that the conditions affecting the mother to 
which such a milk is due can be removed. 

When we see a' fretful, colicky, sleepless infant with either no gain 
in weight or a loss of a few ounces a week, and with stools which never 
approach the normal, and these conditions have lasted for three or four 
weeks, we are justified in taking the child from the breast at once (Fig. 
32). When the symptoms are less pronounced, and especially when, in 
spite of all discomfort and indigestion, the infant is gaining in weight, 
even though not rapidly, further efforts may be made before weaning 
is ordered. 

Summary. — Poor milk is usually low in fat and scanty in quantity, 
while the proteids may be either high or low. Very rich milk is usually 
high both in fats and proteids. Very poor milk can seldom be perma- 
nently improved unless the causes are very definite and of a temporary 
character. Over-rich milk can often be improved if the true explanation 
for it can be reached. Eesults are to be judged not so much by the 
change in the composition of the milk as by improvement in the infant's 
symptoms. On the whole, since artificial feeding, when it can be prop- 
erly done, gives much better results than poor or doubtful nursing, I 
am inclined, as a result of increasing experience, to stop nursing after 
a fair trial — e. g., of two to three weeks — has been made, and begin 
feeding, rather than waste time in prolonged efforts to improve the 
breast-milk. 

Wet-Nursing. — In the selection of a wet-nurse, it is by no means 
so essential as has generally been supposed, that her child shall be of 
about the same age as the child she is to nurse, for, after the first month, 
the changes in the composition of breast-milk are insignificant. It 
is always desirable that the wet-nurse shall have nursed her own infant 
long enough to demonstrate the fact that she has an abundance of good 
milk; hence, taking a wet-nurse at the end of the first or second week is 
always fraught with considerable uncertainty. It is the quality of the 
milk, not its age, which determines whether or not it will agree. For 
an infant over one month old, a good wet-nurse whose milk is anywhere 
between one and six months old will usually answer perfectly well; and 
even for premature infants such a milk may be used without hesitation, 
but it should at first be diluted. 

A good nurse must, first of all, be a healthy woman, free from 
syphilitic or tuberculous taint, and her throat, teeth, skin, glands, scalp, 
and legs should be carefully inspected. She must have good mammary 
glandular development. The breasts should be full and hard three hours 
after nursing. They may be very large and yet supply very little milk, 
being then composed almost entirely of fat. On the other hand, some 
smaller breasts may be almost all glandular tissue. The difference in 
the size of a breast before and after nursing, is one of the best guides as 



WEANING. 



179 



to the amount of milk it is secreting. The nipples should be free from 
erosions or fissures, and long enough for the needs of the child. Prefer- 
ably she should be of a phlegmatic temperament, and of a good moral 
character. This is desirable for personal reasons, although there is no 
evidence of moral qualities being transmitted through the milk. It is 
desirable that a nurse should be between twenty and thirty years of 
age, although much more depends upon the individual than upon the age. 
Other things being equal, a primipara should be chosen. An examina- 
tion of the milk may be of some assistance in selecting a nurse; but the 
best evidence to be obtained of the character of a woman's milk is the 
condition of her own child, which should always be seen before she is 



MONTH OF AGE. 


GMS. 


LES. 


1 2 3 4 5 6 


8 9 10 11 12 


9530 
9070 
8C20 
8100 
7710 
7200 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


21 

20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 

X 

7 
6 
5 
















































































































































































































































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In 


tfc 


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VC- 


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Fig. 33. — Chart showing the effect of pregnancy upon the weight of a nursing infant. Th 
upper line is that of the patient; the lower one is the average line for the first year. 



accepted. It often happens that a woman who has had an abundant 
supply of milk for her own infant, has very little for another infant for 
the first few days in her new surroundings. This is usually the result 
of the nervous disturbance connected with parting from her own child. 
going to a new place, being carefully watched, etc. In such a case ii 
should not be too readily decided tbat she is incompetent as a nurse, for, 
under most circumstances, with proper treatment her normal flow of 
milk will be re-established. 

WEANING. — Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and child. Sudden weaning is apt to 
be followed by an attack of acute indigestion in the infant. This, how- 
ever, is not a necessary result, and usually depends upon the foci thai 
the child is given cow's milk without Bufficienl dilution. Weaning in hot 



180 



NUTRITION. 



weather is usually to be avoided, but the barm from this is not nearly so 
great as sometimes results where lactation is unduly prolonged because 
of a prejudice against a change of food at this time. While there are 
many women of the lower classes who are able to nurse their children to 
advantage for the entire first year, the number of such among the bet- 
ter classes is certainly very small. By the latter, nursing can rarely be 
continued beyond the ninth, and often not beyond the sixth month, with- 
out unduly draining the vitality of the mother and at the same time 
harming the child. The late months of lactation, like the early months, 
require close watching. It is a common mistake to continue both mater- 
nal and wet-nursing too long, owing to a dislike of making a change 



OF age 28 30 32 34 36 38 40 42 44 46 48 60 52 


26 

26 

24 

23 

co22 
Q 

o 

So 

19 
18 
17 

16 


























































































































































































































































































































































































































































































































































































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Fig. 34.— Weight curve of a child properly weaned. Abrupt weaning at eight months ; loss 
of weight "for the first week due to the child's being put upon cow's milk with low percent- 
ages. Formula: Fat l - 6 per cent, sugar 6 per cent, proteids 0-80 per cent. Pei-centages were 
rapidly increased, with subsequent "steady and regular gain in weight. Weaning accom- 
plished without the slightest symptom of indigestion. The lower is the average line. 

when things are going tolerably. It is a safe rule to make the ninth 
month the time to supplement the breast-feeding by other food. But 
here, as in the early months, the child's weight is the best guide. In the 
absence of evident signs of disease, a stationary weight for several weeks 
makes weaning advisable; a steady loss makes it imperative. 

The accompanying weight-chart (Fig. 33) illustrates this point. The 
infant did unusually well until the sixth month. As it did not seem ill, 
the parents were not disturbed until the loss had reached three pounds. 
Feeding was at once begun, and the child gradually regained its lost 
weight. It was subsequently discovered that the mother was pregnant. 



MIXED FEEDING. 181 

When a nursing infant has been accustomed from birth to take one 
feeding a day from the bottle, always a great convenience to a nursing 
mother, gradual weaning is generally an easy matter; otherwise it is 
sometimes an impossibility, the child refusing all food except the breast 
so long as this is given, and nothing but starvation inducing it to take 
food either from a bottle or a spoon. 

Sudden weaning may be required at any time from the development 
in the mother of acute disease of a serious nature, such as typhoid fever 
or pneumonia, of grave chronic disease, such as tuberculosis or nephritis, 
from the intercurrence of pregnancy, or from disease of the mammary 
gland. An infant should not be suckled at a breast which is the seat 
of acute inflammation. Through many of the minor ills — mild attacks 
of bronchitis, pharyngitis, indigestion, and even malarial fever — mothers 
frequently nurse their children without any seeming detriment to them 
or to themselves. In acute illness of short duration, if severe, it is 
usually better, unless we decide to wean altogether, to feed the child 
from the bottle and to maintain the flow of milk by the use of the breast- 
pump three or four times a day rather than allow it to dry up. 

In cases of sudden weaning, the food should in the beginning be very 
much weaker than for an artificially fed child of the same age. The 
change can then be made without causing much disturbance (Fig. 34). 
When the infant has become somewhat accustomed to cow's milk the 
strength of the food may be gradually increased. ■ 

MIXED FEEDING. 
By mixed feeding is meant a combination of nursing and artificial 
feeding. There are no objections to this practice; often there are great 
advantages in giving an infant only a few breast feedings a day when 
more are impossible. This may frequently be done in hospital practice, 
and thus a single wet-nurse may assist in the feeding of two or three 
infants. Mixed feeding may be resorted to whenever the milk supply 
of the mother is insufficient. If at any time the mother's health begins 
to suffer, she may be relieved of night nursing or of one or more nurs- 
ings during the day, and the bottle substituted. In this way she may 
be enabled to continue lactation for some time longer than would other- 
vrise be possible. Mixed feeding is often necessary during the first few 
weeks, while the mother's milk is insufficient in consequence of some- 
thing which has retarded her convalescence. The milk may become 
abundant and of good quality as soon as the mother is well enough to 
be up and out of doors, although it was previously scanty and of inferior 
quality. Two or three feedings a day from the bottle help lo bridge over 
this period and prevent the child's nutrition from suffering. "But before 
allowing a mother partly to nurse and partly to feed her infant, one 
should be sure that the quality of the milk is good. 



182 NUTRITION. 

It is well from the very outset to accustom the infant to take one of 
its feedings, or at least to take water, from a bottle each day. In mater- 
nal nursing, the occasional feeding which is usually necessary becomes 
then a simple matter. If the child is being wet-nursed, the same plan is 
advisable, for it then becomes easy to put an infant upon the bottle 
entirely in the event of the wet-nurse leaving suddenly — a not uncom- 
mon occurrence. 

ARTIFICIAL FEEDING. 

There are several fundamental principles regarding which nearly the 
whole scientific world is agreed. 

1. Woman's milk is not only the best, it is the ideal infant-food. 

2. Any substitute should furnish the same constituents — fat, carbo- 
hydrates, proteids, salts, and water ; furthermore, they should be in about 
the same proportion as they exist in a good sample of woman's milk. 

3. The food should have a caloric value * sufficient to promote growth 
and furnish energy. 

4. The different constituents should resemble those of woman's milk 
as nearly as possible both in their chemical composition and in their 
behaviour toward the digestive fluids. 

5. These conditions are fulfilled only by fresh milk from some other 
animal. 

* From numerous observations, the caloric needs of the average infant in health 
have been shown to be about 100 calories for each kilo, of body weight from the 
third week to the sixth month. These gradually diminish until at the end of the 
first year they reach about 75 to 80 calories per kilo. The caloric requirements are 
greater for very active infants on account of their more rapid metabolism ; also, for 
premature or wasted infants on account of their relatively larger body surface to 
radiate heat. i 

An infant weighing 7 kilos. (15 pounds) requires about 700 calories daily. As the 
caloric value of a good average specimen of woman's milk is about 650 calories per 
litre, the requirements would be supplied by a little over one litre of woman's milk. 

The practical application of these facts in infant-feeding is that one should be 
careful to furnish to an infant who is artificially fed what is needed, but no 
excess. A food much below the normal caloric requirements, or one much above 
them, may be equally improper and therefore unsuccessful. The physician should be 
able to calculate the caloric value of the food given when infants are not thriving, to 
see if possible where the mistake lies. 

The caloric value of any modification of cow's milk of known percentages may be 
calculated as follows : An infant six months old, weighing 15 pounds (7 kilos.), is taking 
six feedings of 6 ounces, or 36 ounces daily, of a milk containing, fat 3*5 per cent, 
sugar 7'per cent, proteids 1 # 75 per cent. 

•035 (fat %) x 9 3 (caloric val. of fat) = 325 caloric val. of fat in 1 grm. food. 

"07 (sugar %) x 4 - l " " " sugar) = - 287 " " " sugar " 1 " " 

•0175 (proteids %) x 4*1 " " " proteids) = 072 " " " proteids " 1 " " 

•684 caloric value of 1 gram of food. 
•684 x 1000 = 684 (caloric value 1 litre food). 

36 ounces«= 106 litres; 1-06 x 684 = 725 (No. calories in food taken daily). 
725 -4- 7 (body wt. in kilos.) =104 (No. calories per kilo.); which is slightly above the 
normal requirements, 



ARTIFICIAL FEEDING. 1§ 3 

In the artificial feeding of infants, cow's milk is selected as being 
the only milk available for general use. Although it furnishes all the 
constituents required, they are not present in the proportions suited to 
young infants, and the constituents are not identical with those in wom- 
an's milk. Cow's milk, therefore, can not be fed to most infants without 
some changes. These changes are technically known as the Modification 
of Cow's Milk. 

Although there is practical agreement among writers and teachers 
regarding the foregoing points, there still exists considerable difference 
of opinion respecting methods of adapting cow's milk to the infant's 
digestion. To make these changes properly it is necessary to know in 
the first place what are the exact differences between cow's milk and 
woman's milk; and, secondly, to devise the simplest method of over- 
coming them. 

The earliest milk modification was simply dilution with water and 
the addition of enough cane sugar to make it taste like breast milk. The 
only change made with the age of the child was simply to vary the 
amount of water. Instead of water as a diluent many have preferred to 
use gruels made from different cereals — oatmeal, barley, arrowroot, etc. 
— believing that thereby the casein was rendered more digestible. Upon 
such simple modifications as these many children have done, and many 
still do, very well, when the matter of dilution is judiciously managed. 
But it is equally true that very many do not do well, and that present 
knowledge enables us to do something better. There are, however, cir- 
cumstances where anything more complex is impossible in the way of 
milk modification; then only should the old methods of simple dilution 
be employed. 

Later, when the composition of woman's milk came to be better 
understood, it was thought that all that was necessary in modified milk 
was to secure the exact percentages of fat, proteids, sugar, and salts 
which exist in a good sample of woman's milk, and that this combina- 
tion would be the best possible substitute for it. Out of this came the 
various mixtures of milk, cream, sugar, etc., which aimed to reproduce, 
according to the views of different writers, the exact proportions of 
woman's milk. 

This was a great step in advance, in that some proper relation be- 
tween the different food constituents was maintained. While frequently 
successful, such formulas often failed for lack of flexibility. The food 
was I be same, but the child was not always the same. Furthermore, the 
difference in the digestibility of both the fats and the proteids was not 
sufficiently taken into account. Experience has shown that no single 
milk-formula can be made to serve as a substitute for woman's 
milk; and intelligent students of the problem have ceased to search 

for one. 

14 



184: NUTRITION. 

The central thought of the newer method of modification — which 
may very properly be called the " American method " — is to consider the 
different elements* of the food separately and to adapt their proportions 
to the child's digestion. Like the method just described, it is based 
upon the percentage composition of woman's milk, and also recognises 
that there is a difference in the digestibility of cow's milk and woman's 
milk, particularly of the proteids. It aims to discover the proper propor- 
tions of fat, sugar, and proteids, and the best methods of gradational 
increase for healthy infants with normal digestion; and also to discover 
for those with abnormal or feeble digestion, the combinations best suited 
to the individual conditions. Where difficulty exists in the digestion of 
milk, it is usually with some one of its elements, or at least chiefly with 
one. In such a condition, instead of stopping milk entirely, or reducing 
the proportion of all the elements by simply diluting the food still fur- 
ther, that one alone which is causing the disturbance is reduced. 

In practice there is necessary an easy method of securing the usual 
percentages which experience has shown to be best for healthy infants, 
following in a general way those existing in woman's milk — a method, 
moreover, which can readily be adapted to special and peculiar condi- 
tions. In brief, the American, or, as it is sometimes called, the " per- 
centage method " of milk modification for infant-feeding, aims at some- 
thing which is definite, exact, and at the same time flexible. It is 
somewhat more complex possibly than the older methods, but not nearly 
so difficult as may at first appear. In practical results, however, it is in 
my judgment, and in the opinion of nearly every one who has taken the 
trouble to master it, a very great step in advance. By this method 
infant-feeding has been placed for the first time upon a scientific basis. 
Percentages are simply a method of stating definitely just what we are 
giving, and furnish the only means by which our observations can be 
recorded and compared with those of others. 

For the fundamental work along this line the world is indebted to 
Prof. T. M. Eotch, of Harvard, and Mr. G. E. Gordon, of the Walker- 
Gordon Laboratory Company. 

The Modification op Cow's Milk for Healthy Infants during 
the First Year. — By the modification of cow's milk is meant its adap- 
tation to the purposes of infant-feeding. It is desirable to consider 
separately the changes required by healthy infants with normal digestion, 
and those required by infants with feeble digestion, or those suffering 
from more or less indigestion. From a failure to make this distinction, 
much confusion has arisen and many errors have crept into the subject 
of infant-feeding. The digestion of all healthy infants is very much 
alike, and they can all be fed in much the same way; while, on the con- 
trary, the variations afforded by unhealthy infants are almost endless, 
and each case must be considered by itself. If it is only healthy infants 



ARTIFICIAL FEEDING. 



185 



that can be fed by rule, it is equally true that if fed from the beginning 
by proper rules most infants will remain healthy. 

In adapting cow's milk for infant-feeding we must realize at the 
outset that, no matter how we may alter it, cow's milk is not a perfect 
substitute for woman's milk. It should not be lost sight of that there 
are inherent differences which will never be altogether removed. The 
following table gives the proportions of the various elements which make 
up the two milks : 





Woman's milk, 
average. 


Cow's milk, 
average. 


Fat 


Per cent. 

4-00 
7-00 
1-50 
0-20 
87-30 


Per cent. 

4-00 


Sugar 


4-50 


Proteids 


3-50 


Salts. 


0-75 


Water 


87-25 








100-00 


100-00 



These quantitative differences in the constituents are important. It will 
be seen that cow's milk has an excess of proteids and salts but is de- 
ficient in sugar. Far more important, however, for the infant are the 
qualitative differences. The sugar in the two milks, it is true, is nearly 
if not quite the same. The fat of cow's milk, however, contains a much 
larger proportion of volatile fatty acids. The salts are excessive in 
amount, particularly calcium phosphate, but are deficient in iron and 
potassium. The most important difference is in the proteids. The total 
proteids of cow's milk are nearly two and a half times as great as in 
those of woman's milk. In cow's milk the soluble proteids (lactalbumin, 
etc.) are only about one-third or one-fourth as abundant as the insoluble 
proteids (casein) ; while in woman's milk the soluble proteids form more 
than half the total. Furthermore, the difference in the digestibility of 
the proteids, particularly the casein, is even greater than this difference 
in (juantity. Other important conditions relate to the reaction of milk, 
its freshness, bacterial contamination, etc. The modification of milk 
must aim, therefore, at something more than overcoming the quantita- 
tive differences in the constituents. 

Fat. — The average amount of fat of cow's milk which a healthy 
infant can digest varies from 2 to 4 per cent. With many infants it is 
often necessary to begin with a slightly lower amount than 2 per cent. 
The increase is made very gradually, the upper limit being reached usu- 
ally at four or five months. I have seldom found it advantageous to 
increase the fat above 4 per cent, and constantly see Berious derange- 
ments of digestion produced by the use of higher percentages.* The 

* Archives of Pediatrics, January, 1005. 



186 NUTRITION. 

danger of disturbing the infant's digestion by rising too high fat is not 
sufficiently appreciated. This mistake is frequently made when rich 
Jersey milk is employed, and also when the fat percentage is steadily 
raised for the purpose of overcoming chronic constipation. There are 
many healthy infants who can not digest even 4 per cent of fat at any 
time, and many more who during hot weather do much better when a 
reduction to 3 or 35 per cent is made. No modification of the fat of 
cow's milk is possible except in the amount. There seems to be no 
difference in the digestibility of gravity and centrifugal cream. Fresh- 
ness is a very important consideration in all extra fat added to milk; 
since undoubtedly the fermentative changes, some of which may take 
place in the fat quite early, seriously affect its digestibility. 

Sugar. — In woman's milk the percentage of sugar varies but little; 
it is usually between 5-5 and 7 per cent. In feeding cow's milk it is 
seldom required to have the sugar less than 5 or more than 7 per cent. 
To obtain the proper proportion of sugar is the simplest part of the 
modification. It is only necessary to calculate the amount to be added 
to bring this up to the 5, 6, or 7 per cent desired. The milk sugar should 
first be dissolved in boiling water, and, when it contains impurities, fil- 
tered through absorbent cotton. The advantages of lactose over other 
sugars have already been considered (page 127). When, however, good 
milk sugar can not be obtained, cane sugar may be substituted; the 
amount added should be but little more than half that of milk sugar on 
account of its sweeter taste and greater liability to undergo fermentation. 
It should be distinctly understood that the purpose of adding sugar is 
not to sweeten the food, but to furnish the proper proportion of soluble 
carbohydrates necessary for the infant's nutrition. 

Proteids. — The modification of the proteids is the most important 
change necessary in cow's milk, for it is the proteids which give most of 
the trouble to the infant's digestion. The density of the coagulum which 
forms in the stomach from cow's milk is greatly lessened by diluting the 
milk, but the coagulum differs much from that formed from woman's 
milk even when the total proteids are made the same. 

Several different methods have been proposed for modifying the pro- 
teids of cow's milk : ( 1 ) Eeducing the total proteids by dilution ; ( 2 ) par- 
tially predigesting them by peptonizing; (3) separating the proteids by 
removing the casein after precipitation with rennet; (4) adding lime 
water or other alkalies; (5) adding sodium citrate; (6) using as a 
diluent, instead of water, gruels made of different cereals — oatmeal, bar- 
ley, arrowroot, etc., for their mechanical effect upon the coagulation of 
the casein. 

These different methods are more fully discussed in the later pages 
devoted to Difficult Cases of Feeding. For healthy infants with average 
digestion, reduction in the quantity of the proteids is often all that is 



ARTIFICIAL FEEDING. 



18' 



necessary. During the early months it is not enough to reduce the pro- 
teids to the average amount present in woman's milk — i. e., 15 per cent. 
Better results are usually obtained by making the proteicls for the first 
few days only Oo per cent; then, as the stomach becomes somewhat 
accustomed to cow's milk, gradually raising the proportion until after 
a few weeks the child is usually taking 1 per cent; by the end of the 
second or third month, 15 per cent; and by the end of the fourth or 
fifth month, 2 per cent proteids. It is seldom that the total quantity 
of proteids present in cow's milk can be given before a child is a year 
old. I believe the secret of success in feeding cow's milk is to begin 
with the proteids so low as not to disturb the infant's digestion, and then 
slowly but steadily to raise the quantity. While the infant's stomach 
was not intended to digest cow's milk, but woman's milk, it is perfectly 
certain that by this method it can gradually be trained to digest cow's 
milk of the percentages mentioned. 

Except to start with too high proteids no more common mistake is 
made than to continue long with too low proteids. Anaemia, malnu- 
trition, and, I believe, not infrequently scurvy are seen as a consequence 
of this practice. The gradual increase is therefore just as important as 
the low beginning. 

Inorganic Salts. — These may generally be calculated as one-fifth the 
total proteids. No separate modification of the salts is usually attempted. 
When the proper dilution is made for the proteids, the proportion of the 
total salts will be nearly correct. But it should not be forgotten that 
this dilution, while it brings down those salts which are in excess to a 
proper proportion, reduces to the same degree those which were origin- 
ally deficient. The influence of this upon nutrition is something deserv- 
ing further study. 

The amount of reduction obtained by the different dilutions is shown 
in the following table : 





Cow's 
milk. 


Diluted 
once. 


Diluted 
twice. 


Diluted 
3 times. 


Diluted 
4 times. 


Diluted 
times. 


Diluted 
9 times. 


Proteids 


3-50 
0-75 


1-75 
0-37 


1-16 
0-25 


0-87 
0'18 


0-70 
0-15 


0-50 

o-io 


0-35 


Inorganic suits 


0-07 



Reaction. — It has been customary to overcome the acidity of cow's 
milk by adding cither lime-water or bicarbonate of soda. 01' the former, 
there is required about one ounce to each twenty ounces of the food: of 
the latter, about one grain to each ounce of the food. The value of these 
additions to milk is probably due more to the retardation of coagulum 
formation in the stomach than to the neutralization of any increased 
acidity of the milk taken. 



188 NUTRITION. 

Bacteria. — These are always present in cow's milk. * They have been 
already considered in the pages devoted to the Sterilization of Milk. 

The Observation of Cases of Infant-Feeding. — For the first few weeks 
it is essential that the physician see the infant every few days, inspect 
the stools, hear the nurse's report, and see how his directions are being 
carried out. When the child is well started and has begun to gain regu- 
larly in weight, a weekly visit will be sufficient. Still later a regular 
weekly report in writing, to be continued up to the seventh or eighth 
month, may be all that is required; after that time monthly reports are 
usually sufficient. My plan is to have the weekly report include only 
answers to certain questions — viz. : 

1. Weight: gain or loss since last report. 

2. Stools : frequency and general character. 

3. Vomiting or regurgitation — when? and how much? 

4. Flatulence or colic? 

5. Appetite: is the child satisfied? Does he leave any of his food? 

6. Is he comfortable and good-natured? 

7. How much does he sleep? 

8. Date. 

9. Date of last report. 

An excellent plan is to furnish the patient with printed forms con- 
taining these questions to be filled out and returned. This is a simple 
matter, and there are very few intelligent mothers who will be unwilling 
to cooperate with the physician to this extent. With information regard- 
ing the points indicated, it is possible for the physician to know pretty 
accurately how the case is doing, what changes, if any, are desirable in 
the food, and whether he ought to see the patient. It is only by some 
systematic method of observation that one can secure the best results 
with any form of infant-feeding. 

Milk Laboratories. — The first milk laboratory was established in 
Boston by the Walker-Gordon Company in 1892; one in New York in 
1893, and since that time others in many American cities. They under- 
take to furnish " modified milk " of any desired proportions, upon the 
prescription of physicians. The elements chiefly used by the Walker- 
Gordon laboratories are: (1) Cream containing 32 per cent fat; (2) 
separated milk, from which the fat has been removed by the centrifugal 
machine; (3) a standard solution of milk sugar, 20 per cent strength. 
These contain fat, sugar, and proteids in the following proportions : 





Cream. 


Separated 
milk. 


Sugar 
solution. 


Fat 


Per cent 

32-00 
3-40 
2-50 


Per cent. 

0-05 
5-00 
3'55 


Per cent. 


Sii£?ar 


20.00 


Proteids 









ABTIF1CIAL FEEDING. 189 

By combining these it is possible to vary the percentages of fat, sugar, 
and proteids in the milk to almost any degree desired, and to do this 
with very great accuracy. By using whey, a separate modification of 
the proteids is accomplished; so that within certain limits a larger pro- 
portion of whey proteids, chiefly lactalbumin, can be given. The highest 
proportion of whey proteids with the lowest proportion of casein can be 
given when the total proteids do not exceed 115 per cent; of this, 090 
per cent may be whey proteids and 0-25 per cent casein. The alkalinity 
is usually obtained by adding lime-water in any desired amount. The 
laboratory uses either gravity or centrifugal cream, as preferred by 
physicians ; it also adds, when requested, gruels of wheat, oats, or barley 
of any desired strength; and, flnalty, it delivers the milk raw, or heats 
it for sterilization to an}?- temperature ordered by the physician. 

The food-suppty for the entire day is delivered each morning in the 
bottles from which it is to be fed. The empty bottles returned are 
washed and sterilized at the laboratory. In ordering the food the physi- 
cian simply writes for the percentages of fat, sugar, and proteids which 
he desires, together with the number of feedings for twenty-four hours 
and the quantity for each feeding, in the following form : 

Yf, Fat 3 per cent. 

Sugar 6 " 

Proteids 1 " 

Alkalinity, lime-water 5 " 

Number of feedings 8 

Amount for each feeding 4 ounces. 

Heat to 155° F., 30 minutes. 

The milk laboratory and the percentage method of milk modification 
mark a great advance in infant-feeding. The laboratory bears the same 
relation to the physician as does the apothecary shop. ' It does not 
attempt to prescribe; it does not prepare a food. It aims only to sup- 
ply the physician with any milk modification which he may desire to 
use. The results with milk from the laboratory will depend, therefore, 
upon the physician's knowledge and experience in prescribing milk. One 
who is ignorant of the principles of Infant-feeding is not helped by the 
laboratory, any more than is the careless diagnostician or the uneducated 
practitioner by a good apothecary. The responsibility of the laboratory 
is only to see that the patient gets exactly what has been ordered. Too 
often the physician has wrongly laid the blame for his failures in feed- 
ing at the door of the laboratory, when the cause was really his own 
want of experience in ordering milk. 

In using the laboratory, one is not restricted to any method or plan 
of feeding, but is free to carry out his own ideas with a much greater 
assurance of accuracy than is possible when the milk is prepared in the 



190 



NUTRITION. 



average home. He is independent of the ignorance, carelessness, or 
caprice of the nurse who otherwise would probably prepare the food. 
While there are many physicians who find little difficulty in calculating 
percentages from the materials in ordinary use for the home modification 
of milk, it must be admitted that this calculation is a stumbling-block 
to the majority. The laboratory makes it an easy matter to vary the 
percentages at will without making arithmetical calculations. But by 
whatever method the child is fed the physician who assumes the respon- 
sibility to direct must be familiar with the subject and he must keep in 
touch with the case if he expects good results. 

The practical advantages of laboratory-feeding are sufficiently attested 
by the fact that laboratories have been established in sixteen of the larger 
cities of the United States and Canada, and have received the indorse- 
ment of the great body of the most intelligent physicians of the country. 
The principal objection to laboratory-feeding is the expense. 

After over twelve years' experience with laboratory-feeding I am more 
than ever convinced of its scientific value and its practical utility, and 
have, therefore, no hesitation in placing it, when intelligently used, next 
to maternal nursing. As a general guide to the modification of milk 
for an average healthy infant the following table is introduced, showing 
the manner in which the changes required by the development of the 
child are made : 



Table Showing Percentages of Fat, Sugar and Proteids which May Be 
Ordered from the Milk Laboratory and are Suitable for the First Year. 





Fat. 


Sugar. 


Proteids. 


Whey proteids. 


Casein. 


Weak Formulas. I. 


1-00 


4-00 


025 


or 0-20 and 


005 


II. 


1-00 


5-00 


0-50 


" 045 " 


005 


III. 


1-50 


5-00 


075 


" 070 " 


005 


IV. 


1-50 


6-00 


1-00 


" 0-85 " 


0-15 


Medium Formulas. V. 


2-00 


6-00 


1-00 


" 0-85 " 


0-15 


VI. 


2 


00 


6-00 


1 


10 


" 


80 " 





30 


VII. 


2 


50 


6-00 


1 


20 


" 


80 " 





40 


VIII. 


2 


50 


6-00 


1 


30 


11 


80 « 





50 


IX. 


3 


00 


6-00 


1 


40 


" 


80 " 





60 


X. 


3 


00 


6-00 


1 


40 


" 


60 " 





80 


XI. 


3-00 


6-00 


1-50 


" 0-50 " 


1-00 


Strong Formulas. XII. 


3-50 


7-00 


1-60 






XIII. 


3 


50 


7-00 


1-75 






XIV. 


3 


50 


7-00 


2-00 






XV. 


3 


50 


7-00 


2-25 






XVI. 


3 


50 


7-00 


250 






XVII. 


4 


00 


7-00 


250 






XVIII. 


4 


00 


600 


300 






XIX. 


4-00 


4-50 


350 


(Whole milk.) 





ARTIFICIAL FEEDING. 191 

The first group, classed as weak formulas, are designed for normal 
infants during the first few weeks, or for those with feehle digestion, 
of whatever age. 

The second group are designed for the needs of normal infants from 
ahout one month to four or five months, although there are many who 
can not take a stronger food for a much longer time. 

The third group is expected to cover, for children with good diges- 
tion, the period from about the fifth month to the twelfth or thirteenth 
month, gradually leading up to whole milk. 

It is important to begin with a weak formula for a young infant, 
and for one with feeble digestion, whatever its age. One may then 
gradually increase the strength of the milk according to the indications 
afforded by the child's appetite and powers of digestion. With some the 
increase can be made more rapidly than with others, but with all chil- 
dren it is important that the steps of increase should be gradual 
and not greater than are indicated in the formulas of the table; it may 
even be desirable at times to make them more slowly than is there 
suggested. 

In the table the total proteids to be used are indicated and also the 
quantities of whey proteids and casein, when one desires to order these 
separately. The advantage of so dividing the proteids, when a child 
has special difficulty in digesting proteids, is very great. By this means 
one may carry the ^percentage of total proteids much higher than is 
otherwise possible. The ability to order the proteids separately and to 
vary them readily constitutes one of the great advantages of laboratory- 
feeding. Formulas containing the divided proteids are to be recom- 
mended for routine use with young infants or with those with feeble 
digestion. 

Home Modification of Milk. — Inasmuch as milk laboratories are 
as yet inaccessible to the great body of the profession, the problem pre- 
sented is how the advantages of the laboratory method may be utilized 
where milk is prepared at home. No plan of home modification yet 
proposed secures more than approximate accuracy in the percentages of 
fat, sugar, proteids, etc. Yet, if the directions given below are carefully 
carried out, a degree of accuracy sufficient for all practical purposes can 
be secured. The physician thus can not only know the percentages he 
is giving, but he can himself readily vary them within the range usually 
required, according to the indications presented. The thing desired is 
a method simple enough to be readily grasped by the average mother 
or nurse who is to carry out the physician's directions. The method 
here given is one which in principle T have followed for many years; 
and I have found little difficulty in making patients understand how to 
use it. Several other methods have been proposed, which have their 
merits; all require a little study to enable one to use them freely. 



192 



NUTRITION. 



The requisites for success in the home modification of milk are: 

Good raw materials — the freshest and cleanest milk obtainable. 

Knowledge on the part of the physician of at least the approximate 
composition of the milk and cream used in the home. 

Directions which are clear, explicit, and in writing, that they may 
not be misunderstood. 

The cooperation of an intelligent mother or nurse, that they may 
be properly carried out. 

How to Obtain the Formulas Required for General Use. — If one has 
at command three series or groups of formulas in which the fat has 
certain definite relations to the proteids, he will be equipped for the 
great majority of cases met with in practice. The three groups are as 
follows : 

First Series, those in which the fat is three times the proteids. 

Second Series, those in which the fat is twice the proteids. 

Third Series, those in which the fat and proteids are nearly equal. 

Once thoroughly familiar with these groups of formulas, variations 




Fig. S5.— The percentage of fat in different layers of milk. (Compare page 152.) 

from them to suit the needs of the particular case can readily be made. 
In general, the First and Second Series, in which the fat is consider- 
ably higher than the proteids, are adapted to the early months, because 
at this period the infant as a rule has more difficulty in digesting pro- 
teids than in digesting fat. In the later months a higher proportion 
of proteids can be taken with the same percentage of fat. There are, 
however, other -conditions besides age which must be taken into account, 
such as the vigour of constitution, the weight, and most of all the 
peculiarities of the child's digestion. It is, therefore, impossible to say 
that at certain months certain proportions are desirable, and certain 
others at another period. 



ARTIFICIAL FEEDING. 



193 



Formulas in which the fat is three times the proteids. — This is 
nearly the relation which the fat and proteids bear to each other in a 
good sample of woman's milk. The easiest way to arrive at this would 
seem to be, first, to secure some milk or milk combination containing 
three times as much fat as proteids, and then dilute this according to 
the infant's age and digestion. After such dilution it will be necessary 
only to add the requisite amount of sugar and, when desired, lime-water 
to complete the modification. This, in brief, is the whole process. 

The most convenient combination for dilution is one containing 10 
per cent fat and 3 3 per cent proteids. I shall call it a 10-per-cent milk, 
and refer to it subsequently as the primary formula of the First Series. 
The 10-per-cent milk may be obtained by removing the upper portion 
(see Fig. 35) from a quart bottle of milk, as described (pp. 151, 15?). 
This method will answer for persons who can obtain milk fresh from 
the cow, or for those who use bottled milk, provided the bottling is done 
at the dairy before the cream rises. The upper milk may be taken off 
with a siphon, spoon, or small dipper (Fig. 36) ; pouring off is not so 
accurate. For those who do not get their milk as above described, the 
additional fat can be secured by adding cream to the milk. To secure 
a combination containing 10 per cent fat, equal parts of plain milk and 
the ordinary (16-per-cent) cream should be used. 

The next step is the manner and degree of dilution of the primary 
formula. It is convenient in our calculation to make up 20 ounces of 
the food at a time. For such a 20-ounce 
mixture it is seldom necessary to use less 
than 2 ounces of our 10-per-cent milk. 
When one wishes to strengthen the food 
he gradually increases the amount of the 
10-per-cent milk, 1 ounce at a time, mak- 
ing it successively 3 ounces, 4 ounces, 5 
ounces, 6 ounces, etc., in a 20-ounce mix- 
ture, the water, of course, being reduced 
by the same amount. 

These mixtures may readily be trans- 
lated into percentages by remembering 
that the percentage of fat is always ex- 
actly one half the number of ounces of 
the 10-per-cent milk used in a 20-ounce 
mixture. Thus using 3 ounces will give *»■ ^f 6 h $£$Kf Silk."' 
15 per cent fat; 4 ounces, 2 per cenl 

fat; 6 ounces, 3 per cent fat, etc. The proteids will continue to be in 
every instance exactly one third tin 1 fat. as in the primary formula. 

The amount of milk sugar needed to bring this up to the percentage 
usually required (55 to 65) is 1 ounce in each 20-ounce mixture 






One 



194 NUTRITION. 

may obtain from a druggist a box holding exactly 1 ounce of sugar, or 
may measure in a tablespoon, calculating 2^ even tablespoonfuls as 1 
ounce. This sugar is dissolved in the water used for diluting the milk. 
The usual proportion of lime-water added is 5 per cent, or 1 ounce 
in a 20-ounce mixture; this may be easily increased to any desired quan- 
tity. The foregoing directions may be expressed in the following table: 

First Series of Formulas. — Fat to proteids, 3:1. 

Primary Formula. — Ten-per-cent milk — or fat 10 per cent, sugar 4*3 per cent, 
proteids 3*3 per cent. Obtained (1) as upper portion of bottled milk (p. 152), or (2) 
equal parts milk and (16-per-cent) cream. 

Derived Formulas, giving Quantities for Twenty-ounce Mixtures. 

r Milk sugar. . . 1 OZ. \ Per cent. Per cent. Per cent. 

I. -j Lime-water . . 1 oz. C with 2 oz. of 10$ milk = fat 1-00, sugar 5*50, proteids 33. 

( Water, q. s. to 20 oz. ) 

II. " " " " 3oz. " " " = " 150, " 5-50, " 0-50. 

III. " " " " 4oz. " « " =" 2-00, " 6-00, " 0-66. 

IV. " " " " 5oz. " " " = " 2-50, ." 6-00, " 0*83. 
V. " " " " 6oz. " " " =" 3-00, " 6-00, " 1-00. 

VI. " " " " 7oz. " " " = " 3-50, u 6-50, " M6. 

Making more than a 20-ounce mixture will be found very simple if 
we calculate for 25, 30, 35 ounces, etc. Thus for 25 ounces we add one- 
fourth more of each ingredient; for 30 ounces one-half more, etc. For 
25 ounces of II, therefore, the exact formula would be: 10-per-cent milk, 
3| ounces; milk sugar, 1^ ounces; lime-water, 1J ounces; water q. s. to 
make 25 ounces — i. e., 20 ounces.* 

Formulas in which the fat is twice the proteids. — Here we first 
obtain a combination, or primary formula, in which the fat and pro- 
teids stand in the relation of two to one, and then dilute this, adding 
milk sugar and lime-water to complete the modification. 

The primary formula most conveniently obtained for this purpose is 
one containing 7 per cent fat and 35 per cent proteids, or a 7-per-cent 
milk. This we may get by removing the upper portion from a quart 
bottle of milk, as described on page 152. Or in case milk and cream 
are used, instead of this upper milk, it will be necessary to add one 
part ordinary (16-per-cent) cream to three parts milk. The dilution is 
accomplished in the same general way as with the First Series. 

These formulas may readily be translated into percentages by re- 
membering that the percentage of fat in any formula is exactly seven- 
twentieths, or about one-third, the number of ounces of the 7-per-cent 
milk in a 20-ounce mixture. Thus 3 ounces in the mixture will give 



* For method of calculating any number of ounces of any formula derived from 
10-per-cent milk, see footnote, page 195. 



ARTIFICIAL FEEDING. 195 

about 1 per cent fat; 5 ounces will give 16 per cent.; 9 ounces about 3 
per cent, etc. In the following table these directions are expressed: 

Second Series of Formulas. — Fat to proteids, 2 : 1. 

Primary Formula. — Seven-per-cent milk — or fat 7 per cent, sugar 4'40 per cent, 
proteids 3*50 per cent. Obtained (1) as upper portion of bottled milk (p. 152), or (2) 
by using three parts milk and one part (16-per-cent) cream. 

Derived Formulas, giving Quantities for Twenty ounce Mixtures. 

Milk sugar ... 1 OZ. \ Per cent. Per cent. Per cent. 

I. \ Lime-water . . 1 oz. y with 3 oz. of 7% milk = fat 1*00, sugar 5 "50, proteids 0*50. 
Water, q. s. to 20 oz. 



II. 


" 


" 


" 




" 4oz. 


III. 


" 


" 


" 




11 5 oz. 


IV. 


" 


M 


u 




" 6 oz. 


V. 


" 


« 


" 




" 7 oz. 


VI. 


it 


" 


" 




" 8 oz. 


VII. 




" 


" 




" 9oz. 


VIII. 


a 


" 


" 




" 10 oz. 


IX. \ 


Milk 


sugar. . . 


f oz. 


I 




Lime 


-water . . 


1 oz. 


" 12 oz. 



1-40, 


' 5-75, k 





70. 


1*75, 


' 6-00, < 





87. 


2-10, 


' 6-00, ' 


1 


05. 


2-50, 


' 6-50, ' 


1 


25. 


2-80, 


' 6-50, ' 


1 


40. 


3-15, 


' 7-00, « 


1 


55. 


3 50, 


' 7-00, " 


1 


75. 



'ater, q. s. to 20 oz. 



4-00, " 7-00, " 2-00. 



With these, as with the First Series, if more than 20 ounces are 
required, we may make 25, 30, or 40 ounces by using of each ingredient 
one-quarter more, one-half more, or twice as much.* 

Formulas in which the fat and proteids are nearly equal. — In general 
these formulas are more often used for healthy infants during the later 
months; but there are many conditions' of disturbed digestion in which 
formulas having this relation of fat and proteids are desirable during 
the early months. This series of formulas is obtained by using as a 
starting-point plain milk and variously diluting it. The exact percent- 
ages of fat and proteids obtained with the different dilutions of milk, 
and the amount of sugar necessary to bring this up to the desired quan- 

*One may readily calculate any formula of any number of ounces which may be 
desired in either the first or the second series in the following way : 

There is wanted, for example, 35 ounces of a mixture containing 3 per cent fat, 
per cent sugar, 1*50 per cent proteids. In this combination the fat is twice the pro- 
teids. It will therefore be derived from 7-per-cent milk. 

35 (Xo. ounces needed) X 3 (percentage fat desired) = 105 (parts of fat required). 
105 -^ 7 (parts of fat in milk used) = 15 (Xo. ounces of 7-per-cent milk needed). 

The amount of sugar required is found as follows : 

7-per-cent milk has 4*40 per cent sugar. 

15X4*40 = 66 (parts of sugar in the milk used in the formula). 

66 -r- 35 = 1-88 (percentage of sugar in the formula of 3d ounces). 

There is needed therefore an addition of about 4 per cent of sugar to bring it to 
the desired percentage. 

4 per cent of 35 = 1'40 (Xo. ounces sugar to be added). 



196 NUTRITION. 

tity, are shown in the table below. The sugar in the higher formulas 
is reduced for the reason that with them the child will probably be tak- 
ing a considerable part of his carbohydrates in the form of starch. 

Third Series of Formulas. — Fat to proteids, 8 : 7. 

Primary Formula. — Whole milk : Fat 4 per cent, sugar 4.5 per cent, proteids 3.5 
per cent. (When using Jersey or Alderney milk add one-fourth water.) 

Derived Formulas, giving Quantities for Twenty-ounce Mixtures. 

i Milk sugar... 1 oz. \ Percent. Percent. Percent. 

Lime-water.. 1 oz. y with 5 oz. whole milk = fat 1* 00, sugar 6 '00, proteids 0' 87. 
Water, q. s. to 20 oz. 



II. 


U (( it 


it 


" 6 oz. 


«( 


it 


= « 1-20, 


« 


6-00. 


« 


1-00. 


III. 


« a « 


a 


" 8 oz. 


c( 


(i 


= " 1-60, 


<( 


6-50, 


« 


1.40. 


IV. 


a (( (( 

/ Milk sugar . . . 


a 

£oz. ) 


" 10 oz. 


«« 


« 


= " 2-00, 


« 


7'00, 


K 


1-75. 


v.. 


| Lime-water . . 


1 oz. 1 


" 12 oz. 


u 


cc 


= " 2*40, 


(C 


5-00, 


a 


2-10. 




( Water, q. s. to 20 oz. ) 


















VI. 


a a u 


" 


" 14 oz. 


it 


" 


=. " 2-80, 


" 


5-50, 


n 


2-50. 


VII. 


a a u 


" 


" 16 oz. 


" 


a 


= " 3-20, 


" 


5-50, 


a 


2-80. 



The Application of the Foregoing Formulas in Practice. — General 
Rules for Varying Milk Percentages. — We have indicated on page 190 
the series of formulas most used in laboratory-feeding and have shown 
how similar formulas can be obtained when the milk is prepared at home. 
A schedule like that given in the table is useful to indicate in a general 
way what percentages an average infant may be expected to take. But 
no schedule can be closely followed with any given child. One can not 
conclude that because a child is six weeks old he is able to digest milk 
containing certain percentages, nor certain others because he is six 
months old. To attempt to follow a schedule too closely is to violate 
the fundamental principle of percentage feeding, which is to adapt the 
milk to the child's digestion at any time. In brief, one should begin 
with weak formulas and gradually increase their strength according to 
the child's needs and his ability to digest cow's milk (Fig. 37). 

How and where to begin. — With infants having any form of dis- 
turbed digestion the formula first used should be determined, as will be 
more fully explained in the later pages, by the nature of these disturb- 
ances. With infants having presumably normal digestion it is desirable 
to begin with the weak formulas: (1) With a newly born infant; (2) 
with a delicate infant or one much under average weight, of whatever 
age; (3) with one just weaned; (4) with one who has not previously 
taken cow's milk; (5) with any infant whose digestion is unknown. 

Having decided that we shall begin with weak formulas, it is not 
always easy to determine with which series the start shall be made. It 
is true that most young infants digest fat so much more readily than 
proteids, that those formulas in which the proteids are only one-third 



ARTIFICIAL FEEDING. 



197 



the fat (First Series) are "usually to be preferred. However, this is not 
true of all infants ; and in the event of any disturbance of digestion aris- 
ing, especially vomiting or diarrhoea, the Second Series should be used. 
Xothing is easier than to derange the digestion in the beginning by 
the use of too high percentages ; such disturbances, though they may not 
be severe, often continue for many weeks (Fig. 38). The closest atten- 
tion is required in the beginning. If a good start is made subsequent 



OF E AGE 2 4 6 8 10 12 14 16 18 20 22 24 26 


17 
16 
15 
14 
13 

Wl 2 

a 

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31 I 
O 

■So 

9 
8 
7 
6 
6 














































































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K \ 










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Fig. 37.— Weight curve of bottle-fed infant for first six months. Heavy line that of patit-nt ; 
light line.' the normal average. Small child, not particularly vigorous, never put to the 
breast; feeding beyrun on the second day from the milk laboratory. Formula: Fat l per 
cent, sugar 5 per cent, proteids 0-33 per cent; at live weeks, taking fat 8 per cent, sugar 
6 per cent, proteids 1 per cent- at five months, taking fat 4 per cent, sugar 7 per cent, pro- 
teids 2 per cent; not the slightest discomfort or any symptom of indigestion during the 
entire period. Weight at twelve months, 21 pounds, 8 ounces. 



progress is easy; but with a bad start there is likely to be trouble mosl 
of the time. As soon as an infant's capacity to digesi cow's milk is 
ascertained, the food can be increased accordingly. 

Again, at weaning, or with a child who has previously had no cow's 
milk, one must begin, even with one whose digestion Beema quite normal, 
with percentages considerably lower than the age and weighl would 
appear to require. A stationary weight for a week or two, or even a 
loss of a few ounces, is of no importance, provided the change in diei 
can be effected without deranging digestion; for as booh as a fluid 
becomes accustomed to cow's milk the percentages can be raised, and 
progress is assured (Fig. 34, page 180). 



198 



NUTRITION. 



Indications for increasing the food. — While it is important to begin 
with low percentages, it is a serious mistake to continue with them. We 
increase the power of digestion by gradually increasing the work the 
organs are given to do. Abrupt increases are almost certain to 
disturb digestion. A proper rate of increase is mentioned in the tables 
of formulas. In them the increase in the fat is usually half of one 
per cent, and the increase in the proteids one-fourth of one per cent, or 
less. This is about right for an average child. For many who are 
delicate the steps of increase should be made only half as great. This 
can easily be done by using a formula intermediate in strength between 
any two of those given in the tables. 



OP-AGE 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 62 


23 
22 
21 
20 
19 
18 
17 

Q 
ZI6 

D- 
O l4 

13 

12 

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10 
9 
8 

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+ ' 












































































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r 7 










































































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tf 


























































































































































































































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, 
































































































































































































































































































































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Fig. 38. — Weight curve of artificially fed infant, showing the effect of beginning with too high 
percentages. Eobust child ; digestion deranged when a few days old by beginning with 
fat 2 per cent, sugar 6 per cent, proteids - 75 per cent ; food in two or three days was in- 
creased to fat 3 per cent, sugar 6 per cent, proteids 1 per cent. A good deal of indigestion 
resulted, and the disturbance was such that it was eight weeks before the digestion became 
normal and the gain in weight regular ; progress for the rest of the year satisfactory. 



In increasing the quantity, it is seldom wise to add more than 
a fourth of an ounce to each feeding. During the early weeks both the 
quantity and the strength of the food should be increased every few 
days. It may be difficult to tell which of these it is best to do. It is 
well to alternate; thus, when the infant requires more food, first to 
increase the quantity; then, after a few days, if still unsatisfied, to in- 
crease the strength; the next time, to increase the quantity again, etc. 
In this way will be avoided the error into which mothers and nurses so 



ARTIFICIAL FEEDING. 199 

often fall, who adopt a single formula and keep on simply increasing 
the quantity indefinitely whenever the child is unsatisfied. I have fre- 
quently seen infants of two or three months taking as much as 7 or 8 
ounces every two hours, and even then crying from hunger. After a 
daily total of 32 to 36 ounces is reached, as happens with most infants 
by the fourth month, the increase in the food should be chiefly in 
strength; for the same child at eight months will rarely require more 
than 40 to 48 ounces. 

How rapidly the increase is made will vary much with the individual 
infant. With a vigorous child, above average weight, with good diges- 
tion, the percentages may be raised rather rapidly, and also the quantity 
given at one feeding. With a small or delicate child, or one with feeble 
digestion, one must advance much more slowly both with respect to the 
strength and quantity of food. No greater mistake can be made than 
to attempt to measure the increase in food by the age of the child. We 
can not raise the percentages every week or every month regardless of 
other conditions. The progress in weight is important, yet one should 
not be guided by it alone in increasing the food. On the low percent- 
ages necessary at first no material gain in weight is to be expected. 
However, if there is no vomiting or colic, if the child is entirely com- 
fortable and sleeps most of the time, and if the stools have a normal 
colour and odour, conditions may be considered entirely satisfactory. 
The food may be cautiously strengthened with the demands of the child's 
appetite, and soon the increase in weight will begin, and when once 
begun it is likely to continue. On the contran^, if the weight is made 
the chief concern, there is a constant temptation, when the child is not 
gaining as rapidly as the mother thinks he should, to increase the food, 
regardless of conditions, usually with the result of seriously disturbing 
digestion. The best of all guides to increasing food is the child's demon- 
strated powers of digestion. If the child is not satisfied and digesting 
well it is always safe to increase the food. 

A caution is necessary against changing the formula too frequently. 
It is not possible to modify the milk in such a way as to relieve every 
trivial discomfort or disturbance an infant may have. Nurses arc usu- 
ally ready to ascribe every slight symptom to the food, particularly if 
they have strong opinions of their own upon the subject of feeding, and 
are not in full sympathy with modern ideas of milk modification. Very 
often the cause is outside of the food and even of the organs of dig 
tion. (See Fig. 39, page 207). Unless sonic very definite symptoms of 
indigestion, such as severe colic, vomiting, etc., arc produced by tin 1 
formula ordered, it is usually better to continue with if for at leasi two 
days, as it is hardly possible in a shorter time to determine wlial ili« i 
child's digestive organs are capable of doing. For slight disturbances of 
a transient nature it is usually enough to dilute the food for a day or 



200 NUTRITION. 

more; just before the bottle is given, one ounce or more of milk may 
be poured off and replaced by boiled water. 

To Reduce Milk Formulas to Percentages. — In order to appreciate 
the composition of any milk formula which a patient may be taking it 
is necessary to reduce this to its approximate percentages. This is par- 
ticularly important as regards the fat and proteids. One who forms the 
habit of making such calculations soon finds it easy, and secures a basis 
for comparison with the percentages given as proper for the average nor- 
mal child. A simple method of calculation is as follows : To determine 
the percentage of any constituent in the food, multiply its percentage 
in the original milk, cream, or top-milk (compare pp. 146, 151, and 
152) by the number of ounces of each in the food, and divide by the 
total number of ounces of food prepared.* 

Special Modifications Required by Particular Symptoms. — Many of 
the children for whom the physician's advice is sought in matters of 
feeding are not thriving, or, besides, are suffering from some evident 
symptoms of indigestion, and for these reasons changes in the food are 
required. In adapting milk for such cases one must rid his mind entirely 
of the notion that the food can be prescribed according to the child's 

* A patient is taking a formula composed of cream 4 ounces, milk 16 ounces, milk 
sugar 1^ ounces, in a mixture containing 36 ounces. The cream is ordinary centrif- 
ugal cream, estimated to have 20 per cent fat ; the milk is good average milk, estimated 
to have 4 per cent fat. 

4 X 20 = 80, the parts of fat in the cream 
16 X 4 = 64, " " " milk 

144; " " " total food 

144 -f- 36 (number of ounces of food) = 4, the percentage of fat in the food. 
The proteids are calculated in the same way. In the illustration we estimate the 
proteids of 20-per-cent cream at 3*05 ; in the whole milk, at 3*50. 

4 X 3*05 = 12*20, the parts proteids in the cream 
16 X 3-50 = 56-00, " " " milk 

68-20, " " " total food 

68*20 -r- 36 = 1'90, the percentage proteids in the total food. 

In a similar way, sugar is calculated. The sugar of a 20-per-cent cream may be 
estimated at 3*90 ; in the milk, 4-50. 

4 X 3*90 = 15-60, the parts of sugar in the cream 
16 X 4-50 = 72-00, " " " milk 

87-60, " " " mixture 

87'60 -r- 36 (number of ounces of food) = 2'40, the percentage of sugar in the 
food before any is added. 

To add 1-J ounces to a 36-ounce mixture adds approximately 4 per cent of sugar ; 
for 1-5 is 4 per cent of 36 [1-5 ~ 36 = -04]. 

The total sugar in the mixture therefore is 2*40 -f 4, or 6*40 per cent. 

The formula contains therefore approximately, 4 per cent of fat, 1*90 per cent of 
proteids, 6 - 40 per cent of sugar. 

This method of calculating percentages from ounces is exactly the converse of that 
given on page 195, for calculating ounces from percentages. 



ARTIFICIAL FEEDING. 201 

age or even its weight, although both must he taken into account. The 
essential thing is the condition of the digestive organs, and unless this 
is carefully considered, failure is almost inevitable. To decide as to 
proportions with which it is best to begin one must know, besides the 
age and weight, the previous gain or loss, the nature and quantity of the 
food which has been taken, the appetite, the number and character of 
the stools, and also whether any such symptoms are present as vomiting, 
colic, constipation, discomfort, or disturbed sleep. In any case the first 
prescription is somewhat in the nature of an experiment, but if the 
symptoms have been intelligently judged the experiment is likely to 
prove successful. 

Even with infants who are properly fed there are few whose diges- 
tion remains perfectly normal throughout the entire first year. Changes 
in the food are necessary from time to time, even in the most healthy, 
to meet special symptoms which may arise. Many of these are due to 
disturbances of a minor character, but are none the less important, as 
they may lead to serious consequences when not immediately recognized 
and properly treated. 

Vomiting. — The common causes of habitual vomiting are: too fre- 
quent feedings, too much food at one time, too high fat or too high 
sugar, especially if the sugar is maltose or cane sugar. 

An infant who vomits should never be fed at shorter intervals than 
three hours, even if only four or five weeks old. If considerable quan- 
tities are ejected almost immediately after feeding, it is usually because 
too much food has been given. Other causes must be considered also — 
the food may be too rapidly taken, the child may be moved about too 
much, the abdominal band may be too tight, etc. The frequent regurgi- 
tation, often one or two hours after feeding, of sour, curdled milk or 
of a watery fluid, is usually an indication that the proportion of fat is 
too high. Sometimes it is the sugar that is in excess, and sometimes 
both fat and sugar are at fault. The first indication is to reduce the 
fat. Formulas from 10-per-cent milk should not be used, and. if the 
symptom is at all aggravated, formulas from whole milk (page L96) 
are to be preferred even for very young infants. The sugar also should 
be reduced by one-third or one-half, and only milk sugar should lie used. 
Other changes which are sometimes helpful are to use twice the usual 
amount of lime-water, making this 10 per cent, or 2 ounces in each 20- 
ounce mixture. It is also important that the food be taken slowly and 
that the child be kept perfectly quiet, on its back, a fief feeding. 

Constipation. — The principal causes of constipation referable to the 
food are too low total solids, too low fat, too high proteids. Ilahil and 
general training are also important factors. Sterilization, and in a slight 
degree pasteurization, causes milk to he somewhal constipating. During 
the first few weeks, if the percentages are low, as 1 believe they should 



202 NUTRITION. 

be, there is often a species of constipation present which is simply the 
result of the low total solids in the milk formula given. The bowels 
usually move every clay, sometimes even twice a day; but the stools are 
often small and rather dry. Unless there is manifest discomfort on 
the part of the child, such a condition may be disregarded, especially 
if the odour and colour of the discharges are nearly normal. As the 
proportions of all the elements of the food are gradually increased along 
the general lines previously indicated, this form of constipation passes 
away. Mothers and physicians often expect that the bottle-fed infant 
will have during its first month or two the two or three large stools 
daily to which they have been accustomed with healthy breast-fed infants. 
But finding instead only one movement a day, and that small and some- 
times dry, they at once resort to laxatives or enemata, and by. their use 
really cause much of the trouble they are seeking to remove. Again, if 
the physician tries to remedy the constipation by rapidly raising only 
the fat, as is often done, the constipation is rarely relieved, but there is 
frequently produced a serious disturbance both of the stomach and the 
intestines. 

The low fat is very often the explanation of the constipation seen 
when infants are fed upon formulas derived from whole milk. If such 
is the case relief may be afforded by changing to formulas made from 
7-per-cent milk or to those from 10-per-cent milk, by which means higher 
fat with the same, or, if desired, lower proteids may be obtained. The 
increase in the fat to overcome constipation can only be carried up to a 
certain point; this is generally about 3 per cent for a young infant and 
4 per cent for one who is older. If the fat is raised much beyond this 
other disturbances of digestion, particularly habitual vomiting, are likely 
to result. Some other means of overcoming the constipation should be 
resorted to. 

Too high proteids are often given with too low fat, as in mixtures 
derived from whole milk, and the constipation may be the result of one 
factor quite as much as the other. A reduction in the proteids and an 
increase in the fat may be accomplished at the same time by using 
modifications made from top-milk as suggested just above. The consti- 
pating proteid of cow's milk is the casein. By the use of whey modifica- 
tions (page 210) the amount of casein given can be reduced to a very 
low point and at the same time the total proteids, in these mixtures 
chiefly lactalbumin, can be kept sufficiently high for the child's nutrition. 
This is one of our most effective means of relieving chronic constipation. 

The substitution of the milk of magnesia for lime-water as an ant- 
acid in milk modifications is often of service. Its use may be continued 
for several months without harm. One teaspoonful added to the total 
food for the day is usually sufficient; this amount may be slightly in- 
creased or lessened according to the effect produced. 



ARTIFICIAL FEEDING. 203 

The slightly laxative effect of maltose may be utilized in milk modi- 
fications. It may take the place of the lactose which is added in any 
of the groups of formulas already given. The most convenient form is 
some one of the malted foods. 

Colic and flatulence. — The habitual colic of early infancy is usually 
due to too high proteids, exceptionally to too high sugar. Excessive 
flatulence may occur also when cereal gruels are used as diluents in place 
of plain water. The symptom may be relieved by a reduction in the 
total proteids by using a weaker formula of any series than the one em- 
ployed; or, often better still, by the use of whey modifications, it being 
the casein which is at fault, as in the case of chronic constipation. The 
coexistence of constipation of course greatly increases the amount of 
both flatulence and colic. 

Curds in the stools. — The appearance of curds in the stools is due 
to the same cause as habitual colic, and is usually associated with it. 
The curds generally appear as white masses or lumps; sometimes they 
are gray or green, coated with mucus, and expelled with effort. Colic, 
curds in the stools, and constipation are a frequent combination, and are 
usually due to too high proteids or to inability to digest the casein of 
the milk given. The treatment of the condition has been considered in 
the foregoing paragraphs. 

Loose, green, or yellowish- green stools of a sour odour. — These are 
sometimes due to too high a percentage of sugar, sometimes to an excess 
of fat. The number of stools is usually from two to five daily. In 
appearance the stools resemble thin scrambled eggs. The small yellowish 
masses are often mistaken for curds. Stools such as those described are 
often seen in nursing infants as well as in those artificially fed, and the 
condition is not incompatible with steady and regular gain in weight. 
After it has persisted any length of time mucus is regularly present, and 
an intractable intestinal catarrh may be produced. 

Large, dry, white or gray stools. — These are often smooth, and are 
generally due to an excess of fat. They have usually a peculiarly foul 
odour, owing to the presence of fatty acids; the masses may be distin- 
guished from curds by their solubility in ether. 

No gain in weight without evident symptoms of indigestion. — This is 
sometimes due to too weak mixtures, all the percentages being too low. 
the child usually manifesting signs of hunger. Occasionally it is due 
to the fact that all the percentages, particularly the fat, are too high. 
In the latter case it frequently happens that the appetite is much reduced, 
so that the infant takes perhaps less than half his usual allowance Too 
frequent feedings and the practice of constantly coaxing the in Inn I to 
take more food, often produce the same aversion to food. ]i is much 
better to offer food at three-hour intervals and take away the bottle as 
soon as the child shows that he does not want more. 



204 NUTRITION. 

Modifications in the food to meet the indications afforded by more 
serious conditions than those here described are considered in the later 
pages devoted to Difficult Cases of Feeding. 

The Apparatus required for the Preparation of Milk at Home. — This 
includes an 8-ounce glass graduate, a glass or agate funnel, a cream 
dipper, a pitcher for mixing food, feeding-bottles, a tall cup for warm- 
ing the food, a small ice-box, and a sterilizer. Other articles needed are 
lime-water, boiled water fresh every day, milk sugar, rubber nipples, 
absorbent cotton, bottle-brushes, borax or boric acid, bicarbonate of soda, 
and an alcohol lamp, or better, if gas is available, a Bunsen burner, 
which should stand upon a zinc-covered table in a room adjoining the 
nursery. The best style of bottle is that which can be most readily 
cleaned. The graduated cylindrical bottles with wide mouths are to be 
preferred. The best nipples are those of plain black rubber, which slip 
over the neck of the bottle, and are not so thick as to prevent their 
being turned inside out for cleansing. Those with a long rubber tube 
going to the bottom of the bottle should not be used. In many cities 
their use is prohibited by law. The hole in the nipple should be large 
enough for the milk to drop rapidly when the bottle is inverted, but not 
so large that it will run in a stream. When not in use, nipples should 
be kept covered in a solution of borax or boric acid. The most scrupu- 
lous care of both nipples and bottles is necessary. Bottles should first 
be rinsed with cold water, then washed with hot soap-suds and a bottle- 
brush. When not in use they should stand full of water to which borax 
or boric acid has been added. Before the milk is put into them they 
should be rinsed and again boiled. 

Directions for Preparing the Food. — All the food needed for twenty- 
four hours should be prepared at one time. This saves much time and 
trouble, and is in every way simpler than preparing each feeding sepa- 
rately. The first thing to be decided is the formula to be used; next, 
the quantity of food for twenty-four hours with the number of feedings 
into which it is to be divided. 

Let us suppose that we wish to give 3 per cent fat, 6 per cent sugar, 
and 1 per cent proteids — formula V of the First Series — and that we 
wish to prepare 7 feedings of 5 ounces each, or 35 ounces of food. For 
a 20-ounce mixture containing 3 per cent fat we will require (see page 
194) 6 ounces of 10-per-cent milk, 1 ounce of sugar, and 1 ounce of lime- 
water; the balance will be water; since the sugar dissolves, 13 ounces 
of water will be needed. Now to make 35 ounces, we will require three- 
quarters more of each ingredient than for 20 ounces — i. e., 10J ounces 
of the milk, 1J ounces of sugar, 1} ounces of lime-water, and the bal- 
ance, or 22 4 ounces, of water. The amount of water need not be cal- 
culated each time; enough is added to make the quantity required. 

If instead of bottled milk, or milk and cream, the patient is using 



ARTIFICIAL FEEDIXG. 



205 



milk fresh from the cow, as soon as received it should he strained through 
three thicknesses of cheese cloth or a layer of ahsorbent cotton, into quart 
jars or milk bottles, and allowed to stand in ice-water or cold spring 
water for at least four hours. The top-milk, in this case the upper third, 
may then be removed. 

The milk sugar should be dissolved in boiled water, which is then 
mixed with the milk in a pitcher and the lime-water added. The food 
is now divided into the seven bottles, which are stoppered with cotton. 
They are placed at once in an ice-chest, or first sterilized, then cooled, 
and afterward placed upon ice. 

Directions for Feeding. — The food should be warmed to about 100° 
F. before feeding, best by placing the bottle in a tall pitcher or cup 
filled with water at a little above this temperature, not by pouring the 
food from the bottle into a saucepan. The temperature of the food may 
be tested by the nurse with a thermometer, or by pouring a few drops 
upon the front of the wrist ; it should feel warm, but not hot. The nurse 
should never take the nipple of the bottle into her own mouth. A bottle 
should not be warmed over for a second feeding. A child should not be 
more than twenty minutes in taking its food, and should not sleep with 
the nipple of the bottle in its mouth. It is preferable to have a young 
infant held while taking its bottle. If this is not done, the bottle should 
at least be held in such a position that the neck of the bottle is kept full, 
so that the child gets milk, and not air. It is even more necessary than 
in breast-feeding that rules as to frequency and regularity of meals be 
observed. The table which follows indicates the size and the number of 
meals and the intervals of feeding. This is to be taken only as a general 
guide. The quantity for one feeding can not always be definitely stated. 
Few children, however, will require less than the smaller quantities, and 
still fewer will require more than the larger quantities mentioned. 

Schedule for Feeding Healthy Infants during the First Year. 



Age. 



3d to 7th day 

2d and 3d weeks 

1' li and 5th weeks. . . 
5 weeks to 2 months. 

2 to 5 months 

5 to 9 months 

9 to 12 months 



Interval 


Night 


No. of 


between 


feedings 


feed- 


meals, 


10 p.m. to" 


ings. 24 


by day. 

Hours. 


7 A.M. 


hours. 






2 


2 


10 


2 


2 


10 


2 


1 


10 


2* 


1 


8 


3 


1 


7 


3 





6 


4 





5 



Quantity for 
one feeding. 



Ounces. 
1 -H 

1HH 

3 -5 

4 -G 

5 -7£ 
7 -9 



Quantity for 

24 hours. 



30- 45 

45-110 

75-110 

90-155 

125-185 

150-235 

220-280 



Ounces. 

10-15 
15-35 

25-:i5 
24-40 
28 !■-' 
30 15 
35 15 



310 160 
460 1,090 
775-1,090 
745-1,250 
870-1,800 
980-1,400 
1,090-1,400 



The Use of other Food than Milk during the First Year. — In the 
discussion up to this point nothing but the elements of milk has been 



206 NUTRITION. 

considered. Upon these alone I believe that the average healthy infant 
is best nourished for the first four or five months. The use of the vari- 
ous cereal decoctions as an addition to the milk for young infants is a 
subject much discussed, and the question can not be regarded as settled. 
I am quite convinced that this is a useful measure for some infants, 
but not that it is desirable for all. Surely no point in infant-feeding 
is better established than that the early use of much farinaceous food 
often results in serious harm. The addition to milk of farinaceous 
food in any considerable quantity should, I think, in the feeding of 
young infants be limited to those in whom some special conditions are 
present, particularly those who have more difficulty than usual in digest- 
ing the milk proteids. This subject will be considered more fully under 
the discussion of Difficult Cases of Feeding. 

For the average healthy infant it is desirable to begin with farina- 
ceous food in some form by the fifth or sixth month. By this time the 
power of digesting starch is sufficiently strong for the infant to receive 
some of its carbohydrates in this form, instead of all of it in the form 
of sugar, as has been previously the case. As starch is added, the sugar 
should be gradually reduced. The form of starch used may be a gruel 
made of barley, oatmeal, or arrowroot, or some of the farinaceous foods 
(page 165). This will take the place of part or all of the boiled water 
in the preparation of the food. It is thus given with each of the feed- 
ings. By the eleventh or twelfth month the quantity of the cereal may 
be increased. The choice between the different cereals will depend upon 
the individual case. Where there is a tendency to constipation, oatmeal 
is to be preferred; at other times barley or wheat flour. 

The only other things to be advised during the first year are beef 
juice (for preparation see page 163) and the juice of some fresh fruit. 
Beef juice may be begun in the tenth or eleventh month; at first not 
more than two teaspoonfuls should be given daily. The best fruit juice 
is that of the orange, which may with advantage be given to most infants 
over ten months old. Beginning with half an ounce, the quantity may 
be gradually increased to two ounces, given preferably about one hour 
before the second milk-feeding. 

FEEDING IN DIFFICULT CASES. 

Two distinct groups of cases are included under this head : (1) Infants 
who, owing to feeble digestion or individual peculiarities, do not thrive, 
even from the outset, upon the usual milk modifications, although they 
may be used intelligently; (2) the much larger class, who have prolonged 
disturbances of digestion, or chronic indigestion, the result of previous 
improper methods of feeding or equally improper nursing. In the aggre- 
gate the number of children included in these two groups is quite large, 
and few cases -in the practice of the physician cause him more trouble or 



ARTIFICIAL FEEDIXG. 



20' 



anxietv. Even one of large experience often finds himself baffled for a 
long time by the problems which individual cases present. The difficulties 
are greatest with voting infants, in cities, in institutions, in hot weather, 
with infants suffering from constitutional debility, and in cases of long 
standing. That chronic indigestion in a young infant is a serious thing 
is often not appreciated. The mother is apt to think the problem one easy 
of solution; she only wants to be told what to feed her baby, imagining 
that a single food prescription should set the child right at once. The 
physician, too, sometimes regards the condition lightly because these in- 
fants do not seem really ill; he therefore considers the subject hardly 
important enough for his serious, continuous attention. What I wish to 
emphasize is that these cases are serious, that they are difficult, that in 
most of them nothing can be accomplished without close and continuous 



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Fig. 39— Weight chart showing the effect of intelligent care. Maternal nursing in the begin- 
ning; -/, began part feeding; 7?, attack of indigestion; C. weaned entirely. The 
departure and return of the trained nurse are indicated upon the chart. In tin' interval 
there was constant indigestion for which no sufficient explanation could be found in 
the fond. Subsequently this was discovered to be due to the carelessness and neglect of 
the nurse. Immediate improvement on the return of the trained nurse without an\ 
important change in the food, it will be noticed that during the four and one-half 
months of the trained nurse's absence the net gain in weight was only 1 pound 8 out 

personal observation, thai they do not lend to righl themselves, and thai 
infants' lives are often sacrificed as a result of had management. 

While these infants present great variety in their symptoms, and 
must be carefully individualized in their management, there are some 
general principles applicable to all. One should begin by obtaining a care- 
ful history of what has been previously tried, in order to gel all possible 
15 



208 NUTRITION. 

information respecting the type of indigestion which the child presents. 
These previous efforts in feeding should be studied with great minute- 
ness; the different changes made and the effect of each one upon the 
principal symptoms, the vomiting, the stools, and the child's weight 
should be considered. With a good history obtained from an intelligent 
mother or nurse one can often at once determine where the mistakes 
have been made, and in many cases the same mistake has been repeated 
with each change of food. 

A thorough investigation into the nursery routine should be made to 
ascertain not only what has been tried, but how it has been tried. It 
is frequently found that the failure is due not to any fault with the 
food prescription (Fig. 39), but because the food has been improperly 
prepared or administered — e. g., the food has been cold, the bottles dirty, 
the nipples sour, the food too rapidly given, too much at one time, or at 
too short intervals, etc. General statements of nurses and mothers, no 
matter how experienced, can not be trusted. Success in treatment will 
depend largely upon how accurately one is able to discover the essential 
cause or causes of trouble and the nature of the disorder of digestion 
in the case under treatment. Without such knowledge all is haphazard 
experimentation. 

In dealing with these cases drugs are of little assistance; in most 
cases they are better omitted altogether. 

In carrying out any line of treatment little can be accomplished 
without continuous observation at fairly frequent intervals on the part 
of the physician and the co-operation of an intelligent mother or nurse. 
Particular attention should be paid to the stools, which the physician 
should always see for himself, to the presence of colic or flatulence, 
vomiting, the appetite, and the body weight. A daily record is of great 
assistance. The weight though important is not the only guide as to 
progress. It should be taken regularly in order that a steady loss may 
not go on unnoted; but the first signs of improvement are usually 
observed in other symptoms — the child is more comfortable, sleeps bet- 
ter, and suffers less from its special disturbances of digestion. 

Quantities, Intervals of Feeding, Concentration of Food. — With some 
children one succeeds better with smaller quantities and more frequent 
feedings; with others, larger quantities and longer intervals are prefer- 
able. Generally speaking, the intervals should be longer than in health. 
It is seldom wise to make them less than three hours for young infants, 
or less than four hours for those who have passed the eighth or ninth 
month. 

Regarding the effect upon the digestion of the concentration of the 
food (i. e., a large quantity of a weak food, or a small quantity of a 
strong food), great variations are seen with different children. The 
usual tendency when an infant suffers from indigestion is to dilute the 



ARTIFICIAL FEEDING. 209 

food, and in most cases this is perfectly proper ; but to continue increas- 
ing the dilution because the patient does not do well may be the very 
worst treatment. This may do harm by causing too much dilution of 
the digestive fluids. Small feedings, not weak food, are what benefit 
some of these children most, the balance of the daily amount of water 
needed by the child being given between the feedings. Thus, instead of 
giving eight ounces of a weak food every four hours, we may do better 
with four ounces of a much stronger food, allowing the child three or 
four ounces of water one hour or one hour and a half before the feeding. 

In very troublesome, protracted cases minor variations in the com- 
position of the food or slight changes in the plan of feeding rarely 
accomplish much. Eadical changes are usually necessary. If small 
feedings and short intervals have failed, one may succeed with larger 
feedings and much longer intervals. If very dilute food in large quan- 
tities has failed, improvement may follow much smaller feedings and 
a much stronger food. For similar reasons the most brilliant results 
are often obtained from as complete a change in the diet as possible. 
An infant who has been long on farinaceous foods is most likely to 
improve when these are stopped entirely and suitable percentages of 
cow's milk given. One whose digestion has become seriously deranged 
while taking milk, and whose symptoms have continued in spite of many 
variations in percentages, is sometimes helped by nothing so much as 
temporarily withdrawing all milk. (See Fig. 40, page 216.) 

The Modification of Cow's Milk in Difficult Cases. — Many more prob- 
lems in difficult feeding are solved through a proper adaptation of cow's 
milk to the digestion of the infant than in any other way, excepting 
possibly a resort to wet-nursing, which in most cases is not available. 
One should therefore be slow to discard coVs milk and adopt any of the 
lauded substitutes which the manufacturer offers; but should seek rather 
to discover how he can modify the milk to enable the child to digesi it. 
stopping milk entirely only as a last resort. 

For purposes of treatment the cases may be divided into several 
groups according to the nature of the disturbance of digestion which 
the child presents and the special element of the food with which he lias 
most difficulty. Those who have especial trouble with the proteids con- 
stitute probably the largest group. The symptoms are varied, the mosl 
frequent ones being colic, flatulence, sometimes diarrhoea, but generally 
constipation, with stools which are dry, granular, hard, and often coated 
with mucus. There is also anaemia and general malnutrition. To over- 
come the difficulty in digesting the proteids of cow's milk several means 
may be employed. 

Reduction in the total proteids. — This may he accomplished without 
nuking any change in the proportions of fat or BUgar by using weaker 
formulas derived from 10-per-cent milk, rather than those from 7-per- 



210 



NUTRITION. 



cent milk, or those from whole milk. For some cases it may be desirable 
to use with a given percentage of fat even lower proteids than those of 
the First Series. Such formulas may be obtained from a 16-per-cent 
cream (the upper 6 ounces from one quart). In this the proteids are 
approximately one-fifth the fats. Any formula desired may be calcu- 
lated in the manner indicated on page 195. This plan is suited to a 
small number of cases, but is not so likely to succeed with the majority 
as some of the methods which follow. 

The use of milk from which the casein has been removed — whey 
modifications. — After the casein has been coagulated by rennet and then 
strained out, the whey (page 162) is left, which will contain all the 
soluble proteids — lactalbumin, lactoglobulin, etc. Most of the fat is 
removed by the process, but this can be supplied by adding cream, in 
which the percentage of casein is small. 



Table Showing Composition of Formulas Made from Whey. 



I. 

II. 


Whey 

(C 

a 

a 


14 

19 

15 

11 

9 

8 

6 

5 


parts ; 

u 
u 

a 
u 


20$ cream 

a a 
a a 


1 part ; 

a 

1 " 
1 " 


water 5 


parts 


F 

= 1 
= 1 

= 2 
= 2 
= 2 
= 3 
= 3 
= 4 


at. 

60. 

90. 
10. 
50. 
80. 
00. 
60. 
00. 


Sugar. 

..4-00. 
..5-00. 
..5-00. 
..5-00. 
..5-00. 
..5-00. 
..5-00. 
..5-00. 


Whey r „„ pin 
Proteids> asein ' 

..0-65. ..0-10 

..0-90...010 


III. 








..0-90.. .0-15 


IV. 








..0*90. ..0-20 


V. 








..0-90. ..0-25 


VI. 

VII. 

VIII. 


milk 


1 

2 

2 


part 

a 


..0-85. ..0-50 
..0-85. ..0-85 
..090. ..0-90 



The sugar may readily be raised to 6 per cent by adding one even 
tablespoonf ul of milk sugar to each 40 ounces of the food ; to 7 per cent, 
by adding two tablespoonfuls to each 40 ounces of the food. The addi- 
tion of one part lime-water to each 20 parts will cause a negligible reduc- 
tion in all the percentages of the table. 

Where slightly lower fat is desired with the same proportion of 
proteids, it may be readily obtained by substituting 16-per-cent cream 
for 20-per-cent cream; a still greater reduction in the fat, by using a 
10-per-cent top-milk. Lower proteids than are given in the table, with 
the same proportion of fat, may be obtained by replacing part of the 
whey with water. 

Whey modifications are applicable to a large number of conditions. 
By using them we are able to raise the total proteids to a much higher 
point than is otherwise possible, thereby avoiding the dangers incident 
to keeping infants long on very low proteids. These modifications, on 
account of the high proportion of soluble proteids which they contain, 
form a much nearer approach to woman's milk than any other combina- 
tions now available. With them constipation is relatively infrequent, 
while colic and flatulence seldom cause any trouble. 



ARTIFICIAL FEEDING. 211 

There is no objection to the use of these modifications of milk for 
several months. With improvement in digestion infants may gradually 
be brought to digest the larger percentage of casein in the usual modi- 
fications, which are somewhat simpler in preparation. 

The use of peptonized milk. — This aims at partial predigestion of 
the milk proteids before the food is given. The method of peptonizing 
milk has already been described (page 158). It is important that proper 
percentages be obtained before the peptonizing is done. The proportions 
usually recommended with the peptogenic milk powder give -1 per cent 
fat, 7 per cent sugar, and 2 per cent proteids; these are too high for most 
infants with feeble digestion, as are also the other formulas generally 
advised for use with the peptonizing tubes or tablets. I have obtained 
better results with such percentages as those of formulas III, IV, and V 
of the Second Series; sometimes, however, even with lower fats than 
these, as in IV, V, and VI of the Third Series. The duration of the pre- 
digestion of the food will depend upon the amount of assistance required 
by the child. As it takes about two hours to peptonize milk completely, 
the process at the end of fifteen minutes wall be only one-eighth com- 
pleted, and at the end of half an hour only one-fourth, leaving thus in 
the one case seven-eighths and in the other three-quarters of the work 
of proteid digestion to be done by the child. Where required at all, I 
have usually found it best to continue peptonizing for at least fifteen 
minutes, often for half an hour or even an hour. I prefer to peptonize 
each bottle separately immediately before feeding, since the ferment in 
such cases continues its action in the stomach. If the amount for the 
entire day is peptonized at one time and the milk raised to boiling point 
the ferment is destroyed. The bitter taste produced at the end of about 
fifteen minutes is evidence of the conversion of some of the proteids into 
peptones, but in practice is rarely found to interfere with its use. except 
with children over seven or eight months old. After the firsl two or 
three bottles younger infants take this bitter milk as willingly as any 
other food. 

The partial predigestion of the milk proteids may be continued for 
several weeks, the amount of assistance given the child being gradually 
lessened by shortening the duration of the process, as the stomach be- 
comes more and more, able to do its normal work. There is a serious 
objection to tin; use of predigested food- for as long ;i period as live or 
six months; in ,-uch cases the organs do not gain, but rather lose in their 
digestive power. 

The addition of the citrate of soda. — The use of the citrate of soda 
to aid in the digestion of milk was firsl suggested by Wright (London) 
a number of years ago. It has been more recently revived by Poynton 
and others. The theory of the action of the citrate of soda is thai ii 
delays casein coagulation in the infant's stomach by uniting with its 



212 NUTRITION. 

calcium. In sufficient amount it may entirely prevent the coagula- 
tion of the casein. Outside the body its effect can readily be demon- 
strated. 

Practically, the use of the citrate of soda has some value ; although 
in my experience, which has been considerable, it has not met expecta- 
tions. It is, however, one of the means to be tried and may succeed 
where others fail. With it higher percentages of casein can certainly 
be given without causing disturbance. For the wasted infant who sim- 
ply will not gain, it is useless. Better results attend its use where symp- 
toms of proteid indigestion are more evident. It is of some value in 
relieving constipation. The citrate of soda is best given with formulas 
derived from 7-per-cent milk or with those from whole milk. It is used 
in the proportion of from one to three grains to each ounce of milk in 
the formula. It should not be used with lime-water. 

The use of fermented milks. — Kumyss, matzoon or zoolak, and other 
forms of fermented milk have a certain place in infant-feeding. Their 
chief value in this connection seems to be due to the peculiar curd for- 
mation owing chiefly to the presence of lactic acid. The loose, flocculent 
curd is very different from that produced in the stomach when plain or 
diluted cow's milk is taken. 

When administered to infants, kumyss should be poured back and 
forth from one glass to another to allow the greater part of the carbonic- 
acid gas to escape. All these preparations should be diluted with an 
equal volume, or half the volume, of water or they will not pass through 
the ordinary nipple. They are seldom taken well at first, but if nothing 
else is given nearly all infants will take them after three or four feed- 
ings. Fermented milks are not adapted to prolonged use, but are some- 
times of great value for short periods, partly owing to the changes in the 
milk proteids, and partly owing to their low fat. 

Buttermilk (page 162) is quite similar in effect to the above, differ- 
ing in that it is practically fat-free and adapted on this account to some 
acute conditions. 

With those infants who have special difficulty with the fat gastric 
symptoms are rather more frequent than intestinal. There is vomiting 
and regurgitation of food in small amounts and finally vomiting of 
mucus. There may be diarrhoea or constipated grayish white stools of 
a foul odour. For such a condition when severe few things are more 
likely to give relief than formulas from skimmed milk. 

Modifications from shimmed milk.-^-Ii the upper six ounces is re- 
moved from a quart of 4-per-cent milk, what remains will have the 
following approximate composition: fat, 1-80 per cent; sugar, 4-50 per 
cent; proteids, 3-60 per cent. We have thus about one-half as much 
fat as proteids, which is a convenient proportion for use. The percent- 
ages obtained after dilution are as follows : 



Sugar. 


Proteids. 


4-50 


3*60 percent. 


2'25 


1-80 " « 


1-50 


1-20 " " 


1-12 


0-90 " " 



ARTIFICIAL FEEDING. 213 

Fat. 

I. Skimmed milk (upper 6 ounces removed) has.. 1'80 

II. Diluted once gives ' 90 

III. " twice " 0-60 

IV. " three times " 0*45 

The sugar can be raised to about 7 per cent by adding half an ounce 
of milk sugar to each 20 ounces of No. I ; one ounce to each 20 ounces of 
Nos. II and III; \\ ounces to each 20 ounces of No. IV. If possible, 
without disturbing digestion, the percentages of sugar should be raised 
to 7 per cent or even higher to prevent the loss in weight. 

Modifications whose basis is skimmed milk are to be recommended 
for the relief of special digestive symptoms, particularly vomiting. As 
they are rather constipating they are also applicable to intestinal con- 
ditions if the bowels are loose. But children seldom gain in weight 
properly upon them, as their caloric value is very low. As soon as pos- 
sible the fat should be raised to the amount present in whole milk. The 
value of skimmed milk modifications is often much increased if they are 
partially or completely peptonized. 

There are many infants who have almost equal trouble with both fats 
and proteids. If the symptoms due to these elements are not severe and 
the child can tolerate low percentages, very weak formulas made from 
whole milk should be used — e. g., 1 ounce in a 20-ounce mixture, in 
which, if a 4-per-cent milk is used, the fat will be 20 per cent and the 
proteids 17 per cent. The sugar should be raised to 7 50 per cent 
(1J ounces in 20-ounce mixture), and in some cases it can be increased 
to even 10 per cent (2 ounces in 20-ounce mixture). 

The use of cereal gruels as diluents for milk. — I believe cereal gruels 
to be unnecessary and on the whole during the early months undesirable 
for healthy infants with normal digestion; also, that used in consider- 
able amounts with young infants they are capable of producing, and as 
commonly used do actually produce, much intestinal indigestion. But 
for many infants with disturbed digestion, especially for those whose 
trouble is particularly with the proteids, they are of undoubted value. 
Various theories have been held regarding the effect of the add i I ion of 
cereals upon the digestibility of milk. Some hold that their effed is 
simply that of diluents, they acting like so much water. The traditional 
belief, however, has been that their effect is a purely physical one, 11k? 
admixture of such substances with cow's milk preventing the coagulation 
of the casein in the stomach into large, solid masses, hut instead produc- 
ing a softer curd, the digestion of which is attended with less difficulty. 
When a cereal gruel is substituted for water as a diluent for milk, it 
is sometimes found that the percentage of proteids can he increased 
without disturbing digestion. At the same time constipation may be 
relieved because of the possibility of thus increasing the total solids 



214 NUTRITION. 

in the food given. Improvement in nutrition and gain in weight may 
follow. 

Cereal gruels are made from the grains, or more readily from the 
prepared flours of barley, oatmeal, or rice, or from arrowroot, wheat 
flour or corn starch. One even tablespoonful of any of these flours to 
one pint of water makes a gruel of about the right consistency. This 
adds about one per cent of starch to any of the foregoing formulas. 
Gruels made from flours should be cooked for at least twenty minutes. 
When made from the grains, from four to six hours' cooking is required. 
Lately the dextrinization of cereal gruels has been much practised, but 
when they are used as diluents this has seemed to me to have no marked 
benefit. 

The use of larger amounts of farinaceous food for infants — Keller's 
"Malt Soup." — The experiments of Keller (Breslau) indicate that carbo- 
hydrates may have an important action in checking the decomposition 
of milk proteids in the intestine, and thus saving nitrogen to the body. 
He found that a decided diminution in the elimination both of nitrogen 
and phosphoric acid occurred with the use of additional carbohydrates. 
He advocates the use of a very much larger amount of farinaceous food 
with milk than is suggested above. Milk to which starch and malt are 
added according to his directions, is known as Keller's " Malt Soup." * 

Whether Keller's explanation be the correct one or not, it is certainly 
true that, if used as he has advised, many young infants can take a much 
larger proportion of starch than was formerly thought possible. Fur- 
thermore, it is rare that the stools of infants so fed show evidences of 
proteid indigestion. 

The indications for the use of these additions to milk are found with 
infants who show no marked symptoms of indigestion, but who can not 
be made to gain in weight with our ordinary milk modifications. In 

*~Keller's formula is as follows : Wheat flour, 3 ounces by volume ; Loeflund's 
malt soup extract, (an extract of malt with potassium carbonate) 3^ ounces ; water, 
16 ounces ; milk, 16 ounces. The malt extract is mixed with warm water. The wheat 
flour is carefully rubbed up with the milk and strained ; then all the ingredients are 
mixed and brought slowly to the boiling point with constant stirring. For young 
infants this is diluted with an equal amount of water. 

I have found it advantageous to modify the formula in some important particulars : 
First, by using smaller amounts both of the wheat flour and malt extract ; for most 
infants half the quantity specified and sometimes even less than this are I think 
preferable ; secondly, by cooking the wheat flour in the water for twenty minutes 
before the ingredients are mixed and heated. 

To secure the best results it is necessary to vary the proportions of milk, flour and 
malt according to the indications afforded by the symptoms of the individual child. 
Beginning with the proportions suggested, the amount of milk may gradually be 
increased until with older infants it may form two-thirds to three-fourths of the total 
food. Where there is special difficulty in the digestion of fat it is sometimes best to use 
skimmed milk. 



ARTIFICIAL FEEDING. 215 

this class belong many infants of the marasmus type. With them, when 
the low percentages of the fat or proteids of milk that they can take 
without disturbing digestion are given, the weight is either stationary 
or they lose. But if the percentages are raised, digestion is immediately 
disturbed. The addition of the large amount of carbohydrates in the 
form specified, is sufficient to raise the caloric value of the food to a 
point adequate for the needs of the child. But it is essential that the 
condition of the digestive organs be such that these additional carbohy- 
drates can be tolerated, or disastrous results may follow. If there is 
present a catarrhal condition of the stomach or intestines, or even marked 
functional disturbance attended by vomiting or by looseness of the 
bowels, the large amount of carbohydrates is contraindicated ; they almost 
invariably aggravate the symptoms. It is not wise to continue this food 
for a long period. If the limitations laid down are carefully observed, 
it is possible to greatly benefit a large group of infants whose nutrition 
is very difficult. 

Substitutes for Milk. — There are conditions in w T hich for the time 
being infants seem incapable of digesting even the smallest proportions 
of the fat and proteids of milk, no matter how modified. This is most 
frequently seen in acute derangements of digestion, especially when asso- 
ciated with acute gastro-enteric intoxication. There are also some chronic 
derangements of digestion in which the same procedure is of value. 
In ordinary practice, however, the mistake usually made is that of resort- 
ing too early to this expedient instead of carefully adjusting the milk 
percentages to the symptoms. Another mistake is that of continuing 
for too long a time a food containing no fresh milk. 

The advantage which results from stopping milk in these cases is 
due chiefly to change of diet. Where fat and proteids are very difficult 
of digestion it may become necessary to give temporarily a food com- 
posed almost entirely of carbohydrates. They may be administered either 
as some of the farinaceous or malted foods. Such a change is more 
likely to be successful in intestinal than in gastric cases, and chiefly 
where colic, constipation and failure to gain in weight have long been 
prominent symptoms. If the bowels are loose, farinaceous foods are 
more likely to be useful ; if they are constipated, the malted foods. These 
may be continued alone for a limited time — a few days or a few weeks 
— according to the severity of the symptoms, and then milk in some 
form added; for it does not follow because a child at one time can Qol 
digest milk that it can never do so. While one must begin with some- 
thing which the child can digest and assimilate, he musl gel back to 
rational milk-feeding as soon as possible. For example, it may be ad 
visible to withhold milk for two or three weeks, and then to begin with 
as small a quantity as one ounce in the total food of a day: after two 
or three days a second ounce may be added, and so on, gradually increas- 
16 



216 



NUTRITION. 



ing the proportion of milk as the child is able to digest it (Fig. 40). 
In some cases it may be better to begin by adding whey to the farina- 
ceous food ; and in still others small quantities of condensed milk. Since 
some are able to take fat sooner than proteids, very small quantities of 
cream may be tried as an addition to the food. All substitutes are to be 



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Fig. 40. — Weight curve, showing the advantage of temporarily stopping milk. A fairly vigor- 
ous child, nursed entirely by a nervous mother for live weeks, but did badly. A, began 
part feeding ; B, weaned entirely on account of constant indigestion ; C, because of con- 
tinued indigestion, colic, and general discomfort, all milk stopped for two weeks and a 
malted food substituted ; D, milk resumed. Subsequent progress satisfactory. 

regarded merely as temporary expedients, and the purpose should be to 
get the child back gradually to a suitable milk formula. 

If such addition of fat or milk proteids causes digestive disturb- 
ance, nitrogenous food may be supplied in the form of beef juice, beef 
peptones, broth, white of egg, somatose, plasmon, etc., these being added 
to the farinaceous or the malted food which is given. There is always 
great risk in continuing indefinitely a food which does not contain some 
fresh milk; extreme anaemia, malnutrition, rickets, or scurvy may be 
the result. 

SUMMARY OF INFANT-FEEDING. 

Choice of Methods of Feeding. — A faithful trial of maternal nurs- 
ing should always be made unless there are some very urgent reasons 
against it; but nursing should not be continued if the child is per- 
sistently uncomfortable, suffers constantly from symptoms of indiges- 
tion, and does not gain in weight. 



ARTIFICIAL FEEDING. 217 

Wet-nursing, although theoretically the next choice to maternal nurs- 
ing, is so difficult that in private practice it should be reserved for 
certain special cases. In infants' hospitals and foundling asylums the 
difficulties of artificial feeding are greatly increased, and wet-nursing 
should be employed when possible. 

Artificial feeding has become the general alternative to maternal 
nursing. If circumstances are such that maternal nursing is almost 
certain to be a failure, and if at the same time they permit the best 
artificial feeding, the infant should not be put to the breast at all. 

Methods of Artificial Feeding. — The only reliable substitute for 
breast-feeding is some modification of fresh cow's milk. My own opin- 
ion is, that for healthy infants it is best in the early months to use 
only the milk elements — fat, sugar, proteids, and salts — with lime- 
water, varying the percentages of these to suit the infant's digestion. 
The milk laboratories afford facilities for obtaining the best results. 
Next to laboratory-feeding is milk modified at home by the percentage 
method. For the very poor in cities results depend less upon exact meth- 
ods of modification than upon the kind of milk used and the intelligence 
with which it is fed. 

The Principles of Percentage Milk Modification. — In modifying 
milk for healthy infants the secret of success is to begin with low per- 
centages, especially of the proteids, and gradually increase according 
to the infant's digestion. To continue with very low proteids frequently 
leads to disturbances of nutrition, which are sometimes very serious. 

During the early weeks the best guide to progress is not the weight, 
but the comfort of the child and the absence of all signs of disturbance 
of digestion. 

In general, the most important indications for varying the percent- 
ages may be stated as follows : If the infant is not gaining in weight 
and has no special signs of indigestion, increase the proportions of all 
the ingredients; for habitual colic, diminish the proteids; for vomiting 
i in mediately after feeding, reduce the quantity; for the frequent regur- 
gitation of sour masses of food, reduce the fat, and sometimes also the 
sugar; for obstinate constipation, increase both fat and proteids. 

Difficult Cases of Feeding. — One should not ignore the results of 
previous experience with any infant; in most eases ii is unwise to 
repeal what has once worked badly. One should endeavour to deter- 
mine whether the trouble is chiefly with the I'ai, the sugar, or the 
proteids of the milk; also whether it is the stomach or intestines whose 
functions are most, disturbed. 

It should not be forgotten also that failure may be due to other 
causes than the food ordered — to ignorance or carelessness in preparing 
or administering it or to the surroundings. 

In all protracted cases, change of diet is important; the more pro- 



218 NUTRITION. 

tr acted the condition, the more radical should the change be. Not much 
is to be expected from fractional variations in the milk percentages, 
when those given are producing a great deal of disturbance. 

Eadical changes are often necessary in the manner of feeding as well 
as in the food; with reference to intervals between feedings and quan- 
tities at single feedings, one often succeeds best by trying the exact 
opposite of what has previously failed. 

A careful regulation of the milk percentages is more often success- 
ful than any other method. Success will be proportionate to the accu- 
racy of the diagnosis as to the cause of the symptoms, and to the degree 
of error in the previous prescriptions employed. 

The trouble is most often with the milk proteids. With many in- 
fants a proper adjustment of the total proteids given is all that is 
necessary. Some are helped in digesting proteids by the addition of 
the citrate of soda. Whey modifications, however, are more often suc- 
cessful than either of the methods just mentioned, and may advantage- 
ously be continued for several months. They are particularly useful 
with young infants. Partially peptonized milk meets the needs of a 
certain number of infants better than anything else; but caution is 
necessary not to continue its use too long, and to see that proper per- 
centages are furnished in the milk to be peptonized, especially that the 
proportion of fat be not too high. 

Children who have especial trouble with the fat are often temporarily 
benefited by the use of formulas made from skimmed milk. 

The substitution of cereal gruels for water as diluents for milk 
possesses a certain amount of value, and is more apt to be beneficial in 
cases with intestinal than in those with gastric symptoms. The dextrin- 
ization of the gruels does not appear to increase their value. 

The use of much larger quantities of farinaceous food with malt 
in the form of Keller's " Malt Soup " is a resource of much value 
when infants have great difficulty in digesting both the fat and pro- 
teids of milk. Infants whose digestive organs can tolerate a large 
amount of carbohydrates are often very much benefited for a considerable 
time by their use in this form. But the malt soup should not be con- 
tinued too long, and if gastric or intestinal catarrh is present with vom- 
iting or diarrhoea, it should not be used at all. 

Withholding all milk is often necessary in acute illness, but in cases 
of chronic indigestion it is done too frequently and often where a 
better treatment is to discover and give correct milk percentages. 

Success in infant-feeding is largely a question of careful attention 
to details. Without these the proportion of failures by any method 
will be very large. 



FEEDING DURING THE SECOND YEAR. 219 

CHAPTER IV. 

FEEDING AFTER THE FIRST YEAR. 

HEALTHY INFANTS DURING THE SECOND YEAR. 

The physician should not relax his vigilance in the feeding of a child 
after the first year has passed. The ideas of the laity in regard to what 
a child can digest after it has outgrown an exclusive milk diet, are very 
erroneous. The majority of infants are given solid food too early and 
in too large quantities. Most of the attacks of indigestion during the 
second year are directly traceable to such gross dietetic errors. The diet 
of a healthy child during the second year should consist of milk, some 
farinaceous food, bread, a small amount of animal food — beef or mutton, 
beef juice, eggs — and fruit. 

Milk should be the basis of the diet. The popular idea that there 
are many children who can not take milk is an erroneous one; the real 
trouble usualty is that they will not take it because other food pleases 
the palate better, and they are allowed to have their own way in this 
as in other things. It is of the utmost importance that the transition 
from a purely fluid diet to one of solid food should be made very slowly, 
and that the habit of drinking milk should not be discontinued. 

During the second year with average milk and average infants very 
little modification of the milk is required. The addition of milk sugar 
is unnecessary, since the child is now able to take a considerable part of 
its carbohydrates in the form of starch. If the milk is very rich, such 
as that from a Jersey herd, it should be diluted with at least one-fourth 
water. In hot weather a still greater dilution may be necessary. If 
the milk is poor in fat, and constipation is present, the use of only the 
upper two-thirds from each quart bottle will make the percentage of 
fat about right. 

'Weaning from the bottle. — This should always be begun by tin 1 thir- 
teenth month; by the fifteenth month an infant should take all its milk 
from a cup, except possibly the 10 p.m. feeding, when the bottle may 
he allowed for the sake of convenience. Early weaning from the bottle 
is a matter of no small importance. ^Vhere the hot tic is continued, as 
it often is, until a child is two or three years old, the greatesi difficulty 
may be experienced in getting rid of it, and this difficulty is increased 
the longer it is delayed. I have seen many children with the "bottle- 
liahit " so developed that throughout childhood, although at any time 
they would take milk from the bottle, they could never he induced to 
take it any other way. 

From Twelve to Fourteen Months. — The daily schedule at (hi- period 
should be about as follows : 



220 NUTRITION. 

6.30 a.m. Milk, six to seven ounces; diluted with barley or oat gruel, two to three 
ounces. 
9 a. m. Orange juice, one to two ounces. 
10 a.m. Milk, two parts; oatmeal or barley gruel, one part; from ten to twelve 

ounces in all may be allowed. 
2 p. m. Beef juice, one to two ounces ; 

or, the white of one egg, slightly cooked ; later, the entire egg; 
or, mutton or chicken broth, four to six ounces. 
Milk and gruel in proportions above given, four to six ounces. 
6 p. m. Same as at 10 a. m. 
10 p. m. Same as at 6.30 a. m. 

In preparing the food, the milk and the gruel are simply mixed 
together while the latter is warm, and salt and a very small quantity of 
cane sugar added to make it palatable. It is then divided into as many 
feedings as are required for the day, each one being placed in a separate 
bottle. As to handling the bottles and pasteurizing or sterilizing, the 
same rules apply as during the first year. 

From Fourteen to Eighteen Months. — The diet may be increased by 
the addition of more solid food. The average child will take: 

Milk, warmed, eight to ten ounces. 
Fruit juice, one to three ounces. 

Cereal: one, later two or three, tablespoonfuls of oatmeal, hominy or 
wheaten grits, cooked for at least three hours; for the first month this 
should be strained ; upon the cereal from one to two ounces of thin 
cream, or milk and cream, with plenty of salt, but without sugar. 
Crisp dry toast, one piece ; or, unsweetened zwieback ; 

or, one Huntley and Palmer breakfast biscuit. 
Milk, warmed, six to eight ounces. 
2 p. m. Beef juice, one to two ounces ; and one egg (soft boiled, poached or cod- 
dled) ; and boiled rice, one tablespoonful, cooked four hours; 
or, broth (mutton or chicken), four ounces ; one or two breakfast bis- 
cuits, or zwieback ; and (if most of the teeth are present) rare scraped 
meat, at first one teaspoonful, gradually increasing to one tablespoonful. 
6 p. m. Cereal : two tablespoonfuls of farina, cream of wheat, or arrowroot, cooked 
for at least one half hour, with milk, plenty of salt, but without sugar ; 
or, bread and milk or milk toast. 
Milk, warmed, eight to ten ounces. 
10 p. m. Milk, warmed, eight to ten ounces, which may be given from a bottle. 

From Eighteen Months to Two Years. — The amount of solid food 
may be somewhat increased. The number of the meals should be the 
same as for the preceding period. In addition, cooked fruits, such as the 
pulp of stewed prunes or baked apple, strained, may be given at the mid- 
day meal. It is generally best not to give fruits and milk at the same 
meal. Nothing but water should be given between meals. Potato and 
other vegetables are best deferred until the child has passed two years. 



6.30 


A. 


M. 


9 


A. 


M. 


10 


A. 


M. 



FEEDING DURING THE SECOND YEAR, 221 

DIFFICULT CASES DURING THE SECOND YEAR. 

The number of children whose nutrition is a matter of difficulty dur- 
ing the second year is much smaller than during the first year; yet the 
difficulties may be just as great. Some of these are infants that have 
been very delicate from birth, and carried through the first year only 
by the greatest effort. Others are healthy at birth, but their digestion 
has been badly deranged in consequence of improper feeding. Still others 
did well until they were weaned. The conditions may be the result of 
a severe attack of acute disease of the stomach or intestines during the 
first year. Other important causes are the early use of solid food and 
the too exclusive use of farinaceous foods of all varieties. 

Whatever the special cause of the condition, cases of chronic indi- 
gestion in the second year are usually improved by putting them back 
upon essentially a first-year diet. Usually the first thing to be done is 
to stop all solid food except possibly rare scraped meat. Starches must 
be reduced to a minimum or prohibited altogether. In most cases milk, 
meat, and a little suitable fruit should constitute the diet. While it is 
undoubtedly true that the use of plain cow's milk often fails entirely, 
it is certain that nothing is more likely to succeed than cow's milk when 
properly modified. This must be continued as the principal diet, some- 
times as the sole diet, for the greater part of the second year. The milk 
should be modified as for healthy infants who are from eight to twelve 
months younger than the patient under treatment. The daily quantity 
should generally be somewhat larger than for a young, healthy in fan i 
taking food of the same strength. The regular intervals of feeding 
should never be shorter than three hours, and in many cases intervals of 
four hours are to be preferred. 

Striking improvement often follows the administration of rare meat- 
pulp, especially to those who are over eighteen months old. From one 
to two ounces may be given daily. Generally the proteids in the food 
have been previously deficient. Many of these children digest meat when 
given in this way better than they do the casein of the milk. Raw beef 
juice and the whites of eggs, partially cooked, may also be given. 

Tin- same fruits should be allowed as for healthy infants, the quan- 
tity being smaller. As it is with the starches that the greatesl difficulty 
is experienced, the carbohydrates should be administered chiefly in the 
form of milk sugar or some of the mailed foods. When starch is firsi 
allowed it should be given with some reliable preparation of diastase. 

When the child is once well started and gaining steadily, the food 
may he gradually modified, until the diet recommended for healthy in- 
fants of the same age is reached. All changes musl be made very 
gradually, and it should never be forgotten thai there is n constanl dis- 
position on the part of all mothers and nurses to over-feed these children. 



222 NUTRITION. 



FEEDING FROM THE THIRD TO THE SIXTH YEAR. 

Articles allowed. — From the following list the diet of a healthy child 
may be arranged: 

Milk. — This should be the basis of the diet; most children require 
about one quart daily. This usually needs no modification, but if some- 
what difficult of digestion, it should be prepared as follows : Six ounces 
of milk, one ounce of cream, and three ounces of water. The milk 
should usually be given warm. 

Cream. — This is of great value, especially when there is a tendency 
to constipation. From two to eight ounces may be given daily. It may 
be 'used upon cereals, upon potato, in broths, and mixed with milk. In 
many cases it is advisable to withhold milk and give only cream. 

Eggs. — These are a valuable form of proteid. They should be fresh, 
soft-boiled or poached, but never fried. Usually eggs should not be 
given oftener than every other day, as many children soon tire of them. 

Meats. — Some form of meat should be given once a day. The best 
are "beef-steak, mutton chop, and roast beef or lamb ; next to these the 
white meat of chicken, or fresh fish, which should be boiled or broiled. 
Beef and mutton should be given rare. 

Vegetables. — Potato may be given once a day, preferably baked, with 
the addition of cream or beef juice rather than butter. Of the green 
vegetables the best are asparagus tops, spinach, stewed celery, string 
beans, and fresh peas. One of these vegetables should be given daily — 
always well cooked and mashed. 

Cereals. — Nearly all these may be used — oatmeal, wheaten grits, 
hominy, rice, farina, and arrowroot. The most important part of the 
preparation is thorough cooking. If the grains are used, cereals should 
be cooked at least three hours, after having been previously soaked for 
several hours. They should always be well salted, and given with milk 
or cream, but with little or no sugar. 

Broths and soups. — The meat broths are preferable to the vegetable 
broths. Nearly all varieties may be given. Plain broths are not very 
nutritious, but when thickened with arrowroot or cornstarch, and when 
cream or milk is added, they are very palatable, and at the same time a 
valuable addition to the iiet. Beef juice may be used as directed for 
the second year. 

Bread and biscuits (crackers) . — In some form these may be given 
with nearly every meal, better without butter until the fourth year, as 
for young children cream is a better form of fat. All varieties of bread 
may be allowed when stale; also dried bread, zwieback, and oatmeal, 
Graham, or gluten biscuits. 

Desserts. — The only ones that should be allowed up to the sixth year 
are junket, plain custard, rice pudding without raisins, and, no,t oftener 



FEEDING FROM THE THIRD TO THE SIXTH YEAR. 223 

than once a week, ice-cream. Of the last three, the quantity given 
should be very moderate. 

Fruits. — Some fruit should be given every day. Oranges, baked 
apple, and stewed prunes are the most to be depended upon. Raw 
apples should not in most cases be given. Peaches, pears, and grapes 
(with seeds removed) may be given when thoroughly ripe and fresh, 
but only in moderate quantity. Special care should be exercised in the 
use of fruits in very hot weather, and in cities where they may not 
always be fresh. The juice of fresh berries may be given in the second 
year; but the whole fruit should be very sparingly given to all young 
children, and always without cream. 

Articles forbidden. — The following articles should not be allowed 
children under four years of age, and with few exceptions they may be 
withheld with advantage up to the seventh year : 

Meats. — Ham, sausage, pork in all forms, salt fish, corned beef, dried 
beef, goose, duck, game, kidney, liver and bacon, meat stews, and dress- 
ings from roasted meats. 

Vegetables. — Fried vegetables of all varieties, cabbage, potatoes (ex- 
cept when boiled or roasted), raw or fried onions, raw celery, radishes, 
lettuce, cucumbers, tomatoes (raw or cooked), beets, egg-plant, and 
green corn. 

Bread and cake. — All hot bread and rolls ; buckwheat and all other 
griddle cakes ; all sweet cakes, particularly those containing dried fruits 
and those heavily frosted. 

Desserts. — All nuts, candies, pies, tarts, and pastry of every descrip- 
tion; also all salads, jellies, syrups, and preserves. 

Drinks. — Tea, coffee, wine, beer, and cider. 

Fruits. — All dried, canned, and preserved fruits; bananas; all fruits 
out of season and stale fruits, particularly in summer. 

From the third to the. sixth year four meals should usually be given 
daily and at regular intervals — e. g., 7 and 10.30 a. m.; 1.30 and 6 P. if. 
The second meal should, in most cases, be smaller than the others. 

The following is a sample diet for a child of four years : 

First meal. — Half an orange, two tablespoonfuls of some cereal well 
salted, will) two or three tablespoonfuls of cream, a glass of milk, one 
piece of bread with a little butter. •, • 

Second meal. — A glass of milk or cup of broth with bread or two <>r 
three biscuits (crackers). 

Third meal. — Two tablespoonfuls of finely divided steak or chop, one 
tablespoonful of baked potato, one tahlespoonful of spinach, bread and 
butter, a cup of junket, water to drink. 

Fourth meal. — Milk with bread,, or milk toast. 

From the list of articles given above, a sufficient variety in the diet 
can be secured. The only way for the physician to be sure that propel 



224 NUTRITION. 

food is given to young children, is to write out for the guidance of the 
mother or nurse two lists somewhat similar to the above, of articles for- 
bidden and articles allowed. This plan I have followed for several years 
with the happiest results. It is rarely safe to trust to the judgment of 
the mother. 

There are a few simple rules in feeding which should always be fol- 
lowed : 

A child should be taught to eat slowly and thoroughly masticate his 
food. The food must always be very finely divided, for, as a rule, mas- 
tication is very imperfect even up to the sixth or seventh year. If the 
child is fed by the nurse, plenty of time should be taken for the meal. 
It is almost always the case that the food is given too rapidly. It is un- 
wise continually to urge children to eat when they are disinclined to do 
so at the regular hours of meals, or when the appetite is habitually poor, 
and under no circumstances should children be forced to eat. Indigesti- 
ble articles of food should not be given to tempt the appetite when ordi- 
nary simple food is refused, nor should these be allowed because of the 
notion that " the child must eat something." Food should not be allowed 
between meals when it is habitually declined at meal-time. If a child re- 
fuses to eat, and examination reveals no fault with the food prepared, it 
should seldom be offered again until the next feeding time. In all cases 
of temporary indisposition, no matter of what nature, and during peri- 
ods of excessive heat in summer, the amount of solid food should be re- 
duced and more water given. If milk is the food, it should be diluted. 

FEEDING DURING ACUTE ILLNESS. 

Infants. — This is an important part of the treatment of every acute 
disease in childhood, but especially so in infancy. Whether the illness 
is one of the eruptive fevers, diphtheria, pneumonia, or influenza, all 
cases must be fed in about the same way. It is much easier by proper 
feeding to prevent disturbances of digestion, than to allay them. In 
infancy this complication often turns the scale against the patient. In 
every severe acute illness, especially if it is of a febrile character, the 
power of digestion is much diminished. One evidence of this is the 
onset with vomiting; another is the anorexia which accompanies the 
early stage of nearly all acute diseases. We should respect this disin- 
clination and make it our guide in the treatment. But water is needed ; 
withholding this will often cause the temperature to rise even higher 
than before. 

In all acute febrile diseases the general rule should be, less food 
and more water than in health.* For bottle-fed infants this is easily 

* Some valuable suggestions as to the character of food most suitable in acute 
disease may be obtained from the experiments of Jacubowitch (Jahrbuch fur Kinder- 



FEEDING DURING ACUTE ILLNESS. 005 

accomplished by simply increasing the dilution of the food ; for nursing 
infants by making the nursing time shorter and giving water freely 
between feedings either from a spoon or bottle. 

Eegularity in feeding is too often entirely ignored. While it is true 
that with some capricious children all rules must be disregarded, it is 
with the great majority a decided advantage to adhere to proper food 
and regular intervals. Food should seldom be given at less than two- 
hour intervals, and generally a three-hour interval is better, although 
there is no limit to the frequency with which water may be given, and 
unless the stomach is irritable, almost no limit as to quantity. Stimu- 
lants, when required, are often best given in a very dilute form with the 
water. 

Forced feeding — gavage. — Not a few cases, however, are seen in 
which, after a child has been several days sick, in consequence of deliri- 
um, stupor, sepsis, or some other serious condition, it may refuse all 
food or take so little that it is in danger of death from inanition. At 
this juncture forced feeding or gavage (see page 64) serves an excel- 
lent purpose. Both food and stimulants can thus be introduced at regu- 
lar intervals with slight disturbance, and lives saved which would other- 
wise be lost. If gavage is employed, the stomach should be first washed. 
The intervals of feeding should be made at least one hour longer than 
is customary in health, and usually predigested foods given. 

Older Children. — The same conditions with reference to digestion 
exist as in the case of infants. Older patients, however, are not so 
easily disturbed, and the disturbance of digestion is not so likely to be 
serious as in the case of infants. Even here the physician should direct 
the food to be given at regular intervals, usually not oftener than every 
three hours, but should never — as is so often done — order milk to be 
given to the child every time it asks for a drink. In most cases, for 
children under five years old, milk should be somewhat diluted, usually 
with lime-water, and partially peptonized if the child's digestion is fee- 
ble. Children who do not take milk readily may be given beef tea, brol Ik 
gruel, or kumyss, but rarely ice-cream or jellies so frequently prescribed, 
as these, if given in any considerable quantity or very often, are likely 
to disturb the stomach and take away what little desire for food the 



heilkunde, xlvii, 195) upon the activity of the digestive ferments derived from the 
different organs of children, removed immediately after death, usually occurring from 
acute general disease. The greatest activity was found in the diastatic ferment <>f 1 he 
pancreas, although its power to emulsify fats was weak, and in one-third the cases it 
was absent. The peptonizing power both of the stomach and the pancreas was very 
weak. The practical inference from this is that the food of acutely sick children 
should consist chiefly of carbohydrates, either as sugars or starches, that fats should 
be very sparingly given, and that proteids in many cases should be partially pre- 
digested. This accords with clinical experience. 



226 NUTRITION. 

child may have. Eaw eggs are palatable when beaten up with sherry, 
a little sugar, and cracked ice. Fruits, particularly oranges, grapes, and 
grape-fruit, may be allowed in almost every febrile disease, but never 
given within two hours of a milk feeding. 

The water given may be plain boiled water, but better, in most cases, 
are some of the carbonated waters, Vichy, Seltzer, or Apollinaris, these 
being less likely to disturb the stomach. 

It is certainly a mistake to force food upon older children in any dis- 
ease in which their condition is not dangerous. But when there is sepsis, 
delirium, or coma associated with other dangerous symptoms, gavage 
may be resorted to with but little more difficulty, and with no less satis- 
factory results, than in infants. 



CHAPTER V. 
TEE DERANGEMENTS OF NUTRITION. 

The derangements of nutrition form a distinct and a very large class 
in the ailments of infancy, particularly during the first year. The 
symptoms are sufficiently definite and characteristic for them to be re- 
garded as separate diseases, and to be discussed as such. In adults such 
symptoms are seldom seen except in connection with organic disease. 
These cases are often very puzzling, and in a large number of them a 
diagnosis of some constitutional disease, such as hereditary syphilis, or 
tuberculosis, or organic disease of the stomach or intestines, is errone- 
ously made. At other times the symptoms resemble those of acute tox- 
aemia. The essential condition in all these cases is the inability of the 
infant to get from its food what its system needs. It can not digest or 
assimilate enough to support life. It is unable to replace from its food 
the daily waste of its tissues. The constructive metabolism is not equal 
to the destructive metabolism of the body; the process is, therefore, 
essentially one of starvation, which may be rapid or slow, according to 
circumstances. 

The fault in these cases is partly with the digestion, but principally 
with the food. The problem is, to adapt the food to the digestion of the 
individual child under consideration. The solution is often very easy at 
first, but the difficulties multiply rapidly the longer the condition has 
lasted. It is therefore essential that the true explanation of the symp- 
toms should be recognised at the earliest possible moment. Changes 
occur so rapidly in very young infants that a mistake in diagnosis and a 
consequent delay of a few days, may be sufficient to determine a fatal re- 
sult. The outcome in cases of imperfect nutrition depends almost en- 



ACUTE INANITION. 227 

tirely upon their management. The condition is not one which tends to 
right itself. Spontaneous improvement or recovery rarely takes place. 
In order to recognise the condition and anticipate the result, nothing is 
so important as a close observation of the body-weight. A child whose 
nutrition is a matter of difficulty should be weighed regularly, in the 
early months twice a week, and once a week throughout the first year. 
If this is done, the first symptoms of failing nutrition are unerringly 
detected. If a child does not gain in weight something is wrong, and a 
steady loss in weight in an infant is a warning which should never be 
unheeded; for, unless the conditions are changed, it is practically cer- 
tain to continue, and generally with increasing rapidity, until the in- 
fantas vitality has been reduced to such a point that no means of treat- 
ment can restore it. The younger the child, the more rapid the loss, 
and the longer it has continued, the greater is the danger. 

For convenience of description these derangements of nutrition have 
been divided into three groups, differing, however, rather in degree than 
in kind. 

1. Cases of acute inanition, which are quite rapid, generally lasting 
from a few days to a few weeks. They are rare except in young infants, 
being most frequently seen in the first three months. 

2. Cases of malnutrition, in which the symptoms are much less se- 
vere than in the other groups, although they may be of long duration. 
While it is most common in the first two years, malnutrition may be 
seen at any age. 

3. Cases of marasmus. This is similar to inanition, but a much 
slower process, lasting usually for several months. It may be seen in 
infants of any age. 

ACUTE INANITION. 

Inanition, or starvation, is a condition depending upon lack of assim- 
ilation. It is common in early infancy, when it often simulates serious 
organic disease. In older children it is not so frequent, and not usually 
so obscure. In all the acute diseases of the digestive tract many of the 
symptoms are due to inanition. The cases considered in (lit 1 presenl 
chapter, however, are those in which there is no such association, or 
where the digestive symptoms, strictly speaking, are not prominent. 

Etiology. — The essential cause of inanition is that the child does not 
get sufficient food, or that the food taken is not assimilated. H usually 
develops under one of the following conditions: (1) When a child re- 
fuses all food, whether from the breast or the bottle, or can be made to 
take only an insignificant amount. The cause of this il is often im- 
possible to discover. I have seen it in a variety of circumstances, once 
in an infant five months old, previously healthy, who was Buffering from 
whooping-cough, This infant utterly refused the breast, and from the 



228 NUTRITION. 

spoon would take less than two ounces a day. After four days and the 
production of most alarming symptoms, gavage was begun, and its life, I 
think, saved by it. It is sometimes seen at weaning, where a child per- 
sistently refuses to take food from a bottle or spoon. (2) When the 
food given is entirely inadequate, as when an infant is nursing upon a 
dry breast, or one in which the milk supply is so scanty that the child 
gets practically nothing. I have occasionally seen it later, when the 
breast-milk, for some unexplained reason, had suddenly failed. (3) 
Where the character of the food is improper. Breast-milk may be not 
only scanty, but of very poor quality. On account of extreme poverty, 
the infant may be getting only tea, as I have known to be true in several 
cases before admission to the hospital. Some cases occur in young in- 
fants who are fed entirely on starchy food. (4) Where the infant at 
birth has such feeble powers of digestion, because premature or delicate, 
that it is unable to take or to digest sufficient food to maintain life. 
Sometimes this food is breast-milk, which, though abundant, is of infe- 
rior quality and can not be assimilated. Very often it is some proprie- 
tary food. (5) When a sudden change of food is made to one so diffi- 
cult of digestion that the child is unable to assimilate it. This may 
happen after sudden weaning. In such cases the symptoms of inanition 
are mingled with those of acute indigestion, but the former usually pre- 
dominate. 

In children over one year old, and sometimes in younger ones also, 
the symptoms of inanition may follow those of some acute disease, such 
as influenza, malaria, pneumonia, or even otitis. Although the child 
may recover from the acute process, the general vitality is so much low- 
ered that assimilation is not sufficient to replace the waste of the body. 

Symptoms. — The mode of development depends upon the antecedent 
condition. In young infants inanition often follows malnutrition where 
perhaps there has been nothing noticeable except a gradual loss in 
weight ; or if the weight has not been watched, it may be observed only 
that the infant has not been doing well. Severe symptoms may come on 
quite suddenly, and if the nature and the gravity of the condition are not 
appreciated the case may terminate fatally in two or three days. The 
loss in weight is now rapid, amounting often to three or four ounces a 
day. The temperature in the newly born may be high, but it is more 
often subnormal. The pulse is always weak and rapid. The urine is 
scanty and very low in chlorides. The extremities are cold, and the 
peripheral circulation poor. There is usually complete muscular relaxa- 
tion, almost collapse. The skin may be dry or covered with a clammy 
perspiration. There is extreme pallor, and often there is cyanosis. 
This is always a grave symptom, and when it is marked the case usually 
ends fatally. Cyanosis may be present in children who have previously 
cried well and in whom there is no suspicion of atelectasis. The respira- 



ACUTE INANITION. 229 

tions are rapid and may be irregular. There may be constant worrying 
and fretfulness, or a condition of semi-stupor, in which the child makes 
no sign of wanting food. The fontanel is sunken and the pupils are 
often contracted. The stools contain undigested food, or if predigested 
foods are given they seem to pass through the intestines unchanged. 
The bowels usually move frequently, although there may be constipation, 
due to the small amount of food taken. When all food is refused for 
two or three days the stools may resemble meconium, as I once saw in 
a child six months old. While no desire for food is manifested, infants 
will sometimes swallow food when it is offered, retaining everything 
given for several feedings, when the whole quantity is vomited. 

The course of the disease depends much upon the age of the infants. 
Those under one month succumb most quickly. In them the symptoms 
sometimes last but two or three days, seldom more than a week or ten 
days, the children simply drooping steadily until death occurs. With 
proper treatment complete recovery may take place in a week. In 
older infants the progress, whether upward or downward, is usually less 
rapid. 

Prognosis. — The outcome of these cases is always uncertain. In few 
conditions is it more so. It is hard for one who is not familiar with the 
condition to appreciate the great and even the immediate danger in 
which a young infant may be from inanition, especially in the ab- 
sence of both vomiting and diarrhoea. It is difficult to estimate the 
gravity of an individual case except after twenty-four hours' observa- 
tion. The best of all guides is perhaps the weight. Where the loss 
is several ounces each day the chances of recovery are small. The pres- 
ence also of frequent vomiting or of diarrhoea makes the outlook very 
bad. A high temperature, very marked relaxation, copious perspiration, 
cold extremities, and cyanosis are all bad symptoms. 

Diagnosis. — Inanition is distinguished from malnutrition by its 
greater severity, and from marasmus by its more acute character. The 
usual mistake is that of confounding inanition with some local or consti- 
tutional disease. It may be mistaken for acute indigestion, meningitis, 
^astro-enteritis, pneumonia, and some of the fevers. The temperature 
when elevated is especially likely to mislead. In some eases the absence 
of chlorides from the urine may be of diagnostic value. 

Treatment. — The existence of inanition in young infants presupposes 
only the feeblest powers of digestion and assimilation. If possible, a 
good wet-nurse should be secured, for in most of the eases the time for 
action is so short that there is no opportunity to experiment with arti- 
ficial feeding. 

The breast-milk should usually be diluted, at first with an equal vol- 
ume of water or lime-water, and the quantity should be only a i'cw 
drachms. It may be given with a spoon or a medicine-dropper. If there 



230 NUTRITION. 

is diarrhoea, the milk should be pumped from the breasts, and the cream 
removed, since the high fat of good breast-milk is apt to excite vomit- 
ing or copious purgation. Gradually the quantity and strength of the 
milk are increased until the child is allowed to take the breast entirely. 

When no wet-nurse can be obtained, whey mixtures (page 210) may 
be tried or a milk formula containing low proportions of fat and proteids, 
such as No. II, Second Series (page 195), or No. I, Third Series (page 
196). Sometimes these should be peptonized. When food^is not readily 
taken, it may be given by gavage. Rectal feeding may be of some assist- 
ance for a short period. Other things which may be tried are diluted 
kumyss, animal broths, malted foods, farinaceous foods, and beef pep- 
tones. 

Often the symptoms are due quite as much to a lack of water as to a 
lack of food. Injections of a normal salt solution may be given per rec- 
tum or even under the skin with very great advantage. Rectal injec- 
tions should be given at 104° to 110° F. and carried high into the colon 
by a catheter; they should be repeated every four or five hours. 

The other treatment required by these cases is the reduction of high 
temperatures by sponging or tepid baths, and the raising of subnormal 
temperatures by hot-water bags, rolling in cotton, or even by the use of 
an incubator. Stimulants are indicated, but are not very well borne; 
alcoholic preparations by the mouth often excite vomiting, but by the 
rectum they may be better tolerated. Drugs are of no use whatever. 
Oxygen inhalations are of the greatest value, and should be used if pos- 
sible in all very acute cases whether cyanosis is present or not. Heat, 
oxygen, and diet are really the sum of treatment. 

Inanition in older infants is usually seen at weaning or in connec- 
tion with or following some acute illness. Completely peptonized milk 
by gavage is often useful. There are some patients, usually over ten 
months old, who refuse fluid food of every description, and vomit it 
when it is coaxed or forced, yet who will take and digest in a most 
surprising manner some form of solid food, such as beef-steak, oatmeal, 
bread, crackers, or even potatoes. For the time one must give what- 
ever the child will take, and gradually change to a suitable diet as soon 
as circumstances will permit. The needed water may be given per 
rectum. 

All children who have suffered from acute inanition need the closest 
attention for a long time, particularly as to their feeding, regarding 
which suggestions will be found in the pages devoted to Infant-Feeding. 

MALNUTRITION. 

Cases of malnutrition are exceedingly common, and occupy a large 
part of the time and attention of one engaged in practice among chil- 
dren. Although these children can not be said to be actually ill, they 



MALNUTRITION. 231 

are very far from well, and their condition is often the cause of the great- 
est solicitude on the part of anxious parents, not only from the existing 
state of health, but from the apprehension of the development of some 
serious organic or constitutional disease, especially tuberculosis. 

Etiology. — Malnutrition may depend upon inherited conditions. 
Certain children are delicate from birth, possessing only feeble physical 
vitality, though without giving evidence of any actual disease. They are 
often the offspring of parents of delicate constitution, or of those with 
inherited tuberculosis, gout, syphilis, or alcoholism. Very many city 
children are included in this group. They are a product of modern life, 
and inherit a too highly developed nervous organization with a corre- 
sponding amount of physical deterioration. In another group of cases 
the children are premature or very small at birth, weighing perhaps only 
three or four pounds. Many cases are traceable to improper feeding or 
equally poor nursing during the first few months. These children get a 
poor start in life, and on that account are handicapped throughout in- 
fancy. In many cases malnutrition develops as a result of the patient's 
surroundings. While this is common among the poor, it is not rare 
among the better classes. One of the most frequent causes is the perni- 
cious custom of keeping infants in close apartments where the thermom- 
eter ranges from 72° to 78° F., and where the greatest anxiety is con- 
stantly felt lest the children take cold. Such infants may lose in weight, 
become anaemic, and exhibit all the signs of malnutrition where nothing 
else is wrong except the conditions mentioned. In infants, malnutri- 
tion often depends upon some previous acute disease, especially of the 
stomach and intestines, and sometimes of the lungs. 

In children who are over two years old the condition of malnutrition 
may be due to any of the factors above mentioned — inherited feebleness 
of constitution, bad feeding and its resulting indigestion, too little fresh 
air, and close confinement indoors. It is, however, at this period much 
more frequently than in infancy, dependent upon some previous acute 
disease. This may be acute broncho-pneumonia, acute ileocolitis, in- 
fluenza, malaria, or any of the eruptive fevers. As a result, an im- 
pression is left upon the child's constitution which lasts for months, 
often for years, and which manifests itself not by any special local symp- 
toms, but by a general condition of debility or malnutrition. Somel imes 
such diseases, instead of being directly the cause of the symptoms, are 
the occasion which brings out some latent inherited taint or constitu- 
tional weakness in children who up to this time, perhaps, have appeared 
exceptionally healthy. In other cases malnutrition depends upon faulty 
methods in education, especially upon overpressure in schools. 

Symptoms. — In infants. — The weighl is much below the average, and 
is either stationary or the gain is very slow, often only five or six ounces 
a month at a period when it should be from one to two pounds. In a 



232 NUTRITION. 

case recently under treatment, a child at fourteen months weighed but 
eight and a half pounds. This infant at birth weighed three and a half 
pounds, but in a few weeks the weight dropped to two pounds. 

Not only the weight but the general physical development is much 
below the normal. At one year the body length may be three or four 
inches less than the average. Dentition is usually but not always de- 
layed. Muscular development, too, is backward; many of these chil- 
dren do not sit alone until a year old, and barely walk at two and a half 
years. The muscles are soft and flabby, and the ligaments so weak that 
paralysis is often suspected. The body is so small that the head seems 
unnaturally large, and a diagnosis of incipient hydrocephalus is fre- 
quently made. Mentally these infants are often above the average. 
Some symptoms of rickets may be present, but often there are none; 
to apply the term rachitic to all of them seems to me a mistake. 

Anaemia is invariably present, and varies much in degree, being rare- 
ly extreme. The circulation is usually poor, the hands and feet are fre- 
quently cold. In many children the skin is unnaturally dry ; in others 
there is a disposition to excessive perspiration, particularly about the 
head. Nervous symptoms are usually present. These children are rest- 
less, fretful, and irritable; they sleep badly during the day, and often 
worse at night. Enlargement of the lymph glands is common, especially 
those of the neck. The cervical adenitis may have started from a slight 
catarrhal cold, but the glands continue to swell after this has subsided 
and may remain enlarged for months. 

One of the most characteristic things about these infants is their 
feeble powers of digestion and assimilation. Unremitting care and con- 
stant watchfulness are required to keep them up to even a moderate 
standard of health. The most trivial changes in food may upset them. 
Attacks of acute indigestion are usually brought on by overfeeding — the 
mistake which is almost invariably made by mothers who are discouraged 
with the slow progress made, and are anxious to make their children grow 
fat and strong. The balance is so delicately adjusted that the slightest 
deviation from proper rules of feeding, either as to the quality of the 
food or the quantity given, is immediately followed by an attack of acute 
indigestion, often by severe diarrhoea. As a result, the child may lose as 
much in two or three days as it has gained in a month or more. These 
acute attacks, if in summer, not infrequently prove fatal. Not only do 
these patients have but little resistance to acute disturbances of the 
stomach and intestines, but any acute disease is serious — measles, whoop- 
ing-cough, and pneumonia being especially fatal. 

Among the poor or in institutions, cases of malnutrition like those 
described, if in children under nine months old, are almost certain to go 
on from bad to worse until they have reached the condition described 
as marasmus. Between this and malnutrition no sharp distinction can 



MALNUTRITION. 933 

be drawn ; they are rather different degrees of the same general process. 
In private practice, where it is possible to have the best care and sur- 
roundings, with the co-operation of an intelligent mother or nurse, a 
very large number of these infants can be reared. After the second year 
has passed the problem becomes a much simpler one, and if infectious 
diseases and other forms of acute illness can be avoided, the probabili- 
ties are in favour of the child's becoming stronger each year and growing 
to maturity. 

In older children. — In general appearance these children are thin, 
pale, and very often undersized, particularly if the condition is constitu- 
tional or hereditary. Sometimes they are taller than the average for 
their age, and their symptoms are often attributed to too rapid growth. 
One of the most striking things about children suffering from malnutri- 
tion is their vulnerability. They " take " everything. Catarrhal pro- 
cesses in the nose, pharynx, and bronchi are readily excited, and, once 
begun, tend to run a protracted course. There is but little resistance to 
any acute infectious disease which the child may contract. One illness 
often follows another, so that these children are frequently sick for 
almost an entire season. Their muscular development is poor, they tire 
readily, are able to take but little exercise, and their circulation is slug- 
gish. Mentally they are usually bright, often precocious. Many would 
be called nervous children. They are cross, fretful, and any unusual 
excitement produces an effect which lasts for some time; for example, 
after a children's party or a Christmas tree they may lie awake half 
the succeeding night, and may be really ill for two or three days. Their 
sleep is usually disturbed and restless ; they waken frequently, and occa- 
sionally suffer from night-terrors. At a later age they are favourable 
subjects for chorea, neuralgia, and all functional nervous disorders. 

Digestive symptoms, if not constant, are very easily excited. In fact, 
they do not suffer so much from chronic indigestion as from a delicate or 
feeble digestion, which is easily upset by the slightest deviation from 
the regular routine. Children of five or six years have to be fed as care- 
fully as infants of eighteen months or two years. The appetite is usu- 
ally poor, and mothers are distressed because their children eat bo little 
yet, when food is urged upon them, attacks of indigestion follow with 
singular uniformity. The tongue is slightly coated the greater pari of 
the time. The bowels are apt to be constipated, apparently more from 
lack of muscular tone than from anything else. From lime to time 
from slight causes, such as exposure to cold, or even from fatigue, there 
may be large quantities of mucus in the stools for two or three day- a! 
a time, although this is not a prominent feature of most of tin 
When they are not fed with the greatest care these children Buffer con- 
stantly from indigestion. A moderate amount of anaemia is always 
present, and this may be the most striking feature. In very many chil- 



234 NUTRITION. 

dren with a marked disturbance of nutrition, there is an excessive elimi- 
nation of uric acid. 

The duration of the condition depends very much upon the cause. If 
the cause is constitutional or inherited, the condition may last through- 
out childhood. Where it follows some acute illness it commonly lasts 
for a few months only; but the effect of an acute attack of broncho- 
pneumonia or of ileo-colitis may last for years. If the malnutrition is 
the result only of the child's surroundings, like the confinement incident 
*to city life, very rapid improvement may follow a removal to the coun- 
try. In some children marked improvement is seen about the seventh 
year; in others, a great change comes at puberty. 

Diagnosis. — The physician should not be too ready to make a diagno- 
sis of simple malnutrition. Before accepting such a diagnosis, he should 
examine the child with the greatest care, to exclude the common organic 
and constitutional diseases. Much regarding inherited constitutional 
tendencies can be learned from the family history and from the condi- 
tion of other children in the family. In the first place, tuberculosis, 
syphilis, and rickets should be excluded; then chronic malaria and the 
diseases of the blood ; and, finally, organic diseases of the lungs, heart, 
stomach, intestines, liver, and kidneys. Even malignant disease, though 
rare, should not be overlooked. It may take careful observation for sev- 
eral days, and sometimes for weeks, with repeated physical examina- 
tions, before all these conditions can be positively excluded. 

The next step in the diagnosis is to discover upon which one of the 
many possible causes, malnutrition depends. In private practice the 
great proportion of cases are due to improper feeding or nursing; next 
in importance are improper surroundings ; and last come inherited con- 
stitutional conditions. In other words, most of these children are born 
healthy, but become ill or delicate in consequence of improper manage- 
ment. 

In older children, after excluding constitutional and local diseases, 
the whole life of the child must be investigated to discover the funda- 
mental condition which is at fault. A carefully obtained history from 
infancy is of the greatest assistance. It is often difficult, and some- 
times impossible, to get at the primary factor, for in cases of long stand- 
ing there may be symptoms connected with almost every function of the 
body. One should scrutinize closely the quality and quantity of food 
given, the amount of sleep, the hours of study and recreation, the 
amount of exercise in the open air, and the physical conditions sur- 
rounding the child. Usually the most important factor in the case can 
be discovered. 

Prognosis. — This depends much upon the cause of the condition ; if 
it is one that can be removed, the prognosis is good not only for im- 
provement but for complete recovery. The longer the condition has 



MALNUTRITION. 235 

lasted and the greater the general disturbance the slower will be the 
improvement. The great danger is the supervention of some acute 
disease while the child's resistance is so greatly reduced. Acute indi- 
gestion, gastro-enteritis, and broncho-pneumonia are, especially to be 
dreaded. 

Since everything depends upon the fidelity with which directions as 
to diet and general management are carried out, the cases which present 
the greatest difficulties are those in which these conditions are hardest 
to control. When a child is not only suffering from malnutrition, but 
has been indulged and spoiled in every way by anxious but unwise par- 
ents, no success is to be expected unless the child can be placed in the 
hands of an experienced and trustworthy nurse. Cases due to improper 
feeding or to bad surroundings usually improve when these are cor- 
rected, and the worse these conditions have previously been the greater 
the improvement to be expected. Those depending upon an inherited, 
delicate constitution are not so hopeful, and require the closest atten- 
tion throughout childhood. 

Treatment. — This is a problem of nutrition to be solved by diet and 
general management, drugs occupying a very small place. 

In infants. — In very young infants treatment is chiefly a question of 
feeding. This should be carried on according to the rules given in the 
chapter upon Feeding in Difficult Cases (page 208). These children 
often do fairly well during the first year, but after this time frequently 
do very badly, on account of the failure to appreciate the fact that, 
although over twelve months old, in point of development they re- 
semble healthy infants of four or five months, and are to be managed 
as such. If they are nursing, weaning should often be deferred 
until the sixteenth or eighteenth month, or at least partial nursing 
should be continued until that time. "When cow's milk is begun it 
should always be very largely diluted, usually modified as for a healthy 
infant two or three months old. It is surprising to see with what 
uniformity the giving of cow's milk, pure or slightly diluted, will 
produce attacks of indigestion in some of these infants. 1 have seen 
a -ingle feeding in which one ounce of milk was given, and that diluted 
three times, produce a violent attack of acute indigestion which proved 
well-nigh fatal. Feeding during the entire second year should be car- 
ried on very much as in ordinary healthy children from the sixth to the 
twelfth month. A deviation from this rule almosl invariably results 
disastrously. One must be guided as to the amounl and character of the 
food not so much by the child's age as by his digestive capacity, and in 
mosl cases tins is much feebler than the mother or even tin' physician 
supposes. In many of these cases, cow"- milk — for them the most valu- 
able of all foods — has been excluded from the diet, when the only trou- 
ble is that it has not been given in sufficient dilution. For some chili 



236 NUTRITION. 

it must be partially peptonized during periods when digestion is espe- 
cially feeble. 

Next in importance to diet is fresh air. Often these patients will 
not improve with any variation in diet until fresh air is secured. 
Then increased digestive power is seen in the course of a few weeks, 
sometimes in a few days. The natural tendency of a mother who has 
a delicate infant, or one suffering from malnutrition, is to house it 
closely and never allow it a breath Of fresh air. It is of the greatest 
assistance if these children can be sent to a warm climate for the winter. 
If this is not possible, fresh air may be obtained by changing apartments, 
or by an airing in the room with the windows open. In the beginning 
this should be done for a few minutes only, the time being gradually in- 
creased to two or three hours each day. The child should be clothed 
as for the street, and, if necessary, hot bottles should be placed at the 
feet. 

Cold sponging is another valuable tonic. After the morning bath is 
given, at 95° F., the entire body should be sponged for a moment with 
water at a temperature of 60°, or even 55° F. This produces a certain 
amount of shock and causes loud crying, which is of itself beneficial. 
How frequently this should be done will depend upon the reaction fol- 
lowing it. If the child remains blue and cold for some time afterward, 
the cold sponging should not be repeated. If there is a good reaction, 
it may be used daily. 

Friction and massage are useful in many cases. The child should be 
laid upon the lap of the nurse, if possible before an open fire, and should 
always be covered with a blanket. The entire body should then be rubbed 
for ten or twenty minutes with the bare hand, or, better, with cocoa but- 
ter. Simple rubbing may be used, or the movements of massage em- 
ployed. If the latter, they should be very gentle at first, and only for 
a short time. Professional operators are inclined to be too energetic 
for little children. There is no advantage in rubbing with cod-liver 
oil instead of cocoa butter, while the odour makes it decidedly objec- 
tionable. 

The only tonics I have found of much value are alcohol, nux vomica, 
and cod-liver oil. Alcohol may be given in the form of port or sherry 
wine. Nux vomica may be given alone or with the wine. Cod-liver oil 
is too much used in these cases, and in too large doses. Many of these 
infants can not take it at all. It should rarely be given when the tongue 
is coated and the appetite very poor. The dose should always be small, 
e. g., ten drops of the pure oil three times a day, or twice as much of an 
emulsion. In these doses it may be given for a long time without dis- 
turbance. 

The secret of success in treating cases of malnutrition is, to hold the 
patient to a regular routine in feeding, sleep, and in everything relating 



MALNUTRITION. 237 

to his life. Experiments are nearly always unfortunate. The physician 
should lay down in writing for the guidance of the mother, specific rules 
with regard to the amount of food, the time at which it is to be given, the 
hours of bathing, sleep, and airing. He should see the patient at regu- 
lar intervals and often enough to be sure that his orders are being en- 
forced. Good results are obtained only by constant watchfulness, and 
although improvement may not be seen at once, it is in most cases 
sure to come if the mother will co-operate. In my own experience no 
class of patients have given me so much satisfaction as cases of malnu- 
trition in infancy. 

In older children. — The same general principles are to be applied to 
them as to infants. The diet is of the first importance. Only the sim- 
plest, plainest, and most easily digested articles of food should be given. 
Milk, beef, eggs, the lighter and more easily digested cereals, bread, and 
fruit should form the diet. All sweets, pastry, highly seasoned food, 
candy, nuts, tea, and coffee should be absolutely prohibited, and, in fact, 
all the articles mentioned as " forbidden " on page 223. When the appe- 
tite is poor and simple food not well taken, the child should not be 
allowed to take indigestible articles for the sake of eating something. 
Nothing should be given between meals, and regular hours of feeding 
must be followed. Usually I have found three meals a day, for children 
over three years old, better than the practice of giving more frequent 
feedings. But this is not always the case. Under no circumstances 
should children be coaxed, urged, or hired to eat ; much less should they 
be forced to do so. There is a popular misapprehension in regard to 
the variety in diet which children need. Most cases do better when 
a very simple and fairly uniform diet is continued. 

The general habits of children should be directed; there should be 
regular and early hours for retiring, freedom from undue excitement, 
and interest should be awakened in out-of-door amusements. A pony or 
dog will be found useful. Children should be kept as much as possible 
in the open air; usually they do much better if they can be in the coun- 
t ry during the entire year. Only a limited amount of reading and s< iidy 
should be allowed; and if children are at school, care should be taken 
that overpressure is not the cause of the symptoms, particularly in ail 
ambitious child. The cold sponging given in the morning, as described 
on page 57, is extremely beneficial to children who take cold readily. 
Massage is useful for the benefit which it affords to the chronic consti- 
pation which is so frequently a symptom of malnutrition. 

Of the tonics, iron, arsenic, and cod-liver oil are required in mosi 
cases, and the amount and combination may be varied from time to 
time, with the season of the year and the condition of the child's diges- 
tion. In general, these children require early hours, a simple diet, a 
quiet, regular life, and very little medicine. 



238 NUTRITION. 



MARASMUS. 
Synonyms : Athrepsia, infantile atrophy, simple wasting. 

Wasting is a symptom of many conditions in infancy. It occurs in 
tuberculosis, in infantile syphilis, and also as a result of acute or chronic 
disease of the stomach and intestines. Cases of wasting dependent upon 
such causes are not included in this chapter. 

Marasmus is the extreme form of malnutrition seen in infancy, occur- 
ring, so far as is known, without constitutional or local organic dis- 
ease. It is a vice of nutrition only. 

Etiology. — Marasmus is not very often seen in the country or in pri- 
vate practice ; but it is frequent in dispensary practice in all large cities, 
and is especially common in institutions for young infants. In my own 
experience in four institutions, more than one half the deaths under one 
year were directly or indirectly from this cause. Marasmus is a very 
large factor in the immense infant mortality of large cities in summer. 
Although the cause of death is usually reported under some other name, 
the determining factor in the fatal result is the previous marantic condi- 
tion of the patient. The primary cause may be a congenital weakness 
of constitution which may depend upon heredity. It is often seen in 
premature children and in the illegitimate offspring of girls of sixteen 
or eighteen. In the vast majority of cases, however, it depends upon two 
factors — the food and the surroundings. Among the poor who live in 
tenements, infants who are artificially fed almost invariably do badly. 
This is due to ignorance in regard to the proper methods of infant-feed- 
ing and inability to procure what the child requires, especially pure 
cow's milk. A country infant may be neglected in many respects, and is 
often badly fed; but it has plenty of pure air, and usually thrives. In 
the city, as long as an infant has a plentiful supply of good breast-milk 
it continues to do well in most instances, in spite of the fact that its 
surroundings are bad. When there are not only bad feeding and un- 
healthful surroundings, but also an inherited constitutional vice, we 
have all the factors required to produce marasmus in its most marked 
form. The odds are so against the infant that its feeble spark of vital- 
ity flickers for a few months only and gradually goes out. 

Another prominent factor in the production of marasmus is the over- 
crowding of infants in institutions. Even though artificially fed after 
the most approved methods, I have seen scores of infants who were 
plump and healthy on admission lose little by little, until at the end of 
three or four months they had become wasted to skeletons — hopeless 
cases of marasmus, dying of some mild acute illness, such as an attack of 



MARASMUS. 239 

indigestion or bronchitis, the essential cause, however, being marasmus. 
The common mistake is that of placing too many children in one ward, 
with no chance of obtaining a^ proper amount of fresh air. No house- 
plant fs -more delicate or sensitive to-" its surroundings than an infant 
during the first few months of life. T ■> ■-*- - - -- - 

Lesions. — The post-mortem findings in cases of marasmus are ex- 
ceedingly unsatisfactory, and throw little if any light upon the disease. 
Every now and then general tuberculosis is discovered in patients dying 
apparently of marasmus, the existence of which was not previously 
suspected. An occasional lesion is fatty liver. This may lead to such 
enlargement of the organ that its weight is increased by one half. Both 
to the naked eye and under the microscope the usual changes of fatty 
infiltration are present, often to an extreme degree. In the past too 
much has doubtless been made of this condition of the liver in maras- 
mus. From figures given elsewhere (see article on Fatty Liver), it will 
be observed that the lesion is not more frequent in this condition than 
in infants dying from other diseases. The most marked examples are 
seen in cases of marasmus which have lasted for seven or eight months. 
Its exact relation to the condition of wasting has not yet been deter- 
mined. 

With these exceptions the autopsies show nothing striking, and 
I have had the opportunity to make at least two hundred of them. The 
lesions usually found are the following : The brain is commonly anaemic, 
with dark fluid blood in the sinuses, marantic thrombi being rare. A 
strip of hypostatic pneumonia, from one to two inches wide, may be 
seen along the posterior border of both lungs, involving the lung to the 
depth of half an inch, or less. In the younger infants there are fre- 
quently areas of atelectasis in the lower lobes. The pleura is almost 
invariably normal. The heart is pale, with perhaps a slight increase in 
the pericardial fluid. The spleen and kidneys are pale, but otherwise 
normal. The stomach may be dilated ; the mucous membrane is usually 
pale, often coated with tenacious mucus. The intestines contain undi- 
gested food, sometimes mucus. The solitary follicles of the colon and 
small intestine, and sometimes Peyer's patches, are slightly enlarged, 
the mucous membrane in other respects being normal. The mesenteric 
glands are often slightly enlarged. In addition to the above, there may 
be evidence of some recent infection, which has been the cause of death ; 
there may be acute bronchitis, broncho-pneumonia, or intestinal ca- 
tarrh. 

The above lesions represent what has been found in the great ma- 
jority of the cases, and very disappointing they are to one who sees (hem 
for the first time. Nor does the microscopical examination of the organs 
throw any light upon these cases. I have personally examined with care 
the stomach and intestines of more than a dozen cases, several of (hem 
17 



240 NUTRITION. 

in which autopsies were made only two or three hours after death, with- 
out finding anything of pathological importance. The theory advanced 
by certain German writers, that atrophy of the intestinal tubules is the 
explanation of marasmus, has found no support in my observations, nor 
in those of other American writers. 




Fig. 41. — Marasmus; a patient in the Babies' Hospital, ten months old, weight six pounds. 
Weight at birth reported to have been nine pounds. 

The true pathology of marasmus seems to me to be a failure of as- 
similation, owing to imperfect digestion, improper food, unhygienic 
surroundings, or feeble constitution. As a result, there is a progressive 
loss in weight, feeble circulation, imperfect lung expansion, imperfect 
oxidation of the blood, lowered body temperature, and, finally, a deteri- 
oration of the blood itself. Each of these effects becomes in turn a cause 
aggravating all the others, continuing until a condition is reached which 



MARASMUS. 241 

is incompatible with life, for resistance becomes so feeble that the slight- 
est functional disturbance proves fatal. 

Symptoms. — The general history of these cases is strikingly uniform. 
The following is the story most frequently told at the hospital: "At 
birth the baby was plump and well nourished, and continued to thrive for 
a month or six weeks while the mother was nursing it ; at the end of that 
period, circumstances made weaning necessary. From that time the 
child ceased to thrive. It began to lose weight and strength, at first 
slowly, then rapidly, in spite of the fact that every known form of in- 
fant-food was tried." As a last resort the child, wasted to a skele- 
ton, is brought to the hospital. 

The most constant symptom is a steady loss in weight. The general 
appearance of these patients is characteristic. They have an old look; 
the skin is wrinkled, has lost its tone, and hangs in folds upon the ex- 
tremities (Fig. 41). The legs are like drumsticks; the abdomen is 
prominent; the temples are hollow; the fontanel is sunken; the eyes 
large ; the features sharp ; and the hands resemble bird-claws. Often the 
children are reduced literally to skin and bones. Anaemia is a very 
marked and almost a constant symptom, the amount of haemoglobin 
being frequently reduced to 30 per cent, and in one of my cases to 18 
per cent. Anaemic heart-murmurs are frequently heard. The body 
temperature is usually subnormal, unless artificial heat is used. A 
rectal temperature of 95° or 96° F. is very common, and one of 93° 
or 94° F. is occasionally seen. In addition to the pallor of the 
face, there may be a leaden hue due to congenital or acquired atelec- 
tasis. A frequent symptom is general oedema, depending upon the 
abnormal condition of the blood or blood-vessels. The first thing 
which calls attention to this is often an unexpected gain in weight. 
The oedema may increase until the cellular tissue of the whole body is 
affected. I have never, however, seen effusions into the large cavities. 
QSdema is usually associated with marked anaemia, and is generally a 
grave symptom. The stools are sometimes normal, but usually contain 
undigested food, and are large in proportion to the amount of food 
taken. No matter how carefully fed, these patients are easily upset. 
Now and then mucus is seen in the stools, but this is not a constant nor 
a marked feature. Vomiting is excited from the slightest cause, and 
often food is regurgitated almost as soon as swallowed. The appetite, 
in a severe case, is almost entirely lost; children refuse to take food 
from the bottle or spoon, and unless fed by gavage they die of inanition. 
In the earlier cases there may be an unnatural hunger, so that the chil- 
dren cry much of the time, and are relieved only when the bottle is 
given. 

The complications are thrush, erythema of the buttocks, and bed- 
sores, sometimes over the sacrum and heels, but most frequently upon 



242 NUTRITION. 

the occiput. Occasionally there is seen a .reflex spasm of the muscles of 
the neck, producing a marked opisthotonus, which may last for several 
days or weeks. 

The course of the disease in most cases is steadily downward. It may 
be cut short at any time by acute disease. Frequently these infants die 
suddenly when apparently they have been as well as for several weeks. 
In many instances the autopsy reveals no explanation of the sudden 
death; but in other cases it may be due to the regurgitation of food, 
and its aspiration into the larynx, the patient being too weak to 
cough. Earely, death occurs from convulsions. In summer, these chil- 
dren wilt with the first days of very hot weather, and die often in a 
few hours from a slight functional derangement of the stomach and 
bowels. 

Diagnosis. — No sharp line can be drawn between marasmus and mal- 
nutrition. In the wasting which follows chronic disease of the stomach 
and intestines there is usually a history of an antecedent acute attack. 
The chief difficulty in the diagnosis of marasmus is to exclude tubercu- 
losis. In some cases a differential diagnosis is impossible during life. 
Not infrequently tuberculosis is found at autopsy, even in infants of a 
few months, in whom there have been no symptoms except those of 
marasmus. Even when signs in the lungs are present, if situated pos- 
teriorly, they may be due either to tuberculosis or to the hypostatic 
pneumonia which is present. Signs in front are more significant; and 
consolidation anteriorly makes tuberculosis almost certain. In simple 
wasting there is often a history that the child was in splendid condi- 
tion at birth, and continued so until it was weaned, from which date 
it had gone down steadily. In tuberculosis no such definite cause may 
be present; the children are often very delicate from birth. Simple 
wasting is so much more common that the chances are always in its 
favour. 

Prognosis. — This depends on the age of the infant and the extent 
and duration of the disease. If the child is over eight months old, the 
chances of recovery are much better than in one under four months, for 
the fact that it has lived so long is generally evidence of pretty strong 
vitality. Very young infants are always difficult subjects to deal with. 
They go down more rapidly, and build up more slowly than those who 
are older. In most other circumstances the prognosis is much worse 
in cases of long duration. In a given case much depends upon whether 
everything possible can be done for the child : whether a wet-nurse can 
be secured or artificial feeding done in the best manner, and whether the 
patient can have the benefit of the best surroundings, in the country in 
summer and in winter a warm climate where it can be kept out of doors 
the greater part of the time. In institutions cases under four months old 
are usually hopeless. Of those over eight months quite a proportion can 



MARASMUS. 243 

be saved by proper treatment, even though the body-weight is reduced to 
eight or nine pounds. When recovery occurs it may be complete, and 
the child at three years may be as vigorous as any child of its age. All 
these statements refer only to cases of simple marasmus. The presence 
of organic disease puts the case into another category. 

Treatment. — The most important is that which relates to prophy- 
laxis. This, for large cities, may be summed up in a single sentence: 
Give the poor the opportunity to obtain pure cow's milk and teach 
them how to feed it to young infants, and at the same time give ample 
opportunities for obtaining fresh air. In institutions the most impor- 
tant thing is to give adequate air-space for each child. Often only four 
or five hundred cubic feet are allowed, when one thousand are necessary, 
even with the best ventilation. Children should be changed from one 
apartment to another and opportunity given for thorough airing, and 
there should be perfect ventilation, not only in the daytime but at 
night. 

As far as possible, wet-nurses should be obtained if the infants are 
under four months old. For these very young patients success by arti- 
ficial feeding is generally impossible. With those of six months or over, 
good artificial feeding is very frequently successful. In modifying cow's 
milk for these cases the formulas most likely to agree are those with low 
fat, low proteids — partially peptonized in many cases — and relatively 
high sugar. Further suggestions will be found in the chapter on Feed- 
ing in Difficult Cases. In institutions we seldom succeed without wet- 
nurses. 

For very young infants, with a temperature which is habitually sub- 
normal, the incubator may be used. If this is impossible, children 
should be rubbed with oil, rolled in cotton, and surrounded with hot- 
water bags or bottles. The general management should be much the 
same as described in the chapter on Malnutrition. At least once every 
day — by means of spanking, mild flagellation, or, better, by the alternate 
use of the hot and cold baths — children should be made to cry vigorously, 
in order to insure proper expansion of the lungs. They require no 
drugs, but a great deal of careful nursing. 



244: NUTRITION. 



CHAPTEE VI. 
DISEASES DUE TO FAULTY NUTRITION. 

The diseases due to faulty nutrition are numerous. There are two, 
however, which have been so clearly shown to originate in this way that 
they may be put in a class by themselves. These are scorbutus and 
rickets. The prevailing opinion of the medical profession is that both 
of these are essentially " food-diseases/' The purpose of considering 
them in connection with the disturbances of nutrition is to emphasize 
this relationship. 

SCORBUTUS (SCURVY). 

Scorbutus is a constitutional disease, due to some prolonged error in 
diet. It is characterized by spongy, bleeding gums, swellings and ecchy- 
moses about the joints, especially the knee and ankle, haemorrhages from 
the nose, and occasionally from other mucous membranes, extreme hy- 
peresthesia, and often pseudo-paralysis of the lower extremities. Added 
to these local symptoms there is usually a general cachexia with marked 
anaemia. While scorbutus and rickets are very frequently associated, 
they are not necessarily connected, and can hardly be considered as dif- 
ferent forms of the same disease ; although cases of scorbutus have been 
described in older writings under the title of Acute Rickets. In Ger- 
many it is known as Barlow's disease. 

For the statistical matter here presented I am indebted to the report 
of the American Psediatric Society's Collective Investigation of Infantile 
Scurvy in 1898, embracing 379 cases, reported by 138 observers. Of 
these, 31 cases were from my own practice. 

Etiology. — Age is an important factor ; more than four-fifths of the 
cases occur between the sixth and the fifteenth months, and half of 
them between the seventh and the tenth months. Scurvy has been seen 
in infants under a month old. The great majority of the cases reported 
have been observed in private practice, often in the best surroundings. 
Previous disease is not a factor of much importance. Most of the chil- 
dren attacked have been in good health up to the development of 
scurvy. In about one-fourth of the number some previous derangement 
of the digestive tract has existed. 

The only etiological factor yet known to bear any constant relation 
to the production of scurvy is diet. The important facts regarding 
the previous diet brought out by the Society's investigation are as 
follows: 



SCORBUTUS. 245 

' Breast-milk in 12 cases ; alone in 10. 

Raw cow's milk " 5 " " "4. 

^ . ■. , J Pasteurized milk " 20 " " "16. 

Previous food ^ Condensedm . lk u 6Qil u u ^ > 

Sterilized milk " 107 " " "68. 

I Proprietary infant-foods " 214 cases. 

This table shows that while scurvy may occasionally develop with 
almost any variety of food, three stand out prominently — viz., pro- 
prietary infant-foods, condensed milk, and sterilized milk. In all of 
these it would appear that something needed for normal healthy nutri- 
tion is wanting. Scurvy is not likely to follow unless an improper diet 
is continued for a long period, usually several months. In some in- 
stances where it developed in nursing infants, the nurse's milk has been 
examined and found totally inadequate to the needs of nutrition, many 
of the children having exhibited serious disturbances of nutrition before 
any signs of scurvy appeared. 

In several of the cases reported as occurring with a diet of raw or 
pasteurized milk it is certain that the milk formula used was at fault, 
the most common condition being low proteids. Several cases have come 
under my personal observation where children had been kept for four or 
five months upon percentages which should have been continued only a 
few weeks. However, I have seen at least three cases of scurvy which 
developed while taking pasteurized milk where no such explanation was 
possible, and the heating (167° F. for thirty minutes) seemed to be the 
cause. The number of cases occurring while upon a diet of sterilized 
milk (usually heated to 212° F. for one hour) is so large that we are 
driven to the conclusion that the heating alone was the cause, especially 
since prompt recovery has frequently followed when no other change was 
made than to discontinue the heating. These facts show that steril- 
ized milk should always be prescribed with caution, its effects watched, 
and patients warned of its possible danger; it should not be continued 
as the sole diet for long periods. 

No one fact in the etiology of scurvy is better established than its 
development after the prolonged use of condensed milk or the proprie- 
tary infant-foods. In this respect, as with reference to sterilized milk, 
my personal experience, including now upward of sixty cases of scurvy, 
coincides with the findings of the Society's report. 

While it may be regarded as established that the cause of scurvy is 
dietetic, no single dietetic error can be held responsible for the disease. 
At present it seems impossible to go further than to say that something 
necessary to normal nutrition is lacking in the food. None of the the- 
ories yet advanced in explanation of how diet causes scurvy is wholly 
satisfactory. 

Lesions. — The most marked effects of scurvy are scon in the bones, 
blood-vessels, and the blood. The number of recorded autopsies is not 



246 NUTRITION. 

yet large, only six being included in the Society's report. I have 
myself had the opportunity of making examinations in three cases. 
The findings are remarkably uniform, but represent, of course, the ex- 
treme results of the disease. The most striking lesion is subperiosteal 
haemorrhage, which is practically constant and may occur almost any- 
where in the body, but affects chiefly the bones of the lower extremities ; 
it is often very extensive, and may reach from the knee to the great 
trochanter, or from the ankle nearly to the knee. Extravasations may 
also be found between the muscles, and blood may infiltrate the cellular 
tissue in the neighbourhood of the joints. Besides these lesions result- 
ing from haemorrhagic periostitis the bone itself may be affected. Sepa- 
ration of the epiphyses from the shaft of some of the long bones, gen- 
erally at the lower end of the femur or lower end of the tibia, is found 
in most of the fatal cases. Notwithstanding the serious lesions near 
the large joints, the joints themselves are usually normal. 

The minute bone changes are very similar to those of rickets. But 
there are also differences of importance. The disposition to haemorrhage, 
which is altogether the most characteristic feature of scurvy, is entirely 
wanting in rickets. The visceral lesions are inconstant. Those most 
frequently found are small haemorrhages beneath the pleura, pericardi- 
um, and peritonaeum, sometimes into the various organs, also broncho- 
pneumonia, and nephritis. There may be small extravasations found 
upon the surface of any of the mucous membranes. The alterations in 
the blood-vessels are undoubtedly an important factor in bringing about 
the disposition to haemorrhage, but as yet they have been very imper- 
fectly studied. The changes in the blood, in the gums, and the lesions of 
the skin will be considered with the symptoms. 

Symptoms. — In most cases a period of indisposition, fretfulness, 
pallor, and failing nutrition precedes the local symptoms, but usually 
tenderness of the legs is the first symptom noticed. In the beginning 
this is occasional and so slight as to cause the infant to cry only 
upon handling. Later it becomes almost constant and is very acute. 
At first this soreness is not very definitely localized, but is generally 
more marked about the knees and ankles. Some swelling may be no- 
ticed, often just above the ankle-joints. Coincident with these may be 
seen the changes in the mouth. The gums are of a deep purplish colour, 
swollen, particularly about the upper central incisors, and may quite 
cover the teeth. They bleed from the slightest rubbing, and sometimes 
spontaneously. The child becomes fretful and cross, sleeps badly, loses 
colour, weight, and appetite. It may become quite cachectic in appear- 
ance. All these symptoms come on gradually, often with periods of a 
few days in which apparent improvement is seen. Sometimes they may 
continue for several weeks without making any perceptible impression 
upon the child's previously good condition. 



SCORBUTUS. 247 

If the disease is recognised, and proper treatment instituted, rapid 
improvement follows, with complete and permanent recovery. If not 
recognised, and the faulty diet is continued, the disease advances to the 
more severe form. The tenderness of the legs becomes exquisite, so that 
any movement or even the slightest touch causes the child to scream 
with pain or apprehension. The legs often lie motionless, and no vol- 
untary movement can be excited by any means. Paralysis is often sus- 
pected. The disability is chiefly owing to the extreme pain which mo- 
tion provokes, but may depend upon epiphyseal separation. Small 
ecchymoses are frequently seen about any of the large joints, resembling 
the ordinary " black-and-blue " spots, and these often confirm the opin- 
ion previously formed that the child has met with some accident. The 
swelling near the joints, particularly the knee, may be so great that the 
limb is nearly twice the size of its fellow. The mouth symptoms are 
usually striking. In addition to spongy, swollen, bleeding gums, dark 
purplish bags may be seen over teeth not yet through. There may be 
bleeding from the roof of the mouth or from the pharynx. The pain is 
sometimes so severe as seriously to interfere with taking food; there is 
moderate though rarely extreme salivation. Blood may be vomited or 
passed with the faeces or the urine. In the severe cases the stools 
are rarely normal, more or less catarrhal colitis usually being present. 
The general condition is one of grave anaemia, accompanied by a 
marked cachexia and progressive wasting. The child cries almost con- 
stantly, sleeps little, and is truly a pitiable object. Slight fever is often 
present during the last few weeks. Unless recognised and the cause 
removed, the condition grows steadily worse, the symptoms continuing 
until death occurs either by a slow asthenia, suddenly from heart failure, 
or from some intercurrent disease, such as broncho-pneumonia or acute 
gastro-enteritis. The duration of the illness in the fatal cases is from 
two to four months. 

The onset is gradual in the great majority of the cases, the earliest 
symptoms noticed in the order of frequency being pain and tenderness 
of the legs, soreness and sponginess of the gums, disability, anaemia, 
cutaneous haemorrhages, and very rarely haematuria. 

Pain and tenderness are very prominent, being noted in 95 per cent 
of the Society's cases ; in the majority they were present only on motion 
or handling. The location of the pain and tenderness in 184 cases was 
as follows: Lower extremities alone, 133; upper extremities alone, 2; 
lower and upper, 42; lower and trunk, 7. In all but two cases, there- 
fore, the lower extremities were affected, the lower part of the thigh 
and the leg just above the ankle being the usual seat. 

Disability, or pseudo-paralysis, is a very common symptom, and in 
all severe cases a constant one. It exists in varying degrees from the 
slight disinclination to use the limb to complete helplessness. In many 
18 



248 NUTHITION. 

cases it is more marked than the pain, and has led to a diagnosis of 
poliomyelitis. 

Swellings are associated with pain and tenderness in most of the 
severe cases. They are most marked near the joints, but may extend 
for some distance along the shafts of the bones. In nearly all cases the 
location is the lower part of the thigh or the lower part of the leg, and 
usually of both sides. Swellings are occasionally seen near the wrists, 
elbows, shoulders, and hip-joints; in rare cases, over the ribs, scapula, 
or ilium. Redness is not generally present, but the parts may have a 
dark purplish colour. It is to the haemorrhage that both the swellings 
and the discoloration are chiefly due. 

Protrusion of the eyeball is present in about 10 per cent of the 
cases ; an extreme exophthalmus is sometimes seen, and is due to orbital 
haemorrhage. 

The gums are affected in nearly all cases, the exceptions being those 
recognised and treated early. Haemorrhage occurs in about one-half the 
cases, and frequently there is ulceration not unlike that of a mercurial 
stomatitis. It is rather curious that, though the lower teeth are cut first, 
the upper gum is almost always most affected, and in the milder cases 
usually alone involved. Of 45 cases in which no teeth had been cut, the 
gums were affected in 24 and normal in 21. This is sufficient to dis- 
prove the old opinion that the gums are affected only when teeth have 
appeared. The severe inflammation and ulceration sometimes seen 
seem to be the result of secondary infection. 

Haemorrhages beneath the skin are present in about half the cases. 
They are rarely extensive, usually multiple, and their location is no 
doubt often determined by a slight traumatism. Haemorrhages from 
the mucous membranes are not quite so frequent. There may be bleed- 
ing from the gums, nose, bowels, kidneys, and rarely from the stomach. 
Haemorrhages in most cases are frequently repeated, but seldom profuse. 

Epiphyseal separation is seen 6nly in very severe cases. It is nearly 
always either of the lower epiphysis of the femur or the tibia, and is 
often bilateral. The separation is usually caused by some slight injury, 
the condition of the bone predisposing to this occurrence. In a case of 
my own which recovered, rapid union occurred under anti-scorbutic treat- 
ment. 

Anaemia is slight in the early stage, but steadily increases as the 
disease progresses. Blood examinations show great reduction of the 
haemoglobin, sometimes to 35 or 40 per cent ; also in nearly all cases a 
proportionate reduction of the red cells. Leucocytosis and poikilocytosis 
may be present. 

The urine contains albumin in one-fourth of the cases ; in nearly half 
of those containing albumin casts also are found. In rare cases haema- 
turia has been the first symptom noticed; usually, however, it occurs 
later, and is seen in about 5 per cent of the patients. 



SCORBUTUS. 249 

Evidences of general malnutrition are present in all advanced cases, 
varying, of course, greatly in degree. In a few infants under my own 
observation the weight, colour, and general appearance of health have 
continued in spite of very decided local symptoms. In most of them 
the impaired nutrition is shown by loss of appetite, occasional attacks of 
vomiting, and still more frequently by derangements of the bowels, which 
vary from slight indigestion to a serious catarrhal condition of both 
small and large intestine. It is with the latter that the discharge of 
blood is usually seen. 

Association with Rickets. — In the Society's investigation great pains 
were taken to obtain definite and accurate data regarding this. Of 
the cases, 340 in number, in which this point was noted, symptoms of 
rickets were present in 152, or 45 per cent; these symptoms were re- 
corded as slight in 72; marked in 64; and not specified in 16. In the 
remainder of the cases, 55 per cent, it is definitely stated that symptoms 
of rickets were absent. It is also stated that in 50 of the patients which 
were rachitic, the rickets antedated the development of the scurvy. 
From these facts it would seem to be pretty well established that 
though rickets and scurvy have points of resemblance, such as the age 
when they are seen, bony changes, dependence on defective nutrition, 
etc., they can not be regarded as different forms of the same disease. 
The two most striking characteristics of scurvy — viz., tendency to haem- 
orrhages and prompt curability by fresh food and fruit juices — have no 
counterpart in rickets. However, their coexistence in the same patient 
is of common occurrence. 

Diagnosis. — The disease with which infantile scurvy is most fre- 
quently confounded is rheumatism. In fully four-fifths of the cases 
which have come to my own notice this has been the previous diagnosis. 
The extreme rarity of rheumatism under one year should always make 
one-cautious; pain and tenderness of the legs only, should, in an infant, 
invariably suggest scurvy rather than rheumatism. The extreme disa- 
bility has often led to a diagnosis of poliomyelitis, but here again the 
acute tenderness should set one right. Many cases of scurvy come 
into the hands of the orthopaedic surgeon with a diagnosis of joint or 
spinal disease. Where the swelling was mainly of one limb I have twice 
known a diagnosis of malignant disease to be made, from the cachexia, 
the shape of the swelling, the discoloration, and the pain. I have known 
two cases to be operated upon by eminent surgeons, once with a diag- 
nosis of sarcoma and once of ostitis of both tibiae. Not until the sub- 
periosteal haemorrhages and epiphyseal separation were discovered was 
the nature of the trouble suspected. 

The diagnosis of scurvy seldom presents any difficulties to one who 
has once seen a case. No one need err if the essential features of the 
disease are kept in mind: the extreme soreness of the legs, spongy, 



250 NUTRITION. 

swollen gums, swelling near the large joints, a tendency to haemor- 
rhages, and usually a history of the prolonged use of some proprietary 
infant-food, of sterilized or condensed milk. If any doubt exists, this 
will be removed by the prompt improvement and generally rapid cure 
following an anti-scorbutic diet. 

Prognosis. — This is invariably good if the disease is recognised early. 
No patients with symptoms so serious improve with such marvellous 
rapidity as do the great majority of those with scurvy under proper 
management. The figures of the Society's report on this point are 
interesting. The average duration of the disease before treatment was 
begun in over three hundred cases was somewhat over three weeks. In 
80 per cent striking improvement was noticed during the first week of 
treatment, and in 40 per cent within three days. Over two-thirds of 
these cases were well within three weeks, and nearly one-third within 
one week, after the beginning of treatment. 

It is only when the disease is of long standing, when the malnutri- 
tion is severe, or when serious complications, usually involving the 
digestive tract, are present that the symptoms persist and the issue 
becomes doubtful. It is difficult to tell what the exact mortality of 
scurvy is. Any case allowed to go on may result fatally. The younger 
the infant the more likely is this to occur. I have seen three deaths 
in about sixty cases. Barlow's early article included thirty-one cases 
with seven deaths. It is rare that scurvy leaves any permanent effects. 
Recovery is not only rapid but complete. Relapses are extremely rare 
and have been observed only in one or two cases, where chronic indiges- 
tion existed of so extreme a character that proper feeding was impossible. 
The after-effects are usually the result of prolonged malnutrition, of 
which the attack of scurvy was only one manifestation. 

Treatment. — This is remarkably simple — viz., to discontinue all pro- 
prietary foods, condensed milk or sterilized milk, and to substitute a 
diet of fresh cow's milk, modified to suit the child's digestion. With 
this treatment alone improvement will soon begin and complete recov- 
ery follow. However, the addition of fresh fruit juice is of the greatest 
value, and when it is given improvement is much more rapid. Hence 
it should always be combined with the change in diet. Orange juice is 
possibly to be preferred, but the juice of any fresh ripe fruit will answer 
the purpose. From half an ounce to four ounces a day may be given, 
best in divided doses, given about one hour before the milk-feeding. 
The only really difficult cases to manage are those in which the general 
condition approaches one of marasmus, or when scurvy is accompanied 
by marked gastric or intestinal disturbance. When an intestinal catarrh 
is present, with the bowels moving five or six times a day, one may hesi- 
tate to give the fruit juice for fear of increasing these symptoms. In" 
a number of instances I have seen intestinal symptoms, which had re- 



RICKETS. 251 

sisted ordinary measures, immediately improved by the fruit juice, thus 
establishing their intimate connection with the scorbutic condition. 

Other things of value are fresh beef juice, and for older children 
fresh vegetables, especially potato. The anaemia and malnutrition call 
for iron, cod-liver oil, and other tonics, which should be given after 
active symptoms of the disease have disappeared. Infants with scurvy 
should be handled as little as possible, and should be particularly pro- 
tected against exposure in their extremely susceptible condition. 



RICKETS (RACHITIS). 

Rickets is a chronic disease of nutrition. While the only important 
anatomical changes are found in the bones, it is not to be regarded as a 
bone disease ; but as a very complex pathological process which affects the 
bones, muscles, ligaments, mucous membranes, and nearly all the organs 
of the body, particularly those of the nervous system. It occurs especially 
between the ages of six months and two years. It is not common in the 
country, but is exceedingly frequent in most large cities. While not a 
fatal disease per se, rickets adds very greatly to the danger from all acute 
diseases in infancy, and even to some degree also to those of later life. 
Under proper conditions of diet and hygiene it tends to spontaneous 
recovery. 

Etiology. — The essential cause of rickets is dietetic, although hygienic 
influences play a very important role in its production. While it seems 
to be demonstrated that diet alone may produce rickets, nevertheless this 
condition is much more easily produced when there are also unfavourable 
hygienic surroundings. Rickets is not common in nursing children un- 
less lactation be unduly prolonged,* as, for example, where nursing is 
continued for fifteen to eighteen months without other food. Arti- 
ficially-fed children are much more prone to the disease, especially those 
who are badly fed. The diet in these cases is usually very deficient in fat, 
and often at the same time in proteids, while it contains an excess of car- 
bohydrates. It is somewhat difficult to separate the effects which these 
different conditions produce. It appears, however, that the most impor- 
tant factor is a great deficiency in fat. Rickets is exceedingly common in 
children reared upon the proprietary foods, nearly all of which are very 
low in fat and contain an excess of carbohydrates. It is also common in 
children who are reared upon sweetened condensed milk, and for precisely 
the same reason. When both fat and proteids are low, rickets is more 
liable to result than when only the fat is deficient. 

* An exception to this statement must be made in the case of Italian and X. jjrc 
children. In this class as observed in New York it is very common to see marked 
rickets in those getting nothing but the breast. 



252 NUTRITION. 

Hygienic surroundings are next in importance to diet. Although, as 
previously stated, rickets is essentially a disease of cities, being princi- 
pally seen in children living in crowded tenements where the effects of 
improper food are most strikingly shown, yet even here the disease is rare 
in those who get a plentiful supply of good breast milk. 

Animal experiments. — Bland-Sutton experimented, in the Zoological 
Gardens, London, upon lion whelps. Those which were weaned early and 
fed solely upon raw meat invariably became extremely rachitic. Two 
young cubs, fed upon rice, biscuits, and raw meat, died from rickets. 
Two young monkeys, upon an exclusively vegetable diet, became rachitic. 
To the young lions who had developed rickets, milk, cod-liver oil, and 
pounded bones were given in. addition to the meat, and in three months, 
although the hygienic condition of the animals remained unchanged, all 
signs of rickets had disappeared. Guerin produced typical rickets in 
puppies which were kept upon a meat diet for four or five months, while 
others of the same litter, which were suckled, remained in good health. 
Other animal experiments by various observers with different articles of 
food have given results that were not uniform. It seems, however, to be 
pretty positively established, that withholding milk from young animals 
and putting them upon a diet of meat, vegetables, or starches is sufficient 
to produce rickets, and that the earlier this is done the more certain is 
the result. This may occur apart from any change in the hygienic sur- 
roundings. These animal experiments strengthen the opinion above 
given, that the essential cause of rickets is improper food, and that the 
element most uniformly lacking is fat. 

Distribution of rickets. — According to Palm, the disease is almost un- 
known in the extreme north — Greenland, Iceland, Norway, and Den- 
mark. It is also very rare in China, Japan, Greece, Turkey, and the 
southern portions of Italy and Spain. Its greatest frequency is in the 
temperate zone. The general immunity of children in southern latitudes 
appears to be due to the out-of-door life, and the almost universal custom 
of maternal nursing. In the cities of America no race is exempt from 
the disease. In New York the greatest susceptibility is among the Negroes 
and the Italians. Extreme cases of rickets are almost invariably in one 
of these nationalities. It is exceptional to see in a dispensary or hospital 
a child of either of these races who does not show, to a greater or less 
degree, the signs of rickets. These two southern races seem to bear very 
badly the climate and the confined life of the northern cities. So far as 
my observations are concerned, there is no peculiarity in the food of these 
people which explains the prevalence of rickets among them, and this 
must be attributed to a race peculiarity. In the country, the immunity 
from rickets is due partly to the more prevalent custom of maternal nurs- 
ing, and partly to the better surroundings; the increased resistance of the 
children rendering them much less susceptible to the influences of bad 



RICKETS. 253 

feeding than those of the cities. In New York among dispensary and 
hospital patients, rickets is exceedingly common, and is seen in all na- 
tionalities, although chiefly in the foreign elements of the population. 

Heredity. — There is no evidence that rickets is a hereditary disease. 
Any cachexia in the parents, such as syphilis, tuberculosis, or alcoholism, 
may, however, by diminishing the child's resistance, be a predisposing 
cause of rickets. The later children in a family are more likely to be 
affected than the earlier ones, especially when the interval between the 
pregnancies has been short, or where anything else has caused a deterio- 
ration in the general health of the mother. 

Previous disease. — Rickets not infrequently develops in syphilitic 
children; the connection, however, seems to be no closer than with any 
other cachexia. The relation of rickets to other diseases, particularly 
to those of the digestive tract, is very much less intimate than one 
would expect. Acute diseases of the stomach and intestines are very 
frequently followed by marasmus, but only exceptionally by marked 
rickets. There is no sufficient ground for believing that rickets exerts 
any protective influence against tuberculosis, as has been asserted. In 
fact the thoracic deformity of rickets may be a predisposing cause to 
tuberculosis. 

Rickets affects both sexes with equal frequency. The symptoms usu- 
ally manifest themselves between the sixth and fifteenth months. Con- 
genital and late rickets will be considered separately. 

Rickets is therefore a complex disease of nutrition, whose exact 
pathology has not yet been definitely settled. It is more difficult to 
believe that the general nutritive disturbances are the result of the bone 
changes, than to regard both as having a common origin. Kassowitz 
regards the bone changes as inflammatory, excited by the presence of 
some irritant. The irritant has been believed by many to be lactic acid, 
originating in the digestive tract ; but the evidence in support of this 
theory is not conclusive. It is very doubtful whether the process is as 
simple as the formation of lactic acid in the intestine and its circulation in 
the blood. It is, however, clear that it is something which interferes with 
the assimilation of the lime salts. At the present time, the disposition is to 
regard rickets as a disease of nutrition, which may be produced in animals 
by certain dietetic changes. In infants, it seems to be settled that it may 
be produced by similar changes in diet, aided very greatly, however, by 
unhygienic surroundings. The effect of these abnormal conditions is 
shown upon the whole organism, but the only constant and regular ana- 
tomical changes are in the bones. These osseous lesions resemble those 
of chronic inflammation. Precisely how the dietetic and other causes 
produce the bone changes is still a matter of speculation. The constancy 
of bone changes in rickets gives it a place as an essential disease, and not 
merely a form of malnutrition. 



254 NUTRITION. 

Lesions. — The only constant and characteristic lesions of rickets are 
found in the bones. It is still a matter of dispute whether these bony- 
changes are to be considered as inflammatory, or simply as the result of 
disordered nutrition. Disordered .nutrition and chronic inflammation 
are closely allied, and it really makes but little difference which view is 
taken. Occurring at a time when the growth of bone is so rapid, the 
effects of rickets are very striking and very serious. 

In order to appreciate how the bones are affected by rickets, it must be 
remembered that the long bones grow in length by the production of bone 
in the cartilage between the epiphysis and the shaft ; that the shaft grows 
in thickness by the production of bone beneath the inner layer of the 
periosteum ; and that the medullary canal is continually increasing in 
size by the absorption of the inner layers of the bone. In rickets there is 
an exaggerated production of cartilage at the epiphysis, and excessive cell- 
growth beneath the periosteum, while the process of ossification in these 
tissues goes forward slowly and imperfectly, or is entirely arrested. At 
the same time the absorption of the medullary layers may be even more 
rapid than normal. In health the growth of bone in length is much 
more rapid than its increase in diameter, owing to the greater activity of 
the changes taking place at the epiphysis; so, in rickets, it is at the 
extremities of the long bones that the most marked changes are seen. 

One of the most striking features of rachitic bones is their unnatural 
flexibility. This is due to deficient ossification in the superficial layers of 
the shaft of the long bones, and also at their extremities. Normally, 
bone contains about one third organic and two thirds inorganic matter. 
In marked rickets the proportions are reversed, the bones often containing 
twice as much organic as inorganic matter. Changes are seen in all the 
long bones, but all are not affected to the same degree. Sometimes those 
most affected will be the bones of the leg, sometimes those of the forearm, 
and sometimes the ribs. The extent varies with the severity of the process. 

There are characteristic changes in form. The most constant is en- 
largement of the epiphyses of all the long bones. This is most strikingly 
seen in the lower extremities of the radius and tibia. The enlargement 
may be so marked that the width of the epiphysis is increased by one 
half. All the sharp angles, borders, and prominences of the bones are 
rounded off. The curvatures of rachitic bones are more fully described 
under the head of Symptoms. They may be due to a variety of causes. 
Some are simply an exaggeration of the normal curves, much increased 
by the swelling of the epiphyses ; others are due to muscular action, to 
atmospheric pressure, to some unnatural posture, such as the cross-legged 
position, to the weight of the limbs, or to the weight of the body. The 
principal change in the form of the flat bones consists in the production 
of large bosses or prominences due to thickening of the bone, usually 
about the centre of ossification. These bosses are soft and spongy. Frac- 






PLATE IV. 




^^^^&ikm^ &] 



Bone in Rickets. 

Longitudinal section of a rib at the junction of the costal cartilage, in a severe 
case of rickets (slightly magnified). C = costal cartilage, B = bone, A = proliferating 
cartilage-zone, which is much widened. Between the hypertrophied cartilage cell- 
columns (a) making up this proliferating zone, are seen medullary spaces (b) contain- 
ing blood-vessels. In this zone lie masses of bone (c) not calcified*. The calcification 
zone is almost wanting, only scattered islands (d) of calcified cartilage-cells being seen. 

Beyond this proliferating zone (A) is a layer of bony tissue (B) made up of small 
bands of which only a few have a nucleus containing lime (e). These nuclei appear 
black. The bony bands differ both in form and arrangement from those of normal 
ossification. Between the bony masses are medullary spaces which appear light in the 
illustration. At (g) the beginning of cartilage proliferation is seen. Above this zone 
the cartilage is normal. (From Karg and Schmorl.) 



RICKETS. 255 

tures are not uncommon. The bones most frequently broken are the 
radius and ulna ; next, the clavicle or the ribs. The fractures are usually 
of the green-stick variety. There is a bending of the outer and a frac- 
ture of the inner layers of the shaft of a long bone. This results in more 
or less impaction, and is usually followed by the production of consider- 
able callus. The epiphyseal changes result in arrested growth in length, 
rachitic bones being usually much shorter than normal. Increased vascu- 
larity is seen in the bosses upon the flat bones, at the extremities of the 
long bones and upon stripping the periosteum from the shaft. 

In a longitudinal section of one of the long bones, the principal change 
seen at the extremity is that the cartilaginous layer which unites the epi- 
physis and the shaft is very much enlarged, both in width and thickness, 
the latter being sometimes four or five times the normal. This cartilagi- 
nous area is of a bluish colour, rather softer than normal cartilage. On one 
side it blends with the cartilage of the epiphysis, on the other it presents 
an irregular dentated border, and in it the calcified areas are irregular and 
scattered. The epiphyseal centres of ossification are enlarged, softer, and 
more vascular than normal, thus increasing the size of the extremity of 
the bone. In the shaft, the outer layers of bone are thickened and soft, 
like decalcified bone, the deeper parts being, firmer, while the deepest 
layers may be completely ossified. The medullary canal is much more vas- 
cular than normal, its contents resembling granulation tissue. Toward 
the extremities the trabecular spaces are much increased in' size, so that 
the bone appears unnaturally porous. On vertical section of one of the 
flat bones — e. g., one of the bosses upon the skull — there is found a great 
increase in the size of the trabecular spaces. The bosses are made up of 
large spongy masses, so soft as to be easily indented with the finger, and 
on pressure there oozes blood and serum in a considerable quantity. 

Microscopical chayiges. — At the junction of bone and cartilage at the 
extremity of one of the long bones, there are readily traced in normal 
bone (Fig. 42) several distinct zones. Next to the hyaline cartilage (a) 
there is a proliferating zone (&), made up of cartilage cells and matrix, 
the cells having no orderly arrangement. Next to this is a columnar 
zone (c, d) y in which the cartilage cells are arranged in regular rows or 
columns. Adjoining this is the zone of calcification (e) ; and, finally, there 
is the zone of ossification (/, g), where true bone is formed. 

In rickets (Plate IV and Fig. 43), the principal changes are seen in t lie 
proliferating and columnar zones. The proliferating zone (Fig. 43, b) is 
increased chiefly by the multiplication of new cells; it is also more vas- 
cular than normal. The columnar zone (c) is aiTccted in a similar way 
and to a much greater degree. It is less regular in its forma 1 ion, and, 
instead of containing but few vessels, it shows large vascular channels, 
sometimes surrounded by medullary spaces (e). The ossification zone, 
instead of being narrow and sharply outlined, is broad and very irregular. 



256 



NUTRITION. 



Calcified areas (/) may be seen in the midst of regions which are carti- 
laginous, while masses of cartilage (h) occupy areas which should be com- 
pletely calcified. In some places there appears to be a transformation of 
cartilage into bone-tissue of an inferior sort by a direct or metaplastic 
process. In the shaft there is seen more or less thickening, and au in- 
creased vascularity of the periosteum. Beneath the inner layer there is 




Fig. 42. — Section through ossification zone of normal bone (Ziegler). a, hyaline cartilage; 6, 
zone of beginning cartilage proliferation ; c, columns of cartilage cells ; d, columns of hyper- 
trophic cartilage ; <?, zone of temporary calcification ; /, zone of primary medullary spaces ; 
o, zone of primary bone formation ; A, fully developed spongy bone ; i, blood-vessels ; £, 
layer of osteoblasts. 



excessive cell-proliferation, while calcification of this new tissue is imper- 
fect or absent, and instead of hard, compact bone, we find irregular, spongy 
masses. In the spongy bone there is considerable thickening, with an 
erosion of bony trabecule, which results in the formation of large medul- 
lary spaces filled with blood-vessels and connective tissue rich in cells. 



RICKETS. 



257 



Termination of the rachitic process. — After a variable time, usually 
from three to fifteen months, the active proliferative process going on in 
the cartilage and beneath the periosteum ceases, and is gradually replaced 




Fio. 43.— Rachitic bone (Ziegler). Longitudinal section through ossification zone of the upper 
diaphysis of the femur of a moderately rachitic child one year old (highly magnified (. a. 
unchanged hyaline cartilage ; &, beginning cartilage proliferation; c, columns ofprolit'eratea 
cartilage cells; <l, columns of proliferated hypertrophic cells; e. medullary spaces contain- 
ing blood-vessels lying within the cartilage ; ,/ 2 calcified cartilage; p,bony tissue; /'.re- 
mains of cartilage within the bony tissue ; 7, point of unealeilied bony tissue; /•, calcified 
bony tissue. 



by ossification. The bone becomes less vascular, and a rapid formation 
of bone takes place in the normal way. In addition, there is in BOme 
places a direct transformation of cartilage into bone. Condensation and 



258 NUTRITION. 

contraction take place in the spongy masses of bone. As the result of 
this, the affected bone may become even harder than normal ; often it is 
ivory-like. Its structure, however, is never quite like that of healthy bone. 

In the long bones the epiphyseal swellings slowly diminish, and may 
quite disappear; the slighter curvatures may be entirely overcome, and 
the greater ones much lessened. The beading of the ribs becomes almost 
imperceptible ; the bosses upon the skull shrink very markedly, and may 
leave scarcely a trace of their existence. In most cases the active process 
in rickets has come to an end by the time the child is two and a half years 
old, often at two years. 

Visceral lesions. — These are not infrequent, but are not essential to 
rickets. In the lungs they are due to deformities of the chest wall and 
to complications. Beneath the deep lateral furrows which are so common, 
there is found a part of the lung in a state of more or less complete col- 
lapse. This is accompanied by emphysema of the portion just anterior to 
it. Acute and chronic bronchitis and broncho-pneumonia are exceed- 
ingly frequent. A low grade of chronic catarrhal inflammation of the 
stomach and intestines is common, and is often associated with dilata- 
tion of these organs. The spleen is enlarged in most cases during the 
period of active symptoms. This is usually moderate in degree, although 
marked enlargement is not at all rare. The swelling of the spleen is due 
to simple hyperplasia, and not to amyloid degeneration. Enlargement 
of the liver is less frequent, and may occur with or without that of 
the spleen. There are no constant changes in the structure of these 
organs. The lymph nodes (lymphatic glands) are frequently enlarged. 
Eachitic patients are more prone to these swellings than are other chil- 
dren. They are due to simple hyperplasia, and have no close connection 
with rickets. Cerebral changes are rare, and those described are rather 
of accidental occurrence than dependent upon the rachitic process. As 
stated under Symptoms, enlargement of the head is usually due to thick- 
ening of the cranial bones. Although hydrocephalus is occasionally seen, 
it is extremely doubtful whether it is more frequent than in patients not 
rachitic. Hypertrophy of the brain has been described in connection 
with rickets, but as yet this does not seem to be established by sufficient 
pathological evidence. The muscles are flabby from imperfect nutrition, 
and sometimes atrophied from disuse, but no essential anatomical changes 
have been demonstrated in them. 

Symptoms. — A well-marked case of rickets makes a striking picture 
(Plate V), and one not easily mistaken. There are seen the large head, 
beaded ribs, narrow chest, prominent abdomen, symmetrical swellings of 
the epiphyses of the wrists and ankles, and curvatures of the extremities. 
The beginning of symptoms is nearly always insidious, and the patient 
does not usually come under observation until they have existed for sev- 
eral weeks, often several months. 



PLATE V. 




Typical Rickets. 

<*t^^^^iZ™Z^ &° minent » bdom «n, marked enlargement 
and legs which are not so well sho™ ^ "* aI * U curvatur « of the forearms 

The patient a child two and a half years old. 



RICKETS. 959 

Early Symptoms. — The most constant early symptoms are sweating 
of the head, extreme restlessness at night, constipation, beading of the 
ribs, and cranio-tabes. The head-sweating is rarely absent, and may con- 
tinue for several months. It is especially profuse during sleep, the per- 
spiration standing out in large drops upon the forehead, often being 
sufficient to wet the pillow. This is one of the causes of the nasal and 
bronchial catarrhs so common in rachitic infants. There is marked rest- 
lessness during sleep : the children tossing about the crib, kicking off the 
clothes, and never having the quiet, natural slumber of healthy infants. 
This may be due to many causes, but when persistent and associated with 
marked perspiration of the head, rickets should be suspected. Constipa- 
tion is frequently seen as an early symptom, although it is more marked 
in the later stages of the disease. 

The beading of the ribs is almost invariably the first appreciable 
change in the bones, and it is well-nigh constant. This forms the so- 
called " rachitic rosary," consisting of nodules at the line of junction of 
the costal cartilages and the ribs. It may be slight, or there may be a 
row of knobs as large as small marbles. In many cases with marked 
thoracic deformity, little or no beading of the ribs is seen externally, 
although at autopsy it is found to be very marked upon the internal sur- 
face of the chest (Plate VI). Beading of the ribs was noted in all but 
two of one hundred and forty-four successive cases of rickets, at the time 
of the first examination. In infants under six months there may be 
found soft spots in the cranium, usually over the occipital or posterior 
portions of the parietal bones. These are from one fourth to one inch in 
diameter, and there are usually several of them present. By pressure with 
the finger they give a sort of parchment-crackling sensation. This condi- 
tion is known as cranio-tabes. Cranio-tabes is believed to be more fre- 
quent when syphilis is associated with rickets, and it is seen also in 
syphilitic cases which are not rachitic. A rachitic cachexia is not usu- 
ally present until the symptoms have existed for several months, and in 
many cases it is not seen at all. 

Deformities. — The deformities of rickets are almost invariably sym- 
metrical in character, and usually numerous. In extreme cases almost 
every bone in the body is affected. 

Head. — This usually appears to be too large, and although il may not 
be greater in circumference than that of a healthy child of the same age, 
it is out of proportion to the rest of the body. In marked cases the 
increase in circumference may be one or two inches. The enlargemenl 
is chiefly due to thickening of the cranial bones. In one case with 
marked deformity, I found the skull over the parietal bones Half an inch 
in thickness (Fig. 44). This thickening diminishes with recovery, but 
in most cases the head remains throughout life larger than if should 
be. The shape of the rachitic head is somewhat square ( Fig. 15), owing 



260 



NUTRITION. 



to the formation of large bosses over the parietal and frontal eminences. 
It is flattened at the occiput from pressure, and flattened also at the ver- 
tex. In extreme cases, the prominences upon the frontal and parietal 
bones may be so great as to produce quite a marked furrow along the line 
of the sagittal and frontal sutures, and one at right angles to this along 
the coronal suture (Fig. 46). This condition gives unusual prominence 
to the forehead. Marked deformity of the head has been observed in 
thirty-three per cent of my cases. The sutures may remain open for an 




Fig. 44.— Rachitic skull from colored child two years old, horizontal section, inner surface 
showing thickening of the bones, especially the frontal, and open fontanel. 

unnatural time, occasionally until the end of the first year. The fontanel 
is late in closing, being frequently found open at two and a half, and 
sometimes even at three years. Often at eighteen or twenty months 
the fontanel is two inches in diameter. The veins of the scalp are 
often prominent, and the hair is frequently worn from the occiput, 
owing to restlessness during sleep. Occasionally rickets and hydrocepha- 
lus are associated, but the latter is the least frequent of all causes of the 
enlargement of the head. 



PLATE VI. 





Deformity of the Chest in Severe Rickets. 

In the upper picture, giving the external view, is shown a deep oblique furrow at 
the junction of the ribs and costal cartilages, these meeting at an acute an°-le. 

In the lower picture the ribs have been separated from the spine and spread open 
showing the same deformity as it appears from within, looking forwards. 

Prom a coloured child ten months old. 



RICKETS. 



261 



Chest. — Beading of the ribs has already been mentioned. This is the 
most characteristic feature, but in the majority of cases there are, in 
addition, lateral depressions over 
the lower third of the chest, at 
the line of junction of the car- 
tilages with the ribs, with ever- 
sion of the lower borders of the 
ribs. In severe cases these de- 
pressions or furrows are so great 
as to cause serious deformity 
(Plate VI). Usually there is a 
great diminution in the trans- 
verse and an increase in the 
antero-posterior diameter of the 
chest. Fig. 47 shows the out- 
line of the chest of a rachitic 
child of two years, compared 
with that of a healthy child of 
the same age. Another frequent 
deformity is the " rachitic gir- 
dle," which consists in a trans- 
verse depression about two 
inches broad, extending from 
one side of the chest to the 
other, just above its lower bor- 
der. A less frequent deformity is the " funnel chest," a deep central de- 
pression over the ensiform cartilage. This is sometimes nearly an inch 
and a half in depth. Marked thoracic deformity was seen in twenty per 
cent of my cases, but in only a small proportion was the chest normal. 

The factors in the production of the thoracic deformity are atmos- 
pheric pressure and soft chest walls, these sinking in at the point where 
they have least resistance, viz., at the junction of the costal cartilages and 
the ribs. When there is any obstruction to the entrance of air, as with 
bronchitis, hypertrophied tonsils, or adenoid growths of the pharynx, the 
thoracic deformities are exaggerated. Irregular chest deformities depend 
upon the coexistence of pathological conditions in the lungs. Pigeon- 
breast is occasionally seen, but it is doubtful if this depends upon rickets 
alone. 

Spine. — In very many of the milder cases this is normal. The most 
characteristic deformity consists in a posterior curve (.kyphosis), which 
is a general one, usually extending from the mid-dorsal to the sacral re- 
gion. This existed in forty-six per cent of my cases. In the early part 
of the disease it disappears entirely on suspending the child, or making 
extension upon the extremities ; but in cases of long standing it may not 




Fig. 45. — Kachitic head ; Italian child two years old ; 
square, prominent forehead and flat vertex. 



202 



NUTRITION. 



disappear entirely by these tests. Very much less frequently there is seen 
a rotary curvature. This, in my experience, has been more frequently to 
the left side than to the right — the opposite of the common form of lat- 




Fig. 46. — Rachitic skull from child one year old, showing frontal and parietal bosses and wide 

fontanel. 



eral curvature seen in young girls. Marked lateral curvature in children 
under three years is usually rachitic. 

The clavicle is affected only in severe cases. The usual deformity 
consists in an exaggeration of the anterior curve at the inner third of the 






Fie. 47.— A, horizontal Beotion of a rachitic chest, child two years old, showing lateral furrows; 
H, section of chest of healthy child of the same age. 

bone, which is somewhat shortened and its extremities enlarged. It is 
not infrequently the seat of green-stick fracture. 



RICKETS. 



263 



Deformities of the pelvis belong to obstetrics rather than to pediatrics. 
The most common rachitic change is a diminution of the antero-posterior 
diameter and a narrowing of the subpubic arch. Irregular deformities, 
sometimes described as " crumpling of the pelvis," are not infrequent. 

Extremities. — Deformities of the upper extremities are usually sym- 
metrical. The humerus is affected only in severe cases. It has a forward 
and outward curve, although rarely a very marked one. Both the epi- 
physes are enlarged, although the upper one can not often be made out 
unless the child is very thin. The radius and ulna are frequently affected. 
They present a convexity upon their extensor surfaces (Plate V), which in 
some cases is very marked, particularly in children who have been creep- 
ing about. Green-stick fractures here are quite frequent. Eachitic 
changes at the epiphyses are more common than in the shaft, enlarge- 
ment of the epiphyses at the wrist being one of the most constant bony 
deformities of rickets (Plate V). It was present in ninety-five per cent 
of my cases. Less frequently similar swellings are seen at the elbow. 
Enlargement of the ends of the meta- 
carpal bones or the phalanges I have 
seen in but two or three extreme cases. 

The lower extremities are rather 
more frequently affected than the upper, 
but in a similar way. The femur is in- 
volved only in severe cases ; it common- 
ly presents a general forward and out- 
ward curve, which is mainly due to the 
weight of the legs as the child sits. 
Occasionally there is also an outward 
rotation of the femur, where children 
have been allowed to sit much in a 
cross-legged posture. When such chil- 
dren begin to walk, the toes are turned 
very far outward. The principal de- 
formities of the lower extremity are 
bow-legs (Fig. 48) and knock-knees 
(Fig. 49). Knock-knees are more com- 
mon in females, and are believed to be 
due to an overgrowth of the inner con- 
dyles of the femur. Enlargement of 
both condyles can be demonstrated in 
most of the marked cases of rickets. The 

cases of slight bow-legs may be due simply to swelling of the epiphyses, 
the shaft of the bone being quite normal. This point I have verified by 
post-mortem observations. Such are probably most of the deformities 
which disappear spontaneously. The most severe cases of bow-legs are 




Fig. 48. 



-Typical bow-legs of severe 
form. 



264 



NUTRITION. 




often associated with some degree of anteroposterior curvature, and the 
latter may be the principal deformity. An exaggerated case of this kind 
is shown in Fig. 50. Enlargement of the epiphyses at the ankle is 

usually present when 
it is seen at the wrists, 
and nearly to the same 
degree. Enlargement 
of the upper epiphyses 
of the tibia and the 
fibula is seen only in 
severe cases. The cause 
of the deformities of 
the leg is not, prima- 
rily at least, walking 
too early, since they 
are common in chil- 
dren who have never 
walked ; slight deform- 
ities, however, may be 
\ aggravated by early 

\ walking. A change 

"^ X which has not been 

v sufficiently emphasized 
•^v^^m*^?; is the arrested growth 
.Kw^r.s of the long bones ; this 
is one of the most char- 
acteristic features of 
rickets. A rachitic child of three years often measures in height six or 
eight inches less than a healthy child of the same age, the difference being 
almost entirely in the lower extremities. 

All the ligaments, but particularly those about the large joints, are lax 
and frequently elongated. This may lead to the deformity known as weak 
ankles, or to an over-extension at the knee (genu recurvatum) ; also to 
unnatural mobility at the hips, shoulders, elbows, and wrists. The condi- 
tion of the ligaments plays an important part in the production of spinal 
deformities. 

Muscles. — The muscular symptoms of rickets are almost as constant 
and as characteristic as those of the bones. The muscles are small, very 
flabby, and poorly developed; hence rachitic children are unable to sit 
erect, or to stand or walk at the proper age. Of one hundred and fifty- 
one cases in which the date of walking alone was investigated, only twenty- 
seven, or eighteen per cent, walked before the fifteenth month; forty- 
seven per cent were not walking at the eighteenth month ; twenty per 
cent not at two years ; and ten per cent not at two and a half years. Late 



Fig. 49.— Knock-knees. 



RICKETS. 



265 



/ 



walking is one of the most common symptoms for which advice is sought 
by parents with rachitic children. The muscular power in the extremities 
is sometimes so feeble as to suggest paralysis. I have seen a number of 
cases in which the symptoms so resembled paralysis, that even expert diag- 
nosticians were unable to differentiate rickets from poliomyelitis except 
by the electrical reactions, those in rickets being usually normal or exag- 
gerated. In other cases the symptoms may suggest cerebral palsy of the 
flaccid type. The muscular symptoms may be marked when the bony 
changes are slight, and conversely. As no lesions of the muscles have 
been demonstrated, the symptoms are probably due to imperfect nutri- 
tion. Two other symptoms depend chiefly upon the condition of the mus- 
cles, viz., pot-belly and constipation. 

Pot-belly is quite an early symptom, and in most cases a very marked 
one (Plate V). It was noted in sixty per cent of my cases. The en- 
largement of the abdomen is uniform. It is everywhere tympanitic, and 
it may be as tense as 

a drumhead. It is due /T '"'' ^1 

to a loss of tone in 
the abdominal mus- / 

cles, and in the mus- 
cular walls of the stom- 
ach and intestine. It 
is aggravated by chron- 
ic indigestion and con- 
sequent intestinal pu- 
trefaction. The en- 
largement is thus 
mainly from tympa- 
nites. There may be 
a marked degree of 
dilatation both of the 
stomach and the colon. 
To a very small degree 
only, does the large 
abdomen depend upon 
swelling of the liver or 
spleen. 

The Constipation of p IO 50.— Extreme rachitic deformities of the lega 

rickets, as already 

suggested, depends upon the loss of tone in the muscular walls of the in- 
testines. It may alternate with diarrhoea. It rarely happens that a 
rachitic child has habitually normal evacuations from the bowels. Hard, 
dry, constipated stools frequently set up a condition of chronic catarrh 
of the colon in which large masses of mucus are discharged. 




c 




206 



NUTRITION. 



During the most active part of the disease — viz., from the third to 
the ninth month — tenderness may sometimes be elicited by pressure upon 
the epiphyses. This, however, is not a constant symptom, and a very 
unreliable one for diagnosis. In my own experience it has been present 
in but a very small proportion of the cases. Acute tenderness should 
always suggest scurvy rather than rickets. 

Fever. — According to some observers there is a febrile movement 
which belongs to the active stage of rickets, but I have never been able to 
satisfy myself of the truth of this observation. 

Dentition. — As a rule, dentition is late and apt to be difficult — i. e., it 
is associated with attacks of indigestion or other disturbances which may 
be serious. Individual cases, however, present great variations in regard 
to this symptom. A study of the progress of dentition in one hundred 
and fifty rachitic children gave the following results : in fifty per cent the 
first teeth were cut on or before the eighth month, and in thirteen per 
cent on or before the fifth month ; however, twenty per cent of the cases 
had no teeth at twelve months, and in eight per cent none had appeared 
at fifteen months. Even though the first teeth come at the usual time, 
the progress of dentition is often arrested by the development of rickets, 
and no advance made for five or six months. The difference in the 
cases appears to depend very much upon the age of the child when rick- 
ets begins. Those who give no evidence of it until nine or ten months 
old often have a nearly normal dentition, while the cases developing 
early show a marked retardation of this process. The order in which 
the teeth appear may be very irregular, but there is no rule in this 
respect. The character of the teeth in rickets, in the great majority of 
cases, is good. This was true in eighty-four per cent of one hundred and 
twenty-six cases examined with reference to this point. This is in strik- 
ing contrast to hereditary syphilis, where the tendency to early decay is 
so constantly seen. 

General appearance. — Eachitic patients are almost always ansemic. 
The blood is low in haemoglobin, often down to thirty or forty per cent. 
In some few cases there is in addition quite marked leucocytosis. The 
number of red globules is not often nor uniformly affected. The majority 
of rachitic patients are fat and flabby. The tissues are soft and have but 
little resistance. Rarely, they may be thin, like patients suffering from 
marasmus. 

Rachitic patients are very prone to suffer from hypertrophied tonsils, 
adenoid growths of the pharynx, and enlargements of the lymph nodes of 
the neck. In all forms of acute illness the feeble resistance of these 
patients is very evident. This is especially true of acute disease of the 
lungs. 

The mucous menibranes are very vulnerable in all rachitic patients. 
From the slightest indiscretion in diet an attack of acute indigestion or 



RICKETS. 267 

diarrhoea is brought on, and from a very insignificant exposure, catarrhal 
inflammation of the upper or lower air passages is excited. In rachitic 
patients all such attacks are prone to run a protracted course. Inflam- 
mation of the trachea and larger bronchi is liable to extend to the smaller 
bronchi and the lungs. 

The downward displacement of the liver and spleen from contraction 
of the chest should not be mistaken for enlargement of these organs. 
Moderate enlargement of the spleen is very common during the stage of 
most active symptoms — i. e., from the sixth to the twelfth month* Great 
enlargement of either liver or spleen is infrequent. 

Blood. — From a study of the blood in twenty cases of rickets. 
Morse (Boston) concludes that anaemia is present in most cases, its in- 
tensity varying with the severity of the rachitic process. All the usual 
forms of anaemia are seen. Leucoc}'tosis may or may not be present ; it 
is more marked in cases attended by an enlarged spleen. All or any of 
the white cells may be increased. 

Nervous symptoms are among the most frequent manifestations of 
rickets. Restlessness at night has already been mentioned as a promi- 
nent early symptom. Pain and tenderness are rare. A disposition to 
muscular spasm is seen in many cases. There may be laryngismus strid- 
ulus, tetany, or general convulsions. The first two are rare except in 
rachitic patients. All of these probably depend upon defective nutrition 
of the nervous centres. While in all infants, owing to the irritability of 
the nervous centres, convulsions are easily excited from relatively slight 
causes, in those who are rachitic this susceptibility is greatly intensified. 
As a predisposing cause of convulsions in infancy, rickets takes the first 
place. The younger the child and the more active the rachitic process, 
the more frequently do convulsions occur. They belong especially to the 
first year, being most frequent between the third and ninth months. 
The exciting cause of convulsions in these cases is usually to be found in 
the stomach or intestine. 

Course and termination. — Eickets is essentially a chronic disease, and 
its course is measured by months. The active symptoms in most cases 
continue from three to fifteen months, although they occasionally last 
a much longer time. The duration of the symptoms depends chiefly 
upon the duration of the exciting cause. That active symptoms cease 
when a child reaches the age of eighteen months or two years, is no 
doubt due largely to the fact that at this age the diet is more general, 
and is more likely to furnish what the child needs, and that more fresh 
air is likely to be secured than at an earlier age. 

The earliest symptoms of improvement are a diminution in the nerv- 
ous symptoms, especially in the restlessness at night ; increased muscular 
power, as shown by a disposition to stand or walk; diminution in the 
head-sweats ; disappearance of the cranio-tabes ; and improvement in the 
anaemia. The changes in the deformities are very slow, and from month 



2fi8 NUTRITION. 

to month almost imperceptible. When improvement once begins, how- 
ever, it usually goes steadily forward, relapses being exceedingly rare. 

Congenital rickets. — Infants may present at birth the characteristic 
deformities of rickets, and there may be found even the minute bone 
changes of the disease. Such cases are reported to be common in Vienna 
and other large cities of Europe, where mothers during pregnancy have 
lived under unfavourable conditions. In America, however, congenital 
rickets is a very rare disease. Single cases have been reported by several 
writers; but it must be remembered that cretinism and achondroplasia 
have often been improperly included under this head. 

Late rickets. — Rare instances have been reported of bony deformities 
in all respects like those of rickets, developing in children from six to 
twelve years old. A number of such cases have been observed in England. 
I have not seen this disease, nor has a case been seen during the past 
twenty years at the Hospital for Ruptured and Crippled, New York, 
where more deformities come under observation than anywhere else in 
this country. 

Acute rickets. — Although from time to time cases have been reported 
with this title, from a study of the histories it is clear that the great 
majority, if not all of them, were cases of infantile scurvy. It is doubtful 
whether, strictly speaking, there is such a thing as acute rickets. 

Diagnosis. — The diagnosis of rickets is not usually difficult, and after 
carefully examining a case one can not often be in doubt. It is the mild 
cases and the early stages of the disease that are most likely to be over- 
looked. The most important early symptoms for diagnosis are sweating 
of the head, cranio-tabes, great restlessness at night, delayed dentition, 
and enlarged fontanel. All these, taken separately, may mean something 
else, but collectively they can mean nothing but rickets. In the later 
stages some of the characteristic deformities are usually present; the 
most constant are beading of the ribs, enlargement of the epiphyses of 
the wrists and ankles, and bow-legs. 

Special symptoms, when unusually prominent, may give rise to diffi- 
culty in diagnosis. The enlargement of the head may be mistaken for 
hydrocephalus. The delayed dentition and large fontanel of the cretin 
may be mistaken for rickets. Muscular weakness may be so great, espe- 
cially when affecting the legs, as to make it easy to mistake a rachitic 
pseudo-paralysis for actual paralysis due to a cerebral or spinal lesion. 
When walking is much delayed, rickets may be passed over as simple 
backwardness. In nearlj all of the last-mentioned group of cases the 
diagnosis may be cleared up by a careful search for the bony changes, 
and by the fact thai in rickets there is only a general weakness of all 
the muscles, and not actual paralysis of any limb or group of muscles.. 
The greatest difficulty is usually found where the muscular symptoms are 
marked and the bony changes slight, as is not infrequently the case. Here 






RICKETS. 269 

the question is, whether rickets is sufficient to explain all the symptoms, 
or whether in addition some other condition is present. The electrical 
reactions will decide the question of poliomyelitis, while the presence of 
cerebral symptoms, exaggerated knee-jerks, and rigidity of the legs, will 
usually mark a cerebral birth-palsy. The bony enlargements of syphilis 
are not likely to be confounded with rickets, if it is remembered that the 
early lesions of syphilis are more like boggy infiltrations over the bones 
than actual swelling of the bone itself, and that when the bone is affected 
it is not at the extremity, but at the junction of the epiphysis and the 
shaft ; the bone changes of late syphilis affect the shaft rather than 
the extremities of the long bones ; where the bone is enlarged near 
the joint it is usually upon one side only. In syphilis there may be 
necrosis, while in rickets breaking down of bone is never seen. From 
scurvy, rickets is differentiated by the absence of marked hyperesthe- 
sia, ecchymoses, and other haemorrhages, the changes in the gums, and 
most of all by the fact that anti-scorbutic diet produces no immediate 
change in the symptoms. The diagnosis of rachitic curvature of the 
spine from vertebral caries will be considered in connection with the 
latter disease. 

Prognosis. — Rickets per se is never a fatal disease. It is, however, a 
large factor in the mortality of the first two years, as the cachexia which 
it produces predisposes strongly to every form of acute disease. It is an 
important etiological factor in certain serious nervous conditions, espe- 
cially convulsions. According to Gowers, ten per cent of the cases of 
epilepsy are in children who previously suffered from rickets. Rickets 
adds very greatly to the danger from all acute diseases of infancy, par- 
ticularly those of the respiratory tract. This depends partly upon the 
feeble muscular power and partly upon the thoracic deformities. The 
encroachment upon the capacity of the lungs by a marked thoracic de- 
formity, may in itself be enough to keep a child in a delicate condition 
and retard its growth. At the same time such a condition is a constant 
invitation to acute attacks of bronchitis or pneumonia. The effect of 
rickets upon the future health of the child, depends chiefly upon the 
presence and extent of the thoracic deformity. When this is absent, as 
a rule no serious after-effects are seen, and although children may re- 
main somewhat dwarfed on account of their short legs, in other respects 
they may be as well as if they had never been the subjects of rickets. 

Prophylaxis. — As rickets is primarily clue to improper food or feed- 
ings and secondarily to bad surroundings, it may be prevented by the 
observance of proper rules of feeding as laid down elsewhere, and by re- 
moving children from their faulty surroundings. Especial care should be 
given to the later children of a family where fche earlier ones have shown 
even the mildest symptoms of rickets, as the predisposition i> Bure to in- 
crease with each successive child. 



270 NUTRITION. 

Treatment. — In considering the treatment of rickets, the natural 
course of the disease is to be kept in mind, viz., that active symptoms 
frequently continue only until the tenth or twelfth, rarely longer than the 
eighteenth month, and that after this time the patient suffers more 
from the results of the disease than from the disease itself. The most 
important period for treatment, therefore, and the one in which it is 
most effective, is from the sixth to the fifteenth month. The earlier 
the treatment is begun the better will be its results. Constitutional treat- 
ment after the fifteenth or eighteenth month, has very little effect upon 
the disease, for by this time most of the harm has been done. The course 
of the disease when untreated is toward spontaneous recovery, from the 
changes in diet and life which are usually made when children have 
reached the latter half of the second year. Most of the cases seen in 
private practice are of a mild type and recover without special treat- 
ment, often no diagnosis being made until later in life, when the bony 
deformities or stunted growth indicate the previous existence of rickets. 
The first step in treatment is to remove the cause, and is therefore to be 
directed to the diet and hygiene of the patient. The results will depend 
upon how completely these causes can be removed. 

Diet. — Carbohydrates, including sugars, proprietary infant-foods, and 
all farinaceous substances, should be reduced to the minimum, and in 
some cases prohibited. So far as possible the diet should consist of 
nitrogenous food and fats, especially milk, cream, eggs, red meat and 
fresh fruit. These articles are to be given according to the rules laid 
down in the chapters on Infant Feeding. In addition, cod-liver oil — 
which in these cases may be considered quite as much a food as a medi- 
cine — should be administered as soon as the stomach will tolerate it. 

Hygiene. — This is the most difficult part of the treatment. In large 
cities it is almost impossible to secure for rachitic patients the surround- 
ings they require. Whenever possible, such children should be sent to the 
country ; but where this is out of the question, much may be accom- 
plished by frequent excursions upon the water or into the country, by 
keeping children as much as possible in the parks and open squares of the 
city, and securing plenty of fresh air in sleeping rooms. Mothers are 
often very much afraid of fresh air, on account of the tendency of these 
children to take cold. If cold sponge-baths are given every morning, 
much can be done to lessen this susceptibility. Sunshine, though diffi- 
cult to obtain in large cities, is a most efficient therapeutic agent. The 
establishment of suburban hospitals and homes for these cases would do 
more than anything else to lessen the mortality from rickets. 

In a disease which tends so uniformly to recovery when causal condi- 
tions are removed, it is difficult to estimate the real value of medicinal 
treatment. No one thinks of relying upon drugs alone in the treatment 
of rickets, and where they arc used in conjunction with other means it 



RICKETS. 271 

is illogical to attribute all the improvement to the drugs employed. 
Those most used are cod-liver oil, phosphorus, and various prepara- 
tions of lime. Regarding the value of cod-liver oil, there can be no 
question. While it can not be ranked as a specific in rickets, it should 
be given in every case unless contra-indicated by the condition of the 
stomach, except possibly during very hot summer weather. Phosphorus 
has been popularized in the treatment of rickets by Kassowitz, who 
regards it as a specific for the disease. I have been unable to satisfy 
myself, after several years' trial, that in the great majority of the cases 
it had any decided influence upon the course of the disease. The best 
results from phosphorus are obtained in the early cases, where there are 
cranio- tabes and marked nervous symptoms. But even here I have not 
seen the striking benefit reported by others. In the later stages of rick- 
ets, it has been difficult to see any special result from its use. Phos- 
phorus may be administered either in the form of the officinal oil of 
phosphorus diluted with olive oil, or as Thompson's solution. The dose 
is gr. -g-J^ three times a day, given after meals ; it should be continued 
for several months. In such doses I have never seen it cause unpleasant 
symptoms. 

The absence of lime in rachitic bones has led to the use of various 
preparations of lime as remedies. Those most employed are the phos- 
phate, the lactophosphate, and the hypophosphite. While these may be 
beneficial as tonics, they are not in any sense to be classed as specifics. It 
is probable that when lime is given in excess of the amount furnished by 
ordinary breast-milk t>r cow's milk, this excess passes through the bowels 
unabsorbed. Arsenic and iron are valuable in the treatment of rickets, 
the special indication for their use being the presence of marked anaemia. 
Profuse sweating may be relieved by small doses of atropine — i. e., gr. 
g-J-g-, three or four times a day, to a child of six months. 

Treatment of the rachitic deformities. — The deformities of the chest 
are less amenable to treatment than most of the others. After the third 
year something can be done by gymnastics to develop the chest muscles 
and to increase the pulmonary expansion. The employment of the pneu- 
matic cabinet, in which it is sought to overcome these deformities by the 
use of rarefied air, has never been given the trial which it deserves. From 
the very meagre reports published, this appears to be of considerable value. 

The deformity of the spine (kyphosis) may usually be overcome by 
postural treatment. The patient should lie upon a hard bed ; no pillow 
should be allowed under the head, but in severe cases one should be 
placed beneath the back, so that the head and buttocks are slightly lower 
than the lumbar spine. While sitting, the shoulders should be kept back 
and the trunk supported. For a few minutes each day the child should 
be placed upon the face, and the deformity overcome by raising the but- 
tocks while pressure is made upon the spine. In severe cases, an apparatus 
19 



272 



NUTRITION. 



for giving spinal support, either by a steel brace or a plaster-of-Paris 
jacket, may be worn a few hours each day when the child is sitting up. 
Other means should be employed, especially friction and massage, to 
develop the spinal muscles. 

In very many cases slight deformities of the extremities are outgrown 
when the general treatment can be properly carried out. Where these 
exist, the physician should take the curve of the limbs by seating the 




Fig. 51.— Tracing, showing the curve in a case of bow-legs. 



child upon a flat surface and tracing their outline with a pencil held per- 
pendicularly (see Fig. 51 ) . A fresh tracing should be taken once a month. 
If the deformity is not very great and no increase takes place, it is safe 
to continue with general treatment only. If the deformity is marked or 
if it increases in spite of the constitutional treatment, braces should be 
applied. Something may be done toward straightening the bones by 
intelligent manipulation. Walking should be discouraged until the bones 
are quite firm. Friction of the extremities, and even the use of electricity, 
will do very much to increase muscular development. The habit of sitting 



RICKETS. 273 

cross-legged — a very common one in rachitic children — should be pre- 
vented, and in fact any other habitual posture, on account of the danger 
of increasing certain deformities. But iittle is to be expected from the 
use of apparatus for the correction of rachitic deformities after the child 
is two and a half years old; since at this time, and often even at two 
years, the bones are so firm that no amount of pressure from a steel 
brace will have any effect. 

Without going fully into the question of the surgical treatment of 
rachitic deformities, for which the reader is referred to text-books of 
general and orthopaedic surgery, I will only state that osteotomy seems 
to me to offer decided advantages over the other means of treating severe 
deformities. A vast amount of time and patience is wasted in the vain 
attempt to overcome very marked deformities by apparatus. The best 
results in osteotomy are obtained when the operation is delayed until the 
fourth or fifth year, by which time the bones are sufficiently firm and 
solid. Operations in the second year are generally unsatisfactory, and 
those in the third year often so, because of the bending of the bones 
which takes place subsequently. The deformities which require opera- 
tion are bow-legs and knock-knees, less frequently the curvatures of the 
femur or of the bones of the forearm. 



SECTION III. 
DISEASES OF THE DIGESTIVE SYSTEM. 

CHAPTER I. 

DISEASES OF THE LIPS, TONGUE, AMD MOUTH. 

MALFORMATIONS. 

Harelip. — This is one of the most frequent congenital deformities. 
It is caused by an incomplete fusion of the central process with one or 
both of the lateral processes from which the upper half of the face is de- 
veloped. This deformity may be single or double ; the fissure is never in 
the median line, but usually just beneath the centre of the nostril. There 
may be simply a slight indentation in the lip, or the fissure may extend to 
the nostril. Both single and double harelip — more frequently the latter — 
may be complicated by fissure of the palate. Double harelip is usually 
accompanied by a fissure between the intermaxillary and the superior 
maxillary bone of each side. 

Cleft Palate. — This is second in frequency to harelip. It may involve 
the soft palate only, or the fissure may extend into the hard palate, pro- 
ducing a wide gap in the roof of the mouth. The most frequent form 
is that in which only the soft palate is affected. 

For the surgical treatment of both these deformities the reader is re- 
ferred to text-books upon surgery. As to the time of operation, in cases 
of harelip it is wisest to defer interference until the child is well started in 
its growth — usually the second month— and in cleft palate during the 
second year. The medical treatment of these cases consists in the care 
of the mouth and in the nutrition of the patient. The mouth in all cases 
must be kept scrupulously clean, but the greatest care is necessary not 
to injure the epithelium. A camel's-hair brush and plain lukewarm 
water, or a weak alkaline solution, are to be recommended. Both these 
deformities are exceedingly likely to be complicated by thrush. This is 
a serious menace to the success of any operation, and even to the life of 
the patient. The nutrition is always a matter of much difficulty, and a 
very large number of these cases die of inanition or marasmus. In cases 
of harelip, if the fissure is so great as to interfere with nursing, the child 
may be fed with a spoon or a medicine dropper until the operation 

274 



DISEASES OF THE TONGUE. 275 

can be done. In cleft palate there may be attached to the rubber nipple 
of the nursing bottle a flap of thin sheet rubber in such a way that it 
closes the fissure in the mouth when once the nipple is in place. This 
flap should be shaped like a leaf, one extremity being sewed to the neck 
of the rubber nipple and the other end left free. In many cases, both 
before and immediately after operation, gavage (page 64) may be resorted 
to with the greatest benefit and with very little inconvenience. 

Congenital Hypertrophy of the Tongue. — This is usually due to disease 
of the lymphatics, and is to be regarded as a lymphangioma. In a few 
cases hypertrophy of the muscular fibres has been present. The tongue 
may reach an enormous size, so that it is impossible for it to be contained 
within the cavity of the mouth, and it may thus interfere with nursing, 
deglutition, and even with respiration. The treatment is surgical. Cases 
like the above are to be distinguished from those of enlargement of the 
tongue seen in sporadic cretinism. In this disease the tongue is consider- 
ably enlarged and may protrude slightly from the mouth, but it is rarely, 
if ever, large enough to cause other symptoms. It diminishes notably 
under treatment with the thyroid extract. 

Bifid Tongue. — These cases are extremely rare. Brothers has reported 
to the New York Pathological Society a case of cleft tongue in a child of 
one month. There was, in addition, a fissure of the soft palate. 

Tongue-Tie. — This deformity is' due to such a shortening of the frenum 
that it is impossible to protrude the tongue to a normal extent. It 
differs considerably in degree in different cases. In some, the tongue 
can not be advanced beyond the gums. Tongue-tie may interfere with 
articulation, and even with sucking. The treatment consists in liberating 
the tongue by dividing the frenum with scissors and completing the oper- 
ation with the finger nail. This should be done in every case unless the 
child is a bleeder. In many cases the mother may think the tongue tied 
when the frenum is of normal length. 

Bifid Uvula. — This is not very uncommon. It usually occurs in con- 
nection with cleft palate, but is occasionally seen when there is no other 
deformity present. It may be complete or partial, and it does not of itself 
require treatment. 

DISEASES OF THE LIPS. 

Herpes. — Herpes labialis is an exceedingly common affection in chil- 
dren, occurring in acute febrile diseases, particularly pneumonia, and 
sometimes alone. It is the familiar u fever sore " or " cold sore " of do- 
mestic medicine. The appearance is similar to herpes in other parts of 
the body. There is first a group of vesicles, then rupture and the forma- 
tion of crusts. It is often quite difficult to cure on account of the dispo- 
sition of children to pick the lip with the fingers. Although it heals with- 
out treatment, recovery is facilitated by the use of some antiseptic lotion, 



276 DISEASES OF THE DIGESTIVE SYSTEM. 

such as dilute boric acid, followed by a dusting powder of zinc oxide and 
boric acid. This treatment is generally more successful than the use of 
ointments. Young children should wear mittens at night, to prevent 
picking at the crusts. 

Eczema of the Lip. — This is an exceedingly common condition, and 
a very troublesome one. The vermilion border is dry and rough, and 
prone to deep cracks or fissures. These are usually seen at the angles of 
the mouth or in the median line. When severe they are exceedingly 
painful, bleed freely, and are the cause of very great discomfort, especial- 
ly in the cold season. The lips should be covered at night by simple oint- 
ment, and this should be used as much as possible during the day. 
Where deep fissures form, they should be touched with burnt alum, or 
with the solid stick of nitrate of silver. Syphilitic fissures are considered 
with the symptoms of that disease. 

Perleche (French, perlecher — to lick). — This name was first given by 
Lemaistre, in 1886, to a form of ulceration occurring usually at the angle 
of the mouth. It begins in most cases as a small fissure, which, by con- 
stant licking and irritation, to which there is usually added infection, 
may produce an intractable ulcer of considerable size. It often resembles 
the mucous patch of hereditary syphilis. The ulcer is of a grayish colour, 
is quite painful, and is associated with considerable swelling of the lip. 
It lasts from two to four weeks. The 'treatment is the same as in simple 
fissure — viz., the use of burnt alum or nitrate of silver, and covering the 
part with bismuth or oxide of zinc. 

DISEASES OF THE TONGUE. 

Epithelial Desquamation. — This is a disease of the lingual epithe- 
lium, which is characterized by the appearance upon the dorsum or mar- 
gin of the tongue, of circular, elliptical, or crescentic red patches, with 
gray margins which are slightly elevated. It is sometimes improperly 
called psoriasis of the tongue. It is quite a common condition. 

The beginning of the disease is not often seen. It is stated first to 
appear as a white or gray patch, like thickening of the epithelium. These 
patches enlarge quite rapidly, and are followed by detachment of the 
epithelium and the formation of bright red areas, which are the parts 
denuded of epithelium. As usually seen, there exists upon the tongue 
from two to half a dozen of these red patches surrounded by a gray bor- 
der, which is about one twelfth of an inch wide, and slightly elevated. The 
outline of the patch is nearly always crescentic (see Fig. 52). From day 
to day the configuration of the patches changes; the gray lines advance 
across the tongue from side to side, or from base to tip, disappearing as 
they reach the border or the extremity. They are followed by the red 
patches, and as the old ones fade away new ones form and run the same 
course. The white border seems to be made up entirely of epithelium. 



GLOSSITIS. 



277 



The red patches are of a bright colour nearest the border, gradually 
shading off into the normal colour of the tongue. Only the epithelium is 
involved, the deeper structures being unaffected. The duration of the 
disease is indefinite; it usually lasts for months, and often for years. 
Guinon reports several cases which recovered during an intercurrent 
attack of measles or scarlet fever. 

The cause is unknown. The condition occurs rather more frequently 
in females than in males, and Gubler has reported an instance of several 
members of the same family being affected. 
Most of the cases are seen in infancy and 
early childhood. The condition has been 
thought to depend upon nearly every disease 
of this period. Parrot believed that it was 
always syphilitic, but this view has been 
effectually disproved by subsequent observa- 
tion. The disease is not accompanied by 
pain, salivation, or by other symptoms of 
stomatitis, and it is of little practical impor- 
tance. Its symptoms are so characteristic 
that it can hardly be mistaken for any other 
condition. Treatment is unnecessary. 

Two other forms of epithelial desquama- 
tion have been observed, both much more 
rare than that described. In one of these 
the red denuded portion occupies the margin of the tongue, while the 
centre is gray or white ; the irregular wavy outline which separates the two 
suggests strongly an outline map, and the condition is sometimes called 
the " geographical tongue." In another variety nearly the whole organ 
may be uniformly red, from loss of the epithelium, there being no borders 
or patches. Both these varieties are of much shorter duration than the 
more common form, usually lasting only a few weeks.* 

Glossitis. — Inflammation of the tongue is not very common in chil- 
dren. It is usually of traumatic origin. The injury may be due to biting 
the tongue in a fall or in an epileptic seizure. Glossitis is sometimes 
excited by the irritation of a sharp tooth, causing a wound which may be 
the avenue of infection ; or it may result from taking into the mouth 
irritant or caustic poisons. In a small number of cases no cause can be 
found. The symptoms are marked swelling of the tongue, so that it may 
protrude from the mouth ; and it may even be so great as to cause se- 
vere dyspnoea. There are also profuse salivation, difficulty in swallowing 




Fig. 52. — Epithelial desquamation 
of the tong ue. ( Guinon. ) 



* For a fuller description and literature of the subject, see Guinon, Revue Men- 
suelle des Maladies de l'Enfance, 1887, p. 385 ; and Gautier, Revue Medicale de la 



Suisse, Romande, October and November, 1881. 



278 DISEASES OF THE DIGESTIVE SYSTEM. 

and in articulation, and often considerable local pain. There may be 
a rise of temperature to 102° or 103° F. The treatment consists in 
the use of fluid food, which in severe cases may be introduced through 
the nose by means of a catheter. Ice may be used externally, or, 
better still, pieces of ice should be kept in the mouth continually. If 
there is obstruction to respiration, and in all severe cases, scarifica- 
tion should be done on the dorsum of the tongue along the side of the 
raphe. 

The acute swelling of the tongue and lips occurring in some cases of 
urticaria may be mentioned in this connection. This is a rare condi- 
tion in children, but it may develop rapidly and to such a degree as to 
cause alarming symptoms. The treatment consists in the use of ice 
locally, free purgation by salines, and in extreme cases needle punc- 
tures to relieve the oedema. 

Tongue-swallowing. — This term is used to describe a rare condition 
seen in infants, in which the tongue is turned backward into the pharynx, 
so as to obstruct respiration. It may be drawn quite into the oesophagus. 
Several marked cases have been collected by Hennig.* While most fre- 
quently occurring with paroxysms of pertussis, tongue-swallowing has 
been seen in other diseases. This should not be forgotten as one of the 
explanations of sudden asphyxia in a young infant. The conditions 
necessary to its production are a somewhat relaxed organ or a long 
frenum. In none of the fatal cases reported, however, had the frenum 
been divided. In some weak infants, falling back of the tongue, so that 
its base partly covers the epiglottis, produces asphyxia, precisely as it 
occurs in adult life under full anaesthesia. The recognition of the con- 
dition is a very easy one, and its treatment is to relieve the obstruction 
by drawing the tongue forward by the finger or forceps. 

Ulcer of the Frenum. — The friction against the sharp edges of the 
lower central incisors frequently causes an ulcer of the frenum in in- 
fants. I have never seen it in older children. It usually occurs in 
pertussis, but is seen in other conditions. In some it appears to be pro- 
duced by friction of the teeth during nursing from the breast or bottle. 
It is more often seen in children who are delicate or cachectic than in 
those who are healthy and well nourished. The ulcer may be confined 
to the frenum, or it may extend quite deeply into the tongue. It is 
usually about one fourth of an inch in diameter, and of a yellowish-gray 
colour. When not readily cured by touching with alum or nitrate of 
silver, the child may be fed by gavage for several days, or the teeth may 
be covered by a bit of absorbent cotton. 

* Jahrbuch fur Kinderheilkunde, xi, 299. 



ALVEOLAR ABSCESS— DIFFICULT DENTITION. 279 

ALVEOLAR ABSCESS. 

This is common in children, especially among the class of hospital and 
dispensary patients, in whom little or no attention is given to the care of 
the teeth. It causes severe pain and acute swelling, which may be limited 
to the gum, or it may involve to a considerable extent the periosteum of 
the jaw, and even cause swelling of the whole side of the face. If there 
is retention of pus, there may be quite severe constitutional symptoms, 
such as a chill and high temperature ; but in most of the cases these are 
wanting. The abscess usually opens spontaneously into the mouth, but it 
may open externally if the molar teeth are the ones affected. It may 
even lead to necrosis of the jaw. If its site is the upper jaw, the pus may 
find its way into the nasal cavity or into the maxillary sinus. 

The treatment is, in the first place, prophylactic. This requires atten- 
tion to the teeth to prevent decay, and the removal of old carious fangs, 
which are a constant menace to the health of the child in more ways than 
one. The free use of the toothbrush and some antiseptic mouth-wash 
will, in the great majority of cases, prevent the occurrence of this disease. 
It is important that the abscess be opened early and free drainage secured. 
If there is a carious tooth it should be drawn. 

DIFFICULT DENTITION. 

The place of dentition as an etiological factor in the diseases of infancy 
is one which has given rise to much discussion. From a very early period 
the view has descended, that a large number of the diseases occurring be- 
tween the ages of six months and two years are due to difficult dentition. 
The list of such diseases is a long one, but year by year it has been short- 
ened as one after another has been shown to depend upon other causes, 
dentition being only a coincidence. 

At the present time many good observers deny that dentition is ever a 
cause of symptoms in children ; some even going so far as to say that the 
growth of the teeth causes no more symptoms than the growth of the 
hair. Without doubt the usual mistake made in practice is in overlooking 
serious disease of the brain, kidneys, lungs, stomach, and intestines, because 
of the firm belief that the child was " only teething." The physician who 
starts out with the idea that in infancy dentition may produce all symp- 
toms usually gets no further than this in his etiological investigations. 
Although I strongly believe that the importance of dentition as an etio- 
logical factor in disease has been in the past greatly exaggerated, and 
although I once held the opinion that simple dentition never produced 
symptoms, I have been compelled by clinical observations to change my 
opinion upon this subject; and I am now willing to admit that, particu- 
larly in delicate, highly nervous children, dentition may produce many 
reflex symptoms, some even of quite an alarming character. 
20 



280 DISEASES OF THE DIGESTIVE SYSTEM. 

Speaking from general impressions, not from statistics, I should say 
that in my experience about one half of the healthy children cut their 
teeth without any visible symptoms, local or general ; in the remainder 
some disturbance is usually seen, and though in most cases it is slight 
and of short duration, it may last for several days or even a week. The 
symptoms most commonly seen are disturbed sleep, or wakefulness at 
night and fretfulness by day, so that children often sleep only one half 
the usual time. There is loss of appetite, and much less food than usual 
is taken. There is often, but not always, an increase in the salivary 
secretion, a slight amount of catarrhal stomatitis, and a constant dispo- 
sition on the part of the child to stuff the fingers into the mouth. The 
bowels are often constipated or there may be slight diarrhoea. The ther- 
mometer may show a slight elevation of temperature to 100° to 101 -5° 
F. The weight may remain stationary for a week or two, and there may 
even be a loss of a few ounces. The duration of these symptoms in most 
cases is but a few days, and they require no special treatment. If the 
food is forced beyond the child's inclination, attacks of indigestion with 
vomiting and diarrhoea are easily excited. 

Symptoms more severe than the above are rare in healthy children, 
but are not infrequent in those who are delicate or rachitic. In such 
susceptible children, even so slight a thing as dentition may be the cause, 
or at least the exciting cause, of quite serious symptoms. Often there 
is some other factor in the case, such as bad feeding or feeble digestion. 
In delicate or rachitic children there may be seen the symptoms already 
mentioned as occurring in healthy infants, but in greater severity; and 
in addition there may be severe attacks of acute indigestion. Occasion- 
ally there is an elevation of temperature to 102° or 103° F., lasting usu- 
ally only two or three days, and accompanied by no symptoms except 
almost complete anorexia. Convulsions which could fairly be attributed 
to dentition I have seen but once; they are more apt to occur in rachitic 
children. There are certain cases of eczema in which the symptoms 
undergo a distinct exacerbation with the eruption of each group of 
teeth. As regards almost all the other diseases which are commonly 
attributed to dentition, I believe that it is a delusion to trace them to 
this cause. 

The physician should watch a child carefully, and examine it fre- 
quently, to be sure that he is not overlooking some serious local or con- 
stitutional disease before he allows himself to make the diagnosis of 
difficult dentition. Probably in ninety-five per cent of the cases in which 
symptoms are present, they are due to some cause other than denti- 
tion. When, however, symptoms such as any of those mentioned disap- 
pear immediately when the teeth come through, and when we see them 
repeated four or five times in the same child with the eruption of each 
group of teeth, and accompanied by red and swollen gums, I think we 



CATARRHAL STOMATITIS. 281 

can not escape the conclusion that dentition is a factor in their pro- 
duction, though perhaps not the only one. 

In the treatment of this condition drugs occupy but a small place. It 
should be remembered that infants are at this time in a peculiarly sus- 
ceptible condition as regards the digestive tract, and attacks of indiges- 
tion, and even severe diarrhoea, are readily excited from slight causes, 
especially from overfeeding. Special care should be exercised in this 
respect. The strength of the food should be reduced, as well as the 
amount given. The poor appetite indicates a feeble digestion, which 
should not be overtaxed. As attacks of bronchitis and acute nasal ca- 
tarrh are readily induced, even slight exposure should be guarded 
against. The nervous symptoms, when severe, may be relieved by the 
use of moderate doses of the bromides and phenacetine, better than by 
opiates. All soothing syrups should be discountenanced. All the vari- 
ous devices for making dentition easy are a delusion. In a small num- 
ber of cases lancing the gums is of decided value. I have myself seen 
marked and undoubted relief given by it. This is likely to be the case 
where the gums are tense, swollen, and very red, with the teeth just 
beneath the mucous membrane. To press a tooth through the gum by 
simply rubbing gently with the finger covered with sterile gauze is fre- 
quently much more effective than an incision. It is seldom, however, 
that the relief expected is seen from any of these measures. 

CATARRHAL STOMATITIS. 

This is characterized by redness and swelling of the mucous mem- 
brane, and by increased secretion of the salivary and the muciparous 
glands of the mouth. It usually involves a large part of the mucous 
membrane. 

Etiology. — Catarrhal stomatitis may result from traumatism. This 
injury may be mechanical, or due to heat or any irritant accidentally 
taken into the mouth. It frequently occurs at the time of the eruption 
of a tooth. It complicates measles, scarlet fever, diphtheria, influenza, 
and many other infectious diseases. In these cases, and in many others, 
the disease is probably due to direct infection. 

Lesions. — The lesions are essentially the same as in catarrhal inflam- 
mations of other mucous membranes. There are congestion with des- 
quamation of epithelial cells, and sometimes the formation of superficial 
ulcers. The process may be a very superficial one, or it may extend to 
the submucous tissue. 

Symptoms. — The mucous membrane is intensely injected, all the 
capillaries are dilated, and small haemorrhages easily excited. The mu- 
cous membrane is swollen, this being most apparent over the gums or 
about the teeth. There may be some swelling of the lips. The mouth 
seems hot, and the local temperature is certainly increased. There is con- 






282 DISEASES OP THE DIGESTIVE SYSTEM. 

siderable pain, as shown by f retf ulness, but particularly by the disinclination 
to take food : infants, though evidently hungry, either refusing the breast 
or bottle altogether, or dropping it after a few moments. The increase in 
secretion is sometimes marked, so that the saliva pours from the mouth, 
irritating the lips and face and drenching the clothing. In other cases 
the saliva is swallowed. On close inspection there may be seen swelling 
of the muciparous follicles, and even the formation of tiny cysts from the 
accumulation of secretion within them (Forchheimer). The tongue is 
usually coated, the edges reddened, and the papillae prominent. In febrile 
diseases, such as typhoid, etc., we may get an accumulation of dead epi- 
thelium with the formation of cracks and fissures of the tongue, and the 
lips may present a similar condition. The neighbouring lymphatic glands 
are slightly enlarged and tender. The constitutional symptoms accom- 
panying simple stomatitis are not severe, but some disturbance is almost 
always present. There may be derangement of digestion with vomiting, 
and even a mild attack of diarrhoea. In the majority of cases the disease 
runs a short course, recovery taking place in a few days when the primary 
cause is removed. In very delicate children it may be prolonged, and 
from the interference with nutrition may even lead to serious conse- 
quences. 

Treatment. — The mouth and teeth should be kept clean. Food is 
more acceptable if given cold. In very severe cases, where food is refused, 
gavage may be resorted to three or four times daily. In all cases children 
may be given ice to suck. This is refreshing, both on account of the cold 
and from the relief to the thirst. The mouth should be kept clean with 
a solution of boric acid, ten grains to the ounce, or an alkaline solution, 
such as D obeli's, diluted with an equal amount of cold boiled water ; or 
simply water may be used. In the severe forms, where there is much 
swelling and slight catarrhal ulceration, astringents are required. In my 
experience alum is the best ; this may be applied in the form of the pow- 
dered burnt alum mixed with an equal amount of bismuth, or in solution, 
ten grains to the ounce, with a swab or brush. Where ulcers are slow 
in healing and very painful, the powdered burnt alum may be applied 
directly. 

HERPETIC STOMATITIS. 
Synonyms : Aphthous, vesicular, follicular stomatitis. 
In this form of stomatitis we have the appearance first of small 
yellowish-white isolated spots, and subsequently the formation of super- 
ficial ulcers. These ulcers are first discrete, but may coalesce and form 
others of considerable size. It is a self-limited disease, usually running 
its course in from five days to two weeks. 

Etiology. — Very little is as yet positively known regarding the cause 
of herpetic stomatitis. It is not common in the first year, but after that 






HERPETIC STOMATITIS. 283 

is very frequently seen throughout childhood. It occurs in the strong as 
well as in the delicate. It is often associated with some disturbance of 
the stomach, and occasionally with dentition. I have adopted the term 
herpetic because the condition is analogous to herpes of the lips and face, 
the difference in appearance being due chiefly to location. It is appar- 
ently caused by something which acts upon terminal nerve filaments. 

Lesions. — The generally accepted opinion is that there is first a vesi- 
cle, followed by a death of epithelial cells covering it, and then a super- 
ficial ulcer. The white appearance is due to the fact that the ulcers, 
being on a mucous membrane, are always moist. These ulcers may 
extend superficially, but never deeply; they heal quickly with the for- 
mation of new epithelial cells, leaving no cicatrices. Herpetic stoma- 
titis is always associated with more or less catarrhal inflammation. 

Symptoms. — The disease is characterized by local and general symp- 
toms. The former are quite indefinite — general indisposition, loss of 
appetite, and slight fever. The local symptoms consist in the develop- 
ment of small, shallow, circular ulcers, usually coming in successive 
crops. While most frequent at the border of the tongue and the inside 
of the lips, they may be found upon any part of the mucous membrane 
of the mouth or the pharynx. There may be only half a dozen present, 
or the mouth may be filled with them. They are first of a yellowish 
colour, and on an average about one-eighth of an inch in diameter. By 
the coalescence of several smaller ones there may form patches of con- 
siderable size, sometimes nearly covering the lips. The older ulcers are 
apt to have a dirty grayish colour, and in places may look not unlike a 
diphtheritic membrane. The smaller ones are surrounded by a red areola, 
and when healing the margin is of a bright-red colour. Their appear- 
ance is often more like that of an exudation upon the mucous membrane 
than an excavation into it. The other symptoms are much the same as 
in catarrhal stomatitis, but usually of greater severity. The pain is par- 
ticularly intense, it being often difficult to induce children to take any- 
thing in the form of food. The tongue is frequently coated, but there is 
never the foul breath of ulcerative stomatitis. The duration of the dis- 
ease is from one to two weeks, and, if the child is in good condition, com- 
plete recovery takes place even without any special treatment. In badly 
nourished children the disease may last for two or three weeks ; relapses 
may occur, and the condition may interfere very seriously with the child's 
nutrition. 

Treatment. — This is the same as in catarrhal stomatitis, with the 
addition that to each one of the ulcers finely powdered burnt alum should 
be applied with a camel's-hair brush. If this is not effective, the solid 
stick of nitrate of silver may be used. The ulcers will usually yield rap- 
idly to this treatment. In my experience, drugs given with the purpose 
of affecting the lesion in the mouth have been without benefit. 



284 DISEASES OF THE DIGESTIVE SYSTEM. 

ULCERATIVE STOMATITIS. 

Ulcerative stomatitis is believed to occur only when teeth are pres- 
ent. It is characterized by an ulcerative process, beginning at the junc- 
tion of the teeth and the gum, and extending along the teeth; it occa- 
sionally involves other parts of the mouth, but never spreads beyond the 
buccal cavity. 

Etiology. — A form of ulcerative stomatitis is produced by certain 
metallic poisons, especially mercury, lead, and phosphorus ; but all these 
are now rare. Ulcerative stomatitis also occurs in scurvy ; and it seems 
probable that an allied disturbance of nutrition, with spongy, swollen 
gums, precedes some other forms of ulcerative stomatitis. Bad surround- 
ings and improper food act as predisposing causes; for the disease is 
quite common in hospital and dispensary patients, although rare in pri- 
vate practice. Local causes of some importance are want of cleanliness 
of the mouth and teeth and the presence of carious teeth. Conditions 
which produce a lowered vitality of the gums act as a predisposing cause, 
and infection as an exciting cause of the disease. The constant clinical 
features of ulcerative stomatitis and the occasional occurrence of epi- 
demics indicate a specific cause.* 

Lesions. — The disease may begin at any part of the mouth, but most 
frequently upon the outer surface of the gum along the lower incisor 
teeth. From this point it extends behind the teeth, and from the in- 
cisors to the canines and molars, usually of one side only; but it may 
involve the entire gum of both jaws. From the gums the process may 
spread to the lips, affecting the fold of mucous membrane between the 
gum and the lip, and also to the inner surface of the cheek, especially 
opposite the molar teeth, where large ulcers often form. In neglected 
cases the disease may extend into the alveolar sockets, the teeth loosen- 
ing and falling out. The periosteum of the alveolar process may be in- 
volved, and even superficial necrosis of the jaw may occur, as has hap- 
pened in several cases that came under my observation. 

Ulcers similar in appearance may also be present in other parts of 
the mouth — i. e., on the soft palate or the tonsils, sometimes even when 
the gums are not involved. 

Symptoms. — The first things noticed are the very offensive breath 
and the profuse salivation. It is usually for one of these symptoms that 

* The most important bacteriological investigations of this disease are those of 
Bernheim and Pospischill (Jahrbuch fur Kinderheilk., xlvi, 434). Of thirty cases 
studied, in all but two, both mild ones, they found two micro-organisms associated ; 
sometimes one and sometimes the other predominated. One was a fusiform bacillus 
often bent, with sharp ends, somewhat resembling the diphtheria bacillus but larger; 
it was stained by methyl blue and decolourized by Gram. The other was a spiral 
form. It is interesting to note that similar bacteria were found by Miller in carious 
teeth, and by Vincent in ulcero-membranous tonsillitis (see page 308). 



ULCERATIVE STOMATITIS. 285 

the patient is brought for treatment. On inspection of the mouth, there 
are seen in the mild cases, swollen, spongy gums of a deep-red or purplish 
colour, which bleed at the slightest touch. There is a line of ulceration, 
usually along the incisor teeth, most marked in front, which may ex- 
tend to any or to all of the teeth; sometimes it affects only the gum 
along the molar teeth, the incisors escaping. At the junction of the 
teeth and gum is seen a dirty, yellowish deposit, on the removal of which 
free bleeding takes place. The diseased parts are very painful, and the 
child cries and resists any attempt at examination. In the more severe 
cases and in those of longer duration the teeth are loosened, sometimes 
being so loose that they can be picked from the gum. There may be 
necrosis of the jaw, and even a loose sequestrum may be found. In 
these cases the ulceration along the gums is deeper, and there may be 
ulcers in the cheek opposite the molar teeth, or inside the lip. The 
swelling may be so great that the teeth are almost covered ; this is seen 
particularly in the scorbutic form. The saliva pours from the mouth, 
adding greatly to the discomfort of the patient. Beneath the jaw are 
felt the large, swollen lymphatic glands, which are painful and tender to 
the touch, but show no tendency to suppurate. The tongue is somewhat 
swollen, and shows at the edges the imprint of the teeth ; it has a thick, 
dirty coating. 

The disease is attended by little or no fever or other constitutional 
symptoms. The general condition of these patients is often poor, and 
there may be quite a marked cachexia. Other forms of stomatitis may be 
associated, and it should not be forgotten that the gangrenous form may 
follow. 

When not recognised or not properly treated, ulcerative stomatitis 
may last for months. When properly treated it tends in all recent cases 
to rapid recovery, usually in a few days. No deformity of the mouth 
is left, the only untoward results being shrinking of the gum, sometimes 
loss of some of the incisor teeth, and more rarely a superficial necrosis 
of the alveolar process. All these are quite uncommon. Ulcerative 
stomatitis can hardly be confounded with any other form, and not only 
should a diagnosis of the lesion be made, but the condition upon which 
it depends should, if possible, be discovered; scorbutus, particularly, 
should not be overlooked. 

Treatment. — The first thing to be done is to remove the cause. When 
dependent upon metallic poisoning the source should be discovered. 
Scorbutic cases should have the usual anti-scorbutic diet. Cleanliness of 
the mouth is of great importance, and this may best be accomplished by 
the use of peroxide of hydrogen diluted with from one to four parts of 
water. It should be followed by plain water, and repeated several times 
a day. In other cases an astringent solution of alum, five grains to the 
ounce, or a mouth-wash of chlorate of potash, three grains to the ounce, 



286 DISEASES OF THE DIGESTIVE SYSTEM. 

may be employed. The only objection to the last mentioned is the pain 
which it usually produces. 

The specific remedy for ulcerative stomatitis is chlorate of potash. 
The best method of administration is to give two grains, or one-half tea- 
spoonful of a saturated solution, largely diluted, every hour during the 
day for the first twenty-four hours and subsequently every two hours; 
when improvement occurs the dose may be still further reduced. 
Marked benefit is usually seen in one or two days even in cases that have 
lasted for several weeks. If the case does not yield readily to this treat- 
ment there is probably disease at the roots of the teeth, and when loose 
these should be removed, and the jaw examined to see if there is necro- 
sis. Occasionally when there is no disposition to heal, the shreds of 
necrotic tissue should be carefully removed, and burnt alum or nitrate 
of silver applied. 

The constitutional and dietetic treatment in all these cases should 
be the same as that employed in scurvy — i. e., plenty of fruit, fresh vege- 
tables, .and sometimes the internal administration of mineral acids, espe- 
cially aromatic sulphuric acid. Iron is indicated in most of the cases. 

Ulceration of the Hard Palate. — This is usually seen in the first few 
weeks of life, but may occur in any child suffering from marasmus. The 
primary cause may be the injury inflicted in cleansing the mouth. In 
other cases it is due to the friction of the rubber nipple, or something 
else which the child is allowed to suck. In still others it is apparently 
produced by the habit of tongue-sucking frequently observed in these 
young infants. The appearances are quite characteristic : there is found, 
rather far back upon the hard palate, usually in the middle line, a super- 
ficial ulcer, from a fourth to a half inch in diameter. There are no signs 
of acute inflammation. Thrush may coexist, but it has no relation to 
the production of the disease. Spontaneous recovery usually occurs in 
from one to three weeks, provided the cause can be removed. In children 
suffering from marasmus these ulcers are very intractable, and in many 
instances their cure is practically impossible. It is therefore especially 
important to prevent, if possible, their formation by care in cleansing the 
mouth, and in avoiding the other causes referred to. When ulcers have 
appeared they should be treated as cases of herpetic stomatitis. 

THRUSH. 
Synonyms : Sprue ; German, Soor ; French, Muguet. 

Thrush is a parasitic form of stomatitis characterized by the appear- 
ance upon the mucous membrane, usually of the tongue or of the cheeks, 
of small white flakes or larger patches. It is common in infants of the 
first two or three months, and in all the protracted exhausting diseases 
of early life. 



\ 






THRUSH. 



287 



Etiology. — The exact class to which the vegetable parasite which 
produces thrush belongs has not yet been definitely settled. Robin's opin- 
ion was long accepted that it was the o'idium albicans ; the view of Gra- 
witz, that it ia the saccharomyces albicans, is now more generally adopted. 
If a little of the exudate from the mouth is placed upon a slide and a 
drop of liquor potassae added, the structure of the fungus is readily seen. 
With the low power of the microscope there can be made out fine threads 
(the mycelium) and small oval bodies (the spores). With a high power 
the threads can be seen to 
be made up of a number of 
shorter rods, at the ends of 
which the spore formation 
takes place (Fig. 53). The 
mycelium is produced from 
the spores. The spores of 
this fungus are of very com- 
mon occurrence in the at- 
mosphere. It is difficult or 
impossible for thrush to de- 
velop upon a healthy mucous 
membrane. Its growth is 
favoured by slight abrasions, 
such as are often produced 
by rough methods of cleans- 
ing the mouth ; also by catar- 
rhal stomatitis, a scanty salivary secretion and want of cleanliness. The 
fungus may grow in a medium of any reaction, but best in one which 
is slightly alkaline or neutral. The nature of the process which it pro- 
duces is in all probability a sugar fermentation, the acid reaction of the 
mouth being the result of the growth rather than its cause. Infection 
may come from another patient by means of a rubber nipple or a cloth 
which has been used for the infected mouth, from the nipple of the 
nurse, or directly from the air. The disease is an exceedingly common 
one in foundling asylums, in all places where many young infants are 
crowded together, and where cleanliness of mouths, bottles, etc., is 
neglected. It is especially frequent in children suffering from malnutri- 
tion, marasmus, or other wasting diseases, and in those who have hare- 
lip, or any deformity of the mouth. 

Lesions. — According to Forchheimer, the spores lodge between the 
epithelial cells and gradually separate the different layers. This occurs 
before the formation of the white pellicle. Later the disease spreads on 
the surface of the mucous membrane, and also penetrates the deeper 
structures. It may invade the blood-vessels and cause thrombosis or 
even be carried to distant parts. Although the saccharomyces albicans 




Fig. 53. — Thrush fungus (highly magnified), a, my- 
celium ; b, spores ; c, epithelial cells from the 
d, leucocytes ; e, detritus. (Jaksch.) 



mouth 






288 DISEASES OF THE DIGESTIVE SYSTEM. 

is commonly found upon flat epithelium, its growth is not confined to it. 
It usually begins at many distinct points upon the mucous membrane, 
and gradually spreads until coalescence takes place ; a continuous mem- 
brane may be thus formed. No pus is produced by the process. 

The usual seat is the tongue, the inside of the cheeks, and the hard 
palate, but not infrequently it involves the lips, the tonsils, the pillars of 
the fauces, and the pharynx. Further extension in the digestive tract 
than this is rare, although the stomach, and even the intestines, may be 
invaded. I have seen it but once or twice in the oesophagus and never 
in the stomach, and I know of but two reported cases in this country in 
which thrush has been found there. Cases involving the oesophagus and 
the stomach appear from reports to be much more common in Europe. 
In three cases in the Babies' Hospital the saccharomyces albicans has 
been found in the lungs of infants suffering from broncho-pneumonia. 

Symptoms. — The essential symptoms of thrush are the appearance 
upon the mucous membrane of the mouth — usually beginning upon the 
tongue or the inner surface of the cheek — of small white flakes which 
resemble desposits of coagulated milk, but which differ from them in the 
fact that they can not be wiped off. If forcibly removed, they usually 
leave a number of bleeding points. There may be only a few scattered 
patches, or the mouth and pharynx may be covered. The mouth is gen- 
erally dry, the tongue coated; food may be refused on account of pain, 
and there may be some difficulty in swallowing. The other symptoms 
depend upon the conditions with which the thrush is associated. 

Diagnosis. — This is rarely difficult. The deposit may be mistaken for 
coagulated milk, but is distinguished by the features just mentioned. 
When existing upon the pharynx and fauces it has been confounded with 
diphtheria, although this mistake can hardly be made if all the facts 
of the case are taken into consideration — the age of the patient, the in- 
volvement of the lips and tongue, the dry mouth, the absence of glandu- 
lar enlargement, etc. In any case of doubt the examination of the de- 
posit under the microscope at once reveals its true nature. 

Prognosis. — Thrush is not in itself a dangerous disease, except in the 
very rare instances where it may obstruct the oesophagus, and this can 
hardly occur except in a condition of exhaustion which is necessarily 
fatal. In a feeble and delicate infant, thrush may be a serious complica- 
tion by interfering with the taking of sufficient nourishment. With 
proper treatment most of the cases involving only the mouth are readily 
cured. 

Treatment. — Thrush may be prevented in almost every case by due 
attention to cleanliness of the mouth, rubber nipples, bottles, cloths, etc. 
All rubber nipples should be kept in a solution of borax or salicylate of 
soda, and the child's mouth should be cleansed several times a day. On 
no account should a feeding-bottle be passed from one child to another. 



GONORRHEAL STOMATITIS. 289 

In the treatment of the disease the essential things are cleanliness, 
and the use of some mild antiseptic month- wash. The best routine treat- 
ment is to cleanse the mouth carefully after every feeding or nursing 
with a solution of borax or bicarbonate of soda, and to apply twice 
a day a 1-per-cent solution of formalin. Occasionally better results fol- 
low the use of nitrate of silver, a 3-per-cent solution applied twice daily. 
All application should be carefully made, so as not to injure the epi- 
thelium. The best method of cleansing is by the finger wrapped in 
absorbent cotton, or by a swab. Applications to be especially avoided are 
those mixed with honey or any syrup. In several hospital cases the dis- 
ease seemed to be prolonged by the irritation of the rubber nipple of the 
feeding-bottle. In such it has been our practice to feed by gavage for 
two or three days, as all cases improved much more rapidly when this 
was done. 

GONORRHEAL STOMATITIS. 

There has been described by Dohrn and Eosinski a form of stomatitis 
in the newly born, due to a gonorrheal infection. This is not likely to 
take place unless the epithelium has been removed. The infection in all 
cases occurred from the mother. The lesion consists in the formation of 
yellowish-white patches upon the tongue or hard palate — regions in 
which the epithelium is liable to be injured by rough attempts at cleans- 
ing the mouth. There may be other evidences of gonorrheal infection, 
especially ophthalmia. The diagnosis rests upon the discovery of the 
gonococcus in the exudate. In all the cases cited the general health was 
not affected, and recovery followed in the course of a week or ten days. 

The treatment consists in thorough cleanliness and in the application 
of a saturated solution of boric acid, as in thrush. 

SYPHILITIC STOMATITIS. 

The buccal symptoms of hereditary syphilis are important both from 
a diagnostic and therapeutic standpoint. The most frequent lesions are 
fissures, ulcers, and mucous patches. Fissures are found upon the lips, 
most frequently at the angle of the mouth, and are usually multiple. 
They may he quite deep and cause frequent haemorrhages. Mucous 
patches are superficial ulcers developing from papules which form upon 
the mucous or muco-cutaneous surfaces. In cases of acquired syphilis 
in children the primary sore may be seen upon the tongue, the lip, or the 
tonsil. All these symptoms are more fully considered in the chapter on 
Syphilis. 

DIPHTHERITIC STOMATITIS. 

In severe cases of diphtheria the membrane is found not only upon the 
pharynx and tonsils, but it may appear anywhere upon the buccal mucous 






290 DISEASES OP THE DIGESTIVE SYSTEM. 

membrane or the lips. It is questionable whether the diphtheritic pro- 
cess ever begins in the mucous membrane of the mouth, or is ever 
limited to this part. In my own experience diphtheritic stomatitis has 
always been associated with deposits upon the tonsils and pharynx. It 
is seen only in the severest cases, and in those which, from other con- 
ditions present, are almost necessarily fatal. Bearing in mind the above 
points, it can hardly be mistaken for any other variety of stomatitis, 
although not infrequently the mistake is made of regarding as diph- 
theritic, cases of herpetic stomatitis in which the ulcers have coalesced. 
The treatment, so far as the mouth is concerned, consists in cleanliness 
by frequent gargling or syringing with a saturated solution of boric acid 
Forcible removal of the membrane is not to be advised. 

GANGRENOUS STOMATITIS— NOMA. 
Synonym : Cancrum oris. 

The term noma is used to designate all forms of spontaneous gan- 
grene occurring in children, which involve mucous membranes or muco- 
cutaneous orifices. The most frequent situation being the mouth, noma 
and gangrenous stomatitis are often used synonymously. Noma may, 
however, affect the nose, external auditory canal, vulva, prepuce, or anus. 
It is a rare disease, and usually terminates fatally. 

Etiology. — Noma is seldom seen outside of institutions for children, 
where small epidemics are not uncommon. It is usually secondary to 
some of the infectious diseases, most frequently following measles, and 
next to this scarlet fever, typhoid, or whooping-cough. While it may 
occur at any age, most of the cases are in children under five years, and 
in those of poor general condition. Noma seldom attacks parts previ- 
ously healthy. In the mouth it may be preceded by catarrhal, or more 
often by ulcerative stomatitis; in the auditory canal, by a chronic otitis 
media. There seems little doubt that the disease is contagious. In 
1899 I saw five cases in a single ward, all beginning in the auditory 
canal, which were apparently produced by the use of the same syringe to 
clean the ears without proper disinfection. All these children were suf- 
fering from whooping-cough at the time. 

The results of bacteriological studies of noma are not uniform nor 
as yet conclusive. In the gangrenous tissue pyogenic cocci and putre- 
factive bacteria are usually abundant. In the border zone, and extend- 
ing into the adjacent healthy tissue, bacilli have been found which are 
regarded by Babes, Bartels, Schmidt, and others as the specific organism 
of the disease, although they do not altogether agree in their descrip- 
tions. In cases reported by Freymuth, Petruschky, and in one of my 
own, bacilli closely resembling, if not identical with, diphtheria bacilli 
were found. Others have ascribed the disease to streptococci. It is not 
improbable that more than one micro-organism, or even other agents, 



GANGRENOUS STOMATITIS— NOMA. 291 

may under certain conditions have the power of causing this form of 
gangrene. 

Lesions. — The process is one of slowly spreading gangrene. In most 
of the cases there are thrown out inflammatory products in quite large 
amount, but there is little or no tendency to limitation of the disease. 
This usually advances steadily until death occurs. In a small number of 
cases a line of demarcation finally forms, and the slough separates, leav- 
ing a large area to be partially filled in by granulation and cicatrization. 
Other infectious processes are liable to accompany the disease, particu- 
larly broncho-pneumonia. 

Symptoms. — The constitutional symptoms are not usually severe 
until the local disease has existed for several days. Then those of 
marked prostration and sepsis develop, sometimes quite rapidly. The 
temperature is usually elevated to 102° or 103° F., and sometimes to 
104° or 105° F. There are dulness, apathy, feeble pulse, muscular re- 
laxation, and very often diarrhoea. Before death the temperature may 
be subnormal. 

Of the local symptoms, often the first to attract attention is the odour 
of the breath; sometimes it is the dusky spot on the cheek or lip. On 
examination of the mouth, there usually is found upon the gum or inside 
of the cheek a dark, greenish-black necrotic mass, surrounded by tissues 
which are swollen and cedematous, so that the cheek or lips may be 
two or three times their normal thickness. Externally the parts are 
tense and brawny from the swelling, this infiltration always extending 
for some distance beyond the gangrenous part. As the process extends, 
the teeth loosen and fall out ; there may be necrosis of the alveolar pro- 
cess of the jaw and perforation of one or both cheeks or lower lip. Ex- 
tensive sloughing of the face may take place, usually upon one side, 
sometimes upon both, giving the patient a horrible appearance, as shown 
in Fig. 54. In this patient the process began in the right cheek, subse- 
quently involving the left; perforation occurred in both cheeks, and 
before death a large part of the face was gangrenous. The odour from 
a severe case is very offensive, and, in spite of all efforts at disinfection, 
it may fill the ward or even the house. Pain is rarely severe, and in many 
cases it is absent. Extensive haemorrhages are rare. 

I have notes of seven cases in which noma affected the ear, being 
preceded by chronic otitis media in every instance. The disease began 
in the deeper structures of the canal, the first symptom noticed usually 
being a nodular swelling just beneath the ear, crowding the lobe upward. 
Shortly afterward there appeared the dirty brown discharge with a gan- 
grenous odour; later, the gangrenous circle surrounding the meatus. 
This gradually extended, until in some cases the whole side of the face 
and head were involved. A probe could readily be passed into the cra- 
nial cavity. All these cases ended fatally. 



292 



DISEASES OF THE DIGESTIVE SYSTEM. 



The usual duration of the disease is from five to ten days. If recov- 
ery takes place, there is first seen a line of demarcation; then the slough 
is thrown off, and granulation and cicatrization begin, but require a long 
time, usually leaving an unsightly deformity. 

The prognosis is grave, about three-fourths of the cases proving 
fatal. The results depend not only upon the disease itself, but upon 
the condition of the patient with which it is associated. 




Fig. 54. — Gangrenous stomatitis, following measles. (From a photograph lent by 
Dr. Henry Moffat.) 

Gangrenous stomatitis can hardly be mistaken for any other form of 
disease occurring in the mouth, and early recognition is of great impor- 
tance, since only early treatment is likely to be successful. 

Treatment. — Much can be done to prevent the disease by careful 
attention to all the milder forms of stomatitis, particularly to the ulcera- 
tive variety. Frequent and thorough cleansing of the mouth in all acute 
infectious diseases is a part of the treatment which is too often neglected. 
This should be a matter of routine in every severe illness in a young 
child. Recognising the malignant nature of gangrenous stomatitis, its 
treatment should be radical from the very outset. Of the measures 
which have been proposed, that which seems to offer the best chance of 
arresting the process is excision with cauterization. This should be 
done under anaesthesia. In excising, one should go some distance into 
tissues apparently healthy, for the reason that the process has always 



ACUTE PHARYNGITIS. 293 

advanced farther in the subcutaneous tissues than in the skin. The 
edges of the wound should then be thoroughly cauterized, best by the 
Paquelin cautery. Of the other means employed, the use of strong car- 
bolic acid immediately followed by alcohol is probably the best. This is 
to be used after excising, or curetting the necrotic tissue. Cases have 
been reported in which the use of anti-streptococcus serum, and also the 
diphtheria antitoxin, have appeared to arrest the disease. The mouth 
should be kept as clean as possible by the use of peroxide of hydrogen. 
The general treatment should be supporting and stimulating. As the 
possibility of contagion exists, every case should be isolated. 



CHAPTER II. 

DISEASES OF THE PHARYNX. 

ACUTE PHARYNGITIS. 

Acute pharyngitis may exist as a primary disease, or with any of the 
infectious diseases, particularly scarlet fever, measles, diphtheria, or 
influenza. Secondary pharyngitis will be considered in connection with 
these different diseases. 

Certain children have a constitutional predisposition to attacks of 
acute pharyngitis, and contract it upon the slightest provocation. In 
some of them there is a strongly marked rheumatic diathesis. Attacks 
of acute pharyngitis often follow exposure. In many cases they are 
associated with acute disturbances • of digestion. All of the above 
causes probably act by producing local and general conditions favour- 
able to the development of micro-organisms already present in the 
mouth. They are cases of auto-infection. The bacteria most frequently 
associated with severe attacks are streptococci, less frequently staphylo- 
cocci and pneumococci. 

In acute catarrhal pharyngitis the inflammation may involve the en- 
tire mucous membrane of the tonsils, fauces, uvula, posterior and lateral 
pharyngeal walls, or any part of it. It may exist alone, or in connection 
with a similar inflammation in the rhino-pharynx or in the larynx. In 
the beginning there is seen an acute erythematous blush, usually involv- 
ing the entire pharynx. This may entirely subside after twenty-four 
hours, or it may be followed by the usual changes of acute catarrhal in- 
flammation — dryness, swelling, and oedema. Later there is increased 
secretion of mucus, and finally there may be muco-pus. Occasionally 
slight haemorrhages are present. 

There is pain at the angle of the jaws, which is increased by swallow- 
ing, also a sensation of dryness and roughness in the pharynx, and often 
an irritating cough. There may be slight swelling of the neighbouring 






294 DISEASES OF THE DIGESTIVE SYSTEM. 

lymphatic glands. The constitutional symptoms in young children are 
often severe. Not infrequently there is a sudden onset with vomiting, 
and a rise of temperature to 102° or even 104° F. These symptoms are 
usually of short duration, frequently less than twenty-four hours, and in 
two or three days the patient may be entirely well. In other cases the 
pharyngitis may be accompanied or followed by laryngitis. 

Acute primary pharyngitis is to be distinguished from scarlet fever, 
measles, and influenza. A positive diagnosis from scarlet fever is im- 
possible until a sufficient time has elapsed for the eruption to appear, 
and the patient should be closely watched for the first sign of this. 
If scarlet fever is prevalent, a child with the symptoms of severe phar- 
yngitis should at once be isolated while waiting for the diagnosis to be 
settled. There is commonly less difficulty in excluding measles because 
of the presence of Koplik's sign on the buccal mucous membrane, and 
the accompanying catarrh of the eyes and nose. Influenza is recognised 
only by the greater severity of the constitutional symptoms and the prev- 
alence of an epidemic. 

The first step in the treatment of acute pharyngitis is to open the 
bowels freely by means of calomel, castor oil, or magnesia. The child 
should be kept in bed, and the diet should be fluid, or, in the case of 
infants, the amount of food should be much reduced. Pieces of ice may 
be swallowed frequently for the relief of pain and thirst. Internally 
there may be given two grains of phenacetine every four hours to a child 
of three years. It is important at the outset to induce free perspira- 
tion. The disease is not serious, and the indications are to make the 
child as comfortable as possible during the short attack. I have seen 
but little benefit from the use of aconite, although for years I saw it 
used as a routine treatment. 

UVULITIS. 

Acute inflammation of the uvula, with swelling and oedema, occurs as 
a part of the lesion in acute pharyngitis. In rare instances the uvula 
may be the principal or the only seat of inflammation. Huber (New 
York) has reported two cases, one of which is unique. An infant ten 
months old was apparently well until two hours before it was seen, when 
there was noticed a constant irritating cough, accompanied by consider- 
able gagging. Later there could be seen in the mouth a prominent red 
mass, the enlarged and elongated uvula. It was accompanied by parox- 
ysms of cough, which interfered both with nursing and deglutition. The 
general symptoms were quite alarming. The uvula was found to be fully 
one inch long and half an inch wide, red and cedematous; in other 
respects the throat was normal. The symptoms were relieved by multiple 
needle punctures and the use of ice. In such conditions the greatest 
relief is often afforded by the application of adrenalin, or its use as a 
spray or gargle. 



\ 



RETRO-PHARYNGEAL ABSCESS. 205 

ELONGATED UVULA. 

Probably this is primarily a congenital condition. It is increased by 
repeated attacks of acute or subacute inflammation. The degree of 
elongation varies in different cases; in some it may reach an inch in 
length. According to Bosworth, only the mucous membrane is involved 
in the elongation. The symptoms are those of local irritation, espe- 
cially a cough upon lying down, and the sensation of a foreign body in 
the pharynx. In some cases it may be a reflex cause of asthma, or, more 
frequently, of catarrhal spasm of the larynx. The diagnosis is very 
easily made by inspecting the throat. The treatment consists in grasping 
the tip of the uvula with forceps and cutting off the excess with the 
scissors, or a uvulatome. Care should be taken not to cut off too much 
of the uvula, or severe haemorrhage may occur. 

RETRO-PHARYNGEAL ABSCESS. 

Two distinct varieties are seen : ( 1 ) the so-called idiopathic abscesses 
which belong to infancy, and (2) abscesses secondary to caries of the cer- 
vical vertebras. 

Retro-pharyxgeal Abscess of Infancy. — All of the later investi- 
gations regarding this disease go to show that primarily it is not a cellu- 
litis, but a suppurative inflammation of the lymph nodes (lymphatic 
glands) with a surrounding cellulitis. Jules Simon has described the 
retro-pharyngeal lymph nodes as forming a chain on either side of the 
median line between the pharyngeal and the prevertebral muscles. These 
nodes are said to undergo atrophy after the third year, and in some cases 
to disappear entirely. Retro-pharyngeal abscess — or more properly retro- 
pharyngeal lymphadenitis, since the process does not invariably go on to 
suppuration — is probably never primary, but secondary to infectious 
catarrhs of the pharynx, and is set up by the entrance of pyogenic bac- 
teria, usually the streptococcus. Its pathology is the same as the more 
frequent suppurative inflammation of the external cervical lymph nodes, 
with which it is sometimes associated. Usually only a single node is 
involved, but sometimes two or three are affected, and these may be 
situated upon opposite sides. I have seen retro-pharyngeal lymph- 
adenitis so severe as to give* rise to marked local symptoms, although it 
did not go on to suppuration. This is rare ; Kormann's observations, 
however, show that swelling of these glands in diseases of the mouth and 
throat is very much more common than is generally supposed. Similar 
abscesses from suppurative inflammation of other lymph nodes in the 
neighbourhood of the pharynx may occur. I have seen one situated be- 
tween the epiglottis and the base of the tongue. 

Etiology. — These cases almost invariably occur in infancy. Fully 
three-fourths of those that have come under my observation have been in 



296 DISEASES OF THE DIGESTIVE SYSTEM. 

patients under one year. Bokai (Buda-Pesth) reports that of sixty cases 
observed, forty-two occurred during the first year, eleven during the sec- 
ond year, and only seven at a later period. The primary disease is usu- 
ally a severe rhino-pharyngitis, or an attack of epidemic influenza, but 
rarely it occurs as a sequel of scarlet fever or measles. In six hundred 
and sixty-four cases of scarlet fever, Bokai noted retro-pharyngeal ab- 
scess in seven cases. After measles it is even more rare. Betro-pharyn- 
geal abscess usually occurs in winter or spring, on account of the preva- 
lence of the diseases upon which it depends. It is seen in children pre- 
viously robust, but more often in those who are delicate and who in con- 
sequence are prone to severe catarrhal affections. 

Symptoms. — The early symptoms in most cases are merely those of an 
ordinary rhino-pharyngeal catarrh. After this has subsided the tem- 
perature may remain slightly elevated, often for a week or more, before 
local symptoms are noticeable. Sometimes, without any distinct history 
of previous catarrh, there are seen quite high temperature, from 102° to 
104° F., loss of flesh, and prostration. A careful examination may be 
required, and sometimes observation for a day or two, before the expla- 
nation of these constitutional symptoms is discovered. In other cases 
the early constitutional symptoms are so slight as to escape notice, and 
the physician is summoned on account of the local symptoms, usually 
the dyspnoea, which in a short time may assume an alarming character. 
The duration of the inflammatory process before abscess forms is gen- 
erally five or six days, but it may be several weeks. The temperature is 
invariably elevated, usually from 100° to 103° F. ; occasionally it may be 
104° or 105° F., with symptoms of prostration seemingly out of all pro- 
portion to the local disease, but which are to be explained by the tender 
age and feeble resistance of the patient. 

The first local symptom may be a sudden attack of dyspnoea severe 
enough to cause asphyxia. This is due to the pressure forward of the ab- 
scess which encroaches upon the opening of the larynx. Usually before 
it occurs the breathing is noisy, especially during sleep, and on account 
of the obstruction to nasal respiration the patient breathes with the 
mouth open. The mouth may be dry, or there may be a copious secretion 
of pharyngeal mucus. The dyspnoea is in most cases greater on inspira- 
tion, and in some it is noticed only then, expiration being normal. The 
dyspnoea is sometimes increased by attempts at swallowing. The degree 
to which deglutition is interfered with depends upon the size and the 
position of the tumour. It is more difficult when the tumour is low 
down. The child may find it impossible to swallow, and in consequence 
may refuse to nurse ; or the difficulty in nursing may depend upon the 
nasal obstruction. Sometimes there is regurgitation of food through the 
nose or mouth. The voice is usually nasal. Generally there is no hoarse- 
ness, but a peculiar short cry which is quite characteristic. There may be 



RETRO-PHARYNGEAL ABSCESS. 297 

complete aphonia; often there is a short, dry cough. In many of the 
cases a tumour is to be seen externally, just below the angle of the jaw 
and in front of the sterno-mastoid muscle; exceptionally this may be 
more prominent than the internal swelling. The head is thrown back in 
order to relieve the pressure upon the larynx, and is held somewhat rig- 
idly. In one or two cases I have noticed torticollis as an early symptom. 

A positive diagnosis is made by an examination of the throat. On in- 
spection there is seen a distinct bulging of the lateral wall of the phar- 
ynx, usually a little above the base of the tongue. The swelling may be 
so great as to crowd the uvula to one side and nearly fill the pharynx. 
It is rarely if ever in the median line. There is usually redness of the 
mucous membrane and oedema of the uvula and of the adjacent parts. 
On digital examination the swelling is made out even better than by in- 
spection. It may be situated so low down as not to be visible at all. In 
the early stage there may be felt only a localized induration or a some- 
what diffuse swelling, but by the time the swelling is large enough to 
produce marked symptoms, fluctuation can generally be discovered. 

Prognosis. — When left to itself the abscess may open into the phar- 
ynx, the pus being swallowed or expectorated. The cavity may close rap- 
idly by granulation, and in a few days the patient be entirely well ; or the 
abscess may refill. It is rare for much burrowing to occur. In young or 
very delicate infants the constitutional symptoms may be so severe that 
the child continues to fail even after the evacuation of the abscess, and, 
gradually sinking, dies usually from broncho-pneumonia. In other chil- 
dren a fatal result is generally due to the fact that the disease was not 
recognised. 

Death may occur from asphyxia due to pressure upon the larynx, 
to cedema of the glottis, or from rupture of the abscess into the air 
passages, especially if this occurs during sleep. Carmichael, Bokai, and 
others have reported deaths from ulceration into the carotid artery, or 
one of its large branches. Carmichael's patient was only five weeks old. 
The general mortality is from five to ten per cent; many deaths are 
owing to a failure to make the diagnosis. Gautier has collected ninety- 
five cases, with forty-one deaths. In my experience death has most fre- 
quently resulted from late broncho-pneomonia ; in one case it was due to 
a secondary retro-cesophageal abscess. 

Diagnosis. — lletro-pharyngeal abscess is to be suspected if in an 
infant there is difficulty in swallowing, noisy dyspnoea, mouth-breathing, 
and the head drawn backward. A positive diagnosis is possible only by 
a digital examination of the pharynx. The mistake most often made 
is, that the physician, called to a young child suffering from great 
dyspnoea, has jumped at a diagnosis of laryngeal stenosis, and forth- 
with performed tracheotomy or intubation, without taking the trouble 
to get the history or to make a careful examination of the pharynx. 



298 DISEASES OF THE DIGESTIVE SYSTEM. 

Many such cases are reported in which the child has died during the 
operation or immediately afterward, the autopsy first revealing the 
nature of the disease. A sudden attack of dyspnoea like that caused 
by the rupture of an abscess might be produced by the lodgment of a 
foreign body in the pharynx or larynx. A digital examination would 
aid in the diagnosis. I once saw in an infant a sarcoma of the pharyn- 
geal lymph glands which gave an external and internal tumour exactly 
like that of a retro-pharyngeal abscess. 

Treatment. — Before the abscess has pointed, hot applications should 
be made to the throat to relieve the symptoms and to hasten the forma- 
tion of pus, since resolution is not to be expected. Spontaneous opening 
should never be waited for, on account of the danger of the rapid devel- 
opment of serious symptoms from pressure or oedema, or of suffocation 
from an opening into the air passages, especially during sleep. 

As soon as the diagnosis is made the case should be carefully watched, 
and as soon as well-marked fluctuation is detected, the pus should be 
evacuated. External incision has its advocates, and in a few cases, when 
the tumour is chiefly external, it offers some advantages; but as a 
routine operation the internal opening is, to my mind, much to be pre- 
ferred. In opening through the mouth the patient should be seated in 
an upright position and the head firmly held. The introduction of a 
mouth-gag may cause asphyxia; but a tongue depressor may be used, 
and a bistoury which has been guarded to its point plunged into the 
abscess at its thinnest portion and the incision made toward the median 
line. The head should then be bent forward, to allow the pus to escape 
through the mouth. It is well to insert the finger into the cavity and 
break down any septa; for after a simple puncture the abscess may 
refill. Incision, although usually easy, in some cases may be quite diffi- 
cult on account of the swelling and the small pharynx of the infant. For 
the past few years I have adopted the plan of opening these abscesses 
with the finger nail, a procedure simple, efficient, and free from danger. 
While the patient is held as above described, the wall of the abscess is 
perforated where it points, by the nail of the forefinger which has been 
sharpened to a cutting point. I have seldom seen a case in which this 
was difficult. The amount of pus evacuated is from one drachm to half 
an ounce. In the majority of cases no after-treatment is required. The 
relief of the dyspnoea and dysphagia is immediate, and recovery rapid. 

Ketro-pharyngeal Abscess from Pott's Disease. — This form is 
rare in comparison with that just described, and under three years of age 
it is extremely so. These abscesses are usually larger, and the amount of 
pus contained may be from four to eight ounces. They form very much 
more slowly, often lasting for months, and as with other secondary ab- 
scesses, the constitutional symptoms are seldom severe. The swelling 
is frequently in the median line, and is not so circumscribed as in the 



ADENOID VEGETATIONS OF THE PHARYNX. 299 

idiopathic cases. The pus often burrows along the spine for several 
inches. 

The symptoms of Pott's disease of the cervical region are usually 
present for several months before the appearance of the abscess. Some- 
times the abscess precedes the deformity, and it may be the first intima- 
tion of the existence of bone disease. The local symptoms resemble 
those of the idiopathic cases, but they develop more slowly, and sudden 
attacks of fatal asphyxia are very rare. External swelling is usually 
seen, and it may be quite large, extending almost from one ear to the 
other, forming a distinct collar. On digital exploration there may be 
found an irregularity of the anterior surface of the cervical vertebrae, 
and occasionally a marked angular prominence. 

When left to themselves these abscesses may open externally in front 
of the sterno-mastoid muscle just below the jaw, sometimes nearly as low 
as the clavicle ; they may rupture internally into the pharynx, the oesoph- 
agus, or the air passages ; or they may burrow a long distance in front 
of the spine. Death may result from pressure upon the larynx, or from 
rupture into the larynx, trachea, or pleura ; all these, however, are rare. 
The abscesses not infrequently refill after they are evacuated, and occa- 
sionally a discharging sinus is left for many months. 

Treatment. — These abscesses should be opened as soon as they are 
large enough to give rise to local symptoms. The external incision just 
in front of the sterno-mastoid muscle is generally to be preferred to 
opening through the mouth, since it gives better drainage, and the after- 
treatment is more easily carried on; and a sinus opening externally is 
less objectionable than one opening into the pharynx. 

ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 

This is a very common condition and one much neglected by the 
general practitioner. It is the source of more discomfort and the origin 
of more minor ailments than almost any other pathological condition of 
childhood. 

There is a mass of lymphoid tissue situated at the vault of the phar- 
ynx which in structure closely resembles the tonsils. It is often spoken 
of as the " pharyngeal tonsil." Like the faucial tonsils, this may become 
greatly hypertrophied, so as to form a tumour large enough to fill the 
rhino-pharynx completely. These tumors have a broad attachment 
which is sometimes more to the roof, and sometimes more to the poste- 
rior wall of the pharynx. The term adenoid vegetations was given to 
them by Meyer, who first described them in 1868. In infancy these 
growths are soft, vascular, and spongy; in older children they become 
firm, dense, and more fibrous. Their appearance is well shown in Fig. 
55. Adenoid vegetations are associated with hypertrophy of the faucial 



300 DISEASES OF THE DIGESTIVE SYSTEM. 

tonsils in about one-third the cases. Growths large enough to cause 
decided nasal obstruction may in time produce changes in the facial 
bones amounting to positive deformity. The bony palate is dome- 
shaped or even acutely arched; the dental arch of the upper jaw be- 




Fio. 55. — Adenoid vegetations, natural size. 

(1) From child eight months old; (2) from child twenty-two months old; (3) from child 
two and one half years old ; (4) from child two and one half years old ; (5) from child three 
years old. With the exception of (5) all were removed with a single sweep of the curette. 

Although the growths represented are somewhat larger than the average for the ages men- 
tioned, just such ones are constantly met with in practice. 

comes almost V-shaped. Deformities of the thorax also occur, which 
will be described with the Symptoms. 

Etiology. — The constitutional condition described elsewhere as 
" lymphatism," sometimes called the status lymphaticus, is the one with 
which adenoid growths are very frequently associated. Very often, how- 
ever, they are the most marked manifestation of the condition. I have 
frequently known every one of a large family of children to be affected, 
and. often the parents have suffered from the same disease. There can 
be no doubt regarding the influence of heredity in the production of 
adenoids. In many cases they are congenital. Eachitic children are 
somewhat oftener affected than others, but no connection with syphilis 
has been traced. Much interest has lately been awakened regarding the 
relation of adenoid growths to tuberculosis. Of 945 cases collected by 






ADENOID VEGETATIONS OF THE PHARYNX. 301 

Lewin in which specimens of adenoids were examined, tuberculosis was 
present in 5 per cent. Though this proportion is no doubt much higher 
than will be found in private practice, the fact is an important one; 
for it is highly probable that this is the channel of infection in not a 
few cases of tuberculous meningitis. Adenoids are most common in 
damp, changeable climates. Their first symptoms often follow an attack 
of measles, scarlet fever, or diphtheria. The repeated head colds are 
more often a result than a cause of the condition. 

Symptoms. — The symptoms of adenoid growths are usually first no- 
ticed when children are from eighteen months to three years old; but 
they may be present almost from birth. I have in several instances seen 
them to a marked degree in infants only a few months old. The symp- 
toms generally increase in severity as age advances, being always better in 
summer and worse in winter, until the age of six or seven is reached. 
The chief symptoms are those which relate to (1) chronic rhino-pharyn- 
geal catarrh, (2) mechanical obstruction, (3) deafness, (4) general 
malnutrition and anaemia, (5) reflex nervous phenomena. 

The rhino-pharyngeal catarrh shows itself by a persistent nasal dis- 
charge, frequently recurring acute attacks, or head colds, during the 
entire winter season. In susceptible children these attacks are often the 
beginning of a bronchitis, which may keep a young child indoors almost 
the entire winter. 

The obstructive symptoms are inability to blow the nose, mouth- 
breathing constantly or only during sleep, and a nasal voice. The 
difficulty in breathing is increased when the child lies upon the 
back. In consequence of this, children sleep in all sorts of positions — 
lying upon the face, sometimes upon the hands and knees, and often toss 
restlessly about the crib in the vain endeavour to find some position in 
which respiration is easy. The attacks of dyspnoea at night may amount 
almost to asphyxia, and are the explanation of many of the so-called 
night-terrors from which children suffer. When the obstruction has 
existed from infancy there are often deformities of the chest ; these are 
most marked in rachitic subjects. The most frequent one consists in 
deep lateral depressions of the lower part of the chest, with a promi- 
nence of the sternum — the familiar pigeon-breast (Fig. 56). The de- 
formity is due to interference with pulmonary expansion. 

Some impairment of hearing exists in a large proportion of the cases. 
Blake (Boston) found this to be true in 39 out of 47 cases examined; 
in 35 of these marked improvement in the hearing followed removal 
of the adenoid growths. Deafness may be due to tubal catarrh or to 
otitis. Often a history is given of several attacks of suppurative otitis. 

The reflex symptoms associated with adenoid growths are many. 
One of the most important is catarrhal spasm of the larynx, or the famil- 
iar spasmodic croup. In my experience the majority of young children 



302 



DISEASES OF THE DIGESTIVE SYSTEM. 



who are subject to such attacks have adenoids, the removal of which 
is frequently followed by their complete cessation. The crowing attacks 
of newly born infants are believed by Eustace Smith always to depend 
upon adenoids. I have not been able to satisfy myself upon this point. 
Other respiratory symptoms associated with adenoids are intractable 
coughs, frequently of a spasmodic character, without bronchial symptoms 
or signs; and persistent hoarseness, lasting for months or even years, 
and recurring every cold season. Both these conditions are often cured 
by the removal of the adenoids after all other treatment has been with- 




Fig. 56— Pigeon-breast due to adenoids of the pharynx. 



out effect. To these growths bronchial asthma also is very frequently 
due. Their relation to incontinence of urine is often an intimate one ; 
the two coexist in a large number of patients, and in a certain num- 
ber removal of the adenoids cures the incontinence. Headaches are very 
common; stammering may be present; chorea and even epileptiform 
seizures have been attributed to adenoids, although I have never seen 
either. 

The general health of patients suffering from adenoids may be im- 
paired from lack of oxygen due to obstructed respiration, from loss of 



ADENOID VEGETATIONS OF THE PHARYNX. 303 

sleep, and from confinement to the house, necessitated by attacks of 
bronchitis or head colds. Marked anaemia is often present. In old and 
neglected cases of a severe character, children may be stunted in growth, 
and their facial expression dnll and stupid. They are languid, listless, 
often depressed, and this with their deafness frequently causes them to 
be regarded in schools as children who are somewhat deficient mentally. 

These patients are always better in summer and worse in winter. 
The natural course of the growths if left to themselves is to increase up 
to a certain point, and then to remain stationary until puberty, when 
they usually undergo a certain amount of atrophy. This, with the 
marked increase in the capacity of the rhino-pharynx which occurs at this 
time, results in a disappearance of the most aggravated symptoms. A 
removal to an elevated region with a dry atmosphere will often result 
in a relief from all the symptoms, and a diminution in the size of the 
growth, but unless such a change in residence is permanent the symp- 
toms are liable to return. Under ordinary circumstances there is little 
or no tendency to spontaneous recovery. Children with adenoid growths 
contract diphtheria and tuberculosis more easily than do others, and in 
them attacks of diphtheria, scarlet fever, measles, and whooping-cough 
are all likely to be more severe. 

Diagnosis. — In a well-marked case the condition is usually evident 
from the history, and can scarcely be overlooked. The intractable nasal 
catarrh, upon which no treatment, local or general, has more than a tem- 
porary influence, the mouth-breathing; the disturbed sleep, and the 
slight deafness — all are characteristic. In some even of the marked 
cases, attention may be drawn to the larynx, bronchi, or ears as the seat 
of disease. At other times the patients come for treatment on account 
of the general symptoms — the nervous depression, the headaches, or the 
anaemia. In rare cases the leading symptom may be epistaxis. The 
symptoms do not always depend upon the size of the growth, for in a 
small throat quite a small growth may cause very marked symptoms. 

Although the history is in most cases clear, only an examination can 
make us certain that an adenoid growth exists. The best method of ex- 
amination consists in a digital exploration of the pharynx; but this 
requires a little practice before it is very satisfactory. The head is stead- 
ied by one hand, and the forefinger of the other is passed up behind the 
palate. The growth is ordinarily felt as an irregular, granular, soft, 
velvety mass, or sorr;etimes as a firm tumour completely blocking the 
passage; and the finger, when withdrawn, is almost invariably covered 
with blood. By anterior rhinoscopy, after the use of cocaine, the growth 
can often be seen. 

Treatment. — The disappearance of adenoid growths by absorption is 
possible only when they are small. This may be aided by the prolon 
use of guiaquin, one grain three times a day, or the syrup of the iodide 
21 



304 DISEASES OP THE DIGESTIVE SYSTEM. 

of iron, fifteen drops three times a day; but most of all by removal to 
a warm, dry climate for the winter season. All possible means should 
be employed to prevent these patients from taking cold, such as proper 
clothing, cold sponging, cod-liver oil, etc. With the larger growths these 
methods may improve the catarrhal symptoms, but can hardly affect 
the mechanical ones. The reduction of tumours of any considerable 
size by local applications is, I think, a delusion; every case that has 
come to my notice has been relieved only by operation. 

Eemoval of adenoid growths is indicated: (1) When the obstructive 
symptoms — habitual mouth-breathing, disturbed sleep, nasal voice, 
chest deformities, etc. — are marked; (2) for a chronic nasal discharge, 
constantly recurring head colds, particularly when these tend to attacks 
of bronchitis or laryngitis; (3) where there is asthma or repeated at- 
tacks of catarrhal spasm of the larynx; (4) with deafness, chronic 
otitis, or repeated attacks of acute otitis; (5) for certain nervous symp- 
toms — enuresis, stammering, chorea, headaches, night terrors, etc. Al- 
though striking improvement is not infrequent, one should be cautious 
about promising too much from operations where these nervous condi- 
tions exist; also in an older child when there is deafness or asthma. 

The preferable time for operation is the spring or early summer, 
in order that during the warm months the mucous membranes may have 
an opportunity to regain their normal condition; however, operation 
may be done at any time except during attacks of acute catarrh. Unless 
the symptoms are very marked, I prefer to defer operation until a child 
is at least two years old. 

Removal of adenoids by scraping with the finger nail is possible 
only when the growths are very soft; it is at best a very uncertain 
method, and is not to be advised. Except in the case of children under 
two or two and a half years old, where the growths are generally small 
and the patients easily handled, I prefer to operate with general anaes- 
thesia : first, for the sake of thoroughness ; secondly, to avoid the fright 
and pain which so bloody an operation is apt to cause in those who are 
older, and especially in very nervous children. So many deaths from 
operations for adenoids or tonsils under chloroform have now been re- 
ported (Hinkel in 1898 collected eighteen, and a number have since been 
added), and so many narrow escapes have occurred that have not been 
published, that chloroform anaesthesia should, I think, be given up alto- 
gether. My preference is for ether ; in older children it may with advan- 
tage be preceded by nitrous oxide, and sometimes with such patients the 
nitrous oxide alone may be used, but this is not to be advised with very 
young children. Deep anaesthesia is not usually necessary, and if the 
semi-erect position is assumed it increases the danger of the entrance of 
blood or portions of the growth into the larynx, which might cause fatal 
asphyxia. 



ADENOID VEGETATIONS OF THE PHARYNX. 305 

The only instruments required are a mouth-gag, like that used for 
intubation, and modified Gottstein's curettes, which should be sharp. 
The physician should have several sizes with different curves to suit the 
size and attachment of the growth and the capacity of the throat. Many 
of the instruments used for young children are too large, the smaller 
ones being more easily manipulated and less liable to do harm. 

If no anaesthetic is used, the patient's arms are pinioned to the side 
by two or three turns of a sheet around the body, the head firmly held 
by an assistant, upon whose lap the patient sits, as for the operation of 
intubation. With anaesthesia there is an advantage in using the sheet 
in the same way. During operation I prefer to have the patient raised 
to a little more than a half-reclining posture and the head firmly stead- 
ied. This position gives the operator a decided advantage over the 
low-head position, which is necessary when chloroform is used. After 
the introduction of the gag, the pharynx should be carefully explored 
with the finger to determine the size and position of the growth. The 
tongue is then depressed by the left forefinger, while with the right hand 
the curette is carefully passed high up behind the soft palate until it 
meets the nasal septum. The handle of the curette is grasped as one 
holds a pen. The cut is made with a downward movement, depressing 
the blade and elevating the handle of the curette, it being given a lever- 
like motion by the action of the wrist. When the curette is grasped 
with the entire hand, and the full arm used with simply a downward 
movement, the pharyngeal mucous membrane is often stripped down 
for some distance below the growth, but not cut off. Care should be 
taken to keep the blade well against the bony wall of the vault and pos- 
terior pharyngeal wall, and the handle in the median line, and not to 
employ too much force. The majority of the growths encountered in 
ordinary practice, such as Nos. 1, 2, and 3 in Fig. 55, can be removed 
with one sweep of the curette, the mass usually coming away in a single 
piece. Others may require the instrument to be used two or three times. 
The patient is now turned face downward until most of the haemor- 
rhage has ceased. Then the cavity should be explored with the finger 
to ascertain whether the removal has been complete. The forceps (Low- 
enberg's and various modifications) are quite unnecessary, and in un- 
skilled hands are capable of doing much harm. One unfamiliar with 
their use may easily tear away pieces of the uvula, soft palate, pharyn- 
geal wall, and even portions of the Eustachian tubes. 

The entire operation consumes in most cases less than a minute. 
Haemorrhage is always abundant, and seems alarming to one who sees 
it for the first time. In an average case it amounts to one or two 
ounces, but generally ceases in a few minutes. A child should not | 
from the physician's observation until all bleeding has stopped. It often 
happens that the patient swallows the growth, a disappointing but not 




306 DISEASES OF THE DIGESTIVE SYSTEM. 

a serious accident. The child should be kept quiet, preferably in bed, 
for twenty-four hours ; and in the house for five or six days, unless the 
weather is warm. No after-treatment is necessary, or at most a spray 
of a weak antiseptic solution. Recurrences are extremely rare, except 
after incomplete operations, such as those performed with the finger 
nail, etc. The improvement is usually in proportion to the severity of 
the previous symptoms. It generally begins in a few days, sometimes 
at once, though the full benefit may not be seen for a month. The 
breathing becomes freer, the sleep more quiet; the mouth may soon be 





Before operation. Three months after operation. 

Figs. 57 and 58. — Adenoid vegetations of the pharynx; girl twelve years old. (Hooper.) 

habitually closed; voice and hearing improve, and the benefit to the 
general health is soon apparent. The pallor, listlessness, and inattention 
disappear, and a rapid increase in weight often follows. The entire ap- 
pearance of the child may in a few months be transformed (Figs. 57, 58). 
Dangers and Accidents from Operation. — While it is rare that any 
accidents of a serious nature are met with, it should not be forgotten that 
they may occur. Undue laceration of the parts may result from a bun- 
gling operation particularly with too large curettes or with the forceps. - 
Haemorrhage may be excessive or even fatal. In over two hundred oper- 
ations I have had but one case of serious haemorrhage. A fatal result is 
exceedingly rare. Newcomb in 1893 could find but four examples. 
Haemorrhage may be continuous after operation, or secondary, in which 
case it almost invariably occurs within twenty-four hours. It is impor- 
tant, therefore, that the patient be kept under observation for that 
time. Bleeding is best controlled by injecting into the rhino-pharynx 
through the nostrils one or two drachms of hydrogen peroxide, full 
strength, or, this failing, a solution of suprarenal extract may be used in 



DISEASES OF THE TONSILS. 307 

the same manner. As a last resource plugging of the posterior nares 
may be resorted to. In all cases the patient should be kept absolutely 
quiet. 

Occasionally an acute attack of bronchitis or otitis occurs after oper- 
ation ; and in a few recorded instances acute meningitis, simple or tuber- 
culous, has followed. The danger of asphyxia from the entrance of blood 
or the tumour into the larynx has already been mentioned. 

The danger from chloroform anaesthesia is due not so much to the 
nature of the operation as to the condition of the patient. It is now 
well established that all children in whom the condition known as lym- 
phatism is marked, bear chloroform very badly. 



CHAPTEE III. 
DISEASES OF THE TONSILS. 

The tonsils * are lymphoid structures closely resembling Peyer's 
patches, but, instead of having a flattened surface, the lymphoid tissue in 
the tonsil is folded upon itself, forming quite deep depressions — the ton- 
sillar crypts. These crypts, like the surface of the tonsils, are lined by 
epithelial cells. They contain lymphoid cells, desquamated epithelium, 
particles of food, and bacteria. Under normal conditions the tonsils 
take no part in absorption from the mouth. When, however, their epi- 
thelium is rarefied or removed, the tonsils absorb with very great facility 
every sort of poison which the mouth may contain. Such poisons are 
taken up by the lymphatics, and through them reach the general circu- 
lation. 

Acute inflammation of the tonsils, like that of the pharynx, occurs 
regularly in diphtheria, scarlet fever, and measles, less frequently in the 
other infectious diseases. The secondary forms will be considered with 
the diseases with which they are associated. 

Acute catarrhal tonsillitis, or inflammation of the mucous membrane 
covering the tonsils, occurs as part of the lesion in acute pharyngitis, 
but very rarely is seen alone. 

Croupous Tonsillitis. — This is a more severe form of inflammation 
than catarrhal tonsillitis. It involves the mucous membrane of the ton- 
sils, the tonsillar crypts, and to a greater or less degree the whole struc- 
ture of the tonsil. Fibrin is poured out upon the surface in sufficient 
quantity to form a distinct pseudo-membrane, which usually covers the 

* See Hodenpyl, American Journal of the Medical Sciences, March, 1891, on Anat- 
omy and Physiology; Packard, Philadelphia Medical Journal, April 21, 1900, on In- 
fection through the Tonsils. 



308 DISEASES OF THE DIGESTIVE SYSTEM. 

tonsils, but in primary cases it does not extend beyond them. In most 
cases both sides are affected. The exudation sometimes begins in iso- 
lated dots, like a follicular tonsillitis, which afterward coalesce to form 
a continuous patch. The membrane is usually of a yellowish gray col- 
our. It can often be completely removed with the swab. The constitu- 
tional symptoms are generally marked and resemble those of follicular 
tonsillitis. 

The disease is differentiated with certainty from diphtheria only by 
means of cultures, which should be made in every case. (See Diagnosis 
of Diphtheria.) Croupous tonsillitis is nearly always due to the strep- 
tococcus. Though never severe when it occurs as a primary affection, 
it may be very serious when it is secondary to measles or scarlet fever. 
Its clinical features are more fully considered under the head of Pseudo- 
diphtheria. 

Ulcero-membranous Tonsillitis. — This is an inflammation somewhat 
resembling croupous tonsillitis, but it is often unilateral and associated 
with superficial ulceration. The tonsil is covered with a dirty yellowish 
exudation, which may be mistaken for diphtheria. There is superficial 
necrosis, and when this tissue is wiped away with a swab, bleeding occurs. 
The disease is further distinguished by the swollen lymph nodes at the 
angle of the jaw, and by the fact that the constitutional symptoms which 
accompany other forms of tonsillitis are either very slight or absent alto- 
gether. The pathological process is similar to, if not identical with, 
ulcerative stomatitis (see page 284), with which it is sometimes asso- 
ciated. At such times the breath is foul and there is often profuse sali- 
vation. 

Ulcero-membranous tonsillitis was first described by Vincent,* and 
by him attributed to a fusiform bacillus, which he described, although a 
spirillum was found associated with it. Vincent's observations have 
since been confirmed by a number of writers, f 

The chief interest in ulcero-membranous tonsillitis lies in the diag- 
nosis, although it is not an infrequent disease. It is to be treated, like 

* La Presse Medicale, March 12, 1896. 

+ See Sobel and Herrmann, New York Medical Journal, December 7, 1901, for 
recent literature. 

Vincent's bacillus is described as about twice as long as the Klebs-Loeffler bacillus. 
It is thin, with pointed ends, and sometimes bent ; it is negative to Gram, and has not 
yet been isolated in pure culture, although Vincent was able to make it grow in 
bouillon with other organisms from the mouth. It is not yet determined whether the 
disease is due to the fusiform bacillus alone, or that the spirillum plays any part; the 
spirillum may possibly be merely a morphological variation of the bacillus. The 
fusiform bacillus is occasionally found alone ; the spirillum, never alone. The bacillus 
is found in smears from an affected tonsil, in making which it is recommended to go 
deeply into the necrotic tissue, since the superficial parts are crowded with other 
bacteria. 



FOLLICULAR TONSILLITIS- 309 

ulcerative stomatitis, by the internal administration of chlorate of pot- 
ash, combined with the local use of some antiseptic, such as peroxide of 
hydrogen or nitrate of silver. 

FOLLICULAR TONSILLITIS. 

This is the most frequent and most characteristic form of inflamma- 
tion of the tonsil. It is essentially an inflammation of the tonsillar 
crypts, and secondarily of the whole glandular structure. 

Etiology. — There is seen in certain children a predisposition to at- 
tacks of tonsillitis, so that from very slight exciting causes these occur — 
sometimes from exposure, sometimes from derangement of the stomach, 
and sometimes without any evident reason. Children with a rheu- 
matic inheritance appear to be more susceptible than others. One at- 
tack predisposes to a second. Patients suffering from chronic hyper- 
trophy of the tonsils are exceedingly prone to acute tonsillitis. It is not 
very common in infancy, but after this period it is very frequent through- 
out childhood. The disease, in all probability, begins as an infectious 
inflammation at the bottom of the crypts, due to the presence of strep- 
tococci or staphylococci, which readily enter from the mouth, and excite 
an attack whenever favourable conditions are present. 

Lesions. — As a result of the inflammation, the tonsillar crypts are 
filled with epithelial cells, pus cells, mucus, and bacteria. These form 
masses which appear at the mouth of the crypts as small yellow dots, 
often miscalled ulcers. Sometimes, in addition, fibrin is poured out, and 
forms, with the other inflammatory products, little plugs which project 
somewhat from the surface of the mucous membrane, and which can 
easily be pressed out. Accompanying the changes in the mucous mem- 
brane above mentioned, there are acute congestion and swelling of the 
whole tonsil, with more or less proliferation of the lymphoid tissue. Fol- 
licular tonsillitis is always bilateral. Although the pathological process 
is generally limited to the tonsils, there may be more or less pharyngitis 
associated. 

Symptoms. — The general symptoms usually appear before the local 
ones, and are often quite severe. The onset is abrupt, with chilly sensa- 
tions, occasionally a distinct rigour. In infants there is often vomiting, 
and sometimes diarrhoea. There is pain in the back, in the muscles of 
the extremities, and in the head. Sometimes there is pain in the lateral 
cervical muscles. The temperature rises rapidly to 102° or 103° P.; 
often it touches 104° or 105° F. 

The first local symptoms are some swelling of the tonsils and the ap- 
pearance of isolated yellow spots a little larger than a pin's head. Often 
these can be wiped off with a swab, or the little plugs can be squeezed 
out, leaving slight depressions. Later there is acute congestion of the 
tonsil, with more swelling. Even when the disease is at its height the 



310 DISEASES OF THE DIGESTIVE SYSTEM. 

local pain and discomfort are only moderate, and in many cases scarcely 
noticeable. The swelling and tenderness of the lymph glands behind the 
angle of the jaw are not great, and may be absent. 

The constitutional symptoms, as a rule, last three days, and are most 
severe upon the first day. The local symptoms last somewhat longer, but 
usually by the end of the fourth day the exudate has disappeared, although 
enlargement of the tonsil may persist for a week or even longer. On ac- 
count of the connection of tonsillitis with rheumatism, the heart should 
be watched during attacks, especially in those who are subject to them. 

Diagnosis. — Tonsillitis may be confounded at its onset with scarlet 
fever. Its constitutional symptoms in the beginning closely resemble 
malaria, influenza, or pneumonia. The great frequency of tonsillitis 
makes inspection of the throat imperative in every case of acute illness 
in children. The diagnosis from diphtheria is considered in connection 
with that disease. 

Treatment. — Follicular tonsillitis is a mild disease without danger to 
life, and one which runs a short, self-limited course. The indications 
are, therefore, to make the patient as comfortable as possible by the relief 
of individual symptoms. Older children, particularly those who are 
rheumatic, should be treated with sodium salicylate, four grains every 
three hours being given for the first twenty-four hours, and later less 
frequently. In infants this drug must be given in smaller doses and 
with care, lest it upset the stomach. The general muscular pains of the 
first day are best relieved by phenacetine, two grains every four hours 
to a child three years old. Later it may be used in smaller doses, but 
enough should be given to make the patient comfortable. 

Local treatment is better omitted in infants. Older children may 
gargle with a solution of boric acid or weak bichloride (1 to 10,000). 
Benefit often follows painting the tonsils with tincture of iodine or a 
ten-per-cent solution of silver nitrate. In all doubtful cases the patient 
should be isolated and the same treatment adopted as in diphtheria. 

PHLEGMONOUS TONSILLITIS— PERITONSILLAR ABSCESS— QUINSY. 

This is an inflammation of the cellular tissue surrounding the tonsil, 
sometimes invading the tonsil itself. It may terminate in resolution, but 
usually goes on to the formation of an abscess. Phlegmonous tonsillitis 
is much less common in children than in adults, and, compared with the 
other forms, it is a rare disease in early life. It is the only variety which 
is regularly unilateral. In most cases the inflammatory process is cir- 
cumscribed, but in rare instances there is seen a diffuse phlegmonous 
inflammation of the pharynx. 

In certain patients there exists a constitutional predisposition to the 
disease, which is often associated with rheumatism. The exciting cause 
may be exposure, or anything which may reduce the patient's general 



PHLEGMONOUS TONSILLITIS. 311 

health, to which there is added local infection. Catarrhal pharyngitis 
predisposes to this disease. 

Symptoms. — The onset resembles that of follicular tonsillitis, except 
that the general symptoms are usually less marked, the temperature is 
commonly not so high, and the muscular pains and prostration less se- 
vere. The local symptoms, however, are more striking. There is very se- 
vere pain in the throat, which is increased by deglutition, and finally may 
be so great that swallowing is almost impossible. It is difficult to open 
the mouth. There is pain in the lateral muscles of the neck, and often 
tenderness. In the beginning but little can be seen on inspection, even 
though the patient complains of a very sore throat. This is always a 
suspicious circumstance, and should lead one to look out for quinsy. It 
is due to the fact that the inflammation begins in the deeper tissues, 
and that the mucous membrane is affected later. After twenty-four or 
forty-eight hours there is usually quite marked swelling, which is rather 
more behind the tonsil than elsewhere, pushing it upward and forward; 
sometimes it is more in front of the tonsil. A little later there is in- 
tense inflammation of the mucous membrane covering the tonsil, fauces, 
and uvula, with marked congestion and oedema; the uvula may be pushed 
to one side, and the isthmus of the fauces diminished to less than one 
half its natural size. In one of my own cases marked torticollis was 
present, and existed for two or three days before the diagnosis of quinsy 
could be made by the other symptoms. 

In most cases the recognition of quinsy is quite easy by attention to the 
symptoms above mentioned. By inspection of the throat, less information 
is sometimes obtained than by palpation ; by this means a fulness, and 
later a point of fluctuation, can readily be made out. Acute phlegmonous 
tonsillitis generally involves no danger to life. In very young infants 
serious results may follow spontaneous rupture during sleep ; and in 
older children occasionally there may be oedema of the glottis. If not 
treated, abscess usually forms in from five to seven days, and opens spon- 
taneously. 

Treatment. — If an early diagnosis is made an attack of quinsy may 
occasionally be aborted. For this many drugs have been advocated, but 
to my mind the best is salol, which should be given in doses of two 
grains every two hours to a child of five years. In some patients larger 
doses may be used. This may be combined with small doses (gr. J) of 
Dover's powder. Relief may be afforded by very hot or cold applications, 
according to the sensations of the patient. The holding of ice in the 
mouth and the application of an ice-bag externally, often give great com- 
fort. In other cases, gargling with very hot water and the application of 
hot flaxseed poultices externally, will be preferred. As soon as fluctuation 
is detected an incision should be made with a guarded bistoury. If made 
too early, only a small amount of pus is evacuated and the abscess may 



312 DISEASES OF THE DIGESTIVE SYSTEM. 

refill. After spontaneous rupture the relief to symptoms is usually im- 
mediate. 

CHRONIC HYPERTROPHY OP THE TONSILS.— CHRONIC TONSILLITIS. 

The condition known as chronic hypertrophy, is a permanent enlarge- 
ment due to a proliferation of the lymphoid tissue of the tonsils, and an 
increase in the connective-tissue stroma. If the increase in the connective 
tissue is slight, the tonsil is soft ; if it is great, the tonsil is firm and hard, 
almost like a fibrous tumour. All degrees are found. Associated with 
hypertrophy of the tonsils there are frequently found adenoid growths of 
the pharynx, both of these depending upon similar local and constitu- 
tional conditions. There is in nearly all marked cases a chronic pharyn- 
geal catarrh which may involve the Eustachian tubes. 

Etiology. — Hypertrophy of the tonsils is an exceedingly common con- 
dition in the cities of the seacoast and lake districts of the temperate 
zone. In a routine examination of 2,000 New York school children, 
Chappell found enlargement of the tonsils sufficiently marked to be con- 
sidered pathological, in 270 cases. The causes are constitutional and local. 
The constitutional causes relate to the conditions described in the chapter 
upon Lymphatism. This is often found in certain families for several 
generations. The condition is not connected with tuberculosis. It oc- 
curs in children who are in other respects healthy. Hypertrophy of the 
tonsils is often a congenital condition, increasing slowly during infancy, 
so as to produce marked symptoms by the time the child is two years old. 
The most important of the local causes are attacks of acute or subacute 
pharyngitis. While it is true that attacks of acute inflammation are often 
the cause of hypertrophy, it is also true that hypertrophy is one of the 
most frequent predisposing causes of acute attacks, and that it may be 
seen in children who have never had tonsillitis. 

Symptoms. — Hypertrophy of the tonsils is rarely marked enough to 
cause any decided symptoms before the end of the second year, although 
I once saw in a younger child enlargement sufficient to bring the two ton- 
sils into contact. The most important local symptoms, formerly ascribed 
to hypertrophied tonsils, are now known to depend upon adenoid growths 
of the pharynx. As these conditions are so frequently associated, it is 
somewhat difficult to determine which symptoms are due to the tonsils 
alone. In a marked case, the most prominent symptoms are mouth- 
breathing, disturbed sleep accompanied by snoring, and nasal voice — the 
patient in some cases talking as though he had food in his mouth. There 
may be some difficulty in swallowing solid food. Enlarged tonsils may 
often be felt externally. As a consequence of the obstruction of the 
Eustachian tubes there may be deafness. Deformities of the chest, such 
as pigeon-breast, are occasionally seen, but probably depend more upon 
obstructed respiration by adenoids than by the tonsils. 



CHROMC HYPERTROPHY OF THE TONSILS. 313 

The soft tonsils may diminish somewhat in size spontaneously. They 
sometimes shrink very decidedly after an attack of acute tonsillitis, scar- 
let fever, or diphtheria. As a rule the tonsils become firmer and harder 
as time passes. They usually increase in size up to a certain point, and 
then remain nearly stationary until about puberty, when they may 
diminish considerably. During intercurrent attacks of inflammation, the 
swelling is much increased, and the symptoms are proportionately aggra- 
vated. In cases of marked enlargement very little spontaneous improve- 
ment is to be looked for during childhood. 

Treatment. — Very large tonsils are a source of continued danger to 
the patient, and in every case of marked hypertrophy treatment should 
be advised. The danger may be from Eustachian catarrh and deafness, 
or from repeated attacks of acute tonsillitis. But quite as important as 
these is the fact that they increase the liability to contract diphtheria, 
and add to the dangers both from diphtheria and scarlet fever. If the 
patient is removed from the locality in which acute tonsillitis is liable to 
occur, to a dry climate, considerable improvement is likely to result in 
a young child in whom the tonsils are soft, but not much is to be ex- 
pected in older children with hard, fibrous tonsils, except, perhaps, a 
cure of the accompanying pharyngeal catarrh. 

The only internal remedy offering much chance of benefit is, in my 
experience, the syrup of the iodide of iron, which must be given in quite 
large doses (twenty drops three times a day to a child of five years), and 
continued for several months. In a small number of cases marked im- 
provement is seen from this treatment, but in the majority but little 
change occurs. Astringent applications may accomplish something in 
recent, but practically nothing in old cases. In a marked case, operation 
is the only thing which can be relied upon to effect a cure. In those in 
which it is decided not to operate, or in which operation is refused, a 
faithful trial may be made with the other measures referred to. The 
question to be decided always is whether or not operation shall be done. 
For convenience of consideration, the cases may be divided into three 
groups: (1) those in which the tonsils are nearly or quite in contact; (2) 
those in which they project not more than one fourth of an inch beyond 
the faucial pillars; (3) the intermediate cases. All of the first group 
should unquestionably be operated upon, unless the patient's general con- 
dition is such as to forbid operation of any kind. Of the second group, 
few if any require operation. Whether an operation is done in the third 
group will depend upon the individual case. If there are frequent attacks 
of acute tonsillitis, and some deafness, an operation should be performed. 
If little or no local discomfort is experienced it may be postponed. 

Of the various operations proposed, excision with the guillotine is the 
one which has in children superseded all others in the practice of New 
York physicians. The risk of haemorrhage at this age is very slight. 



314 DISEASES OF THE DIGESTIVE SYSTEM. 

The child is held as for the operation of intubation, except that the head 
is thrown backward. No after-treatment is required, excepting fluid diet 
and confinement to the house for two or three days. Excessive haemor- 
rhage may be controlled by digital pressure, or by the application of 
styptic cotton upon a swab ; in extreme cases, by transfixing the tonsil 
stump with a hare-lip pin and the application of a ligature. I have more 
than once seen physicians greatly alarmed at the gray wound on the day 
following tonsillotomy, the appearance being such as to lead in several 
cases to the diagnosis of diphtheria. This mistake will not be made if 
the possibility of it is borne in mind. It is seldom that any but good 
results follow the operation of tonsillotomy if properly performed. It is 
too often neglected. Where adenoids of the pharynx are- also present, the 
symptoms may depend more upon them than upon the enlarged tonsils, 
and little benefit is seen until the adenoid growths also are removed. 
Both may be operated upon at a single sitting, or at two sittings if pre- 
ferred. 

It is not usually necessary to remove the tonsil to a point even with the 
faucial pillars, but the more nearly we can come to this the better. The 
amount of shrinkage from cicatrization after operation has been, in my 
experience, generally less than was expected. As a rule, enlargement 
of the tonsil subsequent to an operation is not seen ; but one should be 
careful about promising parents that it will not occur. I have seen it in 
two or three instances to a striking degree, and think it more likely to 
occur if children operated on are very young — i. e., under three years. 



CHAPTER IV. 
DISEASES OF THE (ESOPHAGUS. 

MALFORMATIONS. 

Congenital anomalies of the oesophagus. are much less frequent than 
those of the lower part of the respiratory tract, with which, however, they 
are often associated. 

There may be, (1) Congenital fistula of the neck, due to a want of 
closure between the second and third branchial arches. This gives an 
external opening just above and to the outside of the sterno-clavicular 
articulation, which communicates with the upper part of the oesophagus 
or the lower part of the pharynx. (2) The oesophagus may be absent, 
the pharynx ending in a blind pouch. (3) The oesophagus may be oblit- 
erated in certain portions, being represented only by a fibrous cord. (4) 
There may be stenosis and dilatation or diverticula. (5) There may be a 



ACUTE OESOPHAGITIS. 315 

fistulous communication with the trachea, existing either alone or asso- 
ciated with some of the other deformities mentioned. 

Congenital narrowing of the oesophagus and fistula of the neck are 
amenable to surgical treatment. The cases of complete obstruction in the 
oesophagus are almost of necessity fatal, the patients dying from inanition 
two or three days after birth. 

The symptoms of oesophageal obstruction are regurgitation on attempts 
at swallowing and the impossibility of passing the stomach tube. 

ACUTE (ESOPHAGITIS. 

It is quite remarkable, considering the frequency of pathological pro- 
cesses in the pharynx, that these so rarely extend to the oesophagus. 
Thrush, when very extensive in the pharynx, may "involve the upper part 
of the oesophagus ; but there it gives rise to new symptoms. Diphtheria 
and pseudo-diphtheria of the pharynx may invade the oesophagus, but 
this is seen only in very rare instances. In about seventy-five autopsies 
which I have seen in cases of diphtheria, the oesophagus was involved in 
but one, and in this case for three or four inches only. Diphtheria of 
the oesophagus produces no symptoms, and can not be diagnosticated dur- 
ing life. 

Catarrhal Oesophagitis is very rarely met with. It may be caused by 
lacerations due to swallowing a foreign body, which may excite a simple 
catarrhal inflammation, or, if the foreign body is sharp and angular, 
lacerations may be produced which result in ulcerations of variable depth. 
The chief symptoms of catarrhal oesophagitis are soreness and pain on 
swallowing. These lacerations, when slight, are healed in a few days, and 
are rarely followed by any after-effects. 

Corrosive (Esophagitis. — This is altogether the most frequent form, 
and the only one which is of clinical importance. The usual causes are 
the same as of corrosive gastritis, viz., the swallowing of caustic alkalies or 
strong acids. It is often in the oesophagus that the most extensive injury 
is done. The effects are superficial or deep, according to the amount 
of the irritant swallowed and its degree of concentration. There may 
be simply a destruction of the epithelial layer, which is followed by no 
serious consequences, or the mucous membrane may be destroyed and the 
submucous coat invaded ; rarely, however, does the injury extend to the 
muscular layer. If the patient survives the dangers incident to the 
irritant poisoning and the acute inflammation which follows, healing by 
granulation and cicatrization takes place, the contraction of the cicatrix 
gradually narrowing the lumen of the oesophagus until stricture is pro- 
duced. 

The early symptoms of corrosive oesophagitis are mingled with those 
of inflammation of the mouth, pharynx, and stomach. There is a burn- 
ing pain in the parts, great thirst, spasm of the oesophagus on attempts at 



316 DISEASES OF THE DIGESTIVE SYSTEM. 

swallowing. There follows a period of acute inflammation of several 
days' duration, with great dysphagia and pain, and in which the principal 
danger is oedema of the glottis. After this the patient may be compara- 
tively well until the symptoms of stricture begin, usually in from three 
to six months after the injury. 

The indications for treatment in the early stage, are to neutralize the 
caustic in order to prevent if possible its deep action, and to give oils, 
demulcent drinks, and ice for the local effect, and morphine for the pain. 

The treatment of oesophageal stricture is purely surgical. 

RETRO-CESOPHAGEAL ABSCESS. 

Acute retro-oesophageal abscess occurs in infancy, though very rarely, 
the pathology being the same as in acute retro-pharyngeal abscess, the 
difference being merely one of location. A striking case of this kind 
occurred in the New York Foundling Hospital in 1904. An infant six 
months old was admitted with high fever (104° F.), severe dyspnoea, 
but with no loss of voice, which were the prominent symptoms until 
death occurred four days later. There was a leucocytosis of 100,000. 
At autopsy an abscess was found containing about three ounces of pus 
between the oesophagus and the spine, extending from the larynx to below 
the bifurcation of the trachea. Shortly afterward I saw a very similar 
case at the Babies' Hospital, following a retro-pharyngeal abscess which 
had been opened two weeks before. Similar abscesses have also been 
observed after acute pharyngitis with the acute infectious diseases. 

Retro-cesophageal adenitis, or enlargement of the lymph nodes in 
this situation without suppuration, is also rare. I once met with a case 
of this sort in which the gland formed a tumour nearly an inch in diam- 
eter at the upper part of the oesophagus, causing pressure symptoms 
necessitating tracheotomy. The growth was at first thought to be malig- 
nant, but completely disappeared after a summer in the country. 

Retro-oesophageal abscess may result from the breaking down of 
tuberculous lymph nodes in the posterior mediastinum, and may give rise 
to symptoms like those which result from an abscess due to Pott's disease. 

Perforation of the oesophagus and a food-fistula connecting the oeso- 
phagus and the trachea, may result from ulceration caused by a tracheal 
canula or by a foreign body. This may be accompanied by abscess. 

The most common variety of retro-cesophageal abscess is that due to 
Pott's disease of the lower cervical or upper dorsal region. The symp- 
toms are obscure, and an exact diagnosis is not often made during life. 
Death may occur quite suddenly where the previous symptoms have been 
so slight as to be easily overlooked. The following is a fair example: 

A girl two years old was admitted to the Babies' Hospital with caries 
of the upper dorsal region of two months' duration. The patient was 
kept in bed and a plaster-of-Paris jacket applied. About a month later 



. RETRO-CESOPHAGEAL ABSCESS. 317 

dyspnoea was first observed ; this was at times quite intense, and again 
almost absent. It was always on inspiration, expiration being easy. No 
explanation for this was found in the lungs. There was no difficulty in 
swallowing, and very little cough. After these symptoms had lasted for 
about a week, the child while eating was suddenly seized with violent 
dyspnoea, and in a few moments became completely asphyxiated. Trache- 
otomy was immediately done, and by means of artificial respiration the 
patient was restored to comparative comfort. About two hours later a 
second attack occurred, and the patient died in an hour. At the autopsy 
there was found an abscess a little larger than a hen's egg, containing 
about two ounces of curdy pus, overlying the bodies of the first three 
dorsal vertebrae and communicating with them. These vertebras were 
carious. The right pneumogastric nerve, an inch and a half above the 
bifurcation of the trachea, was compressed between the abscess and a 
large tuberculous lymph node, with the capsule of which it was blended. 
In the lungs were a few small tuberculous deposits and the usual condi- 
tions found in death by asphyxia. The dyspnoea seems to have been of 
nervous and not of mechanical origin, and caused by irritation of the 
pneumogastric. The fatal issue was apparently from an increase of the 
pressure upon the nerve. 

I have seen but one other case, and this closely resembled the one 
reported. Griffith has collected (Archives of Paediatrics, January, 1898) 
twelve cases from the literature, and added one of his own. The symp- 
toms in all were much alike. Dyspnoea, usually of a spasmodic character, 
was prominent in nearly all, and generally it was the most marked symp- 
tom. It was more marked on inspiration, and often accompanied by a 
spasmodic cough, suggesting laryngeal stenosis. The voice was affected 
in but two cases, in one complete aphonia being present. It is striking 
that in no case was there any difficulty in swallowing, in marked contrast 
to retro-pharyngeal abscess. Swelling in the neck was noted in but three 
cases. Spinal caries was stated to be present in seven cases and absent in 
two. The final attack of asphyxia sometimes came without warning, 
sometimes was preceded for several days or longer by milder attacks. 

The diagnosis of this condition is very difficult, and a positive diag- 
nosis almost impossible. It may be suspected in cases of Pott's disease of 
the lower cervical or upper dorsal regions, when there is spasmodic inspir- 
atory dyspnoea, especially if accompanied by irritative cough. It should, 
"however, be remembered that precisely similar symptoms may depend 
upon the irritation of a tuberculous node, and that the sudden asphyxia is 
exactly like that caused by the ulceration of such a node into the trachea 
or a large bronchus. The latter, however, may occur without the pres- 
ence of Pott's disease. If the abscess is higher up, there may be a lateral 
swelling on either side of the neck, just above the clavicle. In most of 
the cases there are no external signs of disease. Such abscesses are too 



318 DISEASES OF THE DIGESTIVE SYSTEM. 

low to be reached by digital examination of the pharynx. The attack 
of asphyxia may also be confounded with that due to the presence of a 
foreign body in the larynx. 

The prognosis in cases of retro-oesophageal abscess is exceedingly bad. 
Death usually results from pressure upon the pneumogastric, as in the 
cases reported. The abscess may rupture into the oesophagus and recov- 
ery follow. This termination is very rare, but such a case has been re- 
ported by Knight. A fatal one is reported by Loschner and Lambl. The 
abscess may burrow along the oesophagus into the abdominal cavity and 
excite peritonitis ; finally, it may open externally. 

But little is to be said under the head of Treatment. The symptoms 
are rarely definite enough to justify a radical surgical operation. Trache- 
otomy gives but temporary relief to the asphyxia. This operation should 
be performed, however, in every case, because of the impossibility of 
making a diagnosis of retro-oesophageal abscess from other conditions 
in which the operation might be curative. 



CHAPTEE V. 
DISEASES OF THE STOMACH. 

It is difficult wholly to separate diseases of the stomach from those 
of the intestines. Although in older children they are often quite dis- 
tinct, in infancy they are more frequently associated; but at one time 
the gastric symptoms may be prominent, and at another the intestinal 
symptoms. Functional disorders particularly are likely to involve the 
whole tract. Serious organic lesions are more frequently limited in 
their extent either to the stomach or to the intestine. The former are 
rare, while the latter are very common. The diseases in which the stom- 
ach is alone or chiefly involved will be considered by themselves. Those 
in which both the stomach and intestine are involved are classed with 
the intestinal diseases, as the intestinal symptoms usually predominate. 

DIGESTION IN INFANCY. 

The first step in the process of digestion in the newly-born infant is 
sucking. During this act the nipple is grasped between the lower lip and 
tongue below, and the upper lip and jaw above. The back of the mouth 
is closed by the fall of the palate. A strong downward movement of the 
lower jaw rarefies the air in the mouth, and produces the suction force 
which causes the milk to flow. Sucking can be carried on only when the 
nose is free for respiration and the palate and upper jaw intact. Children 
with deformities of the mouth, like cleft palate and harelip, suck only 



PLATE VII 




* 



DIGESTION IN INFANCY. 



319 



with the greatest difficulty, and complete nasal obstruction prevents 
nursing. 

The Saliva. — This is present at birth only in very small quantity, and 
the part which it plays in digestion in early infancy is an insignifi- 
cant one. During the third and fourth months it increases markedly in 
amount, and at this time it possesses quite actively the power of trans- 
forming starch into sugar. This property is present only to a very slight 
degree during the first eight or ten weeks. With the advent of the teeth 
there is a further increase in the amount of saliva secreted, indicating a 
change in the digestion of the infant. 

The Stomach. — The position of the stomach in the foetus is nearly 
vertical. In the newly-born child it lies obliquely in the abdomen, and 
at the end of infancy has almost reached the transverse position. The 
stomach at birth is nearly cylindrical, but the fundus increases in size 
very rapidly during the first year, although it does not reach its full de- 
velopment until quite late in childhood. In Plate VII are shown the 
actual size and shape of the stomach at the various periods of infancy. 
In the following table are given the results of post-mortem measure- 
ments of the stomach, which I have personally made in ninety-one in- 
fants under fourteen months of age : 



The Capacity of the Stomach. 



Age. 



Birth. . 
2 weeks 
4 " 
6 " 
8 " 
10 " 



Number 


Average 


of cases. 


capacity. 


5 


l-20oz. 


7 


1-50 " 


4 


2-00 " 


11 


2-27 " 


4 


3-37 " 


2 


4-25 " 



Age. 



12 weeks 

14 to 18 weeks 
5 to 6 months 
7 to 8 
10 to 11 " 
12 to 14 " 



Number 
of cases. 



12 

14 
9 

7 
10 



Average 
capacity. 



4-50 OZ. 
5-00 " 
5-75 " 
6-88 " 
8-14 " 
8-90 " 



In brief, the average capacity was, at birth, one and one fifth ounce ; 
at three months, four and a half ounces ; at six months, six ounces ; at 
twelve months, nine ounces. 

Gastric digestion. — The part taken by the stomach in digestion is 
smaller than was formerly supposed, and not so important in infants as in 
adults. The food leaves the stomach so rapidly that a large part of the 
casein must pass into the intestine before it is converted into peptones. 
The opinion has been steadily gaining ground that the function of the 
stomach is largely that of a reservoir, into which the milk is received and 
from which it is allowed to pass gradually into the intestine ; and that the 
gastric process is only a preliminary and partial one, even in the digestion 
of proteids, this being completed in the intestine. 

The only part of the food acted on in the stomach is the proteids, 
which are transformed successively into acid-albumin, albumoses, and 
peptones. This is accomplished by the agency of the pepsin and the acid 



320 DISEASES OF THE DIGESTIVE SYSTEM. 

of the gastric juice — generally hydrochloric acid, although lactic acid 
may take its place. Pepsin is found in the stomach at birth, and even in 
the embryo as early as the fourth month (Kriiger). The reaction of the 
stomach contents in fasting is acid, and at this time usually free hydro- 
chloric acid can be demonstrated ; soon after a meal of human milk it is 
alkaline or neutral ; after one of cow's milk it is acid or neutral. In fif- 
teen minutes after feeding the reaction is always acid (Leo). Free 
hydrochloric acid can not usually be demonstrated until about an hour 
after feeding, then only in small quantities, and in very many cases not 
at all. Some good observers go so far as to say that in health free acid 
is never found during digestion. The reason for this apparently is, that 
the acid combines with the casein of the milk, that of cow's milk in par- 
ticular having a very great power of combining with hydrochloric acid. 

Lactic acid is feebler in its digestive power than hydrochloric acid. 
It is more abundant early in infancy than later; it is derived from the 
milk sugar. It is rarely found as free acid; never in health, according 
to many observers. 

The coagulation of milk in the stomach is accomplished through the 
agency of the rennet ferment (the lab-ferment of Hammarsten). This is 
independent of both the pepsin and the acid of the stomach. It acts in 
acid, alkaline, and neutral media. Coagulation is the first change in the 
milk in the stomach. Human milk coagulates in loose flocculi and quite 
imperfectly, more firmly if the stomach is very acid. Cow's milk, unless 
diluted, coagulates in firm, compact masses. Under the influence of pep- 
sin and hydrochloric acid, solution of this coagulum now begins ; but this 
is only partially accomplished in the stomach. It goes forward much 
more rapidly in the case of human milk, because the amount of casein 
is less and because of the smaller curds. The milk begins to leave the 
stomach very soon after the meal, and even during the first half hour 
a considerable part passes into the intestine. At the end of an hour 
the stomach in a young infant is often empty. In the case of cow's milk, 
not only are the coagula firmer, but the amount of casein present is 
much larger, and hence the milk is detained in the stomach a longer 
time ; even then a considerable portion of it must pass but little changed 
into the intestine. 

The duration of gastric digestion varies with the age of the infant 
and with the food. During the first month the stomach of healthy 
nursing infants is usually found empty in an hour and a half after feed- 
ing; often in one hour. In those taking cow's milk the average is at 
least half an hour longer. In infants from two to eight months old 
the average is two hours for those receiving breast-milk, and two and a 
half to three hours for those fed upon cow's milk. This is influenced by 
the size of the meal taken. This period is very much longer in all cases 
of disordered digestion. 



DIGESTION IN INFANCY. 321 

The bacteria of the stomach are very few as compared with those of 
the intestine, and no varieties are constantly present (Booker). 

The Intestines. — The length of the small intestine at birth is about 
nine feet; that of the large intestine about eighteen inches. The great 
length of the sigmoid flexure is the most striking peculiarity, this being 
nearly one half the length of the large intestine. , 

Intestinal digestion. — All the important elements of food — proteids, 
carbohydrates, and fats — are acted upon by the pancreatic juice. The 
proteids are converted into peptones by the trypsin, which is active only 
in an alkaline medium. How much of the proteids of the milk is left 
for intestinal digestion, depends upon how well the stomach has done its 
part. In every case something is left ; in most cases a large part of the 
proteids passes but little changed into the intestine. The amylolytic fer- 
ment of the pancreas has the power of converting starch into sugar. 
This action is feeble during the first five or six months, but we can not 
accept the statements of Koronin and Zweifel, that it is entirely absent 
in early infancy. Fats are partly emulsified and partly saponified by 
the pancreatic juice, in connection with bile, which probably furnishes 
the needed alkali. The pancreatic juice actively emulsifies fat, even at 
birth. 

The very large size of the liver in the newly born indicates how im- 
portant are its functions in digestion. The biliary secretion is present as 
early as the third month of fcetal life (Zweifel). Bile assists in the diges- 
tion and absorption of fats, as has already been mentioned. In addition 
it is a stimulus to peristalsis, and in this way aids in the absorption of all 
kinds of food. Its antiseptic effect is very doubtful. It has a feeble 
diastatic action upon starch. The greater part of the bile is reabsorbed 
from the intestine. 

Milk sugar is changed into galactose (Biedert), cane sugar into dex- 
trose and levulose, all three being closely allied substances. Through 
what agency these changes are accomplished is not now positively known, 
but it is probably the pancreatic juice. 

The action of the intestinal juice is not perfectly understood ; its chief 
function is thought to be diastatic. It is alkaline in reaction, and prob- 
ably facilitates the action of the trypsin, the diastatic ferment, and the 
absorption of fats. 

Absorption. — From the stomach, absorption of water, salts, sugar, and 
peptones may take place directly into the blood. From the small intestine, 
in addition to the above elements, fat is absorbed especially by the villi. 
Absorption is less active than secretion in the small intestine, except in 
the duodenum. It is accomplished through the agency of the villi and 
the simple follicles of the mucous membrane. It is perhaps partly by 
filtration and endosmosis, but chiefly through the activity of the epithelial 
cells themselves (Hoppe-Seyler, Haidenhain). Absorption from the large 



322 DISEASES OF THE DIGESTIVE SYSTEM. 

intestine is quite imperfect. There are no villi, and hence fat absorption 
is very slight. Sugar, salts, and peptones, however, may be absorbed with 
moderate facility. Since there is little or no digestive activity in the 
large intestine, if this is used as a means of nutrition, the food must be 
given in a condition in which it is ready for absorption. 

Even in healthy nursing infants complete absorption is possible only 
in the case of milk sugar. From two to five per cent of the proteids and 
fats taken pass through the intestinal canal. In infants taking cow's 
milk the fat-residue is from one to three per cent greater than in those 
who are breast-fed (Uffelmann). Even when the amount of fat given is 
considerably greater than that usually present in cow's milk, it may be 
almost entirely absorbed. In infants taking cow's milk the proteid resi- 
due is relatively much greater than that of the fat. 

In cases of indigestion the increase in the food-residue in most cases 
is first in the proteids, next in the fat, and least in the sugar. In some 
of the chronic cases the principal increase may be in the fat. 

Intestinal Bacteria. — For the fundamental work upon this subject we 
are indebted to the researches of Escherich. Bacteria are absent from 
the entire gastro-enteric tract at birth. They quickly enter by the mouth, 
and by the end of twenty-four hours they are usually found in all parts of 
the intestinal tract. The meconium-bacteria are derived from the in- 
spired air, and hence vary somewhat with surroundings. As soon as the 
ingestion of milk begins these varieties are displaced, and throughout the 
period in which the infant has this food exclusively, there have been 
found in healthy conditions but two varieties which are constantly pres- 
ent. These are the bacterium lactis aerogenes and the bacterium coli 
commune. The first is found most abundantly in the upper part of the 
small intestine, diminishing as we descend, in small numbers only in the 
colon, and usually none are in the faeces. It seems to require for its 
growth the presence of milk sugar, hence its absence from that part of 
the intestine where milk sugar is not found. Milk sugar is decomposed 
by it with the formation of lactic acid (acetic, according to Baginsky), 
carbon dioxide, hydrogen, and methane. This action is not hindered by 
the bile. The b. lactis has no action of importance on either the fat or 
casein of the milk. 

The b. coli commune is found in but small numbers in the upper 
small intestine, becoming more abundant as we descend. In the colon 
and in the faeces it is present in immense numbers, and in the faeces is 
sometimes almost the only variety. The activity of the b. coli commune 
apparently begins where that of the b. lactis ends, viz., in the lower part 
of the small intestine. It does not seem to depend for its growth upon 
any part of the food, but upon the intestinal secretions. A change from 
a milk diet to a mixed diet of meat and farinaceous food, produces a con- 
stant change in the bacteria of the intestine. The b. lactis disappears; 



DIGESTION IN INFANCY. 323 

the b. coli commune, however, continues to be found as the principal 
form in the colon. 

Kegarding the action of these bacteria but little is as yet known. 
The b. lactis is believed not to be pathogenic. There seems to be abun- 
dant evidence to show that the b. coli commune, though not ordinarily 
pathogenic, may under a great many conditions become so. 

Faeces. — The first discharges after birth are called meconium ; this is 
of a dark brownish-green colour, semi-solid, and usually passed from 
four to six times daily during the first two or three days. On the third 
day the stools begin to change in character, and by the fourth or fifth 
day they have usually assumed the appearance of healthy milk-fasces. 
Under many abnormal conditions the stools may continue to have the 
character of meconium for a week or more. The composition of meco- 
nium is intestinal mucus, bile, the vernix caseosa, epithelial cells from 
the epidermis, hairs, fat-globules, and cholesterin crystals. For its for- 
mation there are necessary the secretions of the intestine and the liver 
and the swallowing of a considerable amount of amniotic fluid. 

MilJc-fceces. — The normal amount of fasces discharged daily by a 
healthy nursing infant is from two to three ounces. Such stools have the 
colour of the yolk of egg. They are smooth, homogeneous, of a soft, but- 
ter-like consistency, with an acid reaction, and a slightly acid but not 
unpleasant odour. The reaction is due to the presence of fatty acids 
or lactic acid. The colour depends upon bilirubin. The stools of an 
infant fed upon properly modified cow's milk may in conditions of 
perfect digestion differ in no respect from those described; they are, 
however, usually firmer, of a paler yellow colour, and may be neutral 
or even alkaline in reaction, depending upon the decomposition of casein. 
The principal differences depend chiefly upon the presence of unab- 
sorbed casein. 

The only gases present are hydrogen and carbon dioxide (Escherich). 
Sulphuretted hydrogen and marsh gas, to which the odour of adult stools 
is largely due, are not present. The following is the chemical composi- 
tion as given by Wegscheider : 

Water 85 . 13 

Solids] ? rganic . 1B '™\ 14.87 

(Inorganic 1.16) 

100.00 

The proteids of breast-milk are almost entirely absorbed. According 
to Uffelmann, they form but 1.5 per cent of the dry residue of the feces. 
The stools of infants fed upon cow's milk are usually larger, and gener- 
ally contain casein. If the percentage of casein in the milk as feci is ex- 
rive, it may be present in the faeces in large amount, the stools thou 
being of a pale-yellow or white colour, quite dry, often formed, and with 
an odour sometimes cheesy, at other times foul. 



324 DISEASES OF THE DIGESTIVE SYSTEM. 

Fat is always present, and forms, according to Wegscheider and TTffel- 
mann, from 9 to 25 per cent of the dry residue of milk fasces. According 
to Tschernoff and some other recent observers, the proportion is as high 
as 28 to 35 per cent. It is present as neutral fat, fatty acids, and soaps. 
Sugar is not found, but its derivative, lactic acid, may be present in a 
small amount. Inorganic salts form about 8 per cent of the dry residue. 
They are chiefly the salts of lime. Of the biliary elements there are hy- 
drobilirubin, unchanged bilirubin, and cholesterin in considerable amount. 
The presence of biliary acids is doubtful. Mucus is always present in 
considerable quantity ; also columnar intestinal epithelium. Leucin, tyro- 
sin, and other products of albuminous decomposition — phenol and skatol 
— are absent; indol is rarely found (Uffelmann). 

Microscopically there are seen epithelial cells, chiefly of the columnar 
variety, a few round cells, mucous corpuscles, fat-globules and crystals of 
fatty acids, cholesterin, mucin, protein substance, crystalline inorganic 
salts, sometimes bilirubin in crystals, yeast fungi, and bacteria in im- 
mense numbers. 

If the infant is taking a food containing starch, this will appear to a 
greater or less extent in the stools, a larger amount in the case of very 
young infants. Starch is recognised by the blue reaction with iodine, 
or the violet reaction if the starch has been converted into dextrine, as is 
often the case. Starch granules may be seen under the microscope. 

The number of stools during the first two weeks is from three to six 
daily. After the first month two stools a day are the average; many 
infants have three, many others but one. 

As soon as an infant is put upon a mixed diet, the peculiar charac- 
ters of the stools cease, and they come to resemble more closely those 
of the adult, though remaining softer throughout infancy. They be- 
come darker in colour and assume the adult odour, while retaining their 
acid reaction. The bacteria, while still in great numbers, are more 
varied than are met with in milk-fasces. 



MALPOSITIONS AND MALFORMATIONS OF THE STOMACH. 

The stomach is sometimes in the thoracic, cavity in cases of diaphrag- 
matic hernia. It may be found in a vertical (foetal) position, variously 
adherent to the colon and small intestine. Malformations are much less 
frequent than those of other parts of the alimentary tract. There may 
be atresia or stenosis at either orifice, and very rarely a constriction is 
found near the middle of the organ, dividing it into compartments. The 
symptoms of atresia at either orifice are persistent vomiting, and death 
in a few days from inanition. 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 325 



HYPERTROPHIC STENOSIS OP THE PYLORUS. 

It is only during the last few years that this condition has been 
generally recognized. Although many cases have been reported and the 
clinical picture and the pathological anatomy are now clearly under- 
stood, there is still considerable diversity of opinion in regard to many 
points in the pathogenesis and treatment. 

Males are undoubtedly more often affected than females. Of 68 
reported cases, 55 were in boys and 13 in girls. In several instances 
two children in one family have suffered from this condition. The fam- 
ily history bears in no way upon the disease; and that a great majority 
of reported cases have been in breast-fed infants, is probably not sig- 
nificant. 

The view of pathology most widely accepted is that there are two 
factors present: (1) hypertrophic, an abnormal development of the 
pylorus, especially its transverse muscular fibres, a congenital condition; 
(2) spasmodic, consisting of a contraction of these increased fibres. The 
two elements are associated in varying degrees; in some cases the hyper- 
trophic, in others the spasmodic, predominates. 

The reason why vomiting and other symptoms may be delayed for 
several weeks appears to be that the motor power of the stomach may be 
for a time sufficient to force the food through the narrowed orifice. The 
additional spasm at this time may be insignificant. It is, however, after 
the stomach loses its reserve power that the signs of insufficiency present 
themselves. Eecovery may still take place by the stomach regaining its 
compensation, and the pylorus losing its spasmodic contraction. That 
such a thing actually does occur is shown by the occasional finding at 
autopsies upon older children or adults of non-inflammatory constriction 
of the pylorus. Recoveries without operation have been reported by Heub- 
ner, Ibrahim, and others, even after all the typical symptoms were present. 

Another theory advocated by Thomson (Edinburgh) is that the hyper- 
trophy is a secondary condition brought about by a primary spasm of 
the pylorus. Were this so we would not expect such an increase of the 
connective-tissue, submucosa and mucosa, as is often found. Further- 
more, when symptoms have existed from birth the time seems too short 
for the development of such an enormous hypertrophy as is present. 
The same may also be said of cases with symptoms coming on later, but 
acutely. On this account Thomson was obliged to assume that the spasm 
began in intra-uterine life. 

Lesions. — Uniform pathological changes have been found at autopsy 
in all cases which gave typical symptoms during life. 

The pylorus is elongated, greatly thickened, being often as hard as 
cartilage, and projects into the duodenum like a cervix uteri. On section 



326 DISEASES OP THE DIGESTIVE SYSTEM. 

the orifice is seen to be much diminished in diameter, but what is espe- 
cially striking is the great thickness of the wall of the pylorus. It is 
often one-fifth of an inch (5 mm.) or more in thickness, and of this 
fully two-thirds is in the muscular layer. Thick folds of mucous mem- 
brane may diminish the lumen still further. There may be hypertrophy 
of the wall of the whole stomach; and while the organ may be much 
dilated, it is often smaller than usual. Rarely there may be a dilatation 
of the lower end of the oesophagus. 

Microscopically the most marked change is the great increase in 
thickness of the circular muscular layer, but there may be also an 
increase in the longitudinal muscle and in the connective-tissue of the 
submucosa. 

Symptoms. — The symptoms may appear in the first days of life. It 
is, however, more common and more striking for a period of comparative 
or absolute good health with gain in weight and good digestion to con- 
tinue for several days or even weeks before the most important symp- 
tom begins. 

The essential symptom is vomiting. At first there is nothing 
characteristic about it, but it soon becomes more persistent than is 
present in any other condition. It resists all measures which under 
other conditions usually bring relief. Vomiting may come on directly 
after food is taken or it may be delayed for an hour or more. In some 
severe cases almost all the food taken is vomited, in others only a por- 
tion of it. It may happen, especially after considerable dilatation has 
taken place, that the vomiting occurs at much longer intervals, possibly 
only once a day, but the child may then reject the greater part of what 
has been taken for the previous twenty-four hours. 

There need be no exciting cause for the vomiting. It sometimes takes 
place when the child is absolutely quiet, even asleep. The vomited mat- 
ters consist of food, the appearance of which is modified by the length 
of time it has remained in the stomach; there is usually mucus, the 
amount depending largely upon the duration of the condition; there 
may be small clots or streaks of blood from hemorrhagic erosions caused 
by the excessive contractions of the stomach. Bile is not present. There 
is a motor insufficiency of a very marked degree, so that after five or 
six or even ten hours of fasting, food may be removed from the stomach 
by lavage. 

Next to vomiting the most constant symptom is the progressive and 
often rapid loss of weight. At the end of two or three months the child 
may weigh a pound or two less than at birth. There are present all the 
evidences of malnutrition or even marasmus. 

The urine is scanty, of high specific gravity, and deposits a heavy 
sediment of urates upon the napkins. If all the food is rejected there is 
absolute constipation ; when some food passes the pylorus, the stools may 



HYPERTROPHIC STENOSIS OF THE PYLORUS. 327 

be green, but more often are brown and very hard. The condition is not 
accompanied by fever. 

On an examination of the infantas abdomen one is struck by the 
prominent appearance of the epigastrium as compared with the retracted 
and sunken portion below the umbilicus. Especially is this the case if 
emaciation is extreme. 

A very striking symptom is the peristaltic waves. These are usually 
present after food has been taken, but may be seen at almost any time 
and may sometimes be induced by tapping or rubbing the epigastrium. 
They pass from left to right across the epigastrium and only for a short 
distance beyond the median line. They can hardly be mistaken. These 
waves are not diagnostic, as they may be seen in other conditions and 
are sometimes wanting in hypertrophic stenosis. 

Ibrahim describes a tonic contraction of the stomach that he has 
observed, the contraction lasting as long as fifteen seconds; the outline 
of the whole stomach could be seen and the greater curvature distinctly 
felt. The ingestion of food is sometimes followed by signs of pain. 
After a few mouthfuls have been taken eagerly, the infant can with 
difficulty be induced to take more. 

Visible peristalsis may occur, however, without any direct evidence 
of pain. In about one-fourth of the cases a pyloric tumour is present, 
situated slightly to the right of the median line ; but usually this is ob- 
scured by the position of the liver. The tumour is movable, quite hard, 
about the diameter of the little finger, and feels not unlike a large lymph 
gland. The absence of such a tumour is of no importance in diagnosis. 

Concerning the usual course of the disease there is yet considerable 
difference of opinion. It is difficult to believe that most of these patients 
go on to recovery; yet many excellent observers, Heubner among them, 
insist that the vast majority recover completely, even after having ex- 
hibited the characteristic symptoms. In such cases it is stated that the 
vomiting grows less and less and finally ceases, with an improvement in 
all the other symptoms; the peristaltic waves are usually the last evi- 
dences to disappear ; these may be seen weeks and even months after all 
vomiting has ceased. 

The more common belief is that unless relieved the cases usually 
grow slowly or rapidly worse, with progressive loss of weight and 
strength, with death in a state of extreme marasmus, the vomiting per- 
sisting until the end. 

Treatment. — Since it is impossible to make a correct diagnosis until 
the patient has been observed for some time, the early treatment is that 
of persistent vomiting — stomach washing and the most careful attention 
to feeding. Saline enemata should be given regularly to furnish the fluid 
required by the body and occasionally to cleanse the intestine. Nutritive 
enemata are of no value for prolonged use. 



328 DISEASES OF THE DIGESTIVE SYSTEM. 

After a positive diagnosis has been made the question of operation 
must be considered. It is held by many that operation is absolutely 
contra-indicated on account of its great attendant dangers, and as most 
cases recover without it. General experience, however, is opposed to this 
view. If careful and intelligent treatment produces no improvement, 
and vomiting continues until life is threatened, surgery holds out some 
hope of relief, though a slender one. Cases apparently hopeless have been 
rescued by operation. The greatest judgment is necessary not to continue 
the expectant treatment too long, and thus allow the child to become so 
wasted and exhausted that operation is inadmissible. About one fourth 
of the cases operated on thus far have recovered. 

Of the various operations employed, pyloroplasty and anterior gastro- 
enterostomy seem to be the best on account of the small incision neces- 
sary, and the rapidity with which they may be done. Stiles (Glasgow) 
states that after anterior gastro-enterostomy the feeding is much simpler 
than after any other method of treatment.* 



VOMITING. 

Vomiting is one of the most frequent symptoms of disease in in- 
fants and young children, and occurs from a wide variety of causes. 
In disorders of digestion it is the one particular symptom which points 
to the stomach as the seat of disease. At the same time, it is one of 
the most difficult symptoms to control. From both a diagnostic and 
therapeutic standpoint, therefore, it is important that the significance of 
vomiting should be appreciated. 

The physician must have in mind both its common and its un- 
common causes. Vomiting takes place with great facility in young 
infants even from slight causes, owing to the position and shape of 
the stomach. 

1. Vomiting from overfilling of the stomach. — This is often seen in 
nursing infants, and there may be no other symptom of disease. It is 
characterized by the fact that it comes within a few minutes after nurs- 
ing, that it is easy and without effort, and that the food is but little 
changed. It may be excited by moving the child or making undue pres- 
sure upon the stomach. It often comes with eructations of gas or air 
which has been swallowed. 

Vomiting from overdistention may be regarded as a safety-valve, 
and requires no treatment except to diminish the quantity of food. 

* For recent literature see Ibrahim's monograph, Karger, Berlin, 1905 ; Wachen- 
Leim, Amer. Jour, of the Med. Sciences, April, 1905 ; and for references to cases 
treated surgically — Shaw and Elting, Archives of Paediatrics, December, 1904. 



VOMITING. 329 

2. Vomiting is almost invariably present in cases of acute gastric in- 
digestion, whether there is inflammation of the stomach or not. It does 
not usually come immediately after feeding, and it may be delayed for 
several hours. It is often preceded by fever and by marked prostration, 
which in young infants may approach collapse. It may cease when the 
contents of the stomach have been expelled, but often mucus, serum, 
and, in severe cases, bile, may be vomited for some time afterward. In 
these cases vomiting is due to the irritation of undigested food, and to 
the exaggerated reflex irritability of the stomach from congestion of the 
mucous membrane. 

3. In acute intestinal obstruction vomiting is rarely absent, and in 
most cases it is persistent. In the newly born, persistent vomiting is 
almost invariably dependent upon congenital obstruction of the intes- 
tine, which is most frequently in the duodenum. In malformations of 
the colon and rectum it is less constant and appears later. In intussus- 
ception, vomiting is forcible, immediately excited by the taking of food, 
and is at first bilious, but later may become faecal. The vomiting in in- 
testinal obstruction is associated with general symptoms of marked pros- 
tration, and usually with obstipation. 

4. Vomiting is a frequent and almost a constant symptom of general 
peritonitis. It is then associated with abdominal distention, tenderness, 
and fever. 

5. In certain nervous diseases, especially tumour of the brain and 
acute meningitis whether simple or tuberculous, vomiting is very com- 
mon. In tumour it may be the earliest, and for some time the only 
marked symptom. In several cases I have observed, exactly the same 
type of vomiting was present. It occurred only in the morning, some- 
times before breakfast, sometimes suddenly during the meal, and was 
repeated every few days. Cerebral vomiting is usually forcible or pro- 
jectile. It may have no relation to meals. The vomited matters are not 
characteristic, and the tongue may be clean. Headache, dulness, slight 
fever, constipation, and irregular pulse and respiration are usually pres- 
ent sooner or later. 

6. In infants, and less frequently in older children, vomiting is one 
of the usual symptoms to mark the onset of acute infectious diseases, 
especially the beginning of scarlet fever, pneumonia, and malaria. In 
these cases vomiting may be due simply to the arrest of digestion, or to 
the effect of the poison upon the nerve centres. 

7. An accumulation in the blood of various toxic materials may pro- 
voke vomiting; the most frequent example is uraemia. In cyclic vomit- 
ing it is quite probable that the cause is the accumulation of Bome toxic 
agent in the blood. The absorption of ptomaines and other poisons 
taken in with milk or other food, or developed in the gastro-enteric tract, 
may excite vomiting. In some of these conditions it is possible that 



330 DISEASES OP THE DIGESTIVE SYSTEM. 

the vomiting may be eliminative — an effort on the part of Nature 
to get rid of the toxic materials. The cases dependent upon renal 
disease are discovered by frequent and careful examination of the 
urine. The other forms are often exceedingly obscure, and recognised 
only by the exclusion of all other frequent and infrequent causes of 
vomiting. 

8. Vomiting may be reflex from irritation in the pharynx. This is 
frequent in young infants, who may induce vomiting by stuffing the 
fingers into the mouth. In certain cases the irritation from worms in 
the intestinal tract may cause vomiting, and it is possible that even den- 
tition may produce it. 

9. Habit is a frequent cause in cases of chronic vomiting. I have 
seen a child who had the power of vomiting at will anything in the nature 
of food which he did not like, yet whose stomach at the same time would 
bear large doses of quinine, to which he had no aversion, without the 
slightest disturbance. In young infants a habit of regurgitating the 
food may be acquired, so that this takes place more or less during the 
process of digestion after every meal. This is sometimes preceded by a 
movement of the mouth and fauces resembling swallowing, until finally 
the milk appears in the mouth. Habit is a potent cause in continuing 
vomiting where it has occurred frequently. In children who have this 
habit the most trivial cause will provoke it. It may be present without 
any other sign of gastric disease, and appears simply to depend upon 
exaggerated reflex irritability of the organ. I have seen a number of chil- 
dren who up to the third or fourth year objected so strenuously to taking 
solid food that they would immediately vomit it, no matter of what 
variety or in how small a quantity, although fluids were taken and 
digested without the slightest difficulty. 

10. Chronic vomiting may depend upon habit, as just described, or 
upon chronic indigestion ; or it may be associated with chronic pulmonary 
disease — vomiting here being excited by the attacks of cough, at first only 
when the paroxysms are severe, and later even when they are slight. In 
chronic indigestion the vomited matters are always characteristic, they 
have a distinct relation to meals, and they are accompanied by other 
symptoms of deranged nutrition. 

The diagnosis of a case in which vomiting is the chief symptom 
may be difficult. The first important distinction to be made is be- 
tween cases in which the vomiting is of gastric origin, and those in 
which it depends upon other causes, like intestinal obstruction, cerebral 
disease, toxic conditions, etc. It is only by a careful consideration 
of the other symptoms associated that an accurate diagnosis can be 
reached. 

The treatment of vomiting is the treatment of the cause upon which 
it depends. 



CYCLIC VOMITING. 33 1 



CYCLIC VOMITING. 



This is not an infrequent disease; it has, however, as yet attracted 
but little attention except in this country. Although the clinical pic- 
ture is a very clear and definite one, its exact pathology is undetermined. 
It has also been described under the names of periodical vomiting, recur- 
rent vomiting, and a gastric neurosis. It is characterized by periodical 
attacks of vomiting, which recur at regular or irregular intervals of 
weeks or months, apparently without any adequate exciting cause. The 
usual duration of the attacks is two or three days, during which all at- 
tempts to control the vomiting are usually without avail, but at the end 
of this time it generally ceases spontaneously. 

Etiology. — The first attacks are usually seen between the ages of 
two and four years, but they may date back to infancy. The two sexes 
seem to be almost equally liable. A few of the patients are strong chil- 
dren, but the great majority are rather delicate and of a highly nervous 
temperament. The cases are seen chiefly in private practice, often oc- 
curring among those who have the best surroundings. In most cases the 
antecedents of patients are of the neurotic type, and in the family of 
some there is a marked tendency to gouty manifestations. The attacks 
are not traceable to distinct or flagrant errors in diet, and yet the habit- 
ual diet seems to bear some relation to the disease. In my own cases I 
have most frequently found the diet to be excessive in carbohydrates, 
particularly in the amount of oatmeal and potato. The exciting cause is 
often a nervous one — great fatigue or unusual excitement, sometimes a 
railroad journey or a child's party; in many instances it seems to be 
induced by some minor illness having no relation to the digestive tract, 
such as an attack of tonsillitis or bronchitis. 

Symptoms. — The clinical picture presented by these cases is very 
characteristic, and is well illustrated by the history of the following case : 

The patient was a well-nourished boy of six years when he first came 
under treatment. He belonged to a neurotic family, and the attacks 
dated back to infancy. From this time they had recurred usually at in- 
tervals of a few months ; occasionally five or six months would pass with- 
out one. The symptoms in all the attacks were similar in kind, differ- 
ing only in degree. They were preceded by a prodromal period lasting 
from twelve to twenty-four hours, marked by languor, dulness, dark 
rings under the eyes, loss of appetite, and a general sense of discomfort 
in the epigastrium. At this time the temperature was generally slightly 
elevated. The vomiting then began suddenly. It was attended with 
great retching and distress; it was often repeated every half-hour, or 
hour for two days. On one occasion it occurred seventeen times in a 
single night. Vomiting was immediately excited by the taking of any 
food or drink, but it occurred when nothing was taken. The vomited 



332 DISEASES OP THE DIGESTIVE SYSTEM. 

matters consisted of frothy mucus and serum, frequently streaked with 
blood, apparently from the violence of the emesis. The reaction was 
very strongly acid; sometimes there was bilious vomiting. The tem- 
perature usually fell to about 100° F. when the vomiting began, and 
continued at or below this point throughout the attack. By the end of 
the second day the exhaustion was very marked — so severe, in fact, as 
apparently to threaten life. 

The child lay in a semi-stupor, with eyes half open, lips and tongue 
dry, rousing at times to beg for water. The pulse was rapid and weak, 
and sometimes slightly irregular. There was no distention of the abdo- 
men; it was usually flattened. By the third day the vomiting became 
less frequent and then ceased entirely. Convalescence was rapid, and 
by the end of the week the boy was almost as well as usual. The attacks 
continued to recur at gradually lengthening intervals until they finally 
ceased altogether at about the twelfth year. 

Over forty of these cases have come under my observation, and in 
many of them I have had an opportunity to witness several attacks. The 
usual duration is one to three days. In one patient they lasted regularly 
for five days. Occasionally a severe attack will last a week. The average 
number of attacks is three or four a year. 

Prodromal symptoms are present in most of them — headache, gen- 
eral languor, coated tongue, and anorexia are the most frequent; in 
some there is marked constipation, with a history of very white stools 
for some time. The tongue is usually coated at the beginning of an 
attack, and at its height it is often dry and brown. The abdomen seems 
empty and its walls sunken; pain and tenderness are both rare. The 
bowels are constipated and move only by artificial means, and even then 
not freely. 

There is, as a rule, no desire for food, but the continual cry is 
for water to quench the constant, burning thirst. The pulse after the 
second day becomes rapid, soft, and often somewhat irregular. The 
respiration is shallow, and at times this also may be irregular. The 
temperature is seldom over 100.5° F., a point of much diagnostic value. 
The patients are dull, apathetic, and usually wish to be left alone. Head- 
ache is very common. 

The disposition to vomit is sometimes so great that patients are 
afraid to move or even to talk lest it may be provoked. The vomited 
matter is large in amount, considering that the patient is fasting. It 
is essentially gastric juice, containing free HC1, mucus, serum, many 
epithelial cells, and often traces of blood. The urine is concentrated, 
and frequently contains at the height of the attack a trace of albu- 
min, a few hyaline casts, and some blood cells — evidences of a mod- 
erate renal hyperemia. There is usually an excess of indican. A 
condition practically constant, and first pointed out by Edsall (Philadel- 



CYCLIC VOMITING. 333 

phia), is the presence in the urine of acetone, diacetic and oxybutyric 
acids. This is thought to give some reason for the belief that cyclic 
vomiting is a form of acid intoxication. The above findings are so 
constant as to be of some diagnostic valne. On the other hand, it should 
be stated that some hold that these urinary conditions are simply the 
result of the starvation. 

In two cases of my own, where careful determinations of urea and 
uric acid were made during and following attacks, it was observed that 
the excretion of urea was but little altered, while that of uric acid fell 
during the early days of an attack to one-half or one-third the normal 
for the same individual in health. 

The Nature of the Attacks. — These cases have little in common with 
the ordinary attacks of indigestion. With our present knowledge they 
are to be regarded as nervous explosions due to faulty metabolism, having 
many points of resemblance to migraine in the adult. The effect upon 
uric-acid elimination in the case cited is very similar to that which occurs 
in migraine; and Eachford has observed a patient, and I have myself 
seen one, in whom the vomiting attacks were later in life replaced by 
migraine. Whether it is to be looked upon as a manifestation of the 
lithaemic state in children must be determined by future study. It is 
probable that not all the cases depend upon the same condition. 

Prognosis. — Although these patients very often seem to be most alarm- 
ingly ill, the danger to life is slight. I have seen but one fatal case, 
and in this the diagnosis is open to question, as no autopsy could be 
obtained. The patient died in the eighth week of her fifth attack. 

Griffith reports two fatal, cases, the autopsy in one showing nothing 
characteristic; the symptoms in the other case were fairly typical. The 
probabilities are always in favour of a recurrence of the attacks. In 
most of the patients who have been observed they have extended over 
a series of several years, although by a careful regime much may be 
done to reduce their frequency. 

Toward puberty there appears to be a strong tendency to spontaneous 
recovery. 

Diagnosis. — Organic disease of the brain and kidneys must first be 
excluded, the latter only by careful and repeated examination of the 
urine. The first attacks witnessed may strongly suggest the onset of 
tuberculous meningitis; and only the course of the symptoms may show 
that this is not present. Usually a history of many previous attacks 
may be obtained. From acute indigestion, cyclic vomiting is differen- 
tiated by the fact that the attacks are not brought on by indigestible 
food, and also by the persistence of the vomiting. It is distinguished 
from gastritis by its severity, the shorter duration of its symptoms, and 
its self-limited course. 

Appendicitis is excluded by the absence of pain, tenderness, and 



334 DISEASES OF THE DIGESTIVE SYSTEM. 

temperature; intussusception by the fact that the symptoms are less 
severe, by the absence of blood and mucus from the stools, and by the 
fact that most of the attacks occur after infancy. 

' Treatment. — When the premonitory symptoms appear, free purgation 
by calomel offers the best prospect of aborting an attack. If the vomit- 
ing has once begun, nothing seems to have the slightest influence in 
controlling it. It is usually increased by the taking of food or drink 
or by any medication by the mouth, and all should be withheld. The 
patient should be kept absolutely quiet and water given, per rectum, 
at regular intervals, usually six to eight ounces, four or five times a day. 
This keeps up the urinary secretion, allays thirst and often restlessness, 
and adds much to the patient's comfort. In the more protracted cases 
rectal feeding should be employed. When the vomiting has ceased for 
several hours it is not likely to recur if food is very judiciously admin- 
istered, at first in small quantities. Broth, barley water, kumyss, or 
small quantities of iced milk and lime-water in equal proportions may 
then be given. 

The alkaline treatment has been strongly advocated; it consists 
in giving between the attacks bicarbonate of soda in doses of fifteen 
to thirty grains three times daily, and when the prodromal signs of 
an attack appear, to administer very large doses, as much as thirty 
grains every hour. I have used this plan of treatment with some appar- 
ent success and think it deserves further trial, although sufficient facts 
are not yet available to enable one to speak with confidence regarding it. 
Acting upon the theory that the symptoms are analogous to those of 
migraine, the treatment I have adopted in the interval has been dietetic ; 
it consists in excluding all sugar and sweets, and carefully limiting the 
amount of starchy foods. The diet prescribed has been composed princi- 
pally of meat, green vegetables, milk, and stale bread. In addition to 
careful regulation of the diet the general nutrition should be considered, 
and the patient's life so regulated that extreme fatigue and exhaustion 
are prevented. In most cases close attention to these matters has resulted 
in a very great diminution in the frequency of the attacks. 



GASTRALGIA. 

This term is applied to sudden, severe attacks of abdominal pain. 
Gastralgia occurs as a symptom in most of the severe attacks of acute 
gastric indigestion; in such cases it is more marked in older children 
than in infancy. The pain of diaphragmatic pleurisy is often referred 
to the epigastrium, and may be so severe as to lead one to think that 
the stomach is the seat of disease. Another cause may be appendicitis. 
In vertebral caries of the dorsal region epigastric pain is a very frequent, 



ACUTfi GASTRIC INDIGESTION. 335 

early symptom. It is also common in children who suffer from malaria, 
at the onset of acute attacks, and it may be severe when the febrile symp- 
toms are not well marked. In other cases pain in the stomach is of the 
nature of a true neuralgia, which may be excited by exposure to cold, 
by wetting the feet, by drinking ice-water, and by many other causes. 

In mild cases there is an intermittent pain, and usually no other 
symptoms. In severe cases the pain may be so great as to cause pallor, 
faintness, cold perspiration, and very marked prostration. The epigas- 
trium may be hard and sometimes retracted, the stomach appearing to 
be in a state of spasm. 

The principal interest attaches to diagnosis. If the pain is acute, one 
should carefully exclude appendicitis, renal and hepatic colic, and ulcer 
with perforation ; if more chronic, Pott's disease should not be forgotten. 

Treatment. — During the attacks the patient should be put to bed, and 
counter-irritation used over the stomach, best by means of a turpentine 
stupe or a mustard paste. Internally there should be given hot water 
containing brandy or gin and five drops of spirits of chloroform; all 
food should be withheld. Hot bottles should be applied to the feet if 
they are cold. In the interval between the attacks the treatment should 
be directed to the patient's general condition ; especially should the cause 
be discovered, and if possible removed. In cases of recurring pain of a 
neuralgic character arsenic in the form of Fowler's solution, two or three 
drops three times a day, may prove of benefit. In all cases attention 
should be directed to the diet. 

ACUTE GASTRIC INDIGESTION. 

This occurs whenever the stomach is unequal to the task imposed 
upon it. It may be either because the task is too great or because the 
capacity of the stomach for work is diminished. Under these two heads 
we may group the principal causes of acute indigestion. 

Under the first head the most important thing is the giving of im- 
proper food. In infants this is sometimes improper breast-milk; but 
more often cow's milk containing too high proteids — i. e., milk without 
sufficient dilution. Other common causes are sudden weaning or any 
other abrupt change in diet, the too early use of solid food, and overload- 
ing the stomach. In older children the usual causes are indigestible 
articles of food, such as unripe fruits, pastry, etc., overloading the stom- 
ach, and swallowing food without sufficiently masticating it. Conditions 
which may diminish for the time the capacity of the stomach for work 
are fatigue, depression induced by atmospheric heat, chilling of the sur- 
face, especially the extremities, dentition, and the nervous impression 
caused by the onset of any acute disease. The effect is seen both on the 
glandular and muscular apparatus of the stomach. The secretions are 
diminished or altered in character, and the motor activity of the organ 
is arrested. 
23 



336 DISEASES OP THE DIGESTIVE SYSTEM. 

Symptoms. — One of the first consequences of arrested gastric diges- 
tion is that the food remains long in the stomach. Instead of being 
empty in two or two and a half hours after feeding, as is normal in in- 
fancy, the food may remain in the stomach five or six hours, or even 
longer. The irritation from this undigested mass excites vomiting, 
which usually ceases after the stomach has been emptied. The vomiting 
may be preceded by nausea, pain, and constitutional depression which 
varies with the age and susceptibility of the child ; in infants it may be 
very alarming. 

It seems probable that, as a consequence of arrested gastric digestion, 
the proteids are not converted into peptones, but remain in the form of 
albumoses. These products have been shown by experiments on animals 
to be toxic, producing stupor and circulatory disturbances. They are 
diffusible and are undoubtedly absorbed with great rapidity, and may be 
the cause of nervous symptoms of a striking character. There may be 
dulness, stupor, and sometimes contracted pupils, so as to suggest opium 
narcosis, or there may be restlessness, excitement, and even convulsions. 
There is also marked prostration, weak pulse, and fever. The tempera- 
ture in most cases of acute indigestion is from 101° to 103° F. ; not infre- 
quently it rises to 104° or 105° F. The tongue is coated and the appetite 
entirely lost. In infants these symptoms are usually associated with or 
followed by more or less intestinal disturbance — generally diarrhoea, with 
undigested food in the stools. Epigastric distention may be present. 
Usually the vomiting ceases in from six to twelve hours, and after the 
stomach has been thoroughly emptied the temperature falls. Provided 
rest to the organ can be secured, and the exciting cause is one that can 
be removed, the patient may be quite well in two or three days. Eelapses 
are, however, easily excited ; and in a susceptible patient it is surprising 
to see how trivial a cause may excite one. 

The diagnosis between a simple attack of acute indigestion and one of 
gastritis can not be made at the outset. The former is much more fre- 
quent, and may be quite as severe, but is of shorter duration. The con- 
tinuance of the severe symptoms, especially pain, thirst, fever, and vomit- 
ing of mucus tinged with blood, justify the inference that inflammatory 
changes exist. The prognosis in these cases is good, except in very young 
or very delicate infants. In such patients an attack of acute indigestion 
is not infrequently fatal. 

Treatment. — The indications are, to empty the stomach as com- 
pletely as possible and then to secure to it absolute rest. If proper 
treatment is employed at the outset, the majority of such attacks can 
be cut short. Nothing is so efficient in infants as stomach-washing. A 
single washing usually suffices. If for any reason this can not be em- 
ployed, the child may take from its bottle a large amount of lukewarm 
water. The free vomiting which this usually produces may be sufficient 






ACUTE GASTRITIS. 337 

to cleanse the stomach fairly well, but by no means so thoroughly as 
stomach-washing. Persistent vomiting is sometimes arrested by giving 
small quantities of hot water. 

The subsequent treatment is chiefly dietetic. Everything should be 
withheld for three or four hours, when barley water, albumin water,* or 
whey may be given frequently, and in small quantities — e. g,, half an 
ounce to one ounce every hour. After twenty-four hours raw beef -juice 
or broth may be tried, but no milk should be given for at least three days. 
When begun, it should be peptonized and diluted with five or six parts of 
water. In a nursing child, the breast should be withheld altogether for 
twenty-four hours, and then nursing allowed for two minutes every three 
hours, the time of nursing being gradually increased to three, five, and ten 
minutes as improvement occurs. The great mistake made in these cases 
is to begin food too soon and to give too much, especially of cow's 
milk. 

Drugs are relatively of little value. If the measures mentioned have 
been used promptly they will not often be required. In many cases inju- 
dicious medication aggravates the symptoms and prolongs the attack. 
Unless the bowels have acted freely, calomel (gr. ■$• every hour) may be 
given until this effect is obtained. Where there is continuous vomiting 
of very acid mucus and serum, alkalies are indicated — lime-water, chalk 
mixture, or the subcarbonate of bismuth. It is important to keep the 
child as quiet as possible. Local applications to the epigastrium are very 
often useful. Either dry heat may be applied by means of a hot-water 
bag or hot flannels, or more active counter-irritation by mustard. In 
older children the stomach is to be emptied by an emetic accompanied 
by large draughts of warm water. After this it should be kept entirely 
at rest for half a day, only carbonated waters or barley water being 
allowed in small quantities to allay thirst. Later, broth or beef-juice 
may be given, afterward milk diluted with two parts of lime-water. 
The patient should be kept upon a very low diet for four or five days. 

ACUTE GASTRITIS. 

In comparison with the frequency of inflammatory diseases of the 
intestine, those of the stomach .are rare, particularly so in infancy. 
Owing largely to the character of its secretion and its contents, the stom- 
ach is much more resistant to infection than are the intestines. Gastritis 
seldom exists alone, but is usually associated with enteritis or colitis. 

Etiology. — The causes of gastritis arc, in the main, those of acute 
gastric indigestion — improper food or feeding — plus infection. This 

* Albumin water: The white of one fresh egg, one-half pint cold water, previously 
boiled, a little salt, one teaspoonf ul of brandy ; shake thoroughly, and feed cold. 



338 DISEASES OF THE DIGESTIVE SYSTEM. 

may be of many kinds, probably the most frequent being due to the 
streptococcus. Other organisms concerned are the bacillus of tubercu- 
losis, of diphtheria, the bacillus pyocyaneus, etc. Gastritis may also be 
caused by the introduction of irritants, which may either be swallowed 
accidentally or given as drugs. 

Lesions. — The mucous membrane of the stomach may be the seat of 
acute catarrhal, ulcerative, or membranous inflammation, all forms ex- 
cept the catarrhal being rare. There is also seen a mixed form, which 
from its cause is usually termed " corrosive " gastritis. 

Catarrhal gastritis. — This is characterized by hyperemia of the mu- 
cous membrane, exudation of cells into the mucosa, a great increase 
in the secretion of the mucous glands, and changes in the epithelium. 
About the only change which can be recognised by the naked eye is 
congestion and swelling of the mucous membrane. These are usually 
more marked toward the pyloric end and along the greater curvature. 
There may be small extravasations of blood into the mucosa. The stom- 
ach contains undigested food and mucus, which may be thick and tena- 
cious, adhering very closely to the mucous membrane. The mucus may 
be stained brown from the capillary haemorrhages. The stomach may be 
either distended or contracted. Under the microscope the changes are 
seen to be almost entirely in the mucosa. In some places there is loss of 
the superficial epithelium, in others only degenerative changes in it are 
seen. The mucosa is infiltrated with round cells, this process being 
rarely diffuse, but generally occurring in patches. The blood-vessels are 
distended and many small extravasations are seen. Sometimes there is 
a moderate infiltration of the submucosa. Acute catarrhal gastritis 
alone is rarely severe enough to cause death. It is usually seen in cases 
which prove fatal from other causes, particularly diseases of the in- 
testine. 

Gastric softening (gastromalacia) is a condition dependent upon 
post-mortem changes — probably self-digestion of the stomach. It is 
found both where gastric symptoms were present and where they 
were absent. It is situated nearly always in the posterior wall, and usu- 
ally covers a considerable area, about one-third or one-fourth of this 
wall. It is recognised by the gelatinous, translucent appearance of the 
walls of the stomach, which are so softened that the finger may be 
pushed through them without force, or that sometimes the stomach 
ruptures while it is being removed. This condition is rarely seen when 
the stomach is empty. It can scarcely be mistaken for a pathological 
condition, if its occurrence is borne in mind. 

Ulcerative gastritis. — This was met with six times, not including 
tuberculous cases, in 390 consecutive autopsies upon infants in the 
Babies' Hospital. Three of the patients were less than four months old, 
and all were females. The ulcers varied from one twenty-fifth to one 



ACUTE GASTRITIS. 339 

quarter of an inch in diameter, and usually from ten to fifty were pres- 
ent. They seldom extended to the muscular, and never to the peritoneal 
coat. The lesion was most marked in the posterior wall, toward the 
pyloric end and along the greater curvature. Evidences of catarrhal 
inflammation were present in most of the cases, and in four, of mem- 
branous inflammation. Under the microscope these ulcers resemble 
those of the colon. Lesions in some other part of the digestive tract 
were present in all but one case, in two there was thrush in the oesoph- 
agus; in three there was ulceration somewhere in the intestines. Cul- 
tures showed that two cases were due to pyocyaneus infection,* which 
was found to be general throughout the body. 

Membranous gastritis. — This is even more rare than the varieties 
previously mentioned. I have met with it but four times in infants. 
One case was associated with a membranous colitis ; a second case with 
pseudo-diphtheria of the fauces and larynx in an infant but six weeks 
old. The oesophagus was not involved in this case ; and indeed it often 
escapes. No Klebs-Loefner bacilli could be found either in cover-slip 
preparations or by culture. Both these cases have been very fully re- 
ported by Dr. Wollstein.f To the naked eye the membrane appears as 
of a grayish-green colour; it is adherent, but can be detached in quite 
large patches. Only a portion of the stomach was covered in any of the 
cases; in two the principal disease was about the pylorus; in another 
along the greater curvature. In Fenwick's case the entire surface 
of the stomach was lined with membrane. The microscopical appear- 
ances resemble those of membranous colitis. There is a pseudo-mem- 
brane composed of fibrin, granular matter, epithelial cells, and bac- 
teria. The mucosa shows a moderately dense infiltration with round 
cells, and in places superficial ulceration. There is also infiltration 
of the submucosa, and in some places even the muscular coat is 
involved. 

Membranous gastritis occurring in patients dying of diphtheria is 
not common. Councilman, Mallory, and Pearce noted its presence in 
only five of one hundred and twenty-seven autopsies. 

Corrosive gastritis (toxic gastritis). — This form of inflammation is 
excited by various irritating and caustic substances, which are usually 
taken by accident, sometimes for the purpose of producing emesis. The 
most frequent substances are carbolic acid, caustic alkalies, mineral 
acids, arsenic, salts of copper, zinc, or antimony, croton oil, and corro- 
sive sublimate. 

The lesions in the stomach depend upon the amount of the substance 
swallowed, the degree of concentration, and whether the stomach was 

* See Martha Wollstein, M. D., Archives of Paediatrics, 1897, p. TOO, for full report, 
f Archives of Paediatrics, July, 1892. 



340 DISEASES OF THE DIGESTIVE SYSTEM. 

full or empty at the time. Strong caustics, whether acids or alkalies, 
usually act more deeply and extensively in the pharynx and oesophagus, 
for, owing to the spasmodic contraction of the muscles of these parts, 
often but a small amount of the substance reaches the stomach. Concen- 
trated irritant poisons produce in the stomach, especially along the 
greater curvature, irregular ulcers, which may be so deep as to cause per- 
foration, or they may affect the mucous membrane only. In severe cases 
death takes place early, often in a few hours. Dark, ragged ulcers are 
found in the stomach, the surrounding mucous membrane is the seat of 
intense congestion, and in places there are extravasations of blood.. If 
death is delayed there are evidences of intense inflammation, sometimes 
with the production of a pseudo-membrane. If the amount of poison is 
not sufficient to cause death, and if the patient recovers from the re- 
sulting gastritis, a cicatricial condition of the stomach results, which 
later may lead to stenosis of the pylorus or other deformity of the 
organ. 

Symptoms. — Catarrhal gastritis can not be distinguished at its begin- 
ning from an attack of acute indigestion. There are fever, pain, vomit- 
ing, thirst, loss of appetite, coated tongue, and prostration. The pres- 
ence of inflammatory changes is indicated by the continuance of these 
symptoms, particularly the pain, vomiting, fever, and thirst. With the 
pain there may be epigastric tenderness. All food or liquids are imme- 
diately rejected, and even when nothing is taken the retching and vom- 
iting may continue, nothing but frothy mucus or serum being brought 
up, sometimes streaked with blood. The vomited matters are usually 
very sour; they may be bilious. The temperature is rarely high except 
at the outset. After the first or second day it usually ranges between 
100° and 101 -5° F. Thirst is intense, and all liquids are taken with avid- 
ity, especially if cold, even though they are immediately vomited. The 
tongue is thickly coated with a white fur, and the breath may be foul. 
The constitutional symptoms are generally most severe at the outset. 
The usual duration of such attacks is frqm four to seven days, but with 
improper management, especially injudicious feeding, the disease may 
be much prolonged. One attack may follow another until a chronic 
condition is established. In most of the cases there is some disturb- 
ance of the intestines, usually a sharp attack of diarrhoea. Sometimes 
the gastric symptoms subside after a few days and those of the intes- 
tines become the predominant ones. The symptoms above given are 
those in infancy. In older children there is less of fever, prostration, and 
diarrhoea, but pain and vomiting are prominent. The attacks are usually 
shorter and altogether less severe. 

The rare cases of ulcerative gastritis have nothing by which they can 
be distinguished from the form described, except a more prolonged 
course and a greater liability to haemorrhage. 



GASTRO-DUODENITIS. 341 

Membranous gastritis also presents no peculiar symptoms. In fact, 
in the cases I have personally seen, the gastric symptoms were insignifi- 
cant, and the condition not suspected during life. 

In corrosive gastritis the effects of the caustic may be seen in the 
mouth and pharynx, the mucous membrane being of a gray or whitish 
colour. Pain and a sense of constriction are felt in the oesophagus and 
stomach, and thirst is great. Vomiting follows almost immediately, 
and the matters vomited are usually bloody. The subsequent course in 
most of the cases is the rapid development of collapse, and death in a 
few hours from shock. The younger the child the sooner does the case 
terminate. In irritant poisoning not severe enough to produce death, 
the symptoms of acute gastritis follow, usually accompanied by more or 
less enteritis owing to the passage of the irritant into the intestine. 
There is seen a continuance of the vomiting, pain and epigastric disten- 
tion, and diarrhoea, and from these symptoms death may result in two 
or three days. It is extremely rare in infancy for the patient to sur- 
vive both the stage of shock and that of acute inflammation, so that the 
deformities of the stomach and the chronic conditions mentioned, are 
practically never met with excepting in older children. 

Treatment. — Cases of acute catarrhal gastritis are to be managed 
very much like those of acute gastric indigestion. Thirst may be re- 
lieved by swallowing bits of ice. Where there is continuous vomiting of 
acid mucus, relief is sometimes afforded by repeating the stomach-wash- 
ing once in twelve hours with a 1-per-cent solution of bicarbonate of 
soda, at 110° F. In older children, beneficial results sometimes follow 
the use of bismuth subcarbonate (gr. x every two hours) ; but in in- 
fants I must confess to have seen but little effect from any form of 
medication, the reliance being upon rest, careful feeding, and stomach- 
washing. 

Cases of corrosive gastritis require special treatment. The first indi- 
cation is to administer the proper chemical antidote to the substance 
swallowed, and the next to use bland mucilaginous or oily fluids, such 
as milk, albumin-water, oils in large quantities, etc. Especially should 
stomach-washing be avoided. Opium is always required, on account of 
pain, and should be given hypodermically. The general symptoms are to 
be treated according to the indications of the individual case. 



GASTRO-DTJODENITIS. 

This is a catarrhal inflammation of the stomach and duodenum. 
Sometimes only the duodenum is involved. The inflammation com- 
monly extends from the intestine into the common bile duct, the swelling 
of which causes jaundice. The term gastro-duodenitis is sometimes 
used synonymously with catarrhal jaundice. The condition is a rare 



342 DISEASES OF THE DIGESTIVE SYSTEM. 

one in young children, and especially so in infancy. I have never seen 
it in a child under two years old. 

The causes are for the most part obscure. It occasionally compli- 
cates malarial fever. I have seen it several times with influenza, and it 
may occur with any of the infectious diseases. Kehn has described a 
form which occurred epidemically. 

The symptoms of the disease are quite uniform. When primary, the 
onset is like an ordinary attack of indigestion, with vomiting, pain, 
slight fever, and a moderate amount of prostration. The vomiting in 
some of the cases is repeated for several days. The pain may be quite 
severe, and localized in the region of the duodenum. It may be asso- 
ciated with tenderness in this region. The bowels are usually consti- 
pated. After three or four days, icterus, which is the only diagnostic 
symptom, appears. It is first seen in the conjunctiva, afterward in the 
skin, varying in degree according to the severity of the attack, but in 
most cases not being very intense. It is accompanied by the regular 
symptoms of obstructive jaundice. The stools are gray, sometimes 
white ; there is a marked amount of intestinal flatulence. The urine is 
very dark, of a yellowish-green or bronze hue, and stains the clothing. 
There is complete anorexia; the tongue is thickly coated with a white 
fur. Headache, dulness, and languor are present, and the patient feels 
generally wretched. The slow pulse and the itching skin are uncommon 
symptoms in children. The liver is usually found, upon examination, 
slightly enlarged, and sometimes tender on pressure. The duration of 
the disease is about two weeks, the general symptoms disappearing be- 
fore the icterus. 

The diagnosis rarely presents any difficulty, and the prognosis is in- 
variably good. 

Treatment. — In the diet, fats and starches should be reduced to a 
low point or be entirely prohibited. Patients usually do much better 
upon a diet of rare meat, fruit, and a moderate amount of milk. If 
there is very much vomiting, the milk should be largely diluted with 
lime-water or partially peptonized. The amount of food given should 
be small, but water should be allowed freely, particularly the mineral 
waters. The bowels should be opened every other day by calomel, fol- 
lowed by a saline purgative. In most of the cases no other treatment is 
necessary. When the pain is severe it may be relieved by counter-irrita- 
tion by mustard, turpentine, or even cantharides. The gastric symp- 
toms should be managed as are those of ordinary acute gastritis. The 
restricted diet should in all cases be continued for at least a week after 
the jaundice has disappeared. 



CHRONIC GASTRIC INDIGESTION. 343 



CHRONIC GASTRIC INDIGESTION— CHRONIC GASTRITIS— GASTRIC 

CATARRH. 

Although from a pathological point of view these conditions are not 
identical, from a clinical standpoint there is no advantage in attempting 
to separate them. Nothing distinguishes chronic indigestion from 
chronic gastritis except that in the latter, in addition to continued de- 
rangement of function, there is a great increase in the production of gas- 
tric mucus. Chronic indigestion seldom exists long without the pro- 
duction of a slight amount of catarrhal inflammation. This condition 
in the stomach seldom, if ever, exists without more or less involvement 
of the intestine, and in the majority of cases the intestinal condition is 
the more important. In some, however, the gastric symptoms predomi- 
nate, and it is only those which are here considered. 

Etiology. — Chronic gastric indigestion may follow acute attacks, or 
it may be chronic from the outset. If the latter, it depends in infancy 
upon the continued use of improper food or bad methods of feeding. 
The improper food is very often a modified cow's milk of improper pro- 
portions. Sometimes the proteids are too high, but the most frequent 
mistake is the use of too high a percentage of fat. As a consequence of 
imperfect digestion, fermentation in the residuum takes place, and the 
irritating products of this fermentation soon cause a catarrhal inflam- 
mation with a production of mucus, decomposition of which adds still 
further to the irritation. Chronic gastric indigestion also complicates 
most of the constitutional diseases of infancy, especially rickets, syphi- 
lis, tuberculosis, malnutrition, and marasmus. It may follow any of the 
acute infectious diseases. In older children it is due chiefly to the use 
of improper food, sometimes to the habit of rapid eating and insufficient 
mastication. It is associated with constitutional diseases as in infancy, 
and may complicate valvular disease of the heart. 

Lesions. — The changes found in chronic gastritis are usually confined 
to the mucosa. In the mild form there are degenerative changes of the 
epithelium of the tubules, with increased production of mucus; there 
may be a slight infiltration of the mucosa with round cells. The more 
severe form, with marked cell infiltration and the production of new 
connective tissue, is extremely rare. The submucous coat may be 
thickened and the muscular coat attenuated. The lesion can not be 
recognised by the naked eye. The stomach is apt to appear more or 
less dilated, and its surface is coated with thick and very adherent 
mucus. This lesion rarely exists alone, practically never in infancy, 
but is associated with similar lesions in the intestines, the latter being 

more severe. 
24 



344 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms. — In infants. — For our knowledge of the conditions exist- 
ing in the stomach in chronic indigestion we are indebted to the work 
chiefly of- Cassel, Leo, Troitzky, and Wohlmann. The results obtained 
in the examination of stomach contents have not been uniform, and in 
practice one should not lay much stress upon the absence of the normal 
secretions. The constant presence of mucus in the vomited matters ot 
in the washings from the stomach distinguishes chronic gastritis from 
simple chronic gastric indigestion. This greatly interferes with diges- 
tion, even though secretions are normal. The reaction of the stomach 
is almost invariably acid. The rennet ferment is present. Pepsin is 
absent in about half the cases. Hydrochloric acid is generally deficient, 
but is increased by irrigating the stomach. The following changes are 
present in nearly all cases: Fermentation takes place in the fats, the 
carbohydrates, and in the gastric mucus. The results of fermentation 
are the production of lactic, acetic, butyric, and other volatile fatty acids, 
which are especially irritating to a mucous membrane. New products 
are also formed from the decomposition of the proteids, and gases are 
always present. Food remains long in the stomach because of motor 
inactivity, which is partly the cause and partly the result of the disease. 
It often continues after all other symptoms have disappeared. 

The most important local symptoms are vomiting or regurgitation 
of food, vomiting of mucus, regurgitation of a sour watery fluid, belch- 
ing of gas, and pain from gastric distention. Vomiting is almost in- 
variably present, and may occur soon or long after feeding. It is often 
accompanied by regurgitation of food, which may begin soon after one 
feeding and continue in small amounts quite to the time for the next. 
In nearly all protracted cases the vomited matters contain mucus, and 
sometimes this is a conspicuous feature. The regurgitation of a sour 
irritating fluid occurs even when but little food is rejected, and usually 
accompanies the belching of gas. In infants some of the most striking 
symptoms are due to the gas. The stomach may be distended and hard 
most of the time, and often so much gas is present that infants find the 
greatest difficulty in taking food. Though evidently very hungry, they 
can take so little at a time that an hour or more may be required to 
take four or five ounces. That the food remains long in the stomach 
is best demonstrated by stomach-washing. Instead of the stomach being 
empty in two or three hours, as it should be, food is almost invariably 
found four or five hours, and in some cases six or eight hours, after 
feeding. 

The appetite may be abnormally great, or it may be very poor. As 
a rule, children take less food than in health. The tongue is usually 
coated. The general symptoms are those of malnutrition; there is con- 
stant fretfulness and sleep is irregular or disturbed; the weight is sta- 
tionary, or there is steady loss; there is also anaemia, and the child's 



CHRONIC GASTRIC INDIGESTION. 345 

development is arrested. There is nearly always some derangement of 
the bowels — constipation or diarrhoea. There may be dilatation of the 
stomach, especially in rachitic children, when overfeeding has been 
practised. 

There is little tendency to spontaneous improvement or recovery, the 
prognosis depending almost entirely upon the treatment emplo} r ed. Un- 
less relieved the condition is apt to continue, until some serious acute 
disease develops which may be fatal. In young infants, chronic gastric 
indigestion should not be confounded with hypertrophic stenosis of the 
pylorus. 

In older children. — The disease is not so common as in infants. In 
all cases the most constant symptom is vomiting, which may occur regu- 
larly after meals, or only in the morning before breakfast. If the latter, 
the vomited matters consist chiefly of mucus. In addition to these 
regular attacks there may be the frequent regurgitation of small quan- 
tities of food. There are gastric flatulence and pain, due to hyperacid- 
ity or to acid fermentation. The appetite is variable — sometimes inor- 
dinate, sometimes entirely lost; it may be capricious, there being usu- 
ally a craving for highly seasoned food. The tongue is constantly 
furred, and the breath usually disagreeable. These symptoms are seen 
in all degrees of severity. Intestinal disturbances are not so frequent 
as in infancy. Constipation is more common than diarrhoea. The gen- 
eral symptoms are those of malnutrition. There are anasmia, wasting, 
constant fretfulness, disturbed sleep, and various other nervous disor- 
ders. 

Prognosis. — The prognosis depends upon the age of the patient, the 
duration of the disease, the surroundings, and upon how well treatment 
can be carried out. In infants under three months the prognosis as to 
life is bad. If children live to the age of seven or eight months, they 
may recover with proper treatment. These patients do much better in 
private practice than in institutions. Much depends upon the co-opera- 
tion of an intelligent mother or nurse. Chronic gastric indigestion is not 
dangerous to life except in young infants. Its principal danger consists 
in the predisposition it gives to acute diarrhoeal diseases in summer, 
which in such patients are very likely to be fatal. It may also lead to the 
development of marasmus. 

In older children, as in the case of infants, these symptoms may con- 
tinue indefinitely; there is little tendency to spontaneous recovery, but 
under favourable circumstances, with constant care, much may be done 
for all these patients and many of them may be completely cured. 

Treatment. — Infants. — The general treatment is too apt to be ig- 
nored, but it is just as important as measures directed more specifically 
to the stomach. A large, roomy nursery, and plenty of fresh air by 
night and by day, are very important ; sometimes under the influence of 



346 DISEASES OF THE DIGESTIVE SYSTEM. 

these alone improvement begins. General friction of the body with 
cocoa-butter is useful in delicate children with poor circulation. Infants 
must be properly covered, and it is of the utmost importance that the 
feet be kept warm. Of the measures directed to the stomach, two are 
chiefly to be depended upon — stomach-washing and diet. 

Stomach-washing (page 62) is useful, first, in removing the mucus 
which is so abundant in most of these cases; secondly, in cleansing the 
organ thoroughly at least once a day, this of itself being most impor- 
tant; thirdly, as a stimulant to the gastric secretions, especially hydro- 
chloric acid. Plain boiled water, or a weak alkaline solution — sodium 
bicarbonate, one drachm to the pint — may be employed. In the 
early part of the treatment the washing should be done daily; later, 
every second or third day. The time selected is not very important, 
but it is better to make this about three hours after feeding. The 
mother or nurse may easily be taught to wash the stomach, so that it 
may be done as frequently and for as long a period as circumstances 
require. 

The question of diet has been quite fully discussed in the chapter on 
Infant-Feeding, particularly in the pages in which the feeding in diffi- 
cult cases is considered. If milk is being given, one should first en- 
deavour to determine which of the elements is the chief cause of the 
trouble. This is most frequently the fat, next the proteids, and only 
rarely the sugar. The fat should be reduced, and if trouble also exists 
with the proteids, these should be managed in the manner indicated on 
pages 208-211. Where very serious and long-continued trouble exists 
with both the fat and proteids, a change of diet to a farinaceous food 
may be the most efficient means of checking the gastric fermentation. 
Malted foods seldom succeed. 

The quantity of food and the frequency of feeding are both matters 
of importance. As a rule with a serious amount of chronic gastric dis- 
turbance in infants over three months old the feedings should not be 
less than three and seldom more than five hours apart; four hours is 
a good average. Small meals of a somewhat concentrated food are 
usually better than large feedings of a very dilute food. Careful study 
of the individual child is indispensable to success. 

Drugs have a very limited application in the treatment of this con- 
dition in infants. Generally they are too much used, too little attention 
is given to the details of feeding, by which means alone permanent im- 
provement is reached. The continued use of pepsin and hydrochloric 
acid has given me but little satisfaction. But for the relief of one symp- 
tom drugs may be of considerable advantage; wherever the production 
of gas and constant eructations are prominent symptoms, the salicylate 
of soda is useful. It may be given with the feeding in doses of one or 
two grains. 



DILATATION OF THE STOMACH. 347 

The management of these cases in older children must be conducted 
along the lines laid down for infants. With them, stomach-washing can 
not be so easily employed, and other means must be used to clear the 
stomach of mucus. The best is undoubtedly the use of large draughts of 
water, as hot as can be borne, an hour before eating. From six to eight 
ounces should be taken, preferably slowly by sipping. To this may be 
advantageously added, in many cases, fifteen or twenty grains of bicar- 
bonate of soda. 

The diet should consist of milk diluted at least three times, kumyss 
or matzoon, beef juice, raw meat, beef peptones, and a moderate amount 
of starchy food, preferably dried bread or zwieback. Sweet fruits, and 
in many cases all fruits, must be avoided. The amount of water taken 
at meal-time should be carefully restricted. Beneficial results are ob- 
tained in most of these cases by the use of nux vomica or simple bitters 
before meals, and the regular administration of hydrochloric acid (gtt. 
v to viij of the dilute acid) shortly after meals. All pastry, sweets, nuts, 
and candies must be absolutely prohibited. With improvement in the 
symptoms green vegetables may be added to the diet, and the amount of 
starchy food increased. The general treatment must not be neglected. 
The patient should lead an out-of-door life as much as possible, and 
regular but ven^ moderate exercise allowed. Great caution is necessary 
against over-fatigue. Iron may be given in most cases during convales- 
cence; but cod-liver oil should be carefully avoided until the gastric 
symptoms have quite disappeared. Relapses are easily excited, and 
the most constant care regarding the food must be maintained for 
months, or even years. 



DILATATION OF THE STOMACH. 

Moderate dilatation of the stomach is quite a frequent condition, 
although it is not so large a factor in the disorders of digestion in 
infancy and childhood as many who have written upon the subject 
would lead us to believe. A very marked degree of dilatation is rare, 
but in these cases its recognition is important and its treatment diffi- 
cult. 

Dilatation is almost invariably regular or cylindrical ; it is usually 
most marked at the cardiac extremity (Fig. 61). Cases of irregular or 
saccular dilatation, except when associated with cicatricial conditions, are 
of somewhat doubtful occurrence. The irregular shapes of the stomach 
found at autopsy dependent upon the contraction of the muscular coats, 
may be easily mistaken for hour-glass contraction or saccular dilatation. 
The degree of dilatation may be very great; thus, the stomach of a child 
three months old measured at autopsy nine ounces ; another, four and 
a half months old, ten ounces. The greatest dilatation I have measured 



348 DISEASES OF THE DIGESTIVE SYSTEM. 

during life was in a child four months old, where the stomach held twelve 
ounces. 

In rare instances dilatation may result from congenital stenosis of 
the pylorus. The most important predisposing cause, however, is the 
muscular atony which accompanies rickets. It is found to a slight de- 
gree in almost all severe cases of rickets. The principal exciting causes 
are continued distention from overfeeding and chronic indigestion. 

In most cases the only symptoms are those of the chronic indigestion 
which almost invariably accompanies dilatation. If there is pyloric steno- 
sis, vomiting is present. In young infants the pressure symptoms may be 
very serious. This is particularly true in infants with acute bronchitis or 
broncho-pneumonia, or in those with atelectasis. In these patients I have 
seen very grave symptoms accompany the rapid distention of a dilated 




Fig. 59. — A, dilated stomach from rachitic child of six months ; B, stomach of healthy child 
of same age. (Outlines reduced from photographs.) 

stomach, and in one very delicate infant of three months this was appar- 
ently the cause of death. A positive diagnosis of dilatation is only 
made by the physical signs. There are epigastric fulness and distention, 
and in some very thin patients the outline of the stomach can be distinctly 
seen. Dilatation of the transverse colon, however, may be mistaken for 
dilatation of the stomach. In the latter, the lower outline is convex, while 
in the former it is usually slightly concave. The most satisfactory means 
of diagnosis is by percussion. The examination should be made three or 
four hours after feeding, at which time the whole abdomen is apt to be 
tympanitic. The stomach should then be filled with water; the lower 
limit of the area of flatness will be the lower border of the stomach. This 
is much more satisfactory than determining the outline after the genera- 
tion of gas in the stomach. If the lower border comes nearly to the 
umbilicus the stomach is dilated ; if it is below the umbilicus, it is much 
dilated. In many cases the capacity of the stomach can be measured by 
simply seeing how much water can be easily introduced into it by means 
of the funnel and stomach tube. 



ULCER OF THE STOMACH. 349 

In moderate dilatation of the stomach the prognosis is good except 
when it is due to pyloric stenosis. If the infant has any acute or chronic 
pulmonary disease, dilatation of the stomach may add to the discomfort 
and even to the danger from that condition. 

In the management of these cases the first point is to restrict the 
use of fluids, reduce the size of the meals, and regulate the diet in 
accordance with the general plan outlined in the chapter on Chronic 
Indigestion. If the dilatation is marked, the stomach should be washed 
once a day. The general condition of the patient usually requires tonics, 
the best of which is strychnine; and rickets, if present, should receive 
its appropriate constitutional treatment. 

ULCER OP THE STOMACH. 

Ulceration of the stomach may be found in connection with several 
pathological processes which are quite distinct from one another : 

1. Ulcers in the newly born. These have already been referred to in 
the chapter on Haemorrhages of the Newly Born. The only character- 
istic symptom is haemorrhage. 

2. Ulcers resulting from acute gastritis. These also are not fre- 
quent (page 338). As a rule they give no symptoms except those of 
gastritis, although in several cases I have known severe haemorrhage to 
result from them. This symptom will be considered later. 

3. Tuberculous ulcers. These are quite rare. I met with gastric 
ulcers five times in one hundred and nineteen autopsies on tubercu- 
lous cases; however, the evidence was not conclusive in all of them 
that the ulcers were tuberculous ; but in three the tubercle bacilli were 
found. Usually there were several small ulcers; in one case but 
two were present, the larger one being nearly three-fourths of an inch 
in diameter, and situated on the posterior wall near the middle of the 
greater curvature. All but one of these cases were in infants, one child 
being only ten months old. The ulcers gave no symptoms during life, 
and death took place from general tuberculosis. This is the history of 
nearly all the few cases on record. In one, however, reported by Casin, 
a tuberculous ulcer perforated the stomach and caused death from peri- 
tonitis. Active symptoms — bloody vomiting and bloody stools — were 
excited by the use of an emetic. 

4. Simple perforating ulcers. These are of great rarity and uncer- 
tain pathology. I have found but five recorded cases in young children 
in non-tuberculous patients, two of these being young infants. Rotch's 
patient was but seven weeks old, and Cade's but two months. Two othei 
cases were under four years old. 

The symptoms of ulcer before perforation arc gastric pain and ten- 
derness, vomiting of blood, and often bloody stools. In mosl of these 
cases in children there were no symptoms until perforation, then fol- 



350 DISEASES OF THE DIGESTIVE SYSTEM. 

lowed collapse, sometimes high temperature, the rapid development of 
tympanites, and death from shock or from peritonitis. 

The prognosis is bad in all forms of nicer of the stomach, except the 
small follicular variety. In this, however, the diagnosis can not posi- 
tively be made except by gastric hemorrhage, and it is only this which 
makes these cases serious. 

Treatment. — The treatment is absolute rest, ice, small doses of 
opium, rectal feeding, stimulants; later, bismuth, arsenic, or nitrate of 
silver. If symptoms of perforation occur the abdomen should be opened 
without delay, as offering the only chance of recovery. 

TUMOURS OF THE STOMACH. 

Although exceedingly rare, tumours of the stomach occur in child- 
hood, and are seen even in infancy. A case of sarcoma of the stomach in 
a child of three and a half years has been reported by Finlayson (British 
Medical Journal, December 2, 1899). It was apparently primary. The 
microscopical examination showed it to be of the spindle-celled variety. 
This writer could find no other recorded case under the age of fifteen. 

Lymphadenoma of the stomach in a rachitic infant of eighteen 
months has been recorded by Rolleston and Latham (Lancet, May 14, 
1898). There were multiple tumours arising from the mucous mem- 
brane in the pyloric region. The case in many features resembled leu- 
kaemia. 

Six cases of cancer of the stomach in children under ten years are 
collected in an article by Osier and McCrae (New York Medical Jour- 
nal, April 21, 1900). Four of these were in young infants and probably 
congenital. One case, in a child of eight, presented the usual symptoms 
and lesions of the adult disease. 

HEMORRHAGE FROM THE STOMACH (HEMATEMESIS). 

The most frequent variety of haemorrhage from the stomach, that 
met with in the newly born, has already been considered. (See page 
105.) 

I have met with three fatal cases in young infants, the eldest being 
fifteen months old. In the first case there were symptoms of ordinary 
gastro-enteritis. On the seventh day the vomiting of blood began, and 
was repeated about ten or twelve times during the next twenty-four 
hours, when death took place. The blood was quite abundant, as much as 
a drachm of red blood being discharged at once. At autopsy there were 
found in the stomach about two ounces of dark-brown fluid, but no gross 
lesion was discovered, and no explanation of the bleeding. This haemor- 
rhage was apparently capillary. In the second case there were symptoms 
of acute gastro-enteritis of thirty-six hours' duration. After this time 



HEMORRHAGE FROM THE STOMACH. 351 

there was marked abdominal distention with symptoms of collapse ; then 
a profuse haemorrhage from the stomach, the child dying while vomiting 
blood. At least half a pint was discharged. The stomach contained at 
autopsy two ounces of dark fluid blood, and the mucous membrane was 
filled with minute ulcers extending quite through the mucosa. In the 
third case there was no vomiting of blood, but the patient- died, with 
symptoms of internal haemorrhage. There was blood in the upper part 
of the intestine, and the stomach was filled with blood; it contained 
many small follicular ulcers resembling those found in the previous case. 

Haemorrhage from the stomach may occur in purpura, haemophilia, 
scurvy, and rarely in malaria. In young girls about puberty it may be a 
form of vicarious menstruation. Occasionally blood may be vomited in 
cases of haemorrhagic measles. Two cases are reported in which fatal 
haemorrhage followed the swallowing of a foreign body. In both, vomit- 
ing of blood occurred long after the original accident. In one case two 
and a half years had elapsed. The autopsy in this case showed impac- 
tion of the foreign body and ulceration into the arch of the aorta. Spu- 
rious haemorrhages may occur where blood has been swallowed and then 
vomited. The source of this is most frequently the nose or pharynx. 
It may happen in infants at the breast, where the blood is drawn from 
a fissure or ulcer in the nipple. The amount of blood vomited under 
these circumstances may be large enough to be quite alarming. It may 
be recognised by the child's general condition being normal, and by the 
presence of fissures or ulcers upon the nipple. It may sometimes be 
noticed that the vomiting of blood follows nursing from one breast and 
not from the other. 

Symptoms. — There may be no symptoms except those of internal 
haemorrhage, but this is rare. Usually there is vomiting of blood, and 
blood appears in the stools. If the haemorrhage is rapid and vomiting 
speedily occurs, the blood may be of a bright-red colour. If it has been 
long in the stomach it is of a dark-brown or black colour resembling 
coffee-grounds. The stools containing blood from the stomach are 
black and tarry in appearance. The general symptoms will depend upon 
the amount of blood lost. 

In a case where blood is vomited, the first point is to distinguish spu- 
rious from true gastric haemorrhage. The nose and pharynx, especially 
its posterior wall, should be carefully examined. If the child is at the 
breast, the nipples should be examined. In older children it is importanl 
to distinguish vomiting of blood from haemoptysis. This distinction is 
to be made in accordance with the rules laid down in text-books on gen- 
eral medicine. The prognosis is bad if the haemorrhage is duo i<> ulcer, 
if it is very profuse, or if it occurs in young infants. When it occurs in 
connection with constitutional diseases the prognosis depends upon the 
original disease. 



352 



DISEASES OF THE DIGESTIVE SYSTEM. 



Treatment. — Altogether the most efficient remedy is the suprarenal 
extract. It may be given very freely, at least two grains every half hour 
to a child of one year. The patient should be kept quiet, preferably upon 
the back; if there are signs of collapse, stimulants may be given hypo- 
dermically or by the rectum. No food should be given by the stomach 
for at least twenty-four hours after the hasmorrhage has ceased. 



CHAPTER VI. 

DISEASES OF THE INTESTINES. 

MALFORMATIONS AND MALPOSITIONS. 

Malfokmations are not very frequent, but are of great variety. 
With the exception of those situated at the lower end of the intestine 
they are not of much practical importance, for the condition is such 
ordinarily as to be incompatible with life. Malformations may be met 
with at any point in the canal, but most frequently in the rectum and 
anus. Aside from these, malformations of the large intestine are much 
less common than those of the small intestine. 

Malformations of the Rectum. — In Fig. 60 are shown the usual vari- 
eties of malformation of the rectum. The most frequent is atresia of 
the anus (1). In this the cu- 
taneous septum has not been 
absorbed, but the intestine is 
normal to its lower extrem- 
ity. This form is readily 
curable by a surgical opera- 
tion. In the next variety (2) 
the cutaneous orifice and the 
lower part of the rectum are 
normal, but a membrane 
separates this portion from 
the upper part of the gut; 
this is usually situated within two or three inches of the anus. The 
bulging of the lower part of the distended intestine can usually be felt by 
the ringer in the rectum, and a simple division of the membrane by a 
guarded bistoury may relieve the condition. The third form (3) is more 
serious. Here the rectum terminates in a blind pouch at a variable dis- 
tance from the anus, and is represented below by an impervious fibrous 
cord. The diagnosis of this condition can not positively be made without 
opening the abdominal cavity. The bulging of the intestine appreciable 
by the finger in the rectum, is the only point which differentiates the 




Fig. 60. — Malformations of the rectum. 
E, rectum. 



MALFORMATIONS OP THE INTESTINES. 353 

preceding variety from this one. Instead of atresia of the rectum there 
may be stenosis of varying degrees, which may give rise to the usual 
symptoms of stricture. This is often curable by dilatation. 

Malformations of the Small Intestine. — There may be stenosis or 
atresia at any point, often at many points. Obstruction is much more 
frequent in the upper than in the lower part of the small intestine, the 
most common seat being the duodenum.* Atresia is more often seen than 
stenosis. There may be a single point of obstruction, or the lumen of 
the intestine may be obliterated for a considerable distance, the intestine 
being represented only by a fibrous cord which connects the two open por- 
tions, or there may be no connection between them. In all cases the in- 
testine above is found very greatly distended, while that below is empty 
and usually atrophied. The causes of these multiple deformities are 
mainly two — fcetal peritonitis and volvulus, f In fcetal peritonitis there 
are usually found bands of adhesions between the intestinal coils, and be- 
tween the intestine and the solid viscera. Syphilis has been assigned as 
a cause in many cases. Volvulus, or a twisting of the intestine during 
its development, is a more satisfactory explanation for the majority of 
the cases, especially where there are multiple points of atresia. All 
these conditions are beyond the reach of surgical treatment. The symp- 
toms appear soon after birth and are those of intestinal obstruction. 
(See page 117.) The higher the point of obstruction the shorter the 
duration of life; it is rarely more than a week in any case of atresia; 
in stenosis it may be two or three months. 

Meckel's diverticulum. — This is the remains of the omphalo-mesen- 
teric duct, which in fcetal life forms a communication between the intes- 
tine and the umbilical vesicle. It is given off from the ileum, usually 
about a foot above the ileo-caecal valve. Most frequently it exists as a 
blind pouch from one-half to two or three inches long, communicating 
with the intestine. At the extremity of this there may be a fibrous cord, 
which is free in the abdominal cavity or attached to the umbilicus. In 
other cases the duct may remain pervious quite to the umbilicus, so that 
there is a faecal fistula. Prolapse of the mucous membrane of the duct 
may lead to an umbilical tumour. (See page 114.) Meckel's diverticu- 
lum, especially when present as a cord connecting the ileum with the 
umbilicus, may compress a coil of intestine, leading to obstruction or even 
strangulation. This may occur in infancy or later in life. 

Malpositions. — The ascending colon may be found upon the left side. 
There may be a complete transposition of the abdominal viscera. In 



* See Cordes, Archives of Paediatrics, June, 1901, for a report of fifty-seven 
cases. 

t Silberraann (Jahrb. fur Kinderh., Bd. xviii, p. 420) ; Gaertner (Jahrb. fur Kinderh., 
Bd. xx, p. 403). 



354 



DISEASES OF THE DIGESTIVE SYSTEM. 



cases of congenital umbilical hernia a large part of the intestines may be 
found in the tumour, and in diaphragmatic hernia they may be in the 
thoracic cavity. 

DIARRHCEA. 

The term diarrhoea is used to cover all conditions attended by fre- 
quent loose evacuations of the bowels. These depend upon an increase 
in peristalsis and in the intestinal secretions. 

The importance of diarrhceal diseases in children can best be appre- 
ciated by reference to the following table showing the mortality of diar- 
rhceal disease in children under two years as compared with that from 
certain infectious diseases for all ages. 



Deaths in New York City for Five Years. 



Measles, all ages 

Scarlet fever, all ages 

Pertussis, " " 

Typhoid, " " 

Diphtheria, " " 

Total deaths from five diseases. 

Diarrhoeal disease under two years. . 



1900. 


1901. 


1902. 


1903. 


1904. 


816 


449 


710 


508 


895 


465 


1,162 


940 


734 


851 


584 


289 


606 


324 


197 


718 


727 


764 


653 


661 


1,920 


2,068 


2,015 


2,190 


2,084 


5,744 


5,796 


4,938 


4,439 


5,646 



Totals. 



3,378 
4,152 
2,000 
3,523 
10,277 



23 ; 330 
26,563 



There are several important underlying factors upon which diarrhoeal 
diseases depend. Their great frequency belongs to the first two years of 
life; after this time a notable diminution both in frequency and severity 
is seen, and a fatal outcome is relatively rare. The extreme susceptibility 
of infancy is due to several causes. The digestive organs are severely 
taxed to provide for the needs of the growing body. The mucous mem- 
brane of the gastro-enteric tract is very delicate in structure, and has not 
much resistance ; it is constantly exposed to injury by irritation, and to 
infection. 

The next most striking fact about diarrhceal diseases is their preva- 
lence during the summer season. This is graphically shown in Figs. 61 
and 62, where are given by months the cases treated in a large New York 
dispensary for ten years, and the mortality records for the entire city 
during the same period. The enormous increase in the number of cases 
occurring in the summer months does not have reference to any single 
form of diarrhoea, but to all forms. 

While diarrhoeal diseases are especially frequent in cities and among 
the poor, still they are not essentially diseases of the city or of poverty. 
Severe and even fatal cases are constantly met with among all classes 
and in all places. Diarrhoeal diseases are not essentially filth-diseases; 



DIARRHCEA. 



355 



yet their frequency and severity are both increased by want of clean- 
liness in apartments, and in the persons and clothing of infants, espe- 
cially the napkins, chiefly because these lead to a contamination of the 



F. 


C. 


Jan. 


Feb. 


Mar. 


Apr. 


May. 


June. 


July. 


Aug. 


Sept. 


Oct. 


Nov. 


Deo. 


T7 1 


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20° 
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315 289 359 403 660 4103 12,468 6205 3641 1723 548 324 

Fig. 61. — Mortality from diarrhoeal diseases in New York for ten years in children under five ; 

compared with the mean temperature for the same period. , mortality; , 

mean temperature. (Seibert.) 

food. Poverty and bad surroundings predispose to diarrhoea in summer, 
just as they do to other forms of acute disease in the cold season. 

But more important still is the sort of care that the infant receives. 
Intelligent care, even in very poor surroundings, may enable children to 
escape serious diarrhoea in summer. This result is due not only to the 



F. 


C. 


Jan. 


Feb. 


Mar. 


Apr. 


May. 


Jii 


ne. 


July. 


Aug. 


Sept. 


Oct. 


X 


ov. 


Dec. 


77" 


26° 

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168 116 167 177 245 1011 2443 1524 1063 716 215 121 

Fio. 62.— Cases of diarrhoeal disease treated in the German Dispensary (New York | in ten 
years in children under five; compared with the mean temperature for the Bame period. 
, cases of diarrhoea ; , mean temperature. (Seibert.) 



care of the person, but includes intelligenl management of feeding, with- 
out which all methods are alike unsuccessful. 

Anything which lowers the general vitality increases the liability to 
diarrhoeal diseases. Marasmus, malnutrition, and rickets are especially 
important factors. 



356 DISEASES OF THE DIGESTIVE SYSTEM. 

There are cases in which diarrhoea and dentition are closely asso- 
ciated, for the bowels quickly become normal when the teeth have pierced 
the gum. These cases, although rare, do occasionally occur. The infre- 
quency of diarrhoea during dentition in the cold season, is the best argu- 
ment against its importance as an etiological factor. 

Of all etiological factors, the form of feeding is the most important. 
Of 1,943 fatal cases which I have collected, only three per cent had the 
breast exclusively. Fatal cases of diarrhceal disease in nursing infants 
are extremely rare. In most cases, however, it is not artificial feeding 
per se, but artificial feeding ignorantly and improperly done, which is 
to be blamed. If cow's milk is employed as a substitute for breast-milk, 
the differences in composition are either not appreciated or else ignored, 
so that many artificially-fed children suffer from malnutrition. The 
comparative safety of cow's milk in winter and in the country, however, 
shows that the chemical composition of cow's milk is not the most impor- 
tant factor. Another common and very serious mistake is that of over- 
feeding. Artificially-fed children are almost always over-fed. The com- 
mon practice of feeding an infant every time it cries, or of keeping the 
bottle at its mouth the greater part of the time, is productive of untold 
harm. 

The feeding of impure milk is an important cause of diarrhoea, espe- 
cially among the poor in cities during the summer. The different ways 
in which milk may be contaminated have already been considered in a 
previous chapter. It is surprising to see how quickly diarrhoea is excited 
by impure milk. I once saw in the New York Infant Asylum every one of 
the twenty-three healthy children, all over two years old and occupying 
one ward, attacked in a single day with diarrhoea which was traced to 
this cause. Articles of food totally unsuited to the child's digestion are 
often given. Among the poor it is a common practice to give all kinds of 
solid food to children from six to eighteen months old, while those of two 
years often get only the regular diet of the family. The great majority 
of the attacks of diarrhoea in children over two years old can be traced 
directly to improper food, often to unripe or partly decayed fruit. 

The factors mentioned — over-feeding, too frequent feeding, and the 
habitual use of improper food — all combine to produce a chronic indiges- 
tion which is probably the most important predisposing cause of diar- 
rhoeal diseases. 

The opinion has long been held that some close connection exists 
between bacteria in milk and the prevalence of diarrhoeal disease in sum- 
mer. In the years 1901 to 1903 an investigation * was undertaken by 
the Rockefeller Institute in co-operation with the Health Department of 

* The full report of this investigation was published by Prof. William H. Park and 
the author in the Medical News, December 5, 1903. 



DIARRHCEA. 357 

New York to secure more definite data regarding the following points : 
(1) The results in infant-feeding obtained with milk of different de- 
grees of purity both in winter and in summer, as shown by the gain or 
loss in weight, the amount of gastro-intestinal disturbance, and the 
death rate; (2) the relation, if any, existing between the number of 
bacteria present in the milk and the frequency of diarrhceal disease; (3) 
whether any organisms with pathogenic properties could be found in 
milk to which diarrhceal disease could be ascribed as a cause; (4) 
whether the practice of heating milk — pasteurization or sterilization — 
affected the results obtained with any given milk; (5) to what degree 
older children as well as infants were affected by bacterial contamination 
of milk. 

Altogether observations were made upon 592 bottle-fed infants liv- 
ing in tenements of New York; 202 were observed in winter and 390 in 
summer. The infants were well when the observations were begun, and 
were watched for a period of about three months, being visited regularly 
by physicians, who gave advice when needed. For some of the children 
no change was made in the milk which they were already taking; for 
others special milk was provided. Samples of milk as fed to the chil- 
dren were frequently examined as to the number and character of the 
bacteria present. Observations were possible upon infants taking (1) 
condensed milk, (2) the cheapest grade of store milk, such as is usually 
purchased by the poor, (3) a better grade of milk delivered in bottles, 
(•i) the best bottled milk sold in the city, all of the above being pre- 
pared at home, (5) milk modified at central distributing stations and 
furnished to patients in separate feeding-bottles. 

During the winter period of observation, the mortality was but 2.5 
per cent, and in but one instance was death due to disease of the digestive 
tract. The health of the infants observed was not appreciably affected 
by the kind of milk nor by the number of bacteria which it contained. 
The different grades of milk varied much less in the amount of bacterial 
contamination in winter than in summer, the cheap store milk averaging 
only about 750,000 per c.c. 

During the summer period, the mortality was 10.5 per cent, four- 
fifths of the deaths being due to diarrhceal disease. At this season the 
kind of milk influenced greatly both the amount of illness and the 
mortality. The worst results were seen in those who took the cheap 
grade of store milk and those who took condensed milk ; the best results 
in those who took the best grade of bottled milk, or modified milk from 
central distributing stations. 

The number of bacteria which may accumulate in milk before it 
becomes noticeably harmful to the average infant in summer, differs with 
their nature, the age of the milk and the temperature at which it has 
been kept. Of the usual varieties present, no strikingly deleterious re- 



358 



DISEASES OF THE DIGESTIVE SYSTEM. 



suits were seen until the number approached the one million mark. 
If much above this point, however, the injurious effects were usually 
manifest. But below it other factors rather than the number of bacteria 
seemed of greater importance. Thus in the use of condensed milk, 
prepared as it usually was with hot water, the bacterial contamination 
was relatively small, yet the results were almost as bad as with the most 
highly contaminated milk. 

An effort was made to discover whether a relationship existed be- 
tween any special forms of bacteria present in city milk and the health 
of children. The observations were continued for two years and alto- 
gether the pathogenic properties of 139 varieties of bacteria isolated 
from milk were tested upon animals in various ways, chiefly by feeding 
pure cultures to young kittens. The results were entirely negative. Nor 
could a relationship be established in any other way between any special 
form of bacteria in milk and the summer diarrhoeas of infancy. 

To test the effect of heating milk, observations were made in the sum- 
mers of 1901 and 1902 upon 92 infants who were taking the modified 
milk prepared at a central depot. The milk used was from a good farm, 
and had been kept properly cooled. The infants were divided into two 
groups as nearly alike as possible in their surroundings and in the care 
they received. To one group the milk was given pasteurized (165° F. 
for thirty minutes), to the other group it was given raw. All the 
infants were well at the beginning of the period of observation. The 
results are shown in the following table: 



Food. 


Total 

number of 

infants. 


Remained 

well entire 

summer. 


Had 

severe 
diarrhoea. 


Average 

days 
diarrhoea. 


Deaths. 


Pasteurized milk containing 1,000 
to 50,000 bacteria per c.c. at the 
time of use * . . 


41 
51 


31 

17 


10 
34 


4 

1H 


1 


Raw milk containing 1,200,000 to 
20,000,000 bacteria per c.c. at 
the time of use 


2 







Thirteen of the fifty-one infants on raw milk were changed before 
the end of the season to pasteurized milk because of serious diarrhoea; 
but for this the results with raw milk would have been even more un- 
favourable. A similar experiment was made a third season with almost 
identical results. Although the number of cases is not large, the results, 
which were practically uniform for three successive seasons, show un- 
mistakably that in hot weather fairly pure milk given raw, causes illness 
in a much larger number of cases than when it has been previously 
heated. However, a considerable percentage of infants apparently do 
quite well upon raw milk. 

Sterilized milk cannot be kept indefinitely, owing to the development 



DIARRHCEA. 359 

of spore-bearing bacteria. Although heating may destroy all the lactic 
acid groups, which cause souring of milk, such milk, if kept at summer 
temperature for any considerable length of time (over twenty-four 
hours), may contain immense numbers of other bacteria, and be very 
poisonous although not sour. This indicates the particular danger which 
may come from the general sale of pasteurized or sterilized milk, which is 
popularly supposed to be safe for two or three days, even without ice. 

After the first two years, children are less and less affected by bacteria 
in milk. The observations seemed to show that milk from healthy cows, 
produced under cleanly conditions and kept at a temperature below 
60° F., although containing large numbers of bacteria, sometimes 
amounting to many millions per c.c, might be taken in considerable 
quantities and for long periods by children over three years old, without 
any appreciably harmful effects resulting either from the living bacteria 
or their toxins. A single example is typical of a number of observations 
made. An orphan asylum, containing 650 children from three to four- 
teen years old, used during an entire summer, milk in which the bacteria 
ranged from 2,000,000 to 20,000,000 per c.c. ; yet during this period there 
occurred no case of diarrhoea of sufficient severity to call a physician. 
The milk was kept cold (below 60° F.) until used; but was given with- 
out sterilization. 

Mere numbers of bacteria certainly appear to count for much less 
than was once supposed. But the fact should not be overlooked that 
milk abounding in bacteria because of careless handling is also always 
liable to contain pathogenic organisms derived from human or animal 
sources. An important factor is the temperature at which the milk 
has been kept. If this is above 60° F., poisons are much more likely 
to develop, as the history of many epidemics of ptomaine poisoning 
from milk shows. 

The Different Varieties of Acute Diarrhoea. — Mechanical diarrlwa. — 
This includes cases in which diarrhoea is produced by foreign bodies, or 
substances taken as food which virtually act as foreign bodies: such arc 
partially cooked rice or other cereals; green corn, radishes, celery, cab- 
bage, or other vegetables; nuts and unripe fruits. The irritation caused 
by such substances may produce only increased secretion and peristalsis 
by which the offending articles are removed, or, if sufficiently severe and 
continued, it may lead to actual inflammation of the mucous membrane 
of the intestine. 

The indications for treatment are first to give an active cathartic, 
and, after thorough evacuation of the bowel has taken place, fco quiet 
the excessive irritation by opium. For two or three days after such an 
attack the diet should be very light, and of such a character as to leave 
but little residue. The patient should be kept quiet, preferably in bed. 
until the stools are quite normal. 



360 DISEASES OF THE DIGESTIVE SYSTEM. 

Diarrhoea from drugs. — In susceptible infants any of the ordinary 
cathartics may cause an attack of diarrhoea, because the physiological 
effects have been either exaggerated or prolonged. It is doubtful whether 
such attacks are often produced in nursing infants by cathartics taken by 
the mother. 

Diarrhoea from nervous influences. — Certain nervous impressions 
seem to be able to produce diarrhoea when no other factors are present. 
The most important are chilling of the surface, depression caused by 
atmospheric heat, fatigue, exhaustion, fright, and dentition. It is a 
characteristic of many of these cases, that the taking of food into the 
stomach immediately excites a movement of the bowels. The chief ab- 
normal condition in such cases is exaggerated peristalsis. This is best 
controlled by rest and opium. 

Eliminative diarrhoea. — This term has been applied to cases in which 
diarrhoea is evidently an effort on the part of Nature to rid the body of 
some irritant or toxic product. The best-known example is the diarrhoea 
of uraemia. It is, however, very probable that the diarrhoea of many 
acute infectious diseases belongs in this category. 

Acute intestinal indigestion. — Diarrhoea is a constant symptom of 
this condition, which is of such importance that it will be subsequently 
considered at length. 

Diarrhoeas of infectious origin. — In the forms of diarrhoea above 
enumerated there are no lesions, and the bacteria found in the stools 
are the ordinary bacteria of the intestines. There is merely altered 
functional activity, both motor and secretory: so that the normal chem- 
istry of digestion is disturbed. All other forms of acute diarrhoea are 
to be regarded as infectious. 

All infectious diarrhoeas are associated with some anatomical lesions, 
the extent and severity of which depend upon the nature and degree of 
the infection and the duration of the process. In the mildest cases and 
in those of short duration, even though severe, the lesions involve chiefly 
or solely the epithelial lining of the intestine. These changes may be 
compared to acute degenerations of toxic origin in other organs, the kid- 
ney, for example. Nearly the whole intestinal tract is usually affected, 
and often the stomach in addition. The symptoms in this group of 
cases are due not so much to the anatomical changes as to functional dis- 
turbance and to the toxins produced in the intestine. These act as local 
irritants, and are absorbed into the circulation, producing the constitu- 
tional symptoms of the disease. 

These cases have been classed as acute g astro- enteric intoxication. 
•In the more severe forms and in cases of longer duration more ex- 
tensive lesions are present. The epithelium is destroyed; the bacteria 
penetrate into the deeper layers of the intestines, producing lesions which 
vary greatly in character and degree. They are important as modifying 



ACUTE INTESTINAL INDIGESTION. 361 

the symptoms, course, and termination of the disease. These cases are 
sometimes classed as inflammatory diarrhoea ; here, from the location of 
the lesions, they are grouped under the term ileo-colilis. 

The pathological relation existing between the different forms of 
diarrhoeal disease is a very close one. The same case may pass succes- 
sively through the stages of acute indigestion, gastro-enteric intoxica- 
tion, and ileo-colitis. This transition may be very slow, or it may be so 
rapid that the different stages can not be distinguished. Instead of 
passing through the entire series, the process may stop at any stage and 
the case recover, or it may at any stage prove fatal. 

ACUTE INTESTINAL INDIGESTION. 

In infants, acute indigestion is seldom limited either to the stomach 
or to the intestine, although in one case the disturbance of the stomach 
is slight and that of the intestine serious, and in another the reverse may 
be observed. In these little patients the intestinal symptoms are much 
more frequent, and as a rule they are more severe than those referable to 
the stomach. There will be considered in this connection only the intes- 
tinal symptoms of acute indigestion; the gastric symptoms have already 
been described. It should be remembered that these may be seen in all 
possible combinations. In older children it is not uncommon to see the 
intestinal symptoms alone. 

Etiology. — The causes are essentially the same as those mentioned 
under Acute Gastric Indigestion — the use of improper food, over-feeding, 
sudden change of food as in weaning, or the change from some other food 
to a rich breast-milk; also various conditions affecting the nervous sys- 
tem, such as heat, cold, fatigue, or the onset of any acute disease. A pre- 
disposition to such attacks is furnished by summer weather, a delicate 
constitution, a feeble digestion, and by previous attacks of any intestinal 
disorder. In susceptible children, both infants and those who are older, 
the slightest error in feeding may induce an attack. 

Symptoms. — In infants, if the attack develops suddenly, gastric 
symptoms are usually present; if more gradually, they are usually ab- 
sent. The local symptoms are colicky pain, tympanites, and later diar- 
rhoea. The important constitutional symptoms are fever, prostration, 
and various nervous disturbances. In older children the pain generally 
precedes the diarrhoea by some hours, and is referred to the regioD of 
the umbilicus. Pain is indicated by the sharp, piercing cry, great rest- 
lessness, anddrawing up of the legs. Tympanites is rarely very marked. 

The stools are always increased in number and are from four <<> 
twelve a day. If more frequent they are very small. The first stools are 
more or less faecal, but this character is soon lost. In infancy the colour 
is first yellow, then yellowish-green, and finally often grass-green. Weg- 



362 DISEASES OF THE DIGESTIVE SYSTEM. 

scheider has shown that this colour is due to biliverdin. The exact na- 
ture of the process in the intestine, in consequence of which biliverdin 
takes the place of bilirubin as the colouring matter of the stools, is still 
a disputed point, but in infancy this change in colour is nearly constant. 
The reaction of the stools is almost invariably acid. The odour may be 
sour, or it may be very foul. The stools are much thinner than normal, 
and frothy from the presence of gases. Blood is not present, nor is 
mucus seen, unless the symptoms have lasted several days. Undigested 
food is always present; in infants upon a milk diet, this occurs as fat or 
lumps of casein. Fat may appear as small, yellowish-white masses re- 
sembling casein, but distinguished by their solubility in equal parts of 
alcohol and ether. Casein masses are more numerous, larger, and 
whiter. Unchanged starch may be recognized by the iodine reaction. 
The microscope shows, in addition to food-remains, mucus, epithelial 
cells, and bacteria. Epithelial cells, usually of the cylindrical variety, 
are numerous in proportion to the severity and duration of the attack. 
The bacteria are the ordinary forms found in the faeces. 

In the cases with sudden onset the temperature is invariably elevated. 
In infants it ranges from 102° to 105° F. ; in older children from 100° to 
103° F. The high temperature does not continue. Usually after twelve 
or twenty-four hours it falls nearly or quite to normal. In the cases with 
a more gradual onset, or in those of a less severe character, the tempera- 
ture does not often go above 101° F. The general prostration, like the 
temperature, is greatest in infants and in the cases beginning abruptly. 
It is sometimes so severe as to threaten life. There are seen rapid pulse, 
pallor, drawn features, and general muscular weakness. There may be 
restlessness, due to pain and the general discomfort, or there may be 
dulness, apathy, or convulsions. 

The course and termination of the disease depend, upon the previous 
condition of the patient, the nature of the exciting cause, and the treat- 
ment employed. In a previously healthy child, if the cause is at once re- 
moved and proper treatment instituted, the severe symptoms rarely last 
more than a day or two, and in four or five days the patient may be quite 
well. In delicate infants, a severe attack of acute intestinal indigestion 
in the hot season is likely to prove the first stage of a pathological pro- 
cess which may continue until serious organic changes in the intestine 
have taken place. This result may not follow the first attack, but one is 
often succeeded by others until it occurs. If circumstances are such that 
proper dietetic treatment and general hygienic measures can not be car- 
ried out, this termination is very common. 

Diagnosis. — It is impossible to recognize an attack of acute intestinal 
indigestion until the diarrhoea begins; the previous symptoms of fever, 
prostration, etc., are seen in many infantile diseases. From the other 
forms of diarrhoea, this is distinguished by its brief duration, although its 



ACUTE INTESTINAL INDIGESTION. 363 

symptoms* may be very alarming. The nervous symptoms are usually 
less marked than in gastro-enteric intoxication, and vomiting is less fre- 
quent. 

Prognosis. — Such attacks do not endanger life except in very young; 
or very delicate infants, in whom they may be fatal. The worst feature 
of most cases is that such attacks predispose to more serious intestinal 
diseases, many of which have their origin in acute indigestion which has 
been either neglected or badly managed. 

Treatment. — The same general plan is to be followed as in cases of 
gastric indigestion — viz., first to empty the bowels as completely as pos- 
sible of all decomposing or irritating masses of food ; secondly, to secure 
to the patient, and especially to the digestive organs, as complete rest as 
possible. For the first indication nothing is better than calomel, which 
ma} r be given in one-eighth-grain doses, and repeated every hour until 
the full effect is seen. Any other active purge, such as castor oil or 
syrup of rhubarb, may be substituted. Thirst is always great on account 
of the fever and the loss of fluid by the stools, but digestion even in the 
stomach is feeble, and often arrested altogether. For the first twenty- 
four hours no plan succeeds better than that of withholding everything 
in the shape of food, giving to allay thirst such articles as whey, albu- 
min-water, mineral waters, or cold boiled water. Small quantities must 
be given — i. e., one to four teaspoonfuls — but the interval may be as 
short as ten or fifteen minutes. If the prostration is very great, stimu- 
lants may be needed. Brandy is the best form for their administration. 
After the offending materials have all been swept from the intestine, but 
never before, opium may be given in doses large enough to control the ex- 
cessive catharsis. For a child a year old, one-quarter grain of Dover's 
powder after each stool is usually sufficient, and often a smaller dose 
may answer the purpose. 

The difficult problem is to feed these cases during the latter part of 
the attack. In nursing infants, the breast may be given after twenty- 
four hours, the nursing interval being six hours, and the time of one 
nursing not longer than five minutes. Between the nursings other food 
may be given. In the case of infants past the nursing age, or those who 
are being artificially fed, cow's milk should be withheld in all forms for 
three or four days, and the child kept upon a diet of broths, farinaceous 
or malted foods. As improvement continues milk may be cautiously 
and very gradually added, at first to one or two feedings each day, and 
later to every feeding. Jl should be boiled. Since the fat is especially 
likely to cause disturbance, plain milk diluted is better than a milk-and- 
cream mixture. In some cases there is an advantage in using partially 
or completely peptonized milk. 

In the acute stage the diet of older children should be much like that 
of infants. Later it should consist of meat, broths, egg^, boiled milk, 



364 DISEASES OF THE DIGESTIVE SYSTEM. 

and a small quantity of dried bread. All cereals, vegetables, and espe- 
cially all fruits, should be withheld for some time, and then given only in 
small quantities, and the effect on the stools closely watched. Kumyss, 
buttermilk, and matzoon are frequently better borne than plain milk. 

The use of drugs in these attacks, except those already referred to as 
indicated during the early stage, seems to me to influence the disease 
very little. Sometimes good results follow the giving of the extractum 
pancreatis half an hour after meals, or some of the preparations of 
malt when farinaceous food is first allowed. If the diarrhoea following 
the acute symptoms is prolonged or excessive, it usually indicates that 
either intestinal infection or inflammation is present, and the case 
should be treated accordingly. General measures, especially rest, fre- 
quent bathing, fresh air, and change of air, are very important in the 
management of all these cases, especially when they occur during the 
summer. 



CHAPTER VII. 
DISEASES OF THE INTESTINES.— {Continued.) 

ACUTE GASTRO-ENTERIC INTOXICATION. 

Synonyms: Summer diarrhoea, gastro-enteritis, cholera infantum, mycotic 

diarrhoea. 

This is the form of diarrhoea which is so prevalent in summer. It 
occurs regularly each season, being epidemic in most large cities of the 
temperate zone. The lesions in the intestines are slight, amounting in 
most cases only to a superficial catarrhal inflammation, often bearing no 
relation to the severity of the symptoms which are due mainly to the 
absorption of toxic materials, the result of the putrefactive changes in 
the stomach and intestine. This form of diarrhoea may follow closely 
upon an attack of acute indigestion, in which it very often has its begin- 
ning. When the infection is of sufficient intensity and duration, it leads 
to the development of marked structural changes in the intestine, espe- 
cially in the lower ileum and the colon. Acute gastro-enteric intoxica- 
tion thus stands midway between acute indigestion and ileo-colitis. 

Etiology. — Among the causes of acute gastro-enteric intoxication are 
to be mentioned, first, those which give rise to acute indigestion, and, 
secondly, the general factors mentioned as predisposing to all forms of 
diarrhoea! disease — age, surroundings, constitution, food, and methods 
of feeding. The most striking thing about these cases is their prevalence 
during hot weather. While all varieties of diarrhoea are more frequent in 
summer, it is the form under consideration which is especially prevalent. 
Year after year are repeated in New York the conditions which are 



ACUTE GASTRO-ENTERIC INTOXICATION. 365 

graphically represented in Figs. 61 and 62 — viz., an epidemic which, 
beginning in June, rapidly increases in severity, reaching its height in 
July, from which time it diminishes steadily during August and Sep- 
tember, regularly coming to ar end in October. What is true of New 
York is true also of Philadelphia, Baltimore, and other large American 
cities, as well as of Berlin and other cities of central Europe. A study 
of these charts shows that while the mean temperature rises gradually 
during April and May, it is not until June is reached with its mean 
temperature of 61° F., that any notable increase in diarrhceal diseases 
begins. It appears then that an average mean temperature, or, accord- 
ing to Seibert, an average minimum temperature, of about 60° F. is 
needed to start the epidemic. Xot many cases are seen until such a tem- 
perature has lasted for some days, usually about a week. The epidemic 
then begins in force and increases in severity through July. The ex- 
planation of the high mortality of this month appears to be, not the 4° 
or 5° F. by which the temperature of July exceeds that of June and 
August, but that the majority of the susceptible infants are unable to 
withstand the first very hot month. Humidity and rainfall, according to 
the careful investigations of both Seibert in New York and Baginsky in 
Berlin, do not influence either the prevalence of summer diarrhoea or 
its mortality. 

The action of heat in producing diarrhoea was formerly regarded as a 
direct one. Severe cases were looked upon as examples of heat stroke or 
thermic fever. If such a thing exists it must be regarded as extremely 
rare. There is, however, no doubt that the constitutional depression pro- 
duced by high atmospheric temperature does seriously interfere with 
digestion, and that acute indigestion so produced is very often the first 
stage in the pathological process, and prepares the way for infection. 
The view almost universally held at the present time regarding summer 
diarrhoea is that it is of infectious origin. 

Despite the fact that since 1886 many series of bacteriological studies 
of the intestinal discharges have been made by Booker and Park in this 
country, by Baginsky, Escherich, and others in Germany, our knowledge 
of this subject is still very incomplete. The conditions are exceedingly 
complicated, and the problem is a very difficult one. So far as is now- 
known, no one form of bacteria can be assigned as the cause of this 
group of diarrhoeas. The evidence seems to be conclusive that the Shiga 
bacillus may, in a certain percentage of cases, produce diarrheal disease 
of this type. It is, however, wanting in so large a proportion of caso-. 
that it cannot be regarded as the specific cause. With existing knowl- 
edge it seems probable that there are a number of organisms present in 
the intestines in slight disorders of digestion which, under favourable 
conditions, may multiply to such a degree as to produce very serious 
disease. 



366 DISEASES OP THE DIGESTIVE SYSTEM. 

There are certain cases in which toxic symptoms of a severe type 
develop abruptly in children previously quite well. These only are to 
be regarded as examples of acute milk poisoning. Although the bacteria 
in the milk may have been previously destroyed by sterilization, the 
toxins produced by them may still be present. This is doubtless the 
explanation of the simultaneous development of several cases in families 
or institutions. 

With our present knowledge we can not believe that direct contagion 
is the usual way in which this disease is spread. When occurring in in- 
stitutions or in families, it usually happens that a number of children 
are attacked simultaneously rather than successively, this indicating a 
common cause, usually to be found in the food. However, disinfection 
of stools and napkins is indicated in all cases. 

Relation of the different etiological factors.— -The predisposition to 
attacks of summer diarrhoea is partly general and partly local. The gen- 
eral influences are age (under two years), feeble constitution, unhygienic 
surroundings, and a condition of general malnutrition dependent upon 
improper food or feeding. The most important of the local causes is a 
previous derangement of digestion. In addition there may be present a 
low' grade of catarrhal inflammation. The attack may begin as acute 
indigestion, not infrequently the direct result of high atmospheric tem- 
perature. In consequence of the presence of undigested food in the 
stomach or intestines there are furnished conditions in which bacteria, 
previously present in small numbers, may multiply very rapidly ; bacteria 
may be introduced in such numbers and of such virulence as to over- 
power the digestive organs; or, finally, bacterial products may be in- 
gested with the food, requiring only absorption to produce their effects. 

Lesions. — The statements which follow are based upon a study of 
forty autopsies, in twenty-two of which microscopical examinations were 
made. The lesions may be briefly described as a superficial catarrhal in- 
flammation affecting the entire gastro-enteric tract, although it varies 
much in severity in the different regions and in the different cases. The 
colon, the lower ileum, and the stomach, are apt to suffer most, the 
duodenum and the jejunum least. 

The gross appearances. — These are usually disappointing, and may 
often show but little that is abnormal. The stomach is distended with 
gas, and contains undigested food. Its walls may be coated with mucus. 
The upper part of the small intestine is empty. The lower portion con- 
tains particles of food, and yellow, gray, or green material, often offen- 
sive, resembling the stools passed during life. The transverse colon, the 
caecum, and sigmoid flexure are apt to be distended with gas, and contain 
materials similar to those mentioned, while the rest of the large intes- 
tine is usually empty and its walls contracted. It may be coated with 
mucus. The mucous membrane of the stomach may show intense con- 



ACUTE GASTROENTERIC INTOXICATION. 367 

gestion, generally in patches, or it may be pale. The mucous membrane 
of the small intestine may be pale throughout • there are often irregular 
areas of congestion, or a very intense congestion of a large part of its 
surface, j>articularly in the ileum. With this there may be redness and 
swelling of Peyer's patches and the lymph nodules (solitary follicles). 
In the colon the mucous membrane is congested, especially upon the 
rugae. This congestion may be general or in patches. The lymph nod- 
ules are usually swollen; but this may be due to an antecedent process, 
and not to the final attack. There is no thickening of the intestinal 
walls. The changes described are not at all uniform, and do not differ 
very greatly from the appearances often seen in the intestines when 
patients have died of other diseases. 

In the cases classed clinically as cholera infantum, the pathological 
changes are more characteristic. The greater part of the small intes- 
tine, and sometimes the entire colon, are distended with gas, and contain 
material of a grayish-white colour about the consistency of a thin gruel. 
It has a mawkish odour, but usually not a very offensive one. The 
mucous membrane of the entire intestinal tract has in most cases a pale, 
" washed-out " appearance. Sometimes this is seen only in the small 
intestine, while there are areas of congestion in the colon. If cholera in- 
fantum has been ingrafted upon some other pathological process in the 
intestines, as is not infrequent, there is found post-mortem evidence of 
this in the form of severe catarrhal inflammation, sometimes old ulcera- 
tions. In some cases, where the symptoms have been those of choleriform 
diarrhoea, there are found evidences of an intense diffuse gastro-enteritis, 
as shown by congestion of the stomach and almost the entire intestinal 
tract, with swelling of the mucous membrane, and especially of Peyer's 
patches. 

The microscopical appearances. — Unless autopsies are made very soon 
after death — at least within four hours — it is not safe, in most of the 
cases, to draw conclusions from the conditions found, as post-mortem 
changes take place so readily in the intestines, and these changes are so 
like those of the disease under consideration. This applies particularly 
to the condition of the epithelium. One should also be cautious in inter- 
preting the appearances of portions of the intestine which have been 
greatly distended with gas. 

The essential lesion consists in degenerative changes in the epithe- 
lium of the stomach and intestines. The cells may still be present, but 
with the cell protoplasm and nuclei so changed that they do not stain 
normally. Bacteria are found in the epithelial layer and in the upper 
portion of the crypts of Lieberkiihn. In more severe and prolonged 
cases the superficial epithelium in places is entirely destroyed, ami 
through such breaks the bacteria can be seen penetrating into the deeper 
structures of the intestine; these changes mark the beginning of ileo- 
25 



368 DISEASES OF THE DIGESTIVE SYSTEM. 

colitis. In simple intestinal intoxication the bacteria are not, as a rule, 
found in the deeper structures of the intestines nor in the lymph nodes 
of the mesentery. Unless autopsies are made immediately after death, 
little significance can be attached to the presence of bacteria, particularly 
the colon bacillus in the deeper layers of the intestine, in the other 
organs, or in the blood. 

The changes in and about the blood-vessels are variable. The small 
vessels may be distended, and there may be haemorrhages or an exuda- 
tion of leucocytes in their neighbourhood. These conditions are seen 
either in the mucous or submucous layer. The exudation from the blood- 
vessels is usually slight, and in many cases is wanting. Peyer's patches 
and the lymph nodules may be enlarged from cell-proliferation. Patho- 
logically no sharp line can be drawn between these lesions and those of 
the early stage of ileo-colitis ; the latter affect the lower ileum and colon 
chiefly, often exclusively, are more advanced, and involve the deeper 
parts of the intestinal wall. 

Lesions in other organs. — These are much less frequent and less 
severe than in the more protracted cases of ileo-colitis. Acute bronchitis 
and broncho-pneumonia are frequent. Acute degeneration of the kidney 
is found to some degree in every case which is severe enough to cause 
death, and in a few there is acute diffuse nephritis. In rare cases a 
general septicaemia, due most frequently to the streptococcus, is present 
with its usual manifestations. Degenerative changes are sometimes found 
in the liver cells, and even in the nervous centres. Some of these lesions 
are accidental, while others are the direct result of the circulation in the 
blood of toxins derived from the intestines. 

Clinically, there are two quite distinct forms of gastro-enteric intoxi- 
cation, which will be separately considered — (1) the simple form and 
(2) true cholera infantum. 

Simple (Castro-Enteric Intoxication. — There are seen in infants 
mild attacks, which do not differ clinically from cases of intestinal 
indigestion. 

Under favourable conditions and with proper treatment most such 
cases recover after active symptoms lasting from one to three weeks, 
although it may be one or two months before a steady gain in weight 
begins (Fig. 63). Severe symptoms may, however, supervene at any 
time, and the attack become one of a very grave type. This often takes 
place with great suddenness, and is frequently coincident with a few 
days of very hot weather, or follows some gross dietetic error. In other 
cases the symptoms may continue with the gradual formation of follicu- 
lar ulcers, the case becoming one of ileo-colitis. The entire illness may 
continue, with exacerbations and remissions, until the cool weather of 
autumn. 

In the cases developing suddenly, the clinical picture is quite a differ- 



ACUTE GASTRO-ENTERIC INTOXICATION. 



369 



ent one. The attack may begin abruptly in a child previously healthy, 
or there may have been for some days a slight intestinal derangement. 
If an infant, it is restless, cries much, sleeps but a few minutes at a time, 
and seems in distress. The skin is hot and dry, the temperature rises 
rapidly to 102° or 103° F., sometimes to 106°, and all the symptoms 
indicate the onset of some serious illness. The infant may lie in a dull 
stupor, with eyes sunken, weak pulse, and general relaxation, or there may 
be restlessness, excitement, and even convulsions. There may be great 
thirst, so that everything offered is eagerly taken, or everything may be 
refused. Vomiting may be an early and important symptom. It is first 



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Fig. 63. — Weight curve of artificially fed infant for the first year, showing the effect of acute 
gastro-enteric intoxication. Normal progress until A, acute attack with fever ; B, acute 
symptoms relieved, but continued intestinal indigestion ; C, digestion practically normal, 
and child put back upon its modified-milk food. 



of food, often that which was taken many hours before; retching con- 
tinues even after the stomach has been emptied, so that mucus, serum, 
and sometimes bile may be ejected. It does not usually persist through- 
out the attack, and in many cases it is absent altogether. Diarrhoea is 
sometimes delayed for twenty-four hours or even longer after the begin- 
ning of the grave constitutional symptoms. At first there are faecal 
stools, then great bursts of flatus, with the expulsion of a thin yellow 
material with an offensive odour. Four or five such discharges may 
occur in as many hours. At other times the stools are gray, green, or 
greenish-yellow, and sometimes brown. They often do not differ at first 
from those of an ordinary attack of acute intestinal indigestion. The 



370 DISEASES OF THE DIGESTIVE SYSTEM. 

characteristic features are the amount of the gas expelled, the colicky 
pains preceding the discharges, and the foul odour. After the first day 
the stools may be almost entirely fluid, varying in number from six to 
twenty a day, and often large even then. Their offensive character usu- 
ally continues. After two or three days mucus may appear. The micro- 
scopical examination of the stools shows, besides the things mentioned in 
the stools of acute indigestion, great numbers of separate epithelial cells, 
and sometimes groups of cells attached to a basement membrane. In 
addition there may be round cells and some red blood-corpuscles. 

In many cases the free evacuation of the bowels is followed by a drop 
in the temperature and subsidence of the nervous symptoms, and the 
child may fall asleep, to awaken after a few hours for a stool. The 
prostration, though often great in the beginning, may not be of long 
duration. Under the most favourable circumstances, after one or two 
days of severe symptoms, the case may go on to a rapid convalescence. 
The stools continue abnormally frequent for five or six days, but grad- 
ually assume their normal character, and recovery follows. The chief 
factors contributing to such favourable results are a good constitution 
on the part of the child, energetic and intelligent treatment at the out- 
set, and proper feeding afterward. 

If the circumstances are not so favourable, if the patient is a very 
young, delicate, or cachectic infant, there may be no reaction from the 
first severe symptoms, and the attack may terminate fatally in from one 
to three days. In such cases the temperature remains high; the stomach 
may or may not be disturbed ; but the diarrhoea, prostration, and nervous 
symptoms continue, and death occurs from exhaustion, in coma or con- 
vulsions. Instead of a rapidly fatal termination, the severity of the early 
acute symptoms may abate somewhat, and the attack assume the char- 
acter of ileo-colitis, with a lower but continuous temperature of 100° to 
102° F., frequent mucous stools, wasting, etc. The urine is scanty and 
concentrated, and in most of the severe cases with very high temperature 
contains a small amount of albumin, and occasionally a few hyaline and 
granular casts. These are the result of degenerative changes in the renal 
epithelium from the irritating toxins.* In rare cases there are evidences 
of acute nephritis. (See Cholera Infantum.) Broncho-pneumonia is 
also sometimes seen. > . 

Relapses. — Re-infection. — It not infrequently happens, after the storm 
of the acute attack with its high temperature, intense prostration, and 
grave nervous symptoms is passed, and the stools are so much improved 
that the patient is regarded as out of danger, that all the former symp- 
toms may develop with such rapidity and severity as sometimes to carry 
off the patient in from twelve to twenty-four hours. Such relapses are 
usually the result of re-infection of the intestinal tract, generally excited 
by some mistake in the diet, usually that of allowing milk too soon. The 



ACUTE GASTRO-ENTERIC INTOXICATION. 



371 



amount of milk given may be small, and yet the symptoms follow its 
administration so soon that there can be no doubt regarding the con- 
nection between them. This only indicates that virulent bacteria may 
remain in the intestine for a considerable time after the disappearance 
of severe symptoms, waiting only for favourable conditions to develop 
again with all their former intensity (Fig. 64). Besides such severe 
cases, many of a milder grade of re-infection are seen, and the cause is 
usually some error in diet; occasionally, however, it is due to checking 
the discharges by the too free use of opium. 

Cases without diarrhoea. — Attacks of acute intestinal intoxication in 
which there is no diarrhoea, but constipation instead, are most puzzling 
and frequently most serious. Fortunately, they are not of common 
occurrence. I have, however, seen several striking examples with very 



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Fig. 64. — Acute intestinal intoxication with fatal re-infection. 

Infant five months old ; early symptoms, both intestinal and nervous, severe ; rapid im- 
provement followed stopping milk, free catharsis and irrigation. After stools had been nearly 
normal for three days relapse occurred, apparently from adding milk to the diet, although less 
than two ounces a day were given. Autopsy : Intestines showed the usual changes of intoxica- 
tion ; other organs essentially normal. 



high temperature, grave nervous symptoms, and sometimes marked 
abdominal distention in which it seemed almost impossible to move the 
bowels by drugs. Castor oil, calomel, and salines have in some cases 
been tried in succession in four or five times the ordinary doses without 
the slightest effect, even when supplemented by frequent intestinal irri- 
gation. It has sometimes been nearly two days before free movements 
were finally produced. These are often exceedingly foul. It is some- 
what difficult to explain such cases. There seems to exist for tin 4 time 
almost complete intestinal paralysis. The toxic materials are locked 
up in the small intestine, for the colon is frequently quite empty. When 



372 DISEASES OF THE DIGESTIVE SYSTEM. 

one meets such a case he can appreciate the fact that in acute intestinal 
intoxication diarrhoea is a conservative process of the greatest possible 
value. 

In children over two years old there are seen some features which 
differ from those of the cases above described as occurring in infants. 
The attacks are more often due to other causes than to milk. Vomiting 
does not occur so readily as in infants, pain is a more prominent symp- 
tom, and the temperature, as a rule, is lower. The nervous symptoms are 
much less* prominent. Skin eruptions, however, are more frequently 
seen, particularly urticaria, which is a feature of most severe attacks, 
and in obscure cases has some diagnostic value. Although often begin- 
ning with severe symptoms, these cases usually make good recoveries; 
there is much less danger of their going on to the development of ileo- 
colitis than in the case of infants. 

Diagnosis. — Attacks of acute gastro-enteric intoxication can not 
always be distinguished from those of acute indigestion, but as a rule 
they are characterized by a higher temperature, greater disturbance of 
the nervous system, very offensive fluid stools, and by occurring epi- 
demically in summer. To differentiate these cases from those of ileo- 
colitis, may be impossible for the first two or three days. Nor is it im- 
portant to do so. The onset may be similar in both conditions. The 
continuance of high temperature beyond the third day points to inflam- 
matory changes; so also do the appearance of blood and of much mucus 
in the stools, and the existence of continuous pain. 

The acute indigestion manifested by vomiting and diarrhceal stools 
which marks the beginning of so many febrile diseases in infancy, par- 
ticularly scarlet fever, pneumonia, malaria, and influenza, is often diffi- 
cult to distinguish from an attack of intestinal intoxication. The ques- 
tion to decide is whether the digestive symptoms are the cause or the 
result of the fever. It is sometimes not until the case has been watched 
for at least forty-eight hours that one can be certain as to the diagnosis. 
Usually where digestive symptoms are secondary they diminish after the 
' first day or two, although the severity of the general symptoms may 
steadily increase. Where the nervous symptoms are prominent at the 
outset, it is sometimes difficult to distinguish acute intestinal intoxica- 
tion from meningitis. I have seen many cases where great doubt existed 
for several days. One should always hesitate to make a diagnosis of 
meningitis when marked diarrhoea is present. 

Prognosis. — Simple cases of gastro-enteric intoxication do not often 
prove fatal, except in young infants or those already suffering from mal- 
nutrition. Such patients are often overcome in the first stage of intoxi- 
cation. Even an apparently mild attack may prove fatal. 

In other cases the prognosis resolves itself into this question : What 
are the probabilities of arresting the attack before the production of 



ACUTE GASTRO-ENTERIC INTOXICATION. 373 

serious intestinal lesions? If the child is delicate, living in poor sur- 
roundings, has previously suffered from digestive derangements or acute 
diarrhoea, and does not receive proper early treatment, the attack will 
probably result in structural changes in the intestines. In hot weather 
this is especially liable to be the case. The existence of rickets, pertussis, 
or any other disease, greatly increases the gravity of the attack. 

Prophylaxis. — A better understanding of the etiology brings with it 
great possibilities in the prevention of this disease. 

Prophylaxis must have regard, first, to the hygienic surroundings of 
children, and to all sanitary conditions in the cities. City children 
should be sent to the country, whenever it is possible, for the months of 
July and August. Where a long stay is impossible, day excursions do 
much good. The fresh-air funds and seaside homes have done more in 
Xew York to diminish the mortality from diarrhceal diseases in summer 
than all medicinal treatment. 

The second part of prophylaxis relates to food and feeding. Mater- 
nal nursing should be encouraged by every possible means. Nothing is 
better established than the close relation existing between artificial feed- 
ing and diarrhceal diseases. Yet, as stated elsewhere, it is not artificial 
feeding per se, but ignorant and improper feeding. Among infants in 
private practice who are properly fed these attacks are not common. 
The general rules laid down elsewhere on the subject of artificial feeding 
should be carried out, as to the quantity of food, frequency of feeding, 
modification of cow's milk, and all matters relating to the care, trans- 
portation, and handling of milk. The important dangers to be empha- 
sized in this connection are overfeeding, too frequent feeding, the use 
of improper foods or impure foods, especially impure milk. 

Overfeeding is particularly to be avoided during days of excessive 
heat. It is at such times an excellent rule with infants to diminish each 
meal by at least one-half, making up the deficiency with water, and to 
give water very freely between the feedings. All water given to infants 
or young children should first be boiled. Children, like adults, require 
less food in very hot weather, but more water. Infants cry more from 
thirst and heat than from hunger, and even those at the breast are likely 
to 1)0 given too much food. Infants should never be fed more frequently, 
but always less frequently during hot weather. 

No more important work in practical philanthropy can be done among 
the poor of our large cities in summer than to provide means for supply- 
ing pure milk to infants. This has been done on a large scale in many 
American cities, and it has effected a very decided reduction in the 
death-rate from diarrhceal diseases. (See page 43.) In some places 
this has been accomplished through private generosity, in others by the 
Department of Health. It is not enough to furnish to the poor a pure, 
clean milk in bulk, or even in sealed quart bottles. The advantages of 



374 DISEASES OF THE DIGESTIVE SYSTEM. 

such milk may be entirely lost by the way in which it is cared for in 
the home or by the method of feeding. The most successful plan is that 
in which milk is modified and sterilized at central stations, from which 
it is distributed in small feeding-bottles, each containing enough only 
for a single feeding. A twenty-four hours' supply is furnished at each 
daily visit. Sometimes the milk is given free, sometimes a nominal 
charge, generally one cent a bottle, is made. Since the milk must usually 
be kept at home without ice, sterilization at 212° F. is advisable. A 
physician is in charge of the milk distribution who gives advice when 
needed, keeping a general supervision over the children and deciding the 
quantity of food, number of feedings, and the formula to be used. It 
is not necessary to have a large number of formulas. In summer three 
or four simple ones will be found to answer all requirements. Those 
derived from dilutions of whole milk (see page 194) in which the fats 
are low will generally be found to be best for hot weather ; e. g., fat, 1 ; 
sugar, 6; proteids, 0.90 (one-fourth milk) ; or, fat, 2; sugar, 6; proteids, 
1.80 (one-half milk) ; or, fat, 3; sugar, 7; proteids, 2.70 (three-fourths 
milk). The dilution is made with plain water or with barley-water and 
milk-sugar added to bring up the percentage of sugar to the desired 
amount. Further dilution of these formulas to secure lower percentages 
may be made at home by simply adding boiled water before feeding. 
In observations made upon infant-feeding in the tenements of New 
York already referred to (see page 357) the plan of feeding described 
above gave by far the best results, and it is the one to be recommended. 

Second only in importance to proper food is the education of the 
poor in all matters relating to infant hygiene. Early and prompt atten- 
tion should be given to all the milder derangements of the stomach and 
intestines. The larger proportion of serious attacks are preceded for 
some time by mild symptoms, which are often easily managed by prompt 
attention at the outset. 

In brief, prophylaxis demands (1) sending as many infants out of 
the city in summer as possible; (2) the education of the laity as to the 
importance of proper rules of feeding, the dangers of overfeeding, and 
as to what constitutes a suitable diet for infants just weaned; (3) proper 
legal regulations regarding the transportation and sale of milk; (4) 
sterilization of milk used by the poor during the summer ; ( 5 ) scrupulous 
cleanliness in bottles and nipples; (6) prompt attention to all mild 
derangements; (7) reducing the amount of food and increasing the 
amount of water during the days of excessive summer heat. 

Hygienic Treatment. — If the attack occurs in the city in midsummer, 
and does not yield in three or four days to the treatment employed, the 
child should, if possible, be sent to the country. Convalescent cases 
should also be sent away on account of the dangers of relapses. Usually 
the seashore is to be preferred to the mountains, but this is not so impor- 



ACUTE GASTRO-ENTERIC INTOXICATION. 375 

tant as that the child shall go where it is likely to have the best food 
and the best surroundings. Children must not only be sent away; they 
must be kept away until quite recovered. In cases which have become 
somewhat chronic, more can sometimes be accomplished by a change 
of air than by all other means. 

Fresh air is of the utmost importance for all diarrhceal cases in sum- 
mer. No matter how much fever or prostration there may be, these cases 
always do better if kept out of doors the greater part of the day. Noth- 
ing is so depressing as close, stifling apartments. Children should be 
kept quiet, and especially should not be allowed to walk, even if they are 
old enough and strong enough to do so. They can be kept out in car- 
riages, in perambulators, or in hammocks. 

The clothing should be very light flannel; a single loose garment is 
preferable. Linen or cotton may be put next the skin if this is very 
sensitive and there is much perspiration. At the seashore and in the 
mountains, care should be taken that sufficient clothing at night is 
supplied. 

Bathing is useful to allay restlessness, as well as for cleanliness and 
the reduction of temperature. For the reduction of temperature, only 
the tub bath is to be relied on. The temperature of the bath should be 
about 100° F. when the child is put into it, and should then be gradually 
reduced to 80° or 85° F. by adding ice. The bath should be continued, 
with gentle friction of the body, for from five to twenty minutes. 

Scrupulous cleanliness should be secured in the child's person and 
clothing. Napkins, as soon as soiled, should be removed from the child 
and from the room and placed in a disinfectant solution. Excoriations 
of the buttocks and genitals are to be prevented by absolute cleanliness 
and the free use of some absorbent powder, such as starch and boric acid. 

Dietetic Treatment. — It is of the first importance to remember that 
during the early stage of the acute cases, digestion is practically arrested. 
To give food at this time, manifestly can do only harm. 

In nursing infants the severe forms of the disease are extremely 
rare; but the breast should be withheld so long as a disposition to vomit 
continues, and no food whatever given for at least twenty-four hours. 
Thirst may be allayed by giving frequently, but in small quantities, cold 
whey, thin barley water, or albumin water. Stimulants may be added if 
required. If they are refused or vomited, absolute rest to' the stomach 
will do more than anything else to hasten recovery. After the stomach 
has been allowed to rest for twenty-four hours, it is generally safe to 
permit a nursing child to take the breast tentatively. The intervals of 
nursing should not be shorter than four hours, and the amount allowed 
at one feeding should not be more than one-fourth the usual quantity. 
This may be regulated by allowing an infant to nurse at first only two or 
three minutes. Between the nursings may be given whey, barley water. 



3^6 DISEASES OF TfiE DIGESTIVE SYSTEM. 

or albumin water, so that something is given every two hours. Nursing 
may be gradually increased, so that in three or four days the breast may 
be taken exclusively. If there is any reason to suspect the quality of 
the breast-milk, such as menstruation or pregnancy, it may be necessary 
to stop the nursing for a longer time. 

In infants under four months who are being artificially fed, all food, 
and especially milk, should be stopped at once. Milk should be with- 
held during the period of acute symptoms, and for several days there- 
after. Besides the articles mentioned above as suitable for the period 
of most acute symptoms, the following substitutes for milk will be found 
useful : rice or barley water, either plain or dextrinized ; the farinaceous 
foods ; the malted foods ; broth or bouillon made of veal, chicken, or beef, 
and such beef preparations as Mosquera's fluid beef jelly, panopepton, 
liquid peptonoids, or bovinine. Water may be allowed freely at all times 
unless there is much vomiting. 

Sterilized cow's milk should be used at first in very small quantities, 
and the effect upon the stools and temperature watched. The indications 
for modifying milk are the same as in acute intestinal indigestion. But- 
termilk' with barley water (page 160) sometimes agrees better than any 
other milk derivative. Wet-nurses are not to be employed during the 
acute symptoms, but during the period of prolonged malnutrition which 
follows an acute attack, they may be of the greatest service. 

The same general principles of feeding must be applied in older chil- 
dren. All food is to be withheld until the vomiting ceases, when broths 
and beef juice may be given; later, kumyss or matzoon, afterward steril- 
ized milk, or thin gruels made with milk. Solid food should not be 
allowed for several days after the stools have become normal. 

Summary. — All food, but especially cow's milk, should be stopped at 
once. No food whatever should be given upon a very irritable stomach; 
but thirst should always be relieved by bland fluids given frequently in 
small quantities, and cold. Articles requiring the least digestion and 
leaving the smallest residue should next be tried. Food prescriptions 
must be made with the same care and exactness as those for drugs, for 
in most cases they are more important. Quantity and. frequency must 
be definitely stated, as well as the articles ordered. Directions should 
be given in writing, or they will be forgotten before the physician is out 
of the house. A practical acquaintance with the proper appearance and 
taste of every food ordered, is absolutely indispensable. It is a common 
mistake to give too much at a time, to feed too frequently, to try too 
many articles at once, and to change before a thing has been fairly tested. 
For a single feeding the quantity allowed will vary according to the 
tolerance of the stomach, but it should generally be much less than is 
given in health, usually from one-fourth to one-half that amount. It 
is very rarely, if ever, necessary to nurse or feed a sick child oftener 



ACUTE GASTRO-ENTERIC INTOXICATION. 377 

than every two hours, and four-hour intervals are in many cases to be 
preferred. In all cases water should be allowed frequently and freely; 
and if there is great prostration, stimulants should be given in addition. 

It is a difficult problem to feed these children under three years of 
age, capricious as they are by nature and still more by education, and the 
judgment and tact of the physician are taxed to their utmost. We must 
have many resources, for a food which one child takes well the next utterly 
disdains. The best plan is to select from a list of articles of accepted 
value, such as circumstances will permit, and such as are most likely to 
be properly prepared, and try them patiently, one after another, until 
one is found which the child under treatment will take, and which agrees 
best with him. 

Medicinal and Mechanical Treatment. — It must be borne in mind 
that we are not treating an inflammation of the stomach or intestines, 
although such may be the ultimate result of the process. The essential 
condition, it should be remembered, is one of acute intoxication aris- 
ing from the intestinal contents — food-remains from arrested digestion, 
altered secretions, acids, and other toxic substances produced by bacteria 
— to which not only the constitutional symptoms, but the local lesions are 
chiefly due. We can hardly do better than to imitate and assist Nature 
in her treatment of this condition. Let us consider what this is. Lest 
too much food be swallowed, appetite is taken away; by vomiting, the 
stomach is emptied; to neutralize the acid poisons in the intestine, an 
alkaline serum is poured out from the intestinal walls ; to remove irritant 
poisons, increased peristalsis is excited. 

The first indication is, therefore, to evacuate the stomach and the 
entire intestinal tract at the earliest moment, and to do this as thor- 
oughly as possible. Under no circumstances should the treatment be 
begun with the use of measures to stop the discharges. To empty the 
stomach is not necessary in every case, since the initial vomiting may 
have done this effectively. Whenever vomiting persists one should im- 
mediately resort to stomach-washing. A single washing is generally suffi- 
cient, and if employed at the outset may do much to shorten the attack. 
With high fever and great thirst, it is often advisable to leave an ounce 
or two of water in the stomach. If the vomited matters have been very 
sour, ten grains of bicarbonate of soda may be introduced with the por- 
tion which is to be left behind. As a substitute for stomach-washing in 
children over two years old, or where it can not be employed, copious 
draughts of boiled water may be given. This is taken readily, and as 
it is usually vomited almost at once it may cleanse the stomach thor- 
oughly; but it is inferior to stomach-washing. 

To clear out the small intestine, only cathartics are available. For 
the colon, we may in addition employ irrigation. Calomel, castor oil, or 
the salines may be used as cathartics, and enough of any one of thorn 



378 DISEASES OF THE DIGESTIVE SYSTEM. 

must be given not simply to move the bowels, but to clear out the intes- 
tinal tract thoroughly. There is little danger from too free purgation 
at the outset. Calomel has the advantage of ease of administration: 
one-fourth of a grain should be given every hour up to six or eight doses, 
or until the characteristic green stools are seen. When the stomach is 
not disturbed, I prefer castor oil in most cases, as it sweeps the whole 
canal, causes little griping, is very certain, and its after-effects are sooth- 
ing. Two drachms should be given to a child a year old, and half an 
ounce to one of four years. Of the salines, Eochelle salts and magnesia 
are the best; either the sulphate, citrate, or the milk of magnesia may 
be used. Of the sulphate as much as one drachm should be given in 
divided doses in the course of two or three hours, and an equivalent 
amount of the other preparations. 

The occasional use of cathartics is an important part of the later 
treatment. Whenever there are signs of an accumulation, or fresh symp- 
toms of intoxication develop, such as increase in temperature, nervous 
symptoms, etc., another thorough cleaning out of the intestinal tract is 
indicated. The accumulation may not be the result of food, but simply 
of intestinal secretions. So long as the processes of fermentation and 
decomposition continue active, the indications are to facilitate elimina- 
tion, not to check the discharges. 

Irrigation of the colon is advisable in all cases, as it hastens the 
effect of the cathartic and removes at once much irritating and offensive 
material. It should be done two or three times the first day, but after- 
ward once daily is sufficient. A saline solution (one tablespoonful of 
salt to two quarts of water), at a temperature of about 100° F., is to 
be preferred; and a long rectal tube should always be used. Thorough 
initial evacuation, almost no food, but plenty of water for twenty-four 
hours, and careful feeding after that time, are all the treatment that is 
necessary in a large number of cases. 

Other drugs are of secondary importance. Their value is certainty 
very much overestimated. This statement is made after a thorough and 
honest trial, in hospital and private practice, of most of those that have 
been recommended. Since the recognition of the fact that putrefactive 
processes play so important a role in these cases, the drift of opinion and 
practice has been toward the use of drugs believed to act in the alimen- 
tary tract as antiseptics. In comparison with the gastric and intestinal 
contents the amount of any drug which can be given is small, it is true, 
and we have still much to learn regarding the nature of the putrefactive 
processes we are seeking to control. It may therefore be questioned 
whether as yet any scientific antiseptic treatment of the gastro-enteric 
tract is possible. However, clinical experience points to the fact that 
the internal use of antiseptics is of value, even though such remedies do 
no more than inhibit bacterial growth. Those which are soluble can be 



ACUTE GASTRO-ENTERIC INTOXICATION. 379 

expected to influence only the stomach and upper small intestine. The 
insoluble ones may affect the lower small intestine and colon. Those 
which in my experience have been found most useful are bismuth, salol, 
salicylate of soda, and resorcin; although the list might be very greatly 
extended. 

Bismuth has the advantage that it rarely causes vomiting, and that 
most of its preparations can be given in large doses. Of the newer prepa- 
rations, the subgallate is easily superior to the others. This may be 
given in doses of from two to four grains every two hours, to a child of 
one year. Like the subnitrate it is insoluble and is best given suspended 
in mucilage. For most cases, however, I think the subnitrate is still to 
be preferred. To be efficient, from one to two drachms should be given 
daily to a child two years old. It usually blackens the stools. It may 
be kept up throughout the attack. Of the salicylate of soda, to a child 
of one year, two grains may be given, dissolved in water, every two 
hours, after feeding. This is not to be used if the stomach is very irrita- 
ble, as it may excite vomiting. Its best effect is seen after the vomiting 
has stopped, and when the stools are fluid. It should be given alone. 
Salol is decomposed in the intestine into salicylic and carbolic acids. 
To a child of two years one or two grains may be given every two hours ; 
sometimes more will be borne. Eesorcin may be used in doses half as 
large. Either of these, however, may cause vomiting. The best results 
are seen from acids in the later stages and in the subacute cases; of 
the dilute hydrochloric acid, from one to three drops may be given, best 
alone. Alkalies are of value only in the acute stage, especially where 
there is acid fermentation in the stomach, with vomiting and eructations 
of gas. Lime-water, bicarbonate of soda, magnesia, or chalk-mixture 
may be employed. My own experience accords with that of most recent 
writers in according a very limited place to astringents. They do little 
good, and often much harm. They are indicated only in the catarrhal 
diarrhoea which often follows the symptoms of acute intoxication, but 
may be advantageously used in this condition in combination with opium. 
A useful astringent is tannalbin, which may be given in two-grain doses 
every two hours to an infant of one year. 

While opium in some form is required in many cases, as often used 
it undoubtedly does great harm. The chief indications for opium are 
great frequency of movements and severe pain. It is contraindicated 
until the intestinal tract has been thoroughly emptied by cathartics and 
irrigation; also when the number of discharges is small, particularly if 
they are very offensive; it is especially to be avoided in the early Btage 
of very acute cases, and never to be given when cerebral symptoms and 
high temperature coexist with scanty discharges. Opium is admissible 
in the early part of the disease after the tract has been thoroughly emp- 
tied. It is particularly indicated when there is a persistence of large, 



380 DISEASES OF THE DIGESTIVE SYSTEM. 

fluid movements attended by symptoms of collapse, and in all cases 
approaching the cholera-infantum type. In such circumstances mor- 
phine should be given hypodermically, one one-hundredth of a grain to 
an infant of six months, to be repeated in an hour if no effect is seen. 
Opium is useful during convalescence, when the administration of food 
is immediately followed by a movement of the bowels; and when with- 
out an elevation of temperature, often with good appetite, the stools are 
frequent and contain undigested food, because peristalsis is so active that 
the intestinal contents are hurried along with such rapidity that there 
is not time for complete intestinal digestion and absorption. Nothing 
requires nicer discrimination than the use of opium in diarrhoea. It is 
wise to administer it always in a separate prescription, and never in 
composite diarrhceal mixtures. The dose should be regulated according 
to its effect upon the number of stools. Enough is to be given to produce 
a distinct effect — the diminution of pain and the control of excessive 
peristalsis — but never enough to check the discharges entirely, or to cause 
stupor. The uncertainty of absorption must also be remembered ; a sec- 
ond full dose should not be given until a sufficient time has elapsed for 
the effect of the first to pass away. For an average child of one year, 
five minims of paregoric, one-fourth minim of the deodorized tincture, 
or one-fourth grain of Dover's powder, may be used as an initial dose, 
to be repeated every one, two, or four hours, according to the effect 
produced. 

Stimulants are required in the majority of the severe cases. The 
prostration is great and develops rapidly; frequently almost no food can 
be assimilated for twenty-four or thirty-six hours, while the drain from 
the discharges continues. The general condition of the patient is the 
best guide as to the time for stimulation and the amount required. 
Often stimulants are not begun early enough. Old brandy is the best 
preparation for general use, champagne being possibly preferred for older 
children when the stomach is very irritable. An infant a year old will, 
under most circumstances, take half an ounce of brandy in twenty-four 
hours. Stimulants should always be diluted with at least eight parts of 
water, and be given in small quantities, at short intervals. 

In cases of extreme prostration, the hot bath, mustard to the extremi- 
ties, and sometimes the mustard pack, are beneficial. When the drain is 
rapid and very great, and in all cases approaching the cholera-infantum 
type, subcutaneous saline injections should be used, in the manner de- 
scribed under Cholera Infantum. 

General considerations in treatment. — (1) All severe cases must be 
watched very closely, especially those in infants under six months. If 
the temperature is rising and the passages are very fluid, one should 
always be apprehensive. (2) The character of the discharges is a better 
indication than is their number, of the patient's condition and of the 



CHOLERA INFANTUM. 381 

effect of any plan of treatment. (3) Nothing is more simple than to 
give opium enough to reduce the number of passages; but unless there 
is some other sign of improvement, very little good, and probably much 
harm, will be done. (4) We must treat the patient, and not direct all 
our thought to acid or alkaline stools, ptomaines, or bacteria. The value 
of every therapeutic measure is to be estimated by its effect upon the 
patient's general condition. (5) No matter how strongly we may be- 
lieve in the value of any drug or combination of drugs, if they continue 
to disturb the stomach they are worse than useless. (6) Both the 
mother and nurse should be impressed with the fact that the diet is 
an important part of the treatment, and that foods need to be given 
just as carefully as drugs. (7) In the management of any single case 
the important thing is prompt and thorough evacuation of the stomach 
and bowels, then rest for these organs for from twelve to twenty-four 
hours, or, as some one has tersely put it, " bold starvation " ; but it is 
necessary in all cases that water be given freely. No cases do worse than 
those in which the mother or nurse in charge can not be made to appre- 
ciate the value of starvation, but insists upon giving food, especially 
milk, in violation of the rules laid down. (8) Great care is required 
during convalescence, and in fact during the remainder of the summer, 
to prevent relapses; these usually occur from errors in diet, particularly 
during days of excessive heat. 

Cholera Infantum. — This may be regarded as only one clinical 
type of acute intestinal intoxication, yet it differs from the others suffi- 
ciently to deserve separate consideration. It is not, however, the most 
frequent form met with, and it is not a good generic name for the dis- 
ease. As yet this type has not been connected with a specific form of 
intoxication. The peculiar symptoms may depend upon the rapidity of 
absorption and the other conditions present in the intestine, or possibly 
upon some form of infection not yet determined. Cholera infantum is 
more closely connected with impure milk than is any of the other forms 
of diarrhoea, and may be due to some poison developing in the milk 
before its ingestion, or in the stomach or intestines after the milk is taken. 
The symptoms are due primarily to the effects of the poison upon the 
heart, the nerve-centres, and the vaso-motor nerves of the intestine's: 
secondarily to the abstraction of fluid from the various organs and tissues 
of the body, especially the nerve-centres. 

Cholera infantum rarely occurs in an infant previously healthy. As 
a rule, there is some antecedent intestinal disorder. The development 
of the choleriform symptoms is usually very rapid, and a child, who 
perhaps has been regarded as scarcely ill enough to require a physician, 
may be brought, in the course of five or six hours, to death's door. 

Usually there are general symptoms, such as prostration and a steadily 
rising temperature, for a few hours before the vomiting and purging, or 



382 DISEASES OF THE DIGESTIVE SYSTEM. 

these symptoms may be the first to excite alarm. Vomiting may pre- 
cede diarrhoea, or both may begin simultaneously. The vomiting is very 
frequent. First, whatever food is in the stomach is vomited, then serum 
and mucus, and finally bilious matter. If vomiting subsides for a time, 
it is almost sure to begin anew with the taking of food or drink. The 
stools are frequent, large, and fluid, and in the course of half a day 
twelve or fifteen may occur. If less frequent they are proportionately 
larger. They are of a pale green, yellow, or brownish colour in the be- 
ginning, but as they become more frequent they often lose all colour 
and are almost entirely serous. The sphincter is sometimes so relaxed 
that small evacuations occur every few minutes. The first stools are 
usually acid, later they are neutral, and when serous they jnay be alka- 
line. In most cases they are odourless; in rare instances they are ex- 
ceedingly offensive. Microscopically the stools show large numbers of 
epithelial cells, some round cells, and immense numbers of bacteria. 

Loss of weight is more rapid than in any other pathological condition 
in childhood. Baginsky records a case in which it reached three pounds 
in two days. The fontanel is depressed, and in rare instances there may 
be overlapping of the cranial bones. The general prostration is great 
almost from the outset. The face, better, perhaps, than any single symp- 
tom, indicates what a profound impression has been made upon the sys- 
tem. The eyes are sunken, the features sharpened, the angles of the 
mouth drawn down, and a peculiar pallor with an expression of anxiety 
overspreads the whole countenance. In the early stages the nervous 
symptoms are those of irritation. Later, these symptoms give place to 
dulness, stupor, relaxation, and coma or convulsions. 

The temperature, in my experience, has been invariably elevated, and 
usually in proportion to the severity of the attack. In cases recovering, 
it has generally been from 102° to 103° F., while in fatal cases it has 
risen almost at once to 104° or 105° F., and often shortly before death 
it has reached 106° or even 108° F. Such rectal temperatures may occur 
with a clammy skin and cold extremities, and are discovered only by the 
thermometer. The pulse is always rapid, and very soon it becomes weak, 
often irregular, and finally almost imperceptible. The respiration is 
irregular and frequent, and may be stertorous. The tongue is generally 
coated, but soon becomes dry and red, and is often protruded. The 
abdomen is generally soft and sunken. There is almost insatiable thirst. 
Everything in the shape of fluids, especially ice-water, is drunk with 
avidity, even though vomited as soon as it is swallowed. Very little 
urine is passed, sometimes none at all for twenty-four hours ; this depends 
upon the great loss of fluid by the bowels. 

In the fatal cases there is hyperpyrexia, a cold, clammy skin, absence 
of radial pulse, stupor, coma or convulsions, and death. The diarrhoea 
and vomiting may continue until the end, or both may entirely cease for 



CHOLERA INFANTUM. 383 

some hours before it occurs. The patients may pass into a condition 
resembling the algid stage of epidemic cholera, and die in collapse. In 
other cases, after the first day of very severe symptoms, the discharges 
diminish, but the nervous sjmiptoms become specially prominent. There 
is restlessness and irritability or apathy and stupor. The fontanel is 
sunken ; the eyes are half open and covered with a mucous film ; respira- 
tion is irregular and superficial, sometimes even Cheyne- Stokes ; the pulse 
is feeble, irregular, or intermittent; the muscles of the neck drawn back; 
the abdomen retracted. The temperature is not elevated, but normal or 
subnormal. From this condition recovery may take place or the symp- 
toms may merge into those of ileo-colitis ; but much more frequent than 
either of the foregoing is the fatal termination. 

These nervous symptoms are ascribed to cerebral anaemia, cerebral 
hyperaemia (venous), oedema of the meninges, thrombosis of the cerebral 
sinuses, and uraemia. 

Although I have examined the brain in almost all my autopsies 
upon patients dying from diarrhceal diseases, I have never in such 
cases seen sinus thrombosis, and but rarely oedema. Cerebral hyper- 
aemia was often met with in cases dying in convulsions, but not with 
any regularity otherwise. Nor have my observations upon the kidneys 
confirmed the observations of Kjellberg, whom most of the writers since 
his day have quoted, as to the great frequency of nephritis. A scanty, 
concentrated, and hence irritating urine is the rule, and a small amount 
of albumin and an occasional hyaline cast not uncommon; but either 
clinical or pathological evidence of a serious amount of nephritis has 
been, in my own experience, extremely rare. 

We can hardly regard either the renal or the cerebral changes as an 
explanation of the nervous s} r mptoms of most of these cases; they seem 
rather to depend upon impeded circulation due to a thickening of the 
blood, to acute inanition, and intestinal toxaemia. 

Of the cases of true cholera infantum which have come under my 
notice, fully two-thirds have died. The result depends more upon the 
severity of the attack than upon anything else. 

An infrequent complication of cholera infantum is sclerema. This 
condition is found associated with muscular contractions, subnormal tem- 
perature, and other signs of the most extreme depression. These eases 
are invariably fatal. 

Treatment. — Restricting the term to the class of cases described 
above, all who have seen much of the disease must admit thai the results 
of treatment are extremely unsatisfactory, and that the most Bevere ■ ■■ 
pursue their course but little, if at all, influenced by the treatment 
employed. 

The best view of the treatment will be gained if we keep in mind thai 
we are treating cases of poisoning; that the toxic material- cause greal 



384 DISEASES OF THE DIGESTIVE SYSTEM. 

depression of the heart and the system generally by acting on the nerve- 
centres, and by paralyzing the vaso-motor nerves of the intestines. 

The main indications are: (1) to empty the stomach and intestine; 
(2) to neutralize the effect of the poison upon the heart and nervous 
system; (3) to supply fluid to the blood to make up for the very great 
drain of the discharges; (4) to reduce the temperature; (5) to treat 
special symptoms as they arise. 

For the first indication we must rely upon mechanical means — 
stomach-washing- and intestinal irrigation — there is no time to wait for 
cathartics. For the second, nothing in my hands has proved -so useful 
as the hypodermic use of morphine and atropine. I believe this to be 
more efficient than any other means of treatment we possess. Morphine 
is contra-indicated where the purging has ceased or is slight, and where 
there is drowsiness, stupor, or relaxation. The effects of the dose should 
always be carefully watched ; a small dose repeated is better than a single 
large dose. For a child a year old, not more than gr. ? V of morphine 
and gr. -g-^-g- of atropine should be the initial dose. It may be repeated 
in an hour unless the desired effects are produced; these are, arrest of 
the vomiting and purging (or at least their diminution), improvement in 
the heart's action, and in the nervous symptoms. 

For the third indication the only thing that can be depended upon is 
the injection of normal salt solution into the cellular tissue of the 
abdomen, buttocks, thighs, or back. At least half a pint should be given 
in the course of every twelve hours. A very much larger quantity can 
often be used with advantage. This causes no irritation, and is absorbed 
with surprising rapidity. The injection is made slowly, and the exact 
amount introduced at each time measured. 

For the reduction of temperature baths should be used. They may 
be continued from ten to thirty minutes, and to be efficient, must be used 
frequently — as often as every hour if symptoms are threatening. Iced 
cloths or an ice cap should be applied to the head. Cold-water injections 
are a valuable accessory to the treatment by baths. Nothing should be 
allowed by the mouth except ice and brandy. The stimulants must be 
given in small quantities and frequently. When stimulants taken by the 
mouth are vomited, they should be given hypodermically. Brandy, ether, 
or camphor may be used freely. During the stage of most acute symp- 
toms, to attempt to give food or drugs of any kind by the mouth is 
worse than useless. After the stage of violent symptoms has subsided 
and reaction is established, the subsequent management in respect to 
feeding and medication should be the same as in the cases considered 
in the previous chapter. If cerebral symptoms are present, opium is to 
be avoided, stimulants by the mouth used freely, and, if these are not 
retained, they should be given hypodermically. For cold extremities 
and subnormal temperature, hot mustard baths should be used to estab- 



ACUTE ILEO-COLITIS. 385 

lish reaction, mustard paste applied all over the body, and hot- water bags 
and bottles placed about the patient. 



CHAPTER VIII. 
DISEASES OF THE INTESTINES.— {Continued.) 

ACUTE ILEO-COLITIS— DYSENTERY. 

Synonyms : Enterocolitis, enteritis, enteritis f ollicularis, inflammatory diarrhcea. 

The term ileo-colitis is a general one, embracing those forms of 
intestinal disease in which the more serious lesions are present. In 
gastro-enteric intoxication recovery or death takes place before anything 
more than superficial changes have occurred, while in ileo-colitis the 
pathological process continues until there have been produced marked 
lesions, often involving all the walls of the intestine. Sometimes the 
transition is so gradual that it is impossible, by symptoms, to draw a 
line between them. This is especially true of the cases terminating in 
follicular ulceration of the colon. In some of the other forms — acute 
catarrhal and acute membranous colitis — the evidences of a severe in- 
testinal inflammation are often manifest from the very outset. This 
difference is probably due to a difference in the character of the infection. 
The extent of the lesions depends much upon the duration of the process. 

Etiology. — The predisposing causes of ileo-colitis are those common 
to diarrhceal diseases in general, and have already been considered. Al- 
though seen with especial frequency in summer, and in children under 
two years old, it may affect those of any age, and occurs at all seasons. 
Epidemics are not uncommon in the early fall months. While usually 
primary, it often follows infectious diseases, especially measles, diph- 
theria, and broncho-pneumonia. It frequently occurs, in institutions 
chiefly, as a terminal infection in infants suffering from extreme mal- 
nutrition or marasmus. Any other intestinal disease may precede ileo- 
colitis. The question of contagion is unsettled; if at all communicable, 
it is feebly so. When it occurs epidemically a common origin seems 
more probable than that the disease spreads from one patient to another. 

The only bacterium that up to the present time has been shown to 
be capable of producing this form of intestinal disease is the B. dysen- 
terice of Shiga. This organism, or, more properly speaking, this group 
of closely allied organisms, has now been found in all parts of the world 
in a sufficient number of cases to establish its etiological connection with 
ileo-colitis. The B. dysenteries was shown by Shiga, in 1808 and 1899, 
to be the cause of epidemic dysentery in Japan. In 1900, Flexner estab- 
lished its association with tropical dysentery in the Philippines, and in 



386 DISEASES OF THE DIGESTIVE SYSTEM. 

1902, Duval and Bassett, pupils of Flexner, demonstrated its presence 
in a series of cases of diarrhoea in children at Baltimore. 

In the summer of 1903 the Eockefeller Institute undertook a collective 
clinical and bacteriological investigation in New York, Baltimore, Boston, 
and Philadelphia, to discover what part the B. dysenterice played in the 
diarrhoeal diseases of children. In all 412 cases were studied, in 270 of 
which the bacillus was present. It was almost invariably found in cases 
showing blood and mucus, or much mucus in the stools. The number of 
the specific bacteria present, as shown by culture, corresponds in a general 
way with the severity of the symptoms and the lesions of the disease. 
Although usually the B. dysenterice is greatly outnumbered by other 
organisms, it is not uncommon to find it in pure culture. A number of 
minor differences have been found in the bacilli from different cases; 
there are, however, two main groups, the division being made by reason 
of the difference in reaction with litmus mannite; one group is known 
as the "true Shiga," or "alkaline" type; the other, as the " Flexner," 
or " acid " type. The latter has been most frequently found in the 
diarrhoeal diseases of children in this country, although the true Shiga 
is occasionally present, and in rare cases they may be associated. 

The B. dysenterice has been in a few instances discovered in normal 
stools of apparently healthy children, although extended observation by 
Wollstein at the Babies' Hospital upon 56 infants failed to show its 
presence in any normal case. The B. dysenterice has never been found 
outside the body; we are therefore entirely ignorant both of its habitat 
and its mode of entry. There are grounds for believing that it appears 
at times among the saprophytic bacteria of the intestinal contents. 

The role played by other bacteria, especially the streptococcus, in the 
production of the deeper lesions of the intestine may be an important one. 
This appears, however, to be rather in the nature of a secondary invasion. 

Lesions. — It is surprising that, so far as is known, a single specific 
cause can excite such a variety of lesions. The nature of the anatomical 
changes apparently depends upon other factors, such as the intensity 
of the infection, the local resistance, and still more upon the duration 
of the disease. 

The nature of the lesions in ileo-colitis differs greatry, but their 
position is quite constant: they affect the lower ileum and the colon. 
In about half the cases only the colon is affected. The lesions of the 
ileum are usually limited to the lower two or three feet. 

The frequency with which the different varieties of ileo-colitis were 
found in eighty-two of my own autopsies was as follows : 

Follicular ulceration 36 

Catarrhal inflammation 26 

Catarrhal inflammation with superficial ulceration 6 

Membranous inflammation 14 



PLATE VIII. 







Extensive Superficial Ulceration of the Colon. 

Female child nine months old ; symptoms of acute ileo-colitis of fifteen days' dura- 
tion ; temperature, 101° to 104-5° F., and from six to eight stools daily— thin, green, 
and yellow, but no blood. . 

Extensive ulceration throughout the colon, most marked m descending portion, 
from which specimen is taken. 

A A are small circular ulcers ; B B, larger ones from coalescence of several of 
these ; C C, large areas of ulceration, the mucous membrane being almost entirely 
destroyed. 



ACUTE ILEO-COLITIS. 



3S7 



Acute catarrhal ileo-colitis. — In the milder cases there are changes in 
the epithelium and infiltration of the mucosa. In the severer cases the 
submucosa is involved, and the infiltration of the mucosa may be so great 
as to lead to necrosis and the formation of ulcers. 

Gross appearances. — While the lower ileum and the colon are most 
seriously affected, it is not uncommon to find quite marked changes in a 
considerable portion of the small intestine, and even in the stomach. In 
the cases of short duration, the lesions are sometimes more marked in the 
small intestine than in the colon. The stomach contains undigested food, 
and mucus which is commonly stained a dark-brown colour. It may be 
dilated or contracted. The mucous membrane is pale or congested; if 
the latter, it is usually in patches, and more about the pyloric orifice. 




S00$^ 




££*i 



'^MM Wm^M^s^^^; ^^:W^- : - ^ y -2LM 




Fig. 65. — Acute catarrhal inflammation of the ileum. 

At the left is seen the edge of a Peyer's patch (P) greatly swollen. The most striking 
feature of the lesion is the loss of the superficial epithelium, which is shown in all parts of the 
specimen. The significance of this depends upon the fact that the autopsy was made but two 
hours after death. At several points, F, F, the tubular follicles have loosened and fallen out. 
The mucosa, A, is slightly infiltrated with cells, especially near the Peyer's patch. The sub- 
mucosa, 0, and muscular coats, D, F, are normal. F, J 7 , are small veins. History. — Infant, nine 
months old, previously healthy ; sick three days with severe intestinal symptoms ; temperature. 
103° to 105° F. Avtopsy. — Acute catarrhal inflammation of ileum and colon ; Peyer's patches 
red and swollen. The specimen is taken from the lower ileum. The superficial character of 
the lesion is chiefly due to the short duration of the process. 



The intestinal contents are generally green in colour, and thin. The 
mucous membrane is often coated with tenacious mucus. The small in- 
testine is distended with gas, the large intestine nearly empty, except the 
transverse colon. The mucous membrane may appear somewhat swollen. 
In the small intestine there are occasionally seen swelling and oedema of 
the villi, so that they project abnormally and give a plush-like appearance. 
Congestion is a constant feature, and it may be simply upon the folds of the 
mucous membrane, or about the solitary lymph nodules; or it may hv in- 
tense and involve the whole intestine for some distance. Small hemorrhagic 
areas are often seen here and there, widely scattered. In the most severe 
cases there are marked thickening and uniform congestion, and the appear- 
ance is sometimes much like that seen in membranous inflammation. The 



388 



DISEASES OF THE DIGESTIVE SYSTEM. 



lymph nodules (solitary follicles) throughout the colon are usually swollen, 
projecting above the mucous membrane about the size of a pin's head. 
Peyer's patches may be normal, or they may be swollen and congested, 
with other evidences of catarrhal inflammation in the surrounding mucous 
membrane, or more rarely they may be involved when the rest of the mu- 
cosa appears healthy. The same is true of the lymph nodules of the small 
intestine. The lymph nodes of the mesentery are usually swollen and 
acutely congested, but they may appear normal. 

Microscopical appearances. — In interpreting the changes found in the 
mucosa, the same precautions must be observed as previously stated. 

There is usually loss of the superficial epithelium and of that lining 
the tubular glands at their orifices. Upon the surface of the mucosa and 












Acute catarrhal inflammation of the ileum ; severe form. 



The mucosa, (7, is everywhere densely infiltrated with round cells, compressing the tubular 
follicles, and in places, Z, Z, almost effacing them. Upon the surface of the mucosa is a thick 
layer of cells and mucus. Beneath this the epithelial arches, i?, B, covering the villi can be 
seen. The lesions are almost entirely of the mucosa. The only changes in the submucosa, E, 
are groups of cells about the small blood-vessels, F", V. History. — Infant six months old ; mod- 
erate diarrhoea twelve days; severe symptoms with high temperature for six days. There was 
intense inflammation of the entire colon and lower three feet of the ileum. Intestine greatly 
congested and thickened. Specimen is from the ileum. 



within the tubular glands, fine granular matter is seen derived from the 
broken-down epithelium. The goblet cells are distended with mucus, and 
do not stain clearly. The lumen of the tubular glands is narrowed from 
pressure due to the swelling of the lymphoid tissue which separates them, 
which is partly from oedema, and partly from cell infiltration (Fig. 65). 
A thick layer of mucus and round cells, adhering closely to the surface, 
may resemble a pseudo-membrane (Fig. 66). In faftal cases of moder- 
ate severity the superficial portion of the mucosa is infiltrated with 
round cells and crowded with bacteria of many kinds, the depth to 
which this infiltration extends depending upon the severity and dura- 



PLATE IX. 




Deep Follicular Ulcers of the Colon. 

A delicate child, fourteen months old, sick twelve daya ; stools green, yellow, brown, 
and watery; no blood ; temperature, 100 to 101° F. 

The small intestine was normal ; ulcers throughout colon. The specimen is from 
descending colon ; the ulcers are deep, and most of them extend to the muscular coat. 
(For microscopical appearance, see Fig. 68.) 



ACUTE ILEO-COLITIS. 389 

tion of the process. In very severe cases there is found a dense infiltra- 
tion of the mucosa and of the submucosa also, which in places extends 
quite to the muscular coat. These cases closely resemble those of the 
membranous variety, lacking only the exudation of fibrin. The lymph 
nodules of the colon are swollen to a greater or less degree, chiefly from 
an increase in the number of lymphoid cells. This swelling may be the 
most prominent feature of the lesion. If the process is sufficiently pro- 
longed, the lymph nodules may break down and ulcerate. The changes 
in the lymph nodules of the small intestine and in Peyer's patches are 
similar to those seen in the colon, but are less marked, and frequently 
absent altogether. Ulceration in Peyer's patches is extremely rare. 

The small veins and capillaries of the mucosa and submucosa are 
usually distended with blood ; small extravasations are very common, and 
occasionally larger ones are seen. 

Catarrhal inflammation, except in its very severe form, which is not 
frequent, causes no lesions that can not readily be repaired. The most 
persistent change is usually the swelling of the lymph nodules, which may 
last a long time, and appears to be an important factor in the tendency to 
relapses and recurring attacks. If there is a continuance of the exciting 
cause, or the patient's constitution is a bad one, the process may become 
chronic. 

Catarrhal inflammation with superficial ulceration. — In the most 
severe form of catarrhal inflammation which does not prove fatal in 
the earlier stages, extensive ulceration occasionally takes place; usually 
these ulcers are seen throughout the entire colon, and, in rare cases, a 
few are found in the lower ileum. They generally begin in the mucosa 
overlying the lymph nodules, and while they have a wide superficial area, 
they do not extend deeper than the mucosa. The small ulcers are circu- 
lar and usually show at the centre a small granular body — the lymph 
nodule. The larger ulcers result from the coalescence of several small ones, 
and are irregular in shape. They may be two or three inches in diameter. 
Sometimes for a considerable distance a large part of the mucosa may 
be destroyed. Often the entire surface presents a worm-eaten appearance 
(Plate VIII). On microscopical examination there is seen, in the greater 
part of the ulcer, complete destruction of the mucosa, the submucosa 
being densely packed with round cells quite to the muscular coat. 

Inflammation of the lymph nodules with ulceration (follicular ulcer- 
ation). — Follicular ulcers are found at autopsy in about one-third of the 
cases dying from diarrhceal diseases. They are rarely seen in those which 
have lasted less than a week, and not often before the middle of the 
second week. The average duration of the disease in these cases is about 
three weeks. 

In thirty-six cases" in which follicular ulcers were found at autopsy, 
they were present in the small intestine alone in but three cases; in the 



390 



DISEASES OF THE DIGESTIVE SYSTEM. 



small intestine and in the colon in six cases ; in the remaining twenty« 
seven they were present only in the colon. When in the small intestine 
they were seen only in the lower ileum. Ulceration was seen a few times 
in one or two of the nodules of a Peyer's patch. Ulceration of the large 
intestine involved the whole colon in about half the cases ; while in the 
remainder the process was limited to its lower portion. The deepest and 
also the largest ulcers were usually in the descending colon and sigmoid 
flexure. 

In the early stage these ulcers appear as tiny excavations at the summit 
of the prominent lymph nodules. Later, the whole nodule may be de- 
stroyed, and a small round ulcer is formed from one twelfth to one fourth 
of an inch in diameter (Plate IX). These are quite deep and have over- 
hanging edges ; when closely set they give the intestine a sieve-like ap- 




Fig. 67. 



-Lymph nodule of the colon in the early stage of ulceration— Follicular ulcer. 



The nodule, F, is much enlarged, and is breaking down and discharging into the intestine. 
The other changes are not marked. The superficial epithelium is gone : the mucosa, A, shows 
a slight increase of cells, and in the submucosa, O. are nests of cells about the small vessels, F, V. 
History. — Delicate child, thirteen months old ; slight diarrhoea four weeks ; severe symptoms 
five days. The colon was filled with ulcers one twelfth of an inch in diameter, one of which 
is shown in the illustration. 



pearance. By the coalescence of several of them, larger ulcers may form 
which are an inch or more in diameter. At the bottom of these larger 
ones the transverse striae of the circular muscular coat are often plainly 
seen. I have never known them to cause perforation. 

Microscopical appearances. — The lymph nodules are swollen, principally 
from the accumulation within them of round cells. This is followed by 
softening, which usually begins at the summit of the nodule and ex- 



ACUTE ILEO-COLITIS. 391 

tends downward; the reticulum breaks down, and the cellular contents 
escape into the intestine (Fig. 67). Softening may begin at the centre 
of the nodule, which ruptures like an abscess. The destruction of the 
whole nodule leaves a cavity, which is the follicular ulcer. At first the 
ulcers correspond in size to the nodule, but infiltration of the adjacent 
tissue soon takes place, and this may become necrotic. In this way 
the ulcer extends chiefly in the submucous coat. The lesion is never 




^v/^S^ 



^^^^^^%^^te^!" > < f '~ r \ 



■y~ .-->: ■^-- ■ -~ • r ~" - ,-,- "J^'^tW-,- \ . .- .. •*: 






Fig. 68.— Deep follicular ulcer of the colon. 

A deep ulcer is shown at F, a smaller one at F'. The separation of the mucosa at Zfis acci- 
dental. There is no trace of the lymph nodule from which the large ulcer had its origin. The 
destructive process has extended laterally in the submucosa, C, and the mucosa, A, is falling in 
to fill up the space. In the vicinity of the ulcers, the submucosa is densely infiltrated with 
round cells, Z", Z", which also are seen in the lymph spaces between the bundles of circular 
muscular fibres, Z', Z', and some are seen in the longitudinal muscular coat, Z, Z. History. — 
Thirteen months old, delicate; continuous diarrhceal symptoms for three weeks. Ulcers found 
throughout the colon, the largest, one half an inch in diameter. The illustration shows one of 
the small ones like those in Plate IX. 

limited to the lymph nodules ; but the extent of the other changes found 
depends upon the severity and the duration of the process. In cases 
dying after an illness of a week or ten days, we usually find only moder- 
ate changes in the mucosa, and in the submucosa a slight infiltration of 
round cells, especially about the small blood-vessels (Fig. 67, V, V). 
In those which have lasted three or four weeks the ulcers are deeper, and 
all the structures of the intestine in their neighbourhood are usually 
involved (Fig. 68). The mucosa is densely packed with round cells, as 
are also all the tissues in the vicinity of the ulcers; even the muscular 
coat may be infiltrated. The ulcers, however, rarely extend deeper than 
the circular layer. 

Follicular ulceration of the intestine in infancy, usually terminates 
fatally if the process is an extensive one. In less severe eases, recovery 
may take place, the ulcers healing by granulation and cicnl rizal ion in 1 he 
course of from four to eight weeks. 

Acute membranous ileo-colitis. — This is the most severe form of intes- 



392 DISEASES OF THE DIGESTIVE SYSTEM. 

tinal inflammation seen among children. The process differs quite mate- 
rially from that described as occurring among adults. In only one of my 
own cases was it associated with membranous inflammation of any other 
mucous membrane, in that case with membranous gastritis. The most 
frequent type of membranous colitis is that with severe acute symptoms, 
both constitutional and local, with a duration of from six to fourteen 
days. In young infants its symptoms and course are very irregular, and 
it may be found at autopsy when no serious intestinal lesion has been 
suspected. 

Gross appearances. — There is visible to the naked eye usually very lit- 
tle pseudo-membrane and no deep sloughing. The lesion affects the 
last two or three feet of the ileum and the entire colon, sometimes only 
the colon. It is exceedingly rare to meet with any marked lesions higher 
in the small intestine. The most marked changes are near the ileo-caecal 
valve or in the sigmoid flexure and the rectum. frrthe ileum they may 
be quite as severe as in the colon (Plate X). The intestinal wall is 
firm and stiff, and is two or three times its normal thickness. It is not 
thrown into deep folds, as is the healthy intestine when empty. It is 
very rare to find false membrane that can be stripped off in patches of 
any considerable size. When membrane exists, the colour is a yellowish 
or grayish green, and the surface is often fissured, giving a lobulated 
appearance. In the parts where no pseudo-membrane can be seen, the 
surface is usually of an intense red colour and is rough and granular, in 
striking contrast to the normal glistening appearance. Here and there 
small extravasations of blood may be seen. In the regions most affected, 
the normal structures of the mucous membrane — the villi, Peyer's 
patches, and solitary follicles — can not be distinguished. In a single 
instance I found an exudation of fibrin on the peritoneal surface of the 
intestine for a short distance. Except in the lower ileum the small intes- 
tine shows no constant changes, and none are usually found in the 
stomach. 

Microscopical changes. — These (Fig. 69) are much more uniform 
than the gross appearances. The most characteristic feature is the exu- 
dation of fibrin, which forms a distinct pseudo-membrane upon the sur- 
face of the intestine; it may infiltrate the mucosa, and even the sub- 
mucosa. Fibrin is seen under the microscope in parts of the specimen, 
which t,o the naked eye show no distinct pseudo-membrane, but only a 
granular appearance. In rare cases a fibrinous exudation may be found 
upon the peritoneal covering of the intestine. The pseudo-membrane is 
made up of a fibrinous network containing small round cells, some red 
blood-cells, and numerous bacteria. The mucosa, and usually the sub- 
mucosa, are densely infiltrated with small round cells, which in places 
may be so numerous as to efface the normal elements of the intestine. 
The tubular follicles are in some places quite destroyed, not a vestige of 



PLATE X. 




-B 



Membranous Inflammation of the Ilium. 

A delicate child, eleven months old; mild diarrhoea for two weeks without fever; 
acute severe symptoms for twelve days; temperature, 100 to 102-5 P.; green and 

mucous stools : no blood. 

The lesions involved the last foot of ileum and entire colon. Specimen is from 
lower ileum, and shows the abrupt termination of the lesion: the upper part shows 
normal small intestine; A is a Peyer's patch: B is the inflamed part of the intestine; 
it has a rough granular appearance and is much thickened. 



ACUTE ILEO-COLITIS. 



393 



them remaining. In other places they are compressed and distorted by 
the accumulation of cells. The great thickening of the intestine is due 
partly to the cell infiltration, partly to the fibrinous exudation, and partly 
to oedema. All the blood-vessels, both in the mucosa and submucosa, are 











'i- <L 

Fig. 69. — Membranous inflammation of the colon. 

The intestine is covered with a pseudo-membrane, M, which is composed chiefly of granu- 
lar fibrin; the mucosa, A, is densely packed with round cells, and the tubular follicles have 
almost disappeared, traces only being left at T, T. The submucosa, C, is greatly thickened, 
partly from cells, but chiefly from fibrin, which with a high power is seen to be everywhere in 
this coat, as well as the mucosa. Nests of cells are seen in the muscular coats at Z, L. At i^is 
a lymph nodule covered by pseudo-membrane, but breaking down at its centre. V, V, are small 
blood-vessels with nests of cells about them. History. — Fourteen months old ; ill nine days ; 
temperature 101° to 105° F. ; all stools containing blood. Lesions found throughout colon and 
in lower ileum. Intestine greatly thickened. Specimen is from ascending colon, where lesion 
was especially severe. 

gorged with blood, and many small extravasations are seen. A necrotic 
process with the formation of deep ulcers I have never seen associated 
with membranous colitis. 

Associated lesions of ileo-colitis. — The most important one is bron- 
cho-pneumonia. It is found in quite a large proportion of the protracted 
cases, and not infrequently it is the cause of death. I think it is seldom 
due to an infection from the intestine, although such a thing is possible in 
septicemic cases. It occurs rather as it does in any other protracted 
exhausting disease. In a study of sixty cases, Spiegelberg did not find 
bacteria in the pulmonary capillaries, and he regards infection through 
the blood as not yet proved. Pulmonary tuberculosis is not infrequently 
met with in hospital cases, having no relation to the intestinal disease. 
I once saw a pulmonary abscess complicating an attack of ulcerative 



394 DISEASES OF THE DIGESTIVE SYSTEM. 

colitis; it was at the apex, and was not associated with suppuration 
elsewhere. Peritonitis is infrequent. I have met with it but once or 
twice, and then it was localized and of the plastic variety. Inflamma- 
tions of the other serous membranes — pleurisy, pericarditis, and menin- 
gitis — are all very rare. 

The renal lesions of ileo-colitis have been the subject of considerable 
discussion,* some observers holding that nephritis is a frequent compli- 
cation of the severer forms of diarrhoea, while others have held it to be 
rare. The lesions I have usually found in my own cases coincide with 
those described by others, and consist in marked degeneration of the 
epithelium of the tubes with but few glomerular or interstitial changes. 
In three or four instances only have I found well-marked lesions of acute 
diffuse nephritis at autopsy, or seen its symptoms clinically. I believe 
it to be a very infrequent though sometimes a most serious complica- 
tion. The lesions mentioned as usually present are properly classed 
as acute degeneration rather than as inflammation of the kidney. Its 
causes are chiefly the irritation of toxins, intensified no doubt by the 
concentration of the urine. Degenerative changes may be found also 
in the heart muscle, the liver, spleen, and even in the central nervous 
system. 

Considerable attention has been given lately to a study of the blood 
in intestinal inflammations, to determine how frequently and in what 
circumstances a general blood infection (septicaemia) from the intestines 
occurs. In the great majority of the cases studied under proper pre- 
cautions the blood is sterile. It is most likely to become infected when 
there are serious ulcerative lesions; but even these may exist for a long 
time without producing such a result. It is not probable that the bac- 
teria in the blood are an important factor in producing lesions in other 
organs. 

Symptoms. — (1) Catarrhal cases of moderate severity. — The onset is 
usually sudden, often with vomiting, and for twelve, sometimes twenty- 
four hours the symptoms may be those of acute indigestion: vomiting, 
pain, fever, and frequent, thin, green or yellow stools, which are partly 
faecal and contain undigested food. Later the discharges contain blood 
and mucus, are often preceded by pain and accompanied by tenesmus. 
The stools are very frequent, often every half hour and proportionately 
small, sometimes less than a tablespoonful being found upon the nap- 
kin after severe straining efforts. The mucus may be clear and jelly- 
like, or it may be mixed with faecal matter. Blood is seen in some cases 
in almost every stool, but rarely in clots, usually streaking the mucus. 
These stools are almost odourless. After two or three days the blood 

* For a good resume of the subject, see J. L. Morse, Archives of Paediatrics, 1899, 
p. 649. 



ACUTE ILEO-COLITIS. 



395 



usually disappears, or is seen only as traces in an occasional stool; but 
mucus is still present in large quantities. The colour of the discharges 
now becomes dark brown or brownish-green. Prolapsus ani is frequent, 
and may occur with nearly every stool. Abdominal pain is present, and 
is often quite intense just before the stool ; and frequently there is ten- 
derness along the colon. For the first twenty-four hours the tempera- 
ture is usually high, from 102° to 104° F. During the greater part of the 
attack it ranges from 99° to 102° F. There is considerable prostration; 
the loss in weight is usually marked and continuous; appetite is lost; 
the tongue is coated and the general appearance of the children indi- 
cates serious illness, although no really grave symptoms are present. 
Convalescence is always slow, and it may be months before the child 
regains its lost weight (Fig. 70). 



6 MOS. 12 MOS. 18 M 


WEEK 

of age 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 "2 74 76 






2b 


9*- - /- 


25- - f 




24 - jt,-"*" 


w -*-/ 


26 — -' /' 


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9oi -*z-^ ^* 


* 21 "~ Z 


L> ^ ^s 


£ 20 ^ <*£ 


**'' jS 


19 + \zz~~ ^ 




lb !*■■=-—» S~" "/ ™ 


^r -"^ **s y 


17*- --5— - ^ z A 


iik*z.-- ^ 4- / 


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1 



Fig. 70.— Weight curve showing loss from ileo-colitis. 

Well-nourished infant; attack of measles at A (fortieth week), followed by ileo-colitis, 
which though not severe continued with exacerbations during September and October. At B 
all symptoms had disappeared except occasional mucus in the stools. Rapid improvement from 
this time, which was continued during the winter, the child being sent to a warm climate; it 
was, however, live and a half months before the weight reached the normal average line. 

In the milder cases the symptoms point to inflammation of the lower 
part of the colon only. The constitutional symptoms are not at all 
marked. The temperature may not be above 101° F. ; the tongue may 
remain clean and the appetite good ; the child may be bright and active, 
and hardly seem at all ill, and yet have from six to eight small mucous 
and bloody stools a day. 

The duration of the acute symptoms is usually about a week, and 
yet in such cases, even though the child was previously in good condition 
and properly treated, recovery is slow. The first symptom of improve- 
ment is generally the disappearance of blood from the stools, which at 
the same time become less frequent, and the pain and tenesmus cease. 
Gradually the stools assume more of a faecal character, but mucus is likely 



396 DISEASES OF THE DIGESTIVE SYSTEM. 

to persist for two or three weeks; it may be seen in all stools, or only 
occasionally. In some cases both the mucus and blood disappear and the 
stools become thin, brown, or green, like those of an ordinary diarrhoea. 
Although the early stage of very acute symptoms may last but a few 
days, if there is a continuance for three or four weeks of the brown, 
mucous stools, with emaciation and slight fever, ulceration is probably 
present. This is likely to occur if the child is in poor condition, if its 
surroundings are bad, or if it is improperly treated at the outset. Ee- 
lapses are readily excited, but cases like the above are rarely fatal except 
in delicate infants. This is the most common form of ileo-colitis which 
terminates in recovery. 

(2) The severe catarrhal form. — This form of ileo-colitis, like that 
just described, is usually primary. The symptoms closely resemble those 
of the membranous variety, and a diagnosis from it is to be made only 
by the absence of pseudo-membrane from the stools. The most rapid 
case I have seen lasted only three days, but the usual duration is from 
one to two weeks. The temperature is steadily high ; the stools continue 
very frequent and generally contain blood; there is great prostration, 
dry tongue, sordes on the lips and teeth, and prominent nervous symp- 
toms. Death usually occurs from exhaustion and profound sepsis while 
the acute symptoms are at their height. If the patient survives this 
stage, the case may drag on for four or five weeks, very much like one 
of follicular ulceration, and then terminate in recovery or in death from 
slow asthenia, broncho-pneumonia, or from an acute exacerbation of 
the intestinal symptoms. The autopsy in such cases usually reveals the 
presence of superficial ulcers. If recovery is to be the outcome, after 
the symptoms have been nearly stationary for a long time, there is seen 
a gradual improvement first in the general and then in the local con- 
ditions. Convalescence is very slow, often interrupted by relapses, and 
it may be months before the patient is quite well. In some cases the 
child never regains its former vigour. 

(3) Follicular ulceration — ulcerative inflammation of the lymph 
nodules. — Follicular ulceration is often preceded by other forms of intes- 
tinal disease. It is not very frequently met with in infants under six 
months of age. The great majority of those affected are in poor condi- 
tion at the time of the attack. 

To understand the symptoms of these cases, it must be remembered 
that follicular ulceration is a terminal process which may follow acute 
gastro-enteric intoxication. It may be preceded by one or more acute 
attacks, or by a protracted subacute attack. On account of the feeble 
resistance of the child or the continuance of the exciting cause, the 
pathological process gradually extends from the epithelium to the lymph 
nodules of the intestine, chiefly the colon, which, as already described, 
pass successively through the stages of swelling, softening, and ulcera- 



ACUTE ILEO-COLITIS. 



397 



tion. The onset of the illness may therefore be abrupt, with vom- 
iting and high fever; or gradual, without vomiting and with very little 
fever. The patient may be ill for a week before the exact type which the 
disease is assuming can be positively determined. It is not possible to 
mark the transition from acute gastro-enteric intoxication to follicular 
ileo-colitis. Usually the latter may be assumed to exist whenever, after 
a very acute onset, there is a continued temperature above 101° F., and 
when the stools habitually contain large quantities of mucus without 
blood. 

Vomiting is not a feature of these cases ; but it is often present at the 
onset. Throughout the attack it is easily excited by injudicious feeding 
or medication. The temperature is seldom high, except at first ; its usual 



DAY 




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Fig. 71. — Temperature chart of ileo-colitis, fatal on thirty-fourth day. Autopsy showed follicu- 
lar ulcers throughout the colon. 



range is from 99° to 101° F. ; toward the close, even of fatal cases, it may 
be scarcely above the normal. The accompanying chart (Fig. 71) is a 
very good illustration of the course of the temperature in cases begin- 
ning abruptly and ending fatally. 

The stools are seldom very frequent, the number being from four 
to eight a day. The most constant feature is the presence of mucus, 
which is mixed with the stools and usually abundant. Blood is not gen- 
erally present, and a large amount of blood is extremely rare. It was ab- 
sent entirely in more than half of my cases in which the diagnosis was 
confirmed by autopsy. A small quantity of blood early in the attack is 
not uncommon, depending here upon congestion. Large haemorrhages 
from ulcers I have never seen. The colour of the stools is most fre- 
quently dark green or brown. Fluid stools are seen only during ex- 
acerbations. The odour is usually offensive, particularly in protracted 
cases. The microscope shows epithelial cells in great numbers, and very 
often an abundance of small round cells, which may be looked upon as 
the most constant sign of ulceration. 

The failure in nutrition and steady loss in weight are very constant in 
these cases. As emaciation goes on, the skin hangs in loose folds on the 



398 DISEASES OF THE DIGESTIVE SYSTEM. 

thighs ; it becomes dry and scaly and loses its elasticity, and occasionally 
small petechial spots are seen upon the abdomen. The skin over the but- 
tocks becomes excoriated, and bed-sores form over the heels, the sacrum, 
or the occiput. The abdomen may be moderately distended, or it may be 
relaxed and soft. Tenderness is not usually present. The appetite is 
lost, and in most cases great difficulty is experienced in getting children 
to take a proper amount of nourishment. Continued aversion to food 
is an unfavourable symptom. Occasionally, when there is fever, fluids 
are taken eagerly. A returning appetite is always an encouraging sign. 
The mouth is often dry, the tongue coated, sometimes dry and brown ; 
there may be sordes upon the lips and teeth. Superficial ulcers form 
upon the mucous membrane of the mouth, and often thrush is seen. The 
urine is usually diminished, high-coloured, and loaded with urates. Al- 
bumin and casts are rarely present. In only two or three cases have I 
seen nephritis severe enough to be a factor in the result. Tenesmus and 
prolapsus ani are uncommon. 

The average duration of the fatal cases is about three weeks ; their 
course is often marked by exacerbations and remissions. If recovery 
takes place, convalescence is always very slow and relapses are easily 
excited. 

Very few of these cases recover completely. Even those who survive 
the primary illness are likely to suffer from intestinal symptoms for many 
months. Fatal relapses are often brought on by injudicious feeding 
when the children are apparently almost well. The general health is 
usually so undermined that the patients continue to suffer from all the 
symptoms of malnutrition, and ultimately succumb to an attack of some 
intercurrent acute disease. 

The diagnosis of ulceration is to be made from the case as a whole 
rather than from any special symptoms. If a delicate infant which has 
previously been prone to diarrhceal attacks, has green mucous stools with 
low fever, and these symptoms continue with unabated severity for ten or 
twelve days, ulceration is probable. If such symptoms continue for three 
or four weeks with steadily failing strength and loss of weight, the diag- 
nosis is almost certain. If, on the contrary, after three or four days of 
acute symptoms there is improvement in the stools and occasionally some 
which are quite faecal in character, even though it may be a week or more 
before the mucus disappears, we may be quite certain that no ulcers have 
formed. 

(4) The membranous form. — This is the gravest form of inflamma- 
tion of the intestines seen in children, and its symptoms are more often 
obscure than are those of any other variety. This is particularly true 
when it affects young infants. There may be at the onset and throughout 
the course of the disease severe local and constitutional symptoms; or 
with well-marked constitutional symptoms, the local symptoms may be 



ACUTE ILEO-COLITIS. 



399 



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nous colitis ; fatal. 



slight or of very doubtful character, so that it is often mistaken for some 
other disease. 

In the first form it closely resembles the most severe cases of catar- 
rhal inflammation. The disease begins abruptly, with vomiting, high 
temperature, and several large, fluid stools. The vomiting does not 
often continue after the first twenty- 
four hours. The temperature is at 
first from 102° to 105° F., and its 
course may be steadily high (Fig. 72), 
or remittent. The abdomen is often 
tender and sometimes swollen. There 
is severe pain, and at times tenesmus, 
with prolapse of the rectum. This is 
intensely congested, and sometimes 
shows patches of pseudo-membrane 
upon its surface, thus establishing the 
diagnosis. 

The stools often resemble those of 
the catarrhal variety, except that 
blood is more constantly present and 

usually more abundant, but the only positive point of difference is the 
presence of shreds or flakes of pseudo-membrane. If the stools are 
thoroughly washed with water these may be seen as small gray opaque 
masses, which are then easily distinguished from the transparent mucus. 
Large shreds of membrane are seldom seen in children. Both blood 
and mucus sometimes disappear from the stools, which may consist only 
of dirty water. Under the microscope there may be seen epithelial cells, 
red blood-cells, and round cells in great numbers. 

The presence of cerebral symptoms in these cases of membranous 
ileo-colitis may lead to great obscurity in the diagnosis. This is most 
frequently true at the onset. There may be high temperature, great 
prostration, vomiting, stupor, delirium, and even convulsions ; and such 
symptoms may for two or three days completely mask the intestinal con- 
dition. As the case progresses, however, the intestinal symptoms come 
more and more into prominence, and the cerebral symptoms usually sub- 
side. But sometimes this is not the case. I once saw a case closely 
watched for two weeks by three physicians of large experience, who were 
agreed in the diagnosis of a cerebral lesion, but not as to its nature, 
which showed at autopsy only the lesions of membranous colitis. There 
was a continuous but irregular fever, stupor, retracted abdomen, opis- 
thotonus, unequal pupils, and at times irregular respiration. Two or 
three days before death the first blood appeared in the stools, and at 
the same time, during extensive rectal prolapse, a false membrane was 

seen. 

27 



400 



DISEASES OF THE DIGESTIVE SYSTEM. 



Membranous colitis is also obscure when it affects young infants. 
Every year a number of these cases are seen at the Babies' Hospital. 
The prominent symptoms are: rather high, continuous temperature, 
usually ranging between 101° and 104° F., but following no distinct 
curve (Fig. 73) ; wasting, which is not rapid but progressive; frequent 



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Fig. 73. — Temperature chart of membranous colitis. 

Infant fourteen months old, Babies' Hospital. Symptoms for the first two weeks obscure, 
suggesting first pneumonia, afterward meningitis. Intestinal symptoms for the last two weeks 
only, never very severe; stools four to six daily, generally green, thin, with much mucus at 
times, and once or twice traces of blood. Culture four days before death showed streptococci 
and colon bacilli. Autopsy : No lesion of importance except membranous colitis involving 
entire colon; a slight catarrhal enteritis. 

stools, which have no constant or striking characteristics. They are 
usually thin, yellow or greenish in colour, often containing no mucus or 
blood. Occasionally for a day the stools may be almost normal in ap- 
pearance. In number they average five or six a day, but often for days 
only two or three. Outside of a hospital where autopsies are regularly 
made these cases would pass as excellent examples of infantile typhoid. 
In many cases the diagnosis wavered between obscure pneumonia, tuber- 
culosis, and typhoid, and was settled only at the autopsy. 

The duration of membranous ileo-colitis is usually from one to three 
weeks. Death takes place from sepsis, exhaustion, or from complica- 
tions. It is probable that almost every case of the severity described ter- 
minates fatally when it occurs in an infant. In older children the prog- 
nosis is much better as to life, but in them the acute attack may be fol- 
lowed by the chronic form of the disease. 

Diagnosis. — Ileo-colitis is to be distinguished chiefly from typhoid 
fever, intussusception, and meningitis. Typhoid (see chapter on 
Typhoid) is distinguished by the slower invasion, more constant tem- 
perature, enlargement of the spleen, tympanites, and most of all by the 
Widal reaction and the eruption. The fact that the disease is epidemic 
is also to be considered. Acute colitis should not be confounded with in- 
tussusception ; yet the records of intussusception show that a very large 
proportion of the cases were regarded in the beginning as cases of dysen- 
tery. In intussusception, although we have a sudden onset with acute 
pain, tenesmus, vomiting, and marked prostration, there is rarely fever. 
The later symptoms — absolute constipation, tumour, tympanites, rising 



ACUTE ILE0-C0LIT1S. 401 

temperature, stercoraceous vomiting, and collapse — have nothing in com- 
mon with colitis. The membranous form may be confounded with men- • 
ingitis, and in some cases a differential diagnosis is impossible except by 
the course of the disease. Marked diarrhoea, even though the stools are 
not characteristic, should always make one doubt meningitis. 

A diagnosis between the different varieties of ileo-colitis is not 
always possible. Follicular ulceration is distinguished by its lower tem- 
perature, rather subacute course, infrequency of blood in the stools, and 
by the fact that it is usually preceded by one or more attacks of acute 
gastro-enteric intoxication. 

In the catarrhal form, the symptoms of an acute inflammation of 
the colon are usually manifest from the outset — bloody stools, pain, 
tenderness, tenesmus, and fever. In the membranous variety such symp- 
toms are sometimes seen; but, as a rule, the local symptoms are less 
pronounced, while the constitutional symptoms, especially those relating 
to the nervous system, are usually marked. The course is usually shorter 
and more intense than in the follicular form. 

An agglutination reaction of the B. dysenterice with the serum of 
affected children is usually present. But for general use in diagnosis 
this is not of great assistance. It is subject to considerable variation. 
Moreover, it is seldom present until the end of the first week of the 
disease, by which time the nature of the attack is evident by clinical 
symptoms. Agglutination in the higher dilutions is seen only with the 
particular type of organism with which the infant is infected. 

Prognosis. — This is much worse in infants than in older children. It 
is especially bad in institutions, and is rendered unfavourable by previous 
rickets or malnutrition, and by the existence of any complication, espe- 
cially broncho-pneumonia. Summer cases are never out of danger until 
the end of the hot season, on account of the great liability to relapses. 

Prophylaxis. — What has been said regarding general prophylaxis in 
the previous chapter, applies equally well to cases of ileo-colitis. 

Special emphasis should be placed upon the necessity of energetic 
early treatment of all the milder forms of diarrhoea, and particularly 
the cases of acute gastro-enteric intoxication, in order that the process 
may be arrested before serious anatomical changes have taken place — a 
thing which is often possible. Equal stress should be laid upon the 
importance of prompt and radical treatment at the very beginning of 
the cases with a sudden onset. 

Hygienic Treatment. — The general plan recommended in the pre- 
vious chapter should be followed here. A change of air is desirable for 
most cases as soon as the acute inflammatory symptoms have subsided. 
In the protracted cases which drag on a subacute course, this change will 
often do more than anything else. Plenty of pure fresh air is neces- 
sary in all cases. The indications for bathing are the same as in other 



402 DISEASES OF THE DIGESTIVE SYSTEM. 

cases of acute diarrhoea. It is undesirable to crowd these patients in 
institutions, as they always do better when separated. 

The diet during the acute stage should be the same as in cases of 
acute gastro-enteric intoxication. In the protracted cases the diet pre- 
sents great difficulties, as the children have little or no appetite, and 
soon come to refuse everything in the shape of food that is offered. 
In infancy, the articles which are most to be depended upon are 
skimmed milk which has been completely peptonized, animal broths, 
and liquid beef peptonoids. In some cases rice or barley water are well 
borne; in others, some of the malted foods, although these often in- 
crease the number of stools and have to be stopped on that account. 
Food which leaves little residue should always be chosen. Infants, 
when very ill, are much more likely to take too little than too much food. 
A careful record should be kept of the amount actually taken in each 
twenty-four hours. When this is much below the requirements of nutri- 
tion, gavage may be tried. Sometimes all food and stimulants may be 
advantageously given in this way. In no case should food be given 
oftener than every two hours, and usually the interval should be three 
hours, water and stimulants being allowed between the feedings. In 
older children the diet during the acute stage should be much the same 
as in infants. At a later period, raw beef, kumyss, or matzoon will be 
found useful, and during convalescence, eggs, boiled milk, or milk gruels 
made with rice or barley. Special care should be given to the diet for 
a long time. For months after an acute attack the intestines are very 
easily deranged. Eelapses are excited by changes in the temperature, 
by great fatigue or exhaustion, but most of all by improper feeding. 
Especially in older children should such articles be avoided as oatmeal, 
potatoes, corn, tomatoes, and all fruits. I have seen a single peach given 
to a child two years old, excite a dangerous relapse, and a few raisins 
a fatal one. 

Medicinal and Mechanical Treatment. — Cases, the early stage of 
which is marked by vomiting and thin diarrhceal stools, are to be managed 
at the outset according to the plan outlined in the previous chapter — viz., 
free purgation, irrigation of the colon, and stopping all food. When 
the symptoms of acute inflammation are evident from the outset, as 
shown by the frequent bloody and mucous stools with tenesmus and 
pain, the measures to be depended upon are castor oil or saline cathar- 
tics and irrigation of the colon, and later opium and bismuth by the 
mouth. Castor oil should be administered in a full dose at the out^ 
set — one drachm at six months, two drachms at one year, and half an 
ounce at four years. Its primary effect is to clear the intestines, and 
its secondary effect is soothing. The salines may be used as described 
in the previous chapter. If the stomach is at all irritable, calomel, 
one-fourth grain every hour for five or six doses, may be substituted. 






ACUTE ILEO-COLITIS. 403 

Opium is usually required on account of the pain and tenesmus. The 
dose should be regulated by the severity of these symptoms and by 
the frequency of the stools. The deodorized tincture and paregoric are, 
I think, preferable to other preparations. 

Eepeated small doses are better than a single large dose. It is very 
important that opium should be withheld for at least twelve hours after 
the initial purgative. As the pathological process is principally in the 
colon, and most severe in the lower half of the colon, it can often be 
much more effectively treated by injections than by drugs given by the 
mouth. Irrigation of the colon is one of our most valuable means of 
treatment in these cases. For general purposes a saline solution at 
100° to 104° F. should be employed. One or two quarts should be given 
at one time; it should be injected high into the colon through a long 
rectal tube, and early in the disease repeated at least twice a day. When 
the tenesmus is very great and blood abundant, small injections of either 
hot water (106° to 110° F.) or ice water may be used, and later astrin- 
gent injections. 

The most useful astringents are tannic acid and supra-renal extract; 
of the former one drachm, and of the latter two drachms, may be added 
to a pint of hot water. Whether injections are to be used continuously 
or not will depend much upon the patient. 

If they are well borne, they may be given once or twice a day during 
the attack; but if at every attempt to give them the child struggles, 
screams, and resists, they may do more harm than good. Complete 
rest is a very important part of the treatment. 

For cases not influenced by the measures mentioned, or those not 
seen at the outset, bismuth should be tried, but it is of no use whatever 
unless large doses are administered. One or two drachms of the sub- 
nitrate should be given in twenty-four hours to a child two years old, and 
proportionate doses to older children. This should be suspended in 
mucilage. Tenesmus and pain are sometimes relieved by the injection 
of three or four ounces of a starch solution to which from five to ten 
drops of laudanum are added. Severe tenesmus, when not controlled 
thus, and when associated with prolapsus ani, is sometimes immediately 
relieved by a suppository containing cocaine. Not more than one-fourth 
grain should be used for a child of three years. 

Although a serum has been produced which protects animals against 
inoculation with the B. dysenterice, its use in the treatment of the 
various forms of ileo-colitis in children has not been followed by any very 
striking benefit. 

Stimulants are needed in nearly all cases. There are no valid objec- 
tions to their use even in the youngest infant. The feeble digestion and 
assimilation of these patients very frequently compel us to use alcohol. 
Stimulants are indicated by a weak pulse, cold extremities, and great 



404 DISEASES OF THE DIGESTIVE SYSTEM. 

general prostration, no matter at what stage in the disease these symp- 
toms are seen. Old brandy is usually to be preferred. Generally not 
more than thirty drops every two hours are needed for an infant one 
year old, but for short periods a much larger quantity may be required. 
Brandy should always be diluted with at least eight parts of water. 

In cases where symptoms have lasted two or three weeks, and the 
active symptoms have subsided, where the temperature is scarcely above 
100° F., and the stools reduced to four or five a day, it is wise to stop all 
medication and attend only to food and stimulants, with irrigation of the 
colon every two or three days. One is often surprised at this stage to find 
that patients do better without drugs than with them. The prevailing 
tendency is to overdose cases of this type. Careful attention to diet, 
judicious stimulation, occasional irrigation of the bowel, with change of 
air, will do much more than any amount of medication. 

During convalescence general tonics are required, such as arsenic, 
iron, nux vomica, and wine. Cod-liver oil should be deferred until the 
stomach and appetite are quite normal and the stools free from mucus. 
It should, however, be continued throughout the succeeding winter 
months. 

CHRONIC 1LEO-COLITIS. 

The severe forms of chronic ileo-colitis follow acute ileo-colitis, usu- 
ally the catarrhal or follicular form, as the membranous is so severe 
that the patients rarely survive the acute stage. There may be only a 
chronic catarrhal inflammation of the mucous membrane, or ulcers may 
be present. 

The milder forms are usually the result of chronic intestinal indi- 
gestion. 

Lesions. — Catarrhal form. — In its milder form it is quite common, 
but in its severe form it is exceedingly rare. There may be changes in 
a large part of the small intestine and in the stomach, as well as in the 
lower ileum and colon. 

The gross appearance of the intestine often differs very little from 
the normal. The mucous membrane is usually of a dull gray or slate 
colour. Pigmentation may occur as striae in the mucous membrane, but 
more frequently it is limited to Peyer's patches and the solitary lymph 
nodules; these, as well as the mesenteric lymph nodes, are generally 
swollen. 

The microscopical changes are usually marked. The lesion is chiefly 
one of the mucosa (Fig. 74). The important features are a disappear- 
ance of very many of the tubular glands, and in the small intestine of 
the villi also. There is a very marked cell proliferation in the adenoid 
tissue of the mucosa, and if the disease has existed long enough there may 
be a production of new connective tissue. The solitary lymph nodules 



CHRONIC ILEO-COLITIS. 



405 



show usually nothing but cell hyperplasia. The lesions are not uniformly 
distributed, but occur in patches throughout the intestine. When present 
in the stomach, they are of the same kind as those described in the intes- 
tine, although rarely so severe. In milder cases the gross appearances 
may show very little change to the naked eye; except swelling of the 




Fig. 74. — Chronic catarrhal inflammation of the ileum. 

The lesions affect the mucosa, A, almost exclusively. It is somewhat thickened ; there is 
extensive destruction of the tubular follicles, remains being seen at 1\ T\ there is a great in- 
crease in the cells, and some new connective tissue in the mucosa. Large new blood-vessels 
are seen at C, C. History. — Delicate child, thirteen months old; diarrhceal symptoms for four 
months; during the first two weeks there was high fever; at death weighted eight pounds. 
The gross changes at the autopsy were very slight. The section is from the middle ileum. 

lymph nodules. Under the microscope there may be found more or less 
extensive cell infiltration of the mucosa, but rarely any destructive 
changes or new connective tissue. 

Ulcerative form. — This is rather rare, for the reason that in infancy 
a very large proportion of the cases die during the acute stage. 

The ulcers are nearly always of the follicular variety; occasionally 
they are broad and shallow. If the patient dies after an illness of from 
six to eight weeks, the appearances do not differ essentially from those 
described in acute cases. If life is prolonged from two to four months, 
ulcers are found in various stages of repair. Follicular ulcers require 
from one to three months for cicatrization, and the broad superficial 
ulcers even a longer time. It is very doubtful whether stricture ever 
results from these ulcers in children. The mucous membrane shows 
almost invariably evidences of more or less extensive chronic catarrhal 
inflammation. Among the very rare lesions are cysts of the colon. Fully 
developed cysts I have seen but once. The child had an attack of acute 
ileo-colitis, which became chronic, lasting about five months. He never 
regained his health, and died one year later from intercurrent disease. 
In the descending colon and rectum, about twenty cysts the size of a pea, 
and many smaller ones, were found. They had a thin, translucent cover- 
ing. On section, a thick, transparent, gelatinous material escaped. They 
were situated in the submucosa, and were undoubtedly produced by the 
dilatation of some of the tubular glands whose orifices had been oblit- 
erated. 



406 DISEASES OF THE DIGESTIVE SYSTEM. 

Associated lesions. — The important ones are in the lungs, the most 
common being hypostatic congestion, subacute or chronic broncho-pneu- 
monia, more rarely pulmonary tuberculosis. It is rare to find the lungs 
perfectly healthy. The liver is often found extremely fatty in cases asso- 
ciated with great wasting, but in no case have I seen hepatic abscess. 
The kidneys usually show a more or less intense cloudy swelling, and 
sometimes there may be well-marked nephritis. Dropsical effusions into 
the serous cavities are very rare. 

Symptoms. — In the milder cases there are only the symptoms of 
chronic intestinal indigestion with the constant presence of mucus in the 
stools, usually in large amount. 

The severe cases are usually seen in autumn, and are generally the 
sequel of acute attacks occurring during the summer. 

The signs of active inflammation have passed away; the tem- 
perature is usually normal; there is no pain or tenderness. There is, 
however, no improvement in the general condition, and either the weight 
remains stationary, or the child continues to lose slowly until it is little 
more than a skeleton. The face is pinched, the eyes sunken, and the 
cheeks hollow. The lips are pale, often fissured, and bleed readily. The 
fontanel is depressed. The body is so small that the head seems much 
too large. The skin hangs in loose folds on the thighs. The mouth is 
often the seat of thrush, of catarrhal, herpetic, or rarely of ulcerative 
stomatitis. The tongue may be heavily coated, but is more often dry, 
glazed, and red. 

Although they seldom cry for food, as a rule these children will take 
nearly everything given them, and in almost unlimited amount. Not- 
withstanding that it is retained, the more they are fed the more rapid 
seems the wasting. Vomiting is not common, and seldom occurs except 
from overloading the stomach or during acute exacerbations. 

The stools are rarely frequent, five or six a day being the average; 
often there may be only two or three a day for a week at a time. They 
are thinner than normal, but are not often fluid. They contain mucus 
of a green or brownish colour, usually in large quantity ; but rarely blood. 
The stools are sometimes green, often greenish brown, sometimes a pale 
gray. They are always large in proportion to the amount of food taken. 
Undigested food is always present in quantity, and upon the diet de- 
pends very much the gross appearance of the stool, the odour of which 
is almost always offensive. Pus is often found under the microscope, 
but is rarely visible to the naked eye. Nothnagel and Baginsky have 
called attention to a form of stools which they believe to be characteristic 
of wide-spread inflammation of the mucous membrane with atrophy of 
the tubular glands : they are of nearly normal consistence, homogeneous, 
dark green or brown colour, and usually offensive; they sometimes al- 
ternate with stools of a watery character; under the microscope nuclei 



CHRONIC ILEO-COLITIS. 407 

are found, but no unchanged epithelial cells ; the food remains are some- 
times unrecognisable, owing to decomposition. 

Prolapsus ani is not so frequent as in the acute cases; but when it 
occurs it is generally more difficult to control. Flatulence and colic are 
prominent symptoms in some cases, but absent altogether in many others. 
As a rule, there is neither abdominal pain nor tenderness. The abdomen 
is usually distended, and in most cases the enlargement is uniform, but 
sometimes there is marked epigastric prominence, which is more often 
from dilatation of the transverse colon than of the stomach. Although 
the mesenteric glands are enlarged, they can not be felt through the 
abdominal walls. The skin is dry and scaly, and in the worst cases fre- 
quently covered with small petechia? over the abdomen and lower extrem- 
ities. About the anus, and over the sacrum, thighs, genitals, and some- 
times feet, there are excoriations, and not infrequently ulcerations. The 
temperature is elevated only during exacerbations, or from inflammatory 
complications. A subnormal temperature is frequently met with. I have 
occasionally seen it 95° F. in the rectum. The urine often contains an 
excessive amount of indican. Dropsy is often present without albu- 
minuria. The weight is stationary, or steadily falls to an almost in- 
credible degree. I have seen one infant weighing but eight pounds at 
thirteen months; another, thirteen pounds at two years and four 
months. Ulcers of the cornea are not uncommon. Nervous symptoms 
are always present. The children are cross and irritable, sleep badly, and 
frequently have a low, whining cry, which is continued much of the time. 
Sometimes they are dull, apathetic, and quite indifferent to their sur- 
roundings. Persistent opisthotonus is occasionally seen ; and there may 
be contractions of the extremities, but rarely general convulsions. 

The duration of the disease is from two months to a year. Compara- 
tively few patients survive more than four months. The progress is 
irregular, and marked by periods of improvement, during which for a 
time the patient may hold his own, or even gain in weight. Any trivial 
cause may excite a relapse, and the downward progress is rapid. Death 
often occurs during one of these exacerbations, or it may be due to bron- 
cho-pneumonia, tuberculosis, or slow asthenia. 

Diagnosis. — It is important to distinguish the cases with marked 
cachexia and slow convalescence, although ultimately resulting in com- 
plete recovery, from those which present at a certain stage almost iden- 
tical symptoms, and yet go on steadily downward, terminating fatally. 
The difference in these cases is really a difference in the character and 
extent of the lesions. The first group are probably cases of superficial 
catarrhal inflammation, or of follicular inflammation which has not gone 
on to ulceration, these lesions being capable of repair. The second 
group are the cases of ulceration, in which complete recovery from the 
lesions is impossible, and repair only partial, if indeed any occurs. In 
28 



408 DISEASES OF THE DIGESTIVE SYSTEM. 

distinguishing between these groups the most important guide is the 
nature of the symptoms during the antecedent acute attack. The longer 
the acute symptoms have lasted and the higher the temperature, the 
greater is probably the extent of the lesions, and the more severe their 
character. 

The diagnosis of chronic ileo-colitis from general tuberculosis is 
often difficult. Tuberculosis is more likely to be met with in institutions, 
among the poor of cities, and in children previously delicate and with a 
tuberculous family history. In chronic ileo-colitis the wasting and 
anaemia follow the intestinal symptoms, and are usually just in propor- 
tion to their severity. For the differential diagnosis of the pulmonary 
conditions, see the chapter on Tuberculosis. Fever is rarely absent in 
general tuberculosis or in tuberculous ulceration of the intestine if ex- 
tensive, though it is not high and its course is very irregular. It is ab- 
sent in chronic ileo-colitis, except from complications and from the 
occasional acute exacerbations. 

Prognosis. — The prognosis depends upon the child's previous condi- 
tion, upon the duration of the intestinal symptoms, upon our ability to 
carry out proper treatment, upon the presence of complications; but, 
most of all, upon the severity and extent of the intestinal lesions. The 
possibility of error always exists in estimating the gravity of the lesions, 
so that no case should be considered hopeless. The most unpromising 
cases sometimes end in complete recovery. If, however, continuous 
symptoms have existed for eight or ten weeks without any sign of im- 
provement, recovery is extremely doubtful. The patient may linger for 
two or three months longer, but usually only to be carried off by the first 
acute disturbance which occurs. 

Treatment. — No greater mistake is made than to give these children 
week after week the various diarrhoea-mixtures, with the expectation 
that ultimately the formula which exactly meets the particular case will 
be found. Drugs are to be used only for the relief of special symptoms. 
Thus a dose of opium may be needed when the movements are unusually 
frequent, or castor oil, or calomel occasionally when the stools are partic- 
ularly offensive. The essential and important part of the treatment con- 
sists in injections, careful feeding, stimulation, and change of air. As- 
tringent enemata, however, are of some value. They should not be given 
continuously, but from time to time should be omitted for a week or two 
to see what the condition of the stools is without them. I have seen 
several cases of the milder variety where the constant use of such injec- 
tions seemed to be an important factor in keeping up the production of 
mucus. The colon should first be washed with a large amount of a tepid 
salt or borax solution, and then four or five ounces of the astringent solu- 
tion injected, and held in place by compressing the buttocks for half 
an hour. 



AMCEBIC COLITIS. 409 

Alcoholic stimulants must be "given in almost all cases, and they may 
be continued for a long time with advantage. Old port or sherry will 
sometimes do better than brandy or whisky. The diet mentioned in the 
later stages of the acute cases should be continued. The predigested 
foods are useful, especially completely peptonized milk ; also are beef 
preparations as bovinine, and the liquid beef peptonoids, and in some 
cases raw scraped beef, also the whites of fresh eggs, partially cooked. 
Fats and starchy foods should be excluded entirely or given in very small 
quantities. It is usually better to give the carbohydrates in the form of 
the malted foods. Kumyss and matzoon and buttermilk are useful. 
The diet must be directed according to its effect upon the stools. Much 
information may be obtained by thoroughly washing the stools and 
examining the residue. Nutrition may be promoted by inunctions of 
cocoa butter, cod-liver oil, or some other form of fat. 

The patient should first be put in the best possible surroundings ; in 
no disease is a change of air more to be desired than in this. These cases 
are trying ones to the physician; for unless he can absolutely control the 
matter of diet, it is almost useless to attempt to do anything. Still, by 
careful study of the individual case and attention to minute details, suc- 
cess may sometimes be achieved even when the outlook seemed at the 
outset the most hopeless. The danger of relapses and second attacks 
continues long after the primary attack has subsided. 

AMCEBIC COLITIS. 

Amoebic colitis is rare in children; it is particularly so in infants, 
probably owing to the fact that nearly all the water taken at this age is 
boiled. Most of the cases in children thus far reported have been ob- 
served in warm climates, although Amberg * has recorded five which 
occurred in Baltimore, the youngest being two years and eight 
months old. 

The symptoms in the few cases that have been reported in children 
have differed in no important particular from the disease as seen in 
adults. In exceptional cases the onset may be abrupt and the attack 
may run an acute course, terminating fatally in two to three weeks. 
Such cases are characterized by much abdominal pain and tenderness, 
frequent mucous and bloody stools containing amoeba?, and some fever, 
which, however, seldom reaches 102° F. 

More frequently this acute onset is followed by a subacute or chronic 
form of the disease, or the disease may be subacute from the beginning. 
The protracted cases are the type of the disease most frequently seen. 
They are very obstinate to treatment. Periods of constipation and ap- 
parent recovery often alternate with exacerbations in which the bloody 

* See Bulletin of Johns Hopkins Hospital, December, 1901, for references to 
literature. 



410 DISEASES OF THE DIGESTIVE SYSTEM. 

and mucous stools return, with pain, tenesmus, and slight fever. The 
duration may be from a few months to one or two years. Death may 
finally occur from exhaustion with extreme wasting, or from some com- 
plication, such as haemorrhage, abscesses of the liver being very rare in 
children. The diagnosis from other forms of colitis is made only by the 
discovery of amoebae in a freshly voided stool. 

The general treatment is the same as for other forms of acute or 
subacute colitis. The special treatment for the purpose of destroying 
the amoebae is the use of injections of quinine which may be employed 
in solutions varying in strength from 1 to 5,000 to 1 to 250. 

AMYLOID DEGENERATION OF THE INTESTINES. 

This is rarely met with in infants. It is not so infrequent in older 
children, where it is associated with amyloid changes in the liver, spleen, 
and kidneys, usually as a result of prolonged suppuration in connection 
with bone tuberculosis. It is sometimes met with in syphilis. The ileum 
is the part of the intestine most affected. The process begins in the walls 
of the arterioles and capillaries, particularly of the villi, and later in- 
volves the vessels of the submucosa ; subsequently the epithelium may be 
affected. The mucous membrane in these cases is pale, rather translu- 
cent. The condition is recognised by the application of the iodine test; 
the affected villi become of a brownish-red or mahogany colour. 

Amyloid degeneration produces no definite symptoms. Diarrhoea is 
frequent but by no means constant. The anaemia and waxy cachexia 
which are present are probably dependent much more upon the associated 
lesions of the liver and kidneys than upon the changes in the intestines. 

TUBERCULOSIS OF THE INTESTINES AND MESENTERIC LYMPH 
NODES (MESENTERIC GLANDS). 

These two conditions are usually, but not invariably, associated, and 
may be conveniently considered together. 

Frequency. — In one series of 109 autopsies upon tuberculous cases 
from my own hospital records the intestines were involved in 37 per 
cent. In a second series of 103 autopsies they were involved in 54 per 
cent. The great majority of the patients were under three years of age. 
In 131 autopsies upon tuberculous cases published in the Pendlebury 
Hospital Eeports, the intestines were involved in 50 per cent. These 
patients were mainly between four and fourteen years old. In 209 autop- 
sies upon tuberculous children, chiefly infants, reported by Miiller, the 
intestines were involved in 28 per cent. In 1,346 autopsies collected by 
Biedert there were intestinal lesions in 31 -6 per cent. These figures 
show that tuberculosis of the intestines is not one of the most frequent 
forms in children, and that it is rather less frequent in infancy than at 



TUBERCULOSIS OF THE INTESTINES. 41 \ 

a later age. It is most common from the third to the eighth year. The 
mesenteric lymph nodes were tuberculous in about 50 per cent of my 
own autopsies, and in 59 per cent of the Pendlebury cases; occurring 
thus in both series with slightly greater frequency than tuberculosis of 
the intestines. 

Etiology. — In the great majority of cases the mesenteric lymph nodes 
are infected from the intestines. It is possible, but I believe exceptional, 
for the infection to occur through the general circulation. With tuber- 
culous ulcers of the intestine, the lymph nodes are, I think, invariably 
found by inoculation in animals to be tuberculous; although they may 
not yet be caseous. The infection of the intestinal mucous membrane 
is from bacilli in the canal. Much stress has been laid upon tuberculous 
milk as a means by which children are infected. There is little patho- 
logical support to be found for the view that children often contract the 
disease in this way. In 119 autopsies upon tuberculous children, chiefly 
infants, there was not found one in which the most advanced, and there- 
fore presumably the primary, lesion was in the intestines or stomach. 
In 127 autopsies, also upon tuberculous infants, ISTorthrup found the 
most advanced lesion in the intestines in but a single case. While in- 
fection from milk is possible, it is certainly extremely infrequent. In 
my own autopsies, intestinal lesions have been found, with but one excep- 
tion, only in marked cases of generalized tuberculosis. In not more than 
one-fourth of the cases in which such lesions were present were they 
severe. They were usually associated with an advanced pulmonary pro- 
cess, and were doubtless due to swallowing tuberculous sputum. 

Lesions. — Intestines. — The usual seat is the small intestine, chiefly 
the jejunum and lower ileum. With extensive disease the large intes- 
tine may also be involved, most frequently the caecum, and exceptionally 
it alone may be affected. Tuberculous ulcers may be found in the ap- 
pendix. 

The early deposits appear as tiny yellow nodules, generally widely 
scattered and affecting Peyer's patches. Usually, however, ulcers are 
present, and often only ulcers are seen. Their size and number vary 
greatly ; there may be only five or six tiny ulcers, or there may be forty 
or fifty, the largest being two or three inches in diameter. They very 
frequently involve Peyer's patches. The typical tuberculous ulcer is of 
irregular shape, with rounded borders and with its longest diameter at 
right angles to the intestinal axis. When large, it may nearly encircle 
the gut. The ulcers are excavated; they have overhanging, infiltrated 
edges of a deep red colour. The surface is covered with granulations. 
In those which have partially healed a distinct puckering of the intes- 
tine occurs, which is especially noticeable upon the peritoneal surface. 
The small ulcers involve the mucosa only; the larger and older ones the 
submucosa and the muscular coats, and not infrequently also the serous 



412 DISEASES OF THE DIGESTIVE SYSTEM. 

coat. Perforation may occur, but rarely into the general peritoneal cav- 
ity, as a localized plastic inflammation precedes it. There may be ad- 
hesions of adjacent intestinal coils, and fistulae may form, owing to ulcer- 
ation at their point of contact. With these severe cases there is always 
associated more or less extensive tuberculous peritonitis, frequently of 
the ulcerative variety. Like other tuberculous processes, the infiltration 
and ulceration may cease at any stage, and cicatrization follow. If the 
ulcers have been large ones, there is always some narrowing of the lumen 
of the intestine. Stricture rarely results, because the patients die from 
the general disease before it has had time to occur. Monti has reported 
a case of obstruction at the ileo-caecal valve, due to an old tuberculous 
cicatrix, in an infant of twenty-one months. 

Mesenteric lymph nodes. — Usually these tuberculous lymph nodes are 
from half an inch to an inch in diameter; occasionally they may reach 
the size of a hen^s egg. From a fusion of several of them, tumours of 
considerable size may be formed. I have seen one such mass as large as 
the head of a child at birth. 

The process is the same as that which occurs in other lymph nodes of 
the body. There is a tuberculous inflammation, followed by caseation, 
softening, and abscess, or by calcification. Localized peritonitis is found 
in all the marked cases ; this is usually plastic, but may be suppurative 
when due to the rupture of an abscess. Pressure upon the vena cava 
may lead to dropsy in the lower extremities. Ollivier has reported a case 
in which thrombosis of the vena cava occurred. Pressure upon the portal 
vein may lead to ascites and dilatation of the superficial abdominal veins. 
There may be pressure upon the thoracic duct. 

Symptoms. — The symptoms of intestinal tuberculosis are exceedingly 
irregular. Ulcers are very frequently found at autopsy when there have 
been no marked intestinal symptoms ; this is especially true of the small 
ulcers usually seen in infants. On the other hand, diarrhoea is not un- 
common in cases of advanced general tuberculosis where no ulcers are 
present. It is the most frequent symptom, and may be exceedingly obsti- 
nate. The stools do not differ essentially from those in chronic ileo- 
colitis, except in the occurrence of haemorrhages and in the presence of 
tubercle bacilli. Haemorrhages are not very frequent, but they may be so 
large as to be the cause of death. This occurred in one of my cases, an 
infant nine months old, the blood coming from a single ulcer in the 
ileum. Haemorrhage is more common in older children. In some cases 
localized abdominal pain or tenderness is present. In advanced cases 
the symptoms of intestinal ulceration are usually mingled with those of 
peritonitis, and there are also present the enlarged mesenteric lymph 
nodes, which may aid in the diagnosis. In the vast majority of cases, 
these nodes are recognised only by deep palpation. The tumours are 
generally felt as irregular nodular masses, lying close against the spine, 



CHRONIC INTESTINAL INDIGESTION. 113 

not movable, and sometimes tender on pressure. Other tumours from 
deposits in the peritonaeum may be present anywhere in the abdomen; 
they may be superficial or deep. The other symptoms are due to the 
complications already mentioned and to tuberculosis elsewhere. 

Diagnosis. — The only positive evidence of intestinal tuberculosis is 
the discovery of the bacilli in the stools. In the absence of this evidence, 
the disease is differentiated from simple ileocolitis, first, by the signs of 
tuberculosis elsewhere in the body, especially in the lungs, these being 
almost invariably involved; secondly, by the slow onset and gradual 
development of the symptoms, while in chronic ileo-colitis an acute at- 
tack has almost invariably preceded. Large haemorrhages always suggest 
tuberculosis. 

The large mesenteric glands are recognised only as abdominal tu- 
mours. 

Prognosis. — This depends altogether upon the extent of the tubercu- 
lous disease elsewhere, as it is extremely rare for the intestinal lesion to 
be the cause of death. Once formed, the ulcers probably remain, cica- 
trization being very rare, and then only partial. 

Treatment. — The only symptom which ordinarily demands treatment 
is the diarrhoea. When severe, this is to be managed much as in cases of 
ileo-colitis, except that irrigation of the colon is, of course, not called for. 
The chief reliance must be upon diet and internal medication. The 
drugs which are most useful are bismuth, opium, and creosote, which 
should be given in pills coated with shellac. 



CHAPTER IX. 

DISEASES OF TEE INTESTINES.— {Continued.) 

CHRONIC INTESTINAL INDIGESTION. 

As the larger and more complex part of the process of digestion goes 
on in the intestine, so intestinal indigestion is a more common and more 
complicated disturbance than gastric indigestion. In many cases we find 
the two associated, but in perhaps the majority the symptoms relate en- 
tirely to the intestinal process. The conditions seen in young infants are 
so different from those in older children that the cases may be best con- 
sidered separately. 

In Young Infants. — The general causes are the same as those men- 
tioned in connection with chronic gastric indigestion : they are constitu- 
tional debility, either congenital or acquired, unfavourable surroundings, 
and previous attacks of acute disease. Chronic intestinal indigestion is 
especially common during the first six months, and is seen both in nurs- 



414 DISEASES OF THE DIGESTIVE SYSTEM. 

ing infants and in those who are artificially fed. In the case of breast-fed 
infants, the mother is often highly nervous, delicate, and anaemic, and 
may be taking large quantities of fluids of every description, for the pur- 
pose of maintaining an abundant flow of milk. Why it is that the milk 
causes so much disturbance can not always be discovered even by the most 
careful analysis. The difficulty seems to be most frequently with the 
proteids, which are often in excess. Sometimes, proteids differing in 
character from those normally present seem to be produced, as the stools 
show that they are not digested. The microscope in some cases reveals 
the presence of many colostrum corpuscles in the milk. In another group 
of cases, where the condition of the nurse is all that can be desired, the 
trouble is simply that the milk is too rich; it being then high both in fat 
and proteids. It may come, although rarely, from the fact that the child 
gets too much, being nursed either too frequently or for too long a time. 

In infants who are being fed upon cow's milk, the most common cause 
is that the proteids are too high; this is usually the mistake when in- 
fants are fed upon plain milk which has been simply diluted. In other 
cases the fat or sugar may be excessive, as in many of the milk-and-cream 
mixtures in vogue. Next to this mistake in proportions, is that of over- 
feeding. Another very important cause is the use of farinaceous foods 
too early, and in excess. 

Lesions. — Strictly speaking, chronic indigestion is a functional dis- 
order without anatomical changes. When the condition has lasted for 
many weeks or months, as often happens, there may result a low grade of 
catarrhal inflammation in the colon, frequently attended by hyperplasia 
of the lymph nodules of the mucous membrane, and sometimes by a 
similar process in the mesenteric lymph nodes. Chronic indigestion 
may be the principal and the only symptom in cases of chronic ileo- 
colitis which follow acute attacks. 

Symptoms. — The general symptoms are those of malnutrition, or in 
the more severe form, those of marasmus. These have already been fully 
described, and need only be mentioned here. The most important are 
stationary or falling weight, anaemia, poor circulation, often subnormal 
temperature, almost constant fretfulness and crying, with very little 
quiet sleep. The tongue is usually coated and the appetite often good, 
these infants taking food whenever given, and in an almost unlimited 
quantity. There are few cases in which occasional vomiting does not 
occur, but it is rarely persistent. So far as the intestinal condition is 
concerned, the cases may be divided into those with diarrhoea and those 
with constipation. It may happen that the same child will suffer for a 
long time from diarrhoea and then from constipation, or the reverse ; but 
usually one condition or the other is habitual. The diarrhoeal stools 
are thin, green, and almost invariably contain curds, either in large lumps 
or small, flaky masses. They vary in number from three to ten in twenty- 



CHRONIC INTESTINAL INDIGESTION. 415 

four hours. They are commonly passed without pain, although there 
may be flatulence. The stools have usually a sour, unpleasant odour, but 
they are rarely foul. They may be irritating to the skin, and cause 
troublesome excoriations or intertrigo. In some cases the stools contain 
but little solid matter, the character being that of yellowish-green water. 
In most of the cases, after the process has lasted two or three weeks, 
mucus is present, and may then become a constant feature. 

If there is constipation, the stools are usually gray or white; they 
are smooth and pasty or like hard balls passed after much straining, often 
coated with mucus and sometimes streaked with blood. Often the bowels 
will not move for days except after the use of laxatives or enemata. The 
latter often have but little effect, as the rectum may be empty. Con- 
stipated cases are especially prone to suffer much from flatulence and 
colic, the attacks of which may be very severe. 

The duration of these symptoms is indefinite. There is little or no 
tendency to spontaneous improvement, and they may drag on for several 
months or until the problem of diet is solved. The progress of these 
cases is marked by frequent exacerbations, during which there is vomit- 
ing, and usually fever. Such symptoms are generally dependent upon 
intestinal toxaemia. A low irregular fever may continue for days or even 
weeks. Although the general symptoms of failing nutrition are present 
in most cases, a mild degree of chronic intestinal indigestion with fre- 
quent loose movements may sometimes last for months, during which 
the patients may gain steadily in weight and give every indication of 
being well nourished. This is much more common in nursing infants 
than in those who are artificially fed. 

Diagnosis. — It is not generally difficult to determine that an infant is 
suffering from chronic intestinal indigestion ; but one should endeavour 
to go further in his diagnosis and discover which of the elements of the 
food is causing the chief disturbance. Thus, in an infant fed on cow's 
milk, we wish to know whether it is the proteids, the fat, or the sugar; or, 
in another case, whether it is the starch of some proprietary food. Much 
valuable information may be gained from a careful history of what has 
already been tried in the case ; often some gross error can be detected in 
the formula used or in the preparation of the food. Difficulty with the 
proteids is usually shown by colic, constipation more often than diarrhoea, 
and by curds in the stools; often there is vomiting. Difficulty with the 
fat is often indicated by loose movements, usually of a yellow or yellow- 
ish-green colour and sour odour. Sometimes they are white, smooth and 
formed, with a peculiarly offensive odour; there may be vomiting or the 
regurgitation of food in small quantities. Difficulty with the sugar is Less 
common than with either the proteids or the fat, but there may be flatu- 
lence, colic, and diarrhoea, with thin, sour, irritating stools. Difficulty 
with the starch leads to much flatulence and colic, diarrhoea alternating 



416 DISEASES OF THE DIGESTIVE SYSTEM. 

with constipation, and offensive stools. One may find the foregoing 
symptoms in any combination, for the trouble is rarely limited to a single 
element in the food. If one is feeding cow's milk, one should begin with 
what would be a proper formula for a healthy infant somewhat younger, 
and watch the stools closely for two or three days. The proportion of 
the offending element should then be reduced until the symptoms it is 
causing disappear. By carefully modifying milk in this way, a diagnosis 
of the type of disease can usually be reached. 

Prognosis. — This depends almost entirely upon how early the cases 
come under treatment and how they are managed. There is very little 
tendency to spontaneous improvement or recovery. The existence of 
chronic intestinal indigestion is one of the most important predisposing 
causes of more serious forms of intestinal disease. 

Treatment. — Drugs have no part in the treatment of these cases, ex- 
cept now and then for particular symptoms, such as diarrhoea, constipa- 
tion, or colic. These infants are cured by proper dietetic and hygienic 
measures, and by these alone. The diet has already been discussed in the 
chapter on Infant Feeding, and the general management, not less impor- 
tant, in the chapter on Malnutrition. 

In Older Children. — Chronic intestinal indigestion is especially 
common in children from the first to the fifth year. With the younger 
children, solid food has generally been used too early and in too large 
quantities. The articles from which most trouble is seen are imperfectly 
cooked cereals, vegetables of all kinds, but especially potato. Often the 
diet is composed almost entirely of farinaceous foods and bread. Chil- 
dren suffering from rickets are particularly liable to be affected. The 
condition is seen in all grades of society. 

Symptoms. — The clinical picture which these cases present is a very 
common one, and the symptoms are quite uniform. The patients are 
generally very thin, with very small extremities, a small amount of fat, 
and a large protuberant abdomen (Fig. 75). There is much flatulence, 
and usually there is marked tympanites. Such children are pale, anaemic, 
and sallow in complexion ; they have dark rings under the eyes ; they are 
easily fatigued on slight exertion; they are very cross, irritable, and 
emotional to an unnatural degree. They are hard to amuse, hard to con- 
trol, and altogether exceedingly difficult patients to . deal with. Their 
growth is retarded if the symptoms have lasted long. They are much 
below the average in height and weight, but mentally often quite pre- 
cocious. The sleep is always unnatural and disturbed ; and at night they 
toss about their cribs, waking frequently, crying out and often grinding 
their teeth, this sometimes leading to the diagnosis of intestinal worms. 
They perspire very readily, and suffer from cold extremities. 

The bowels are usually constipated, the stools being of a light gray 
colour or perfectly white. They are always formed and generally lumpy. 



CHRONIC INTESTINAL INDIGESTION. 



417 



The odour from the discharges is usually extremely foul. In other cases 
there is chronic diarrhoea. The stools are not very frequent, rarely ex- 
ceeding four or five a day, but they are large, thin, gray, green, or brown 
in colour, often frothy, sometimes offensive, and always contain undi- 
gested food. They are often excited by the taking of food. From time 
to time, in many patients, large quantities of mucus are passed from the 
intestine; in some cases this comes to be 
a constant feature of the disease. It re- 
sults from an intestinal catarrh, which has 
been set up by the irritation from the hard 
faecal masses or from the chronic func- 
tional derangement. Large quantities of 
gas are expelled per anum. Pain is not 
a very common symptom in most cases. 
The appetite is capricious and usually 
poor, though some patients will eat every- 
thing offered. The tongue may be coated; 
but unless the stomach is also affected it 
is usually clean and the breath is not of- 
fensive. 

The nervous symptoms which these pa- 
tients present are exceedingly varied, and 
often of the most puzzling character. In 
many cases they are so severe and so 
persistent as to lead to the diagnosis of 
organic disease of the brain. In addi- 
tion to the condition of general nervous 
irritability, there may be opisthotonus, 
tetany, fainting attacks resembling some- 
what the seizures of petit moil, exagger- 
ated reflexes, attacks of dulness or some- 
times stupor, with retracted abdomen, 
irregular pulse and respiration, and other symptoms strongly suggestive 
of tuberculous meningitis. Convulsions are not very uncommon. They 
are usually accompanied by fever, and may be repeated at intervale of 
a few minutes. Headache and frequent attacks of vomiting which are 
perhaps to be interpreted as instances of migraine, are occasionally seen. 
In fact, there is almost no end to the complexity of these cases and 
the combinations of nervous symptoms which they may present. Most 
of these are toxic in their origin. The skin shows frequently eruptions 
of erythema or of urticaria. 

Slight fever, also of toxic origin, is sometimes present for many 
weeks, the temperature usually varying between 99° and 100*5° F. 
Sometimes for several days it may be normal, and occasionally may rise 




Fig. 75. — Chronic intestinal in- 
digestion. 

Patient four years old ; symp- 
toms of three years' duration, fol- 
lowing attack of acute ileo-colitis. 
Height, 34 inches ; circumference 
of abdomen, 221 inches ; weight, 
24 pounds. 



418 DISEASES OF THE DIGESTIVE SYSTEM. 

to 102° or 103° F. during a slight exacerbation in the symptoms. The 
urine of most of these patients contains a great excess of indican; the 
amount present indicates very accurately the degree of intestinal putre- 
faction present, and often fluctuates regularly with the nervous symp- 
toms. 

Intercurrent attacks of acute indigestion, with diarrhoea and vomit- 
ing, are common and quite easily excited. The course and duration of 
these symptoms are indefinite. In the most severe forms, if untreated, 
the patients gradually waste until they die from exhaustion, or fall easy 
victims of any acute disease which they may happen to contract. There 
is but little tendency to spontaneous recovery. 

Prognosis. — This depends upon the duration of the symptoms, the 
general condition of the patient at the time treatment is begun, and upon 
how thoroughly it can be carried out. The symptoms, in the great 
majority of cases, have existed for several months at the time the case 
comes under observation. Generally, the greater the mistakes in feeding 
have been, and the greater the violation of hygienic and dietetic rules, 
the better the prognosis. A child who has developed chronic intestinal 
indigestion of a severe type, in spite of the fact that the hygienic sur- 
roundings were good, and where the dietetic errors were not flagrant, is 
not nearly so hopeful a subject for treatment as one whose hygienic sur- 
roundings have been poor and whose diet has been especially bad. In 
cases like the latter, a removal of the causes and the institution of proper 
methods of treatment almost invariably result in immediate and striking 
improvement, unless the general vitality of the patient has been reduced 
to a very low point. In the other cases, where the mistakes have been 
less marked, and the condition is due more to constitutional than to local 
causes, the improvement is slower and less striking. Thus, as a rule, 
hospital patients improve more rapidly than those seen in private prac- 
tice, because their previous treatment has been so much worse. 

Treatment. — In no class of cases that the physician is called upon to 
treat are results more satisfactory than in many of those of chronic intes- 
tinal indigestion, where the intelligent co-operation of the parents or a 
trained nurse can be secured. If the parents themselves are lax in disci- 
pline, and are unable to control the child, an efficient trained nurse should 
be secured, into whose hands the exclusive management of the child 
should be placed. The essential part of the treatment is diet and gen- 
eral management. In the second and third years the most important 
thing is to stop all starchy food for a considerable time, and put the 
patient upon an exclusive diet of rare beef or beef juice and milk. The 
milk for many of the patients must be peptonized, as the casein of cow's 
milk is often very difficult of digestion even for children three years old. 
By some the fat also can not be digested, and skimmed milk should then 
be used; in very obstinate cases it should be peptonized for two hours; 



CHRONIC INTESTINAL INDIGESTION. 419 

in the majority of cases, however, it is sufficient to peptonize it from fif- 
teen to twenty minutes. After a few weeks some carbohydrates may be 
added, preferably in the form of one of the malted foods, which may be 
continued until the child can digest some form of starch. The number 
of feedings should not be more than four a day during the second year, 
and three or four a day for children during the third and fourth years. 
These should always be at regular intervals, and nothing whatever given 
between meals. The meat should be rare scraped beefsteak or mutton; 
from one to three tablespoonfuls may be allowed once a day. The juice 
of fresh fruit, especially oranges, may after a time be given once a day, 
one hour before meals. Kumyss and matzoon are often of very great 
value in children who are not fond of milk, or who become tired of the 
diet. Although at first they are taken with difficulty, in many cases a 
fondness for them is very soon acquired. 

After improvement has been going on for two months, bread may be 
added, at first in small quantities and once a day. This should preferably 
be stale bread, cut thin and dried in the oven until it is crisp, and given 
without butter. Two or three times a week raw oysters may be tried. 
Mutton, chicken, or beef broth, without vegetables, may be given occa- 
sionally in the place of one of the milk feedings. After this diet has been 
kept up for three or four months, if improvement continues, one of the 
green vegetables may be added once a day, preferably either spinach, 
stewed celery, or asparagus. After two or three months more of contin- 
ued improvement, thoroughly cooked rice or macaroni may be given twice 
a week. With these articles of diet one can get along very comfortably 
for a year, and no larger variety should be given until all the symptoms 
have disappeared. When starchy food is first allowed, it should be 
only in small quantities, and usually with some preparation of diastase. 
Potato and oatmeal should be forbidden for a long time. 

Intestinal irrigation is useful in some cases in which there is much 
mucus passed. But it should not be forgotten that continued irrigation 
often keeps up the production of mucus. Astringents should not be used, 
but only a warm saline solution, and this not regularly. It should be 
omitted from time to time to see whether the discharge of mucus is not 
less without it. It is of most value during exacerbations. 

The constipation can sometimes be controlled by the diet. Calomel 
frequently seems to exert a very marked influence, even when the con- 
stipation is not severe. It is often wise to administer a full dose every 
five or six days. In some patients castor oil acts more satisfactorily. 
It is sometimes objectionable, however, from its tendency to aggravate 
the constipation. As laxatives in this condition I have found the great- 
est satisfaction from the use of preparations of cascara and the com- 
pound licorice powder. Abdominal massage is also useful. 

Drugs directed against the process of putrefaction are extremely un- 



420 DISEASES OF THE DIGESTIVE SYSTEM. 

satisfactory even in older children, but sometimes diminution in the 
amount of flatulence follows the use of subgallate of bismuth, carbonate 
of creosote, salol, or salicylate of soda. General tonics are required, 
and may add materially to the improvement of the patients. Altogether 
the best one is nux vomica. It may be given in combination with the 
bitter wine of iron just before meals three times a day. This increases 
the appetite and acts favourably upon the constipation. Cod-liver oil, 
particularly in the early stage, is badly borne. It should be withheld 
in all cases until very marked improvement in the condition of the 
digestion is assured. 

Kelapses are easily excited by indiscretion in diet, and parents should 
be impressed at the very beginning with the necessity of adhering rigidly 
to the diet prescribed, for a long period. It very often happens that the 
improvement which is seen after one or two months of careful treatment 
is so marked as to lead the parents to the belief that a cure has been ac- 
complished, so that they relax their vigilance and allow improper articles 
of food which are almost certain to induce a relapse. If the case is an 
aggravated one, and the symptoms of long standing, it is wise to tell 
parents at the outset that a year's treatment is the minimum in which 
anything permanent can be accomplished. 

The general treatment of the patient must not be overlooked. Proper 
clothing, regular exercise in the open air, cool sleeping rooms, massage, 
sponging every morning with cold water, are all of very great importance, 
and contribute almost as much to the results obtained as the special 
measures adopted. (See chapter on Malnutrition.) 

The improvement in the nervous symptoms of the patient is one of 
the first things noticed, and is often marked in a few days after the 
beginning of treatment. From an irritable, fretful, peevish child the 
patient is sometimes totally changed in disposition in a few weeks, so 
as to become quiet, affectionate, docile, and playful. 



INTESTINAL COLIC. 

The term colic is applied to any severe paroxysmal pain occurring in. 
the intestines. It may be due to many causes. The colic of lead and 
arsenic poisoning are both very rare in children; but colicky pains are 
present in appendicitis, intussusception, ileo-colitis, and, in fact, in all 
the severe forms of intestinal inflammation. Colic may be due to swal- 
lowing certain substances, especially foreign bodies and the seeds of 
fruits; and in rare cases it may be excited by the presence of round- 
worms when they are numerous. In all the conditions mentioned, colic 
is only one of the symptoms, although it may be a very prominent one. 

The special and peculiar colic of infancy is that which is associated 
with flatulence, and is due to indigestion. Here it is a symptom only, 



INTESTINAL COLIC. 421 

but may be a most troublesome one. This form of colic belongs essen- 
tially to the first six months of life, and is more frequent during the first 
three months. It may be seen at any time when digestion is very feeble. 
Many young infants suffer from colic a large part of the time; others 
have only occasional attacks, which are often repeated at a certain time 
in the day, usually toward evening. 

The flatulence to which the colic is usually due may be from decom- 
position in the food or intestinal secretions, or in both. It is seen quite 
as often in nursing infants as in those who are artificially fed. Any of 
the elements of the milk may be a cause of colic, but in fully four-fifths 
of the cases it is the proteids. The colic of nursing infants is nearly al- 
ways due to the fact that the milk is excessive in proteids, or else that 
these are digested with special difficulty. If cow's milk is the food, it is 
the proteids which are usually at fault. It is rare that the quantity of 
sugar present in cow's milk is sufficient to be a cause of colic; but this 
may happen when sugar has been added, more frequently with cane 
sugar than with milk sugar. It is extremely rare for the fat to be a 
cause of colic. In infants whose food consists largely of farinaceous 
substances, colic is also very common. 

As a result of the decomposition taking place in the intestine, gas ac- 
cumulates, and, the intestines lacking sufficient muscular force to expel 
it, distention follows. To this in part the pain is due. But spasm of the 
muscular walls of the intestine is also an element in producing the pain. 
In some of the most severe cases it is possible that the spasm may be 
accompanied by a slight transient intussusception. Colic may occur 
without flatulence, as in cases when it follows cold feet or chilling the 
surface. In these cases also, muscular spasm appears to be the principal 
factor in causing the pain. Intestinal colic may occur alone, or it may 
alternate with or accompany gastric colic. 

Symptoms. — These are in most cases so typical as to be easily recog- 
nised. They are always more severe in delicate and highly nervous chil- 
dren. In the severe attacks there is contraction of the features, the loud 
paroxysmal cry, subsiding for a few moments and then beginning with 
renewed intensity, drawing up of the lower extremities, and in male in- 
fants contraction of the scrotum. With these symptoms the abdomen is 
usually found tense and hard. With the expulsion of the gas, the symp- 
toms subside at once, and the child usually falls asleep. In the mosl 
severe attacks there may be considerable prostration, cold extremities, 
and perspiration. When the symptoms are less severe there is only con- 
tinual fretfulness, and the child can not sleep. When colic is habitual 
there are very few hours in the twenty-four when the child seems to be 
entirely comfortable. In nursing infants there may at times be difficulty 
in distinguishing the cry of colic from that of hunger, as infants suffering 
from colic will usually take food eagerly, and this is often followed by 



422 DISEASES OF THE DIGESTIVE SYSTEM. 

temporary relief. In colic, however, the pain soon returns, and often is 
more severe than before. The cry of colic is usually violent and parox- 
ysmal ; that of hunger is apt to be prolonged and continuous, and is not 
accompanied by the other symptoms mentioned as indicating abdominal 
pain. In older children the less frequent causes of colic mentioned at 
the beginning of this article, especially appendicitis, should be borne 
in mind. 

Treatment. — When colic is due to flatulence of the intestine, nothing 
given by the mouth has much effect in relieving the symptoms. Certainly 
food should not be given. The purpose of treatment during the attack is 
to assist the child to get rid of the gas ; as this is usually in the colon, the 
most efficient means is by massage or enemata. At first an injection of 
four or five ounces of lukewarm water should be used. If this is not suc- 
cessful, two ounces of cold water with half a teaspoonful of glycerin may 
be tried. This rarely fails to start peristalsis and expel the gas. In con- 
junction with these measures, dry heat should be applied to the abdomen 
by means of hot flannels or a hot-water bag, and the feet should be well 
warmed. In cases of colic not associated with flatulence, where the pain 
is probably the result of muscular spasm, opium in some form is required 
in addition to heat or counter-irritation. The treatment between the 
attacks and the treatment of habitual colic should be directed toward 
the indigestion, upon which they depend. 

CHRONIC CONSTIPATION. 

Constipation may be said to exist whenever the stools are less fre- 
quent, harder, and drier than normal. During the first six months in- 
fants usually have two movements a day. Many, however, have only one ; 
but if this is normal in character the child is not constipated. In other 
cases, although there are two and even three stools a day, they may all be 
small, dry, and hard, having all the characters of constipated stools, and 
the case should be treated accordingly. 

Etiology. — The causes of chronic constipation are many and far- 
reaching. It may be due to a diminution in the secretion of the intestinal 
glands or of the liver. The movements are then hard, dry, very light- 
coloured, and are associated with much flatulence and other signs of 
intestinal indigestion. Very often the principal factor in constipation is 
insufficient muscular contraction in the intestine. The faecal masses are 
then propelled so slowly and remain so long in the intestine that the fluid 
portion is absorbed, the residue becoming, in consequence, so dry and 
hard that it is difficult to expel. In other cases constipation depends 
upon the fact that there is insufficient volume to the stools, as may be 
the case when the food given leaves very little residue. Constipation may 
depend upon local causes, as, for example, where an evacuation of the 
bowels is resisted on account of pain from fissure of the anus or from 



CHRONIC CONSTIPATION. 423 

haemorrhoids. Although not the primary cause, this condition may be 
sufficient to keep up the constipation indefinitely. It may, in rare cases, 
be due to a congenital condition, such as a narrowing of the large intes- 
tine at some point. The most important causes of constipation may be 
grouped under two heads : diet, and conditions giving rise to muscular 
atony. 

Diet. — In breast-fed infants the trouble is usually a lack of fat and 
an excess of proteids in the milk. In those who are artificially fed it is 
often because the fat is too low, and sometimes because both the fat and 
the proteids are too low, the stool lacking volume. In other cases the 
cause of constipation is indigestion, in still others the use of " sterilized " 
milk. During the second and third years the cause may be too much 
cow's milk, particularly that which has been boiled, or the use of an ex- 
cessive amount of starchy food. As during the first year, the trouble 
with cow's milk is that it contains too much casein, the digestibility of 
which has often been rendered more difficult by the boiling. In older 
children the cause may be an excess of starchy food and a lack of suffi- 
cient green vegetables, meat, and fruit. 

Muscular atony. — The most common cause of muscular atony is 
habit ; in a large number of cases lack of proper training is the principal 
etiological factor. If the inclination to have a stool is regularly disre- 
garded it soon ceases to be felt. The ordinary irritation from faecal 
masses produces no response whatever. The longer such a condition 
continues the more obstinate does it become. This is an important factor 
in all cases. Another potent cause of muscular atony is rickets. In this 
disease the muscular walls of the intestine surfer like the muscles of the 
extremities, and become incapable of doing their work. Again, any form 
of malnutrition in which there is feeble muscular tone may cause or 
aggravate constipation. It is often seen as a sequel to acute attacks of 
diarrhceal diseases, particularly when these have been prolonged. Want 
of sufficient muscular exercise is a frequent cause. There are many chil- 
dren who rarely suffer from constipation in summer when they have 
plenty of out-of-door exercise, who very often do so in winter when such 
exercise is wanting. A loss of muscular tone is not an infrequent result 
of the prolonged and indiscriminate use of purgative drugs or enemata. 

Symptoms. — In many cases no symptoms are present except the local 
ones, the general health being excellent and the nutritioD in no way 
disturbed. In the majority, however, there are symptoms of greater or 
less severity, depending somewhat upon the cause of the constipation. 
There may be simply flatulence and colicky pains, or the irritation of 
the hardened faecal masses may produce a slight catarrhal inflammation 
of the sigmoid flexure and the rectum, so that mncus and sometimes 
traces of blood may be passed with the stool. Haemorrhoids may develop 
even in infancy, and frequently the constant straining leads to the pro- 



424 DISEASES OF THE DIGESTIVE SYSTEM. 

duction of hernia. In many cases there are from time to time nervous 
symptoms resulting from the absorption of various toxic materials from 
the intestine. There may be headache, dulness, fretfulness, disturbed 
sleep, and often associated signs of intestinal indigestion. The urine 
often contains indican in excess, and there may be slight fever. 

Diagnosis. — This includes the discovery of the cause and the principal 
seat of the constipation. To arrive at the former the most careful and 
thorough investigation should be made of the child's diet and habits. It 
is desirable to determine whether the seat of trouble is the rectum, the 
upper part of the colon, or the small intestine. If a suppository is al- 
most immediately followed by a normal stool, one may be sure that the 
rectum only is at fault, and that it needs but a little extra stimulus to 
make it do its work. This is common in infants who are too young to 
make any voluntary efforts. In such cases there are no other symptoms 
present. In others, the white or gray stools, marked flatulence, offensive 
breath, and general irritability, leave no doubt of the fact that the trou- 
ble is in the small intestine and depends upon indigestion. 

Treatment. — This is always difficult, and in obstinate cases must be 
continued for a long time. The co-operation of an intelligent mother 
or nurse is absolutely indispensable. To establish the habit of regular 
stools should be the first step, for without this regularity nothing can 
be done. Even in infants only a few months old proper habits are often 
easily formed if the child is put upon the chamber or chair invariably at 
the same hour. When a local stimulus is required in addition an oiled 
glass rod or a glutin suppository may be inserted. An older child must 
be taught to heed the first impulse to evacuate the bowel. Eegular 
habits can hardly be formed unless the same time each day is chosen 
for the movement. That to be preferred is soon after the morning meal, 
as taking food into the stomach usually starts a peristaltic wave which 
is continued throughout the intestine. With older children breakfast 
should be early enough to allow ample time for this duty before the 
other engagements of the day; and nurses should be impressed with 
the importance of the early formation of proper habits on the part of 
their charges. Stretching the sphincter under an anaesthetic is some- 
times of great benefit, especially where tonic spasm is present. 

Food. — With nursing infants who get good breast-milk constipation 
is rare. Where the milk is low in fat and high in proteids, constipation is 
not uncommon. For the measures by which such milk can be improved, 
see chapter on Breast Feeding. 

In feeding cow's milk, constipation is overcome by getting the exact 
proportions of proteids and fat which are suited to the infant. With 
most infants during the early weeks from 2 to 3 per cent fat and 1 per 
cent proteids succeed best; with those a little older, from 3 to 4 per cent 
fat and 1*5 per cent proteids. During the last half of the first year 4 



CHRONIC CONSTIPATION. 425 

per cent fat and from 2 to 3 per cent proteids will be found satisfactory. 
(See Infant Feeding.) To feed an infant two or three months old upon 
2 per cent fat and 2 per cent proteids — which is what is usually given 
when cow's milk is simply diluted once with water — almost invari- 
ably produces constipation. With most infants during the first year, 
constipation may be, if not cured, at least prevented by proper milk 
modification. 

During the second year, children who suffer from constipation should 
have both cream and water added to the milk, to reduce the proteids 
without lowering the fat. Suitable proportions can be obtained by add- 
ing two tablespoonfuls of cream to two-thirds of a glass of milk, and 
filling up the glass with water. Very great improvement may often be 
brought about by substituting malted foods for farinaceous foods. Meat 
broth and beef-juice are quite laxative on account of their extractives 
and salts. Fruits are valuable in all these cases ; but only the juice should 
be given until a child is eighteen or twenty months old. That of almost 
any fresh fruit may be employed. After two years pulpy fruits may 
be given; baked apples, oranges, stewed prunes, and in summer, fresh 
peaches, plums, and pears, may be given in small quantities; but all 
fruits with seeds should be avoided. 

For older children who are on a mixed diet the amount of starchy 
food should be moderate, oatmeal being perhaps the best cereal. Milk 
should be given rather sparingly, and even then may be advantageously 
modified as for the second year. It is sometimes advisable to stop milk 
altogether and give only cream, from four to six ounces of which may 
be allowed daily. It may be used with the breakfast cereal, mixed with 
potato or rice, added to soups or broths, and taken in various other ways. 
All bread should be made from whole wheat or unbolted flour. Meat and 
broth may be allowed freely, also green vegetables, one of which should 
be given every day. All fruits allowed infants may be used, but in larger 
quantities, and in addition raw apples. Of the dried fruits, only dates, 
prunes, and figs are admissible, and these are better stewed than raw. 
Fresh fruit is preferably given in the morning, oranges being especially 
useful when taken on rising. 

Either hot or cold water, when taken an hour before breakfast, may be 
of considerable benefit to older children. The sparkling waters, like 
Vichy or Apollinaris, are often better than plain water. 

Massage, when properly employed, is useful in conjunction with other 
measures, but rarely succeeds alone. It should be given for five or ten 
minutes after retiring and just before rising. The hand must be warm, 
but no oil used, the purpose being not to make friction upon the skin, but 
to move the skin and abdominal walls upon the intestines. This should 
be done with a circular motion, changing the point from time to time 
until the whole abdomen has been thoroughly covered. In addition to 



426 DISEASES OF THE DIGESTIVE SYSTEM. 

this a general kneading of the abdomen may be employed. Only slight 
pressure should be made until the child becomes accustomed to the process, 
when quite deep pressure will be tolerated. The intestinal coils may often 
be felt contracting under the hand during massage.* In general torpor 
of the intestines massage is usef ill, and when properly done may affect the 
small as well as the large intestine. 

A proper amount of active muscular exercise is necessary and should 
be made a part of the treatment in every case. Yale (New York) has 
called attention to the importance of posture during the stool, he having 
found that in many cases a cure was effected simply by substituting a low 
seat on a nursery chair or closet for the high one previously used. The 
low seat afforded the child an opportunity to strain to some purpose, while 
the higher one with the legs dangling, made this almost impossible. 

Suppositories. — In many cases, particularly in young infants who are 
not old enough to initiate the muscular effort, a slight stimulus to the rec- 
tum is all that is required. The cone of oiled paper has a great reputa- 
tion in domestic practice and is not objectionable. It may be of assistance 
in establishing the habit of a daily movement at a regular time. Soap sup- 
positories produce a more marked irritation ; although their immediate 
effect is quite satisfactory, they should not be continued indefinitely. They 
are, however, less objectionable than glycerin suppositories. The lat- 
ter, for an immediate effect, are convenient and usually efficient; but 
their prolonged use, especially in infants, is likely to set up a catarrhal 
proctitis. The gluten suppositories produce less irritation and are conse- 
quently slower in their effect, but they have not the disadvantages of the 
soap or glycerin. Medicated suppositories are certainly one of our most 
efficient measures ; if drugs must be employed, they are perhaps open to 
the fewest objections when used in this way. The following are the best 
drugs for this purpose, the dose being that for a child of two or three 
years : ext. nux vomica, gr. -fa ; ext. belladonna, gr. fa ; ext. hyoscyamus, 
gr. fa ; sulphur, gr. ij ; purified aloes, gr. J ; aloin, gr. fa. A good com- 
bination is aloin, gr. fa ; ext. belladonna, gr. fa ; ext. nux vomica, gr. fa ; 
ol. theobrom., gr. x. In obstinate cases this may be used night and morn- 
ing, and later at night only. After some improvement has occurred the 
aloin may be omitted. Many of the proprietary suppositories contain the 
ingredients mentioned, particularly belladonna, the dose of which is often 
considerably larger than should be given. Suppositories are chiefly use- 
ful when the trouble is the rectum and lower colon; but very little is 
to be expected from them when it is higher in the intestine. 

Enemata. — These should be restricted to cases in which only temporary 
relief is desired. An injection of an ounce of sweet oil may facilitate the 
passage of very hard and dry stools, and larger injections of soap and water 

* See Karnitzky, Archiv fur Kinderheilkunde, Bd. xii, p. 66. 



CHRONIC CONSTIPATION. 427 

may be used to break up hard faecal accumulations. For immediate effect 
an injection of one drachm of glycerin in half an ounce of water is perhaps 
the most efficient means at our command. Cases of faecal impaction are 
rarely met with in children. They are to be managed as in adults, by 
repeated injections of warm water or of ox-gall, and sometimes by me- 
chanical removal. For continuous use enemata are not to be advised, for 
larger and larger quantities are required to produce the effect. 

Medicinal treatment. — This is the least important part of the manage- 
ment of chronic constipation. No plan is worse than to give some active 
purgative every third or fourth day and trust matters to take care of them- 
selves the rest of the time. The most valuable drugs are those which 
stimulate the muscular walls of the intestine, such as cascara, nux vomica, 
belladonna, and hyoscyamus. These are particularly useful in atonic con- 
stipation associated with rickets and following diarrhceal diseases, but they 
are valuable in all cases. With most drugs the prolonged use of small 
doses is better than the occasional use of large ones. Calomel is indicated 
in cases attended with dry, very white stools and marked flatulence; 
one fourth to one half grain of the tablet triturates may be given for two 
or three successive nights in conjunction with other means. Cascara may 
be used either in the form of the elixir, dose from one half to one drachm, 
or the fluid extract, from one to five drops. Rhubarb, either in the form 
of the syrup or the mixture of rhubarb and soda, may be given occa- 
sionally, but it is not adapted to continuous use. Of salines, phosphate 
of soda is best for continuous use in infants. All the preparations of 
malt possess slight laxative properties, and are useful in conjunction with 
dietetic and other medicinal means ; either Trommer's extract of malt 
or maltine may be employed. Castor oil should seldom be given for 
chronic constipation. The frequent use of small quantities of olive oil 
is often a good means of treatment in the case of young infants, the oil 
being added to the food. 

Summary. — The treatment of constipation is palliative and curative. 
The palliative measures are drugs, suppositories, injections, and enemata. 
Cure is accomplished only by diet, massage, exercise, and the formation of 
regular habits. An average case of chronic constipation in a child four 
years old may be managed as follows : Massage for eight minutes, morning 
and night ; the juice of half an orange and a glass of Vichy immediately 
upon rising ; a breakfast of oatmeal with one ounce of cream, dried bread 
with butter, an egg, half a glass of milk with cream and water added ; 
a dinner of soup, one starchy vegetable — e. g., potato with cream, and 
one green vegetable, beef-steak, baked apple or prunes, dried bread and 
butter, and water to drink ; for supper, cream-toast, egg, dried bread and 
butter, or Graham crackers, half a glass of milk with cream and water 
added ; a suppository containing nux vomica and hyoscyamus given at 
bedtime. 



428 DISEASES OF THE DIGESTIVE SYSTEM. 

Hypertrophy and Dilatation of the Colon. — It is probable that in many 
cases of chronic constipation, especially among rachitic infants, a consid- 
erable degree of dilatation of the colon occurs. However, it seems to be 
but a temporary condition, disappearing by the third or fourth year. 

There is another form of dilatation which may be permanent ; it is 
associated with a marked degree of hypertrophy of the muscular walls of 
the colon. The reported cases thus far are few in number, but have been 
observed both in infants (Hirschsprung,* Myaf) and in older children 
(Osier, Hughes J). The prominent symptoms are two: obstinate con- 
stipation, which in most of the cases has continued from early infancy, 
and is sometimes so severe that the patients have gone for two weeks 
without a movement of the bowels ; and distention of the abdomen, which 
may be extreme, but which may disappear and the abdomen become per- 
fectly flat after the faeces and flatus have been discharged. There is usu- 
ally emaciation, and from time to time there may be diarrhoea. Death 
may occur in infancy, or the patients may live to adult life. 

In the cases which have come to autopsy there has been found an 
enormous dilatation of the large intestine, chiefly of the transverse colon 
and the sigmoid flexure. In one case (Hughes'), in a boy of three years, 
the colon was four inches in diameter, and held fourteen pints of water. 
In none of the cases was there stricture at any point. The mucous mem- 
brane has invariably been found ulcerated, this clearly being a secondary 
process. The muscular walls have been greatly hypertrophied. The con- 
dition is without doubt a congenital one. Treatment is palliative only. 
In some of the cases the condition seems to have been aggravated by the 
use of large enemata. 

INTUSSUSCEPTION. 

Intussusception consists in the invagination of one portion of the 
intestine into another. It occurs most frequently in infancy, being at 
this age the most common cause of acute intestinal obstruction. The 
accident is not a common one, but the life of the patient generally depends 
upon its prompt recognition. 

Varieties. — Usually the upper part of the intestine is invaginated into 
the lower, although the reverse is occasionally seen. Intussusceptions may 
occur at any point in the intestinal tract. Those of the small intestine 
are called enteric ; those of the colon, colic ; and those occurring at the 
ileo-caecal valve, ileo-ccecal (Fig. 7(3). Of 90 cases under ten years of age, 
in which the variety was determined by autopsy or operation, 75 were 
ileo-caecal, 9 colic, and 6 enteric. In the ileo-caecal form a few inches 

* Hirschsprung, Jahrbuch fur Kinderh., Bd. xxvii, p. 1. 

f Mya, Revue Mensuelle des Maladies de l'Enfance, vol. xii, p. 633. 

| Osier, Archives of Paediatrics, vol. xi, p. 112. 



INTUSSUSCEPTION. 



429 



of the ileum pass through the ileo-caecal valve, and then invagination of 
the colon occurs. Cases in which the ileum passes through the valve, but 
without invagination of the colon, are sometimes classed separately as an 
ileo-colic variety. 

Intussusceptions of the dying, as they have been called, are met with 
in my experience in about eight per cent of all autopsies made upon in- 
fants; they are not often found in children over two years of age. They 
are descending, enteric, easily reducible, and multiple — usually from 




Fig. 76. — Ileo-caecal intussusception. 



A specimen removed from a child in the New York 
Infant Asylum. 



eight to twelve invaginations being present. They are more frequently 
in the jejunum than in the ileum. They usually involve but two or three 
inches of the intestine, but may include ten or twelve inches. They are 
found in autopsies upon patients dying of all varieties of disease, and 
are probably produced in the death agony. These intussusceptions are 
without symptoms, and are of no clinical importance. 

Etiology. — Of 358 collected cases under ten years, the following are 



430 DISEASES OF THE DIGESTIVE SYSTEM. 

the ages reported : under four months, 28 cases ; from four to six 
months, 113 ; seven to nine months, 71 ; ten to twelve months, 18; one 
to two years, 32 ; two to ten years, 96. Three fourths of the cases 
which occur in childhood are, therefore, in the first two years, and one 
half of them between the fourth and ninth months. The greater fre- 
quency in infancy is attributed to the thinness of the intestinal walls, the 
greater mobility of the caecum and ascending colon, and the presence 
of other intestinal derangements at this age. 

Males are more often affected than females. Of 268 cases in which 
the sex was mentioned, there were 174 males and 94 females. For this 
fact there is no explanation. The exciting causes of an attack are ex- 
tremely obscure. The great majority of cases occur in children who were 
apparently in perfect health. Some previous intestinal disorder was pres- 
ent in about three per cent of the cases I have collected — diarrhoea, dysen- 
tery, colic, chronic indigestion, and constipation, all being mentioned. In 
four cases the intussusception was ascribed to injury of the abdomen. 
The association with the general diseases is too infrequent to be of any 
importance. 

Lesions. — Nothnagel's vivisection experiments * have shown conclu- 
sively that intussusceptions are formed by the irregular action of the 

muscular walls of the intestine. They 

- — ^ can be produced or released at will 

-, by varying the application of the 

electrical current. In the artificial 
intussusception there is first a con- 
traction of a certain part of the intestine, and if this ceases abruptly the 
normal gut below this point turns upward and folds over upon the con- 
tracted portion, thus forming a minute intussusception (Fig. 77, A). 
When once begun, the intussusception increases solely at the expense of 
the external layer (Fig. 77, B). Thus, while the apex of the tumour D 




Fig. 77, B. — Mechanism of intussusception. (Treves.) 

remains unchanged, the part of the sheath at A passes to B and then to 
C, so that the lower part of the intestine is drawn over the upper, rather 
than the upper crowded into the lower. The mechanism of the invagina- 
tion was apparently the same when a part of the intestine was first para- 

* Beitrage zur Physiologie und Pathologie des Darms, Berlin, 1884. A full abstract 
is to be found in Treves's Intestinal Obstruction, London, 1884, to which I am indebted 
for many points in this article. 



INTUSSUSCEPTION. 431 

lyzed by crushing, as in the cases in which a spasm of the intestine was 
first produced. 

There is no doubt that pathological intussusceptions are produced in 
the same way as in these experiments. As the invagination takes place, 
the mesentery is drawn in with the bowel, and always lies between the 
sheath and the inner layer. To allow intussusception to occur, the mes- 
entery must be unduly long, stretched, or lacerated. Its attachment to 
the spine causes the intussusception to describe an arc of a circle, the con- 
cavity of which is always toward the spine. It also causes a puckering 
of the tumour. Invagination does not necessarily produce either obstruc- 
tion or strangulation, but usually both are present, and are the chief 
causes of the symptoms. Traction upon the mesentery leads to obstruc- 
tion in its vessels, causing congestion, oedema, haemorrhages, and even 
gangrene. Obstruction is chiefly due to swelling. It may be due to 
dragging of the mesentery, which brings the apex of the tumour against 
the side of the gut, or to bending of the intussusception. 

The great cause of irreducibility in the first two or three days is swell- 
ing. I have several times seen at autopsy or operation the intussuscep- 
tion easily reduced, except the last two or three inches of the caecum or 
ileum, which was swollen to the thickness of from a fourth to half an 
inch. Adhesions may prevent reduction, but rarely before the fourth day ; 
they are often absent as late as the sixth or seventh day. They are usually 
between the internal and middle layers of the intussusceptum, and are due 
to local peritonitis. In chronic cases, however, they form the principal 
obstacle to reduction. Other causes of irreducibility are twisting of the 
tumour and pinching of the prolapsed intestine, especially of the ileum 
by the ileo-caecal valve. 

Gangrene and sloughing of the gangrenous portion of the intestine 
occur much more often in acute than in chronic cases. Portions of 
intestine were passed per anum in 24 of 362 cases under ten years, or 
about six per cent ; but only two of these were in infants. Toward the 
end of the second week is the time when the separation of the sloughs is 
to be looked for. The amount of intestine discharged, varies from a few 
inches to several feet. Two cases are on record in which the entire colon 
was passed, the patients recovering, but dying several months later from 
other causes. At the autopsies the ileum was found attached to the lower 
part of the rectum just above the anus. In acute cases gangrene occurs 
about the upper end of the tumour, and the intestine usually comes away 
in one large mass. In chronic cases shreds of intestine may be discharged 
for several weeks. 

Symptoms. — The clinical picture of a case of intussusception is a 
striking one, and when acute the symptoms are so uniform that, 
seen, it can scarcely be overlooked a second time. The patient, 
usually between six and twelve months of age, is taken suddenly ill 
29 



432 DISEASES OF THE DIGESTIVE SYSTEM. 

with severe pain and vomiting; the pain recurring paroxysmally every 
few minutes, and the vomiting being first of the contents of the stom- 
ach, and afterward bilious. There may be one or two loose faecal stools, 
then only blood or blood and mucus are passed without any admixture of 
fasces. The general symptoms are those of great prostration, or even col- 
lapse — pallor, feeble pulse, apathy, and normal or subnormal tempera- 
ture. The abdomen is relaxed. A tumour is present in the left iliac 
fossa, or it is felt per rectum. Later there is tympanites ; the vomiting and 
pain continue ; there is a steady increase in the prostration, and toward 
the end a rapidly rising temperature, which may reach 105° or 106° R 
before death occurs from collapse. If the symptoms continue longer the 
signs of peritonitis are added. In subacute cases the onset is less abrupt, 
and pain, vomiting, and constipation less constant and less severe ; but 
the same symptoms are present. In chronic cases the onset is with vague, 
indefinite intestinal symptoms ; pain, vomiting and bloody discharges are 
usually wanting; there are progressive wasting and more or less diar- 
rhoea, but only the presence of the tumour leads to the recognition of 
the condition. 

Onset. — Of 193 cases under ten years in which data upon this point 
could be obtained, the onset was sudden in 181 and gradual in 12 cases. 
By far the most frequent symptoms of onset are pain and vomiting. In 
a smaller number of cases the initial symptom is diarrhoea or a discharge 
of blood and mucus. 

Pain. — This is rarely continuous, but is intermittent, recurring in 
paroxysms like those of ordinary colic, but of great severity. No pain in 
infancy is to be compared with it. The child often shrieks so as to be heard 
all over the house. Pain is a prominent symptom in over three fourths 
of the cases, and is very rarely absent. It is generally more marked for 
the first two days, but may continue throughout the attack. In a few 
cases the pain is localized, being usually referred to the region of the um- 
bilicus. 

Vomiting is more marked at the onset, but may continue throughout 
the attack. Like pain, it is more frequent in the acute cases. It is due 
to intestinal obstruction. Vomiting is present in fully four fifths of all 
cases. Usually it is persistent and uncontrollable ; it is often projectile. 
If food is given, vomiting often occurs as soon as it reaches the stomach. 
Stercoraceous vomiting occurs in about fifteen per cent of the cases in 
children under ten years, but is not common in infancy. It is rarely pres- 
ent before the third or fourth day. Although a bad sign, it is not by 
any means a fatal one, as nearly one half the cases in which it has been 
noted have recovered ; it is to be regarded as indicating complete intes- 
tinal obstruction rather than strangulation. 

Tumour. — This is one of the most important symptoms for diagnosis 
because of its frequency and its peculiar character. It is present early in 



INTUSSUSCEPTION. 



433 



the disease, often in a few hours after the initial symptoms. The follow- 
ing table shows the frequency with which a tumour was present in the 
different varieties, and the position which it occupied in each. The an- 
atomical variety was determined either by autopsy or operation. 

The Relation between the Tumour and the Different Varieties of Intussus- 
ception in 188 Cases under Ten Years. 







SEAT OF INTUSSUSCEPTION. 




Seat of Tumour. 


Ileo- 
cecal. 


Tleo- 

colic. 


Colic. 


Enteric. 


Not 
stated. 


Total. 


Region of caecum 


i 

3 
3 
4 
25 
9 

i 


3 

'i 


'i 

7 
1 


1 

'i 
l 


7 
12 
13 
18 

8 
28 
12 

'2 


11 


" " ascending colon 

" " transverse colon 

" " descending colon.. . 

" " sigmoid flexure .... 

Rectal 


13 

16 
21 
13 
61 


Protruding from anus 

Umbilical region 


22 
1 


Movable 


3 


Site unknown 


1 






Total 


46 
10 


4 

2 


9 


3 

1 


100 
13 


162 


No tumour felt 


26 



Tumour was thus made out during life in eighty-six per cent of the 
cases; and in the great majority of these it was discovered at the first 
careful examination. 

It will be noted that in one half of the cases the tumour was either 
felt in the rectum or protruded from the anus, and that in over two thirds 
it had advanced as far as the descending colon or beyond. The tumour 
may reach the rectum in a surprisingly short time, even when the invagi- 
nation begins at the ileo-caecal valve. In one of my own cases it was felt 
in the rectum in less than twelve hours from the onset. The usual de- 
scription, " sausage-shaped," is accurate when the invagination is large, the 
tumour then being from four to six inches long and about an inch and a 
half in diameter. It is often curved. 

During manipulation, or during an attack of pain, the tumour may be- 
come more prominent and may be distinctly erectile. To the touch the 
rectal tumour closely resembles the os uteri, the central opening being the 
apex of the intussusception. When protruding from the body, the tu- 
mour is rarely more than two inches long. It is usually of a deep purplish 
colour, and may be gangrenous. It has been mistaken for prolapsus ani, 
polypus, and even haemorrhoids. In a case which came subsequently 
under my observation, the tumour was discovered by the mother before 
the physician had suspected the condition. 

Condition of the bowels.— Bloody stools are a very constant symptom. 
Of 186 cases under ten years in which this condition of the bowels was 



434 DISEASES OF THE DIGESTIVE SYSTEM. 

noted, blood in the stools was present in seventy-six per cent. There are 
very often two or three thin, diarrhoeal movements, and then only blood 
and mucus are passed with no trace of faeces and with no faecal odour. 
The amount of blood varies from a quantity sufficient to stain the mucus 
to an ounce of semifluid blood. It rarely occurs without some mucus. 
Such discharges frequently follow attacks of severe colicky pain, and may 
occur several times in an hour. They may continue, or after a day or two 
they may be succeeded by absolute stoppage. Diarrhoea throughout the 
attack is rare in children, particularly so in infants. It belongs generally 
to chronic cases. Constipation is complete in most of the acute cases, 
neither gas nor faeces being passed ; a fact which the discharge of blood 
and mucus may lead one to overlook. 

Tenesmus is very common if the tumour is rectal. Relaxation of the 
sphincter is met with in a considerable proportion of the cases when the 
tumour is in the sigmoid flexure, or rectum. 

During the first twenty-four or forty-eight hours the abdominal walls 
are soft and relaxed, and may even be retracted. Usually there is then 
little resistance to abdominal palpation. After the second or third day 
there is usually tympanites; but this does not necessarily mean that 
peritonitis exists. Localized tenderness is a symptom of some impor- 
tance when a tumour is absent. Scanty urine has been noted in a few 
cases, but is of no special value in showing the seat of obstruction. 

In the acute cases the general symptoms are very striking. They are 
the ordinary ones of severe shock — marked prostration, pallor with an 
anxious expression of the face, general muscular relaxation, cold extrem- 
ities, cold perspiration, and often a subnormal temperature. Early there 
is marked restlessness, and even convulsions may occur. Later there are 
apathy, dulness, and semi-stupor. The temperature during the first twenty- 
four hours is usually not elevated, and is frequently subnormal. Toward 
the close of the disease it rises rapidly to 103°, 104° R, or even higher, 
quite independently of peritonitis. A rapidly rising temperature is always 
a bad symptom, and usually betokens death within twenty-four hours. 
Wasting is seen in the chronic cases, and may be quite rapid. 

Course, Duration and Termination. — Of 198 cases under ten years, 155 
were classed as acute, lasting less than seven days ; 33 as subacute, last- 
ing from one to four weeks ; 10 were chronic, lasting over four weeks. 
Nearly all the cases occurring in infancy are acute. The duration of the 
disease in 92 fatal cases was as follows : less than twenty-four hours, 2 
cases ; two to four days, 44 cases ; five to seven days, 22 cases ; one to two 
weeks, 18 cases; two to three weeks, 6 cases. Thus one half the cases 
died upon the third, fourth, or fifth day. Of 57 cases terminating in 
recovery, 66 per cent were reduced in the first or second day. (See, table, 
page 436.) 

Spontaneous reduction is, without doubt, possible in intussusception. 



INTUSSUSCEPTION. 435 

Treves and others are of the opinion that this happens much more fre- 
quently than is generally supposed, and that many cases of severe colic are 
really cases of slight intussusception. There are seen in both conditions 
the tendency to vomit, the paroxysmal pain, the constitutional depression, 
and often the sudden cessation of the symptoms, especially under the 
influence of opium ; but to make a positive diagnosis of invagination in 
such cases is impossible. Intussusception may be cured spontaneously by 
sloughing of the invaginated part, the continuity of the intestine being 
preserved by adhesions. Such a result is rare at all ages, and is almost 
never seen in infancy. Even though recovery from the attack takes place, 
complete restoration to health is very rare. 

The most frequent cause of death in acute cases is shock. Peritonitis 
is not found at autopsy or operation so often as might be expected. In 
58 autopsies, it was seen but twenty times, and in seven of these it was 
limited to the intussusception. In but 7 cases was there perforation. In 
chronic cases death is usually from exhaustion or complications. 

Diagnosis. — This usually presents no difficulty in acute cases provided 
the physician has the condition in mind. The great majority of such 
cases present nearly all the classical symptoms — viz., sudden onset, re- 
curring colicky pains, frequent vomiting, bloody and mucous stools 
without faecal matter, general prostration or collapse, and low tempera- 
ture. The records show that the most common error is to regard the case 
for the first few days as one of gastro-enteritis or ileo-colitis, the physi- 
cian's attention being engrossed by the vomiting and bloody stools. Given 
the other usual symptoms, the presence of the characteristic tumour is 
conclusive evidence of intussusception. Unless the patient is very much 
relaxed, a satisfactory examination is possible only under full anaesthesia. 
In any case of acute obstruction in infants, intussusception should first be 
considered. Chronic cases present no diagnostic symptoms except the 
tumour. In both acute and chronic cases the rectal examination is most 
important for diagnosis, and often settles the question at once. 

Prognosis. — The prognosis of intussusception depends upon the age of 
the patient, upon the variety of the disease — whether acute, subacute, or 
chronic — and upon the time when proper treatment is begun. 

There were collected by Pilz* in 1870, 94 cases under one year, the 
mortality being 84 per cent. Of 135 cases of the same age reported be- 
tween 1870 and 1891 the mortality was 59 per cent. In Pilz's table, of 51 
cases between one and ten years of age, the mortality was 68 per cent ; 
while of 82 cases between one and ten years of age, from 1873 to 1891, 
the mortality was but 46 per cent. Formerly recovery was rare, except 
in cases of sloughing; but with earlier diagnosis and a better under- 
standing of the proper methods of treatment, the mortality has been very 

* Jahrbuch fur Kinderh., Bd. iii, p. 6. 



436 



DISEASES OF THE DIGESTIVE SYSTEM. 



much reduced. Combining the figures of Pilz with my own, there are 
362 cases with 231 deaths, or 63 *5 per cent. 

Gibson (New York) in 1900 collected 187 operations for intussus- 
ception, with a general mortality of 51 per cent; in 126 cases, in which 
the tumour was reducible, it was but 36 per cent; in 61, in which it 
was irreducible or gangrenous, it was 80 per cent. The table gives the 
mortality in relation to time of operation : 



Time of Operation. 


Number of 
operations. 


Number 
reducible. 


Mortality. 
Per cent. 


First, day 


35 
36 
33 
15 


33 

30 

20 

6 


37 


Second " 


39 


Third " 


61 


Fourth " 


67 


Fifth " 


73 


Sixth " 


75 







After the second day the chances of success are greatly reduced. 

Treatment. — One should first attempt reduction by inflation or injec- 
tions with the assistance of taxis, and, this failing, resort early to 
laparotomy. 

Inflation should always be done under an anaesthetic, unless there is 
extreme relaxation. Occasional inversion of the child may be practised, 
to get the assistance of traction of the intestine above upon the seat of 
invagination. An ordinary hand bellows with a catheter attached is the 
best apparatus; air should be injected very slowly, and prevented from 
escaping by pressing the buttocks tightly together. The best guide to the 
amount introduced is the tension of the abdominal walls. A thorough 
trial of this method should not occupy more than fifteen or twenty 
minutes. 

Eeduction is sometimes indicated by rumbling sounds, and by the 
abdomen resuming its normal contour because the whole of the colon is 
filled, in place of the unequal distention before present. In some cases 
a gush of fluid faeces has followed disinvagination. Not infrequently all 
such decisive symptoms are absent, and the physician may be in doubt 
whether or not reduction has taken place. The air is allowed to escape 
and the abdomen examined while the patient is still under chloroform. 
The right iliac fossa should be examined with the greatest care, as it 
often happens that all the tumour except the last few inches has been 
reduced. The question of reduction must be frequently decided by the 
general symptoms. If vomiting continues, if no gas or faeces pass the 
bowels, if there is no improvement in the pulse or the general condition, 
and, besides, if the temperature rises, it is almost certain that reduction 
has not been effected. In a very acute case a few hours' delay may turn 
the scales against the patient. The abdomen should be opened if the 



INTUSSUSCEPTION. 437 

child is strong enough to bear the operation. Even in cases not so acute, 
it is not admissible to postpone operation more than a few hours, since 
all delay adds to the difficult} 7 of reduction and diminishes the chances 
of success. 

Injections of fluids. — A saline solution may be used, milk and water, 
or thin gruel. The temperature should be from 100° to 105° F. for the 
relaxing effect. The fluid is placed in a fountain syringe suspended four 
or five feet above the patient's bed. The injections should be made 
through a catheter, the escape of the fluid being prevented as in inflation. 
From time to time the patient should be inverted. It may be desirable 
to increase the pressure by raising the syringe to the height of five or six 
feet, but more is rarely advisable. After from ten to twenty minutes 
the water is allowed to escape and the abdomen examined. 

The choice between inflation and injection depends somewhat upon 
individual experience. The danger of rupturing the intestine belongs 
alike to both ; but that it is not likely to occur with either is conclusively 
shown by the fact that in a series of 225 collected cases, all in children, and 
including nearly all those reported between 1870 and 1891, this accident 
has been recorded only once. In rare cases the symptoms may continue 
after reduction. Pick records such a case in which laparotomy was done 
with the belief that reduction had not been effected. No intussusception 
was found, and the continuance of the symptoms was attributed to intes- 
tinal paralysis. 

After reduction the patient should be kept absolutely quiet and mod- 
erately under the influence of opium for two or three days. The diet 
should be very light. Cathartics especially should be avoided for several 
days. 

Recurrence of the invagination is not uncommon. It was noted in 
13, or about six per cent, of my collected cases under ten years; of this 
number nine recovered and four died. Recurrence is more likely to 
happen in the first twenty-four hours after reduction ; this was the time 
in nine of the thirteen cases. It may, however, be as late as a month, 
rarely later. In one half the cases there was but a single recurrence, but 
three, four, and even six recurrences in the course of a few weeks have 
been seen. Ludwig reports a case in an infant eight months old in whom 
twenty-two recurrences were seen in one month. This was of the colic 
variety; it could hardly happen in any other form. 

Laparotomy is indicated as soon as a thorough trial of reduction by 
inflation or injection has been made without success. In the very acute 
cases the operation should not be delayed an hour after such failure is 
evident. Needless delays have caused death in many instances. The 
operation should not be looked upon as a last resort in hopeless cases, bul 
as a measure which, if employed reasonably early, offers a fair prospect 
of success where disinvagination can not be accomplished by any other 



438 DISEASES OF THE DIGESTIVE SYSTEM. 

means. All statistics show that the result depends more upon the time 
when the operation is done than npon any other single factor. With 
earlier diagnosis and more prompt resort to operation in case of failure 
of reduction by mechanical means, the mortality from intussusception 
has during the past ten years been steadily falling. A large proportion 
of the infants who surfer from this accident may be saved if they receive 
proper treatment in season. 



CHAPTER X. 

DISEASES OF TEE INTESTINES.— {Continued.) 

APPENDICITIS. 

The terms typhlitis, perityphlitis, and perityphlitic abscess were for- 
merly much used to denote certain forms of inflammation occurring in 
the right iliac fossa. Of late these terms are but little employed, as it 
has been shown that these conditions are almost invariably due to disease 
of the vermiform appendix. The existence of typhlitis as a separate and 
independent disease is exceedingly rare, if indeed it ever occurs except as 
a result of faecal impaction. 

Etiology. — The predominance of the male sex holds even in child- 
hood. Of 101 cases under fifteen years, 72 were males and 29 were 
females. Appendicitis is exceedingly rare in infancy, the condition hav- 
ing never once been found in about 2,000 autopsies, nearly all upon chil- 
dren under two years old, in three institutions with which I have been 
connected. It does, however, occasionally occur even in very young in- 
fants. The youngest cases that have come under my observation were 
infants of nine and fourteen months respectively. Goyen's case was in 
an infant only six weeks old; Shaw's, seven weeks; Demme's, seven 
weeks; and Savage's, nine weeks old. 

Appendicitis is rather more frequent in children who have suffered 
from digestive disturbances, particularly chronic constipation, than in 
others. Regarding the exciting cause of an attack but little is yet defi- 
nitely known. In only a very small proportion of the cases is a foreign 
body discovered in the appendix. In one of my own a pin was found, and 
a number of similar cases are on record. There is, however, almost in- 
variably a fsecal concretion which is moulded into the shape of a foreign 
body, and formerly often regarded as such. This probably has some rela- 
tion to the attack by causing disturbances of circulation and increasing 
fhe chances of infection. The bacteria most frequently found in abscesses 
from appendicitis are streptococci usually associated with colon bacilli. 

Lesions. — The position of the appendix is extremely variable. It 
may be found low in the pelvis, as high as the liver, in front of the 



APPENDICITIS. 439 

kidney, and sometimes near the umbilicus. This anatomical peculiarity 
accounts for the variation seen in the situation of the abscesses due to 
appendicitis. Inflammation of the appendix may be acute catarrhal, 
suppurative, or gangrenous, and it may be recurrent or chronic. 

Catarrhal appendicitis. — In this form there is an inflammation of the 
mucous membrane with swelling of the follicles and infiltration of the 
mucosa with round cells; the process may extend to the muscular 
and possibly also to the serous coat. As a result, the appendix is thick- 
ened and stiffer than normal. It may become distended with mucus or 
muco-pus to the size of the thumb or even larger. The inflammation 
sometimes results in the formation of superficial ulcers involving the 
mucous membrane. Catarrhal appendicitis may subside without any 
serious consequences, and complete recovery follow. In most cases, 
however, some changes remain; there may be adhesions; the lumen 
may be constricted at any point; and sometimes communication 
with the caecum may be shut off entirely. Catarrhal appendicitis may 
be followed by a chronic form of inflammation or by the suppurative 
form. 

Suppurative appendicitis. — This may follow one or more attacks of 
the catarrhal form, or the inflammation may be of the suppurative type 
from the beginning. In this variety the inflammation of the mucosa is 
much more extensive; the infiltration of the muscular layer is more 
marked, and the serous coat is usually involved. As a result, the appen- 
dix usually becomes distended with a foul, purulent fluid. This process 
may terminate in several ways. Drainage into the intestine may be re- 
established and the pus escape in this way, the inflammation of the coats 
of the appendix undergoing resolution, but leaving some thickening and 
adhesions. This termination is not common. A more frequent course is 
for perforation to take place either by ulceration or localized gangrene. 
Perforation may be followed by a general septic peritonitis, or the in- 
flammation may be circumscribed by adhesions and result in a localized 
peritoneal abscess. Such an abscess may subsequently burst into the gen- 
eral peritoneal cavity, or spontaneous opening may occur into the intes- 
tine, the bladder, or the vagina; or the abscess may burrow for a long 
distance. Secondary lesions are occasionally seen in children ; there may 
be suppurative pylephlebitis, abscess of the liver, empyema, pneumonia, 
or general pyaemia. 

Gangrenous appendicitis. — Gangrene of the appendix may be local- 
ized, in which case it is usually one of the forms of termination of the 
suppurative inflammation; or it may be general, in some cases involv- 
ing the entire appendix, in others only the distal portion. Such a pro- 
cess is the result of some cause which completely arrests the circulation. 
The rupture of a gangrenous appendix is usually followed by a general 
septic peritonitis which develops with great rapidity ; less frequently the 
30 



440 DISEASES OF THE DIGESTIVE SYSTEM. 

peritoneal inflammation is localized and there develops a peritoneal 
abscess. 

Chronic appendicitis. — This -usually follows one or more attacks of 
the catarrhal form. It results in thickening, adhesions, constrictions, 
and more or less interference with the communication with the caecum, 
the appendix being sometimes distended with mucus or muco-pus. 

Symptoms. — Catarrhal appendicitis is often not recognised, and in 
many cases a diagnosis is impossible. The milder attacks are usually 
passed over as acute indigestion. The only suspicious symptoms are 
acute abdominal pain and tenderness. In a very large proportion of the 
cases the pain is not in the region of the appendix. It may be referred 
to almost any part of the abdomen, and is frequently about the umbili- 
cus. When the abdomen is carefully examined, by making pressure with 
the finger point, there is generally found well-defined localized tender- 
ness, in the right iliac fossa, one or two inches from the spine of the 
ileum on an arc described with the spine as a centre. The onset is often 
with vomiting, and there is some fever, though rarely over 101:5° F. 
The bowels are usually constipated, although occasionally diarrhoea is 
present. The disease gradually subsides in the course of four or five 
days, the local symptoms being the last to disappear. 

In the more severe attacks the pain and tenderness are much more 
marked. There is never any area of induration, but the swollen appen- 
dix may sometimes be felt if the abdominal walls are thin and relaxed. 
The onset is usually more severe than in the cases first described; the 
vomiting may be repeated several times, and constipation is often 
marked. The early temperature frequently reaches 102° or 102 -5° F. ; 
but it soon falls to 100° or 101°, and in two or three days may be nor- 
mal, and the symptoms gradually subside, the whole duration being usu- 
ally less than a weak. Subsequent attacks, however, occur in the great 
majority of cases. 

Suppurative appendicitis. — The onset resembles the more severe at- 
tacks of catarrhal appendicitis, but both the local and the general symp- 
toms are apt to be more acute. The disease may follow one of three 
courses, according as the termination is a localized plastic peritonitis, 
a peritoneal abscess, or general peritonitis. 

1. With localized plastic peritonitis. — The symptoms in this variety 
usually last about ten days. They are severe only for the first two or 
three days, and then gradually subside. There is present, in addition to 
the symptoms described in the catarrhal variety, a distinct inflammatory 
induration in the region of the appendix. At first this is somewhat dif- 
fuse, but later it becomes more and more circumscribed, until after three 
or four days a small mass not much larger than an egg remains, which 
after another week can scarcely be felt. In such cases there is a suppu- 
rative inflammation of the wall of the appendix with localized plastic 



APPENDICITIS. 441 

peritonitis, or a slow perforation occurs which is immediately surrounded 
by an exudate of lymph protecting the general peritoneal cavity. 

2. With peritoneal abscess. — In some of the cases with an acute onset 
there is a continuance of the high fever, pain, and tenderness, with the 
rapid formation of an abscess. A distinct tumour may be noticed at the 
end of two or three days, and pus may be found at operation as early as 
the third day from the onset. At other times the course in the early 
stage resembles that of the cases which terminate in resolution. Marked 
improvement takes place after four or five days of rather severe symp- 
toms. The temperature does not, however, quite reach normal. After 
a variable period of quiescence, lasting from two or three days to as 
many weeks, the temperature gradually rises; the pain and tenderness 
become more severe and are felt over a larger area ; the induration, which 
has been stationary, enlarges and becomes more prominent, and the 
existence of abscess is unmistakable. In a small number of the cases 
terminating in abscess the onset is very gradual, without any of the acute 
symptoms mentioned. It may be accompanied by slight pain only, re- 
traction of the right thigh, and moderate fever. Whether the formation 
of the abscess is rapid or slow, the subsequent course may be the same. 
The sac is gradually distended with pus, which may accumulate in im- 
mense quantities; as much as five pints have been evacuated. At the 
present time but few abscesses are allowed to open externally, incision 
being commonly made before that time. The situation of the abscess 
depends upon the position of the appendix. It may be in the pelvis, in 
the lumbar region, and occasionally just below the liver. Pelvic abscess 
may be recognised by rectal examination. The termination in a single 
abscess is a favourable one, for with proper surgical treatment these 
cases almost invariably recover. 

3. With general peritonitis. — This may occur early in the disease 
with a rapidly spreading inflammation of the suppurative variety termi- 
nating in perforation ; or it may develop late, being caused by the rup- 
ture of an abscess into the general peritoneal cavity. It is seen more 
frequently with gangrenous appendicitis, with which its symptoms are 
described below. 

Gangrenous appendicitis. — At the outset this form of appendicitis is 
not characterized by any distinctive symptoms. For two, three, or even 
four days, things may go so smoothly as to excite no apprehension, nei- 
ther the general nor local symptoms indicating anything more serious 
than an ordinary attack of catarrhal appendicitis of moderate severity; 
when suddenly without warning a marked change for the worse occurs, 
as perforation into the general peritoneal cavity takes place. Sometimes 
there are no early symptoms which are recognised, the signs of perfora- 
tion being the first to attract attention to the abdomen. 

In the most severe cases the symptoms immediately become alarm- 



442 DISEASES OF THE DIGESTIVE SYSTEM. 

ingly worse, and death may occur within twenty-four hours. Eupture 
of a gangrenous appendix is usually indicated by a sudden attack of 
vomiting, very severe abdominal pain, followed by great prostration or 
even collapse. The temperature varies greatly in the different cases, 
and is no guide to the gravity of the condition. It may rise rapidly to 
105° or 106° F., or it may be subnormal. The pulse is uniformly rapid, 
small, and compressible. The expression of the face is anxious and 
the features are drawn, and usually the forehead is covered with a 
cold perspiration. The abdomen soon becomes tense and tympanitic. 
In the most severe cases there is no reaction, and prostration deepens 
with the occurrence of stercoraceous vomiting, hiccough, clammy skin, 
collapse, and death. 

In other cases, after the first shock of perforation, there is some 
reaction, and the usual symptoms of general septic peritonitis develop, 
with which the child may live for from two to five days. The tempera- 
ture is not usually very high, generally averaging from 102° to 104° F. ; 
vomiting is almost invariably present, and is of greenish material, indi- 
cating regurgitation from the small intestine into the stomach ; pain and 
tenderness are acute and rapidly extend over all or the greater part of 
the abdomen. The other important symptoms are, absolute constipation, 
tympanites, a rapid, feeble pulse, and general prostration. There is 
mental dulness or apathy, and occasionally convulsions. The case usu- 
ally goes on steadily from bad to worse; sometimes, after the first in- 
tense onset, there may be a lull in the symptoms for a day or two, to be 
followed by a recurrence of the severe pain, vomiting, and collapse. Such 
a course indicates that the first perforation has been followed by some 
limiting adhesions, which subsequently give way, causing all the symp- 
toms of a new perforation. 

When general peritonitis occurs from perforation due to ulceration its 
symptoms are rather less violent in their onset, less intense in their de- 
velopment, and slower in their progress, the usual duration being 
from five to fourteen days. When the peritonitis is the result of an 
abscess which has ruptured into the general peritoneal cavity the symp- 
toms are like those of a sudden perforation. This accident may come as 
late in the disease as the second or third week. 

Course and Termination. — Few diseases differ more widely in their 
course than does appendicitis. So often do cases apparently mild sud- 
denly develop most severe symptoms that all such patients should be 
very carefully watched from the outset in order to determine what the 
course of the disease is likely to be. 

It is hard to state in figures the relative frequency of the dif- 
ferent terminations. Of 102 cases in children under fourteen years old, 
in which this was definitely known, 11 ended in resolution, 52 in ab- 
scess, and 40 in general peritonitis. These figures probably do not 



APPENDICITIS. 443 

represent correctly the proportion of those terminating in resolution, 
for many such are doubtless overlooked or wrongly diagnosticated. Of 
the 52 cases which terminated in abscess, all but 6 were operated upon ; 
4 of the latter opened into the rectum with a favourable result; 1 
opened externally, and 1 ruptured into the general peritonaeum, caus- 
ing death. From these statistics it would appear that general perito- 
nitis is a more frequent termination in children than in adults, and this 
is, I think, borne out by general surgical experience. 

Prognosis. — The prognosis in young children is not good; but in 
those over seven years old it is rather better than in adults. The results 
depend much upon early diagnosis and proper treatment. General peri- 
tonitis is the cause of death in about 80 per cent of the cases, pyaemia 
being next in frequency. Of 43 fatal cases, nearly all of them from 
general peritonitis, only 6 died during the first three days, 19 from the 
fourth to the seventh day, 13 in the second week, and 5 in the third week. 
Cases terminating in the formation of a single abscess usually recover 
when properly treated. If general peritonitis occurs, whether early or 
late, the chances of recovery are small ; but it has occasionally followed 
when general peritonitis existed at the time of operation. 

Diagnosis. — The diagnostic symptoms of appendicitis are a sudden 
onset with vomiting, sharp pain in the abdomen, and persistent acute 
localized tenderness in the right iliac fossa. Eigidity of any or all of 
the abdominal muscles is also significant. Constipation is much more 
frequent than diarrhoea. There is almost invariably some elevation of 
temperature, but not often high fever. The different forms can seldom 
be distinguished from each other at the outset. In some of the catarrhal 
cases the onset may be acute and severe ; while, on the other hand, per- 
foration or rupture may take place without any preceding characteristic 
symptoms. Abscesses out of the usual situation, due to an abnormal 
position of the appendix, often lead to mistakes in diagnosis. 

Appendicitis may be confounded with colic, indigestion, and in in- 
fants with intussusception ; in older children with abscesses due to pso- 
itis. Colic is distinguished by the absence of localized tenderness and 
fever, by its short duration, and by the fact that the pain is generally 
less intense. Severe colic with fever in children over three years old 
should, however, always be regarded with suspicion. From acute indi- 
gestion the diagnosis of appendicitis is difficult at the onset, and it may 
be impossible for twenty-four hours. However, the pain of indigestion 
is rarely so severe while the fever is usually higher. It should be remem- 
bered that the pain in appendicitis is not always localized, nor is the 
tumour always in the right iliac fossa. The presence of pain, vomiting, 
and localized tenderness, and the greater severity of the constitutional 
symptoms, indicate appendicitis. I have twice known pneumonia at the 
right base to be mistaken for appendicitis. There was severe localized 



444 DISEASES OF THE DIGESTIVE SYSTEM. 

pain in the iliac fossa, which was evidently to be explained by pleurisy 
involving the lower intercostal nerves. Intussusception, with its pain, 
colic, and vomiting, may suggest appendicitis, but is very rare except in 
infants. Acute or subacute suppuration in the right iliac fossa is almost 
invariably due to appendicitis. 

The leucocyte count may be of considerable assistance in differentia- 
ting appendicitis from colic, ileo-colitis, intussusception; also in distin- 
guishing the catarrhal from the suppurative form. As between the two 
conditions last mentioned, it is not only the actual number of leucocytes 
present, but their rapid increase, which indicates the presence of sup- 
puration. It should, however, be remembered that in some of the gravest 
cases the leucocytosis may be slight or there may be none at all. On the 
whole, while the presence of marked leucocytosis — i. e., above 20,000 — 
may be of considerable assistance in the diagnosis, no inference can be 
drawn from a normal count or a slight leucocytosis. 

Whenever, in children over two years old, there are symptoms point- 
ing to acute peritonitis, no matter what their combination or variety, 
appendicitis should always be suspected. 

Treatment. — Absolute rest in bed can not be too strongly insisted upon 
whenever appendicitis has been diagnosticated or is suspected, no matter 
how mild the attack may appear. As a local application the ice-bag is to 
be preferred. Morphine often does harm by obscuring important symp- 
toms and increasing constipation. The colon should be kept empty by 
the daily use of enemata. After a thorough clearing of the bowels in the 
beginning, preferably by a saline, cathartics are to be avoided. 

Appendicitis is a surgical disease, and surgical advice should be sought 
early. In deciding as to the time of operative interference, it should be 
remembered that the natural course of the disease in children is less likely 
to be favourable than in older patients. In general the statement may 
be made, that the younger the child the less the local and constitutional 
resistance, the more rapid the progress, and the greater the chances that 
the general peritonaeum will be invaded. 

If the symptoms are sufficiently clear to admit of a positive diagnosis 
being made early, while the disease is still limited to the appendix and 
before rupture has taken place, immediate operation should be urged. 
At this time the operation is simple, practically free from danger, and 
prompt recovery is almost certain to follow. No doubt some such cases 
might recover without it; but against this argument should be placed 
the great risks which are assumed when the disease is allowed to follow 
its natural course, and the probability, amounting almost to certainty, 
of subsequent attacks. 

If the patient is not seen early, or if a positive diagnosis has not been 
possible until considerable local inflammation has developed, the decision 
as to operation should depend upon the course of the symptoms in the 



INTESTINAL WORMS. 445 

individual case. If the disease is progressing favourably — i. e., the in- 
flammatory area not increasing and the constitutional symptoms steadily 
subsiding — one may often wait, with advantage, for abscess to form before 
interfering. If suppuration does not occur and the case ends in resolu- 
tion, operation may be deferred until the acute attack is over. It should, 
however, be remembered that the gravest symptoms not infrequently 
develop with great suddenness in cases which, to all appearances, have 
been progressing favourably, and sometimes in waiting to secure a more 
favourable time for operation, the only favourable time has been lost. 
All these cases should be very closely watched, being seen every few hours, 
and the surgeon should stand ready to operate immediately should the 
inflammation take an unfavourable turn, as when symptoms point to a 
rapid extension of the disease or to perforation into the general peritoneal 
cavity. 

On the whole, in very } r oung children, the earlier the operation is 
done the better. The risks of waiting are great and a comparatively 
small proportion of the cases can be expected to terminate in resolution. 



INTESTINAL WORMS. 

Judging by published reports, intestinal worms are much more com- 
mon in Europe than in this country. In 10,000 patients treated for med- 
ical diseases in my dispensary service, there was positive evidence of 
worms in but 79 cases. Of these, 9 had tapeworms, 40 roundworms, 27 
threadworms, and 3 both round and threadworms. In private practice 
among the better classes, worms are certainly rare. 

Cestodes — Tapeworms. — Cestodes are usually introduced into the 
body by the ingestion of some form of food containing larvae (cysticerci). 
The larva of the taenia solium is most frequently found in pork ; that of 
the taenia mediocanellata in beef; that of the bothriocephalus latus in 
fish; that of the taenia cucumerina inhabits dog or cat lice, being intro- 
duced into the intestinal tract accidentally by the hands. 

In the intestine the larvae develop into the mature tapeworms, usually 
in from three to three and a half months ; after which the terminal seg- 
ments becoming mature, separate, and are discharged in the faeces, some- 
times singly, sometimes connected. New segments continually form 
next to the head as the terminal ones are cast off, so that the length of 
the worm is not diminished. The duration of life of the worm is estimated 
to be from ten to thirty years. Each mature segment is provided with 
both male and female sexual organs, and contains ova in great numbers. 
The ova escape after the rupture of the segment outside the body. They 
find their way into the stomach usually of herbivorous animals with their 
food. Here the thick shells of the ova are dissolved by the gastric juice 
and the embryo set free. By means of the hooklets with which it is pro- 



44:6 



DISEASES OF THE DIGESTIVE SYSTEM. 



vided, it migrates from the stomach or intestine and may be found in the 
muscles or in any organ of the body, even the brain and eye. When it 
reaches its final resting place it loses its hooks and gradually becomes 
transformed into a vesicle, from the inner surface of which there projects 
something resembling the head of the future tapeworm. In this stage it 
is known as the bladderworm or cysticercus. The cysticerci of the tcenia 
solium are sometimes found in man, but the other varieties very rarely. 
For the further development of the larval form it must be taken into the 
stomach of man or some carnivorous animal. This occurs when pork, 
beef, or fish containing cysticerci is eaten. The vesicle wall is now dis- 
solved, and the head passing into the intestine develops into the mature 
tapeworm. Several varieties of taenia are found in the human intestine : 

Taenia Saginata or Mediocanellata— Beef Tapeworm (Fig. 78). This 
is the most frequent form found in children, all others being rare. In- 
fection results from eating raw or partially cooked beef containing cys- 
ticerci. The worm is from twelve to twenty feet in length, and has a 
square pigmented head without hooks but provided with four suckers. 
The full-sized segments are from one half to three fourths of an inch 
long and about half as wide. 

Taenia Solium — Pork Tapeworm (Fig. 79). This is a rare form in 
children, and comes from eating raw or partially cooked pork or sausage. 
It is from six to ten feet in length, the segments being nearly square. 





Fig. 78. — Taenia saginata ; head, segment, 
and egg. (Jaksch.) 






Fig. 79. — Taenia solium ; head, segment, 
and egg. (Jaksch.) 



The head is about the size of a mustard seed and is pigmented. It also is 
provided with four suckers and a proboscis, surrounding which is a circle 
of about twenty-six hooks. 

Taenia Cucumerina or Elliptica (Fig. 80). The larva? of this form 
develop in a louse found on the skin of dogs and cats. Children who 
play with infected animals are the ones affected, the parasite being con- 
veyed to the mouth usually by means of the hands; it may thus be 
found even in young infants. Most of the tapeworms in infants are of 
this variety. This form of taenia is much smaller than either of the pre- 
ceding varieties, the full length being only from six to twelve inches. 



INTESTINAL WORMS. 



447 



Bothriocephalic Latus (Fig. 81). This is a rare form except in the 
sea countries of northern Europe and Switzerland, where it is said to be 





Fig. 



). — Head and segment of taenia 
cucumerina. (Jaksch.) 



Fig. 81. — Bothriocephalus latus; a, J, front 
and side views of head ; c, segments ; 
d, eggs. (Jaksch.) 



very common. The larvae are harboured by certain fish, through which 
they are introduced into the body. The full-grown worm is from twenty- 
five to thirty feet in length. 

Taenia Nana and Taenia Flava Punctata. These are two rare varieties 
that have been found in children in a few instances. 

Usually but a single worm is present, although as many as five or six 
have been found. Earely taeniae have been associated with roundworms 
and also with threadworms. 

Symptoms. — The only positive evidence of tapeworm is the discharge 
of the separated segments, either singly or in groups. Occasioually worms 
pass into the stomach and are vomited. Various abdominal symptoms 
may be associated with worms, but most of these are very indefinite in 
character and are more often due to other causes. The most frequent 
symptoms are bad breath, various annoying sensations, colicky attacks, in- 
ordinate or capricious appetite, and diarrhoea. Usually, if the patient is 
in good health, no constitutional symptoms are seen. Sometimes, particu- 
larly with the bothriocephalus latus, there is a very grave degree of anaemia. 
Many cases are now on record, some of them in children, in which the 
symptoms of pernicious anaemia have been present and have disappeared 
after the expulsion of the tapeworm. Nervous symptoms are not so often 
seen as with roundworms, and will be discussed in connection with them. 

Treatment. — Prophylaxis requires the cooking of meat to a sufficient 
degree to destroy the cysticerci. There is especial dauger in eating raw 
pork or sausage; that from rare beef is much less. The list of drugs 
used for the expulsion of the worm is a long one ; probably the most sat- 
isfactory is the oleoresin of male fern, which should be given in capsule, 
in TTtxv doses to a child of ten years, four capsules usually being adminis- 
tered at hourly intervals. The vermifuge should be preceded by several 
hours' fasting, and the bowels should be previously opened by a laxative. 



448 



DISEASES OF THE DIGESTIVE SYSTEM. 



The following plan of administration has been found satisfactory : A light 
supper of milk, and in the morning a saline laxative on rising, but no 
breakfast ; after the saline has acted freely the capsules are to be given, 
one every hour, and following the last one, half an ounce of castor oil or 
some other active purge. The effect of the cathartic is aided by an injec- 
tion. Only milk should be given that day. The fragments passed should 
be carefully examined to see if the head has been expelled, as the worm is 
very likely to be broken at the neck. If this occurs it will grow again, and 
in about three months segments will appear in the stools. Other drugs 
useful for taenia are infusion of pomegranate root, turpentine, and chlo- 
roform. 

Nematodes. — Two varieties are found in the intestinal canal, the as- 
caris lumbricoides and the oxyuris vermicularis. 

Ascaris Lumbricoides — Roundworm. — This worm occupies the small 
intestine. It is much more frequently met with in children than is the 

tapeworm. It is exceedingly rare in infancy, 
but is usually seen between the third and 
tenth years. In over one thousand autopsies 
upon infants I have only once found a round- 
worm in the intestine. 

The roundworm is from five to ten inches 
long, the female being longer than the male. 
It is of a light gray colour with a slightly 
pinkish tint, cylindrical, and tapering toward 
the extremities (Fig. 82). The eggs are oval 
in form, about xot i ncn i n diameter, and are 
numbered by millions. These worms rarely 
exist singly ; usually from two to ten are pres- 
ent, but there may be hundreds. When 
very numerous they coil up and form large 
masses, which may cause intestinal obstruc- 
tion. 

The life history of the roundworm is not 
yet perfectly understood. Epstein cultivated 
outside of the body eggs taken from the stools, and found that under 
favourable conditions of sun and air five weeks were required for the 
development of the embryo. These were then fed to children. In three 
months the ova appeared in the stools, and after the administration of 
santonin many worms were discharged. From these experiments it would 
appear that no intermediate host is required, although this was pre- 
viously supposed to be the case. It was believed that the ova were swal- 
lowed by some worm or insect, and in this form were taken into the intes- 
tinal canal with green vegetables, fruit, or drinking water. 

The migration of these worms is curious, and in some instances truly 
remarkable. They frequently enter the stomach and are vomited. Ocea- 




nia. 82. — Ascaris lumbricoides 
a, entire worm ; ft, head ; c 
eggs. (Jaksch.) 



INTESTINAL WORMS. 449 

sionally one may appear in the nose. They have been known to pass 
through the Eustachian tube into the middle ear and to appear in the ex- 
ternal meatus. Entering the larynx they have produced fatal asphyxia. 
It is not very rare for them to enter the common bile duct and pro- 
duce jaundice. They may even enter in great numbers the smaller bile 
ducts and produce hepatic abscesses. They have been found in the pan- 
creatic duct, in the vermiform appendix, and in the splenic vein. It 
has long been known that they would perforate an intestine which was the 
seat of ulceration, but well authenticated cases have been reported in which 
they have perforated an intestine previously healthy, setting up a fatal 
peritonitis. In Archambault's case they perforated the stomach. In cases 
of a persistent Meckel's diverticulum, worms have been discharged from an 
umbilical fistula. They have been found in umbilical abscesses. Consid- 
ering, however, the frequency of roundworms, migrations are rare. 

Symptoms. — The symptoms of roundworms are of the most indefinite 
kind; often there are none until the worm is discovered in the stools. 
It is then fair to assume that other worms are also present. The most 
frequent abdominal symptoms are colic, tympanites, and other symptoms 
of indigestion, loss of appetite, restless, disturbed sleep, grinding of the 
teeth at night, and picking the nose. These symptoms are much more 
frequently due to other causes than to worms, but when all are present 
the existence of worms should be suspected. 

A great variety of nervous symptoms may be associated with intestinal 
worms. They are more often seen with lumbricoids than with either of 
the other varieties. The symptoms may be of the most puzzling character, 
and may simulate very closely those of serious organic disease. There 
may be chills, headache, vertigo, hallucinations, hysterical seizures, epi- 
leptiform attacks, convulsions, tetany, transient paralyses such as strabis- 
mus, and even hemiplegia and aphasia. All these have been observed 
in connection with intestinal worms, and from che fact that the symptoms 
disappeared completely after the worms were expelled there seems to be 
but little doubt that they were the cause of the symptoms. As in the case 
of the abdominal symptoms, however, intestinal worms are only one of the 
causes of such nervous disturbances, and certainly not the most frequent ; 
but the possibility that they may depend upon worms should not be 
overlooked. 

The only positive evidence of the existence of roundworms is the dis- 
charge of a worm from the body, or the discovery of the ova in the stools. 
A microscopic examination of the stools is a valuable means of diagnosis, 
and one that is too infrequently employed. When worms are present the 
ova may be found in great numbers. Their continued presence after the 
discharge of one worm, indicates that other worms remain. 

Treatment. — Altogether the most efficient agent for the removal of 
the worms is santonin. The same plan of administration may be fol- 



450 



DISEASES OF THE DIGESTIVE SYSTEM. 



lowed as in the case of the tapeworm — viz., to give the drug on an empty 
stomach, preceded by a laxative. Santonin is best given in powdered 
form mixed with sugar. For a child of five years three grains are usually 
required. This amount should be given in three doses at intervals of four 
hours, soon followed by a purge of calomel or castor oil. 

Oxyuris Vermicularis — Pinworm — Threadworm. — The oxyuris (Fig. 
83) resembles a short piece of white thread. The female is about one- 
third of an inch long, the male about one-half that length, but is less fre- 
quently seen. The worm tapers toward the tail. The ova are of slightly 
irregular size, and are considerably smaller than those of the round- 
worm. 

The oxyuris inhabits chiefly the rectum and lower colon; less fre- 
quently it may be found as high as the caecum. These worms have been 
seen in the stomach, and even in the mouth. If present in the rectum they 
are usually discovered by separating the folds of the anus. The number 

of worms is usually large. The 
irritation to which they give 
rise, causes a great production 
of mucus, and frequently leads 
to a chronic catarrh of the 
colon of considerable severity. 
The worms are imbedded in the 
mucus; often they form with 
it small balls. According to 
Leuckart, they are incapable of 
multiplying in situ. For devel- 
opment, the ova must be swal- 
lowed. The ova as well as the 
worms are passed in enor- 
mous numbers with the stools. 
They attach themselves to the 
folds of the skin, the hairs 
about the anus, and even to the 
genitals. The patient may, 
through lack of cleanliness of the parts, continually re-infect himself. 
After discharge from the body, the ova may be carried by flies and de- 
posited upon fruits, vegetables, or in drinking water. 

Symptoms. — The principal symptom caused by the oxyuris is itching 
of the anus or the genitals. This is caused by the migration of the worms 
from the bowel, and usually comes on at about the same hour at night, 
generally soon after the patient has retired. It is sometimes so intense 
as to be almost intolerable. It leads to frequent micturition, to incon- 
tinence of urine, in the male to balanitis, and in the female to vaginitis 
or vulvitis, and in both, but especially in the latter, it may be the cause 




I 



Fig. 83. — Pinworms. 

0, female and male, natural size 
(Jaksch.) 



head ; S, female ; c, male ; 
a, ova. 



INTESTINAL WORMS. 45 ^ 

of masturbation. Owing to the catarrhal colitis which is excited, there is 
discharged a large quantity of mucus. The irritation may lead to pro- 
lapsus ani. Nervous symptoms are not so frequently associated as with 
the other varieties of worms, although I have seen at least one case of 
chorea in which they were almost certainly the cause. They have been 
known to excite convulsions. 

Treatment.— This is usually spoken of as a very simple matter, and no 
doubt in recent cases, or where the number of worms is small, this is true ; 
but where the number is large, and considerable catarrhal inflammation of 
the colon is present, it is often a matter of the greatest difficulty to rid the 
bowel of these parasites. Oases often resist the most approved methods 
of treatment for months, even though carefully and thoroughly applied. 
The reason for this difficulty is, that the whole colon is doubtless infected, 
and that the upper part is very imperfectly reached by injections. While, 
therefore, injections are important and indeed invaluable, they can not 
be relied upon exclusively. The most scrupulous attention to cleanliness 
is an absolute necessity as the first step in the treatment of all cases. It 
is well to bathe the parts about the anus after each stool, and even two 
or three times a day, with a bichloride solution, 1 to 10,000. Itching is 
best controlled by the application of mercurial ointment to the folds of 
the anus at bedtime, this effectually preventing the escape of the worms 
from the bowel. The local application of cold will sometimes have the 
same effect. The most efficient of the injections is probably the bichlo- 
ride. The colon should first be thoroughly cleansed by an injection of 
lukewarm water containing one teaspoonful of borax to the pint, in order 
to remove the mucus. When this has been discharged, half a pint of the 
bichloride solution mentioned should be injected high into the bowel 
through a catheter, and retained as long as possible. This should be re- 
peated every second or third night. On other nights a simple saline 
injection may be employed. The infusion of quassia, asafcetida, aloes, 
and garlic are also useful. 

When the worms are high in the colon, drugs by the mouth must 
be combined with injections. The worms must be dislodged by the use of 
saline cathartics, and simple bitters, especially quassia and gentian, 
should be given by the mouth. I have known one case, which resisted for 
over two years everything which had been tried, to be cured in two or three 
weeks by injections of a decoction of garlic, in connection with which 
garlic was given in large quantities by the mouth. 



452 DISEASES OF THE DIGESTIVE SYSTEM. 



CHAPTER XL 

DISEASES OF THE RECTUM. ' 

PROLAPSUS ANI. 

Under this term are included two conditions. In the first, or partial 
prolapse, there is simply an eversion of the mucous membrane which pro- 
trudes beyond the sphincter. In the second, or complete prolapse, there 
is invagination of the rectal wall for a variable distance, usually two or 
three inches. 

Etiology. — Prolapse is most common in children during the second 
and third years. Its frequency 'in early life is partly due to the lack of 
support furnished by the levator-ani muscles. It also occurs very readily 
when the ischio-rectal fat is scanty ; it is therefore often seen in children 
suffering from marasmus. The exciting cause may be anything which pro- 
vokes severe and prolonged straining. This may be either the tenesmus 
accompanying inflammation of the rectal mucous membrane or chronic 
constipation. It may come from phimosis or stricture of the urethra, and 
it is a very frequent symptom of stone in the bladder. 

Symptoms. — Prolapse usually occurs during the act of defecation. It 
is generally easily reduced, but shows a great disposition to return with 
every stool. In obstinate cases the bowel comes down at other times. 
The appearance of the tumour varies with its size. In the slighter form 
there is simply a ring composed of a fold of mucous membrane surround- 
ing the anus. In the more severe form there is a flattened, corrugated 
tumour, usually about the size of a small tomato (Fig. 84). The mucous 
membrane covering the tumour is of a deep purplish-red colour, and 
bleeds readily. It may be the seat of catarrhal or membranous inflamma- 
tion. The diagnosis in most cases is easy, although the tumour has been 
confounded with polypus and intussusception. 

Treatment. — In most cases reduction is easily accomplished by laying 
the child upon its face across the lap, and making gentle pressure upon the 
tumour with oiled fingers. The application of cold, either by means 
of ice or cold cloths, is of assistance in cases which are not at once reduced 
by pressure. After reduction, in the milder cases the child should be kept 
upon its back for at least an hour. Where the tumour tends to come 
down with every stool, special attention should be given at this time. If 
an infant, the bowels should always move while the child lies upon its 
back, and during defecation the buttocks should be pressed together by a 
nurse. Older children should use an inclined seat placed at an angle of 
about forty-five degrees, but should never sit upon a low chair or assume 



PROLAPSUS ANI. 453 

any position in which straining is easy. After defecation the patient 
should lie down for at least half an hour. Where there is constipation, the 
bowels should be kept free by means of laxatives. If there is a diarrhoea, 








Fig. 84. — Prolapsus ani. 



tenesmus may be overcome by frequent sponging with ice water, or by 
the use of small injections of ice water and tannic acid, in the proportion 
of twenty grains to the ounce. In more severe cases it may be controlled 
by the use of suppositories of opium or cocaine. Where the bowel tends 
to come down frequently, this may be prevented by the use of an adhesive 
strap two or three inches wide, placed tightly across the buttocks. This 
is better in the milder cases than a T-bandage. The great majority of the 
cases are cured by these means in the course of a few weeks. 

In the most severe cases the bowel not only protrudes during defeca- 
tion, but also in the interval, and it may be down for weeks at a time. 
Such cases are rarely seen except in infants who have very flabby muscles, 
and but little adipose tissue at the floor of the pelvis. Keduction is some- 
times difficult in cases where the prolapse has lasted a long time. It 
is often facilitated by painting the protruding part with a 4-per-cent solu- 
tion of cocaine, and then dilating the sphincter by passing the finger into 
the central opening of the tumour. After reduction, suppositories con- 
taining from one fourth to one grain of cocaine may be inserted. They 
are more efficient than those containing opium or belladonna. A firm pad 
should be applied over the anus, held in position by a T-bandage. The 
tone of the levator and sphincter-ani muscles is often greatly improved by 
local injections of strychnia. For a child two years old y^- grain may be 
used twice a day. Where these measures fail, the protruding part may 
be touched with the Paquelin cautery, linear markings being made at in- 
tervals of an inch. Amputation or excision is not required in children. 



454 DISEASES OP THE DIGESTIVE SYSTEM. 

FISSURE OF THE ANUS. 

This is not a very uncommon condition in children. The most fre- 
quent cause is the passage of a large, hard, faecal mass. Sometimes it re- 
sults from traumatism inflicted with the nozzle of a syringe while giving 
an enema. It may be produced by the scratching excited by pinworms. In 
the beginning there is a simple tear at the margin of the anus. The 
laceration which is produced usually heals promptly ; but if the cause is 
repeated, healing is prevented, and there is finally produced a linear ulcer, 
or a true fissure, which may last for some time and be a source of great 
annoyance. 

A fresh fissure has the appearance of any other tear at a muco-cuta- 
neous orifice. One of longer standing has a gray base, slightly indurated 
edges, often discharges a small amount of pus, and bleeds a drop or two 
with nearly every movement of the bowels. The most constant symptom 
is pain, which usually occurs with the act of defecation, and continues for 
some time afterward. It is most severe when the fissure is just at the 
margin of the sphincter, and leads the child to resist every inclination to 
have the bowels move, so that it becomes a cause of chronic constipation, 
which condition again greatly aggravates the fissure. The pain is often 
referred to other parts in the neighbourhood. 

The treatment is simple and usually efficient. It consists in clean- 
liness, overcoming the constipation, and touching the fissure with nitrate 
of silver, preferably with the solid stick. If the case is not speedily re- 
lieved by such measures, the sphincter should be stretched as in adult 
patients. 

PROCTITIS. 

Proctitis, or inflammation of the rectum, usually occurs with inflam- 
mation of the rest of the large intestine, but it may occur alone. It is 
to the cases in which only the rectum is involved that the term is gen- 
erally applied. 

The causes are for the most part local. A frequent one in infants 
is the use of irritating injections or suppositories, either for the relief of 
constipation or as a means of administering certain drugs. I have seen 
one obstinate case in an infant a year old, following the prolonged use of 
glycerin suppositories. It is sometimes caused by traumatism, especially 
by the careless giving of an enema. It accompanies pinworms. In 
certain cases it may result from direct infection through the anus. This 
may be from a gonorrhoeal inflammation extending from the vagina or 
urethra, or from an infection due to other bacteria, particularly in cases 
of measles, scarlet fever, and diphtheria ; or finally, it may be due to syph- 
ilis. The varieties of inflammation are the same as in the rest of the in- 
testine. Proctitis may thus be catarrhal, membranous, or ulcerative. 



PROCTITIS. 455 

Catarrhal Proctitis. — The pathological conditions are the same as in 
ordinary catarrhal inflammation of the intestinal mucous membrane. By 
the introduction of a speculum, or by simply everting the mucous mem- 
brane, it is seen to be reddened, swollen, and bleeds easily. There is a 
copious secretion of mucus. In cases of long standing there may be 
superficial ulceration appearing as a white or yellowish-white surface, 
usually just inside the sphincter. 

The symptoms are chiefly local, although a condition of general irrita- 
bility may result from the local condition. There is heightened reflex 
action, so that the stool often comes with a squirt. There is pain with 
defecation, and mucus is discharged, usually as a clear, jelly-like mass, 
and sometimes in the form of a cast, but not generally mixed with the 
stool. There are usually traces of blood, sometimes quite large hasmor- 
rhages. In the most acute cases, tenesmus is present both during and 
after the stool. There may be prolapsus ani. The skin in the vicinity is 
irritated by the discharges, most frequently so in infants. If the cause 
is pin-worms, there may be intense itching. The duration of the disease 
is indefinite, depending upon the cause. It may be a few days or many 
months. The inflammation may extend from the rectum to neighbouring 
parts, leading to ischio-rectal abscess. 

Membranous Proctitis. — It has been customary to describe this as a 
complication of diphtheria, usually occurring with diphtheria of the exter- 
nal genitals. As very few of these cases have been studied bacteriolog- 
ically, it is impossible to say what proportion of them, if any, are to be 
regarded as true diphtheria. It is probable that the great majority are 
due to infection by streptococci.' When the infection is from the intestine 
above, the rectum is never affected alone. When it is from below, this 
may be the case. The lesions are the same as in membranous inflamma- 
tion occurring higher in the colon. The symptoms resemble those of the 
catarrhal variety, with the addition that the stools contain pieces of 
pseudo-membrane. This can be made out only by repeatedly washing 
the discharges with water. If accompanied by prolapse, the pseudo- 
membrane may be seen. Membranous proctitis may be complicated by a 
membranous inflammation of the genitals or the perinseum. Although 
it is usually acute, it may last for weeks. 

Ulcerative Proctitis. — Ulcers of the rectum may be the result of a ca- 
tarrhal inflammation ; these, however, are usually superficial, affecting the 
mucous membrane only, and in most cases heal rapidly. Sometimes they 
extend more deeply into the submucous or even the muscular coat. They 
are then chronic, often very obstinate, and may last indefinitely. Follicu- 
lar ulcers of the rectum are nearly always associated with the same con- 
dition in the sigmoid flexure. These are always multiple and usually 
small, rarely being more than a quarter of an inch in diameter. Some- 
times the small ones coalesce, producing much larger ulcers. Membranous 



456 DISEASES OF THE DIGESTIVE SYSTEM. 

proctitis is rarely followed by ulceration, although this is a possible result 
where sloughing has occurred. Single ulcers may be of tuberculous ori- 
gin. Steffen reports two cases of tuberculous ulcer of the rectum in 
children of seven months and three years respectively. I have seen one 
such ulcer in a young infant, which was fully three-fourths of an inch in 
diameter, and was not associated with other tuberculous disease of the 
large intestine. Syphilitic ulcers are extremely rare in children. 

The symptoms of ulcer of the rectum are mainly two — pain and haem- 
orrhage. The pain is of variable intensity, and may be referred to the 
coccyx, or to any of the neighbouring parts. The amount of bleeding 
may be small, the blood coming in clots, or it may be fluid and in so large 
a quantity as to produce general symptoms. It usually accompanies every 
stool. In addition the stool contains more or less pus, particularly in 
chronic cases. When the ulcer is low down, tenesmus is present and may 
be a prominent symptom. A positive diagnosis of ulcer can be made only 
by examination with a speculum. 

Treatment. — In cases of acute catarrhal proctitis injections of some 
bland fluid should be employed, such as a starch- water, limewater, a mixture 
of oil and limewater, or a warm one-per-cent saline solution. The local 
cause, if one is present, should be removed. Where the stools are excess- 
ively acid, alkalies may be given by the mouth. The disordered digestion, 
when present, is to be treated according to its special symptoms. In the 
most acute cases the patient should be kept in bed. Where the tenesmus 
is severe, suppositories of opium or cocaine may be used. In the more 
chronic cases saline injections should be given, and followed by a mild 
astringent like tannic acid, ten grains to the ounce, or a one-per-cent solu- 
tion of hamamelis. Cases associated with pinworms are especially obsti- 
nate. Here the treatment is first to be directed to the worms, and after- 
ward to the proctitis. 

In the membranous cases the same measures are to be employed, and 
in addition the injection of a warm boric-acid solution two or three 
times a day. 

Oases of ulcer require the most careful treatment. In many there is 
but little tendency to spontaneous recovery. An examination with the 
speculum should be insisted upon in all cases of chronic proctitis, to 
make sure of the diagnosis. Rest in bed is essential to a rapid improve- 
ment. The patient should be put upon a bland diet, especially of milk, 
and the bowels kept freely open by the use of laxatives, and injections 
twice a day of a saturated boric-acid solution. Locally there should be 
applied a solution of nitrate of silver, one grain to the ounce, the bowel 
having previously been washed with tepid water. If a stronger solution 
than this is used, it should be neutralized after half a minute by the 
injection of a salt solution. 



HEMORRHOIDS. 457 



ISCHIO-RECTAL ABSCESS. 

This is not a very rare condition even in infancy. Infection from the 
rectum, usually through the lymph channels, seems to be the most com- 
mon cause, although sometimes the abscess maybe traced directly to trau- 
matism. In a single year I have seen six cases. All but two were small, 
circumscribed abscesses and quite superficial, apparently starting as an 
acute inflammation of the lymph glands of the region. They are analo- 
gous to a similar process in the lymph glands of the neck, seen in in- 
fancy. These cases healed promptly after incision. In other instances 
there is seen a disposition to burrow, as in adults. Only once have I met 
with diffuse suppuration in the ischio-rectal region, terminating in slough- 
ing and death, and this was in an infant only three months old. 

Essentially the same varieties of inflammation are seen in early life as 
in adults. Most of these cases recover promptly after simple incision and 
cleanliness, fistula being a rare sequel. 

HEMORRHOIDS. 

These, fortunately, are not often seen in children, although they occur 
in those as young as three or four years, and in some cases may even be 
congenital. The principal cause is chronic constipation, rarely diarrhoea. 
The tumours are generally small and external, the chief symptom com- 
plained of being pain on defecation. Bleeding sometimes accompanies 
the pain, but the haemorrhages are usually small. The treatment is to be 
directed toward the underlying cause. In most of the cases this suffices 
to cure the condition. I have rarely seen in a young child a case requir- 
ing operation, although neglect may make this procedure necessary. 

INCONTINENCE OF FECES. 

Inability to control the faecal evacuations is seen in certain cases of 
paraplegia due to myelitis, in injury of the lumbar portion of the spinal 
cord, and in spina bifida. It is also seen in the coma of meningitis, and 
occasionally in the typhoid condition and in extreme adynamia, no matter 
in the course of what diseases they develop. In all these conditions in- 
continence of faeces is a symptom giving rise to much annoyance and 
needing careful attention. Uncleanliness with reference to excreta, seen 
in idiocy, can hardly be classed as incontinence. 

Besides these familiar forms, the condition is sometimes seen from 
causes somewhat resembling those of incontinence of urine. The tone 
of the sphincter becomes so feeble that it does not resist even the slightest 
impulse to evacuate the rectum. The discharge may take place with but 
little warning, and may occur either by day or night. In some cases a 
local cause exists, such as stretching of the sphincter by a rectal prolapse 



458 



DISEASES OF THE DIGESTIVE SYSTEM. 



or by impaction of faeces ; more frequently, however, the causes relate to 
the general nervous condition of the patient. Fowler * (New York) has 
reported two very typical cases of this variety, and I have seen one. They 
are, however, very rarely met with in practice. Of the cases reported in 
literature, the majority have occurred in highly nervous, anaemic children. 
Fowler's cases were cured by the use of ergot given by the mouth and by 
suppository. In cases not relieved by this treatment, strychnia should be 
injected locally as described under Prolapsus Ani. In all cases the gen- 
eral condition should receive careful attention. 



CHAPTER XII. 
DISEASES OF THE LIVER. 

Aside from the different forms of degeneration which are seen in the 
various infectious diseases, the liver is not often the seat of serious dis- 
ease in infancy and early childhood. In later childhood nearly all the 
forms seen in adult life are occasionally met with, although even then 
they are quite rare. 

Size and Position. — The weight of the liver, in the newly-born child, 
from one hundred and seven observations of Birch-Hirschfeld, is 4-5 ounces 
(127 grammes), or about 4*2 per cent of the body weight. The following 
table gives the results of one hundred and seventy-four observations upon 
the liver in infancy in the autopsy room of the New York Infant Asylum : 

Weight of the Liver in Infancy. 





AVERAGE. 


Per cent of 
body weight. 


Age. 


Ounces. 


Grammes. 


3 months 


6-3 

7-5 
11-0 
14-0 
16-0 


180 
212 
311 
397 
453 


31 


6 " 


3*0 


12 " 


3-40 


2 years 


3-37 


3 " 


3-26 







In adults, according to Frerichs, the weight of the liver is about 2*5 
per cent of the weight of the body. 

The upper border of the liver is best made out by percussion. In the 
child, the upper limit of the liver dulness in the mammary line is found 
in the fifth intercostal space ; in the axillary line, in the seventh space ; 
posteriorly, in the ninth space. The lower border is best determined by 
palpation. This, as a rule, in the mammary line is found about one half 
an inch below the free border of the ribs. According to Steffen, the left 
lobe is relatively larger in the child than in the adult. The liver may be 



* American Journal of Obstetrics and Diseases of Children, October, 1882. 



FUNCTIONAL DISORDERS OF THE LIVER. 459 

displaced downward by contraction of the chest, as in rickets, or by an 
accumulation of fluid in the pleural cavity. It is frequently found lower 
than normal in conditions of great emaciation, owing to relaxation of the 
abdominal walls and its ligamentous supports. Upward displacement is 
much less frequent, and depends usually upon ascites or abdominal tumours. 

Malformations and Malpositions. — Congenital malformations relate 
chiefly to the bile ducts. These have been considered in the chapter de- 
voted to Icterus in the Newly Born (page 78). 

The liver may be found upon the left side in cases of general transpo- 
sition of the viscera. In fissure of the diaphragm it has been found in the 
thoracic cavity. 

ICTERUS. 

Icterus, or jaundice, occurs in children, as in adults, from two general 
classes of causes. The first includes those cases in which there is some 
obstruction to the flow of bile from the liver into the intestine, or obstruc- 
tive jaundice. In the second group, in which the jaundice is classed as 
non-obstructive, it depends upon certain changes in the blood itself. This 
is seen in the physiological jaundice of the newly born, in that associated 
with septic conditions and as the result of certain poisons. 

Obstructive jaundice from pressure upon the bile ducts is extremely 
rare in children. Obstruction by a roundworm entering the common 
duct has been recorded, but is also very rare. The principal form of ob- 
structive jaundice seen in early life, is catarrhal. This has already been 
considered in connection with Gastro-duodenitis. 

FUNCTIONAL DISORDERS. 

Functional derangements of the liver are undoubtedly exceedingly com- 
mon in childhood. They are as yet but little understood, and it is almost 
impossible to separate them from the other symptoms of intestinal indiges- 
tion with which they are associated. These are described in the chapter 
upon Chronic Intestinal Indigestion. Some of these symptoms depend 
upon a diminution in the quantity, or the impoverished quality of the 
biliary secretion. There are gray or white stools, flatulence, and other evi- 
dences of increased intestinal putrefaction. These in all probability depend 
upon imperfect absorption in consequence of the absence of bile, rather 
than upon the absence of some antiseptic property, as recent experiments 
seem to show that the bile is not an intestinal antiseptic. The other 
functional disturbances of the liver relate to its effect upon the proteid 
substances which undergo destructive metamorphosis in this organ. The 
nature of this change, and the symptoms which result from this disturbance 
are as yet but imperfectly understood. It is quite probable that many of 
the nervous functional disorders of children — for example, attacks of 
migraine or of cyclic vomiting — may depend upon such a cause. 



460 DISEASES OF THE DIGESTIVE SYSTEM. 

NEW GROWTHS. 

New growths of the liver are rare in children and are usually sec- 
ondary to deposits elsewhere, most frequently in the kidney. They are 
generally sarcomatous. Primary sarcoma of the liver has, however, been 
observed, and at so early an age as to make it practically certain that 
the condition was a congenital one. A single example of primary adeno- 
sarcoma of the liver has fallen under my observation. This was in an 
infant only seven months old. In a report of this case I collected from 
literature ten cases of sarcoma of various types in infants under one year.* 
In most of the cases there is simply a slowly increasing abdominal 
tumour and progressive asthenia. 

ACUTE YELLOW ATROPHY. 

This form of hepatic disease, although rare in adults, is still more 
rare in children. Greves has reported a well-marked case in an infant of 
twenty months, and has collected seventeen other cases under ten years 
of age ; the youngest was in an infant three months old. The symptoms 
and course of the disease are essentially the same as in adults. 

CONGESTION OF THE LIVER. 

Congestion of the liver occurs from the same causes in children as in 
adults. Acute congestion is not often seen. Chronic congestion is more 
common, and is usually secondary to general venous obstruction depend- 
ent upon congenital or acquired heart disease, atelectasis, or other 
pulmonary conditions, particularly chronic pleurisy, chronic interstitial 
pneumonia, and emphysema. Chronic congestion of the liver causes no 
characteristic symptoms except a moderate enlargement of the organ. 
In acute congestion, there may be in addition some localized pain or 
tenderness. The treatment is that of the primary disease. 

ABSCESS OF THE LIVER— SUPPURATIVE HEPATITIS. 

In 1890 Musser found but thirty-four recorded cases of abscess in 
children under thirteen years. Since that time a few additional cases 
have been reported. In the above collection, there have not been included 
cases of suppurative hepatitis occurring in the newly born. 

As in adults, abscess of the liver may result from traumatism, or it 
may be secondary to suppurative pylephlebitis, which depends upon a 
focus of infection in the umbilical vein, or in some part of the abdomen 
from which the branches of the portal vein arise. Pylephlebitis may fol- 
low appendicitis (Bernard's case), it may follow typhoid fever directly 
(Asch's case), or be due to suppuration of the mesenteric glands or peri- 
tonitis following typhoid. In seven of the cases collected by Musser the 

* Archives of Paediatrics, April, 1905. 



ABSCESS OF THE LIVER. 



461 



disease was due to migration of round worms from the intestine into the 
hepatic ducts. Menger (Texas) has reported one case following dysen- 
tery, the only one, I think, on record in this country. In quite a number 
of cases no adequate cause can be found. 

In the cases occurring in pyaemia and in those associated with pyle- 
phlebitis there are usually several abscesses ; in traumatic cases generally 
but one. If untreated, the majority of cases prove fatal either from 
exhaustion or from rupture into the pleura or peritonaeum. In Asch's 
case spontaneous cure took place by rupture into the intestine. 

Symptoms. — Occasionally abscess in the liver is latent, but in most of 
the cases the symptoms are marked and sufficiently characteristic to make 
the diagnosis a matter of no great difficulty. The most constant general 
symptoms are chills, which may be single, but are usually repeated ; fever, 
which is commonly of the hectic variety and followed by sweating ; pros- 
tration, vomiting, diarrhoea, and cachexia. Jaundice is present in less than 
half the cases, and is rarely intense. The liver is almost invariably suffi- 
ciently enlarged to be easily made out by palpation or by percussion ; the 
enlargement in most cases is chiefly downward. Tumours on the surface 
of the liver are often present ; these may be recognised as abscesses by the 
presence of fluctuation. Pain is quite constant, and frequently intense, 
but not always in the region of the liver. It may be in the epigastrium, 
at the umbilicus, in the lower part of the abdomen, and occasionally 
in the right shoulder. Tenderness over the liver is usually present. A 
positive diagnosis of hepatic abscess is to be made only by aspiration and 
the withdrawal of a fluid having the characteristics of " liver pus." Pul- 
monary symptoms usually exist with an abscess occupying the convexity 
of the right lobe. There may be cough and dyspnoea from pressure, or 
pleurisy from extension of the inflammation through the diaphragm, or 
from rupture into the pleural cavity. The usual duration of abscess of 
the liver after the beginning of the symptoms is from one to two months. 
The prognosis will depend upon the cause of the disease. The pyaemic 
cases are usually fatal. In Musser's collection, the proportion of recov- 
eries was about thirty per cent. At the present time, with improved 
methods of treatment and earlier diagnosis, the outlook is somewhat 
better than this. 

Treatment. — This is purely surgical. Without operation the chances 
of recovery are very slight. A small number of cases have been cured 
by aspiration, but in the vast majority only incision and drainage are to 
be depended upon, and, if the abscess is accessible, should be resorted to 
as soon as the diagnosis is established. 

CIRRHOSIS. 

Cirrhosis of the liver is exceedingly rare in early life, although quite 
a number of cases are now on record between the ages of seven and four- 



462 DISEASES OF THE DIGESTIVE SYSTEM. 

teen years. Sixty-five have been collected by Howard * and fifty-three by 
Laure and Honorat.f Nearly all the cases in these collections were be- 
tween nine and fifteen years old. Cirrhosis in infancy is usually of syphi- 
litic origin. Two-thirds of those in Howard's collection were males. 
The etiology in most of the cases is obscure; in over half of those re- 
ported no cause could be discovered. Fifteen per cent of Howard's cases 
were traced to alcoholism, eleven per cent to syphilis, and eleven per cent 
to tuberculosis. Laure and Honorat believe that the eruptive fevers 
sometimes play an important part as an etiological factor, and that at 
other times the cause is possibly malaria. 

The anatomical features of cirrhosis in early life are. essentially the 
same as in adults. The liver is sometimes enlarged, but usually it is 
smaller than normal. The connective tissue may be distributed around 
the lobules, along the bile ducts, in irregular patches, or in striations 
through the organ. Associated with this there is atrophy and fatty 
degeneration of the liver cells. In some of the cases reported there has 
been also a similar increase in the connective tissue of the spleen and 
kidneys. 

Symptoms. — These are very much the same as in adult life. In the 
beginning there are the indefinite disturbances referable to the digestive 
organs, and the liver may be found to be slightly enlarged; later there is 
ascites, enlargement of the spleen, and dilatation of the abdominal veins. 
Ascites is a pretty constant symptom, and is generally marked. Slight 
icterus is often present, but a marked amount is rare. There may be 
haemorrhages from the stomach, from the nose, or from other organs ; in 
a few cases there is slight fever. The late symptoms are a small liver, 
marked ascites with the consequent embarrassment of respiration, ca- 
chexia, and sometimes general dropsy. Diarrhoea is a much more con- 
stant symptom than in adults. Death usually takes place from exhaus- 
tion. The course of cirrhosis in children is commonly more rapid than 
in adults, and the progress is steadily downward. 

Treatment. — Medicinal treatment is of avail only in cases which are 
syphilitic. These should be put upon mercury and large doses of the 
iodides. The treatment in other respects is symptomatic and palliative. 
As largely as possible patients should be kept upon a milk diet. The 
ascites may require aspiration or puncture, as in adults. 

AMYLOID DEGENERATION (WAXY, LARDACEOUS LIVER). 

From the experiments of Krawkow, Davidsohn, and others there 
seems now little doubt that amyloid degeneration is produced by the 
prolonged action of the toxins of the staphylococcus pyogenes aureus. 

* American Journal of the Medical Sciences, 1887, p. 350. 

f Revue Mensuelle des Maladies de PEnfance, 1887, pp. 97, 159. 



FATTY LIVER. 463 

Amyloid degeneration of the liver is associated with similar changes in 
the spleen and kidneys, and sometimes in the villi of the small intestine, 
and is usually seen in children after long-continued suppuration in 
chronic bone or joint disease, empyema, tuberculosis, or syphilis. 

The liver is generally very much enlarged ; in extreme cases a weight 
of six or seven pounds may be reached. It is of a glistening, waxy ap- 
pearance, very firm and hard. With a solution of iodine, a mahogany- 
brown reaction is obtained. The amyloid degeneration affects first the 
arterioles, and finally the hepatic cells. 

Amyloid liver per se produces few symptoms. Ascites is rarely pres- 
ent except in cases in which the liver is very large, and jaundice does not 
occur. In addition to the symptoms of the original disease in the eourse 
of which the amyloid degeneration occurs, there is the peculiar waxy 
cachexia which is seen in no other condition, but resembles somewhat 
that belonging to malignant disease. The face has the appearance of ala- 
baster, and the skin has a singular translucency. The liver may be so 
large as to form a tumour, sometimes nearly filling the abdominal cavity. 
Not infrequently it extends to the umbilicus, and even to the crest of the 
ilium. The surface is smooth and hard, and the edges usually rounded. 
There is no localized pain or tenderness. The spleen is invariably en- 
larged. As a result of the associated amyloid degeneration of the kidney, 
there may be dropsy and albuminuria. Dropsy may occur from pressure 
of the large liver upon the vena cava, apart from the condition of the 
kidney. 

Amyloid changes usually take place slowly, the whole course of the 
disease being marked by years, the patient dying from slow asthenia, 
from nephritis, or from some acute intercurrent disease. As a rule, cases 
go on steadily from bad to worse; but sometimes, after the disease has 
reached a certain point, the condition is stationary for a long time. 

The prognosis is always bad, although in a few cases improvement, 
and even cure, are stated to have occurred after the excision of the dis- 
eased joints upon which the amyloid degeneration depended. When due 
to syphilis, the usual anti-syphilitic remedies should be given. 



FATTY LIVER. 

Fatty infiltration of the liver is generally a secondary condition in 
early life, and causes no symptoms by which it can be positively recog- 
nised. Considerable discussion has of late arisen regarding its frequency 
in infants. From our records at the Babies' Hospital, Dr. Martha Woll- 
stein has tabulated 345 consecutive autopsies in which the condition of 
the liver was carefully noted. The liver was fatty in 201, or 58 per cent. 
Of these autopsies, 63 were cases of tuberculosis, in 43 of which, or 68 
per cent, the liver was fatty. 
31 



464 DISEASES OF THE DIGESTIVE SYSTEM. 

The general nutrition of the 345 infants was as follows : 

Wasted 188 : liver fatty, 104, or 55 per cent — very fatty in 17. 

Fairly nourished 80: " " 52, " 65 " " " " " 9. 

Well nourished 77 : " " 45, " 59 " " " " « 20. 

These figures coincide very closely with the observations of Freeman 
at the New York Foundling Hospital, and indicate that fatty liver is not, 
as has been so often asserted, much more frequent in wasted infants than 
in others. The cause of this change in the liver is as yet but little under- 
stood. 

The liver is moderately enlarged, smooth, with rounded edges, of a 
yellowish-red or a lemon-yellow colour, and can be indented with the 
finger. A warm knife becomes coated with oil after cutting. Microscop- 
ically there is seen an accumulation of fat in the liver cells, usually irreg- 
ularly distributed. Jaundice, ascites, and the other peculiar symptoms of 
hepatic disease, are absent. The liver is moderately increased in size and 
its functions are interfered with, but not in such a way as to be recog- 
nised by the symptoms. The treatment is that of the original disease. 

HYDATIDS. 

Echinococcus disease of the liver, while rare among adults in this 
country, is almost unknown in children. I have been able to find but two 
recorded cases in America. From twenty-two European cases collected 
by Pontou (Paris, 1867), it appears that unilocular cysts are especially 
frequent in young subjects. If the upper surface is affected, pulmonary 
symptoms, cough and dyspnoea, are usually present; if the under surface 
of the organ, there is pressure upon the portal vein, the vena cava, bile 
ducts, stomach, and intestines. This pressure may cause icterus, dilata- 
tion of the superficial abdominal veins, and sometimes ascites. The local 
signs are enlargement of the liver with a tumour, which is easily recog- 
nised in children because of the thin abdominal walls. The hydatid 
fremitus is usually obtained. By aspiration a clear fluid is withdrawn, 
showing under the microscope the presence of the hooklets, which es- 
tablishes the diagnosis. Occasionally cure may take place by spon- 
taneous rupture or suppuration of the cyst, but in most cases, when left 
to itself, the disease proves fatal. The treatment is surgical, and con- 
sists in aspiration or in incision, and the evacuation of the cyst. 

BILIARY CALCULI. 

Up to the age of puberty calculi are extremely rare. Still (Transac- 
tions London Pathological Society, 1899) was able to collect but twenty 
cases from medical literature, eleven of which occurred in newly born 
infants or else gave symptoms during the first month of life. The 
prominent symptom was intense and persistent jaundice. Nearly all 
died within the first month, the autopsy usually showing multiple calculi 
in the common duct. 

The cases in older children do not differ from those in adults. 



ACUTE PERITONITIS. 



465 



CHAPTER XIII. 
DISEASES OF THE PERITONEUM. 

Inflammation of the peritonaeum is not very frequent in childhood, 
because at this time most of the causes which are operative in later life 
either do not exist at all or are infrequent. An analysis of 187 collected 
cases of peritonitis — not including those associated with appendicitis — 
gave the following results, which are of some interest as showing the 
relative frequency of the different forms in early life : 





Acute. 


Chronic. 


Total. 


Fibrinous 


22 
22 
46 

18 


10 
15 

16 
38 


32 


Serous 


37 


Purulent 


62 


Tuberculous 


56 






Total 


108 


79 


187 







We shall consider separately acute, chronic, and tuberculous perito- 
nitis. 

ACUTE PERITONITIS. 

Acute peritonitis may occur at any period of infancy or childhood. 
It may even exist in intra-uterine life. In the newly born, peritonitis is 
quite frequent. After this time it is exceedingly rare during infancy, 
only four cases, including all varieties, being met with in 726 consecutive 
autopsies in the New York Infant Asylum. After the fifth year the dis- 
ease is relatively much more common. Of the 187 cases above referred 
to, 25 per cent occurred in the newly born, 21 per cent between one and 
five years, and 54 per cent between the fifth and the sixteenth years. 

Etiology. — In the newly born, peritonitis is seen as one of the most 
frequent lesions of acute pyogenic infection (page 83) . It is usually due 
to direct infection through the umbilical vessels. In infancy and child- 
hood, peritonitis occurs both as a primary and secondary inflammation. 
The primary form is rare. It may be due to traumatism, such as falls or 
blows, or to surgical operations upon the abdomen ; it has occurred after 
an injection for the cure of a congenital hydrocele. In a very small 
number of cases the inflammation seems to have been excited by cold 
or exposure, and it may follow severe burns. 

The secondary form is more common. The most frequent of all 
causes is appendicitis, which should always be suspected in acute perito- 
nitis occurring without definite cause. Extension of inflammation from 
the viscera to the peritonaeum is very much less frequent in children than 
in adults. I have seen it but once in autopsies in acute intestinal dis- 
eases. It is also rare in typhoid fever, being noted but twice among my 



4:66 DISEASES OF THE DIGESTIVE SYSTEM. 

collected cases. It is occasionally due to abscess of the liver, ulcer of 
the stomach, acute intestinal obstruction from internal strangulation, 
intussusception, volvulus, or congenital atresia. It may extend from in- 
flammation of the pleura. This may be in the form of empyema which 
burrows through the diaphragm, or, without burrowing, the infection 
may take place through the lymph channels. It is not very infre- 
quently due to infection through the female genital tract, especially in 
gonorrheal vulvo-vaginitis in young girls. Extension of inflammation 
from the male genital organs is not common. In one case at the New 
York Infant Asylum, fatal peritonitis in an infant started from a sup- 
purative inflammation of the tunica vaginalis of unknown origin, the 
infection extending into the peritonaeum through the inguinal canal. 
Any abscess in the neighborhood may rupture into the peritonaeum and 
excite peritonitis. The most frequent in children are those connected 
with Pott's disease, perinephritis, and cellulitis of the abdominal wall. 

Of the acute infectious diseases, peritonitis is most frequently seen 
with pneumonia and scarlet fever, occasionally with influenza. In four 
cases occurring in the New York Infant Asylum, the disease was twice 
secondary to pneumonia, in both complicated by extensive pleurisy. It 
may be accompanied by pericarditis, and even by meningitis. 

The bacteria most frequently associated with acute peritonitis in chil- 
dren are : the streptococcus, especially in the newly born ; the micrococcus 
lanceolatus (pneumococcus), in cases complicating pneumonia or empy- 
ema ; and the bacterium coli commune in those following intestinal per- 
foration. Those mentioned may be associated with other pyogenic bac- 
teria, or less frequently the latter may occur alone. 

Lesions. — In the fibrinous form we have changes similar to those oc- 
curring in inflammation of the pleura and the other serous membranes. 
The peritonaeum is injected and lymph is thrown out in considerable 
quantity, usually accompanied by a small amount of serum. The process 
may be localized or general. It is more frequently general in the child 
than in the adult. The peritonaeum lining the abdominal wall, as well as 
that covering the coils of intestine and the solid viscera, is covered by 
patches of yellowish-gray lymph, causing adhesions between the various 
viscera and often matting the intestines together. In recent cases these 
adhesions are soft, and easily broken down; in old cases they are quite 
firm, and they may result in the formation of connective-tissue bands 
which are the source of subsequent trouble. 

In the serous form there is a moderate amount of lymph, generally 
less than in the plastic variety, and, in addition, an outpouring of serum 
in considerable quantity. This is usually clear, but may be turbid from 
flakes of lymph, or it may even be bloody. In most cases the amount is 
not very large, usually varying from half a pint to two pints. In cases 
going on to recovery the serum is absorbed, but there may result adhe- 
sions as in the preceding variety. 



ACUTE PERITONITIS. 467 

In the purulent form the products are serum, lymph, and pus. When 
peritonitis results from perforation it is, as a rule, purulent from the out- 
set, and the pus is foul and stinking. The amount of pus is generally 
larger than in adult cases. When the disease proves fatal in a few days 
there is found an extensive exudation of plastic lymph, with the forma- 
tion of small pockets containing pus, among the coils of intestine. Occa- 
sionally there may be larger collections of pus in the peritoneal cavity. 
In cases which have lasted a longer time — generally those of localized 
inflammation — the process results in the formation of a peritoneal ab- 
scess. This consists in a collection of pus in some part of the peritoneal 
cavity, the situation depending upon the cause, but it is usually in one 
iliac fossa or in the pelvis. The abscess is shut off from the rest of the 
peritoneal cavity by a thick wall of fibrin. If left alone, such abscesses 
may open into the rectum, vagina, bladder, pelvis of the kidney, or exter- 
nally, usually at the umbilicus. After the discharge of pus the cavity 
may contract and fill up by granulations, and the patient recover. 

Inflammations of the other serous membranes, especially the pleura, 
are often associated with peritonitis. 

Symptoms. — The symptoms of acute peritonitis in older children, as 
in adults, are usually well marked and sufficiently characteristic to enable 
one to recognise the disease easily ; but not so in the case of infants. In 
them the symptoms are often obscure, and the disease may be found at 
autopsy when not suspected during life. The onset is nearly always 
abrupt, with fever and vomiting. As a rule, the temperature is high — 
from 103° to 105° F. Vomiting may be only at the onset, but it often 
continues ; vomited matters are usually green. Older children complain 
of pain, which may be localized or general ; and in younger ones this is 
indicated by crying and fretfulness. The abdomen very soon becomes 
swollen and tympanitic, this being one of the most constant features 
of the disease. The distention is generally uniform, but it may be irreg- 
ular. It is very rare in acute cases that there is a sufficient amount of 
fluid present to give the sensation of fluctuation. There is tenderness 
on pressure, and usually marked rigidity of the abdominal walls. The 
position assumed by the patient is generally dorsal, with the thighs 
flexed. The bowels are in most cases constipated, but diarrhoea is by no 
means rare. The abdominal distention causes dyspnoea and thoracic 
breathing. There may be retention of urine or frequent micturition. 

The general symptoms, almost from the beginning, are those of a seri- 
ous disease. The pulse is small, rapid, and compressible. The prostra- 
tion is great, from the very outset. The face is pinched, the mouth is 
drawn, and the features indicate pain. In severe cases there may be hic- 
cough, cold extremities, clammy perspiration, and collapse. The mind is 
usually clear. In infants there may be convulsions. 

In the most severe forms of general peritonitis the course is short and 



468 DISEASES OF THE DIGESTIVE SYSTEM. 

intense, and the disease goes on rapidly from bad to worse until death 
occurs. In infants this is often on the third or fourth day. The most 
severe forms of general peritonitis in older children run the same rapid 
course. In other cases the course is slower, lasting a week or ten days. 
If the patient lives longer than this the case is more hopeful, because the 
process is more apt to be localized. The development of peritoneal ab- 
scess is indicated by the continuance of the temperature, which may 
assume a hectic type, and be accompanied by chills and sweating. There 
are the local signs of an abdominal tumour. 

Prognosis. — Acute general peritonitis, whatever its cause, is a very 
serious disease in childhood. Of eighty cases of all varieties under six- 
teen years of age, sixty-nine per cent died. In the newly born and in 
infancy the disease is almost invariably fatal. In older children the out- 
look is not quite so hopeless, and depends upon the exciting cause. It is 
better in localized than in general inflammation; also in the fibrinous 
than in the purulent form ; but the most favourable cases are those with 
a sero-fibrinous exudation. 

Treatment. — The medical treatment of acute general peritonitis in 
children is extremely unsatisfactory, as the disease is usually fatal unless 
it can be relieved surgically. Opium is indicated only for the relief of 
the single symptom, pain ; according to its severity, the size of the dose 
and the frequency of its repetition should be determined. On account 
of vomiting it is well to administer it hypodermically. The only other 
medical measures deserving much consideration are catharsis by salines, 
and saline injections. Used early, and in sufficient amount, free purga- 
tion by salines seems to produce a derivative effect upon the peritoneal 
inflammation, which is sometimes very marked. Either the sulphate 
or the citrate of magnesia may be used, often advantageously preceded 
by calomel. Much larger doses than in most conditions are necessary on 
account of the constipation which belongs to the disease, this being one 
reason why so little effect is sometimes seen. High saline injections are 
useful in aiding the elimination of poisonous products from the intes- 
tinal tract. A normal salt solution should be given at a little above the 
body temperature, at least one quart being employed for a single injec- 
tion, to be repeated two or three times a day if the effect upon the gen- 
eral condition is favourable. " 

As a local application cold is usually to be preferred. It may be 
applied either by an ice-bag or by a Leiter's coil. If children rebel 
against the use of cold, heat must be substituted. Turpentine stupes 
may aid in relieving tympanites. 

Feeding is always a difficult matter on account of the strong tendency 
to vomiting ; this is due to the regurgitation from the intestine into the 
stomach, which in some cases is almost continuous. In such conditions 
I have found great benefit from washing the stomach shortly before 



CHRONIC PERITONITIS. 469 

feeding, repeating this several times each day. In this way vomiting 
may often be controlled and the stomach made ready for food. The 
diet should be peptonized milk, broth, or kumyss. As stimulants, brandy 
with ice, or if this is vomited, champagne may be given. 

Surgical treatment. — In every clear case of acute peritonitis of doubt- 
ful origin, an early exploratory operation should be done if the child's 
general condition will permit. Appendicitis is often found to be the 
cause when least expected; besides, in most other conditions this gives 
the only chance for recovery. Acute perforative peritonitis in a child 
is usually fatal under any treatment; but immediate laparotomy should 
be tried. Operation is also indicated in peritoneal abscesses. 

CHRONIC (NON-TUBERCULOUS) PERITONITIS. 

Peritonitis may occur in fcetal life with the production of extensive 
adhesions, which may interfere with the development of the intestine and 
result in various malformations. These cases have been ascribed by Sil- 
bermann * to syphilis. 

Chronic peritonitis may follow the acute form, in which there are left 
adhesions which slowly increase owing to the production of new connect- 
ive tissue. Such cases are sometimes chronic from the beginning. 

The peritoneal abscesses which follow the suppurative form may run 
a chronic course. Chronic localized peritonitis may occur in connection 
with disease of any of the organs covered by the peritonaeum. 

Chronic Peritonitis with Ascites. — In most cases this is chronic from 
the outset and independent of the causes above mentioned. By far the 
most frequent form of inflammation is that due to tuberculosis, and by 
some writers the opinion is still held that this form is always tuberculous. 
After the observations reported by Henoch, Vierordt, Fiedler, and others, 
there seems to be no longer any room for doubt regarding the existence 
of a chronic non-tuberculous form of peritonitis with ascites, although 
it must be considered a rare disease. In its pathological and clinical 
aspects it is to be compared to subacute or chronic pleurisy with effusion. 

Etiology. — Nearly all the cases thus far reported have occurred in 
children over six years old. The causes are for the most part obscure. 
The disease has been attributed to exposure, rheumatism, and injury. 
In a few instances it has followed measles. It may be associated with 
disease of the intestines or the solid viscera of the abdomen, especially 
with new growths of the kidney, liver, etc. 

Lesions. — The post-mortem observations thus far have been few. In 
the reported cases there has been found a large amount of greenish 
serum in the general peritoneal cavity, with a very moderate amount of 
fibrin and adhesions, which are sometimes few and sometimes very 
numerous. Chronic pleurisy may be associated. 

* Jahrbuch fur Kinderh., Bd. xviii, 420. 



470 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms. — The early symptoms are of a very indefinite character, 
such as a decline in the general health, or dyspeptic symptoms ; but often 
nothing whatever is noticed until the swelling of the abdomen begins. 
The enlargement comes on rather gradually in the course of a few weeks. 
Pain is slight, or wanting altogether. There may be some abdominal ten- 
derness, but this is rarely marked. The bowels are irregular ; sometimes 
there is diarrhoea and sometimes constipation. The abdomen is usually 
distended with fluid, the umbilicus protruding, and the superficial veins 
prominent. The enlargement is generally regular and symmetrical, and 
the wave of fluctuation is readily obtained. The general symptoms are 
very few. In some cases there is a slight evening rise of temperature of 
one or two degrees. There may be general weakness, loss of appetite, 
and moderate anaemia. 

The usual course of the disease is for the fluid to remain for a time 
and then undergo slow absorption, the case going on to complete recov- 
ery. Occasionally relapses are seen. The results are not always so favour- 
able, for in some instances there is no tendency to absorption of the fluid, 
the general health is gradually undermined, and the patients die from 
exhaustion or from some intercurrent disease. The diagnosis rests upon 
the presence of ascites, developing gradually without any signs or symp- 
toms of disease in the heart, liver, or other organs. The points which 
distinguish it from tuberculous peritonitis are considered under that dis- 
ease. In the cases which recover, the fact that no other signs of tubercu- 
losis subsequently develop is an important point in diagnosis. The prog- 
nosis is in most cases favourable, but must be guarded on account of the 
difficulty in making a positive diagnosis from the tuberculous form. Ee- 
covery is usually complete and permanent. 

Treatment. — It is important that the patient should be kept at rest, 
preferably confined to bed. The best results are usually obtained by the 
adoption of a general tonic plan of treatment. If absorption of the 
fluid does not begin with such means, saline diuretics should be given and 
the amount of fluid allowed the patient limited. When there is no tend- 
ency to absorption after a thorough trial of the above measures, and 
especially when the patient's general health begins to suffer, the fluid 
should be removed by aspiration. If it continues to accumulate after 
repeated aspirations, laparotomy may be performed, for in some cases 
this has the same beneficial effect as in tuberculous peritonitis. 

TUBERCULOUS PERITONITIS. 

The peritonaeum is quite frequently the seat of tuberculous inflamma- 
tion in early life; but not so often in infants as in older children. Of 
56 collected cases, 7 were under three years of age, 26 from three to eight 
years, and 23 from eight to sixteen years. In 119 autopsies upon tubercu- 
lous patients, most of them under three years old, of which I have records, 



TUBERCULOUS PERITONITIS. 471 

the peritonaeum was involved in 8 -5 per cent. In 105 autopsies, for the 
most part upon older tuberculous children, Ashby found the peritonaeum 
involved in 36 per cent. In 883 collected autopsies upon tuberculous chil- 
dren of all ages, Biedert * found the peritonaeum involved in 18 *3 per 
cent. These figures do not represent the number of cases of tuberculous 
peritonitis, as in many of them only a few miliary tubercles were present. 

It is no doubt possible for peritonitis to occur as the primary lesion 
of tuberculosis, but in the great majority of cases it is secondary. It 
may, however, appear as the most important tuberculous lesion in the 
body. The peritonaeum may be infected directly from the intestine, the 
mesenteric glands, or the pleura, or from more distant parts, such as the 
lungs, the bronchial glands, the cervical, or other external glands. In a 
small number of cases there is a history of some local exciting cause, 
such as a fall or blow upon the abdomen. The disease may follow expo- 
sure, or occur as a sequel to one of the exanthemata. 

Tuberculous peritonitis may be acute or chronic. It presents several 
varieties, quite distinct from one another, both in their pathological and 
clinical features. 

1. Miliary Tuberculosis of the Peritonaeum accompanying General 
Tuberculosis. — The peritonaeum may be involved as one of the lesions in 
acute or subacute general miliary tuberculosis. This is the most common 
form seen in infants. The lesions consist in a deposit of miliary tuber- 
cles, which are generally rather sparsely scattered over the peritonaeum. 
The evidences of inflammation are very slight, or they may be absent 
altogether. These cases do not come under observation as cases of peri- 
tonitis, as there are no abdominal symptoms. 

2. Miliary Tuberculosis of the Peritonaeum with Ascites. — Although 
not the most common variety in children, these cases form an important 
group. The peritonaeum is thickly sown with miliary tubercles, both dis- 
crete and in conglomerate masses. They are found in the omentum and 
the mesentery, upon the surface of the intestines and the solid viscera. 
The peritonaeum shows in varying degrees the changes of acute or sub- 
acute inflammation. There is congestion, with the production of a mod- 
erate amount of fibrin and a large amount of serum. In the most acute 
cases the fluid is in the general peritoneal cavity. In those of longer du- 
ration it may be sacculated. The fluid is usually abundant, but not excess- 
ive. It is most commonly an olive-coloured serum, but it may be sero- 
purulent, and even bloody. There are commonly other lesions of tubercu- 
losis in the body, but they are less marked than those of the peritonaeum. 

These ascitic cases generally run an acute or subacute course, the usual 
duration being from one to four months. Clinically they present the 



* Jahrbuch fur Kinderh., xxi, 178 ; see also Osier, Johns Hopkins Hospital Reports, 
vol. ii. 

32 



472 DISEASES OF THE DIGESTIVE SYSTEM. 

symptoms of a moderate grade of peritoneal inflammation with ascites. 
The onset is rather gradual, with indefinite general symptoms. There is 
usually some fever— 100° to 101-5° F. There are general weakness, pros- 
tration, and loss of flesh, but not rapid emaciation. Vomiting is not 
prominent, and pain and tenderness are rarely very marked. There may 
be nothing distinctive until distention of the abdomen is seen. This at 
first is due to gas, but later to fluid, which may accumulate in sufficient 
quantity to fill the general peritoneal cavity. The bowels are constipated, 
or there may be diarrhoea. 

The usual course, when untreated, is for the disease to go on to a fatal 
termination from exhaustion. Less frequently the fluid is absorbed, and 
the case becomes one of the fibrous type, with a tendency to relapses ; 
rarely it is followed by the ulcerative form. 

3. The Fibrous Form. — This, in its general characters, may be com- 
pared to the fibroid form of pulmonary tuberculosis. There is a tuber- 
culous inflammation, the products of which have undergone transfor- 
mation into fibrous tissue. This may in a certain sense be regarded as 
a method of cure. The essential feature of the lesion in these cases is the 
production of extensive organized adhesions between the intestinal coils, 
and between the intestines and the abdominal walls. The intestines may 
be compressed against the spine by bands. Ascites may be present, but it 
is frequently absent altogether. If there is fluid, it may be in the gen- 
eral peritoneal cavity, or it may be sacculated. The fluid may consist 
either of serum or of sero-pus. There is no tendency to caseation or 
breaking down. 

Clinically these cases are distinguished by their slow, irregular course. 
They are the most chronic of all the forms. The disease may be chronic 
from the outset, or it may follow the variety previously mentioned. The 
onset is generally insidious; fever is slight, or entirely absent. There 
is rarely vomiting. The bowels may be constipated or loose. For a 
long time the general health may remain good. The only characteristic 
symptom is the enlargement of the abdomen. In the early part of the 
disease this is chiefly from the tympanites, but later it may depend wholly 
or in part upon an accumulation of fluid. Ascites usually develops very 
slowly, but may be abundant. The adhesions of the intestines may give 
rise to irregularities in the outline of the abdomen. Ascites may be pres- 
ent for a time and then disappear spontaneously, and the general health 
may so improve that the patient is considered quite well. There may 
even be a permanent cure. In other cases, after symptoms have been 
absent for some time, relapses occur, and more fluid is poured out. In 
addition to these symptoms, others are present depending upon the me- 
chanical effects of pressure from the contracting adhesions. There may 
be more or less constriction of the intestine, pressure upon the vena cava, 
the renal or portal veins, the thoracic duct or, its branches, or upon the 



TUBERCULOUS PERITONITIS. 473 

stomach. These may give rise to dyspeptic symptoms, emaciation, 
oedema of the lower extremities, and albuminuria. 

In some cases the disease is entirely latent, and it is discovered at 
autopsy when there have been either no abdominal symptoms during life, 
or only colicky pains of an indefinite 'character. The course of this form 
of peritonitis is slow and irregular; it generally lasts for from three to 
twelve months, although with intermissions and exacerbations it may ex- 
tend over several years. The fatal result may be due to an acute exacer- 
bation, to exhaustion, or to the development of tuberculosis elsewhere. 

4. The Ulcerative Form. — This is an inflammation associated with 
large tuberculous deposits which go on to caseation and softening. It 
may be compared to ulcerative phthisis. In point of chronicity it stands 
midway between the two preceding varieties. It is one of the most fre- 
quent forms seen in children, and, while it may be localized, it is usually 
general. 

There is commonly a very abundant fibrinous exudate, matting the 
coils of intestine together and causing them to adhere to the solid viscera 
and to the abdominal walls. In this exudate there are seen tuberculous 
deposits consisting of small, yellow nodules and larger caseous masses, 
often broken down at the centre. These caseous deposits are also found 
in the mesentery and in the omentum, which may be very greatly thick- 
ened. Pockets are formed by the adhesions which sometimes contain 
clear serum, but more frequently pus or a brownish fluid. The tuber- 
culous deposits are found upon the peritoneal surface of the intestine, 
and infiltrate the intestinal walls, often leading to perforation, and some- 
times to fistulous communications between adherent intestinal coils. 
There may also be tuberculous infiltration of the abdominal walls, ac- 
companied by cellulitis, resulting in abscesses, which may open exter- 
nally, usually in the neighbourhood of the umbilicus. 

The ulcerative form may succeed either the miliary or fibrous form, 
or the inflammation may be of this type from the outset. Tuberculous 
lesions are always found in the other organs, especially in the lungs, 
where they are usually advanced. 

Clinically the ulcerative cases are characterized by well-marked con- 
stitutional symptoms, which are due partly to the peritonitis and partly 
to the general tuberculosis. Fever is regularly present, the temperature 
usually ranging from 99° to 102° F. Sometimes it assumes a distinctly 
hectic type. There is progressive emaciation, anaemia, prostration, and 
sweating. Diarrhoea is frequent and the intestinal discharges may at 
times be bloody. The abdomen is large, but not so much distended as in 
some of the other forms ; the superficial veins are often prominent. It 
is rare that ascites can be made out by percussion, although fluid can 
often be found by puncture. Areas of dulness and tympanitic resonance 
are irregularly distributed, Nodular masses from one to two inches in 



474 DISEASES OP THE DIGESTIVE SYSTEM. 

diameter may be felt anywhere in the abdomen. The epigastric and um- 
bilical regions may be occupied by a smooth, hard tumour — the thickened 
omentum — which may resemble the liver. There may be the signs of 
phlegmonous inflammation of the abdominal wall in the neighbourhood 
of the umbilicus, and even an abscess, which, after opening, may leave a 
fistulous communication with the peritonaeum. There are usually some 
signs of disease in the lungs, and the pulmonary symptoms may mask 
those of the abdomen. The course of the disease is steadily progressive, 
the usual duration being two to six months. Death results from the 
pulmonary disease, from tuberculous meningitis, from exhaustion, and 
occasionally it is due to accidents associated with perforation. 

5. Peritonitis associated with Tuberculosis of the Mesenteric Lymph 
Nodes. — These nodes may be tuberculous in any of the preceding varie- 
ties. In certain cases this is the principal lesion, and it is accompanied 
by localized peritonitis, which results in the formation of a large, irregu- 
lar, nodular mass lying close against the spine. It is usually associated 
with tuberculous ulcers of the intestine. There may be no symptoms 
except those depending upon the pressure of the glandular masses upon 
the great vessels. This may lead to oedema of the lower extremities or to 
thrombosis of the vena cava, and may give rise to an abdominal tumour. 
There may be diarrhoea due to the intestinal lesions. 

Diagnosis of Tuberculous Peritonitis. — In children, chronic ascites 
with fever usually means tuberculous peritonitis. If the abdominal effu- 
sion is sacculated instead of diffuse, the probabilities of peritonitis are 
much increased. If there are added the physical signs and symptoms of 
disease of the lungs, the diagnosis is almost certain. Cirrhosis of the 
liver is much more chronic in its course, and is very rare previous to the 
ninth year, being almost unknown in infancy and early childhood. In it 
there is often a history of syphilis, and jaundice may be present. If 
ascites is absent, tuberculosis of the peritonaeum may be suspected if 
there are irregular nodules or tumours in various parts of the abdo- 
men, with tenderness, emaciation, moderate pain, and persistent fever. 
Chronic abscess in the neighbourhood of the umbilicus is always suspi- 
cious. The ulcerative form is generally accompanied by evidences of tu- 
berculous disease in the lungs and other organs, and is easily recognised. 
The fibroid form may be suspected if, with tuberculosis of other organs, 
there are irregular colicky pains and abdominal tenderness. From the 
abdominal symptoms alone it can not be recognised unless there is as- 
cites. In all doubtful cases an exploratory incision should be made. 

Between tuberculous and non-tuberculous chronic peritonitis a diag- 
nosis is at times impossible. If there is a good family history; if there 
are no signs of tuberculosis in the lungs or elsewhere ; if abdominal ten- 
derness is slight or absent ; if there are no nodular tumours ; if fever and 
marked emaciation are wanting ; and if the amount of fluid is excessive, 



TUBERCULOUS PERITONITIS. 475 

the probabilities are in favour of a simple inflammation. There are, 
however, some cases in which the diagnosis can be made only by an 
exploratory incision, and sometimes not even then without an examination 
of the fibrous nodules by the microscope or by inoculation experiments. 
In doubtful cases the chances are always much in favour of tuberculous 
inflammation on account of its greater frequency. 

Prognosis. — Cases of the ulcerative type are hopeless. In the ascitic 
and fibrous forms the prognosis is better; a certain number recover 
under medical treatment, others are cured by operation. Exactly in what 
proportion the cure is permanent, it is at present impossible to say, 
for most of the reported cases were not under observation long enough 
to make it certain that relapses did not occur. 

Treatment. — The general treatment of tuberculous peritonitis is the 
same as that of tuberculosis in other parts of the body. The essentials 
are, rest in the recumbent position, a climate mild enough to permit the 
patient to remain out of doors the greater part of the time, and very care- 
ful attention to feeding with the purpose of improving the general 
nutrition. Under this treatment a very considerable number of patients 
recover. Such a termination is more likely if the diagnosis has been 
made early and if the disease is limited to the peritonaeum. Specific 
drugs play but a small part in the treatment of these cases. 

In cases not progressing favourably under general medical treatment, 
the question of operation must be considered. By means of laparotomy 
very many cases have been cured completely. The most favourable cases 
for operation are those of the ascitic variety. Aldibert, in his monograph, 
gives the indications and contra-indications for operation as follows : 
Laparotomy is indicated in all forms accompanied by ascites, although 
in acute cases it may be only palliative ; in suppurative forms which are 
diffuse, or with a unilocular cyst; in all cases of intestinal obstruction 
in the course of tuberculous peritonitis ; and in all cases of doubtful diag- 
nosis. Operation is contra-indicated in the fibrous form not attended 
by pain, this usually tending to spontaneous recovery ; in the dry ulcera- 
tive form, except at the outset; in the suppurative form with multilocular 
cysts. The existence of other foci of tuberculosis does not contra- 
indicate operation except when these are chiefly intestinal, or when 
there is general tuberculosis with extensive and rapidly progressing 
lesions. 

Aldibert has collected statistics of fifty-two operations, with seven 
deaths and forty-five recoveries. Xine patients were reported well one 
year after operation. It is possible that among these cases Bome of sim- 
ple inflammation were included; of eighteen cases, however, in which the 
diagnosis of tuberculosis was established by the microscope or inocula- 
tion experiments, all recovered, and six were well one year after operation. 
Why opening the abdomen and draining or washing out the peritoneal cav- 



476 DISEASES OF THE DIGESTIVE SYSTEM. 

ity should have such an influence in arresting the disease, has not yet 
been satisfactorily explained. For the surgical aspect of the treatment 
the reader should consult works upon surgery. 

ASCITES. 

Ascites consists in an accumulation of fluid, usually clear serum, in 
the general peritoneal cavity. It is a symptom of the various forms of 
peritonitis, especially the chronic varieties described in the preceding 
pages. It may be due also to portal obstruction from cirrhosis of the 
liver, or pressure upon the portal vein by peritoneal adhesions or large 
lymphatic glands. It is occasionally seen in all forms of abdominal 
tumours. Ascites may occur in general dropsy from cardiac disease, 
chronic pleurisy, or interstitial pneumonia, or from any condition caus- 
ing pressure upon the vena cava. It is also seen in the general dropsy of 
renal disease. A moderate amount of ascites is often met with in ex- 
treme anaemia or leukaemia. 

Small accumulations of fluid in the peritoneal cavity are difficult of 
detection. Large amounts are generally easily made out. There is a uni- 
form smooth distention of the abdomen and dilatation of the superficial 
veins, especially about the umbilicus. On palpation, the wave of fluctu- 
ation can be obtained by placing one hand against the abdomen upon one 
side and giving the opposite side a sharp tap. A similar wave may be felt 
when there is tympanitic distention. The two are, however, readily dis- 
tinguished by having an assistant make pressure with the edge of the hand 
along the linea alba while the test is being made ; this obstructs the wave 
transmitted through the abdominal wall, but does not affect that through 
the fluid. On percussion in the sitting posture, there are dulness below 
and resonance above. When the patient is recumbent, there are resonance 
in the median line and dulness or flatness in the lateral portion of the 
abdomen. 

The prognosis and treatment of ascites will depend upon its cause. 

Chylous Ascites. — This term is applied to certain cases in which the 
abdominal fluid contains fat. The colour may be milky-white or light 
brown, and the fluid, after standing, may have at its surface a thick, 
creamy layer. The amount of fat present has been as high as five per cent. 
This condition is rare in childhood. In 1884, Letulle * could find but 
seven cases on record. The exact pathology is as yet not well understood. 
In the cases which have thus far come to autopsy there has usually 
been found chronic peritonitis, sometimes simple, sometimes tuberculous. 
The lymph vessels in some of the cases have been empty, and often no 
obstruction of the lymph circulation could be discovered. The fat is 
believed by some to be derived from fatty degeneration of the products of 
chronic inflammation, but this seems hardly sufficient to explain the large 

* Revue de Medecine, 1884, No. 9. 



SUBPHRENIC ABSCESS. 477 

amount of fat sometimes found. In some of the cases it has been due 
to a wound of the thoracic duct. The amount of fluid is frequently very 
large. The prognosis is usually bad, although Pounds has reported (Brit- 
ish Medical Journal, 1892) a case in a girl of ten years, where recovery 
followed laparotomy. Tuberculous peritonitis was present. 

SUBPHRENIC ABSCESS. 

In the group of cases of localized peritonitis or peritoneal abscess 
must be included subphrenic abscess. This is a rare condition in child- 
hood, and consists in an accumulation of pus just beneath the diaphragm 
and above the liver. Its cause may be either in the thorax or in the abdo- 
men. It may complicate acute pneumonia, usually of the right lower 
lobe, by a direct extension of infection through the lymph channels. 
Sometimes it has been associated with phthisical cavities. In the abdo- 
men it may be associated with disease of the liver. The accumulation of 
pus is sometimes very great, so that the diaphragm is crowded high into 
the thorax. 

The symptoms and physical signs closely resemble those of empyema, 
and most of the cases have been operated upon with the belief that the 
surgeon was dealing with empyema. Meltzer has reported a case in a 
child of two years which followed pneumonia of the right base. At the 
operation only a few drops of pus were found in the pleural cavity; but 
there was discovered a pinhole opening in the diaphragm, from which the 
pus had escaped from a large subphrenic abscess. This was evacuated, 
and the patient recovered perfectly. Subphrenic abscesses may contain 
air; they are then likely to be mistaken for pneumothorax. These ab- 
scesses require incision and drainage like other forms of peritoneal abscess. 



SECTION IY. 
DISEASES OF THE RESPIRATORY SYSTEM. 

CHAPTER I. 

NASAL CAVITIES. 

ACUTE NASAL CATARRH— CORYZA. 

Although the symptoms of acute nasal catarrh are chiefly nasal, the 
principal seat of the pathological process is the rhino-pharynx. 

Etiology. — Certain children are predisposed to attacks of acute nasal 
catarrh. This predisposition, as it sometimes extends to entire families, 
may be inherited ; but more frequently it is acquired, and usually by the 
following mode of life : It is seen in children who get very little fresh air, 
because they are kept indoors unless the weather is perfect ; who live in 
houses always overheated ; whose sleeping rooms are kept carefully closed 
at night for fear they may take cold; who are for the same reason so 
overloaded with clothing that they can not engage in any active play 
without being thrown into a profuse perspiration. These conditions 
after a time result in a great sensitiveness of all the mucous membranes, 
but especially those of the nose and pharynx, which is much increased 
by residence in a damp, changeable climate. A small adenoid growth is 
very often present. Young infants and those who are rachitic, are 
frequent sufferers from acute nasal catarrh. Attacks are often brought 
on by insufficient covering for the head, by wetting the feet, by cold and 
exposure, especially to the raw winds of spring, accompanied by the 
dampness which occurs with melting snow. In susceptible children the 
exciting cause is often a very trivial one. A draught of cold air for a 
few minutes may be sufficient to excite sneezing and a nasal discharge. 
Atmospheric conditions are probably not the only cause of acute nasal 
catarrh. Micro-organisms certainly play an important part, particularly 
in the purulent variety. Although pyrogenic germs are always present 
in the nose, they do not excite an attack of acute catarrh without the 
vascular changes which are produced by other causes. Acute catarrh may 
be sporadic or epidemic; it is probably contagious, being communicated 
by children using the same handkerchief or occupying the same bed. 

Acute nasal catarrh may be a symptom of measles, nasal diphtheria, 
or influenza, and it may accompany erysipelas of the face. 

478 



ACUTE NASAL CATARRH. 479 

Symptoms. — The changes in the mucous membrane of the nose are not 
great, and are usually secondary to those of the rhino-pharynx, being in a 
large measure due to the discharge. There are redness and slight swell- 
ing. The nasal passages may be for the time quite occluded by the dis- 
charge, which is usually profuse, at first sero-mucous, and finally, if the 
attack is severe, muco-purulent. The symptoms may be very transient, 
sometimes passing away in a few hours, in which cases there is only a vaso- 
motor disturbance ; or they may continue and develop into a true inflam- 
mation. The discharge excoriates the nostrils and the upper lip. At the 
onset there is usually sneezing, and in infants often a slight fever. In 
older children there is no rise of temperature except in the most severe 
cases. The obstruction to nasal respiration causes mouth-breathing, and the 
dryness and discomfort which result from it produce disturbed sleep, snuf- 
fling and difficulty in nursing, this being in severe cases almost impossible. 
The inflammation may extend to the lachrymal duct, involving the eyes in 
a mild conjunctivitis. There may be closure of the Eustachian tubes, 
causing deafness and otalgia. There may also be secondary otitis. The 
process often extends to the larynx and bronchi, with hoarseness and cough. 

In infants, severe cases may be followed by inflammation of the lymph 
glands of the neck or of the retro-pharyngeal region ; in either it may ter- 
minate in abscess. Less frequently these catarrhal colds are accompanied 
by disturbances of the digestive tract, and there is vomiting, or diarrhoea 
with large mucous stools. 

Attacks of acute nasal catarrh are stated by some writers to cause 
death in young infants by interfering with respiration. I have never 
seen dangerous symptoms, and believe them to be exceedingly rare, if, in- 
deed, they ever occur as a result of a simple coryza. In the mild form 
the attack lasts from two to three days; in the severe form from one 
to two weeks. Repeated attacks are frequently followed by the develop- 
ment of the chronic form of the disease. 

Diagnosis. — It is important to distinguish between a simple acute ca- 
tarrh and one due to measles, influenza, nasal diphtheria, or hereditary 
syphilis. Measles and influenza cause more fever and general constitu- 
tional disturbance than does simple catarrh. Nasal diphtheria is usually 
characterized by the appearance of membrane in the anterior nares and 
by patches upon the tonsils. These may be wanting, however, and there 
may be only a very profuse discharge tinged with blood. When persisting 
for two or three weeks this is always to be regarded with suspicion, even 
though the constitutional symptoms may be very slight. The only posi- 
tive means of excluding diphtheria is by cultures. A persistent acute 
nasal catarrh in a young infant should aways suggest syphilis, and the pa- 
tient should be carefully watched for trn development of other symptoms. 

Treatment. — A child suffering from acute coryza should always be kept 
indoors in a room with an even temperature of about 70° F., the bowels 
ireely opened, and the amount of food somewhat reduced. The only drug 



480 DISEASES OF THE RESPIRATORY SYSTEM. 

which seems to have much influence upon the secretion is belladonna. 
A good combination is that known as the " rhinitis " tablet (camphor 
gr. J, quinine gr. £, fluid extract of belladonna TT[ -J) • one half a tablet 
may be given every hour to a child of five years. 

Useful local applications are albolene oil, oleo-stearate of zinc, alka- 
line sprays, such as Seller's solution, to clear away the secretions, to be 
followed by a spray containing adrenalin. If the nasal obstruction causes 
great interference with respiration or nursing, the following may be used 
with a medicine dropper or spray : 

9 Adrenalin (1-1,000 sol.) 3 iss. ; 

Acidi carbolici gr. v ; 

Acidi borici v . gr. xx ; 

Glycerini lit x ; 

Aquae destillat q. s. ad. % ij. 

M. k 

In all cases the upper lip and nostrils should be protected by vase- 
line or some simple ointment. Under no circumstances should irritat- 
ing or astringent injections be given. In older children inhalations of 
spirits of camphor may be used with advantage. 

Prophylaxis consists in solving the perplexing question, so often put to 
the physician, of how to prevent children from "taking cold." This is a 
matter of the utmost importance, and follows what has been previously 
said under the head of Etiology. No amount of cod -liver oil and iron 
will remove this tendency to catarrh so long as bad hygienic conditions 
continue. Sleeping rooms should be large and well ventilated, and a 
window should be kept open at night, except in very severe weather or 
during acute attacks. The temperature of the house during the day should 
be from 68° to 70° F., but never above this. Children should be accus- 
tomed to go out of doors unless the weather is especially bad. So firmly 
rooted in the minds of the laity is the idea that acute catarrhs come from 
cold, that the habit of coddling delicate children is always likely to be 
carried to an extreme. 

With every delicate and " catarrhal " child one should begin in the 
summer by having him live in the open air as much as possible, seeping 
in a room with free ventilation, with moderate covering, and continuing 
the same practice into the fall and early winter. If begun gradually in 
this way there is little difficulty in continuing throughout the winter. 

The next point to be insisted on is cold sponging immediately upon 
rising in the morning, especially about the chest, throat, and spine (page 
57). The use of chest protectors, cotton pads, and extremely thick cloth- 
ing should be prohibited. Flannel underclothing should be worn upon 
the chest throughout the year, and upon the legs also in winter ; the very 
lightest in summer, and only a medium weight in winter. 

Frequently repeated attacks point to the presence of adenoid vegeta- 
tions in the pharynx, and no measures are of much avail until these are 
removed. 



CHRONIC NASAL CATARRH. ' 481 

CHRONIC NASAL CATARRH. 

This term is rather loosely used to designate a chronic nasal discharge. 
Such a discharge is frequent both in infancy and childhood. It is a con- 
dition much neglected by the general practitioner. Patients are too often 
subjected to routine constitutional treatment by cod-liver oil and prep- 
arations of iodine, with the idea that such cases are " scrofulous," while 
local treatment is either neglected altogether, or consists only of the use of 
the nasal douche or syringing with a saline solution. Sometimes, when 
suggested by parents, local treatment is opposed by the physician in the 
case of young children, and a great amount of harm follows. Permanent 
damage to the organs of hearing, smell, speech, and respiration may result 
from neglecting or ignoring chronic nasal catarrh in childhood. 

Chronic nasal catarrh is not to be regarded as a disease, but only as 
a symptom which may be due to any one of a variety of pathological con- 
ditions, each of which requires very different treatment — viz., adenoid 
growths of the pharynx, foreign bodies in the nose, polypi, deviation 
of the septum or any other congenital deformity of the nasal passages, 
the various forms of chronic rhinitis, and syphilis, which causes a form of 
rhinitis peculiar to itself. 

Adenoid Growths of the Pharynx. — These are more fully discussed 
elsewhere. They are by far the most frequent cause of chronic nasal 
discharge in infants and young children, and should be the first one 
suspected. Every general practitioner can easily familiarize himself with 
the method of digital exploration of the rhino-pharynx, by which means 
these growths can in most cases be easily recognized. The nasal dis- 
charge accompanying adenoid growths is due to a chronic rhino-pharyn- 
gitis. Treatment is without avail unless the growths are removed. After 
this is done the nasal discharge usually disappears quite promptly. 

Foreign Bodies in the Nose. — This condition should be suspected 
whenever there is an abundant muco-purulent discharge limited to one 
nostril. Foreign bodies in the nose are quite frequent in young children. 
Peas, v 3ans, beads, or shoe buttons are most frequently lodged there. 
The efforts at removal on the part of the child, or even of the mother, 
generally result in pushing the body farther into the nose. It first Bets 
up a mechanical irritation, accompanied by pain, swelling, sneezing, and 
sometimes haemorrhage. This is followed by a catarrhal inflammation, 
which in the course of a few days becomes purulent, and may last indefi- 
nitely. The discharge is generally quite abundant. The symptoms point 
to an obstruction of one nostril, and an examination with the probe readily 
detects the presence of the foreign body. 

In recent cases the removal of the foreign body may sometimes be 
accomplished by compressing the empty nostril and having the child blow 
his nose strongly. Often the sneezing which the foreign body excit- 



482 DISEASES OP THE RESPIRATORY SYSTEM, 

sufficient to remove it. Before any attempt is made to seize the body 
with forceps cocaine should be used, not only for the purpose of prevent- 
ing pain, but in order to shrink the mucous membrane so as to allow 
better manipulation. In many cases chloroform is necessary. In most 
circumstances ordinary foreign bodies can with proper forceps be ex- 
tracted without difficulty. No subsequent treatment is required, except 
the use of some mild antiseptic to keep the nose clean for a few days, as 
the inflammation quickly subsides after the removal of the cause. 

Nasal Polypi. — These are among the infrequent causes of chronic 
nasal discharge in childhood. They are especially rare before the seventh 
year, but both mucous and fibrous polypi are seen. The symptoms are 
those of a chronic nasal catarrh with partial or complete obstruction of 
one or both sides. Polypi increase in size with the occurrence of every 
acute coryza, and are always especially troublesome in damp weather. 
They may be accompanied by reflex symptoms, such as cough, sneezing, 
and even by attacks of asthma. There may be headache, and sometimes 
disturbances of smell, taste, and hearing. The symptoms are of much 
longer duration than in the case of obstruction from a foreign body, the 
discharge is not so abundant, and is not purulent. The diagnosis is made 
only by examining the nose with the mirror and nasal speculum. 

Polypi may be removed with the forceps, but this is best accomplished 
by the use of the wire snare. When they have been present for a long 
time the accompanying chronic rhinitis may require subsequent treat- 
ment. 

Deviation of the nasal septum, and other congenital deformities 
which cause narrowing of the nasal respiratory tract, are conditions which 
belong to the specialist. 

CHRONIC RHINITIS. 

Three forms of chronic rhinitis are recognised — simple, hypertrophic, 
and atrophic. 

Simple Chronic Rhinitis. — Simple chronic rhinitis existing alone is of 
rare occurrence in young children. In the cases so classed the symptoms 
are usually due to rhino-pharyngitis, which almost invariably depends 
upon an adenoid growth. The growth may be a small one, so that the 
symptoms of obstruction are slight or absent. A frequent complication 
is chronic enlargement of the cervical lymph glands. 

The only constant symptom is an excessive nasal discharge, which is 
usually mucous, but which may be muco-purulent. It is easily removed 
by blowing the nose, if the child is old enough to be taught to do this. 
Children too young to clear the nose in this way, suffer from almost con- 
stant discomfort. The amount of discharge depends upon the severity of 
the case. It frequently causes irritation of the upper lip, which may be 
the seat of eczema or impetigo, especially in infants. The lip may be 



CHRONIC RHINITIS. 483 

swollen and prominent. The condition of the external parts is aggra- 
vated by the constant disposition to pick the nose, which may be over- 
come by the application of a short anterior splint to each elbow. 

Epistaxis sometimes occurs. The duration of the disease is indefi- 
nite ; it may last for months or even for years, the symptoms in summer 
being insignificant, but returning every cold season. It may terminate 
in recovery, or, in children with flabby tissues and delicate constitution, 
it may be followed in later childhood by hypertrophic rhinitis. 

Treatment. — Prophylaxis is very important. The main purpose 
should be to prevent attacks of acute nasal catarrh by the measures men- 
tioned in the discussion of that disease. The general treatment should 
not be routine, but directed according to the indications of each case. 
There should be careful attention to diet and to the condition of the 
bowels. Iron and arsenic are needed when there is anaemia. A general 
tonic treatment is required in most cases. Cod-liver oil and the syrup 
of the iodide of iron are both useful, but are not specifics, and must be 
intelligently combined with other measures. 

Local treatment consists first in cleanliness, and, secondly, in the use 
of astringents in the form of powder or solution. For cleansing, a solu- 
tion which is both alkaline and antiseptic is desirable. This may be used 
in the form of a spray, after which the nose is cleared by blowing ; or in 
infants, if the discharge is abundant, the only efficient method of getting 
rid of it is by nasal syringing. This is attended by some risk of forcing 
materials into the middle ear; but if carefully done, the danger seems 
to me to be less than that of allowing the discharge to remain. Syring- 
ing should always be done with the mouth open and the head inclined 
forward. All solutions are to be made with sterilized water and used 
warm. But little force should be employed, and it may be well to have 
a syringe the nozzle of which does not completely fill the nostril. Either 
DobelPs or Seller's solution may be employed, diluted with an equal 
amount of water. As a spray the following may be used : 

3 Listerine * 1 ss. 

Sodii bicarb., 

Sodii biborat aa 3 ss. 

Aquae 5 iv - 

If this is to be used with a syringe, twice as much water should be added. 
Ordinarily, the nose should be cleansed thoroughly twice a day, more 
frequently in very severe cases. Once a day, after the nose has been 
cleansed, an astringent solution or powder should be applied. One of the 
best solutions is sulpho-carbolate of zinc (gr. v to water | j). This may 
be used as a spray, or, better, dropped into the nostril with a medicine 

* Listerine is a combination containing the essential oils of thyme, eucalyptus, bap- 
tisia, gaultheria, and mentha arvensis. 



484 DISEASES OF THE RESPIRATORY SYSTEM. 

dropper, the head being held far back. A good powder is a combination 
of salicylic acid gr. iij, tannic acid gr. xxx, and stearate of zinc §j, which 
may be used with an insufflator once daily. 

Hypertrophic Rhinitis. — This is a chronic inflammation of the nasal 
mucous membrane, accompanied by a marked hypertrophy of all its nor- 
mal structures, particularly its blood-vessels. The parts chiefly affected 
are those covering the inferior turbinated bones. The mucous mem- 
brane and submucous tissue are so thickened and relaxed that they may 
greatly encroach upon the nasal respiratory space, and when these venous 
sinuses are filled with blood, they may entirely occlude the passage. 
There is usually associated with this condition some degree of hyper- 
trophy of the adenoid tissue of the pharyngeal vault. 

In young children hypertrophic rhinitis is a very infrequent disease, 
if, indeed, it ever occurs. It is fairly common in moderate degree in 
older children, although its severe forms are rare. It usually follows re- 
peated attacks of acute nasal catarrh in children of a lymphatic diath- 
esis. A frequent local cause is a deflected nasal septum. 

The symptoms are those of nasal catarrh with bilateral nasal stenosis. 
The discharge is usually abundant, thick, and tenacious, being increased 
by dust and dampness. All the symptoms of nasal obstruction are pres- 
ent in varying intensity — the " wooden" voice, mouth-breathing, dis- 
turbed sleep, etc. There may be reflex cough, catarrh of the larynx or 
bronchi, accompanied by muscular or vaso-motor spasm, giving rise to 
spasmodic croup or asthma. Ehinoscopic examination shows the large 
pendulous masses of mucous membrane, usually red and irregular, more 
or less completely blocking the nasal passage. It is only by this exami- 
nation that the disease is differentiated from adenoids of the pharynx, 
with which, however, it is frequently associated. In infants and young 
children the adenoid growth is much the more frequent, and throughout 
childhood generally the more important factor in producing these symp- 
toms. 

The treatment of these cases falls largely to the specialist, although 
very much can be done by the general practitioner if he will learn to use 
intelligently a few remedial agents. Constitutional treatment is indi- 
cated as in simple rhinitis, but if employed alone it accomplishes little 
or nothing. The purpose of local treatment is the reduction of the 
hypertrophied tissue by cauterization under cocaine anaesthesia, by 
glacial-acetic or chromic acid, or by the galvano-cautery. Each has its 
advantages and its advocates. If the hypertrophied tissue forms pendu- 
lous tumours, it may be removed by the wire snare. Both nostrils should 
not be operated upon at the same time. In most cases cauterization 
must be repeated several times at intervals of a few weeks. In the 
meantime one of the cleansing solutions mentioned on page 56 may be 
employed. 



CHRONIC RHINITIS. 485 

The following formula of Lefferts is an excellent one for a spray to 
be used in this condition: 

^ Iodi gr. iv 

Potass, iodidi gr. x 

Zinci iodidi, 

Zinci sulpho-carbolat aa gr. xx 

Listerine % j 

Aquae 1 iv 

To be used as a spray once daily. 

Atrophic Rhinitis {Fetid Catarrh). — This is rare in young children, 
and only occasionally seen in those over twelve years old. It is char- 
acterized by the formation of crusts in the nose, which decompose and 
produce a horribly fetid odour. By some writers the term ozama is ap- 
plied to this disease, but usually this term is limited to rhinitis associ- 
ated with disease of the bones. Atrophic rhinitis has been regarded by 
some as the late stage of the hypertrophic form. This view, however, is 
strongly combatted by Bosworth, who considers it the result of a puru- 
lent form of acute rhinitis. The changes consist in an atrophy of the 
mucous membrane and the destruction of many of the secreting glands. 
The nasal fossae are large and roomy. The voice is not affected, but the 
sense of smell may be much impaired. There are no symptoms of obstruc- 
tion. The discharge is scanty, and tends to accumulate between the bones, 
forming large crusts, which are expelled with difficulty by blowing the nose. 

In the severe cases the treatment is only palliative, yet this is of the 
utmost importance for the comfort of the patient and those about him. 
The object of treatment is to prevent as much as possible the forma- 
tion of crusts by the frequent use of an oil spray, such as liquid albolene, 
.in order to coat the dry mucous membrane. For the removal of crusts 
they must first be macerated by a prolonged nasal douche as hot as can be 
borne. This should be thoroughly used morning and evening as a part 
of the patient's toilet. In employing the douche, a bag containing from 
one to two pints should be suspended a few inches above the patient's 
head. One of the alkaline and antiseptic fluids mentioned on page 56 
may be added to the douche. The head should be slightly inclined for- 
ward and the mouth kept open during the douche. The mechanical 
removal of the crusts may be necessary if they are large, hard, and im- 
pacted. Benefit may be derived in some cases from the daily use of a 
stimulating spray containing ten grains of menthol to one ounce of liquid 
albolene. One of the very best deodorizers for general use is listerine, 
which, diluted with two or three parts of water, may be employed as a 
spray several times a day, in addition to the other measures mentioned. 

Syphilitic Rhinitis. — Rhinitis is seen both in early and late hereditary 
syphilis. Coryza, or snuffles, is one of its earliest and most constant 
symptoms. It usually begins between the third and sixth weeks of life, 



486 DISEASES OF THE RESPIRATORY SYSTEM. 

rarely after the third month. The pathological condition is a sub- 
acute catarrhal rhinitis, sometimes with the formation of superficial 
ulcers or mucous patches. The disease is attended by a profuse nasal 
discharge of sero-mucus or muco-pus, occasionally tinged with blood. It 
may continue from a few weeks to two or three months. It usually re- 
quires only constitutional treatment, and protection of the nostrils and 
lips by the use of the ointment of the yellow oxide of mercury diluted 
with four parts of vaseline. This may be introduced with the finger or 
brush for some distance into the nostrils. When the discharge is very 
abundant, any one of the cleansing solutions previously mentioned may 
be used as a spray. 

The rhinitis of late hereditary syphilis is a very different patholog- 
ical condition. There are here gummatous deposits which break down, 
and form ulcers of the mucous membrane and deeper tissues. There is 
also periostitis, with extension of the disease to the cartilages and bones 
of the nasal fossae, particularly of the septum. There may be perforation 
of the triangular cartilage, necrosis of the vomer or nasal bones, perfora- 
tion of the hard or soft palate, and at times extensive ulceration of the 
alae nasi and the face. This may be followed by cicatrization, causing ste- 
nosis of the nostril. These lesions in the nose are generally accompanied 
by deep ulceration of the pharynx and soft palate. They usually occur in 
children who have presented the early symptoms of hereditary syphilis, 
but are occasionally seen when no such history can be obtained. Such 
was the case in a patient recently under observation in the Babies' Hos- 
pital, who had perforation of the nasal septum and of the floor of the 
nasal fossae, causing a free communication with the mouth. These are 
cases of true ozaena. The odour from the discharge is at times almost 
intolerable. When neglected, these cases go on from bad to worse, and 
may continue for years, producing unsightly deformities. 

The treatment is, to bring the patient fully under the influence of 
mercury, first by means of the mercurial ointment or by small doses of 
calomel — i. e., one-tenth grain four or five times a day. Later the bin- 
iodide or the bichloride should be substituted, and iodide of potassium 
given in doses of ten to twenty grains three times a day. Tonics are 
needed in most cases, as the general health is frequently undermined and 
the patients are usually anaemic. 

Locally there may be used a spray of one of the cleansing solutions 
already mentioned, or black wash, or a solution of bichloride of mercury, 
1 to 10,000. For purposes of deodorization, listerine is one of the best 
remedies. Although improvement may take place quite promptly, the 
results of treatment are often unsatisfactory, as the disease has usually 
progressed so far before treatment is begun that some deformity of the 
nose results, usually a sinking in of the bridge and flattening of the alae, 
giving rise to the so-called " saddle-back " deformity. 



MEMBRANOUS RHINITIS. ±87 



MEMBRANOUS RHINITIS. 

The results of bacteriological examinations have shown that these 
cases, whose etiology was formerly the subject of considerable contro- 
versy, are nearly always due to the Klebs-Loeffler bacillus, and hence are 
to be regarded as true nasal diphtheria. It has been difficult, from clin- 
ical features alone, to establish this relationship, as the disease differs in 
several important particulars from diphtheria of the pharynx and rhino- 
pharynx — viz., its prolonged course, the absence of glandular enlarge- 
ments, and the presence of very mild constitutional symptoms, which are 
sometimes altogether wanting. These peculiarities are due to the very 
slight absorption which takes place from the nose, which is in striking 
contrast with that from the rhino-pharynx. The importance of recognis- 
ing such cases as true diphtheria can not be overestimated, as they have 
often been the means of spreading infection in schools and institutions 
before their true nature was determined. The possibility of membranous 
inflammation of the nose arising from other micro-organisms than the 
diphtheria bacillus is not to be denied, but such cases are extremely rare. 

The most striking clinical feature of primary nasal diphtheria is a 
nasal discharge of serum or sero-mucus, frequently streaked with blood. 
It is sometimes very abundant, at other times slight. There are also the 
symptoms of moderate nasal obstruction. The false membrane can in 
most cases be seen in the anterior nares as a gray or whitish exudation. 
It may cover the whole inner surface of the nose. It often remains for 
two or three weeks, when it may loosen and come away en masse, some- 
times forming an entire cast of the nose. After forcible removal it may 
reform. The disease in very many cases remains limited to the nose, but 
it may at any time extend to the rhino-pharynx or to the larynx. When 
such an extension takes place it is accompanied by an increase in the con- 
stitutional symptoms, glandular swellings, etc. A positive diagnosis can 
be made only by means of cultures. 

In addition to the use of antitoxin, the nose in these cases should 
be syringed frequently with a warm saturated solution of boric acid, 
or bichloride of mercury, 1 to 10,000, with 5 per cent of glycerin. Such 
cases must be isolated, like ordinary cases of diphtheria. 

EPISTAXIS. 

The haemorrhage may come from any part of the nasal fossa, but it 
is generally from the anterior nares, and most frequently from the ves- 
sels of the septum. Epistaxis is a rare symptom in the hsemorrhi 
of the newly born, and when present indicates syphilis. It is infrequenl 
throughout infancy, but in childhood it is quite common, occurring in 
boys more frequently than in girls. In the latter it is especially common 



4S8 DISEASES OF THE RESPIRATORY SYSTEM. 

about the time of puberty. Children who are kept much indoors in over- 
heated apartments, and who have susceptible mucous membranes and 
flabby tissues, are particularly prone to it. The exciting cause may be a 
local one, like a fall or blow; it may be due to picking the nose, or to 
any kind of mechanical irritation; it may be associated with nasal ca- 
tarrh; and it is often caused by a small ulcer upon the septum. An 
attack may be brought on by mental or physical excitement. It occurs 
as an occasional, often an early symptom, in typhoid or malarial fever, in 
measles, or during severe paroxysms of pertussis. It is seen in the haem- 
orrhagic form of all the eruptive fevers, in certain cases of diphtheria, 
most commonly late in the disease, in haemophilia and scorbutus, in grave 
anaemia, leukaemia, and in diseases of the heart and blood-vessels. 

Symptoms. — Epistaxis is frequently preceded by a sense of fulness or 
pain in the head, which is relieved by the bleeding. The blood is usu- 
ally from one nostril, and comes slowly by drops. The amount lost is 
generally small, but it may be large enough, when repeated, to produce a 
serious grade of anaemia even in strong children, and the haemorrhage 
may prove fatal. Epistaxis may be overlooked if the blood finds its way 
into the pharynx and is swallowed. In most of the cases the haemor- 
rhage ceases spontaneously in from ten to twenty minutes, recurring at 
longer or shorter intervals, according to the nature of the cause. Haem- 
orrhage from adenoid growths of the pharynx may closely resemble that 
from the nose, but otherwise there can rarely be any difficulty in recog- 
nising epistaxis. In doubtful cases an inspection of the pharynx reveals 
the presence of blood-clots. 

Prognosis. — This depends upon the cause. In the great majority of 
the so-called idiopathic cases epistaxis is not serious. Occurring early in 
the course of the infectious diseases, it does not ordinarily affect the prog- 
nosis unless it is very severe. When it occurs late, however, it is always 
a bad sign, and particularly so in diphtheria. It may be serious in any 
of the haemorrhagic diseases or in diseases of the blood, where it is not in- 
frequently a cause of death. 

Treatment. — To remove the predisposition, a child should receive 
general tonic treatment, especially plenty of outdoor exercise, and every 
means should be taken, by the use of cold baths, friction, and proper food, 
to tone up the vascular system. 

An efficient means of arresting the haemorrhage is compression of the 
nose between the thumb and finger. This may be combined with the 
application of ice over the nose, and sometimes small pieces of ice may 
be introduced into the nostrils. The application of cold to the back of 
the neck or its use in the mouth may be of service by exciting reflex 
contraction of the capillary vessels. All tight clothing or bands about 
the neck should be loosened, and the patient kept quiet in the sitting 
posture. After the haemorrhage has ceased the child should not blow 



CATARRHAL SPASM OF THE LARYNX. 489 

his nose for some time. The supra-renal extract in solution is one of 
the most efficient local means of checking the bleeding. Another valu- 
able remedy is the peroxide of hydrogen, used full strength. If bleeding 
continues in spite of all the above measures, the anterior nares should 
be plugged with styptic cotton, and if this does not control it, the pos- 
terior nares should be plugged. Usually very little effect is seen from 
drugs given internally, although in frequently recurring haemorrhages 
where no local cause can be discovered ergot should be given a trial in 
full doses. 

In severe cases of nasal haemorrhage recurring at short intervals with- 
out any apparent cause, ulcer of the septum should be suspected, and, if 
present, should be touched with chromic acid. 



CHAPTER II. 

DISEASES OF THE LARYNX. 

The characteristic feature of laryngeal disease in infants and young 
children is the association of muscular spasm with all forms of inflam- 
mation. Often it is the laryngeal spasm, rather than the inflamma- 
tion, which gives rise to the principal symptoms. This spasm is only one 
expression of the great reflex irritability of young children. 

CATARRHAL SPASM OF THE LARYNX. 

Synonyms : Spasmodic laryngitis, spasmodic croup, catarrhal croup (sometimes 
improperly called laryngismus stridulus). 

The term catarrhal spasm, first suggested, I think, by Goodhart, is 
fairly descriptive of this disease, which is characterized by a very mild 
degree of catarrhal inflammation associated with marked laryngeal 
spasm. 

Etiology. — It is not often seen during the first six months, but is fre- 
quent from this time up to the third year. After five years it is rare. It 
occurs in children who are well nourished, as well as in those who are 
cachectic. Certain children have a predisposition to such attacks ; those 
who have had one attack are likely to have others. Heredity seems to 
have some influence in producing this susceptibility. Catarrhal spasm of 
the larynx is most frequently associated with enlarged tonsils and ade- 
noid growths of the pharynx, sometimes with elongated uvula. The ex- 
citing cause may be exposure to cold or an attack of indigestion. 

Lesions. — The catarrhal inflammation of the larynx affects chiefly 
the parts above the cords; there is congestion and dryness, and later 
increased secretion of mucus. To this there is added a spasm of the 



490 DISEASES OP THE RESPIRATORY SYSTEM. 

muscles of the larynx, especially the adductors. There is no submucous 
infiltration, and no tendency to oedema glottidis. 

Symptoms. — The attack may be preceded for several hours by slight 
hoarseness, or by a nasal discharge. During the day the child may ap- 
pear perfectly well. Usually there is heard during the evening a hol- 
low, barking cough, at first infrequent and not severe. About midnight 
this is apt to increase in severity, and there is now difficulty in breathing. 
As soon as this becomes marked the child wakes, and presents the char- 
acteristic symptoms of an attack. In the mildest cases the dyspnoea is 
not sufficient to waken the child. In severe cases there is marked dysp- 
noea, especially on inspiration, and a loud stridor as the air is drawn 
through the narrowed opening of the glottis. This may often be heard 
in an adjoining room. There is seen on inspiration deep recession of tho 
suprasternal fossa, the supraclavicular spaces, and the epigastrium; also 
depression of the intercostal spaces, and even of the walls of the chest. 
The terror of the child or any excitement increases the spasm and aggra- 
vates the dyspnoea. The distress is very great; the breathing usually 
slow and laboured; the voice hoarse, but rarely lost; the cough stridulous, 
hoarse, and metallic; the pulse rapid; the temperature normal or slightly 
elevated, rarely over 101° F. The child sits up and struggles for breath, 
its forehead covered with perspiration. There may be slight lividity of 
the finger-tips and of the lips, and sometimes considerable prostration. 
In the course of three or four hours the attack slowly wears away and 
the child falls asleep. During the following day, aside from slight 
hoarseness and occasional cough, the child is apparently well. Most of 
the cases are not so severe as this; there are the croupy cough, hoarse- 
ness, and general discomfort, but not marked dyspnoea. On the second 
night there is a repetition of the experience of the first, usually quite as 
severe unless affected by treatment; and on the third day a remission 
similar to that of the day previous. On the third night the attack, if it 
occurs at all, is generally a mild one. Slight hoarseness persists for 
several days, but otherwise the child is apparently well. Many children 
have such attacks every few weeks in the course of the cold season, the 
slightest exposure or an indiscretion in diet being sufficient to induce one. 

Prognosis. — This is good, the disease never, I think, proving fatal, 
although nothing is more alarming, at least to parents, than to witness 
for the first time one of these severe attacks of catarrhal croup. 

Diagnosis. — Catarrhal spasm may be confounded with laryngismus 
stridulus and with membranous croup. Laryngismus stridulus is a rare 
disease, and occurs only in infancy. In it we have not simply stridulous 
breathing, but periods of complete cessation of respiration. These may 
be repeated many times during the day, and may continue for weeks, 
being often complicated by carpo-pedal spasm, sometimes by general 
convulsions. 



CATARRHAL SPASM OF THE LARYNX. 491 

From membranous laryngitis, catarrhal spasm is distinguished by its 
sudden onset, the mildness of the symptoms of inflammation, the spas- 
modic character of the dyspnoea, and the daily remissions. The history 
of previous attacks will often aid in diagnosis. In case of doubt, a posi- 
tive diagnosis can often be made by allowing the child to inhale a little 
chloroform. This at once relieves dyspnoea due to spasm, while it has 
scarcely any effect upon that due to membrane. 

Treatment. — The purpose of treatment during the attack is to pro- 
duce relaxation of the laryngeal spasm. This is accomplished by the use 
of emetics, steam, and hot fomentations over the larynx. A favourite 
emetic is a tablet triturate of antimony and ipecac, gr. ^-^ each. To a 
child of two years, one tablet may be given every ten or fifteen minutes, 
until free vomiting occurs ; or a teaspoonful of the syrup of ipecac and 
fifteen drops of the wine of antimony at the same interval. When chil- 
dren do not vomit after two or three doses the antimony should not be re- 
peated, as it may produce serious depression. 

Emetics have a double value if the attack is due to indigestion. If 
there is constipation, an enema should be given. Following the free 
vomiting there is generally some improvement in the symptoms, but 
there may be a recurrence of the spasm unless other means are em- 
ployed. To prevent this, antipyrine is one of the most useful drugs. 
Two grains may be given to a child two years old. This may be repeated 
in four or five hours if necessary. Quite as much relief as that obtained 
from the drugs mentioned is seen from the use of steam inhalations. For 
this purpose the child should be placed in a closed tent, and steam intro- 
duced from a croup kettle (page 60). This may be used in conjunction 
with other measures, and continued as long as necessary. Poultices or hot 
fomentations over the larynx are often useful. In one case in which se- 
vere spasm had recurred for eight successive nights in spite of everything 
that was tried, the child being in great distress from the dyspnoea, I per- 
formed intubation, which gave instant relief. Tracheotomy, however, 
would scarcely be advisable. 

During the day following the first night attack, it is well to continue 
the antimony and ipecac in doses too small to produce vomiting — e. g., 
gr. ^ each, every four hours. After 6 P. M. the doses should be 
doubled, and at bedtime two grains of antipyrine given. If so treated, 
the symptoms may not recur upon the second night, or 'there may be 
only the cough without the severe dyspnoea. The child should be con- 
fined to the house for two or three days after one of these attacks, the 
drugs being gradually reduced; but the antipyrine should be given at 
bedtime for three or four successive nights. 

To prevent a repetition of the attacks and remove the tendency to 
them, it is most important that the child should have plenty of fresh air 
and cold bathing, especially cold sponging about the neck and chest. 



492 DISEASES OF THE RESPIRATORY SYSTEM. 

Everything which experience has shown to bring on the attack should be 
carefully avoided. Local causes, such as adenoid growths, hypertrophied 
tonsils, elongated uvula, etc., should receive appropriate treatment. Gen- 
erally it is not necessary to exclude fresh air from the sleeping room. 
Although an open window on a cold, damp night may sometimes excite 
the attack, plenty of fresh air tends rather to diminish the suscep- 
tibility. If the child's condition is poor, general tonic treatment is to 
be employed. 

ACUTE CATARRHAL LARYNGITIS. 

Acute laryngitis is not nearly so frequent as the disease just described, 
although it is much more severe, and may even be fatal. It occurs espe- 
cially in children from one to five years of age, usually in the cold season. 
Predisposition to attacks is induced by the same conditions as in the case 
of acute rhinitis. Catarrhal laryngitis may be primary, when it is usually 
excited by cold or exposure,* or it may be secondary to measles, influenza, 
scarlet fever, or other infectious diseases. It may also be of traumatic 
origin, from the inhalation of steam or irritating gases. 

Lesions. — There is a moderately intense congestion of the laryngeal 
mucous membrane, sometimes general and sometimes localized. This may 
be seen with the laryngoscope, but is not always visible after death. With 
the congestion there are swelling and dryness, followed by increased secre- 
tion. In the milder cases the process is limited to the mucosa. In the 
more severe cases it involves the submucosa also, which is congested, 
cedematous, and may be infiltrated with cells. The changes are especially 
marked in the lymphoid tissue of the subglottic region. The swelling 
may be sufficient to produce a very marked degree of laryngeal stenosis. 
In many mild and in all the severe cases there is associated catarrhal 
inflammation of the trachea, and often of the larger bronchi. In young 
children there is very little tendency to oedema glottidis, so frequent a 
complication in adults. 

Symptoms.— In the mild form, such as that which is usually seen in 
older children, there is hoarseness, or even loss of voice, and a laryngeal 
cough which is sometimes hard and teasing, always worse at night. There 
may be pain and soreness over the larynx. Constitutional symptoms 
are mild or absent, the patient not usually being sick enough to go to bed, 
and often rebelling even at being kept indoors. The duration of the dis- 



* The following case is a good illustration of a severe attack excited by cold: A 
rather delicate infant, eight months old, an inmate of the New York Infant Asylum, 
was taken out on a raw December day with very slight covering. In a few hours 
hoarseness and stridor were noticed, and the temperature was 101° P. ; three hours 
later it was 103°, and in spite of the usual remedies which were employed the dyspnoea 
had reached such a degree as to require intubation. The tube was worn only three 
days and the case made a prompt recovery. 



ACUTE CATARRHAL LARYNGITIS. 493 

ease is from four to ten days, with a strong tendency to relapses from 
slight causes. 

The severe form of catarrhal laryngitis is sometimes preceded by acute 
coryza, or there may be mild laryngeal symptoms for a few days before the 
development of the more severe ones. In other cases the disease develops 
rapidly and severe symptoms are present within a few hours from the onset. 

When the case is fully developed the voice is metallic and hoarse, 
and occasionally but not usually lost. There is a hoarse, dry, barking 
cough, which is very distressing, and sometimes almost constant. The 
cough, like the voice, is stridulous, and more or less stridor is present on 
inspiration. There is a slight amount of constant dyspnoea, but this is 
scarcely noticeable unless the chest is bared. Severe dyspnoea occurs in 
paroxysms, usually at night. Then, we may get the signs of obstructive 
dyspnoea similar to those mentioned in severe attacks of catarrhal spasm. 
This dyspnoea is chiefly inspiratory, but in some cases it increases steadily 
from the beginning of the attack, and may be indistinguishable from that 
due to membrane. Constitutional symptoms are usually present and 
may be severe. The temperature ranges in most cases from 101° to 
103° F., but may go to 104° or 105°. The pulse is rapid and full and res- 
piration is accelerated. Children sometimes complain of pain in the 
larynx and trachea, increased by coughing. The symptoms are severe 
for two or even three days, the fever continuing with moderate prostra- 
tion and paroxysms of dyspnoea, sometimes even attacks of suffocation and 
cyanosis. Usually after two or three days there is a gradual subsidence 
of the dyspnoea and inflammatory symptoms, and the case goes on to re- 
covery. At other times the inflammation extends downward to the large 
and then to the small bronchi, and finally results in broncho-pneumonia. 
The attack may prove fatal from laryngeal obstruction due to swelling 
and spasm. 

Diagnosis. — This disease is chiefly to be distinguished from membra- 
nous laryngitis. The onset of the two diseases may be very similar, and 
for the first twelve hours we have no absolute means of distinguishing 
between them, except possibly by the use of the laryngoscope, which is 
often conclusive in older children but not usually so in infants. All OS 
therefore, should be looked upon with a degree of apprehension. The 
temperature in the catarrhal is usually higher than in the membranous 
form. The dyspnoea is mainly paroxysmal, with daily remissions and 
nightly exacerbations, and is chiefly inspiratory, while that of membra- 
nous laryngitis is constant, steadily and often rapidly increasing, and is 
present both on inspiration and expiration. In catarrhal laryngitis the 
voice is not usually lost, but in the membranous form this is the rule. 
There can be little room for doubt when there are enlarged glands, mem- 
branous patches on the tonsils, nasal discharge, and albumin in the urine. 
Very often, however, all these evidences of diphtheria are wanting, the 



494 DISEASES OF THE RESPIRATORY SYSTEM. 

really difficult cases being those in which the process begins in the larynx. 
The prevalence of diphtheria and a known exposure count for something 
in favour of membranous laryngitis. If cultures from the pharynx show 
the presence of Klebs-Loeffler bacilli, diphtheria of the larynx is certain ; 
but no conclusions can be drawn when cultures give negative results. 
In catarrhal as well as in membranous laryngitis there may be extreme 
dyspnoea, cyanosis, pallor, prostration, and even death. 

Prognosis. — This depends somewhat upon the cause of the disease and 
also upon the age of the patient. It is much worse when it is secondary 
to measles or scarlet fever. It is better in children over three years of age 
than in infants, also when the general condition of the child is good. The 
prognosis in severe catarrhal laryngitis should always be guarded, not only 
on its own account, but also because it is impossible to be certain that 
the case may not be one of membranous laryngitis. 

Treatment. — In all cases children affected are to be kept in bed ; and 
the temperature of the room should be between 70° and 72° F. The diet 
should be light and fluid, and the bowels should be freely opened by calomel 
or a saline. A hot mustard foot bath should be given at the outset ; also, 
benefit may sometimes be derived, from aconite, given in one-quarter- 
minim doses every fifteen minutes for the first five or six hours. An- 
tipyrine (two grains every four hours to a child two years old) is useful if 
there is much spasmodic dyspnoea. For this symptom emetics are bene- 
ficial, given as in catarrhal spasm. The use of ipecac and squills in smaller 
doses than is required for emesis (five drops each of the syrups of ipecac 
and squills every two hours) may give relief, especially in the early stage, 
when the cough is dry, hard, and severe. 

All the remedies mentioned are to be regarded as accessories to the 
essential treatment, which consists in the use of inhalations. The child 
should be placed in a tent (page 60) into which steam is introduced from 
a croup kettle or vapourizer. Simple steam may be used, or turpen- 
tine, lime-water, or creosote may be added. In moderately severe cases 
inhalations should be used for fifteen minutes every two hours ; in very 
severe ones they should be continued the greater part of the time. Poul- 
tices or hot fomentations may be applied over the larynx. Eelief is some- 
times obtained by using counter-irritation by a mustard paste, but blister- 
ing should never be allowed. In my experience the local use of cold is 
very unsatisfactory, on account of the difficulty of applying it properly, and 
the objection to it on the part of young children. Stimulants may be re- 
quired late in the disease, the amount of prostration being the guide to 
their use. 

In cases of extreme dyspnoea operative interference may be needed. It 
is required more often in infants and young children than in those who 
are older, and especially in the subglottic form of the disease. Opinions 
will of course differ as to when the dyspnoea has reached the danger point. 



MEMBRANOUS LARYNGITIS. 495 

One should not wait for general cyanosis. If pallor, marked prostration, 
and steadily increasing dyspnoea are present the case should not be al- 
lowed to go on without interference. Intubation has, to my mind, every 
advantage over tracheotomy, and is always to be preferred in these cases. 
One should not hesitate to operate, even though he may be perfectly sure 
that the case is one of' catarrhal inflammation only. The severity of the 
dyspnoea is the only guide, and more than once I have seen cases shown 
at autopsy to be catarrhal, which were regarded during life as undoubt- 
edly membranous. If intubation is done, the tube can generally be dis- 
pensed with in two or three days. Convalescence is usually rapid, but 
there is danger of recurring attacks during the remainder of the cold 
season. 

MEMBRANOUS LARYNGITIS. 

Synonyms : Membranous croup, true croup, laryngeal diphtheria. 

Bacteriology has settled many questions long debated with reference 
to this disease. For nearly half a century the identity of membranous 
eroup and laryngeal diphtheria has been contended for by some observers, 
and denied by others equally good. The extensive bacteriological re- 
searches made since 1890, both in this country and in Europe, have 
yielded results sufficiently uniform to warrant the following statements : 

1. Membranous inflammation beginning in the larynx is almost in- 
variably true diphtheria — i. e., it is due to the Klebs-Loeffler bacillus. 

2. Membranous laryngitis following a primary membranous inflam- 
mation of the tonsils, pharynx, or nose, is, in the great majority of cases, 
due to the Klebs-Loeffler bacillus. 

3. Membranous laryngitis following membranous inflammation of 
the tonsils, nose, or pharynx, occurring as a complication of measles, 
scarlet fever, or influenza, is sometimes due to another kind of infection 
(usually the streptococcus), but more often to the Klebs-Loeffler bacillus. 

The etiology, lesions, pathological relations, and bacteriological diag- 
nosis of membranous laryngitis are considered in the chapter devoted to 
Diphtheria. In the present chapter there will be considered only the 
clinical aspect of the cases, especially of those in which the disease begins 
in the larynx ; for even though in most cases the cause is diphtheria, the 
clinical picture is that of laryngitis. 

In cases of primary laryngeal diphtheria there are wanting most of 
the characteristic clinical features which distinguish diphtheria of the 
pharynx. There are two reasons for this : one is the relatively rapid course 
of the disease, often producing death from local causes before the consti- 
tutional symptoms resulting from the absorption of the toxin have devel- 
oped ; the second reason is, that absorption of the poison by the laryngeal 
mucous membrane is very feeble as compared with that which takes place 
from the pharynx. Henoe it follows that glandular enlargements, albumi- 
33 



496 DISEASES OF THE RESPIRATORY SYSTEM. 

nuria, and asthenic symptoms are generally wanting ; also, that in the cases 
which come to autopsy early, the parenchymatous degenerations of the 
heart, kidney, and other organs are seldom found, but instead only such 
lesions as are connected with the laryngeal disease. The feeble contagion 
is due to the fact that the course is much shorter, and that the discharge 
from the nose and mouth is slight, or absent altogether. 

Symptoms. — In its onset, membranous inflammation of the larynx is 
indistinguishable from the catarrhal form. It is perhaps a trifle less 
abrupt, and apparently not quite so severe for the first twelve hours or 
even for a longer time. We have the same hoarse cough and voice, with a 
slight stridor, gradually increasing. The constitutional symptoms are 
usually not quite so marked, the temperature ranging from 99° to 101° 
F. The pulse is accelerated, but not weak or intermittent. It is the 
progress of the disease which indicates its character, usually during the 
first twenty-four hours. A child beginning in the morning with such 
symptoms as have been described, may by evening show a decided change 
for the worse, or the symptoms may increase with great rapidity during the 
night. At first the voice is hoarse ; later it is entirely lost. Dyspnoea in 
the beginning is scarcely noticeable, but steadily increases hour by hour. 
At times of excitement it may be very great, but as the spasm subsides it 
diminishes. During the second twenty-four hours all the symptoms are 
usually well developed. The respiration is often somewhat accelerated, 
but it may be slower than normal. The face is pale and anxious. The 
alae nasi dilate with each inspiration. The loud, " sawing," stridulous 
breathing is present. As the dyspnoea increases, all the accessory muscles 
of respiration are brought into action. There is now with every inspi- 
ration deep recession of the suprasternal fossa, the supraclavicular re- 
gions, and the epigastrium. The child tosses uneasily from side to side in 
its crib, at times struggling violently to get more air into the lungs. The 
pulse grows rapid and weaker. There is slight blueness of the finger nails 
and the lips ; the face is usually pale ; but later this too may be cyanotic. 
The skin is covered with clammy perspiration. On auscultating the 
chest, very rude respiratory sounds are heard, but no vesicular murmur. 
As the symptoms increase in severity the temperature usually rises gradu- 
ally, in some very severe cases at the rate of a degree an hour, until shortly 
before death it reaches 104° or even 106° F. Late in the disease the in- 
tellect becomes dull, the violent struggles for air cease, and the child passes 
into a condition of semi-stupor which gradually deepens until death occurs, 
which may be preceded by convulsions. 

Such is the usual course of the disease when unrelieved by treatment. 
Its progress is most rapid in infants, in whom death usually takes place in 
from thirty-six to forty-eight hours from the first symptoms. In older 
children the course is rather slower, and the attack may last from two 
days to a week, death occurring more frequently from bronchial croup or 



MEMBRANOUS LARYNGITIS. 497 

pneumonia. These are indicated by continued high temperature, rapid 
respiration, cyanosis, and increased prostration. 

The course of the disease is not always so regular. Occasionally for a 
week or more the symptoms are precisely like those of catarrhal laryngitis 
of moderate severity — hoarseness, laryngeal cough, little or no fever, and 
slight or occasional dyspnoea. Then there may be the sudden develop- 
ment of very severe symptoms, and death in a few hours. Great improve- 
ment may follow the dislodgment of the membrane by vomiting or cough- 
ing, although in most cases it forms again. 

Prognosis. — The issue of every case of membranous laryngitis is 
doubtful. The prognosis is worse in infants and very young children 
than in those over three years of age, and worse when secondary to 
measles or scarlet fever than when primary. Before the days of antitox- 
in the mortality of cases not operated upon was from 80 to 90 per cent. 
Later statistics are given in the chapter on Diphtheria. 

Diagnosis. — The first point to be decided in any case is whether the 
dyspnoea is due to laryngeal inflammation; the second whether this in- 
flammation is catarrhal or membranous. The dyspnoea of retro-pharyn- 
geal abscess, of foreign bodies in the larynx or trachea, or of broncho- 
pneumonia, may be mistaken for that due to laryngitis. But in none of 
these conditions should there be any doubt if a careful examination is 
made and a history obtained. Eetro-pharyngeal abscess may be recog- 
nised by digital examination of the pharynx ; broncho-pneumonia by the 
signs in the lungs, the difference in the character of the dyspnoea, and 
especially by the absence of the noisy stridor ; in the case of foreign bod- 
ies, whether they enter through the mouth or consist of ulcerating caseous 
glands which have ruptured into the trachea, the dyspnoea comes sud- 
denly, and is not accompanied by fever. The main points by which ca- 
tarrhal laryngitis is distinguished from the membranous form have been 
considered under the former disease. In brief, membranous inflamma- 
tion may be assumed if there is severe, constant, and increasing dyspnoea 
with aphonia. Membranous laryngitis should always be regarded as 
diphtheria until the opposite has been proved by repeated cultures. 

Treatment. — All cases of membranous laryngitis should be isolated 
like those of diphtheria of the pharynx, and should receive a full dose 
of antitoxin upon a clinical diagnosis without watiting for this to be con- 
firmed by a bacteriological examination. Nowhere else are the beneficial 
effects from antitoxin so evident and so striking as in these cases. For 
dosage and other details regarding the use of antitoxin the reader is 
referred to the article on Diphtheria. 

Emetics, inhalations of steam, and solvents for the membrane, al- 
though they all sometimes give relief, are never to be relied upon alone. 
In fact, leaving out antitoxin and surgical operation, the only therapeu- 
tic measure that can be said to be of much avail is calomel fumigation. 



498 DISEASES OF THE RESPIRATORY SYSTEM. 

This is in no sense a substitute for antitoxin, but may be employed where 
the use of antitoxin is impossible, and in the few cases of membranous 
laryngitis due to streptococci. From ten to fifteen grains of calomel are 
vapourized upon any hot metal plate under a closed tent, in which the 
child is placed. This may be repeated every one to four hours, accord- 
ing to circumstances. One should watch both the child and the attend- 
ants for symptoms of mercurial poisoning. This treatment was intro- 
duced by Corbin, of Brooklyn, and was much in vogue from 1890 until 
the introduction of antitoxin. 

Operative measures. — Opinions will always differ as to the time when 
operative interference is called for. One should never wait for general 
cyanosis, for often this does not occur until just before death. It is bet- 
ter to operate too early than too late. If, in spite of other measures, 
the dyspnoea increases steadily, and especially if the temperature begins 
to rise, operation should not be deferred longer. When this has been 
decided upon, the physician has the choice between intubation and 
tracheotomy. In America intubation has almost universally superseded 
tracheotomy as a primary operation for the relief of membranous laryn- 
gitis. In Europe also its advantages are coming to be appreciated, and 
its use has extended greatly since the introduction of antitoxin. Trache- 
otomy is still needed at times for the cases, very few in number, in which 
intubation fails to give relief on account of the position of the mem- 
brane or some other complication. 

The general treatment of the child is important, and should not be 
overlooked. It includes careful feeding, and the use of alcoholic stimu- 
lants according to the amount of prostration present. All patients with 
membranous laryngitis should be closely watched, for marked changes 
may take place in the course of a few hours. 

INTUBATION. 

Intubation is the introduction of a tube through the mouth into 
the larynx for the relief of laryngeal dyspnoea. For the operation, as 
now performed, the world is indebted to the late Dr. Joseph O'Dwyer, 
of New York. 

A set of O'Dwyer's instruments (Fig. 85) consists of six tubes, an 
introductor, an extractor, a mouth-gag, and a gauge. In the later tubes 
the lower extremity is made somewhat bulbous and not straight, as 
appears in the illustration. His latest tubes are made of hard rubber 
and lined with gold-plated metal, these proving much less irritating 
than the solid metal tubes formerly used. So carefully did O'Dwyer 
perfect his instruments that nothing of importance has been added by 
others. It is interesting to note that nearly all the modifications which 
have been suggested since his first publication had already been tried 
by him and discarded. No one thing is more essential to success with 



INTUBATION. 



499 



intubation than properly constructed instruments. The operation is not 
difficult, if one has had practice on the cadaver. Without this it should 
not be attempted. The tube is selected according to the age of the 
patient, this being indicated on the gauge. A very large child will often 
require a tube of larger size than its age would call for. 

Introduction of the Tube. — Either one of two positions may be 
employed, the choice depending upon the preference of the operator. 
Formerly the usual method was to have the child seated upon the 
lap of a nurse while his head was steadied by a second assistant stand- 
ing behind. In the other position the child lies upon his back upon a 
table, his head being steadied by an assistant. In both positions the 
arms should be pinioned to the sides by a sheet. In the recumbent 
position the child can be held more firmly; it has also the advantage 
of dispensing with one assistant, and in an emergency with both of 
them. The tube is attached to the introductor, and the gag is inserted 
into the left angle of the mouth and opened as widely as possible. The 
slipping of the gag and laceration of the mouth may be prevented by 
using a piece of rubber tubing to cover each arm of the gag where it 




Fig. 85. — O'Dwyer's intubation set. 
1, introductor ; 2, gag ; 3, extractor ; 4, gauge ; 5, tube. 



comes in contact with the gum. The attempts at introduction must be 
made quickly, for during them respiration is practically arrested. Sev- 
eral short attempts are always better than a single prolonged one. Very 



500 DISEASES OF THE RESPIRATORY SYSTEM. 

little force is ordinarily required in introducing the tube, that used in 
passing a catheter being a good general guide. In cases of subglottic 
stenosis, however, quite a little force may be necessary. 

The index finger of the left hand is used as a guide in introduction. 
This is passed well back into the pharynx, then brought forward until a 
hard nodule — the upper border of the cricoid cartilage — is encountered. 
This is the best of all landmarks, since the soft parts are often distorted 
by swelling. Directly in front of the cricoid cartilage may be felt the 
epiglottis and the opening of the larynx, which are readily recognised 
after the touch has become somewhat educated. The tube is passed along 
the palmar surface of the left index finger, by which it is guided into the 
larynx ; it is then pushed off the introductor by a thumb-piece attached 
to its handle. When it is certain that the tube is in position, and the 
patient breathes properly, the loop of silk attached to the head of the 
tube is cut off and pulled through, the removal of the tube being pre- 
vented by placing the left forefinger upon its head. The silk is not usu- 
ally left attached unless there is evidence of loose membrane below the 
tube. It may be desirable to leave the silk attached in case no one can 
be within reach who is able to remove the tube should it become ob- 
structed. The child's arms and hands should then be secured to pre- 
vent him from seizing it himself. When not removed the silk is fastened 
to, the cheek by a piece of adhesive plaster. The tube is known to be in 
place, first, by the hissing breathing sounds, somewhat similar to what 
is heard when the trachea is opened; secondly, by a severe paroxysm 
of coughing, which is usually excited by a tube in the larynx; thirdly, 
by the relief of the dyspnoea. If this relief is not very apparent the 
physician may still be in doubt as to whether the tube is in the larynx 
or the oesophagus. If in the former, it can not be pushed down by the 
finger without depressing the larynx with it; and by introducing the 
finger into the pharynx, the posterior wall of the larynx can be felt 
between the finger and the tube. The most common mistake made 
is to pass the tube into the oesophagus. This sometimes happens be- 
cause the position of the child's head is improper — too far forward 
or too far backward — but more often because the operator has not 
been quite sure of his landmarks. If this has occurred, there is no 
relief to the dyspnoea, no hissing sound, and the tube can be pushed 
down indefinitely. When this condition is recognised, the tube is with- 
drawn by the loop of silk and after a few moments a second attempt 
made. 

False passages in the larynx are most frequently made by employing 
too much force or because the operator has worked at the angle of the 
mouth instead of keeping in the median line. The tube usually goes 
into one of the ventricles, and may be pushed quite through the larynx 
into the cellular tissue. This is not likely to happen unless undue force 



INTUBATION. 501 

has been used. The production of a false passage is recognised by the 
fact that, although the tip of the tube can be felt to enter the larynx, it 
does not descend, but projects above the epiglottis. 

False membrane which has become loosened is sometimes crowded 
down by the tube and obstructs the larynx just below it. This is one of 
the most serious accidents that may occur, but fortunately it is not a 
frequent one. It is more likely to happen where the disease has existed 
for several days than in recent cases. The tube may be in place in the 
larynx as shown by all the signs above mentioned, except relief of the 
asphyxia. In such a case the immediate withdrawal of the tube is neces- 
sary, it being often followed by the discharge of masses of loose mem- 
brane. This is aided by the administration of a teaspoonful of pure 
whisky or brandy to excite a strong cough. Artificial respiration may be 
required, and if there is no relief by any of these means tracheotomy is 
indicated. Asphyxia is sometimes produced by prolonged and injudi- 
cious attempts at introduction. 

After-treatment. — So far as the tube itself is concerned no treatment 
is required. The original disease is to be treated as before. The opera- 
tion has removed only one danger from the patient, viz., that of asphyxia 
from mechanical obstruction of the larynx. A good expulsive cough 
should occur after the tube is in place. This is necessary to clear the tube 
of mucus, as the pharynx and larynx are generally filled with it as a re- 
sult of the manipulation. 

The child should not be allowed to lie upon its face, nor should it be 
held over the nurse's shoulder face downward, for in either position a 
slight cough is enough to expel the tube. Nursing infants may continue 
at the breast after the operation; ordinarily they have but little diffi- 
culty in swallowing. Older children often experience considerable trou- 
ble in taking liquids. This may be overcome by the device suggested by 
Casselberry (Chicago), of having the patient's head lower than his body 
while he drinks. If there is still trouble in taking fluids, semi-solid arti- 
cles, such as condensed milk, wine jelly, corn starch, or scrambled eggs, 
may be tried. Feeding is always easier after the first day or two, and 
patients who wear a tube for chronic disease soon experience no trouble 
whatever, showing that the difficulty depends more upon the inability to 
co-ordinate the movements of the muscles of deglutition when the tube 
is in place than upon mechanical causes, for the head of the tube is effec- 
tually covered by the epiglottis. 

It sometimes happens that the tube is coughed out soon after its 
introduction, because too small a size has been used. In some cases 
this occurs repeatedly. It happened in a case of my own twenty-eight 
times during four days. Such cases are probably due to paralysis of the 
laryngeal muscles. The dyspnoea does not usually return for two or three 
hours after the tube has been coughed out, so there is ample time to 



502 DISEASES OF THE RESPIRATORY SYSTEM. 

notify the physician. It may happen that the tube is coughed up and 
not seen by the nurse, or it may be coughed up and swallowed by the 
child. When called because of dyspnoea after operation, the physi- 
cian should make a digital examination of the pharynx to be sure 
that the tube is still in place. Swallowing the tube generally causes 
no harm to the child, for tubes have repeatedly passed through the in- 
testines. 

The entrance of food into the bronchi through the tube is a danger 
that does not exist, as has been shown by the extensive post-mortem ob- 
servations of Northrup in the New York Foundling Asylum. My own 
experience in the New York Infant Asylum coincides in every particu- 
lar with his statement, that the broncho-pneumonia following intubation 
does not depend upon the entrance of food into the bronchi. 

Ulceration at the head of the tube very rarely occurs, provided prop- 
erly made tubes are employed.* The tube rests not upon the vocal cords, 
but upon the inferior ventricular bands. When ulceration occurs, it is 
usually of the anterior wall of the trachea, at the lower end of the tube, 
and appears to be produced by the movements of the tube during deglu- 
tition. With O'Dwyer's latest tubes there is much less liability of this 
occurring. The ulcers are usually small and superficial. Deep ulcers 
extending to the tracheal rings may be seen in ill-conditioned children, 
usually in connection with other complications severe enough to cause 
death. 

Spontaneous descent of the tube into the larynx is impossible, and it 
can not be crowded down without using considerable force and severely 
lacerating the larynx. 

Sudden blocking of the lower end of the tube by membrane loosened 
from the trachea or bronchi is an infrequent accident. The usual result 
of this is the immediate expulsion of the tube by coughing, the discharge 
of the loose membrane following. This condition is one of the safety 
valves of the operation. One of the strong points in favour of intuba- 
tion is that the forcible cough which the patient is able to make on ac- 
count of the narrow opening of the tube, often enables him to expel large 
accumulations of mucus, and even membrane, more readily than through 
a much larger tracheal opening. 

The period for which the tube is required varies much in different 
cases. It is the experience of practically all operators that it has been 
materially shortened by the use of antitoxin. According to the statis- 
tics of Rosenthal (Philadelphia), the average reduction amounts to two 
and a half days, the average time of wearing the «tube is five days, and 

* This and many other bad results obtained after intubation are due to improperly- 
constructed instruments. Those made by George Ermold, 201 East Twenty-third 
Street, New York, are the most reliable. 



INTUBATION. 503 

in man}' it can be dispensed with in two or three days. Should the 
tube be coughed out at any time, its introduction should be delayed until 
dyspnoea returns. 

Eemoval of the Tube — Extubation. — This is rather more difficult 
than its introduction. The general arrangement of the patient and as- 
sistants is the same as for introduction. The left index finger is placed 
upon the head of the tube, which is steadied externally by the thumb of 
the same hand. The beak of the extractor is introduced within the open- 
ing of the tube, its jaws are then separated by pressure upon the lever at 
the handle, and the instrument withdrawn, very slight force being re- 
quired. 

The tube is first removed tentatively, the physician waiting to see if 
dyspnoea returns. It is well to give a full dose of morphine an hour 
before the removal of the tube, since the contact with the air almost 
invariably excites a marked degree of laryngeal spasm which lasts for 
ten or fifteen minutes. To avoid the production of vomiting and the 
entrance of food into the larynx, food should not be given for two hours 
previously. If dyspnoea does not return in the course of three or four 
hours, the probabilities are that the tube will no longer be required. 
It is very exceptional that the patient has great difficulty in dispensing 
with the tube, as so often happens after tracheotomy. 

The Advantages over Tracheotomy. — The advantages claimed by 
O'Dwyer for this, operation over tracheotomy are conceded by most of 
those who have had any considerable experience in the operation, viz. : 
(1) It is quicker, simpler, and adds no danger to the original disease ; (2) 
there is no shock or haemorrhage; (3) no anaesthetic is required; (4) no 
fresh wound is made which may prove an avenue of infection; (5) it 
gives an opportunity for a better expulsive cough, which is of great value 
in dislodging false membrane and mucus ; (6) there are usually no objec- 
tions on the part of the parents to be overcome — a point of great impor- 
tance; (7) the air is warmed and moistened as it is normally, by passing 
over the nasal and buccal mucous membranes ; (8) no skilled after-treat- 
ment is required : as the largest proportion of the cases of diphtheria 
are among the very poor, living under conditions in which the careful 
after-treatment required in tracheotomy is difficult or impossible to ob- 
tain, this is an important point; (9) in infancy, all who have had ex- 
perience with both operations admit the great superiority of intuba- 
tion; (10) the intubation tube can be dispensed with earlier than the 
tracheal canula, and also with much less difficulty; (11) if tracheot- 
omy is subsequently required, the operation may be done upon the tube 
as a guide. 

The only objection of much force urged against intubation is that 
asphyxia may be produced by crowding down loose membrane into the 
larynx. This is a very infrequent accident; should it happen, and the 
34 



504: DISEASES OF THE RESPIRATORY SYSTEM. 

asphyxia not be relieved by coughing up the membrane, tracheotomy may 
be performed. 

There is always some degree of hoarseness following intubation, but 
in the majority of cases it disappears within a week, occasionally it con- 
tinues as long as three or four weeks, but it is very rarely if ever perma- 
nent. The duration of the aphonia seems to have no relation to the 
length of time the tube is worn. 

Experience has clearly proved that intubation relieves the dypsnoea 
due to laryngeal stenosis promptly, efficiently, and certainly ; it does this 
without many of the dangers and objectionable features of tracheotomy, 
while at the same time it does not deprive the patient of any essential 
advantage which tracheotomy affords. 

Retained Intubation Tubes — Prolonged Intubation. — Difficulty is ex- 
perienced in dispensing with the intubation tube much less frequently 
than with the canula after tracheotomy; yet when this condition occurs 
it is the cause of much concern and even danger. Trouble of this sort 
is seen, according to Rogers, in about one per cent of the cases of in- 
tubation. In the majority of these the patient is able to do without the 
tube in a few weeks, and such cases require very close attention, but 
no special treatment other than the substitution at times of a special 
O'Dwyer tube with an extra large " retaining swell." But occasionally 
there are met with cases in which every effort to dispense with the tube 
seems fruitless. Although the children breathe well with the tube in place, 
still if it is removed or expelled by coughing, in a short time, varying 
from a few minutes to an hour or two, the dyspnoea returns with such 
severity that the tube must be replaced immediately to prevent asphyxia. 
Inasmuch as these patients sometimes expel the tube several times a 
day, surgeons have often resorted to tracheotomy to avert the danger of 
suffocation, which might easily occur if no one were at hand who could 
replace the tube. This operation, however, gives only temporary relief. 
Many of these children, after wearing tubes of one sort or another for 
years, ultimately die from some accident connected with the tube or 
from pneumonia. 

The causes and the exact pathological condition underlying this diffi- 
culty are subjects regarding which there has been much difference of opin- 
ion. O'Dwyer's opinion was that the cause of the returning dyspnoea was 
subglottic swelling and oedema which occurred in tissues which were the 
seat of chronic inflammation as soon as the pressure of the tube was re- 
moved. The primary cause of the condition he believed to be the injury 
inflicted by improperly made or badly fitting tubes, or by unskilful ef- 
forts at introduction. In a few cases a cicatricial condition, the result 
of previous ulceration, has been found; but it is doubtful if granulations, 
so frequent a cause of retained canula after tracheotomy, play any part 
whatever. Rogers's view is that the chronic inflammation of the mu- 



SUBMUCOUS LARYNGITIS. 505 

cous and submucous tissues of the subglottic region of the lar}mx which 
produces the symptoms, is due neither to a faulty tube nor to a clumsy 
operation, but to the nature of the pathological process. 

For the relief of this condition, O'Dwyer advised in recent cases 
the application of astringents by means of an intubation tube coated with 
gelatine with which some astringent was combined. For those pa- 
tients who cough out the tube frequently, tracheotomy is at times a 
necessity to prevent sudden death. But this does not affect the original 
condition, for the same difficulty exists in doing without the tracheal 
canula. The operations of laryngotomy, curetting, etc., have been such 
signal failures as to discourage one from repeating tHem. 

The most successful method of treatment thus far proposed is that of 
Rogers,* which consists in increasing intra-laryngeal pressure by the in- 
sertion of larger and larger intubation tubes. This is not to be adopted 
until long, after all acute symptoms have subsided. The first tube used is 
as large a one as can be introduced without force; after a few weeks, the 
next larger size, and after a longer interval, possibly a still larger one. 
When the very large tube had been worn for several weeks he was finally 
able to dispense with all tubes. In this way he succeeded in curing com- 
pletely and permanently several cases of two or three years* standing. 

True cicatricial stenosis may best be relieved by opening the trachea 
and dilating from below, and afterward inserting an intubation tube. 
When there is complete destruction of the cricoid cartilage, as sometimes 
occurs, tracheotomy is the only remedy, but this is only palliative, as the 
tube must be worn permanently. 

SUBMUCOUS LARYNGITIS— (EDEMA OF THE GLOTTIS. 

These two conditions are not quite identical, although they are close- 
ly associated and may be conveniently considered together. They are 
both rare in early life. In true oedema of the glottis there is simply a 
dropsical effusion into the submucous cellular tissue of the aryteno-epi- 
glottic folds, causing them to project as large rounded swellings on either 
side of the superior isthmus of the larynx. They may be of sufficient size 
to cause serious or even fatal obstruction to respiration. With the laryn- 
goscope they appear as pale red tumours, lying usually in contact near 
the base of the tongue. By the finger their presence can be quite as 
readily distinguished. (Edema of the glottis occurs principally in the 
late stages of nephritis. 

In the inflammatory form of oedema, or true submucous laryngitis, 
there is the same sort of swelling of these structures, but in this case it is 

* Post-Diphtheritic Stenosis of the Larynx, John Rogers, M. D., Annals of Surgery, 
May, 1900. See also monograph by von Bokay, Ueber das Intubations-trauma, Leip- 
zig, 1901. 



506 DISEASES OF THE RESPIRATORY SYSTEM. 

due to some active inflammation in the neighbourhood. The swelling is 
partly from the oedema and partly from cell infiltration. Usually all the 
parts surrounding the upper opening of the larynx are in a state of acute 
inflammation. The epiglottis may be swollen to the thickness of a finger, 
and easily seen by depressing the tongue. 

The exciting causes may be the mechanical irritation of foreign bodies, 
the inhalation of steam or irritating gases, erysipelas of the neck, primary 
catarrhal laryngitis, or retro-pharyngeal abscess. 

The symptoms in both cases consist of great inspiratory dyspnoea 
with attacks of suffocation, while expiration may be quite easy. In true 
oedema there are in addition the symptoms of the primary disease. In 
the inflammatory form there are the evidences of local inflammation — 
hoarseness, cough, pain, and difficulty in swallowing. A positive diag- 
nosis may be made by a digital examination. The symptoms develop with 
great rapidity in either variety, and frequently prove fatal in a few hours. 

The treatment of true oedema consists in scarification or multiple 
puncture, the application of ice externally, and even the swallowing of 
ice ; in the inflammatory form, in addition, local blood-letting by leeches 
and, as a last resort, tracheotomy. Intubation is useless in either form. 



CHRONIC LARYNGITIS. 

The following varieties are seen : (1) a simple form usually associated 
with adenoid vegetations of the pharynx ; (2) tuberculous ; (3) syphilitic ; 
(4) that associated with new growths. 

1. With Adenoid Vegetations of the Pharynx. — This is not very uncom- 
mon. The larynx is kept in a state of chronic congestion by the adenoid 
growth, and there finally develops a sight superficial catarrhal inflamma- 
tion. The symptoms may continue for many months. These cases are 
often treated for a long time unsuccessfully by the use of sprays, inhala- 
tions, etc., but the symptoms disappear rapidly after the removal of the 
adenoid growth. Similar symptoms may be associated with hypertrophic 
rhinitis. In this also the treatment should be directed to the primary 
condition. 

2. Tuberculous Laryngitis. — This belongs to later childhood, and is rare 
even then. In infancy it is almost unknown. Eheindorf * has reported 
a case in a child of thirteen months, which was regarded during life as 
syphilitic, but was shown by autopsy to be tuberculous. Of sixteen cases 
in children, reported by Rilliet and Barthez, none occurred during the 
first three years, and only four before the seventh year. The larynx alone 
may be affected, or the larynx and trachea, or the larynx, trachea, and 
lungs. Pulmonary tuberculosis is usually found to be present at autopsy, 

* Jahrbuch fur Kinderh., Bd. xxxiii, p. 71. 



CHRONIC LARYNGITIS. 507 

even though there may have been no pulmonary symptoms. Demme has 
reported a case of tuberculous laryngitis in a boy of four years, whose 
lungs were healthy, death resulting from tuberculous meningitis. 

The symptoms are hoarseness, aphonia, laryngeal cough, and muco- 
purulent, sometimes bloody, expectoration. The sputum may contain 
tubercle bacilli. With the laryngoscope tuberculous deposits may be 
seen, but more frequently tuberculous ulceration of the mucous mem- 
brane. In children this is usually superficial, the deep destructive ulcera- 
tion seen in adults being very rare. 

It is to be differentiated from syphilis chiefly by the general symptoms, 
as the laryngoscopic appearances may be very similar. The treatment con- 
sists in keeping the ulcers as clean as possible by the use of sprays and 
the local application of astringent powders, like nitrate of silver and sul- 
phate of zinc or iodoform. 

3. Syphilitic Laryngitis. — In the early stage of syphilis the larynx is 
often the seat of a catarrhal inflammation, which presents nothing espe- 
cially characteristic except its protracted course. The laryngitis of late 
hereditary syphilis is quite rare, and is liable to be overlooked because of 
the difficulties in the way of a thorough examination, and because the dis- 
ease is usually painless. 

Strauss * has collected fourteen cases between the ages of three and 
fifteen years, and added three of his own. He states that deep-seated pro- 
cesses are much more rare than among adults. The parts most frequently 
affected are, first, the epiglottis ; secondly, the aryteno-epiglottic folds ; 
thirdly, the posterior laryngeal wall. The epiglottis was involved in 
twelve of fourteen cases. Usually there was only perichondritis ; in the 
more severe cases there was partial or complete destruction of the cartilage. 
In four cases papillomatous masses were seen. In five cases the process 
extended from the epiglottis to the epiglottic folds of one or both sides. 
In several instances the superior vocal cords were thickened from hyper- 
plasia, and occasionally small tumours were formed. In only one case was 
there ulceration of these folds. Changes in the vocal cords and the aryte- 
noid cartilages were rare, occurring only with extensive inflammation. 
The symptoms are those of chronic laryngitis ; hoarseness, sometimes 
aphonia, and in a few cases chronic laryngeal stenosis. The diagnosis 
can be made only by means of the laryngoscope. In most of the cases 
there are present ulcerations of the palate or uvula, or scars from pre- 
vious ulcers ; sometimes the disease extends into the nose. Serious 
symptoms often result when to old syphilitic lesions there is added acute 
laryngitis or oedema. 

In addition to the usual constitutional remedies for tertiary syphilis, 
and to the means ordinarily employed for the relief of chronic laryngitis, 



* Archiv fur Kinderh., Bd. xiii. 



508 DISEASES OF THE RESPIRATORY SYSTEM. 

intubation may be required in these cases for the relief of laryngeal ste- 
nosis. Nowhere are its advantages over tracheotomy more striking than 
here. The tube must usually be worn for many months. 

NEW GROWTHS. 

New growths of the larynx are not very rare in children. Excluding 
the granulations which follow the use of the tracheal canula, the only one 
that is likely to be met with is papilloma. This may occur even in in- 
fancy. According to Eauchfuss, the majority of the cases begin during 
the first year. Boys are more frequently affected than girls. 

The symptoms depend upon the size and location of the tumour. The 
earlier manifestations are usually ascribed to chronic laryngitis. There 
is hoarseness, sometimes loss of voice, and a paroxysmal cough ; later, 
dyspnoea develops. The symptoms are slowly progressive, and it may be 
several months before they are sufficiently severe to attract special atten- 
tion. A positive diagnosis is made only by the laryngoscope. There is 
seen a whitish granular tumour, sometimes pedunculated, sometimes with 
a broad base, attached to any part of the larynx. 

The treatment of these cases belongs to the specialist. Small pedun- 
culated growths may be removed through the mouth by means of the 
forceps or snare. Larger ones require thyrotomy. The prognosis is 
generally unfavourable, on account of the danger of recurrence after 
operation. Operative measures are very frequently followed by bron- 
chitis or broncho-pneumonia. 

FOREIGN BODIES IN THE LARYNX. 

The aspiration of foreign substances into the larynx is not a very rare 
accident in children. It usually happens from an attempt to cough, 
laugh, or cry while the child has something in its mouth. If the body is 
sharp and irregular, like a pin, the shell of a nut, or a fragment of bone, 
it is liable to become impacted in the larynx. If smooth, like a pea or 
a bead, it is usually drawn into one of the bronchi, generally the right. 

When the body enters the larynx there is immediately excited a violent 
paroxysmal cough, with dyspncea amounting almost to suffocation. Often 
the body is dislodged by this initial attack of coughing. If it becomes 
impacted in the larynx, it may cause sudden death by occluding the 
glottis ; elsewhere it may excite acute laryngitis, usually of considerable 
severity. 

The impaction of a foreign body in one of the primary bronchi, or one 
of the lobar divisions, is indicated by cough and a severe localized pain in 
the chest. There may be expectoration of blood. On auscultating the 
chest, there is found an absence of respiratory murmur over one lung or 
one lobe, according to the situation of the foreign body. Percussion gives 



THE LUNGS IN INFANCY AND CHILDHOOD. 509 

increased resonance, which may even be tympanitic, owing to emphysema 
which rapidly develops. If the foreign body remains impacted in one of 
the bronchi, it usually excites a localized inflammation,, which extends to 
the surrounding lung and terminates in the formation of an abscess. 
This may result fatally, or there may follow a prolonged illness, with 
hectic symptoms resembling pulmonary tuberculosis ; and finally, after 
weeks or months, the foreign body may be expelled by an attack of cough- 
ing, and the patient recover completely. 

The diagnosis of a foreign body in the larynx is made by the sudden- 
ness of the attack and the violence of the early symptoms. In older chil- 
dren the body may be seen with the laryngoscope, but in young children 
this is very difficult. The prognosis is always doubtful, and depends upon 
the nature of the foreign body and the point at which it has been arrested. 

Treatment. — The first thing to be tried is inversion of the patient. 
By this means, assisted by the cough, the foreign body is not infrequently 
expelled, even though it has passed below the larynx. The symptoms of 
laryngeal obstruction may call for immediate tracheotomy or laryngotomy, 
intubation not being applicable to these cases. If, after tracheotomy, the 
foreign body can be located in the larynx, but can not be extracted through 
the tracheal wound, the thyroid cartilage should be divided in the median 
line. The removal of a foreign body from the bronchi or the tracheal 
bifurcation should be attempted only by a skilled surgeon. 



CHAPTER III. 
DISEASES OF THE LUNGS. 

THE PECULIARITIES OF THE LUNGS IN INFANCY AND EARLY 

CHILDHOOD. 

Thorax. — The general shape of the thorax is somewhat cylindrical, 
the conical or dome-shape of the adult thorax not being attained until 
puberty. The ant'ero-posterior and the transverse diameters are nearly 
equal in the newly born, but after the third year the transverse diameter 
is always greater, the difference increasing steadily up to adult life. On 
account of the shape of the chest, the lungs are situated rather more 
posteriorly in the infant than in the adult. 

The thoracic walls are very elastic and yielding, owing to the carti- 
laginous condition of a large part of the framework. They are rela- 
tively thinner than in the adult, chiefly from the imperfect develop- 
ment of the thoracic muscles. The greater part of the thickness of the 
thoracic walls is due to the deposit of fat, generally abundant in well- 
nourished infants; but where the fat is scanty the walls are extremely 



510 DISEASES OF THE RESPIRATORY SYSTEM. 

thin. The capacity of the thorax is considerably encroached upon by the 
high position of the diaphragm, the large size of the thymus gland, and 
the frequent distention of the stomach and intestines. 

Respiration. — According to Uffelmann, the rapidity of respiration dur- 
ing sleep at the different ages is as follows : 

At birth 35 per minute. 

At the end of the first year 27 " 

At two years 25 ;< " 

At six years 22 " " 

At twelve years 20 " " 

During waking hours this rate is very materially increased, and from com- 
paratively slight disturbance it may be nearly twice as rapid. 

The type of respiration in infants is diaphragmatic, and it continues to 
be chiefly so until after the seventh year, when the costal element grad- 
ually becomes more and more prominent. The rhythm of respiration is 
easily disturbed. In very young infants the regular rhythm is seen only 
in sleep. The lungs do not always expand equally ; at certain times and 
in certain positions respiration may be carried on for a few moments 
almost entirely with one lung. For some moments it may be very super- 
ficial, and then quite deep. The length of the interval between inspira- 
tion and expiration varies much at different times. Eegular rhythmical 
respiration is not fully established before the end of the second year. 
After this time disturbances of rhythm are chiefly due to pulmonary or 
cerebral disease ; but in infancy quite marked irregularity may have little 
or no significance. It is very common in all asthenic conditions. 

Structure. — As compared with the adult, the trachea of the young 
child is larger ; the bronchi are larger, more numerous, and occupy a 
greater space ; the air cells are much smaller and occupy less space ; and 
the interstitial tissue is much more abundant. 

Physical Examination. — This requires tact and time, but yields results 
which are quite as satisfactory as in adults. It should be undertaken only 
in a room having a temperature of about 72° F., or before an open fire. 

Inspection. — This should be made with the chest bare. There should 
be noted, the shape of the chest, the presence of deformities from rickets, 
the want of symmetry in the two sides, bulging of the intercostal spaces, 
whether the two lungs expand equally or not, also variations in rhythm, 
and the presence and extent of any recession of the soft parts or bony 
walls as an indication of obstructive dyspnoea. 

Palpation. — This also should be made upon the bare skin, always with 
the hand well warmed. Although we can not get the fremitus of the 
voice, we can get that of the cry. This is usually more intense than in 
adults, on account of the thinness of the chest walls. We frequently get 
a bronchial fremitus — a vibration produced by mucus in the tubes. This 
may enable one to recognise bronchitis quite as positively as by the ear. 



THE LUNGS IN INFANCY AND CHILDHOOD. 511 

The position of the apex beat of the heart should be determined, it being 
remembered that in infancy this is normally in the mammary line, or just 
outside of it, and usually in the fourth intercostal space. 

Percussion. — For the examination of the back, the child may be laid 
face downward upon the nurse's lap, or be seated upon her arm. For the 
front and the lateral regions of the chest, the child is most conveniently 
placed upon its side across a hard pillow. The percussion blow must be 
light, either with a single finger or a small percussion hammer, using a 
finger of the opposite hand as a pleximeter. Percussion should be made 
both during inspiration and expiration. The normal percussion note is 
somewhat tympanitic, this being due to the relatively large bronchi and 
the thin chest walls. This note is exaggerated in the interscapular region 
and beneath the clavicle, especially upon the right side. Here cracked- 
pot resonance may be obtained even in health. In early infancy the 
thymus gives dulness over the sternum as low as the third rib, sometimes 
even below this point, this gradually diminishing as age advances. 

Auscultation. — This may be practised with the naked ear or with the 
stethoscope. A stethoscope is absolutely necessary for a thorough exam- 
ination of the apices of the lungs in front and in the axillary regions. 
Most children are less frightened by the instrument than by the head of 
the physician during anterior auscultation. For the posterior part of the 
lungs, the stethoscope may be dispensed with. One with a small bell 
from one-half to three-fourths of an inch in diameter is of great advan- 
tage. In auscultating with the ear it is not necessary to bare the skin. 
The physician should always auscultate the posterior part of the chest 
first, because he is most likely to find signs of disease there, and also 
because this is not so apt to frighten the infant. Every part of the chest 
should, however, be thoroughly auscultated, not omitting the high axil- 
lary regions. A convenient position for posterior auscultation is to have 
the child held over the nurse's shoulder. 

The normal respiratory murmur of the infant is generally described as 
puerile. In quality this has been likened to the bronchial breathing of 
the adult, but the resemblance is not a very close one. It is rude, rather 
loud, and seems very near the ear. Its peculiar character is due to the 
fact that the tracheal and bronchial sounds are more distinct, because 
not transmitted through so thick a layer of lung and chest wall. It is 
especially loud in the regions where the bronchi a re superficial, as between 
the shoulder-blades and beneath the clavicles, particularly of the right 
side. A careful comparison of the two sides of the chest will generally 
enable an observer to avoid errors. The irregularity of rhythm which 
occurs from slight, causes should be remembered, and (Ih i infant's position 
changed several times during auscultation, t<> avoid the mistake of at- 
taching too much importance to a feeble respiratory murmur of one side 

On account of the thinness of the chesl walls, there is always great 



512 DISEASES OF THE RESPIRATORY SYSTEM. 

difficulty in distinguishing between rales produced in the bronchi and 
pleuritic friction sounds. Before drawing any inference from the auscul- 
tatory signs, both lungs must be examined for several minutes, changing 
the child's position, and often inducing a cry or compelling a deep inspi- 
ration by other means, in order to bring out signs which otherwise may 
be overlooked. As auscultation is extremely difficult or impossible in a 
crying infant, this part of the physical examination should first be made 
if the child is quiet, since upon it we must chiefly depend for diagnosis. 
Inspection and percussion can be deferred until later. 

Peculiarities in Disease. — There are several peculiarities connected 
with the respiratory organs in infancy and early childhood which must be 
constantly borne in mind in studying their diseases. The muscular de- 
velopment of the thoracic wall is feeble. The soft, yielding character of 
the thoracic framework causes the chest to sink in readily from atmos- 
pheric pressure whenever there is obstructive dyspnoea. On account of 
the small size of the air vesicles, acute congestion may interfere with their 
function almost as completely as does consolidation. Because of the 
delicate walls of the air vesicles, emphysema is readily produced in ob- 
structive dyspnoea, but it is rarely permanent. There is a tendency to 
collapse, either on the part of lobules or groups of lobules, but very 
rarely of an entire lobe. This is a much less important factor in the 
production of symptoms in acute pulmonary disease than many writers 
would lead us to suppose. The tendency of inflammation to spread 
from the large to the small bronchi is very much greater than in adults. 
In all forms of pulmonary disease the rapidity of respiration is much 
greater than in adults, on account of the rapid metabolism of the child. 
Areas of consolidation often exist without appreciable changes in the 
percussion note, because they are superficial and are surrounded by 
healthy or emphysematous lung. Flatness should always suggest the 
presence of fluid. Disease is often overlooked, from a failure to examine 
the whole chest. 

Probably the most common mistakes are to confound bronchial rales 
with friction sounds, exaggerated puerile breathing with bronchial breath- 
ing, and to overlook the existence of fluid because of the presence of 
bronchial breathing. 

ACUTE CATARRHAL BRONCHITIS. 

Acute catarrhal bronchitis is one of the most frequent conditions for 
which the physician is called upon to prescribe in children. It occurs at 
all ages, from early infancy up to puberty. Its frequency, however, di- 
minishes steadily after the second year. The predisposition to acute 
bronchitis exists with the same constitutional conditions, and is acquired 
in the same manner as the predisposition to the acute catarrhal inflam- 
mations of the upper respiratory tract. ^See Acute Rhinitis). Bronchitis is 



ACUTE CATARRHAL BRONCHITIS. 513 

very common in children who are suffering from rickets and malnutrition. 
It is much more frequent in the cold months, especially in the late winter 
and early spring, when there are sudden atmospheric changes and high 
winds. 

Bronchitis may be a primary or a secondary disease. The primary form 
is excited by cold, exposure with insufficient clothing in severe weather, 
wetting of the feet, or chilling of the surface in any manner. Under 
these conditions it may occur alone, or be associated with or preceded 
by acute catarrh of the nose, pharynx, or larynx. In rare cases it is 
caused by the inhalation of irritants. Bronchitis is an almost invariable 
accompaniment of measles and influenza. It is very common in pertussis, 
in scarlet and typhoid fevers and diphtheria, and may occur in any acute 
infectious disease ; it also complicates pneumonia and pleurisy. The rela- 
tion of micro-organisms to the other etiological factors is the same as in 
the other acute catarrhs. < (See Ehinitis). 

Lesions. — Acute catarrhal bronchitis is an inflammation of the mucous 
membrane of the bronchi. As a rule it is bilateral, both sides being 
involved to the same degree. Localized bronchitis is secondary to some 
other pathological process in the lungs, usually tuberculosis or pneumonia. 
In acute bronchitis only the larger tubes may be affected, this usually 
being complicated with inflammation of the trachea (ordinary tracheo- 
bronchitis) ; or, in addition, the process may extend to the medium-sized 
tubes (severe bronchitis) ; or, in infants especially, it may extend to the 
smallest tubes (capillary bronchitis). In the last-mentioned form there 
are invariably changes in the zones of air vesicles surrounding the bron- 
chi, and these cases are therefore more properly classed as broncho-pneu- 
monia. In the first form the inflammation is superficial, and affects only 
the mucous membrane of the bronchi. In the second form it may involve 
the entire thickness of the bronchial wall, and in the third form it does so 
regularly. 

The pathological changes consist in congestion and swelling of the 
mucous membrane, desquamation of the epithelium, and an exudation of 
mucus and pus-cells. At autopsy the injection of the mucous membrane 
is usually distinct; pus and mucus line the walls of the larger bronchi, 
and by pressure ooze from the cut extremities of the smaller tubes. The 
chief lesion of the walls of the bronchi consists in an infiltration with leu- 
cocytes. In infants dying from bronchitis, the lungs are much more fre- 
quently emphysematous than collapsed. There is swelling of the lymph 
glands at the root of the lungs, which in most of the acute cases is slight, 
but in protracted cases, and after recurring attacks, may be quite marked. 

Symptoms. — It is convenient to consider separately the symptoms in 
infants and in older children. 

The bronchitis of infants. — 1. The mild form (bronchitis of the larger 
tubes). — The onset is generally gradual, and the symptoms of bronchitis 
may be preceded by those of catarrh of the nose, pharynx, or larynx. The 



514 DISEASES OF THE RESPIRATORY SYSTEM. 

change in the character of the cough, the slightly accelerated breathing, 
and a further rise in temperature, indicate an extension to the bronchi. 
The cough may be constant and severe, or very slight. There is no ex- 
pectoration. The secretions are usually coughed up into the mouth or 
pharynx, and swallowed. This sometimes excites vomiting. At other 
times the mucus is coughed only into the trachea or larynx, and aspirated 
again into the lungs. The respirations are from 40 to 50 a minute, and 
often accompanied by a rattling sound, due to mucus in the large bron- 
chi or trachea. The general symptoms are not severe, and unless the in- 
fant is very young or very delicate no apprehension need be felt as to the 
outcome. The temperature is generally from 100° to 102° F. for two or 
three days, then below 100° F. There are a moderate amount of restless- 
ness dependent upon the severity of the cough, usually anorexia, and 
sometimes vomiting and diarrhoea. 

The physical signs in the first stage are dry, sonorous rales over the 
whole chest. A little later these give place to coarse mucous rales heard 
everywhere, but especially distinct between the scapulae and in the infra- 
clavicular regions. On palpation there is usually a marked bronchial 
fremitus. Often there is not enough dyspnoea to cause recession of the 
soft parts of the chest. Unless the disease extends to the smaller bronchi 
and the air vesicles, the illness usually lasts about a week. Coarse rales 
in the chest may remain for some time after the symptoms have subsided. 
Relapses are exceedingly common. In a delicate or susceptible child, or in 
one whose surroundings are bad, one attack is likely to be followed by a 
succession of others, so that the child may not be really well until warm 
weather comes. The general health may suffer from the prolonged con-, 
finement to the house, although the patient may never have been seri- 
ously ill. 

2. The severe form (bronchitis of the smaller tubes). — This differs 
from the preceding variety mainly in the greater severity of all its symp- 
toms. The onset may be like that just described, the severe symptoms not 
appearing until the patient has been sick two or three days, or they may 
be severe from the outset. If the latter, it is indistinguishable from 
broncho-pneumonia. There is cough, dyspnoea, accelerated breathing, 
fever, and moderate, sometimes severe, prostration. The cough is tighter, 
and more frequently of a short, teasing character than severe and parox- 
ysmal. There is difficulty in nursing. Dyspnoea may be quite marked 
and is shown by the active dilatation of the alae nasi and the recession of 
all the soft parts of the chest on inspiration. The respirations as a rule 
are from 50 to 80 a minute. The temperature for the first day or two is 
usually 101° or 102°, but it may be 103° or 104° F. So high a tempera- 
ture does not continue unless pneumonia develops. The prostration is in 
most cases more closely related to the dyspnoea and the rapidity of respi- 
ration than to the temperature. Often there is slight cyanosis. 



ACUTE CATARRHAL BRONCHITIS. 515 

In the beginning the chest is filled with sibilant and sonorous rales, 
many of them of a musical character. In twelve or twenty-four hours 
these are replaced by moist rales — coarse or fine, according as they are 
produced in the large or medium-sized tubes. There are often loud, 
wheezing rales on expiration. The respiratory murmur is feeble; the 
resonance on percussion is normal or slightly exaggerated. As the case 
progresses toward recovery, the finer rales are the first to disappear. The 
rales are always best heard behind, but they are present all over the chest. 

At the onset of such a case it is impossible to say whether the disease 
will be limited to the medium-sized bronchi or will extend to the smallest 
bronchi and air vesicles. In young or very delicate infants, and during 
measles, it is very common for the disease to spread rapidly to the air vesi- 
cles. In other cases, usually in infants under six months old, there may 
develop attacks of respiratory failure or suffocation. These may occur in a 
severe case at any time, and, because of the infant's iuability to empty the 
tubes of secretion, the dyspnoea steadily increases until the respiratory mus- 
cles are exhausted, the inspiratory force being too feeble to overcome the 
obstruction in the tubes. The symptoms which follow are usually ascribed 
to pulmonary collapse. I am, however, by no means certain that this is the 
correct explanation, for in autopsies made in such cases I have usually 
found the lungs to be the seat of acute emphysema. The clinical picture is 
a clear one. There is no disposition to cough or cry ; the pulse is feeble ; 
the respiration very rapid, superficial, often irregular ; the skin cyanotic, 
and often clammy. Finally, there may be added to the others signs of car- 
bonic-acid poisoning — dulness, apathy, and stupor. Such attacks may 
come on quite suddenly even in robust infants, and unless the treatment 
is energetic, even heroic, death often follows in a few hours, being fre- 
quently preceded by convulsions. 

The usual course of the disease in infants previously in good health 
is that the severe symptoms continue for two or three days only, after 
which the temperature falls to 100° or 100-5° F., and gradually becomes 
normal. The constitutional symptoms usually decline with the tempera- 
ture, and, except during the first thirty-six hours, they rarely give cause 
for anxiety. Recovery almost invariably occurs unless the disease ex- 
tends to the finer bronchi. 

Bronchitis is principally to be distinguished from broncho-pneumonia. 
The differential diagnosis is more fully considered under that disease. The 
most important points are that in pneumonia the temperature is higher 
and more prolonged, the prostration greater, the rales very often localized 
— being heard only behind, often over only one lung — the duration is 
more protracted, and all the symptoms are more severe. 

The bronchitis of older children. — This is not nearly so serious as in 
infants, because the same danger does not exist of extension of the inflam- 
mation to the finer bronchi and air cells. 



516 DISEASES OF THE RESPIRATORY SYSTEM. 

1. The mild form. — This is very common. The constitutional symp- 
toms are slight, and often entirely absent after the first day. The patient 
is never sick enough to go to bed. The first symptoms are cough and 
soreness or a sense of oppression beneath the sternum. The cough is 
always worse at night. It is at first tight, hard, and racking ; later it is 
loose, and in children over five years old there is usually expectoration — 
first of white, frothy mucus, but after a few days it becomes more abun- 
dant, and of a yellow or yellowish-green colour, from the presence of pus. 
The physical signs are only coarse rales, at first dry, and later moist, but 
heard over both sides of the chest, in front and behind. There may be 
some disturbance of digestion, anorexia, constipation, or diarrhoea. The 
usual duration of the attack is from one to two weeks. If the patient is 
not kept indoors the disease may pass into a subacute form, lasting for 
several weeks as a protracted " winter cough," but without any other im- 
portant symptoms. 

2. The severe form. — The onset is abrupt, with fever, chill, pains in 
the back, headache, cough, and sometimes pain in the chest. There is a 
feeling of tightness or constriction beneath the sternum. The onset re- 
sembles that of pneumonia, except that the symptoms are less severe. 
The temperature for the first two or three days ranges between 100° and 
103° F. It is generally highest in the first twenty-four hours. The 
cough resembles that of the mild form, but it is usually more severe. 
The expectoration is more profuse, and occasionally, in the early stage, it 
may be streaked with blood. 

The coarse rales of the mild form are present, and in addition there 
are finer rales — at first dry, and later moist — heard all over the chest. Fre- 
quently, wheezing rales are heard on expiration. The duration of the at- 
tack is ordinarily from two to three weeks, the patient being sick enough 
to be confined to bed for three or four days only. There is frequently 
a cough for some time after all physical signs have disappeared. Eelapses 
are easily excited by any indiscretion before the patient has quite recovered. 

The prognosis in the primary cases is good, such almost invariably ter- 
minating in recovery, and very exceptionally passing into broncho-pneu- 
monia; but this not infrequently happens when the attack complicates 
measles or pertussis. 

Treatment of Bronchitis. Prophylaxis. — To remove the predisposi- 
tion to bronchitis the same means should be employed as those men- 
tioned in acute rhinitis. General measures also should be adopted to 
build up the health of delicate infants. Those with tuberculous ante- 
cedents, and those who are especially prone to pulmonary disease, should 
if possible spend the winter in a warm climate. In all such patients 
the systematic administration of cod-liver oil should be continued 
throughout every cold season. The sleeping apartments of susceptible 
infants should not be too cold — never below 60° F, — but they should be 



ACUTE CATARRHAL BRONCHITIS. 517 

well ventilated, best by an open fire. Such children should sleep in flan- 
nel night clothes, care being taken to see that the feet are always warm. 
While bronchitis of the large tubes is not per se a serious disease, it may 
become so by extension to the smaller tubes. It is consequently very im- 
portant in infants and young children that these apparently mild attacks 
should not be neglected. 

General management. — Every young child who has an acute catarrh of 
the nose, pharynx, larynx, or bronchi should be kept indoors. In every 
such catarrh accompanied by fever the child should be kept in bed while 
the fever lasts, even if the temperature does not go above 100*5° F., and is 
accompanied by no other constitutional symptoms. In infants and young 
children, many cases of bronchitis result from an extension of an acute 
rhinitis or laryngitis, hence this precaution is of more importance than 
everything else in preventing the extension downward of a catarrhal in- 
flammation. A very large number of the cases will recover promptly when 
no other treatment is employed than to keep the child in bed. The tem- 
perature of the room should be about 70° or 72° F. It should be well 
ventilated and frequently aired, the child being removed to another room 
while this is done. Infants should not be allowed to lie for hours in the 
same position as there is a great advantage in changing from the crib to 
the nurse's arms. Careful attention should be given to feeding and to 
the condition of the bowels. A cathartic, preferably castor oil, should 
be administered at the outset. Distention of the stomach and bowels 
with gas adds greatly to the discomfort of the patient, and may cause 
serious symptoms. 

Abortive measures are rarely successful, for, by the time the physician 
is summoned, the disease is generally so well established that they are 
futile. Mild cases may sometimes be cut short by a hot foot-bath, free 
catharsis, and diaphoresis, especially by the use of one or two doses of 
phenacetine and Dover's powder (phenacetine two grains, Dover's pow- 
der one grain, to a child of three years). 

Local applications. — Poultices are objectionable on account of their 
weight and the difficulty in getting them properly applied. For infants 
the oiled-silk jacket (page 61) is decidedly preferable. This should be 
applied in the beginning, and may be worn throughout the attack. It ac- 
complishes all that a poultice does, with much less disturbance to the 
patient. Counter-irritation is very valuable. In infants the best results 
are obtained by the frequent use of a mustard paste (page 54). It should 
be large enough to envelop the chest, and covered by a towel, so as not to 
soil the oiled-silk jacket or the clothing. The paste is removed as soon as 
the skin is thoroughly reddened, which will be in from five to ten min- 
utes, according to the strength of the mustard and the condition of the 
child's skin. The skin should then be powdered and the oiled-silk jacket 
again pinned snugly about the chest. This may be repeated, according to 



518 DISEASES OF THE RESPIRATORY SYSTEM. 

indications, from two to eight times a day. If properly used, it may be 
continued for a week without causing any soreness of the skin. 

Inhalations. — The value of these is not sufficiently appreciated. They 
may in the great majority of cases take the place of the administration of 
drugs by the mouth, a very great advantage in infants. They may be 
used by means of the croup kettle or vapourizer (pages 60 and 61), the 
child always being placed in a tent. In the early part of the disease 
relaxing inhalations, like simple watery vapour or lime-water, may be 
used. Later turpentine, creosote, terebene, or eucalyptol may be added. 
Of these, creosote has given me the most satisfaction. Inhalations are 
to be used for ten or fifteen minutes from four to twelve times a day. 

Expectorants. — In infancy this class of drugs may usually be advan- 
tageously dispensed with. For older children the relaxing expectorants, 
especially antimony and ipecac in combination, may be used in the first 
stage. When the secretion is more abundant, either the alkaline or the 
stimulating expectorants may be given. Of the former, the best are liquor 
potassae, citrate of potassium, and muriate of ammonia ; of the latter, creo- 
sote, turpentine, terebene, and squills. Small, frequently repeated doses 
usually give the best results. 

Opium. — This should be given very cautiously to young infants, as it 
is capable of doing great harm. The dry, harassing cough of the early 
stage sometimes yields to nothing so quickly as to small doses of Dover's 
powder (e. g., one tenth of a grain every two hours to a child of one year). 
In the case of infants, late in the disease, and especially in severe cases, 
opium should be withheld altogether. It disturbs the stomach, consti- 
pates the bowels, and, most of all, it greatly depresses the respiration. 

Emetics may sometimes be used with advantage when the secretion is 
very abundant and the cough feeble, but they should be avoided with weak 
pulse, great prostration, and slight stupor. Syrup of ipecac is the best 
emetic under these conditions. 

Cardiac stimulants. — These are required in most of the severe cases. 
The best is alcohol. It should be begun as soon as indicated by weak 
pulse and general prostration. For a child a year old, half an ounce of 
brandy, diluted with from six to eight parts of water, may be given in 
each, twenty-four hours, in small doses at short intervals. 

Respiratory stimulants. — The most valuable drugs are strychnine 
and atropine. To an infant of six months ^J-g- grain of strychnine and 
itVo grain of atropine may be given every two hours. For a short time 
twice these doses may be used. They are needed only in the most severe 
cases, and may be used in combination or alternately. An important re- 
spiratory stimulant is counter-irritation over the entire body by the mus- 
tard paste or hot mustard bath. 

The management of mild cases in infants. — In the great majority of 
cases the disease is self-limited, tending to spontaneous recovery. Often 



ACUTE CATARRHAL BRONCHITIS. 519 

no treatment is needed, except the hygienic measures mentioned. An 
oiled-silk jacket should be applied. If the cough is excessive, inhalations 
of creosote or turpentine three or four times a day may be used, or small 
doses of Dover's powder or phenacetine. The oppression which often 
comes on toward evening may be relieved by a mustard paste at bedtime. 
Stimulants are not required. All other drugs may be advantageously 
omitted, but during convalescence cod-liver oil should be given. 

The management of severe cases in infants. — These must be treated 
very much like cases of broncho-pneumonia. The temperature is rarely 
high enough to require interference, but the chief danger is due to the 
inability of the child to get rid of the secretion by the cough. In my 
experience the two most valuable means of treatment have been the use 
of inhalations and counter-irritation. The former should be repeated for 
ten or fifteen minutes every two hours, and for a short period may often 
be given with advantage every hour. Early in the disease, vapour of 
plain water or limewater may be used ; later, creosote is best. Counter- 
irritation by the mustard paste should be repeated every three hours, 
and the oiled-silk jacket worn continuously. Alcoholic stimulants are 
usually needed in delicate children, and in secondary bronchitis accom- 
panying the infectious diseases. In most of the cases the medication 
should consist only of cardiac and respiratory stimulants. In strong chil- 
dren the occasional use of an emetic at bedtime is admissible. 

Attacks of suffocation and respiratory failure. — The indications here 
are to get as N much blood as possible to the surface and to the extremities, 
in order to relieve the overloaded right heart, and to co'mpel the child to 
make full and deep inspiratory efforts. One plan of treatment is to 
induce frequent crying by flagellation or spanking, this being kept up for 
several hours. Another is to use alternately hot and cold douches to the 
chest until some reaction is obtained, and then to follow up this by the 
occasional use, for a few moments, of a very hot bath (110° F.). Both 
these means, but especially the first mentioned, are of great value, as I 
have had abundant opportunity to verify. Other useful measures are 
the hot mustard bath, the hot mustard pack applied to the entire body, 
and dry cups. In conjunction with the above means, both heart and res- 
piratory stimulants should be given in full doses. If possible, oxygen 
should be administered. As these symptoms are liable to recur every few 
hours for a day or two, a repetition of the treatment will be needed, and 
if possible the physician should remain with the patient. 

If a young infant can be tided over these critical attacks, recovery is 
probable. After this danger is past, the treatment previously indicated 
may be pursued. The use of expectorants, particularly the composite 
cough mixtures containing opium, can not be too strongly condemned 
in all severe cases of infantile bronchitis. 

The management of cases in older children. — In the non-febrile 



520 DISEASES OP THE RESPIRATORY SYSTEM. 

confinement in bed is unnecessary, but children should be kept indoors. 
In the early stage, with hard, dry cough, one of the best remedies is brown 
mixture (the mistura glycyrrhizae composita of the U. S. P.). It will 
be found advantageous in most cases to have the formula made up with 
one half the usual amount of opium. When the cough is especially hard 
and dry, a single inhalation may be used at bedtime. In the second stage, 
muriate of ammonia may be added to the mixture; or terebene, two or 
three drops upon sugar, may be given four or five times a day. Inhala- 
tions of creosote or turpentine should be used. 

In the more severe cases the patients should be kept in bed and coun- 
ter-irritation to the chest employed. In the beginning the liquor am- 
moniac acetatis and spiritus setheris nitrosi may be given for their effect 
upon the skin and kidneys. For the general discomfort, pain, headache, 
etc., nothing is better than phenacetine and Dover's powder (two grains 
of the former to one half grain of the latter to a child of five years), 
repeated every three to six hours. Heroin is a valuable remedy for the 
relief of troublesome cough, but should be used with caution; not more 
than gr. ■£$ should be given every three hours to a child of five. All 
patients should be kept in bed as long as the temperature is above normal. 

The protracted cough of convalescence. — It often happens, both in 
infants and in older children, that after all physical signs and constitu- 
tional symptoms have disappeared, a cough continues sometimes for weeks. 
Expectoration is scanty, or is wanting altogether ; the cough is hard, dry, 
often paroxysmal, and in some cases occurs at night only. For this con- 
dition the best remedies are quinine, cod-liver oil, and creosote. The last 
named may easily be given to young infants as well as to older children, in 
combination with liquid beef peptonoids.* It may be also used in pill form 
or by inhalation. These measures may be tried alternately or in combina- 
tion. Where they are not effective a change of climate should be advised. 

FIBRINOUS BRONCHITIS (BRONCHIAL CROUP). 

Fibrinous bronchitis is seen in diphtheria, usually as an extension from 
the larynx or trachea. There is, however, another form of bronchitis 
attended by a fibrinous exudate, which occurs as a primary disease. This 
is very rare in children. Weil has, however, collected twenty cases of the 
primary form. The etiology is obscure. It is seen at all ages, from in- 
fancy up to puberty, and it may be either acute or chronic. From the cases 
thus far reported it would appear that the acute form is relatively more 
common in children than in adults. The disease may be confined to cer- 
tain branches of the bronchial tree, or it may affect all the bronchi, even 
to the minute subdivisions. The fibrinous membrane is found loose in 

* A preparation put up by the Arlington Chemical Company, and a very palatable 
way of giving creosote. 



CHRONIC BRONCHITIS. 521 

the tubes or adherent. There are generally associated other pulmonary 
changes, such as emphysema, areas of atelectasis or of broncho-pneumonia. 

The acute form somewhat resembles ordinary catarrhal bronchitis. 
The diagnostic features are the severity of the. dyspnoea and the expectora- 
tion of tube casts from the larger bronchi, or elongated cylinders from 
the smaller ones, the former resembling macaroni, the latter vermicelli. 
The expectorated masses are often in balls or plugs, and their peculiar 
character is not recognised until they are placed in water. The casts 
are dissolved by alkalies, especially by lime-water. After the expulsion of a 
large cast, improvement in all the symptoms occurs. These, however, 
return as the exudate reappears. The ordinary duration of acute cases 
is from one to three weeks. 

In the chronic form there are no constitutional symptoms, but only 
dyspnoea and cough, often recurring in paroxysms, with the expectoration 
of fibrinous casts. The patient may have these attacks at intervals of a 
few days or weeks, extending over a period of months, or even years. 
There are no characteristic physical signs. The diagnosis rests upon the 
peculiar character of the expectoration. The prognosis in acute cases is 
unfavourable, the mortality being 75 per cent (Weil). Chronic cases are 
not dangerous to life. 

Treatment. — This is quite unsatisfactory. To loosen the membrane and 
facilitate its expulsion, the most efficient means are inhalations of the 
vapour of limewater and the internal administration of pilocarpine. Oc- 
casionally emetics are of value. Improvement in some of the chronic 
cases has resulted from the use of iodide of potassium. 

CHRONIC BRONCHITIS. 

Chronic bronchitis is not a common disease in children, particularly 
in young children, one reason being that chronic emphysema, so fre- 
quently an associated condition in adults, is rare in early life. Chronic 
bronchitis always accompanies chronic pulmonary tuberculosis and chronic 
interstitial pneumonia, with or without the occurrence of bronchiectasis. 
It is seen in chronic cardiac disease, especially with lesions of the mitral 
valve. It may occur as a late symptom of hereditary syphilis. Excluding 
the varieties mentioned, it usually follows attacks of acute bronchitis, the 
process becoming chronic because of the patient's constitutional condition 
or his unhygienic surroundings. The acute attack may be primary, but it 
often follows measles and whooping-cough. Rickets, general malnutrition, 
and lymphatism are the constitutional conditions in which acute bronchitis 
is most likely to pass into the chronic form. Deformities of the chest, 
the result either of rickets or of Pott's disease, are occasionally a cause. 

Symptoms. — The only constant symptom is cough, which is persistent, 
obstinate, and nearly always worse at night or early in the morning. It 
often occurs in paroxysms strongly suggestive of pertussis. Expectora- 



522 DISEASES OF THE RESPIRATORY SYSTEM. 

tion is not generally abundant, but in older children it is usually present, 
and in a few cases it is profuse. A copious morning expectoration of 
fetid pus or muco-pus indicates bronchiectasis. There is no fever, little 
or no dyspnoea, and although the patients are thin they are not emaci- 
ated, and in many cases the general health is not much affected. There 
may be coarse mucous rales, or no physical signs whatever. The dura- 
tion of the disease is indefinite, depending upon the cause. All these 
patients are better in summer and worse in winter, and suffer frequently 
from exacerbations of acute or subacute bronchitis. 

The diagnosis is to be made mainly from pertussis and tuberculosis. 
From mild attacks of pertussis the diagnosis may be impossible except by 
the course of the disease. Tuberculosis may be suspected if the thermom- 
eter shows regularly a slight evening rise of temperature, if there is much 
anaemia, and steady loss of flesh. A positive diagnosis can be made only 
by the discovery of tubercle bacilli in the sputum. 

Treatment. — The first indication is to treat the primary disease. In 
cardiac cases digitalis is the best remedy, and all sedatives are to be 
avoided. Attention should be directed to the general condition — rickets, 
malnutrition, and lymphatism each receiving its appropriate treatment. 
In most cases a general tonic plan of treatment is best, particularly the 
continuous use of cod-liver oil. In many cases a change of climate is the 
only thing which is really curative. For the relief of cough, opiates are 
to be avoided as much as possible. The main reliance should be upon 
potassium iodide, heroin, creosote and terebene, the last two being given 
both by mouth and by inhalation. 

REFLEX COUGH— NERVOUS COUGH. 

Strictly speaking, all cough is reflex and of nervous origin. The term 
" reflex cough " is, however, commonly used to denote that which occurs 
without any evidence of disease in the. larynx, trachea, bronchi, lungs, or 
pleura. On account of the close connection through the vagus and its 
branches between the mouth, ear, throat, stomach, and thoracic organs, 
it is possible for cough to be produced by many forms of irritation in 
these organs or cavities. Clinically, the following varieties of nervous 
cough are observed: 

1. That dependent upon rhino-pharyngeal irritation. This is the 
most frequent form, and is sometimes caused by an elongated uvula, 
but is usually due to adenoid growths of the pharynx, though enlarge- 
ment of all the lymphoid tissues of the neighborhood no doubt have a 
part. The cough is generally excited by an accumulation of mucus in 
the posterior pharynx, and is dry, tickling, or hemming in character. 
It occurs chiefly at night and in some patients only then; it may begin 
soon after the child falls asleep and continue the greater part of the 



REFLEX COUGH. 523 

night, often for months, especially in the cold season. Formerly, such 
coughs were often ascribed to disorders of digestion, to dentition, to 
inflammation of the ears, etc. 

2. Cardiac cough. This is usually associated with mitral disease, 
and is due to pulmonary congestion. The cough is dry, hard, and often 
severe. 

3. The variety which occurs usually about the time of puberty, and 
often associated with anaemia, chorea, or spinal irritation. It is a short, 
hacking, or teasing cough : sometimes very distressing, and it seems to 
be a manifestation of extreme nervous irritability. 

4. The periodical night cough, which is generally ascribed to irrita- 
tion of the vagus or its branches by enlarged, sometimes caseous, lymph 
nodes of the tracheo-bronchial group. This often occurs in severe 
paroxysms, the character of which is very much like pertussis. The 
attacks are apt to come on about the middle of the night and last for 
several hours. Vomiting is rare. The cough may recur regularly every 
night for months. On account of the loss of sleep the patient's general 
health may be considerably undermined. 

5. A very similar cough may occur in connection with abscesses in 
the posterior mediastinum due to Pott's disease. 

Symptoms and Diagnosis. — These cases are not common in infants, 
but are quite frequent in older children. In nearly all the varieties 
the cough is worse at night, and in many it may be confined to that 
time. The influence of habit is often seen, the attacks coming on regu- 
larly at certain periods. The general health may not be affected, except 
from the disturbance of sleep. The diagnosis between the different 
forms is often very difficult. The precise cause in a given case is discov- 
ered only by a careful examination of the ear, nose, pharynx, heart, stom- 
ach, lungs, and a consideration of the patient's general condition. The 
existence of enlarged or tuberculous bronchial glands may be suspected in 
patients of tuberculous antecedents, in those who have previously suffered 
from measles, pertussis, or repeated attacks of bronchitis, and when the 
cough is very severe and paroxysmal. A similar group of symptoms may 
exist with abscesses from Pott's disease. In either of these conditions 
there may be attacks of suffocation. 

Treatment. — Opium and expectorants are not indicated, and inhala- 
tions are of little value. The only successful treatment is that which is 
directed to the cause of the disease. If no cause can be found, and the 
cough appears to be of purely nervous origin, the best results follow the 
use of the bromides or the administration of antipyrine at bedtime. 

ASTHMA. 

Asthma may be defined as a vaso-motor neurosis of the respiratory 
tract. It is characterized by attacks of severe spasmodic dyspnoea, which 



524 DISEASES OF THE RESPIRATORY SYSTEM. 

may be preceded, accompanied, or followed by bronchial catarrh of greater 
or less severity. In the asthmatic attacks of infancy the catarrhal ele- 
ment is very prominent, and these cases present quite a different clinical 
picture from the disease as seen in older children, which differs in no 
essential points from the asthma of adults. 

Writers differ very much in their statements regarding the frequency 
of asthma in early life, mainly because of a want of agreement in re- 
gard to what shall be included under this term. The asthmatic attacks 
of infants are considered by some as a stage of bronchitis, by others as 
distinct from that disease. Typical attacks resembling those of adult life 
are rare in children, and extremely so before the seventh year. How- 
ever, of 225 cases of asthma reported by Hyde Salter, the disease began 
before the tenth year in nearly one third the number. 

Etiology. — The general or constitutional causes are the same in chil- 
dren as in adults. Asthma may be hereditary. It occurs especially in 
children whose antecedents have suffered from gout or from other neu- 
roses. The local cause may be any form of irritation in the nose or 
pharynx — hypertrophic rhinitis, adenoid growths of the pharynx, hyper- 
trophied tonsils, or elongated uvula — or in the bronchial mucous mem- 
brane, as a result of previous attacks of acute bronchitis. It is probable 
that it may also be caused by the irritation of enlarged bronchial glands. 
In susceptible persons a paroxysm may be excited by cold or damp air, 
indigestion, constipation, or the inhalation of various irritating sub- 
stances, such as dust, the pollen of certain plants, etc. First attacks of 
asthma in children are apt to follow bronchitis. 

Symptoms. — Four quite distinct clinical types of asthma are seen in 
children : (1.) Cases which in their onset simulate attacks of capillary 
bronchitis. (2.) Those in which asthmatic symptoms follow an attack of 
bronchitis, continuing for weeks or months, but not necessarily recur- 
ring. (3.) Hay fever, or the periodical form which occurs every summer. 
(4.) That which resembles the ordinary adult asthma, with the nervous 
element predominating. The prominence of the catarrhal symptoms is 
characteristic of all asthma in children, the first two varieties mentioned 
being peculiar to early life. 

Attacks resembling capillary bronchitis. — These cases are rare, but 
may be seen even in infants. The onset is sudden, with moderate fever, 
incessant cough, severe dyspnoea, and sometimes symptoms of suffocation 
— cyanosis, prostration, and cold extremities. The chest is filled with 
sonorous, sibilant, and soon with subcrepitant rales. Instead of running 
the usual course of bronchitis of the finer tubes, the symptoms may pass 
away very rapidly, and in forty-eight, sometimes in twenty-four hours 
the patient may be quite well. It is only by the course of the disease and 
by recurring attacks that their true nature can be recognised. In infants 
this form of asthma may be fatal. 



ASTHMA. 525 

Cases following attacks of bronchitis — Catarrhal asthma. — This form is 
not uncommon, though it is frequently designated by some other term than 
asthma — sometimes as spasmodic bronchitis, or catarrhal spasm of the bron- 
chi. The symptoms are, however, indistinguishable from asthma, and 
they evidently belong in the same category. This form is usually seen in 
infants, being rare after the third year. Many of the patients are rachitic ; 
others have large tonsils, or adenoid growths of the pharynx ; while in 
still others there is every reason to suspect the presence of large bronchial 
glands. Usually there is nothing peculiar about the antecedent bronchitis ; 
in most cases it is not especially severe, and is limited to the larger tubes. 
The febrile symptoms subside in a few days, but the cough continues, 
as do also the dyspnoea and wheezing. When the symptoms are fairly 
established they are very uniform and characteristic. The respiration is 
accelerated, usually to 50 or 60, sometimes to 70 or 80, a minute. The 
temperature from time to time may be very slightly elevated, or it may 
remain normal. The respiration is noisy, laboured, and accompanied by 
distinct wheezing. 

On auscultation, there is prolonged expiration accompanied by loud, 
wheezing rales, either sonorous, sibilant, or musical, and occasionally 
moist rales are heard. In cases which have lasted some time a moderate 
amount of emphysema can be inferred from prominence of the infra- 
clavicular regions, and exaggerated resonance over the chest in front. 

These symptoms and signs may continue for three or four weeks only, 
and gradually wear off, or they may last as many months — if they begin in 
the winter or spring, often continuing until the middle of the summer. 
While they are constantly present, they vary in intensity from time to time, 
being usually much worse at night. The symptoms are always increased 
by exposure to a cold, damp atmosphere, by any fresh accession of bron- 
chitis, and often by trivial digestive disturbances. The usual duration 
of the cases I have seen has been two to six weeks. The cough is not 
usually severe, and expectoration in most cases is absent. The general 
health is often but little affected. With recovery from the asthmatic 
symptoms the emphysema usually disappears gradually, although I have 
seen one severe case in which it persisted. 

What proportion of these children afterward develop ordinary asthma, 
from personal experience I am unable to say. Some undoubtedly do, but 
in others which I have been able to follow, recovery has seemed to be 
permanent. This would appear more likely in those cases closely associ- 
ated with rickets, or with other causes which disappear spontaneously 
with time or as a result of treatment. 

Hay fever. — This is very rare before the seventh, and but few well- 
marked cases are seen before the tenth year. In its clinical aspects it does 
not differ essentially from the disease as seen in adults, except possibly 
by the greater prominence of the bronchial catarrh. 



526 DISEASES OF THE RESPIRATORY SYSTEM. 

Ordinary attacks of the adult type. — These usually occur at inter- 
vals of a few weeks or months, depending upon the nature of the exciting 
cause. The beginning is usually at night, with dyspnoea, a short, dry 
cough, and loud, wheezing respiration. Deep recession of the soft parts 
of the chest is seen, as in laryngeal stenosis. There is prolonged ex- 
piration, accompanied by loud, sonorous, sibilant and wheezing rales, and 
the vesicular murmur is very feeble. Later, moist rales may be heard. 
After many attacks emphysema is present. This occurs more rapidly than 
in adults, and may be extreme, giving rise in marked cases to serious 
thoracic deformity. On account of the loss of sleep and interference with 
nutrition, the general health may become seriously impaired. 

Diagnosis. — Typical attacks of asthma are easily recognised. Some of 
the catarrhal forms seen in infancy, however, present great difficulty, and 
a positive diagnosis may be impossible except by the progress of the case. 

Prognosis. — This is best in the cases of catarrhal asthma in infants, 
and in older patients when it depends upon some local cause which can 
be removed, as when the disease is due to reflex nasal or pharyngeal irrita- 
tion. In the majority of other cases, asthma is likely to become chronic 
unless the child is removed to some climate in which the attacks do not 
occur. The younger the child, the shorter the duration of the disease, 
and the less marked the hereditary tendency, the better the prognosis. 

Treatment. — The nose and the rhino-pharynx should be carefully 
examined in every case of asthma, and any pathological condition there 
present should receive attention as the first step in the treatment. Spe- 
cial importance, in children, should be attached to the removal of ade- 
noid growths of the pharynx. During attacks, the best means of reliev- 
ing the symptoms is the inhalation of fumes of nitre paper or stramoni- 
um leaves. Most of the proprietary remedies (Papier de Fruneau, Him- 
rod's cure, and Kidder's pastilles) contain these ingredients. The two 
preparations last mentioned are by most children particularly well toler- 
ated. The sleeping room may be filled with the fumes of these sub- 
stances, or the child may be placed in a tent into which the fumes are 
introduced. Emetics should be employed when the attack is brought 
on by indigestion. Lobelia is the most satisfactory remedy for this pur- 
pose. . To prevent the recurrence of night attacks, nothing in my experi- 
ence has been so valuable as a full dose of antipyrine at bedtime — four 
grains at five years and six grains at ten years. Between the attacks the 
main reliance should be upon the syrup of hydriodic acid and potassium 
iodide, which are to be given for a long time in moderate doses. Tonics 
are to be used in nearly all cases. Those especially valuable in asthmatic 
patients are cinchonidia and arsenic. 

In the cases of catarrhal asthma following bronchitis, expectorants 
and ordinary cough remedies are useless. Cod-liver oil and the iodide of 
potassium are valuable in some of the cases. Others are greatly relieved 



PNEUMONIA. 527 

by the regular use of creosote inhalations several times a day, with a 
nightly dose of antipyrine. The fumes of nitre and stramonium often 
afford no relief, and sometimes the eases are made distinctly worse by 
them. The best of all measures is to send the child at once to a warm, 
dry climate. 

For all children who have had repeated attacks, whether in the form 
of hay fever or the ordinary variety, the most important thing is removal 
to a place where they do not have the disease, and a residence there long 
enough to break up the tendency to recurrence. This will usually require 
at least three or four years. The region best suited to most asthmatics is 
one which is high, dry, and moderately warm. Patients often suffer less 
in cities than in the country. If taken early, asthma in children is fre- 
quently curable by these means ; if neglected, the disease is almost sure 
to continue until adult life. 



CHAPTER IV. 

DISEASES OF TEE LUNGS.— {Continued) 
PNEUMONIA. 

In early life the lungs are more frequently the seat of organic disease 
than any other organs in the body. Pneumonia is very common as a pri- 
mary disease, and ranks first as a complication of the various forms of 
acute infectious disease of children. It is one of the most important 
factors in the mortality of infancy and childhood (page 41). 

Cases of acute pneumonia aj;e divided, from an anatomical point of 
view, into two principal groups : (1.) Broncho-pneumonia, also known as 
catarrhal and as lobular pneumonia. (2.) Lobar pneumonia, also known 
as croupous and as fibrinous pneumonia. These differ from each other 
as to the products of inflammation, the distribution of the disease in the 
lung, and somewhat as to the parts involved and the nature of the changes 
in them. 

In broncho-pneumonia the large bronchi are the seat of a superficial 
inflammation, while in those of small size the entire bronchial wall is 
affected ; the exudation into the air vesicles is mainly cellular, being 
made up of epithelial cells, leucocytes, and red blood-cells (Fig. 8G), 
fibrin being either absent, or present only in small amount. In many 
cases there are marked changes both in the alveolar septa and in the in- 
terstitial tissue of the lung ; resolution is often imperfect, and there is a 
strong tendency of the inflammation to pass into a chronic form, in- 
volving the connective-tissue framework of the lung. The lesion is 
widely and often irregularly distributed, usually being most marked in 
35 



528 DISEASES OF THE RESPIRATORY SYSTEM. 

the vicinity of the small bronchi from which the inflammation spreads, 
and in the most superficial lobules of the lung. 

In lobar pneumonia, bronchitis, when present, is usually superficial, 
the walls of the bronchi being very slightly or not at all affected; the 
same is true of the alveolar septa. The principal product of the inflam- 
mation is fibrin (Fig. 87), which fills the alveoli and the terminal bron- 
chi, the cells being relatively few and chiefly leucocytes. The process is 
usually sharply circumscribed, involving an entire lobe or a part of a lobe. 
In most cases it clears up rapidly and completely, there being but little 
tendency to involve the framework of the lung in a chronic process. 

While in typical cases the two forms of inflammation are quite dis- 
tinct, there are seen many intermediate forms which partake of the char- 
acters of both, and one may be in doubt, even after a microscopical ex- 
amination, into which group to place a case. It not infrequently happens 



*. * ; j£*.^ 

Fig. 86. — Broncho-pneumonia. The picture shows at its centre one entire air vesicle, and at its 
margin parts of four or live other vesicles; they are filled with large epithelial cells having 
small nuclei. There are also seen leucocytes with intensely black nuclei and narrow proto- 
plasm. Between the cells is a finely granular material, which is the exudation fluid coagu- 
lated during the hardening process. The alveolar septa are somewhat infiltrated. — From 
Karg and Schmorl. 

that both varieties of pneumonia are present in different parts of the 
same lung or in both lungs at the same time. These mixed forms are 
especially frequent during the second and third years; but during the 
first year, and after the third, the types are usually well marked. 



PNEUMONIA. 



529 



The following table shows the relative frequency of lobar and broncho- 
pneumonia in three hundred and seventy cases,* nearly all taken from 




US" ' 




Fig. 87. — Lobar pneumonia. In the air vesicle shown in the picture there is a firm, close net- 
work of fibrin, in the meshes of which are leucocytes. At the lower part the exudation has 
contracted away from the wall in consequence of the process of hardening. — From Karg 
and Schmorl. 

one institution (New York Infant Asylum). There are included all the 
cases of acute primary pneumonia occurring during a period of seven 
years : 

Under six months, broncho-pneumonia, 73 cases; lobar pneumonia, 11 cases. 
Six to twelve " " 96 " " " 29 " 

Second year, " 73 " " " 40 " 

Third " " 19 " " " 23 " 

Fourth " " " " " 6 " 

Totals, " 261 " " " 109 " 

Thus it will be seen that, of the cases of acute pneumonia occurring 
during the first two years, 25 per cent were lobar and 75 per cent were 
broncho-pneumonia. 

When we come to a consideration of the micro-organisms with which 
the different forms of pneumonia are associated, we find that they do not 



* The division was here made according to the predominant clinical or pathological 
features. Most of the doubtful cases were classed as broncho-pneumonia. 



530 DISEASES OF THE RESPIRATORY SYSTEM. 

correspond to the anatomical varieties. Lobar pneumonia is regularly 
associated with the presence of the pneumococcus (micrococcus lanceo- 
latus), which is frequently found pure. In broncho-pneumonia no single 
form is regularly present. In the primary cases the pneumococcus is most 
frequently found, and in many cases it is alone. In the secondary cases 
there is almost always mixed infection. In measles and diphtheria the 
streptococcus is usually present, such cases being generally of a very 
severe type. In other secondary cases there is found the staphylococcus, 
and sometimes Friedlander's bacillus. Each of these varieties of bacteria 
may be found alone, but they are often associated, and with any of them 
may be found the pneumococcus, or other specific germs, most frequently 
the bacillus of influenza, diphtheria, or tuberculosis. 

Why the same cause — the pneumococcus — in one case produces bron- 
cho-pneumonia and in another lobar pneumonia, is in part owing to 
the difference in the structure of the lung at the different ages — that 
of infancy being more bronchial, and that of older children more ves- 
icular. Another reason is to be found in the constitution of the pa- 
tient: in the very young and in feeble and delicate children, the pro- 
cess tends to become diffuse and the products are chiefly cellular; in 
those who are older and more vigorous it is likely to be circumscribed, 
with fibrin as its chief product; in the intermediate ages and interme- 
diate conditions the types are often mingled. 

Etiologically as well as clinically, lobar pneumonia is a single disease, 
usually running a regular self-limited course. Broncho-pneumonia, on 
the other hand, includes a number of quite distinct diseases, which are 
not only etiologically but clinically different. Sometimes when it is due 
to the pneumococcus it has more features in common with lobar pneu- 
monia than with cases of broncho-pneumonia due to another kind of 
infection, such as the streptococcus. 

The immediate source of infection of the lungs is the mouth, the 
nose, or the pharynx. All the forms of bacteria found in pneumonia are 
found in these cavities, some of them constantly, others only at certain 
times, especially during an attack of any of the acute infectious diseases. 
What part direct contagion plays in the spread of pneumonia can not be 
settled without fuller data than at present exist." There seems to be no 
doubt, from clinical observations alone, that the secondary forms, espe- 
cially those complicating measles and diphtheria, are sometimes com- 
municated in this way. This is probably not often true of primary cases 
except in hospitals for infants where the rapid development of case after 
case in the same ward can not be well explained on any other hypothesis. 

The different forms of pneumonia which will be considered are: (1) 
Acute broncho-pneumonia. (2) Acute fibrinous pneumonia. (3) Acute 
pleuro-pneumonia. (4) Hypostatic pneumonia. (5) Chronic broncho- 
pneumonia. 



ACUTE BRONCHO-PNEUMONIA. 



531 



Tuberculous broncho-pneumonia will be discussed in the chapter de- 
voted to Tuberculosis. 

ACUTE BRONCHO-PNEUMONIA. 

Synonyms : Catarrhal pneumonia, lobular pneumonia, capillary bronchitis. 

This is essentially the pneumonia of infancy. Under two years, the 
great majority of the cases of primary pneumonia are of this variety, and 
throughout childhood nearly all the cases of secondary pneumonia. The 
term broncho-pneumonia describes a lesion rather than a disease, several 
quite distinct forms of infection being included under this head. Its mor- 
tality is high, because of the tender age of the patients in which the pri- 
mary cases occur, and also because when secondary it complicates the 
most severe forms of the acute infectious diseases of children. 

Etiology. — Age. — The 426 cases of broncho-pneumonia of which I 
have notes occurred as follows : 

During the first year 224 cases, or 53 per cent. 

" " second year 142 " " 33 " " 

" third " 46 " " 11 " " 

" fourth " 10 " " 2 " " 

" " fifth " 4 " " 1 " " 

426 100 

After four years broncho-pneumonia is very infrequent as a primary 
disease, although it is seen throughout childhood as a complication of the 
infectious diseases. 

Sex. — In the primary cases males are more frequently affected than 
females, the proportion being five to four. In the secondary cases the 
sexes are about equally affected. 

Season. — Of the cases referred to, 38 per cent occurred during the win- 
ter months, 31 per cent during the spring, 13 per cent during the sum- 
mer, and 18 per cent during the autumn. While, therefore, nearly 70 per 
cent of the cases occurred in the cold months, broncho-pneumonia is seen 
throughout the year. 

Previous condition. — Broncho-pneumonia affects all classes, but is 
most frequent in children having poor hygienic surroundings, especially 
in inmates of institutions, and in those previously debilitated by constitu- 
tional or local disease. In 24G consecutive cases of primary pneumonia, 
110 were in good condition prior to the attack, and 12G were delicate, 
rachitic, or syphilitic. 

Previous disease. — The following table gives a good idea of the condi- 
tions with which acute broncho-pneumonia is most frequently seen ; 443 
cases were classed as follows : 



532 DISEASES OP THE RESPIRATORY SYSTEM. 

Primary * 164 

Secondary to bronchitis of the large tubes 41 

Complicating measles 89 

" pertussis 66 

" diphtheria « 47 

" acute ileo-colitis 19 

" scarlet fever 7 

" influenza 6 

" varicella 2 

" erysipelas 2 

443 

A large number of the patients had previously suffered from one or 
more attacks of bronchitis, and fifteen previously had broncho-pneumonia. 
As an exciting cause, exposure to cold must still be classed among the 
potent factors of primary pneumonia. 

Bacteriology. — Much light has already been thrown upon broncho- 
pneumonia by bacteriology, but many points still remain to be settled. 

In 1892 Netter published a report upon 42 cases. He did not sepa- 
rate the primary and secondary cases. Of 25 cases in which but one 
form of bacteria was found, the pneumococcus was present in 10, the 
streptococcus in 8, the staphylococcus in 5, and Friedlander's bacillus in 
2. In the 17 cases of mixed infection, the streptococcus was present in 
15, the pneumococcus in 9, the staphylococcus in 8, and Friedlander's 
bacillus in 4. 

In 1897 Pearce (Boston) published a report upon 82 cases of bron- 
cho-pneumonia complicating various infectious diseases : 62 were asso- 
ciated with diphtheria alone; 9 with diphtheria and scarlet fever; 2 
with diphtheria and measles ; 9 with scarlet fever alone. In the 73 
diphtheria cases the Klebs-Loeffler bacillus was present in 63, and in 17 
it occurred alone. The streptococcus was present in 38 cases, 27 of these 
being in diphtheria uncomplicated by scarlet fever or measles, and 
in 7 of these it was the onty organism found. The staphylococcus 
aureus was present in 26 cases, but never alone. It is surprising that 
the pneumococcus was present in but 8 cases, 5 of these being scarlet 
fever. 

Dr. Martha Wollstein has studied bacteriologically one hundred cases 
of broncho-pneumonia. Most of these were under my personal observa- 
tion in the wards of the Babies' Hospital. Her results have been pub- 
lished in the Journal of Experimental Medicine, vol. vi, 1904. All of 
these children were under three years old ; in 33 the pneumonia was pri- 
mary and in 67 secondary. Of the latter, 25 complicated tuberculosis, 
19 marasmus, 5 diphtheria, 3 measles, 3 malaria, 4 septicaemia, 2 pyaemia, 
2 meningitis, 3 intestinal disease, 1 abscess of the brain. 

* It is probable that a number of cases complicating influenza were included 
among these primary cases. ( 



37 


« 


12 


25 


29 


" 


10 


19 


3 


" 


— " 


3 


2 


" 


u 


2 


2 


" 


— " 


2 


2 


IC 


— " 


2 


4 


it 


— " 


4 


1 


a 


— " 


1 


3 


" 


1 


2 



ACUTE BRONCHO-PNEUMONIA. 533 

Cases. Cases. Cases. Cases. 

The pneumococcus was present in 67 — primary, 24; secondary, 43 — alone in 31 

" streptococcus " " 

" staphylococcus aureus " " 
" staphylococcus albus " " 
" bacillus pyocyaneus " " 

" bacillus diphtheriae " " 

" bacillus lactis aerogenes " " 
" bacillus coli communis " " 
" proteus vulgaris " " 

" sacchyromyces albicans " " 

The absence of the bacillus of Pfeiffer is partly explained by the fact 
that cases of influenza were rarely seen at that time in the hospital. 

Our present knowledge of the bacteriology of broncho-pneumonia 
may be summarized as follows : In the primary cases the pneumococcus 
is nearly always present, and in a large proportion of the cases it occurs 
alone. In cases of mixed infection it is most frequently associated with 
the streptococcus, and next to this the staphylococcus pyogenes aureus. 
In the secondary cases a large variety of bacteria may be concerned. 
In the pneumonia of diphtheria and influenza it would appear from 
present knowledge that only the specific organisms of these diseases are 
necessary. In most cases of secondary pneumonia an important part is 
played by the streptococcus pyogenes, particularly when it complicates 
the acute infectious diseases. In many cases it is found with the staphy- 
lococcus aureus. The pneumococcus may be associated with any of these 
bacteria or with almost any combination of them. All other forms of 
infection are relatively infrequent. The secondary cases are usually due 
to a mixed infection. The association of the pneumococcus in 18 of 25 
tuberculous cases studied by Dr. Wollstein is of interest, as it explains 
the clinical fact that in cases of tuberculous broncho-pneumonia the 
symptoms are often indistinguishable from the simple form. 

We have not yet sufficient data definitely to connect the different 
forms of infection either with any set of lesions or with any group of 
clinical symptoms. The cases due to streptococcus infection are usually 
the worst forms, and are apt to show widely disseminated lesions. The 
cases in which the onset and clinical history resemble lobar pneumonia, 
and where there are found extensive areas of consolidation, and often 
excessive pleurisy, are usually due to the pneumococcus. 

Lesions. — The term broncho-pneumonia is now generally adopted as 
a generic one, and it is to be preferred either to Lobular or catarrhal pneu- 
monia, as it gives prominence to the bronchial element in tin- inflam- 
mation. The process may begin in the Larger tubes and gradually extend 
to those of smaller calibre, finally involving the pulmonary lobules in 
which these tubes terminate; or it may extend to the air vesicles which 
surround the tube in its course through the lung, so that in whatever 



534 



DISEASES OF THE RESPIRATORY SYSTEM. 



direction the lung is cut, there are seen surrounding the small bronchi, zones 
of pneumonia (Fig. 88). In other cases the process seems to begin almost 
at the same time in the small bronchi and the air vesicles, as both are found 
involved, even when death occurs within a few hours of the first symptoms. 
There are, however, cases in which the parts of the lung affected bear 
no relation to the bronchi — where there are found simply smaller or larger 




Fig. 88. — Broncho-pneumonia, with thickening of a small bronchus. In the centre of the pic- 
ture is seen a small bronchus, B, which is cut somewhat obliquely, so that the degree to which 
its wall, C, is thickened is well shown. It is partially tilled with pus, its mucous membrane 
is nearly destroyed, and its walls greatly thickened from infiltration with leucocytes. This 
infiltration extends to the lung tissue in the neighbourhood ; it forms a peri-bronchitic zone 
of pneumonia. Elsewhere in the picture the lung tissue, A, is practically normal. D is a 
small blood-vessel. E is another smaller bronchus. Throughout the lung everywhere accom- 
panying the small bronchi similar changes were seen, in addition to which there were present 
some large areas of consolidation. The disease was of four and a half weeks' duration ; the 
child, five months old. 



areas of pneumonia irregularly scattered through the lung, usually near 
the surface (Plate XI). From the distribution of the lesions such cases 
might better be termed lobular than broncho-pneumonia. 

Much has been said in the past about pulmonary collapse from ob- 



PLATE XI. 




A< i tk Beoncho-Pnedmonia. 

Primary pneumonia in a child two years old, showing the irregular distribution of 
the hepatization and its incomplete character. A is the pleura somewhat thickened; 
B, lung tissue which is practically normal ; (' (' are hepatized areas, scattered through 
which are groups of air vesicles still containing air. (Slightly magnified.) 



ACUTE BRONCHO-PNEUMONIA. 535 

struction of the small bronchi, as a condition antecedent to this form of 
pulmonary inflammation. So far as my own observations go, there has 
been adduced but little evidence that this is the rule, or, indeed, that it 
often occurs. Even in autopsies made very early in the disease, but little 
collapse was found, most of the cases supporting the view of Delafield,that 
when the disease extends from the bronchi to the air cells it involves those 
surrounding the tube quite as regularly as those to which the tube leads. 

The following observations are made from a study of 170 autopsies of 
which I have records, microscopical examinations having been made in 
about one third of the number. 

Seat of the disease. — In 82 per cent of the autopsies extensive disease 
was found in both lungs. The parts most affected were the lower lobes 
posteriorly ; next to this the posterior part of both the upper and lower 
lobes. The left lower lobe was more extensively diseased than the right 
in over two thirds of the cases. Only a single lobe was involved in but 9 
per cent of the cases. It is not common for the disease to be situated in 
the anterior portion of the lung only, but when this occurs the right 
apex is the most frequent seat. 

Just as the clinical symptoms of broncho-pneumonia follow no regular 
type, so the pathological process does not pass through a regular order of 
changes such as are seen in lobar pneumonia. There are a certain number 
of cases which appear to follow tolerably well-defined stages of conges- 
tion, red hepatization, gray hepatization, and resolution ; but the dis- 
ease may be arrested at any of the stages and the case recover, or death 
may occur at any stage and there may be found at autopsy different por- 
tions of the lung representing all the stages mentioned. In considering, 
therefore, the lesions of broncho-pneumonia, it seems best to describe the 
condition in which the lungs are found at the various periods when death 
is likely to occur, rather than to attempt to describe the different stages of 
the disease, as in lobar pneumonia. 

1. The acute congestive form (acute red pneumonia). — This is the con- 
dition in which the lung is usually found if death occurs during the first 
two or three days of the disease. In the cases severe enough to cause 
death in the first twenty-four hours, very little can be seen by the naked 
eye except acute congestion. The vessels of the pleura are distended, 
and there may be small superficial haemorrhages. Both lower lobes are 
usually heavy and dark-coloured. There is to the naked eye no consolida- 
tion. All, or nearly all, the lung can be inflated. On section, there is 
found intense congestion with some oedema. When the process has lasted a 
little longer the affected areas are more sharply defined. These, usually the 
posterior portions of both lungs, are of a brownish-red colour, and appeal 
partially hepatized, although with a little force they may in most cases be 
inflated. After section, pus and mucus flow from the divided bronchi, 
and the whole lung may be more or less congested or ujdeinatous. 
36 



536 



DISEASES OF THE RESPIRATORY SYSTEM. 



The microscope alone reveals the fact that these are not cases of sim- 
ple pulmonary congestion or bronchitis of the finer tubes. In one case in 
which death occurred twelve hours from the first symptoms, I found well- 








t &*%&™ % 


i 


y^p^v- 









T&lT&m 






Fig. 89. — Acute broncho-pneumonia with intra- alveolar haemorrhage (highly magnified). In the 
picture is shown a small vein, which, as well as the surrounding alveoli, is filled with blood- 
cells. In other respects the lung shown is normal. This is from the border of a consoli- 
dated area. Child fifteen months old: pneumonia of ten days' duration, with a severe ex- 
acerbation forty-eight hours before death, temperature 106° F. Extensive hemorrhagic areas 
were scattered through the lung most affected. 



marked evidences of inflammation of the air vesicles. In these hyper-acute 
cases, the microscope shows great distention of all the small blood-vessels 
of the affected area, and small or large extravasations of blood just be- 
neath the pleura, into the alveoli (Fig. 89) and interstitial tissue of the 
lung. In some cases these haemorrhages form the most striking feature 
of the lesion. The air vesicles are partially, some almost completely, filled 
with red blood-cells, swollen and desquamated epithelial cells, and a few 
leucocytes (Fig. 86). The red blood-cells predominate. The inflamma- 
tion may be diffuse, involving nearly a whole lobe, or in small areas in the 



ACUTE BRONCHO-PXEUMOXIA. 



537 



neighbourhood of the small bronchi. The mucous membrane of the large 
and small bronchi is the seat of catarrhal inflammation, and the walls 
of the latter are infiltrated with round cells. 

When the process has lasted from twenty-four to forty-eight hours 
all the changes described are more marked, but the red colour of the in- 
flammatory products still persists. Such cases give during life only the 
signs of congestion and bronchitis. 

2. The mottled, red and gray pneumonia. — This is the usual appear- 
ance when the disease has lasted somewhat longer, and is found in most 
of the cases dying between the fourth and fourteenth days. There are 
usually at this time quite large areas of consolidation, sometimes affect- 
ing nearly an entire lobe, so that at first sight the case may resemble lobar 
pneumonia. This is sometimes described as the '' pseudo-lobar " form. 
The extent of these areas depends largely upon the duration of the dis- 
ease. In most cases there is pleurisy over the consolidated portions. 




Fig. 90. — Acute broncho-pneumonia. In thi shown a small bronchus, V>, with a z<>ne 

of pneumonia about it. The greater part of the Bection is made up of emphysematous lung 
tissue, E E, showing dilatation of the alveolar spaces and rupture of Borne of the a 
.. At the border, A A A, are seen the margins of consolidated areas of lung. 



This may cause the lung to adhere to the ehesl wall, the firmness of the 
adhesions depending upon the duration of the process. The Burface of 
the lung is usually of a mottled red and gray colour; it often has a gran- 



538 



DISEASES OF THE RESPIRATORY SYSTEM. 



ular feel, due to the consolidation of some of the superficial lobules of 
the lung. On section, it is rarely found that an entire lobe is consoli- 
dated, the superficial portion being most affected, while the central part 
is normal or only congested. The colour is mottled, like that, of the sur- 
face. In some places the hepatization appears complete; in others the 
hepatized areas are separated by healthy, congested, or emphysematous 




Fig. 91. — Broncho-pneumonia. Dense infiltration of pus cells in and about a small bronchus; 
under a low power. The cavity shown in the specimen is a cross-section of one of the small 
bronchi, which is partially filled with pus cells ; the epithelium is destroyed. The bron- 
chial wall and the pulmonary tissue in the neighbourhood are so densely infiltrated with 
leucocytes that almost every trace of normal structure is effaced. Child fifteen months old, 
disease of four weeks' duration. Extensive areas like this were found in both lungs. 



lung tissue (Fig. 90). The gray areas surround the small bronchi and 
vary in size. The smallest ones look very much like miliary tubercles. 
The larger ones are seen where the process has existed for a longer time 
and has gradually invaded the contiguous air cells. If the lung is cut 
parallel with the bronchi, there may be seen small gray striae of pneu- 
monia along their course (Fig. 88, C). From the cut bronchi, pus flows 



ACUTE BRONCHO-PNEUMONIA. 



539 



quite freely on pressure. The bronchial walls can often be seen to be 
thickened even by the naked eye. The parts affected are usually the pos- 
terior portions of the lower lobes of one side, the remainder of the lobes 
being congested or cedematous, while in front the lung is emphysematous. 

Under the microscope the smaller bronchi (Fig. 88) are seen to be 
much thickened and infiltrated with leucocytes. The gray areas sur- 
rounding the bronchi are made up of groups of air vesicles, which are 
packed with leucocytes (Fig. 91). Fibrin is sometimes seen in small 
amount, also red blood-cells and desquamated epithelial cells, but the 
leucocytes predominate. Surrounding the areas densely infiltrated are 
groups of air vesicles which are normal or congested, or which show only 
the earlier stages of the inflammatory process. 

3. Gray pneumonia (persistent broncho-pneumonia) . — This form is 
seen in protracted cases where there have been continuous symptoms 
usually for from three to six weeks. The pleuritic adhesions are more 
general and firmer. The amount of lung involved may be very great, 
often nearly the whole of both lungs posteriorly. The affected lung ap- 
pears completely consolidated and slightly enlarged. On section, it is 
of a nearly uniform gray colour, sometimes of a yellowish-gray. On 
pressure, pus exudes from the smaller and larger bronchi. The bron- 
chial walls are markedly thickened, and in some places there may be a 
slight dilatation of the smaller bronchi. The part of the lung not con- 
solidated may be almost white, owing to vesicular emphysema. In some 
cases there is also interstitial emphysema. Small cavities containing 
pus may be found in the lung. The bronchial glands are frequently 
swollen to the size of a large bean, and are of a reddish-gray colour. 

The microscope shows that the air vesicles of the consolidated por- 
tions are distended chiefly with leucocytes, but there are also epithelial 
and connective-tissue cells. The alveolar septa may be so much thick- 
ened as to encroach upon the alveolar spaces (Fig. 92). Complete reso- 
lution is then impossible. 

Terminations. — Death nay occur at any stage, or the pathological 
process may be arrested at any stage and the case go on to recovery. 
Resolution may take place before any consolidation recognisable by phys- 
ical signs ha- occurred ; in such cases it is usually rapid and complete, 
[f there has been consolidation, resolution may lake place a Tier two or 
three weeks and be complete, or it may be delayed for five or six weeks 
and still be complete. In many cases, especially those in which it is de- 
layed, resolution is only partial, and there are relapses or recurring at- 
tacks. Alter the first, or after several attacks, there may develop a 
chronic interstitial pneumonia; or simple pneumonia may be followed 
by tuberculosis. Such cases as these are to be carefully distinguished 
from the much more frequenl ones in which the broncho-pneumonia is 
tuberculous from the outset. 



540 



DISEASES OF THE RESPIRATORY SYSTEM. 



Associated Lesions of the Lungs. — Pleurisy is almost invariably found 
over every large area of consolidation, and in eases of more than four 
days' duration ; while in most of those fatal within the first two or three 
days the pleura is normal or only congested. It is seen in all grades of 
severity, from a slight gray film of fibrin that can hardly be stripped off, 
to a yellowish-green exudation one fourth of an inch thick. A small 
amount of serum — one or two ounces — in the pleural sac is not uncom- 
mon, but a large serous effusion is very rare. Oases in which there is an 



<***. 




Fig. 92. — Persistent broncho-pneumonia; highly magnified. There is shown at A A marked 
thickening of the alveolar septa, encroaching upon the alveolar spaces. All the alveoli, BB, 
are densely packed with leucocytes. A similar condition also through nearly the whole of 
the affected lung. (For history and temperature, see Fig. 101.) 



excessive inflammation of the pleura are considered elsewhere under the 
head of Pleuro- Pneumonia. Empyema occurs both during the stage of 
acute inflammation of the lung and while this is subsiding, but it is less 
frequent than in lobar pneumonia. 

Bronchial glands. — In all the recent acute cases these are swollen and 
red ; the usual size is that of a pea or a bean. They show microscopically 



ACUTE BRONCHO-PNEUMONIA. 541 

the usual changes of acute hyperplasia. In protracted cases, and after 
repeated attacks, they may be two or three times the size mentioned, and 
of a gray colour. It is rare that they are large enough to give rise to 
symptoms unless they become the seat of tuberculous deposits. 

Emphysema. — In almost all cases a certain amount of emphysema is 
present, it being more marked in the protracted cases. It is usually vesic- 
ular, involving the greater part of the upper lobes in front and the ante- 
rior margin of the lower lobes. Occasionally interstitial emphysema is 
seen, forming either large stria? upon the surface of the lung, or blebs of 
considerable size along the anterior margin. This may occur even in 
cases uncomplicated by pertussis or laryngeal stenosis. 

Gangrene. — Gangrenous areas were found in six of my cases. In four 
of these the pneumonia was primary, in one it followed diphtheria, and in 
one ileo-colitis. It occurred in scattered areas of a grayish-green colour, 
varying from one fourth of an inch to two inches in diameter. 

Abscesses of the lung are by no means uncommon. They were noted 
in seven per cent of my autopsies. They are usually minute and multiple, 
varying in size from one sixth to one half inch in diameter. Sometimes 
a portion of a lobe is fairly honeycombed with minute abscesses. In one 
case a large abscess was found occupying the greater part of a lobe, the 
symptoms resembling those of empyema. Abscesses are usually found in 
regions where the inflammatory process has been especially intense. They 
may be found in prolonged cases, in those of unusual severity, as shown 
by excessively high temperature and rapid extension of the disease, and 
in very delicate subjects. The microscope shows that these abscesses usu- 
ally begin as an accumulation of pus in the small bronchi, whose walls 
become softened and break down on account of the intensity of the in- 
flammation. They may be superficial, but are more commonly in the 
interior of the lung; they contain yellow pus and sometimes broken- 
down lung tissue. Small abscesses can not be recognised clinically; 
the large ones give the symptoms and signs of empyema. They arc dis- 
cussed more fully elsewhere. In several instances they have been suca 
fully operated on, though wrongly diagnosticated. 

The lesions in other organs will ho considered under Complications. 

Symptoms. — Broncho-pneumonia lias no typical course. The cases 
differ from each other \nv markedly, but they may he divided into a few 
quite distinct groups. 

1. The acute congestive type. — This may be Been at any age, bul is 
more frequenl in young infant-. It may he either primary or secondary, 
being nol uncommon in either form. It- Bymptoms are few and irregular, 
and the disease is often unrecognized. The entire duration may he only 
twenty-four hours. Sigh temperature, extreme prostration, cyanosis, and 
rapid respiration may he the only symptoms. The temperature varies be- 
tween 104° and 107° V., usually rising steadily until death occurs. The 



542 DISEASES OF THE RESPIRATORY SYSTEM. 

prostration is extreme from the outset, the patient being overwhelmed by 
the suddenness and severity of the attack. Cyanosis is frequently present, 
and is almost always seen shortly before death. The respirations are from 
60 to 80 a minute, but in most cases not strikingly laboured. Cough is 
frequently absent. Cerebral symptoms are often marked. There are dull- 
ness and apathy, sometimes quite profound stupor, and not infrequently 
convulsions just before death. The physical signs are few and inconclu- 
sive. There is often nothing abnormal except very rude breathing over 
both lungs behind ; sometimes the breathing on one side is feeble, and on 
the other much exaggerated. There may be no rales whatever, and no 
change in the percussion note. 

The suddenness and severity of these symptoms are something which 
it is hard for one who has not observed them to appreciate. I have known 
an infant to die in twelve hours from the time in which it was apparently 
in perfect health, and had an opportunity to confirm the diagnosis of 
pneumonia by a microscopical examination of the lung. The diagnosis 
can not be positively made during life, and in most of the cases the disease 
passes under some other name. It is often regarded as malignant scarlet 
fever or measles with suppressed eruption, or cerebro-spinal meningitis. 

If the children are sufficiently strong to withstand the onset of vio- 
lent symptoms, they may recover completely in four or five days, the 
lung clearing up very rapidly. In other cases these grave symptoms may 
abate in a day or two, to be followed by those of ordinary broncho-pneu- 
monia, which runs its usual course. 

The symptoms of some of these cases may be explained by the sudden 
intense engorgement of the lung, which, owing to the small size of the 
air vesicles, interferes with its function almost as much as does consoli- 
dation. In other cases the symptoms are due not so much to the pulmo- 
nary condition as to a general pneumococcus infection. A case lately 
came under my notice in which death occurred after a thirty hours' ill- 
ness, where the pneumococcus was found by culture in both kidneys, the 
spleen, heart's blood, and both lungs. 

2. Acute disseminated broncho-pneumonia (capillary bronchitis). — 
Although the symptoms in this class of cases are chiefly due to the bron- 
chitis, I have never failed to find at autopsy evidences of pneumonia also. 
These are not very common cases. The process begins as an inflamma- 
tion of the medium-sized and small bronchi, but not of the finest bronchi. 
The onset is acute, with fever, very rapid and laboured breathing, severe 
cough, moderate prostration, and in most cases cyanosis. 

The temperature is not high, usually only from 100° to 102° F., and it 
often continues so for three or four days. The pulse is rapid, and at first 
is full and strong. The respirations are exceedingly rapid, often from 80 
to 100 a minute. There is dyspnoea with marked recession of all the soft 
parts of the chest during inspiration. Cough is always present, usually 



ACUTE BRONCHO-PNEUMONIA. 543 

severe, and sometimes almost incessant. The prostration is not so great 
as in the cases previously described, and the development of the symptoms 
is much less rapid. 

There are at first sibilant and afterward subcrepitant rales over the 
entire chest, with which are usually mingled coarser moist rales. There 
are no evidences of consolidation. The respiratory murmur is everywhere 
feeble, but not otherwise altered. Percussion generally gives exaggerated 
resonance, owing to the emphysema which is present, the note being some- 
times almost tympanitic. 

The symptoms may gradually increase in severity until death takes 
place by the third or fourth day, from respiratory and cardiac failure. 
There is usually marked cyanosis, and toward the end rapidly increasing 
prostration. Just before death the temperature often rises rapidly to 106° 
or 107° F. At the autopsy there are found evidences of bronchitis of the 
tubes of all sizes, and minute zones of pneumonia about the smaller 
bronchi. The lungs are generally in a state of hyper-inflation, on account 
of which they do not collapse on opening the chest. There may be in 
addition extensive congestion or oedema, the development of which has 
been the immediate cause of death. 

In cases which do not prove fatal there is usually by the third or fourth 
day great improvement in the general symptoms ; the finer rales may dis- 
appear, and the coarse ones become more and more prominent. By the 
end of a week there may be complete recovery. Instead of this, there 
may be a continuance of the constitutional symptoms, and disappearance 
of the fine rales in front only' while behind there are gradually added to 
them the signs of consolidation in one of the lower lobes near the spine. 
From this time the case may progress as one of ordinary broncho-pneu- 
monia. 

The prognosis in this class of cases is very much better than in the 
congestive variety, recovery being probable unless the patients are very 
young or very delicate infants. 

3. Broncho-pneumonia of the common type. — When primary, this usu- 
ally begins suddenly with symptoms not unlike those of lobar pneumonia. 
This was the mode of onset in two thirds of my cases. In only ten per 
cent was the pneumonia preceded by bronchitis of the large tubes. In 
these the symptoms of bronchitis may slowly (Fig. 102, p. 552) or rapid- 
ly (Fig. 93) merge into those of pneumonia. When the onset is sudden 
it is marked by high fever, frequently by vomiting, rarely by convul- 
sions. In addition there are rapid respiration, cough, prostration, and 
sometimes cyanosis. The symptoms are more distinctly pulmonary than 
is generally the case in lobar pneumonia. 

The temperature, as a rule, is high; rarely is it continuously so, but 
it is of a remittent type. The daily fluctuations often amouni to four or 
five degrees. The fever usually continues from one to three weeks, and 



544 DISEASES OF THE RESPIRATORY SYSTEM. 

gradually subsides. It is rare for it to terminate by crisis. Although, 
as a rule, we expect a high temperature with acute pneumonia, this 
is not invariable. Primary cases may run their course, and even ter- 
minate fatally, although the temperature has not been above 101° E. 
I have records of several such cases. A low temperature is more often 
seen in young and delicate infants than in those who are older and more 
robust. 

The respirations are frequent and laboured ; there is real dyspnoea. 
On inspiration, there are marked recessions of all the soft parts of the 
chest, and the alae nasi dilate actively. The usual rapidity of the respira- 
tions is from 60 to 80 per minute ; very often, however, it rises to 100, and 
on several occasions I have seen it even 120. Eespiration generally seems 
more embarrassed than the action of the heart, and respiratory failure is 
a more frequent cause of death than cardiac failure. The pulse is always 
rapid — from 150 to 200 a minute — and when so it is often irregular. The 
pulse rate is of much less importance than its character. Early it is full 
and strong, but soon it becomes soft, compressible, and weak. 

The prostration is usually moderate for the first day or two, but 
steadily increases as the lung becomes more and more involved. Toward 
the close of the disease there may be present all the symptoms of the 
typhoid condition. 

Cough is much more constant than in lobar pneumonia, and more dis- 
tressing ; sometimes it is almost incessant. It disturbs rest and sleep, and 
may cause vomiting if the paroxysm occurs soon after eating. There is 
no expectoration. Mucus is sometimes coughed up into the trachea, or 
even the pharynx, to be swallowed again, or more frequently aspirated 
into the lung. If during a severe paroxysm the patient is turned upon 
his face or inverted, much of this mucus may be dislodged. A strong 
cough is a good symptom ; suppression of the cough is always a bad 
symptom, indicating a loss of the reflex sensibility of the bronchial mucous 
membrane and feeble respiratory muscles. 

Pain in the chest is not common, and is rarely an annoying symptom. 

Cyanosis is present at some time in most of the severe cases. It may 
occur at the onset, or at any time during the course of the disease. It is 
usually due to sudden congestion of a portion of the lung not previously 
involved. Even when slight, it is always a danger-signal of respiratory 
failure, and when present only in the finger tips or lips indicates that the 
patient must be carefully watched and energetically treated. In the severe 
cases the whole body may be of a dull leaden hue. 

Nervous symptoms at the onset are not so frequent as in lobar pneu- 
monia, convulsions being rare ; but late convulsions, particularly in the 
pneumonia which complicates pertussis, are exceedingly frequent, and 
usually fatal. Delirium may be present at any time during the attack. 
In infants this shows itself by excitement and inability to recognise the 



ACUTE BRONCHO-PNEUMONIA. 



545 



nurse or mother. Occasionally patients present marked cerebral symptoms 
throughout the disease. In one of my cases nearly every symptom of 
tuberculous meningitis was present, the autopsy revealing only an extreme 
degree of cerebral anaemia. As elsewhere stated, the nervous symptoms 
depend not upon the location of the disease, but upon its extent, the 
intensity of the infection, and upon the susceptibility of the patient, such 
symptoms being especially common in rachitic children and in those suf- 
fering from pertussis. 

Gastro-enteric symptoms are frequent in infancy, and are of much 
importance. Often there are from four to six stools a day, of a green 
colour, containing mucus and undigested food. These symptoms depend 
upon the feeble digestion which is associated with the febrile process, 
and are often from improper feeding. This may lead to vomiting, which 
is also due to over-medication or to severe paroxysms of coughing. Vom- 
iting and diarrhoea add much to the danger of the attack, and not in- 
frequently, when the issue is doubtful, turn the scale against the patient. 
In summer this complication is more frequent and is likely to be more 
severe. Distention of the stomach or intestines from gas may be the 
cause of severe symptoms, owing to the added embarrassment of respira- 
tion produced by this upward pressure. In infants it may lead to attacks 
of cyanosis, and even convulsions. 

The urine in most cases is scanty, high-coloured, and loaded with 
urates. A trace of albumin is often present when the temperature is 
very high ; but casts, renal epithelium, and a large amount of albumin 
are rare. 

The following temperature chart (Fig. 93) is a good example of a very 
frequent course of primary pneumonia of moderate severity terminating 



105° 


12 3 


* 1 5 


6 


7 


8 


9 


10 


11 


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Fig. 93. — Temperature curve in typical broncho-pneumonia of the milder form. 

History. — Male, sixteen months old; delicate child; previous bronchitis; onset gradual; 
signs of consolidation at left base on fifth day, but fine riles over both lower lobes behind ; reso- 
lution slow, rales persisting for a long time in both lungs. 



in recovery. In cases of this type the constitutional symptoms are not 
grave, and follow very closely the temperature curve. 

The next chart (Fig. 94) illustrates a more severe but not uncommon 
course of the disease in which the fever is prolonged. The usual duration 
of cases of this type is between three and four weeks. The irregular fluc- 
tuations of the temperature, rarely touching the normal line, are exceed- 
ingly characteristic of broncho-pneumonia. 



546 



DISEASES OP THE RESPIRATORY SYSTEM. 



The chart shown in Fig. 95 is that of relapsing pneumonia. The first 
attack was fairly typical, with about the usual duration. Eesolution 



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Fig. 94. — Temperature curve of broncho-pneumonia with a prolonged course ; recovery. 



-Female, eighteen months old ; in fair condition ; sudden onset. Early signs were 
localized, line rales over left base ; on fifth day signs of consolidation at left base, with rales on 
both sides behind. General symptoms of moderate severity. Signs of consolidation disappeared 
about a week after cessation of fever: rales persisted nearly two weeks longer. 



had begun, and was apparently progressing favourably, when there was a 
return of the fever, accompanied by new signs in the chest, the second 



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Fig. 95. — Temperature curve of relapsing broncho-pneumonia ; recovery. 

History. — Male, nineteen months old ; delicate. Consolidation on sixth day in left lower lobe 
behind; two days later small area of consolidation in right lower lobe behind; many rales both 
sides ; eighteenth day, signs of consolidation had disappeared, but many rales persisted. Acces- 
sion of fever on nineteenth and twentieth days, accompanied by extension of disease as shown 
by new rales, but no evidences of consolidation during second attack. Slow resolution and con- 
valescence. 

attack being shorter and milder than the first. Very often the tempera- 
ture falls to normal without any signs of resolution, and after an interval 
varying from two or three days to a week there is recurrence of the fever 





1 


2 


3 


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106° 
105° 
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Fig. 96. — Temperature curve of broncho-pneumonia; fatal. 

History. — Male, six months old ; markedly rachitic ; sudden onset. Signs first day were fine 
moist rales throughout the chest, marked prostration, and cyanosis; on third day, a small area 
of consolidation in upper lobe of left lung behind ; increasing prostration, cyanosis, and death. 
Autopsy. — No pleurisy ; consolidation at left apex behind, and posterior two thirds of left lower 
lobe ; consolidation of right apex posteriorly, lower lobe intensely congested. 



ACUTE BRONCHO-PNEUMONIA. 547 

and other constitutional symptoms, the second attack frequently proving 
fatal. 

A frequent course in fatal cases is shown in Fig. 96. The duration of 
the disease, instead of being five days as in this case, is often only three or 
four. The temperature at first fluctuates widel} 7 , then rises gradually 
until death. 

Duration of the fever. — The following figures give the duration of the 
fever in 231 cases. The majority were primary ; none were secondary to 
diphtheria, and only a few complicated measles. Of the 169 cases that 
were fatal — 

There died during the first six days 25-0 per cent. 

" " between the seventh and twenty-first days. .. . 55-5 " " 
" " " " twenty-first and sixtieth days 19*5 " " 

100-0 " " 

Of 78 cases which recovered, the duration of the fever was — 

Less than seven days 11-5 per cent. 

From seven to twenty-one days 66*6 " " 

From twenty- one to ninety days 21 -9 " " 

100-0 " " 

Physical Signs. — In considering the signs of broncho-pneumonia, it is 
better to connect them with the different conditions in the lung than to 
group them in stages, as in lobar pneumonia. 

(a) Without consolidation. — It can not too often be repeated that 
broncho-pneumonia may exist without signs of consolidation at any period 
during the course of the disease. When the attack is primary, the ear- 
liest signs are due to congestion of the lung, associated with bronchitis 
of the fine tubes, which is usually localized, but which may be general. 
If the disease has followed bronchitis of the large tubes, its signs are 
added. Congestion of the lung gives feeble breathing over the affected 
area, and occasionally slight dulness or diminished resonance. With this 
are found coarse sonorous, and finer sibilant rales, due to congestion and 
swelling of the mucous membrane of the larger and smaller bronchi re- 
spectively. These signs are soon replaced by very fine moist rales, which 
are usually localized in one of the lower lobes behind (Fig. 97). These 
localized fine rales are the first distinctive sign of broncho-pneumonia. 
Soon a change in the respiratory murmur is heard in the affected area, 
becoming feebler in intensity and higher in pitch. Elsewhere in the chest 
there may be coarse rdles, due to bronchitis of the large tubes. In such 
cases the areas of pneumonia are so small and so scattered as to give in 
themselves no additional signs, and the case may go on to recovery with- 
out presenting anything more distinctive than the signs mentioned. 

(b) With areas of partial consolidation. — In the lung at this time 
there are small areas of consolidation, generally superficial and separated 



PHYSICAL SIGNS OF BRONCHO-PNEUMONIA. 




Fig. 97. — First stage. Coarse rales over both lungs; Fig. 98. — Second stage. Coarse and fine rales over 
localized fine (subcrepitant) rales at the left both lungs behind ; at left base an area of 

base. No change in breathing sounds. partial consolidation, with broncho-vesicular 

breathing, exaggerated voice, and very sharp 

rales. 




Fig. 99.— Third stage^ A larger area of partial Fig. 100.— Fourth stage. Extensive disease of both 



consolidation, and in the centre a small area of 
complete consolidation, with bronchial breath- 
ing and voice and slight dulness. Signs over 
the right lung similar to what were previously- 
present over the left. 



sides; large area of complete consolidation on 
the left, with dulness, bronchial breathing and 
voice, and no rales ; surrounding this, broncho- 
vesicular breathing, with many rales. Signs 
in the right lung similar to those previously 
present over the left. 



Note. — The disease may stop at any one of these stages and resolution take place. 



548 



ACUTE BRONCHO-PNEUMONIA. 549 

by healthy or congested lobules. Percussion in these cases usually gives 
negative results, but sometimes there is very slight dulness. The vocal 
fremitus is not usually altered. The fine moist rales may be heard over 
quite a large area, but at some point, usually near the spine, over one of 
the lower lobes, they are sharper, louder, higher pitched, and seem close 
under the ear (Fig. 98). Eespiration is feebler here than elsewhere, and 
broncho-vesicular in quality, approaching bronchial breathing more and 
more as the consolidation increases. The resonance of the voice and cry 
is exaggerated. 

(c) With areas of consolidation more or less complete. — On percus- 
sion there is dulness, but surprisingly little in comparison with the other 
signs of consolidation present. It is due to the fact that the consolidated 
portion, though extensive, is superficial, and does not involve the lung to 
any great depth, and also that there are in the consolidated area many 
alveoli which still contain air (Plate XI). On palpation there is usu- 
ally a slight increase in the vocal fremitus. On auscultation, there are 
still present the evidences of bronchitis, usually only behind, but some- 
times over the entire chest. Coarse and fine rales are intermingled. 
Over the consolidated parts are heard bronchial breathing and bronchial 
voice. At the centre of these areas the bronchial breathing is pure and 
rales are usually absent, but at the margin rales are present and the 
breathing approaches the broncho-vesicular type (Fig. 99). The signs of 
consolidation are rarely sharply circumscribed as they are in lobar pneu- 
monia, but shade off gradually. The consolidated area is at first small, 
usually in one of the lower lobes near the spine, but may gradually extend 
until nearly the whole of one or even both lungs behind are more or less 
completely solidified (Fig. 100). The signs are found as far forward as 
the axillary line, but usually stop there. Friction sounds may be heard 
over the consolidated areas, but very rarely except where signs of com- 
plete consolidation are present. It is often impossible to obtain any idea 
of the condition of an infant's lung during quiet, superficial respiration. 
Sometimes over a part which is completely consolidated there is heard 
only very feeble breathing, or the lung may be almost silent. If, how- 
ever, the child be made to cry or to take a deep inspiration, both the bron- 
chial breathing and rales are distinctly brought out. The intensity of 
the consolidation increases as the case advances, and the signs become 
more and more like those of lobar pneumonia. During resolution there 
is first a disappearance of the signs of consolidation, which may be quite 
rapid, but friction sounds and rales of all kinds often persist for three or 
four weeks longer. 

The following statistics are of some interest, as showing the frequency 
with which Bigns of consolidat lob were found, and t he day when t hoy wore 
discovered. Their value is increased by the fad thai the children v 
under observation in an insl itution ai the time they were taken Bick, and 
that in all the fatal cases — thirty-six in Dumber — in which Bigns of con- 



550 DISEASES OF THE RESPIRATORY SYSTEM. 

solidation were absent, the diagnosis of pneumonia was confirmed by 
autopsy : 

Consolidation noted on or before the fourth day 47 cases. 

" " from the fifth to the seventh day 36 

" the eighth to the twelfth day 12 

" " after the twelfth day 9 

No signs of consolidation 62 



In general, it must be borne in mind that in many cases signs of con- 
solidation are never present, as the areas of pneumonia are small and 
widely scattered ; that where there is consolidation it is usually incom- 
plete, because there are small areas of healthy lung tissue between the 
hepatized portions ; that the signs of consolidation usually shade off 
gradually ; and that both sides are almost invariably involved, although 
one side usually to a greater degree than the other. 

(4) The protracted form — Persistent broncho-pneumonia. — This is 
seen in primary cases, especially among delicate children, and it is not 
uncommon in pneumonia complicating pertussis. The onset and course 
of the disease for the first two or three weeks do not differ from an ordi- 
nary attack of moderate severity, but at the end of this period there is seen 
no tendency in the process to subside. The fever continues, but it is not 
high, and by physical examination it is found that the areas of consolida- 
tion are gradually increasing day by day, until sometimes the greater part 
of both lungs behind are involved. The air vesicles become so distended 
with cells that the signs of consolidation are more complete than in ordi- 
nary broncho-pneumonia. There is marked dulness, sometimes almost 
flatness ; bronchial breathing is exaggerated in intensity, until it resem- 
bles cavernous breathing, and it may be impossible to distinguish between 
them. However, the fact that it is heard over so large an area, that it 
shades off gradually, and that it is accompanied by friction sounds, usually 
make a distinction possible. 

The temperature in these protracted cases for the first two or three 
weeks is from 100° to 105° F.; but after this time it is generally lower — 
from 100° to 102° or 103° F. The course is not at all regular, but marked 
by frequent exacerbations and remissions. The general symptoms are 
those of progressive asthenia. There is continued wasting, anaemia, and 
steadily increasing prostration. The appetite is lost, often there is an 
aversion to food, and vomiting is easily excited if food or stimulants are 
forced. The stools show that even what food is taken is very imperfectly 
digested and assimilated. The skin becomes dry and loses its elasticity; 
bed-sores may form; fine punctate haemorrhages are seen over the ab- 
domen, sometimes over the chest and extremities. The latter is always a 
very bad symptom, and I have never seen recovery where it was present. 

The chart in Fig. 101 is typical of the course of one of these protracted 



ACUTE BRONCHO-PNEUMONIA. 



551 



cases terminating fatally. The temperature shows four distinct exacer- 
bations. 

Death takes place from slow asthenia, usually after five or six weeks, 
but the attack may be prolonged for eight or ten weeks. The general 



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Fig. 101. — Temperature curve of persistent broncho-pneumonia, terminating fatally. 

History. — Male, two and a half years old ; healthy ; sudden onset ; for two weeks the only 
signs were very line moist rales throughout both lungs, front and back. The rales in front in 
great part gradually cleared up ; those behind persisted, but it was not until the thirty-fourth day 
that positive signs of consolidation were discovered in the left lower lobe behind; these signs 
gradually extended, and, before death, were present over nearly the whole left lung behind and 
over the right lower lobe. There were also friction sounds over both lungs. Autopsy. — Old and 
recent pleurisy with general adhesions; left lower lobe completely solid, patches of consolida- 
tion in left upper lobe. Right lower lobe about one half consolidated, with patches elsewhere. 
Bronchial glands large, but not cheesy. No evidence of tuberculosis upon either gross or micro- 
scopical examination (see Fig. 92). 



symptoms, the temperature, and the wasting strikingly resemble cases of 
tuberculosis, and such is the diagnosis often made. 

Although the majority of the cases in which the fever lasts over four 
weeks run the fatal course just described, such apparently hopeless cases 
occasionally recover. The temperature gradually falls lower and lower, 
until it remains at the normal point. For some time after this, often two 
or three weeks, little change can be seen, either in the general symptoms 
or in the physical signs. Gradually the appetite returns, the child is 
brighter and begins to take an interest in its surroundings, the cough 
abates, and little by little the signs in the lungs clear up, and the case 
may go on to complete recovery. Convalescence, however, is always slow, 
and may be interrupted by relapses, it being many months before health 
is fully restored. Although the signs of consolidation disappear in a few 
weeks, rales are apt to persist for a much longer time. It is probable in 
such cases, even though all signs of disease disappear from the chest, that 
the lung does not become quite normal, and relapses and second attacks 
are always possible. The general health may be so undermined that the 
child never regains his former vigour ; yet in a surprising number of 
these cases recovery seems to be complete. 

5. Secondary pneumonia. — (a) Complicating pertussis. — It is not 
often that pneumonia develops during the first two weeks of this disease. 
The most frequent time is from the third to the fifth week, when the 
patient has become exhausted from the previous severity of the per- 
tussis. In two thirds of my cases the development of the pneumonia was 
gradual, following bronchitis of the larger tubes. The temperature 
chart shown in Fig. 102 well illustrates this course. 



552 



DISEASES OF THE RESPIRATORY SYSTEM. 



When the onset is sudden, the symptoms do not differ essentially from 
those of primary pneumonia. The temperature of pertussis-pneumonia is 
usually low, in a very large number of cases not rising above 103*5° F., 
and ranging most of the time from 101° to 103° F. These cases are very 
apt to be prolonged, the fever often lasting for three or four and some- 



107° 
106° 
105° 
1<M° 
103° 
102° 
101° 
100° 
99° 


1 


2 


3 


i 


5 


6 


7 


8 


9 


10 


li 


12 


13 


11 


15 


16 
































































/ 






























, / 
































1 




















A 








\r~ 






















/ 


y/ v 






















/ 


, , 


J 


V 






















/ 


\ 


/ 


v 


















98° 






/s* 




J 


X, 


( 


V 



















Fig. 102. — Temperature curve of fatal broncho-pneumonia, complicating pertussis. 

History. — Male, six months old ; delicate ; pertussis for three weeks. Early signs of bron- 
chitis of large tubes only ; on the eleventh day signs of consolidation in right upper lobe. In- 
creasing prostration, cyanosis, and death. Autopsy. — Large areas of consolidation in right middle 
and upper lobe, small scattered spots throughout left lung. 



times even for six weeks. The physical signs of consolidation may per- 
sist for a long time after the temperature has become normal, and yet 
the case may recover entirely. I have seen one case in which complete 
recovery occurred after the signs of consolidation had persisted for six 
months, and another in which they had persisted for over eight months. 
Very often the signs continue during the entire attack of pertussis. 
Cerebral symptoms are common, especially toward the close of the disease. 
Of fifty-four fatal cases twenty-five had convulsions, and in twenty-two 
this was the mode of death. Only one case which developed convulsions 
recovered. 

(b) Complicating measles. — In a small number of cases the pneumonia 
begins simultaneously with the invasion of measles, but generally not until 
the eruption appears. Instead of gradually falling to normal with the 
fading of the eruption, the temperature continues high. Any of the 
clinical types of primary pneumonia may occur in measles, the acute con- 
gestive variety which is fatal in two or three days, being especially com- 
mon. In its course and duration the pneumonia of measles resembles 
the severe form of primary pneumonia. The broncho-pneumonia of scar- 
let fever differs in no way from that of measles. 

(c) Complicating diphtheria. — In many cases this does not give a dis- 
tinct clinical picture of its own, its symptoms being mingled with those of 
diphtheritic bronchitis, with which it is frequently associated. In others the 
forms resemble those seen in measles. The majority of cases occur as a 
complication of diphtheria of the larynx, although it is not infrequent in 
the septic cases in which only the upper air passages are involved. Pneu- 
monia developing after laryngitis is usually seen within two days from 



ACUTE BRONCHO-PNEUMONIA. 553 

the beginning of laryngeal symptoms, and runs a very rapid course. In 
rare cases it may develop as late as the middle or end of the second 
week. When it complicates diphtheritic bronchitis, pneumonia is recog- 
nised by the high temperature, rapid breathing, and increased prostra- 
tion, much more certainly than by the physical signs, which are always 
obscured by the laryngeal sounds. Percussion may aid in the diagnosis 
of consolidation where the signs on auscultation are doubtful. In the 
early cases, death usually occurs before the disease has advanced far 
enough to give the physical signs of consolidation, but in the late pneu- 
monia, which develops more slowly, these may be present. 

(d) Complicating influenza. — Without doubt many cases regarded as 
primary are really secondary to influenza, particularly when that disease 
is prevailing, for very often the pneumonia of influenza differs in no 
essential points from the primary form. There are, however, two types 
which are quite characteristic. In the first, high temperature and pros- 
tration exist for several days before there are any physical signs of pul- 
monary disease, and often before there are any symptoms pointing defi- 
nitely to the lungs. Pneumonia may then develop and run its usual 
course. The second variety are the cases of short duration often lasting 
but three or four days, and sometimes only two, but with excessively high 
temperature and very severe general symptoms. 

(e) Complicating ileo-colitis. — This is usually a somewhat subacute 
form of pneumonia, which is scarcely recognisable except by the phys- 
ical signs. It is seen in the protracted cases of ileo-colitis, usually of the 
ulcerative variety, and occurs late in its course. The temperature is not 
high. Cough, pain, and dyspnoea are slight or entirely wanting. Accel- 
erated respiration is frequently the only symptom suggestive of pulmo- 
nary disease. By physical examination there are found the usual signs, 
generally involving both lungs posteriorly. Very often pneumonia is 
not suspected during life, the constitutional symptoms being sufficiently 
explained by the intestinal lesions, although the autopsy discloses the fact 
that death was due to pneumonia. 

Complications. — Those relating to the lungs have been described with 
the lesions. Pleurisy will be separately considered. Emphysema can 
rarely, and abscess and gangrene never, be recognised by the physical 
signs. 

Purulent meningitis may complicate acute broncho-pneumonia. It 
was met with twice in one hundred and seventy autopsies. It is in all 
respects similar to that occurring with lobar pneumonia. Meningeal 
haemorrhage was seen only once, and was the cause of death in a patient 
eleven months old, who a few days before was seized with convulsions, fol- 
lowed by a gradually increasing stupor, which continued until death. 
The haemorrhage covered the entire convexity of the brain. Endocar- 
ditis is extremely rare ; it was not observed in any of my cases. Acute 



554 DISEASES OF THE RESPIRATORY SYSTEM. 

pericarditis was seen but twice, in both cases complicating pneumonia of 
the left side. Complications referable to the digestive tract are quite 
common. Herpetic stomatitis is frequent, and occasionally the ulcerative 
variety is seen. Thrush often occurs in the protracted cases among 
very young infants. G-astro-enteritis is not very common, considering 
the frequency of vomiting and diarrhoea, these depending usually upon 
functional derangement. In only three of my cases was there nephritis. 
In all it was of the acute exudative variety, and in only one case was it 
severe enough to affect the prognosis. 

Old lesions of tuberculosis — cheesy nodules in the lungs and some- 
times in the pleura — are not infrequently met with in patients dying of 
acute pneumonia of a non-tuberculous character. 

Diagnosis. — An acute onset with continuous high fever, rapid respira- 
tion, and cough, should always lead one to suspect pneumonia. When 
to these symptoms are added prostration and cyanosis, the diagnosis of 
pneumonia is almost certain. Cases of the acute congestive type are 
the ones most frequently unrecognised, and in many of these cases a posi- 
tive diagnosis is impossible during life. Many atypical cases of pneumo- 
nia are seen, particularly in young infants. An unusual temperature 
course is perhaps the symptom most likely to lead to a mistake. While 
this, as a rule, is high and remittent, it is sometimes not so, and may be 
but little above normal. Rapid respiration is almost always present, but 
cough may be very slight, especially in infants. In very young infants, 
the diagnosis often rests upon the prostration, cyanosis, and rapid respi- 
ration, the other acute inflammatory symptoms being absent. Only the 
physical signs of the disease can positively settle the question of diagnosis. 

When pneumonia follows bronchitis of the large tubes, whether the 
bronchitis is primary or complicates one of the infectious diseases, the 
extension of the disease to the lungs is usually marked by three symptoms 
— a steadily rising temperature, more frequent respiration, and increasing 
prostration. It may be twelve or twenty-four hours before the change is 
indicated by the physical signs. 

The diagnosis of broncho-pneumonia from congenital atelectasis has 
to be considered only during the first three or four months of life, it being 
rare for atelectasis to give symptoms after this time. In early infancy the 
danger of confusing the two is increased by the fact that atelectasis and 
broncho-pneumonia may be associated. If the infant has been strong and 
well for the first two months, congenital atelectasis can be excluded. It is 
likely to be found in delicate infants, where there is a history of difficulty 
in resuscitation at birth and feeble cry during the early days of life. The 
temperature is low, often subnormal, the cyanosis is out of proportion to 
the other symptoms, and the physical signs are doubtful or absent. 

At the outset, pneumonia can not be positively diagnosticated from 
severe bronchitis. Such a bronchitis often begins with severe pulmonary 



ACUTE BRONCHO-PNEUMONIA. 555 

symptoms and a temperature of 103° or 104° F. ; but this high tempera- 
ture is of short duration, usually falling after twenty-four or forty-eight 
hours to 100° or 101° F. The prostration is much less, and all the symp- 
toms, possibly excepting the cough, less severe. The only physical signs 
are coarse rales, which are heard throughout the chest. 

The same rules apply to bronchitis of the smaller tubes. The rales are 
heard both in front and behind, and usually over both sides. If with such 
rales the temperature continues to rise for three days in succession above 
103° F., it may be assumed that pneumonia is present, provided there 
is no other disease which might explain the temperature. If, instead 
of being generalized, the signs of bronchitis are limited to a single lung, 
or to one lung posteriorly, the existence of broncho-pneumonia may be 
regarded as certain. Localized bronchitis, then, is always to be inter- 
preted as broncho-pneumonia, provided tuberculosis can be excluded. In 
doubtful cases the chances largely favour broncho-pneumonia rather than 
bronchitis. Attention is again called to the fact already mentioned, 
that there are a large number of cases of pneumonia without signs of 
consolidation. 

The differential diagnosis of broncho- from ""obar pneumonia will be 
considered in connection with the latter disease. On account of the remit- 
tent temperature, broncho-pneumonia may be confounded with malarial 
fever ; if with the latter there is some bronchitis, or if accompanying the 
onset of a severe malarial paroxysm there is pulmonary congestion — two not 
infrequent combinations — the difficulties are increased. A positive diag- 
nosis is often impossible except by careful observations of the temperature 
for one or two days. The points of differentiation are, that the tempera- 
ture of pneumonia, though often remittent, is very rarely intermittent, and 
that it is not affected by quinine. In addition, the characteristic features 
of malaria — enlargement of the spleen, the plasmodium in the blood, and 
a history of exposure — must, of course, be taken into account. 

Both the acute and the persistent forms of simple broncho-pneumonia 
may be confounded with the tuberculous form ; the points of distinction 
are considered in the chapter on Tuberculosis. 

Prognosis. — Broncho-pneumonia is always a serious disease, and in an 
infant dangerous to life. The prognosis depends upon the age, surround- 
ings, and previous condition of the patient, upon the nature of the in- 
fection, whether the disease is primary or secondary, and, if the latter, 
upon the character of the primary disease. In private practice the mor- 
tality from broncho-pneumonia is from 10 to 20 per cent, depending upon 
the conditions mentioned. One whose knowledge of broncho-pneumonia 
is derived from observations in private practice can, however, form but 
little idea of the frequency and severity of this disease in hospitals and 
asylums for infants and young children, particularly when it occurs with 
epidemics of measles, diphtheria, and pertussis. The statistics in the fol- 



556 



DISEASES OF THE RESPIRATORY SYSTEM. 



lowing table are taken from the records of two institutions with which I 
am connected, and fairly represent the results seen in such places in chil- 
dren under three years : 



Forms of Pneumonia. 



Primary broncho-pneumonia 

Following bronchitis of the large tubes. 
Secondary to measles 

" pertussis 

" scarlet fever 

" diphtheria 

" ileo-colitis 

" epidemic influenza 

" varicella 

" erysipelas 



Totals. 



194 



7 
47 
19 
6 
2 
2 



461 



Deaths. 



19 
56 
54 

7 
47 
18 
1 
2 
2 



302 



Percentage 
mortality. 



49-4 

65-5 

62-9 

81-8 

100-0 

100-0 

94-7 

16-6 

100-0 

100-0 

65-5 



The mortality varies directly with the age of the patient, being the 
highest during the first year, and diminishing steadily thereafter, as shown 
by the following table giving the result in three hundred and forty-five 
cases : 



Age. 


Cases. 


Percentage 
mortality. 


During the first vear 


202 

102 

33 

6 

3 


66 


" " second vear 


55 


" " third vear \ 


33 


" " fourth vear 


16 


" " fifth year 









In this table are included no cases secondary to measles, scarlet fever, 
or diphtheria. 

Probably the best of all guides to the nature and virulence of the in- 
fection is the temperature. An excessively high temperature indicates a 
virulent type of infection. Some idea of this may be gained from these 
figures, giving the highest temperature and the mortality in two hundred 
and thirty-one cases, not including cases with measles or diphtheria : 



Highest Temperature. 


Cases. 


Deaths. 


Percentage 
mortality. 


106° F. or over 


55 
94 
53 
22 

7 


47 
56 
26 
13 
5 


85-5 


105° or 105-5° 


60-0 


104° or 104-5° 


49-0 


102° to 103-5° 


60-0 


99-5° to 101-5° 


71-0 







The high mortality of the cases with unusually low temperature is due 
to the fact that they nearly always were seen in infants with very feeble 



ACUTE BRONCHO-PNEUMONIA. 557 

vitality. Cases with a steadily high temperature — between 102-5° and 
104° F. — usually do better than those with wide fluctuations, such as 100° 
to 105-5° F. The probable explanation of this is, that the former are 
due to the pneumococcus, while the latter are apt to be cases of mixed 
infection, or due to the streptococcus. As a rule, the danger from the dis- 
ease increases steadily with every degree of temperature above 104 -5° F. 

An important factor in the prognosis is the previous condition of the 
patient. The association with rickets is unfavourable, both on account of 
the feeble muscular power of these children and their thoracic deformities. 
Any condition which diminishes the general vitality increases the danger 
from broncho-pneumonia. As a rule, second attacks are more serious 
than the primary ones, especially if the interval between them is short. 

In making the prognosis in any given case, the symptoms to be con- 
sidered are the height and course of* the temperature, the presence or 
absence of nervous symptoms, the condition of the organs of digestion, 
the presence of cyanosis and the extent of the disease as shown by the 
physical signs. 

Nervous symptoms early in the disease do not affect the prognosis. 
Three cases in which convulsions occurred at the onset recovered, but 
of thirty-seven cases in which convulsions occurred at a late period during 
the course of the disease, all but one proved fatal. 

So long as the food is well taken and retained and the stools show 
that it is being assimilated, no case is hopeless, no matter how severe the 
other symptoms may be ; but the existence of vomiting, diarrhoea, or 
severe indigestion makes the issue doubtful, even though the other symp- 
toms are very favourable. These conditions are especially important in 
protracted cases, where death is usually due to slow asthenia. 

Treatment. — The most important part of prophylaxis is to give careful 
and early attention to every attack of bronchitis in an infant, for every 
such attack should be regarded as a possible precursor of pneumonia. It 
is striking that one sees broncho-pneumonia so seldom in private practice 
among the better classes, even though bronchitis is very frequent ; while 
among hospital and dispensary patients, where bronchitis is very often 
neglected, broncho-pneumonia is constantly seen. The question of isolat- 
ing cases of pneumonia is one which is lately becoming more and more 
important. While it may not often be the case that primary pneumonia 
is due to contagion, there seems to be little doubt that this is at times true 
of the pneumonia secondary to measles and diphtheria. Twice in one insti- 
tution have I seen regular epidemics of broncho-pneumonia occur with 
outbreaks of measles — in some of the wards nearly every case of measles 
developing pneumonia. In another institution, during <>nc entire season 
(1888-'89), almost every case of diphtheria transferred to a certain isola- 
tion pavilion developed pneumonia, and died from that complication. 
Cases of measles and diphtheria which are complicated by pneumonia 



558 DISEASES OF THE RESPIRATORY SYSTEM. 

should, if possible, be carefully isolated from others, and wards in which 
they are treated should be thoroughly disinfected before they are used 
for simple cases. 

The hygienic treatment of pneumonia is important, and usually it 
receives too little attention. The child should be kept in a large, well- 
ventilated room, preferably one with an open fire; if possible, he should 
be changed from one room to another two or three times a day, to allow 
thorough airing. Nothing is more important for an infant sick with 
acute pulmonary disease than plenty of pure air. Older children should 
be kept in bed. Infants for a considerable part of the time may be held 
in the nurse's arms. A frequent change of position in all cases is essen- 
tial; no child should be allowed to lie for hours directly on the back. 
The general rules previously laid down for feeding all sick children 
should be followed here. As a rule, neither stimulants nor medicine 
should be administered in the food. 

The same local treatment may be employed as in cases of bronchitis. 
Counter-irritation, best by means of the mustard paste, may be em- 
ployed from three to six times daily. It is of the greatest value in the 
early stage of acute pulmonary congestion, and during attacks of cardiac 
or respiratory failure. The oiled-silk jacket may be applied with advan- 
tage in cases with low temperature, but should not be used when the 
temperature is high, as it seriously interferes with the means employed 
for its reduction. Poultices should not be used at all. 

Emetics. — What was said of expectorant mixtures and emetics in the 
treatment of bronchitis applies here with even greater force. 

Stimulants. — Alcoholic stimulants are needed in all secondary cases, 
and in a large proportion of those which are primary. No doubt they 
have been greatly abused, and, when pushed in the early stage, often do 
much harm ; but in most of the severe cases they are indispensable. They 
are usually needed from the outset when the pneumonia is secondary 
to measles, diphtheria, scarlet fever, or other infectious diseases. They 
are called for when the pulse is weak, compressible, rapid, and irregular. 
Whisky or brandy is usually to be preferred, although the taste of the 
patient often has to be consulted, and when these are refused, some wines, 
like sherry or tokay, may be readily taken. (For methods of adminis- 
tration see page 51.) The dose is to be regulated by the condition of the 
patient. From one-half to one ounce daily may be given to an infant of 
one year. It is rarely advisable to go above this quantity except for a 
few hours at a time at critical periods. Stimulants are most needed when 
the temperature is low, or falls suddenly, as at the crisis of the disease. 
When the temperature is high, smaller amounts are generally required. 

In many cases strychnine is even more valuable than alcohol. Usu- 
ally they should be combined, as the indications are the same. When 
the dose is to be repeated every three hours, -3^5- of a grain is as much as 



ACUTE BRONCHO-PNEUMONIA. 



559 



it. is wise to give to an infant a year old. This may be kept up for days, 
and for a shorter time larger doses may be given, the effect always being 
carefully watched. For older children digitalis may be used, but I have 
rarely seen much benefit from it in infants. In attacks of heart failure 
associated with pulmonary congestion, nitroglycerin should be given, to 
a child of one year gr. -^J-g- every hour. 

Eespiratory stimulants are needed in most cases, even more than arc 
cardiac stimulants, but we have none which can be wholly depended upon. 
For a short time, atropine gr. j-J-g-, caffein gr. -J, or strychnine gr. ^J^, 
may sustain a child with sudden failure of respiration, but in the slow 
respiratory failure that results from exhaustion their effect is but tem- 
porary. The doses mentioned are for an infant of one year. The drugs 
may be used successively or together; for immediate effect they should 
be given hypodermically. Oxygen may be classed with the respiratory 
stimulants. It may be given continuously, but always mixed with atmos- 
pheric air. To the rubber tube coming from the cylinder a glass funnel 
may be attached and held one inch from the child's face. Gentle friction 
of the chest wall, without disturbing the patient, is sometimes useful in 
stimulating the respiratory muscles, especially in protracted cases. 

Antipyretics. — It must be remembered that the normal range of tem- 
perature in broncho-pneumonia is from 101° to 104*5° F. This tempera- 
ture is not in itself exhausting, and the chances of recovery are not, I 
think, improved by systematic efforts at reducing it so long as it re- 
mains within these limits. Too much can not be said in condemnation 
of the practice of giving such drugs as phenacetine and other coal-tar 
products in full doses for the reduction of temperature. In small doses 
they are often useful to allay nervous irritability, restlessness, and pro- 
mote sleep. Quinine can not be considered an antipyretic in pneumonia 
except in cases complicated by malaria. Otherwise it does little if any 
good, and often great harm, by disturbing the stomach. 

Antipyretic measures are indicated in cases of hyperpyrexia, which 
we may define as 105° F. or over, or when extreme nervous symptoms 
exist, even though the thermometer may not register the degree men- 
tioned. Under these circumstances, the most certain, the most within 
our control, and hence the safest antipyretic, is cold. It may be used by 
the evaporation bath, the cold pack (pages 49, 50), sponging, cold com- 
presses, or an ice-bag applied to the chest. 

The most convenient and efficient methods of using cold arc the bath 
and the cold pack — the bath for infants, and the pack for older children. 
The peripheral circulation should be closely watched, and maintained by 
friction of the body during the bath, and the application of heal to the ex- 
tremities immediately after it. In most cases the bath should be preceded 
by stimulants. The effects are often very striking; when there have been 
a flushed face, hot dry skin, extreme restlessness, and muscular twileli- 
ings, all these symptoms may subside rapidly and a quiel sleep follow. 



560 DISEASES OF THE RESPIRATORY SYSTEM. 

The bath should be repeated as soon as these symptoms return, whether 
the thermometer has risen to its former height or not. Not all children 
bear cold well, and in its use and frequency of repetition one must be 
guided by its effect upon the child's general condition as well as upon the 
temperature. When with hyperpyrexia we have general cyanosis, cold 
surface, feeble pulse, shallow respiration, and stupor, cold is contraindi- 
cated and a hot mustard bath should be used. 

Inhalations. — These are of more value in relieving cough and in pro- 
moting bronchial secretion than any other means we possess. The same 
substances are to be used, and in the same way as mentioned in the arti- 
cle on Bronchitis. 

The nervous symptoms, restlessness, loss of sleep, etc., are often best 
controlled by cold or tepid sponging; in other cases by small doses of 
phenacetine — i. e., one grain every three hours to a child of six months. 
Opium is to be avoided unless there is severe pain, which is very rare ; 
or, when the incessant cough is not relieved by inhalations. Codeine may 
be given in doses of gr. -£-%, or heroin gr. T £o ? every three or four hours 
to a child of one year. 

Sudden attacks of general collapse with cyanosis are frequent in se- 
vere cases of broncho-pneumonia. They may come on at any period in 
the disease. When occurring in the early stage, if promptly and energet- 
ically treated, recovery may take place, but when they come on in the late 
stages they are usually fatal. They may be due to acute congestion or 
oedema of the lung not previously involved. The most efficient treatment 
is to put the child into a hot mustard bath (page 56), to use strychnine 
and nitroglycerine hypodermically, and to give oxygen continuously. For 
a few hours alcohol should be given freely. A valuable remedy for imme- 
diate effect is adrenalin ; from one to three minims of the 1-1,000 solu- 
tion may be used hypodermically. It should be injected deep into the 
muscles. 

Treatment of protracted cases. — When the fever continues for five 
or six weeks, with no disposition on the part of the disease to subside, 
about all that can be done is to continue the sustaining treatment adopted 
in the earlier part of the disease — careful feeding, judicious stimulation, 
and proper hygienic means. Many of these cases will recover if the pa- 
tient's strength holds out; but, unfortunately, in the majority the con- 
tinuance of the pneumonic process is in itself evidence of the weakened 
vitality of the patient, and, though he may live a long time, most such 
attacks ultimately prove fatal. 

When the fever has disappeared, and there is only a persistence of 
the physical signs and the general cachexia, the cases are more hopeful. 
Here, a change of air is more important than all other means of treat- 
ment. If in the winter or spring the child can be removed to a warm, dry 
climate where he can be kept in the open air, or if, in the summer, he can 



ACUTE BRONCHO-PNEUMONIA. 561 

be taken to the mountains, immediate improvement is often seen, fol- 
lowed by rapid recovery. This experience we see repeated every year 
with hospital patients when they are transferred from the city to the 
country in May or June. With the change of air a general tonic plan of 
treatment should be followed, cod-liver oil, arsenic, iron, and quinine 
being used, according to the indications in each particular case. 

One should never declare one of these cases of protracted pneumonia 
to be hopeless, nor should he be too ready to assume that tuberculosis 
is present because the child is wasted and anaemic, and the physical signs 
have persisted. In private practice the cases of simple protracted pneu- 
monia outnumber the tuberculous ones, three to one. 

Summary. — In the treatment of broncho-pneumonia it should be 
borne in mind that, while very little can be done for the disease, very 
much can be done for the patient. The hygienic measures generally 
grouped under the term " careful nursing " are of great importance, and 
many of the mild cases need no other treatment. One should watch the 
digestive organs closely, keep the bowels freely open, and not allow the 
abdomen to become distended with gas, since this often seriously inter- 
feres with the action of the diaphragm. In severe cases, the patient 
may be in great danger in the early stage from two causes: first, from 
the intensity of the general infection, which is best combatted by the 
use of alcohol and strychnia ; and, secondly, from the mechanical embar- 
rassment of the heart and respiration, in consequence of the sudden inter- 
ference with the function of the lungs, partly from inflammation, but 
chiefly from congestion ; this is best relieved by counter-irritation to the 
chest and heat to the extremities. During the later stage the principal 
danger is from exhaustion ; this forbids the use of all depressing meas- 
ures, and necessitates the most careful attention to the nutrition of 
the patient throughout the disease. All unnecessary medication is to be 
avoided, particularly the use of expectorant mixtures, on account of the 
disturbance of the stomach. Opium is to be used very sparingly, and in 
most cases it should be withheld altogether. The cough is best relieved 
by inhalations of creosote, and the nervous symptoms by phenacetine or 
baths. For local use, poultices should be discarded and the oiled-si Ik- 
jacket used only when the temperature is not high. Counter-irritation by 
mustard should be continued throughout the attack, when there is much 
bronchitis. Where antipyretics are required, cold is safer and more effi- 
cient than the use of drugs. Of the cardiac stimulants, alcohol and 
strychnia are most to be depended upon. Care should be taken in all 
cases to maintain a good peripheral circulation. In sudden general col- 
lapse, the most valuable measures are hot mustard baths, strychnia or 
adrenalin hypodermically, alcohol freely by the mouth, and the inhalation 
of oxygen. In protracted cases, and in those with delayed resolution, 
change of air is more important than all other means combined. 
37 



562 



DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER V. 

DISEASES OF THE LUNGS.— (Continued.) 

LOBAR PNEUMONIA. 

Synonyms : Fibrinous pneumonia, croupous pneumonia, pneumonic fever. 

With our present knowledge, lobar pneumonia may be best defined as 
an infectious disease, caused by the micrococcus lanceolatus (pneumo- 
coccus) and accompanied by a local lesion in the lungs. While in most 
cases the general symptoms correspond with the extent and severity of 
the local lesion, they may be out of all proportion to each other. 

Etiology. — Age. — Lobar pneumonia may occur at any age. I have 
recently seen a case in an infant of three months which followed the typi- 
cal course. It may be seen even in the newly born, but it is not until 
after the second year that it begins to be frequent. After the third year 
nearly all the cases of primary pneumonia are of this variety.* 

Of 160 personal cases, and 340 collected from various sources, the ages 
were as follows : 



Age. 


Cases. 


Per cent. 


During the first year 


76 
309 
104 

11 


15 


From the second to the sixth year 


62 


" " seventh to the eleventh year 


21 


" " twelfth to the fourteenth year 


2 






Totals 


500 


100 







The greatest susceptibility appears to be from the second to the sixth 
year, and during this period it is most frequent from the third to the fifth 
year. 

Sex. — Of my own cases, 60 per cent were males, and the same pro- 
portion was noted in 544 collected cases. This predominance of males 
has been everywhere observed, but is as yet unexplained. 

Season. — In my series of cases, the seasons were divided as follows : 





Cases. 


Per cent. 


In the three winter months 


48 

62 

6 

20 


35 


" " spring ' 


46 


" " summer " 


4 


" " autumn " 


15 






Totals 


136 






100 



* For the relative frequency of broncho- and lobar pneumonia during infancy, 
the table in the introductory chapter on pneumonia. 



LOBAR PNEUMONIA. 



563 



Lobar pneumonia, in children therefore, as in adults, occurs most fre- 
quently during the spring months. April shows the largest number of 
any single month. 

Previous condition. — In my hospital cases, 82 per cent of the children 
were previously in good condition, and only 18 per cent were delicate, 
rachitic, or syphilitic. This observation has been borne out by my ex- 
perience in private practice — viz., that as a rule lobar pneumonia affects 
children who were previously healthy. 

Previous disease. — Previous attacks of pneumonia are observed in but 
a small proportion of cases. It was noted only five times in 160 cases. 
In the vast majority of cases lobar pneumonia is a primary disease, 
although it occasionally occurs as a complication of pertussis, measles, 
typhoid or scarlet fever, and even diphtheria — chiefly, however, in chil- 
dren over three years old. 

Epidemics of lobar pneumonia I have never witnessed, although 
on several occasions I have seen two children in a family attacked either 
simultaneously or in rapid succession. Exhaustion, fatigue, and exposure 
are to be ranked as associated exciting causes. 

In addition to other causes, there is required for the production of the 
disease the presence and growth of the pneumococcus. 

Lesions. — The seat of the disease. — In 950 cases in children under 
fourteen years, this was as follows : 



Seat of Disea.se. 


Personal 
cases. 


Collected 
cases. 


Totals. 


Right lung, upper lobe only 

" " middle " " 


39 
13 


137 

4 

142 

64 


176 

12 


" " lower " " 


168 


" u more than one lobe 


77 






Totals, right lung 


86 


347 


433 


Left lung, upper lobe only 


25 

49 

9 


68 

214 

29 


93 


" " lower " " 


263 


" " more than one lobe 


38 






Totals, left lung 


83 


311 


394 


Both lungs, upper lobes 


3 
9 


13 
38 
60 


13 


" " lower " 


41 


" " elsewhere 


69 






Totals, both lungs 


12 


111 


123 







The right lung was thus affected in 45*5 per cent ; the left lung in 
41*5 per cent; both lungs in 13 per cent. In the order of frequency, the 
disease involves, first, the left base ; second, the right apex ; third, the 
right base ; fourth, the left apex. The disease affects, as a rule, a single 
lobe, and often only a circumscribed portion of a lobe, stopping sharply 
at the interlobar fissure. 



564 DISEASES OF THE RESPIRATORY SYSTEM. 

Lobar pneumonia among children is so rarely fatal that the oppor- 
tunities for a study of the peculiarities of the lesion have been somewhat 
limited. I have myself made eleven autopsies, and have among my hos- 
pital records reports of nine others, making twenty cases in all. The 
anatomical changes resemble those seen in the adult lung. There is an 
exudation into the alveoli and smaller bronchi of fibrin, serum, leucocytes, 
and red blood-cells (Fig. 87). There is usually in addition an in- 
flammation of the mucous membrane of the larger bronchi and of the 
pleura. The frequency and severity of the pleurisy is a peculiarity of the 
lesion in children. 

In the first stage, that of congestion, the portion of lung involved is 
dark-coloured, heavy, and cedematous, and shows under the microscope a 
serous and cellular exudation into the air vesicles, with swelling of the 
epithelial cells lining the alveoli. 

In the second stage, that of red hepatization, there is usually some ex- 
udation upon the pulmonary pleura, generally a thin layer of fibrin, giving 
it a dull, granular look. The lung itself is of a uniform dark-red colour. 
It is solid, and cuts like liver. It looks as if it had been inflated to its 
utmost extent and then injected with a material which had solidified. The 
consolidated area is sharply defined. Under the microscope the air vesi- 
cles are seen to be distended with an exudation which is chiefly fibrin, 
but with some leucocytes, red blood-cells, and desquamated epithelial cells. 
The cells are chiefly leucocytes, and are usually more abundant than in 
the pneumonia of adults. 

In the third stage, that of gray hepatization, the lung is more moist, 
and the inflammatory products are partly decolourized. This change takes 
place irregularly throughout the lung, giving it a mottled appearance. 

The fourth stage, that of resolution, follows gray hepatization, and 
consists in the degeneration and liquefaction of the products of inflam- 
mation, which are ultimately carried away by the lymphatics; or pushed 
out into the bronchi and removed by coughing. 

The duration of the stage of congestion is from a few hours to sev- 
eral days; that of the stage of red hepatization from two days to two or 
three weeks. This is the condition in which the lung is most often seen 
at autopsy. The stage of gray hepatization is commonly shorter. Keso- 
lution usually begins when the temperature falls to normal, but occa- 
sionally it may be delayed for several days. It is generally complete 
in about a week. 

Variations in the lesions. — (1.) Instead of clearing up at the usual 
time, the lung may remain consolidated for several weeks, and then re- 
solve. (2.) The stage of gray hepatization may be followed by a great 
exudation of pus cells, which may everywhere infiltrate the affected lung; 
or these may be circumscribed so as to form a single large abscess or many 
small ones. (3.) There may be small areas of gangrene. All these condi- 



LOBAR PNEUMONIA. 565 

tions are very rare in children. Purulent infiltration and delayed resolu- 
tion were noted in none of my cases, and gangrene but once. (4.) There 
may be excessive pleurisy, or pleuro-pneumonia. This was found in one- 
half of my autopsies. These cases will be separately considered elsewhere. 

Lesions in other organs. — With pneumonia of the left side, if compli- 
cated by pleurisy, there may also be pericarditis. This is seen even in 
infants. The pericardial inflammation closely resembles that of the 
pleura. There is a very abundant exudation of fibrin and pus, coating 
both surfaces of the pericardium. Acute meningitis was met with twice 
in my cases. The form was an acute purulent meningitis, with a very 
abundant exudation of greenish-yellow lymph, chiefly at the convexity. 
In one of my cases peritonitis was also present. As the pneumococcus is 
found in all these inflammations, they may be regarded as examples of a 
more generalized infection than usually occurs. In most of these the 
other processes are secondary to that in the lungs, but sometimes they 
begin simultaneously with, or may even precede, the pulmonary lesion. 
In a very small proportion of cases the pneumococcus is found in the 
blood, spleen, the kidney, and liver — i. e., a general pneumococcus septi- 
caemia. 

The heart is generally found in diastole, with the cavities, especially 
those of the right side, distended with soft clots. There may be found 
ante-mortem thrombi, which may extend into the pulmonary artery or 
the aorta. 

Symptoms. — (1.) The typical course— A child three or four years of age, 
after a few hours of slight indisposition, is suddenly taken with vomiting, 
followed by a rapid rise in temperature. He is dull and heavy, complains 
of headache and general weakness, refuses food, and is easily persuaded to 
remain in bed. He has the appearance of being quite ill, even after a few 
hours. Occasionally sharp pain in the side is complained of. The skin is 
dry ; there are marked thirst, restlessness, and the other symptoms which 
accompany fever. The temperature is found to be 104° F., or even higher ; 
the respirations 40 to 50 a minute ; the pulse full, strong, and 120 to 130. 
On the second day the patient is no better. The temperature remains 
high ; the tongue is coated ; the anorexia continues ; the pain is more 
severe ; cough is present and may be quite frequent. 

After the second or third day the patient is usually more comfortable, 
and sleeps better, but may be disturbed by the cough. At times there is 
restlessness, and at night there may even be slight delirium. The respi- 
ration continues rapid and the temperature high. These general symp- 
toms show very little change until the sixth or seventh day, when, after a 
long sleep, which has been more natural than before, the patient wakes, 
decidedly improved as to all his symptoms. There is less fever, and the 
temperature continues to fall rapidly until it touches the normal line, or 
it may even go below this. As the fever subsides the pulse drops to 90 or 
100, and the respirations to 25 or 30 a minute. The appetite soon returns, 



566 DISEASES OF THE RESPIRATORY SYSTEM. 

and convalescence is usually rapid. In a week the patient is ont of bed, 
and in a month from the beginning of the illness he is ont of doors ; but 
it may be another month before he can be considered to have entirely re- 
covered. This is the course seen in fully two-thirds of all the cases of 
lobar pneumonia at this age. 

(2.) Pneumonia of short duration. — Instead of running the usual 
course of from five to eight days, cases are seen in which the duration is 
only three or four days, although the physical signs indicate that the 
process in the lung passes through the usual stages. These differ from 
the ordinary type chiefly in their duration. They are always mild. 

(3.) Abortive pneumonia. — This form of the disease is rarely seen in 
hospitals, but it is not infrequent in private practice where the physician 
is summoned at the earliest signs of illness. The onset is precisely like 
that of ordinary pneumonia, and may even be as severe as the average 
case. The physical examination of the chest gives all the signs of the 
first stage of the disease, but on the second or third day the physician is 
greatly surprised to find that the temperature has fallen to normal, and 
that all the physical signs have disappeared. The process in such cases 
does not seem to go beyond the first stage of congestion; there is no evi- 
dence of hepatization of the lung. The course is often such as to lead 
the physician to the opinion that he has made a mistake in his diagnosis. 
There seems, however, to be no doubt that these are cases of genuine 
pneumonia. D'Espine foun\I the pneumococcus in the sputum of such 
a case. This type of pneumonia corresponds with abortive types of other 
infectious diseases so frequently met with in children. The temperature 
curve in such a case is" shown in Fig. 106. The diagnosis of these cases 
is always attended with some uncertainty. There can be no doubt that 
very many of the unexplained high temperatures of brief duration which 
are seen in children are from this cause. Exactly why it is that the dis- 
ease sometimes terminates in this wa}^ can not always be explained. It 
may be because the resistance of the patient is greater than usual, or the 
virulence of the pneumococcus is less. 

(4.) The prolonged course. — Although usually lasting about a week, 
it is not rare for pneumonia to continue ten, twelve, or even fifteen days. 
This prolonged course is usually due to the fact that the disease spreads 
from one part of the lung to another, or even to the opposite lung, in- 
volving in succession two, three, or more lobes. This is sometimes known 
as " creeping " pneumonia ; it is always severe and the outlook is gen- 
erally unfavourable. A prolonged temperature with physical signs lim- 
ited to a single lobe should always suggest complications, most frequently 
empyema, occasionally pericarditis. 

(5.) Cerebral pneumonia. — This term was first applied by Rilliet 
and Barthez to cases of pneumonia in which the cerebral symptoms pre- 
dominate. They will be considered later. 



LOBAR PXEUMOXIA. 567 

Onset. — Prodromal symptoms of more than a few hours' duration are 
quite rare. The onset of lobar pneumonia is almost invariably sudden, 
with well-marked symptoms — vomiting, diarrhoea, chill, or convulsions. 
Vomiting is altogether the most frequently seen. It was the mode of 
onset in about one half my cases. In summer particularly, there may be 
vomiting and diarrhoea. A distinct chill is rare in a child under five 
years of age, and is not very common even in older children. Convul- 
sions are not very infrequent, being seen in about five per cent of the 
cases. Their occurrence depends upon the suddenness of the invasion 
and the susceptibility of the patient. 

Cough. — This is present in most of the cases throughout the disease, 
but often is not marked for the first day or two. It is seldom a distress- 
ing symptom. A disposition to suppress the cough on account of pain is 
very frequently noticed. 

Expectoration. — This is rarely seen in childhood, and practically never 
under five years of age. Children of ten or twelve may have the same 
expectoration as adults — white and viscid, or brownish-red early in the 
disease, yellow and abundant toward its close. 

Pain. — Headache and general muscular pains in the back and extremi- 
ties are frequent during the invasion. The characteristic pain, however, 
is pleuritic. It is not necessarily felt in the region of the affected lung, 
and often not in the chest at all. It is frequently referred to the loin, the 
epigastrium, or to any region to which the intercostal nerves are distrib- 
uted. In a recent case, in a boy of seven years, for the first twelve hours 
there was intense localized pain in the right iliac fossa, associated with 
such extreme tenderness as to lead to the suspicion that the case was one 
of appendicitis. The pain may last throughout the disease, and occasion- 
ally it is a most distressing symptom ; but usually it is only moderate, and 
rather more severe early than late in the disease. 

Prostration. — This is one of the characteristic features of pneumonia. 
The patient is generally willing to go to bed on the first day of the attack, 
and shows little desire to leave it while the disease continues. "Walking 
cases" are not common in children. 

Respiration. — This is always accelerated, and generally out of propor- 
tion to the pulse. The normal ratio of the respiration to the pulse is one 
to four; in pneumonia, frequently one to two. The respiration is not 
laboured and not quite panting, although this term is sometimes used 
to describe it. It is jerky. There is a short inspiration, then a momen- 
tary pause, followed by a quick expiration, which is accompanied by a short 
moan. This expiratory moan is very characteristic. The rapidity of res- 
piration is usually in proportion to the amount of lung involved, but it is 
also modified by the temperature, as the respirations often drop from GO 
to 30 in the course of a few hours at the crisis. 

Pulse. — In the early part of the disease this is frequent, full, and 



568 



DISEASES OF THE RESPIRATORY SYSTEM. 



strong, from 120 to 150 a minute. Later it may be weak, small, com- 
pressible, and sometimes irregular. It is much more rapid in the child 
than in the adult, 160 and 180 being often seen in cases not especially 
severe. The pulse rate is of less importance than its character. 

Temperature. — The typical temperature curve of lobar pneumonia 
(Fig. 103) is characterized by an abrupt rise usually to 104° or 105° F., 
and by daily fluctuations generally within the limits of two or three de- 



105° 
104° 
103° 
102° 
101° 
100° 
99° 


1 


2 


3 


i 


5 


6 


7 


8 




A 


n 












t 


\ 


V 


A 


A 














1 


A 










V 






\ 


















l 


















^v 


98° 












L" 







Fig. 103. — Typical temperature curve of lobar pneumonia. 

History. — Male, three years old- in fair condition; sudden onset; signs of consolidation — 
bronchial respiration and voice, and dulness — over left lower lobe behind, not distinct until 
the morning of the fifth day. On the seventh day the lung was resolving. 

grees until the crisis, at which time the temperature falls to normal, usu- 
ally in the course of twenty-four hours. After this time it does not go 
above the normal line. Such a curve is seen in the majority of cases over 
three years of age. 

In cases under three years of age it is not uncommon for the tempera- 
ture to be of a more or less remittent type (Fig. 104). 



107° 


1 


2 


3 


1 


5 


6 


7 8 9 10 1 


1 12 13 14 15 


16 


17 


18 


19 


20 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 


































1 






-^ A-4 


1 


















A 




A 


A2UAI 


77 












\ 




J 


1 


A 




A-Hf 


t-i-i 














, / 








M 


r t 7 


t £ 














V 






/ 




r 


^ L 


















\ 




\ 




- c 


























- *xt 












98° 
97° 
















- t 


A 
























I 




V 









Fig. 104. — Lobar pneumonia with remittent temperature. 

History. — Female, eighteen months old ; in fair condition ; sudden onset ; repeated exami- 
nations of chest made, but no abnormal signs until the ninth day, when there were very rude 
respiration and slight dulness at the right apex, in front ; on the twelfth day all the signs of 
consolidation at the same point, no rales ; four days after the crisis the lungs were clear. 



These wide fluctuations often lead to great difficulty in diagnosis, par- 
ticularly if the physical signs appear late, as they not infrequently do. It 
is possible that some of them are to be explained by mixed infection. 

The following chart (Fig. 105) illustrates three features which are 
often seen in pneumonia : (1 ) A temperature which early in the disease is 
steadily high and as the day of crisis approaches becomes remittent; (2) 
a secondary rise after being normal for twenty-four hours, which was due 



LOBAR PNEUMONIA. 



569 



in this instance to an extension of the disease to a new part of the lung ; 
(3) a fall to a point considerably below normal at the time of the crisis. 
In this case the temperature fell in the course of eighteen hours from 



107° 


1 


2 


3 


i 


5 


E 


7 


8 9 


10 


11 12 13 


u 


15 


10 


17 


IS 19 


20 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
















. f\ 




































A t 


. 




l 
















A 






\\i 






















AH 


f\ | 












u 
















I 














1 




L_ 




































I 


































I 




































I 


















97° 
96° 
35° 

91° 


























\ 


IS 


A 






























ft 


A 


sf 


































f 


































V 


















1 ' 















Fig. 105. — Lobar pneumonia with subnormal temperature after the crisis. 

History.— Female, nineteen months old ; fairly healthy ; sudden onset ; symptoms typical 
but physical signs delayed ; consolidation in left mammary region on the eighth day ; on the 
ninth in right lung middle lobe ; on the eleventh day a pseudo-critical drop, followed after 
twenty-four hours of apyrexia by a further rise, which was accompanied by signs of extension 
of the disease in the right lung. Resolution rapid after crisis. 

105° to 95° F., and later still lower; it was two days before it finally re- 
mained at the normal point. A fall to 96 -5° or 97° F. at the time of 
crisis is not uncommon. 

In the foregoing cases the fever terminated by crisis. In Fig. 106 is 
shown one ending by lysis. This is a mode of termination much more 
frequent in young children than in those who are older. Thus, in ninety- 



106° 
105° 
104° 
103° 


1 : 


3 


i 


5 


c 


7 


8 


9 


1(1 1 


1 12 


13 


ii 


17) 


it; 


17 












\ 


A 




















A 








\ 


V 


V\ 


/ 
















/ 








\) 






/ 














102 ° 
101° 


"V 






I 








V , 


\ 












V 


















\ 












100' 




















\ y 












W' J 




L, 




J 














i<-i 


r 


, A 






98 D 






-s 
















r 




V. 


*- 



Fio. 106.— Abortive pneumonia in left lung, followed by typical pneumonia in right lung, 

terminating by lysis" 

Histnr;/. Male, seventeen months old; healthy; sudden onset; on the second day dissemi- 
nated One rales in both lung* behind, end over left lower very feeble respiration, high-pitched 
—i.e., some bronchitis, with congestion < '. ■ of lefl base. On the third, fourth, and lii'ih days, 
genera] Bymptome gone end Bigne nearly disappeared. On the sixth day all symptoms of pneu- 
monia, and on the seventh distinct consolidation of right base, rest of chest clear. Subsequent 
course typical; resolution rapid and oomplete. 



of which were under three veins of age, 



three of my own cases, Dearly a 

the fever ended by crisis in forty-nine, and by lysifl in forty-four: while 
in five hundred and twenty-two collected cases, the majority of which 
were in older children, three hundred and ninety-sii ended by crisis, and 
one hundred and twenty-six by lysis. 
38 



Third " 


22 


Fourth " 


43 


Fifth " 


88 


Sixth " 


83 


Seventh " 


132 


Eighth " 


73 


Ninth " 


55 


Tenth " 


22 



570 DISEASES OF THE RESPIRATORY SYSTEM. 

The following table shows the day of crisis in five hundred and sixty- 
seven cases of lobar pneumonia in children who recovered : 

The Day of Crisis. 

Eleventh day 18 cases. 

Twelfth " 7 " 

Thirteenth day 8 " 

Fourteenth " 7 " 

Fifteenth " 1 case. 

Eighteenth " 3 cases. 

Twenty-first day 1 case. 

Twenty-sixth " . 1 " 

567 

From this table it will be seen that the most frequent critical day is 
the seventh, and that in 66 per cent of the cases it was from the fifth to 
the eighth day. The causes of a post-critical rise in the temperature are 
chiefly two — extension of the disease to a new area, or the development 
of pleurisy, which is apt to be purulent. Less frequently it is due to 
meningitis, pericarditis, gastro-enteritis, or malaria. In fatal cases the 
temperature is generally high until the end. In general, it may be said 
that the temperature is considerably higher in children than in adults ; 
in the majority of cases it reaches 105° F., the usual range being from 
102° to 105° F. In fifteen of one hundred and thirty-seven cases, or 11 
per cent, it reached 106° F. or over. 

Gastro-enteric symptoms. — These are more common in infants than in 
older children. At the onset there is frequently vomiting, sometimes 
also diarrhoea. A continuance of the vomiting is rare, and is generally 
due to improper feeding or medication. It may be a very serious com- 
plication. Diarrhoea is also rare, except at the onset and in summer cases. 
It is sometimes seen at the time of crisis. Throughout the disease there 
are anorexia, coated tongue, and the usual symptoms of high fever. 

Nervous symptoms. — Cerebral symptoms are frequent and very often 
misleading. In seven of my cases the pneumonia was ushered in by convul- 
sions. These differ in no respect from convulsions from other causes, and 
may be repeated two or three times in the course of the first twenty-four 
hours. They are sometimes followed by drowsiness or stupor, sometimes 
by active delirium. Cerebral symptoms may predominate for several days. 
There may be opisthotonus, dilated or contracted pupils, irregular pulse, 
retracted abdomen, and, in fact, almost every symptom of meningitis. 
Occasionally the decubitus en cliien de fusil, or gun-hammer position, is 
assumed. These are often described as cases of cerebral pneumonia, and 
in many of them pneumonia is not suspected until the fourth or fifth day 
of the disease, sometimes not until the crisis occurs, when the rapid dis- 
appearance of all these nervous symptoms indicates their origin. Early 



LOBAR PNEUMONIA. 571 

convulsions are not generally followed by an especially severe type of the 
disease, only one of seven cases beginning in this way proving fatal. On 
the other hand, cases with la,te convulsions are usually fatal. In two of 
the three cases in which I have noted them, the convulsions ushered in 
an attack of meningitis. 

Delirium is much more frequent than convulsions, and is seen in 
nearly one fourth of the cases. Generally it is slight, and noticed only 
at night or when the temperature is very high. It is usually mild, but 
may be low and muttering, like that of typhoid, or wild and active, like 
that of cerebro-spinal meningitis. It is most pronounced at the height 
of the disease. Other nervous symptoms belonging to the typhoid state, 
such as incontinence of urine or faeces, muscular twitchings, and tremor 
of the tongue or protrusion, are occasionally seen, but only in the worst 
forms of the disease. 

There is no relation between the seat of the disease in the lungs and 
the occurrence of cerebral symptoms. They are more frequent in chil- 
dren under five years than in those who are older, and depend upon the 
suddenness of the invasion, the intensity of the infection, and the sus- 
ceptibility of the child. Late in the disease they may indicate exhaus- 
tion, toxaemia, or complicating meningitis. They are frequently asso- 
ciated with very high temperature and extensive disease. The usual 
nervous symptoms — restlessness, headache, sleeplessness, etc. — are 
nearly always proportionate to the height of the temperature. 

Urine. — Throughout the febrile period of the disease the urine is 
scanty, high-coloured, with a high specific gravity, and usually loaded 
with urates. In a small number of cases a trace of albumin may be 
found, and occasionally a few hyaline casts. Evidences of serious renal 
disease I have seldom found in lobar pneumonia, and in the experience 
of all observers it is extremely rare in early life. 

Skin. — The face, in pneumonia, is usually flushed, sometimes on 
both sides and sometimes only on one; in other cases it is pale, but not 
indicative of pain. Cyanosis is rare except toward the close of the dis- 
ease and is usually a sign of respiratory failure. Herpes of the lips or 
face is quite frequent. 

Blood. — The leucocyte count is of considerable value both from a 
diagnostic and a prognostic standpoint. For a discussion of this subject 
see the chapter on Diseases of the Blood. 

Physical Signs. — The earliest signs in pneumonia arc due to the acute 
congestion of the affected lung or lobe, in consequence of which less air 
enters this portion and more air the rest of the lungs. Percussion gives 
diminished resonance or slight dulness over the affected area, and exag- 
gerated resonance over the remainder of this lung and over the opposite 
lung. Auscultation over the affected lobe gives feeble respiratory mur- 
mur, rather high in pitch ; sometimes there may be absence of all breath- 



572 DISEASES OF THE RESPIRATORY SYSTEM. 

sounds so complete as to suggest fluid. The normal respiratory murmur 
over the healthy portions of the lungs is intensified. In children this ex- 
aggerated breathing is not infrequently mistaken for bronchial breath- 
ing, and the physician may be led into the error of locating the pneu- 
monia upon the wrong side. Exaggerated breathing does not differ 
from normal breathing except in intensity, and is heard only on in- 
spiration. Bronchial breathing is higher in pitch, and is heard with 
nearly equal intensity, both on expiration and inspiration. If the chest 
is frequently auscultated, crepitant rales (Figs. 107 and 108) may usu- 
ally be heard at some period at the end of full inspiration, but often they 
are present but for a few hours, and they may be missed altogether. 

In the second stage, that of consolidation (Fig. 109), no air enters the 
affected part of the lung. Upon palpation there is found here exaggerated 
vocal fremitus, and on percussion there is marked dulness, but very rarely 
flatness. Over the rest of this lung there is exaggerated, sometimes even 
tympanitic, resonance ; this is especially frequent at the apex of the lung 
in front, when there is consolidation at the base behind. Under these 
conditions cracked-pot resonance may sometimes be obtained. Over the 
healthy lung there is exaggerated resonance. On auscultation over the 
consolidated portion there are bronchial breathing and bronchial voice, 
the area over which they are heard being sharply defined. Rales are usu- 
ally absent, but there may be pleuritic friction sounds. 

In the stage of resolution there is a gradual disappearance of the 
signs of consolidation. The pure bronchial is replaced by broncho- vesic- 
ular breathing, the vesicular element gradually predominating. Moist 
r&les of all varieties are heard. Usually the most persistent signs ara 
slight dulness or diminished resonance, with a respiratory murmur which 
is feebler than normal and a little higher in pitch ; sometimes there are 
also dry friction sounds. These signs may persist for two or three weeks. 

Exceptional physical signs. — While in the majority of cases the signs 
of consolidation are distinct on or before the fourth day, in not a few they 
may be delayed much longer. Of eighty-two cases in which the day was 
noted on which consolidation was found, it was not until the fifth day or 
later in one fourth the number. In six of them, although carefully and 
repeatedly examined, no consolidation was found until the seventh day or 
later and in one case not until the twelfth day. It has been customary 
to look upon these cases of delayed or concealed physical signs as cases 
of central pneumonia. That pneumonia may exist in the centre of a 
lung for a number of days is, to my mind, extremely improbable. At 
autopsy, superficial pneumonia I have very frequently seen, but central 
pneumonia never. There are two regions in which pneumonia may exist 
and yet not be accessible by our means of physical examination, viz., at 
the apex of the lung in the part covered by the shoulder, and along the 
posterior border of the lung where it lies against the vertebrae. In either 



PHYSICAL SIGNS OF LOBAR PNEUMONIA. 




Fig. 107.— First sta»e. Congestion of left lower Fig. 108. — In the centre of the area, a small spot ot 
"lobe," with crepitant rales. Feeble breathing pure bronchial breathing and voice; surround- 

of a rude character, with slight dulness. ing this an occasional crepitant rale, with bron- 

cho-vesicular breathing and slight dulness. 




Via. 109. — Second Btage. Complete consolidation of left lower lobe. Pure bronchial breathing nnd 
bronchia] voice; marked dulnei ed vocal fremitus, and al the lower pari a few friction 

sounds. 



N"otk. — During resolution the signs take the inverse order : those of Pig. 109 give place 
to those of Fig. 108, and these in turn to those of Pig. 107. En addition, many coarse rfcles 

may be heard. 

578 



574 DISEASES OP THE RESPIRATORY SYSTEM. 

of these situations pneumonia may be present without our being able to 
find it. It is quite common in cases with late physical signs that the first 
distinctive evidences of disease are found high in the axilla, or beneath 
the clavicle in front, and these regions should be closely watched in 
doubtful cases. Sometimes the delay is best explained by assuming that 
constitutional symptoms due to a pneumococcus infection, may be present 
for several days before the development of the local lesion in the lung. 

Complications. — The occurrence of dry pleurisy over the consolidated 
portion of the lung is so constant that it can hardly be considered a com- 
plication. A slight serous exudation of two or three ounces is not un- 
common, but more than this is very rare in young children. In the most 
severe cases of pleurisy there is an excessive exudation of fibrin and pus. 
This occurred in eight per cent of my cases. This variety is known clin- 
ically as pleuro-pneumonia, and will be considered separately. Pericar- 
ditis is rare ; it was seen only twice in the series of cases reported, being 
associated with pleuro-pneumonia of the left side. It rarely gives rise to 
any new symptoms. Endocarditis was not seen in my cases, though it 
occasionally occurs. Meningitis is rare, and generally develops late in 
the disease. It is nearly always ushered in by repeated attacks of vomit- 
ing or convulsions. Its course is short and progressive. Peritonitis 
causes few new symptoms except abdominal distention, pain, and tender- 
ness. 

Course and Termination. — In the great majority of cases lobar pneu- 
monia terminates either in perfect recovery or in death. When ending 
in recovery, resolution commonly begins immediately upon the cessation 
of the fever, and is complete in about a week. Delayed resolution is not 
common in children; chronic pneumonia and tuberculosis are rare 
sequelse, but empyema is very common. Its symptoms sometimes de- 
velop immediately after the pneumonia, the temperature continuing 
high ; or there may be an interval of a few days before the development 
of the pleural symptoms. Some pleuritic adhesions probably remain in 
every case in which there has been much dry pleurisy, and when severe 
and extensive, these may be the cause of subsequent symptoms, like any 
other dry pleurisy. 

Death from uncomplicated pneumonia may be due to exhaustion, or 
to heart failure, with or without failure of the respiration. The signs of 
heart failure sometimes develop quite rapidly in cases which are appar- 
ently doing well. The symptoms are: coldness of the hands and feet, 
then of the legs and arms ; a rapid, compressible, and sometimes irregu- 
lar pulse.; muscular weakness and pallor, but usually no cyanosis. The 
symptoms of respiratory failure are : very rapid superficial respirations, 
sometimes 100 a minute; blueness of the lips and finger nails; often a 
leaden hue of the whole body ; there are loud tracheal rales, and reces- 
sion of all the soft parts of the chest on inspiration. 



LOBAR PNEUMONIA. 



575 



Death may result early in the disease, where the pneumonia has spread 
rapidly, involving both lungs. The earliest deaths I have seen were on 
the fourth day, and were due to a failure of the heart and respiration. 
In most of the uncomplicated fatal cases, death results from heart failure 
.at about the time of the crisis. In the complicated cases death usually 
occurs in the second week. I once knew fatal meningitis to develop at 
the end of the fourth week. 

Diagnosis. — The most characteristic differences between broncho- and 
lobar pneumonia are shown in the following table : 



BRONCHO-PNEUMONIA. 

1. More than half the cases secondary. 

2. Under three, chiefly under two years. 

3. Occurs more frequently in delicate 
and debilitated children. 

4. Bacteria — in primary cases, usually 
the pneumococcus ; in secondary cases, 
usually mixed infection. 

5. Products of inflammation chiefly cel- 
lular ; process often diffuse. 

6. Onset often gradual, sometimes in- 
sidious, especially when secondary. 

7. No typical course ; fever often lasts 
three or four weeks ; rarely terminates by 
crisis. 

8. Involves both lungs as a rule, most 
frequently lower lobes posterioily. 

9. Signs of bronchitis mingled with 
those of consolidation ; rales in other parts 
of the same lung, or in the opposite lung, 
throughout the disease. 

10. Consolidation later — fourth to sev- 
enth day ; there may be none ; apt to be 
incomplete ; shades off gradually. 

11. Resolution slow, one week to two 
months ; often incomplete ; strong tend- 
ency to become chronic. 

12. Relapses and second attacks fre- 
quent. 

13. Sequelae : Empyema, chronic inter- 
stitial pneumonia, sometimes tubercu- 
losis. 

14. Prognosis always serious from the 
age and the circumstances under which 
disease occurs. 

15. Hospital mortality 50 per cent of 
primary cases, 65 per cent of all cases. 



LOBAR PNEUMONIA. 

1. Almost always primary. 

2. Most common between three and 
eight years. 

3. More often in those previously 
healthy. 

4. The pneumococcus, very often alone. 



5. Chiefly fibrin ; process circumscribed. 

6. Onset sudden, with well-marked 
symptoms. 

7. Typical course; crisis usually from 
fifth to eighth day. 

8. Usually one lobe or a part of a lobe ; 
left base most frequently, right apex next. 

9. Rales only early, and during reso- 
lution ; frequently no signs in opposite 
lung. 

10. Consolidation earlier ; second or 
third day. Consolidation complete; area 
usually sharply defined. 

11. Resolution rapid, usually complete 
within a week. 

12. Both are rare. 

13. No sequelae except empyema. 



14. Prognosis good ; rarely fatal ex- 
cept from complications — empyema, men- 
ingitis, pericarditis. 

15. Mortality 4 per cent of all cases. 



576 DISEASES OF THE RESPIRATORY SYSTEM. 

In the majority of cases the symptoms are plain and the physical 
signs so typical that it is difficult to overlook pneumonia if any degree 
of care is used in the examination of the patient. The characteristic 
features are the sudden onset, with vomiting, convulsions, or chill ; pros- 
tration; rapid respiration, with the expiratory moan; a temperature of 
102° to 105° F. ; cough and thoracic pain ; and the physical signs of a 
rapidly developing, circumscribed consolidation in one lobe or a portion of 
a lobe. The difficulties in diagnosis are due to the great variation that is 
seen in the general symptoms, and to the late appearance of the physical 
signs. The error usually made is to mistake pneumonia for some other 
disease, rather than to mistake some other disease for pneumonia. On 
account of its frequency in children, pneumonia should always be ex- 
cluded before accepting any other explanation of a continuously high 
temperature. It is surprising to find how often obscure and indefinite 
symptoms accompanied by high fever, are due to pneumonia. The rule 
should be followed, in all cases of acute illness, of making a thorough 
examination of the chest daily until the diagnosis is clear. If to high 
temperature rapid respiration is added, one should always suspect the 
lungs, no matter what the other symptoms may be. It not infrequently 
happens that the general symptoms are quite characteristic and yet the 
physical signs appear late. In such cases pneumonia should always be 
looked for high in the axilla or just beneath the clavicle, since it is par- 
ticularly in the cases of apex pneumonia that this obscurity is likely to 
exist. If frequent and thorough examinations of the chest are made, very 
few cases will be overlooked. 

In their onset, scarlet fever, tonsillitis, and gastro-enteritis may all re- 
semble pneumonia. Scarlet fever is recognised by the sore throat and the 
characteristic eruption on the second day; tonsillitis, by the local symp- 
. toms. In infancy, pneumonia often begins with vomiting and sometimes 
there is also diarrhoea, which may lead one to mistake the disease for 
gastro-enteritis. The constitutional symptoms of influenza often closely 
resemble those of pneumonia ; the diagnosis is frequently in doubt for sev- 
eral days until definite physical signs of pneumonia make their appear- 
ance. Malaria is distinguished from lobar pneumonia by the points men- 
tioned in the diagnosis of broncho-pneumonia. From all other general 
diseases, pneumonia is to be differentiated by the physical signs. 

Pneumonia with marked cerebral symptoms sometimes resembles cere- 
brospinal meningitis. In both we may have the abrupt onset, convul- 
sions, delirium or stupor, opisthotonus, and prostration. In pneumonia 
the temperature is more often steadily high than in meningitis; the 
pulse is never slow and intermittent; the respiration is rapid; the 
stupor is usually less profound; and there are no localized paralyses. 
In meningitis there is usually a steady increase in the severity of the 
nervous symptoms for the first three or four days; in pneumonia they 



LOBAR PNEUMONIA. 577 

are as a rule most marked during the first twenty-four or forty-eight 
hours, and then gradually diminish, always subsiding completely at the 
crisis. While most of the individual symptoms belonging to meningitis 
may be present, they are usually less severe and less persistent in pneu- 
monia. 

The question sometimes arises, in a case of pneumonia, whether the 
cerebral symptoms are functional, or whether meningitis also exists. 
If the nervous symptoms are present from the beginning, there is prob- 
ably no meningitis. If they develop suddenly during the course or to- 
ward the close of the disease, meningitis should be suspected. 

Lobar pneumonia is to be differentiated from a pleuritic effusion. 
The most common mistake which I have seen made is to confound em- 
pyema with unresolved pneumonia. The latter is very infrequent, so 
that the probabilities are always strongly in favour of the diagnosis of 
empyema. In pneumonia rarely, if ever, is the whole lung affected. 
There is increased local fremitus, dulness, bronchial voice and breath- 
ing, and occasional rales of friction sounds. In empyema the whole lung 
is often affected, there is displacement of the heart, flatness on percus- 
sion, diminished or absent vocal fremitus, and although bronchial voice 
and breathing are present, they are usually distant and feeble. There 
are no rales or friction sounds. In doubtful cases an exploratory punc- 
ture should always be made. Serous effusions give the same physical 
signs as empyema, but are relatively rare. 

Prognosis. — There is probably no disease in which the patient appears 
so ill, and yet so often recovers completely, as in lobar pneumonia in a 
child over three years old. Of 1,295 collected cases, chiefly from hos- 
pital practice, there were but 39 deaths, a mortality of three per cent. 
In 187 cases of my own there were 21 deaths, a mortality of eleven 
per cent. Only one of the fatal cases was over two years old. The dif- 
ference between the mortality among my cases and the general mortality 
given, is due to the fact that a large proportion of the first group were 
observed in children under two years, while of the collected cases the 
vast majority were in older children. Combining the above figures, we 
have a total of 1,482 cases with 60 deaths, a mortality of four per cent. 
In nearly all my cases death was due either to complications or to very 
extensive disease, as when both lungs were involved, or nearly the whole 
of one lung. In only one case was an uncomplicated pneumonia of a 
single lobe fatal. 

The prognosis depends upon the age of the patient, the presence or 
absence of complications, and the extent of the disease. These factors 
are to be taken into consideration rather than any special symptoms. 
Early convulsions do not materially affect the prognosis. Of Beven such 
cases only one was fatal. Late convulsions are always very unfavourable, 
indicating either exhaustion, toxaemia, or the development of meningitis. 



578 DISEASES OF THE RESPIRATORY SYSTEM. 

The occurrence of vomiting, diarrhoea, or marked tympanites late in 
the disease is always unfavourable. 

A temperature range between 102° and 105° F. is the rule, and within 
these limits the fever does not affect the prognosis. Even very high 
temperature does not increase the danger from the disease as much as 
might be expected. Of fifteen cases in which the temperature reached 
106° F. or over, all but three recovered; while of six cases in which it was 
106.5° or over, only one died. The highest recorded temperature in 
my cases — 107.5° F. — was in a patient who recovered. A transient rise, 
even though the temperature may go very high, is seldom serious. 
Much more serious is a fever which remains steadily above 105° F., as in 
most cases this accompanies either very extensive disease or pleuro-pneu- 
monia. The continuance of the fever after the tenth day is a bad symp- 
tom, for, although the crisis may be postponed until the twelfth day and 
occur normally, such a prolonged temperature is apt to be an indication 
of a new focus of disease or the development of complications. In a 
severe attack, the extension of the disease to a new lobe after the fifth day 
is always unfavourable. If resolution does not begin soon after the tem- 
perature becomes normal a relapse should then be apprehended, or the 
development of empyema, or some other complication. 

Treatment. — In. the treatment of lobar pneumonia in children, several 
cardinal facts are to be kept in mind. It is a self -limited disease, having 
a strong tendency to recovery in the great majority of cases regardless 
of the treatment adopted. The fatal cases are almost always in children 
under three years of age; the rare deaths in older ones are usually due 
to complications. I believe that there is no means of treatment by which 
we can abort pneumonia or shorten its course. It follows, therefore, that 
the indications are, so far as possible, to make the patient comfortable 
during his illness, to prevent complications, and to treat the individual 
symptoms as they arise. 

In perhaps the majority of cases, hygienic treatment is all that is 
required. The patient should be kept in bed, no matter how mild the 
attack; he should be lightly covered, disturbed just as little as possible, 
and allowed plenty of fresh air in the room. An open window is desirable 
even though the room temperature is constantly as low as 60° F. Food 
should be given at regular intervals, seldom oftener than every three 
hours. It should not be forced when the patient is suffering only from 
thirst, especially early in the attack when the appetite is often com- 
pletely lost. Water should be allowed freely at all times. 

These measures, careful nursing, an occasional dose of codeine (gr. 
T V to a child of three years) when the patient is very restless, fretful, or 
sleepless, and cold sponging when the temperature makes him uncom- 
fortable, are usually all that is necessary, except to keep a sharp lookout 
for complications. 



PLEUROPNEUMONIA. 579 

Special symptoms may require treatment. When not severe, the 
nervous symptoms may be controlled by codeine alone or in combination 
with phenacetine or the bromides. Sometimes sponging with warm water 
is better than drugs. Severe nervous symptoms, such as delirium, stupor, 
great restlessness with impending convulsions, when associated with high 
temperature, call for ice to the head, cold sponging, or the cold pack 
or bath. Pain, if moderate, may be relieved by counter-irritation by a 
mustard paste or by a hot poultice; if severe, codeine may be used 
in addition. The cough is rarely severe enough to require treatment. 
When it is so severe as to prevent sleep, small doses of Dover's powder 
or codeine should be given. Antipyretic measures are not necessarily 
called for even if the temperature is very high. Some nervous children 
are less disturbed by the temperature than by the means used to reduce 
it. Under such conditions the temperature should be closely watched, 
but not necessarily interfered with unless other symptoms develop. The 
nervous symptoms are a better guide than the thermometer to the use 
of antipyretics. Cold I believe to be the safest and most certain anti- 
pyretic we possess. It may be used as a cold sponge bath, the cold 
pack or an ice bag to the chest. There is no objection to the bath except 
the prejudice of the laity. While cold is applied to the trunk the ex- 
tremities should be closely watched, and heat applied if necessary. The 
duration of the pack or bath, and the frequency of their use, will depend 
upon the individual case. In the majority of cases stimulants are not 
required. They are called for when the pulse is weak, compressible, and 
rapid, when the face is pale and the extremities are cold. The same 
stimulants are to be employed, and in the same way, as in broncho- 
pneumonia. Cardiac stimulants are usually required in larger quantity 
at the time of and just after the crisis. Eespiratory stimulants are indi- 
cated as in broncho-pneumonia. 

Pleuro-pneumonia. — Under this term are included cases of pneu- 
monia with an excessive amount of pleurisy, the two processes uniting 
to produce a single clinical type of disease. 

In nearly all cases of lobar pneumonia there is a certain amount 
of inflammation of the pulmonary pleura, and also in those cases of 
broncho-pneumonia which are accompanied by any marked degree of 
consolidation. In both of these the pleurisy is usually coextensive with 
the consolidation. But in certain cases, in both forms of pneumonia, the 
amount of pleurisy is excessive, and this so modifies the symptoms and 
course of the disease as to require for them a separate consideration. 
In some it appears that the inflammatory process begins almost simul- 
taneously in the lung and in the pleura; while in others the pleurisy 
follows the pneumonia. These cases are, T believe, almost invariably 
due to the pneumococcus, although in some there is a mixed infection. 

In 398 hospital cases of pneumonia there were 27, or 6.8 per cent, 



580 DISEASES. OF THE RESPIRATORY SYSTEM. 

which could be classed as pleuropneumonia, the diagnosis being con- 
firmed either by autopsy or operation. Of 190 fatal cases, 12*5 per cent 
were pleuro-pneumonia. Most of these hospital patients were under three 
years of age, and the disease is, I think, more frequent at this period than 
in older children. 

Lesions. — Of these 27 cases, 17 were classed as broncho-pneumonia and 
10 as lobar pneumonia. The left lung was more frequently affected than 
the right in the proportion of three to two. In most of the cases the 
pleura covering the entire lung was involved, even though the pneumonia 
affected but a single lobe, or only a part of a lobe. In nearly half the cases 
both lungs were involved, but one to a very much less extent than the 
other. In a small number of cases the pleurisy was limited to the pos- 
terior surface of the lung, stopping at the axillary line. 

In pleuro-pneumonia both the visceral and the parietal pleura are 
coated with a layer of yellowish-green fibrin, in thick, shaggy masses, by 
which the lung is adherent to the chest wall, the diaphragm, and the 
pericardium (Plate XII). The exudation varies between one eighth 
and one half an inch in thickness. It can often be stripped from the 
lung or scraped from the chest wall by the handful. In its meshes small 
pockets may form, which contain only a few drops, or sometimes a 
drachm of pus, or less frequently serum. This is the condition in which 
the lung is usually found where death has occurred at the height of the 
disease. If the process has lasted longer, larger collections of pus may be 
present. The lung itself shows the usual changes of pneumonia, and if 
there has been any considerable accumulation of fluid, there are in addi- 
tion the evidences of compression. 

With pleuro-pneumonia of the left side, the pericardium is occa- 
sionally involved. This was seen in two of my cases, the lesions closely 
resembling those of the pleura. In two cases there was also meningitis, 
and in one peritonitis, the exudation in all cases having the same charac- 
teristics. 

An inflammation of the intensity described is very often fatal in the 
acute stage, if the patient is a child under two years old. Occasionally 
at this age, and very frequently in older children, we see the later stages 
of the process. The most frequent course is for more and more pus to be 
poured out from the inflamed pleura until the chest is filled, the case 
becoming thus one of empyema. Sometimes the fluid is serous instead of 
purulent, but this is very rare in infancy. Under other circumstances the 
exudation is partly absorbed, but the greater part becomes organized so as 
to form a thick jacket of fibrous tissue which binds the lobe or lung to 
the chest wall, and interferes seriously with its subsequent full expansion. 
Chronic interstitial pneumonia may follow. 

Symptoms. — There is little which distinguishes a case of pleuro-pneu- 
monia except the severity of all the constitutional symptoms ; the tern- 



PLATE XII. 



CD <D 



b£ 

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S~\ 



5M -B 




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^ 




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C c3 



■ ■8 

CD ?H 

a 



. <3 



K £ 



5 

««4 



• CU B 
I „ o 

" Q c« <u 
■« &^ 
fe S » 



B ~ ~'-5 

£ * r~ 

w * w 

d ■ - ~ t3 
r bfl£ c 

c^ _ - 
C - £ _i 

^ Z- k 2 

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! 7 - 3 

B , — 3 
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— — (-. 



— 



PLEURO-PNEUMONIA. 581 

perature is often higher, the prostration greater, and the patient in every 
way impresses one as being more seriously ill than with ordinary pneu- 
monia. Sometimes the thoracic pain is more severe and more constant 
than is usual in pneumonia. The diagnosis, however, is to be made by 
the physical signs. 

In the early stage the pleuritic friction sounds are unusually promi- 
nent ; after two or three days the signs of consolidation come out clearly 
in most cases, but still accompanied by loud friction sounds. After the 
fibrinous exudation is very abundant, the signs are often obscure and con- 
fusing, and there may be at no time well-defined signs of consolidation. 
There is usually a mingling of the signs of consolidation with those of 
effusion. There is marked dulness, and sometimes flatness. The vocal 
fremitus is apt to be diminished, and it may be absent. Bronchial voice 
and breathing are heard, but they are not distinct as in consolidation ; 
they are, however, feeble and distant, as over fluid. There are usually 
coarse, moist, crackling pleuritic sounds, but these may be absent. The 
signs may be found over one entire lung, or they may be limited to 
the posterior region, and even to a single lobe. They resemble those 
present over fluid, with one exception — viz., the heart is not displaced. 
If an exploratory puncture is made, nothing is found ; occasionally the 
exploring needle happens to strike one of the small pockets of pus 
in the meshes of the fibrin, and a few drops of clear pus are withdrawn. 
If an incision is made under the supposition that the case is one of em- 
pyema, no more pus may be found, the surgeon coming upon the pul- 
monary adhesions as soon as the chest is opened. There is scarcely any 
condition in the chest giving signs more puzzling than those just enu- 
merated. They are, however, easily explained by the pathological con- 
ditions present. 

Prognosis. — The prognosis in pleuro-pneumonia is much worse than 
in simple pneumonia. In infants the outlook is very bad, the majority of 
cases dying during the acute stage, usually in the second week. Very 
young children may be overwhelmed with the extent and the intensity of 
the inflammation, and die in four or five days. In children over two years 
old the most frequent result is for the case to go on to empyema, which 
with proper treatment usually terminates in recovery. Where there is 
organization of the fibrin with the production of extensive adhesions, the 
ultimate result is often not so favourable as when empyema develops. 
Convalescence is usually slow, and the patients are liable to exacerbations of 
pleurisy; they may suffer for years from the partial crippling of one lung. 

Diagnosis. — This is to be made only by the physical signs. A differ- 
ential diagnosis from fluid in the chest can in some cases be made only 
by an exploratory puncture. 

Treatment. — Cases of pleuro-pneumonia require no special treatment. 
In general they are to be managed like the ordinary cases of pneumonia 



582 DISEASES OF THE RESPIRATORY SYSTEM. 

of the severe type. In some, the excessive pain may call for more active 
counter-irritation and a freer use of opium than in other forms of pneu- 
monia, and the greater prostration may require that stimulants I)e given 
earlier and in larger quantities. 

HYPOSTATIC PNEUMONIA. 

This can not often be recognised clinically, but it is very frequently 
seen upon the post-mortem table. It is present in some degree in al- 
most every case where an infant has died of chronic disease. It is par- 
ticularly frequent in those who have died of marasmus. It is sometimes 
described as " strip pneumonia/' on account of its position. It invari- 
ably occupies a strip along the posterior border of both lungs, and usu- 
ally of both the uper and lower lobes. This is from one to two inches 
wide, of a uniform dark-red colour, and is sharply outlined. The pleura 
is not involved, and the remainder of the lung may be normal, congested, 
or slightly emphysematous. On section, it is seen that the pneumonic 
area is quite superficial, rarely involving the lung to a greater depth 
than half an inch. Under the microscope there is found a distention of 
the small blood-vessels in the affected area, and the air vesicles are filled 
with many red blood cells, epithelial cells, and a few leucocytes. Be- 
tween the areas of consolidation are groups of air vesicles which are 
normal, congested, or collapsed. It is a lobular rather than a broncho- 
pneumonia. The lesions in this form of pneumonia are probably the 
result of venous stasis, owing to the child's recumbent position. 

At autopsy the condition may be confounded with atelectasis ; this, 
however, is almost invariably more marked in the interior of the lung, 
while pneumonia is always more marked upon the surface. The two con- 
ditions are sometimes associated. Little significance is to be attached 
to the finding of hypostatic pneumonia at autopsy, and it alone should 
never be regarded as a sufficient cause of death, although it is perhaps 
the only lesion present. During life it may give rise to fine moist rales, 
which are heard along the spine, usually upon both sides; but there is 
neither dulness nor bronchial breathing. 

The treatment is that of the primary disease. 

CHRONIC BRONCHO-PNEUMONIA— CHRONIC INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

Chronic broncho-pneumonia is an inflammation of the connective- 
tissue framework of the lung, involving the stroma, the alveolar septa, 
the walls of the bronchi, and the pleura. It is usually accompanied by 
cylindrical dilatation of the bronchi — bronchiectasis. 

Etiology. — In children, as in adults, this process is most frequently 
associated with pulmonary tuberculosis ; but in early life it is not an in- 



PLATE XIII. 




Chronic Broncho-Pneumonia. 

In the greater part of the specimen the disease is limited to the vicinity of the 
small bronchi, AAA, each of which is surrounded by a zone of new connective 
tissue, the result of the inflammatory process, the intervening lung tissue, B B, being 
normal. In the lower left-hand portion, the disease is more diffuse; the air vesicles, 
C, between the areas of new connective tissue are greatly compressed, and in some 
places entirely obliterated. (After Delafield.) 



CHRONIC BRONCHO-PNEUMONIA. 583 

frequent condition apart from tuberculosis. The non-tuberculous cases, 
as a rule, are preceded by an attack of acute broncho-pneumonia, some- 
times by several such attacks, separated by longer or shorter intervals. 

Lesions. — The part of the lung affected may be an entire lobe, but 
usually it is a portion of one lobe, or there are areas in more than one 
lobe. There are dense connective-tissue adhesions binding the diseased 
part to the chest wall, to the diaphragm and to the pericardium, often 
so firmly that the lung is torn on removal. The affected lung is smaller 
than in health; it is hard, tough, and fibrous. Surrounding the fibrous 
portions are emphysematous areas. On section, the process is seen to 
be somewhat irregularly distributed through the lung, the lesion being 
usually most marked in the vicinity of the smaller bronchi, and some- 
times seen only there, the intervening lung being nearly normal (Plate 
XIII). In some portions, where the process is most advanced, almost 
all trace of lung tissue has disappeared, the part resembling a solid 
fibrous tumour, through which run the bronchial tubes, usually much 
dilated. In places this dilatation may be sufficient to form cavities of 
considerable size. The bronchial glands are often enlarged to the size 
of a hazelnut, and they may be tuberculous. 

Upon examination with the microscope, the pleura is found greatly 
thickened, with bands of new fibrous tissue passing from it into the lung. 
The walls of the small bronchi are in most places thicker than normal, 
but elsewhere they have undergone cylindrical dilatation, and are filled 
with pus. The walls of the alveoli show a marked proliferation of the 
connective-tissue elements, and the alveoli are filled with organized in- 
flammatory products, so that they are nearly or quite obliterated. The 
stroma is much increased in amount throughout the affected lung. 

Symptoms. — In most of the cases there is a history of an attack of 
acute broncho-pneumonia, from which the child made a slow convales- 
cence, remaining pale, anaemic, and sometimes wasted for several months. 
Improvement then took place in the general symptoms, the appetite and 
strength returned, and in many cases the lost weight was nearly or quite 
regained. However, neither the pulmonary symptoms nor the physical 
signs entirely disappeared. There remained a dry, hard cough, which at 
times was severe. Pains in the chest were occasionally complained of, 
and perhaps shortness of breath on exertion was noticed. 

Examination shows a persistence of the dulness on percussion, with 
a rude or broncho-vesicular respiratory murmur of very feeble intensity. 
Little change may take place in these signs for months; then an acute 
attack of bronchitis or bronchopneumonia may occur. If the latter, the 
same lung is affected, and a fresh consolidation is added to the previous 
disease. This attack may not be very severe, but it drags on for several 
weeks, with slight fever and little or no change in the physical signs. 
Partial resolution may then take place, but the lung is left much more 



584 DISEASES OF THE RESPIRATORY SYSTEM. 

seriously crippled than before. Often there is a history of several such 
attacks, each one leaving the lung a little worse than it found it. 

The characteristic physical signs of chronic broncho-pneumonia are 
not usually present until the process has continued for many months. 
They may be found over part of a lobe, or over an entire lobe, or even the 
greater part of one lung. On inspection, there is seen in a well-marked 
case, retraction of the chest, which is especially noticeable when the 
disease is situated at the apex of the lung. The vocal fremitus is usually 
increased, but it may not be abnormal. There is marked dulness, often 
flatness, over the affected area, with exaggerated resonance over the rest 
of the lung. The area of flatness shades off gradually. The most strik- 
ing thing on auscultation is the very feeble respiratory murmur ; in many 
cases the lung is almost silent. Bales and friction sounds are usually 
absent except during an acute exacerbation of the symptoms, when they 
may be heard as in any attack of broncho-pneumonia. In recent cases 
there is no displacement of the heart; in those of long standing it may 
be drawn far to the affected side by contraction of the adhesions. 

When the lesions are once present complete recovery is impossible, 
and there is always a tendency for them to increase rapidly or slowly, 
according to the child's vigour of constitution, its surroundings, and the 
frequency with which exacerbations occur. If the disease is extensive 
the patient often succumbs to some intercurrent disease or to an acute 
attack of pneumonia ; if limited in area, the process may be arrested and 
the patient recover, always, however, to be more or less embarrassed be- 
cause of the crippling of a part of one lung. Not a small number of 
these children ultimately die of tuberculosis, and in such cases it is always 
a difficult matter to decide whether tuberculosis was present from the 
beginning, or whether there was subsequent infection. 

The cases in which bronchiectasis is the most important condition 
are not common. The only characteristic additional symptom is a copious 
muco-purulent expectoration which is usually very fetid. It may amount 
to several ounces a day, and is expelled after paroxysms of coughing 
which usually occur in the morning. This may continue for months or 
even years, and yet these patients are generally without fever, seldom lose 
weight, and may give the appearance of being in very good health. It 
is rare that the physical signs of a cavity are present. 

Prognosis. — This depends on the extent of the disease, the patient's 
age and constitution, and on our ability to prevent by treatment, climatic 
and otherwise, the occurrence of acute exacerbations. Under the most 
favourable conditions, a few patients may recover completely so far as 
symptoms are concerned ; but the majority remain at best delicate during 
childhood, or even throughout life. 

Diagnosis. — The most important thing is to distinguish between the 
simple and the tuberculous cases, and this, it must be confessed, is in the 



ABSCESS OF THE LUNG. 585 

majority impossible. I have repeatedly seen a process proved at autopsy 
to be simple, which all who had observed the case had unhesitatingly pro- 
nounced to be tuberculous, and quite as often the opposite has been true. 
If the family history is good, if the patient lives in the country, if his 
symptoms begin with a well-defined acute attack of pneumonia, if the 
seat of disease is the base posteriorly, and if the examination of the 
sputum is negative, the process is probably simple. If the family history 
is doubtful or is positively tuberculous, if the patient lives in the city, and 
especially if he is an inmate of an institution or if his home is among 
the tenements, if the initial symptoms are indefinite, if the disease is 
situated anteriorly, the process is probably tuberculous. The discovery 
of tubercle bacilli in the sputum is, of course, conclusive. 

Treatment. — Nothing has any essential influence upon the disease 
except change of climate. This should be the same as for tuberculous 
cases. The treatment of the patient has for its object the maintenance 
of the general nutrition at its highest point, by careful feeding, judicious 
exercise, and by most of the measures enumerated in the chapter on Mal- 
nutrition. Cod-liver oil should be given throughout every winter season. 
The cough may be treated as in cases of chronic bronchitis. 

Cases of bronchiectasis may obtain considerable relief from inhala- 
tions of creosote. They should not be operated upon. 

ABSCESS OF THE LUNG. 

Multiple small abscesses are not uncommon as a termination of acute 
broncho-pneumonia, in which connection they have already been consid- 
ered. Larger non-tuberculous abscesses of the lung are rare, very obscure 
in their symptoms, and apt to be mistaken for localized empyema, some- 
times for interstitial pneumonia with bronchiectasis. Three such cases 
have come under my observation.* One was discovered at autopsy, the 
other two were recognized during life and successfully treated by opera- 
tion. Other examples in young children have been reported by Huber 
and by Hedges. The cause of these -ingle abscesses is usually a previous 
attack of acute primary pneumonia, less frequently an inflammation ex- 
cited by a foreign body in the lung. 

An abscess due to a foreign body is usually accompanied by wasting, 
and a widely fluctuating temperature of a hectic type — symptoms sug- 
gestive of a rapidly advancing tuberculous process. If the abscess follow - 
an ordinary pneumonia the course is generally less intense. The consti- 
tutional symptoms differ little from those of empyema. There Is an 
irregular type of fever, sometimes quite high, but more often only from 
99° to 1.01° or 102° F., a moderate cough, not much waling and gener- 
ally not very marked prostration. A leucocytosis of 30,000 to 50,000 is 

* Archives of Pediatrics, January, 1904. 



586 DISEASES OP THE RESPIRATORY SYSTEM. 

usually present. The physical signs are somewhat confusing and are a 
combination of those present in effusion and consolidation. There is an 
area of flatness shading off into dulness. The vocal fremitus may be 
increased or it may be diminished. The respiratory murmur is very 
feeble or absent over the abscess, often it is broncho-vesicular in charac- 
ter. Friction sounds and rales are usually present. The heart is slightly 
or not at all displaced. If an exploratory needle is introduced, pus may 
not be found even by repeated punctures; or it may be obtained at one 
time and not at another, although introduced in the same intercostal 
space, the difference in result being due to the direction in which the 
needle is passed into the lung. When pus is found, the diagnosis of a 
localized empyema is generally regarded as established, and it is not until 
the chest is opened that the mistake is discovered. The operator then 
comes upon the lung, which may or may not be adherent. If the abscess 
follows an acute pneumonia the pus may show a pure culture of the 
pneumococcus. If it is due to a foreign body, there is invariably mixed 
infection, and the pus is apt to be fetid. 

When not treated surgically abscess of the lung may rupture into the 
pleural cavity, producing a secondary empyema, or spontaneous evacu- 
ation may take place through a bronchus and recovery follow. When 
the cause is a foreign body rapid recovery often follows its expulsion by 
coughing. If the diagnosis is made and proper surgical treatment is 
instituted, recovery occurs in probably the majority of cases. 

The general plan of treatment should be the same as in empyema. In 
a small proportion of cases aspiration may suffice for a cure. However, 
incision is usually necessary. If the pleura is not adherent, adhesions 
should be excited by packing the thoracic wound with gauze, and after 
a few days a second operation may be done. The lung should be opened 
with a blunt instrument, following the line of the exploring needle, and 
a drainage-tube inserted as in empyema, the subsequent treatment being 
the same as for that disease. 

GANGRENE OF THE LUNG. 

Pulmonary gangrene is rare in children, although probably more com- 
mon than in adults. It is most frequently associated with pneumonia. 
It is usually circumscribed, and seldom diagnosticated during life. 

Etiology. — All my cases have been in children under three years old, 
the youngest an infant of four months. Gangrene occurs for the most 
part in children who are ill-conditioned, feeble, or cachectic, and often 
follows one of the infectious diseases, particularly measles. Of nine cases 
which have come under my personal observation, six complicated acute 
broncho-pneumonia and one, lobar pneumonia. It has been present in 
three per cent of my autopsies upon cases of pneumonia. The immediate 
cause of the necrotic process is interference with the circulation in a part 



GANGRENE OF THE LUNG. 587 

of the lung, which is usually due to thrombosis or embolism of some of 
the branches of the pulmonary artery. To this there is added the en- 
trance of putrefactive bacteria. In some cases pulmonary gangrene may 
begin as a septic thrombosis, this infection originating in some process in 
a distant part of the body. 

Lesions. — The lower lobes are more frequently affected than the up- 
per, and the surface of the lung rather than the central portions. 

Two forms of gangrene may be seen : the diffuse form, which affects 
a whole lobe, or even a whole lung; and the circumscribed form, which 
occurs in a number of small scattered areas. The latter is the variety 
usually seen in children. In the diffuse form the lung is of a dirty 
green or brown colour, moist, and emits a gangrenous odour. In the 
circumscribed form, when occurring in pneumonia, the parts affected 
are of a gray or green colour, usually wedge-shaped, with the base at the 
surface of the lung. In the early stage they are not softened, and have 
no gangrenous odour; later, both these conditions may be present, and 
masses of necrotic lung tissue may be found in a cavity with ragged walls, 
partly filled with fetid pus. Careful dissection will reveal, in many cases, 
the presence of thrombi in the vessels leading to the gangrenous parts. 

Symptoms. — There are but two distinctive s}^mptoms of pulmonary 
gangrene : the gangrenous odour of the breath, and the expectoration of 
masses of necrotic lung tissue. In the cases associated with acute pneu- 
monia, which include the majority of those seen, death nearly always 
takes place before there is any separation of the sloughs, and even before 
very active decomposition in the necrotic areas has occurred. Both the 
peculiar symptoms are therefore wanting, and the diagnosis is made only 
at the autopsy. This has been true of nearly all the cases which have 
come under my own observation. But these patients, with one exception, 
were infants. In older children, particularly in cases secondary to the 
entrance of a foreign body, the characteristic symptoms are more fre- 
quently seen, and there may be a third symptom — haemorrhage. This 
is present in about one fourth of the cases (Rilliet and Barthez), and 
may be fatal. The general symptoms associated with gangrene are those 
of profound asthenia, resembling the typhoid condition. 

From what has been said, it will be evident that the diagnosis is very 
difficult. If the characteristic odour of the breath is present, conditions 
in the mouth From which it mighl arise musl be excluded. The physical 
signs differ in no respect from those of ordinary cases of pneumonia. 
The termination is almost always in death. This is due not only to the 
condition itself, bui to the circumstances in which it is Been. 

Treatment. — Tin- amoral treatment should he supporting and stimu- 
lating, as in all severe cases of pneumonia. For the local process hut 
little can be done, except the inhalation of antiseptics, of which creosote 
and turpentine are undoubtedly the best. 



588 DISEASES OF THE RESPIRATORY SYSTEM. 



ACQUIRED ATELECTASIS— PULMONARY COLLAPSE. 

These terms are applied to a state of the lung resembling the foetal 
condition, but occurring in a lung which has once been expanded. It 
may be due to compression or to obstruction. 

Collapse from Compression. — The principal cause of this form is pleu- 
ritic effusion. It may also be produced by pneumothorax, enlargement 
of the heart, pericardial effusion, deformities of the chest from rickets 
or Pott's disease, and tumours of the mediastinum or the thoracic wall. 
In these conditions, on account of the external pressure, the air vesicles 
are not filled, although the bronchi are pervious. After collapse has ex- 
isted for a considerable time, changes may take place in the lung which 
render expansion difficult or impossible. Unless, however, there are 
pleuritic adhesions, expansion often takes place readily after many weeks 
and even months. The symptoms and signs are those of the original 
disease. 

Treatment is available chiefly in that form which follows pleuritic 
effusion, and will be considered in the chapter on Empyema. 

Collapse from Obstruction. — This is due to two factors : blocking of 
either the large or small bronchial tubes, and feeble inspiratory force. 
The importance of collapse from obstruction in the acute diseases of 
the lung in infancy has, I think, been exaggerated. Whenever a large 
or small bronchus is completely obstructed by a foreign body, the portion 
of the lung to which the bronchus is distributed gradually becomes 
collapsed. If it is one of the primary bronchi which is occluded, a whole 
lung may be collapsed; if one of the lobar divisions, an entire lobe; if 
one of the smaller divisions, only a small area. The collapse does not 
take place immediately, but the contents of the air vesicles are gradually 
absorbed by the blood. The collapsed portion is slightly depressed below 
the surface of the lung. It is of a dark-red colour, very vascular, and 
to the naked eye resembles a pneumonic area, which it may subsequently 
become. 

Many writers explain the development of broncho-pneumonia from 
bronchitis of the smaller tubes, through the intervention of pulmonary 
collapse, assuming that the obstruction of the small bronchi from swelling 
of their walls and the accumulation of secretion, produces the same re- 
sult as the plugging of a bronchus by a foreign body. In my own autop- 
sies I have found little support for this theory. In acute bronchitis of 
the smaller tubes the lumen is narrowed, but seldom enough to prevent 
the entrance of air. The result is usually emphysema, not atelectasis. 
Such, at least, has been the condition I have most frequently found in 
autopsies in the earliest stage of broncho-pneumonia following bronchitis 
of the fine tubes. There are very often groups of collapsed air vesicles 
surrounding pneumonic areas, but these are neither an essential nor a 



EMPHYSEMA. 589 

very important part of the lesion. Collapse of a large part of the lung, 
or even of a lobe, I have never seen, either in pertussis or in acute 
bronchitis. 

There is seen in delicate or rachitic infants a form of collapse which 
comes on very gradually. It is accompanied by bronchitis affecting the 
tubes in the dependent part of the lung. It may resemble the congenital 
form of atelectasis. Under the microscope there is almost invariably 
found accompanying the collapse, lobular pneumonia and bronchitis of 
the tubes in the affected regions. 

The symptoms of acquired atelectasis are much the same as in the 
persistent congenital form. The respiration is rapid, and there may be 
inspiratory dyspnoea with deep recession of the chest walls, especially if 
there is rickets. There is also cyanosis of variable intensity. The tem- 
perature is not elevated, but frequently is subnormal. The physical signs 
are very uncertain. There is usually feeble respiratory murmur over the 
affected areas, occasionally accompanied by moist rales. The essential 
point of difference between these cases and those of congenital atelectasis 
is that in the former the patients are often strong at birth, crying and 
breathing well, giving no signs of anything wrong in the lungs until the 
general nutrition has suffered from some other cause. 

The following is a fairly typical case : A female infant thirteen months 
old had been under observation for several months before death. During 
this period she suffered a great part of the time from mild bronchitis. 
The chest was extremely rachitic. The respiration was always acceler- 
ated, and on inspiration the lateral recession of the chest was at times 
extreme. There was occasionally seen slight cyanosis, and during the 
last few weeks it was constant. Death occurred quite suddenly. At 
autopsy there was found very marked vesicular emphysema of both lungs 
in front. Nearly the whole of both lower lobes were in a condition of 
collapse, and of a uniform grayish-purple colour. The posterior portion 
of the upper lobes was similarly affected, but to a less degree. With 
moderate force all of the collapsed areas could be completely inflated. 
Bronchitis was present, but the pleura was normal. 

The treatment of these cases is the same as that outlined in the chap- 
ter upon Congenital Atelectasis (page 74). 

EMPHYSEMA. 

Pulmonary emphysema consists primarily in overdistentioo of the air 
vesicles. It may result in their rapture and the escape of air into the 

interlobular connective tissue of the lung. In infancy and childhood 
emphysema is usually associated with acute processes. 

Etiology. — Cases of emphysema are divided into two groups which are 

due to quite different causes. In one group it is compensatory, and consi.-t - 



590 DISEASES OP THE RESPIRATORY SYSTEM. 

in overdistention of the air vesicles in certain parts of the lungs because 
the full expansion of other parts is prevented either because they are con- 
solidated, as in pneumonia or tuberculosis, bound down by adhesions 
from old pleurisy,; or subjected to external pressure, as from chest de- 
formities due to Pott's disease or rickets. In these conditions it is prob- 
able that the emphysema is produced during inspiration. It may also be 
produced by the artificial inflation of the lungs of the newly born. 

In the second group of cases emphysema is produced by obstructive 
expiratory dyspnoea or cough. It is seen in all forms of laryngeal stenosis, 
in acute bronchitis' and broncho-pneumonia, in asthma, pertussis, and 
occasionally it is produced by any condition which requires deep inspira- 
tion and holding the breath. A case has been reported to me which 
occurred in a little boy, who, while playing that he was a steam engine, 
would hold his breath for a long time and then issue short, forcible ex- 
piratory puffs. In bronchitis the obstruction may be caused by swelling 
of the mucous membrane or by an accumulation of secretion. In this 
group of cases air enters the lung, but as it can not readily escape, the air 
vesicles are distended, sometimes to such a degree that their resiliency is 
almost entirely lost. 

Lesions. — The most common form in early life is acute vesicular 
emphysema, which occurs when the force distending the air cells is only 
moderate. In this form there is dilatation of the vesicles with very slight 
structural changes, there being usually rupture of a few alveolar septa 
only (Fig. 90). Although the dilatation may be quite marked, the emphy- 
sema is not permanent. The parts most affected are the upper lobes, par- 
ticularly the anterior borders. In appearance the emphysematous lung is 
pale, sometimes almost white. The areas are prominent, and do not col- 
lapse upon opening the chest. With a lens, or even with the naked eye, 
the individual air vesicles can often be distinguished as minute pearly 
bodies, at times resembling miliary tubercles. When the disease is 
secondary to acute bronchitis or laryngeal stenosis it may affect nearly the 
whole of both lungs. 

With a greater distending force rupture of many of the air vesicles 
results, and this may give rise to interstitial or interlobular emphysema. 
At times blebs are formed, varying in size from a pin's head to a cherry. 
These are usually seen at the anterior border or at the root of the lung on 
its inner surface. Again, the air finds its way between the lobules, dis- 
secting them apart in all directions throughout the lung. Sometimes a 
large part of the surface of both lungs is seamed with irregular deep 
crevasses containing air, the largest being an inch or more in length and 
nearly one fourth of an inch wide. The most severe cases occur in per- 
tussis. On two or three occasions I have seen this form of emphysema, 
once to an extreme degree, where children had died from diseases uncon- 
nected with the respiratory tract, and where no history could be obtained 



PLEURISY. 591 

which threw any light upon the etiology of the emphysema. Kupture of 
the blebs which form at the root of the lung may lead to emphysema of 
the mediastinum, or even of the subcutaneous connective tissue of the body. 
This is occasionally seen in whooping-cough and in laryngeal stenosis. 
The primary or substantive form of emphysema seen in adult life rarely 
if ever occurs in childhood. 

Symptoms. — Emphysema occurring in acute pulmonary diseases gives 
rise to no peculiar symptoms and to no physical signs except exag- 
gerated resonance upon percussion. If the patients recover from the 
original disease, the emphysema undoubtedly disappears completely in 
the course of a few weeks or months. Acute interlobular emphysema 
can not be diagnosticated during life. The lesion is of such a nature 
that complete recovery is impossible, although improvement often takes 
place. 

The treatment of emphysema is that of the disease with which it is 
associated. 



CHAPTER VI. 
PLEURISY. 

All the common forms of inflammation of the pleura are seen in 
childhood. In the great majority of cases they are secondary to disease 
of the lung itself. Serous effusions are much less frequent than in 
adults, and under three years they are extremely rare. Purulent effu- 
sion (empyema) is, however, much more often seen than in adult life, 
and it is the most important variety of pleurisy with which the physi- 
cian has to deal. 

Whether inflammation of the pleura ever occurs as a strictly primary 
disease is still a mooted point. Cases are occasionally observed clinically 
in which both the serous and purulent forms of the disease appear to be 
primary, but these are extremely rare. Acute pleurisy may, however, fol- 
low inflammation of the lung so rapidly that it is not easy to determine 
that the lung was first affected. In infants, extension from the lung is 
almost the sole cause. It occurs both with lobar and broncho-pneumonia, 
existing to some degree in Dearly every ease in which there is consolida- 
tion of the lung. Next in frequency to simple pneumonia as a cause of 
pleurisy are the tuberculous processes of the lung. Tuberculous pleurisy 
without tuberculosis of the lungs or the bronchial glands is of doubtful 
occurrence. Acute pleurisy 18 not an infrequent complication of the 
infectious diseases, particularly scarlet and typhoid fevers, measles, and 
influenza. In most of these cases also it is secondary to disease of the 
^ung. Pleurisy in older children occasionally follows cold and exposure, 



592 DISEASES OF THE RESPIRATORY SYSTEM. 

although it is doubtful whether in any case this is the only cause. In 
them also it may occur as a complication of rheumatism. 

The most important cause of acute pleurisy being extension from 
pneumonia, it follows that it is most frequent in the cold season, that it 
occurs more often in males than in females, and between the ages of one 
and five years. It may, however, be seen at all ages, and may even occur 
in intra-uterine life. The youngest case in which I have found extensive 
pleuritic adhesions as an evidence of previous inflammation was in an in- 
fant of three months, who died at the Randall's Island Hospital. In this 
case firm connective tissue adhesions were found over the whole of both 

lungs. 

DRY PLEURISY. 

In infants and young children this usually accompanies pneumonia or 
tuberculous processes in the lung. In older children it may be primary. 

Lesions. — On account of the frequency with which this occurs in 
pneumonia we have an opportunity of observing it in all stages. In the 
mildest varieties it affects only the pulmonary pleura, and occurs over the 
pneumonic areas. The pleura is injected, has lost its lustre, and appears 
dull or roughened. This is due to an exudation of fibrin upon its surface. 
If the process continues, more fibrin is poured out, and there are in addition 
swelling and a proliferation of the connective-tissue cells, and an exuda- 
tion of leucocytes from the blood-vessels. The pleura is then coated with 
a layer of fibrin of variable thickness, in which are entangled pus cells 
and new connective-tissue cells. The layer of fibrin varies from the thick- 
ness of tissue paper to that of an ordinary book cover. In recent cases it 
may easily be stripped off, while in older ones it becomes organized and is 
firmly adherent. The colour of the exudate varies with the number of 
pus cells. It is gray, grayish-yellow, or yellowish-green, according as 
these cells are few or numerous. As a rule, dry pleurisy is localized, but 
the two opposing surfaces are affected. Part of the exudate is usually 
absorbed, but it is doubtful if complete recovery occurs, there being left 
behind some adhesions between the visceral and parietal layers. 

In some cases of dry pleurisy there is an excessive exudation of pus 
cells. These cases are most common in young children, and usually oc- 
cur with pneumonia, constituting what is known as " pleuro-pneumo- 
nia." The process is essentially the same as in the cases just mentioned, 
yet the gross appearance differs very much from that of ordinary dry 
pleurisy. The lesions have already been described under the head of 
Pleuro-Pneumonia. 

In the dry form of tuberculous pleurisy there may be only an exudation 
of fibrin, or the pleura may be covered with gray tubercles and yellow 
tuberculous nodules. These are not only seen upon the pleura, but develop 
in the exudation. In this form, which is usually chronic, great thickening 
of the pleura may take place. Both the serous and purulent effusions 



PLEURISY WITH SEROUS EFFUSION. 593 

occurring in conjunction with tuberculosis are likely to be sacculated be- 
cause of the previous existence of adhesions. 

After nearly every case of dry pleurisy there probably remains some 
slight thickening of the pleura. In certain cases there follows a chronic 
inflammation of the pleura with the production of new connective tissue, 
which results in thickening and adhesions, which may be so extensive as 
to entirely obliterate the pleural cavity. Either one or both sides may be 
affected. This form is extremely rare in childhood. 

Symptoms. — As an independent clinical disease, acute dry pleurisy has 
no existence in infancy or early childhood. The cases which are occa- 
sionally so diagnosticated have in my experience invariably proven to be 
broncho-pneumonia. In children from ten to fourteen years old, dry 
pleurisy may occur under the same conditions as in adults. 

The symptoms are sharp, localized pain, increased by full inspiration, 
sometimes tenderness upon pressure, and a short, teasing cough. The pain 
is not always felt upon the affected side, and it may be referred to the ab- 
domen. Upon physical examination, dry pleurisy is recognised by the pres- 
ence of a pleuritic friction sound. This is usually of a moist, crackling 
character, generally localized, and heard both on inspiration and expira- 
tion. It is quite superficial, and not changed by coughing. This form 
of pleurisy, as a rule, runs a course of a few days or a week, without con- 
stitutional symptoms. When dry pleurisy occurs as a complication of 
pneumonia it is recognised by the signs just mentioned ; but it usually 
causes no new symptoms except pain. 

Treatment. — The treatment consists in counter-irritation by mustard, 
iodine, or blisters, according to the severity of the inflammation, and in 
the use of opium. Severe pain can sometimes be relieved by firmly en- 
circling the chest with a broad band of adhesive plaster. 

PLEURISY WITH SEROUS EFFUSION. 

This form of pleurisy is infrequent in children, and under three years 
it is very rare. It may occur as a complication of pneumonia, nephritis, 
acute rheumatism, scarlet fever, or any of the other acute infectious dis- 
eases. It may be tuberculous. In rare cases it appears to be primary. 
Bacteria are occasionally present in the exudation, even in cases which do 
not become purulent, but their number is usually small. The pnenmo 
coccus, the streptococcus, and the tubercle bacillus are the forms most 
often seen. 

Lesions. — The early changes are much the same as in dry pleurisy, 
but in addition Berum lb [mured mit from the blood-vessels, in Borne cases 
almost from the beginning of the inflammation. This may be .-mail in 
amount, or it may fill the pleural cavity. The lesions are similar to i '•■ 
Been in adults, excepl thai in children there is apt to he more fibrin. The 
process usually terminates in absorption of the serum, hut, as in dry 



594 DISEASES OF THE RESPIRATORY SYSTEM. 

pleurisy, more or less extensive adhesions are left behind from the fibri- 
nous exudation. 

Symptoms. — The small serous effusions of one or two ounces, occurring 
with the dry pleurisy that complicates pneumonia, rarely cause either 
symptoms or physical signs by which they can be recognised. In the 
present connection only those cases will be discussed in which the amount 
of effusion is considerable. This form of pleurisy sometimes follows a 
well-defined attack of pneumonia. Other cases come on with acute febrile 
symptoms somewhat resembling those of pneumonia, but with all the 
symptoms less severe, except the pain. After an illness of only two or 
three days the chest may be found full of fluid. In a third class the dis- 
ease comes on insidiously, with little or no fever, and often with no dis- 
tinct pulmonary symptoms except shortness of breath. There are general 
weakness, sometimes loss of flesh, anaemia, and moderate prostration ; but 
usually the patients are not sick enough to go to bed. The symptoms 
of pleurisy with effusion vary greatly. When it occurs as a complication of 
some acute infectious disease, it is often latent, and the diagnosis is to be 
made only by the physical examination of the chest. 

The usual course of the disease is for the fluid to disappear gradually 
by absorption, the case going on to spontaneous recovery. Serious symp- 
toms resulting from pressure upon the heart and lungs are not common, 
but may occur when the fluid accumulates rapidly ; hence they are most 
likely to be seen early in the attack. There may be great dyspnoea, some- 
times orthopnoea, cyanosis, weak pulse, and even attacks of syncope. 
Death may occur with these symptoms. In certain cases there is seen no 
tendency to spontaneous absorption, and the exudation may remain sta- 
tionary for months. There may then be fever, usually slight but some- 
times quite regular, with a decline in the general health, pallor and 
anaemia, which may strongly suggest the existence of pus, although this 
is not present. Others are regarded as cases of tuberculosis. 

Physical Signs. — The signs in the chest are essentially the same whether 
the fluid is serous or purulent. On inspection, there is diminished move- 
ment of the affected side, sometimes bulging of the intercostal spaces, and 
if the effusion is large, an increase in the measurement of the affected side 
of the chest. The apex beat of the heart will usually be considerably dis- 
placed if the effusion is upon the left side. It may be found at the epi- 
gastrium, at the right border of the sternum, or even in the right mam- 
mary line. In disease of the right side the displacement is less, and 
occurs only with a large effusion. It may then be found in or near the 
left axillary line. On palpation, the vocal fremitus is usually diminished 
or absent, but it may be but little changed. Percussion gives marked dul- 
ness or flatness. In a large effusion this is over the entire lung. There 
is also a sensation of increased resistance appreciable by the percussing 
finger. With a smaller effusion there is usually flatness over the lower 



PLEURISY WITH SEROUS EFFUSION. 595 

part of the chest and dulness or tympanitic resonance above ; sometimes 
dulness is found behind and tympanitic resonance at the apex in front. 
The line of flatness may change with the position of the patient. The 
signs on auscultation are variable, and probably lead to more frequent 
mistakes in diagnosis than in any other pulmonary affection. Bronchial 
breathing and bronchial voice over the fluid are the rule in children ; they 
are generally more distinct the greater the effusion. Absence of both voice 
and breathing is sometimes met with, but it is exceptional. The bronchial 
breathing over fluid usually differs from that over consolidation, in that it 
is feebler and distant ; in some cases, however, it is indistinguishable from 
that heard over consolidation. Friction sounds may be heard above the 
level of the fluid, or when the fluid is subsiding, and there may be bron- 
chial rales. 

Diagnosis. — The most reliable signs for diagnosis are displacement of 
the heart, flatness on percussion, absence of rales and friction sounds, and 
(usually distant) bronchial breathing. In an infant, flatness should always 
lead one to suspect fluid. If there is flatness over one entire lung, the 
existence of fluid is almost certain. Between serous and purulent effusions 
a positive diagnosis is possible only by the use of the exploring needle. 
This should be employed in every case, as for treatment it is important to 
know at once whether or not we have a purulent effusion to deal with. 
The amount of fluid in serous pleurisy is generally less than in the puru- 
lent variety. 

Pleurisy is further to be differentiated from pneumonia, and from tuber- 
culosis. From pneumonia, the acute cases are distinguished by the lower 
temperature, the less severe prostration, and the fact that all the general 
symptoms are milder, but especially by the physical signs. The differential 
diagnosis by the physical signs between effusion and the various forms of 
consolidation is considered under the head of Empyema. 

Prognosis. — These cases, as a rule, terminate in recovery, death being 
very infrequent. In cases coming on without definite cause there should 
always exist a suspicion of tuberculosis, and hence every patient should be 
closely watched for the development of the other signs of that disease. 

Treatment. — In the great majority of cases, only symptomatic treat- 
ment is required daring the acute period. The patient should be kept 
in bed, and pain relieved by opium, counter-irritation, or hot poultices. 
After the fever has ceased the patient maybe allowed to sit up, but all 
exertion should be carefully avoided if the effusion is large. Sudden 
death has Often occurred when this pule has been violated. The patient 
Bhould in Suitable weather be kept in the open air as niueh as possible. 

In the course of a few weeks the effusion usually subsides under simple 
tonic treatment. Absorption may sometimes be hastened by counter- 
irritation and diuretics; but convalescence is apt to be slow, and it mav 
be several months before the health is entirely restored. 
80 



596 DISEASES OF THE RESPIRATORY SYSTEM. 

The removal of the fluid by operation is indicated in the acute stage 
when it is accumulating so rapidly as to endanger life from the pressure 
upon the heart and lungs ; also when there is no tendency to absorption 
after from two to three weeks of constitutional treatment. In such cases 
nothing is to be gained by waiting, and harm may be done to the lung by 
the delay. The usual method is by aspiration. In the acute stage enough 
should be removed to relieve the patient's symptoms, aspiration being re- 
peated if necessary in twelve or twenty-four hours. In the sub-acute stage 
the removal of a portion of the fluid may be all that is required, spontaneous 
absorption of the remainder often taking place then quite promptly. A 
few cases of serous pleurisy have been incised and drained as cases of 
empyema. Scharlau (New York) operated on such a case in an infant 
two years old. The effusion came on acutely and was excessive, the chest 
having refilled very quickly after aspiration. The chest was incised and 
drained and the patient recovered in five days. In chronic cases, in which 
there are slight fever and a gradual failure of general health, the opera- 
tion of incision is by some preferred to aspiration. 

EMPYEMA. 

Fully nine tenths of the cases of empyema in children under five years 
either occur with or follow pneumonia, being usually the sequel of the 
form described as pleuro-pneumonia. In some of these cases, however, 
the pleurisy masks the pneumonia, so that the former appears to be the 
primary disease. Tuberculosis is a rare cause in early childhood, but be- 
comes more frequent after the seventh year. Empyema may complicate 
scarlet fever, measles, or any of the other acute infectious diseases. It is 
met with in pyaemia from all causes. It may occur in the newly born as 
the result of infection through the umbilical wound or the skin. It is 
seen with suppurative inflammations of the joints and in osteo-myelitis. 
It may complicate suppurative processes in the abdomen, such as ap- 
pendicitis or purulent peritonitis. Among the local causes may be men- 
tioned traumatism, necrosis of a rib, and the rupture into the pleural cav- 
ity of abscesses originating in the mediastinum, in the thoracic wall, or 
below the diaphragm. 

Bacteriology. — Much light upon the etiology of empyema has been 
thrown by the bacteriological investigations of the past few years, espe- 
cially by the work of Fraenkel, Weichselbaum, Levy, and Netter in 
Europe, and Prudden and Koplik in this country. Bacteriologically, we 
may divide the cases into several groups : 

1. Those containing the pneumococcus (micrococcus lanceolatus), usu- 
ally in pure culture. This is the largest group, and includes nearly all the 
cases secondary to pneumonia. The pleura is usually involved by direct 
infection from the lung. 

2. Those containing other pyogenic germs, particularly the strepto- 



EMPYEMA. 597 

coccus and the staphylococcus. Of these the streptococcus is the most 
important. It may be found alone, but is usually associated with the 
pneumococcus. This combination is likely to be found in cases sec- 
ondary to the pneumonia which occurs with the infectious diseases. The 
streptococcus and staphylococcus occur in the pleurisy of pyaemia, and 
usually also when the disease is due to the rupture of abscesses into the 
pleural cavity. 

3. The cases due to tuberculosis. In this group the presence of the 
tubercle bacillus is very often difficult to demonstrate, and it may be 
absent. From this fact the statement is made by Levy that, if no bac- 
teria can be found in a purulent exudate, tuberculosis should always be 
suspected. It is not, however, safe to conclude that under these circum- 
stances tuberculosis is always present. 

Of nineteen successive cases of empyema occurring in my own prac- 
tice, the pneumococcus was found alone in fourteen; the streptococcus 
alone in three ; the pneumococcus and streptococcus in one ; and the 
staphylococcus alone in one. 

Lesions. — Empyema is an inflammation with the production of 
serum, fibrin, and pus. In most of the cases — and the younger the 
child the more frequent its occurrence — it succeeds pleuro-pneumonia. 
There is first an exudation of fibrin with an excess of pus cells. As the 
process continues, more and more pus is poured out, with serum. At 
first the fluid collects in small pockets formed by the slight adhesions. 
As it accumulates these are broken down, and the pleural cavity may be 
filled with pus. If the original inflammation involved but a portion of 
the pleura the empyema may be sacculated. This is often seen even in 
infants. Sacculated empyema is usually posterior, but may be in any 
part of the chest. In very rare cases there may be several sacs contain- 
ing pus, separated by septa. This I have never seen in empyema follow- 
ing pneumonia. The cases just described are those in which, in infants 
and young children, the pneumococcus is regularly found. The amount 
of fibrin is large, covers both surfaces of the pleura, and many large 
masses float in the fluid. The pus is usually thick, creamy, and odour- 
less. In another group of cases the evidences of inflammation of the 
pleura are much less marked, and in souk- they may be slight. There is 
but little fibrin in the exudate, and adhesion- are rare. In this form the 
streptococcus or the staphylococcus are the organisms usually found. In 
these cases the inflammation may be purulenl from the outset, and the 
pus i> thinner than in the preceding variety. It i< rare that empyema 
in a young child results from a serous effusion which ha- been gradu- 
ally converted into a purulent one. I ean recall but a single instance. 

Even when the fluid i- moderate in quantity it Is qo1 all at the bottom 
of the chest, hut i- generally distributed over a considerable pari of its 
surface, and it- depth at the middle and upper part of the chesl may he 



598 



DISEASES OF THE RESPIRATORY SYSTEM. 



only half an inch, or even less. When the accumulation is larger, the 
lung does not float on the surface of the fluid, but the fluid surrounds 
the lung, which is compressed on all sides (Fig. 110). The heart is dis- 
placed ; the diaphragm and 
the abdominal viscera are 
somewhat depressed, and 
there may be bulging of 
the chest on the affected 
side. The amount of fluid 
in ordinary cases is from 
half a pint to two pints, 
although in neglected cases 
it may accumulate until it 
amounts to four or five 
pints. The effect upon the 
lung will depend upon the 
amount of fluid and the 
duration of the compres- 
sion. When the quantity 
is small, or when the pres- 
sure is removed early, the 
lung in most cases readily 
expands, air being forced 
into it from the opposite 
lung, especially during the 
act of coughing. If the 
pressure is great and has 
been long continued, the 
adhesions over the lung 
may become so dense and firm that expansion is difficult, and can at best 
be only partial. In such cases recession of the chest wall occurs. In very 
old cases, expansion is still further interfered with by the changes taking 
place in the lung itself, usually a low grade of interstitial pneumonia. 

In cases of empyema receiving proper surgical treatment reasonably 
early, full expansion of the lung occurs, and, with the exception of adhe- 
sions, recovery may be complete. Although wide in extent, the adhesions 
are not usually strong enough to interfere seriously with the function of 
the lung. In cases receiving no treatment, absorption of the pus is pos- 
sible, but is not to be expected. It generally seeks an external outlet ; the 
lung may be perforated and the pus evacuated through the bronchi, or 
external rupture may occur, generally in the neighbourhood of the nipple. 
In still other cases the pus may burrow along the spine, or through the 
diaphragm may reach the peritonaeum. 

Empyema is more often of the left than of the right side, the propor- 




Fio. 110.— Section of a lung to illustrate the distribution of 
the fluid in the chest in a moderately large eifusion 
(diagrammatic). 



EMPYEMA. 



599 



tion being about three to two. It is double in about three per cent of all 
cases, but much oftener in infants. The most serious complication in 
young children is pericarditis, usually with empyema of the left side ; in 
older children the most frequent complication is pulmonary tuberculosis. 
Symptoms. — When it occurs as a sequel of pneumonia, the symptoms 
of empyema may follow those of the original disease without any inter- 



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Fig. 111. — Empyema following pneumonia. 

Private patient, ^irl, eight years old ; severe pneumonia terminating by lysis ; development 
of empyema indicated by secondary temperature; operation on seventeenth day; recovery. 

mission ; or after the temperature has been normal or nearly so for sev- 
eral days it may rise again, sometimes quite suddenly, but more often 
gradually. Willi this accession of fever there are other symptoms point- 
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After scarlet fever or other infectious diseases, the onset of empyema is 
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lution, I 
curv 



Kuipj ema follow ing pnei 

single lobe pneumonia wi 
>lopment of signs of empyema closely following the temperature 



Hospital patient, two yean old ; single-lobe pneumonia with orista on ninth day; do 

■ »tea«l irradual d 



of pulmonary disease. In the cases w*here empyema appears to be pri- 
mary, the onsel is sudden, with high temperature and general and local 
symptoms resembling those of pneumonia. After Buch a beginning, tin* 



600 DISEASES OF THE RESPIRATORY SYSTEM. 

chest may be found full of pus by the third or fourth day. In older chil- 
dren empyema may come on with gradual, and even insidious symptoms, 
there being only slight fever, dyspnoea, and cachexia. Marked leucocy- 
tosis, 30,000 to 50,000, is almost invariably present. 

Whatever may have been the mode of onset, when the pus has been 
in the chest for some time the symptoms are fairly uniform. There is 
cachexia, pallor, anaemia, and prostration which is generally sufficient to 
keep the child in bed. The respirations are always accelerated, being 
usually from forty to seventy a minute. Cough is present ; there is dysp- 
noea, sometimes marked, but more often it is scarcely noticeable. Fever 
is exceedingly variable; it is not usually above 102° or 103° F. ; in 
many cases it is not over 100° F., and it may be absent altogether. A 
typical hectic temperature with sweating, is in my experience very rare. 
The pulse is rapid but of fair strength. There is loss of flesh, sometimes 
even emaciation and anorexia ; occasionally there is diarrhoea. In chronic 
cases the general symptoms closely resemble those of tuberculosis. There 
may be clubbing of the fingers, albuminuria, swelling of the feet, and 
often marked lateral curvature of the spine. 

Diagnosis. — The physical signs do not differ essentially from those 
present in serous effusions. If the patient is under three years of age, the 
fluid is almost certain to be purulent; and from the third to the seven th 
year, pus is much more often found than serum. Marked leucocytosis 
always makes pus more probable. In every case in which fluid is sus- 
pected the exploring needle should be used, because of the great impor- 
tance of an early diagnosis. The skin should be washed and the needle 
sterilized. Pus may not be found because the needle is too small, too 
short, or because it is introduced too far into the chest; for when the 
layer of pus is thin, the needle may be pushed through this into the lung. 

The physical signs upon which most reliance is to be placed are, 
marked dulness or flatness on percussion, feeble breathing, and displace- 
ment of the heart. When in a young child these signs are present, 
whether general or localized, a needle should be inserted, and if pus is not 
found at the first trial, repeated punctures should be made until the pres- 
ence or absence of fluid is definitely settled. 

Empyema is most frequently confounded with unresolved pneumonia. 
The differential points are that in unresolved pneumonia the dulness is 
usually over a single lobe, rales or friction sounds are heard, and there is 
no displacement of the heart ; empyema may give flatness over the whole 
lung, or over the lower half of the chest in front and behind, rales and 
friction sounds are absent over this area, and the heart is usually dis- 
placed. In both conditions we may get bronchial breathing and voice. 
The confusion of acute pneumonia or tuberculosis with empyema, gen- 
erally arises from placing too much reliance upon auscultation. In 
pleuro-pneumonia, with an excessive exudation of fibrin, the signs may 



EMPYEMA. 601 

be identical with those of empyema, except that the heart is not dis- 
placed. I once saw pulmonary tuberculosis, with caseation of an entire 
lobe, which gave signs that were identical with those of a sacculated 
empyema. It is by the exploring needle, and by that alone, that empy- 
ema is positively differentiated from these pulmonary conditions. 

There are some other thoracic diseases from which the diagnosis 
may be even more difficult. A large pericardial effusion gives signs 
which are in some cases identical with those of empyema of the left 
side. Marked displacement of the heart to the right is always a strong 
point in favour of empyema; besides, such pericardial effusions are ex- 
tremely rare in young children. A pulmonary abscess of considerable 
size — also a rare condition — gives signs identical with those of localized 
empyema, and is only distinguished from it by autopsy or operation. 
Abscesses from broken-down tuberculous glands may give signs resem- 
bling those of localized empyema, and may point like an empyema be- 
tween the ribs in the upper part of the chest. The constitutional symp- 
toms of empyema may at times resemble typhoid fever or malaria; but 
it is distinguished from them by the physical signs. 

Prognosis. — The outcome of a case of empyema depends chiefly upon 
the cause, the age and general condition of the patient, the duration of 
the symptoms, the presence or absence of serious complications, and the 
treatment. The best results are obtained in the cases that follow pneu- 
monia. Tuberculosis before the seventh year is an exceedingly infre- 
quent cause, and gangrene of the lung and general pyaemia are both rare 
causes in early life. It is these three conditions that make the prognosis 
of the disease in adults so serious. The mortality in infants under one 
year, particularly hospital cases, is high — fully 75 per cent — not only 
because of the tender age, but because of the wretched general condition 
of most of these patients. Empyema in children over two years old seen 
reasonably early — i. e., within six or eight weeks — and receiving proper 
treatment, almosl invariably terminates in recovery, unless the disease 
is double or serious complications exist. Great delay in operation makes 
the prognosis worse, because the more difficult the expansion of the lung 
the more tedious is the disease, and the greater the likelihood of a sinus 
remaining. Willi proper early treatment these patients n<>( only re- 
cover, hut in most cases the recovery is surprisingly complete. Retrac- 
tion of the chest and it- resulting lateral curvature of the -pine are rare, 
and -ecu only in neglected eases. In very many of the ease- I have seen, 
in which a reasonably early operation was don.', it was impossible, after 

the lapse of two Or three years, to detect any dill'erence whatever in the 

physical Bigns of the two sides of the chest. There are few serious dis- 
eases the treatment of which is more satisfactory than that of acute 
empyema following pneumonia. 

Spontaneous recovery in empyema may take place by absorption ; but 



602 DISEASES OF THE RESPIRATORY SYSTEM. 

this is so rare that it is not to be expected. The pus may be evacuated 
spontaneously through a bronchus, rupture haying taken place through 
the visceral pleura. When this occurs, a large amount of pus may be 
coughed up in a few hours, usually followed by immediate, but not 
always lasting, improvement. This is the most favourable of the natu- 
ral terminations. External opening may take place, usually about the 
nipple. There is an area of redness, then a fluctuating tumour, and 
finally the pointing of an abscess. The discharge may continue for 
months, or even for years. External opening rarely occurs until the 
disease has lasted several months. Of 19 cases of empyema in children 
collected by Schmidt, in which a spontaneous discharge of pus occurred 
either externally or through a bronchus, there were 17 deaths and 2 
recoveries. Empyema may burrow behind the diaphragm into the ab- 
dominal cavity, appearing as a psoas abscess; it may burrow posteriorly 
into the lumbar region; it may rupture into the oesophagus, or through 
the diaphragm into the peritoneal cavity. All these conditions, how- 
ever, are very rare. The chances of spontaneous cure in empyema are 
small. Of 32 cases, reported by Eilliet and Barthez, which received 
no surgical treatment, 21 proved fatal. The statistics of empyema be- 
fore the general adoption of surgical treatment are simply appalling. 
Patients were either worn out by the protracted suppuration, or died 
from amyloid degeneration, pneumonia, or tuberculosis. 

Treatment. — The medical treatment relates to the patient only; the 
disease is always to be treated surgically. Like any other acute abscess, 
empyema requires free incision and drainage with proper aseptic pre- 
cautions. 

Aspiration as a means of cure has been almost entirely given up in 
New York. Unquestionably it sometimes suffices to cure empyema, most 
frequently when it is localized. How often this occurs is shown by the 
following statistics : Of 139 cases which I collected that were treated by 
aspiration, 25 were cured, 8 of these by a single aspiration; 13 died, and 
the remaining 101 were afterward subjected to other treatment. The 
objections to aspiration are, that it is not possible to remove all the pus; 
that it affords no opportunity for the removal of the large fibrinous 
masses ; and, finally, that it is only a possible means of cure. The terror 
caused by repeated aspirations is almost as great as that of incision with- 
out anaesthesia. Aspiration, therefore, is to be advised in children only 
for temporary relief when the amount of fluid is large and the symp- 
toms are urgent. 

Simple incision and drainage. — If possible I prefer to delay opera- 
tion until the period of most acute inflammation has subsided, as shown 
by lower temperature and stationary physical signs. This is usually seen 
two or three weeks after the pleural invasion. Such delay is not admis- 
sible if either the local condition or the temperature points to a steady 



EMPYEMA. 603 

increase in the disease; nor when the general symptoms indicate in- 
creasing prostration or sepsis. The dangers attendant upon general 
anaesthesia are considerable, and in most cases it is better not to em- 
ploy it. I have known of four deaths on the table during operation, 
and. in several other cases have seen very alarming symptoms occur. 
Chloroform is more to be feared than ether. We should therefore rely 
upon local anaesthesia obtained by cocaine or by a spray of chloride of 
ethyl or ether. The most favourable point for incision is the poste- 
rior axillary line in the seventh intercostal space upon the right side, 
the eighth upon the left. In a case of a localized empyema, the lowest 
point at which pus can be obtained by puncture should be chosen. The 
incision is made in the middle of the intercostal space. No matter what 
has been found by puncture on previous occasions, the exploring needle 
should always be used at the time of operation and at the site of the inci- 
sion before the latter is made. The cutaneous incision should be an inch 
and a half long, and the opening in the pleura made large enough to allow 
the little finger of the operator to pass into the pleural cavity. The haem- 
orrhage is very rarely sufficient to require a ligature. The wound may be 
held open by forceps or a tracheal dilator, and as much of the fibrin as 
possible removed at the time; or, if the patient's condition is bad, the 
tube may be immediately inserted and the dressings applied. The drain- 
age tube should be of heavy rubber, fenestrated, three eighths or half 
an inch in diameter and four or five inches long. It is passed into the 
deepest pocket of the empyema. To secure it from slipping into the 
cavity, its outer end should be transfixed by a large safety-pin before its 
introduction. It is usually advisable for the first few days to insert two 
tubes Bide by side This diminishes the danger of stopping the discharge 
by the plugging of the lube with fibrin. Gauze is placed over the 
wound beneath the safety-pin, and a compress of the same over the 
opening of the tube, the dressing being completed by a large mass of 
absorbenl cotton and a snug roller bandage. The pus now slowly ex-apes 
into the dressing as the lung expands. When there is no reason for haste 
during the operation, a larger part of the pus may be removed before the 
application of the dressing. This should be allowed to escape slowly, 
the opening being closed from time to time by a compress. 'Ten or fif- 
teen minutes may be consumed In evacuating the pus. 

Both the original operation and the Bubsequenl dressings should be 
done with Btrid aseptic precaution- on account of the danger of sec- 
ondary infection, the occurrence of which add.- to the severity ami pro- 
longs the course of the disease. For the firsl day or two the dressings 

ghould he changed twie< daily, then once a day for ten days or two weeks, 

and later ;it longer intervals. After the third day the second tube may 
be omitted and the remaining one gradually shortened. Usually by 
the end of the third week, and often before, the tube may he dispensed 
10 



604 



DISEASES OF THE RESPIRATORY SYSTEM. 



with altogether, the tract being kept open by a small roll of rubber tis- 
sue. The time of redressing and the removal of the tube is determined 
by the amount of discharge and the temperature. While this does not 
usually rise after the second day unless the drainage is imperfect, there 

are a number of conditions which 
may cause it to do so. The most 
important are: pneumonia, either 
a continuance of the old process 
or lighting up of a new one; ab- 
scess of the lung ; empyema of the 
opposite side; pericarditis; tuber- 
culosis; abscess from a necrosed 
rib; or some cause outside the 
chest — otitis, malaria, indiges- 
tion, or the onset of some other 
disease. The drainage should al- 
ways be first suspected. The tube 
is often blocked by masses of 
fibrin, even when one of large size 
is used. At each dressing it is 
well to remove it to see if it is 
clear. The mistake is often made 
of allowing the tube to remain for 
too long a time, so that a sinus 
is kept open which would other- 
wise heal. Another mistake is 
that of allowing a very large tube 
to remain for too long a time; 
this may cause erosion of the pe- 
riosteum and even necrosis of a 
rib. Washing out the pleural 
cavity is indicated only in cases in 
which the pus is foul. A single 
washing for the purpose of re- 
moving fibrin is the routine prac- 
tice of some surgeons. For this 
a warm sterilized salt solution 
should be used. Personally I have not found this necessary. Eepeated 
irrigations should not, I think, be employed. The usual duration of 
the discharge in cases treated by simple incision is from three to six 
weeks, the average being about five weeks. 

Resection of a rib. — Many of the best surgeons favour this as a rou- 
tine procedure, with the belief that with the larger opening which is thus 
made, more perfect drainage is secured, that masses of fibrin can be 




Fig. 113. — Deformity after an old empyema of 
the left side for which Estlander's operation 
was performed. • Portions of five ribs were 
removed. (From a photograph seven years 
after operation.) 



EMPYEMA. 



605 



removed with greater facility, and that it is altogether a more certain 
and efficient means of treatment than is a simple incision. While ad- 
mitting some of the advantages claimed, my own experience has been 
that in the great majority of recent cases in young children, simple inci- 
sion with drainage is all that is required. Bib resection is necessary 
whenever good drainage can not be secured by simple incision; especially 
if there is overlapping of the ribs, or if the intercostal spaces are very 
narrow. These are usually the cases in which the disease has lasted 
much longer than the average time. One inch of rib is all that it is 
necessary to remove. The periosteum is preserved, and there is rarely 
any permanent deformity. 

In chronic cases, or those which have been long neglected, some fur- 
ther operative treatment is often necessary. The lung is so bound down 
by firm adhesions that further expansion is impossible, and even after 
the chest has receded to its utmost, so that the ribs are in contact, there 
still remains a cavity which can not close. For such cases the only hope 
is in an operation by which 
portions of several ribs are 
removed, thus allowing a 
greater collapse of the 
chest wall. This is known 
as thoracoplasty, or Estlan- 
der's operation. The oper- 
ation is of itself a serious 
one, and only to be advised 
as a last resort in inveter- 
ate cases. Such an opera- 
tion is, of course, always 
followed by very greai de- 
formity (Fig. 1 13). 

Methods of inducing ex- 
pansion of Hi" hint/. — hi 
mosl of the cases, pari icu- 
larly the recenl ones, com- 
plete expansion of the lung 
takes place without any dif- 
ficulty, the chief agenl be- 
ing the cough, lu Borne cases this may be insufficient. The apparatus, 
devised by James (New York), Bhown in the accompanying cul (Fig. 
ill) -,!■.,- ;m the same time as a toy for the child's amusemenl and 
as a mosl efficienl means of inducing forced expiration. One bottle is 
placed a few inches higher than the other, and the child blows a coloured 
fluid from the lower into the higher bottle, allowing it to Biphon hack. 
Blowing soap bubbles often answers the Bame purp< 




Fi... Ill 



apparatus for expanding the Lung 



SECTION V. 

DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

PECULIARITIES OF THE HEART AND CIRCULATION IN EARLY 

LIFE. 

The Fcetal Circulation. — During the latter part of foetal life the circu- 
lation may be briefly described as follows : The purified blood comes from 
the placenta through the umbilical vein. Entering the body, it divides at 
the under surface of the liver into two branches, the smaller one, the ductus 
venosus, communicating directly with the inferior vena cava ; the larger 
branch joining the portal vein, so that its blood traverses the liver, and 
then enters the inferior vena cava through the hepatic vein. From the 
inferior vena cava the blood enters the right auricle, like that returned 
from the head and upper extremities by the superior vena cava. A part 
of the blood now passes directly into the left auricle through the foramen 
ovale ; the remainder, through the tricuspid orifice into the right ventricle. 
As the requirements of the pulmonary circulation are not great, only a 
small part of the blood is sent through the pulmonary artery to the 
lungs ; the greater portion passes from the pulmonary artery through the 
ductus arteriosus into the aorta, joining here the blood from the left ven- 
tricle. The blood thus finds its way from the right heart to the left, only 
in small part by way of the lungs, the greater part passing directly from 
the right auricle to the left, or from the right ventricle into the aorta 
through the ductus arteriosus. From the aorta, the blood reaches the 
placenta through the umbilical arteries, which are a continuation of the 
hypogastric arteries, which in turn are given off from the internal iliacs. 

Changes in the Circulation at Birth. — With the ligation of the umbil- 
ical cord, the circulation through the umbilical vein and arteries and the 
ductus venosus ceases. With the establishment of respiration and the 
consequent increased demands made by the pulmonary circulation, the 
blood ceases almost at once to pass through the ductus arteriosus, and very 
soon through the foramen ovale. The umbilical vessels during the first 
few days of life are filled with small thrombi, which become organized. 
By the end of the first week, these vessels, as well as the ductus venosus, 
are usually closed at their extremities, although they may remain patulous 
throughout the greater part of their extent for several weeks. They sub- 
sequently atrophy to the condition of small fibrous cords. For some weeks 

606 



THE HEART AND CIRCULATION IN EARLY LIFE. 



607 



before birth the circulation through the foramen ovale is slight, it being 
gradually obstructed by the growth of a septum which nearly fills the space 
at birth. After the first week of extra-uterine life very little, if any, blood 
passes through it, although complete closure of the foramen often does 
not take place until the middle of the first year. In fully one fourth of 
the autopsies I have made upon infants under six months old, there have 
been found minute openings at the margin of the foramen ovale, but they 
are usually oblique, and closed by the valvular curtain so as effectually to 
obstruct the current of blood. The ductus arteriosus is first closed by a 
clot, which becomes organized and blends with the products of a prolif- 
erating arteritis. It is rarely found open after the tenth day, and by the 
twentieth it is almost invariably obliterated. 

The Pulse. — The pulse in early life is not only more frequent, but it is 
very much more variable than in adults. The following is the average 
pulse-rate in healthy children during sleep or perfect quiet : 

Six to twelve months 105 to 115 per minute. 

Two to six years 90 " 105 " " 

Seven to ten years 80" 90" 

Eleven to fourteen years 75 " 85 " " 

The pulse is a little more frequent in females than in males, and more 
frequent when sitting than when lying down. Muscular exercise or ex- 
citement increases the pulse-rate by from twenty to fifty beats. Very 
trivial causes disturb not only the frequency but the force of the pulse. 
The pulse in young infants may be irregular even in health and during 
sleep. When rapid, it is frequently irregular without any meaning. No 
dicrotism is seen in the pulse wave of early infancy, according to Blanche.* 

The circulation is much more active in infancy than in later childhood ; 
thus, according to Vierordt, the entire round of the circulation is accom- 
plished in the newly born in twelve seconds ; at three years, in fifteen sec- 
onds ; in the adult, in twenty-two seconds. 

Size and Growth. — The relative size of the heart is slightly greater in 
infancy than in later life, it being smallest at about the seventh year. 
The average weight at the different periods of life is as follows : f 





< unices. 


Grammes. 


Ratio to body 
weight. 


Birth 


0-60 

1 ••_».-> 
1-87 
3-36 
2-80 
5 * 84 
8-50 


141 
86 
58 1 
64 | 

166 

211 




1 year 

2 years 

3 " 


1 to 236 


7 " 


1 to 280 


14 " 


I to 322 


Adult 


I to 226 







* See tracings in Archives of Pediatrics, 70I. v, p, 782. 

J The figures in infancy are from one hundred and Rfty-flve observations made En 
the New York Infant Asylum; the "tiiers are taken from Sahli 



608 DISEASES OF THE CIRCULATORY SYSTEM. 

The growth of the heart is rapid during the first three years, and 
nearly proportionate to that of the body. It is slowest from the third 
to the tenth year, and most rapid from the eleventh to the fifteenth 
year. At birth, the thickness of the right ventricle is very nearly the 
same as that of the left, the ratio being 6 : 7. The left ventricle, how- 
ever, grows very much more rapidly than the right, so that at the end 
of the second year the ratio is 1:2, which is nearly that of the rest of 
childhood. 

Position of the Apex Beat. — In the infant the heart is placed some- 
what higher, and occupies a position a little nearer the horizontal than in 
the adult. This is partly due to the higher position of the diaphragm. 
The apex beat is therefore higher and farther to the left than in adult 
life. According to the observations of Wassilewski and Starck, whose 
combined examinations with reference to this point were made upon over 
2,100 children, the apex beat is, as a rule, outside the mammary line until 
the fourth year ; if it is less than one third of an inch beyond the nipple, 
it can not be considered abnormal. From the fourth to the ninth year, 
the apex beat is in or near the mammary line. After the thirteenth year, 
under normal conditions, it is invariably within that line. During the 
first year the apex beat is usually found in the fourth intercostal space ; 
from the first to the seventh year, it is found with about equal frequency 
in the fourth and the fifth spaces ; after the seventh it is usually, and after 
the thirteenth year it is always, when normal, in the fifth space. The 
position of the apex beat may be considerably modified by severe deformi- 
ties of the chest resulting from rickets, Pott's disease, or lateral curvature 
of the spine. 

Examination of the Heart. — Inspection. — Bulging of the prsecordia is 
a frequent and important sign of cardiac disease during childhood. The 
cardiac impulse is generally weaker than in the adult, and often it is diffi- 
cult to locate the apex beat owing to the thick layer of adipose tissue 
covering the chest. 

Palpation. — This is usually a much more satisfactory method than is 
inspection for determining the position of the apex beat. For this pur- 
pose the child should be in the sitting posture, with the body inclined 
slightly forward. Great displacement of the apex beat is always signifi- 
cant, and should lead one to suspect pleuritic effusion ; lesser degrees of 
displacement to the left indicate hypertrophy, especially of the left ven- 
tricle ; to the right, hypertrophy of the right ventricle, usually with a con- 
genital malformation. 

Percussion. — This is best done by means of the percussion hammer. 
A light blow should be used, on account of the thinness and elasticity of 
the chest walls. The outline of the area of " relative cardiac dulness," 
especially in small children, is proportionately larger than in the adult. 
This may lead to the mistaken opinion that the heart is enlarged, when it 



THE HEART AND CIRCULATION IN EARLY LIFE. 



(509 



is really of normal size. According to Sahli,* the limits of this area are as 
follows : Above, the second space or lower border of the second costal car- 
tilage ; to the right, at the para-sternal line, sometimes slightly beyond it ; to 
the left, at or slightly beyond the mammary line, this depending upon the 
age of the child. The lower border is indeterminable on account of the liver. 
The area of " absolute cardiac dulness," or that part of the heart un- 
covered by the lung, resembles in shape the same area in the adult, but it 
is relatively larger. Its upper 
limit is the upper border of the 



third intercostal 



space, some- 




times the third costal cartilage ; 
it extends to the left to a point 
between the para-sternal and the 
mammary lines, and to the right 
as far as the left border of the 
sternum. These two areas will 
be readily understood by refer- 
ence to the accompanying dia- 
gram (Fig. 115). 

Auscultation. — This is of lit- 
tle value unless the child is quiet. 
The preferable position is the 
sitting posture. For an accu- 
rate diagnosis the stethoscope is 
indispensable, but auscultation 
should always be practised with 
the naked ear as well. The 
rhythm and rapidity of the 
child's heart action are much 
more easily disturbed than are 
the adult's, and such disturbances are consequently much less significant. 
The rapidity of the heart in infancy is ordinarily so great as to make it 
practically impossible to distinguish between diastolic and presystolic mur- 
murs. Normally, the loudest sound is the first sound at the apex; the 
weakest sound is the second sound at the aortic orifice. According to 
Bochsinger, the accentuation of the child's heart-sounds is upon the first 

sound, and not. upon the second, as in the adult. 

In consequence of the small size and the thin walls of the chest, all 
sounds, both normal and pathological, appear relatively louder than in the 
adult, and the area of diffusion is therefore much greater. Thus it is a 

frequent occurrence for murmurs to he heard all over the chest both in 
front and behind. 



Fig. 115. — Showing ureas of cardiac dulness: a is 
the mammary line; t>, the para-sternal line; Z, 
the upper border of the liver. The Bpace en- 
closed by the dotted line represents the area of 
relative dulness : the heavily shaded area, that 
of absolute dulness. ( After Sahli, slightly modi- 
fied by Unger.) 



* Topographische Percussion im Kindcsalter. 1HH2. 



610 DISEASES OF THE CIRCULATORY SYSTEM. 

Reduplication of the heart sounds, in consequence of the valves of the 
two sides not closing exactly together, is not uncommon in children, and 
may be due simply to excitement. During the first four years of life 
nearly all the abnormal murmurs heard are systolic. 

Accidental murmurs may be due to anaemia and other blood condi- 
tions, and, although not so common as in older patients, they are by no 
means rare even in infants. 



CHAPTER II. 

CONGENITAL ANOMALIES OF THE HEART. 

Etiology. — The causes of congenital anomalies of the heart may be 
grouped under three general heads : 

1. Malformations resulting from imperfect development of certain 
parts of the heart, most frequently one of the septa. Either the ventricu- 
lar or the auricular septum may be affected, or that dividing the pulmo- 
nary artery from the aorta. Such failure in development perpetuates condi- 
tions which are normal in the early months of foetal life. There may also 
be atresia of any one of the orifices, absence of one or more of the valvular 
leaflets, or of any one of the large vessels. 

2. Foetal endocarditis. The effects of this condition vary according to 
the time of its occurrence. It is almost invariably of the right side, most 
frequently affecting the pulmonic valves. Valvular disease in foetal life 
leads not only to hypertrophy and dilatation, but also interferes with 
the normal development of the heart by preventing the closure of the 
auricular or ventricular septum or the ductus arteriosus, these being kept 
open by way of compensation. 

3. Persistence of foetal conditions, such as the foramen ovale or ductus 
arteriosus. This may be the result of valvular disease, as previously 
stated, or of some condition of the lungs, such as atelectasis. 

Lesions. — In the following table are given the lesions found in two 
hundred and forty-two cases, which I have collected from medical litera- 
ture: 

Frequency of the different lesions in 21^2 autopsies upon cases of congenital 

cardiac anomaly. 

Defect in the ventricular septum 149 cases ; the only lesion in 5 cases. 

Defect in the auricular septum, or patent foramen 

ovale 126 " " " 9 " 

Pulmonic stenosis or atresia 108 " " " 6 " 

Patent ductus arteriosus 68 " " " 3 " 



CONGENITAL ANOMALIES OF THE HEART. $n 

Abnormalities in the origin of the great vessels. 45 cases ; the only lesion in cases. 

Pulmonic insufficiency 17 " u " " 

Tricuspid insufficiency 6 " " " " 

Tricuspid stenosis or atresia 3 " " " u 

Mitralinsufficiency 1 " " " " 

Mitral stenosis or atresia 6 " " " " 

Aortic insufficiency 1 " " " " 

Aortic stenosis or atresia 6 " " •' " 

Transposition of the heart 2 " " " " 

Ectocardia 1 " " « " 

The most frequent associated lesions. 

Pulmonic stenosis, with defect in the ventricular 

septum 92 cases ; the only lesion in 20 cases. 

ulmonic stenosis, with defect in the auricular 

septum 52 " " " 8 " 

Defects in both septa 82 " " " 17 " 

Pulmonic stenosis and defects in both septa 36 *' " " 21 " 

From this table it will be seen that, in the great majority of cases, 
several lesions are present, the most frequent combinations being pul- 
monary stenosis with defective ven- 
tricular septum, pulmonic stenosis 
with defective auricular septum, 
the three lesions associated, or the 
first two with a patent ductus arte- B 1 ^ Ik 4 

EA\w ■ 

Defect in the ventricular scp- V niA- W 

turn. — This is the most frequent ^^2 i^i^K^V 
lesion in congenital cardiac disease, Efl^l jJ^rk^tSw 

and in half the cases was associated rt*^ ^^frp&v 

with pulmonic stenosis. The de- m^Sti 1-" '' 

feet is generally at the upper part B-.^\ V V * \ '-Wi ^ 

of the septum (Fig. L16). Tt is lf^v : v» % y ^4jfi 

usually from one fourth to one half * 'jt'Sj 

an inch in diameter, hut not infre- 
quently there 18 a large defect, and 
the sept inn may be entirely absent, 

the heart then Consisting of but 

r i«i. 1 1 o. Congenital cardiac disease. 1 n*.- n-ti 

three cavities— two auricles and ventricle is shown with a defect in the ven 

. , T - .i -, tricular septum, the opening being just be- 

one ventricle. If the auricular sep- neath the aortic valve! (F&ra a patient dy- 

turn also ifl wanting, afi is often the inginthe Babies 1 Hospital.) 
. the heart has but two cavities. 

Frequently there are also abnormalities in the origin of the great vessels. 

The pulmonary artery and the aorta may be given off from the common 
ventricle, or the aorta may arise partly from cue ventricle and partly from 
the other. If pulmonic stenosis or atresia ifl present, the opening in the 




612 DISEASES OF THE CIRCULATORY SYSTEM. 

ventricular septum is conservative, affording a channel for the passage of 
blood from the right to the left side of the heart. 

Patent foramen ovale, or defect in the auricular septum. — Although 
this is one of the most common congenital malformations, it is not one of 
the most important. It rarely occurs alone, but is frequently found with 
pulmonic stenosis or a defect in the ventricular septum. Small oblique 
openings in the auricular septum — usually at the foramen ovale — are not 
infrequently met with in autopsies upon young infants, but they are of no 
importance. In pathological conditions the opening is from one fourth 
to one inch in diameter, and there may be more than one opening. A de- 
fect in this septum is frequently secondary to pulmonic stenosis, or it may 
be a failure in development. A patent foramen ovale may be due to 
atelectasis. 

Patent ductus arteriosus. — As a solitary lesion this is rare, but it is 
frequently associated with pulmonic stenosis, usually with a defect in one 
or both septa. It is then one of the channels by which the blood may find 
its way to the lungs when the pulmonary orifice is obstructed. It is not 
a malformation, but simply the persistence of a foetal condition usually 
necessitated by other changes in the heart. 

Pulmonic stenosis. — This is one of the most frequent and most im- 
portant lesions. It may be due to foetal endocarditis, or to a mal- 
formation. If the former, there is usually stenosis ; if the latter, there 
may be atresia. It is often a primary lesion, and when marked it is 
always accompanied by other changes, most frequently by a defect in one 
or both septa or by a patent ductus arteriosus. This is important, as be- 
ing more constantly associated with cyanosis than is any other congeni- 
tal lesion. The amount of obstruction varies from a slight narrowing 
of the orifice to complete atresia. If there is atresia, the pulmonary artery 
is very small, and may be rudimentary. 

Pulmonic insufficiency. — This lesion is relatively rare. It is usually 
the result of foetal endocarditis, but there may be absence of the pulmo- 
nary valve. It is most frequently associated with a defect in the ven- 
tricular septum. 

Tricuspid, mitral, and aortic disease are all very infrequent and usu- 
ally seen in cases with multiple defects. Atresia or stenosis is much more 
common than insufficiency. 

Abnormalities in the origin of the large vessels. — These are quite fre- 
quent ; but, as will be seen from the table, they are always associated with 
other lesions. Three forms are seen : (1) Transposition of the large vessels 
— the pulmonary artery is given off from the left, and the aorta from the 
right ventricle. (2) Both arteries arise from a common trunk. This is 
usually due to an incomplete development of the lower part of the sep- 
tum dividing the two arteries. Usually the pulmonary artery appears to 
be a branch of the aorta. This condition is frequently associated with 



CONGENITAL ANOMALIES OF THE HEART. 613 

other abnormalities, often with so large a defect in the ventricular septum 
that there is really but one ventricle. (3) The aorta has an abnormal 
origin, arising from the right ventricle, or partly from both ventricles. 
This also is associated with a large defect in the ventricular septum. 
When described as arising from both ventricles, the aorta is usually given 
off directly above the line of the septum. 

An abnormality in the number of valvular segments is quite frequent, 
but seldom impairs the valve's function. In rare cases a valve is rudi- 
mentary, and it may be absent, generally at the pulmonic or tricuspid 
orifice. Absence of the right auricle and absence of the pericardium have 
been recorded ; also opening of the pulmonary veins into the right auricle, 
and a single pulmonary artery. In one case in the series there was ecto- 
cardia, this being associated with a congenital fissure of the sternum. I 
once saw a very remarkable instance of congenital cardiac displacement; 
the heart was situated in the abdominal cavity. Its pulsations could be 
plainly seen and felt just above the umbilicus. 

Transposition of the heart, or true dextro-cardia, was recorded but 
twice in this series of cases. It was, however, simulated in several others, 
including one of nry own, where the apex beat was to the right of the 
sternum. There was in this case great hypertrophy of the right ventricle 
with a rudimentary ventricular septum. 

Secondary lesions. — In congenital malformations the right heart is 
usually found hypertrophied, since there remain one or more of the foetal 
conditions in which the greater part of the work is thrown upon the 
right ventricle. Such hypertrophy is in most cases accompanied by some 
dilatation. Changes in the wall of the left heart alone are exceedingly 
rare. In four cases there was evidence of malignant endocarditis, which 
was the cause of death, all but one of these patients being adults. 

Symptoms. — The symptoms of congenital cardiac disease arc usually 
manifested soon after birth. Of 128 cases in which the time of the first 
symptoms was noted, they were congenital, or appeared during the first 
month, in 85; after one month and during the firsl year, in L8; from 
one to sixteen war-, in L5; while in 10 no symptoms were observed until 
after puberty. Congenital cardiac disease is one of the causes, hut not 
a frequenl one, of death during the firs! days of Life. 

The mosi striking objective symptom is cyanosis. This is pres- 
ent in over four-fifths of the severe cases; bul cyanosis may be absent, 
even with serious Lesions. It may be slighl and noticed only upon 
exertion, as upon coughing or crying, or it may be intense and con- 
stant, giving the skin a dark, leaden colour, and the mucous membrane 
of the mouth a raspberry hue. 'Ida- view that cyanosis depends upon an 
admixture of arterial and venous blood is generally disci-edited. In the 
great majority of the Cases at least, the explanation is a deficient oxi- 
dation of the blood in the lungs, owing to some interference with the 



614 



DISEASES OP THE CIRCULATORY SYSTEM. 




Fig. 117. — Clubbing of the lingers in congenital heart disease. 
(From a boy five years old.) 



pulmonary circulation. In 63 per cent of the cases of cyanosis in the 
series, there was found pulmonic stenosis or atresia, or a small pulmonary 

artery. Cyanosis is of 
much value in diag- 
nosis, as in acquired 
cardiac disease it 
is rarely persistent. 
The degree of cyano- 
sis and its constancy 
are of some impor- 
tance in determin- 
ing the gravity of 
the lesion, although 
alone not to be de- 
pended upon. An- 
other frequent symp- 
tom is the enlarge- 
ment of the terminal 
phalanges known as 
" clubbing " of the 
fingers (Fig. 117) 
and toes. This en- 
largement, which usually involves all the phalanges, is probably due to 
venous obstruction. Occasionally there are seen dyspnoea, oedema of the 
face or lower extremities, dropsy of the serous cavities, and haemorrhages, 
particularly haemoptysis and epistaxis. 

In cases accompanied b} r cyanosis, or with obstruction to the pulmon- 
ary circulation, a polycythaemia is present. The increase in number of 
red cells is generally proportionate to the cyanosis ; the average is about 
7,000,000, although I have seen as high as 9,400,000. The haemoglobin 
is usually correspondingly increased; in one patient of mine it reached 
140 per cent. The number of white cells is changed very slightly, if at 
all, which disproves the theory of blood concentration. The best explana- 
tion of the polycythaemia seems to be that it is compensatory, and that 
the blood hypertrophies like other tissues. The blood-forming organs are 
stimulated to greater activity by the demands of the tissues for ox}^gen. 
The quantity of blood remains the same, but the number of red cells and 
the haemoglobin, and consequently the oxygen-carrying power, is very 
greatly increased. This in part compensates for the smaller amount of 
blood that can transverse the lungs and there become oxygenated. 

Diagnosis. — The most diagnostic features are cyanosis, the presence 
of a loud murmur, and signs of enlargement of the right heart. 

Murmurs are present in fully nine-tenths of the cases, the most 
characteristic being a systolic murmur, loudest at the left border of the 



CONGENITAL ANOMALIES OF THE HEART. 615 

sternum in the second or third intercostal space, and widely diffused, 
often being audible all over the chest. In the great majority of cases 
this is heard alone; in a smaller number a double murmur is present. 
A systolic murmur may be due to pulmonic stenosis, deficient ventricular 
septum, patent ductus arteriosus, mitral regurgitation, tricuspid regur- 
gitation, or aortic stenosis. Since these conditions are very often as- 
sociated, it is difficult to tell upon which one the murmur depends. 
In a young child, a loud murmur at the base with cyanosis, almost 
always means congenital disease. 

Enlargement of the right heart, chiefly from ventricular hypertrophy, 
is present in most of the cases. 

A diagnosis of the precise nature of the malformation is very difficult, 
and in the great majority of cases only a probable diagnosis is possible. 
Nearly all the cases are complex, and the variety of combinations is very 
great. A study of the histories and autopsies of the cases in this series 
reveals many apparently contradictory facts. Loud murmurs are some- 
times heard which are difficult to explain by the lesions, and murmurs 
may be absent when there is every reason from the post-mortem findings 
for expecting their presence. Certain lesions like aortic stenosis, mitral 
stenosis, and mitral regurgitation may be accompanied by the same signs 
as in acquired disease. With reference to the other conditions, I can not 
do better than give the more frequent clinical symptoms with the results 
of the autopsies in the series of cases which I have collected. 

A systolic murmur at the base, with cyanosis. — This was the most 
common combination met with, and was present in about one third of 
the entire number. In over 80 per cent of the cases with these symptoms, 
pulmonic stenosis was found. The remainder were complicated cases of 
quite a wide variety. Pulmonic stenosis was usually associated with a 
defect in one of the cardiac septa, or a patent ductus arteriosus. 

A systolic murmur without cyanosis. — In this series of autopsies this 
was not a frequent combination, being noted but six times. It is usually 
dependent upon a defect in the ventricular septum without pulmonic 
stenosis. Clinically, however, this is more often -ecu. The murmur is 
generally loudest at the left margin of the sternum at the third space. 
There is a striking absence of all other symptoms. I have watched a 
dumber of such patient- for many years who have remained in perfect 
health. 

A systolic murmur at II"' "/".'• irilh cyanosis. — of the sis cases with 
this combination, all were examples of complex malformation, the mosl 
frequent lesions being ;i defect in the auricular septum, transposition of 
the great vessels, ami patent ductus arteriosus. 

Cyanosis without murmurs was noted fourteen times. II indicates 
either pulmonic atresia or the transposition or irregular origin of the 
great vessels. 



616 DISEASES OF THE CIRCULATORY SYSTEM. 

Diastolic murmurs were heard in two cases, and depended npon pul- 
monic insufficiency. 

Absence of both cyanosis and murmurs was recorded in five cases. 
The lesions found were: atresia of the aorta, both arteries arising from 
the right ventricle, or defective septa. 

The only cases, therefore, in which a fairly certain anatomical diag- 
nosis can be made are those of pulmonic stenosis with a deficient ven- 
tricular septum. 

Diagnosis of congenital from acquired disease, — Congenital disease 
may be suspected if the patient is under two years of age ; if there is no 
history of previous rheumatism ; if the murmur is atypical in its location, 
character, or transmission; if there is a very loud murmur at the base, 
and if there is evidence of enlargement of the right heart. If cyanosis 
and clubbing of the fingers are present the diagnosis is certain. 

Especially difficult are the cases without cyanosis seen in older chil- 
dren. Absence of hypertrophy of the left ventricle, continued absence 
of subjective symptoms, even with a very loud murmur, and a lesion 
which does not increase, all point strongly to a congenital malformation. 

Diagnosis of congenital from ancemic murmurs. — This is often a more 
difficult matter than to decide between congenital and acquired disease. 
From a murmur alone one should be very cautious in making a diagnosis 
of cardiac malformation in a very anaemic infant. Ansemic murmurs are 
systolic, basic, unaccompanied by enlargement of the heart ; usually heard 
in the carotids, often in the subclavian arteries, but are seldom so loud as 
those due to malformations. In some cases it may be necessary to watch 
the effect of treatment before deciding the question. 

Prognosis. — Of 225 cases, 60 per cent were fatal before the end of the 
fifth year, and nearly one-half of these during the first two months ; while 
16 per cent of the cases lived over sixteen years, and 8 per cent over thirty 
years. The prognosis in any given case is to be made from the general 
condition of the patient and how well the circulation is carried on, rather 
than from the intensity of the cyanosis or the character of the murmur, 
although extreme cyanosis is always unfavourable. 

In the cases fatal soon after birth the usual lesions are large defects in 
the septa, transposition of the great vessels, or pulmonic atresia. In five 
of twenty-three cases dying thus early, the heart had but two cavities. Le- 
sions which are compatible with the longest life are minor septum defects, 
and pulmonic stenosis which can be compensated for by hypertrophy of the 
right ventricle. Many exceptional instances are recorded in which patients 
have lived a long time in spite of extreme deformities. One child with 
transposition of the pulmonary artery and aorta lived two and a half years. 
Tiedmann's case lived eleven years with a heart consisting of three cavities 
— two auricles and one ventricle — and with constant cyanosis. In three 
cases reported by Kokitansky, the patients lived over forty years with rudi- 



PERICARDITIS. 617 

mentary auricular septa and no cyanosis mentioned. G-elpke's case had 
cyanosis, and lived twenty-seven years with rudimentary auricular and 
ventricular septa, and with no tricuspid opening. 

Treatment. — No treatment is of the slightest avail in diminishing the 
amount of deformity or promoting the closure of any of the abnormal 
openings. All cases are to be treated symptomatically. 



CHAPTEK III. 
PERICARDITIS. 

Inflammation of the pericardium is a rare disease in infancy and 
early childhood, only two cases being seen in seven hundred and twenty- 
six consecutive autopsies at the New York Infant Asylum. In later 
childhood the disease is more frequent. In its etiology, symptoms, and 
course it resembles quite closely the same disease in adults. 

Etiology. — Of 69 cases of pericarditis in children under fourteen years 
of age, 24 occurred before the third year, 12 between the third and sev- 
enth years, and 33 between the seventh and fourteenth years. It has been 
seen in the newly born, and has been found even in the foetus. 

Pericarditis is almost invariably a secondary disease, following (1) 
pleurisy or pleuro-pneumonia ; (2) acute rheumatism ; (3) acute infectious 
diseases, especially scarlet fever; (4) pyaemia; (5) tuberculosis; (6) local 
conditions. The relative importance of these causes differs with the age 
of the child. In infancy and early childhood most of the cases compli- 
cate disease of the lung or pleura, usually of the left side. After the fourth 
year rheumatism takes the first place as an etiological factor. Pericar- 
ditis is then generally associated with endocarditis, and may precede or 
follow the articular manifestations of rheumatism. Following scarlet fever, 
pericarditis generally occurs in connection with nephritis or multiple joint 
inflammations. In typhoid fever, also, it is usually associated with pneu- 
monia or joint lesions. Pyaemia may be a cause in the newly born, or it 
may occur in connection with disease of the bones or joints in older chil- 
dren ; in both it is usually associated with similar lesions of other serous 
membranes. Tuberculous pericarditis is more frequent after the third 
year, and is generally secondary to pulmonary tuberculosis. Among the 
local causes may be mentioned traumatism, ulceration of a foreign body 
from the oesophagus into the pericardium, disease of the sternum, ribs, or 
vertebras, and abscesses resulting from cheesy bronchial lymph nodes. 

Lesions. — 1. Pericardial transudations, or an increase in the normal 
pericardial fluid, are met with in many conditions in which there is a 



(518 DISEASES OF THE CIRCULATORY SYSTEM. 

very marked degree of anaemia, general dropsy, or a weak heart, particu- 
larly of the right side. Generally from one and a half to two ounces of a 
clear serum are found in the pericardial sac. 

2. External or mediastinal pericarditis is always associated with 
mediastinal pleurisy, and results in more or less extensive adhesions of 
the pericardial and pleural surfaces, with an increase in the connective 
tissue of the mediastinum. It is often a tuberculous process. When 
severe, it may cause compression of the large blood-vessels, and seldom in 
any other way produces symptoms. With this form there may be inflam- 
mation of the internal layer of the pericardium. It is only inflammation 
of the internal layer which is ordinarily considered as pericarditis, the 
other form being preferably classed as mediastinitis. 

3. Dry pericarditis. — This may be either general or localized. If the 
latter, it is more often seen at the base than at the apex of the heart. The 
two opposing surfaces are usually involved. As a result of the inflamma- 
tion they are coated with fibrin, which may be partly absorbed, but usu- 
ally leaves behind bands of adhesions of greater or less extent. From re- 
peated attacks there may result complete obliteration of the pericardial sac. 

4. The sero-fibrinous form— pericarditis with effusion. — This is the 
most common variety. The heart appears roughened from the exudate 
which often completely covers it, forming bands which extend from one 
surface to the other. The serum may be clear, or contain flakes of lymph, 
and varies in amount from a few ounces to a pint. In cases terminating 
in recovery there is gradual absorption of the serum and part of the 
fibrin, but adhesions more or less extensive always remain. 

5. Purulent pericarditis. — If the inflammation is set up by a foreign 
body ulcerating into the sac, by the rupture of a mediastinal abscess, or 
by general pyaemia, the process may be purulent from the outset. More 
frequently, however, in purulent pericarditis there is first an abundant 
exudation of fibrin with pus cells in its meshes, and subsequently the 
pouring out of fluid pus, precisely as in empyema, with which it is very 
often associated. If death occurs in the early stage, both surfaces of the 
pericardium are found coated with a thick exudate of greenish-yellow 
lymph, but little or no fluid pus may be present. At a later period the 
pericardial sac contains pus, which may vary in amount from a few 
ounces to one or two pints. Purulent pericarditis, which is secondary to 
pneumonia or pleurisy, is usually due to the pneumococcus. In other cases 
any of the pyogenic germs may be found. 

6. Pericarditis with an effusion of blood is very rare in children. It 
may occur from the rupture of organized adhesions or in certain blood 
states such as purpura, and very rarely in tuberculosis. 

Pericarditis complicating pneumonia and pleurisy is generally fibrinous 
or fibrino-purulent ; that with rheumatism is sero-fibrinous, and often 
accompanied by endocarditis. With acute tuberculosis there is usually 



PERICARDITIS. 619 

only a deposit of miliary tubercles, or there may be a small serous or sero- 
sanguinolent effusion. In chronic cases there may be a tuberculous in- 
flammation with the formation of caseous nodules, new connective tissue, 
and extensive adhesions. This generally occurs in connection with pul- 
monary tuberculosis — sometimes with tuberculous peritonitis. 

In any form of pericarditis complete recovery, so far as pathological 
conditions are concerned, is rare — if, indeed, it ever occurs. Generally 
adhesions remain, which may be in the form of a few thin connective- 
tissue bands, or so extensive as to produce almost entire obliteration of 
the pericardial sac. Such adhesions are usually followed by secondary 
changes. The growth and development of the heart are interfered with, 
and there may be sufficient pressure upon the coronary vessels to lead to 
degeneration of the muscular walls and dilatation of the heart. With 
large fluid exudations there may be an interference with the systemic circu- 
lation, enlargement of the spleen and liver, and sometimes general dropsy. 

Symptoms. — A pericardial transudation, or dropsy of the pericardium, 
is very rarely large enough to make a diagnosis possible. 

External pericarditis is seldom recognised during life, there being no 
symptoms except those of the pleurisy with which it is associated. Occa- 
sionally there may be heard, particularly if the inflammation is anterior, 
a pleuritic friction sound which is increased with the systole of the heart. 
The pulse may be weak during inspiration, and there may be an increased 
area of cardiac dulness. If the inflammation is chiefly posterior, it causes 
only the symptoms of mediastinitis, which is recognised principally by its 
pressure effects upon the great vessels. It may produce oedema of the 
face or of the lower extremities, ascites, enlargement of the liver and 
spleen, but rarely albuminuria. It is usually progressive, and lasts from a 
few mouths to two or three years, according to its cause. 

Inflammation of the internal layer is the only form usually described 
as pericarditis. This is very frequently overlooked, not only on account 
of its rarity, but from the obscurity of its symptoms. The difficulty in 
diagnosis is particularly great in young children. The symptoms are few, 
and many of them are equivocal. As this disease is nearly always second- 
ary, the physician should be on the watch for it in infants with pleurisy 
or pleuro-pneumonia of the left side, and in older children in the course 
of articular rheumatism. Localized pain and tenderness may be present, 
and also a certain amount of embarrassment of the heart's action, usually 
manifested by precordial distress, palpitation, and slight irregularity of 
the pulse. There may be dyspnoea, and if there is a large effusion present 
there may be orthopncea and cyanosis. Sometimes there is delirium. 
When pericarditis follows pleurisy or pleuro-pneumonia there are fre- 
quently no new symptoms added. 

The physical signs in older children resemble those in adults. In dry 
pericarditis there is usually heard a double friction sound over the prgecor- 



620 DISEASES OP THE CIRCULATORY SYSTEM. 

dial space, the area being generally small and near the base of the heart. 
The sound is not transmitted, and bears no relation to the respiratory 
movements. After effusion has taken place the apex beat may be dis- 
placed upward, diffused, and somewhat indistinct, or it may not be found 
at all. There may be bulging of the chest wall. On palpation, there is an 
absence of vocal fremitus over an area usually occupied by the lung. Per- 
cussion gives an area of marked dulness or flatness of triangular shape, 
the base being below and the apex above. The normal area of cardiac 
dulness is increased in all directions, and this dulness extends beyond the 
limits of the heart. On auscultation, the heart sounds are feeble and dis- 
tant. Friction sounds disappear as serum is poured out, and reappear as 
it is absorbed. Endocardial murmurs may also be present. In infants, 
physical signs are often entirely wanting, or the normal sounds may be 
feeble, distant, or absent. 

The usual duration of 'acute pericarditis is from one to three weeks. 
The ordinary dry form, with its resulting adhesions, may be followed by a 
subacute or chronic form of the disease. In the sero-fibrinous form the 
serum is usually absorbed quite promptly, and only adhesions are left, or 
a chronic inflammation follows, with exacerbations in each recurrence 
of rheumatism. In the purulent form of the disease in young children, 
death is the most frequent termination. If the pus is evacuated, or spon- 
taneous opening takes place, there may be recovery, but always with more 
or less extensive adhesions remaining. 

Prognosis. — Of thirty-five cases in Steffen's collection, only six recov- 
ered. This statement is to be taken rather as evidence of the great diffi- 
culty of diagnosis than of a very high mortality, although the disease is 
always a serious one. The prognosis depends chiefly upon the exciting 
cause. When due to pyaemia or the acute infectious diseases, or when ex- 
tending from pleurisy or pneumonia, the prognosis is bad. Here it is usu- 
ally the primary disease rather than the pericarditis which is the cause of 
death; the latter may be the case, however, if the effusion is large. The 
cases in which the pericarditis itself is the most important disease are 
those depending upon rheumatism. Although immediate danger to life 
may not often be great, yet the remote consequences of the disease, by rea- 
son of adhesions and subsequent dilatation, are frequently very serious. 

Diagnosis. — Owing to the very rapid action of the heart in children, 
acute dry pericarditis presents difficulties of diagnosis in early life which 
are not met with in the adult. The disease is fortunately so rare under 
three years, that in ordinary practice it need seldom be considered. In 
older children the diagnosis is to be made by essentially the same signs as 
in adults. Pericarditis with effusion is to be diagnosticated from dilata- 
tion of the heart and from pleuritic effusions. From dilatation, the diag- 
nosis is not often difficult in childhood, for this is not a common con- 
dition, and is rarely extreme except in advanced valvular disease. From 



CHRONIC PERICARDITIS WITH ADHESIONS. 621 

pleuritic effusions the diagnosis is at times almost impossible. Signs 
pointing to a sacculated empyema of the left side anteriorly should al- 
ways be regarded with suspicion, particularly if the apex beat is not dis- 
placed to the right, and if the heart sounds are very feeble. When empy- 
ema and pericarditis coexist, it may be impossible to recognise the condi- 
tion. The diagnosis between serous and purulent effusions can be made 
only by aspiration. Fluid effusions in infants are almost invariably 
purulent, and so also are they in the majority of cases in older children,, 
unless due to rheumatism. 

Treatment. — In the early part of an attack of acute pericarditis the 
patient should be kept in bed and as quiet as possible, and hot poultices 
or counter-irritation by mustard used over the heart. Sometimes an ice 
bag may with advantage be substituted. Excessive heart action may be 
controlled by aconite, and severe pain requires usually opium. If the dis- 
ease is due to rheumatism, anti-rheumatic remedies should be employed. 
Serous effusions usually subside under simple tonic treatment. If ab- 
sorption is slow, it may be hastened by counter-irritation. When a large 
effusion forms rapidly there may be danger of death from syncope. 
Symptoms which indicate an unfavourable termination are cyanosis, 
weak, irregular pulse, and great dyspnoea, or orthopnoea. Under these 
conditions aspiration may afford temporary relief, and free diuresis 
should be induced by citrate of potash and caffein. The inhalation of 
oxygen is at times of great value in cases presenting such urgent symp- 
toms. If pus is shown to be present by puncture, incision and drainage 
should be practised, as in empyema. The results of aspiration in such 
cases are extremely unfavourable. Of eighteen cases of aspiration of the 
pericardium collected by Keating, only four recovered. In puncturing 
the pericardium the point usually selected is a little to the left of the 
border of the sternum in the fifth intercostal space, the needle being 
directed upward and outward. 

CHRONIC PERICARDITIS WITH ADHESIONS. 

This is not a very uncommon condition. It may be general or local- 
ized. The youngest case which has come under my observation was in a 
female child sixteen months old, who died from acute broncho-pneu- 
monia. The adhesions were old and general, the pericardial sac being 
completely obliterated. Chronic adhesive pericarditis may follow single 
or repeated attacks of acute rheumatic pericarditis ; or there may be no 
history of any prior attack, the condition being apparently chronic from 
the beginning. Osier has reported a case in which a similar lesion of the 
peritonaeum was present. The pericardium may become very greatly 
thickened and its cavity obliterated; it may be adherent externally to the 
pleura, diaphragm, or chest wall. Other changes are usually present in 
the heart. It is often the scat of chronic myocarditis; the cavities may 



622 DISEASES OF THE CIRCULATORY SYSTEM. 

be greatly dilated, and the heart walls very much hypertrophied. Valv- 
ular lesions may be present. 

Partial adhesions cause no symptoms by which they can be recognised, 
and even general adhesions sufficient to obliterate the pericardial sac may 
be found at autopsy when not suspected during life. This is one of the 
conditions in which, after it has led to considerable dilatation of the 
heart, sudden death sometimes occurs. 

The heart is almost invariably much enlarged, chiefly from dilatation. 
On inspection, there may be bulging of the chest wall, with a diffused and 
often feeble or absent apex beat. The characteristic signs are a systolic 
retraction of the chest at or near the apex of the heart, sometimes at the 
tip of the sternum. This is due to the external pericardial adhesions, 
and is often better appreciated by palpation than by inspection. It is 
followed by a rapid rebound, associated with diastolic collapse of the 
jugular veins. A similar retraction, according to Broadbent, is to be seen 
behind in the infra-scapular region, sometimes on the left and sometimes 
on the right side. Percussion shows an increase in the cardiac dulness 
in all directions. The position of the apex and the percussion outline of 
the heart do not change with the posture of the patient, and the cardiac 
dulness is but little affected by full inspiration. A systolic murmur is 
often present. The diagnosis of adherent pericardium always presents 
difficulties, but it can be made with tolerable certainty in a considerable 
proportion of the cases. On account of the enlargement of the heart and 
the frequency of murmurs, it is usually mistaken for valvular disease. 
The lesion is a permanent one, and tends to increase. The treatment is 
symptomatic. 

CHAPTER IV. 
ENDOCARDITIS AND VALVULAR DISEASE. 
ACUTE SIMPLE ENDOCARDITIS. 

Acute endocarditis may occur even in foetal life. At this period it 
usually affects the right side of the heart, and is one of the important 
causes of congenital malformations. In infancy, acute endocarditis is 
exceedingly rare, not a single instance being found in over one thousand 
autopsies upon children under three years of age of which I have records. 
From the third to the fifth year it is not so rare, and after this period it 
is quite common. Of 95 cases observed by Steffen, 15 occurred before 
the sixth year, and 80 between the sixth and fourteenth years. 

Acute endocarditis may be primary, but it is much more frequently a 
secondary disease. The primary cases have been the subject of much dis- 
cussion, but I agree with those who regard the great majority of these 
as rheumatic. Cheadle (London) has well said that we are to look 
upon endocarditis in children not as a complication of rheumatism, so 



ACUTE SIMPLE ENDOCARDITIS. 623 

much as a manifestation — often the first — of that disease. Sometimes 
endocarditis occurs alone, and sometimes it is associated with chorea 
without articular symptoms; but the latter almost invariably appear 
sooner or later. Endocarditis is seen as a frequent complication both of 
acute and of subacute articular rheumatism. The proportion of rheu- 
matic cases in which it occurs is much larger in children than in adults. 
Compared with rheumatism, all other causes of acute endocarditis are 
very infrequent. It is seen occasionally in the course of nearly all the 
acute infectious diseases, most often with scarlet fever, and it sometimes 
complicates pleurisy and pneumonia, being usually associated with peri- 
carditis. It may follow acute tonsillitis. In infectious diseases, and in 
pleurisy and pneumonia, the endocarditis is probably excited by patho- 
genic germs. Fraenkel and Sanger have found the staphylococcus in 
cases of simple endocarditis, and cultures by others have shown the 
presence of other pyogenic organisms, including the pneumococcus. 

Lesions. — Acute inflammation may affect any part of the endocar- 
dium, but in extra-uterine life it usually affects the valves of the left 
side, involving the mitral much more frequently than the aortic valve. 
Steffen's figures give only four examples of aortic disease in ninety-five 
cases. (Compare statistics of valvular disease.) 

The pathological changes consist first in an extensive growth of new 
connective-tissue cells and an infiltration of round cells beneath the endo- 
thelial layer. This results in the formation of small masses of granulation- 
tissue upon the valves or the endocardium of the heart wall, and upon 
these there is deposited fibrin from the blood. In this way the tiny wart- 
like excrescences known as vegetations are produced. Bacteria may also 
be caught in the exudate. As a consequence of the inflammation, the valve 
is swollen, somewhat shortened, and consequently insufficient. The results 
of the process may be ulceration of this new-formed tissue, which in ordi- 
nary cases is small in amount, or organization and cicatrization. Masses 
of fibrin may be detached from the vegetations and swept into the general 
circulation, lodging as emboli in the kidneys, spleen, brain, or other 
organs. This is not common in acute endocarditis, at least not in the 
first attacks. 

In the milder forms of inflammation it is possible for complete recov- 
ery to take place, with the exception of a slight valvular thickening, not 
enough, however, to interfere in any way with the function of the valves. 
But this result is rare. In most cases they remain slightly insufficient, as 
the least serious consequence of the inflammation. Unfortunately, it more 
often happens that an acute inflammation which may not be at first seri- 
ous, proves the beginning of the progressive changes of a chronic inflam- 
mation, the full effects of which are not seen for years. Chronic inflam- 
mation may follow the first attack immediately, or after a considerable 
interval, or occur after several acute attacks. 



624 DISEASES OP THE CIRCULATORY SYSTEM. 

Symptoms. — When acute endocarditis occurs as a primary disease, or 
when it is the only manifestation of rheumatism, it usually begins abruptly 
with rather severe general symptoms — high temperature, often 102° to 
105° F., prostration, exaggerated heart action, restlessness, and some- 
times dyspnoea. There is nothing distinctive about these symptoms, and 
it is not until the heart is examined that the disease is recognised. If the 
heart is not watched, the diagnosis is not made, and there may be no sus- 
picion of the nature of the attack until some time afterward, when the 
existence of valvular disease is discovered. If the heart is carefully 
examined from day to day, nothing abnormal may be found until the third 
or fourth day, or even later, when there is heard the characteristic soft, 
blowing, systolic murmur at the apex. The murmur is generally trans- 
mitted to the left. It may be accompanied by a thrill and by an accentu- 
ated pulmonic second sound, and later there may be evidence of slight dila- 
tation with the usual signs of some degree of cardiac insufficiency. The 
murmur gradually increases in intensity until the maximum is reached, 
and then in most cases somewhat subsides. 

Acute endocarditis sometimes occurs in the course of, or simultane- 
ously with an attack of chorea, with symptoms quite similar to those 
above described. Finlayson (Glasgow) has called attention to endocarditis 
as a frequent cause of obscure fever in choreic patients, either when occur- 
ring alone or with articular symptoms. It may develop at any time 
during the choreic attack or subsequent to it. When endocarditis oc- 
curs as a complication of articular rheumatism, there may be an in- 
crease in the temperature and in the severity of the general s3^mptoms, 
but rarely anything more definite. Endocarditis complicating other 
diseases is recognised only by the physical signs. 

The usual duration of acute endocarditis is from one to three weeks, 
the febrile symptoms frequently subsiding in a few days and the cardiac 
symptoms slowly diminishing. 

The attack may terminate fatally in the course of a few weeks, owing 
to the rapid development of acute dilatation, accompanied by the usual 
signs of cardiac insufficiency, with dropsy, cyanosis, and often pulmonary 
complications. Cerebral embolism may occur, which usually produces 
hemiplegia, but rarely results fatally. If emboli lodge in the spleen or 
kidneys, they may lead to swelling of the spleen or to hematuria. The 
patient may recover with a murmur which lasts but a few weeks and 
gradually disappears — a rare result. Usually there is a persistent mur- 
mur, with the subsequent development of the ordinary signs of valvular 
disease. Lastly, there may be recurrent attacks of inflammation, with the 
ultimate development of chronic valvular disease. 

Diagnosis. — The diagnosis of acute endocarditis is very frequently not 
made ; not because it is difficult, but because in young children the heart 
is not examined as frequently and as carefully as it should be. The symp- 



ACUTE SIMPLE ENDOCARDITIS. 625 

toms are few and not diagnostic. It is therefore very important that 
not only in chorea and rheumatism, but in all acute febrile attacks, par- 
ticularly those of obscure origin, the heart should be watched. Endo- 
carditis affecting the wall of the heart can not be diagnosticated. The 
murmur of valvular endocarditis may be confounded with pericarditis, 
or with functional murmurs occurring in the course of febrile attacks, 
or with those of anaemic origin. From pericarditis it is distinguished by 
the fact that the murmur is single, has a soft blowing character, is usu- 
ally located at the apex, is transmitted beyond the border of the heart, 
and is diminished by a full inspiration. Murmurs are often heard late in 
acute infectious diseases, especially diphtheria, scarlet fever, and typhoid, 
which closely simulate those of acute endocarditis. They are most fre- 
quently due to a relative insufficiency at the mitral orifice, generally 
caused by dilatation of the left ventricle. This produces a systolic murmur 
at the apex, transmitted to the left, often accompanied by an accentuated 
second pulmonic sound. A differential diagnosis between these condi- 
tions is often impossible except by following the course of the disease. 

Prognosis. — The danger to life in acute endocarditis is not often great, 
as the disease seldom proves fatal. However, death may occur when it is 
associated with chorea, but here usually when an acute process is ingrafted 
upon an old valvular disease. In other cases, death results from compli- 
cations, particularly pneumonia. Only the progress of the case enables 
one to decide how extensive is the damage which has been done to the 
valves. There is always the danger of recurrent attacks. 

Treatment. — The most important thing in the management of these 
cases, and the one frequently overlooked, is to secure for the heart as 
complete rest as possible, not only during the period of acute inflamma- 
tion, but for several succeeding weeks. With children this can be accom- 
plished only by keeping them in bed, after mild attacks for at least a 
month, after severe attacks for three months. It is luring this early 
period of the disease that changes take place most rapidly in the heart 
walls, and the gravest results sometimes follow the neglect of these pre- 
cautions. Children are often allowed out of bed as soon as the fever has 
subsided, and the heart disease is unnoticed until a grave amount of dila- 
tation has developed, with dropsy, palpitation, shortness of breath, slight 
cyanosis, irregular pulse, and cough. All the so-called primary cases, as 
well as those occurring with chorea and articular symptoms, should have 
the benefit of anti-rheumatic remedies, as this is the only plan which 
offers any chance of limiting the inflammation, although the effect upon 
the heart is rarely striking. Excessive cardiac action is sometimes al- 
layed by aconite, sometimes best by opium. All children who have once 
suffered from endocarditis should be protected as much as possible 
from subsequent attacks of rheumatism. 



626 



DISEASES OF THE CIRCULATORY SYSTEM. 



MALIGNANT ENDOCARDITIS. 



Malignant or ulcerative endocarditis is a rare disease in childhood. 
The youngest case I have found reported is that of -Harris, which occurred 
in a boy four years old, and affected the right side of the heart. It was 
secondary to a cardiac malformation. Of the cases thus far reported in 
early life, about twenty-five in number, the great proportion have been in 
children over ten years of age, in whom the disease does not differ essen- 
tially from the adult type. For the most exhaustive study of this subject 
we are indebted to Osier's Oulstonian Lectures. 

Malignant endocarditis rarely occurs as a primary affection. Of the 
acute diseases, it is most frequently secondary to pneumonia, next to 
rheumatism and meningitis. It may be met with in any infectious dis- 
ease or septic process. In 75 per cent of the cases, according to Osier, it 
is ingrafted upon a previous valvular disease. In my series of collected 
cases of congenital malformations of the heart, there were four deaths 
from malignant endocarditis, all but one, however, occurring in adult life. 

The bacteria most frequently associated are the staphylococcus and 
streptococcus, and, in the cases complicating pneumonia, the pneumo- 
coccus. These micro-organisms are believed to play an important part 
in the production of the disease. Circulating in the blood, they lodge 
upon the endocardium of the valves, all the more readily when the 
valves are previously diseased. 

Lesions. — Malignant endocarditis may result in the production of 
vegetations which subsequently break down, or there may be superficial 
ulceration affecting only the endocardium, or deeper ulceration involving 
the valve, the septum, or even the heart wall. In other cases there is sup- 
puration of the deeper tissues of the valve first affected, with the produc- 
tion of small abscesses at the base of the vegetations. These conditions 
may lead to large perforations, or even to the destruction of the valve, to 
valvular aneurisms, or to abscesses of the heart wall. According to Osier, 
the different parts of the heart are affected in the following order : mitral 
valve, aortic, mitral and aortic combined, tricuspid and pulmonic valves, 
and the cardiac wall. The secondary lesions of malignant endocarditis 
are due to emboli. These are most frequent in the spleen and kidney, 
next in the brain, intestines, and skin, and, if the right side of the 
heart is diseased, in the lungs. These emboli lead to the formation of 
red or white infarctions, to haemorrhages, or to multiple abscesses in the 
various organs and tissues in which they lodge. 

Symptoms. — Malignant endocarditis presents a great variety of symp- 
toms, making the diagnosis extremely difficult in perhaps the majority of 
cases. There is generally a remittent type of fever, sometimes repeated 
rigors, profuse sweating, low delirium, stupor or coma, and extreme pros- 
tration. In many cases there is a fine petechial eruption upon the skin; 






CHRONIC VALVULAR DISEASE. £27 

diarrhoea is also frequent. The cerebral symptoms may be so prominent 
as to suggest meningitis. There is usually a cardiac murmur, the location 
of which depends upon the seat of disease. It is most frequently the 
murmur of mitral regurgitation. This murmur is sometimes faint, and 
may be absent. The spleen is in most cases enlarged. From the emboli 
there may be hemiplegia, rapid swelling of the spleen, bloody urine, cough, 
and symptoms of pneumonia. The disease lasts from a few days to six 
weeks, death being the almost invariable termination. It is due to ex- 
haustion or to some embolic process. 

Diagnosis. — The most characteristic features of malignant endocarditis 
are the development of pyaemic or typhoid symptoms with a petechial 
eruption, in a patient who has previously had valvular disease. Malignant 
endocarditis is differentiated from typhoid fever by its sudden onset, 
irregular temperature, recurring chills, profuse sweats, petechial eruption, 
and dyspnoea. It may be confounded with malarial fever. 

Treatment. — This is entirely symptomatic ; no known measures have 
any influence upon the disease itself. 

CHRONIC VALVULAR DISEASE. 

Chronic valvular disease of the heart in children is usually the result 
of endocarditis ; in a small number of cases it depends upon congenital 
malformation ; but the degenerative lesions to which many adult cases are 
due have no place in early life. 

Lesions. — The changes of chronic endocarditis may be briefly described 
as follows : The valvular segments are thickened by the production of new 
connective tissue, the contraction of which results in retraction, shorten- 
ing, puckering, and imperfect closure of the valves. The valvular leaflets 
may adhere to each other, so that the opening is very much narrowed. 
This is sometimes reduced to a funnel-shaped orifice barely admitting the 
tip of the finger, and it may even be much smaller. The leaflets are some- 
times adherent to the wall of the heart ; the chordae tendineae are short- 
ened, and sometimes entirely disappear ; and, finally, the valves may be the 
seat of calcareous deposits. These changes take place very slowly, requir- 
ing many years for their full development. From time to time there may 
be attacks of acute inflammation. The changes described may bring about 
(1) valvular insufficiency, owing to imperfect closure, causing a regurgita- 
tion of blood through the opening guarded by the valve ; or (2) stenosis, 
with such a narrowing of the opening that the outflow of blood is ob- 
structed. In early life it is usually the mitral valve that is affected. 

Of 141 cases in children under fourteen years old, observed clinically by 
Dr. F. M. Crandall and myself, the mitral valve was alone affected in 79 per 
cent ; the aortic valve alone in 3 per cent ; and both were associated in 
18 per cent. Lesions of the aortic valve in early life are therefore com- 
paratively rare. 
41 



628 



DISEASES OF THE CIRCULATORY SYSTEM. 



Following valvular lesions, important changes take place in the wall 
and cavities of the heart : these are hypertrophy and dilatation. 

Hypertrophy. — This consists in an increase in the thickness of the 
heart wall, due to an increase in the size and number of the muscular 
fibres. It is principally of the ventricles, and is always conservative. It 
may continue indefinitely, or it may be followed by degeneration and dila- 
tation. Hypertrophy occurs as a result of any obstructive lesion at one of 
the cardiac orifices, in renal disease when the obstruction is in the small 
arteries, also when extra work is thrown upon the ventricles as a result of 
regurgitation, and it may follow primary dilatation. 

Dilatation. — This consists in an enlargement of the cavities of the 
heart, usually with thinning of their walls. It is generally most marked 
in the auricles. Primary dilatation is produced by regurgitation of blood 
into any of the cavities as a result of valvular insufficiency. This may to 
a slight extent be regarded as a conservative lesion. Secondary dilatation, 
or that resulting from degeneration of the cardiac muscle, is always in- 
jurious. It is usually caused by imperfect nutrition of the heart which 
may be due to local or general causes. In most of the cases both hyper- 
trophy and dilatation continue for a long time. So long as hypertrophy 
predominates, the circulation may be well carried on ; but when dilatation 
comes to exceed hypertrophy, there are signs of great embarrassment to 
the circulation and of cardiac insufficiency. 

There are other lesions accompanying chronic valvular disease, de- 
pending upon obstruction to the venous circulation. If this obstruction 
is in the pulmonary veins, it leads to congestion of the lungs, chronic 
bronchitis, or chronic pneumonia ; if of the systemic venous circulation, 
it leads to chronic congestion of the spleen, liver, kidneys, peritonaeum, 
and sometimes to general dropsy. 

Etiology. — The following table gives the age and sex in the cases ob- 
served by Dr. Crandall and myself : 



Age. 


1 

yaar. 


2 
year*. 


3 

years. 


4 
years. 


5 

years. 


6 
years. 


7 
years. 


6 
years. 


9 
years. 


10 
years. 


ii 

years. 


12 
years. 


13 
years. 


14 
years. 


Totals. 


Males 

Females. . . 


•• 


1 
1 


2 
3 


2 
5 


4 

7 


6 
9 


4 
10 


9 
3 


8 
11 


6 
12 


5 
14 


7 
4 


6 

2 


1 

3 


55, or 38£ 
90, " 62£ 


Total.... 




2 


5 


7 


11 


15 


14 


12 


19 


18 


19 


11 


8 


4 


145 



The difference in sex is very nearly the same as in my eases of rheuma- 
tism. Sturges, in 100 cases of chronic endocarditis gives 56 per cent 
females and 44 per cent males. Sansom's figures alone give a predomi- 
nance of males. 

The chronic endocarditis of early life is, as a rule, secondary to the 
acute or subacute form. Its etiological factors are therefore those of 
acute endocarditis. Of 117 cases in my own series, 93, or 80 per cent, 
gave a history of previous rheumatism — 7 cases of chorea without ar- 
ticular symptoms being included as rheumatic. Of the 31 cases which 



CHRONIC VALVULAR DISEASE. 629 

at the first examination gave no history of rheumatism, 8 subsequently 
developed articular rheumatism, and 2 chorea, so that nearly 90 per cent 
of this series of cases presented, to my mind, conclusive evidence of a 
rheumatic diathesis. Thirty per cent had chorea previously, or developed 
it while under observation. The more closely I study cases of rheumatism, 
chorea, and valvular disease, and the longer the patients are kept under 
observation, the deeper becomes my conviction of the very close relation- 
ship between these three conditions in childhood. The percentage of 
rheumatic cases in this series is considerably larger than that given by 
many writers, but it corresponds very closely with Cheadle's careful obser- 
vations. Valvular disease is occasionally traced to an attack of endo- 
carditis complicating scarlet fever, and in rare cases to that occurring with 
other infectious diseases. 

Symptoms. — The symptoms of chronic valvular disease in most cases 
come on slowly, often insidiously, and frequently there are none until the 
disease has lasted a long time, the condition being discovered by accident. 
The course of valvular disease is usually divided into two periods, the first 
being that while compensation is present, and the second after compensa- 
tion has failed. The duration of the stage of compensation is indefinite ; 
it may last a lifetime. The only subjective symptom that is of much diag- 
nostic value is shortness of breath on exertion. Occasionally other symp- 
toms are present, such as precordial pain, attacks of palpitation, head- 
ache, epis taxis, anaemia, and cough. These are rarely constant, but come 
on when the patient's general condition for any reason is below normal. 
As a rule, there is in young subjects a tendency to an increase in the dis- 
ease, although this is often slow, and may be interrupted by long periods 
in which the process appears to be stationary. At such times the patients 
either have no symptoms, or suffer only from a slight amount of incon- 
venience on marked exertion. 

Failure in compensation is generally brought about by one of the fol- 
lowing causes : There may be an intercurrent attack of acute endocarditis, 
which in a short time leads to a very great increase in the heart's disability. 
It may be due to additional work thrown upon the heart from excessive 
muscular exertion, or to the strain of a prolonged attack of some acute ill- 
ness, especially one that is liable to produce changes in the heart muscle, 
such as typhoid or scarlet fever. It is sometimes the increased work which 
is physiologically thrown upon the heart at the time of puberty, owing to 
the rapid growth of the body. It may result from any cause which seri- 
ously affects the patient's general nutrition, particularly when this is 
associated with marked anaemia. 

The symptoms indicating failure of compensation are those depending 
upon a weak heart, with imperfect filling of the arteries and overfilling of 
the veins. The embarrassment of the pulmonary circulation leads to con- 
stant dyspnoea or orthopnoea and cough, sometimes accompanied by profuse 



g30 DISEASES OF THE CIRCULATORY SYSTEM. 

expectoration, which may be bloody, and in rare cases there may be larger 
pulmonary haemorrhages. The obstruction to the systemic venous circu- 
lation leads to dropsy, which begins in the feet. There may be general 
anasarca and dropsy of the serous cavities, especially the peritonaeum and 
pleura; also enlargement and functional disturbances of the liver, en- 
largement of the spleen, dyspeptic symptoms, and chronic congestion of 
the kidney, with scanty urine and albuminuria. There may be dilatation 
of the superficial veins, with clubbing of the fingers, and cyanosis ; and 
there may be cerebral symptoms, such as headache, dizziness, and faint- 
ing attacks. The pulse is small and soft, and the heart's action rapid 
and irregular. 

It is rare to see all the symptoms of cardiac failure in children 
under ten years, but about the time of puberty they are not uncommon. 
The symptoms may increase in severity until death occurs, or they may 
be severe for a time and then nearly disappear, to return again after a 
longer or shorter interval.* Death may be due to sudden cardiac paralysis, 



* The course and termination of these cases of chronic valvular disease is well 
illustrated by the following history of a little girl who was under my observation for 
nine years : When first seen she was seven years old, and gave a history of cardiac 
symptoms for one year. There was then present a loud mitral regurgitant murmur, 
with considerable hypertrophy. There was general dropsy, and all the symptoms 
pointed toward acute dilatation. Under treatment, the dropsy and other symptoms 
disappeared, and she went on comfortably for over a year. In her eighth and ninth 
years there were frequent attacks of subacute rheumatism, during which time the 
heart lesion steadily increased in severity. At twelve years there was an eruption of 
subcutaneous tendinous nodules, which remained for over two years. During this 
year there was heard for the first time a mitral direct murmur, accompanied by a very 
marked thrill, mitral stenosis having been gradually brought about by the slowly pro- 
gressing endocarditis. This murmur gradually increased in intensity from that time, 
while the mitral regurgitant murmur became less distinct. The apex beat was then in 
the sixth space, two and a half inches to the left of the nipple. From the twelfth to the 
fifteenth year she grew very little in height or weight, and showed no signs of matu- 
rity, the cardiac symptoms being nearly stationary. In the fifteenth year she devel- 
oped a marked enlargement of the liver and spleen with general dropsy and all the 
symptoms of cardiac insufficiency, these being the first symptoms of this character 
since she was seven years old. There was now heard for the first time an aortic re- 
gurgitant murmur in addition to the others formerly present. The symptoms dis- 
appeared under treatment in the course of a few months, but six months later returned 
with greater severity and were accompanied by albuminuria, the patient dying from 
heart failure in a few weeks. During the last exacerbation there was heard a double 
aortic as well as a double mitral murmur. 

At autopsy the heart weighed fifteen ounces. There was a very great hypertrophy, 
especially of the right ventricle, which was as thick as the left. All the cavities were 
much dilated. The most important valvular lesion was mitral stenosis, the orifice not 
admitting the end of the little finger. The valves were the seat of calcareous deposits. 
The curtains of the aortic valve were thickened and adherent ; there was also thicken- 
ing of the pulmonic and tricuspid valves. 



CHRONIC VALVULAR DISEASE. 631 

to intercurrent nephritis, pneumonia, embolism, inflammation of the se- 
rous membranes, or to oedema of the lungs. 

Clinical Varieties. — Of the 141 cases of valvular disease in children 
under fourteen years, previously referred to, the following were the forms 
and combinations recorded. It is to be noted that these figures are based 
upon clinical and not pathological examinations : 

Mitral insufficiency 131 cases ; alone in 99 cases. 

Mitral stenosis 17 " " " 4 " 

Aortic insufficiency 9 " " " " 

Aortic stenosis 28 " " " 3 " 

Double mitral 8 " 

Double aortic 1 case. 

Double mitral and double aortic 3 cases. 

Mitral insufficiency and double aortic 3 " 

Mitral insufficiency and aortic stenosis 18 " 

Mitral stenosis and aortic insufficiency 2 " 

Mitral insufficiency. — This is usually the result of attacks of acute 
endocarditis. It is by far the most frequent form of valvular disease in 
early life, occurring in 93 per cent of the above cases, and alone in 70 per 
cent. In mitral insufficiency there is regurgitation of blood from the left 
ventricle into the left auricle during systole. This is compensated for by 
hypertrophy of both ventricles. It causes dilatation of the left auricle, 
increased pressure in the pulmonary veins, afterward in the pulmonary 
arteries, hypertrophy of the right ventricle, and, finally, there is dilata- 
tion of the right ventricle, tricuspid insufficiency, dilatation of the right 
auricle, and general systemic venous obstruction. Coincident with the 
changes in the right heart there is hypertrophy of the left ventricle, fol- 
lowed by dilatation. 

In mitral insufficiency there is heard a systolic murmur which is syn- 
chronous with the apex impulse and with the first sound of the heart, and 
may in part replace the first sound. It is loudest at the apex, trans- 
mitted to the left, and heard with almost equal distinctness at the inferior 
angle of the left scapula. This is a very diffusible murmur, and may be 
audible all over the chest. It is accompanied by an accentuation of the 
pulmonic second sound heard at the left border of the sternum in the 
second space, and by signs of hypertrophy of the heart. When both these 
signs are wanting, the existence of mitral insufficiency is somewhat doubt- 
ful, as a similar murmur may be of functional or accidental origin. In 
the early stages of the disease the signs of hypertrophy predominate ; in 
the later stages, those of dilatation. 

In hypertrophy of the left ventricle or of the whole heart, the apex 
beat is displaced downward and to the left.* It may be in the fifth or 

* For normal position of the apex in childhood, see page 604. 



632 DISEASES OF THE CIRCULATORY SYSTEM. 

the sixth space, but rarely lower, and as far to the left as the axillary line. 
There is often bulging of the praecordia, so marked as to cause a deformity 
of the chest. The impulse is forcible and heaving, and over a larger space 
than normal. The area of cardiac dulness is increased in all directions, 
but particularly downward and to the left. In hypertrophy involving 
chiefly the right ventricle, there may be bulging of the lower part of the 
sternum, and the area of dulness is increased to the right, in extreme cases 
extending from one to one and a half inches beyond the right border of the 
sternum. The heart sounds in hypertrophy are loud and distinct, and 
often have a somewhat metallic character. With hypertrophy of the right 
ventricle there may be reduplication or accentuation of the second sound. 
The pulse is full and strong. 

In dilatation the apex beat is indistinct, diffuse, and undulatory. 
There is an increase in the area of cardiac dulness, the outline being nearly 
square. The cardiac sounds are feeble, and murmurs previously present 
may be lost. The heart's action is irregular, and the pulse small and 
weak. 

Mitral stenosis. — This is apt to occur from repeated attacks of sub- 
acute rheumatism, with a slowly progressing endocarditis. It is usu- 
ally associated with mitral regurgitation. With this lesion there is 
obstruction to the flow of blood from the left auricle into the left ven- 
tricle. It is mainly compensated for by hypertrophy of the right ven- 
tricle, but to a certain degree by hypertrophy of the left auricle. The 
secondary changes following the lesion are hypertrophy of the left au- 
ricle followed by dilatation, increased pressure in the pulmonary veins, 
followed by hypertrophy and dilatation of the right ventricle. The left 
ventricle is usually normal or small. 

Mitral stenosis produces a presystolic murmur which is somewhat 
prolonged, usually rough in character, and terminates sharply with the 
first sound of the heart. It is loudest at or near the apex, but is audible 
over only a small circumscribed area. Quite as constant and important 
for diagnosis is the presence of a " purring thrill," which is very distinct 
upon palpation, and terminates sharply as the apex strikes the chest wall. 
The pulse of mitral stenosis is usually small. The symptoms are few, 
but those which are present depend chiefly upon pulmonary congestion. 

Aortic stenosis. — This is not very common in early life, and rarely 
occurs as the only lesion, being most frequently associated with mitral 
insufficiency. It is sometimes a congenital lesion. Aortic stenosis is 
compensated for by hypertrophy of the left ventricle, which may be 
complete for a long period, but ultimately it is followed by dilatation of 
the left ventricle, with mitral insufficiency and its consequences. In 
aortic stenosis there is an interference with the outflow of blood from 
the left ventricle into the aorta. It causes a systolic murmur, which is 
usually loudest at the right border of the sternum in the second space, 



CHRONIC VALVULAR DISEASE. 633 

and is transmitted upward, being distinct in the carotids. The second 
sound is generally weak. There are associated the signs of marked hyper- 
trophy of the left ventricle. 

Aortic obstruction is more frequently confounded with conditions giv- 
ing accidental or functional murmurs than is any other valvular lesion. 
Without the signs of hypertrophy of the left ventricle, a positive diagnosis 
should not be made. On account of the almost perfect compensation, 
this form of the disease causes fewer symptoms than any other variety, 
possibly excepting mitral obstruction. The danger of embolism is some- 
what greater than in mitral disease. 

Aortic insufficiency. — This is one of the rarest valvular lesions in chil- 
dren. In no case on my list did it occur as the only lesion. It causes a 
regurgitation of blood from the aorta into the left ventricle during dias- 
tole. It is compensated for by dilatation and hypertrophy of the left 
ventricle. The order in which the secondary changes take place is : dila- 
tation followed by hypertrophy of the left ventricle, ultimately followed 
by further dilatation due to degeneration, this leading to mitral insuffi- 
ciency with all its remote consequences. The signs of aortic insufficiency 
are a prolonged diastolic murmur, with, or taking the place of, the second 
sound of the heart, generally loudest at the left border of the sternum in 
the second space, and transmitted downward to the apex of the heart or the 
ensiform cartilage. This is invariably accompanied by signs of hyper- 
trophy and dilatation of the left ventricle., which are usually marked. 
In the stage of compensation the signs of hypertrophy predominate, and 
when compensation has failed, the signs of dilatation. A characteristic 
symptom is the intense throbbing of the carotids, with the sudden disten- 
sion and complete collapse of their walls, and the " ball-pulse " of Corri- 
gan. Early in the disease there may be headache, flashes of light before 
the eyes, and other evidences of cerebral congestion. In the late stages 
there may be fainting attacks. With this lesion compensation may be 
complete for a long time. 

Tricuspid insufficiency. — This is usually secondary to disease of the 
left side of the heart, occurring in its late stages. It most frequently fol- 
lows mitral insufficiency, where it is usually due to dilatation of the right 
ventricle without changes in the valves. It may be secondary to certain 
diseases of the lungs, such as emphysema, chronic interstitial pneumonia, 
or chronic pleurisy, and it may be due to congenital malformation. Tri- 
cuspid insufficiency gives a systolic murmur, loudest over the lower part of 
the sternum, but heard usually over a small area. It is generally associated 
with signs of dilatation of the right ventricle. The jugular veins stand 
out prominently, and often show systolic pulsation, especially upon the 
right side. The symptoms associated with tricuspid regurgitation are due 
to general systemic venous obstruction, already mentioned in connection 
with mitral insufficiency. 



534 DISEASES OP THE CIRCULATORY SYSTEM. 

Tricuspid stenosis, pulmonic stenosis, and pulmonic insufficiency 
are practically unknown in childhood, except in congenital cardiac 
disease. 

Prognosis of Valvular Disease. — Complete recovery from valvular dis- 
ease is possible only when the lesions are very slight. Few children die 
from cardiac disease before reaching the age of fourteen years, sudden 
death being extremely rare. A large proportion of the cases do fairly 
well up to about the time of puberty, when they begin to lose ground, 
often failing rapidly. Others do well until a fresh endocarditis is lighted 
up by an intercurrent attack of rheumatism, after which the disease may 
make rapid progress. The proportion of children who have serious cardiac 
lesions before the age of eight years, and reach adult life in good condition 
is comparatively small. 

There are several features of cardiac disease in children, in conse- 
quence of which, serious lesions tend to progress more rapidly than in 
adults. The muscular walls are less resistant, and hence rapid dilata- 
tion occurs much more readily than in adult life. The heart must pro- 
vide not only for constant needs, but for the growth of the body. If the 
patient's general nutrition is poor during the period of most rapid growth, 
this tells quickly and seriously upon the heart, and dilatation makes rapid 
progress; but if the general nutrition continues good the heart may do 
more than hold its own throughout childhood. The demands made upon 
the heart at puberty are especially severe, by reason of the rapid growth 
of the body and the frequency of anaemia and malnutrition. There is 
always present the danger of rapid advances in the disease from inter- 
current attacks of rheumatism, from which children are more likely to 
suffer than are older subjects. Extensive pericardial adhesions are fre- 
quent, and seriously handicap the heart, greatly increasing the tendency 
to dilatation. The effect upon the heart of poor food, unhygienic sur- 
roundings, and general malnutrition is much more marked than in adults. 

These unfavourable conditions are in part offset by others in which 
the child has an advantage over the adult. Disease of the coronary ar- 
teries is very rare, and the valvular lesions which are most frequently met 
with — mitral insufficiency and aortic obstruction — are those which admit 
of the most complete compensation. 

In making a prognosis in any given case, the amount of hypertrophy 
or dilatation which exists is of much more importance than the location 
or the special character of the murmur. The condition of the arterial 
and venous circulation must also be taken into consideration ; also how 
rapidly the disease is progressing, the condition of the patient's general 
health, and how well circumstances will admit of proper hygienic and 
general management. The presence of valvular disease in childhood in- 
creases the danger from every acute disease, especially pertussis, diph- 
theria, pneumonia, and scarlet fever. 



CHRONIC VALVULAR DISEASE. 535 

Diagnosis. — Valvular disease is to be particularly distinguished from 
conditions in which there are heard functional or accidental murmurs. 
According to my own experience the latter are quite common even in 
young children. Mistakes usually arise from attaching too much impor- 
tance to the presence of murmurs, and too little to the changes in the 
walls and cavities of the heart, with which valvular disease is almost in- 
variably associated. It is not always possible to decide whether a mur- 
mur is organic or functional until the patient has been for some time 
under observation and treatment, particularly when anaemia is present. 
The diagnostic points, so far as the murmurs are concerned, are men- 
tioned in connection with anaemic murmurs . 

Treatment. — A child who is the subject of a -serious chronic valvular 
disease should be constantly under a physician's observation. Irrepa- 
rable harm often results from wilful, but more frequently from ignorant, 
disregard of the simplest and most important rules of life for these 
patients. At the very least the patient should be carefully examined 
three or four times each year, in order that the physician may note the 
progress of the disease, and be able to modify the child's occupation, ex- 
ercise, and surroundings so as to meet, as far as possible, the changing 
conditions. 

Several distinct conditions may be present which call for quite differ- 
ent management. The essential points may be stated in a few words : 
for all recent cases and during all exacerbations, rest, complete and pro- 
longed ; for deformed valves with good heart walls and perfect compen- 
sation, fresh air, moderate exercise, and general tonics ; for feeble heart 
walls, failing compensation and dilatation, rest and specific heart tonics. 

During the stage of compensation, treatment directed especially to 
the heart is rarely necessary. The main purpose should be to maintain 
the patient's general nutrition at the highest possible point during the 
period of active growth. To this end, diet, sleep, study, and exercise 
should receive the most careful attention. If malnutrition and anaemia 
are allowed to go on unchecked until they become severe, the cardiac dis- 
ease may make rapid strides, and as much harm be done in a few months 
as otherwise might not occur in years. The question of exercise and rec- 
reation is always a difficult one to settle. Often too little latitude is 
given, and the heart, like the voluntary muscles, loses its tone. Every 
form of exercise requiring a prolonged severe strain should be forbidden, 
particularly swimming and competitive games, like ball and tennis, and 
others requiring much running ; but skating, rowing, mountain-climbing, 
horseback exercise, gymnastics, and even cycling on the level — all in 
moderation — may be allowed not only without harm, but with the great- 
est benefit ; but any of these, used immoderately, may be productive of 
great injury. All exercise should be taken with regularity and system, 
the amount being carefully measured by the child's condition. If the 
42 



636 DISEASES OF THE CIRCULATORY SYSTEM. 

patient is a boy who must earn his own living, the physician should see 
to it that the occupation chosen is not one likely to make special demands 
upon the heart. 

Special watchfulness is required at the time of puberty to prevent 
overpressure in schools, and the development of anaemia or chlorosis. 
The first symptoms of these conditions should be treated energetically, 
and if the heart seems to be overtaxed the child should be put to bed. 
Patients should be so far as possible removed from conditions likely to 
induce fresh attacks of rheumatism. To this end, if possible, they 
should spend the winter and spring months in a warm, dry climate. 

In the stage of failing compensation, the same general conditions are 
present as in adults, and they are to be managed in pretty much the same 
way. When such symptoms are first seen, prolonged rest in bed should 
be insisted upon as the thing most likely to restore the normal conditions. 
Cardiac dropsy with low arterial tension and weak pulse, calls for digitalis. 
An overloaded venous circulation may be relieved by diuretics, or, better, 
by saline purgatives. Iron and tonics generally are indicated, particularly 
strychnine and cod-liver oil. In cases of sudden heart failure, nitroglycer- 
in, ether, and ammonia are as valuable as in adults ; but better, probably, 
than any of these is the use of strychnine hypodermically. 

MYOCARDITIS. 

Disease of the muscular wall of the heart is rare in children, and of 
comparatively little importance, except in connection with the acute in- 
fectious diseases. Myocarditis may, however, occur at any age, even in 
foetal life. As seen in children, it is almost invariably a secondary lesion, 
usually the result of some infectious process. The two diseases which 
furnish most of the cases are scarlet fever and diphtheria. The most 
important local cause is pericarditis with adhesions. 

Lesions. — In extra-uterine life, myocarditis, as a rule, affects the wall 
of the left ventricle, the papillary muscles, or the septum. The heart is 
pale or of a yellowish- white colour, very soft and flabby, and there is fre- 
quently dilatation of the cavities. Small ecchymoses may be seen beneath 
the pericardium. 

Two varieties of myocarditis are described : In the parenchymatous 
form there is a degeneration of the muscle fibre which, according to 
Romberg, is most frequently albuminous, next fatty, and least frequently 
hyaline. There is a loss of the transverse striations, and there may be 
complete disintegration of the fibres. This process may be circumscribed, 
but it is usually diffuse. In the interstitial form the lesion usually occurs 
in small, circumscribed areas. There is an infiltration of round cells be- 
tween the muscular fibres of the heart. The process, when acute, may re- 
sult in absorption or in the production of small abscesses. There may also 
be congestion and minute blood extravasations. In chronic cases it may 



ANEMIC MURMURS. 637 

lead to the formation of larger or smaller areas of dense connective tissue 
resembling cicatrices, in the heart wall. Either the interstitial or the pa- 
renchymatous form may occur alone, but in most of the acute cases they 
are combined. In addition, there is usually some degree of mural endo- 
carditis and inflammation of the pericardium next to the heart wall. 
Dilatation frequently follows ; rarely abscesses may form, which may open 
into the heart or into the pericardium. Cardiac aneurism, and even rup- 
ture, have been known to occur in a child of six years (Hadden's case). 

Symptoms. — These are very rarely sufficiently marked to enable one 
to make a positive diagnosis. In many cases in which advanced lesions 
have been found at autopsy there have been no symptoms during life, 
and in others none until the occurrence of sudden death. This is usu- 
ally from cardiac paralysis, rarely from rupture. In eight cases studied 
by Romberg, which occurred in the course of diphtheria, not one had 
cardiac symptoms during life and two died suddenly. When symptoms 
are present, they are generally those of feeble heart action — a faint apex 
impulse, a slow, weak pulse of irregular rhythm, pallor, dyspnoea, and 
attacks of syncope. In the late stages there may be the physical signs of 
dilatation, with dropsy of the feet or the serous cavities, and scanty urine, 
sometimes containing albumin. 

Diagnosis. — A positive diagnosis of myocarditis is impossible. It may 
be suspected in the course of diphtheria, scarlet or typhoid fever, when 
cardiac symptoms like those mentioned occur, and when pericarditis and 
endocarditis can be excluded by the physical examination. 

Treatment. — This is mainly symptomatic. After severe attacks of 
those infectious diseases in which myocarditis is liable to occur, and at 
any time when it is suspected, patients should be kept recumbent for 
several weeks, and special care exercised to prevent any sudden exertion, 
as death has occurred from so slight a thing as suddenly sitting up in 
bed. Iron, alcohol, and tonics should be given, the best of all of these 
being strychnine. Digitalis should be used with caution, and never in 
large doses. In some cases with symptoms indicating imminent heart 
failure, more striking benefit follows the use of morphine hypodermically 
than any other plan of treatment. 

ANAEMIC MURMURS. 

As already stated, anaemic murmurs are not rare even in infancy. 
They may be confounded with organic murmurs, either from congenital 
malformations or acquired disease. I have several times found the heart 
normal at autopsy in cases where a diagnosis of congenital disease had 
been unhesitatingly made during life, the murmur having been of anaemic 
origin. In any anaemic infant, as well as older child, one should hesitate 
to make a diagnosis either of congenital or acquired organic disease, from 
the mere presence of a murmur. 



638 DISEASES OF THE CIRCULATORY SYSTEM. 

An anaemic murmur is usually systolic, generally but not always loud- 
est at the base of the heart, audible in the carotids, often in the subclav- 
ian, and occasionally over any large artery. The murmur varies from day 
to day, and sometimes it is altered by changing the position of the patient. 
It may be loud enough to be heard over a great part of the chest in front, 
and even behind. There is frequently present a venous hum in the neck. 
There are no signs of hypertrophy, nor is there the accentuated second 
sound so characteristic of mitral disease. The pulse is not usually strong. 
Anaemic murmurs diminish in intensity and ultimately disappear with 
improvement in the general condition of the patient. In some cases one 
must wait for the effects of treatment before giving a positive opinion. 



FUNCTIONAL DISORDERS OF THE HEART. 

Disturbances in the heart's action unconnected with organic disease, 
are rare in infants and young children ; but after the seventh year they 
are not uncommon, becoming in fact quite frequent as puberty approaches. 
One of the most important causes is indigestion ; another is overpressure 
in schools, or anything else leading to nervous exhaustion. In these cir- 
cumstances it is usually associated with other mental or psychical dis- 
turbances. An important predisposing cause is the demand made upon 
the heart by the rapid growth of the body about the time of puberty, 
particularly when this is associated with anaemia. In some of the cases 
there is a definite exciting cause, such as fright or great excitement, and 
it may be due to the excessive use of tea, coffee, or tobacco, especially in 
the form of cigarette-smoking. In a few instances it has been traced to 
masturbation. It may follow any acute disease, such as typhoid fever, 
malaria, or one of the exanthemata, and occasionally it occurs in the 
course of these diseases, or with bronchitis or pneumonia. 

Symptoms. — The usual manifestations are attacks of palpitation ; less 
frequently there is tachycardia (rapid heart) or bradycardia (slow heart). 
The majority of children complain more with functional disturbances 
than with organic disease, certainly while the latter is accompanied by 
compensation. Attacks of palpitation occur in paroxysms. In the severe 
form there is usually a sense of oppression in the region of the heart, 
with some dyspnoea, or even orthopncea. The pulse is usually rapid, from 
120 to 130, and is irregular both as to force and rhythm. The carotids 
pulsate strongly. The apex impulse is felt over an increased area, the 
heart sounds are usually strong but irregular, and sometimes a slight mur- 
mur is heard. The face is pale or flushed. There may be headache, ver- 
tigo, spots before the eyes, and noises in the ears. Sometimes there is 
slight cyanosis with cold hands and feet, and general perspiration. The 
frequency of these attacks depends upon the nature of the exciting cause. 
Their duration is from a few minutes to several hours. 



DISEASES OF THE BLOOD-VESSELS. 039 

Diagnosis. — Functional disorders are differentiated from organic car- 
diac disease only by careful and repeated examinations of the heart. In 
the diagnosis of functional disturbance especial importance is to be at- 
tached to a neurotic or neurasthenic condition of the patient, to the 
presence of some adequate exciting cause, the absence of evidence of 
enlargement of the heart, and the fact that the pulmonic second sound is 
not increased. 

Prognosis. — This in most cases is favourable, for with improvement 
in the patient's general condition, with the growth of the body, and in 
girls with the establishment of menstruation, the attacks usually disappear. 

Treatment. — During the attacks, digitalis in moderate doses should be 
given, also bromides or valerian. The curative treatment is to be directed 
toward the cause. Where no special cause can be discovered a general 
tonic plan of treatment should be adopted, with careful regulation of 
the patient's diet, exercise, and mode of life. All stimulating food, tea, 
coffee, and tobacco should be prohibited. Anaemia should receive its ap- 
propriate remedies. The hours of sleep and study, and the amount and 
character of exercise allowed, should be carefully regulated. Between 
attacks no treatment of the heart is necessary. 

DISEASES OF THE BLOOD-VESSELS. 

AbnormaHy SmaU Arteries {Arterial hypoplasia). — This condition is 
not a very common one, but it has attracted a good deal of attention, 
having been studied especially by Virchow. The only thing which is ab- 
normal in the circulatory system may be that the aorta, and sometimes all 
the large vessels are only two thirds or three fourths their usual calibre, 
or even less. This may interfere seriously with the growth and develop- 
ment of the body, especially of the genital organs, although this result is 
not a constant one. The condition is found occasionally in cases of chlo- 
rosis, and in the congenital cases it may be the chief cause. There is 
usually associated a certain amount of hypertrophy of the heart. The 
other symptoms are anaemia, and sometimes an imperfect development of 
the body. A positive diagnosis during life is impossible. 

Aneurism and Atheroma. — In early life chronic disease of the blood- 
vessels is exceedingly rare, yet a sufficient number of observations have 
been recorded to show that even young children are not exempt from this 
form of disease. There had been reported up to 1890 twenty-eight cases 
of aneurism in patients under twenty years of age (Jacobi).* Of these, 
however, only twelve were under fourteen years. Sanne f records the 
youngest case, which occurred in a foetus born at about the eighth month, 

* A. Jacobi, Archives of Paediatrics, vol. vii, p. 161. 

f Sanne, Revue Mensuelle des Maladies des l'Enfance, vol. v, p. 56. In these arti- 
cles will be found references to most of the reported cases. 



640 DISEASES OP THE CIRCULATORY SYSTEM. 

in whose body there was found a large aneurism, of the abdominal aorta 
just below the origin of the renal arteries. Of the eleven remaining cases 
occurring in children under fourteen years, in over one half the number 
the arch of the aorta was the part affected. In one case the seat was the 
femoral artery, in another the external iliac, and in still another the 
abdominal aorta. 

Probably the most important etiological factor, as in adult life, is 
syphilis, but in only a few of the cases reported was the evidence of syphi- 
lis conclusive. In two cases there was general tuberculosis. In addition 
to these general causes, aneurism may be due to some local condition, 
such as an erosion from bone, an abscess in the neighbourhood, or to em- 
bolism. The symptoms and course of aneurism in young children do not 
differ essentially from those of the disease as seen in adults. 

In addition to the cases of aneurism referred to above, I have found 
reports of seven cases of atheroma in very young subjects. In Sanne's 
case the patient was but two years old, and patches of atheromatous de- 
generation were found in several places in the aorta. In Hawkins's case, 
eleven years old, there was found extensive atheromatous disease of the 
aorta, subclavian and carotid arteries. In Filatoff's case, atheromatous 
degeneration affected the arteries at the base of the brain, causing death 
from cerebral haemorrhage. It is interesting to note that in this patient, 
who was only eleven years old, there was also present chronic diffuse 
nephritis with contracted kidneys. A similar condition of the kidneys 
and arteries was observed by Dickinson in a girl of six years. 

Embolism and Thrombosis. — Embolism has already been referred to in 
connection with acute endocarditis. It may be seen at any age, even in 
infancy, but generally occurs in patients over five years old. The emboli 
are usually swept into the circulation from vegetations upon the valves 
of the heart. The symptoms which they produce will depend upon the 
nature of the emboli and the vessels occluded by them. If they lodge in 
the brain they may cause paralysis or convulsions ; if in the spleen, pain 
and swelling of this organ ; if in the kidneys, pain, tenderness, and some- 
times haematuria ; if in the lungs, cough, sometimes accompanied by 
haemoptysis and occasionally by a sharp thoracic pain. If the emboli are 
infectious, they may give rise to abscesses. The pathological results fol- 
lowing embolism are similar to those which are seen in adults. 

The most frequent form of thrombosis, that occurring in the sinuses of 
the brain, is discussed in connection with Diseases of the Nervous System. 
Cardiac thrombi, especially of the right side of the heart, are not infre- 
quently found in patients dying from heart disease, pneumonia, and occa- 
sionally also from other acute inflammatory processes and acute infectious 
diseases, particularly diphtheria. These thrombi are in most cases pro- 
duced during the last few hours of life, or just at the time of death, and are , 
of no clinical importance. They frequently extend from the heart into the 



DISEASES OF THE BLOOD-VESSELS. 641 

large blood-vessels, particularly the pulmonary artery. Thrombosis occa- 
sionally occurs in all the large vascular trunks in childhood as well as in 
adult life. 

Thrombosis of the internal jugular vein. — Pasteur * reports a case in a 
child two and a half years old, in which the middle of the vein was filled 
with an organized thrombus, and the lower portion obliterated and re- 
duced to a fibrous cord. The symptoms were swelling, oedema, and cya- 
nosis of the face, and dilatation of the facial vein, but not of the external 
jugular. There were clubbing of the fingers and oedema of the feet, but 
not of the arm. The heart was found to be dilated and hypertrophied, 
but was not the seat of valvular disease. The symptoms had existed since 
an attack of pneumonia, eighteen months before death. 

Thrombosis of the vena cava. — Quite a number of cases are on record 
where this has occurred as the result of pressure from large abdominal 
tumours ; it has followed new growths of the kidney and large masses of 
tuberculous lymph nodes. Neurutter and Salmon have recorded a case of 
thrombosis, apparently of marantic origin, in a child seven years old. 
The thrombus filled the vena cava, and extended to the origin of the 
hepatic veins and into both femorals. Death occurred from tuberculosis. 
In Scudder's case (seventeen years old) there was apparently obliteration 
(probably congenital) of the inferior vena cava ; there was an extensive 
varicose condition of all the abdominal veins. The symptoms of throm- 
bosis of the vena cava are swelling and oedema of the feet — sometimes of 
the abdominal walls and the groin — and very great dilatation of the super- 
ficial abdominal veins. 

Thrombosis of the aorta. — A case has been reported by Leopold in a 
newly-born child which was delivered by version. The thrombus was of 
recent origin, and filled the lower aorta, extending into the femoral artery. 
A case of thrombosis of the aorta occurring in a girl of thirteen years has 
been reported by Wallis. The aorta was very narrow, and probably the 
seat of syphilitic disease. The thrombus extended from the origin of the 
renal arteries to the cceliac axis. 

Thrombosis in infectious diseases. — There is occasionally seen in 
typhoid fever, but more frequently in diphtheria, thrombosis of some of 
the large venous trunks, usually of one of the lower extremities. The 
symptoms are pain, localized swelling, and partial paralysis. If the artery 
is affected, there may be gangrene. 



Lancet, February 11, 188a 



SECTION VI. 

DISEASES OF THE URO-GENITAL SYSTEM. 

' CHAPTER I. 
TEE URINE IN INFANCY AND CEILDHOOD. 

While a study of the urine is of much less importance in early life 
than of the symptoms referable either to the digestive or respiratory sys- 
tem, it is deserving of much more attention than it has generally re- 
ceived. In infancy especially it is attended with difficulty, owing to the 
fact that it is by no means an easy matter to secure specimens for exami- 
nation. 

Methods of Collecting Urine. — In male infants this may be done by 
placing the penis in the neck of a small bottle which lies between the 
thighs and is secured in position by pieces of tape passing over the hips 
and beneath the perinseum. A still better plan is to use in the place of a 
bottle a condom large enough to include both the scrotum and penis. 
The urine of female infants can sometimes be collected in a similar way 
by placing a small cup over the vulva and holding it in place by the nap- 
kin. A plan nearly always successful is to put the infant upon a chamber 
after a long sleep. It should be done on the instant of waking, or the 
child may be wakened for the purpose. A cold hand over the bladder 
facilitates matters. A small amount, sufficient to test for albumin, may 
often be obtained by placing absorbent cotton over the vulva or penis. 
The most certain of all means, however, is catheterization; in females 
sometimes nothing else will answer the purpose. A soft rubber catheter, 
size 6 or 7, American scale (9 or 11 French), should be used for infants. 

Daily Quantity. — This is relatively much larger in infants than in 
older children and in adults, on account of the more active metabolism of 
the young child and the large amount of water taken with the food. The 
quantity fluctuates widely from day to day according to the amount of 
fluid food taken and the activity of the skin and bowels. The following 
figures are the averages obtained by combining the results of the investi- 
gations of Schabanowa, Cruse, Camerer, Pollak, Martin-Ruge, Berti, 
Schiff, and Herter : 

642 



THE URINE IN INFANCY AND CHILDHOOD. 



643 



Average Daily Quantity of Urine in Health. 



Age. 



First twenty-four hours . . 
Second twenty-four hours. 

Three to six days 

Seven days to two months 

Two to six months 

Six months to two years. . 

Two to five years 

Five to eight years 

Eight to fourteen years.. . 



Grammes. 


Ounces. 


Oto 


60 


Oto 2 


10 " 


90 


i " 3 


90 " 


250 


3 " 8 


150 " 


400 


5 " 13 


210 " 


500 


7 " 16 


250 " 


600 


8 " 20 


500 " 


800 


16 " 26 


600 " 


1,200 


20 " 40 


1,000 " 


1,500 


32 " 48 



Frequency of Micturition. — This is greatest in young infants, and 
diminishes steadily as age advances. In the first two years, during the 
waking hours, the urine is generally passed as often as twice an hour, while 
during sleep it is retained from two to six hours. By the third year the 
urine may be held during sleep for eight or nine hours, and at other times 
for two or three hours. Such control of the sphincter of the bladder is 
often obtained at two years, and sometimes even at an earlier period. 
From slight nervous disturbances or minor ailments of any kind, this con- 
trol is impaired, and the water may be passed by children of four or five 
years with the frequency seen in infants. 

Physical Characters. — The urine of the newly born is usually highly 
coloured. During later infancy it is pale and frequently turbid, even 
when practically normal, owing to the presence of mucus ; this turbidity 
often no amount of filtration will entirely remove. Less frequently tur- 
bidity depends upon urates. The urine of the first few days of life often 
shows a deposit of urates or uric acid in the form of a reddish-yellow 
stain upon the napkin. The reaction of the urine at this time is usu- 
ally strongly acid, but throughout the rest of infancy it is faintly acid or 
neutral. 

The specific gravity is higher during the first two days than at any 
time in infancy on account of the scanty supply of fluid taken; it is 
usually lowest from the third to the sixth day, but from this time it rises 
steadily until puberty is reached. The specific gravity will of course vary 
with the quantity. From the writers already referred to the following 
figures are taken : 

Specific gravity. 

First to third day 1-010 to 1*012 

Fourth to tenth day 1-004 " 1-008 

Tenth day to sixth month 1-004 " 1-010 

Six months to two years 1*006 " 1-012 

Two to eight years 1-008 " 1-016 

Eight to fourteen years 1-012 " 1-020 

Microscopically, the urine of the newly born shows the presence of 
many squamous epithelial cells, mucus, granular matter, and crystals of 
43 



644 DISEASES OF THE URO-GENITAL SYSTEM. 

uric acid and amorphous or crystalline urates. It is not uncommon to 
find hyaline and even granular casts. Martin-Ruge found hyaline casts 
in the urine of fourteen out of twenty-four healthy nursing infants ex- 
amined during the first week. Granular casts were much less frequent. 
The microscopical appearances of the normal urine of later infancy and 
chi-ldhood present no peculiarities. 

Composition. — Urea. — The following figures show the average daily 
quantity of urea eliminated at the different ages : 

Age. Daily quantity of urea. 

Firstday 0*076 to 0*114 gramme. 

Second to seventh day 0-140 " 0*660 " 

One to two months 0*90 " 1-40 " 

Three to five years -. 13*09 " 14*01 grammes. 

Five to thirteen years 16*05 " 21*03 " 

Uric acid. — Few observations have been made upon the elimination 
of uric acid, but all authorities agree that it is much higher in the newly 
born than at any subsequent period of life. The quantity is better ap- 
preciated by giving the ratio between the uric acid and urea than by the 
absolute quantity of the former. The figures here given for the newly 
born are taken from Martin-Euge ; the others are from Herter. 

Ratio of Uric Acid to Urea. 

In the newly born 1 to 14 

Under one year 1 " 60-80 

From two to five years 1 " 50-70 

From five to fifteen years 1 " 45-60 

The inorganic salts (phosphates, chlorides, sulphates) are all present 
in the urine of the newly born, but in relatively small quantities, increas- 
ing as age advances. The colouring matters are also less abundant. 

Albumin is often present in the urine during the first days, but usu- 
ally in small amount. Cruse found it twenty-eight times in ninety obser- 
vations upon healthy infants ; usually the quantity was small, amounting 
to traces only, but in two cases it was quite large upon the second day. 
These observations are confirmed by the investigations of Martin-Ruge, 
and also of Pollak. 

Sugar is frequently found in the urine of healthy infants during the 
first two months. This subject is referred to later under the head of 
Glycosuria. 

FUNCTIONAL OR CYCLIC ALBUMINURIA. 

Etiology. — This condition, although a rare one in young children, is 
occasionally seen between the ages of ten and sixteen years. I shall not 
in this connection include cases sometimes classed as febrile albumi- 
nuria, in which there is usually present the condition described as acute 
degeneration of the kidneys. 



FUNCTIONAL OR CYCLIC ALBUMINURIA. 645 

The causes of functional or physiological albuminuria, and the cir- 
cumstances in which it has been observed, are many and varied. It is 
much more common in males than in females. In many patients it is 
regularly cyclic in character, albumin being absent in the urine passed 
during the night or early morning, but present during the day, diminish- 
ing in the evening and absent at bed-time. In a case reported by Tie- 
mann, the morning urine showed no trace of albumin in seventy-eight of 
eighty-four examinations. At noon albumin was present in ninety-eight 
of one hundred and thirteen examinations. In certain cases albuminuria 
is distinctly traceable to cold bathing ; in others, to fatigue following ex- 
cessive muscular exercise; in still others, to dyspeptic conditions. It 
may be associated with a diet rich in nitrogenous food. Sometimes none 
of these conditions exist, and there is simply the occasional presence of 
albumin in the urine. 

Many theories have been advanced in explanation of cyclic albuminuria. 
Sometimes it appears to be clearly traceable to irritation of the kidney by 
uric acid, urates, or oxalates. Kinnicutt believes this to be one of the 
prominent causes, and that albuminuria is due to vaso-motor disturbances 
in the kidney. Delafield compares the exudation of serum from the ves- 
sels of the kidney to the dropsy of the feet seen in anaemia. Da Costa 
believes that it always depends upon slight changes of an evanescent char- 
acter in the kidney. 

Symptoms. — Many of the patients exhibiting cyclic or periodical al- 
buminuria are well nourished, and have no other signs of disease ; others 
show dyspeptic -symptoms, and are anaemic and poorly nourished, suffering 
from headaches and other neuroses. In the cases distinctly periodical the 
amount of albumin is commonly small. It is not infrequently associated 
with temporary glycosuria. As a rule, casts are absent, although it is not 
uncommon to find a few hyaline casts, and occasionally granular casts are 
also present. A gouty family history exists in a certain proportion of the 
cases, and some of the patients themselves present other evidences of this 
diathesis. 

Diagnosis. — Pavy mentions the following points as characteristic of 
physiological or functional albuminuria : (1) The time of its occurrence. 
The absence of albumin early in the morning, its presence in the fore- 
noon, and diminution toward evening. When this is repeated day after 
day the diagnosis is, he believes, quite positive. (2) The absence of seri- 
ous impairment of the general health and of the characteristic symptoms 
of nephritis, such as dropsy, cardiac hypertrophy, a pulse of high tension, 
retinal changes, etc. (3) The fact that casts are, as a rule, absent. (4) 
That crystals of oxalate of lime are present, and the urine is of high 
specific gravity. 

Too much stress is certainly laid by Pavy and many other writers 
upon the fact that the albumin is found in the urine only at certain 



646 DISEASES OF THE URO-GENITAL SYSTEM. 

times in the day. This is not peculiar to functional albuminuria, as the 
same thing occurs in many cases of chronic nephritis, especially in the 
early stages when the amount of albumin present is small. All these 
cases must be carefully watched for a long time and many observations 
made, before nephritis can positively be excluded. 

Prognosis. — The prognosis in purely functional albuminuria is good. 
But many patients who for a considerable time were thought to have 
only functional albuminuria have ultimately developed nephritis. A 
favourable prognosis is therefore possible only after long observation. 

Treatment. — This is to be directed toward the patient's general con- 
dition. Dyspeptic symptoms must be relieved, the patient's mode of life 
regulated, only moderate exercise allowed, and a simple diet given. If 
the urine is of high specific gravity, and contains oxalate-of-lime crystals, 
alkalies and mineral waters should be given in addition. Iron is indicated 
if there is anaemia. 



HEMATURIA. 

Hematuria is characterized by the presence of red blood-cells in the 
urine, and is to be distinguished from hemoglobinuria where only blood 
pigment is present. 

Hsematuria may result from local or general causes. In infancy it 
may be due to new growths of the kidney. Such haemorrhages, though 
rare, may be abundant, and may be seen early. Hsematuria may occur 
also as a symptom of acute nephritis, especially that complicating scarlet 
fever, or it may result from the irritation of a calculus in the kidney, the 
ureter, or the bladder. In rare instances its cause is a new growth of the 
bladder, and it may be due to traumatism. It may sometimes be pro- 
duced by the irritation of a highly concentrated urine, owing to the fact 
that too little fluid is taken. I saw a marked example of this in an infant 
eight months old, where no other explanation could be found. I once 
saw hsematuria following uric-acid infarctions in the newly born. It 
may also occur at this time as one of the symptoms of sepsis. Among 
the general causes the most important are: the haemorrhagic dis- 
ease of the newly born; the blood dyscrasiae, such as scurvy, purpura, 
and haemophilia; and infectious diseases, particularly malaria, typhoid, 
variola, scarlet fever, and influenza. In most of these cases the 
amount of blood passed is small. When it is large it may appear in the 
urine as clear blood, or as clots, or it may impart simply a reddish or 
smoky colour to the urine. The colour, however, is not so reliable as 
a microscopical examination. For a simple chemical test guaiacum may 
be used. 

Large haemorrhages are much more likely to come from the kidneys 
than from the bladder. The presence of blood casts from the renal 



GLYCOSURIA. 647 

tubules, or larger ones from the ureter, are conclusive evidence of the 

renal origin of the haemorrhage. 

In children, renal haemorrhage in itself rarely requires treatment; 
when it does, the same remedies are indicated as in the adult, viz., ergot, 
gallic acid, and rest in bed. Some obstinate cases have been cured by 
drinking water from alum springs. 

HEMOGLOBINURIA. 

In this condition blood pigment appears in the urine in large quantity, 
but red blood-cells are very few in number, or are absent altogether. In 
severe cases the urine may be almost black. There is commonly a small 
amount of albumin. This condition may be recognised by the appearance 
of granules of pigment under the microscope, or by Heller's test; the 
most conclusive means of diagnosis, however, is the spectroscope. 

Epidemic haemoglobinuria (Winckel's disease) has already been de- 
scribed in the chapter on Diseases of the Newly Born. Haemoglobinuria 
may be due to certain poisons, as carbolic acid or chlorate of potash, or to 
certain infectious diseases, as scarlet fever, typhoid fever, malaria, syphilis, 
and erysipelas. 

Paroxysmal haemoglobinuria occurs in childhood, although it is an 
exceedingly rare condition. A typical case in a child of four and a half 
years has been reported by Mackenzie. This was a delicate child of syphi- 
litic parents ; the haemoglobinuria was preceded by fever and chills, with- 
out any other evidence of the presence of malaria. 

The exact pathology of haemoglobinuria is at present unknown, and 
its treatment is very unsatisfactory. 

GLYCOSURIA. 

By this term is understood the occasional or transient appearance of 
sugar in the urine. This is not very infrequent in children, and may be 
met with even during the first month of life. Grosz has published some 
careful investigations upon the glycosuria of early infancy.* He made 
many observations upon fifty infants during the first month of life, from 
which the following conclusions were drawn : Glycosuria is not uncommon 
in nursing infants; but it is not seen in nursing infants who are per- 
fectly healthy. It occurs particularly with certain disturbances of diges- 
tion, whether functional or inflammatory. The sugar found in the urine 
under these conditions reacts strongly to the reduction test (Fehling's), 
but not to the fermentation test ; sometimes the polariscope shows that it 
has the power of dextro-rotation. This is believed to be milk sugar, or one 
of its derivatives. It is not of constant or regular occurrence. It may be 

* Jahrbuch f lir Kinderheilkunde, Bd. xxxiv, p. 83. 



648 DISEASES OF THE URO-GENITAL SYSTEM. 

produced artificially by increasing the amount of milk sugar above that 
which can be normally absorbed. This quantity Gr6sz places at 3*3 
grammes for each kilogramme of the body weight. If more than this is 
given, or if there is diminished capacity for the absorption of sugar, gly- 
cosuria occurs. 

Koplik has made some observations upon the urine of patients 
fed chiefly upon infant foods composed largely of sugar. He found 
sugar in five out of ten cases examined ; in three, the sugar responded 
both to Fehling's and the fermentation test ; in two cases to Fehling's 
test only. 

There seems to be no doubt regarding the existence of dietetic glyco- 
suria in infants and in older children. Eepeated examinations of the 
urine are, however, necessary in order to exclude more serious disease. 

PYURIA. 

Pus in the urine may exist as an acute or a chronic condition. In 
either case, in a child, it is much more likely to come from the pelvis of the 
kidney than from any other source. It may, however, come from any part 
of the genito-urinary tract— the kidney or its pelvis, the ureters, the blad- 
der, the urethra, or the vagina. Sometimes it comes from an outside 
source, as when an abscess from perinephritis, appendicitis, or caries of 
the spine opens into the urinary tract. 

Coming from the pelvis of the kidney, pus may indicate, if the con- 
dition is an acute one, pyelitis, pyelo-nephritis, or pyonephrosis ; if it is 
chronic, it points to renal tuberculosis or calculus. The amount of pus 
in any of these conditions may be quite large. The urine is turbid and 
usually acid in reaction. It contains many epithelial cells of the transi- 
tional variety. A urine containing much pus is always albuminous. A 
turbidity due to pus may be mistaken for an excessive deposit, of urates; 
they are distinguished by the microscope and by the fact that urates 
clear up on heating. It is rare that pus comes from the ureters except 
in connection with congenital malformations or the impaction of cal- 
culi. Pus from the bladder is not usually in large quantity, and may be 
mixed with mucus. The urine may be alkaline or acid in reaction; there 
may be associated the symptoms of vesical irritation or of cystitis. Pus 
from the lower genital tract is rare in children, and its causes may often 
be recognised by a local examination. When the cause of pyuria is 
the opening of an abscess into the urinary tract there is generally a 
sudden appearance of pus in large amount. The pyuria is in most cases 
of short duration, possibly only a few days, and it may disappear quite 
rapidly. 

The treatment of pyuria depends altogether upon its cause. Improve- 



LITHURIA. 649 

ment in the symptoms nearly always follows the use of urotropin, which 
may be given in doses of from two to five grains three times a day to a 
child of five years. 

LITHURIA. 

Lithuria is a condition in which there is an excessive elimination in 
the urine of uric acid or of urates. The amount of nitrogen compounds 
eliminated by the kidneys as uric acid and urea, varies much from day to 
day with the nature of the food and other conditions. Hence in estimat- 
ing an excess of uric acid, the absolute quantity eliminated in twenty- 
four hours is much less significant than the ratio of the uric acid to the 
urea (page 644). Whenever this ratio is continuously disturbed, the ex- 
cretion of uric acid may be considered abnormal, except, of course, in 
grave pathological conditions of the kidney, where there is an insufficient 
elimination of urea. Regarding the source of uric acid, the theory of 
Horbaczewski is that most widely accepted, viz., that it results from the 
destruction of the nuclein of the cells of the body, particularly of the 
white blood-cells. 

For accurate knowledge as to the amount of uric acid eliminated, 
nothing short of a quantitative chemical analysis can be depended upon. 
But if amorphous urates are deposited in large amount, uric acid may be 
considered excessive if the specific gravity is not high (above 1.025). If 
the specific gravity is high, the precipitation may be explained simply by 
the concentration of the urine. The deposition of the crystals of uric 
acid, forming the familiar brick-dust deposit, is not in itself evidence of 
excessive elimination. For a quantitative clinical test, that of Haycroft 
is probably the best.* 

Lithuria is not a specific condition, but rather a very general symp- 
tom associated with many kinds of disturbances of nutrition. It may be 
found in anaemia, malnutrition, chorea, rheumatism, chronic dyspepsia, 
and in a great variety of other disorders. Regarding the significance of 
lithuria, thus much may be positively asserted : The excessive elimination 
of uric acid when continuous is always evidence of a serious disturbance of 
nutrition. The gravity of the condition will depend upon the degree of 
this excess and upon its duration. 

The treatment of lithuria is the treatment of the condition upon 
which it depends. The essential pathological condition is not so much 
excessive elimination as excessive production. 

Urine containing Crystals of Uric Acid in the Form of Brick-Dust 
Deposit. — This condition is not to be confounded with the one just de- 
scribed. As already stated, such precipitation is not to be taken as evi- 
dence of an excess of uric acid, and, in fact, in most of these cases there 
* — ■ 

* See Haig on Uric Acid in Health and Disease. 



650 DISEASES OF THE URO-GENITAL SYSTEM. 

is no excess. The condition is rather one in which the solvent power of 
the urine for uric acid is much reduced. Such urine, as a rule, is high- 
coloured, strongly acid, and may have a high specific gravity. 

This condition also is dependent upon a disturbance of nutrition, and 
one which is most frequently associated with a gouty diathesis. It is 
not very common in children except in those of gouty antecedents. In 
such patients it is only occasionally present, and is usually associated 
with some other disturbance of nutrition, often of digestion. It is fre- 
quently the cause of local irritation of the urinary passages, which is 
frequently manifested by incontinence of urine. 

In my experience these cases are most improved by cutting off sugar 
from the diet almost entirely, by greatly reducing the amount of starchy 
food and substituting a diet rich in nitrogen and fat, viz., meat, milk, 
and cream, together with plenty of outdoor exercise. The continued use 
of alkaline waters is also of decided advantage in most cases. 



INDICANURIA. 

Indicanuria is a condition characterized by the presence of indican in 
the urine. To Herter is due the credit of bringing this subject promi- 
nently to the minds of the profession in this country. Indican (indoxyl- 
potassium sulphate) is derived from indol, which is formed in the intes- 
tine by the agency of bacteria from the excessive putrefaction of the 
proteids. It may also be produced in other parts of the body where putre- 
factive processes are going on, as in extensive suppuration without drain- 
age, in pulmonary cavities, empyema, etc. Indican is only one of the 
ethereal sulphates produced in the manner above indicated, and when 
other conditions like those mentioned are excluded it may be taken as an 
index of the amount of putrefaction going on in the intestine. 

The presence of indican in the urine is demonstrated by adding certain 
oxidizing agents, which produce an indigo-blue colour.* The existence 

* The commonly employed test for indican is that known as Jaffe's test. It is 
described by Herter as follows : Pour into a test-tube equal quantities of urine and 
strong hydrochloric acid so as to fill the tube to within half an inch of the top, and 
shake. If there is much indican, a dark blue or purple colour will be produced. Then 
add sufficient chloroform to completely fill the tube and shake thoroughly. It is 
important that the chloroform should completely fill the tube so that no air bubbles 
get in by the agitation. If, after standing, the chloroform assumes a deep-blue or vio- 
let colour, there is certainly an excess of indican. The reaction may not appear at 
first, but may come out after standing several hours, or if slight at first it may in- 
crease in intensity. Sometimes, when no reaction is obtained, it may be produced by 
adding one drop of a saturated solution of chloride of lime or of peroxide of hydro- 
gen. No more than one drop should be added at a time, or the blue colour may be 
bleached. In alkaline urine the indican is usually destroyed, so that the test may be 
negative. 



ACETONURIA— DIACETONURIA. 651 

of indicanuria in children was formerly believed to be pathognomonic of 
tuberculosis. Later investigations have shown that this is not the case ; for 
in cases of tuberculosis indican is almost as frequently absent as present. 

Herter gives the following as the conditions under which indicanuria 
is likely to be present : It is found in chronic intestinal indigestion ; in 
very many cases of chronic constipation ; in many cases of epilepsy, just 
about the time of the seizures ; in some cases of masturbation ; frequently 
in children who are the subjects of night terrors, and in whom there 
are usually disturbances of digestion. According to other observers, 
it is found with great constancy in acute putrefactive diarrhoeas. With 
the exceptions above noted, the source of the indican is always the 
same, viz., the excessive putrefaction of the proteid substances in the 
intestine. 

Indicanuria is most frequently a symptom either of acute or chronic 
intestinal disease. It is important as being a guide by which we may 
estimate the other symptoms in these conditions, and the effects of 
treatment. While a trace of indican is frequently present in health, a 
strong indican reaction is always to be considered abnormal in a child. 
The indications for treatment are to diminish intestinal putrefaction. 
This is mainly dietetic. Indicanuria is usually increased by a meat diet 
and diminished by a milk diet. Other measures are referred to in the 
treatment of chronic intestinal indigestion. 

ACETONURIA— DIACETONURIA. 

Acetone exists in small quantities in the urine of healthy children. 
According to Baginsky and Schrach, it is found in large quantities in 
many febrile diseases. It increases with the height of the fever and 
subsides with it. Acetone is probably formed from the destruction of 
the nitrogenous material of the body, as it is increased by a nitrogenous 
diet, and may disappear by a diet of carbohydrates. Baginsky found it 
also in children with epilepsy, sometimes during the attacks. It is not, 
however, believed to be the cause of the convulsive seizures, as it is absent 
in convulsions occurring under other conditions. There is no connection 
between acetonuria and the nervous symptoms accompanying fever. 

Acetone and diacetic acid are regularly found in the urine of patients 
suffering from cyclic vomiting; they are probably a result, not the cause 
of the attacks. In progressing cases of diabetes and in diabetic coma 
both these substances are present. 

Binet found diacetic acid in sixty-nine out of one hundred and fifty 
examinations in febrile diseases, chiefly in scarlet fever, measles, and 
pneumonia. Schrach found diacetonuria exceedingly common in easts 
of continuous high lever. It is more frequently present than acetonuria, 
and ceases with the fever.* 

* For literature, see Baginsky, Archiv fur Kinderheilkunde, Bd. xi, p. 1. 



652 DISEASES OF THE URO-GENITAL SYSTEM. 



ANURIA. 

By this term is meant an arrest of the urinary secretion. To that form 
which occurs in the course of renal disease the term " suppression " is gen- 
erally applied. Anuria is to be carefully distinguished from retention, 
from the scanty secretion which occurs whenever food is refused or with- 
held on account of illness, and also from that which accompanies acute 
diarrhoea, with large, watery discharges. Anuria is sometimes seen in the 
newly born, where it depends upon some malformation of the genital 
tract ; or, more frequently, upon uric-acid infarctions in the kidneys. The 
first urine passed after such an attack is very often highly acid, and 
may contain an abundance of uric-acid crystals and larger masses visible 
to the naked eye. Other cases admit of no such explanation, and the 
condition must be regarded as of nervous origin. For the time, the 
secretion appears to be completely arrested, as the bladder, both by pal- 
pation and catheterization, is found to be empty. This condition is not 
a very uncommon one in infancy, and it may continue for from twelve 
to thirty-six hours. So long as infants appear to be perfectly normal 
in every other respect, the suspension of the urinary secretion even for 
twenty-four hours need excite no anxiety. 

The treatment is very simple and effectual, and consists in the admin- 
istration of sweet spirits of nitre, either alone or in combination with the 
acetate or citrate of potash, and plenty of water. To an infant of three 
months one minim of the nitre and one grain of the citrate of potash may 
be given every hour in half an ounce of water until the urinary secretion 
is established, which will usually be in six or eight hours. If the urine is 
very highly acid, and stains the napkins, the potash should be continued 
for several days. Hot fomentations over the kidneys may be used with 
advantage. 

DIABETES INSIPIDUS (POLYURIA). 

This is a chronic disease characterized by the excretion of a very large 
amount of pale urine of low specific gravity. It is invariably accompanied 
by polydipsia. The disease is an exceedingly rare one in children. 

The exact pathology of diabetes insipidus is not known ; but from the 
conditions under which it occurs it is believed to be a neurosis. The 
irritation which gives rise to it may be in or near the floor of the fourth 
ventricle, or it may affect the renal nerves. 

Etiology. — Of eighty-five cases collected by Strauss, twenty-one were 
under ten years of age and nine under five years. In Eoberts' collection 
of seventy cases, the disease began in twenty-two before ten years, and 
in seven during infancy. In some cases it begins soon after birth. Males 
are more frequently affected than females, and in certain cases heredity is 
an important factor. Weil has published a remarkable example of the 



DIABETES INSIPIDUS. 



653 



disease existing in many members of a single family. Falls or blows upon 
the head, concussion of the brain, tumours of the brain, especially of the 
occipital region, tuberculous or cerebro-spinal meningitis or chronic hy- 
drocephalus, all have been found associated with diabetes insipidus. It 
sometimes has followed the acute infectious diseases ; but in many cases 
no cause whatever can be found. 

Symptoms. — The quantity of urine is enormous, usually exceeding even 
that in diabetes mellitus. From five to twenty pints daily may be passed. 
The urine is pale, the specific gravity from 1-001 to 1*006, and it contains 
neither albumin nor grape sugar. In a few cases the presence of inosite 
(muscle sugar) has been found. Eestricting the amount of fluid taken 
causes a very marked diminution in the amount of urine. The intense 
thirst leads patients to drink enormously of water and other fluids. Vari- 
ous contradictory statements are made by different writers regarding the 
quantity of uric acid and urea eliminated in these cases. The following 
are the results obtained in a case recently under observation in the Babies' 
Hospital.* The child was three years old, quite anaemic, and losing in 
weight. On January 20th the fluids were unrestricted, on the other days 
they were restricted : 



Date. 


Daily quantity of 
urine. 


Specific 
gravity. 


Total 
urea. 


Total 
uric acid. 


Indican 
reaction. 


Inosite. 


January 20 


Grammes. 

3,300 

750 

775 

1,320 


Ounces. 

101i 

25 

49 


1-006 
1-010 
1-010 
1-007 


Grammes. 

22-276 

9-049 

6-478 

12-113 


Grammes. 

0-173 
0-072 

6 : iio 


None. 
Strong. 

None. 


None. 


25 


None. 


" 26 


None. 


February 8 


None. 







The elimination of urea in this case is excessive, but the uric acid is 
not far from the normal. 

Nervous symptoms are usually present. There may be disturbed sleep 
from the frequent micturition, palpitation, flushing of the face and other 
vaso-motor disturbances, headache, restlessness, and neuralgia. There 
may be incontinence of urine. The skin is pale and dry, and perspiration 
is scanty. The general health may not be disturbed. In most cases, how- 
ever, it is somewhat affected, and there may be the usual symptoms of 
malnutrition, and even neurasthenia. If it affects young children, their 
growth may be considerably retarded. The appetite usually remains quite 
good. The temperature is at times slightly subnormal. The course of 
the disease is indefinite. It is very chronic, and may last for many years, 
death taking place only from intercurrent affections. 

Prognosis. — A few of the cases recover spontaneously. Those of short 
duration are often cured by treatment. Of the chronic cases in which 



* The analyses were made by Dr. C. A. Herter. 



654 DISEASES OF THE TTRO-GENITAL SYSTEM. 

the disease is well established very few are controlled. The prognosis is 
worse if there are marked disturbances of the digestive tract or organic 
brain disease. 

Diagnosis. — This is easily made from the two marked symptoms, ex- 
cessive thirst and polyuria. From diabetes mellitus it is easily distin- 
guished by the lower specific gravity and the absence of sugar from the 
urine. In older children, chronic nephritis with contracted kidney may 
be confounded with it. 

Treatment. — Fluids should be moderately restricted. It is a serious 
mistake to reduce the quantity of fluids too much, since the drinking is 
not the cause of the diuresis. The diet should be simple and nutritious, 
consisting largely of meat, with a moderate amount of carbohydrates. The 
general treatment should be directed to the condition of malnutrition. 
The clothing should be warm, and a moderate amount of exercise should 
be allowed. Drugs are of little use ; those which have sometimes been 
beneficial are arsenic, belladonna, ergo tine, the bromides, and antipyrine. 
Treatment must be continued for many months to be of any value. 



CHAPTER II. 

DISEASES OF THE KIDNEYS. 

MALFORMATIONS AND MALPOSITIONS. 

Malfokmations of the kidney are not infrequent. In seven hun- 
dred and twenty-six consecutive autopsies at the New York Infant Asy- 
lum malformations of the kidney or ureters were met with in seventeen 
cases. This does not represent the actual frequency with which they 
occur, for in about half that number of autopsies in two other institutions 
only a single example was seen. Adding to the cases mentioned two 
others seen elsewhere, there are twenty cases of renal malformation of 
which I have notes, classed as follows : 

Fusion of the kidneys, or horseshoe kidney 4 eases. 

Supernumerary ureters 4 " 

Hydronephrosis (alone) 8 " 

Cystic degeneration of the kidney (alone) 2 " 

Hydronephrosis and cystic kidney 1 case. 

Single kidney 1 " 

In all malformations the left kidney is much more frequently affected 
than the right, the proportion being nearly two to one. Malformations 
are more often seen in males than in females. 



MALFORMATIONS AND MALPOSITIONS OF THE KIDNEY. 655 

Fusion of the Kidneys. — In one case, in a child who died of pneumonia 
at the age of three years, the kidneys were fused into one irregular ovoid 
mass, lying upon the lumbar vertebrae ; in another case the mass lay upon 
the promontory of the sacrum ; in both there were two renal arteries and 
two ureters. In the two other cases the organs were united at their lower ex- 
tremities, and in both of these there were two ureters passing in front of the 
kidney. In one there was also hydronephrosis and chronic diffuse nephritis. 
The children died at the ages of four and five months respectively. 

Cystic Degeneration of the Kidneys. — In two of these three cases the 
right kidney was affected, and in one the left. The ages at which the chil- 
dren died were from seven to ten months. No renal symptoms were pres- 
ent. In all the cases the cystic kidney was very small, about an inch and 
a half in length and one inch in width. The organ was entirely made up 
of smaller and larger cysts containing a clear fluid, held together by loose 
connective tissue. The ureter was small and rarely pervious throughout. 
In one case there was hydronephrosis of the opposite side ; in the others 
the opposite kidney was considerably enlarged, being about one half larger 
than normal. In addition to these small cystic kidneys there has been 
described a cystic degeneration in which very large cysts have formed even 
in utero, sometimes filling the abdominal cavity of the child and seriously 
interfering with delivery. 

Single Kidney, the other being rudimentary or absent. — Of this I have 
seen but one example, which was found in a young man twenty-two years 
of age, who died of typhus fever in Bellevue Hospital. The right kidney 
weighed seven and a half ounces ; the left was represented by a nodular 
mass about the size of an ovary, showing no trace of renal tissue. The 
ureter was pervious to within four inches of the kidney ; the suprarenal 
capsule was normal. Macdonald has reported a case in which there was 
no trace whatever of the right kidney ; the left was greatly enlarged, and 
weighed nine ounces. There were two suprarenal capsules but only one 
ureter. Schaeffer has reported absence of both kidne} 7 s in a seven-months' 
foetus, associated with many other malformations. 

Hydronephrosis. — Of the ten cases of which I have notes, this existed 
as the principal deformity in eight. In two cases it was associated respec- 
tively with cystic degeneration of the opposite kidney and horseshoe kid- 
ney. In seven cases only the left side was affected ; in three there was 
double hydronephrosis. Seven patients were males and three females. 
Six died before they were six months old, and only two lived to be two 
years old. This condition is undoubtedly the result of some obstruction 
to the outflow of urine in the ureter, bladder, urethra, or prepuce, but in 
only three of my cases could there .be found an obstruction sufficient to 
explain the deformity. In two there was marked hypertrophy of the 
bladder. In no case was a calculus found as the cause of the obstruction. 
In most of the cases the ureter was dilated to a diameter of from one 



656 DISEASES OF THE URO-GENITAL SYSTEM. 

fourth to one half of an inch, and in two it was so large as to be easily 
mistaken for the small intestine. Usually the ureters appeared much 
elongated and sacculated; the pelvis of the kidney was dilated to the 
capacity of half an ounce or more, the calices forming pockets about half 
an inch in diameter. Less frequently the greater part of the kidney was 
destroyed, leaving only a series of communicating pockets surrounded 
by a thin cortex of renal tissue from one fourth to one eighth of an 
inch in thickness. In five cases there was chronic diffuse nephritis of 
the affected side, and sometimes both kidneys were involved, even though 
the hydronephrosis was unilateral. The nephritis was usually of a very 
advanced type. In two cases, typical examples of the atrophic form (con- 
tracted kidney) were seen, one of these children dying at the age of one 
month.* The organs are shown in Fig. 118. 

Urinary symptoms were noted in but one case, and in that they were 
due to pyelo-nephritis dependent upon the presence of calculi in the kidney 
not the seat of hydronephrosis. In no other case was the malformation sus- 
pected during life. Four patients died of marasmus, two of acute broncho- 
pneumonia, and one of ileo- colitis. In only one was there any malforma- 
tion outside the urinary tract, this being a case of congenital heart disease. 

Double hydronephrosis is generally associated with, or results in, such 
changes in the kidneys that the patients die during infancy. It may 
give rise to one or more tumours, which sometimes attain a large size. 
Changes in the urine may not be present until the disease is very far 
advanced. There may be the general and local symptoms of chronic 
diffuse nephritis, or, when infection of the genital tract occurs, there are 
added the symptoms of pyelitis. In the great majority of cases the con- 
dition is unrecognised, the patient dying of some disease not perhaps in 
itself fatal, but rendered so by the condition of the kidneys. 

If hydronephrosis is unilateral there may be no symptoms until the 

* This was in every way a remarkable case. The child died apparently of maras- 
mus. There was double hydronephrosis, the ureters being three fourths of an inch in 
diameter. The right kidney was nodular upon the surface, and had a very adherent 
capsule. Just beneath the capsule there were small cysts containing pus. The left 
kidney was the seat of hydronephrosis, only its cortex remaining, this being about one 
sixth of an inch in thickness. Microscopical examination showed great thickening of 
the capsule of the right kidney, and several small abscesses situated in the cortex 
just beneath the capsule. The rest of the kidney was converted into a mass of dense 
fibrous tissue in which were scattered many uriniferous tubules, the epithelium of 
which was clear, nucleated, and of the embryonic type. The left kidney was the seat 
of chronic diffuse nephritis of the atrophic variety, with well-marked changes in the 
medullary portions. The cortex showed much exudation and less atrophy, being nearly 
normal in thickness. The small size of the organ was due chiefly to atrophy of the 
pyramids. The walls of the bladder were greatly hypertrophied, being in places one 
fourth of an inch thick. The urethra and prepuce were normal. 



MALFORMATIONS AND MALPOSITIONS OF THE KIDNEY. 657 

dilatation of the pelvis of the kidney has reached a sufficient size to form 
an abdominal tumour. In most of the cases in children this condition 
has been noted between the third and the eleventh years. This tumour 
may be situated in the lumbar region, or it may fill the abdomen. It is 
cystic, and may be confounded with a dermoid cyst of the ovary. On 




Fig. 118. — Congenital hydronephrosis, dilated ureters, and hypertrophied bladder. (From a child 

one month old.) 

aspiration a fluid is withdrawn which may be clear, or of a brownish 
colour, and recognised as urine by the fact that it contains urates and 
urea. After aspiration the urine passed per urethram may be bloody. 
Aspiration affords only temporary relief, as the tumour quickly refills. If 
an incision is made and the kidney drained, a cure may result with the 
formation of a fistula. This may continue indefinitely, or infection of 
the fistulous tract may occur and suppurative nephritis be set up, which 



658 DISEASES OF THE URO-GENITAL SYSTEM. 

speedily carries off the patient. A better operation is nephrectomy, 
which may result in a permanent cure if the opposite kidney is healthy, 
which is usually the case if the child is over three years of age for the 
reason above stated, viz., that a child with malformation of both kidneys 
usually dies in infancy. 

Supernumerary Ureters. — These were noted in four cases, more fre- 
quently on the left side. The usual deformity was for two ureters to be 
given off, one from the upper and one from the lower part of the kidney, 
each ureter having a separate pelvis. The ureters either joined just 
above the bladder, or entered this organ by separate openings. This 
condition is of no practical importance, and was not found associated 
with other renal changes. 

Malposition of the Kidney. — This was noted in my series of autopsies 
only once, in the case of fusion of the kidneys already mentioned. Of 
21 cases collected by Eoberts, the displacement was always of one kidney 
only; the left being displaced 15 times, the right 6 times. Northrup 
has reported two cases, both displacements of the left kidney; in one, 
the organ lay in the hollow of the sacrum ; in the other, in the median 
line, partly above and partly below the promontory of the sacrum. Mal- 
positions of the kidney are compatible with perfect health and develop- 
ment. In most of the cases there is no other deformity present. 

Movable Kidney. — This is a very rare condition in early life. Comby 
(Paris) has collected 18 cases, of which 16 were in girls and 2 in boys. 
Movable kidney was recognised before the tenth year in 8 cases, and in 
2 of these before the fourth month. It has been ascribed to too long a 
pedicle, which may be congenital; also to pressure from abdominal 
tumours, and to injury. The most important symptoms are paroxysmal 
pain which may follow exertion, and a movable tumour. A twist in the 
ureter may produce hydronephrosis. 

URIC-ACID INFARCTIONS. 

These consist in a deposit in the straight tubes of the kidneys of uric 
acid or of amorphous or crystalline urates ; usually both kidneys are af- 
fected, and all the pyramids of each kidney. The infarctions appear to 
the naked eye as fine, brownish, fan-shaped striae. Associated with them 
there may be granular deposits of uric-acid salts in the pelvis of the kid- 
ney, and sometimes evidences of catarrhal inflammation of the pelvis, 
including even the presence of blood. This condition probably occurs, 
to some degree at least, in nearly all infants during the first ten days 
of life. It was formerly supposed that the discovery of these appear- 
ances was proof that an infant had breathed, and a certain medico-legal 
importance was therefore attached to them. This is now known not to 
be the case, as they are sometimes found in still-born infants. 

The cause of this condition is the excretion of uric acid before there 



CHRONIC CONGESTION OF THE KIDNEY 659 

is sufficient water to dissolve it, so that the crystals are deposited in the 
tubes. Uric-acid infarctions are found chiefly in children dying before 
the end of the second week, although it is not uncommon to see them as 
late as the third or fourth or even the sixth month. In most of the 
cases, as the urinary secretion becomes more abundant, the deposits are 
washed out in the urine and appear as brownish red or pink stains upon 
the napkins. Infarctions may give rise to a slight inflammation of the 
renal tubules, but very rarely to any serious lesion ; sometimes they re- 
main as deposits in the calices or the pelvis of the kidney or in the 
bladder, forming the nucleus of a calculus. The symptoms to which 
they give rise are mainly scanty urination during the first week of life, 
and occasionally anuria for the first day or two. Sometimes there is 
evidence of severe pain; priapism may be present, and there is the stain 
upon the napkin already referred to. The treatment is to give water 
freely and some alkaline diuretic such as citrate of potash. One grain 
should be given every two hours until the secretion is fully established ; 
this in most cases will be within twenty-four hours. 

ACUTE CONGESTION OF THE KIDNEY. 

In acute congestion of the kidney all its blood-vessels contain much 
more blood than normal, and from them there may be an escape of serum 
and even of the red blood-cells by diapedesis. This congestion may 
result from traumatism, the ingestion of certain poisons, from any of 
the infectious diseases, or from cold. 

The urine is usually scanty, of high specific gravity, and contains 
albumin and red blood-cells, sometimes blood casts. This may be only a 
temporary condition passing off in a few days without further symptoms, 
or it may exist as the first stage of acute nephritis. It is most serious 
when it occurs in kidneys already the seat of serious disease. There are 
sometimes no symptoms except those of the urine; or there may be 
headache, pain in the back, and some general indisposition. 

The treatment consists in free catharsis, the use of hot vapour 
baths, and counter-irritation over the kidneys by means of hot poultices 
or dry cups. 

CHRONIC CONGESTION OF THE KIDNEY. 

This results from interference with the return circulation of the 
kidney, and may be caused by congenital malformation or valvular dis- 
ease of the heart, chronic broncho-pneumonia or chronic pleurisy; also 
by the pressure of any abdominal tumour upon the inferior vena cava 
or the renal veins. 

The kidneys are generally enlarged, firmer than normal, and dark- 
coloured. All the capillary vessels are swollen and distended with blood, 
and their walls are thickened. In addition to the symptoms of the pri- 



660 DISEASES OF THE URO-GENITAL SYSTEM. 

mary disease, the amount of urine passed is usually scanty and of high 
specific gravity. Albumin and casts are generally present, but are not 
constant. The treatment should be directed toward the primary con- 
dition, and, in addition, an effort should be made to increase the urine 
by alkaline diuretics, caffein, digitalis, and the sweet spirits of nitre. 

ACUTE DEGENERATION OF THE KIDNEYS. 

In the succeeding pages devoted to the kidney I have followed in 
the main Prudden's classification. 

In acute degeneration of the kidney the principal or only change is 
in the epithelium of the tubules. It is exceedingly common both in in- 
fancy and in childhood, being found to a greater or less degree in all 
autopsies upon patients dying of acute infectious diseases, but it is most 
marked in cases of scarlet fever, diphtheria, and acute pleuro-pneumo- 
nia. It may be found in any disease characterized by prolonged high 
temperature; and it is the explanation of the cases of so-called febrile 
albuminuria. The cause is in all probability direct irritation of the 
epithelium of the tubules by the toxins eliminated by the kidneys. It 
may also be induced by irritating drugs, such as cantharides or turpen- 
tine. By some writers these cases have been classed as examples of 
acute nephritis ; hence the great discrepancy which exists in statements 
made as to the frequency of nephritis in the different infectious diseases. 

The kidneys are usually slightly enlarged, softer, and paler than 
normal. On section the cortex may be somewhat thickened, and the 
straight tubules marked by yellowish-gray lines. It is the appearance 
commonly spoken of as cloudy swelling. The kidneys are seldom much 
congested. The microscope shows a granular degeneration and death of 
the epithelium of the tubules, and when severe this may be accompanied 
by congestion and the exudation of serum. 

Acute degeneration of the kidneys gives rise to no symptoms in addi- 
tion to those of the original disease, except the appearance of a moderate 
amount of albumin in the urine, with a few hyaline, epithelial, or gran- 
ular casts. It can not be said that such a condition adds much to the 
danger from the original disease. In cases that recover, the condition of 
the kidney entirely clears up. The development of the symptoms of 
degeneration of the kidneys in infectious diseases calls for no special 
treatment beyond a continuance of the fluid diet. 

ACUTE DIFFUSE NEPHRITIS. 

Synonyms : Acute interstitial nephritis, acute exudative nephritis, 
glomerulonephritis, acute Bright's disease. 

Etiology. — This variety of nephritis occurs apparently as a primary 
disease both in infants and in older children. Most such cases are un- 
doubtedly of infectious origin, although the point of entrance of the 



ACUTE DIFFUSE NEPHRITIS. 661 

infection may be difficult or impossible to determine. Acute diffuse 
nephritis is very frequently secondary to the acute infectious diseases, 
especially to scarlet fever and diphtheria. It occasionally follows 
measles, varicella, empyema, typhoid fever, acute diarrhceal diseases, 
pneumonia, meningitis, influenza, and malaria. It is the characteristic 
variety of secondary nephritis occurring in severe septic conditions. The 
exciting cause of the inflammation is in some cases the irritation from 
toxins; but usually there is in addition the entrance of pathogenic or- 
ganisms carried by the circulation. Thus in post-scarlatinal nephritis, 
of which the one under consideration is the characteristic form, the 
cause is now generally admitted to be the toxins of the primary disease, 
to which in many cases is added infection by the streptococcus. While 
nephritis is more frequent after severe attacks of scarlet fever, it may 
occur after those which are very mild, even when patients have been kept 
in bed throughout the disease. I have seen two cases of acute nephritis 
in infants, the apparent cause of which was the irritation of a highly 
concentrated urine. This was the result of the infants taking for a long 
time very little food, and almost no water. The frequency of nephritis 
as a sequel of scarlet fever varies much in different epidemics ; the average 
is from six to ten per cent. 

Lesions. — In severe cases the kidneys are usually enlarged, soft, and 
cedematous. The capsule is non-adherent. The cortex is thickened, 
either reddened or pale ; frequently it is mottled with red, owing to the 
presence of small haemorrhages. There may be congestion of the entire 
organ; or the pyramids may seem unusually red by contrast with the 
pale and thickened cortex. 

All the structures of the kidney — glomeruli, tubular epithelium, and 
interstitial tissue — are involved in the inflammatory process. The cells 
covering the glomerular tufts of capillaries are swollen and proliferated. 
They have frequently undergone fatty degeneration and separated. The 
epithelial cells lining Bowman's capsule may undergo the same changes, 
but usually to a lesser degree. The space between the capsule and the 
tuft may contain exfoliated epithelium in considerable quantity, also 
cell-detritus, albuminous (granular) exudate, leucocytes, and red blood- 
cells. The tubular epithelium undergoes albuminous and fatty degen- 
eration and may desquamate. Thus the tubules may contain epithelial 
fragments, serum, red blood-cells and leucocytes, and some form of casts. 
The interstitial connective tissue is infiltrated with serous or fibri- 
nous exudate and in places with small round cells. In cases of longer 
duration a general increase of the connective tissue may take place, 
which is permanent. 

When the glomerular changes are especially marked, as in acute 
nephritis following scarlet fever, the process is often spoken of as 
glomerulo-nephritis. If the degeneration of the tubular epithelium is 



662 DISEASES OE THE URO-GENITAL SYSTEM. 

extreme, as in severe cases of diphtheria dying shortly after the onset, 
the nephritis may be described as the parenchymatous or degenerative 
type. In the hemorrhagic form there are haemorrhages into the tubules, 
glomeruli, or interstitial tissue. In infants and young children the 
exudative type of acute diffuse nephritis is especially frequent. In 
this there is an exudative inflammation with large accumulations of 
leucocytes, serum, and red blood-cells in the glomeruli and tubules, the 
parenchyma and interstitial tissue sometimes being markedly and some- 
times but slightly changed. Should the interstitial tissue suffer early and 
severely, the nephritis becomes of the productive or interstitial type. 
This form is most frequently seen with severe, protracted cases of scarlet 
fever and diphtheria,* especially in older children. It sometimes occurs 
as an apparently independent process. 

Symptoms. — 1. Primary form in infants. — These cases are not com- 
mon, and the symptoms are so obscure that they are usually overlooked. 
In 1887 f I published five cases of my own, and collected from literature 
fourteen other examples of nephritis, apparently primary, in children 
under two years of age. Since that time five additional cases have come 
under my observation. The inflammation in most of them was of the 
exudative type. 

In the exudative type the onset in nearly every instance was abrupt, 
usually with high fever and vomiting, the temperature being in several 
cases over 104° F. Dropsy was very exceptional, being noted in but six 
cases ; in most of these it was slight, and seen only toward the close of 
the disease. Fever was present in all cases. In those observed by my- 
self it was high and irregular in type, ranging from 101° to 105° F. The 
duration of the disease was from eight days to four weeks, the average 
being about two and a half weeks. Vomiting and diarrhoea were noted 
in half the cases, but were rarely prominent, and marked either the onset 
of the attack, or were traceable to indigestion accompanying the fever; 
very rarely did they exist as symptoms of uraemia. Anaemia was a 
prominent symptom in nearly every case, and it was this which enabled 
me in several instances to make a correct diagnosis. Nervous symp- 
toms were usually prominent. In several patients there was dyspnoea 
without pulmonary disease, partly due, no doubt, to the anaemia. In 
nearly all cases there was marked restlessness or muscular twitchings : 
and in three there were convulsions. Dulness and apathy were present 
in the majority of the fatal cases, but deep coma was never seen. Sev- 
eral patients presented the typical symptoms of the typhoid condition. 
The urine was rarely scanty until near the close of the disease, and 
sometimes not even then. Suppression of urine occurred in but a few 

* Councilman, Mallory, and Pearce, Diphtheria : A Study of the Bacteriology and 
Pathology of Two Hundred and Twenty Fatal Cases, 1901. 
f Archives of Paediatrics, vol. iv, pp. 1, 103 ; and ix, p. 263. 



ACUTE DIFFUSE NEPHRITIS. 663 

cases. Albumin was frequently absent early in the attack, but was in- 
variably present at a late period, although rarely in large amount. Casts 
were found in all cases that were carefully examined microscopically. 
They were not usually numerous, and were chiefly of the hyaline, granu- 
lar, and epithelial varieties. No blood casts were seen. There were 
usually many pus cells and renal epithelial cells, together with red 
blood-cells in moderate numbers. 

Of the twenty-four cases, sixteen died and eight recovered. Of my 
own ten cases, nine were fatal, the diagnosis being confirmed by autopsy 
in every case but two. Whether these figures represent the actual mor- 
tality of the disease it is difficult to say. No doubt there are many mild 
cases which are unrecognised. The severe ones, however, are quite uni- 
formly fatal, chiefly on account of the tender age of the patients. 

2. Primary form in older children. — This also is a rare form of renal 
disease. As compared with the same condition in infants, the onset is 
usually less abrupt, the febrile symptoms are less marked, and the ter- 
mination is less frequently fatal. Dropsy is rarely marked, and often 
there is none at all. The urine is only slightly diminished in quantity; 
the amount of albumin is small; casts are not numerous, and usually 
hyaline, epithelial, or granular ; very rarely is there much blood present. 
Uraemia is infrequent, and the prognosis is better than in infancy. 

The interstitial type may begin abruptly with febrile symptoms, 
dropsy, headache, lumbar pains, scanty urine, and often with vomiting; 
or it may come on somewhat insidiously with few constitutional symp- 
toms, but with dropsy and changes in the urine. 

3. Secondary form. — The secondary nephritis of acute infectious dis- 
eases usually occurs at the height of the febrile process, and its severity 
is generally proportionate to the intensity of the infection. The general 
symptoms of nephritis are often not marked, and dropsy is rare; so 
that unless the urine is examined the condition may be overlooked. The 
urinary changes are essentially the same as those already mentioned in 
the primary cases. Suppression of urine and the development of the 
symptoms of acute uraemia are infrequent. While nephritis adds con- 
siderably to the danger from the primary disease, it is seldom itself the 
cause of death, although this is sometimes the case in scarlet fever or 
diphtheria. 

The characteristic type of nephritis which follows scarlet fever most 
frequently develops during the third or fourth week of the disease. The 
onset may be gradual, dropsy being first noticed. Or it may begin 
abruptly without dropsy, but with headache, vomiting, scanty urine, fever, 
and even convulsions. The temperature generally ranges from 100° to 
101.5° F., but in very severe attacks it may be 104° or 105° F. While 
dropsy is usually present, it may be slight or absent in severe and even in 
fatal cases. It is first seen in the face, next in the feet, legs, and scrotum ; 



BB4 DISEASES OF THE URO-GENITAL SYSTEM. 

itiexQ may be general anasarca, with, dropsy of the serous cavities of the 
"body, the pleura, or the peritonaeum, rarely the pericardium. As the 
disease progresses there is always a very marked degree of anaemia. 

The urine is, as a rule, greatly diminished in quantity, and may be 
suppressed. Albumin is invariably present, and usually in large amount, 
often enough to render the urine solid upon boiling. The urine is of a 
dark, reddish brown or smoky colour, owing to the presence of red blood- 
cells or haemoglobin. The total amount of urea eliminated is far 
below the normal. The specific gravity may be low, even though the 
quantity is very small. Casts are present in great numbers, chiefly hya- 
line, granular, and epithelial casts from the straight tubes; not in- 
frequently there are blood casts. Occasionally twisted or cork-screw 
casts are seen. Red blood-cells are present in great numbers; also many 
leucocytes, and always a large amount of renal epithelium. 

The duration of the active symptoms in cases terminating in recovery 
is from one to three weeks. The temperature and dropsy gradually sub- 
side. Improvement in the urine is shown by an increase in quantity, by 
increased elimination of urea, and by a diminution in the amount of 
blood, albumin, and the number of casts. A few casts may persist for 
several weeks, a&d a small amount of albumin for two or three months. 

In the graver cases, where the onset is accompanied by high temper- 
ature, pain in the back and loins, and a rapid, full pulse of high tension, 
the urine is very scanty and is often suppressed. Then follow the symp- 
toms of uraemia. In children this is usually manifested by vomiting, 
great restlessness or apathy, and often by diarrhoea. Less frequently 
there is headache, dimness of vision, stupor developing into coma, or 
convulsions. If the secretion of urine is re-established, the nervous 
symptoms abate and the patient may recover. This has been known to 
occur after complete suppression has lasted thirty-six hours. Care 
should be taken not to mistake retention for suppression. If doubt 
exists, percussion of the bladder and the use of the catheter will quickly 
settle the question. 

There are several complications for which the physician must con- 
stantly be on the lookout during attacks of acute nephritis; the most 
frequent are pneumonia, pleurisy, pericarditis, and endocarditis; more 
rarely there may be meningitis and oedema of the glottis. It is from 
complications or acute uraemia that death usually occurs. 

Prognosis. — This is to be considered from two points of view : first, 
the danger to life during the acute stage of the disease, and, secondly, 
the danger of the development of chronic nephritis. The great majority 
of patients survive the acute stage, and not infrequently even those re- 
cover who have presented grave symptoms of uraemic poisoning. The 
quantity and specific gravity of the urine, and the number and variety of 
the casts, are a much better guide in prognosis than the amount of albu- 



ACUTE DIFFUSE NEPHRITIS. 665 

min. The existence of severe nervous symptoms, such as stupor, intense 
headache, dimness of vision, and persistent vomiting, add much to the 
gravity of the case, as does also the presence of any serious complication. 
In general it may be said that if there is no suppression of urine, or if 
there are no symptoms of uraemia and no complications, recovery is 
almost certain if the child is over three years old; in younger children 
the outlook is less favourable. The general opinion prevails that acute 
diffuse nephritis in childhood, whether it is primary or occurs as a com- 
plication of scarlet fever, is rarely followed by the chronic form of the 
disease; and such was the view I formerly held. Larger experience, 
however, has convinced me that this sequel is not very uncommon. The 
interval of apparent health may sometimes cover a period of several 
years, and the later nephritis may be attributed to other causes ; but all 
cases of scarlatinal nephritis should be carefully watched for a long time, 
and after a severe attack a guarded prognosis should always be given as 
regards the ultimate result.* 

Treatment. — Prophylaxis is important, and relates principally to the 
secondary form which occurs in the course of infectious diseases, espe- 
cially post-scarlatinal nephritis; but the measures here outlined apply 
equally to all varieties. The inflammation of the kidney being in most 
of these cases the result of direct irritation by the toxins which are elim- 
inated by them, it follows that elimination through the skin and intes- 
tines should be increased, and that the urine should be rendered as little 
irritating as possible by largely increasing its quantity. The first indi- 
cation is met by frequent sponging, warm baths, and keeping the bowels 
freely opened by saline cathartics, sufficient being given to produce one or 
two loose movements daily. To meet the second indication, the patient 
should be kept upon a fluid diet, preferably milk, at least for the three 
weeks of the disease, and, if possible, for a full month. At the same 
time he should drink very freely of alkaline mineral waters, or of plain 
water to which a small dose (two or three grains) of some alkaline diu- 
retic like the citrate of potassium has been added. If milk is not well 
borne, kumyss, whey, buttermilk, or junket may be used, or thin gruels 
mixed with milk. When the first trace of albumin appears in the urine 
this plan of treatment should invariably be followed. In addition to 
these measures, after an attack of scarlet fever the patient should be 
kept in bed for at least a week after the temperature has become normal. 

i * The following case may be cited as an illustration of this point : A girl at the age 
of seven years had scarlet fever, followed by nephritis ; the dropsy having lasted, it 
was reported, for three months. She was believed to have recovered perfectly, and 
remained in apparent health until she was sixteen, when, as a supposed result of a 
severe chilling, she developed dropsy and all the symptoms of acute nephritis. From 
that time, although she lived for three years, and was often for months at a time 
seemingly in the best of health, her urine was never free from casts and albumin, and 
she finally died in uraemic convulsions. 






666 DISEASES OP THE URO-GENITAL SYSTEM. 

The mild cases of acute nephritis tend to spontaneous recovery under 
the hygienic and dietetic treatment mentioned — i. e., rest in bed, fluid 
diet, the drinking of large quantities of water, and attention to the 
action of the skin and bowels. These measures should be continued so 
long as the urine contains any considerable amount of albumin, or so 
long as the patient's general condition will permit. Should he become 
very anaemic, or lose much in weight, it may be necessary to enlarge the 
diet by the addition of solid food. This should at first be of the car- 
bohydrates only, usually in the form of some farinaceous food. An in- 
crease in the diet and exercise should be made very gradually, and the 
effect upon the urine carefully watched. 

The severe cases, with scanty urine, fever, and marked dropsy, require 
more active treatment. Free diaphoresis should be maintained by the 
hot pack or vapour bath (page 56). Active counter-irritation should 
be maintained over the kidneys by dry cups followed by poultices, or 
the mustard paste. Two or three loose movements 'from the bowels 
should be secured by the administration of calomel, or, better, by Ko- 
chelle, or Epsom salts. Harm is sometimes done by carrying this deple- 
tion too far, and its effect upon the patient's general condition must 
be closely watched. If suppression of urine occurs with the development 
of uraemic symptoms — delirium, high temperature, flushed face, vomit- 
ing, and a pulse of high tension — nitroglycerin is indicated; a child of 
five years may take gr. s fa every hour for five or six doses, or until an 
effect is produced. 

In addition to these measures rectal injections of a normal salt solu- 
tion should be given high in the colon, at a temperature of from 104° 
to 108° F. At least a pint should be given several times a day, to be 
continued until a free flow of urine is established. This is one of the 
most valuable means we possess of increasing elimination by the kidneys 
and skin. 

The nervous symptoms of uraemia are best relieved by chloral or 
chloralamid, which should be given per rectum. When such symptoms 
are marked, from six to ten grains are required for a child of five years, to 
be repeated in two hours if no improvement is seen. Uraemic convulsions 
may sometimes be averted by the use of morphine hypodermically. In 
extreme conditions not relieved by the measures mentioned, venesection 
should by all means be practised ; from three to six ounces of blood may 
be drawn from a child of five years, according to his general condition 
and the urgency of the symptoms. The depressing effect may largely be 
overcome by immediately following this with an intravenous injection 
of a normal salt solution. Twice as much as the fluid drawn should be 
introduced. This will almost invariably give at least temporary relief, 
which may afford time for the operation of other measures such as ca- 
tharsis and diaphoresis. Pulmonary oedema is no contra-indication to 



CHRONIC NEPHRITIS. 667 

bleeding; the best of all guides as to its use is a pulse of very high 
tension. 

One should always be on the lookout for complications, especially 
dropsy of the serous cavities, pericarditis or endocarditis, and oedema of 
the lungs. Convalescence is nearly always slow, and a patient who has 
suffered from nephritis needs careful attention for a long time. Anaemia 
is always present, and iron is required. The diet must consist largely of 
fluids for several months. If the disease tends to pass into a subacute 
form, the child should, if possible, be sent to a warm climate, and kept 
there during the succeeding winter, and every means taken to improve 
the general nutrition. Flannels should be worn next to the skin, and 
special precautions taken against any exposure which might cause an ex- 
acerbation of the disease. 

CHRONIC NEPHRITIS. 

Chronic inflammation of the kidney is an infrequent condition in 
childhood. In infancy it is almost unknown, except in connection with 
congenital hydronephrosis or other malformations of the kidney. Two 
pathological varieties are met with: (1) Chronic diffuse nephritis of 
the parenchymatous or degenerative type. (2) Chronic diffuse nephri- 
tis of the interstitial or productive type. As the disease progresses the 
former may assume the characteristics of the latter variety. 

Etiology. — Chronic nephritis is most frequently seen as a sequel of 
the acute nephritis of scarlet fever. It also occurs with the prolonged 
suppuration of chronic bone or joint disease, where it may be chronic 
from the beginning. The only other important causes in early life are 
hereditary syphilis, alcoholism, chronic tuberculosis, and valvular dis- 
ease of the heart. Nearly all the cases occur in children over five years 
of age. 

Lesions. — The lesions of chronic nephritis in childhood do not differ 
essentially from those seen in later life. In the chronic parenchymatous 
type the kidneys are usually enlarged, the surface is smooth or slightly 
nodular, and the thickened cortex yellowish white on section. These are 
often called " large white kidneys." On the other hand, the kidneys may 
be nearly normal in appearance, or smaller and with a thinner cortex 
than is usual. In the so-called " large red kidneys " the cortex is red or 
mottled red and yellow, owing to haemorrhages into the tubules or inter- 
stitial tissue. The microscope shows that the renal epithelium is 
swollen, granular, fatty, and degenerated. The tubes contain leucocytes, 
red cells, cast matter, and the detritus of broken-down epithelial cells. 
In some places they are dilated, in others atrophied. In the glomeruli 
there is a growth of capsule cells, compression and atrophy of the tufts, 
with the formation of new connective tissue. When there is waxy de- 
generation, the kidneys are usually considerably enlarged, and of a glis- 
tening gray colour. Amyloid degeneration is seen especially in the 
44 



DISEASES OF THE URO-GENXTAL SYSTEM. 

small arteries of the kidney and the capillary vessels of the tufts. With 
iodine the mahogany-brown reaction is obtained. Amyloid changes in 
the kidney are nearly always associated with similar lesions in the liver 
and spleen, and sometimes also in the intestinal villi. 

In the chronic diffuse nephritis of the interstitial type (granular 
kidney) the organs are smaller than normal, with a nodular surface and 
adherent capsule. The cortex is thinned, and the colour is gray or red. 
In addition to the lesions found in the preceding variety, there is an 
extensive production of new connective tissue, which is irregularly dis- 
tributed throughout the kidneys. The tubules in some places are dilated 
to form cysts of considerable size, while in others they have completely 
disappeared. The glomeruli may be atrophied to little fibrous balls; 
or if chronic congestion has preceded the inflammation, some may be 
large and the capillaries dilated. 

Symptoms. — 1. Chronic nephritis of the parenchymatous type. — This 
form of the disease may be chronic from the outset, or follow an acute 
attack from which the patient is often believed to have recovered com- 
pletely. The symptoms sometimes immediately follow the acute attack-; 
at others there is an interval of apparent recovery, extending over a few 
months or even years. Very rarely no such history of an antecedent 
acute attack can be obtained, and the symptoms come on gradually and 
insidiously. Such cases occur chiefly in older children, and their clinical 
features do not differ essentially from those of adult life. 

As a rule dropsy is present, although it is variable in amount, and 
fluctuates considerably from time to time. There may be not only 
oedema of the cellular tissue, but effusion into the pleura, peritonaeum, 
and even the pericardium. As the case progresses, anaemia is always a 
marked symptom. There are various disturbances of digestion — loss of 
appetite, occasional vomiting, and attacks of diarrhoea. From time to 
time nervous symptoms may be quite prominent, such as headaches, 
sleeplessness, neuralgia, fatigue upon slight exertion, and dyspnoea. At- 
tacks of epistaxis are not infrequent. 

For the greater part of the time the urine contains albumin and casts. 
They vary much in amount at different periods in the disease, according 
to the rapidity of its progress. During periods of exacerbation, both 
albumin and easts are very abundant, while in the intervals the amount 
of albumin may be small and the casts few. The casts are hyaline, 
granular, epithelial, and fatty. The daily quantity of urine is much re- 
duced during the periods of exacerbation, while at other times it may be 
nearly normal. The specific gravity is usually normal or high. 

If waxy degeneration is present, there are generally associated with 
the renal symptoms, others dependent upon waxy changes in other or- 
gans. The spleen and liver are enlarged; there may be ascites and 
diarrhoea, and there is usually present the peculiar " alabaster cachexia." 



CHRONIC NEPHRITIS. 669 

The duration of this form of chronic nephritis depends much upon 
the surroundings of the patient and the treatment. It is rarely shorter 
than two years, and it may last for many years. The progress is always 
irregular, and marked by periods of exacerbation and remission. The 
patients die from acute uraemia, or from complicating pneumonia, pleu- 
risy, pericarditis, endocarditis, or from pulmonary oedema. 

2. Chronic nephritis of the interstitial type. — This is a very rare 
disease in early life, being much less frequent even than the preceding 
variety of nephritis. In some cases there is a history of hereditary 
syphilis ; in others, of chronic alcoholism. The early symptoms are few, 
and the disease usually develops insidiously. The urine is pale, exces- 
sive in amount, and of low specific gravity — 1 *001 to 1 -008. Albumin 
is often absent, and, when found, the quantity is small. Dropsy like- 
wise is rare, and never marked. Nervous symptoms are often prominent, 
such as headache, attacks of spasmodic dyspnoea resembling asthma, 
neuralgias, and disturbances of vision. High arterial tension and hyper- 
trophy of the left ventricle are regular symptoms ; and even atheroma- 
tous degeneration of the arteries may be present. Dickinson reports an 
instance of this in a patient only six years of age. Late in the disease, 
haemorrhages may occur, and these may be the cause of death. Filatoff 
has reported a cerebral haemorrhage in a child of eleven. Acute uraemia 
is, however, the usual termination of this form of nephritis. The course 
is slow, and the disease may be overlooked until the final uraemic symp- 
toms occur. 

Prognosis. — The prognosis of chronic nephritis as to complete re- 
covery is always unfavourable; and although cases are seen in which 
symptoms are absent for several years, they almost invariably return. 
Cases have been reported of recovery from waxy degeneration of the 
kidney after removal of the bone disease upon which the condition 
depended. An extended period of observation is necessary before the pa- 
tient can be pronounced cured. As to the duration of the disease, no 
exact prognosis can be given, because, from the symptoms, it is difficult 
or impossible to determine exactly the extent of the disease in the kidney 
and the rapidity of its progress. The continued passage of a large 
amount of urine of low specific gravity is invariably to be interpreted as 
evidence of fibroid changes in the Malpighian tufts, and is a bad symp- 
tom. A large amount of dropsy, the coexistence of valvular disease of 
the heart, and marked renal insufficiency, as shown by the quantitative 
examination of the urine, are all very unfavourable symptoms. 

Diagnosis. — Chronic nephritis, like the acute forms, is likely to be 
overlooked because of the failure to examine the urine in children. 
Eegular and frequent examinations should be made in all cases of con- 
vulsions, of persistent or frequent headaches, severe anaemia, hyper- 
trophy of the heart, high arterial tension and of general malnutrition, 



670 DISEASES OF THE URO-GENITAL SYSTEM. 

as well as when the more obvious symptoms of renal disease, such as 
dropsy and scanty urine, are present. Nor should one be too ready to 
make the diagnosis of functional albuminuria because he finds albumin 
only occasionally and in small quantity. All such cases demand most 
careful observation and the closest attention for a long period before 
excluding organic renal disease. 

Treatment. — Children with chronic nephritis are to be treated on the 
same general plan as adults. The purpose of treatment is to retard as 
much as possible the progress of the disease and to relieve the symptoms 
as they arise. It is of the greatest importance to remove the patient 
from conditions in which exacerbations are liable to occur. If it is 
possible, he should be sent to a warm, dry climate in winter, and all 
exposure to cold avoided; an out-door life is desirable. Most patients 
require general tonic treatment with very moderate but regular exer- 
cise, never carried to the point of fatigue, as much rest as possible in a 
recumbent position, a fluid diet, consisting largely of milk as long as 
this can be borne, and the administration of iron, particularly the tinc- 
ture of the chloride. Excessive dropsy calls for diuretics, saline cathar- 
tics, and heart stimulants. If uraemia develops, with high arterial ten- 
sion and stupor, headache, and convulsions, venesection should be re- 
sorted to, or nitroglycerin used. Morphine may be given hypodermically 
if the pupils are dilated and nervous symptoms are very marked. 

TUBERCULOSIS OF THE KIDNEY. 

In general tuberculosis, miliary tubercles are frequently seen both 
upon the surface of the kidney and in its substance. These give rise to 
no symptoms and are of no clinical importance. Larger tuberculous 
deposits are extremely rare in early life. They usually occur in patients 
who are the subjects of general tuberculosis, and are associated with 
tuberculosis of other parts of the genito-urinary tract, or they may exist 
as the primary, or even the only, tuberculous lesion in the body. Hamill * 
(Philadelphia) observed one case of primary renal tuberculosis in an 
infant seven months old, and collected 54 others in children under four- 
teen years. A number of these, however, are very doubtful. Boys were 
more often attacked than girls. Only 2 cases were under one year of 
age; 13 were between one and five years; 11 were between five and ten 
years old. 

A study of these cases shows that ascending infection occurs occa- 
sionally but that it is rare ; and that nearly all cases are of the descending 
type — i. e., primary in the kidney. Infection of the kidney therefore 
generally takes place through the circulation and not from the bladder. 

* S. M. Hamill, Primary Tuberculosis of the Kidney in Children. From the 
Pepper Laboratory for Clinical Medicine, Philadelphia, 1896. International Medical 
Magazine, 1896, v, JJo, % 



MALIGNANT TUMOURS OF THE KIDNEY. 671 

Aldibert's figures show that in children the bladder usually escapes even 
when the kidneys are tuberculous, for of 13 cases of renal tuberculosis 
the bladder was involved in but 2. The disease when primary begins in 
the cortex, but soon extends to the mucous membrane of the pelvis and 
the calices of the kidney, and also to the pyramids. As a rule, but one 
kidney is affected. The process may be confined to the pyramids, where 
are found cheesy nodules which may be single or multiple. These ulti- 
mately break down and form abscesses. The process may result in al- 
most complete destruction of the pyramids, and even of portions of the 
cortex, so that the kidney may consist of a mere shell of renal tissue. 
Suppuration in the neighbourhood of the kidney (perinephritic abscess) 
often coexists. 

The symptoms are quite indefinite. There may be localized pain and 
tenderness in the region of the kidney, and a tumour if there is perine- 
phritis. The symptoms of irritability of the bladder may be almost as 
severe as in cases of calculus. Pus usually appears in the urine as a con- 
stant symptom, and blood is often present. But the only thing that is 
diagnostic is the discovery of tubercle bacilli in the urine. 

The treatment of renal tuberculosis is purely surgical. Of the 17 
cases collected by Hamill in which operation was done for this condition, 
there were 11 recoveries and 6 deaths, 2 of the deaths, however, not 
being traceable to the operation or to the original disease. Xephrotomy 
was done 4 times, with 2 recoveries, 1 improvement, and 1 death. !N"e- 
phrectomy was done 9 times, with 5 recoveries, 1 improvement (died 
later from perforation of the duodenum), and 3 deaths. Xephrectomy 
followed nephrotomy in 4 cases, of which 2 recovered, 1 died, and 1 
improved. Xo recurrence had taken place in one case at the end of 
eight years, and none in another after three years. 

MALIGNANT TUMOURS OF THE KIDNEY. 

In the great majority of cases tumours of the kidney are malignant. 
Of 51 cases collected by Aldibert which were operated upon, -48 were 
malignant and 3 benign. 

Malignant growths are almost invariably primary. In children under 
five years, although not common, they are yet more frequent than any 
other variety of malignant tumour of the abdomen. The earlier cases 
reported were classed as carcinoma. It is now well established that car- 
cinoma is very infrequent, and that nearly all the cases are varieties of 
sarcoma. Fischer reports 19 of sarcoma and 2 of carcinoma ; Aldi- 
bert, 38 of sarcoma and 5 of carcinoma. The sarcoma may be round- 
or spindle-celled, or myo-sarcoma. In some of the cases there are 
both sarcomatous and carcinomatous features, so that they might be 
classed as sarcomatous carcinoma. The tumour grows from the cor- 
tex of the kidney, or from the pelvis, sometimes from the adrenals. 



672 DISEASES OF THE URO-GENITAL SYSTEM. 

It may infiltrate the whole kidney, so that there is no trace of renal 
structure remaining, or it may form an immense tumour on one side of 
the kidney, which is only partially invaded. These tumours are very 
rarely cystic, hut they are quite soft, and haemorrhages often occur into 
their substance. There may be secondary growths in the liver, the lungs, 
the retroperitoneal glands, in the opposite kidney, in the intestines, or 
in the pancreas. Pressure of the tumour upon the ureter may lead to 
hydronephrosis ; and upon the inferior vena cava, to thrombosis of that 
vessel. As it grows, the tumour sometimes becomes adherent to nearly 
all the abdominal organs by localized peritonitis. It may lead to ascites, 
but it very rarely causes general peritonitis. The growth may reach a 
great size, usually from 5 to 15 pounds, but in 1 case reported by 
Jacobi it weighed 36 pounds. In Seibert's collection of 48 cases the right 
kidney was involved in 24, the left in 22, and both kidneys in 2 cases. 

Etiology. — These tumours of the kidney may be congenital. This 
was true of 5 cases in a series of 55 collected by Jacobi. The majority 
occur in early childhood. In the collection of 130 cases by Longstreet 
Taylor in which the ages are given, 106 were in the first five years, and 
57 of these in the first two years of life. The sexes were about equally 
affected. In a small number of cases the history of a fall was given. 

Symptoms. — The principal symptoms are tumour, haematuria, and 
cachexia. The tumour is usually first noticed. It is in most cases dis- 
covered in the loin, but grows forward toward the median line. Its sur- 
face may be lobulated and irregular or quite smooth ; and although solid, 
it is sometimes so soft as to give an obscure sensation of fluctuation. 
It may grow to an enormous size, causing displacement of the liver, 
spleen, intestines, and lungs. The progress of the growth is usually 
rapid, so that from the size of a fist, the tumour may grow in the course 
of five or six months so as to fill the abdomen. By careful palpation it 
will be found — certainly when the tumour is small — that although it 
may be quite freely movable, its attachment is near the lumbar spine. 
Aspiration may show blood, but more frequently the result is negative. 

Haematuria was observed before the tumour in 19 of 50 cases (Sei- 
bert), it being then the first symptom noticed. The amount of blood 
passed is sometimes quite large, but is usually small, and may be discov- 
ered only by the microscope. Pain is rare, and is due to localized 
peritonitis. Constitutional symptoms are absent until the tumour has 
attained a large size, when a cachexia develops and the patient wastes 
steadily while the tumour continues to grow. The pressure effects are 
dyspnoea, from compression of the lungs ; oedema of the lower extremi- 
ties, from pressure upon or thrombosis of the vena cava; vomiting and 
indigestion, from pressure upon the stomach and intestines. Secondary 
deposits very rarely cause any symptoms except in the lungs, where they 
may give rise to cough, and even to haemoptysis, 



674 DISEASES OF THE URO-GENITAL SYSTEM. 

The course of the disease is steadily from bad to worse. The usual 
duration of life in patients not operated upon, is from three to ten 
months after the tumour is large enough to be easily discovered. 

Diagnosis. — The important points are, the position and attachment 
of the tumour, its steady growth and solid character, hematuria, and the 
age of the patient (under five years). It may be confounded with hydro- 
nephrosis, dermoid cyst of the ovary, enlargement of the spleen, retro- 
peritoneal sarcoma, tumours of the liver, or even of the abdominal wall. 

Treatment. — Nothing is to be said regarding the medical treatment 
of these cases. Unless operated upon, I believe they invariably termi- 
nate fatally. Some of the results of operation during recent years have 
been so encouraging that no case should be abandoned, no matter how 
young the patient. Lewi * has collected the results of 60 cases operated 
upon: 20 deaths occurred soon after operation, from causes connected 
with it; in 20 cases the cause of death was recurrence of the growth; 
this raises the total mortality to 67 per cent. In the Babies' Hospital, 
my colleague, Dr. Eobert Abbe, operated upon a nursing child, thirteen 
months old, where the tumour weighed 7 pounds, and the child after the 
operation only 15 pounds. This case made an uninterrupted recovery, 
and ten years after the operation was still in perfect health. The ac- 
companying illustrations (Figs. 119 and 120) are from photographs of 
this patient. A second child operated on at two years remained well for 
three and a half years and died from a recurrence in the opposite kidney. 

For a discussion of the surgical aspects of this question, and details 
of the operation, see the papers of Abbe f and Aldibert.J 

Benign Tumours. — These are distinguished by their slow growth, and 
by the fact that the constitutional symptoms are mild or wanting. Of 
the three cases mentioned by Aldibert, one was adenoma, one fibroma, 
and one was fibro-cystic. 

PYELITIS— PYELO-CYSTITIS. 

Pyelitis is an inflammation of the mucous membrane lining the 
pelvis of the kidney; cystitis is an inflammation of the mucous mem- 
brane of the bladder. They may exist separately or together. With 
pyelitis there may be inflammation of the ureter or of the kidney itself 
(pyelo-nephritis), and it may be acute or chronic. It may result in the 
accumulation of pus in considerable amount in the pelvis of the kidney 
(pyelo-nephrosis). 

Etiology. — The most frequent local cause of pyelitis is irritation from 
renal calculi. It is also associated with congenital malformations of 
the kidneys or ureters, with renal tuberculosis and renal tumours. It 
may result from an extension of inflammation from the tissues surround- 

* Archives of Paediatrics, February, 1896. f Annals of Surgery, January, 1894 

$ Revue Mensuelle des Maladies de l'Enfance, November, 1893. 



PYELITIS— PYELO-CYSTITIS. 675 

ing the kidney (perinephritis), or from an abscess opening into the 
pelvis of the kidney. An infections form of acute pyelitis sometimes 
occurs as a complication of scarlet or typhoid fever, diphtheria, malaria, 
or pyaemia; but it is also seen apart from these diseases, when it occurs 
apparently as a primary affection. In most of the severe cases of pye- 
litis there is also present a certain amount of nephritis. 

Acute pyelitis may also be secondary to acute cystitis even in in- 
fants. In such cases the inflammatory process travels upward along the 
ureter, which may or may not be involved. These cases of cystitis occur 
chiefly in female infants and have been especially studied by Escherich, 
Trumpp, and Finkelstein, who found the characteristic features of the 
disease to be the presence of the colon bacillus in pure culture in freshly 
voided urine ; the term " coli-cystitis " has been applied to them. Of ten 
cases observed by Escherich and seven by Finkelstein, all were girls. I 
have myself seen six severe cases, all in female infants from six to twelve 
months of age, which corresponded closely with the type described by 
these writers. The infection probably occurs through the urethra, and 
originates from the stools through the napkins or the passage of the 
stools over the vulva. This more frequently occurs in diarrhceal diseases, 
with which the cystitis has often been found associated. It is surprising 
that vulvo-vaginitis is seldom present. It seems quite possible that in- 
fection may also occur, especially in male infants, by a direct extension 
from the intestine to the bladder, or through the blood. . Trumpp exam- 
ined the urine in sixteen patients with gastro-enteritis and found the 
colon bacillus in thirteen, of whom nine were females. The association 
of cystitis and gastro-enteritis deserves further study. 

Lesions. — When pyelitis develops from a local cause it is usually 
unilateral; otherwise both sides are involved. In the cases of acute 
cystitis or pyelo-cystitis there are the usual appearances of an acute 
catarrhal inflammation of the mucous membrane, with congestion, swell- 
ing, and sometimes minute haemorrhages. In chronic cases there is 
thickening and sometimes a granular condition of the lining membrane. 
There may be an accumulation of pus of considerable size, distending 
the pelvis and calices (pyonephrosis). If the condition is one depending 
upon a calculus or congenital deformity, and in all protracted and 
severe cases, the kidney itself is involved to a greater or less degree ; the 
extent of the nephritis will depend upon the nature of the exciting cause 
and the duration of the process. 

Symptoms. — The history of the following case illustrates the main 
clinical features of acute infectious pyelitis, in this instance occurring 
apparently as a primary disease: 

A previously healthy female infant of eight months was taken sud- 
denly with a chill, followed by a very high fever. The child was ill for 
ten days before the nature of the disease was suspected. During this 
44* 



676 DISEASES OF THE URO-GENITAL SYSTEM. 

time the temperature ranged between 101° and 106° F., touching 105° 
nearly every day; but the chill was not repeated. The other constitu- 
tional symptoms were not severe. At the first examination of the urine 
there was found a large amount of pus, which on standing was equal to 
one twelfth of the volume of the urine passed ; the reaction was strongly 
acid. There were no signs of vaginitis or vulvitis, no ardor urince, no 
evidence of local pain either in the bladder or kidney, no abnormal fre- 
quency of micturition, no localized tenderness, and no vomiting. At 
later examinations there were found in moderate numbers epithelial cells 
from the bladder, and the tubules and pelvis of the kidney, also a few 
hyaline casts, but not more albumin than would be explained by the 
amount of pus. Under no treatment except alkaline diuretics, the tem- 
perature gradually fell to normal, and the pus steadily diminished in 
quantity, and at the end of five weeks had practically disappeared from 
the urine. A report sixteen months later stated that the child had re- 
mained well and entirely free from urinary symptoms. 

In some cases there are recurring chills, with wide fluctuations in 
temperature; in others there may be only pyuria, with moderate fever 
and few other constitutional symptoms. If the disease complicates one 
of the acute infectious diseases, pyuria may be the only symptom. If 
cystitis is also present micturition is frequent and may be painful. The 
urine in acute pyelo-cystitis is turbid from the presence of pus, the 
amount of which may be from one to fifty per cent of the volume of the 
urine. The quantity of urine is generally somewhat diminished, and it 
may be quite scanty. The reaction is usually acid, even though the 
amount of pus is large. Albumin is present in proportion to the amount 
of pus or the degree of nephritis. Red blood-cells are found under the 
microscope in most of the very acute cases, and may be in sufficient num- 
bers to colour the urine. The pus cells in recent cases are usually well 
preserved, but in old cases they may be degenerated. There are many 
epithelial cells — conical, fusiform, and irregular cells with long tails. 
There may be renal epithelium and hyaline, granular, or epithelial casts, 
varying in number with the severity of the nephritis. The colon bacillus 
may be present in pure culture. 

In chronic pyelitis only pyuria may be present, or there may be a 
tumour owing to the pyonephrosis. From time to time in the chronic 
form there may be intermittent attacks of acute pyelitis resembling those 
above described. In pyelitis depending upon congenital malformations, 
pyuria is usually the only symptom, unless pyonephrosis is present. 
With calculi we may have acute or chronic pyelitis ; there may be local- 
ized pain, tenderness, sometimes a tumour, occasionally hsematuria, and 
perhaps a history of renal colic or the passage of gravel. With tuber- 
culosis we have chronic pyuria and the presence of tubercle bacilli in the 
urine. There are commonly associated the symptoms of general tuber- 



RENAL CALCULI. 677 

culosis. If associated with perinephritis, the inflammation is usually 
acute, and there are present the local symptoms of the original disease. 
If an abscess opens into the pelvis of the kidney we may have a sudden 
discharge of pus in large quantity with a subsidence of previous local 
symptoms, including the tumour. With neoplasms we have congestion 
and haemorrhage more frequently than pus, but both may be present. 

Diagnosis. — The characteristic symptoms of acute pyelitis are chills, 
which may be repeated, high and fluctuating temperature, scanty urine, 
frequently pain and tenderness over the kidneys, and p3niria. The diag- 
nosis of pyelitis is made only by an examination of the urine, which 
should never be omitted in cases of obscure high temperature, even in 
infancy, particularly if chills are present. ^Yhen cystitis is associated, 
the only additional symptoms may be pain and other signs of vesical 
irritation. These symptoms, with an acid urine containing a large 
amount of pus and epithelial cells like those described, are sufficient to 
establish the diagnosis of pyelo-cystitis. If the pus comes from the 
opening of an abscess into the bladder, ureter, or pelvis of the kidney, 
the local signs of such abscess will usually be present. 

Prognosis. — In cases apparently primary, and in those complicating 
infectious and other diseases, the prognosis is good. The danger is 
chiefly from the nephritis which follows or complicates the process. In 
cases depending upon local conditions, the prognosis will depend upon 
the nature of the exciting cause. Here, also, the principal danger is 
from nephritis. If calculi are present and if pyonephrosis occurs, the 
patient may die from exhaustion before a serious degree of nephritis has 
developed. 

Treatment. — Water should be given freely, and alkalies up to the 
point of neutralizing the excessive acidity of the urine. In infants, from 
twelve to twenty-four grains of the citrate of potash are required daily 
for this purpose. If the urine is alkaline, benzoic acid may be used in 
the same doses. The most important remedy is urotropin, which should 
be given in doses of one or two grains every three hours to an infant 
of a year, and proportionate doses to older children. In acute cases, 
counter-irritation over the kidney by means of poultices or dry cups may 
be employed. If calculi are present the same treatment is indicated. 
Surgical interference is called for if pyonephrosis develops, or if the 
disease is evidently unilateral and the kidney is seriously involved. The 
advisability of surgical interference will depend upon the clearness of 
diagnosis and the severity of the symptoms. 

RENAL CALCULI. 

Small renal calculi are very common in infancy. In the autopsy- 
room we frequently see, on opening the kidneys of young infants, fine 
brown granules in the pelvis and calices, and occasionally a calculus as 



678 DISEASES OF THE URO-GENITAL SYSTEM. 

large as a small pea is found. They are usually composed of uric acid. 
Only once in over one thousand autopsies of which I have records, was 
a stone of any considerable size seen in an infant. In this case it was 
an inch in length and half an inch wide. It is surprising that these are 
so rare, when we consider how very frequently the minute calculi are 
met with. The probable explanation is, that the majority of them are 
dissolved or washed down into the bladder and passed per urethram 
because of the fluid diet of the first two years. The granular deposits 
are usually lodged in the pelvis of the kidney, and are generally seen 
upon both sides. With the larger collections there is often a slight 
catarrhal pyelitis. 

Symptoms. — The small deposits give no symptoms, and even quite 
large calculi may be found at autopsy where no indication of their pres- 
ence had existed during life, as in the case above mentioned. In some 
cases symptoms are produced which resemble those of renal calculi in the 
adult. In infants less definite symptoms are often passed over as merely 
intestinal colic. 

In well-marked cases in older children there is tenderness, pain local- 
ized over the affected kidney, or radiating to the bladder, the perinseum, 
and even the opposite kidney, and there may be irritation and retraction 
of the testicle. The urine may show, especially after exercise, a trace of 
blood; there may be the added symptoms of pyelitis, with some fever, 
localized tenderness, and the appearance in the urine of pus and epithe- 
lial cells from the pelvis of the kidney. 

Renal colic is produced when a stone of any considerable size passes 
from the kidney to the bladder. It is characterized by symptoms similar 
to those seen in the adult. There are sudden attacks of severe sickening 
pain in the loins, shooting down the thigh or to the testicle. There may 
be vomiting and even collapse. The urine is passed frequently, in small 
quantities, and contains blood. The symptoms quickly subside when the 
stone reaches the bladder. The calculus may sometim.es become im- 
pacted in the ureter and give rise to hydronephrosis or pyonephrosis, 
which soon becomes pyelo-nephritis. 

The existence of small calculi may be suspected from the symptoms 
above 'mentioned; the diagnosis is made positive by the appearance of 
gravel in the urine. The use of the Rontgen rays is of service in recog- 
nising even small calculi.* 

Treatment. — The only medical treatment consists in a fluid diet, the 
free use of alkaline mineral waters, and a sufficient quantity of some 
drug to render the urine alkaline. Such measures will relieve only the 
milder conditions. With larger calculi and more marked symptoms, a 
surgical operation should be considered and should be urged in propor- 

* Abbe, Annals of Surgery, August, 1899. 



PERINEPHRITIS. 679 

tion to the severity of the symptoms and the clearness of the diagnosis. 
If calculous pyelitis exists, it is certain sooner or later to lead to serious 
nephritis, and it is only a question of time when the kidney will be dis- 
abled. The same is true of hydronephrosis from the impaction of a cal- 
culus in the ureter. Aldibert has collected four cases of nephrectomy in 
children for renal calculi in which the kidney was healthy, with three 
recoveries and one death from shock. In nine cases of operation for cal- 
culous pyonephrosis, there were six recoveries and three deaths. This is 
certainly an encouraging showing, and should lead one to consider opera- 
tion seriously in many cases for which formerly nothing was done. The 
earlier the operation the greater the chances of success, because of the 
better condition of the other kidney. Although the continued use of 
water and the so-called solvents may relieve some of the symptoms, it 
is very questionable whether they do more. 

TRAUMATIC HYDRONEPHROSIS. 

In addition to the hydronephrosis which results from congenital mal- 
formations and from the impaction of calculi, a form is occasionally seen 
following severe injury to the kidney. The pathology of hydronephrosis 
in these cases is not well understood. After the early symptoms of 
traumatism have subsided, there develops in from two weeks to two 
months a tumour in the region of the kidney, which may reach a consid- 
erable size and present all the ordinary characteristics of hydronephrosis 
arising from other causes. This tumour may disappear spontaneously, 
or it may increase in size and demand surgical intervention for its cure. 
In seventeen cases which Aldibert has collected there was only one of 
spontaneous recovery ; aspiration was done in seven cases, with six cures 
and one death ; incision with or without nephrectomy was practised in 
nine cases, with seven recoveries and two deaths. 

PERINEPHRITIS. 

This consists in an inflammation in the cellular tissue surrounding the 
kidney, which may terminate in resolution or in suppuration. It is not 
of very uncommon occurrence, and is of importance chiefly from the fre- 
quency with which it is confounded with disease of the hip or spine. 
Perinephritis may be secondary to suppurative processes in the kidney 
itself, whether from calculi or tuberculous deposits, or it may be primary. 
In children the latter is the common form. Primary perinephritis is 
attributed to traumatism, cold, or exposure, or it may develop without 
assignable cause. It usually runs an acute or subacute course ; very rarely 
it may be chronic. 

For the clinical picture of this disease I am chiefly indebted to a 
paper by Gibney, who published in 1880 a report of twenty-eight cases of 



680 DISEASES OF THE URO-GENITAL SYSTEM. 

primary perinephritis in children. I was at that time an interne in the 
Hospital for the Kuptured and Crippled, New York, where these cases 
were under observation, and had an opportunity to see many of those 
reported in Dr. Gibney's paper.* 

The ages of these patients were between one and a half and fifteen 
years, the majority being between three and six years. The two sides 
and the two sexes were about equally affected. About one third of the 
cases were clearly traceable to traumatism ; in the others no adequate 
exciting cause could be discovered. The majority of the cases were re- 
ferred to the hospital with the diagnosis of hip-joint disease or caries of 
the spine. Kesolution followed in twelve of these cases, and sixteen ter- 
minated in suppuration. 

When abscess forms, it usually burrows between the lumbar muscles 
and comes to the surface posteriorly near the middle of the ilio-costal 
space ; it may burrow forward between the abdominal muscles and point 
just above Poupart's ligament ; very rarely it may follow the psoas muscle 
and appear at the upper and inner aspect of the thigh, like an ordinary 
psoas abscess ; or it may open into the peritoneal cavity. 

Symptoms. — The onset of acute perinephritis may be quite abrupt, 
with chill, fever, and localized pain ; or it may be gradual, with stiffness of 
the spine, lameness referred to the hip, and deformity due to contraction 
of the flexors of the thigh. The pain is usually felt in the loin, but may 
be referred to the groin, to the inner side of the thigh, or to the knee. 
It is often severe, and increased by using the limb. It is in most cases 
accompanied by localized tenderness in the neighbourhood of the kidney. 
There is lameness upon the affected side which may come on gradually, 
being sometimes referred to the hip and sometimes to the spine. These 
symptoms often develop slowly in the course of two or three weeks. They 
are usually accompanied by a slight elevation of temperature. In the 
most acute cases the temperature is high (102° to 104° F.), and prostration 
severe. 

As the disease progresses fever is a constant symptom, the temperature 
usually varying between 101° and 103° F. There is in most cases increas- 
ing deformity, and finally the patient may be unable to walk at all. On 
examination at the height of the disease there is found in a typical case 
a deviation of the spine with the concavity toward the affected side ; the 
thigh may be held flexed to a right angle ; passive extension is resisted 
and causes pain, although all the other movements at the hip joint are 
normal. In the lumbar region there is tenderness, and there may be an 
area of infiltration filling the ilio-costal space. At first this is only ap- 
preciable by percussion, but later a distinct tumour is present. In 



* Chicago Medical Journal and Examiner, 1880, where will be found a very full 
bibliography. 



PERINEPHRITIS. 681 

addition to the tumour in the usual region, there is sometimes one at 
the upper and inner aspect of the thigh, owing to a burrowing of pus, and 
the sacs may communicate. 

Lameness, pain, deformity, and fever sometimes exist for two or three 
weeks before any tumour can be made out. The constitutional symp- 
toms are often severe, and symptoms of the typhoid condition may even 
be present. The bowels are usually constipated. The size of the abscess 
is sometimes very great. In one case I have seen it extend from the spine 
to the median line in front, and from the crest of the ilium nearly to the 
free border of the ribs. The amount of pus varies from a few ounces to 
two or three pints. Urinary symptoms are sometimes wanting ; at other 
times there is increased frequency of micturition, accompanied by pain 
from an irritation referred to the bladder. The urine may contain pus 
from a complicating pyelitis. In only one of Gibney's cases was this 
present. It developed in the fourth week, and the case recovered. 

The duration of the disease in the acute cases varies from three to 
eight weeks ; in the subacute it may be five or six months. When sup- 
puration occurs the symptoms subside quite rapidly after the pus has been 
evacuated, and recovery is complete. Where resolution takes place, there 
is a gradual subsidence of the symptoms, and often some stiffness of the 
thigh, with slight lameness for several months. In the series of cases 
above referred to, 65 per cent recovered completely in three months. 

Diagnosis. — In many cases a diagnosis of hip-joint disease is made, and 
they are reported as " hip-joint disease cured without deformity," etc. 
The points of differential diagnosis are quite distinct, and if a careful ex- 
amination is made there is no excuse for confounding the two conditions. 
Hip-joint disease develops more insidiously, is very much more chronic, 
and rarely produces so great deformity in a year as is often seen in peri- 
nephritis in two or three weeks; abscess is infrequent during the first 
year of the disease ; on examination, there is found limitation of all the 
movements of the joint, and not of extension alone ; atrophy of the thigh 
and joint tenderness are present. In perinephritis, on the other hand, we 
have a tolerably acute onset, sometimes with chill, fever, marked lameness, 
and deformity, developing in two or three weeks ; abscess often forms in 
a month, and complete and permanent recovery usually follows after a 
few months at most ; the deformity is due solely to flexion of the thigh ; 
all other movements at the hip may be free, and joint tenderness is absent. 
Psoas abscess from Pott's disease may cause deformity, tumour, and lame- 
ness similar to that seen in perinephritis, but on examination there is 
found the angular prominence and other signs of disease of the lumbar 
vertebrae. 

Prognosis. — Primary perinephritis in children almost invariably termi- 
nates in complete recovery. Of the twenty-eight cases referred to, and 
eight subsequently observed by Gibney, all recovered perfectly. The only 



682 DISEASES OP THE URO-GENITAL SYSTEM. 

condition liable to prove fatal is rupture of the abscess into the peritoneal 
cavity. 

Treatment. — The patient should be put to bed and kept as quiet as 
possible throughout the attack. In the early stage, a blister, hot fomen- 
tations, or an icebag, should be applied over the affected side; heat is gen- 
erally to be preferred. When suppuration is inevitable and pain severe, 
a poultice may be used. Abscesses should be opened early, to prevent 
burrowing, and danger of a possible rupture into the peritoneal cavity. 

GENERAL (EDEMA NOT DEPENDENT ON RENAL DISEASE. 

This is a frequent occurrence in infants and young children. In 
the Babies' Hospital, at least a score such cases are seen every year. 
Nearly all are in infants under six months of age, and the majority un- 
der three months. This general dropsy is invariably associated with 
extreme malnutrition and anaemia. It comes on gradually in the course 
of four or five days, often the first thing noticed being that a wasting 
child has unexpectedly increased half a pound or a pound in weight. 
On closer inspection there will be found oedema of the feet, ankles, thighs, 
face, hands, and sometimes of the abdominal walls, and the back. This 
may be quite marked, so that it may be almost impossible to open the 
eyes, and the extremities may be nearly double their normal size. I 
have occasionally seen dropsy in the serous cavities. ~No explanation of 
this oedema is found in the urine. It is not albuminous ; it is frequently 
very scanty, but is sometimes apparently normal in amount. Oppor- 
tunities for the examination of the kidneys have been afforded in several 
instances, and these organs have been in all cases normal, even upon 
microscopical examination. 

The cause of this oedema was ascribed by Tarnier, who had observed 
it in connection with premature infants fed by gavage, to the giving of 
too much fluid food. He states that it disappeared when the amount of 
food was reduced. This has not been my experience. Many children 
who were fed by gavage showed no signs of it, and others who took a 
comparatively small quantity of food became oedematous. The best expla- 
nation seems to me to be that it depends upon a condition of hydremia, 
associated with feeble resistance in the walls of the small blood-vessels, 
through which a transudation of serum readily takes place. The degree 
of anaemia noted in these patients is sometimes extreme. 

The prognosis in this condition is extremely bad, as it rarely occurs 
except in hopeless cases of marasmus. This is not, however, invariably 
the case. The dropsy may disappear to return again, or it may disappear 
permanently and the case go on to recovery. 

If the urine is scanty, such diuretics as the citrate of potash and the 
sweet spirits of nitre often cause a diminution and sometimes even a 
disappearance of the dropsy in a short time. The best of all remedies, 



MALFORMATIONS OF THE GENITAL ORGANS. 683 

however, is digitalis. To an infant of two months, ttl ^ of the fluid 

extract may be given every two hours for two or three days ; and for a 
short period somewhat larger doses may be employed. 



CHAPTER III. 
DISEASES OF THE GENITAL ORGANS. 

MALFORMATIONS. 

Adherent Prepuce. — This condition is sometimes called false phimosis. 
It is so constantly present that it can hardly be regarded as a malforma- 
tion. It is, however, a condition needing attention in every male infant. 
The prepuce should be forcibly retracted so as to expose the glans com- 
pletely. The smegma should then be washed away, the glans covered 
with a drop of oil, and the skin drawn forward. This should be repeated 
daily until there is no disposition to a recurrence of the adhesions. 

Phimosis. — This is such a narrowing of the prepuce that it can not be 
retracted over the glans. The degree of phimosis varies greatly. In very 
rare cases there is no preputial opening. In other cases the orifice is so 
small that no part of the glans can be exposed, and there is obstruction to 
the outflow of urine ; but usually a small part of the glans can be seen. 
Phimosis may be complicated by an elongated prepuce (hypertrophic phi- 
mosis), and the elongation may exist without any narrowing of the orifice, 
although this is usually present to some degree. 

The presence of phimosis makes cleanliness impossible in many cases, 
and want of cleanliness leads to infection and to balanitis. This is quite 
frequent even in infants. It may be complicated by urethritis, and even 
by cystitis. Another consequence of the straining induced by phimosis 
is hernia, which may be either inguinal or umbilical. To cure the 
hernia is often impossible, unless the phimosis is relieved. Straining 
also leads to prolapsus ani, and, from pressure on the spermatic vessels, to 
hydrocele. More important even than these mechanical results of phimo- 
sis are the reflex conditions resulting from the irritation. Such symptoms 
may come from preputial adhesions as well as from phimosis. The 
hyperaesthetic condition and the resulting pruritus cause frequent pria- 
pism, and are among the most common causes of masturbation. It may 
produce other nervous symptoms, such as insomnia, night terrors, etc. 
Phimosis often causes frequent micturition, dysuria, and, in fact, most of 
the symptoms of stone in the bladder. It sometimes leads to vesical 
spasm and retention of urine, but more frequently to nocturnal inconti- 
nence. 



684 DISEASES OF THE URO-GENITAL SYSTEM. 

The list of reflex phenomena which have been attributed to phimosis 
is a long one, and includes most of the functional nervous diseases of 
childhood. There is abundant evidence that phimosis may be a cause, 
although a rare one, of chorea, convulsions, epilepsy, hysterical mani- 
festations, pseudo-paralysis, spasm of the muscles about the hip causing 
symptoms resembling the early stage of hip- joint disease, strabismus, 
amaurosis, diarrhoea, and many other nervous conditions. There is, how- 
ever, no evidence that cases of spastic diplegia or paraplegia are ever 
caused by phimosis or improved by circumcision. There has been in the 
past a disposition on the part of some writers to attribute nearly all the 
nervous disturbances of boyhood to phimosis, and an exaggerated im- 
portance has certainly been attached to this condition. Still, in a delicate, 
anaemic child with unstable nervous centres, phimosis is capable of giving 
rise to nervous symptoms of a most serious and alarming character. It 
is an important etiological factor in many neuroses, and one which 
should not be overlooked. On the other hand, a very marked degree of 
phimosis often exists in robust children without producing any symp- 
toms whatever. 

Treatment. — Every case of phimosis should receive attention in in- 
fancy. Often very little treatment is needed; but trouble is likely to 
come sooner or later if it is neglected. When there is a very long prepuce 
with phimosis, the operation of circumcision should invariably be done, 
even when the degree of phimosis is slight. Many cases of phimosis in 
which the prepuce is not long can be relieved by stretching. If no part 
of the glans can be exposed, the simplest plan is to slit up the dorsum 
of the prepuce with a pair of scissors and forcibly break up the adhesions. 
The corners of the flaps thus made can then be snipped off and one stitch 
inserted on either side. This is very easily done, and gives most ex- 
cellent results. In the case of obscure nervous symptoms in older boys, 
the condition of the prepuce should be examined and the same rules of 
treatment applied. In all cases of hernia, hydrocele, or prolapsus ani, 
when phimosis is present it should be relieved as the first step in the 
treatment. 

Hypospadias. — In this condition the urethra is not continued to the 
tip of the penis, but opens on the inferior surface some distance back, 
being represented in front of this only by a shallow furrow. In more 
severe cases there is a deep fissure which divides the scrotum, and some- 
times even the perinaeum. Into this fissure the urethra opens. This is a 
condition likely to be mistaken for that of hermaphrodism, especially as 
the testicles are frequently in the abdominal cavity. It may be impossible 
to decide the sex of the child until puberty. Surgical operations for the 
relief of these deformities are not very successful. 

Epispadias. — This is a condition in which the urethra opens on the 
dorsal surface of the penis. It is much less frequent than hypospadias. 



MALFORMATIONS OF THE GENITAL ORGANS. 685 

There may be simply a division of the glans, or the fissure may extend the 
whole length of the organ and be complicated by exstrophy of the bladder. 

Exstrophy of the Bladder. — In the complete form there is a median 
fissure from the nmbilicus to the tip of the penis. It includes the an- 
terior abdominal wall, the pelvic bones, and the urethra. The bones are 
entirely separated at the symphysis, or connected behind the bladder by 
a fibrous band. The hypogastric region is occupied by a red, mucous 
surface, slightly corrugated, which is all there is of the bladder. In the 
lower lateral portions of the red mucous membrane two slightly rounded 
elevations are seen, from which urine oozes. These are the openings of 
the ureters. The penis is short, and presents a shallow furrow on its 
dorsal surface. The testes are often in the abdominal cavity. 

An analogous deformity is sometimes seen in girls. There is a divi- 
sion of the clitoris and the labia minora and majora. The fissure may 
be so deep as to reach nearly to the anus. The vagina is usually absent. 
The rectum may open into the prolapsed bladder. 

All these deformities are compatible with long life. In most of them 
the individual is incapable of procreation. In exstrophy of the bladder, 
whether complete or partial, patients are a nuisance to themselves and to 
all about them. It is almost impossible to prevent the clothing from 
being soaked with urine, which gives everything connected with the 
patient a strong ammoniacal odour. The skin is often excoriated. Op- 
eration for the relief of these cases should, I think, always be undertaken. 
Brilliant results have been obtained even in some of the most severe cases. 

Undescended Testicle — Cryptorchidism. — In foetal life the testes are 
situated in the abdominal cavity below the kidneys. They usually descend 
into the scrotum during the ninth month, but in children born at term 
the testicles may be in the inguinal canal, or even in the abdomen. The 
former condition is quite frequent, being present in fully ten per cent of 
all male children. In most of these the descent takes place without diffi- 
culty during the first weeks of life, and causes no symptoms. In others 
the condition may persist. Spontaneous descent may take place at any 
time before puberty, the chances, however, steadily lessening as age 
advances. When in the inguinal canal, an account of its exposed situa- 
tion, the testicle may be injured, or become painful and tender as puberty 
approaches. In any abnormal position it probably will not develop prop- 
erly, and may remain without function, but interference with the devel- 
opment of the body is rare. Hernia is a frequent complication. 

AYhen in the inguinal canal, descent of the testicle may sometimes be 
facilitated by manipulation. If the condition is unilateral, operation is 
unnecessary excepl for relief of pain. If it is double, operation should 
be performed before puberty, preferably in the eleventh or twelfth year. 
Transplantation into the scrotum is at this time simple, and usually suc- 
cessful. Should pain be persistent, and transplantation impossible, the 



DISEASES OF THE URO-GENITAL SYSTEM. 

testicle may be replaced in the abdominal cavity. Eemoval is indicated 
only when degeneration has taken place. 

With the exceptions already mentioned, deformities of the female geni- 
tals belong rather to gynaecology than to paediatrics, since they are chiefly 
of the internal organs, and do not usually give symptoms before puberty. 

DISEASES OF THE MALE GENITALS. 

Balanitis. — Balanitis, or inflammation of the prepuce, is one of the 
results of phimosis. It may follow decomposition of the smegma, infec- 
tion of the mucous membrane, injury, or masturbation. The parts are 
swollen, cedematous, red, painful, and sometimes bathed in pus. Be- 
traction of the prepuce is impossible. Under proper treatment the 
inflammation usually subsides in two or three days, but there may be 
some discharge for a considerable time. Abscess may follow, and even 
gangrene of the prepuce. The most severe cases are likely to be com- 
plicated by anterior urethritis. I have frequently seen erysipelas start 
from balanitis, and occasionally diphtheria occurs here. 

The object of treatment is to remove the irritating and infectious 
material lodged beneath the foreskin. This may be quite difficult. It is 
best accomplished by syringing with a l-to-5,000 bichloride solution, and 
the constant application of a wet antiseptic dressing. Ice is often useful 
where the oedema is great. It is sometimes necessary to slit up the 
prepuce before the parts can be thoroughly cleansed, and in severe cases 
this is often the quickest method of cure. Circumcision should not be 
done during an attack. 

Urethritis. — This, like the same disease in females, may be simple or 
specific. Both forms are less frequent in little boys than in the other 
sex. In simple urethritis the inflammation usually affects only the 
anterior part of the canal, the fossa navicularis. There is a slight dis- 
charge of pus, and sometimes pain on micturition. The most frequent 
cause is want of cleanliness. 

Gonorrhoeal inflammation is more common. This occurs even in boys 
as young as eighteen months, but most of the cases are in those over 
seven years old. The usual cause is direct contagion. The symptoms 
are more severe than in the simple form, and resemble the same disease 
in the adult, with the exception that constitutional symptoms are usually 
absent. A microscopical examination of the discharge is the only posi- 
tive means of diagnosis between the two varieties. In these cases it 
reveals the gonococcus in great numbers. Conjunctivitis and arthritis 
are seen as complications, just as in the female. Orchitis is very rare, 
but balanitis and bubo are not infrequent. Poynter has reported a case 
in a boy of three years, who, when five years old, required treatment for 
a urethral stricture. He was infected by a nurse. 

The first thing in the treatment is always to keep the parts covered, 



HYDROCELE. 687 

otherwise the infection is almost certain to be carried by the hands to 
other mucous membranes, usually the conjunctiva. In other respects the 
treatment is the same as in the adult. 

Hydrocele. — Hydrocele consists in an accumulation of serum in some 
part of the serous pouch brought down by the testicle in its descent. In 
infants it is usually due to the imperfect closure of this pouch at some 
point, where a fluid accumulation occurs. Four varieties of hydrocele 
are met with in young children: 

1. Congenital hydrocele. — In this the condition is a congenital one, 
although the tumour is not necessarily present at birth. The tunica vagi- 
nalis communicates with the general peritoneal cavity. There is present 
an elongated tumour, extending from the bottom of the scrotum through- 
out the whole length of the cord. The tumour is reducible, sometimes 
spontaneously by position, sometimes, when the opening is smaller, only 
by pressure. It reduces slowly, without gurgling, never going back en 
masse like a hernia. The tumour is translucent, and is flat on percussion. 
The testicle is above and posterior, and usually indistinctly felt. Con- 
genital hydrocele may be complicated by hernia. 

2. Hydrocele of the tunica vaginalis with the canal closed. — In this 
form the accumulation of fluid is in the scrotum, communication with the 
peritoneal cavity having been entirely cut off by the complete obliteration 
of this pouch in the canal in the normal way. This is one of the most 
frequent forms. It gives rise to an oval or pear-shaped tumour, quite 
tense and firm, usually about two inches in length. The cord is distinctly 
felt above it, the testicle is behind and somewhat above it, and not always 
felt very distinctly. This variety gives translucency and the usual elastic 
feeling of a hydrocele. 

3. Hydrocele of the cord. — This is one of the rare forms. The serous 
pouch which accompanies the spermatic cord is open above, and com- 
municates with the peritoneal cavity ; but below it is closed. The scrotum 
is normal, and the testicle is in its usual position. The tumour is small, 
elongated, and reducible, and entirely above the scrotum. Usually it 
stops at some point in the inguinal canal. This hydrocele also may be 
complicated by hernia. The diagnostic points are the same as in the 
form first mentioned. 

4. Encysted hydrocele of the cord. — The peritoneal pouch of the cord 
in this variety is closed for some distance above, and again below, but 
somewhere in its course it is open, and here the fluid accumulates in 
the form of a cyst. When small it resembles an undescended testicle; 
but on examination this organ is found below and in its normal posi- 
tion. When in the canal, it is often mistaken for a lymph gland, some- 
times for a small hernia. The tumour is usually about the size of an 
almond. It is ela>tic and irreducible, and translucent like the other vari- 
eties. In cases of doubt it may be punctured by a hypodermic needle. 



688 DISEASES OP THE URO-GENITAL SYSTEM. 

Treatment of Hydrocele. — In the congenital form the application of 
a truss will sometimes canse obliteration of the canal, so as to shut off the 
hydrocele sac from the general peritoneal cavity. It is subsequently 
managed like an ordinary hydrocele of the tunica vaginalis. In infants 
and young children it is rare that active operative measures are called 
for in any variety of hydrocele, as these usually tend to disappear spon- 
taneously in the course of a few months. The internal administration 
of iodide of potassium, six or eight grains a day, sometimes aids absorp- 
tion. Iodine may be applied locally over a hydrocele of the cord, but 
should not be applied to the scrotum. Some cases are cured by a simple 
puncture with a needle, allowing the fluid to drain off into the cellular 
tissue of the scrotum from which it is absorbed ; others by a single aspira- 
tion with a hypodermic syringe. It is seldom necessary to resort to the 
injection of irritants like iodine or carbolic acid. 

DISEASES OF TEE FEMALE GENITALS. 

VAGINITIS. 

This is a catarrhal inflammation usually affecting only the vaginal 
mucous membrane, but may involve the urethra, bladder, and, in older 
girls, the lining membrane of the uterus, the tubes, and even the peri- 
tonaeum. It may be simple or specific (gonorrheal), both forms being 
fairly common. 

Simple Vaginal Catarrh. — This may be seen at any age, even in in- 
fancy, but is most frequent after the second year. It occurs especially 
in girls suffering from malnutrition and anaemia, and whose personal 
cleanliness is neglected. It may follow any of the infectious diseases, 
particularly measles. It sometimes complicates varicella with a local 
lesion in the vagina. It may be traumatic, as from attempted rape or 
the introduction of foreign bodies. Other causes are pinworms and 
scabies. It is sometimes the cause, sometimes the result of masturbation. 

Symptoms. — The disease generally begins as a subacute catarrhal in- 
flammation, the discharge being the first, and in mild cases the only 
symptom. It is of a white or yellowish white colour and not very abun- 
dant. If the parts are not kept clean the odour of the discharge is quite 
foul. In severe cases the discharge is abundant, and may excoriate the 
skin of the labia and thighs. The mucous membrane is swollen, red, 
and bathed in a muco-purulent secretion. Microscopical examination of 
the discharge shows bacteria in large numbers and of many varieties, but 
they are chiefly the ordinary cocci. The urethra and bladder may be 
involved so that micturition is frequent and painful. The inguinal 
glands are sometimes swollen. With proper treatment and in children 
who are in good general condition, the disease usually lasts from one to 



VAGINITIS. 689 

three weeks ; or, under unfavourable conditions, there may be a persistent 
leucorrhoeal discharge for a long time. 

Gonococcus Vaginitis. — So far from being rare, as was once thought, 
this disease has been shown by recent observations to be very common 
among girls of all ages, even young infants. It is especially in hospitals 
and other institutions that it is seen, and here it must be considered one 
of the most frequent and most troublesome of house infections. Eoutine 
microscopical examinations which I have had made of the vaginal dis- 
charges of children in various institutions, usually revealed the exist- 
ence of gonococcus vaginitis, often in a mild form, in from two to 
ten per cent of the inmates. Epidemics in institutions are exceedingly 
common and very difficult to control. Only one who has experienced 
such epidemics can appreciate what a scourge vaginitis may become. 
No less than four such epidemics were observed in the Babies' Hospital 
between the years 1899 and 1904. During this period 273 cases were 
observed in this institution.* Gonococcus vaginitis often exists in day- 
nurseries or homes for foundlings, as well as in general hospitals and 
asylums for older children. In out-patient practice, and among the poor 
in tenements, cases are constantly seen, and even among the well-to-do 
this disease is by no means rare. From the manner in which it is con- 
tracted, it should not, in young children, be considered a venereal disease. 

In institutions, gonococcus vaginitis can generally be traced to some 
child admitted with an acute form of the disease. Before the condition 
is recognised and the patient quarantined, an entire ward or dormitory 
may be infected, and a local epidemic may be the result; and once well 
under way this may last for months. 

In infants and young children the disease is seldom acquired by 
direct contact, either sexual or manual, but most frequently through 
the medium of napkins. Other possible means of infection are towels, 
sponges, wash-cloths, underclothing, bed-linen, thermometers, syringes, 
bath-tubs, or bath water. Even when the most careful attention has been 
given to these matters, I have frequently seen ward epidemics continue 
unabated. Atmospheric infection seems unlikely. The most probable 
explanation under these circumstances is that the disease is spread by 
nurses in washing, feeding, dressing, or bathing children, but especially 
in the changing of napkins. In many cases it was found impossible to 
check epidemics until both the patients and their attendants were quar- 
antined. 

In girls from six to twelve years old other means of contagion must 
be considered. This may be by direct contact, manual or sexual, or sleep- 
ing with parents or others who may have the disease. Pott found in 90 

* See author's article on Gonococcus Infections in Institutions, New York Medical 
Journal, March, 1905. 



690 DISEASES OP THE UBO-GENITAL SYSTEM. 

per cent of his cases that the mother had a leucorrhceal discharge. The 
mode of contagion may be difficult to trace, but this fact should cast no 
doubt upon the diagnosis. 

Symptoms. — In infants and young children, in the mild cases the 
disease is limited to the mucous membrane of the vagina. There is a 
moderate yellow discharge which, by microscopical examination, contains 
pus cells and gonococci. There is little redness and no symptoms of 
discomfort. In more severe cases the discharge is copious, often thick 
and of a yellow or yellowish-green colour. It may be tinged with blood 
from slight erosions. It often causes excoriation of the labia or thighs. 
In many cases, but by no means in the majority, the urethra is involved, 
causing frequent, painful micturition. Less frequently the inflammation 
extends to the bladder, but seldom or never at this age to the mucous 
membrane of the uterus. The symptoms are chiefly local, but there may 
be a slight rise of temperature to 100° or 101° F. during the period of 
most acute inflammation. 

In girls past the age of six or seven years, the symptoms resemble 
those of the adult: copious secretion, the formation of crusts on the 
labia, frequent, painful micturition from involvement of the bladder and 
urethra, and difficulty in locomotion. There may be slight fever and 
general malaise. The inflammation may extend to the lining membrane 
of the uterus and, through the Fallopian tubes, to the pelvic peritonaeum. 
Sanger has reported such a case in a child of three years. The endome- 
tritis may be demonstrated by the use of a small speculum, by which the 
discharge may be seen coming from the cervix. Swelling, and very rarely 
suppuration, of the inguinal glands may take place. 

A positive diagnosis between simple and gonococcus vaginitis can be 
made with certainty only by a microscopical examination of the dis- 
charge, though in default of such examination an abundant purulent 
catarrh should be assumed to be due to the gonococcus until the opposite 
is proved. In simple catarrh the discharge is made up of epithelial and 
pus cells, with quite a wide variety of bacterial forms, chiefly cocci and 
bacilli, occasionally a few diplococci. In gonococcus vaginitis the gono- 
cocci are found in large numbers, and are usually the only bacteria 
present. To be diagnostic, they should be demonstrated within the pus 
cells as well as outside them. The gonococcus decolourizes when stained 
by Gram's method, which fact distinguishes it from the other organ- 
isms likely to be present in the vagina. The staining is quite as diag- 
nostic as the cultural characteristics of this organism. Cases of vaginitis 
are to be regarded as suspicious if pus is found and few organisms are 
detected; in such conditions subsequent examination usually reveals the 
gonococcus. In my hospital experience the gonococcus cases have out- 
numbered the simple purulent forms, fully ten to one. 

In infants, where the amount of discharge is small and likely to be 



VAGINITIS. 691 

overlooked, it is an advantage to apply between the labia a fold of gauze 
upon which the yellow stain of a purulent discharge is readily noticed, 
which might otherwise escape observation. 

Gonococcus vaginitis may be complicated by conjunctivitis, arthritis, 
endo- or pericarditis, peritonitis, and proctitis. Conjunctivitis is the 
most frequent, the infection usually being carried by the hands. Gono- 
coccus arthritis is not uncommon even in young infants. It is usually 
a multiple arthritis, with the constitutional symptoms of pyaemia. The 
wrist, ankle, knee and elbow, and small joints of the ringers and toes are 
most frequently involved. These cases are considered more fully in the 
chapter on Acute Arthritis in Infants. 

The diagnosis in all the complicating conditions is based upon the 
presence of the gonococcus. 

Prophylaxis. — The highly contagious character of gonococcus vagi- 
nitis makes it imperative that such cases should not be received into the 
same ward or dormitory with other children. Only in this way can 
house epidemics be prevented. Cases which are mild should be excluded, 
as well as those which are severe. The only effective measure is to make 
the microscopical examination of vaginal discharges of children admitted 
to an institution as much a matter of routine as the taking of throat 
cultures if there is a tonsillar exudate. Cases showing the gonococcus 
should be quarantined or excluded. When there are a great many ad- 
missions every month, a case occasionally escapes detection. The rule 
which we have followed in the Babies' Hospital has been to make not 
only an examination on admission, but routine examinations of all pa- 
tients at stated intervals. Only by this means has it at times been 
possible to eradicate the disease. 

The attendants, both day and night nurses, as well as the children, 
should be quarantined. Napkins, underclothing, and sheets from the 
beds of infected children, also towels and wash-cloths, should not go into 
the common laundry, but should be first soaked in a strong solution of 
carbolic acid, and afterward boiled. All articles connected with the 
children's toilet, also syringes, thermometers, etc., should be carefully 
disinfected. The organism is one that is fairly easy to kill, and if proper 
precautions are taken epidemics may be prevented. The essential meas- 
ure is a prompt recognition and isolation of the first case in the hospital. 
Quarantine should continue not only until the catarrhal inflammation 
has subsided and the organism has disappeared, as shown by a single 
negative microscopical examination, but for a considerable time longer, 
since a slight discharge containing a few organisms may remain for 
weeks after the case Is eonsidcred cured. Relapses are very frequent. 

Treatment. — Cases of simple vaginal catarrh should be irrigated twice 
daily with a warm saturated solution of boric acid or 1 to 5,000 bichlo- 
ride. Cleanliness should be secured by frequent bathing and the skin 
45 



692 DISEASES OF THE URO-GENITAL SYSTEM. 

protected by ointments. In more severe cases, astringent injections, such 
as sulphate of zinc or tannic acid, should be used, or protargol applied 
in solutions of from one to five per cent strength. The general health 
should be built up by iron, cod-liver oil, and other tonics. 

In gonococcus vaginitis more energetic treatment is necessary. Every 
child should wear a napkin, to prevent carrying the infection to the eyes 
by means of the hands. Irrigations should be used at least twice a day, 
and stronger antiseptics employed than in the simple cases. The best 
are protargol, in solutions from one to ten per cent strength, and argyrol, 
in solutions from five to twenty-five per cent strength. Applications 
should be made with a cotton swab ; the same substances may be used in 
the form of suppositories, or the vagina may be packed with gauze wet 
in these solutions. The closest attention to cleanliness is required in all 
cases. This disease is very tedious ; many weeks, and often months, may 
be required for a cure. On the whole, treatment is very unsatisfactory 
on account of the difficulties in the way of making thorough local appli- 
cations. When the disease involves the bladder and urethra, the same 
general measures as in adults are indicated. 

GANGRENOUS VULVITIS (NOMA). 
This is the same process as that seen in the mouth and known as 
cancrum oris. It usually follows one of the infectious diseases, most 
frequently measles, occurring in patients whose general vitality has been 
greatly reduced. There is first noticed a tense, brawny induration, the 
skin being shiny and swollen over a circumscribed area. In the centre 
of this there soon appears, usually upon one of the labia major a, a dark, 
circumscribed spot. Day by day the gangrenous area advances, preceded 
by the induration. It may involve the whole labium, extending even to 
the mons veneris and the perinseum. These cases are generally fatal. 
If recovery takes place, it is with considerable deformity of the parts in 
consequence of the extensive sloughing and cicatrization. As sequelae, 
there may be fistula?, stenosis, or atresia of the vagina. The prognosis 
is very bad. The only radical treatment is early excision, and the appli- 
cation of the actual cautery, carbolic or nitric acid. 

CHAPTER IV. 

ENURESIS. 
Synonyms : Incontinence? of urine ; bed-wetting. 

Enuresis may be due to some malformation of the genital tract, such 
as an abnormal opening of the bladder into the vagina, to extroversion 
of the bladder, or to the persistence of the urachus; in the latter case 
the urine is discharged from the umbilicus. It also occurs m organic 
diseases of the central nervous system, such as idiocy, cerebral palsy, 



ENURESIS. 693 

acute meningitis, tumours of the brain, certain forms of myelitis, and 
in injuries of the cord. In many of these conditions there is associated 
incontinence of faeces. Both of the groups of cases mentioned are quite 
distinct from the ordinary form of incontinence of urine which is seen in 
childhood. The latter is to be regarded as a neurosis, and is the only 
variety which will be considered here. 

It is in many cases possible to teach infants to control the evacuation 
of the bladder before the end of the first year; usually, however, control 
is not acquired even during waking hours until some time during the 
second year, and in some healthy infants not before the end of the second 
year. The time depends very much upon the training. If a child during 
its third year can not control the evacuation of the bladder during its 
waking hours, incontinence may be said to exist. 

Etiology. — Incontinence of urine may be due to a continuance of the 
infantile condition, to anything which increases the irritability of the 
spinal centre, or which interferes with the cerebral control over this 
centre, or to anything which increases the irritability of the terminal 
filaments of the vesical nerves or of those in the neighbourhood. The 
causes of incontinence thus may be in the central nervous system, in the 
urine, in the bladder, or in any of the adjacent organs. 

The causes relating to the central nervous system are in the main 
those of the other neuroses of childhood; these are anaemia, malnutrition, 
an inherited nervous constitution, or a condition of extreme nervousness 
or neurasthenia, the result of the child's surroundings. In such cases 
incontinence is often associated with chorea, epilepsy, hysteria, headaches, 
neuralgia, and other nervous symptoms. In these conditions there may 
be not only an increased irritability of the nerve centres, but also of the 
peripheral nerves, accompanied by loss of tone of the vesical sphincter. 
A similar condition may exist with almost any form of acute illness, 
usually, however, being only temporary. 

Incontinence may be caused either by a highly acid, concentrated urine 
where an Lnsufficienl amount of fluid is taken, or to the opposite condi- 
tion, where, owing to the drinking of a large quantity of water, often 
only a matter of habit, tin- amount of urine is very greatly increased and 
passed at frequenl intervals. 

In the bladder itself, cystitis and vesical calculus, although infre- 
quent, should not he overlooked a> possible causes. In a few cases, where 
incontinence has existed a long time, the bladder becomes so contracted 
that it will hold only an ounce or two of urine. This condition, although 
not the primary cause of enuresis, may be enough to continue it. 

Local irritation in the Qeighbouring organs may he due to adherent 
prepuce, balanitis, phimosis, or to a narrow meatus. All of these condi- 
tions are frequently associated with incontinence. Ixectal irritation may 
be due to pinworms, anal fissure, or rectal polypus; and vaginal irrita- 



694 DISEASES OF THE URO-GENITAL SYSTEM. 

tion to vulvovaginitis or adherent clitoris ; but these are. rarely the only 
cause. Often we have incontinence as the result of a combination of sev- 
eral causes, no one of which alone would have been sufficient to produce 
it. Thus, in a healthy child phimosis may give rise to no symptoms, while 
in one who is anaemic or neurasthenic it may produce enough local irri- 
tation to cause incontinence. In many cases heredity seems to be a 
factor of some importance, parents often having suffered in their child- 
hood from the same condition ; quite frequently two and sometimes even 
three children in the same family are affected. In many cases the con- 
dition seems to be mainly the result of habit, and in all cases habit is 
a potent factor in continuing the incontinence, sometimes after the orig- 
inal exciting cause has been removed. Frequently no adequate cause 
can be found. Both sexes are about equally liable to enuresis, and it 
may be seen in all ages up to puberty. 

Symptoms. — Enuresis may be nocturnal or diurnal, or both. Of 184 
cases, 73 were nocturnal, 9 diurnal, and 102 were both nocturnal and 
diurnal. Cases differ greatly in severity. Incontinence may be habitual, 
occurring every night, often several times during the night, and fre- 
quently during the day ; or it may be only occasional under the influence 
of some special exciting cause, where it continues a few days or weeks 
until the cause is removed. In a considerable number of cases, the condi- 
tion lasts from infancy until the sixth or seventh year. It may even con- 
tinue until puberty ; but it generally ceases at that period, unless its cause 
is mechanical, or depends upon some organic disease of the brain or cord. 
In ordinary enuresis there is never dribbling of the urine, but usually a 
contraction of the walls of the bladder follows almost immediately upon 
the desire before the patient can make his wants known or reach a con- 
venient place for micturition. At night the same thing may occur with- 
out wakening the child, the contraction being of purely reflex origin. 

Prognosis. — The condition is usually hopeless when it depends upon 
organic disease of the brain and cord ; also in cases due to malformation, 
unless these are amenable to surgical treatment. In the ordinary cases 
seen, the prognosis depends upon the age of the child, the duration of the 
symptom, and the nature of the exciting cause. In children of from 
three to five years a cure can usually be accomplished with proper man- 
agement. Those who are older are much less amenable to treatment, 
especially if the condition has persisted since infancy; but if the incon- 
tinence has lasted only for a year or so, the outlook is much more encour- 
aging. When some cause can be discovered which can be removed, the 
prognosis is better than if none can be found. There are, however, some 
cases in which no other cause than habit can be discovered which resist 
all treatment, the condition finally ceasing spontaneously at or a little 
before puberty ; in very few does it continue beyond this period. 

Treatment. — The first indication is to remove the cause, where one 



ENURESIS. 695 

can be found. If there are preputial adhesions, they should be broken 
up and irritating smegma removed. If phimosis is present, it should be 
relieved by stretching or circumcision. A narrow meatus should be cut 
to proper dimensions. If stone in the bladder is suspected, as it should 
be when the incontinence is worse by day and accompanied by straining 
and painful spasm of the bladder, the patient should be sounded for stone. 
Pinworms in the rectum should receive the appropriate treatment by 
injections. While the local conditions mentioned should always be 
attended to, the fact remains that few cases are cured simply by reliev- 
ing them, except those due to vesical calculi. The explanation of this 
is that habit is so important a factor in keeping up incontinence where 
it has existed a long time. 

A concentrated urine of high acidity with deposits of uric acid, is an 
indication for alkalies and the free use of all fluids, especially water. 
On the other hand, when there is passed a large quantity of urine with 
low specific gravity, the amount of water and other fluids should be 
restricted. During the night, water should be forbidden and the amount 
given in the latter part of the day greatly reduced. In these cases the 
incontinence is often simply the result of the polyuria, which in turn 
depends upon polydipsia. 

To Institute a proper general regime should be the next step in the 
treatment. Care should be taken to secure for the child a simple, natural 
life, preferably in the country. There should be no overtaxing of the 
nervous Bystem at home or in school. Every cause of unnatural excite- 
ment should be avoided. Early hours and plenty of sleep must be insisted 
u j mil. Certain articles of diet are to be avoided, and coffee, tea, and beer 
should be absolutely prohibited. Sweets and all highly seasoned food 
should be very sparingly allowed, or not at all. Although it is believed 
by many thai a diet into which meat enters largely is injurious, from 
personal experience I have not found the exclusion of meat to be of any 
advantage. The diel which succeeds besl is a simple one composed of 
milk, vegetables, fruits, meats, and cereals. With most patients who nave 
nocturnal incontinence, it is well to allow fluids freely during the early 
pari of the day, hut little or none after ;> or 1 p. m.. b dry supper being 
given juM before retiring. The child should be taughl to hold his water as 
long as possible during the day, to accustom the bladder to full distention. 

Measures directed toward improving the genera] muscular and nervous 
tone are of the greatest Importance, and they are required in mosl cases, 
excepting the very young children. It Bhould be remembered thai incon- 
tinence of urine i> a neurosis, depending like mosl neuroses of childhood 
upon disturbed nutrition. Anaania, chlorosis, malnutrition, indigestion, 
and constipation should each receive careful attention. Any local con 

(lit ion, such as adenoid growths of the pharynx, which mighl Berve I" 
increase the general nervous irritability, should he removed. 



696 DISEASES OP THE TJRO-GENITAL SYSTEM. 

The moral treatment of the case is important. One should work 
upon the child's pride and use every possible means to strengthen his 
will. Punishments whether corporal or otherwise do little good, and 
with most children they are absolutely harmful. With children in whom 
incontinence is chiefly a matter of habit, I have often found rewards 
more efficacious than any other means of treatment. One should first 
find out what it is that the child desires most — a new doll, a bicycle, a 
pony — and allow him to have it if his bed is dry, taking it away if it is 
wet. A reward of five cents for every dry night sometimes works marvels. 

The measures described — removal of local causes, building up of the 
general health, institution of a proper regime, and mental and moral 
means — in a very considerable number of cases suffice for a cure. They 
generally constitute the most important part of the treatment, and their 
value is not sufficiently appreciated. Personally I have found these 
means more effective than the use of specific drugs. Drugs are useful as 
accessories, but alone seldom accomplish a cure. Of those employed bella- 
donna is certainly the most effective, but its administration should be 
continued for a long time. Atropine either in solution or in tablet form 
is the most convenient method of administration. For nocturnal in- 
continence, tVo o °f a grain for each year of the child's age up to seven 
years, is a suitable initial dose. A child of five would thus be taking 
2^-5- of a grain. At first, a single dose should be given at bedtime ; after 
a few days a second dose may be given three or four hours earlier. To 
push the drug much further than this, causes much discomfort and is 
of doubtful advantage. After the condition is under control, the same 
dose should be continued for some time and then reduced, the atropine 
being given for at least two months in gradually diminishing doses after 
the incontinence has ceased. This is very important if the cure is to 
be permanent, as there is so strong a tendency in these cases to relapse. 

Strychnine may be added in cases not yielding to the atropine alone. 
It is particularly advantageous when there is diurnal as well as nocturnal 
incontinence, for under these conditions there is usually a lack of tone in 
the sphincter, as well as increased irritability in the mucous membrane 
of the bladder. The initial dose for a child of five years should be xJ^ 
of a grain twice daily; this may be gradually increased to -^ of a grain 
three times a day; but there is rarely any advantage in pushing it fur- 
ther. Ergot is sometimes useful in conjunction with other drugs, but 
rarely gives relief when both strychnine and atropine have failed. Some 
obstinate cases are reported to have been relieved by f aradism ; the posi- 
tive pole is attached to a small electrode passed into the rectum and the 
negative pole applied over the bladder. The sitting should last for ten 
minutes and be repeated three times a week. My own experience with 
this method of treatment has been disappointing. If there is reason to 
suspect a contracted bladder, as when the incontinence has lasted for 



VESICAL SPASM. 



697 



years and the bladder will never hold more than an ounce or two of 
urine, cure is sometimes accomplished by daily distending the organ 
up to its normal capacity with warm water. 

Careful, intelligent, systematic training is a most valuable adjunct 
to all measures employed for the relief of this very annoying condition. 



VESICAL SPASM. 

This is quite a common condition, and often passes under the name 
of genital irritation. It is characterized by frequent, sometimes by diffi- 
cult and painful, micturition. It occurs in children of all ages, even in 
infants, but is especially frequent between the ages of two and five years. 
This symptom has already been referred to in connection with uric-acid 
infarctions in very young infants. 

The usual cause is the irritation of the bladder, by a concentrated, 
highly acid urine. It often results from cold; it may accompany acute 
febrile processes, and is sometimes merely a symptom of nervous irrita- 
bility. The cause may thus be in the bladder or in the urine. It may be 
accompanied by enuresis, but usually occurs without it. It is sometimes 
symptomatic of disease in adjacent parts, as in the rectum or the pelvic 
peritonaeum, or it may be associated with inflammation of the vulva or 
urethra. It is also one of the symptoms of vesical calculus. 

The symptoms of vesical spasm are local only. The child passes 
water very frequently, often several times an hour. The accompanying 
pain may be intense, not infrequently sufficient to cause the child to 
cry out. Often there is pain and severe vesical tenesmus with the pas- 
sage of only a few drops of urine at a time, but blood is not present. If 
the condition depends upon the character of the urine, or is only an 
expression of an extreme vesical irritability, the symptoms are generally 
of short duration, possibly a day or two. If it depends upon vesical 
calculus, it may be intermittent. If it is associated with disease of the 
adjacent pelvic viscera, it is inconstant, and may continue for a con- 
siderable period, depending upon the nature of the cause. 

The treatment^ in the ordinary cases, consists in the administration 
of an abundance of water, with alkaline diuretics, and cither belladonna 
or hyoscyamus. The following formula is one that I have usually found 
efficient : 

Ij Tincture hyoecyami 7 

Potussii citratis 3 j 

Aqua destflkri : i.i 

M. Sig. : Ilalf a teaspoon ful in water every hour to a child <>f t n 

If the cause is outside the bladder, it should receive appropriate 
treatment. 



698 DISEASES OF THE URO-GKENITAL SYSTEM. 



VESICAL CALCULI. 

The nucleus of a vesical calculus is usually a renal calculus which 
has passed the ureter, but has been prevented by its size from going 
farther. Stone in the bladder is extremely rare in infancy, probably 
owing to the fluid diet, but it is not infrequent in children from two 
to ten years of age. The most common variety of calculus at this time 
is the uric acid. The other forms, although occasionally seen, are all 
quite rare. 

The symptoms in children are somewhat different from those in 
adults, and the condition is often overlooked. There is frequently pain 
upon micturition, especially at the close of the act, which may be felt 
at the end of the penis or in the perinaeum. There may be a sudden 
stoppage in the flow of urine. The straining often leads to rectal tenes- 
mus and even to prolapse. This complication is so frequent that, in a 
case of persistent prolapse, stone should always be suspected. Incon- 
tinence of urine is a prominent, and often the principal symptom; in 
many cases it is noticed only during the day. The urinary changes are 
not generally marked; hematuria is rare, and mucus and pus are in- 
frequent and in small quantity. The genital irritation may lead to the 
habit of masturbation. A stone of any considerable size may often be 
felt by a bimanual examination, one finger being placed in the rectum 
and the other hand above the pubes. This is easier in males than in 
females, but it is not very trustworthy, and not conclusive when it gives 
a negative result. A positive diagnosis is made only by exploring the 
bladder with a sound. 

The treatment of calculus is purely surgical. In young children the 
suprapubic is now generally preferred by surgeons to the perineal opera- 
tion, if the calculus is too small to be easily removed by crushing. 



SECTION VII. 

DISEASES OF THE NERVOUS SYSTEM. 

CHAPTER I. 

INTRODUCTORY. 

The Weight of the Brain. — From ninety-eight observations made in 
the post-mortem room of the New York Infant Asylum, the following 
were the average weights noted : 

At three months 21 oz. (602 grammes). 

At six months 25£"(712 " ). 

At twelve months 32£ " (916 " ). 

At two years 35 " (990 " ). 

The following are the figures given by Boyd and Schafer : * 



At birth (full terra) 

Under three months 

From three to six months 

From six to twelve months. . . 

Prom one to two years 

From two to four years 

From four to Beveri years 

From seven to fourteen years. 
From fourteen to twenty years 



Males. 



Ounces. 

in 

m 

21 

27 
33 
39 
40 
40 
48* 



Grammes. 

330 

493 

602 

776 

941 
1.095 
1,188 
1,801 
1,374 



Females. 



Ounces. 
10 
16 
20 
26 
30 
35 
40 
40* 
44 



Grammes. 

283 

451 

560 

727 

843 

990 
1,186 
1,154 
1,244 



At birth the weight of the brain to that of the body is aearly 1 : 8. 
Daring Infancy and childhood the following is the ratio, according to 
BiscliolT: during the first year, 1 :6; the second year, 1:14; the third 
year, 1 :18; at the fourteenth year, 1:15 to 1:25; in adults, 1:43. 

The Spinal Cord.— The weight of the cord to the weigh! of the body 
at birth is 1:500; in adult life it is 1 :1500. According to Kdlliker, the 
spinal cord and the vertebral column are the same length until the end of 
the third month of foetal life, there being al this time no cauda equina. 
At the ninth month the lower end of the cord is opposite the third lum- 
bar vertebra; in the adult it is opposite the first. 



46 



* Quoted bj Sachs. 
899 



700 DISEASES OP THE NERVOUS SYSTEM. 

Some Peculiarities in the Diseases of the Nervous System in Infancy 
and Childhood.* — The relatively large size, the rapid growth, and the im- 
maturity of the brain and cord during early life, explain much that is 
peculiar in the nervous diseases of this period. 

At this time, apparently trivial causes are enough to produce quite pro- 
found nervous impressions, because of the instability of the nervous centres 
and the greater irritability of the motor, sensory, and vaso-motor nerves. 
These are conditions which are very much increased by all disturbances of 
nutrition. These disturbances may be manifold in character, but they lie 
at the root of very many of the neuroses of early life, — e. g., extreme nervous- 
ness, disorders of sleep, stuttering, chorea, incontinence of urine, tetany, 
and convulsions. The great liability to convulsions depends not only 
upon the greater irritability of the peripheral nerves, but on the instability 
of the nervous centres and the lack of inhibition over the motor ganglion 
cells of the spinal cord. The nervous centres are more easily exhausted 
than later in life. Prolonged or continuous overstrain from any cause 
whatsoever, frequently leads to headache and chorea, and sometimes even 
to epilepsy and insanity. 

Another peculiarity is the serious consequences which often follow 
reflex irritation, although this is rarely the only factor in the case. 
Conditions which in adult life produce almost no effect may in infancy 
be the cause of most alarming symptoms. As a few examples may be 
cited, reflex symptoms due to phimosis or intestinal worms, convulsions 
from disturbances of digestion, nervous symptoms due to eye-strain, or to 
adenoid growths of the pharynx. In the production of some of these, 
especially attacks of convulsions, there are several factors, such as the 
great irritability of the peripheral nerves, the instability of the nervous 
centres— often a result of disturbed nutrition, as in rickets— and the lack 
of inhibitory action of the cortex of the brain. 

As a third point of importance may be mentioned the grave permanent 
results which often follow relatively small organic lesions. A good illus- 
tration is seen in the lesions which produce cerebral birth-palsy. Here 
the damage is only in small part the immediate effect of the haemorrhage, 
for this often is not great, but it is the interference with the development 
of certain parts of the cortex that makes this condition so serious. 

From what has been said, it follows that the hygiene of the nervous 
system is of the utmost importance in infancy and childhood. It is 
essential for the healthy development of the nervous system that all 
stimulants should be avoided,— not only tea, coffee, and alcohol, but 
undue and unnatural excitement, the effect of which in infancy is almost 
as serious. A normal development can take place only in the midst of 



* See Rachford ; Some Physiological Factors in the Neuroses of Childhood. Cin- 
cinnati, 1895. 



CONVULSIONS. Y01 

quiet and peaceful surroundings, with plenty of time for rest and sleep. 
The conditions of modern life, especially in cities, are such that these 
laws are almost invariably violated, and the consequences of this are seen 
in the marked and steady increase in nervous diseases among children. 



CHAPTER II. 

GENERAL AND FUNCTIONAL NERVOUS DISEASES. 

CONVULSIONS. 

Under this head are included attacks of acute transient nervous dis- 
turbance, characterized by involuntary rhythmical spasm of the muscles, 
either of the face, trunk, or extremities, or all of them, usually accom- 
panied by loss of consciousness. They may be regarded as " motor dis- 
charges " from the cortex of the brain. 

Etiology. — The principal predisposing causes are infancy, conditions 
affecting the nutrition of the brain, and hereditary influences. Of all these 
factors, the most important one is the instability of the nerve centres which 
is characteristic of infancy and is associated with the non-development of 
the voluntary centres of the cortex. The brain grows more during the 
first year than in all later life, and this rapidity of growth is in itself an 
important predisposing cause of functional derangement. After infancy, 
attacks of convulsions are much less frequent, and after seven years they 
are relatively rare. While convulsions occasionally occur in children pre- 
viously healthy, the majority of attacks are in those in whom there is at 
least some disturbance of the nutrition of the brain, — the cerebral insta- 
bility of infancy being greatly exaggerated by such nutritive disorders. The 
most frequent one is rickets, which may be regarded as altogether the most 
important predisposing cause of infantile convulsions. They are often 
one of the earliest symptoms of that disease, and where convulsions occur 
in infancy without evident cause, rickets should always be looked for. 
Any disturbance of nutrition may predispose to convulsions, such as ex- 
haustion, anaemia, malnutrition, syphilis, and debility resulting from any 
acute disease, especially those of the digestive tract. Children who in- 
herit from their parents a peculiarly nervous temperament are more liable 
to convulsions than are others. This predisposition is often seen in sev- 
eral members of the same family. Females are rather more frequently 
affected than males. 

The exciting causes include a wide variety of pathological conditions, 
among which disturbances of digestion take the first place. Where the 
susceptibility is very great, the exciting cause may be a trivial one. These 



702 DISEASES OF THE NERVOUS SYSTEM. 

causes may be grouped under three general heads : (1) direct irritation of 
the cortex of the brain ; (2) reflex irritation ; (3) toxic influences. 

Under the head of direct irritation may be included all convulsions 
occurring with the various forms of cerebral disease ; the most frequent are 
meningitis, meningeal or cerebral haemorrhage, tumour, abscess, hydro- 
cephalus, embolism, and thrombosis. As examples of reflex irritation 
may be classed the convulsions following severe injuries, like compound 
fractures or burns, renal or intestinal colic, retention of urine, phimosis, a 
foreign body in the ear, or intestinal strangulation. A case has been re- 
lated to me in which the application of cold to the skin repeatedly induced 
convulsions. Other conditions classed under this head are dentition and 
worms, but both must be regarded as exceedingly rare causes of convul- 
sions. The exciting cause is very frequently the presence in the stomach 
or intestines of undigested food; such attacks are sometimes ascribed 
to reflex irritation, but the majority are better regarded as toxic. Acute 
and chronic indigestion are to be ranked among the most frequent 
causes of convulsions, both in infants and older children. In either 
there may be but one attack, or attacks may recur at intervals of a 
few months with a repetition of the cause. Of toxic origin may be 
considered not only the convulsions resulting from conditions like 
uraemia and asphyxia, but also those which occur at the onset or in the 
course of various infectious diseases, sometimes classed as febrile con- 
vulsions. They are very frequent at the onset of certain diseases, particu- 
larly pneumonia, scarlet fever, malaria, acute indigestion, and gastro-enteric 
intoxication; less frequently measles, typhoid fever, ileo-colitis, and 
diphtheria. In these cases the convulsions seem due partly to the in- 
tensity of the poison and partly to the suddenness with which it affects 
the nervous system. Convulsions occurring late in the course of many 
diseases may be due to toxic influences, especially when associated with 
exhaustion of the nerve centres, from the prolonged disturbances of 
nutrition accompanying the febrile condition. 

In pertussis, which of all infectious diseases is the one in which con- 
vulsions are most frequent, several factors may be present: asphyxia 
due to a severe paroxysm, cerebral congestion or haemorrhage resulting 
from such a paroxysm, or simply from the peculiar susceptibility of the 
patient brought about by the disease itself. 

Convulsions may be associated with enlargement of the thymus gland. 
I have seen several fatal cases of convulsions where there was found at 
autopsy great enlargement of the thymus, which weighed from one to 
one and a half ounces. Some of these infants were previously healthy; 
some were rachitic. The similarity of all these cases indicated that the 
convulsions were in some way due to the enlarged thymus, possibly from 
pressure either upon the lungs, the large vessels, or the pneumogastric 
nerves, or in some other way, not yet understood. 



CONVULSIONS. 703 

There are some cases of convulsions for which no cause can be dis- 
covered even at autopsy, and for the present we must be content to class 
them as idiopathic. One attack of convulsions renders the patient more 
liable to a second, and where there have been several, they occur from 
causes which are less and less marked. 

Pathology. — The "nervous discharge " which occurs in an attack of 
convulsions differs in no essential particulars from that of ordinary epi- 
lepsy. In the latter disease there is seen a tendency to recurrence with 
greater or less frequency, until the discharge may take place from very 
slight causes. 

The part of the brain most intimately concerned in the production of 
convulsions is the cortex. Such attacks may be regarded as involuntary 
discharges of nerve force from the cortical motor centres, which result 
from direct irritation of these parts by disease ; or from an irritation aris- 
ing in some other part of the brain, as from the vaso-motor centres of 
the medulla ; or from a reflex irritation in a distant part of the body. 
Convulsions may depend upon the fact that while nerve cells may be able 
to generate nerve force they can not control its discharge, as in the con- 
vulsions of rickets. An important element in the convulsions of infancy, 
according to Hughlings Jackson, is the lack of development of the higher 
cerebral functions, in consequence of which they do not exert the control- 
ling influence over the discharge of nerve force which they do in later life. 

The condition of the brain in the beginning of an attack of convul- 
sions is one of anaemia; this is shortly followed by venous hyperemia 
which may be very intense. In infants who die during convulsions the 
brain and its meninges are usually found intensely congested. They may 
be the seat of punctate haemorrhages, and sometimes of more extensive 
ones. The lungs are also deeply congested, and the right heart is generally 
distended with dark clots. The other lesions found are accidental. 

Symptoms. — In some cases prodromal symptoms are present, such as 
extreme restlessness, irritability, slight twitchings of the muscles of the 
face, hands, feet, or eyelids. More frequently, however, the attack comes 
quite suddenly with but momentary warning. Usually the first thing 
noticed is that the face is pale, the eyes fixed, sometimes rolled up in 
their orbits; in a moment or two convulsive twitchings begin in the 
muscles of the eye or face, or in one of the extremities, which usually 
rapidly extend until all parts of the body participate. In most cases the 
convulsions become general, but they may, however, remain unilateral 
even when not due to a local cause, — a point which is often forgotten. 
The contraction of the facial muscles causes a succession of grimaces ; the 
neck is thrown back ; the hands are clenched ; the thumbs buried in the 
palms ; and a quick spasmodic contraction of the extremities occurs. 
There may be some frothing at the mouth, and in all true convulsions 
there is loss of consciousness. Respiration is feeble, shallow, and may be 



704 DISEASES OF THE NERVOUS SYSTEM. 

spasmodic. The pulse is weak ; it may be slow or rapid ; often it is irreg- 
ular. The forehead is covered with cold perspiration. The face is first 
pale, then becomes slightly blue, especially about the lips. Unnatural 
rattling sounds may be produced in the larynx. The bladder and rec- 
tum may be evacuated. The convulsive movements consist in an alter- 
nation of flexion and extension occurring rhythmically. All varieties 
of tonic and clonic spasm may be seen, and in all degrees of severity. 
The contractions of the two sides of the body are usually synchronous. 
After a variable time, from a few moments to half an hour, the convulsive 
movements are gradually less frequent, and finally cease altogether, usually 
leaving the patient in a condition of stupor. They may recur after a 
short time or there may be but one attack. A period of general relaxa- 
tion usually follows the convulsive seizures, frequently accompanied by 
marked evidences of prostration. Transient paralysis, apparently due to 
exhaustion of the nerve centres, is not an uncommon sequel. 

Death may take place from a single attack ; this, however, is rare ex- 
cept in very young infants, especially those who are rachitic. There may 
be no sequel to the convulsions if the cause is a temporary one, or they 
may produce some serious brain lesion, particularly meningeal haemor- 
rhage. Death from convulsions is generally due to asphyxia, or to exhaus- 
tion from the rapidly recurring attacks. Many cases recover in which 
the children for several minutes had the appearance of being moribund. 

One attack of convulsions is very apt to be followed by others; for 
the occurrence of the first one usually reveals a peculiar susceptibility 
of the nervous system, and each succeeding attack comes from a less 
powerful exciting cause than the previous one. The longer the interval 
which has passed, the less likely is there to be a repetition, especially if 
the child has passed its third year. The number of attacks may be very 
great. In a case under the care of Dr. A. M. Thomas and myself in 
1896, an infant during the latter part of its second year had during six 
months over thirty-five hundred distinct attacks of convulsions. For a 
considerable period they reached the almost incredible number of eighty 
a day, and yet the mental condition of the child in the interval was ap- 
parently normal.* 

Diagnosis. — There can rarely be any difficulty in recognising an at- 
tack of convulsions. The difficulty consists in determining with which 
of the many possible exciting causes we have to do in the case before us. 
Is it epilepsy ? Does it depend upon cerebral disease ? Does it mark the 
onset of some other acute disease ? Is it reflex, and if so to what is it 



* The microscopical examination of the brain showed only degenerative changes 
in the nerve cells of the cortex in the motor area and an increase in the neuroglia. 
These changes existed over quite an extensive area, and were more marked upon 
one side. 



CONVULSIONS. 705 

due ? To answer these questions a careful history must be obtained, and 
all the circumstances surrounding the patient, the character of the convul- 
sions, and all the other symptoms present must be taken into consideration. 

In infancy, epilepsy is certainly the least probable diagnosis. In older 
children the most important points indicating that disease are : the pres- 
ence of some of the stigmata of degeneration, a history of previous attacks, 
a distinct aura preceding the seizure, or a sudden onset with a cry or 
fall, biting of the tongue, a tonic spasm preceding the clonic, and, finally, 
perfect recovery in the course of a few hours after the attack. Convul- 
sions which come on with high fever, even though a patient may have 
repeated attacks, are seldom epileptic. However, in some cases only pro- 
longed observation can enable one to decide positively whether or not 
epilepsy is present. 

Convulsions occurring in brain disease, except acute meningitis, are 
not as a rule accompanied by any marked rise in temperature. Focal 
symptoms are often present, such as localized paralysis or rigidity, 
changes in the pupils, and strabismus. The convulsive movements are fre- 
quently limited to one side of the body. It should, however, be borne in 
mind that unilateral convulsions, even when repeated, do not always mean 
a local lesion, as I have seen proved by autopsy more than once. In 
haemorrhage or meningitis, convulsions are likely soon to recur. In tu- 
mour they may recur after a longer interval. 

Convulsions may be thought to indicate the onset of some acute dis- 
ease when they occur in a child over two years old, and when they come 
on suddenly or with only slight premonition in a child previously well ; 
but the most important point is that they are accompanied by a high tem- 
perature, — 104° to 106° F. Acute meningitis is the only other condition 
likely to produce these symptoms. Whether the convulsions mark the 
onset of lobar pneumonia, scarlet fever, malaria, or some other disease, 
can be determined only by carefully watching the patient's symptoms for 
twenty-four or thirty-six hours. 

In convulsions depending upon some disorder of the alimentary tract, 
one may get a history of chronic constipation or improper feeding, and 
in nursing infants sometimes of passion or intoxication in the wet- 
nurse. Convulsions are so frequently due to digestive derangements 
that the condition of these organs should be one of the first things to be 
looked into. 

Iv\a urination of the urine should never be omitted in any case of con- 
vulsions of doubtful origin, even where no dropsy is present. This, both 
in infants and older children, is too often overlooked. Asphyxia may be 
suspected in the case of convulsions occurring in the newly born, late in 
pneumonia, in some cases of pertussis, in spasmodic or membranous lar- 
yngitis, or in laryngismus stridulus. Dentition and worms should be con- 
sidered among the least probable, never as the most probable, causes of 



706 DISEASES OP THE NERVOUS SYSTEM. 

reflex irritation, and should not be so accepted without positive evidence. 
Worms are so rare in infancy that at this period they may be practically 
ignored. Dentition seldom, if ever, causes convulsions except in patients 
who are markedly rachitic. In all cases of convulsions of doubtful or 
obscure origin occurring in infants, rickets should be suspected as the 
underlying cause, and the child carefully examined for other evidences 
of that disease. 

Prognosis. — This depends upon the age of the patient and the cause 
of the convulsions. Idiopathic or reflex convulsions are rarely dangerous 
to life except in very young or in rachitic infants. Convulsions associated 
with enlarged thymus are often fatal. Convulsions occurring at the onset 
of acute febrile diseases are seldom fatal, and not often serious ; they may 
not even indicate an unusually severe type of the disease. Especially fatal 
are the convulsions of pertussis and of asphyxia when they occur late in 
any form of laryngeal or pulmonary disease. In nephritis, while always 
serious, convulsions are by no means invariably fatal. The conditions 
during an attack which should lead one to make a bad prognosis are when 
the convulsions are prolonged or recur frequently; also the presence of 
very great prostration, a feeble pulse with cyanosis, or deep stupor. 

In the prognosis one must take into account not only the immediate 
result of the attack, but its possible outcome. Except where convulsions 
mark the beginning of epilepsy, they are much less serious than they are 
generally supposed to be by the laity. In a highly nervous or susceptible 
child a convulsion may often mean no more than does an attack of severe 
migraine in an older person. Such are undoubtedly most of the attacks 
seen in practice. Permanent injury to the brain, simply as a result of 
an attack, although possible, is still rare. But when convulsions are re- 
peated the development of epilepsy is to be feared. There is little doubt 
that some cases of epilepsy have their origin in attacks of convulsions, 
which in the beginning were the result simply of digestive derangements ; 
by a constant repetition of the exciting cause the convulsive habit finally 
becomes established. This possibility is therefore to be borne in mind in 
all cases where children have had several convulsions, although it is un- 
usual that this result is seen. The farther apart the attacks are and the 
more definite the exciting cause, the less likely is this to be the case. 

Treatment. — Summoned to a child in convulsions, a physician should 
go at once and remain until the attack has subsided. He should take 
with him chloroform, a hypodermic syringe with morphine, a soft cath- 
eter or rectal tube, and a solution of chloral. In order to treat convul- 
sions intelligently one must have in mind the prominent pathological 
conditions. These are acute cerebral hyperemia, a more or less severe 
asphyxia with pulmonary congestion, an overtaxed right heart, and in 
fact a tendency to congestion of all the internal organs. The nervous 
centres are in a condition of such unnatural excitability that the slight- 



CONVULSIONS. 707 

est irritation may bring on convulsive movements when they have tempo- 
rarily subsided. The patient should therefore be kept perfectly quiet, 
and every unnecessary disturbance avoided. Cold should be applied to 
the head — best by means of an ice cap or cold cloths — and dry heat and 
counter-irritation to the surface of the bod}^ and extremities. The time- 
honoured mustard bath causes so much disturbance of the patient that it 
can usually be dispensed with and the mustard pack (page 54) substituted. 
The feet may be placed in mustard water while the child lies in its crib. 
The mustard pack and footbath should be continued until the skin is well 
reddened. The degree to which counter-irritation of the skin should be 
carried will depend upon the condition of the pulse and the cyanosis. 

In controlling convulsions the three remedies which may be depended 
upon are the inhalation of chloroform, morphine hypodermically, and 
chloral. Chloroform is undoubtedly the most reliable remedy for an 
immediate effect, and should be used even in the youngest infant. At 
the same time that it is being administered, chloral should be given 
per rectum. The initial dose should be, at six months, four grains ; at 
one year, six grains ; at two years, eight grains, dissolved in one ounce 
of warm milk. It should be injected high into the bowel through a 
catheter, and prevented from escaping by pressing the buttocks together. 
It may be repeated in an hour if necessary. The effect of the drug is 
generally obtained in twenty minutes. If, in spite of the chloral, the 
convulsions show a marked tendency to continue as soon as the chloro- 
form is withdrawn, or if the enema of chloral has been expelled, morphine 
should be given hypodermically. Where the heart's action is weak, this 
is probably the best of all remedies. Objections are urged against it only 
by those who have had no experience with its use. To a well-grown child 
two years old, -fa of a grain may be given ; one year old, -fa of a grain ; 
six months old, -£ s of a grain. This dose may be repeated in half an 
hour if no effect is seen. The tolerance of opium in cases of convulsions 
is very marked, and sometimes double the doses mentioned may be re- 
quired. The only other agent of much value is oxygen. I have seen con- 
vulsions which continued in spite of all other means, yield immediately 
to oxygen. This is most likely to be valuable in cases of convulsions due 
to asphyxia. 

When once under control, the recurrence of the convulsions may be 
prevented by keeping the patient for two or three days under the influ- 
ence of chloral with bromide of sodium, the amount of chloral being 
gradually reduced. If it is badly borne by the stomach and not easily re- 
tained by the rectum, either antipyrine or phenacetine may be used with 
the bromide. Where there is a strong tendency to recurrence of the con- 
vulsions, urethan is sometimes even more efficient than chloral. It may 
be given in the same or in slightly larger doses. 

As soon as the convulsions have ceased, the cause should be sought 



708 DISEASES OF THE NERVOUS SYSTEM, 

and treated. In infancy it is wise in every case to irrigate the colon 
thoroughly with warm water, to remove any possible source of irritation. 
If there is reason to suspect the presence of undigested food in the 
stomach, this may be washed out. Much more frequently it is in the 
intestines, and free purgation by calomel is advisable. If there is high 
temperature, this should be reduced by the cold bath or pack. Secondary 
attacks are to be prevented by careful feeding, by improving the general 
nutrition by means of fresh air, iron, cod-liver oil, and phosphorus. The 
last two are especially valuable in cases due to rickets. 

EPILEPSY. 

Epilepsy may be defined as a disease in which there is an established 
disposition to convulsions of a certain type, with loss of consciousness, 
which have recurred until a habit of convulsions has become fixed. 

A distinction must be made between cases of so-called " idiopathic " 
epilepsy and those which are secondary to a definite lesion of the brain, 
such as tumour, sclerosis, or abscess. Convulsions of the latter character 
are designated as " symptomatic " epilepsy, and are discussed in connec- 
tion with the various diseases in which they occur. The nature of the 
attack may, however, be identical in both varieties, and may not differ 
from an ordinary attack of convulsions or eclampsia. 

The proportion of idiopathic cases in children is not so large as was 
formerly supposed ; many of these have been shown to depend upon lesions 
once overlooked, particularly mild infantile cerebral paralyses. 

Etiology. — From a consideration of 1,450 cases of epilepsy, Gowers 
states that 12 per cent begin in the first three years of life, and 46 per cent 
between ten and twenty years. The greatest tendency to the development 
of the disease is shown about the time of puberty. Females are rather 
more liable to be affected than males, although the difference in sex is 
slight. Heredity plays an important role in the production of the dis- 
ease. In one-third of the cases, according to Growers, there is a family 
history either of epilepsy or insanity. All hereditary nervous diseases 
predispose to epilepsy, but it is a question whether other hereditary dis- 
eases have any special influence. 

Not very infrequently epilepsy may be traced to convulsions occurring 
(lining infancy. In what proportion of the cases this is true it is impos- 
sible to state with accuracy. Infantile convulsions are very common, and 
usual Ly the cause which produces them is a transient one. The proportion 
of such cases which develop epilepsy later in life is certainly small. One 
frequently meets with children from two to five years old who have occa- 
sional attacks of convulsions, often from apparently trivial causes. In 
my experience, the great majority of these also recover completely with 
proper treatment ; a very few become epileptic. Given a strong predispo- 
sition to epilepsy, it is easy to see how convulsions early in life so often 



EPILEPSY. 709 

associated with rickets may have been the first of the epileptic series. 
The first seizure is sometimes traceable to fright, great excitement, 
heat-stroke, or blows or falls upon the head even without any gross 
lesion. It may follow any of the acute diseases of childhood, particu- 
larly scarlet fever, rarely measles or typhoid. In none of these, however, 
is it often seen. As reflex causes may be mentioned intestinal worms, 
phimosis, adenoid vegetations of the pharynx, delayed or difficult men- 
struation, and masturbation. Most of these are rare causes, but they may 
be sufficient to produce the disease where a strong predisposition exists. 
Syphilis may be the cause of epilepsy even when there is no local disease 
of the brain. 

Among the most important factors in producing a paroxysm, is in- 
testinal putrefaction associated with chronic constipation and chronic 
intestinal indigestion. This subject has been investigated with great 
care by Herter and Smith,* who studied 238 specimens of urine from 31 
epileptics. In 72 per cent of their observations there was unmistakable 
evidence of excessive intestinal putrefaction, as shown by the presence 
of ethereal sulphates in the urine in large amount, just before the occur- 
rence of the paroxysm. The inference seems warranted that this intestinal 
condition was closely connected with the epileptic seizures. The state- 
ment of Haig, that there is an excessive elimination of uric acid preceding 
the paroxysm, was not borne out by the observations of Herter and Smith. 
The association of intestinal putrefaction with seizures of epilepsy is very 
important as furnishing a clew to the management of many of these 
cases. I believe it to be one of the most important etiological factors in 
cases occurring in children, particularly as an exciting cause of the first 
attacks. 

Pathology. — It is not within the scope of this work to discuss the 
various theories which have been advanced. The following are the con- 
clusions reached by Gowers : f 

" The muscular spasm is to be regarded as the result of the sudden 
overaction (discharge) of nerve cells, the violent liberation of nerve force, 
and the sensations which the patient experiences before losing conscious- 
ness must be due directly or indirectly to the same cause. The disease 
which excites convulsions is most frequently at the cortex, and when 
organic disease causes convulsions that begin locally, the disease is almost 
invariably at the cortex. In idiopathic epilepsy the convulsions some- 
times begin in this way, and this suggests very strongly that in such cases 
the change occurs in the cortex. Epilepsy must then be regarded as a 
disease of the gray matter, most frequently of the gray matter of the 
cortex." 

* New York Medical Journal, August and September, 1892. 
f Diseases of the Nervous System, American ed. 1888, p. 1098. 



Y10 DISEASES OP THE NERVOUS SYSTEM. 

While there is pretty general agreement that the seat of the morbid 
changes in true epilepsy are in the cortex, but little is yet definitely 
known as to the nature of these changes. Van Gieson has published * 
some very careful observations made upon portions of the cortex removed 
at surgical operations from two epileptic patients. In one of these the 
disease was primarily due to a foreign body ; in the other, to an old cica- 
trix. The conditions found represent the earlier changes of the disease, 
and were essentially the same in both cases. There were degenerative 
changes in certain of the ganglion cells, which in places had resulted in 
almost complete dissolution of these cells. In addition there was a distinct 
hyperplasia of the neuroglia tissue. Diffuse neuroglia sclerosis starting 
from the focus of disease has been reported by certain French writers — 
Marie, Fere, and Chaslin. 

Symptoms. — Two distinct types of epileptic seizures are met with : the 
major attacks, or grand mal, in which there are severe convulsions lasting 
from two to ten minutes, with loss of consciousness, etc. ; and minor 
attacks, or petit mal, in which the convulsive movements are slight and 
may be absent, and in which the loss of consciousness is often but mo- 
mentary. Between these two extremes all gradations are seen. 

Grand mal. — The onset may be sudden, without premonition, or it 
may be preceded by certain prodromal symptoms known as the aura. 
The aura may be motor, such as a local spasm of the hand, face, or leg ; or 
sensory, such as numbness and tingling in any part of the body, or some 
abnormal sensation rising gradually to the head, at which time loss of 
consciousness occurs. The variety of sensations described by patients as 
indicating an attack is endless. There may be a sensation in one finger, 
in the face, tongue, eye, or in any part of the body ; or the warning may 
be of a general character, like a tremor or a shivering sensation, or a feeling 
of faintness. There has also been described a visceral or pneumogastric 
aura, in which there is epigastric pain, sometimes nausea, and a sensation 
of a ball in the throat ; or there may be palpitation, or cardiac distress. 
There may be general giddiness or vertigo, or a sensation of fulness in 
the head ; or feelings of strangeness, or a dreamy, dazed condition ; and, 
finally, the aura may have reference to any of the special senses, most 
frequently to sight. Sparks may appear before the eyes, or flashes of light 
or colour, or strange objects may be seen ; or there may be a momentary 
loss of hearing ; or strange sounds may be heard. In most cases the aura 
is peculiar to the individual, whose attacks are likely to be preceded by 
the same symptoms. 

At the beginning of the seizure the face becomes pale, the pupils 
widely dilated, the eyes rolled up in their orbits and fixed. Speedily there 
is loss of consciousness. Simultaneously with these symptoms, or imme- 



New York Medical Record, April 24, 1893. 



EPILEPSY. 711 

diately following them, there occurs a violent tonic muscular spasm to 
which are due the characteristic symptoms of the early part of the seiz- 
ure — viz., the fall, cry, biting of the tongue, cyanosis, and evacuation of 
the bladder or rectum. The fall is forcible, violent; in fact, the patient is 
precipitated usually forward, and frequently suffers injury, never sinking 
down as in a faint. The head is often strongly rotated to one side. The 
position of the hands is often that assumed in tetany. The cry is a hoarse, 
inarticulate sound, not very loud, and is due to forcible expiration, owing 
to spasm of the muscles of respiration with the glottis partially closed. 
The cyanosis is the result of tonic spasm of the muscles of respiration ; it 
may be quite intense, so that the face is livid, bloated, and the features 
distorted. The spasm of the muscles of mastication causes the biting of 
the tongue. Evacuation of the bladder and rectum may result from con- 
traction of their walls, or from spasm of the abdominal muscles. The vio- 
lence of the muscular spasm in this stage may be very great ; it has caused 
fracture of bones, rupture of muscles, and even dislocation of joints. 

The stage of tonic spasm may be only momentary, the patient passing 
almost at once into the stage of clonic convulsions. The usual duration 
is from ten seconds to half a minute. In the stage of clonic spasm which 
follows, the symptoms are those of an ordinary attack of convulsions. 
The muscular contractions are violent, and there is often frothing at the 
mouth. Gradually the muscles of respiration relax, air enters the lungs, 
and the cyanosis passes off. After the clonic spasm has continued for a 
variable time — from two or three minutes to half an hour — the muscular 
contractions become less and less frequent, and finally cease altogether. 
In a few minutes the patient may regain consciousness, look vacantly 
around, and in a dazed way perhaps ask what has happened, he being com- 
pletely oblivious to all that has occurred. More frequently, however, he 
passes at once into a deep sleep, which continues for an hour or more, 
but from which he can be aroused. From this he usually wakens with a 
severe headache, which may continue for several hours. After this he often 
feels better than for several days preceding the attack. During the seizure 
the temperature may be elevated one or two degrees, but rarely more. 
The attack may be followed by a slight temporary paresis, or aphasia, 
hysterical phenomena, vomiting, and intense hunger. In very rare cases 
the urine may contain a trace of sugar. 

Petit mat. — The minor attacks of epilepsy may present a very great 
variety of symptoms, and at times it is almost impossible to decide that 
these are epileptic, except from their periodical occurrence. They pass 
under the names of "spells," "attacks of dizziness," "fainting turns," etc. 
The most striking thing which stamps them as epileptic is the loss of con- 
sciousness, and this may be of short duration, sometimes only momentary, 
and so pass unnoticed. In some cases it is absent altogether. There is 
no fall, but there may be a slight dropping of the head, a fixed stare for a 



712 DISEASES OF THE NERVOUS SYSTEM. 

moment or two, and that is all. This may or may not be preceded by an 
aura. After such a mild attack the patient's mind may be somewhat 
confused, and he may do or say strange things. All sorts of curious acts 
have been performed in an automatic way by patients in the condition 
which follows an attack of epilepsy, which may perhaps be regarded as 
part of the attack. In rare instances even acts of violence may be done. 

The mental condition of epileptics. — In this connection a careful dis- 
tinction must be made between cases in which epilepsy is secondary to 
some organic brain disease, such as infantile cerebral palsy, which may 
itself be a cause of mental impairment, and the mental disturbances seen 
in cases of idiopathic epilepsy. The children who are the subjects of the 
latter disease, and who are perfectly normal mentally, are certainly few. 
All degrees of disturbance may be seen, from those who are simply dull, 
apathetic, backward in development, and uncontrollable in temper, to 
those who are melancholic, idiotic, and even maniacal. The earlier in 
childhood epilepsy develops, the greater is usually the mental disturbance 
seen, because of the effect of the seizures upon the brain during its period 
of active growth. Speech and all mental development may be greatly re- 
tarded. The more frequent and more severe are the attacks, the more 
marked are the mental symptoms present. 

Symptomatic epilepsy. — This occurs most frequently in children as a 
sequel of cerebral palsy, usually with hemiplegia, and it may follow either 
the congenital or acquired form. Epilepsy may come on at any time after 
the onset of the paralysis — from a few months to five or six years. At 
first the attacks may be separated by long intervals, but they gradually 
become more frequent as time passes. The convulsions in post-hemiplegic 
epilepsy begin, as a rule, on the paralyzed side, and for a long time they 
may be confined to that side ; but later they may become general, in which 
cases they are indistinguishable from attacks of idiopathic epilepsy. Se- 
vere seizures are more likely to be seen than are the mild ones. 

Course of the disease. — This is extremely irregular. In most cases 
seizures at first occur at long intervals, of perhaps a year, but later they 
become more and more frequent. Either the mild or the severe attacks 
may be first seen, and may remain throughout as the only type present, or 
they may be associated in the same case. There are most frequently seen, 
occasional major attacks with a large number of minor ones. The inter- 
val between the epileptic seizures in most cases is from two to four weeks, 
although they may be of daily occurrence. Sometimes three or four 
seizures will follow one another closely, and then there will occur a long 
interval of immunity. The seizures may come on either during sleep or 
in the waking hours, and in some cases for a long time they may occur 
only in sleep. Such cases present peculiar difficulties in diagnosis, and 
are often long unrecognised as epileptic. The general health of patients 
may be quite normal. 



EPILEPSY. 713 

Death rarely, if ever, results from epilepsy, except from some acci- 
dent at the time of the seizures, or from the condition known as the 
status epilepticus ; in this the attacks come on with great frequency and 
severity, the patient at times passing rapidly from one convulsion into 
another, the temperature rising to 105° or 106° F., and death occurring 
either from exhaustion, owing to the severity of the convulsions, or from 
coma. 

Diagnosis. — In most cases there is little difficulty in recognising the 
major attacks when they occur by day. Nocturnal attacks may be diag- 
nosticated by the cry, the biting of the tongue, blood upon the pillow, 
sub-conjunctival extravasation, evacuation of the bladder or rectum, and 
the severe headache. Minor attacks present the greatest difficulties, and 
a positive diagnosis is often impossible until the patient has been watched 
for a long time. The most important points to be noted are sudden 
pallor, dilatation of the pupils, temporary loss of consciousness, or sim- 
ply mental confusion, and sometimes the evacuation of the bladder. 
The duration of the attack is shorter than is usual in an ordinary faint. 
The difficulty of distinguishing epilepsy from hysteria rarely occurs in 
childhood. 

It is not always possible to distinguish between secondary or symp- 
tomatic epilepsy and the idiopathic or hereditary form, particularly if the 
case comes under observation late in the course of the disease. The points 
which go to establish the first form are : that the convulsive movements are 
partial, or limited to one side ; that when they are general, they always 
begin in the same part of the body ; or that there is a history of partial or 
unilateral attacks for some time before the occurrence of any general 
convulsions. It is important in all cases to examine the patient care- 
fully for signs of an old hemiplegia, the symptoms of which may be so 
slight as to be readily overlooked. A marked increase in the reflexes of 
one side is, according to Sachs, quite as conclusive evidence as a distinct 
weakness of the arm or leg. In idiopathic epilepsy some of the stigmata 
of degeneration are usually present. The sudden development of epi- 
leptic seizures in a child previously healthy, and in whom there is no 
hereditary history of the disease, should always arouse the suspicion of 
organic brain disease, especially tumour; and if there are besides, severe 
headache, vomiting, and optic neuritis, the existence of tumour is reason- 
ably certain. 

Prognosis. — The danger to life in epilepsy is very slight. Death is 
generally due to some accident, particularly drowning, at the time of a 
seizure. The tendency to spontaneous cessation of the attacks is small, 
while the tendency to recurrence is very great. 

The prognosis in any given case depends upon the cause of the disease 
and the duration of the symptoms. Where the cause can be removed, 
and where the Bymptoms have lasted less than a year, the prospects of per- 



714 DISEASES OF THE NERVOUS SYSTEM. 

manent cure are fairly good. This is particularly true of cases in which 
the epilepsy clearly depends upon gross errors in diet, with chronic intes- 
tinal indigestion. In such cases, if the patient can be placed under proper 
control and dietetic measures well carried out, the development of chronic 
epilepsy can be arrested in a considerable number of cases. If, on the 
contrary, the hereditary tendency to the disease is marked, if the epileptic 
seizures have developed apart from any adequate exciting cause, and if 
they have continued untreated or in spite of treatment for two or three 
years, the symptoms may perhaps be relieved, but there is no prospect 
whatever of permanent cure. In the cases also which are due to local irri- 
tation, like that resulting from an old meningeal hemorrhage, the prog- 
nosis is invariably bad, and only temporary relief is to be expected. A 
few cases of traumatic epilepsy have been cured and many have been 
greatly improved by a surgical operation. 

Treatment. — The first indication is to remove the cause where one can 
be found. If in the male phimosis exists, or other evidence of genital 
irritation, circumcision should be done, or the prepuce retracted and ad- 
hesions broken up. Adenoid growths of the pharynx should be removed, 
and likewise every other cause of reflex irritation. Particular attention 
should be given to the digestive organs. The most hopeful cases are those 
associated with acute and chronic disturbances of digestion, especially 
chronic intestinal indigestion with constipation. These cases are to be 
managed like others of the same sort in which epileptic attacks are not 
present (page 418). Meat should be allowed once a day and in mod- 
erate quantity. Milk should be given, diluted if necessary, also kumyss 
and matzoon. Green vegetables, except peas and beans, may be given 
freely ; also all fresh fruits. Tea, coffee, and alcohol in every form must 
be absolutely prohibited; also potatoes and oatmeal. The most careful 
attention should be given to the bowels. Under no circumstances should 
a condition of chronic constipation be neglected. A dose of calomel 
once a week and intestinal irrigation two or three times a week are of 
great value in many cases. Where the symptoms of intestinal putrefac- 
tion are marked, borax is at times of decided value — two grains three 
times a day to a child of five years — or salicylate of sodium, salol, or the 
benzoate of sodium may be given ; the dose of each being from two to 
ten grains, according to the age of the child, after each meal. The gen- 
eral hygiene of the patient must receive careful attention. He should 
lead a simple, regular life, as much as possible out of doors, away from 
the excitements of a large city, or from association with many children, 
and in short the nervous system should be kept as quiet as possible. 

All the foregoing means of treatment are of equal importance with 
the use of special drugs. The most common mistake is to rely only upon 
drugs, ignoring the other measures mentioned. It not infrequently hap- 
pens that drugs are without any effect when they are the only means of 



EPILEPSY. 715 

treatment employed, whereas in conjunction with other measures marked 
improvement is seen. 

The bromides are unquestionably the best means of combating the epi- 
leptic habit. Either the sodium salt alone or a combination of the sodium 
and ammonium bromides is to be preferred. The purpose should be to 
give the smallest doses which will control the seizures. Children require 
proportionately larger doses than adults, and in most cases a child of five 
years will need from twenty-five to fifty grains a day. Seguin's * method of 
administering the bromides is largely followed in New York, and is of great 
value. It is to give the larger part of the quantity for twenty-four hours, 
shortly before the time when the seizures have usually occurred ; in the inter- 
val to give much smaller doses, and in all cases to give the dose largely di- 
luted, — in from six to eight ounces of water. He gives a full dose early in the 
morning, and, where the seizures are apt to come at night, one at bedtime. 

Cases of petit mat are especially difficult to control. For such there is 
often an advantage in combining belladonna with the bromides. In all 
cases the treatment must be continued for a long time if anything is ac- 
complished. The bromide should be gradually reduced after the attacks 
are controlled, but must be given in moderately large doses for at least 
two years after the seizures have ceased. The addition of borax seems 
occasionally better than the bromides alone in cases where there is ex- 
cessive intestinal putrefaction. Sometimes the combination of chloral or 
antipyrine with bromides is advantageous, particularly if the latter are 
badly borne or cause an annoying amount of acne. Seguin states that he 
has been able to control the acne in many cases by giving at the same 
time moderate doses of arsenic. Other drugs occasionally useful as adju- 
vants to the bromides are strychnine and digitalis. 

The surgical treatment of epilepsy has of late attracted much atten- 
tion. An operation is to be considered in cases in which the paroxysms 
are very frequent and severe, and when there is present a definite local 
cause, such as an old fracture of the skull, or where epilepsy has followed 
an injury to the head even without fracture. Sachs sums up the present 
status of this question as follows : "Ina case due to a traumatic or organic 
lesion an early operation may prevent the development of cerebral sclerosis. 
If early operation is not done, the occurrence of epilepsy is a warning that 
secondary sclerosis has been established and an operation may prevent it 
from increasing. Operation must include the removal of the diseased 
area ; here, if all other parts are normal, a cure may result. Under favour- 
able conditions a few cases of epilepsy may be cured by surgery and many 
more improved." 

The education of epileptic children is a subject of great difficulty and 
is often neglected. There are many reasons why it is impracticable to 

* New York Medical Journal, March 29, 1890. 



Y16 DISEASES OF THE NERVOUS SYSTEM. 

send them to ordinary schools, and it is very desirable that special schools 
and colonies for them should be established. 

The management of the attack. — Abortive measures are sometimes 
successful in cases with a distinct aura, the most reliable being the inha- 
lation of nitrite of amyl. While the seizure lasts, the patient should be 
prevented from injuring himself. The clothing should be loosened, a 
spool or cork should be placed between his teeth to protect the tongue, 
but no effort made to restrain his movements unless he is liable to do vio- 
lence to himself. An epileptic child should never be without some com- 
panion. 

TETANY. 

Tetany is a condition characterized by tonic muscular spasm, which 
may be intermittent or continuous. It usually affects the muscles of the 
extremities, especially the hands and feet, more rarely the neck, face, and 
trunk. When limited to the hands and feet it is known as carpo-pedal 
spasm or arthrogryposis; and although sometimes classed separately, 
this seems to be really only one manifestation of the same general condi- 
tion. In infants, tetany is very frequently associated with laryngismus 
stridulus, this being present in fully two thirds of the cases ; but in older 
children this association is quite rare. General convulsions occur in from 
twenty to thirty per cent of the cases. Tetany is not a frequent disease 
in America. In a pretty large hospital service I seldom see more than 
four or five cases a year, while in some European cities tetany is re- 
ported to be very common and at times to occur epidemically. It is 
probable that more than one pathological condition has been included 
under this term. 

Etiology. — While tetany may occur at any age, it is most frequent in 
infancy. Of eighty-seven cases reported by Barthez and Sanne, fifty per 
cent were observed in the first two years, twenty per cent from three to 
six }rears, and twenty-five per cent from twelve to fifteen years. Of thir- 
ty-eight cases in children collected by Griffith, sixty-six per cent were 
under two years of age. In infancy males are much more frequently 
affected; but when the disease occurs in older children, females appear 
more liable to it. Tetany rarely occurs as a primary disease. It is most 
frequently associated with rickets; in fact, rickets is almost invariably 
found in the infantile cases. It sometimes occurs with chronic diarrhoea 
and with marasmus. It has been known to follow broncho-pneumonia, 
pertussis, typhoid fever, rheumatism, and measles. Of the exciting 
causes, the most frequent one is some irritation in the gastro-enteric 
tract. This may be the products of chronic indigestion, or acute intoxi- 
cation, worms, and sometimes even intussusception. Attacks in older 
children are frequently ascribed to cold. In girls, tetany may occur at 
the time of puberty, especially where menstruation is delayed ; it has fol- 
lowed removal of the thyroid gland. 



TETANY. 717 

Pathology. — Up to the present time no constant anatomical lesions 
have been demonstrated in tetany. The circumstances in which it oc- 
curs, its symptoms and course, all indicate that it is a neurosis probably 
depending upon disturbances of nutrition in the nerve cells of the spinal 
cord and medulla. 

Symptoms. — The spasm may develop abruptly, or it may be preceded 
by sensory disturbances, such as pain, numbness, or tingling. The up- 
per extremities are usually first affected, the spasm gradually becoming 
more severe and finally involving the lower extremities. Both sides of 
the body are equally affected. The position assumed by the hands is 
very characteristic: The fingers are flexed at the metacarpo-phalangeal 
joint and the phalanges extended; the thumbs are adducted almost to 
the little finger; the wrist is flexed at an acute angle, and the whole hand 
drawn somewhat to the ulnar side (Fig. 121). No motion is allowed 
at the wrist, but movements at the elbow and shoulder are usually nor- 
mal. The feet are strongly extended, sometimes in the position of typi- 
cal equino-varus. The first phalanges of the toes are flexed, and the 
second and third rows extended; the plantar surface is strongly arched, 
and the dorsum of the foot is very prominent, standing out like a cush- 
ion. The typical position of the feet is well shown in Fig. 121. The 
tendo-Achillis stands out prominently. Motion at the hip and knee is 
generally free. The spasm in many cases is limited to the hands and 
feet; more rarely the muscles of the thigh, usually the adductors, may 
be involved. In very rare cases the muscles of the trunk, the face, or 
the eye may be involved. 

The knee-jerk and the cutaneous reflexes are exaggerated, and there 
is abnormal excitability both to the galvanic and faradic currents and to 
mechanical irritation. Light percussion upon the nerve trunk often in- 
duces marked contraction of the muscles supplied by the nerve. This 
is particularly striking in the face. The contraction of the facial mus- 
cles following such irritation is known as " Chvostek's symptom " or the 
facial phenomenon. Spasm may also be excited by pressure upon the 
large nerve trunks and arteries of the parts affected. This is known as 
" Trousseau's symptom." 

Pain owing to the spasm is frequently present. It is usually sharp 
and lancinating, and may be so severe as to cause children to cry out. 
Pain is induced by any attempt to overcome the spasm, and sometimes 
it is constant. Other disturbances of sensibility are even more common 
than pain. There is no loss of consciousness and no fever. The spasm 
is generally continuous, although there may be periods of remission or 
even of intermission. When associated with laryngismus stridulus, the 
spasm is much increased during these attacks. 

The duration of the disease is from a few days to several weeks. The 
mild form, which is usually seen in infants, in most cases passes away 
spontaneously in one or two weeks, although there may be relapses and 



18 



DISEASES OF THE NERVOUS SYSTEM. 



second attacks at variable intervals. The most important complication 
is general convulsions. These may come on at any time in the course of 




Fig. 121.— Tetany, showing the characteristic position of the hands and feet, in a child two 

years old. 

the disease. Spasm of the glottis may either precede or follow tetany. 
When associated they generally cease at the same time. Slight paralysis 
may follow or alternate with the spasm. 

Diagnosis.— The diagnostic features of the disease are bilateral spasm- 
in infants usually limited to the hands and feet — without loss of conscious- 
ness, the spasm being increased or excited by pressure upon the nerves, 
exaggerated reflexes, and the presence of some previous disease, especially 



LARYNGISMUS STRIDULUS. 719 

rickets or some disorder of the intestines. The severe form may be mis- 
taken for tetanus ; but this is very rare except in the newly born ; and 
trismus is the rule, and generally it is the first symptom. Trismus is 
extremely rare in tetany. From meningitis, tetany is distinguished by 
the absence of cerebral symptoms ; from cerebral tumour, by the bilateral 
character of the spasm, the absence of headache and focal brain symp- 
toms ; from haemorrhage, by the absence of cerebral symptoms ; from 
malarial spasm, by the fact that it is constant, not intermittent. 

Prognosis. — Tetany per se is not fatal, but death may result from the 
development of general convulsions or from the original disease which 
tetany complicates. Recovery is usually perfect, although Gowers states 
that in rare cases it is followed by muscular atrophy. 

Treatment. — The first indication is to remove the cause, and this in 
most cases is found in the digestive tract. If rickets is present it should 
receive the usual treatment, both dietetic and medicinal. If worms are 
suspected a vermifuge should be given. For the relief of the spasm, the 
hot bath is a most valuable remedy ; friction may also be employed. Drugs 
which have the power of allaying spasm should be given, — chloral, bromides, 
and antipyrine. In the event of failure by these methods galvanism may be 
tried. After the attack the child's general nutrition should receive careful 
attention, to prevent relapses. 

LARYNGISMUS STRIDULUS— SPASM OF THE GLOTTIS. 

Idiopathic spasm of the glottis, or laryngismus stridulus, is a rather rare 
disease, and belongs especially to infancy. It is a pure neurosis, not often 
seen except in children who are rachitic. It is frequently associated with 
carpo-pedal spasm and with general convulsions. The disease is not to be 
confounded with ordinary spasmodic croup or catarrhal spasm of the 
larynx, which is of very frequent occurrence. 

Spasm of the larynx may be seen in several conditions quite different 
from laryngismus stridulus. It forms one of the essential features of per- 
tussis. It occurs both in infants and in older children from pressure upon, 
or irritation of, the pneumogastric or recurrent laryngeal nerve by a tumour 
in the mediastinum, — usually a tuberculous lymph node, or retro-oesophageal 
abscess. Reflex spasm of the larynx is also associated with enlarged ton- 
sils, adenoid growths of the pharynx, and elongated uvula. There is 
a form of reflex spasm which occurs in the newly-born accompanied by 
crowing inspiration ; this is not frequent, and is rarely serious. 

Idiopathic spasm of the larynx is quite different from any of these 
conditions. It is peculiar to infancy, the great proportion of cases oc- 
curring between the sixth and eighteenth months. Males appear to be 
more susceptible than females. The constitutional condition with which 
it is usually associated is rickets. In a large number of cases, but not in 
all, there is cranio-tabes. Many writers believe that laryngismus is in- 



720 DISEASES OF THE NERVOUS SYSTEM. 

variably of rachitic origin. Of fifty cases observed by Gee, there were 
found in all but two unmistakable evidences of rickets. The disease 
occurs in delicate infants who have been closely confined in warm rooms, 
and it is probably on this account that it is more often seen in the winter 
and spring than at other seasons. The exciting causes of this spasm 
may be a breath of cold air, or any form of nervous excitement, such as 
passion, fright, or crying. 

Pathology. — There are no anatomical changes in this disease. It is 
a pure neurosis, and it is generally believed to be of central origin, de- 
pending essentially upon imperfect nutrition of the motor centres of the 
spinal cord and medulla. 

Symptoms. — The disease is often unnoticed by the parents until the 
attacks have become quite frequent, the first ones being mild, and the 
later ones more and more severe. Occasionally the very first paroxysms 
may be severe. The attack comes on suddenly. The child throws back 
his head, the face becomes pale, then livid, and for the time there is com- 
plete arrest of respiration. This continues for a few moments, during 
which the cyanosis deepens, and the child seems in great distress, making 
violent efforts to breathe. If the paroxysm is a severe one, the asphyxia 
may be so great as to lead to loss of consciousness, and it may even be 
fatal, or the attack may terminate in general convulsions. In milder at- 
tacks, after fifteen or twenty seconds the muscular spasm relaxes, the 
glottis opens, and a long, deep inspiration occurs, with the production of 
a crowing sound. The so-called "holding-breath spells" and the 
" crowing attacks " of infants are usually of this nature. Such forms 
of spasm are often brought on by passion or any excitement, and may 
occur from two or three to twenty times a day. Between them the 
condition of the child may be normal, or carpo-pedal spasm may be 
present. It is important to note that in this disease there is not a 
stridor due to narrowing of the glottis, as in ordinary croup, but a 
condition of apncea from its complete closure. Not all the paroxysms 
in the same case are equally severe. A child may have in the course 
of a day a great many mild attacks, but only a few severe ones. Gen- 
eral convulsions are seen in over one third of the cases, and carpo-pedal 
spasm or tetany complicates a still larger proportion. If tetany is pres- 
ent in the interval, it is always increased during the attacks. 

The duration of the disease varies from a few days to several weeks, 
or even months. In cases which terminate in recovery there is a gradual 
diminution in the frequency and severity of the paroxysms, until they 
finally cease altogether. 

Prognosis. — This is good, except when there are general convulsions. 
The cases in which fatal asphyxia occurs are very rare. Usually with 
proper treatment marked improvement begins in the course of a few days. 

Diagnosis. — This is to be made from catarrhal spasm of the larynx. 
The differential points have been mentioned under the latter disease. 



CHOREA. 721 

Owing to the occurrence of the paroxysms and the crowing sounds, the 
disease may be mistaken for whooping-cough, and in fact this diag- 
nosis is not infrequently made by parents. A careful examination 
of the patient during the attacks, the absence of cough, and the fre- 
quent association of tetany, are sufficient to differentiate this from 
pertussis. 

Treatment. — During the attack the object is to break the spasm. In 
mild cases this may be done by sprinkling water in the face. In severe 
cases inhalations of chloroform may be required, and even intubation. 
Between the attacks the patient should be given either bromide and 
chloral, or antipyrine. Sodium bromide, gr. v, and chloral, gr. ij, may be 
given every three or four hours to a child a year old until the frequency 
and severity of the attacks are controlled ; afterward three times a day. 
My own experience with antipyrine in this disease leads me to the belief 
that it is more effective than bromide and chloral. When the symptoms 
are severe, two grains of antipyrine may be given every four hours to a 
child a year old, the dose being gradually diminished as the symptoms 
improve. 

The general treatment of the child is quite as important as drugs di- 
rected toward relieving the spasm. Cold sponging should be used in 
every case unless it occasions so much fright as to increase the number of 
paroxysms. Careful attention should be given to the diet. Children 
should be kept in the open air as much as possible. Cod-liver oil is 
needed in most cases, and rachitic cases are sometimes much benefited 
by phosphorus. Any source of local irritation, such as enlarged tonsils, 
elongated uvula, or adenoid growths, should be removed ; for, if not the 
actual cause of the attack, they may be the means of aggravating the 
symptoms. In all cases the treatment should be continued for several 
weeks after the paroxysms have subsided. 

CHOREA— SAINT VITUS'S DANCE. 

Chorea is a functional nervous disease characterized by aimless, irreg- 
ular movements of any or all the voluntary muscles. Choreic move- 
ments are of a somewhat spasmodic character, often accompanied by an 
apparent or real loss of power in the groups of muscles affected, and by 
a mental condition of extreme irritability. 

Etiology. — Chorea is most frequently seen between the ages of seven 
and fourteen years. Of 146 cases, 6 were under five years, 72 between five 
and nine years, and 68 between ten and fourteen years. The youngest 
case of which I have record was that of a child four years old. It is ex- 
tremely rare before the third year, although it may occur even in infancy, 
and in a few recorded cases it was undoubtedly congenital. My own obser- 
vations coincide with those of nearly all writers, that the disease is more 
than twice as frequent in females as in males. While chorea may be seen 



722 DISEASES OF THE NERVOUS SYSTEM. 

at all seasons, it is much more frequent in the spring months. Of 717 at- 
tacks studied by Lewis (Philadelphia), the largest number began in March, 
and the next largest number in May; in my own cases May stood first. 

The relation of chorea to rheumatism is of much importance, and has 
during late years attracted a great deal of attention. Thus far the inves- 
tigations of different writers have given results which are somewhat con- 
tradictory. Some have found evidences of rheumatism in but a small 
proportion of the cases — in not more than 5 or 10 per cent — while the 
statistics of others have placed the percentage of rheumatism as high as 
50 or even 60 per cent. It is rather striking that the statistics of neu- 
rologists, almost without exception, have given a very much smaller per- 
centage of rheumatism in choreic cases than those taken from children's 
clinics and hospitals. The question hinges largely upon what is to be 
admitted as evidence of rheumatism in a child; if cases of acute articular 
inflammation only, then the number will be very small; if subacute cases 
with joint swellings are included, the proportion will be considerably 
larger; while if we admit cases of acute endocarditis without articular 
symptoms, and those of articular pains and joint stiffness but without 
swelling, the proportion will be very much increased. My own belief is 
that there is a very close connection between chorea and the rheumatic 
diathesis as manifested by all the symptoms above noted, and accom- 
panied by a family history of rheumatism. On careful scrutiny, the 
number of cases of chorea in which unmistakable evidence of this di- 
athesis is found, is very large, including in my own observations over one 
half the cases. There seems, then, to be a large group of cases which 
may be classed distinctly as rheumatic chorea. There are, however, many 
others in which no such element can be found. 

My former associate, Dr. F. M. Crandall, has analyzed 146 cases of 
chorea treated by us at the New York Polyclinic and elsewhere, with the 
following results: Of 111 cases in which the question of rheumatism was 
investigated there was a definite history of it in 63. In 41, rheumatism 
occurred before the chorea; in 13, the first evidence of rheumatism was 
coincident with the chorea; and in 9 it first occurred subsequently to the 
chorea, usually within three months. In about one third of the cases, at- 
tacks or rheumatism occurred during or subsequent to the chorea as well 
as before it. It may then be stated that previous rheumatism was evi- 
dent in 37 per cent, concurrent rheumatism in 24 per cent, and subse- 
quent rheumatism in 15 per cent of the cases. Excluding cases men- 
tioned twice, and also all those in which there was a history only of 
" growing pains," there was evidence of articular rheumatism in 56.7 per 
cent of the cases. Many of these patients have now been under obser- 
\ alien for several years, and it has been interesting to see, as time has 
passed, how the evidences of the rheumatic diathesis have multiplied the 
longer the cases have been followed. 

In the above statistics only articular symptoms have been accepted as 



CHOREA. 723 

evidence of rheumatism. If the cases of endocarditis without articular 
symptoms were included, as I think they might fairly be, it would raise 
the proportion of rheumatic cases still higher. The great proportion 
of cardiac murmurs persisting after chorea, if not all of them, should, I 
believe, be classed as rheumatic, even if no articular symptoms have been 
present. 

Overpressure in school is often an important factor in the production 
of chorea, as has been shown by Sturges (London). Anaemia, if not an 
essential factor, is certainly a very important one, and the great propor- 
tion of cases present very distinct evidences of it. Chorea may develop as 
a sequel of any of the infectious diseases, more particularly scarlet and 
typhoid fevers. It is seen quite often in cases of chronic malarial poi- 
soning. Among the reflex causes may be mentioned phimosis, either 
lumbricoids or pinworms, delayed menstruation, and ocular defects, — 
although the latter more frequently cause a local spasm of the muscles of 
the eyes, which can hardly be considered choreic. It has been claimed 
that chorea may result from the reflex irritation arising from adenoids of 
the pharynx and enlarged tonsils. Whether this is directly or only indi- 
rectly a cause is not evident. The association of the two conditions is not 
very infrequent. 

Hereditary influence is of considerable importance in the production 
of chorea. It is much more frequent in children of neurotic families, and 
very often several successive generations, or several children in the same 
family, may sutler from the disease. 

The exciting cause of chorea in a certain proportion of cases is fright; 
occasionally it arises from imitation, and the disease has been known to 
occur epidemically in institutions. Choreiform movements may follow 
hemiplegia. Chorea and epilepsy may be associated in the same patient, 
or one disease may follow the other. 

The causes which underlie the occurrence of chorea therefore, seem to 
be a rheumatic diathesis, a neurotic constitution, anaemia, and some severe 
disturbance of general nutrition. When these predisposing factors are 
present, an attack may be induced by many things. The greater the pre- 
disposition the less important may be the exciting cause. A very large 
number of the cases of chorea are in children who present distinct evi- 
dences of rheumatism, although the explanation of this relationship is not 
yet understood. In another group the neurotic element predominates, and 
in these there may be no connection whatever with rheumatism. 

Pathology. — The exact pathology of chorea is at the present time not 
settled. The seat of the morbid process is undoubtedly the central nerv- 
ous system, probably the motor areas of the cortex. The cases asso- 
ciated with rheumatism are now generally regarded as of infectious 
origin. In some severe cases which were fatal, owing to association with 
acute endocarditis, capillary emboli have been found in the brain. Ilow- 
47 



724 DISEASES OF THE NERVOUS SYSTEM. 

ever, it is by no means established that this is the condition present in 
most of the rheumatic cases. The fact that in the great majority of such 
cases complete recovery occurs in the course of a few weeks or months, 
speaks strongly against any important structural change in the nervous 
centres. In cases not rheumatic, the most probable explanation of the 
symptoms is to be found in vascular changes, having their origin in dis- 
turbances of nutrition. 

Symptoms. — An attack of chorea generally comes on gradually. At 
first the child may be considered simply as unusually nervous ; if at school, 
there may be noticed a difficulty in writing, drawing, or in using the 
hands for other delicate operations. At home, the child is continually 
dropping things, has difficulty in feeding himself, sometimes in buttoning 
his clothes, and very frequently he is not brought to the physician until 
the symptoms have lasted a week or two. Sometimes the legs are first 
affected, and a history is given of frequent falls, a stumbling gait, diffi- 
culty in going upstairs, etc. At other times the spasm is first seen in the 
facial muscles, with disturbance of articulation, twitchings of the eye 
muscles, and the child may be punished for making grimaces. In most 
cases the spasmodic movements soon extend to all parts of the body. 
According to Starr, they remain limited to one side of the body (hemi- 
chorea) in about one-third of the cases. When fully developed, the move- 
ments of chorea are quite unmistakable. They are irregular, jerking, 
spasmodic, never rhythmical, rarely symmetrical, and vary in intensity 
from an occasional muscular contraction to almost constant motion. The 
movements are not under the control of the patient's will, and are usually 
intensified by efforts to repress them. They are increased by excitement, 
embarrassment, or fatigue, but do not continue during sleep. 

Very often there is some weakness of the affected muscles, which may 
be so great as to lead to the suspicion that actual paralysis exists. Not in- 
frequently I have had patients brought to the clinic for supposed paralysis, 
either of one extremity or of one side of the body, where the choreic move- 
ments have not been severe enough to attract the attention of the mother. 
This paralysis usually disappears in the course of a few weeks. 

In severe forms of chorea the patient may be unable to help himself 
or even to walk. The symptoms may be so intense as even to endanger 
life. Such cases, however, are dangerous, not from the choreic move- 
ments, but from the acute endocarditis with which they are frequently 
associated. 

The mental condition of choreic patients is one of marked irritability. 
They are fretful, emotional, easily provoked to tears or laughter, and 
difficult to control. In extreme cases a mental disturbance bordering 
upon acute mania has been observed. In other cases the facial expression 
and manner of speech strongly suggest beginning imbecility. All degrees 
of speech disturbances are seen from the slight difficulty in articulation 



CHOREA. 725 

due to inability properly to control the movements of the tongue and lips, 
to a condition in which speech is almost impossible. In rare cases speech 
has been temporarily lost. Heart murmurs are frequent in chorea. Some 
of these are of anaemic origin, some possibly are due to chorea of the heart- 
muscle itself — although this is a matter of some uncertainty — but a large 
number, probably the majority, are due to concurrent endocarditis, as is 
shown by the fact that they are permanent, and are followed by all the 
signs of organic heart disease. During every attack the heart should be 
closely watched, especially in children in whom there is a strong predis- 
position to rheumatism. 

The urine in chorea has recently been studied with care by Herter and 
Smith, who have shown that in very many cases there is an excessive 
elimination of uric acid. This is neither the cause nor the effect of the 
chorea, but is to be regarded as evidence of a profound disturbance of 
nutrition, of which the choreic movements are but another manifestation.* 
The general condition of choreic patients is usually much below normal. 
They are anaemic ; the appetite is poor, often capricious ; they sleep very 
badly ; they suffer frequently from headaches ; they are easily fatigued by 
slight muscular exertion ; and in short they have all the symptoms of a 
greatly disturbed nutrition. 

Course and Duration. — The ordinary form of chorea tends to spon- 
taneous recovery in from six to ten weeks. Exceptionally it may last for 
three or four months. In a small number of cases the disease may be- 
come chronic and continue indefinitely. Certain forms of local spasm, 
particularly choreiform movements of the muscles of the face, eyes, or 
neck, may be permanent. In any case of chorea which lasts longer than 
the usual time, the patient should be carefully examined for some cause of 
peripheral irritation. The tendency to relapses and second attacks is very 
marked. Later attacks are likely to occur in the spring succeeding the 
first illness, and in a small number of patients attacks may come every 
year for four or five years. 

Diagnosis. — There is little difficulty in recognising chorea from the 
sudden, irregular, spasmodic contraction of the muscles coming on under 
the circumstances indicated. No other movements of childhood are 
likely to be confounded with it. The form of chorea following hemi- 
plegia is usually more athetoid than choreic, yet at times it closely simu- 
lates ordinary chorea. The difficulty in distinguishing between the two is 
often increased by the fact that the weakness of simple chorea may, if uni- 
lateral, closely simulate hemiplegia. The existence of rigidity, contractions, 



* Dr. Herter has called my attention to the fact that in many cases of well-marked 
chorea the urine contains a peculiar reddish colouring matter called haemato-porphyrin. 
This is also found in many cases of rheumatism, another evidence of the close relation- 
ship existing between these two diseases. 



726 DISEASES OF THE NERVOUS SYSTEM. 

and increased reflexes belongs exclusively to hemiplegic cases, and these 
will usually suffice to clear up all doubt with reference to the diagnosis. 

Prognosis. — As a rule this is favourable, and complete recovery can be 
predicted, the exceptions being few in number. Parents should always 
be warned of the tendency of the disease to return in succeeding years, 
and the fact should be stated that in a certain proportion of eases the 
disease may be permanent. The prognosis of the cardiac murmurs oc- 
curring in chorea should always be guarded, although some of these are 
functional and disappear with recovery from the chorea ; but the number 
of those which do not disappear is sufficiently large to make one always 
apprehensive as to the ultimate result. Acute chorea accompanied with 
endocarditis may be fatal ; a number of such cases are on record in which 
there was no other evidence of rheumatism. 

Treatment. — The general management of the case is equally impor- 
tant with the administration of drugs. A child with chorea should at 
once be taken from school, and should never be subjected to punishment 
or to ridicule on account of the movements. Special attention should 
be given to the patient's diet and general nutrition. Tonics, especially 
iron, are indicated in most cases. The food should be simple and nutri- 
tious, and all stimulants, particularly tea and coffee, should be absolutely 
prohibited. While fresh air is desirable, exercise should be prescribed 
with great caution and its effect should be carefully watched. It should 
never be carried beyond the point of slight fatigue. A certain amount of 
moral restraint is absolutely necessary; thus it often happens that 
choreic patients do very badly at home where they are indulged and re- 
ceive sympathy, while in a hospital, where they are under restraint and 
made to control themselves, they begin to improve immediately. Gym- 
nastics, although useful in some of the milder cases, may do positive 
harm in those which are severe. They should be regularly and systemat- 
ically practised twice a day, but not continued too long. In all severe 
cases the " rest treatment " should be employed, which is equally bene- 
ficial in the milder ones ; the patient is put to bed, and complete mental 
and physical rest secured. This may be combined with gentle massage 
for fifteen or twenty minutes a day. The daily use of warm baths, either 
alone or in conjunction with massage, is decidedly beneficial. In other 
cases the regular use of cold sponging is of the greatest value. 

With reference to the use of drugs, it is advisable to separate from 
other cases those in which the connection with rheumatism is very close. 
In the rheumatic cases, salicylate of soda is often efficient, while the drugs 
usually employed may be absolutely without effect. In a case recently 
under observation, arsenic had been continued for two weeks without the 
slightest improvement, when the patient had an intercurrent attack of 
subacute rheumatism for which salicylate of soda in full doses was given, 
with the effect of controlling the choreic symptoms promptly and perma- 



HABIT SPASM. 727 

nently. In the non-rheumatic cases, arsenic is almost universally ad- 
mitted to be the most valuable remedy we possess. The method of admin- 
istration is important; failure frequently results from the use of too 
small doses. Beginning with four drops of Fowler's solution three times 
a day for a child of eight years, the daily quantity may be increased by one 
drop each day until a disturbance of the stomach or bowels is produced, 
with puffiness under the eyes. The drug should now be stopped for two or 
three days, and then the same doses resumed and gradually increased, 
usually up to eight drops three times a day, sometimes to ten, and 
even twelve drops, unless the movements cease before that time ; but when 
this occurs the drug should be stopped. Arsenic should always be given 
after meals, and largely diluted, the dose being taken in a full glass of 
water, but not necessarily drunk at one time. The possibility of arsenical 
poisoning should be remembered, although it is extremely rare. Semple 
has reported a case in which multiple neuritis and general pigmentation 
of the skin occurred after four weeks' administration of the drug. 

In the event of the failure of arsenic alone, it should be combined with 
the rest treatment. Drugs which sometimes succeed where arsenic fails 
are antipyrine and strychnine. From fifteen to twenty grains of anti- 
pyrine should be given daily in divided doses to a child of eight years. 
There are a certain number of cases in which striking improvement fol- 
lows the use of this drug if given in the full doses mentioned. To a child 
of eight years strychnine should be given in doses of -gV of a grain three 
times a day, the dose being gradually increased until double this quantity 
is given ; sometimes even larger doses than these are well borne. Galvan- 
ism is of some value in cases not relieved by drugs. Acute chorea of great 
severity may require opium, bromides and chloral, or even chloroform. 

In estimating the value of drugs in the treatment of chorea, the natu- 
ral course of the disease should be kept in mind, since those drugs which 
are taken after the third or fourth week are much more likely to be 
thought beneficial than those used in the early period of the attack. 

There is no doubt that chorea may be dependent upon some ocular 
defect, and a correction of this will then form an essential part of the 
treatment, although few, if any, cases are cured by attention to the eyes 
alone. 

Chorea has a strong tendency to recur, especially in the spring of the 
year. Children who have had one attack should be closely watched, par- 
ticularly with reference to their work in school. They should not be 
crowded in their studies, they should have long vacations, and the nervous 
system should not be put upon any severe tension for a long time. 

OTHER SPASMODIC AFFECTIONS. 

Habit Spasm. — This term is used to describe certain spasmodic mus- 
cular movements which at first are only occasionally noticed, but which 



7^8 DISEASES OP THE NERVOUS SYSTEM. 

may persist until they become habitual and almost entirely involuntary. 
The movements usually affect the muscles of the face, but they may be 
seen in almost any part of the body. The most frequent varieties consist 
of blinking or sudden frowning, raising the eyebrows, or some peculiar 
grimace. At other times there is sudden twisting of the head, shrugging 
of the shoulders, or jerking of the hands. It is not often seen in the 
lower extremities, but the muscles of respiration are quite frequently 
affected. There may be a half -sigh, a sort of sob, or a peculiar dry, laryn- 
geal cough. 

These movements are at first infrequent; but as the habit becomes 
more firmly fixed the spasm recurs every few minutes, and in severe cases 
it may be almost continuous. The form of spasm is not always the same; 
one may disappear and another take its place. The condition may last 
for months or years, and it may even be permanent. 

Habit spasm is really little more than exaggerated nervousness con- 
tinuing in some definite form until by repetition a fixed habit is estab- 
lished. It is different in cause, course, prognosis, and treatment from 
chorea, with which, however, it is often confounded. 

The causes are those of neuroses in general. In the beginning, at least, 
there is usually a somewhat depreciated general health. The patients 
are nervous children of neurotic antecedents. There may be a history of 
some definite exciting cause, such as illness or overwork in school. The 
spasm of the muscles about the eyes may be associated with pathological 
conditions of these organs. 

Habit spasm is to be differentiated from chorea : this is usually easy, 
from the limitation of the movements to one part or group of muscles and 
from the duration of the disease. 

Treatment is quite unsatisfactory after the habit has become fixed, 
hence it is of very great importance that it should be arrested at the 
earliest possible age. Punishments are of no avail, and usually aggravate 
the condition. Eewards are much more effectual. The general health 
should receive attention and nerve tonics should be given, especially 
strychnine. 

Athetosis and Athetoid Movements. — This term, introduced by Ham- 
mond, is used to describe a chronic form of spasm usually seen in the 
hand, but sometimes also in the foot, and even the face. It may affect 
both sides, but in most cases it is unilateral. The movement is slow, 
irregular, and inco-ordinatc — a sort of "mobile spasm," it has been 
called — and there may be associated a certain amount of muscular rigidity. 
Such movements may occur in persons otherwise healthy, but are usually 
seen as a sequel of cerebral palsies, generally hemiplegia. Kecovery from 
the paralysis may be so nearly complete that the athetoid movements 
are looked upon as primary. In some cases the movements are more 
rapid and somewhat resemble those of chorea, the condition being 



NYSTAGMUS. 729 

sometimes classed as post-hemiplegic chorea. Athetosis is not influ- 
enced by treatment. 

Rotary and Nodding Spasm of the Head. — These are rare forms of 
irregular movements usually observed in infancy. The condition was 
described long ago by Henoch, and since then cases have been reported by 
Hadden,* Peterson, and others. The most frequent is the rotary spasm, 
which consists in a side-to-side oscillation of the head, which may be slow 
or rapid, and in some cases is almost continuous. Some children have at 
times the nodding spasm also, and in others this is the only movement 
seen. Nystagmus is frequently associated, and may affect one or both 
eyes. In a few of the reported cases convergent strabismus was present. 

The causes of the condition are extremely obscure. It is usually seen 
in infancy between the third and eighteenth months, and, like most nerv- 
ous symptoms of this period, has been ascribed to dentition, but without 
any special reason. In three of the cases reported by Hadden, it followed 
an injury to the head, and might perhaps be regarded as a result of cere- 
bral concussion. 

As a rule, the condition lasts for several months and improves, recov- 
ery generally taking place. The prognosis is therefore usually favour- 
able. In most of the reported cases improvement has followed the use 
of bromides ; from ten to twelve grains daily should be given. 

Nystagmus. — This term is applied to rhythmical, involuntary, oscillatory 
movements usually of both eyes. They are caused by the alternate con- 
traction of opposing muscles. Nystagmus may be either vertical or hori- 
zontal. It is most often seen in infants a few months old, and is a 
symptom of irritation which may be general or local. In some cases the 
movement is almost continuous, occurring even in sleep ; in others, it is 
only noticed at times of special excitement. 

The etiology of nystagmus is obscure, and it may occur in quite a 
variety of conditions, — sometimes referable to the eye, at other times to 
the central nervous system. On the part of the eye, nystagmus may be 
due to blindness from any cause, to congenital cataract, corneal opacity, 
disease of the choroid or retina, or to errors of refraction. It may be 
seen in almost any organic disease of the nervous system, both with focal 
and diffuse lesions, especially in chronic hydrocephalus, insular sclerosis, 
tuberculous meningitis, and in diseases in which sight is impaired. Nystag- 
mus may be of reflex origin, as in a case recently occurring in the Babies' 
Hospital, where an infant with a severe diarrhoea had repeated attacks, 
which disappeared each time after intestinal irrigation. While it is of no 
importance as a localizing symptom, nystagmus usually indicates some- 
thing more than functional disturbance. An exception to this may per- 
haps be made when it follows cerebral concussion. In such cases it is 

* Lancet, June 14, 1890. 



730 DISEASES OP THE NERVOUS SYSTEM. 

usually temporary, disappearing in a few days or weeks. Under most 
other conditions it may continue indefinitely. 

The condition of the eyes should be investigated in every case of 
nystagmus ; it is only when the cause is here, and can be removed, that 
habitual nystagmus is amenable to treatment. 

Hiccough (Singultus). — This is a spasm of the diaphragm which is 
usually seen in young infants. In them it is in most cases due to some 
irritation in the stomach. It is seen after eating, and may depend upon 
overfilling of the stomach by food, swallowing of air, etc. In other 
cases it has no relation to the taking of food, and is to be regarded as 
a form of reflex spasm, which may occur from a variety of causes, such as 
cold feet, chilling of the surface during bath, or suddenly taking an in- 
fant from a warm bed into a cold room. In cases like the above, hic- 
cough, though sometimes annoying, is of little importance. It may be 
associated with gastric indigestion, with intestinal flatulence or inflamma- 
tion, with peritonitis or intestinal obstruction. With the last two condi- 
tions it is always an unfavourable symptom. In older children hiccough 
sometimes occurs as a pure neurosis. 

The object of treatment is to remove the cause. In infants this is to 
aid in the expulsion of the gas from the stomach by manipulation, position, 
or the other means useful in gastric colic. Where it is a nervous symptom 
only, it may be arrested by holding the breath, by prolonged forced ex- 
piration, as in blowing a trumpet, and sometimes it may be relieved by 
drugs which control muscular spasm — e. g., antipyrine or chloral. 

Thomsen's Disease (Congenital Myotonia). — This rare disease is usually 
congenital. It may occur in several members of the same family, and is 
often hereditary. The characteristic symptoms are a peculiar rigidity of 
the muscles which is observed when they are first brought into action after 
repose. This rigidity is spasmodic, and usually continues but a few 
moments. It may recur when voluntary movements are again attempted. 
If, however, muscular eifort is persisted in, it soon passes off. It is in- 
creased by apprehension, excitement, or cold, and by observation. The 
legs are most frequently affected, the condition being often noticed when 
the patient starts to walk ; any of the voluntary muscles, however, may 
be involved. It may be greater upon one side of the body than upon the 
other. The muscles are abnormally sensitive to mechanical stimulation, 
and often to galvanism. They are above normal size, and the fibres them- 
selves are enlarged. 

The pathology of this disease is, according to Growers, an altered func- 
tional condition of the muscle fibres, and an abnormal functional state of 
the nerve cells of the cord and the cortex. It is incurable, although the 
symptoms iray be improved by active muscular exercise. 

Cervical Opisthotonus. — This is usually a symptom of disease at the 
base of the brain, occurring with simple, tuberculous, and chronic basilar 



TORTICOLLIS. 



'31 



meningitis, sometimes with tumours of the posterior fossa of the skull. 
However, in certain cases it occurs as a form of reflex spasm, particu- 
larly in young infants who are suffering from diarrhceal diseases or maras- 
mus. In these cases it may last for days or weeks. The deformity is 
produced by a contraction of the superior fibres of the trapezius and by the 
posterior group of cervical muscles. 

Torticollis — Wry-Neck.— Torticollis is usually produced by a tonic 
spasm of one sterno-mastoid muscle, with which may be associated spasm 
of the posterior cervical muscles, 
including the trapezius. In re- 
cent cases there is simply a con- 
dition of muscular spasm ; in those 
of long standing there may be 
permanent shortening of the af- 
fected muscle, atrophy, and par- 
tial paralysis. A somewhat simi- 
lar deformity may be caused by 
cicatricial contraction of the tis- 
sues of the neck following burns. 

The deformity varies some- 
what according as the sterno-mas- 
toid muscle is alone affected, or 
the posterior muscles also, and as 
to which predominates. In sim- 
ple sterno-mastoid spasm the head 
is inclined to the affected side and 
rotated toward the opposite side; 
the chin is raised, and the ear 
approaches the clavicle. When 
other muscles are involved the 

deformity is modified. If the trapezius is affected (Fig. 122) there is less 
rotation of the head, but it is drawn to the affected side and somewhat 
backward, while the shoulder is raised and the spine curved. Both of 
these symptoms may be seen to a slight degree in almost any marked case 
of sterno-mastoid spasm. Sometimes the spasm of the posterior muscles 
affects both sides ; the head is then drawn backward and held rigidly but 
without rotation. In most of the recent cases the deformity can be 
partially or entirely overcome by passive force ; but after a time this is 
impossible, owing to muscular shortening. In recent cases also localized 
pain and tenderness are frequently present, and sometimes they are severe. 

Etiology. — Spasmodic torticollis may be produced by anything causing 
irritation of the trunk or the branches of the spinal accessory nerve ; the 
source may be in the spinal canal, in the cranium, along the course of the 
nerve trunk, or of any of its peripheral fibres. 




Fig. 122. — Spasmodic torticollis from malaria. 
Trapezius and sterno-mastoid of the left 
side are aft'ected. 



732 DISEASES OF THE NERVOUS SYSTEM. 

Cases are usually divided into congenital and acquired. Whitman,* 
from the records of the Hospital for the Ruptured and Crippled, New 
York, for nineteen years, gives the following statistics of 264 cases, — torti- 
collis from Pott's disease not being included : Males, 109 ; females, 155 ; 
congenital, 32 ; under two years, 33 ; from two to ten years, 153 ; over 
ten years, 46 ; acute (i. e., of less than two months' duration), 77 ; chronic, 
60, of which number 22 had lasted two years or longer. 

Regarding the cause of congenital torticollis there is some dispute. 
Such cases have often been attributed to the contraction resulting from 
haematoma of the sterno- mastoid (page 96). My own experience coin- 
cides with Whitman's, that this is rarely if ever the case. While it is pos- 
sible that the deformity is sometimes the consequence of injury received 
during delivery, the cause of most of the congenital cases goes back to con- 
ditions existing before birth. It may be compared to club-foot, and 
may be due to a faulty position of the child in utero, or it may come 
from more serious conditions, such as malformations, or unequal develop- 
ment of the two sides of the body. 

One of the most frequent causes in the acquired cases, is irritation of 
the spinal accessory nerve by an enlarged cervical lymph gland ; this was 
the cause assigned in nearly half of Whitman's cases ; such is the usual 
etiology of torticollis following scarlet fever, measles, or diphtheria. I 
have seen it in the early stage of quinsy, and it may occur in cellulitis of the 
neck. A cause which the physician should always have in mind is cervical 
Pott's disease ; torticollis may be the earliest, and for several weeks some- 
times almost the only, objective symptom of this disease. Torticollis 
coming on acutely is most frequently due to cold (rheumatism?) or 
malaria. I have notes of eight cases clearly traceable to malaria, and have 
seen at least a dozen others. In several of these there was a distinct perio- 
dicity in the spasm, it recurring regularly at about the same time each 
day until quinine was given ; in some cases it was accompanied by fever, 
in others not. In the so-called rheumatic torticollis, muscular pain and 
soreness are rather more prominent than in the other forms. In fourteen 
of Whitman's cases the spasm was attributed to injuries other than burns ; 
and in only nine was it associated with some other disease of the nervous 
system, most frequently with chorea. 

Prognosis. — The result in a case of torticollis depends upon the cause, 
the severity, and the duration of the deformity. Most of the acute cases 
from malaria, rheumatism, etc., recover, under appropriate treatment, in 
the course of a few weeks, sometimes in a few days, and not a few re- 
cover spontaneously. The congenital cases with slight deformity are 
usually amenable to mechanical or postural treatment if begun early. 
There is, however, in most of the other varieties a disposition of the de- 



* Observations upon Torticollis, Medical News, October 24, 1891. 



HYSTERIA. 733 

formity, if untreated, to persist, and even to increase. If it has lasted 
several months the probabilities of spontaneous recovery or even of im- 
provement are small. 

Treatment. — The first indication is to remove or treat the cause where 
one can be found. Malarial cases require quinine ; rheumatic cases are 
benefited by rest in bed, hot applications, counter-irritation, friction, and 
sometimes by anti-rheumatic remedies. Cases which have lasted a month 
usually require some orthopaedic head-support, and those which have 
lasted six months or more are rarely cured without a surgical operation. 
This may be either a subcutaneous tenotomy or myotomy of the sterno- 
mastoid, or an open incision. Whitman gives the result of thirty-two cases 
admitted for treatment to the hospital mentioned, as follows : In 17 in 
which the deformity had lasted less than six months, 10 were cured, the 
average duration of treatment being three months; 4 were improved, and 
3 not improved, the average duration of treatment in these cases being 
eleven months. Of 15 cases in which the deformity had lasted over six 
months, none were cured and only 6 improved, after an average of about 
eight months' treatment. In the foregoing series of cases the treatment 
consisted mainly in the use of orthopaedic apparatus ; later results from 
incision have been considerably more favourable. But these figures show 
how serious a matter is an old case of torticollis, and emphasize the im- 
portance of resorting to radical measures early in the disease. 

HYSTERIA. 

This is not a disease of childhood, but one which is occasionally seen 
in early life. All that will be attempted in this chapter is to point out the 
most common manifestations of hysteria when it occurs in young children. 
After puberty it is essentially the same as in adults.* 

Etiology. — Hysteria is very rare before the seventh or eighth year, and 
most of the cases seen in children occur after the tenth year. As to sex, 
there is no such predominance of females as in later life, although even in 
childhood they are more frequently affected than males. Hereditary 
influences play an important part in the production of this disease. It is 
seen in children who inherit a nervous constitution, or in whose parents 
nervous diseases, such as insanity, or hysteria, or alcoholism have been 
present. Of the other etiological factors the most important are a dis- 
ordered nutrition, frequently with anaemia or chlorosis, and overpressure 
in schools. Masturbation or phimosis may act as an exciting cause, or, 
indeed, anything which leads to an exalted nervous irritability and depre- 
ciation of the general health. It is occasionally associated with tuber- 

* For a fuller discussion of this subject, and references to recent literature, see 
Mills, in Keating' s Cyclopaedia, vol. iv. 



734 DISEASES OF THE KERVOQS SYSTEM. 

culosis ; it may follow any of the acute infectious diseases ; or it may be 
excited by injury, fright, or imitation. 

Symptoms. — There is scarcely any disease in which the clinical picture 
presented is so varied as in hysteria. It may simulate almost any form of 
organic disease of the brain, lungs, digestive organs, bones, or joints. The 
most common symptoms may be grouped under four general heads. These 
are, however, seen in almost every conceivable combination. 

1 . Psychical symptoms. — Where these predominate there may be seen 
periods of mental depression of longer or shorter duration, a change in 
disposition, an indifference to surroundings, a capricious humour, or a nerv- 
ous condition of extreme irritability with irregular paroxysms of laugh- 
ter or weeping without cause. There may be great excitability of temper, 
and fits of passion almost maniacal in their severity. There may be vari- 
ous hallucinations. Sleep is frequently disturbed, sometimes by attacks 
resembling ordinary night-terrors ; sometimes somnambulism is present. 
There is often a disposition to deception about the most trivial matters, 
which may last for weeks. There is a tendency to imitate the symptoms 
of various diseases, which the patients may have witnessed in others or 
about which they have read. 

2. Sensory symptoms. — These are the most frequent manifestations of 
hysteria in early life. There is often general or local hyperaesthesia 4 
which may be so great as to simulate inflammation of the various internal 
organs. Anaesthesia is much less common, although it may be seen in 
children as young as eight or nine. Headache is an occasional symptom, 
and is sometimes associated with great tenderness of the scalp. There 
may be neuralgias in the different parts of the body, or sharp epigastric 
pain, sometimes accompanied by vomiting. Sometimes the special senses 
are affected, giving rise to hysterical blindness or deafness, usually of short 
duration. 

3. Joint symptoms. — These are really a variety of sensory disturbances. 
They are not uncommon, and are often most puzzling. The symptoms 
may be referable to the spine, or to any of the large joints, particularly 
those of the lower extremity. All forms of organic disease of these joints 
may be simulated, and these patients are often treated for months with 
orthopaedic apparatus, with the belief that they are suffering from Pott's 
disease, lateral curvature of the spine, club-foot, or ostitis of the hip, knee, 
or ankle. Oases of this sort have been very fully described by G-ibney,* 
and by Shaffer, whose articles should be consulted for fuller details. They 
are usually seen between the ages of ten and fourteen years, and occur in 
both sexes. There may be lameness referred to one of the large joints, 
curvature of the spine, or torticollis. The symptoms are most frequently 

* Gibney, Transactions of the American Neurological Association, 1877. Shaffer, 
Archives of Medicine, New York, December, 1879, February and April, 1880. 



HYSTERIA. 735 

referred to the hip, and next to the knee, the ankle, or the spine. The 
pain is often acute. It is increased by motion, and by attempts at over- 
coming the deformity, if any is present. There is a marked hyperesthesia 
of the whole limb, and sometimes of the body. In nearly every case there 
is marked tenderness of the spine upon pressure, especially in the dorsal 
region. The deformity may be very slight from spasm of the flexors 
only, or it may be severe, and followed by contracture, so that the thighs 
may be flexed tightly against the abdomen with the heels against the 
buttocks. Such deformities may last for months. There may be con- 
siderable muscular atrophy, but only that which comes from disuse. A 
special difficulty in diagnosis arises from the circumstance that these 
symptoms occasionally follow an injury. 

Organic disease of bones and joints may usually be excluded by atten- 
tion to the following points : The mode of onset is more abrupt than is 
seen in bone disease, and the course of the disease is quite irregular. The 
degree of deformity is greater than is seen in bone disease of the same 
duration. There are general hyperesthesia of the limb, acute tenderness of 
the spine upon pressure, and undue sensitiveness to heat or cold. The de- 
formity varies from time to time, being always more marked when examina- 
tion is attempted. If the patients are closely watched, other evidences of 
hysteria may be seen. Under complete anaesthesia the contractures may 
disappear entirely. There is no enlargement of the articular ends of the 
bones, no swelling of the soft parts, and no evidence of active inflammation 
or of suppuration. All the symptoms except the deformity are subjective. 
Under proper treatment there is in most cases perfect recovery, often in a 
surprisingly short time. 

4. Motor and convulsive symptoms. — In the milder forms we may 
see many varieties of tonic or clonic spasm. There may be seen local 
spasm of the eyes, face, or mouth, spasm of the muscles of the neck pro- 
ducing torticollis, of the muscles of respiration causing dyspnoea, which 
may be constant or paroxysmal. There may be hiccough, or spasm of the 
larynx causing hysterical aphonia. A very common symptom is hysterical 
cough, which may be so frequent and so severe — even accompanied by 
haemoptysis — that grave disease of the lungs is suspected ; the chest, 
however, is free from the physical signs of disease. There may be fre- 
quent attacks of vomiting with eructations; these maybe continued some- 
times even for months, and in rare instances blood has been vomited. 
There may be dysphagia from spasm of the oesophagus, or regurgitation 
of food on attempts at swallowing. In more severe cases we may have the 
symptoms of chorea major and attacks of hystero-epilepsy. The latter are 
rare in children and do not differ essentially from such attacks in older 
patients. There are usually prodromal symptoms. The convulsive move- 
ments are exceedingly varied in type. There are painful sensations and 
sensitive areas, by pressure upon which hysterical symptoms may be in- 



736 DISEASES OP THE NERVOUS SYSTEM. 

creased or even convulsions excited. The respiration may be rapid or 
irregular. All variations in tonic and clonic spasm may be seen. Opis- 
thotonus is frequent. Consciousness is not fully lost, but is disturbed, and 
hallucinations are present. The temperature is normal. 

Hysterical paralysis is not common in children, but it may be seen 
even in the very young. Gillette has reported the case of a child eighteen 
months old who exhibited the symptoms of hysterical palsy of one arm. 
Other symptoms occasionally seen in hysteria, are persistent anorexia, poly- 
uria, sometimes incontinence of urine, disturbance of the secretion of 
saliva or perspiration, and very rarely hysterical fever. 

The general condition of hysterical patients is usually below the nor- 
mal. They are poorly nourished and anaemic ; they sleep badly ; they have 
capricious appetites, feeble digestion, and faulty assimilation. 

Diagnosis. — Hysteria is apt to be overlooked because its occurrence in 
children is not considered as often as it should be. In most cases the 
diagnosis is easy if hysteria is suspected. A combination of vague discon- 
nected symptoms is usually present which admits of no other explanation. 
Organic disease can be excluded only by careful and repeated examinations. 
It is to be borne in mind, however, that hysteria not infrequently compli- 
cates organic or constitutional disease. Much importance is to be attached 
to a family history of hysteria or of other neuroses. From poliomyelitis, 
hysterical paralysis is differentiated by the presence of faradic contractility 
even though atrophy exists. Hysterical convulsions are differentiated from 
true epilepsy by the absence of any elevation of temperature, of biting of 
the tongue, evacuation of the viscera, of a violent fall, and often by the 
rapid disappearance of the symptoms under appropriate treatment. 

Prognosis. — This is better than in adults, especially if the cases are 
taken in hand early, before the disease has become deeply seated. Very 
much depends upon how well the directions for treatment can be carried 
out. The prognosis is less favourable where the hereditary tendency is 
strongly marked. In many cases there are relapses later in life. 

Treatment. — Prophylaxis is of much importance. When a hereditary 
tendency to nervous diseases exists in a family, or whenever very nervous 
children are placed under the physician's care, every means should be taken 
toward muscular development, keeping the nervous system in the back- 
ground. Such children should lead an out-of-door life as much as possi- 
ble, preferably in the country ; they should keep early hours, have regular 
exercise, and their education should be directed with moderation and judg- 
ment ; special attention being paid to regularity of work, and the preven- 
tion of overpressure in schools. Theatres and exciting books should be 
avoided. All stimulants, including tea and coffee, should be absolutely 
forbidden. The diet should be plain and nutritious. It is highly impor- 
tant that such children should be removed from association with a hysteri- 
cal mother, when this is possible. 



HEADACHES. 737 

In the general management of a case of hysteria, it is of the first im- 
portance that the child should be cared for by a person of firmness, who 
can exercise proper control. Hysterical children are always managed 
more easily when they are removed from their homes and placed under the 
charge of a good trained-nurse. Isolation is absolutely essential in many 
cases. The general health should be carefully looked after, and arsenic, 
iron, cod-liver oil, and other tonics given according to indications. Horse- 
back exercise and other out-of-door sports should be encouraged, and every 
means taken to interest the child in something which requires physical 
exercise. In cases of simulated disease, the child should be put to bed, no 
books or toys allowed, and no effort made toward his amusement. No 
sympathy should be exhibited, but the child should be treated with kind- 
ness and firmness. This moral treatment is quite as important as any 
other part of the therapeutics. In cases with hysterical joint symptoms 
the most valuable thing is counter-irritation to the spine, preferably by 
the Paquelin cautery. Some cases are benefitted by galvanism. The 
moral effect of hypodermics, even of cold water, is sometimes striking. 
Under no circumstances should mechanical force be used to overcome 
deformity. Many cases of hysteria improve under hydrotherapy; the 
cold douche, the cold pack, or the shower bath may be used. This is 
valuable in conjunction with massage and the " rest treatment." 

In attacks of hystero-epilepsy the cold douche may be used, or pres- 
sure made upon the testicle or ovary. In severe cases ether may be given. 
In all hysterical cases the condition of the bowels should receive careful 
attention, as these patients are very prone to obstinate constipation. 

HEADACHES. 

Headaches are not common in little children except in connection 
with disease of the brain or meninges ; in older children they occur from 
causes similar to those seen in adult life. The most frequent headaches 
may be grouped in the following classes : 

1. Toxic headaches. — Such are the headaches resulting from uraemia, 
from carbonic acid in poorly ventilated rooms, and from malaria. Hut 
the largest number are due to absorption of toxiues from the intestines, 
and are associated with chronic indigestion and constipation. 

2. Headaches from anwmia and malnutrition. — These are most fre- 
quently seen in girls from ten to fourteen years old. Some are intellec- 
tually bright, and have been crowded in their school work ; others are dull 
and learn only with difficulty, and in consequence worry over their work 
until their health becomes undermined. They sleep badly, lose appetite, 
and often become choreic. The anaemia may be either the cause or the 
result of these symptoms. The urine in these cases often contains a large 
excess of uric acid. 



738 DISEASES OF THE NERVOUS SYSTEM. 

3. Headaches of nervous origin. — These may occur in children who 
are highly neurotic, either from their inheritance or surroundings, and in 
those who are the subjects of epilepsy or hysteria, and they may be symp- 
tomatic of organic disease of the brain, such as tumour or tuberculous or 
syphilitic meningitis. True facial neuralgia is rare in childhood except 
from carious teeth ; from this cause, however, it is not infrequent. 

4. Headaches due to disease of some of the organs of special sense. — In 
connection with the eyes there may be conjunctivitis, keratitis, iritis, errors 
of refraction, or strabismus ; connected with the nose there may be polypi, 
hypertrophic rhinitis, or adenoid vegetations of the pharynx ; connected 
with the ears there may be otitis or foreign bodies in the canal. Each one 
of these conditions requires special treatment. 

5. Headaches due to inherited gout or rheumatism. — These are not 
very frequent, but they may be severe, and may at times simulate the onset 
of meningitis. They are often accompanied by pains in the joints, mus- 
cles, or nerve trunks ; they may be associated with a urine which is highly 
acid and contains deposits of oxalates or of free uric acid. 

6. Disturbances of the genital tract are rarely a cause of headaches in 
children, although this may be the case in girls about the time of puberty, 
especially where menstruation is delayed or difficult. 

Diagnosis. — The diagnosis of headaches includes the discovery of the 
cause, and this is often difficult. In an infant or a young child, organic 
disease of the nervous system should always be suspected as a cause of se- 
vere headaches. In older children the important things to be considered, 
because the most frequent, are digestive disturbances, nervous exhaustion, 
malnutrition, and visual disorders. An absolute diagnosis in a case of 
persistent headache can be made only by a careful physical examination, 
not omitting a study of the urine ; often there must be a close observation 
of the patient for some time. 

Treatment. — The only successful treatment is that which is directed 
toward a removal of the cause. Each one of the different groups above 
mentioned is to be managed differently, according to the principles else- 
where laid down regarding the treatment of these conditions. For the 
relief of the symptom, cold to the head, a hot foot-bath, and phenacetine 
in moderate doses are perhaps the most certain of all remedies. 

DISORDERS OP SPEECH. 

In this chapter will be discussed only functional speech defects,* 
those depending upon organic conditions being considered in connection 
with diseases of the brain. The most common varieties are stuttering, 
stammering, lisping, alalia, backwardness, and functional aphasia. All 

* See Wyllie, Edinburgh Medical Journal, October, 1891. 



DISORDERS OF SPEECH. 739 

forms are much more frequent in boys than in girls, the proportion being 
more than four to one. 

Stuttering. — This is the most common form of speech disturbance. 
Articulation is distinct and the separate sounds are properly produced, 
but there is a difficulty in connecting the consonant with the succeeding 
vowel ; this seems like an obstacle to be overcome. Stuttering is occa- 
sionally seen in most children. It is more frequent in the third and 
fourth years, before speech is thoroughly mastered. At this age it is 
aggravated or produced by disturbances of nutrition, but is usually of 
temporary duration, lasting for a few weeks or months. Only recently a 
little boy of four was under my care, who became very anaemic, slept 
poorly, and suffered from malnutrition as a result of the confinement inci- 
dent to a home in the city. He soon began to stutter, and in a short 
time it became painfully marked. After a few weeks in the country he 
improved very much in his general condition, gained four or five pounds 
in weight, and his stuttering completely, and I think permanently, disap- 
peared. Such disturbances as this are analogous to chorea. In other cases 
stuttering follows some acute illness, and under such conditions also it is 
usually of short duration. 

Most children who become habitual stutterers do not begin until they 
are six or seven years old, and sometimes even later. Stuttering may arise 
from imitation, and probably inheritance is an occasional factor. It is 
frequently a mark of degeneration. 

It is important that all such cases receive early treatment before 
the habit becomes firmly fixed. The prognosis is good for sponta- 
neous recovery in nearly all the cases seen in very young children, 
and also in those coming on after acute illness. Other cases in which 
the condition has become habitual, should have the benefit of syste- 
matic training under a competent teacher in breathing, vocal and speech 
gymnastics. 

Stammering. — This term is sometimes used synonymously with stut- 
tering. Kussmaul makes the distinction between them that, in stammer- 
ing, individual sounds are difficult of production, while in stuttering it is 
syllabic combinations. Stammering is often accompanied by some defect 
in the organs of articulation — the teeth, lips, tongue, or palate — which 
is not present in stuttering. 

The treatment consists in careful training and in the correction of 
whatever abnormal local conditions may exist. 

Lisping. — In this there is imperfect production of certain sounds, 
owing usually to a faulty position of the organs of articulation. The 
sounds may be so indistinct that they can not be understood. In this 
condition also there may be defective formation of some of the organs of 
articulation, although in the milder forms this is not the case. The treat- 
ment is similar to that of stammering. 



740 DISEASES OF THE NERVOUS SYSTEM. 

Alalia. — This consists in a total inability to articulate. It is seen in 
all young infants during their earliest attempts at talking. In older 
children it is usually associated with some mental defect. 

Backwardness. — Backwardness is carefully to be distinguished from a 
late development of speech due to idiocy. At two years old children not 
deaf are almost invariably able to speak. Speech may be late in conse- 
quence of prolonged or very severe illness, and where it has been acquired 
it may be lost from similar causes. 

Functional Aphasia. — The term has been applied to a temporary loss 
of speech which sometimes occurs in chorea, and sometimes from severe 
fright or anything else which has produced a marked nervous im- 
pression. West records an instance in a girl of eight years, who was 
suffering from an attack of chorea induced by fright. Speech first be- 
came difficult and then was lost altogether. For a month the child could 
say only " Yes " and " No." The case improved very slowly, but at the 
end of nine weeks had recovered completely. 

Loss of speech sometimes follows the acute infectious diseases, espe- 
cially typhoid fever. 

In all disorders of speech, the functional cases are to be distinguished 
from those which depend upon deafness and mental deficiency. The 
frequency with which these disorders are due to disturbances of general 
nutrition, and to local causes in the mouth and throat, should be borne 
in mind, and these conditions should receive their appropriate treatment 
early, before the habit of defective speech becomes firmly established. 
For the latter class of unfortunates, special training at the hands of a 
competent teacher should be advised, preferably in an institution. 

DISORDERS OF SLEEP* 

Disturbed Sleep, Sleeplessness. — Disturbed or restless sleep is much 
more common in infancy and childhood than is true insomnia, although 
the causes of the two conditions may be the same. 

Etiology. — In infancy these symptoms are most frequently due to 
hunger or to indigestion resulting from overfeeding or improper feeding. 
Very often disturbed sleep is the result of bad habits, such as rocking 
during sleep or night-feeding. Sometimes it arises from dentition, or the 
pain of colic or otitis ; at other times it may be simply the expression of a 
condition of nervous irritability, the result of inheritance or of the child's 
surroundings. 

In later childhood the first thing to be suspected when sleep is much 
disturbed is some derangement of the digestive organs ; in this will be 
found the explanation of fully half the cases. The most frequent type, 

* For the characteristics of the sleep of infancy, and the average amount taken at 
the different ages, see pages 5 and 6. 



DISORDERS OF SLEEP. 741 

where the symptom is of long duration, is chronic intestinal indigestion, 
often associated with indicanuria, a condition in which the diagnosis of 
the mother is usually worms. Other cases are due to obstructed respira- 
tion from adenoid growths of the pharynx or enlarged tonsils, sometimes 
to nocturnal attacks of asthma. A lack of fresh air in the sleeping room, 
excessive or insufficient bedclothing, and cold feet, are other frequent 
causes. Disturbed sleep with " starting pains " is one of the earliest 
symptoms of hip-joint disease. In the nervous exhaustion resulting 
from overpressure in schools, and in malnutrition and anaemia, dis- 
turbances of sleep are well-nigh constant. They are also seen in organic 
cardiac disease and in all pulmonary conditions accompanied by dysp- 
noea or cough. Sleep may be disturbed in consequence of bad dreams 
which have their origin in exciting stories heard or read just before bed- 
time, or in too violent or exciting play. To discover the cause in almost 
any case it is necessary to investigate carefully the whole routine of the 
child's life. 

Symptoms. — The condition may be one of real insomnia which may 
last for weeks or months ; or the sleep may be simply disturbed and rest- 
less, the child waking many times during the night, and when asleep will 
not lie quietly, but constantly changes his position. Sometimes children 
wake suddenly with a scream, but immediately drop oh* to sleep again. 

Treatment. — The essential treatment consists in the discovery and re- 
moval of the cause of the disturbance. This will often involve a radical 
change in the manner of feeding, in the hygiene of the nursery, and in 
all the surroundings of the child ; but in this way only should these cases 
be managed. Under no circumstances should the physician countenance 
the use of drugs to promote sleep in children, except in the case of severe 
acute disease. Soothing syrups and all nostrums for " teething " should 
be absolutely forbidden. Mothers and nurses are only too ready to fall 
into the habit of using them, because the injurious effects are not appre- 
ciated. When the cause of sleeplessness is found and removed the child 
will sleep, but compulsory sleep obtained under other conditions is always 
productive of more harm than good. If food, diet, and all bad habits 
have been corrected, nervous causes should be investigated. When no 
cause can be discovered the treatment should consist in putting the 
child upon the simplest possible diet, and in attention to such general 
conditions as anaemia, malnutrition, and neurasthenia, some of which 
are almost certain to be present. In many cases a warm bath at bed- 
time will be found beneficial. A quiet, darkened room, plenty of fresh 
air, and the stopping of both eating and drinking during the night, are 
essential to a cure in most cases. When the condition accompanies some 
acute disease, the drugs which are most useful are codeine and trional. 
A child of two years may take -gV of a grain of codeine or two grains of 
trional as an initial dose, to be increased if necessary. 



742 DISEASES OF THE NERVOUS SYSTEM. 

Night Terrors — Pavor Nocturnus. — Two classes of cases have been 
grouped under this head, both having this in common, that sleep is dis- 
turbed by fright. In an excellent article upon this subject,* Coutts calls 
attention to the necessity of sharply distinguishing between them. 

The condition in the first group partakes of the nature of nightmare. 
It may be due to partial asphyxia from adenoid growths of the pharynx, 
or to other causes mentioned under disturbed sleep, or it may be gastric 
or intestinal in its origin. These cases are quite frequent. Sleep may 
be disturbed from the outset, and the attack may be merely the culmina- 
tion of such disturbance. The child wakes in a state of fright and ex- 
citement, and often says he has had a bad dream. His mind is clear, he 
recognises those about him, but it may be a long time before he is suffi- 
ciently calm to sleep again. The attack may be remembered perfectly 
the next day. Cases like this are to be managed in the same general way 
as those of disturbed sleep above mentioned. 

In the second group are the only cases to which the term " night ter- 
rors " should really be applied. These are relatively rare, but the condi- 
tion is a much more serious one. The symptom is due to some disturb- 
ance of the central nervous system. According to Coutts, it occurs espe- 
cially in those of neurotic antecedents, or those who have previously suf- 
fered from infantile convulsions, and it is often the precursor of other 
nervous attacks — migraine, hysteria, epilepsy, and even insanity. The 
attack usually comes suddenly where a child has previously been sleep- 
ing quietly, and more frequently in the early part of the night than later. 
He is generally found sitting upright in his bed in a bewilderment of 
terror, being " afraid of the dog," or " the bear/' or there is some other 
vision or hallucination which has produced the fright. Often this is asso- 
ciated with somethiug of a red colour. The child does not recognise 
those about him, does not know where he is, and may go to sleep again 
without coming to full consciousness. The next day there is no recollec- 
tion of what has happened. Usually no after-effects are seen, but some- 
times a large amount of pale urine is passed. The attacks may be re- 
peated at intervals of a few months, or they may occur every few nights ; 
but whatever the peculiar nature of the vision, it is likely to be repeated 
in nearly the same form. Such attacks have something in common with 
epileptic seizures, and the diagnosis between them may at times be diffi- 
cult. They are always to be regarded seriously, not only on account of 
what they are in themselves, but on account of what may follow. 

Treatment. — All mental and nervous strain should be most carefully 
avoided, and where the attacks are frequent the bromides should be given 
at bedtime. Some person should sleep in the same room with the child, 
or in an adjoining one with the door open. 



* American Journal of the Medical Sciences, February, 1896- 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD. f43 

Excessive Sleep. — It is rare that either infants or children sleep an un- 
natural amount of the time unless one of two causes is present — organic 
brain disease or the use of drugs. The latter is always to be suspected if 
with the sleep there is associated obstinate constipation. Opium in the 
form of " soothing syrup " or paregoric, is the drug which has usually 
been given. 

INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 

On account of the close connection of such habits with disturbances 
of the nervous system, they may be properly considered with the func- 
tional nervous diseases. Although some of these habits may not be of 
serious importance, yet as a group they have received altogether too little 
attention at the hands of the physician. 

Sucking. — This is a very common habit in infants, and during the first 
few months it is seen to some degree in most of them. If they are care- 
fully watched the habit is easily stopped; otherwise it may continue in- 
definitely. Young infants usually suck the fingers when hungry, and this 
can scarcely be considered abnormal, but an effort should always be made 
to stop it, lest the habit become fixed. Lindner * distinguishes between 
simple sucking and sucking with combinations. In the former, the child 
sucks some part of the body, such as the thumb, fingers, toes, tongue, lips, 
back of the hand or arm, or it may be some foreign substance, such as 
part of the clothing, the blanket, a rubber nipple, or the " pacifier." This 
is the most common form that is seen. In the second variety the suck- 
ing is accompanied by the rubbing of some other parts, which seems to 
afford a pleasurable excitement ; this may be the ear, the genitals, or any 
other portion of the body. Sometimes sucking is accompanied by some 
practice which produces actual pain, such as pulling of the hair or scratch- 
ing the body. Habits of sucking often persist throughout infancy, and 
not infrequently throughout childhood; they have often been known to 
continue up to puberty. The longer the habit has lasted the more diffi- 
cult is it to break. 

The results of sucking may be serious. Deformities of the thumb or 
finger, of the lips and teeth, and even of the jaws, are sometimes pro- 
duced. I know a lady, now in advanced life, whose thumbs to this day 
show a deformity resulting from the habit of thumb-sucking while a child. 
In her case the habit was not broken until she was eight or nine years 
old. Probably the most pernicious result of sucking is its tendency to 
develop the habit of masturbation. Habitual sucking of one hand or 
finger may lead to spinal curvature. 

Treatment. — In the management of these cases the most important 
thing is to arrest the habit early, before it becomes fixed. Too often the 

* Jahrbuch fur Kinderheilkunde, vol. xiv, p. 68. 



744 DISEASES OF THE NERVOUS SYSTEM. 

habit of thumb-sucking, or of sucking a rubber nipple, is encouraged by 
mothers, nurses, and sometimes even by physicians because of the 
temporary quiet which is thereby produced. Under no circumstances 
should it be resorted to as a means of putting children to sleep or other- 
wise quieting the nervous system. With infants, the only treatment 
which is at all successful is mechanical restraint. It is of no use to 
cover the part which is sucked with bitter solutions. The hands of 
young infants may be covered with mittens, or with the long sleeves of 
a night-gown which is pinned to the bed, so that it is impossible for the 
child to get the part to the mouth; or pasteboard splints may be applied 
at the bend of the elbow, so as to prevent flexion of the arms. In the 
milder cases the habit is often discontinued spontaneously; but when 
it has been indulged until a child is four or five years old, it is broken 
only with the greatest difficulty. Punishments are of little avail, but 
rewards are often successful. 

Masturbation. — This is not uncommon even in infancy. Many cases 
have been observed during the first year, and some as early as the seventh 
or eighth month. It is seen in children of all ages and in both sexes ; 
but in infants and young children it is, in my experience, much more 
common in girls than in boys. 

Etiology. — Local causes are present in a large number of the cases, 
and this is usually something which produces undue irritation. The 
most frequent are, long or adherent prepuce, phimosis, balanitis, vulvo- 
vaginitis, eczema of the labia, threadworms, and tight clothing. A urine 
which is irritating because of excessive acidity or the presence of crystals 
of uric acid may be a cause. Any irritation may lead the child to rub 
the parts in some way, and a pleasurable sensation being excited, this 
action is repeated until a habit is formed. Other causes are exercises 
in which the legs are rubbed together, or the body against a pole, as in 
climbing. To these causes must be added, in infants at least, the habit 
of sucking. After infancy the habit of masturbation is usually ac- 
quired from other children, sometimes taught by vicious nurses. 

General causes are also important as predisposing factors. These 
are the same as underlie most of the neuroses of childhood — viz., marked 
anaemia, general malnutrition, and a highly neurotic constitution, which 
is often an inheritance, and is always aggravated by surroundings which 
tend to unnatural stimulation of the nervous system. When masturba- 
tion develops in a young child without any local cause, it may be an 
early sign of either mental deficiency or moral delinquency; if looked 
for, other stigmata of degeneration will usually be found, and in most 
cases other vicious traits will soon appear. 

Symptoms.— In infants and very young children masturbation is 
often accomplished by thigh friction or by rubbing the body against a 
pillow, chair, or some other object. The variety of ways is almost end- 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 745 

less. Frequently the child will simply lie upon the floor with the thighs 
crossed and rigidly held, and only a backward and forward motion of 
the body made. This lasts for a few moments, is accompanied by flush- 
ing of the face and some appearance of excitement, followed by relaxa- 
tion, and often by perspiration. It frequently happens with little chil- 
dren that these " queer tricks," as they are often regarded, have been 
continued for months before their true nature is suspected. 

A consciousness that they are doing something wrong early leads 
even young children to get by themselves when they repeat the habit. 
It is especially likely to be practised when children lie long awake alone 
after they go to bed, or if they wake early. The habit is always made 
worse by any deterioration of the general health. I have known chil- 
dren, who were thought to be cured, to relapse under such conditions. 

It is somewhat difficult to separate the general symptoms with which 
masturbation is associated, and upon which it largely depends, from 
those which are the direct result of the habit. There are some children 
in whom the condition is chiefly or entirely dependent upon a local 
cause, or when it is only occasionally practised, in whom no general 
symptoms are seen, or at most only an unnatural shyness and a disposi- 
tion to seek seclusion. Others are precocious and excitable with an ex- 
cessive amount of nervous sensibility. There are others in whom more 
marked nervous symptoms are present; the most striking are absent- 
mindedness, loss of power of concentration, loss of interest in all amuse- 
ments, and mental depression. In some cases nymphomania, or even 
insanity, may be the result. Epilepsy, chorea, or hysteria may develop, 
particularly where a strong predisposition to them already exists in 
the family. The effect of masturbation upon the physical and mental 
development of the child may be serious when it is begun at an early 
age or is frequently practised. But even more striking is the change 
sometimes brought about in a child's moral nature. Even little children 
of eight or nine years may become centres of moral infection, which 
may involve a group of playmates or even a whole school. 

Local symptoms of masturbation are not always present; in the 
male there may be redness and slight swelling of the prepuce; the or- 
gans may be abnormally large or simply much relaxed. In the female 
similar conditions may exist, and sometimes there is vaginitis. 

Prognosis. — Masturbation in children is at all times a most difficult 
condition to deal with. The outlook is better in infants and young chil- 
dren than in those who are older, because the latter are more difficult to 
watch and control ; besides, in them the habit has usually become more 
firmly fixed. Tn young children local causes are frequently found to be 
at the root of the trouble; in those who are older general causes are 
more often present, and these it may be impossible to remove. When 
masturbation is a symptom of degeneracy it is usually hopeless. 



^46 DISEASES OF THE NERVOUS SYSTEM. 

Treatment.— The most important thing is an early recognition of 
the condition. The physician should put parents and nurses on their 
guard, and the first suspicions should be reported and the child care- 
fully watched until all doubt is removed. In young infants much may 
be accomplished by mechanical restraint. The kind of restraint which 
is necessary will depend upon the manner of masturbating. If by the 
hands, they should be tied during sleep, so that the child can not reach 
the genitals ; if by the thigh-friction, the thighs should be separated by 
tying one to either side of the crib. In inveterate cases, a double side- 
splint, such as is used in fracture of the femur, may be applied. In 
children that are over three years old, all such contrivances are almost 
invariably unsuccessful. It is of the utmost importance in every case to 
have the child under the close surveillance of a competent and trust- 
worthy person. He should be especially watched just after being put 
to bed and immediately after waking. Corporal punishment is often 
useful in very young children, but of little or no benefit in those who are 
over three years old. In fact, in such cases it may do positive harm, for 
deception and lying are soon added to the previous vice. The mother 
should secure the child's confidence, and in every way possible seek to 
strengthen his will and stimulate his self-control, using her influence to 
help him break the habit. The local causes, too, must be examined into 
and removed whenever found. Circumcision should be done if phimosis 
exists, and even where it is not, the moral effect of the operation is 
sometimes of very great benefit. In girls improvement sometimes fol- 
lows a separation under anaesthesia of the preputial hood from the cli- 
toris. If a dorsal slit is made in the prepuce a recurrence of the adhe- 
sions can easily be prevented. Complete circumcision is sometimes done 
with advantage, and in very obstinate cases the clitoris may be cauterized. 
Blistering the inside of the thighs, the vulva, or the prepuce is sometimes 
useful. Care should be taken that the clothing does not irritate the 
parts. The child should not only be removed from all vicious compan- 
ions, but constant watchfulness should be exercised in the home and at 
school, that the child should have no opportunity to teach other children 
the habit. In the most serious cases the child should be sent away from 
home and kept from other children. The co-operation of a trustworthy 
nurse or companion is indispensable. General treatment should be di- 
rected to the child's condition; it is required in most of the cases. 
A child suffering from malnutrition and anaemia should be sent to 
the country, kept out of doors and away from books, studies, and from 
everything which stimulates or excites the nervous system. Almost all 
exercises except horseback may be recommended. Every means should 
be employed to build up the child physically. Cure results in most 
cases only by using all these measures and for a long time. 



MALFORMATIONS. 



747 



Nail-biting and Tongue-sucking are two forms of habit which are less 
frequent and less important than those already mentioned. The former 
is best remedied by keeping the nails cut very short. Tongue-sucking 
seldom becomes a fixed habit, and the child usually ceases it of his own 
accord as he grows older. 



CHAPTER III. 

DISEASES OF THE BRAIN AND MENINGES. 

MALFORMATIONS. 

The malformations of the brain are of great variety, and many of 
them are solely of anatomical interest, as the conditions are incompatible 
with life. Only the most frequent and the best-known types will be men- 
tioned, and those which are of interest from a clinical point of view. 

Meningocele, Encephalocele, and Hydrencephalocele. — These three 
conditions have in common a protrusion of some part of the cranial con- 




Fig. 123. — Meningocele. 



Fig. 124. — Encephalocele. Fig. 125. — Hydrencephalocele. 



tents through an opening in the 
skull. In meningocele (Figs. 123, 
12G) there is protrusion of the 
membranes alone. These form a 
sac, which is usually, but not inva- 
riably, distended by fluid. In en- 
cephalocele (Fig. 124) there is a 
protrusion of a portion of the brain 
substance; this is connected with 
the rest of the brain by a constrict- 
ed neck or pedicle. The tumour 
may or may not contain fluid. In 
hydrencephalocele (Fig. 125) there 

is a protrusion of a portion of the brain substance which contains within 
it a cavity filled with fluid, this cavity communicating with the distended 
lateral ventricles. 




Fig. 120. — Meningocele. 
From a patient in the Babies 1 Hospital. 
The autopsy showed that the sac communi- 
cated with the lateral ventricles. 



748 



DISEASES OF THE NERVOUS SYSTEM. 



1 


■ 


wtr 




WI 




1 


1 


h * 


4 


r r 


m t 


f -v ■ 


< 



Fig. 127. — Frontal men- 
ingocele. From a pa 
tient in the 
Hospital. 



In all chese conditions there is a tumour, usually pedunculated, of a 

round or pyriform shape, with a smooth or lobulated surface. The ordi- 
nary size is that of a mandarin orange ; it may be as small as a walnut, or 
as large as the patient's head. It is generally cov- 
ered by the scalp, which is often denuded of hair; 
but it may be covered only by granulation-tissue, 
or it may show a central cicatrix, like that of spina 
bifida. Other deformities, such as spina bifida, 
club-foot, and hare-lip are frequently present. 

All these conditions are rare, but the most fre- 
quent and most serious one is hydrencephalocele, 
this being usually associated with hydrocephalus. 
The next in frequency is encephalocele, which has 
the best prognosis. This is frequently termed 
hernia cerebri. If fluid is present, it is external to 
the brain. In meningocele (Figs. 126 and 127) 

there is simply an accumulation of fluid in the arachnoid cavity, which 

communicates by a small opening with the general arachnoid cavity of 

the brain. 

Of one hundred and five cases collected by Schatz, fifty-nine occupied 

the occipital region and forty-six were frontal. The aperture through 

which the occipital protrusion takes place is usually 

in the median line. It may communicate with the 

posterior fontanel, with the foramen magnum, or with 

the cleft of a spina bifida. The occipital bone may 

be divided in the median line, or rarely it may be 

absent. 

In the naso-frontal form (Fig. 128) the tumour 

is usually at the root of the nose, a little to one side 

of the median line. The aperture is most frequently 

between the cribriform plate of the ethmoid and the 

frontal bones. It may be between the lateral halves 

of the frontal bone, causing a median tumour. The 

point of protrusion may also be the lateral region 

of the skull, generally about the lateral fontanel, or along the line of the 

sutures; it may project into the mouth or the pharynx. These anterior 

tumours are usually small, although large ones containing the anterior 

lobes of the brain have been seen. 

The theory of the origin of these malformations which is most widely 

accepted is that they are primarily cases of intra-uterine hydrocephalus, 

and as the cranial cavity is gradually closed by the development of the 

bones, a certain portion of the brain is left outside. 

Symptoms. — The tumour is always congenital, although after birth 

it frequently increases very much in size. A typical tumour is round 




.'lipft' 



Fig. 128.— Naso-frontal 

meningocele (after 
Demme). 



MALFORMATIONS OF THE BRAIN. 749 

and elastic, usually giving evidences of fluid ; it pulsates synchronously 
with the heart; during screaming or forced inspiration, it increases in 
size ; partial and in some cases complete reduction is possible, but this is 
usually followed by marked cerebral symptoms, even by convulsions. After 
partial reduction, an opening in the skull may often be made out. Micro- 
cephalus may be present, or there may be unequal development of the two 
sides of the head. 

The following differential points given by Treves, indicate the most 
characteristic features of the three varieties : In meningocele, the tumour 
is at first small, but increases ; it has a smooth surface ; it is pedunculated ; 
there is distinct fluctuation, perfect translucency, rarely pulsation ; often 
it is completely reducible; compression of the tumour causes cerebral 
symptoms ; the skull is normal. In encephalocele, the tumour is small 
and smooth ; it is rarely pedunculated ; fluctuation is absent ; it is not 
translucent ; there is distinct pulsation ; it is usually reducible ; pressure 
causes cerebral symptoms; the skull is normal. In hydrencephalocele, 
there is a large pendulous tumour with an irregular or lobulated sur- 
face ; it is pedunculated ; translucency is rarely complete ; fluctuation is 
distinct ; it is irreducible ; pressure rarely causes symptoms ; microcepha- 
lus and other deformities are often associated. 

The occipital tumours are usually more serious than the frontal ones. 
The majority of cases die in the course of the first few weeks of life, 
death resulting from meningitis, convulsions, or rupture. In meningocele 
the tumour usually grows slowly, and ultimately may be shut off from the 
cranial cavity ; but gradual thinning of the membrane may take place, and 
spontaneous or accidental rupture occur. In encephalocele the tumour 
grows slightly, or not at all. Most of these patients exhibit signs of 
mental impairment or other evidences of organic brain disease. 

Treatment. — According to Treves, operation is justifiable only in 
case of impending rupture. The conditions present are essentially the 
same as in spina bifida. Meningocele may be aspirated, injected with 
iodine, or with Morton's iodine and glycerin solution; the sac may be 
laid open and a plastic operation performed for the closure of the com- 
munication with the cranial cavity; or the skin may be divided, and a 
ligature or clamp applied to shut off the communication with the brain. 
All these methods have been at times successful, but cure has in many 
instances been followed by the development of chronic hydrocephalus. 
Encephalocele is to be treated by protection and compression. Aspiration 
may be resorted to if fluid is present. In hydrencephalocele the prognosis 
is absolutely bad under all circumstances. Schatz * gives the following 
statistics, showing the results with and without operation, all varieties 
being included : Of twenty-four occipital tumours not operated on, three 



* Berlin, klin. Wochenschrift, No. 28, 1885. 



750 DISEASES OF THE NERVOUS SYSTEM. 

recovered ; of thirty-five operated on by excision, ligation, or injection, 
six recovered. Of forty-six frontal tumours, there were six recoveries in 
thirty-two cases without operation, and two recoveries in fourteen cases 
with operation. 

Microcephalus. — This is generally regarded as due to premature ossi- 
fication of the skull ; but this theory is certainly inadequate to explain 
all the cases. In many children suffering from marasmus, the sutures 
ossify and the fontanels close much earlier than in healthy infants of 
the same age, chiefly because, with the rest of the body, the brain also 
has ceased to grow. So it is true of some of the cases, at least, of micro- 
cephalus, that the early ossification of the skull is due to arrested growth 
of the brain, and not the reverse. The reasons for the developmental 
arrest in the brain are for the most part unknown. The condition usually 
dates back to intra-uterine life, although in some cases it appears to begin 
after birth. 

It is well known that there is not an invariable relation between the 
size of the head and the size of the brain, although generally the two cor- 
respond. If the circumference of the head is much below the average for 
the age (page 20), and relatively much less than the measurements of the 
rest of the body, microcephalus may be assumed to exist. Sachs calls 
attention to the fact that the circumference of the head may be nearly 
normal and yet the essential conditions of microcephalus exist, owing to 
imperfect development of the anterior part of the brain. 

The symptoms of microcephalus are those of idiocy and cerebral 
paralysis, existing in all possible combinations and with variable degrees 
of severity. 

A new surgical interest in these cases has been awakened during the 
last few years by the operation of craniectomy. The purpose of this oper- 
ation, which was devised by Lannelongue, is to relieve the intracranial 
pressure by making a longitudinal opening in the skull, on one or both 
sides. The opening made is usually about half an inch wide and four 
or five inches long. It is one or two inches from the sagittal suture, to 
which it is parallel. For the time being the cranial capacity is increased, 
but it is doubtful if even this is permanent. Jacobi * gives a report of 
thirty-three cases operated upon by American surgeons, with fourteen 
deaths and nineteen recoveries. At the time of report the condition in 
the cases which survived the operation was as follows : no improvement 
in seven; slight, in seven; "some," in one; much, in two; no history, in 
one ; uncertain, in one. I quite agree with him that such results do not 
justify the performance of this operation. 

Congenital Hydrocephalus.— These cases may fairly be considered as 
belonging .n this group, although they have been discussed elsewhere. 



* New York Medical Record, May 19, 1894. 






PACHYMENINGITIS. 751 

Porencephalia (literally, a hole in the brain) is a condition in which 
there is a large depression in some part of the brain, but with surrounding 
parts well developed. Such depressions may involve a whole lobe, and 
they may be deep enough to reach the lateral ventricles. 

Porencephalus is described as congenital or acquired. In the congeni- 
tal form, the defect is usually found in the anterior or middle part of the 
brain. The origin of these conditions is still a disputed question. They 
are probably due to early vascular changes. Children sometimes live 
several years with very large defects, the symptoms depending upon the 
seat of the lesion. The acquired form of porencephalus is usually one of 
the late results of meningeal haemorrhage. It may affect one or both 
sides. Such cases present the symptoms of spastic paralysis — usually 
diplegia. In all cases with large brain defects, the space is filled with fluid. 

PACHYMENINGITIS. 

Pachymeningitis, or inflammation of the dura mater, occurs both as 
an acute and a chronic disease. 

Acute Pachymeningitis. — This is very rare in children. Only pachy- 
meningitis externa is generally included under this term, as acute pachy- 
meningitis interna does not occur alone, but usually with inflammation of 
the pia mater (leptomeningitis). It may be associated with disease or 
injury of the bones of the skull, but is most frequently seen in connection 
with middle-ear disease. It generally begins as a localized process, but 
the inflammation may extend to the inner layer of the dura, and to the 
pia mater; or it may remain circumscribed, and terminate in the forma- 
tion of an abscess between the dura mater and the bone. 

The symptoms of acute pachymeningitis are distinctive only when 
the process is localized. They are then usually associated with middle- 
ear disease, and are indistinguishable from those of cerebral abscess. 
The treatment is surgical. 

Chronic Pachymeningitis. — This, in children, almost invariably af- 
fects the inner layer of the dura mater (pachymeningitis interna) ; it is 
also known as pseudo-membranous and as hcemorrhagic pachymeningitis 
or hcematoma of the dura mater. Its causes are for the most part un- 
known. It is not very rare, being usually discovered at autopsy in chil- 
dren, chiefly cachectic infants, who have died of other diseases. In the 
Report of the New York Pathological Society for 1890 Northrup records 
six such cases. I have seen five similar ones, as well as one other asso- 
ciated with chronic hydrocephalus. 

Two classes of cases are to be distinguished — those with, and those 
without extensive haemorrhages. In the lattergroup there is found a thin, 
translucent, vascular membrane lining the inner surface of the dura. It 
may be only a delicate film which can be scraped off ; it may be as thick 
as ordinary blotting-paper, or even twice that thickness. The membrane 



752 DISEASES OF THE NERVOUS SYSTEM. 

is often cedematous ; it is exceedingly vascular, and the vessels have very 
thin walls. There are usually scattered, punctate haemorrhages, and 
there may be a few of larger size. This membrane may cover the whole 
inner surface of the dura, but in most cases it is principally over the con- 
vexity and may be found only here ; it is apt to be more upon one side 
than upon the other. In cases of long standing there may be adhesions 
between the dura and the pia. When large haemorrhages have taken place, 
quite a different pathological appearance is presented. The lesions found 
in a case upon which I made an autopsy in the New York Infant Asylum, 
are fairly typical : The infant was six months old, and the symptoms had 
existed for six days. The fontanel was bulging to a marked degree, and 
the sagittal and coronal sutures were separated. A thin recent clot from 
one eighth to one fourth of an inch in thickness covered nearly the whole 
of the right hemisphere and part of the convexity of the left. The entire 
dura was lined both at its convexity and base by a pseudo-membrane of 
grayish color, about one sixteenth of an inch in thickness. The brain 
was anaemic. 

In cases of longer standing partial organization of the clot may be 
seen ; in more recent ones the blood is partly or entirely fluid. I once 
found acute leptomeningitis with a purulent exudation, associated with 
haemorrhagic pachymeningitis. In cases where life is prolonged for years, 
there may be partial or even complete absorption of the clot, followed by 
the formation of cysts, considerable inflammatory thickening of the pia 
with deposits of blood pigment, and finally atrophy and sclerosis of the 
cortex. The source of the haemorrhage may be the rupture of a single 
large vessel, but more frequently the blood comes from many small 
vessels. 

Symptoms. — These are due to the haemorrhage, and not to the inflam- 
matory process. Until haemorrhage occurs there are no symptoms by 
which the disease can be recognised. Thus in many of the cases in which 
pachymeningitis is found at autopsy, its existence is not suspected dur- 
ing life. The occurrence of haemorrhage is sometimes marked by vomit- 
ing or convulsions, and usually there is loss of consciousness. It may 
be a question whether the convulsions are the cause or the result of 
the haemorrhage. In most cases they seem to be the result. They are 
usually general and repeated. If the haemorrhage occurs slowly, there 
may be stupor without convulsions until nearly the close of the disease. 
In the fatal cases the symptoms generally continue from two days to a 
week. There are dulness, stupor, and finally coma, death occuring in coma 
or convulsions. If the haemorrhage is diffuse — and this is apt to be the 
case — there is rigidity of all the extremities ; if it is of one side only, the 
rigidity affects only one arm and leg. The pupils are more frequently 
contracted, but may be dilated or unequal. There is diplegia, hemi- 
plegia, or monoplegia, according to the seat and extent of the haemor- 



PACHYMENINGITIS. 753 

rhage. The respiration is slow and irregular and may be of the Cheyne- 
Stokes variety. The pulse is slow, irregular, and sometimes intermittent. 
The temperature is at first normal, but rises slowly until death occurs, 
when it is from 100° to 103° F. Generally the cranial nerves are not 
affected, and opisthotonus is absent. The knee-jerk is often exagger- 
ated. In cases which do not prove fatal — these being chiefly in older 
children — we have a similar onset, but after a few days consciousness is 
regained, and only hemiplegia or monoplegia remains. The course of the 
paralysis is that seen after meningeal haemorrhage due to other causes. 
Wagner has reported a case in which recurring haemorrhages took place 
at intervals of several months, the autopsy showing distinct evidences of 
both old and recent lesious. 

Pachymeningitis, I believe, plays a much more important role in the 
production of meningeal haemorrhages in children than has generally been 
accorded to it. From the frequency with which this lesion is found as a 
cause of sudden meningeal haemorrhages which are fatal, it is not unlikely 
that many of the cases which recover with hemiplegia or monoplegia, may 
be due to the same cause. 

The prognosis depends upon the age of the patient and the extent of 
the haemorrhage. Extensive haemorrhages are usually fatal in infancy, 
but small ones are seldom so, for they are rarely at the base. The prog- 
nosis of the paralysis in cases not terminating fatally, is the same as after 
meningeal haemorrhage due to other causes, with perhaps an added liabil- 
ity to recurrent attacks. 

Without large haemorrhages, pachymeningitis interna can not be diag- 
nosticated ; and it is impossible to differentiate the haemorrhagic cases 
from other varieties of meningeal haemorrhage. It is important to make 
a diagnosis between pachymeningitis with haemorrhage, and acute simple 
meningitis. In the former we have a sudden onset; stupor occurring 
early, usually on the first day, gradually diminishing in cases of recovery, 
or deepening into coma in fatal cases ; localized or general paralysis, also 
occurring early ; there is no fever in the beginning, and only moderate 
fever at the close. In acute meningitis we usually have a higher tem- 
perature, especially early in the disease ; coma develops later, and rigidity 
of the extremities is less pronounced. In certain cases, however, where 
the haemorrhage occurs in the course of some other disease, a differential 
diagnosis may be impossible. 

Treatment. — The treatment of pachymeningitis haemorrhagica is symp- 
tomatic. The indications are, to relieve cerebral congestion by applying 
ice to the head, to allay irritative symptoms by the use of bromides, and 
to keep the patient perfectly quiet. 



754 



DISEASES OP THE NERVOUS SYSTEM. 



ACUTE MENINGITIS. 

Three distinct varieties of acute meningitis are met with in children. 

1. Cerebrospinal meningitis. This is the only variety of meningitis 
which prevails epidemically, but it also occurs sporadically. It is due to 
a specific cause, the diplococcus intracellular is of Weichselbaum, known 
also as the meningococcus. It may be regarded as a general infectious 
disease, but with its essential lesions in the brain and cord. 

2. Simple acute meningitis, which may be due to a wide variety of 
micro-organisms. Although this is sometimes primary, it is usually a 
secondary disease. 

3. Tuberculous meningitis. 

CEREBROSPINAL MENINGITIS EPIDEMIC MENINGITIS— CEREBRO- 
SPINAL FEVER. 

Epidemics of cerebro-spinal meningitis are separated by quite long 
intervals and occur without any assignable cause. The following chart 
(Fig. 129) represents the prevalence of the disease in New York city 
during the last fifty years. This shows that very little was seen of 





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Fig. 129. — Chart showing deaths from cerebro-spinal meningitis in New York city, for fifty 
years, per 100,000 of population. 

cerebro-spinal meningitis until the epidemic of 1872. After this time 
a certain number of deaths from this cause occurred each year, there 
being two or three times as many in some years as in others; but there 









CEREBRO-SPINAL MENINGITIS. 755 

was no extensive epidemic until that of 1904-5. What has been said of 
New York is true of almost every large city. In remote country towns, 
epidemics are occasionally witnessed, and after prevailing a few months 
the disease disappears as mysteriously as it came. Epidemics are usually 
seen in the winter and early spring, lasting for several months, gen- 
erally reaching their height in March or April and slowly subsiding as 
warm weather approaches. 

With reference to the cause of epidemics very little has been settled. 
When the disease prevails in cities it usually occurs in crowded tene- 
ments, being relatively infrequent in private houses. Many cases may 
occur in certain districts, while in others not very far removed there 
may be very few. These facts suggest a connection with unsanitary con- 
ditions, but nothing that is positive has been demonstrated. 

Cerebro-spinal meningitis is not contagious. Whether the disease is 
in any way communicable is not yet established. The fact that in a 
considerable number of cases (about 15 per cent according to the obser- 
vations of the New York Health Department) an organism closely 
resembling the meningococcus, if not identical with it, has been found 
in the noses of children and adults exposed to the disease, affords some 
grounds for believing the disease to be communicable; probably very 
much as lobar pneumonia sometimes is. However, when we consider 
that in fully 70 per cent of the cases but one person in a household is 
affected, although no effort at isolation is made, it will be apparent that 
the danger of spreading the disease in this way is slight. I have never 
known the disease to originate in a hospital, although in New York 
patients with cerebro-spinal meningitis are regularly received into hos- 
pital wards with other children. Sporadic cases of meningitis occur after 
epidemics from no apparent cause and without any connection with one 
another. Children of all ages are about equally susceptible to this dis- 
ease. The youngest case I have seen was in a child of two and a half 
months. 

Cerebro-spinal meningitis is due to a specific organism, the diplo- 
coccus intracellularis or meningococcus. This is present in the menin- 
geal exudate, in the cerebro-spinal fluid obtained by lumbar puncture, 
and in some cases can be demonstrated in the blood. It is almost invari- 
ably found in pairs or tetrads within the leucocytes. It is decolourized 
when stained by Gram's method. The portal of entry is as yet not 
settled; but from the fact that early in the disease the organism has 
been so often obtained from the upper part of the nose, the inference has 
been drawn that infection of the brain takes place through this channel. 
Outside the body the organism is unknown. 

Lesions. — In epidemic meningitis death may take place so early that 
the changes found at autopsy are slight. There may be only a serous 
exudation and intense hyperaemia, which is doubtless much less marked 
49 



756 DISEASES OF THE NERVOUS SYSTEM. 

after death than during life. The cerebro-spinal fluid is turbid and 
much increased in amount. The microscope, however, may show, even 
in these early cases, an abundant exudation of leucocytes in the pia mater. 
After the third day the lesions are quite uniform. The convolutions 
appear somewhat flattened from pressure due to distention of the ven- 
tricles. The inner surface of the dura is usually normal or only con- 
gested. There may be thrombi in any of the cerebral sinuses, or in the 
meningeal veins of the convexity. There is an exudation of greenish- 
yellow fibrin, which is sometimes very abundant. It is generally widely 
distributed, but is most marked over the anterior half of the brain and 
at the base. In some cases it is limited to the base, but very rarely 
limited to the convexity. There is an increase in the quantity of cerebro- 
spinal fluid. The ventricles are moderately distended with serum or 
sero-pus, and their walls may be slightly softened. The brain substance 
of the cortex may be reddened or may appear normal. In the meninges 
of the cord, lesions similar to those of the brain are usually seen. The 
exudation is principally upon the posterior surface, and may extend 
throughout the entire length of the cord, or be limited to its upper or 
to its lower portion. 

Microscopical examination shows the exudation to consist of fibrin 
"and pus cells, which infiltrate the pia mater. The superficial layers of 
the cortex in the inflamed areas often show minute haemorrhages and 
very marked cell-infiltration. Minute abscesses may be present. Very 
marked degenerative changes can usually be demonstrated in the nerve 
cells themselves. The cells of the neuroglia are also affected; they are 
swollen and increased in number; and there may be proliferation of the 
connective tissue about the blood vessels. Changes in the cord similar 
to those just described may be found, but these are less frequent and as 
a rule much less severe than those in the brain. Inflammatory products 
are sometimes present in the central canal of the cord and in the walls 
of the lateral ventricles of the brain. The inflammatory process fre- 
quently extends along the cranial nerves, especially the optic and audi- 
tory, and this may result in choroiditis or otitis; from the cord, it may 
extend along either the anterior or posterior nerve roots. Descending 
degeneration is found in the nerves both of the brain and cord. 

In patients that die after the disease has lasted two or three months, 
the later results of these lesions may be seen. There is usually present a 
chronic meningo-encephalitis, sometimes diffuse, sometimes localized. 
The pia mater is cloudy, thickened, and frequently adherent to the brain. 
Here and there are seen small, yellow, opaque patches which are the result 
of fatty changes in the cells and fibrin of the exudate, with some prolifer- 
ation of connective tissue. The lesions are usually most marked at the 
base, where the thickening of the meninges and the adhesions may lead 
to the development of a secondary hydrocephalus. 



CEREBRO-SPINAL MENINGITIS. 757 

In cases which have lasted a much longer time the most marked 
changes are in the brain substance. There may be generalized meningeal 
adhesions,* with a diffuse cortical atrophy, but more frequently there 
are areas of sclerosis, especially over the frontal and temporo-sphenoidal 
lobes, with which there are almost always associated marked descending 
degenerative changes in the cord. Such lesions are, of course, perma- 
nent, and seriously interfere not only with the functions, but also with 
the growth and development of the brain. 

The visceral lesions most frequently found in epidemic meningitis 
are pulmonary. There may be lobar or broncho-pneumonia, and in the 
exudation may be found the same organism as in the brain. Acute de- 
generation of the liver and kidneys is also frequent. The other viscera 
are seldom affected. 

Symptoms. — The symptoms of cerebro-spinal meningitis do not differ 
essentially in the sporadic and epidemic cases, except that the most severe 
forms of the disease are seen in the latter. They may be divided into 
several quite distinct groups : 

1. Hyper-acute form. — Cases of this kind are rarely seen except in 
an epidemic, and usually occur at its height. The onset is very abrupt, 
the course short and intense, and death may take place in from twelve 
to thirty-six hours. The following case illustrates this type: A little 
girl of ten years was well enough at 2 p.m. to carry a bundle of clothes 
a dozen city blocks. Eeturning home, she complained of intense head- 
ache, vomited frequently, and was so weak that she was obliged to go to 
bed. In a few hours she passed into deep coma, with very high fever, 
and died at 11 p.m. 

The earliest symptoms are usually intense headache, repeated attacks 
of vomiting, and very high fever. There is great prostration and the 
nervous symptoms increase so rapidly that in a few hours the patient 
may become comatose and death occur in a short period. The tempera- 
ture rises rapidly to 104° or 106° F. A few petechial spots may be dis- 
covered over the face, chest, or extremities. There is usually no rigidity, 
but rather general relaxation. The pulse is weak, in most cases rapid, 
but sometimes slow and irregular. The respiration is usually irregular 
both in frequency and depth. 

* This lesion and its effects are well illustrated by one of my own patients who 
died six months after an attack. She was a bright little girl of four and a half years, 
and had a typical attack of meningitis of moderate severity. Convalescence was slow, 
but at the end of two months recovery was perfect in everything but her mental con- 
dition. She remembered nothing which she had previously learned in the kinder- 
garten, where she had been an exceptionally bright pupil. Her mind was a blank. 
She was dull, listless, and her face had a vacant, idiotic expression. The special 
senses seemed unaffected, and speech was retained. She died during an attack of 
convulsions. At the autopsy the pia was everywhere thickened and adherent, 
while in the cortex were present the earlier changes of a general encephalitis. 



758 



DISEASES OF THE NERVOUS SYSTEM. 



The symptoms appear to be due to two factors: first, the intensity 
of the infection; second, the rapid accumulation of cerebro-spinal fluid, 
causing coma with cardiac and respiratory paralysis. Usually both 
these factors are present, but I believe that the second one is the more 
important. In support of this view is the striking infrequency of cases 
of this type in infants with an open fontanel. Should the patient sur- 
vive the violence of the onset, a period of reaction occurs, and after a 
day or two the disease follows the regular course. 

2. Usual form. — In this also the onset is generally abrupt, but not 
so violent as in the cases just described. It may be marked by intense 
headache, vomiting, convulsions, delirium, chills, and fever with general 
hyperesthesia and rigidity. The initial temperature is from 101° to 
104° F. Opisthotonus, with severe pains in the back of the neck and 
along the spine, and general muscular rigidity are usually present. 
There is often active delirium, but rarely stupor or coma. The pulse is 
generally rapid, 120 to 150, and sometimes irregular. The respiration 
is often slightly irregular, and it may be rapid or slow. The eruption 
is not so frequently seen as in the very acute cases. 




Fig. 130. — Posture in cerebro-spinal meningitis. (Smith.) 



As the disease progresses, the nervous symptoms often change but 
little from day to day for two or three weeks. They are mainly of the 
irritative type — moderate delirium, extreme hyperesthesia, tremor and 
muscular rigidity. The posture is quite characteristic (Fig. 130). 
Owing to the opisthotonus the child cannot lie upon the back, but rests 
upon the side, with arched spine and neck, and general flexion of the 
extremities. There is a rather rapid loss in weight, steadily increasing 
prostration, and a weak, rapid pulse. The bowels are usually constipated. 
From time to time attacks of vomiting occur. In most cases there is 
considerable difficulty in feeding. The duration of this form of the dis- 
ease is from three to six weeks. The course is often marked by periods 



CEREBRO-SPINAL MENINGITIS. 759 

of remission and exacerbation. If recovery is to take place, the tem- 
perature gradually falls to normal and often at times it is subnormal. 
The mind becomes clear, and one by one the nervous symptoms dis- 
appear, the muscular rigidity being usually the last to go. Convalescence 
is always protracted. 

In cases ending fatally, the patient usually passes into a deep stupor 
or coma, with extreme prostration, a slow, weak, irregular pulse, shallow 
respiration of the Cheyne- Stokes variety, sunken abdomen, general relax- 
ation, and death occurs from exhaustion or from broncho-pneumonia. 

Occasionally the attack is much prolonged, the fever and all the 
active symptoms continuing from eight to twelve weeks. Emaciation 
sometimes becomes extreme, and with a few nervous symptoms may con- 
tinue long after the fever ceases. In infants, death is often due to 
marasmus. While a fatal outcome is more frequent in these prolonged 
cases, not a few recover completely, even where symptoms have lasted 
for eight or ten weeks. 

3. Mild form. — Especially toward the end of an epidemic, and some- 
times occurring sporadically, there are seen cases which in their onset 
and for the first two or three days resemble those just described; but 
instead of running the usual course, the fever and the nervous symptoms 
subside rapidly and convalescence is established early. 

4. Chronic form. — Owing sometimes to the extent, sometimes to the 
position of the lesions, the disease does not subside at the usual time, but 
nervous symptoms continue after the temperature and most of the other 
constitutional symptoms have passed away. These cases are chiefly of 
the basilar type, and often lead to the development of chronic basilar 
meningitis with secondary hydrocephalus. They are more fully con- 
sidered in a later chapter. 

' Onset. — One of the most striking features of this disease is the 
abruptness with which it develops. Occasionally there are indefinite 
symptoms for a day or two before active symptoms begin; but in the 
great majority not only the day, but the hour of the onset is definitely 
marked. The most frequent initial symptoms are the simultaneous 
occurrence of severe headache and vomiting, followed by high fever and 
marked prostration. The vomiting is usually repeated, projectile, and 
has no relation to meals. Convulsions occurred in the beginning of 30 
per cent of my cases. Occasionally a decided chill is seen. After twenty- 
four hours acute general pains and hyperesthesia are usually present, 
together with rigidity of the muscles of the neck and extremities, giving 
rise to opisthotonus and muscular contractions. 

Skin. — Eruptions upon the skin vary much in frequency in different 
epidemics. The most characteristic one is the appearance of small punc- 
tate haemorrhages, resembling flea bites ; they are not numerous, but may 
be found on almost any part of the body, most frequently upon the ex- 



760 DISEASES OF THE NERVOUS SYSTEM. 

tremities, the upper part of the chest and neck. In my experience they 
have been present in about 14 per cent of the cases. From this symptom 
the name " spotted fever " has arisen. This petechial eruption belongs 
to the early stage of the disease, fades quickly, and is rarely visible after 
the third or fourth day. In some cases a general erythema is present; 
in others, an eruption closely resembling measles. Herpes upon the lips 
and face is common in older children, but is rare in infants. Bedsores 
have been seen in about one- third of my cases. They are found over 
pressure points — the trochanter, the malleoli, and the side of the head; 
in several instances the ear has been the part affected. 

Nervous system. — Headache is a frequent initial symptom and is 
usually severe ; it is more often frontal than elsewhere, and may be asso- 
ciated with vertigo. There are acute pains in the back of the neck, along 
the spine, and marked general hyperesthesia, which is often so intense 
that any movement of the body causes agonizing cries. This is one of 
the most striking symptoms of the disease, and may continue throughout 
the acute stage. The mental state varies much in different cases. De- 
lirium is frequent in the early stage of the severe form; it is usually 
wild and active. After delirium a stage of dulness or apathy ensues, 
giving place to great irritability when the patient is disturbed. Convul- 
sions are sometimes seen early, but are seldom repeated in the course of 
the disease or toward its close. There is rarely continuous deep coma ex- 
cept toward the end of fatal cases. In some cases with high temperature 
and quite severe symptoms, after the subsidence of a short early stage of 
excitement or delirium, the mind remains perfectly clear throughout the 
attack. Under these circumstances an erroneous diagnosis is often made, 
particularly if the physician has not observed the case from the beginning. 

Tonic spasm of the various muscular groups is seldom absent, and, like 
the hyperesthesia, is persistent. The rigidity and contraction of the mus- 
cles of the neck and back produce cervical or general opisthotonus ; cervi- 
cal opisthotonus is most marked with lesions chiefly at the base, but may 
be wanting in the rare cases when the lesion is almost entirely at the con- 
vexity. Tonic spasm of the extremities usually causes general flexion of 
the thighs, legs, and arms. Late in the disease this may be replaced by 
complete extension of the lower extremities with dropping of the feet. 
The tonic muscular spasm gives rise to Kernig's sign, viz., inability to ex- 
tend the leg when the thigh is flexed upon the body. In young children 
one should not place too much dependence upon this sign. While rarely, 
if ever, wanting in cerebro-spinal meningitis, it is often present in other 
conditions. Muscular rigidity is one of the most common symptoms 
and one of the last to disappear. Almost the only times when it is 
absent is in the early stage of the hyper-acute cases, and very late in 
fatal cases, when there may be general relaxation. Other nervous symp- 
toms frequently present are ankle clonus, muscular tremor, especially 



CEREBROSPINAL MENINGITIS. 



761 



of the hands, and paralysis, which may be facial, monoplegic, or hemi- 
plegia Early in the disease the knee-jerks are usually increased; in the 
later stages they are often lost. 

Eye and ear. — The pupils in the early stage are generally contracted ; 
toward the close they are usually widely dilated. Ocular paralyses are 
not so frequent nor so marked as in tuberculous meningitis. The same 
is true of the changes in the optic disc, although these vary much in 
different epidemics. There may be congestion of the fundus, retinitis, 
or optic neuritis. In some epidemics such changes have been observed in 
fully half the cases. In that of 1904-5, in my own hospital cases, they 
were rarely seen, and then were but slightly marked. Conjunctivitis is 
most frequently present and may be severe. There may be choroiditis 
and sometimes complete destruction of the eye, but usually this is uni- 
lateral. In most epidemics the ears are more frequently affected than 
the eyes. Early deafness may be due to a lesion of the auditory nerve, 
is generally bilateral, and often permanent. Acute otitis media occurs 
as a complication, and the meningococcus is occasionally found in the 
discharge. This was true of three of my hospital cases. Permanent 
deafness is sometimes due to changes in the brain itself. 



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Fig. 131. — Cerebro-spinal meningitis. Eecovery. 

Fairly typical chart of prolonged case, showing remissions and exacerbations. Private 
patient, three and a half years old; unconscious, blind, and deaf for two and a half months; 
practically complete recovery. 



Fever. — This disease is usually attended by high fever, but the curve 
is apt to be an irregular one and shows wide variations. The tempera- 
ture is nearly always high at the onset; in the hyper-acute cases it may 
reach 106° F. or higher. The usual range during the disease is from 
100° to 105° F. (Fig. 131). Sometimes it is steadily high; not infre- 



762 DISEASES OF THE NERVOUS SYSTEM. 

quently a few days after a sharp acute onset it falls nearly or quite to 
normal and remains there for several days. Cases seen in this afebrile 
period are most difficult of diagnosis. This stage may be followed by 
another sharp rise, and afterward continuous fever. Periods of remis- 
sion and exacerbation in the temperature are seen in a large proportion 
of the prolonged cases. Often it becomes subnormal. The temperature 
may bear no relation to the severity of the other symptoms. The dura- 
tion of the febrile period is usually from three to six weeks. 

Respiration is disturbed very early in the disease, when it is often 
irregular and may be slow or rapid. Throughout the greater part of 
the attack it may be nearly normal. Occasionally it is of the typical 
Cheyne-Stokes variety. 

Pulse. — Through the greater part of the disease the pulse is rapid. 
In the early stage it is often weak, and sometimes irregular. The average 
frequency in young children is from 130 to 150. A slow, irregular pulse 
is occasionally seen late in the disease in patients who are in deep 
coma. 

Blood. — A leucocytosis is present in nearly all cases. The count has 
varied in my experience between 7,000 and 64,000. The average of 
fifty-six observations was as follows : during the first week, 19,000 ; second 
week, 17,000 ; third week, 30,000 ; fourth week, 20,000 ; fifth week, 16,000. 
The increase is chiefly in the polynuclear cells. Blood cultures made 
early in the disease have in a few instances shown the presence of the 
characteristic organism. 

Digestive system. — Vomiting is one of the most frequent symptoms 
of onset but rarely persists throughout the attack. Late in the dis- 
ease it may be most troublesome. As a rule constipation is present. 
The tongue is coated, dry, glazed, sometimes covered with sordes. In a 
small proportion of cases jaundice has been observed. On account of 
the loss of appetite, great irritability, delirium, and stupor, the greatest 
difficulty is often experienced in feeding these patients. In young chil- 
dren gavage is much more satisfactory than rectal feeding. Early in the 
disease the abdomen is natural. In the late stage it is often very much 
retracted. 

General nutrition. — This is impaired in nearly all cases. There is a 
progressive wasting, greater than would be explained by the disturbance 
of digestion. In the protracted cases it may be extreme. Infants and 
young children often die of inanition or marasmus long after the active 
symptoms of the disease have subsided. 

Other symptoms of importance are the tense, bulging fontanel, in 
infants rarely absent early in the attack, but often wanting in the late 
wasting stage; incontinence of urine and faeces, and retention of urine, 
very frequent and often overlooked; occasionally swelling of some one 
of the large joints is seen. 



CEREBROSPINAL MENINGITIS. 763 

Course, Duration, and Termination. — Excluding the hyper-acute cases 
in which death occurs very early, the usual duration of active symptoms 
is from three to six weeks. Of the cases which have come under my 
personal observation, more than half have lasted over four weeks, while 
active febrile symptoms of from six to eight weeks have not been uncom- 
mon. A very considerable proportion of these protracted cases terminate 
favourably. I have seen one child recover completely after 84 days of 
fever, and another after 102 days. In infants, the duration is shorter 
than in older children, as their resistance is sooner exhausted. The 
progress of the disease is an irregular one; most of the prolonged cases 
are marked by periods of exacerbation with increase in the fever and 
nervous symptoms, followed by periods of remission, with such improve- 
ment that it is thought that the disease is surely at an end. Not until 
the temperature has been normal for several days, the mind become clear, 
and the hyperesthesia and rigidity of the neck and extremities have 
entirely disappeared, can we consider convalescence as established. Ee- 
covery is slow, and it may be many months before the child is able to 
walk and talk as usual, and has regained its lost weight. 

In cases ending fatally, death may come early from coma, convul- 
sions, or heart failure. It may occur in the middle period from com- 
plications, most frequently pneumonia, or the terminal stage of the 
disease may be seen with extreme wasting, continuous stupor, general 
relaxation, sunken abdomen, shallow, irregular respiration, feeble pulse, 
and finally death from exhaustion. 

Complications and Sequelae. — Most of the complications have already 
been mentioned. The chief ones are pneumonia, otitis, conjunctivitis or 
choroiditis, and bedsores. Earely, nephritis and arthritis are seen. 
Sequelae are, unfortunately, very common. There may be perfect recov- 
ery so far as physical functions are concerned, but the child be left men- 
tally deficient. This may be seen in all degrees. In some cases the 
defect is so slight as not to be evident for several months or even years ; 
in others the mental faculties are entirely lost. There may also be vari- 
ous types of paralysis — strabismus, facial paralysis, monoplegia, hemi- 
plegia or diplegia, and often contractures, which are sometimes tempo- 
rary, but apt to be permanent. The acute attack may be followed by 
chronic meningitis with hydrocephalus. Of the special senses, hearing 
is most frequently affected, deafness being quite common, usually of 
both ears, and deaf -mutism is not an infrequent result in young children. 
Blindness is rare and is usually unilateral. As a late result epilepsy 
may develop. 

Prognosis. — The mortality of cerebro-spinal meningitis varies much 
in different epidemics and in the same epidemic at different periods. It 
is usually greatest at the height, and lowest toward the end of the epi- 
demic. The average is about 70 per cent. Of fifty consecutive cases 



764 DISEASES OP THE NERVOUS SYSTEM. 

treated in my hospital wards in one epidemic, the mortality was 86 per 
cent. All these patients were infants or very young children. Of twenty 
cases under one year, not one recovered. Of cases seen in private prac- 
tice, chiefly in older children, the mortality was 50 per cent. In no 
disease is it more difficult to foretell the outcome than in this one when 
it affects older children. Some cases, apparently the most hopeless, 
recover, while others which do not appear to be especially severe ulti- 
mately prove fatal. One should never despair of a patient no matter 
how unpromising the outlook. The symptoms indicating a good prog- 
nosis are a clear mental state, absence of marked or continuous opis- 
thotonus, a good pulse, and a good digestion. The temperature is no 
guide. 

Diagnosis. — Lumbar puncture is by far the most important means 
of diagnosis we possess. By it we can not only differentiate meningitis 
from other diseases with nervous symptoms, but can determine the 
variety of meningitis. Furthermore, this is possible very early in the 
disease. With suitable precautions I believe it to be absolutely free 
from danger, so that it may be employed whenever there is any question 
of meningitis. Properly performed, it gives conclusive information in 
nearly every case. The procedure is simple, but the technique is impor- 
tant.* The quantity of fluid which may be removed at one time varies 
from a few drops to three ounces, the average being two or three drachms. 
Its character varies with the stage of the disease. During the first day 
or two it is usually a turbid serum; later it is purulent, often thick and 
containing flocculi of fibrin. The gross pus gradually diminishes, and 
after the fourth or fifth week may nearly or quite disappear, but may 
reappear with an exacerbation of the symptoms. Many leucocytes may 
be found in the sediment for a much longer time. The fluid in other 



* Puncture may be made with an ordinary surgical exploring needle, but the spe- 
cial lumbar needle devised by Quincke is preferable. This is merely a fine trocar and 
cannula and is made somewhat stronger than an exploring needle, which sometimes 
breaks. The child is placed upon the right side with the thighs tightly flexed against 
the abdomen to separate the spines and laminae of the vertebrae as much as possible. 
The point chosen for puncture is in the median line between the third and fourth 
lumbar vertebrae. This is on a level with the highest part of the iliac crest. The 
skin should be carefully cleansed and the needle boiled. The pain is no greater than 
from exploratory punctures elsewhere, and no anaesthetic is necessary unless the child 
is extremely nervous or sensitive. The introduction is not difficult and the canal 
is reached at the depth of about one inch. The trocar is now withdrawn and the 
fluid usually flows freely through the cannula, sometimes spurting forth some dis- 
tance, owing to high pressure. A dry puncture may be due to the fact that the canal 
has not been entered ; but more frequently it is because the exudate is too thick to 
flow through the small needle, or the needle has been plugged by fibrin. Raising the 
patient to a sitting posture usually causes a freer flow, as does also flexing the head 
upon the chest if opisthotonus is extreme. 



CEREBRO-SPINAL MENINGITIS. 765 

diseases and in non-inflammatory brain conditions is a perfectly clear 
serum. The presence of many leucocytes always indicates meningitis, 
but the variety can be determined only by microscopical examination of 
the sediment after standing, or, better, after centrifuging. In cerebro- 
spinal meningitis there are found within the pus cells many diplococci; 
some are also free in the fluid. The number of organisms may be few 
or many, but their presence establishes the diagnosis, which is possible 
in no other way during life. Sometimes when not obtained in the smears 
the diplococci are found by culture. 

The diagnostic value of lumbar puncture, when properly performed, 
is very great; not only are positive findings conclusive, but a negative 
puncture in the first two weeks almost certainly excludes meningitis. 
Observations upon thirty-nine of my hospital cases gave the following 
findings : of twenty-one punctures during the first week, all gave positive 
results, i. e., fluid containing the organisms; of thirty-two made in the 
second or third week, twenty-eight gave positive results, and in four no 
fluid was obtained, though former punctures had given positive results. 
Fluid which did not show the organisms either in smears or culture was 
found only once during the first five weeks of the disease. In one case, 
very prolonged but not especially severe, the organisms were still present 
as late as the ninetieth day of the attack. 

The diagnosis of cerebro-spinal meningitis by symptoms alone pre- 
sents peculiar difficulties at the beginning of the attack, most of which 
disappear when the disease is fully developed. The most valuable early 
symptoms for diagnosis are, a sudden onset with intense headache, vom- 
iting, high temperature, prostration and a petechial eruption, early 
rigidity of the neck and extremities, great mental excitement, irritability 
or delirium. Later in the disease three symptoms are rarely wanting — 
persistent hyperesthesia, muscular rigidity of the neck and extremities, 
and fever. Kernig's sign is frequently seen in other conditions and is 
not diagnostic. These spinal symptoms are more to be relied upon for 
diagnosis than the cerebral symptoms, which are subject to greater varia- 
tion. The mind in some cases remains perfectly clear; in others there 
is delirium and excitement, but not often continuous, deep coma. One 
should not lay too much stress upon the presence or absence of any single 
symptom, but rather consider the whole clinical picture. 

At its beginning, cerebro-spinal meningitis may be confounded with 
scarlet fever, pneumonia, acute indigestion or influenza ; the first is dis- 
tinguished by the eruption and sore throat ; the second, by rapid respira- 
tion and physical signs; the third and fourth, by less intense nervous 
symptoms, and the course of the disease. From all these, cerebro-spinal 
meningitis is differentiated by lumbar puncture. It is often difficult to 
distinguish between cerebro-spinal and tuberculous meningitis. At cer- 
tain stages the symptoms of the two may be almost identical. 



166 



DISEASES OF THE NERVOUS SYSTEM. 



The most distinctive features are the following : 



CEREBROSPINAL MENINGITIS. 

1. Infrequent except when epidemic. 

2. Affects the robust quite as often as 
the delicate. 

3. Previous history not significant. 

4. Onset abrupt with definite symp- 
toms. 

5. Temperature usually high and wide- 
ly fluctuating ; 100° F. to 105° F. 

6. Pulse generally rapid until late ; 
respiration often is not disturbed. 



7. Petechial rash may be seen early. 

8. Fluid obtained by lumbar puncture 
always cloudy in early weeks ; microscope 
shows meningococcus. 

9. Great mental irritability ; irritative 
symptoms often present throughout the 
attack. 

10. Rigidity and hyperesthesia marked 
and continuous. 

11. Course prolonged; often lasts three 
to eight weeks ; progress irregular. 

12. Mortality about 70 per cent. 



TUBERCULOUS MENINGITIS. 

1. Occurs at all times and seasons. 

2. Much more frequent in the delicate 
and in those giving signs of other tuber- 
culous lesions in bones, joints, lungs, etc. 

3. Often a history of exposure to tu- 
berculous infection. 

4. Gradual with indefinite prodromal 
symptoms. 

5. Generally low, 99°. to 101° F., unless 
complicated by tuberculosis elsewhere. 

6. Pulse frequently slow, irregular, and 
intermittent through greater part of the 
illness ; respiration usually disturbed ; in 
most cases of Cheyne-Stokes variety. 

7. None present. 

8. Never a cloudy fluid ; often no or- 
ganisms found. 

9. Only present early, followed by 
drowsiness merging into deep stupor. 

10. Seen in early stage only, never very 
marked ; relaxation after the onset. 

11. Seldom more than three weeks after 
beginning of definite cerebral symptoms ; 
progress then steadily from bad to worse. 

12. Practically always fatal. 



Treatment. — The treatment of cerebro-spinal meningitis is at present 
very unsatisfactory, and it is doubtful whether the results are greatly 
modified by any special plan of treatment; they seem to depend rather 
upon the age of the patient and the severity of the attack, than upon the 
management. The course of the disease is so irregular that physicians 
have often been inclined to attribute great benefit to particular plans of 
treatment, which larger experience proved to be valueless. Of the vari- 
ous specific measures proposed, the only one to be seriously considered is 
lumbar puncture. Eegarding its therapeutic value opinion is still much 
divided. From my own experience, I am inclined strongly to advocate 
its use as early as possible in the attack, especially in cases characterized 
by the rapid development of severe nervous symptoms. The withdrawal 
of one or two ounces of fluid at this time may not only relieve coma, but 
very greatly improve the pulse and respiration. I think it should be 
tried in every case. Too often, to be sure, the relief is only temporary, 
but I am convinced that some cases are saved by early lumbar puncture. 
Of its value later in the disease, one must speak more guardedly. At 



SIMPLE ACUTE MENINGITIS. ?67 

times lumbar puncture seems to be distinctly beneficial to the pulse, 
respiration, and nervous symptoms; at others it is without any effect. 
It surely does no harm and deserves further trial. An ice-cap should be 
applied to the head, and at times an ice-bag along the spine. The bowels 
should be kept freely open by calomel or saline cathartics. 

Treatment otherwise is directed toward the symptoms of the disease. 
Drugs for the purpose of affecting the inflammatory process I believe to 
be absolutely useless. Of the symptoms which call for special treatment, 
the most prominent one is pain, which when severe requires morphine 
or codeine sometimes in quite large doses. It is often necessary to give 
it hypodermically. For other nervous symptoms— delirium, sleepless- 
ness, etc. — the bromides and chloral, sulfonal, or trional may be given, 
or warm sponge or tub baths. Stimulants are required in most of the 
cases at some time in the course of the disease. They are indicated by a 
weak, rapid, and irregular pulse. Alcohol and digitalis or strophanthus 
should be used, but not strychnine. 

One of the most important duties of the physician is to look after 
the nutrition of the patient. The difficulties in feeding are sometimes 
great, but they can often be overcome by the use of gavage (page 64), 
which may be advantageously employed as a routine practice in a very 
large number of the severe cases. One should be on the watch for bed- 
sores, and endeavor to prevent them by cleanliness, frequently changing 
the patient's position, etc. The bladder also must not be forgotten, as 
retention of urine is not uncommon and may require the use of the 
catheter. 

For the residual paralysis, massage, warm baths, and friction should 
be employed, but electricity only when all symptoms of central irritation 
have subsided. The prolonged use of iodide of potassium, especially in 
combination with mercury, seems to have some influence in promoting 
absorption of the inflammatory products in cases where there is a persist- 
ence of symptoms for two or three months. 



SIMPLE ACUTE MENINGITIS. 

This term may be used to include all the varieties of acute meningitis 
due to other causes than the diplococcus intracellularis and the tubercle 
bacillus. Although the cases in this group may differ widely in etiology, 
they are closely related clinically, and may therefore be advantageously 
considered together. 

Etiology. — A larger number of cases are probably due to the pneumo- 
coccus than to any other single organism. From this cause we may have 
not only secondary meningitis following pneumonia, empyema, and other 
forms of pneumococcus infection, but also primary meningitis. A con- 
siderable number of this variety sometimes occur in a single season, and 



768 DISEASES OF THE NERVOUS SYSTEM. 

to them the term " epidemic " has been improperly applied. It is from 
such data that some writers have drawn the conclusion that epidemic 
meningitis may be due to this organism as well as to the diplococcus 
intracellularis. Such a group of cases is very different from a general 
epidemic of cerebro-spinal meningitis. It therefore seems best, with our 
present knowledge, to limit the term epidemic meningitis to the disease 
caused by the diplococcus intracellularis. 

When meningitis is due to other causes than the pneumococcus, it is 
nearly always a secondary disease. It may be caused by the streptococcus, 
staphylococcus, gonococcus, influenza bacillus, typhoid bacillus, or the 
colon bacillus. 

Meningitis from the streptococcus is seen in the newly born following 
umbilical infection, and in older children associated with otitis media or 
mastoiditis. It also occurs from traumatism, from general pyaemia, and 
with erysipelas of the scalp. Under many of the same conditions the 
staphylococcus may be the bacterial cause of meningitis. I have once 
seen meningitis in the newly born from the colon bacillus, originating 
probably after an umbilical infection. The pus from lumbar puncture 
during life contained this organism in pure culture. Meningitis due to 
the gonococcus, to the bacillus of typhoid fever, or of influenza, is very 
rare in children. 

Lesions. — In a general way the anatomical changes resemble those 
described in cerebro-spinal meningitis, with the exception that the marked 
changes in the brain substance which are usually dependent upon the 
long course of that disease are wanting. As a rule, also, in simple acute 
meningitis the lesions are limited to the meninges of the brain. If the 
cord is involved, it is only to a slight degree. Almost the only cases in 
which cord involvement is seen are those in which the exciting cause 
is the pneumo coccus. 

Acute simple meningitis due to the pneumococcus is characterized by 
a more abundant exudation of fibrin and pus than is seen in any other 
variety of meningitis. It affects the convexity as well as the base, and 
is especially marked over the anterior lobes. Often the exudate almost 
conceals the convolutions. (See Plate XIV.) There is usually less dis- 
tention of the ventricles than in cerebro-spinal meningitis. When due to 
other causes than the pneumococcus, the lesions are not distinctive, and 
do not differ greatly from the cerebral lesions of cerebro-spinal meningitis. 

Symptoms. — The primary cases are nearly always of the pneumo- 
coccus variety. As in these the membranes of the cord are sometimes 
involved, the symptoms may be almost or quite identical with those of 
cerebro-spinal meningitis, the only possible method of differentiation 
being by lumbar puncture. The course, however, is usually shorter and 
the termination almost invariably in death. 

Acute secondary meningitis presents quite a different clinical picture, 



PLATE XIV. 




Acute Meningitis, complicating Pleuro-Pneumonia. 

Child twenty months old ; on twenty-third day of a protracted attack of pneumonia, 
vomited six times, and the temperature, which had been nearly normal for four days, 
rose to 103° F. On the following day general convulsions, which were repeated fre- 
quently during the next few days; temperature, 101° to 104° F. ; death in convulsions 
on twenty-eighth day. 

Autopsy. — Pleuro-pneumonia of left side; lung resolving. Anterior portion of 
brain enveloped in lymph and pus, more marked at the convexity, but present also 
over the base. 



SIMPLE ACUTE MENINGITIS. 769 

and th^ symptoms are greatly modified by those of the original disease. 
Meningitis is often latent, and the lesions may be found at autopsy 
where no very marked cerebral symptoms have existed during life. This 
is particularly true when the pathological process is chiefly at the con- 
vexity. 

The symptoms of acute secondary meningitis are essentially the same 
no matter what the bacterial cause. The involvement of the brain may 
be indicated by the abrupt occurrence of vomiting or convulsions, rapidly 
followed by stupor and coma, or there may be simply headache and a 
gradual increasing apathy or drowsiness. The later symptoms resemble 
the later stage of cerebro-spinal meningitis, except that the spinal symp- 
toms — general hyperesthesia, rigidity, and contractions — are wanting, 
while the cerebral symptoms may be more prominent. The most signifi- 
cant are the following : continuous deep stupor ; dilated or unequal pupils 
which do not respond to light ; strabismus, ptosis, or some other localised 
paralysis; in infants, a tense, bulging fontanel; a slow, irregular, or 
intermittent pulse, especially when associated with high temperature; 
irregular, shallow, sighing respiration, interrupted by long pauses; gen- 
eral relaxation or paralysis, and constipation. Often present, but of less 
diagnostic value, are opisthotonus, retracted abdomen, the tdche cere- 
lrale J marked irritability, increased knee jerks, sharp cries, delirium, and 
convulsions. 

As compared with the cerebro-spinal form, simple acute meningitis 
runs a much shorter course, rarely lasting a week. Its progress is steadily 
from bad to worse, periods of remission in the symptoms being infre- 
quent. It almost invariably terminates fatally. 

Diagnosis. — The toxic symptoms of many acute diseases, notably 
pneumonia, typhoid and scarlet fever, gastro-enteric intoxication, and 
ileo-colitis, may very closely simulate acute meningitis. Almost every 
single symptom of meningitis may be present, even though the brain is 
not involved ; but rarely, if ever, is such a combination of symptoms seen 
as is present in meningitis. Without such a grouping of symptoms one 
should hesitate to make a diagnosis of meningitis when another acute 
disease is present, especially if that one be any form of diarrhceal disease. 
The mistake is more frequently made of diagnosticating meningitis where 
there is none than of overlooking it when present. Our only certain 
means of differential diagnosis is by lumbar puncture. This not only 
distinguishes meningitis from other diseases with nervous symptoms, but 
determines the form of meningitis. In most of the varieties a turbid 
fluid is present, which shows by smears the particular organisms causing 
the disease. 

Treatment. — This is symptomatic purely, and should be carried out 
along the same lines as have been already laid down under cerebro-spinal 
meningitis. 



770 DISEASES OP THE NERVOUS SYSTEM. 

TUBERCULOUS MENINGITIS. 
Synonyms : Acute hydrocephalus ; basilar meningitis ; water on the brain. 

Tuberculous meningitis is a tuberculous inflammation of the pia 
mater of the brain, sometimes involving also that of the cord. It is 
doubtful if it ever occurs as the only tuberculous lesion of the body. It 
is quite frequently seen, and is more uniformly fatal than any other 
disease of early life. In infancy it is usually associated with general or 
pulmonary tuberculosis ; in older children with tuberculosis of the bones, 
joints, or lymph nodes. Of my own cases, twenty-five per cent of all 
deaths from tuberculosis in children were due to meningitis. 

Lesions. — The lesion consists in the production of miliary tubercles, 
with which are frequently found tuberculous nodules of variable size, and 
in almost every case there are also the products of ordinary inflammation 
of the pia mater — fibrin and pus — together with an accumulation of 
fluid in the lateral ventricles of the brain. Frequently there are tubercles 
in the pia mater of the upper portion of the cord. The miliary tuber- 
cles appear as small gray or white granules, situated along the vessels 
of the pia mater. When few in number they are usually only at the base, 
especially along the Sylvian fissures and in the interpeduncular space. 
When numerous they are most abundant at the base, but are also seen 
scattered over the convexity in small groups. In about half of my autop- 
sies they were limited to the base, and in no case were they seen 
exclusively at the convexity. Tubercles are often found in the choroid 
coat of the eye. The amount of fibrin and pus present is rarely great, 
and never equal to that seen in simple acute meningitis. It is often a 
matter of surprise at autopsy to find the lesions so few, after very marked 
symptoms. The inflammatory products are most abundant at the base. 
In addition to the patches of greenish-yellow fibrin, there are adhesions 
between the lobes of the brain and thickening of the pia. In cases which 
have lasted for several weeks, the pia mater in places is often very much 
thickened, owing to cell infiltration and the production of new connective 
tissue, and it is studded with miliary tubercles, sometimes with small 
yellow tuberculous nodules; frequently there is arteritis, which is some- 
times obliterating. 

In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The lateral ventricles are usually dis- 
tended with clear serum, sometimes with serum containing flocculi of 
fibrin or pus ; the amount present varies from one to four ounces in each 
ventricle, being always greater in the subacute cases. The walls of the 
ventricles may be softened. The distention of the ventricles leads to 
flattening of the convolutions from pressure against the skull, to bulging 



TUBERCULOUS MENINGITIS. 



771 



of the fontanel, and sometimes to separation of the sutures, if they are 
not completely ossified. 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not so 
often in infants. These nodules may be connected with the meninges, 
or they may be situated within the brain substance, usually in the cere- 
bellum. The larger ones are classed as brain tumours. Inflammatory 
products are rarely found in the spinal canal. 

Although it is not infrequent to see meningitis without symptoms of 
tuberculosis elsewhere, I have never failed at autopsy to find other tuber- 
culous lesions in the body. In my own experience the following are those 
most often met with, given in the order of frequency : 

(1) In infants, associated with general or pulmonary tuberculosis; 
(2) in children from three to twelve years of age, with tuberculosis of 
the vertebrae, hip, knee, or ankle; (3) at any age, with tuberculosis in- 
volving only the tracheal, bronchial, or mesenteric lymph nodes ; (4) much 
less frequently with the pulmonary tuberculosis of older children. There 
seems now to be good reasons for believing that meningitis may follow 
tuberculous adenoids. 

Etiology. — Tuberculous meningitis is produced only by the transpor- 
tation of the tubercle bacilli to the brain. They may find their way by 
the blood-vessels or lymphatics. 

The following table shows the age at which the disease is most fre- 
quently observed : 



Age. 


Personal cases. 


Oxley. 


Total. 


Under one year 


14 
9 

24 

15 

5 


3 
16 
26 

18 



17 


One to two years 


25 


Two to five years 


50 


Five to nine years 


33 


Nine to sixteen years 


5 






Totals 


67 


63 


130 










In this series males were a little more frequently affected than females. 
In two or three instances traumatism was apparently an exciting cause. 
Tuberculous meningitis is occasionally seen in young children who have 
been previously healthy, whose family history is free from tuberculosis, 
and where no exposure can be traced. It is probable that in all such 
cases there has been latent tuberculosis somewhere in the body, and that 
the exposure was long antecedent to the symptoms. In the majority, 
however, this is not the case. There is usually a history of exposure to 
infection; or there have been previous evidences of tuberculosis in the 
lungs, bones, or lymph nodes. 

Symptoms. — In forty-three of sixty-three cases the onset was gradual; 

but in a considerable number of those classed as sudden, careful inquiry 
50 



772 



DISEASES OF THE NERVOUS SYSTEM. 



elicited a history of previous indisposition. The most frequent early 
symptoms are: disinclination to play, or drowsiness, sometimes constant 
fretf ulness or irritability. Often there is a distinct change in disposi- 
tion. In a case recently under observation this was most striking; a 
little girl previously devoted to her mother, could not endure her pres- 
ence in the room. There is loss of appetite, and usually constipation 
Sleep is restless and disturbed ; there may be grinding of the teeth. Older 
children often complain of headache. At all ages a suggestive symptom 
is frequent attacks of vomiting without apparent cause. In addition to 
these there may be a slight but continuous elevation of temperature. In- 
definite symptoms may last for four or five days, or they may be spread 
over two or three weeks without perhaps being sufficiently severe to attract 
much notice. Finally, unmistakable evidence of brain disease develops, 
and then it is recollected that symptoms like the above had existed for 
some time. These early disturbances are often ascribed to dentition, to 
worms, or to indigestion ; and sometimes they are regarded simply as the 
result of the constipation. 

In the midst of such indefinite symptoms there may come an attack 
of convulsions, and, in the course of a few hours, deep stupor. The early 
symptoms of the active stage are indicative of cerebral irritation. There 
is headache, often located in the frontal region, and occasionally photo- 
phobia ; sometimes there is sudden screaming out at night without waking. 
The skin is usually somewhat hypersesthetic ; the reflexes are apt to be 
exaggerated ; the muscles of the neck may be rigid and the head is drawn 
back, or there may be rigidity of one or more of the extremities. The 
pupils are normal or contracted ; there may be nystagmus. The child is 
fretful, wishes to be left alone, and cries if disturbed ; but otherwise is apt 
to be unnaturally drowsy. Such symptoms may continue for a day or 
two, or even for a week. If prolonged, they are likely to alternate with 
periods of more marked apathy and dulness. During this stage there is 
occasional vomiting, and the bowels are obstinately constipated. The 
pulse is usually somewhat accelerated, but may be slow and occasionally 
is irregular. The respiration is of normal frequency, but a careful ob- 
servation during sleep or perfect quiet will often show a slight irregu- 
larity which is very significant. This becomes more marked as the disease 
progresses. The temperature is invariably elevated, but never very much 
so, generally being from 99° F. to 101° F. When a high temperature is 
seen, it is usually due to tuberculosis elsewhere than in the brain. 

During the intermediate or second stage, the irritative symptoms sub- 
side, and stupor becomes deeper and more continuous. If undisturbed, 
the child may sleep a great part of the time, but can be roused, and then 
appears quite rational. Later the stupor becomes so profound that the 
child can not be roused at all; or, again, this condition may alternate 
with periods of complete lucidity. Active delirium is rare. The pupils 



TUBERCULOUS MENINGITIS. 



773 



respond slowly to light or not at all; they may be unequal; occasionally 
there is seen strabismus, ptosis, or paralysis of the face. More often there 
is hemiplegia, or paralysis of one arm or leg. Such paralyses are often 
transient, disappearing after a day or two. Automatic movements of the 
extremities, particularly of the arms, are frequent. Muscular twitchings 
may be noticed. Opisthotonus is marked and well-nigh constant. In 
infants the fontanel is tense and bulging ; the abdomen is retracted, giving 
the typical " boat-belly. v On drawing the finger-nail along the skin of 
the abdomen, there appears, after a few seconds, a distinct red streak one 
or two inches wide, which remains for three or four minutes. This is the 
taclie c'erebrdle, and while not pathognomonic, it is almost always present. 
Other vaso-motor disturbances may be seen. The reflexes are variable; 
in the early part of the disease 

thev are usually increased, later * f\ n(\ J\ 

they are diminished or abolished. —^^ V ^^^ U--_W\AA L 

The pulse now becomes slow and FlG - 132.-Tracing of respiration in tuberculous 

1 meningitis. 

irregular, often intermittent. 

The respiration assumes the characteristic type, which consists in the 
movements becoming deeper and deeper until there is a long sigh, then a 
complete arrest of respiration for several seconds, after which the move- 
ments begin again, at first shallow, but gradually increasing in depth 
until the sigh is repeated. The accompanying tracing illustrates the 
type (Fig. 132). An examination with the ophthalmoscope usually 
shows the presence of choked discs and possibly choroid tubercles. 



DAY 




1 


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4 


5 


6 


7 


8 


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DATE 


OCT. 


10 


11 


12 


13 


14 


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16 


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18 


19 


20 


21 


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24 


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M.E. 


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Fig. 133. — Fairly typical temperature curve in tuberculous meningitis; boy, twenty months 
old ; death on seventeenth day. 

The duration of this stage is from three to ten days. The progress 
is irregular, and subject to great variations, especially as regards the 
mental symptoms. Sometimes a child will be seen in quite deep stupor. 
and on the following day will be sitting up in bed playing with his toys. 

In the third stage there is complete coma. The child can not be 



774 DISEASES OF THE NERVOUS SYSTEM. 

roused at all. The pupils are widely dilated, and do not respond to light. 
There is general muscular relaxation. There may be retention of the 
urine. Deglutition is difficult, sometimes almost impossible. The boat- 
belly and opisthotonus are still marked. The respiration is more rapid, 
but still irregular. There are sordes on the lips and teeth, emaciation, 
and anaemia. Toward the end the temperature rises rapidly to 104° F., 
sometimes to 106° or 107° F. (Fig. 133). The pulse becomes very rapid 
and feeble, often 160 to 180 a minute. Death usually takes place from 
exhaustion in deep coma; or convulsions develop and continue from 
twelve to twenty-four hours until death. The duration of the stage of 
coma is from two days to a week. Often the patient will live for four 
or five days in a condition of prostration so- extreme that death is hourly 
expected. A rapidly rising temperature or the occurrence of convulsions 
indicates approaching death. Of fifty-seven cases, fifty died in coma, 
seven in convulsions. 

The entire duration of the disease from the beginning of definite 
symptoms, in sixty-five of my own cases, was as follows : 

One week, or less 17 

One to two weeks 15 

Two to three weeks 17 

Three to four weeks 14 

Five weeks 2 

65 

Variations in the course of the disease. — There are few diseases which 
present a greater variety of symptoms than tuberculous meningitis. Typ- 
ical cases like those above described are seen most frequently in children 
over two years old, in whom the cerebral symptoms predominate over 
those of general tuberculosis. In infancy, especially when the disease 
follows acute tuberculous pneumonia, the duration of the cerebral symp- 
toms may be only three or four days. The stages then are not marked. 
The onset is usually with convulsions, and in less than twenty-four hour8 
there may be marked stupor, and all the symptoms belonging to the third 
stage of the disease. 

In older children the symptoms are from pressure due to the great 
accumulation of fluid in the lateral ventricles. There is persistent drow- 
siness, but rarely deep coma, sometimes rigidity of all the extremities, 
and sometimes paralysis. Opisthotonus is nearly always marked in these 
cases. 

Diagnosis. — There are no diagnostic symptoms in the first stage. If 
the patient has previously suffered from local or general tuberculosis, and 
symptoms develop which are enumerated as prodromal, meningitis may 
be suspected. If the child has previously given no evidence of tubercu- 
losis, an early diagnosis is impossible. The indefinite symptoms that 
belong to this stage of the disease are frequent in young children suffer- 






CHRONIC BASILAR MENINGITIS IN INFANTS. 775 

ing from chronic indigestion associated with constipation. Such is the 
usual explanation of the indisposition rather than incipient meningitis. 
Some cases of cyclic vomiting may present many of the symptoms of 
meningitis. 

The most frequent symptoms of tuberculous meningitis enumerated 
in the order of their occurrence in fifty-eight cases were as follows: 
obstinate constipation, persistent drowsiness, irregular respiration, vomit- 
ing without apparent cause, irregular pulse, convulsions, opisthotonus, 
and fever which was usually slight. Equally important for diagnosis, 
and especially significant when associated with the above, are strabismus, 
facial paralysis, and loss of the pupillary reflexes. 

The fluid drawn by lumbar puncture is usually perfectly clear. In 
some cases, after standing, a very few leucocytes may be found in the 
deposit. Tubercle bacilli can be demonstrated in but a small proportion 
of the cases, even after centrifuging. A few bacilli are, however, present, 
as may be shown by inoculation of a guinea-pig. This affords a positive, 
though late, means of diagnosis. The symptoms which distinguish tuber- 
culous from cerebro-spinal meningitis have already been considered in 
the discussion of the latter disease. 

The cerebral symptoms of ileo-colitis and other diarrhceal diseases 
sometimes closely resemble those of tuberculous meningitis; but when- 
ever in a young child there is some other disease present which may 
furnish an explanation for the cerebral symptoms, the diagnosis of men- 
ingitis should be made with great caution. The development of menin- 
gitis in the course of an ordinary attack of pneumonia may simulate very 
closely pulmonary tuberculosis with tuberculous meningitis. A diagnosis 
may be impossible during life. In doubtful cases the probabilities are 
greatly in favour of tuberculosis, since it is so much more common. 

Prognosis. — Although there have been recorded a few isolated in- 
stances of recovery after the tubercle bacilli have been found in the fluid 
obtained by lumbar puncture, such an outcome is so exceedingly rare 
as not to be expected. I have never seen it. Cerebro-spinal meningitis 
may at times very closely simulate the tuberculous variety, and it is 
probable that most of the cases of alleged recovery were not tuberculous. 

Treatment. — From what has been said regarding prognosis, it follows 
that if the diagnosis is correct the case is practically hopeless, no matter 
what treatment is employed; but as a positive diagnosis is not always 
possible, all cases should be treated like those of simple acute meningitis. 

CHRONIC BASILAR MENINGITIS IN INFANTS. 

It was first pointed out in 1898 by Still (London) that this disease 
is usually due to the diplococcus intraccllularis; in other words, that it is 
a chronic form of cerebro-spinal meningitis. Chronic basilar meningitis 
is most frequently seen after epidemics of cerebro-spinal meningitis, but 



776 



DISEASES OF THE NERVOUS SYSTEM. 



it is occasionally met with at other times as a sequel of a sporadic case. 
It occurs after an acute attack, when the basilar lesion persists and 
becomes chronic. As acute cerebro-spinal meningitis in infants is in- 
variably fatal if the attack is severe, it follows that the chronic form 
is seen only after the mild attacks. It is chiefly for this reason that 
the early symptoms often are not recognized as types of cerebro-spinal 
meningitis. The patient frequently does not come under observation 
until all acute symptoms have passed away, the persistent opisthotonus 
being the chief feature of the case. 

There is also seen in children, though very rarely, a chronic basilar 
meningitis of syphilitic origin. At least two such cases have come under 
my observation in the Babies' Hospital. One was cured by anti-syphilitic 
treatment, and the other diagnosis was confirmed by autopsy. 

Lesions. — This process is usually limited to the base of the brain. 
The pia mater is thickened about the interpeduncular space, also over the 
medulla, pons, and cerebellum. These different parts may be adherent to 
each other, or to the inner surface of the dura. The cranial nerves may 
be compressed. The openings in the fourth ventricle are usually obliter- 




l_ 

Fig. 134. — Chronic basilar meningitis — extreme deformity. 

Ill for five months ; followed cerebro-spinal meningitis ; posture shown in the picture 
maintained for the last six weeks ; death at ten months. Autopsy showed typical lesions. 

ated, and there results a distention of the lateral ventricles with clear 
serum, sometimes in sufficient amount to be regarded as hydrocephalus. 
Rarely, pus may be found in the ventricles. 

Symptoms. — The onset is usually gradual, although in most cases 
there can be obtained a fairly distinct history of an early active period. 
The most prominent symptoms are cervical opisthotonus, moderate hydro- 
cephalus, and usually general muscular rigidity. The opisthotonus is 
often extreme (Fig. 134) and is greater than is seen in any other disease. 



CHRONIC BASILAR MENINGITIS IN INFANTS. 



777 



If placed upon its back the body of the child often touches the table only 
at the occiput and the sacrum (Fig. 135). The head is usually some- 
what enlarged, but never to the degree seen in primary hydrocephalus; 
the fontanel bulges, and the sutures are separated. These symptoms 
are due to an accumulation of fluid in the lateral ventricles; they are 
never so marked as in primary hydrocephalus. The rigidity of the ex- 
tremities is very great and in most cases constant; the legs and feet 
are usually extended, while the forearms are flexed and the hands 




Fig. 135. — Chronic basilar meningitis; a patient in the Babies' Hospital (diagnosis 
confirmed by autopsy). 



clenched. All the reflexes are greatly exaggerated. There is rarely coma, 
but mental dulness alternating with periods of great irritability in which 
general convulsions may occur. Vision may be impaired or wanting en- 
tirely. The fact that in most cases optic neuritis is absent is of some 
value in differentiating this disease from tumour. Nystagmus is often 
present and attacks of vomiting occur without evident cause. There is 
no fever except for a few days at a time during acute exacerbations. The 
usual duration of the disease is from two to five months ; death may occur 
from convulsions, from some intercurrent disease, such as pneumonia, 
but most frequently from marasmus. The prognosis is very bad except 
when the cause is syphilis, when recovery may take place. 

Diagnosis. — The disease is to be distinguished from tuberculous men- 
ingitis, and from the opisthotonus of reflex origin which is occasionally 
seen in infants suffering from marasmus. It differs from tuberculous 
meningitis in its more protracted course, in the absence of fever, paraly- 
sis, and also in the greater prominence of the opisthotonos and hydro- 



778 DISEASES OF THE NERVOUS SYSTEM. 

cephalus. The opisthotonus which is seen in cases of marasmus is never 
so extreme or so continuous, and is not accompanied by any enlargement 
of the head, or by other cerebral symptoms. 

Treatment. — If there is any reason to suspect syphilis, iodide of po- 
tassium should be administered. At least fifteen grains daily should be 
given for several weeks to an infant six months old, and still larger doses 
if the stomach will tolerate it. Lumbar puncture is useful for diagnosis 
only. The establishment of auto-drainage of the ventricles, as practiced 
in primary hydrocephalus, has recently been advocated for this condition, 
and tried with some measure of success. 

THROMBOSIS OF THE SINUSES OF THE DURA MATER. 

This is not very frequent. It may depend upon certain general condi- 
tions, when it is usually classed as cachectic or marantic thrombosis ; it 
may be associated with local pathological processes, when it is known as 
inflammatory or septic thrombosis. 

Cachectic Thrombosis. — This is seen in infants and young children, 
but is very rare after the age of five years. It occurs in the course of 
various diseases, the most frequent being pneumonia, pertussis, diphtheria, 
nephritis, tuberculosis, and the acute intestinal diseases. In connection 
with the last-mentioned group, altogether too much has been made of it, 
as it is really rare, and in only a very few cases does it explain the cerebral 
symptoms present. This statement is made from personal observations 
upon over two hundred autopsies upon cases of acute intestinal disease. 
The actual cause of the thrombosis is the altered condition of the blood 
and the feeble circulation, as the walls of the sinuses are normal. 

The most frequent seat of cachectic thrombosis is the superior longi- 
tudinal sinus. At autopsy one must be careful not to confound the soft, 
partly-decolorized, non-adherent thrombi of post-mortem origin, with those 
of ante-mortem formation. The latter are firm, and when of long stand- 
ing may be very hard and even show a laminated structure. They usually 
fill the sinus completely, and are adherent. The thrombus extends from 
the sinuses to the veins emptying into it, which stand out like dark worms 
upon the surface of the brain. The brain itself may be deeply congested, 
or it may be covered with a diffuse haemorrhage, but more frequently the 
brain and the membranes are simply cedematous. 

The symptoms of cachectic thrombosis are few and uncertain, and 
in a large number of cases the disease is latent. Very rarely is a posi- 
tive diagnosis possible during life. When the thrombosis occurs just 
before death, its symptoms are so mingled with those of the original 
disease that they can not be separated. In some cases there may be 
localized or general convulsions, or paralysis, loss of consciousness, and 
strabismus. 

The prognosis is bad, cases generally proving fatal in the course of a 
few days. The diagnosis is so uncertain and obscure that the treatment 



THROMBOSIS OF THE SINUSES OF THE DURA MATER. 779 

must be symptomatic, and directed toward the general rather than the 
local condition. 

Inflammatory Thrombosis — Septic Thrombosis — Sinus-Phlebitis. — This 
condition is most frequent in children in connection with acute meningitis. 
It may exist either with the simple or the tuberculous variety. It also fol- 
lows otitis — especially old and neglected cases — usually with necrosis of the 
petrous bone, but sometimes without it. It is much less frequently asso- 
ciated with disease of the ear in children than in adults. It may arise 
from traumatism, necrosis of the cranial bones, or from septic processes 
involving any of the cavities or any of the structures adjacent to the brain, 
such as the scalp, orbit, nasal fossa, mouth, or pharynx. Infection from 
the mouth or pharynx is most frequent in children in connection with 
scarlet fever or diphtheria ; while usually secondary to otitis it may occur 
without it, the infection being carried by the blood-vessels. Infection 
from the nose may have its origin in ulceration from syphilis or tubercu- 
losis. In the orbit, the source may be malignant disease. 

The seat of the thrombosis will depend upon the original disease. If 
this affects the cranial bones or the scalp, it will be the longitudinal sinus ; 
if the ear, the lateral sinus ; if the base of the skull, the orbit, the mouth, 
the jaw, or the nose is affected, it will be the cavernous sinus. When 
thrombosis occurs with meningitis the lesions are much the same as in 
the cachectic form, with the exception that there are sometimes slight 
changes in the walls of the sinuses. If the patient has suffered from a 
local septic process, there may be puriform softening of the clot, and gen- 
eral pyaemia, with the development of secondary abscesses in the brain, 
in the lungs, and in other organs. With such cases there may be asso- 
ciated a general or localized meningitis. 

Symptoms. — The symptoms of septic thrombosis are more decided than 
those of the cachectic form. When occurring in the course of meningitis, 
it usually adds no new symptoms to those of the original disease. In the 
pyaemic form the symptoms are more characteristic, particularly when 
associated with otitis. There are recurring chills with very high and 
widely-fluctuating temperature. There is headache, and often localized 
tenderness of the scalp ; the other symptoms which are present are usually 
the same as those of meningitis. If metastasis occurs, there may be evi- 
dences of abscesses of the brain or in other organs, and sometimes there 
are signs of suppuration in the jugular vein. 

The local symptoms of the thrombosis differ somewhat according to 
the sinus affected : if its seat is the superior longitudinal sinus, there may 
be cyanosis of the face, dilatation of the temporal and frontal veins, and 
sometimes epistaxis ; if the lateral sinus is involved, the process may ex- 
tend to the jugular vein, which may be felt in the neck as a hard cord, 
and there may be dilatation of the veins of the mastoid region, and even 
localized oedema ; when the cavernous sinus is affected, there may be pro- 



780 DISEASES OF THE NERVOUS SYSTEM. 

trusion of the eyeball of the affected side, oedema of the lid, and with the 
ophthalmoscope the retinal veins appear enlarged and tortuous, sometimes 
being the seat of thrombosis. The process may affect either one or both 
sides. The course of septic thrombosis is rather irregular, varying from a 
few days to three weeks. In fatal cases death takes place from menin- 
gitis, cerebral abscess, or pyaemia. The prognosis is very grave, unless the 
disease is so situated that it is accessible to surgical operation. 

Treatment. — The only successful treatment is surgical. Operation 
is easiest in thrombosis of the lateral sinus, being much more difficult 
if involving the superior longitudinal sinus. So many cases are now on 
record of successful operation upon septic thrombosis of the lateral sinus, 
that it should always be urged when the diagnosis is clear. Eecurring 
chills and high, fluctuating temperature, associated with disease of the ear, 
either with or without symptoms of meningitis, are sufficiently character- 
istic to justify operative interference. 

CEREBRAL ABSCESS. 

Cerebral abscess is quite rare in children, decidedly more so than is 
cerebral tumour. In Gowers' collection of 223 cases, only 24 were under 
ten years of age. In infants, abscess is one of the least frequent diseases 
of the brain, and up to five years it is exceedingly rare. 

Etiology. — By far the most frequent cause in children is otitis. This 
is the origin of the great majority of the cases. Abscess rarely compli- 
cates acute otitis, but is seen with the chronic form. Exactly how otitis 
causes cerebral abscess it is not always easy to determine. Toynbee was 
the first to call attention to the fact that cerebellar abscess was most 
frequent with disease of the mastoid cells, and cerebral abscess with otitis 
media. Usually there is caries of the petrous bone, but there may be 
none. The infection may extend through the small veins traversing this 
bone, or along the lateral sinuses to the cerebellum. Abscess is often 
attributed to the retention of pus in the ear, but it may occur when the 
discharge is free. 

Traumatism is the second important etiological factor. Abscess may 
be associated with fracture of the skull, or follow simple concussion. The 
abscess is generally in the neighbourhood of the injury, but occasionally 
is produced by contre coup. In one instance, reported by Wagner, thrush 
was believed to be the cause of cerebral abscess, the same fungus that 
existed in the mouth being found in the brain, which in this case was 
studded with small abscesses. Abscess may be the result of infectious 
emboli, associated with general pyaemia, though this is rare in early life ; 
and finally it may occur without any assignable cause. 

Lesions. — The most frequent seat of the abscess is, first, the temporo- 
sphenoidal lobe ; secondly, the cerebellum ; thirdly, the frontal lobes. 
Other locations are very rare. Abscesses are usually single. In size they 



CEREBRAL ABSCESS. 781 

vary from that of a small cherry to an orange. One case was observed by 
Meyer, in which an abscess occupied one entire hemisphere. The con- 
tents are usually thick greenish-yellow pus, which may be very fetid. 
When abscesses have lasted for some time they are usually surrounded 
by dense pyogenic membrane, and may become encysted. The patho- 
logical process may be slow, and often is apparently stationary for a long 
period. Abscesses may rupture into the ventricles, less frequently upon 
the surface of the brain, causing meningitis, or the pus may even escape 
externally through the auditory meatus, as in Lallemand's case. 

Symptoms. — These are general and local. The general symptoms are 
much the more important for diagnosis, and often are the only ones present. 
The local symptoms are those of a tumour. The clinical history of a case 
of abscess of the brain may be divided into three stages : First, the period 
of onset, or early acute inflammatory symptoms, fever, etc., which attend 
the formation of pus. Secondly, the latent period, or period of remission, 
in which very few symptoms are present. In many acute cases this stage 
is wanting altogether ; in the chronic cases it may last for months, or even 
years. Thirdly, the final period, with recurrence of active cerebral symp- 
toms, followed by death in a few days. 

The onset may be accompanied by symptoms so slight as almost to 
escape notice. In most cases, however, headache and fever are present. 
The headache is usually severe, and often localized upon the affected side ; 
in cerebellar abscess it may be occipital. The fever is moderate in inten- 
sity, and continuous. In addition there may be vertigo, vomiting, gen- 
eral convulsions, and cessation of the aural discharge, if one has been 
present. The duration of this stage is variable ; it may be only a few 
days, or several weeks. It is shorter in traumatic cases, and in those which 
are due to pyaemia. 

The latent stage, or period of remission of symptoms may be quite 
short — only a few days' duration — and it is often absent. During this 
period the temperature may fall quite to the normal, and the headache 
disappear, or be only occasional and slight. However, if any focal symp- 
toms have been present they remain unchanged. 

The symptoms of the terminal stage are due to a rapid extension of 
the inflammatory process, with oedema and softening about the abscess, 
sometimes to rupture into the ventricle, and sometimes to meningitis. 
The fever now returns, and may be high. There is headache, often 
very intense and continuous; there may be delirium and convulsions, and 
the gradual development of coma. In addition there may be vomiting, 
paralysis, opisthotonus, retracted abdomen, and the other symptoms of 
meningitis. Occasionally all the earlier symptoms may be latent, and the 
terminal symptoms may be the only ones present. In infants, the fontanel 
is usually large and bulging ; convulsions are rather more frequent than 
in older children. 



782 DISEASES OF THE NERVOUS SYSTEM. 

The local symptoms of abscess are rather indefinite, owing to its usual 
situation. Abscesses of considerable size may exist in the temporo-sphe- 
noidal lobe, in the central part of the frontal lobe, or in the cerebellum, 
without any definite local symptoms. If the abscess is near the motor area, 
there are the usual symptoms of disease in this location, spasm, or paraly- 
sis of the face, arm, or leg. A cortical or sub-cortical abscess is likely to 
cause convulsions. Cerebellar abscess may give rise to occipital headache, 
frequent vomiting, and when the abscess is large enough to press upon 
the middle lobe, there may be inco-ordination of the muscles of the 
extremities. Optic neuritis may be present, but other symptoms relating 
to the cranial nerves are rare. Localized tenderness over the scalp, when 
persistent, is a symptom of importance, and may serve to locate the ab- 
scess, if it is superficial. 

Diagnosis. — Of the general symptoms, the most important for diagnosis 
are fever, headache, delirium, and terminal coma. These become particu- 
larly significant when following otitis or traumatism. The differential 
diagnosis of abscess is to be made principally from tumour and meningitis, 
and from these conditions more by the history and general course of the 
disease than by any special symptoms. The diagnosis of abscess from 
tumour is considered in connection with the latter disease. It is more 
difficult to distinguish between meningitis and abscess, since the two pro- 
cesses are often associated. With meningitis convulsions are more com- 
mon, but they are rarely localized ; rigidity and the inflammatory symp- 
toms are more intense ; the course is usually more rapid and more regular, 
being rarely interrupted, as is the course of abscess. From the cerebral 
symptoms occurring with otitis it is extremely difficult to distinguish 
abscess, for, according to Gowers, optic neuritis may be present in the 
former as well as in the latter condition. The more intense and pro- 
longed are the cerebral symptoms and the more marked the neuritis, the 
greater are the probabilities of abscess. 

Prognosis. — The prognosis in cerebral abscess is always grave, unless 
accessible to surgical operation. The progress may be slow, or rapid, but 
it is inevitably from bad to worse, and sooner or later the disease, if not 
interfered with, proves fatal. 

Treatment. — The medical treatment of abscess in its active stage is 
that of any acute intracranial inflammation, — ice to the head, absolute 
quiet, free catharsis, and full doses of the bromides or antipyrine or mor- 
phine, if pain is intense. The absolutely hopeless condition of these cases 
when left to themselves, and the recent brilliant results from surgical 
operations, should lead the physician to urge operation in every case.* 



* For a discussion of the surgical aspects of this question, see " Brain Surgery," by 
M. Allen Starr, M. D., and " Pyogenic Infectious Diseases of the Brain and Cord," by 
William McEwen, M. D. 



CEREBRAL TUMOUR. 783 

CEREBRAL TUMOUR. 

Very little has been added to our knowledge of cerebral tumour in 
children since the exhaustive monograph of Starr, which appeared in 
Keating's Cyclopaedia in 1890. It is to this article that I am indebted 
for most of the facts in this chapter. 

Varieties and Location. — Tumour of the brain is not very infrequent, 
and may be seen even in infancy. From this time up to puberty there is 
no period of special susceptibility. In two hundred and sixty-nine of the 
cases in Starr's collection, in which the nature of the tumour was stated, 
the following were the varieties : 

Tubercle 152 cases. 

Glioma 37 " 

Sarcoma 34 " 

Glio-sarcoma '. 5 " 

Cyst 30 " 

Carcinoma 10 " 

Gumma 1 " 

"269 " 

Tuberculous tumours are more often multiple than are other varieties. 
Their most frequent seat is the cerebellum ; next to this the pons and 
crura cerebri. They are rarely cortical or central. Glioma is most often 
found in the cerebellum or in the pons, and next in the cortex ; but it is 
rarely central. Sarcoma is most frequently in the cerebellum ; next to 
this, in the order of frequency, in the pons, the basal ganglia, and the cor- 
tex. Cystic tumours are either central or cerebellar. Taking the cases 
as a whole, the most frequent seat of tumour in children is, first the cere- 
bellum, second the pons, third the centrum ovale. 

Tuberculous tumours are occasionally seen in infancy, but they occur 
most frequently between the ages of five and twelve years. They are 
usually secondary to tuberculosis elsewhere, especially in the lungs and in 
the bronchial lymph nodes. They most frequently start from the mem- 
branes, rarely being centrally situated, and extend inward, infiltrating 
the superficial portion of the cerebellum or cerebrum. There is almost 
invariably localized meningitis at the site of the tumour; there maybe 
adhesions between the dura and pia mater, and the disease may extend to 
the cranial bones. In size, these tumours vary from a small pea to a 
child's fist. They may be softened and broken down at the centre, or 
cheesy throughout. They are the result of a localized tuberculous in- 
flammation, which does not differ essentially from that seen in other 
parts of the body. 

Glioma is not infrequent in infancy. It is probably connected in 
every case with the ependyma of the ventricle. It repeats the structure 
of the neuroglia, being composed of connective tissue and branching cells. 



784 DISEASES OF THE NERVOUS SYSTEM. 

Sarcoma may be of the spindle-celled or the mixed variety. It grows 
much more rapidly than glioma. The two varieties are not infrequently 
combined in the same tumour — glio-sarcoma. 

Cystic tumours are sometimes sarcomatous in origin, the wall of the 
cyst containing sarcoma cells, and they may also be parasitic, from the 
growth of the echinococcus. They may be found in any part of the brain. 

The other varieties of sarcoma, gumma and vascular tumours, are 
exceedingly rare until after puberty. 

As the tumour grows, secondary lesions are produced in most of the 
cases. These are the result of pressure upon arteries, causing localized 
anaemia, or even cerebral softening ; or upon veins, producing congestion 
and oedema. When affecting the middle lobe of the cerebellum, pressure 
upon the venae Galeni may lead to effusion into the ventricles. Localized 
meningitis over tumours superficially situated is the rule, and this may be 
the cause of some of the symptoms. Earely, cerebral haemorrhage may be 
associated. 

Etiology. — The causes of cerebral tumours are for the most part un- 
known. In a few instances there is a history of definite traumatism. 
Sarcoma or carcinoma may be secondary, and tuberculous tumours are 
probably always so. 

Symptoms. — These may be divided into two groups : first, the general 
symptoms which are common to tumours of all varieties, and are inde- 
pendent of location ; secondly, the local symptoms depending upon the 
situation of the growth. 

General symptoms. — One of the most frequent is headache. Though 
it varies much in its severity, character, and position, it is rarely absent. 
It is apt to be severe, and may continue for a long period, or it may be 
intermittent. The location of the pain has no definite relation to the sit- 
uation of the tumour. It may be accompanied by sensations of tightness, 
compression, or tension in the head. It may be associated with localized 
tenderness of the scalp; when this is constant it is a valuable symptom 
for diagnosis, as it often occurs with tumours superficially located. 

General convulsions are frequent in the early stage, but separated by 
quite long intervals ; they become more frequent and more severe as the 
disease progresses. All degrees of severity are seen, from slight twitch- 
ings and temporary loss of consciousness, to typical epileptiform seiz- 
ures. They are most common when the growth is rapid and when com- 
plicating meningitis is present. Attacks of vomiting or of localized 
spasm may for a considerable time precede general convulsions ; and in a 
single attack there may be first localized and then general convulsions. 

Mental symptoms are generally present in great variety and complex- 
ity. There may be only fretfulness and irritability, or a marked change in 
disposition. These symptoms are so frequent from other causes in chil- 
dren that they excite no apprehension, unless to them are added dulness, 



CEREBRAL TUMOUR. 785 

apathy, and somnolence. Later in the disease there may be attacks of 
hypochondriasis, or of melancholia ; there may be periods of wild, almost 
maniacal excitement ; and, finally, the mental impairment may approach 
a condition of imbecility. 

Optic neuritis and optic-nerve atrophy are very frequent, occurring, 
according to Starr, in eighty per cent of the cases. This is only recog- 
nised by the ophthalmoscope, as there may be no disturbance of vision. 
The optic neuritis is generally double, appears earlier, and is more con- 
stant in basal tumours than in those at the convexity, or those centrally 
located. 

Vomiting is very frequent, but diagnostic only when it occurs sud- 
denly without assignable cause, and without nausea or other symptoms 
of indigestion. It is especially significant when frequently repeated, and 
of more importance in older children than in infants. 

Vertigo is often associated with vomiting. At first it is occasional and 
seen upon changing position, but later it may be quite constant, espe- 
cially with tumours in the posterior fossa. 

Disturbances of sleep are frequent. There is usually insomnia, but 
sleep may be broken by hallucinations, accompanied by attacks of scream- 
ing ; rarely is there persistent drowsiness until toward the end of the dis- 
ease. 

Local symptoms. — These depend upon the situation of the tumour, 
but not at all upon its anatomical character. Local symptoms may be 
wanting entirely, and they may vary much in different cases even with 
tumours in the same situation. They are modified by the size and by 
the rapidity of growth, and by the existence of local meningitis. 

In tumours of the cortex, the meninges are likely to be involved, espe- 
cially with tuberculous and gliomatous growths. The pathological process 
may extend from within outward or from without inward. The most 
frequent general symptoms in such cases are headache, circumscribed ten- 
derness of the scalp, convulsions, and mental symptoms. Optic neuritis, 
vomiting, and vertigo are not so common. Tumours situated in the fron- 
tal lobe, as a rule, present few symptoms and may be entirely latent. 
Irritation of the frontal lobe may extend to the motor area and cause 
convulsions either local or general ; but not often is there paralysis. Tu- 
mours of the left side (of the right side in left-handed persons) in the 
third frontal convolution may cause motor aphasia. 

Tumours in the motor convolutions along the fissure of Rolando pro- 
duce the most definite and uniform local symptoms. When situated at 
the upper portion the leg is affected, at the middle portion, the arm, 
and at the lower, the face. Irritative symptoms, such as rigidity or clonic 
spasm, commonly precede for some time the paralysis which results from 
pressure or destruction. These attacks of localized convulsions may begin 
in the face, arm, or leg ; but they usually extend more or less rapidly 



786 DISEASES OF THE NERVOUS SYSTEM. 

until all three are involved. There is no loss of consciousness, but there 
may follow a slight transient paralysis. Such attacks are known as " Jack- 
sonian epilepsy," and form one of the most diagnostic symptoms of cere- 
bral tumour. Localized spasm may be associated with anaesthesia or 
other disturbances of sensation. The paralysis generally first affects one 
extremity — the arm or leg, according to the location of the tumour — and 
afterward it may involve the entire side, including the face. 

If the tumour is centrally located, or at the base, hemiplegia maybe an 
early symptom from pressure on the motor tract. With cortical paralysis 
there may be associated ataxia and anaesthesia. 

Tumours of the parietal lobe may give no local symptoms. At times 
there are disturbances of muscular sense, tactile sensibility, or sensations 
of pain and temperature. If the inferior parietal lobule of the left side 
is affected, there may be word-blindness, or inability to understand writ- 
ten language. 

Tumours of the occipital lobe produce, as the only constant local symp- 
tom, hemianopsia. This is usually bilateral, affecting the same side of 
both eyes, being on the side opposite to that of the lesion — i. e., a tumour 
on the right side causes blindness in the left half of both eyes, so that 
the patient sees nothing to the left of a line directly in front of him. 
Instead of hemianopsia, there may be only irritation and various disturb- 
ances of sight. 

Tumours of the temporo-sphenoidal lobe may be latent, or, if on the 
left side, may cause word-deafness — i. e., inability to understand the sig- 
nificance of spoken language. 

Tumours in the island of Eeil when situated upon the left side (right 
side in left-handed persons) may cause motor aphasia or disturbances of 
speech. If they are large they may produce symptoms by pressure upon 
the motor tract, — hemiplegia or monoplegia. 

Tumours of the basal ganglia cause marked general symptoms, but 
none of a definitely local character. The important symptoms relate to the 
various tracts or bundles of fibres which pass from the cortex through the 
internal capsule. These include the motor and the various sensory tracts, 
the olfactory, auditory, visual, and speech tracts. Any of these may be 
pressed upon, and the nature of the symptoms will depend upon the size 
of the tumour and the extent of the pressure. If only the anterior part 
of the capsule is affected there may be no symptoms ; if the middle 
fibres, hemiplegia and disturbances of articulation ; if the posterior fibres, 
hemianaesthesia. All these may be associated, and any of them may be 
complete or partial. Tumours in this situation are apt to implicate the 
cranial nerves. Optic neuritis is quite constant, and appears early. Lo- 
calized or general convulsions are rare. 

The peculiar symptoms pointing to tumours of the crura cerebri are 
nystagmus, strabismus, and loss of pupillary reflex, sometimes with general 



CEREBRAL TUMOUR. 787 

muscular incoordination, and a staggering gait. There is usually third- 
nerve paralysis on the side of the tumour, and on the side opposite to the 
hemiplegia with which it is often associated. This variety of crossed 
paralysis is quite diagnostic. The symptoms of third-nerve paralysis are 
external strabismus, dilatation of the pupil, and ptosis. In these cases 
optic neuritis appears early. There may be a complicating hydrocephalus. 
While hemiplegia is commonly present with large tumours, it may be ab- 
sent with small ones, or may appear later than paralysis of the third nerve. 

Tumours of the pons are quite common. The diagnostic symptoms 
consist in crossed paralysis, the cranial-nerve symptoms being on the side 
of the tumour, and the general motor and sensory symptoms on the oppo- 
site side. When the seat is the upper half of the pons, the third and fifth 
nerves are apt to be implicated, giving rise to ptosis, dilatation of the 
pupils, external strabismus, trophic disturbances such as ulceration of the 
cornea, and neuralgic pain in the face. Tumours in the lower half of the 
pons involve the sixth, seventh, and eighth nerves, causing internal strabis- 
mus, contracted pupils, facial paralysis, sometimes deafness, and auditory 
vertigo. Other symptoms associated with tumours of the pons are head- 
ache, vomiting, and optic neuritis ; convulsions being rare. 

Tumours of the medulla are recognised by the involvement of the 
glossopharyngeal, pneumogastric, spinal accessory, and hypoglossal nerves. 
There are difficulty of deglutition, irregular respiration, irregular pulse, 
and vaso-motor disturbances, such as flushing of the face and perspiration. 
There may be projectile vomiting, polyuria or glycosuria, opisthotonus, 
difficulty in articulation or in sucking, and in protrusion of the tongue. 
When large, these tumours may produce symptoms of pressure upon the 
motor or sensory tracts, — paralysis, partial anaesthesia, with rigidity and 
exaggerated reflexes. 

Tumours of the cerebellum are especially important, this being the most 
frequent location in childhood. When only one hemisphere is affected 
there may be no local symptoms. Tumours involving the middle lobe, or 
those large enough to produce pressure upon the middle lobe, give rise to 
vertigo and cerebellar ataxia. Vertigo is especially frequent ; it may 
occur with headache. Cerebellar ataxia is different from the ataxia due 
to a spinal-cord lesion, and strikingly resembles that of intoxication. 
It may increase until the patient is unable to walk, although there is 
no loss of muscular power. Vomiting is a frequent symptom, as are also 
optic neuritis, and headache which is usually occipital. When there is 
secondary hydrocephalus, as is not uncommon, mental symptoms are 
present, and there may be enlargement of the head. Opisthotonus is 
occasionally seen, but general convulsions are rare. 

Diagnosis. — The size of the tumour is to be determined mainly by the 
general symptoms, special attention being given to the order of their 
development. A diagnosis as to the nature of the tumour is really not of 
51 



788 DISEASES OP THE NERVOUS SYSTEM. 

much importance ; but some information upon this point may be gained 
from the consideration of its etiology, the rapidity of its growth, and the 
age of the patient. Cerebral tumour may be confounded with abscess, tuber- 
culous meningitis, chronic basilar meningitis, and chronic hydrocephalus. 
The symptoms distinguishing tumour from abscess are the following : Tu- 
mour may occur at any age ; without definite etiology, excepting when 
tuberculous ; the progress is steady, but generally slow, new symptoms be- 
ing continually added; headache is more constant and more severe; optic 
neuritis more frequent ; cranial nerves more often involved ; mental dis- 
turbances more marked ; focal symptoms are often definite ; fever is absent ; 
duration, six months to two years. As compared with the above, abscess 
is not so frequent, being especially rare in infancy ; there is a definite his- 
tory of traumatism or ear disease; progress more irregular; symptoms 
often intermittent ; headache less severe ; mental symptoms less marked ; 
optic neuritis and involvement of the cranial nerves less frequent ; focal 
symptoms usually indefinite ; localized tenderness over the scalp more 
constant ; fever present except in the latent period ; the most frequent 
complication is acute meningitis. 

Cases of tuberculous meningitis which may be confounded with tumour 
are those of slow course sometimes seen in older children. The diffi- 
culty in diagnosis is increased by the frequent association of tuberculous 
tumours with tuberculous meningitis. The main points of difference are 
that in tumour the symptoms are more localized and the course gen- 
erally much slower. Almost every individual symptom, however, may be 
present in the two conditions. 

Chronic basilar meningitis may produce symptoms almost identical 
with those of tumour in the posterior fossa. It is, however, confined to 
infancy, and is frequently syphilitic. Hydrocephalus and opisthotonus 
are much more marked than are usually seen with tumour. 

Chronic hydrocephalus may resemble tumour; this occurs so frequent- 
ly as a lesion secondary to tumour that the question often arises whether 
there is only hydrocephalus, or there is in addition a tumour. Primary 
hydrocephalus is usually congenital, and commonly attains to a greater 
degree than is seen in secondary hydrocephalus. 

Prognosis. — The prognosis in cerebral tumour, while bad, is not hope- 
less. Cases are occasionally seen which exhibit all the characteristic 
symptoms of tumour, even including optic neuritis, which recover per- 
fectly. These are probably syphilitic, although often no such history 
can be obtained. In other cases, most frequently of a tuberculous na* 
ture, an arrest of the growth occurs and the patient recovers with some 
function of the brain impaired; usually there is loss of vision or some 
paralysis. In most cases, however, the progress is steadily downward 
until death. 

Treatment. — If there is any reason to suspect syphilis, the iodide of 
potassium should be given in large doses and continued for a long period; 



CHRONIC INTERNAL HYDROCEPHALUS. 789 

the effect of this drug even in tumours not syphilitic is sometimes bene- 
ficial. Starr refers to a case in which symptoms of six months' duration, 
including optic neuritis, entirely disappeared under the use of mercury 
and the iodide. The tumour was supposed to be gumma, but an autopsy 
obtained six months later showed it to be a sarcomatous cyst. For a 
discussion upon the surgical aspect of the treatment of brain tumours, the 
reader is referred to Starr's work on Brain Surgery. 

HYDROCEPHALUS. 

Hydrocephalus or " water on the brain," consists in an accumulation of 
serum in the cranial cavity. This may be between the dura mater and 
the pia (external hydrocephalus) or in the ventricles of the brain (internal 
hydrocephalus). The former is secondary and is quite rare, while the lat- 
ter is not uncommon. Hydrocephalus may be acute or chronic. 

Acute Hydrocephalus is secondary to basilar meningitis, which is usu- 
ally of tuberculous origin. The terms tuberculous meningitis and acute 
hydrocephalus are sometimes used synonymously. A moderate distention 
of the ventricles is frequent in all varieties of acute meningitis. The 
amount of fluid in acute hydrocephalus is not great, there being rarely 
more than three or four ounces present. 

Chronic External Hydrocephalus except in its mild form is extremely 
rare, and is nearly always a secondary lesion. It may follow meningeal 
haemorrhage, pachymeningitis or any lesion causing cerebral atrophy. It 
is seen in its most marked form associated with congenital malforma- 
tions of the brain, particularly imperfect development of the hemispheres. 
(See Fig. 137.) On incising the dura mater a few ounces, or sometimes 
even a pint, of serum may escape. The convolutions are somewhat flat- 
tened, and may be greatly atrophied. Other lesions are found either in 
the brain or in the dura mater. External hydrocephalus may cause 
enlargement of the head and separation of the sutures, and in fact most 
of the symptoms of the internal variety; but usually it is not severe 
enough to give rise to any decided symptoms. 

CHRONIC INTERNAL HYDROCEPHALUS. 

This is the important variety, and when no qualifying term is men- 
tioned this is the form of hydrocephalus which is always understood. 

Etiology. — This occurs both as a primary and a secondary condition. 
When secondary it is usually associated with tumours of the base of the 
brain or with chronic basilar meningitis, either simple or tuberculous. It 
is in these cases a mechanical condition caused by pressure which oblit- 
erates the openings from the lateral ventricles into the fourth ventricle, 
or the foramen of Magendie. 

The causes of primary hydrocephalus are as yet very little understood. 
In a large proportion of the cases the disease is congenital, generally 



790 DISEASES OF THE NERVOUS SYSTEM. 

beginning in the latter months of intra-uterine life. Some of these cases 
are clearly syphilitic. D'Astros * has collected nine cases and added 
three others, in which hydrocephalus was associated with lesions un- 
doubtedly syphilitic. When due to syphilis, the disease may at the same 
time be congenital. Eickets and hydrocephalus are occasionally associ- 
ated, but so infrequently as to make a definite etiological connection be- 
tween them very doubtful. The rachitic head has been so often mistaken 
for hydrocephalus that an erroneous notion has arisen as to the frequent 
association of these two diseases. This point will be referred to more 
fully under diagnosis. Chronic hydrocephalus is often attributed to 
tuberculosis, but here again the connection is a very doubtful one. 
Heredity is a factor of some importance; numerous instances are on 
record where two children in the same family have been affected. Hydro- 
cephalus not infrequently develops after successful operations upon spina 
bifida or encephalocele. 

Lesions. — The difference between the primary and secondary cases is 
chiefly one of degree. The amount of fluid in secondary cases is rarely 
more than three or four ounces. In primary cases it is usually from half 
a pint to one pint, but it may be very great. In one of my own cases 
there was removed from the head of a child, who died at four months, five 
pints of fluid. Larger quantities than this have been reported, but not at 
so early an age. In composition this resembles the cerebro-spinal fluid. 
An examination in one of my cases showed it to be a clear, translucent 
fluid, slightly alkaline in reaction, specific gravity 1005, containing sodium 
and potassium chlorides, alkaline phosphates, and a trace of albumin. In 
some specimens sugar is found. In cases of inflammatory origin the 
amount of albumin is generally larger, and the fluid may be slightly tur- 
bid. The effusion may become purulent from accidental infection re- 
sulting from operation, from rupture, or, as in one of my cases, from in- 
fection through the sac of a spina bifida with which it was complicated, 
the process extending to the brain through the central canal of the cord. 

The changes in the brain result from the gradual accumulation of 
fluid in the ventricles. The septum lucidum is usually broken down, 
and all the avenues of communication between the ventricular cavities 
are greatly enlarged. The continuous distention results in a gradual 
thinning of the brain substance which forms the ventricular walls ; often 
these are found only one fourth of an inch in thickness, or even less 
than this, the cortex being a mere shell (Fig. 136). In one of my 
autopsies the ependyma of the ventricle and the pia mater were in 
places actually in contact, all of the brain tissue having been absorbed ; 
the brain resembled a large double cyst. In a case of Peterson's, with 
the exception of a small portion of one temporo-sphenoidal lobe, all 

* Revue Mensuelle des Maladies dc l'Enfance, ix, 481, 513. 



CHRONIC INTERNAL HYDROCEPHALUS. 



191 



of both hemispheres had disappeared, the cerebellum and basal ganglia 
alone being intact. The brain is always anaemic, and the gray and white 
substance may be indistinguishable. The changes are largely mechanical, 
the microscope showing, in my case just referred to, only granular matter 
and round nuclei evidently from broken-down nerve cells. In less severe 
cases the changes may be slight. It is, however, always surprising to see 
the amount of compression which the cortex will tolerate without inter- 
ference with its functions, provided the pressure comes gradually. The 
ependyma may be normal, but it is usually somewhat thickened and pale, 
sometimes granular, and may be infiltrated with new cells. When infection 
takes place an acute ependymitis may be set up. Chronic inflammation 

of the ependyma is thought 



to be the essential lesion in 
many of the primary cases, 




whether of simple or syphi- 
litic origin. 

The bones of the skull are 
markedly affected ; the su- 
tures at the vault are widely 
separated, and sometimes 
even those at the base. After 
the removal of the fluid the 
head collapses, giving an ap- 
pearance which has been well 
likened to a "bag of bone?." 
It should not be forgotten, 
however, that hydrocephalus 
may coexist with premature 
ossification, in which case the 
head may be small. In the 
cases which recover, the wide 
gaps in the skull may be closed by the development of wormian bones ; but 
ossification is often not complete until the fifth or sixth year. 

The most frequent lesion associated with congenital hydrocephalus is 
spina bifida, in which cases there may also be a patency of the central 
canal of the spinal cord ; more rarely meningocele or encephalocele are met 
with. Sometimes there are deformities in other parts of the body, such as 
club-foot or hare-lip. 

Symptoms. — Hydrocephalus may exist with a small head. In this 
condition there is usually premature ossification of the cranial bones. 
Four such cases have come under my notice, one child having lived to 
be fourteen months old. These children are usually idiotic, and die at an 
early age, often from convulsions. In such cases other malformations of 
the brain are frequently associated. 



Fig. 136.— Vertical transverse sec-lion of a brain in con- 
genital hydrocephalus, from a child who died at the 
age of three weeks. A, distended lateral ventricle ; 
B, its descending horn. 



792 



DISEASES OP THE NERVOUS SYSTEM. 



Hydrocephalus, with the exceptions mentioned, is recognised by the 
increased size of the head. In order to estimate the amount of enlarge- 
ment, it must be remembered that at birth the circumference of the 
normal head is about 14 inches, and at one year from 18 to 19 inches. 
The degree of enlargement in hydrocephalus may be very great. In one 
of my cases, the head at four months measured 24^ inches. In another at 
ten and a half months, 26f inches. Steiner has reported a remark- 




Fig. 137. 



-Brain in external hydrocephalus, showing imperfect development of the 
hemispheres. • 



Patient three and a half months old; head measured 20£ inches; increase in size, 2 inches 
in the six weeks before death ; symptoms were typical of ordinary internal hydrocephalus. In 
the picture the small size of the cerebrum is best judged by comparison with the cerebellum, 
which is normal. The hemispheres were rudimentary; the basal ganglia were normal; the 
cranial cavity contained about one pint of fluid. 



able case in which the head at eight months measured 32J inches'. 
When the enlargement of the head is not great the diagnosis is not so 
easy. Hydrocephalic enlargement is commonly symmetrical and in all 
directions. The head is sometimes globular in outline and sometimes 
pyramidal (Fig. 138). The forehead is exceedingly high and project- 
ing, and there is a prominence of the frontal eminences seen in no other 
form of enlargement. The sutures may be separated from half an inch 
to two or three inches; the fontanel is very large, tense, and bulging; 



CHRONIC INTERNAL HYDROCEPHALUS. 



793 



the veins of the scalp are enlarged and prominent. In marked cases 
fluctuation may be readily obtained, and the head may even be distinctly 
translucent. 

In the acquired form all these symptoms are less marked, and if ossi- 
fication of the skull has taken place it is often impossible to discover 
any increase in size. The rate of growth of the head varies much in dif- 
ferent cases, and it is the surest measure of the progress of the case. The 
increase in circumference is usually from one to three inches a month. 

The primary cases are for the most part of congenital origin, and the 
child may die in utero. At other times the process may have advanced so 




Fig. 138. — Chronic hydrocephalus of average severity ; head of pyramidal shape ; showing char- 
acteristic expression of the eyes. 

far before birth that puncture of the head is necessary before delivery is 
possible. In perhaps the majority of cases no symptoms are observed at 
birth, or the head is only slightly larger than normal. Usually nothing 
is noticed until the child is two or three months old, when it is discov- 
ered that the head is increasing in size at an abnormal rate. If the 
progress is rapid, other symptoms are soon evident : the infant can not 
hold up its head ; it is lethargic, and all its perceptions are dulled, sight 
and hearing included ; there may be a general flaccid condition of all the 



794 DISEASES OF THE NERVOUS SYSTEM. 

muscles of the extremities due to a slight general paresis, but more often 
there is rigidity, which is usually most marked in the legs, but sometimes 
in the arms ; the hands are often clenched, with the thumbs adducted ; 
the reflexes are exaggerated ; the pupils are generally contracted and 
equal, though they may be dilated ; nystagmus and convergent strabismus 
are often present. Convulsions may occur from time to time, or may be 
deferred until near the close of the disease. As the head enlarges the 
body usually wastes, and the disproportion between the two may seem 
greater than it really is. 

Such congenital cases rarely see the end of the first year, and are often 
fatal during the first six months. The causes of death are marasmus, con- 
vulsions, and intercurrent disease, rarely rupture of the head. 

In the cases which develop more slowly, the symptoms are quite differ- 
ent. The head may not attain at eighteen months the size reached in the 
other cases at the third or fourth month. The surprising thing about many 
of these cases is that the distinctly cerebral symptoms are so few. Where 
the pressure develops gradually, the brain seems able to tolerate an almost 
indefinite amount of it. The more readily the bones of the skull yield to 
pressure the fewer are the nervous symptoms ; hence, other things being 
equal, they are less marked where the disease begins before the sutures 
are firmly ossified than in the later cases. A comparatively small amount 
of effusion may cause very marked symptoms in a child two or three years 
old, while a much larger amount in an infant of a year, may produce much 
less disturbance. It is for this reason that secondary hydrocephalus 
causes such striking symptoms, although the accumulation of fluid is 
small. 

Whether the progress of these cases is slow or rapid, the development of 
the children is greatly retarded. Many are not able to support the head 
until two or three years old ; frequently they do not walk until five or six 
years old. The special senses are generally not noticeably affected, but in- 
telligence in most cases is interfered with, — in some only slightly, in others 
very markedly, while some are idiotic. Contractions of the extremities 
are occasionally seen, but usually more of the hands than the legs. Sen- 
sation is not often affected. The course is a very chronic one. From 
time to time there are exacerbations of the symptoms, and even inter- 
current meningitis may be excited. 

Prognosis. — Most of the congenital cases are fatal before the end of 
the first year. It is very rare that a hydrocephalic child reaches the age of 
seven years. The process may go on up to a certain age and then cease 
spontaneously, and the child may go through life with a head very much 
larger than normal and usually with a mental condition somewhat im- 
paired. Retrogression of the symptoms is, however, never to be looked for. 
Diagnosis. — The most important symptom is the enlargement of the 
head, and this can only be arrived at by careful measurement and com- 






INFANTILE CEREBRAL PARALYSIS. 795 

parison with the normal size. The rapidity of growth is quite as impor- 
tant for diagnosis as the fact of enlargement. If the head grows more 
than an inch a month there can be little doubt. The enlargement most 
frequently confounded with hydrocephalus is that which occurs in rickets. 
In the latter disease it is almost invariably irregular; there are promi- 
nences over the two frontal eminences and over the parietal bones, often 
with furrows between them ; the size of the head is chiefly due to thicken- 
ing of the bones of the skull ; the marked prominence of the forehead is 
not seen, and the increase in the bi-parietal diameter is not present ; fur- 
thermore, there are other signs of rickets. 

Treatment. — If there is any suspicion of syphilis, mercurial inunc- 
tions should be employed, and potassium iodide given internally in full 
doses. Of all the operative measures that have been proposed for this 
condition, and their name is legion, the only one at the present time 
which seems to hold out any reasonable prospect of permanent improve- 
ment is auto-drainage. This consists in establishing a communication 
between one of the lateral ventricles and the sub-arachnoid space. By 
this means the fluid is conducted to a place from which it can be ab- 
sorbed. A considerable number of cases have now been treated in this 
way. The dangers of the operation are very great; fully half the pa- 
tients having died as the direct result of it. Of those who have survived, 
a number have shown improvement and a few very striking improve- 
ment, but no complete cures have been reported.* 

INFANTILE CEREBRAL PARALYSIS. 

Synonyms : Spastic diplegia, paraplegia, or hemiplegia. 

Under the term cerebral paralysis are included several groups of cases 
with causes quite dissimilar, but having certain definite clinical features 
in common. While the symptomatology is quite clear, there are many 
questions relating to the pathology that are not yet fully settled, although 
much has been added to our knowledge within the last few years. Paraly- 
sis depending upon cerebral tumour, abscess, or hydrocephalus is not in- 
cluded in this chapter. 

The cases of cerebral paralysis may be divided into three groups, 
according as the paralysis depends upon conditions existing prior to 
birth, upon those connected with birth, or upon those of subsequent 
development. 

I. Paralysis of Intra-Uterine Origin. — This is the least frequent con- 
dition. In such cases there is some congenital defect in the brain, due 
sometimes to arrest of development, at others to such intra-uterine lesions 
as haemorrhage or thrombosis. There may be porencephalia, or cysts ex- 
tending deeply into the substance of the brain, sometimes communicating 

* For a discussion of the surgical aspects and literature, see A. S. Taylor, American 
Journal of Medical Sciences, August, 1904. 
52 



796 DISEASES OF THE NERVOUS SYSTEM. 

with the ventricles. The origin of this condition is for the most part un- 
known. In rare cases the paralysis is due to cortical agenesis,* a condition 
in which the brain may seem normal to the naked eye, but the microscope 
shows a complete arrest in the development of the cells of the cortex, usu- 
ally affecting both hemispheres. In still other cases there are found gross 
defects in development in the motor centres of the cortex. Such a lesion 
is shown in Fig. 149, page 806. Cases in which there is conclusive evi- 
dence of intra-uterine haemorrhage are very rare. 

Symptoms. — In most of the paralyses due to intra-uterine lesions, loss 
of power is only one of the symptoms, and usually not the most promi- 
nent. It is rare that there is not some mental impairment, and usually 
idiocy is present. The type of paralysis is nearly always diplegic or para- 
plegic. Where this is due to arrested cortical development, a general flac- 
cidity of the muscles may be seen instead of the rigidity so characteristic 
of the other forms of cerebral paralysis. 

II. Birth-Paralysis. — Cerebral birth-paralysis is due in nearly all 
cases to meningeal haemorrhage. The primary lesions and the early 
symptoms have already been described in connection with the Diseases of 
the Newly Born. The secondary lesions present considerable variety. 
There may be found (1) meningoencephalitis, (2) atrophy and sclero- 
sis of the cortex, (3) cysts upon the surface, (4) secondary degenerations 
in the spinal cord. 

1. Meningo-encephalitis. — This lesion is often quite diffuse. There 
is thickening of the pia mater, and it is usually adherent to the brain 
substance. The cortex is involved to a variable degree, depending some- 
what upon the time which elapses between the initial lesion and the au- 
topsy. The following were the microscopical changes found by Sachs \ in 
the brain of a child in my wards at the Babies' Hospital, who died at the 
age of one year of measles : The lesions were found everywhere in the 
cortex. The pia was universally adherent, and showed general cellular 
infiltration; its blood-vessels showed marked cellular proliferation, and 
the veins in the sub-pial space were dilated and filled with blood. In the 
pia dipping in between the convolutions similar changes were present. In 
the cortex few if any normal pyramidal cells were found, but in the outer 
layers were an enormous number of small glia cells. Many of the 
blood-vessels showed a cell-proliferation of their walls. There was also 



* For fuller description, see Sachs's Nervous Diseases of Children, 1895, p. 601. 

f The clinical features of this case are quite as interesting as the pathological find- 
ings. The child was a first-born, delivered after a dry labour of forty-eight hours. 
It was asphyxiated, and from the first days of its life it had attacks of convulsions, 
usually repeated many times a day. During one of these convulsions the photograph 
from which Fig. 140 was made, was taken by Dr. Peterson. The child had the symp- 
toms of typical spastic paraplegia — the arms being, however, slightly involved — retarded 
mental development, and convergent strabismus. 



INFANTILE CEREBRAL PARALYSIS. 797 

a degeneration in the pyramidal tracts of the anterior columns of the 
cord. 

2. Atrophy and sclerosis. — These changes vary much in extent and 
degree. There may be only a circumscribed area in which the convolu- 
tions are small, firmer than usual, and covered with an adherent pia, or 
there may be an atrophy so extensive as to involve a large part of one 
hemisphere (Fig. 139), or sometimes of both hemispheres. Usually the 
lesion is somewhat diffuse over the convexity of both sides, and much 
more frequently of the anterior than of the posterior half of the brain. 




Fig. 139. — Extensive atrophy and sclerosis of the right hemisphere, from an infant seven and a 
half months old; probably the result of a meningeal haemorrhage at birth (lateral view). 

History. — Twelve hours after birth was seized with general convulsions, which continued 
for three days. No other symptoms noticed till one month before death, when weakness of left 
arm was observed. Never held head erect. Was plump and well nourished ; died from erysipelas. 

Autopsy. — Pia not adherent; a large cyst occupied the region of the occipital and posterior 
part of the parietal lobes, showing in its floor discolouration'and pigmentation, evidently from 
an old haemorrhage. Right optic' nerve, tract, and crus much smaller than the left. 

Where a depression of the brain exists the space is filled with cerebro- 
spinal fluid, and in many cases there is a deformity of the skull. 

3. Cysts upon the surface may occur alone or in connection with the 
lesions just mentioned. These are usually small, about the size of a wal- 
nut, but they may cover a large part of a hemisphere. Such large cysts 
are sometimes classed as cases of external hydrocephalus. 

4. Secondary degenerations of the internal capsule and the lateral col- 
umns of the cord are found in most of the cases associated with extensive 
atrophy and sclerosis, and in many of those in which only meningo- 
encephalitis is present. 

Symptoms. — The type of paralysis will of course depend upon the 
extent and position of the original lesion. A diffuse lesion is followed by 
diplegia ; one not quite so extensive by paraplegia ; one affecting one side 
only by hemiplegia, or even monoplegia, though this is very rare. The 



798 



DISEASES OF THE NERVOUS SYSTEM. 



relative frequency of the different forms will vary according to the age 
at which the patients come under observation. Thus in the statistics of 
Sachs and Peterson,* there were twenty-seven cases of diplegia or para- 
plegia, and twenty-two of hemiplegia. These cases were drawn from 
miscellaneous sources, chiefly from a general neurological clinic. Ac- 
cording to my own observations, which have been chiefly upon infants, 
the cases of diplegia and paraplegia have outnumbered those of hemi- 
plegia more than four to one. My belief is that the great majority of 
the congenital cases, or those due to haemorrhage occurring at birth, are 
diplegias or paraplegias, and that very many of them succumb during the 
first two years, and never come under the observation of the neurologist ; 
however, the cases of hemiplegia, because of the less serious lesion, live 
much longer, and hence are more likely to be seen by the specialist. 
Diplegia and paraplegia will therefore be considered as the characteristic 
types of cerebral birth-palsy, as the cases of hemiplegia do not differ from 
those due to later causes — i. e., the acquired form. 

In the most severe cases that survive the symptoms of the early 
days of life there remains some rigidity of the extremities, chiefly of the 
legs, which is constant or intermittent, slight or well marked. There 




Fig. 140.— Convulsions in spastic paraplegia: from a photograph by Dr. Frederick Peterson 

during an attack. 

is often spasm of the muscles of the neck and trunk, giving rise to opis- 
thotonus. In many cases there are frequent attacks of convulsions (Fig. 
140). The general physical development of the child is often interfered 
with, so that he remains small and delicate, and perhaps dies of some 
acute disease in early infancy, never having been able to sit erect, or even 



* Journal of Nervous and Mental Disease, May, 1890, 



INFANTILE CEREBRAL PARALYSIS. 799 

support his head. In other cases the general nutrition is not affected, 
and life may be prolonged indefinitely, but usually with some degree of 
mental impairment. This is seen in all degrees ; it may be so slight as 
not to be noticed until the child is two or three years old, or the child 
may be idiotic. Often these children are not able to stand until they 
are over three years old, and do not walk alone until they are four or 
five years old, and then with a peculiar cross-legged gait, owing to spasm 
of the adductors of the thighs. This may be so great as to entirely pre- 
vent walking, and while sitting or lying the thighs may cross each other. 
These form the typical cases of spastic paraplegia (Fig. 141). All the 
reflexes are greatly exaggerated. The arms are much less affected than 
the legs and in about half the number they are not involved at all. 

In the mild cases the early symptoms may be overlooked, and noth- 
ing excite suspicion until the infant is six or eight months old. There 
is then discovered unmistakable muscular weakness; the child does not 
sit up, or even hold up the head when the trunk is supported. Often 
there is observed before this time a tendency to stiffen the body and to 
throw the head backward, owing to spasm of the cervical or spinal mus- 
cles. The muscular weakness is often mistaken for rickets, or regarded 
simply as backwardness. A closer examination usually discloses the pres- 
ence of some rigidity of the extremities, particularly of the legs, and 
exaggeration of the knee-jerks. As the child grows older other symptoms 
of imperfect development become more and more evident. 

There are changes in the shape of the skull, this being usually smaller 
than normal in all its diameters, or there may be asymmetry. There is an 
arrest of development in the paralyzed limbs. These are both smaller 
and shorter than normal. In many cases abnormal movements are seen, 
which may be of an irregular choreic type, or they may be athetoid. Epi- 
lepsy develops in from 33 to 50 per cent of all these patients. 

III. Acute Acquired Paralysis. — This is usually of the hemiplegic 
type, although diplegia and paraplegia may in rare instances be met with. 
This group includes cases developing at any time after birth, but the 
great majority of those seen in childhood begin before the fifth year. 

Etiology. — The etiology is often obscure. The paralysis sometimes 
follows traumatism. It is occasionally seen in the course of scarlet fever, 
measles, diphtheria, variola, and pneumonia. Much more frequently 
than with any of these diseases it occurs during pertussis, being usually 
the outcome of a severe paroxysm. The frequency with which these 
cases are ushered in with convulsions has led many to assign this as the 
cause of the paralysis. II is possible that the convulsions are sometimes 
the result and sometimes the cause of the lesion. 

Lesions. — The lesions of acute cerebral palsy may be grouped under 
three heads: (1) those of the blood-vessels; (2) those of the membranes; 
(3) those of the brain >ul)stance. 



800 



DISEASES OF THE NERVOUS SYSTEM. 



1. Lesions of the blood-vessels. — There may be haemorrhage, em- 
bolism, or thrombosis. Haemorrhage is by far the most important. It is 
usually meningeal, rarely cerebral. It occurs more frequently at the con- 
vexity than at the base, and is often dif- 
fuse. Meningeal haemorrhage may result 
from pachymeningitis. It may be due 
to traumatism, where it is also from the 
dura mater; or from the acute hyper- 
aemia accompanjdng paroxysms of per- 
tussis, where it may be from the dura 
or the pi a; or it may be secondary to 
thrombosis of the superior longitudinal 
sinus. The association of haemorrhage 
with sinus-thrombosis is not very in- 
frequent. It was found in one of my 
autopsies upon a patient who died of 
pneumonia. Cerebral haemorrhage is ex- 
tremely rare, but it occurs even in in- 
fants ; I once saw it in one only two 
months old. 

Embolism is rarely found unless asso- 
ciated with acute rheumatic endocar- 
ditis, and then usually in children who 
are over seven years old. As in adults, 
the usual seat of the embolus is a branch 
of the middle cerebral artery. It may 
be single or multiple. Thrombosis has 
been met with in a small number of 
cases, but it is extremely rare. 

2. Lesions of the membranes. — These 
are generally the result of an old cerebro- 
spinal meningitis; sometimes they may 
be of syphilitic origin. In both, how- 
ever, the process is rarely confined to the 
membranes ; it is a meningoencephalitis. 
3. Lesions of the brain substance. — Atrophy and sclerosis are ter- 
minal conditions found in a large number of the autopsies made upon 
cases where the paralysis has been of long standing. They vary in se- 
verity and extent, and are followed by secondary degeneration in the 
cord, as in cases of birth paralysis. There may be the same develop- 
ment of cysts of the pia mater, or an accumulation of fluid in the arach- 
noid cavity, these taking the place of the atrophied convolutions. What 
the primary lesion is in these cases is still a matter of debate. A certain 
number of them are due to acute poliencephalitis, analogous to acute 




Fig. 141. — Spastic paraplegia. 

Child two and one half years old, 
New York Foundling Hospital, unable 
to walk or even to stand without assist- 
ance. The habitual position of the 
limbs, which is due to strong adductor 
spasm, is shown in the picture. 



INFANTILE CEREBRAL PARALYSIS. 801 

poliomyelitis. In other cases a chronic diffuse encephalitis with atrophy- 
is found at autopsy, closely resembling the conditions which follow a 
meningeal haemorrhage occurring at birth, yet the children were normal 
up to the second or third year and there was no acute onset. 

Acute paralysis sometimes occurs for which no explanation can be 
found at autopsy. An infant with pneumonia was admitted to the Babies' 
Hospital, who had developed, a few days before, typical right hemiplegia. 
It came on suddenly, with convulsions, and involved the face, arm, and 
leg. The arm and leg appeared to be completely paralyzed, but in the 
face the paralysis was incomplete. The paralysis had begun to improve 
somewhat at the time of the child's death, which occurred a little over a 
week after its onset. At the autopsy no gross lesion could be discov- 
ered. A careful microscopical examination was made by two excellent 
pathologists, Drs. C. A. Herter and J. S. Thacher, who could find no 
explanation of the paralysis. Nothing abnormal was found except " a 
slight increase of small spheroidal cells about some of the meningeal and 
cortical vessels of the motor area. The frontal and occipital lobes were 
normal." 

Symptoms. — While diplegia and paraplegia are occasionally seen, the 
great majority of cases of acquired cerebral palsy are of the hemiplegic 
variety. When diplegia and paraplegia occur, it is usually in early in- 
fancy, and their symptoms and course differ in no wise from the birth 
palsies. We may therefore regard hemiplegia as the chief manifestation 
of acquired cerebral palsy. 

The onset of the paralysis is almost invariably sudden, with convul- 
sions, which are usually repeated, and in severe cases followed by loss of 
consciousness. In the secondary cases these are generally the only symp- 
toms. In one of my cases the patient went to bed apparently well, and 
awoke in the morning with hemiplegia. Such an onset, however, is very 
exceptional. When the paralysis is apparently primary, fever is usually 
present, and in addition to the convulsions there may be vomiting, de- 
lirium, and other symptoms, strongly suggestive of an acute inflammatory 
process in the brain, which continue for a variable time, usually from one 
to three days, before paralysis is seen. The temperature in most cases is 
from 100° to 103° F., and the rise of temperature sometimes follows, some- 
times precedes, the convulsions. After the child recovers consciousness, 
and sometimes before this, the paralysis is discovered. If there is a ver}' 
extensive lesion there may be diplegia, deep coma, and death, but this is 
very infrequent. Usually the lesion is more limited, and the symptoms 
are those of typical hemiplegia. When the face is involved, it soon recov- 
ers, and often it escapes altogether. The paralysis of the arm and leg is at 
first complete, but may improve very rapidly in the course of a few days. 
Disturbances of sensation are usually of a transient character. After a 
variable period, from one to several weeks, the patient begins to use the 



802 



DISEASES OF THE NERVOUS SYSTEM. 



paralyzed extremities, first the leg, afterward the arm, as in adult hemi- 
plegia. The convulsions may be repeated for the first day or two, but 
prolonged or continuous convulsions are rare. With lesions of the left 
side of the brain, speech may be affected, and not infrequently in young 
children when the lesion is upon the right side. The reflexes are in- 
creased upon the affected side, and a slight 
ankle-clonus may be present. 

In the course of a few weeks the child 
may be able to walk, dragging the affected 
leg; the recovery in the leg is sometimes 
complete, but in most cases a slight halt 
in the gait remains. The arm usually re- 
covers more slowly than the leg, and con- 
tractures are likely to develop after a 
variable time, generally two or three years. 
In Fig. 142 is shown a frequent deformity 
of the upper extremity. Contractures of 
the leg lead to various forms of talipes, 
generally equinus, from shortening of the 
tendo-Achillis. Sometimes the arm or the 
leg recovers so perfectly that the case may 
be regarded as one of monoplegia. In old 
cases the paralyzed limbs are atrophied; 
there is more or less rigidity, and the spas- 
tic condition may be quite marked. I have 
seen this limited to a single group of mus- 
cles in the leg. Aphasia is common in 
right hemiplegias, and it is not very rare 
in those of the left side, because infants 
appear to use both sides of the brain with 
nearly equal facility. 

The mental condition of these children 
is often normal, in striking contrast with 
the cases of congenital diplegia. The 
earlier the paralysis occurs the more likely 
are mental symptoms to be present, since we have here not only the direct 
effect of the lesion, but an arrested development of some part of the 
brain. Epilepsy is not an uncommon sequel ; it may be of the Jacksonian 
type, or there may be attacks of general convulsions. In other cases 
there are post-hemiplegic movements of a choreic or athetoid character, 
or irregular incoordinate movements. 

Prognosis of Infantile Cerebral Paralysis. — In diplegia and para- 
plegia the outlook is always unfavourable. A very large number of these 
cases which are due either to intra-uterine or birth lesions, never reach 




Fig. 142. — Deformity of left hand the 
result of contractures following 
an attack of hemiplegia four 
years before ; child seven years 
old. 



INFANTILE CEREBRAL PARALYSIS. 803 

the third year, but die in infancy from marasmus or acute intercurrent 
disease. Those who survive usually show serious mental defects, and 
many are practically helpless on account of the extreme spastic condition 
of the muscles of the extremities. 

In hemiplegia the prognosis is much more favourable. In most of 
these cases the paralysis is of the acute acquired variety, and the later the 
period of onset, the less likely is the brain to be seriously damaged. In 
some of these patients complete recovery takes place ; in others the residual 
paralysis is so slight as to be easily overlooked except on careful examina- 
tion, the occurrence of epilepsy being perhaps the first thing which leads 
one to suspect that a previous paralysis has existed. The great majority of 
children who have suffered from infantile cerebral palsy have some degree 
of permanent paralysis and usually some deformities from contractures, 
the extent of both varying, of course, with the severity of the primary 
lesion. In all cases seen in young infants it is exceedingly difficult to 
give a prognosis in regard to future mental development. As a rule, the 
impairment is directly proportionate to the extent of the paralysis and 
its intensity; although in exceptional cases we find a good deal of men- 
tal disturbance with only moderate paralysis, and vice versa. 

Diagnosis. — The diagnosis between the congenital and acquired forms 
of cerebral palsy is of no great practical importance, and it may be im- 
possible; for the symptoms in congenital cases are often not sufficiently 
marked to attract attention until children are old enough to sit alone or 
to walk. 

It may be quite difficult to distinguish cerebral paralysis from infan- 
tile spinal paralysis. The history of an acute onset, the atrophied limbs, 
the deformities, and the absence of sensory disturbances, may be found in 
both conditions. Spinal paralysis is, as a rule, monoplegic, and often af- 
fects but a single group of muscles. Cerebral paralysis is either diplegic 
or hemiplegic in character, and even though only a leg or an arm may 
seem to be affected, a critical examination will usually reveal the fact that 
the other limb of the same side has also suffered. The presence of rigid- 
ity and exaggerated reflexes is quite as important evidence of this as loss 
of power. The electrical reactions, however, are conclusive; the reac- 
tion of degeneration is absent in cerebral paralysis, while it is present in 
spinal paralysis. 

Simple as the differentiation may .seem in most cases, the mistake is 
frequently made of confounding cerebral diplegia, particularly of the 
flaccid type, with rickets. But a careful history and a thorough exami- 
nation will usually dispel all doubt (see article on Eickets). Cases of 
acute acquired paralysis at the onset may be mistaken for acute menin- 
gitis, but early loss of consciousness, the early development of the 
paralysis, its permanent character, and the short duration of the acute 
symptoms, distinguish cases of haemorrhage from those of meningitis; 



804: DISEASES OF THE NERVOUS SYSTEM. 

but when it follows traumatism, and when it occurs in the course of 
some other disease such as pneumonia or scarlet fever, it may be diffi- 
cult or impossible to make a diagnosis between the two conditions. 

Treatment. — The course and the result of cerebral paralysis depend 
upon the extent of the injury to the brain, its nature, and the age at 
which it is inflicted, — all these being conditions which are beyond the 
power of the physician to modify or control. The treatment of cerebral 
palsy is therefore extremely unsatisfactory. For the congenital cases 
practically nothing can be done, except for the deformities and compli- 
cations. The acquired cases during the acute onset are to be managed 
like all other cases of acute cerebral congestion or inflammation, — ab- 
solute rest, ice to the head, and bromides. Electricity is never to be 
used in early cases, and little or nothing is to be expected from it in the 
late ones. Much can be accomplished in an educational way for the men- 
tal derangements resulting from cerebral palsy. An important part of 
the treatment relates to the deformities. Many of these may be pre- 
vented by the early use of orthopaedic apparatus. Serious deformities 
in old cases may be greatly benefited by tenotomy or myotomy, followed 
by the use of suitable apparatus. Epilepsy is to be treated as when it 
depends on other causes. 

MENTAL DEFECTS. 
DEFICIENCY, IDIOCY, IMBECILITY. 

All grades of mental defects are seen in children. While the terms 
above used characterise the chief clinical types, it should be remembered 
that these shade into each other by almost imperceptible degrees. They 
may be the result either of arrested development or of disease or injury 
of the brain. 

The backward child does not belong in this group, although often 
placed here by parents or teachers. Such children may present many 
mental peculiarities, but differ from the normal standard chiefly in the 
slowness with which the mental functions are developed, the most notice- 
able of these being speech. It is backward children and those who present 
the milder grades of mental defect that are of the greatest clinical inter- 
est and importance, for in them the mental condition often depends upon 
some physical cause which time and proper treatment may remove. Com- 
mon causes are defective sight, or hearing, severe early rickets, prolonged 
malnutrition, etc. 

Following somewhat the classification of Ireland, the mental defects 
of children may be divided into the following groups : 

1. Those depending upon such congenital conditions as porencephalia, 
arrested development of the brain as a whole, or of some portion, par- 
ticularly the frontal lobes. An excellent illustration of this class of 



MENTAL DEFICIENCY. IDIOCY, IMBECILITY. 805 

cases is seen in Fig. 149. Another variety is known as " Agenesia cor- 
ticalis (page 796). 

2. Those associated with external or internal hydrocephalus. 

3. Those associated with microcephalus, either with or without pre- 
mature ossification of the cranial bones (Figs. 146-148). 

4. The paralytic cases, including the varieties which occur in the dif- 
ferent forms of cerebral paralysis, the greater part of which are due to 






Fig. 143. 



Fig. 144. 



Fig. 145. 






Fig. 146. 



Fig. 147. 
Various types of mental defects. 

type. 
; di< 



Fig. 148. 



Figs. 143-145. — Mongolian tyr 

Fig. 143. — Six months old; died at twenty-two months; could not hold up the head, or 
understand any tiling. 

Fig. 144.— Boy "six and a half years old; did not walk or talk till four years old; now 
quite intelligent, almost normal. 

Fig. 145. — Girl four years old ; mental development like that of a normal child of two 
and a half years; walks very awkwardly. 

Fig. 146. — Boy twelve years old; microcephalic; walked at about four years; can read 
and write; development like that of a normal child of eight years. 

Fig. 147. — Microcephalic, seven years old ; understands most of what is said; cannot talk 
intelligibly. 

Fig. 14S. — Girl of eight years ; imbecile; cannot walk without help. 

Note that the expression in 144, 145, and 146 is not due to adenoids; 144 and 146 have had 
them removed. 



meningeal haemorrhage at birth, and which are clinically associated with 
spastic diplegia or paraplegia; a smaller number are associated with 
acquired cerebral paralysis, most frequently following meningeal haem- 



orrhage. 



806 



DISEASES OP THE NERVOUS SYSTEM. 



5. Those of inflammatory origin. They follow cerebro-spinal menin- 
gitis and acute poliencephalitis. 

6. Those associated with epilepsy, in which the condition is a result 
of changes in the brain produced by the repetition of the epileptic 
seizures. 

7. Mongolian idiocy. — This is a form characterised by a peculiar 
Chinese type of skull and face, with marked backwardness of physical 




Fig. 149. 



•Arrested development of the frontal lobes of the brain, particularly of the right side 
from an idiotic child twelve months old.* 



and mental development (Figs. 143-145). The head is somewhat flat- 
tened from before backward; the nose rather broad and flat; but the 



* A microscopical examination by Dr. Martha Wollstein showed the cortex in the 
affected region to be only one-third the normal thickness ; the cortical layers were ill- 
defined ; there was a striking absence of the characteristic nerve cells, both the large 
and small pyramidal cells being few in number. There was no growth of connective 
tissue. The white substance was normal, as were also the dura and pia. 






MENTAL DEFICIENCY, IDIOCY, IMBECILITY. 807 

most striking thing is the narrow palpebral fissures which have a down- 
ward inclination toward the nose. These patients almost always have 
the mouth open ; and the facial expression like that due to large adenoids 
may lead to the suspicion that this is the only condition present. The 
month breathing is, however, due rather to the peculiar conformation at 
the base of the skull, and the anterior projection of the bodies of the upper 
cervical vertebrae. The Mongolian type is seen in all degrees of severity. 
In early infancy these children may present no striking peculiarities ex- 
cept in facial expression, and a general backwardness of physical develop- 
ment. Dentition is delayed; they may not sit alone until the age of 
eighteen months or two years, and frequently do not walk or talk intelli- 
gently until they are four or five years old. In the milder forms they are 
often regarded simply as very backward children. In the more severe 
forms the mental defect may be great. Their resistance is feeble and 
many die in early childhood. Little is known of the etiology of this con- 
dition. Cases occur in all classes of society, and when other children in 
the family are quite normal. 

8. Amaurotic family idiocy. This name, proposed by Sachs,* indi- 
cates the prominent features of the malady, which is not a very rare one. 
The first symptoms are usually noticed between the third and sixth 
months in apparently healthy infants. It is then discovered that the 
infant, who before this has seemed to see well, no longer notices objects ; 
the expression becomes stupid; the infant does not hold up its head and 
never learns to sit. There is relaxation of the voluntary muscles, espe- 
cially those of the trunk. The characteristic features of the disease are 
revealed by the ophthalmoscope. There is a milky blue or white area, 
with bright cherry-red centre, occupying the place of the macula lutea, and 
atrophy of the optic disc. The ocular changes are symmetrical. The vol- 
untary muscles show more or less the reaction of degeneration. The dis- 
ease is progressive, and usually fatal within a year ; but occasionally the 
blind, helpless child may live for two or even six years. Whether the dis- 
ease is a developmental degeneration or an inflammation is not yet deter- 
mined. The brain shows defective development, with degeneration and 
chromatolysis of the nerve cells, sclerosis, and thickening of the mem- 
branes. Nearly all of the reported cases have been in Hebrews. The 
prognosis is at present hopeless. 

9. Both sporadic cretinism and chondro-dystrophy have many symp- 
toms suggesting mental defects, but they do not strictly belong in this 
category. They are considered separately later. 

In addition to the etiological factors belonging to the different con- 
ditions above described, the influence of heredity is to be considered; 
there may be hereditary nervous diseases, alcoholism, syphilis, or some 

* New York Medical Journal, July, 1896 ; also Keating's Cyclo., Supplement, 1899. 



808 DISEASES OF THE NERVOUS SYSTEM. 

other vice of constitution. Intermarriage among blood relations is one 
of the causes most frequently assigned ; but after an exhaustive study of 
the question, Huth reaches the conclusion that this view is not supported 
by the facts. 

Diagnosis. — Certain types of mental defect may easily be recognised 
after the age of three or four years, especially the more marked forms 
where they are due to the graver cerebral lesions, — hydrocephalus, micro- 
cephalus, various cerebral palsies, amaurotic idiocy, etc. In the milder 
forms and in infancy, however, this is not so easy a matter; it is often 
impossible without a considerable period of observation to distinguish 
a backward or peculiar child from one who has some serious mental 
defect. 

To appreciate the abnormal, one must be familiar with the mental 
and physical development of healthy children. A normal infant of 
average muscular development can usually support the head steadily be- 
fore five months old, often at three months; it can usually sit erect at 
seven or eight months, and stand with assistance at twelve or thirteen 
months. Toys are held and usually handled with facility at five or six 
months. The recognition of the nurse or mother comes at about the same 
time. Usually the first distinct words are pronounced about the end of 
the first year, and at two years most children put words together in 
short sentences. Variations of a few months from the averages above 
mentioned can not be considered abnormal. 

To determine whether an abnormal mental state is simply the result 
of poor general nutrition, ' or is dependent upon actual disease or imper- 
fect development of the brain, is frequently a matter of the greatest 
difficulty. The backward infant is usually distinguished chiefly by the 
things which he does not do; while with those who are deficient not 
only are the proper signs of development wanting, but many new and 
peculiar symptoms may be observed. The backward child may not sit 
alone until he is twelve or fifteen months old, and may not walk until 
he is two and a half years old, but the cerebral development is in most 
cases proportionate to the physical condition. Speech may be so delayed 
that the first words do not come until two years, and short sentences not 
until three years old, and yet in understanding what is said to and done 
for him, the child may seem bright and his development steady and pro- 
gressive, although slow. 

All children whose development is delayed should be examined for 
local signs of cerebral disease ; the symptoms mentioned under the vari- 
ous heads of early hydrocephalus, meningeal haemorrhage, and cretin- 
ism should be sought. Sight and hearing should be tested, and the eyes, 
if possible, examined with an ophthalmoscope; the co-ordination of the 
hands should be tested in various ways ; the reflexes examined, and gen- 
eral rigidity or slight paralysis noted, also the muscular power in the 



MENTAL DEFICIENCY, IDIOCY, IMBECILITY. 809 

trunk, neck, and extremities. Many children who are mentally deficient 
do not show any disturbances of nutrition during the first year. The 
growth of the body in height and weight may be quite normal ; although 
this is rarely true of the muscular power. Some of them show marked 
signs of backwardness in physical development, and in nearly all there 
are some other striking symptoms. Among the most frequently noticed 
are drooling, an open mouth, a protruding tongue, a fixed aimless stare, 
the production of some inarticulate sounds, which are usually peculiar 
to the child and may be repeated many times a day. Occasionally there 
are sharp screams without any evident cause, also irregular aimless 
movements of the hands. Objects are not properly held, and if grasped, 
they are soon dropped by an infant of twelve or fourteen months as by 
a normal one of three or four months. The child does not recognise its 
bottle or its nurse. Nystagmus is often present; and there may be ill- 
defined attacks of a convulsive nature, or typical convulsions. The in- 
fant is not attracted by bright colours or toys, and, in short, seems dull 
and unresponsive to every mental impression. 

An accurate diagnosis usually carries with it the data for a definite 
prognosis. Few misfortunes which can befall a family are worse than 
to have a mentally defective child, and the physician's opinion is sought 
early and eagerly as to the probable outlook for all children who are 
suspected to be in any way abnormal. The possibilities of error in the 
early years are great, and much needless suffering is often caused to 
parents by an erroneous opinion. It is the experience of all who see 
many of these children, that some who were regarded at the age of 
three or four }<ears as seriously defective, have in the end turned out 
to be entirely normal. One should therefore always put the best pos- 
sible interpretation upon the facts. The amount of improvement which 
takes place in many of these cases is most surprising. The above state- 
ment applies of course chiefly to children in whom there are no evidences 
of gross cerebral lesions. The deviations from what is normal are many 
and wide, and careful observation for a long period is necessary before a 
child is pronounced idiotic or even feeble-minded. 

Most cases of idiocy exhibit to a greater or less degree the stigmata 
of degeneration. In an examination of 517 idiots by Howe, there was 
found blindness in 21 ; deafness in 12; some defect of the nose or mouth, 
such as hare-lip, high palatal arch, or cleft palate, in 23 cases; and some 
deformity of the hands or feet in 5-i cases ; while in 9G there was paralysis 
of one or more limits. 

Treatment. — The problem is essentially an educational one, and for 
such education special teachers and often special schools are indispensa- 
ble. With such advantages it is surprising to see what can be accom- 
plished with many children who have a severe grade of mental de- 
fect. To furnish a proper means for educating these children is a duly 



810 DISEASES OF THE NERVOUS SYSTEM. 

of the State, and up to the present time very inadequate provision has 
been made for them. Except in the mild forms, defective children are 
better trained and educated in institutions than in the home, and j)arents 
should be urged to place them in institutions wherever practicable as 
soon as they have passed the age or development of infancy. 



CHONDRODYSTROPHY. 

Synonyms : Achondroplasia — Congenital or foetal rickets. 

This rather rare condition is the cause of some of the most marked 
examples of dwarfism known. It was recognised as an. abnormality by 
the early Egyptians and has figured in art in various ways since that date. 




Fig. 150. — SUull in chondrodystrophy, showing frontal prominence and prognathism. Girl six 

years old. 

Paintings show that many of the old court jesters were of this type. 
Because of their striking appearance, these dwarfs have always excited 
much curiosity and interest. 

The causes of chondrodystrophy are unknown; only in rare cases has 
any hereditary connection been traced. The pathological process begins 
in foetal life and consists in a disturbance of the normal ossification 
of primary cartilage. It affects endochondral ossification only, never 
intra-membranous ossification. The flat bones and the vertebras there- 
fore escape while the bones of the extremities suffer most. The dis- 



CHONDRODYSTROPHY. 



811 






Fig. 151. — Normally developed long 
bones of a foetus compared with 
those of chondro - dystrophy. 
(Spillmann.) 



ease does not affect bones which are cartilaginous or almost entirely 
so through the greater part of intra-uterine life. One of the most 

striking changes in the skull is the synosto- 
sis or early ossification of the tribasilar bone ; 
this is formed of two parts of the sphe- 
noid and the sphenoidal process of the occipi- 
tal bone. Normally this ossification does 
BBf^l not take place until adult life; in children 
I 'fll'^l w ^ cnon( lro-dystrophy it often begins in 
F -T r^ utero. This prevents a normal expansion 
at the base of the skull, and the brain as it 
grows is thus crowded upward and forward 
causing the great prominence of the fore- 
head (Fig. 150). The upper jaw appears 
very prominent on account of the depression 
at the root of the nose. 

In the long bones, there is a marked 
interference with the normal row-formation 
of the proliferating cartilage cells, which 
may be seen in all degrees. In some cases a 
periosteal lamella pushes its way between the 
epiphysis and the diaphysis, still further re- 
stricting the growth of the long bones. As bone formation beneath the 
periosteum goes on normally, the bones in this condition are thick as well 
as short. 

Symptoms. — The majority of children suffering from this condition 
are either born dead or die shortly after birth. Those who survive are 
delicate during infancy, but afterward may be- 
come strong and healthy. The most striking 
thing about their appearance is the very short 
legs and arms as compared with the length 
of the body. At birth the arms in many 
cases do not reach to the waist line, and the 
length of the body may be less than the cir- 
cumference of the head. The epiphyses appear 
somewhat enlarged, the abdomen is prominent, 
the skin of the extremities is in deep folds, the 
soft parts seeming to be much too abundant 
for the shortened bones (Fig. 152) . In infancy 
these children are often quite fat. The facial 
expression is characteristic. There is usually 
a deep depression and flattening at the base of 
the nose with a very marked prominence of the forehead. The head may 
not only seem large, but by measurement may be one or even two inches 




Fig. 152.— Chondro-dystrophy 

— infantile figure. (Marie.) 



812 



DISEASES OF THE NERVOUS SYSTEM. 




Fig. 153. — Characteristic hand 
of chondro-dystrophy. (Ma- 
rie.) 



above the normal average. An erroneous diagnosis of hydrocephalus is 
often made in the early stage. Dentition is slightly later than normal, 
but not more so than is seen in moderate rick- 
ets. Marked relaxation of the ligaments and 
rather feeble muscular power often delay walk- 
ing until the third or fourth year. If the head 
is large the fontanel may not close till the fourth 
or fifth year. The appearance of the fingers is 
quite characteristic, causing the so-called " tri- 
dent hand." The fingers are very short and of 
nearly equal length and an angular separation 
is seen at the second joint (Fig. 153). 

Although not normal in their mental devel- 
opment, these children are far from being 
feeble-minded. They are often several years be- 
hind the normal in speech and in most intel- 
lectual efforts. The average patient is able to 
read and do many ordinary things, but throughout life always remains 
somewhat peculiar, and on critical examination is found to be subnormal 

in his mental growth. These dwarfs are 
good-natured, often amusing, easily con- 
trolled, and frequently live to a great age. 
With advancing years the figure assumes 
a very peculiar and characteristic appear- 
ance. The prominent hips with the 
marked lordosis, shortened extremities, 
and late bowing of the legs, present a 
striking picture (Fig. 154). The maxi- 
mum height attained is often not more 
than three and a half or four feet. Al- 
though while young of feeble muscular 
power, later in life they often become very 
muscular. When adult life is reached the 
sexual powers are normal; if the women 
become pregnant, Cassarian section is al- 
most always required on account of de- 
formity of the pelvis. 

In infancy, chondro-dystrophy is often 
confounded with rickets, hydrocephalus 
and cretinism ; but its features are so char- 
acteristic that the mistake can hardly be 
made if the child is carefully examined. No known treatment has any 
influence upon the condition. The use of the thyroid extract is entirely 
without effect. 




Fig. 154. — A. Normally developed 
boy, age eight years. B. Typical 
chondro-dystrophy, age eighteen 
years. (Marie.) 






SPORADIC CRETINISM. 



813 



SPORADIC CRETINISM. 

Synonyms : Cretinoid idiocy, myxedematous idiocy, idiocy with 
pachydermatous cachexia. 

Since the early description of this disease by Fagge, in 1871 and 
1874, numerous cases have been published in England, on the continent 
of Europe, and in America, showing that sporadic cretinism is not con- 
fined to any country. While the condition is relatively a rare one, since 
it has been generally recognised it is found to be much more common than 
was formerly supposed. 

Etiology. — It is now well established that this condition depends 
upon the absence of the internal secretion of the thyroid gland. In 

a series of sixteen autopsies 
collected by Fletcher Beach, 
the thyroid gland was absent 
in fourteen and the seat of 
bronchocele in two. The symp- 
toms closely resemble the 
myxcedema of adults which 
follows the removal of the thy- 
roid. Eegarding the causes 
which destroy the thyroid 
gland or abolish its functions 
little is as yet known. In 
most cases it is probably a con- 
genital condition. In some in- 
stances it has followed acute 
disease. In a certain number 
of cases sporadic cretinism is 
associated with goitre. As a 
rule, only one case occurs in a 
family, the other members of 
which present nothing abnor- 
mal in mental or physical de- 
velopment. 




L~ 



I 



Fig. 155. — A typical cretin; two and a half 
years old ; a patient in the Babies' Hospital. 



Symptoms. — The symptoms 
of cretinism in most cases make 
their appearance during the 
first year, but are sometimes so slight as not to be noticed until children 
are two or three years old, and exceptionally not until the seventh or 
eighth year. The general appearance of the cretin is striking, and so 
characteristic than when once seen the disease can hardly fail to be recog- 
nised ( Figs. 1 55 and 156) . The body is greatly dwarfed, and children of 
fifteen years are often only two and a half or three feet in height. All 




bO be 



814 



SPORADIC CRETINISM. 815 

the extremities, the fingers and the toes, are short and thick. The sub- 
cutaneous tissue seems very thick and boggy, but does not pit upon pres- 
sure like ordinary oedema. The f acies is extremely characteristic : The 
head seems large for the body; the fontanel is open until the eighth 
or tenth year, and it may not be closed even in adults; the forehead is 
low and the base of the nose is broad, so that the eyes are wide apart ; the 
lips are thick, the mouth half open, and the tongue usually protrudes 
slightly; the cheeks are baggy, the hair coarse, straight, and generally 
light coloured. The teeth appear very late — in one of my cases none 
were present at two years — and are apt to decay early. 

Fatty tumours are quite constant in older children, although they are 
often wanting in infantile cases. They are seen in the supra-clavicu- 
lar region, just behind the sterno-mastoid muscle, sometimes in the axilla, 
or between the scapulae, and sometimes in other parts of the body. In 
distribution they are apt to be symmetrical, and are usually about half the 
size of a hen's egg. The neck is short and thick. In rare cases there may 
be a slight depression corresponding to the location of the thyroid gland. 
The chest is not deformed. The abdomen is large, pendulous, and resem- 
bles that of rickets. The skin is dry, perspiration scanty, and eczema is 
common. The voice is hoarse and rough. Patients often do not walk 
until they are five or six years old, and then they waddle in a clumsy way. 
All the movements of the body are slow and lethargic, and everything indi- 
cates mental and plrysical torpor. The rectal temperature is usually sub- 
normal. I had once an opportunity to observe an attack of acute broncho- 
pneumonia in one of these cretins two years old. The symptoms and 
physical signs were typical, but during the greater part of the disease 
the rectal temperature fluctuated between 95° and 98.5° F. Only once 
was a temperature above 99° F. recorded. On account of their low tem- 
perature and torpid condition these patients are very sensitive to cold. 
The mental condition is always impaired, and they are often idiotic. 
Speech is acquired late, and in some cases not at all. Cretins are dull, 
placid, and good-natured, rarely troublesome or excitable; and when 
fifteen or eighteen years old they appear like children of two or three 
years. There is an absence of development of the sexual organs, and 
almost invariably they suffer from chronic constipation. 

Diagnosis. — The diagnosis is usually easy, although the early cases 
are sometimes miscalled rickets. The low temperature, the facial ex- 
pression, the torpor, and the fatty tumours are enough to differentiate 
the two diseases. 

Prognosis and Treatment. — There is no tendency to spontaneous 
improvement. Many of lliese cases die in childhood, but a few live 
to adult life. Until within the last few years they have been con- 
sidered hopeless. The improvement which followed the use of the thy- 
roid extract in cases of adult myxcedema led to a trial of this remedy 



816 DISEASES OF THE NERVOUS SYSTEM. 

in sporadic cretinism. A sufficient number of cases have now been re- 
corded to establish the fact that the thyroid extract is a specific remedy 
for this disease. In many cases the improvement is truly remarkable 
(Figs. 156-159). After a few months' treatment the entire appearance 
of the child is in most cases changed. The idiotic expression of the fea- 
tures is lost; the thickening of the skin and subcutaneous tissues dis- 
appears; there is a marked increase in height, and in the circumference 
of the head; muscular power is rapidly developed, so that many soon 
become able to walk ; and progress is seen in dentition, and in some older 
girls in the establishment of menstruation. Intellectual progress is much 
slower than physical changes; however, nearly all the children become 
brighter and more intelligent, and most of them learn to talk. 

The ultimate results vary with the grade of the affection and the 
time when treatment is begun. I have under observation several cretins 
who have been treated from five to eight years. Although many of these 
children are very intelligent and able to attend school, they are without 
exception somewhat below other children of their ages in mental and 
physical development. There seems to be no reason why complete re- 
covery might not occur if the thyroid were begun in early infancy and 
faithfully continued. 

If the thyroid is omitted relapses occur in a few months, even in 
cases well advanced toward recovery. 

The preparation most used in America is Parke, Davis & Co.'s desic- 
cated extract, prepared from the thyroid gland of the sheep. Of this 
half a grain may be given once or twice a day at first ; after the child be- 
comes somewhat accustomed to the drug the daily dose may be gradually 
increased to four or five grains. Some disturbances are often seen at the 
beginning of the treatment — perspiration, marked irritability, and some- 
times a rise in temperature — but these soon pass off.* 

INSANITY. 

Insanity is so special a subject, that all that will be attempted here 
will be to mention the most frequent varieties seen in early life, with the 
important etiological factors which operate at this period. For a full 
discussion of the subject the reader is referred to works upon insanity, 
and to Sachs, in whose book f will be found quite a full bibliography of 
this aspect of the subject. 

Insanity is distinguished from idiocy in that it affects a mind previ- 
ously sound ; however, the two conditions may be associated. Undoubted 
cases of mental disease have been observed before the seventh year, but 

* See Osier, American Journal of the Medical Sciences, 1897, cxiv, No. 4, and 
Bram well's Monograph on Cretinism. 

f Nervous Diseases of Children, New York, 1895. See also Mills, in American 
Text-Book of Diseases of Children, Philadelphia, 1898. 



INSANITY. 817 

they are extremely rare. From this time up to puberty, however, nearly 
all the varieties seen in adult life occasionally occur, but they are very in- 
frequent even at this period. The form which insanity in childhood most 
frequently assumes is mania. 

Etiology. — Insanity is sometimes seen as a sequel of one of the infec- 
tious diseases, more often typhoid fever than any other, although it may 
follow measles, scarlet fever, diphtheria, or variola. Another cause is 
masturbation, although its effect is much more frequently seen after 
puberty than before. Hereditary syphilis is sometimes the cause of de- 
mentia, which comes on about the fourth or fifth year, or even later. 
Alcoholism, epilepsy, insanity, or other nervous diseases in the parents 
are important causes. Prolonged or continuous mental strain, the result 
of overwork in school, is a cause of considerable importance, especially in 
girls about the time of puberty. As exciting causes may also be men- 
tioned various reflex conditions, such as intestinal worms, phimosis, delay 
in the establishment of menstruation, and abnormal conditions of the nose 
and throat ; these, however, can not have much influence except where the 
predisposition is a strong one. Insanity may be associated with or may 
follow hysteria, chorea, or epilepsy. It has sometimes followed injury to 
the brain, acute meningitis, and occasionally other forms of brain disease. 

Symptoms. — Certain forms of insanity are practically never seen in 
children, such as paranoia or primary delusional insanity, acute demen- 
tia, paretic dementia, periodic or circular insanity, and cataleptic insanity. 

Mania is one of the most frequent forms, and is the most common 
variety of post-febrile insanity. Its symptoms may be quite intense, but 
are usually of short duration, lasting but a few days or weeks. In rare 
cases it may continue for months, and it may even be permanent. 

Melancholia is not uncommon. It is seen as a result of prolonged 
mental strain in school, it may be due to fear of punishment, and some- 
times may follow masturbation. It is usually associated with some very 
marked disturbance of the general health. It shows itself, as in the adult, 
by fits of depression, self-mutilation, and even by suicidal tendencies. 

Epileptic insanity may follow epilepsy in children who were previously 
mentally sound, where it may take the form of true epileptic dementia, 
or there may be attacks of mania which occur in the place of an epileptic 
seizure or follow such a seizure. Transitory attacks of fury or frenzy 
coming on without apparent cause should always suggest the possibility 
of epilepsy. 

Other forms which insanity assumes in early life are : transitory psy- 
choses, such as delirium, night-terrors, attacks of sobbing or weeping, 
sometimes from fright; moral insanity, as shown by perversion of the 
moral sense from injury or disease, and by various vicious tendencies ; 
morbid impulses, which may be homicidal or sexual, or a disposition to 
thieving, lying, pyromania, etc. ; morbid fears, of which there may be an 



818 DISEASES OP THE NERVOUS SYSTEM. 

almost endless variety. These are sometimes associated with a low state 
of physical health ; this, however, is usually not the case. 

Prognosis. — On the whole, insanity in childhood has a better progno- 
sis than in the adult. In most of the cases of mania, melancholia, the 
various transitory psychoses, or the choreic and hysterical forms, recovery 
occurs with proper treatment. The outlook for the other varieties is 
much worse, especially in those in which there is a strong hereditary 
tendency to mental disease. 

The treatment is to be conducted along the same general lines as in 
adults. 

THE STIGMATA OF DEGENERATION. 

These marks are of much importance in relation to the different forms 
of nervous disease in children, especially epilepsy, idiocy, and insanity. 
They are of great value in determining existing nervous disease, or as 
showing latent neuropathic tendencies. 

The physician should be familiar with these various signs in order that 
he may connect them with each other and refer them to their proper 
source, and at the same time, by appreciating their significance, be able 
to advise parents with regard to the care, education, mode of life, and 
occupation of children, in whom to a greater or less degree these signs 
may be present. These stigmata are not of equal importance as marks of 
degeneration. Some of them, such as facial asymmetry and most of the 
deformities of the palate, are always to be so regarded ; the speech defects 
are often so, while many of the others may or may not be, according to 
their association. The stigmata are divided into anatomical, physiological, 
and psychical. The following is the classification given by Peterson : * 

Anatomical Stigmata. — Cranial anomalies : Facial asymmetry ; de- 
formities of the palate ; anomalies of the teeth, tongue, lips, or nose. 

Anomalies of the eye : Flecks on the iris ; strabismus ; chromatic 
asymmetry of the iris ; narrow palpebral fissure ; albinism ; congenital 
cataract ; pigmentary retinitis. 

Anomalies of the ear. 

Anomalies of the limbs : Polydactyly; syndactyly; ectrodactyly ; sym- 
elus ; phocomelus ; excessive length of the arms. 

Anomalies of the trunk : Herniae ; malformation of the breasts and 
thorax ; dwarfishness ; giantism ; infantilism ; femininism ; masculinism ; 
spina bifida. 

Anomalies of the genital organs. 

Anomalies of the skin : Polysarcia ; hypertrichosis ; absence of hair ; 
premature grayness. 

* Deformities of the Hard Palate in Degenerates, by Frederick Peterson, M. D., 
International Dental Journal, December, 1895. 



DEAF-MUTISM. 819 

Physiological Stigmata. — Anomalies of motor function : Walking late; 
tics ; tremors ; nystagmus ; epilepsy. 

Anomalies of sensory function : Deaf- mutism ; neuralgia ; migraine ; 
hyperesthesia ; anaesthesia ; blindness ; myopia ; hypermetropia ; astig- 
matism ; Daltonism ; hemeralopia ; concentric limitation of the visual 
field. 

Anomalies of speech : Mutism ; defective speech ; stuttering ; stam- 
mering. 

Anomalies of genito-urinary function : Enuresis ; sexual irritability ; 
impotence ; sterility. 

Anomalies of the instinct or appetite : Merycism ; uncontrollable ap- 
petites for food, liquor, drugs, etc. 

Diminished resistance to external influences and diseases. 

Eetardation of puberty. 

Psychical Stigmata. — Insanity; idiocy; imbecility; feeble-mindedness; 
eccentricity ; moral delinquency ; sexual perversion. 

DEAF-MUTISM. 

Excluding the cases in which idiocy is present, which are not con- 
sidered in this chapter, deaf-mutism may be due either to congenital or 
acquired conditions ; the larger proportion of the cases belong in the lat- 
ter class. When congenital, deaf- mutism may result from ostitis, or peri- 
ostitis of the temporal bone, encroaching upon the cavity of the middle 
ear, from ankylosis of the ossicles, from absence of the internal ear or 
any of its parts. There may also be colloid degeneration of the labyrinth. 
It may result from atrophy of the auditory nerve, and it may be due to a 
lesion of the brain. These congenital conditions are often hereditary. 
Acquired deaf- mutism is most frequently the result of scarlet fever, and 
is due to otitis. The second important cause is cerebro-spinal meningitis, 
where it may be due to a lesion of the brain, the auditory nerve, or the 
ear. It occasionally follows mumps, diphtheria, measles, and other infec- 
tious diseases. It may result from repeated attacks of acute otitis associ- 
ated with adenoid growths or chronic rhino-pharyngitis. 

The younger the child at the time the deafness occurs the sooner the 
power of speech is lost. In most of the infectious diseases, if the attack 
occurs before the fifth year speech is lost. According to Love,* total deaf- 
ness is rare among deaf-mutes ; hearing for speech is present to a useful 
degree in about twenty-five per cent of the cases, while hearing by cranial 
conduction exists in nearly all cases. Deaf-mutism should be suspected 
if a child not idiotic shows at the end of two years no signs of beginning 
to talk. A careful distinction should be made between deaf-mutism and 
idiocy resulting either from congenital conditions or acquired disease. 

* Deaf-Mutism, by James K. Love. Macmillan & Co.. 1896. 
53 



820 DISEASES OF THE NERVOUS SYSTEM. 

It is necessary that this condition be recognised as early as possible, in 
order that the child may have the advantages of proper training daring 
its early years. The physician should insist upon the child being sent to 
an institution where it may be taught to speak as early as the third, and 
certainly by the fourth year. 

The treatment is mainly prophylactic. The most important relates to 
the care of the ears in scarlet fever, and the removal of adenoid vegeta- 
tions of the pharynx and other causes which produce attacks of acute or 
chronic otitis. For the condition itself education is the only thing to be 
considered. 



CHAPTER IV. 

DISEASES OF THE SPINAL CORD. 

MALFORMATIONS. 

Malformations of the cord are very frequently associated with those 
of the brain, and bear a certain degree of resemblance to them. (1) The 
cord may be absent (amyelia) ; this condition may exist alone or with ab- 
sence of the brain. (2) The lack of development may be only partial 
(atelomyelia), as where some of the tracts are wanting. The most impor- 
tant one is defective development of the lateral tracts, which may be a 
cause of spastic paraplegia (Charcot). (3) There may be a malposition of 
some of the gray matter (heterotopia). (4) There may be a double cord 
(diplomyelia) ; the division is generally incomplete, and is attributed to an 
abnormal development of the central canal ; it is usually associated with 
other deformities. All of these malformations are extremely rare and of 
very little practical interest. 

There remains to be mentioned the only one which is really impor- 
tant — spina bifida. 

Spina Bifida. — This is a malformation of the vertebral canal with a 
protrusion of some part of its contents in the form of a fluid tumour. The 
tumour is elastic, compressible, usually increased by crying, and sometimes 
by pressure upon the anterior fontanel. The contained fluid is clear serum, 
resembling in all respects the cerebro-spinal fluid. It is one of the most 
frequent congenital deformities. 

According to Humphrey, spina bifida is due to an early failure in 
development, — in most cases before the cord is segmentated from the epi- 
blastic layer from which it is developed. Hence it remains adherent to 
the epiblastic covering, and the structures which should be formed between 
the cord and the skin are undeveloped. For this reason we have in the 
wall of the sac a fusion of the elements of the cord, nerves, meninges, ver- 
tebral arches, muscles, and integument. If the error in development occurs 



SPINA BIFIDA. 



821 




Fig. 160. —Meningo- 
cele (partially dia- 
grammatic). A, the 
membranes ; £, the 
spinal cord ; C, the 
integument. The 
accumulation of 
fluid is behind the 
cord, which does 
not enter the sac. 



later, the cord and nerves may be attached to the sac, but not intimately 
fused with it ; in still other cases the cord does not enter the sac at all. 
The malformation may occur before the central canal 
is closed ; or, if closed, it may reopen from the accu- 
mulation of fluid. It is probable that the accumula- 
tion of fluid first occurs, and that this prevents the 
union of the parts of the vertebral arches. 

Although the tumour is generally associated with a 
bifid spine, this is not necessarily the case. The pro- 
trusion may take place through the intervertebral 
notch or foramen, or there may be a fissure of the 
bodies of the vertebrae, and an anterior tumour project- 
ing into the cavity of the thorax, abdomen, or pelvis, — 
spina bifida occulta. The principal anatomical varie- 
ties are meningocele, meningo- myelocele, and syringo- 
myelocele.* 

Meningocele. — In this form there is a protrusion 
of the membranes only (Fig. 160). The accumulation 
of fluid is either in the arachnoid cavity or the subarachnoid space poste- 
rior to the cord. The opening of communication between the tumour and 

the spinal canal is small in this variety, 
usually being about one twelfth to one 
sixth of an inch in diameter. There may 4 
however, be no communication. The 
skin is usually fully developed (Fig. 161). 
] The tumour is frequently globular, some- 
4 times pedunculated, and may attain a 
very large size, being as much as five or 
six inches in diameter. This is because 
spontaneous rupture is not likely to oc- 
cur, and the tumour does not become in- 
fected except by operative interference. 
With such tumours patients may live to 
adult life. This variety is most frequent- 
ly seen in the cervical region. It has 
the best chance of natural recovery, and 
in it operation gives the best results. 

Meningo-myelocele. — This is by far the 
most frequent variety of spina bifida, oc- 
curring in thirty-five of the fifty-seven 
cases reported by Demme. It is the form 




Fig. lDl. 



■Meningocele, in a child one 
year old. 



usually seen in the sacro-lumbar region. 



* See Report of London Clinical Society, 1885: and Humphrey, Lancet, March 
1885. 



822 



DISEASES OF THE NERVOUS SYSTEM. 




The accumulation of fluid takes place in the anterior subarachnoid space, 
less frequently in the anterior arachnoid cavity (Fig. 162). In this form 
the cord is contained in the sac, and usually forms a part of its wall. 
The tumour is smaller than the meningocele, the usual size being that of 
a mandarin orange. It is sessile, never pedunculated. As a rule it is only 
partly covered by skin, but has a central area, elliptical in shape, where 
there is only a thin, translucent membrane. This sur- 
face, which is known as the central cicatrix, is some- 
times covered with granulations, and frequently ulcer- 
ates. The tumour often has a vertical furrow or a cen- 
tral umbilication, corresponding to the attachment of 
the cord on its inner surface. The usual relation of 
the parts is for the cord to run horizontally across 
the upper part of the tumour to the central cicatrix, 
with which it becomes blended, and from which again 
the nerves arise. These re-enter the canal at the lower 
part of the tumour, and are distributed below as usual. 
In other cases the cord joins the wall of the sac soon 
after its entrance, and its attenuated fibres are found 
spread out all over the sac, coming together again be- 
low and entering the spinal canal. 

The following case, upon which I recently made an 
autopsy, is a good example of the common variety : 
The child died on the third day after birth from rup- 
ture of the sac. The tumour occupied the sacral region. The first 
sacral vertebra was normal, and beneath this the cord passed, termina- 
ting in the cauda equina soon after entering the sac, and continued 
back to the central cicatrix. Here nerve filaments blended with the 
other tissues in an indefinite structure, from which again, with toler- 
able distinctness,' they could be seen to pass over the wall of the sac and 
return to the canal. The afferent and efferent nerves and the part of the 
membranes they carried with them formed several septa, making a smaller 
separate sac within the larger one. The large sac was clearly a dilatation 
of the anterior subarachnoid space, and communicated freely with the 
same space in the cord above. 

Sy ring o -myelocele. — In this variety the accumulation of fluid is in the 
central canal of the cord, the lining of the sac being here the attenuated 
and atrophied cord elements. This is the rarest form of tumour, but the 
one most frequently associated with hydrocephalus, and consequently hav- 
ing the worst prognosis. It is usually found in the dorsal or dorso-lumbar 
region, rarely in the lumbo-sacral (Fig. 103). 

With spina bifida other deformities are frequently associated, the most 
common being club-foot, hydrocephalus, more rarely encephalocele or 
cerebral meningocele, and hare-lip. If hydrocephalus exists, there is in 



Fig. 162. — Meningo- 
myelocele (partially 
diagrammatic). A, 
the membranes ; B, 
the cord ; C, the in- 
tegument. The ac- 
cumulation of fluid 
is in front of the 
cord, the filaments 
of which are spread 
out, forming a part 
of the wall of the 
sac. 



SPINA BIFIDA. 



823 




Fig. 163.— Syringomyelocele of the mid- 
dorsal region, in a child four months 
old, who also had hydrocephalus. 



most cases a dilatation of the central canal of the cord and a direct com- 
munication between the tumour and the lateral ventricles of the brain. 

Pressure upon the anterior fontanel 
causes an increase in the size of the 
tumour, and conversely. Club-foot is 
usually double, most frequently tal- 
ipes equino-varus. In a number of 
cases there is a history of some de- 
formity in other members of the fam- 
ily. I once saw two successive chil- 
dren in the same family with spina 
bifida. 

Symptoms. — The tumour is pres- 
ent at birth, and is most frequently 
situated just above the sacrum. Pa- 
¥&&■'■*$.■' ra, ly s i s * s frequent in myelocele and 
/ V jtfr? Vk£& syringo-myelocele, but is not seen in 

meningocele ; its degree and its loca- 
tion depend upon the situation of the 
tumour and the extent to which the 
cord is involved. It is rare in cervi- 
cal tumours, and most marked in those situated in the lumbo-sacral re- 
gion. In the worst cases there is complete paraplegia, with paralysis of 
the bladder and rectum. If the tu- 
mour is sacro-lumbar or sacral, only 
the cauda equina is likely to be in- 
volved, and this but partially, so 
that the paralysis of the extremities 
is incomplete, and the bladder and 
rectum may escape. 

In Fig. 164 is shown a very re- 
markable case of sacral spina bifida 
in a boy of five years, who came 
under observation for incontinence 
of faeces. The tumour was a little 
more to the left than to the right 
side, and had been overlooked. It 
had evidently pressed upon the lower 
branches of the sacral plexus, so as 
to involve the sphincter and the 
gluteal muscles of the left side. The 
atrophy was very marked, as shown 
in the illustration. 

The natural course of spina bifida Fig. 164.— Sacral spina bifida. 




824 



DISEASES OF THE NERVOUS SYSTEM. 



is to increase steadily in size; and if the tumour is covered by skin, 
its growth may be almost unlimited. It has been known to attain a cir- 
cumference of twenty-two inches. If the integument is wanting, and the 
sac wall is very thin, rupture is pretty certain to take place, either 
spontaneously or by some accident, in the course of the first few months ; 
death then results from convulsions owing to the rapid draining away of 



f ^^^'"<W 



2* m 










•sp 



Fig. 165.— Spina bifida, witb dilatation of the central canal of the cord, and spinal meningitis. 
Ihe central canal is filled with round cells, among which are many cocci. XX is the pelli- 
cle of fibrin upon the posterior surface of the pia mater, also containing many cocci. The 
pia is every where infiltrated with cells, even to the bottom of the anterior fissure. The 
gray matter of the cord is much congested. PR is the posterior nerve root. The section is 
from the dorsal region of the cord. 



the cerebro-spinal fluid, or from secondary infection. In a large number 
of cases death is due to marasmus dependent upon the associated condi- 
tions. Infection of the tumour may take place without rupture, the germs 
passing through the wall of the sac. If the opening communicating with 
the spinal canal is small, this infection may excite an inflammation limited 
to the wall of the sac, and result in a cure of the spina bifida, usually with 



SPINA BIFIDA. 825 

sloughing. I have now under observation a girl ten years old in whom 
this occurred in infancy. The site of the former tumour is marked by a 
large dense cicatrix, and there still remains partial paralysis of the legs. 
If the opening into the spinal canal is large, inflammation of the sac is 
usually followed by spinal meningitis, which may extend upward and in- 
volve also the meninges of the brain. In a case published by Van Gieson 
and myself,* in which there was dilatation of the central canal of the 
cord and hydrocephalus, bacteria penetrated the wall of the sac and trav- 
elled up the central canal of the cord (Fig. 165), finally exciting a sup- 
purative inflammation in the ventricles of the brain, in addition to a 
spinal meningitis. Sections of the wall of the sac and of the cord at 
various levels showed the same cocci. The child died at the age of three 
weeks. 

Prognosis. — This depends chiefly upon the anatomical variety and the 
existence of complications. Simple meningocele, when covered by integu- 
ment, gives the best prognosis, and complete recovery may occur. In 
meningo-myelocele, if complete paralysis exists, the prognosis is bad ; and 
if there is hydrocephalus, the case is hopeless. In quite a number of 
cases in which cure has followed operation, hydrocephalus has subse- 
quently developed. Of fifty-seven cases reported by Demme, twenty-five 
were operated upon, with seven recoveries and fifteen deaths, while three 
were unimproved; of the thirty-two cases not operated upon, twenty- 
eight died within the first month, and not one lived over two years — 
the causes of death being marasmus, rupture of the sac, and meningitis. 

Diagnosis. — It is usually easy to recognize spina bifida, but it is often 
difficult to distinguish between the different varieties. The absence of 
a palpable fissure in the spine, perfect translucency, and a pedunculated 
tumour, all point strongly to meningocele. Paralysis of the sphincters 
and lower extremities, umbilication of the centre of the tumour, a sessile 
tumour, a palpable bony fissure, and a large central cicatrix, point to 
meningo-myelocele. The coexistence of hydrocephalus points to syringo- 
myelocele. 

Treatment. — In all cases the tumour should be protected from pres- 
sure, and care taken where it is not covered by integument, that the 
surface is kept absolutely clean and aseptic. It should be covered with 
some antiseptic powder and surrounded by a large pad of absorbent cot- 
ton, or a rubber ring-cushion. Complete paraplegia with involvement of 
the bladder and rectum, hydrocephalus, or extreme marasmus — all con- 
tra-indicate operative interference. If these are absent, operation should 
be considered. The time of operation will depend somewhat upon the 
nature of the tumour. If it is covered by integument and growing slowly, 
it is well to wait until the child is at least six months old. In other cases 

* Journal of Nervous and Mental Diseases, December, 1890. 



£26 DISEASES OP THE NERVOUS SYSTEM. 

delay is dangerous, because of the liability to spontaneous or accidental 
rupture. 

Nothing is to be expected from simple aspiration and compression. 
The methods of treatment which have been successfully employed are 
ligation, aspiration and injection, and excision of the sac. Ligation is 
admissible only where there is a pedunculated tumour; and even for 
these cases some surgeons prefer the clamp. The treatment by aspira- 
tion and injection has been widely used in Europe, but is not so highly 
esteemed in America. The tumour having been aspirated and about one 
half of its contents evacuated, there is injected, without removing the 
needle, a drachm of Morton's fluid (iodine, gr. x; iodide of potassium, 
gr. xxx ; glycerin, §j). If the tumour is pedunculated, pressure should 
be made at its neck to prevent the entrance of fluid into the canal. In 
all cases the child should be kept in a recumbent position for several 
hours. The operation is not entirely free from danger, as in some cases 
it has been followed by convulsions and death in a few hours. Consid- 
erable inflammatory reaction usually occurs, lasting from two to four 
days. After this period there is, in a favourable case, a subsidence of the 
swelling, with a gradual contraction and finally obliteration of the 
tumour. The mortality of cases treated by this method is from forty to 
fifty per cent.* My own experience includes four cases, with two re- 
coveries. 

The dangers of this operation and the uncertainty as to its results 
have led many surgeons to discard it altogether in favour of excision, 
which with the technique of modern surgery is almost devoid of risk. 
For a description of this and the various plastic operations that have 
been proposed in connection with complete or partial excision of the sac, 
the reader is referred to works upon operative surgery. In operating, it 
should not be forgotten that in the great proportion of the cases (ninety- 
five per cent, according to the Clinical Society's Eeport, which, however, 
refers only to fatal cases) some part of the cord is in the sac. The cord 
is often present in tumours situated below the third lumbar vertebra, 
owing to its attachment to the sac. 

Although recovery may follow operation, in a very large number of 
cases it is incomplete ; some degree of paralysis, with atrophy, contrac- 
tures, and deformities, remaining because of the implication of cord ele- 
ments in the sac. In a considerable proportion of cases hydrocephalus 
subsequently develops, as after similar operations upon cerebral menin- 
gocele. 

SPINAL MENINGITIS. 

In acute meningitis usually only the pia mater is involved. This rarely 
occurs alone, unless it is due to traumatism. It is most frequently asso- 
ciated with inflammation of the pia of the brain, and may occur either with 

* Report of the London Clinical Society. 



MYELITIS. 827 

the simple or the tuberculous variety. A certain amount of acute in- 
flammation of the pia mater accompanies most of the cases of acute my- 
elitis. 

Chronic spinal meningitis in children usually involves the dura only. 
Inflammation of the external layer (external pachymeningitis) is usually 
secondary to caries of the vertebrae. This is considered in the article 
on Compression-Myelitis. 

Symptoms. — The symptoms of inflammation of the spinal membranes, 
no matter with what pathological condition it may be associated, are due 
to irritation of, or pressure upon, the cord or nerve roots. Those which 
are most common are : pain in the back, which is increased by move- 
ment, and usually by pressure upon the spinous processes ; radiating pains 
following the course of the spinal nerves, felt in the extremities or in 
the trunk ; rigidity of the spinal column due to spasm of the spinal mus- 
cles, or rigidity of the muscles of the extremities ; and hyperesthesia 
along the spine, which may be quite acute. When pressure upon the cord 
is added, there is paralysis or paresis, sometimes muscular atrophy and 
anaesthesia. Any of the above symptoms may be acute or chronic, accord- 
ing to the nature of the primary disease. 

The diagnosis between spinal meningitis and myelitis is often not easy, 
for except in acute cases the two processes are usually associated ; and in a 
given case it may be difficult to decide whether the lesion of the cord or 
of the membranes is the more important one. In meningitis, pain, ten- 
derness, spasm, and irritative symptoms are generally more prominent, 
while loss of power and anaesthesia are usually partial. In myelitis the 
pain, tenderness, and other irritative symptoms are less marked, while 
paralysis and anaesthesia may be complete. 

Treatment. — This is first of the disease with which it is associated ; in 
addition, counter-irritation by means of the Paquelin cautery, rest in bed, 
and in severe cases even immobilization of the spine by a mechanical sup- 
port. Iodide of potassium is often useful. 

MYELITIS. 

Myelitis is a rare disease in children, with the exception of two varieties 
which are discussed under separate heads, viz., compression-myelitis and 
acute poliomyelitis. Otherwise myelitis usually results from injury, but 
it may occur as a complication of any of the acute infectious diseases, es- 
pecially typhoid or scarlet fever, and diphtheria, and even as a primary 
disease, where it is attributed to exposure or cold, but where it is probably 
infectious. Chronic myelitis may be due to hereditary syphilis. 

Myelitis usually occurs in children over ten years of age. In situation, 
it may be transverse, diffuse, or disseminated ; the process may be acute, 
subacute, or chronic. The lesions and the symptoms are essentially the 
same as when the disease occurs in the adult. 



828 DISEASES OF THE NERVOUS SYSTEM. 

Symptoms. — Myelitis usually comes on rather gradually, with only 
local symptoms ; but the onset may be quite acute, with severe general 
symptoms, — fever, pain, prostration and localized or general convulsions. 
The local symptoms vary with the seat and the extent of the disease. 

In transverse myelitis loss of power and anaesthesia are present below 
the level of the lesion ; either of these may be partial or complete. At the 
level of the lesion there is a zone of hyperesthesia and " girdle-pains." 
All the reflexes below the seat of the lesion are exaggerated. Those at 
the level of the lesion are lost. There may be loss of control of the 
sphincters, bed-sores, degenerative changes in the paralyzed muscles, con- 
tractures, and vaso-motor disturbances. The paralyzed muscles may be 
rigid or flaccid according to the seat and extent of the lesion. 

When transverse myelitis is situated in the cervical region there are 
paralysis and anaesthesia of the arms, legs, and trunk. All the reflexes are 
exaggerated, and there is general rigidity of the paralyzed muscles. There 
are incontinence of faeces and retention of urine, followed by incontinence 
from overflow. The pupils are frequently contracted, and there may be 
optic neuritis. Atrophy, when present, usually affects the muscles of the 
arms, and indicates that the cord to a considerable extent is involved. 
There is great danger to life, owing to paralysis of the muscles of respiration. 

When the seat of disease is the dorsal region, the symptoms are similar 
to those above described, with the exception that the arms escape, and 
that the eye-symptoms are usually wanting. This is the most favourable 
seat of the disease. 

When the disease is situated in the lumbar region, in addition to para- 
plegia and anaesthesia of the legs, there is, from the beginning, inconti- 
nence of urine and faeces. The knee reflexes are lost ; the muscles atrophy, 
and usually give the reaction of degeneration. Bed-sores are frequent. 

In diffuse myelitis the symptoms are a combination of the above 
groups. If a large part of the cord is involved, there are general paraly- 
sis and anaesthesia, loss of reflexes, marked trophic disturbances, bed- 
sores, etc. 

The course of myelitis is slow, and it usually progresses steadily from 
bad to worse. Death is due to exhaustion or complications — cystitis, bed- 
sores, or hypostatic pneumonia — or to some intercurrent disease. In a 
small proportion of the cases there may be partial recovery, but very 
rarely is this complete. The diagnosis is to be made from spinal menin- 
gitis, tumours, and haemorrhage. 

Treatment. — The treatment of the early stage consists in the use of ice 
to the spine, or counter-irritation by means of dry cups, mustard, or the 
Paquelin cautery. Later, the iodide of potassium should be given in all 
cases ; improvement may follow its use, even when there is no suspicion 
of syphilis, but large doses are required, and for a long period. Electricity 
is contra-indicated except in chronic cases, and then but little improvement 






COMPRESSION-MYELITIS. 829 

is likely to result from its use. In these patients the most important 
thing is careful attention to cleanliness and to posture, in order to pre- 
vent bed-sores, cystitis, and pneumonia. 

COMPRESSION-MYELITIS. 

Synonyms : Pressure-paralysis of the spinal cord ; Pott's paraplegia. 

Compression-myelitis is sometimes traumatic, but usually follows 
caries of the spine. It most frequently complicates this disease when the 
cervical or upper dorsal vertebrae are involved, rarely when the lower half 
of the spinal column is affected. This difference is probably due to the 
smaller size of the spinal canal in its upper portion. According to Gib- 
ney,* paraplegia is seen in fifty per cent of the cases of caries of the upper 
half of the spine. Essentially the same condition, so far as the cord is con- 
cerned, may result from tumours of the spinal cord, or from anything else 
causing pachymeningitis. These, however, are exceedingly rare in child- 
hood. 

Lesions. — In spinal caries there occurs as a result of tuberculous dis- 
ease a softening of the bodies of the vertebrae, which fall together from the 
pressure due to the superincumbent weight of the body. This causes a 
backward projection known as the kyphosis, or angular deformity. The 
spinal canal is encroached upon by the remains of the vertebral bodies 
whose ligamentous attachments have been loosened, and also by inflam- 
matory products the result of periostitis, and localized inflammation of the 
dura mater, chiefly of the external layer, but which sometimes affects the 
internal layer also. All these conditions lead to the production of a mass 
of inflammatory material, often containing tuberculous deposits, which is 
chiefly in front of the cord, but may surround it. The compression takes 
place slowly in most of the cases, from the gradual progress of the lesions 
mentioned. In a small number of cases there may be a sudden pressure 
from the slipping backward of one of the vertebral bodies. 

In recent cases the cord at the seat of compression is a little smaller 
than normal. It is usually involved to the extent of from half an inch 
to two inches. Paraplegia may have existed where the changes found in 
the cord are very slight, and sometimes where no changes are visible to 
the naked eye. In more protracted and more severe cases, the cord is 
much smaller at the point of disease, and under the microscope shows the 
changes of interstitial myelitis (Gowers) with meningitis. In old cases 
there are degeneration of the nerve elements, atrophy, and sometimes dis- 
appearance of the ganglion cells, with more or less destruction of the nerve 
fibres; sometimes all distinction between the gray and white substance is 
lost. In addition to these marked changes at the point of pressure, there 
may be ascending or descending degeneration, as from other focal lesions. 

* Journal of Mental and Nervous Diseases, April, 1897. 
54 



§30 DISEASES OF THE NERVOUS SYSTEM. 

There is usually inflammation of the nerve roots, which have also suffered 
compression. It is in many cases surprising to see to what degree the 
cord may be compressed and still preserve its functions. 

Symptoms. — In caries of the cervical region the symptoms of com- 
pression-myelitis not infrequently precede the deformity, and, in fact, the 
other objective symptoms of bone disease. The earliest symptoms of 
caries usually arise from irritation of the nerve roots, and consist of 
acute pains not often referred to the spine, but radiating to the differ- 
ent regions to which these nerves are distributed. They are felt in the 
neck, in the chest, in the epigastrium, and sometimes in the loins. Such 
symptoms indicate the presence of pachymeningitis, and may be present 
whatever the location of the vertebral caries. Accompanying these pains, 
there is noticed a gradual weakness in the lower extremities, and some- 
times also in the arms, according to the location of the disease. This 
may steadily increase for several weeks until there is complete paralysis. 
Other symptoms are then commonly present. There is usually some degree 
of anaesthesia, but in many cases there is none, and there may be numbness, 
tingling, formication, and pain. The sphincters are not often involved. 
When the disease is in the upper half of the cord, there are rigidity of the 
extremities and great exaggeration of all the reflexes, with marked ankle- 
clonus. In the rare cases in which the lumbar enlargement is involved, 
there may be loss of reflexes, paralysis of the sphincters and bed-sores. 

The distribution of the paralysis will depend upon the point of com- 
pression. If this is in the cervical region, all four extremities will be para- 
lyzed ; if in the dorsal region, only the legs. In rare cases the paralysis 
is unilateral, and if there is no spinal deformity the condition may be a 
most puzzling one. According to the extent of the secondary lesions in 
the cord, there may occur muscular atrophy and contractures. With dis- 
ease in the upper cervical region, death may result from sudden pressure 
upon the cord, owing to a dislocation of the odontoid process, which hap- 
pened in one of G-ibney's cases ; or there may be vomiting, pupillary 
symptoms, irritation of the phrenic nerve causing hiccough, or pressure 
causing paralysis of the diaphragm. 

Course and Prognosis. — These depend much upon the treatment of the 
case. In many cases of paralysis occurring early in caries, complete re- 
covery takes place in the course of a few weeks, sometimes in a few days, 
after the application of a proper mechanical support. This may be true 
even where the paralysis has continued for three or four months. In the 
cases which have been long neglected, or those in which the paralysis de- 
velops while proper mechanical treatment is being carried out, the chances 
of improvement, or at least of rapid improvement, are not nearly so good. 
Gibney gives the following statistics of one hundred and thirty-three 
cases under his personal observation : thirty-one proved fatal ; nine dying 
from myelitis, fourteen from other diseases subsequent to recovery from 



ACUTE POLIOMYELITIS. 831 

the paralysis, and six from tuberculosis before complete recovery; sev- 
enty-four recovered from the paraplegia ; twenty-seven were recorded as 
improved or still under treatment. Eelapses occurred in about fifteen 
per cent of the cases; nearly all of these, however, subsequently recov- 
ered. The usual duration of the disease is from three months to two 
years. Complete recovery has often taken place in cases that have per- 
sisted for four or five years. No case should be considered hopeless no 
matter how long the symptoms have lasted, unless there is marked atro- 
phy with loss of electrical reactions, and contractures have taken place. 

Diagnosis. — This is rarely difficult. Spinal caries should be suspected 
in every case where the symptoms point to transverse myelitis coming 
on without definite cause. The gradual onset, the radiating pains, the 
stiffness of the spine in walking, the gradual loss of power, the increased 
reflexes and ankle-clonus — all are usually present and characteristic. 
The) 7 are sufficient to warrant the diagnosis of spinal caries, even when 
no deformity exists. When there is deformity, the symptoms are un- 
mistakable. 

Treatment. — The most important indications are the removal of 
pressure and the fixation of the spine by a proper mechanical support. 
The best results are secured by the recumbent position, the child being 
fixed upon a frame, continuous traction being made upon the head. 
Other measures to be advised are the Paquelin cautery, and the internal 
use of potassium iodide. From his very extensive experience, Gibney 
has more confidence in this drug than in all else except mechanical treat- 
ment. Large doses are required, often from sixty to ninety grains being 
given daily for months. From personal observation of many of Gibney's 
cases I can bear testimony both to the beneficial effect of the iodide, and 
to the ease with which it is generally borne by children in the doses 
mentioned. Very often patients gained steadily in weight while taking 
the drug, and acne was the exception. The iodide should always be 
largely diluted. In all cases patients should be carefully watched, kept 
scrupulously clean, and the position changed frequently to prevent the 
formation of bed-sores. Electricity is contra-indicated. When the pa- 
ralysis develops rapidly or occurs suddenly, relief may sometimes be ob- 
tained by the operation of laminectomy ; but little is to be expected from 
this in the slow cases. 

ACUTE POLIOMYELITIS. 
Synonyms : Infantile spinal paralysis, acute atrophic paralysis. 

This disease is characterized by an acute onset, generally with febrile 
symptoms, by an early and usually extensive loss of power, and by a con- 
siderable degree of spontaneous improvement except in certain groups of 
muscles which remain permanently paralyzed, and undergo a very rapid 
and marked atrophy. A chronic form of the disease is described in 
adults, but this is rarely, if ever, seen in children. 



832 DISEASES OP THE NERVOUS SYSTEM. 

Acute poliomyelitis is the most frequent cause of paralysis in early life 
and it is often designated simply as infantile paralysis. 

Etiology. — In 566 * cases the age at which the paralysis developed was 
as follows : 

During the first year 20 per cent. 

" " second year : 38 " 

" " third year 22 " 

" " fourth, and fifth years 15 " 

After " fifth year 5 « 

From this table it will be seen that the great proportion of cases develop 
before the fifth year, and that eighty per cent of them begin during the 
first three years, the most frequent period being the second year. 

Boys are rather more frequently affected than girls. In the series re- 
ferred to, fifty-five per cent were males and forty-five per cent were 
females. Hereditary influences seem to have but little effect in the pro- 
duction of this disease. It is rare to find several cases in the same family, 
or to trace any relation to nervous antecedents. The onset of the great 
proportion of the cases is in summer. Of Sinkler's cases, eighty per cent 
began during the five warm months. This fact is decidedly against the 
theory so often advanced, that the disease results from exposure to cold. 
There are, however, a few cases in which the connection between exposure 
and the disease seems to be a close one. On account of the time of on- 
set — most frequently in the second year — the disease is often ascribed 
to dentition. In my series this was given as the cause in one fifth of 
the cases. The connection is at most merely a coincidence. Traumatism 
is sometimes given as a cause, but the proportion of cases in which the 
paralysis can be fairly attributed to injury is very small, yet there are a 
few in which a definite injury of considerable severity has immediately pre- 
ceded the onset. In about twelve per cent of the cases above mentioned 
the paralysis came on as a sequel to some other acute disease ; this list in- 
cludes nearly all the diseases of infancy, those most frequently noted being 
diarrhoea, scarlet fever, and measles ; but in the great proportion of the 
cases the patient was in good health at the time of the attack. 

The essential cause of the disease is as yet unknown. On account of 
the close relation of the lesion to the distribution of the blood-vessels, 
many recent writers believe poliomyelitis to be of infectious origin, the 
cord changes being the result of infectious embolism or thrombosis. 
The occasional occurrence of small epidemics strengthens this opinion. 

Lesions. — Infantile spinal paralysis is due to an acute inflammation 
of the gray matter of the anterior portion of the spinal cord. The late 

* These statistics and those which follow in this article are derived from the follow- 
ing sources: Sinkler, in Keating's Cyclopaedia, vol. iv, 355 cases; Galbraith, American 
Journal of Obstetrics, 1894, 75 cases; the remaining 146 are personal cases and others 
taken from the records of the Hospital for Ruptured and Crippled, New York. 









ACUTE POLIOMYELITIS. 833 

changes which occur in the cord as a result of this process have for 
many years been well established ; but the early changes are even yet a 
matter of dispute, owing to the lack of opportunities of examining the 
cord during the stage of acute inflammation. 

In autopsies made upon cases of long standing, the part of the cord 
affected is distinctly smaller than normal. One lateral half is usually 
involved. The microscope shows that the ganglion cells are few in 
number or that they have entirely disappeared. Those that remain are 
shrunken and deformed and scarcely recognisable as ganglion cells. The 
entire gray horn is much smaller than that of the opposite side, and many 
of its normal elements have disappeared. The white matter also is 
smaller than in the sound half of the cord. The anterior nerve-roots 
of the affected side are smaller than normal, and are degenerated quite 
to the muscles. The general changes in the cord are of a sclerotic char* 
acter. The affected muscles are degenerated, and there may be in ex- 
treme cases a complete disappearance of muscle fibres, their place being 
taken by adipose and fibrous tissue. In places where the lesion is less 
severe the fibres are small. The affected limb is shorter and the bones 
smaller than upon the sound side. These lesions are all secondary to 
those of the anterior ganglion-cells. 

The most recent observations upon the early stage of the process by 
Siemerling, G-oldscheider, and others, tend to show that primarily the 
lesion is an interstitial inflammation, and not a parenchymatous one, as 
was formerly believed. Goldscheider's * theory of the disease is that the 
first changes are in the blood-vessels, from which the process extends to 
the neuroglia and produces a proliferation of cells ; the changes in the 
ganglion cells are degenerative in character, and are secondary to those 
just described ; the same is true of the changes in the nerve fibres. 
Accompanying the process in some cases small haemorrhages have been 
observed. 

The region of the cord most frequently involved is the lumbar en- 
largement, but there may be more than one focus of disease. Usually 
only one lateral half of the cord is affected, but it is not rare for both 
sides to be involved. In such cases the lesions are generally more ad- 
vanced upon one side than the other. 

Symptoms. — A frequent form of onset is for a child to be taken quite 
suddenly ill with vomiting, pains in the legs, or general hyperesthesia, and 
a temperature of from 101° to 103° F. After these symptoms have lasted 
a variable time, usually from one to four days, the paralysis is discov- 
ered. In a smaller number of cases — about ten per cent of the entire 
number — the attack is ushered in by more severe constitutional symp- 



* Goldscheider, Zeitschrift fur klin. Med., 1893, p. 494. See also Sachs, Nervous 
Diseases of Children, 1895, p. 310. 



834 DISEASES OF THE NERVOUS SYSTEM. 

toms. There are convulsions, delirium, a temperature of 103° or 104° R, 
marked general prostration, constipation, severe pains in the back and 
extremities, — in short, all the symptoms of a severe acute inflammation. 
These symptoms last from two days to a week, often engrossing the 
attention of the physician, so that the paralysis may not be noticed until 
the patient has been sick for some time, or possibly not until the be- 
ginning of convalescence. In quite a large number of cases the general 
symptoms are very slight, and they may be absent altogether. A not 
infrequent history is that the child went to bed apparently well ; during 
the night was noticed only to be a little restless, and that the next morn- 
ing the paralysis was discovered. In two cases of my series the paralysis 
came on quite suddenly while the child was walking in the street, and 
was able to reach home only with considerable difficulty. In such cases 
it is not improbable that previous symptoms were present, but were so 
slight as to have escaped notice. 

In most of the cases there are pains in the back, in the muscles of the 
extremities, or along the course of the spinal nerves. With these pains 
general hyperesthesia is commonly associated, and there may be other 
disturbances of sensation such as numbness and tingling. The develop- 
ment of the paralysis is quite rapid, it often attaining its maximum in 
twenty-four hours ; although sometimes it will be two or three days, or 
even a week, before its full extent is seen. 

Extent and distribution of the primary paralysis. — In 560 cases in 
which this point was noted the distribution was as follows : 

One lower extremity 229 cases. 

Both lower extremities 176 " 

General paralysis of all extremities, and more or less of trunk 79 " 

One lower and one upper extremity 36 " 

Both lower extremities and one upper extremity 16 " 

One upper extremity alone 14 " 

Both upper extremities 2 " 

All other varieties 8 " 

In paralysis of the trunk, the diaphragm and other respiratory muscles 
are very rarely affected. In combinations of an upper and a lower ex- 
tremity, the limbs are more frequently affected upon opposite sides than 
upon the same side. The sphincters almost invariably escape. 

Course of the disease. — The rapid development of the paralysis is fol- 
lowed by a period of from one to four weeks' duration in which but little 
change is seen in the affected muscles. This is followed by spontaneous 
improvement, which, according to Gowers, begins in the muscles last 
affected, and generally reaches its limit in about three months. After 
this time but little spontaneous improvement is to be looked for, and the 
residual paralysis is likely to be permanent. By the end of two months 
marked atrophy is present in the paralyzed muscles. The affected limb 
is distinctly smaller than its fellow, this being quite apparent even in 






ACUTE POLIOMYELITIS. 



835 



infants. Except at the onset, sensory disturbances are absent ; the knee^ 
jerk is lost in paraplegic cases, and in those in which the extensors of 
the thigh are paralyzed. There is arrested growth in the whole limb 
(Fig. 166). It becomes much smaller and shorter than its fellow. The 
great relaxation of the ligaments at the joints may allow subluxation, 
especially at the knee and at the shoulder. The circulation in the af- 
fected limb is poor ; it is often blue and cold, but bed-sores are never 
seen. 

Electrical reactions. — Very early in the disease the atrophied muscles 

begin to lose their power 
to respond to faradism. 
In the muscular groups 
which are to be perma- 
nently paralyzed, the fara- 
dic response may be lost 
in a week. The muscles 
in which recovery is to 
take place often preserve 
a certain degree of con- 
tractility, although this is 
less than normal, and im- 
proves later. The response 
to the galvanic current 
may be increased for a few 
months, and then slowly 
fail as the muscular fibres 
themselves degenerate, and 
at the end of two or three 
years it may disappear al- 
together. The reaction 
of degeneration is present 
with great uniformity in 
the atrophied muscles, but 
in them alone. 
Residual paralysis and deformity. — Only one lower extremity is in- 
volved in half the cases, and the paralysis is usually incomplete and con- 
fined to certain groups of muscles. The extensors both of the thigh and 
of the leg are nearly always involved to a greater degree than the flexors, 
and in very many cases only the extensor groups are paralyzed. The 
muscles most frequently affected are the anterior tibial group, and next 
the peroneal group. The most frequent deformity resulting from this 
paralysis is talipes valgus, and next to this talipes varus, both of these 
being usually associated with a certain amount of equinus. In very rare 
cases there is talipes calcaneus. Most children with paralysis of only one 




Fig. 166.— An old case of infantile spinal paralysis of the 
entire left lower extremity, showing extreme atrophy 
of the thigh and leg, and a very characteristic deform- 
ity of the foot. 



836 



DISEASES OF THE NERVOUS SYSTEM. 



lower extremity are able to walk alone, or with the assistance of a steel 
brace. 

Paralysis of both lower extremities is the next in frequency. This 
also is rarely complete. In forty-three cases of my series there was 
originally complete paraplegia, but it was permanent in only three. The 
extent of recovery varies much in different cases. Usually one leg re- 





Fig. 167. — An old case of infantile spinal paralysis of the left arm and shoulder muscles, with 
resulting lateral curvature. The spinal deformity is increased by the fact that the patient 
had also suffered from empyema of the left side. 



covers to a much greater degree than the other. Most of these patients 
are able to walk with the assistance of braces, a few only by the aid of 
crutches. Some walk while they are young, but are unable to do so 
when fully grown, because the disproportion between the size of the body 
and the limbs is then much greater. 



ACUTE POLIOMYELITIS. 837 

Paralysis of one upper extremity rarely occurs alone, but is associated 
with paralysis of one or both lower extremities. Complete paralysis of 
an arm is rarely, if ever, seen. The muscular groups affected may be the 
small muscles of the hand, the muscles of the forearm, — especially the 
extensors, — or the shoulder group. Of single muscles, the one most 
frequently involved is the deltoid ; this may result in subluxation of the 
shoulder. From paralysis of the muscles of the trunk or shoulder of one 
side, lateral curvature may develop (Fig. 167). If the serratus magnus is 
affected the scapula stands out prominently, giving rise to the so-called 
" angel-wing " deformity. 

Diagnosis. — The general symptoms of the onset have nothing charac- 
teristic about them, and no diagnosis can be made until the paralysis has 
taken place. The acute onset, the rapid wasting, the spontaneous im- 
provement in certain groups of muscles, the absence of sensory symptoms, 
and finally the reaction of degeneration, — all constitute a type which it is 
difficult to confound with any other disease. 

At the onset this paralysis may resemble that resulting from acute 
transverse myelitis. In the latter, however, we get anaesthesia, exagger- 
ated knee-jerk, ankle-clonus, generally involvement of the sphincters, 
a tendency to bed-sores, slight wasting, and no reaction of degeneration. 
It is, besides, extremely rare. 

Multiple neuritis is in most cases easily distinguished from poliomye- 
litis by its gradual onset, by the presence of pain and other sensory symp- 
toms as well as loss of power, and by the fact that spontaneous recovery 
generally occurs within two or three months. Besides, there is usually a 
history of antecedent diphtheria. But multiple neuritis sometimes begins 
suddenly with febrile symptoms, and paralysis may occur early, precisely 
as it does in poliomyelitis. Furthermore, in some cases of neuritis, the 
sensory symptoms are not marked, and they may have entirely disappeared 
before the patient is seen. In such cases the diagnosis from poliomyelitis 
may be difficult or even impossible except by the course of the disease ; 
for atrophy is common to both conditions, and even the electrical reac- 
tions may be identical. There is no doubt that some cases formerly re- 
ported as examples of poliomyelitis terminating in complete recovery were 
really cases of multiple neuritis. 

The diagnosis from acute cerebral palsy is chiefly difficult when the 
spinal paralysis has been hemiplegic or diplegic in type, or when after 
cerebral hemiplegia the leg or the arm has recovered so completely 
that the case resembles monoplegia. In cerebral palsies there is usually 
rigidity ; there is no reaction of degeneration ; other cerebral symptoms 
are commonly present, or there is a history of an onset with cerebral 
symptoms; and the atrophy is less marked. The most diagnostic point 
is the electrical reactions. 

Acute poliomyelitis may be mistaken for other than nervous diseases. 



838 DISEASES OP THE NERVOUS SYSTEM. 

In the early stage it may be confounded with the pseudo-paralysis of 
scurvy. I have several times seen the mistake made of diagnosticating 
paralysis where scurvy was present. In scurvy, however, there is seen 
excessive tenderness and hyperesthesia, pain upon motion, especially 
about the knees, spongy gums, and sometimes ecchymoses about the 
joints. The muscular weakness of rickets is sometimes mistaken for in- 
fantile paralysis. However, in rickets the symptoms are always bilat- 
eral, the electrical reactions are normal, and other signs of rickets are 
present. In all doubtful cases the chief reliance for the diagnosis of 
paralysis should be placed upon the character of the electrical reactions. 
The lameness resulting from paralysis may resemble somewhat that due 
to hip-disease; but with a careful examination there can rarely be any 
difficulty in making the differential diagnosis. 

Prognosis. — Poliomyelitis is accompanied by little, if any, danger to 
life. It is possible that death may take place during the stage of acute 
inflammation, but this is certainly extremely rare. The most important 
question in early prognosis is whether there will be any permanent pa- 
ralysis, and, if so, what will be its extent. The important symptoms for 
prognosis are the amount of wasting and the condition of the electrical 
reactions. Muscles which in ten days have lost completely their faradic 
contractility are almost certain to waste rapidly and severely. The best 
indication of coming improvement is the return of faradic contractility. 
If this is completely lost for six months, recovery is doubtful; if for 
one year, improvement in these muscles is not to be" expected. If faradic 
contractility has never been lost, very great and early improvement in 
the paralyzed muscles may be confidently predicted. After three months 
but little spontaneous improvement is to be looked for, and after two 
years none at all. Complete recovery is possible only with a lesion of 
very limited extent ; and while it may occur, it is so infrequent that it 
should not be expected. 

Treatment. — Unfortunately, most of the cases do not come under ob- 
servation during the acute stage, or the nature of the disease is overlooked 
until the paralysis has occurred. In the early stage the indications are, to 
induce free perspiration by hot baths, to keep the patient in a prone or 
lateral position, and to use counter-irritation to the spine by means of 
dry cups, mustard, or the Paquelin cautery, or an ice-bag may be placed 
along the spine. The natural course of the disease is to be kept in mind, 
for the tendency is to overestimate the effect upon the paralysis of the 
drugs used in the early stage. On theoretical grounds, ergot is indicated, 
but it is doubtful whether any drugs have much effect. 

After all acute symptoms have subsided, or at the end of two or three 
weeks, electricity may be used, but its curative effects have been very 
greatly overestimated. The object in using electricity is to keep up the 
nutrition of the muscles until the cord has recovered, which it is almost 



TUMOURS OF THE SPINAL CORD. §39 

certain to do to a considerable degree. But no amount of electrization 
can preserve muscles whose ganglion cells have completely disappeared. 
These continue to waste and lose their faradic contractility, no matter 
how early electricity is begun nor how faithfully it is continued. Faradism 
may be used for such groups as respond to it ; otherwise galvanism should 
be employed. The beneficial results from electricity are to be obtained 
in the first year, chiefly in the first six months. Too much can not be 
said against the routine use of electricity in cases which have been para- 
lyzed three or four years, with the vain hope that some good may be done, 
even though there is no response to either current. Strychnine may be 
used in conjunction with electricity after all symptoms of central irrita- 
tion have subsided, but there is still great diversity of opinion regarding 
its effect. 

Friction and massage are of undoubted value in improving the circula- 
tion and the nutrition of a limb, and should be continued regularly twice 
a day for a long period. 

Mechanical Treatment. — The first use of mechanical appliances is the 
prevention of deformity. All cases of paralysis should be carefully 
watched, and braces applied as soon as any tendency to deformity from 
muscular contraction shows itself. This is much easier than to overcome 
deformities which have been allowed to develop, and quite as important 
for the patient. The second use of apparatus is to furnish support to the 
limb in order to enable the child to walk. By such means many get 
about with tolerable comfort, for whom locomotion without apparatus 
is impossible except with crutches. The third purpose of apparatus is, to 
overcome existing deformities in neglected cases.* Braces are generally 
used in conjunction with myotomy or tenotomy of the various shortened 
tendons, excision of portions of elongated tendons, and the production 
of artificial anchylosis in cases of "flail joints." By these means the 
orthopaedic surgeon is able to give a great deal of relief to these unfortu- 
nate and sometimes helpless patients. 

On the whole, the treatment is extremely unsatisfactory, and the result 
depends upon the severity and extent of the original disease, rather than 
upon the particular line of treatment adopted or the time at which it is 
begun. 

TUMOURS OF THE SPINAL CORD. 

Tumours of the cord are exceedingly rare in childhood, and almost 
unknown in infancy. The most common varieties seen in early life are 
glioma, sarcoma, and tuberculous tumours. Eisenschitz has reported a 
case of tuberculous tumour in the dorsal region occurring in a child of 

* See Gibney, New York Medical Journal, April 3, 1886, On the Limitation of 
Therapeutics in Infantile Paralysis. 



840 DISEASES OF THE NERVOUS SYSTEM. 

three and a half years. There was a similar growth in the cerebellum. 
The symptoms were essentially those of compression-myelitis. 

In my service at the Babies' Hospital I have had a case of glioma 
of the cord in a child only one year old, which was in many respects 
unique. The early symptoms were gradual paralysis of the upper ex- 
tremities, to which were added later, stiffness of the neck, and finally im- 
mobility of the head — the position being that of typical cervical caries. 
During the sixteen days of observation there was high fever, from 101° to 
104° F. There were no pupillary or vaso-motor symptoms. At the au- 
topsy the cord was found to be the seat of a diffuse gliosis. In the cer- 
vical region there was marked enlargement, the cord being fully four times 
its natural size. A microscopical examination by Dr. 0. A. Herter showed 
that the growth apparently began in the vicinity of the central canal, 
and that the gliomatous process involved the entire length of the cord.* 

A somewhat similar case has been reported by Miura in a boy of 
eight years. 

The diagnosis of tumours of the spinal cord in infancy is practically 
impossible. In later childhood they are most apt to be mistaken for 
Pott's disease, but the symptoms are the same as those seen in tumours of 
adult life. 

SYRINGO-MYELIA. 

Syringo-myelia, although a rare disease, is sometimes seen in early life. 
The term is applied to a condition in which there is a cavity in the cord 
the result of a pathological process, in contradistinction to the cases in 
which a cavity is the result of a malformation, or hydromyelus, although 
it is not infrequent for the two conditions to be associated. The patho- 
logical process which precedes the cavity formation is now thought 
to be, in most cases at least, an infiltration of the substance of the 
cord with gliomatous cells. The process is somewhat similar to that just 
described in the case of tumour of the spinal cord, with the exception 
that where it results in cavity formation it is slower. The infiltration in 
these cases usually begins near the central canal. It is followed by a de- 
generation and breaking down of the infiltrated areas, beginning at the 
centre. As the cavity forms it extends, and usually first invades the gray 
matter of the commissure, later the posterior gray horns, the posterior 
columns, or the anterior horns. The resulting cavity is usually irregu- 
lar in shape, and may be very small, or may extend through a large part 
of the length of the cord. It is most frequently situated in the lower 
cervical and upper dorsal regions. It is filled with fluid, and surrounded 
by gliomatous tissue. 

* For a full report of this case by Dr. Herter and myself, see American Journal of 
the Medical Sciences, April, 1895. See also Kohts, Beitrag zur Diagnostik der Riick- 
enmarkstumoren im Kindesalter, Dresden, 1886. 



FRIEDREICH'S ATAXIA. 841 

According to Starr, the essential symptoms are of three kinds : (1) 
There is progressive muscular atrophy, with paralysis of some or all the 
muscles of one limb, usually extending to the opposite limb and to the 
trunk, sometimes accompanied by the reaction of degeneration ; (2) vaso- 
motor and trophic disturbances in the affected limb, such as cyanosis, 
coldness, bullous eruptions, ulceration, abscesses, atrophy, and sometimes 
fragility of the bones and diminution of perspiration ; (3) sensory dis- 
turbances, which are probably the most characteristic symptoms of the 
disease, — there is loss of the sense of pain and of temperature in the atro- 
phied part, while the sense of touch and of location may be preserved. 
The extent and distribution of these symptoms will of course depend 
upon the position of the disease. 

The course of syringo-myelia is essentially chronic, the duration being 
usually several years ; and although spontaneous arrest sometimes occurs 
the disease is in most cases steadily progressive. 

The cause is unknown, and it is not influenced by any form of 
treatment. 

FRIEDREICH'S ATAXIA. 

This is a chronic disease of the spinal cord and medulla, which begins 
most frequently in childhood or about puberty. The lesion affects first 
the posterior columns, afterward the crossed pyramidal tracts, the direct 
cerebellar tracts in the lateral columns, and Clarke's vesicular columns 
in the gray matter of the cord. There is probably some disease of the 
medulla, the pons, and possibly of the cerebellum and the posterior 
nerve-roots. In advanced cases other parts of the cord may be involved. 
The disease is seen in certain families, often affecting several mem- 
bers in succession at about the same age. It occurs particularly in 
families where alcoholism, insanity, and other nervous diseases are fre- 
quent. 

Bramwell, in his monograph upon this disease, gives the following as 
the characteristic symptoms : There is ataxia, first of the lower extremities, 
but gradually extending to the upper extremities and the face. Early in the 
disease there is some weakness in the legs, especially in the anterior group 
of muscles. In the late stages this is marked and accompanied by atrophy. 
The gait is peculiar, like that of ordinary ataxic patients, the difficulty in 
walking being due to the ataxia and not to the paresis. After a time there 
is produced a characteristic deformity of the foot, — it is shortened, as if 
from pressure against the toes and the heel, the instep is high, and the ex- 
tensor tendon of the great toe stands out prominently. This deformity is 
seen quite early in the disease. There is often lateral curvature of the 
spine. The knee-jerk is absent. Unprovoked and uncontrollable laughter 
is quite a characteristic symptom of the disease. The patient is unable to 
stand with his eyes closed. There are palpitation, occipital headache, and 



842 DISEASES OF THE NERVOUS SYSTEM. 

sometimes vertigo. In the later stages speech is slow and difficult, and 
the patient talks like one intoxicated. The expression of the face is 
vacant, and often nystagmus is present. There may be choreic move- 
ments. The symptoms steadily progress until the patient may be help- 
less, although the general health may remain good for years. 

The disease is distinguished from locomotor ataxia by the absence of 
the " lightning pains," and of the bladder, rectal, or genital symptoms, the 
pupillary changes, the optic-nerve atrophy, and the trophic changes in the 
bones and joints. It is distinguished from cerebral tumour by the absence 
of headache, vomiting, and optic neuritis, and by its longer course. The 
progress of the disease is slow but steady. It may last from twenty to 
thirty years. It is incurable. 

LANDRY'S PARALYSIS (ACUTE ASCENDING PARALYSIS). 

This rare disease is occasionally seen in early life. In regard to its eti- 
ology but little is definitely known, the usual causes assigned being the 
same as those of myelitis. 

It is characterized by a paralysis — sometimes preceded by general 
symptoms of malaise, fever, etc. — which begins in the legs and spreads 
rapidly to the muscles of the trunk and upper extremities ; finally it may 
involve the neck, diaphragm, and muscles of articulation. The paralysis 
develops quite rapidly, often attaining its height in from twenty-four to 
forty-eight hours, sometimes even proving fatal within this time. In 
other cases it comes on gradually, and may be two or three weeks in reach- 
ing its maximum. There is dyspnoea from involvement of the muscles of 
respiration. The paralyzed muscles are flaccid. There is hyperesthesia, 
followed by partial or complete anaesthesia and loss of reflexes. There are 
no changes in the electrical reactions, no atrophy, no bed-sores, and usually 
no involvement of the sphincters. Occasionally the arms may be affected 
before the legs, and even the bulbar symptoms may be the first noticed. 
Death is the most frequent termination, and in fatal cases the disease lasts 
from two days to a week. If recovery takes place, it is after two or three 
months of illness. 

The pathology of the disease is as yet unknown. The indications for 
treatment are the same as in acute myelitis, for in the beginning the two 
diseases can not usually be distinguished from each other. 

THE MUSCULAR ATROPHIES. 

These cases may be broadly divided into two groups, following in the 
main the classification of Sachs : * (1) Those dependent upon disease of 
the spinal cord, — the spinal atrophies; (2) those which are primarily dis- 
eases of the muscles themselves, — the idiopathic atrophies. 

* New York Medical Journal, December 15, 1888. 






THE MUSCULAR ATROPHIES. 343 

In the group of atrophies of spinal origin belong (1) the "hand type " 
of Aran and Duchenne, which has been shown to be dependent upon a 
lesion of the spinal cord ; (2) the " peroneal type " of Charcot, Marie, and 
Tooth, which as yet lacks positive pathological proof of its spinal origin, 
although its etiology, symptoms, and course leave but little doubt that it 
belongs in the same category with the hand type. 

In the second (idiopathic) group are included (1) muscular pseudo-hy- 
pertrophy, and (2) the so-called " juvenile atrophy " of Erb, which is a 
much less frequent condition. These two varieties have the following fea- 
tures in common : There is progressive wasting, beginning early in child- 
hood, and associated at some period with hypertrophy of certain muscles. 
There are no fibrillary contractions, no reaction of degeneration, and no 
lesions in the cord. From a pathological point of view these diseases 
might be more properly considered elsewhere, but they are so closely asso- 
ciated clinically with the spinal atrophies that it has seemed better to de- 
scribe them in this connection. 

Progressive Muscular Atrophy of the Hand Type.— This disease is char- 
acterized by a very slow but progressive wasting, which usually begins in the 
muscles of the ball of the thumb of one or both hands. Then the palmar 
group of muscles belonging to the little finger are affected, and later the 
interossei. When the wasting has reached a certain degree, there is 
produced a peculiar and characteristic deformity of the hand known as 
main en griffe, or " claw-hand." Following these muscles, those of the 
forearm may be affected. At this point the disease is sometimes arrested, 
or the atrophy may extend to the muscles of the arm and shoulder, espe- 
cially the deltoid, and finally to those of the back. Exceptionally, the 
atrophy begins in the muscles of the shoulder group or even in those of 
the leg. The wasting takes place very slowly, the muscles disappearing 
fibre by fibre, bat the degree which may be reached is often extreme. 
The only other characteristic symptoms are fibrillary contractions in the 
muscles which are soon to atrophy. The patient is not conscious of them, 
but they are visible. The faradic contractility is preserved just in propor- 
tion to the amount of muscle remaining. If the atrophy is complete, it is 
entirely lost. 

The course of the disease is a very chronic one, covering many years. 
It is incurable. In rare cases the process may extend to the muscles of 
the tongue, affecting deglutition and articulation, and death may occur 
from interference with respiration ; otherwise the disease does not tend to 
shorten life. 

In this form of atrophy heredity is an important etiological factor. 
The disease may occur in children, but very often does not begin until 
after puberty. The lesion consists in an atrophy of the ganglion cells of 
the anterior horns of the spinal cord, followed by secondary degeneration 
of the anterior nerve-roots. 



844 DISEASES OF THE NERVOUS SYSTEM. 

Progressive Muscular Atrophy of the Peroneal Type. — This is much less 
frequent than the variety just described. In this form, the first to waste 
are the anterior muscles of the leg, especially the extensor longus hallucis 
and extensor communis digitorum, afterward the peroneal group. The 
small muscles of the foot are next affected, and the disease may then go 
on to involve the muscles of the calf. At this point it may be arrested 
permanently, or for several years, after which the thigh muscles may waste 
like those of the leg. After many years the hands are in some cases involved 
as in the type previously described, and even the muscles of the forearm. 
As a rule, the supinator longus, the muscles of the shoulder, neck, trunk, 
and face, escape altogether. The atrophy is generally symmetrical, but 
not invariably so. The cutaneous reflexes are usually present. There is 
no pain. The reaction of degeneration is present in some of the muscles, 
and fibrillary contractions are frequent, but not always seen. 

In this variety also the influence of heredity may often be traced. It 
is said that boys usually inherit the disease through the mother. Like 
the previous type, it begins late in childhood or not until after puberty. 

As stated above, positive proof that this disease is due to a central 
lesion in the cord is as yet lacking. Analogy, however, leads to the belief 
that it depends upon changes in the ganglion cells of the anterior horns 
in the lumbar region, similar to those found in the cervical region in the 
hand type. The course of the disease is very chronic, and it, too, is incur- 
able. The resulting deformity resembles that seen after poliomyelitis, and 
may require the same mechanical treatment, with similar operations for 
relieving contractions. 

Muscular Pseudo-Hypertrophy (Pseudo-Hypertrophic Paralysis). — This 
is the most frequent and best-known variety of the idiopathic atrophies. 
It is a disease of certain families, often three or four children being af- 
fected, the boys much more frequently than the girls. The symptoms as 
a rule come on early in childhood, nearly always before the tenth year. 
The earlier symptoms relate to a general weakness of the lower extremities, 
which is accompanied by a marked increase in the size of certain muscular 
groups, usually those of the calves, but sometimes more of the thighs or 
the gluteal regions. Children walk late and unsteadily, and fall very easily. 
They have special difficulty in rising from the floor and in mounting 
stairs. The method of rising is quite characteristic : the patient lifts his 
body until he touches the floor only with the hands and feet ; then he 
proceeds to " climb up himself " by putting first one hand upon the 
knee, and then the other, gradually moving his hands higher and higher 
up the thighs until the erect position is attained. This is seen in most 
of the cases, but not in all. 

The size attained by the calves is sometimes very great. Gowers men- 
tions a case in which a boy of twelve had calves measuring fourteen and a 
half inches in circumference. The enlargement may affect almost any 



MUSCULAR PSEUDO-HYPERTROPHY. 



845 



muscular group of the lower extremity. In the upper extremity, the in- 
fra-spinatus is most frequently enlarged, next the supra-spinatus and the 
deltoid. The pectorals and latissimus dorsi are never enlarged, but are 
generally markedly wasted. Most of these patients exhibit while standing 
a marked degree of lumbar lordosis, due to the weakness of the extensors 
of the hip. This is well shown in Fig. 168. The patient may be so weak 

upon his legs that the slightest touch 
will cause him to fall, even with his 
apparently immense muscular devel- 
opment. The small muscles are gen- 
erally weaker than those which are 
enlarged. 

Later in the disease marked atro- 
phy occurs with a corresponding 
weakness of all the affected groups, 
and the patient may be unable to 
walk or even stand. With the ex- 
ception of the use of his hands, he 
may be absolutely helpless. The 
knee-jerk is at first normal, but grad- 
ually diminishes until it is finally 
lost. The electrical reactions are 
normal until marked wasting occurs, 
when there is a lessened response to 
faradism and galvanism, but never 
the reaction of degeneration. There 
are no fibrillary contractions, and no 
sensory disturbances. The progress 
of the disease is generally slow, and 
sometimes irregular. It is often more 
rapid in early childhood, and slower 
after puberty. 

The lesions are confined to the 
[ muscles. At autopsy they appear 
kj yellow, and microscopically there is 
found very marked atrophy of the 
muscle fibres, which in places have 
been almost entirely replaced by fat; 
there may be no trace of muscle left, 
the structure resembling adipose tissue. In other places there is an accu- 
mulation of fat between the atrophied muscle fibres, and a very great 
increase of the interstitial tissue. 

The prognosis is grave, most patients dying before adult life is 
reached. The diagnosis is generally easy from the apparent hypertro- 




Fio. 168.— Muscular pseudo-hypertrophy, 
showing to a moderate degree the large 
calves and gluteal regions with a marked 
lordosis. (From a photograph by Dr. M. 
A. Starr.) 



846 DISEASES OF THE NERVOUS SYSTEM. 

phy and actual weakness of the muscular groups. The disease is incur- 
able. 

The Juvenile Form of Muscular Atrophy. — This is much less frequent 
than the form just described, but, like it, begins in childhood or early 
youth. It is characterized by progressive wasting of certain muscular 
groups, especially those about the shoulders and pelvis, and hypertrophy of 
others. Of the shoulder and upper extremity, the muscles affected are the 
pectorals, the trapezius, the latissimus dorsi, the serrati, the rhomboidei, 
the muscles of the upper arm, and the subscapulars. The deltoid, infra- 
spinatus and supra-spinatus for a long time escape, and may be hyper- 
trophied. The hand and forearm are not involved. In the lower extrem- 
ity, the muscles of the pelvis, thighs, and gluteal regions are affected, 
while those of the leg and foot escape. With this atrophy there may be 
associated a true or pseudo-hypertrophy of certain muscular groups. In 
this disease there are no fibrillary contractions, no reaction of degenera- 
tion, and no sensory disturbances. The course and result of this form 
are essentially the same as in the preceding variety. It is now generally 
regarded as closely allied to it in its pathology, the most important dif- 
ference being that of localization. 

There has been described, chiefly by Landouzy and Dejerine, another 
form of atrophy known as the infantile facial type. In this, wasting be- 
gins in the muscles of the face ; the lips are thickened, but all the rest of 
the facial muscles are markedly atrophied, giving a peculiar expression to 
the mouth known as " the tapir mouth." Later, the atrophy extends to 
the shoulders and arm, but does not involve the supra-spinatus or infra- 
spinatus, or the flexors of the hand and forearm. This is sometimes de- 
scribed as beginning in the shoulders, or even in the legs. The descrip- 
tion therefore corresponds to the juvenile form of Erb, with the addition 
of facial symptoms, and it is probably a variety of the same disease. 



CHAPTER V. 
DISEASES OF THE PERIPHERAL NERVES. 

MULTIPLE NEURITIS. 

Under the term multiple neuritis are included those cases in which 
several nerves are involved in an inflammatory process, which may at times 
be general. In its distribution multiple neuritis is usually symmetrical, 
but it is not necessarily so. 

Etiology. — The chief cause of multiple neuritis in children is diph- 
theria, although it is occasionally seen after other infectious diseases, 
especially malaria, typhoid or scarlet fever, and measles. In diphtheria 



MULTIPLE NEURITIS. 847 

the inflammation is due to the direct action of the toxines upon the nerve 
structures, since it can be induced in animals by injecting toxines into 
the circulation. There is little doubt that in all infectious diseases the 
inflammation is excited in a similar way. The metallic poisons, lead and 
arsenic, are rarely the cause of multiple neuritis in early life, and the 
same is true of alcohol, although a marked case from this cause has 
recently come under my observation in a child only three years old.* 
Lastly, there are cases in which the cause assigned is simply exposure to 
cold, — those classed as rheumatic. 

Lesions. — Almost any nerves in the body may be affected, although 
the distribution varies somewhat with the cause of the disease. The 
musculo-spiral and the anterior tibial nerves are most frequently involved, 
but the inflammation may affect any of the spinal nerves, including the 
phrenic, and occasionally the cranial nerves, especially the pneumogas- 
tric, hypoglossal, oculomotor, and abducens. Several nerves in different 
parts of the body are usually affected, the lesion being in most cases sym- 
metrical. 

The affected nerve is sometimes red and swollen, owing to acute conges- 
tion and oedema or a sero-fibrinous exudation. In other cases the changes 
are almost entirely degenerative. The microscope shows the changes 
sometimes to be chiefly interstitial and sometimes chiefly parenchymatous. 
There is an exudation of cells into the sheath, between the sheath and 
the nerve fibres, and even between the nerve fibres themselves. The 
myeline breaks up into granules, and in places may completely disappear. 

* This case was in many respects a remarkable one. The boy completely emptied a 
decanter containing twelve ounces of whisky, but almost immediately vomited the 
greater part of it. He soon after showed the symptoms of alcoholic intoxication, and 
in a few hours became comatose, in which condition he continued for twelve hours. 
After this he gradually lost power in his legs, and at the end of a week was unable to 
walk at all. He had convulsions, and after this there developed the usual symptoms 
of meningitis at the convexity, with which he was admitted to the Babies' Hospital, 
December 13, 1895, three weeks after drinking the whisky. The child was then un- 
conscious and there was present incomplete paralysis, affecting all four extremities, 
with anaesthesia of the arms. The active inflammatory symptoms continued for six 
weeks longer, during which time there were repeated convulsions, continuous stupor, 
fever, gradually increasing deformities, marked atrophy, loss of reflexes, and great dimi- 
nution in the faradic contractility of all the paralyzed muscles; in the thighs, left leg, 
and abdominal muscles there were no responses to a strong current, but there was no- 
where the reaction of degeneration. The child was at death's door for three or four 
weeks. Three months after the attack the first signs of improvement were observed in 
the cerebral symptoms. Shortly afterward he began to use his hands, and at the end 
of six weeks he was walking alone and talking freely. The improvement was very 
rapid, and eight weeks from the date of the first change for the better, and five months 
from the time of taking the whisky, he was as well as ever. The diagnosis was mul- 
tiple alcoholic neuritis, with a convexity meningitis. (Fig. 169 is from a photograph 
taken while the symptoms were at their height.) 



848 



DISEASES OF THE NERVOUS SYSTEM. 



The late changes are those of subacute or chronic degeneration of the 
nerve fibres.* 

With these changes in the nerves there are associated, in some cases, 
inflammatory and degenerative changes in the ganglion cells of the spinal 
cord, although they are much less severe than are the lesions in the nerves. 
However, they were once regarded as the explanation of some of these 
cases, particularly of diphtheritic paralysis. 

Symptoms. — The onset of multiple neuritis is in most cases a grad- 
ual one, it being usually from two to four weeks before the paralysis 
reaches its height. Very exceptionally the onset may be abrupt, with 
fever, and marked paralysis in - a few days. It is characteristic of this 
disease that both motor and sensory symptoms are present, and that they 




Fig. 169. — Alcoholic neuritis, showing characteristic dropping of the feet. This position 01 the 
lower extremities was maintained for over a month. Boy three years old. 

are the same in their distribution. The symptoms are usually symmet- 
rical. There is first noticed a general weakness in the affected muscles, 
which slowly increases to complete paralysis. As the extensor groups 
of the hands and feet are apt to be affected, there are wrist-drop and 
foot-drop (Fig. 169). The paralysis may begin in the feet and hands, 
and gradually extend until it involves not only the four extremities, but 
even the muscles of the trunk and the neck, although this is rare. The 
child may then be absolutely helpless, unable to sit up, or even to support 
his head. In such cases the head seems loosely attached to the body, ami 
rolls about on the shoulders like a ball. Weakness of the spinal muscles 
leads to deformities (Fig. 170) , which I have seen mistaken for Pott's dis- 



* For a full description of the lesions, consult Starr's Middleton-Goldsmith Lectures, 
New York Medical Record, 1887. 



MULTIPLE XEUKITIS. 



849 



ease, even by experienced observers. In most of the muscular groups 
the paralysis is incomplete. The symptoms which relate to the phrenic 
and the cranial nerves will be described with Diphtheritic Paralysis, for 
they are rarely seen in any other form. It is characteristic of multiple 
neuritis that the bladder and rectum escape. 

The sensory symptoms are marked only in the early stage of the dis- 
ease, while the paralysis is increasing ; they improve so much more rap- 
idly than the motor symptoms, that they 
may be altogether wanting at the time 
that the paralysis is at its height. In 
some cases they are so slight as to be 
overlooked. There is usually pain along 
the course of the affected nerves, which 
is sharp and neuralgic in character, and 
generally associated with acute tender- 
ness of the nerve trunks and of the mus- 
cles. Often there is a general hyperes- 
thesia in the early part of the attack, 
followed by partial anaesthesia. The 
sensations of touch, pain, temperature, 
and the muscular sense are all about 
equally affected. 

Ataxia is not uncommon, and may 
be a more striking symptom than the 
loss of power. All the reflexes are di- 
minished or lost, especially the knee-jerk, 
as the legs are usually most affected. 
Sometimes, particularly after diphtheria, 
there is loss of the knee-jerk, when there 
is no other symptom of neuritis. In the 
severe cases muscular tremor is frequent. 
Atrophy is a prominent symptom of 
neuritis, and it is evident early in the 
disease, often being quite as rapid as in 
poliomyelitis. The electrical reactions 
are altered, — every grade of reduction in 
the responses being seen, from a slight 
diminution in the reaction to farad ism 
to the complete reaction of degeneration. Vaso-motor symptoms, such as 
oedema of the affected parts, glossiness of the skin, etc., are often present. 
Deformities from muscular contraction occur early ; they may be severe, 
and in some cases, permanent. 

Course and Prognosis. — The usual course of the disease is for the symp- 
toms gradually to increase for three or four weeks and then improve, 




Fig. 170. — Multiple neuritis after diph- 
theria in a child four years old. The 
position of the head and spine are 
due to partial paralysis of the trunk 
and neck. The legs were also af- 
fected. 



850 DISEASES OF THE NERVOUS SYSTEM. 

sometimes rapidly, but more often slowly, the case usually going on 
to complete recovery in the course of a few months. Exceptionally 
the paralysis may be permanent. The sensory symptoms always disap- 
pear before the motor ones. Multiple neuritis may prove fatal, from pa- 
ralysis of the heart or the muscles of respiration, or death may be due to 
asphyxia from the entrance of food or foreign bodies into the air passages, 
owing to anaesthesia of the epiglottis and paralysis of the muscles of 
deglutition. Death sometimes follows from complications, especially 
pneumonia. The electrical reactions are of much prognostic value in 
regard to the persistence of the paralysis. If the reaction of degeneration 
is present the paralysis is certain to last many months, and some muscles 
are sure to be permanently affected. Where there is simply a diminution 
in the faradic responses, even though accompanied by marked atrophy, 
complete recovery may be expected, although it is often slow. 

Diagnosis. — The diagnostic features of multiple neuritis are the com- 
bination of motor and sensory symptoms with the same distribution, the 
occurrence of atrophy, and the diminution in the electrical responses, even 
the reaction of degeneration. The gradual onset and the wide-spread 
distribution of the paralysis are also characteristic. If all four extremities 
are paralyzed, it is altogether the probable disease ; and if to this is added 
paralysis of the neck and spinal muscles, the diagnosis is almost certain. 
The facts that the paralysis is often incomplete, and that it involves parts 
distant from each other, are also important. Neuritis may be mistaken 
for poliomyelitis, for Landry's paralysis, or for Pott's paraplegia; an 
important diagnostic point from the last mentioned is the condition of 
the reflexes, — being greatly exaggerated in Pott's paraplegia, while they 
are diminished or lost in multiple neuritis. 

Treatment. — As this disease tends in the great majority of cases to 
spontaneous recovery, it is difficult to estimate the value of any method 
of treatment. Causes, such as lead, arsenic, alcohol, and malaria, are to 
be sought and removed as the first step. During the acute stage the pain 
may be so severe as to require relief, which is best accomplished by the 
application of heat. In using counter-irritation care is necessary, and 
such active measures as cauterization should not be employed, for trouble- 
some ulceration may follow. After the acute stage has passed, or at the end 
of three or four weeks, electricity should be begun, faradism being used if 
the muscles respond to a moderate current, otherwise galvanism. This 
should be continued daily until recovery. Strychnine is much used in 
these cases, but it is doubtful whether it has any specific influence, al- 
though as a tonic it is valuable. Other tonics, such as iron, quinine, 
and most of all cod-liver oil, should be given in every case. Massage is 
also beneficial. The special treatment of cardiac and respiratory paralysis 
will be discussed in the following article. 



DIPHTHERITIC PARALYSIS. 851 



DIPHTHERITIC PARALYSIS. 



This is not only the most frequent variety of multiple neuritis, but it 
has some peculiarities which make a separate consideration of it desirable. 

Frequency. — According to the statistics of various observers, paralysis, 
including all varieties, occurs after diphtheria in from 5 to 15 per cent 
of the cases. Sanne gives 11 per cent in 2,448 cases; Lennox Browne, 14 
per cent in 1,000 cases; the Keport of the Collective Investigation by the 
American Pediatric Society, 9.7 per cent of 3,384 cases which were 
treated by antitoxine. 

It is difficult to state to what degree the frequency of paralytic 
sequelae after diphtheria is affected by the antitoxine treatment ; but the 
figures above given would indicate that the protective power of the 
serum over the nervous tissues is not so great as over others, and 
that unless administered very early it may have little or no influ- 
ence. 

Being one of the direct effects of the diphtheria toxine, neuritis is 
much more likely to follow severe than mild cases ; however, its occur- 
rence after some very mild attacks shows how great is the susceptibility 
of the nervous tissues to the action of this poison. Sometimes the throat 
symptoms have been entirely overlooked, and the development of paraly- 
sis has been the first thing to arouse a suspicion of previous diphtheria. 

Time of Occurrence. — During the second week, and sometimes even 
during the latter part of the first week, the early paralysis occurs, affecting 
the palate, and in some cases the heart. The most frequent and most 
characteristic paralysis — that affecting the throat, eyes, extremities, heart, 
or respiration — begins at a later period, usually from one to three weeks 
after the throat has cleared off, and sometimes even later than this. 

Extent and Distribution of the Paralysis. — Eoss * gives the following 
statistics of 171 collected cases of diphtheritic paralysis : Palate affected 
in 128 ; eyes in 77, in 54 of which the muscles of accommodation were 
involved ; lower extremities in 113 ; upper extremities in 60 ; trunk or 
neck in 58 ; muscles of respiration in 33. I do not think this repre- 
sents the actual frequency of the different varieties so truly as do the 
American Pediatric Society's figures, which give the forms of paralysis 
noted in a series of cases collected for another purpose. In 328 cases of 
paralysis, the variety was mentioned in 189 : in 124 the throat was af- 
fected; in 22 the extremities; in 11 the eyes; in 5 the muscles of respi- 
ration ; in 32 the heart ; in 1 the neck only ; in 8 the paralysis was 
"general." 

Symptoms. — In the great majority of cases the throat is affected, and 
usually the paralysis is first noticed there. It may involve the palate 

* The Medical Chronicle, December, 1890. 



852 DISEASES OP THE NERVOUS SYSTEM. 

alone, or the muscles of the pharynx or larynx in addition. The muscles 
of the extremities or of the eye are often next attacked. In severe cases 
there may also be involved the muscles of the trunk and neck, and some- 
times the diaphragm. Cardiac paralysis not infrequently occurs where 
no other parts have been previously affected, but in nearly all the other 
forms, the throat symptoms have preceded. It is this which distinguishes 
diphtheritic paralysis from other forms of multiple neuritis. Whatever the 
extent or situation of the paralysis, the knee-jerk is nearly always lost. The 
symptoms in the extremities and the trunk do not differ from those of 
multiple neuritis from other causes. The throat paralysis shows itself by 
a nasal voice and by regurgitation of fluids through the nose, sometimes 
by difficulty in swallowing or the entrance of food into the larynx, owing 
to anaesthesia of the epiglottis and paralysis of the muscles of deglutition. 
There may be difficulty in protruding the tongue or in articulation. 
Paralysis of the vocal cords may cause hoarseness, aphonia, or attacks of 
spasmodic dyspnoea. Facial paralysis is very rare. On the part of the 
eye there is most frequently seen inability to read, owing to paralysis of 
the muscles of accommodation ; there may be dilatation of the pupils, 
rarely strabismus or ptosis. 

Next to that of the throat, paralysis of the muscles of respiration and the 
heart are the most characteristic forms of diphtheritic neuritis. Kespir- 
atory paralysis may be due to involvement of the phrenic or the intercostal 
nerves, more frequently the former. Extensive paralysis of other parts — 
the throat, extremities, or trunk — usually precedes. The first warning is 
generally in the form of occasional attacks of dyspnoea, sometimes ac- 
companied by cough. Gradually these attacks increase in frequency and 
severity. The voice is reduced to a whisper. As the diaphragm is usu- 
ally affected, the breathing is entirely thoracic. The respiratory move- 
ments are rapid, but irregular, shallow, and ineffectual. There is cyanosis, 
also great subjective as well as objective dyspnoea. The anxiety, distress, 
and apprehension of the patient are sometimes terrible. There is a con- 
stant dread of impending suffocation, and the respiratory movements are 
continued only by the patient's constant efforts, otherwise they may cease 
altogether. After a few hours these severe symptoms may subside, to re- 
turn after a short respite. There may be several such attacks during two 
or three days, in each of which death seems imminent. Unfortunately, this 
is the most frequent termination. Of thirty-three such cases collected by 
Eoss, only eight recovered. Associated with these respiratory symptoms 
others may be present, indicating that the pneumogastric is involved. 
There may be attacks of abdominal pain, vomiting, and disturbance of 
the heart's action, — usually an irregular or intermittent pulse, which may 
be either unnaturally slow or very rapid. In many cases the heart con- 
tinues to beat normally, even though the respiration is so much disturbed. 

The premonitory symptoms of cardiac paralysis are an irregular or 



FACIAL PARALYSIS. 853 

intermittent pulse, often slow, but becoming very rapid from even the 
slightest exertion. It is always weak and compressible. The first sound 
of the heart is feeble and may be reduplicated. As the symptoms increase 
there are marked pallor, coldness of the extremities, great restlessness, 
anxiety, precordial distress, and perhaps orthopnoea. Within twenty-four 
hours from the beginning of such symptoms death usually occurs. In other 
cases it may come suddenly without any warning, or with a warning so 
slight as to be overlooked. At such times it often follows some muscular 
exertion, such as getting out of bed, walking across the room, or so slight 
an effort as sitting up suddenly in bed. Fits of temper or other excite- 
ment have at times produced it. It is by no means certain that sudden 
heart paralysis is always due to a lesion of its nerves. A not less impor- 
tant cause is toxic myocarditis. In the cases where death occurs sud- 
denly without premonition after some muscular effort, it is in all prob- 
ability the heart muscle which is most at fault. However, in many cases 
the two conditions are associated. 

Death from diphtheritic paralysis is usually due either to cardiac or 
respiratory paralysis. Of one hundred and seventy-one cases of all va- 
rieties collected by Ross, forty-five were fatal. 

Treatment. — Cases of paralysis of the trunk or extremities are to be 
managed like others of multiple neuritis. In severe forms of throat 
paralysis feeding by a stomach tube should always be employed, on ac- 
count of the danger of the entrance of food into the air passages. It 
must in most cases be continued for several days. The tube may be 
passed either through the mouth or the nose. 

The great mortality attending paralysis of the heart and respiration 
shows how unsuccessful is treatment in most of the cases ; still", no doubt 
there are instances where life may be saved by judicious treatment. In 
cases of threatened heart paralysis, the drug most to be depended upon 
is morphine, hypodermically ; this should be used every two or three hours 
in sufficient doses to keep the patient under its influence while threat- 
ening symptoms are present. In some cases it may be advantageously 
combined with strychnine. The patient should be kept absolutely quiet, 
not even being allowed to turn in bed. In respiratory paralysis the gen- 
eral reliance is upon strychnine used hypodermically in full doses, and 
faradisation of the respiratory muscles, particularly the diaphragm; it 
may be used in the attacks of respiratory failure and continued while they 
last. Large doses of diphtheria antitoxins have in some instances ap- 
peared to benefit these cases and should be tried. In the great majority, 
however, the damage al ready done is so great that no improvement follows. 

FACIAL PARALYSIS. 

Peripheral paralysis of the face occurring as a result of injury inflicted 
during delivery has already been described (page 110). There remain to 
55 



854 



DISEASES OF THE NERVOUS SYSTEM. 



be considered here cases which arise from causes that operate at a later 
period. The facial nerve may be affected in any one of three situations, — 
after its exit from the cranium, in the bony canal, and within the cranium. 

In the first situation, the principal cause of neuritis is exposure to cold 
(the " rheumatic " cases), but it occasionally occurs as a complication of 
mumps and disease of the lymph glands of this region. The nerve is af- 
fected just after it has escaped from the stylo-mastoid foramen, and all the 
branches given off beyond its exit are involved. There is paralysis of the 
muscles of the forehead, those about the eye, the cheek, nose, and mouth. 
The affected side of the face is smooth, there is inability to wrinkle the 
forehead, contract the eyebrows, close the eye completely, raise the nos- 
tril, whistle, or blow. The mouth is 
drawn to the healthy side (Fig. 171). 
If the paralysis is complete, there may 
be difficulty in drinking or in articula- 
tion. In partial paralysis the symp- 
toms may not be noticeable while the 
face is at rest. There are no sensory 
symptoms. The electrical reactions 
resemble those of other forms of neu- 
ritis ; there is diminution in the re- 
sponse to the faradic current, which 
is more or less marked according to 
the severity of the lesion, and there 
may be the reaction of degeneration. 

In the bony canal, the facial nerve 
is usually inflamed as a result of dis- 
ease of the ear. In children this is 
much more frequent than from the 
causes just mentioned. While it is 
possible for it to occur in acute cases, it generally accompanies chronic 
otitis, especially where there is caries of the petrous bone. In addition to 
the paralysis there is present or there is a history of a discharge from 
the ear, and generally there is some deafness upon the side affected. The 
facial symptoms are usually the same as in the cases first described. 
However, when the nerve is affected between the stapedius and the genic- 
ulate ganglion, there is a disturbance of the sense of taste, and of the 
secretion of the saliva. 

At the base of the brain the trunk of the nerve may be involved in 
cerebral tumour, basilar meningitis, and in fracture of the skull. In any 
of these conditions the auditory nerve also is likely to be affected. 

Prognosis. — The result is greatly modified by the causes in the dif- 
ferent cases. In those which are due to cold, spontaneous recovery 
usually occurs in the course of a few weeks or months. In those depend- 




\ 



Fig. 171. — Facial paralysis of right side 
from middle-ear disease in a child two 
and a half years old. 



FACIAL PARALYSIS. §55 

ing upon disease of the ear, the outlook is not so favourable, and though 
there may be improvement, it is not rare for some paralysis to be per- 
manent. In the third group of cases, facial paralysis is only one of the 
symptoms, and the result depends entirely upon the nature of the cause. 

Diagnosis. — Facial paralysis is easily recognised. It is important to 
separate the peripheral paralysis from that due to a lesion above the 
pons, as in cases of ordinary hemiplegia. In the latter group only the 
lower half of the face is affected, the muscles of the forehead and those 
about the eye escaping, and the electrical reactions are unchanged. 

Treatment. — This is essentially the same as in other cases of neuritis. 
In cases due to ear disease the primary lesion should receive appropriate 
treatment. 



SECTION YIIL 

DISEASES OF THE BLOOD, LYMPH NODES, SPLEEN, BONES, 

AND JOINTS. 



CHAPTEE I. 
DISEASES OF TEE BLOOD. 

In general, the blood in infancy and childhood, as compared with that 
of adult life, is thinner and contains a larger proportion of water ; it is 
also poorer in solids and has a lower specific gravity. 

Specific Gravity. — This has no constant relation to the number of 
white or red corpuscles, but varies with the amount of haemoglobin. The 
highest specific gravity is seen in the blood of the newly born. During 
the first two weeks of life it sinks rapidly to its lowest point, where it 
remains until about the end of the second year; after this time it rises 
gradually until about puberty. The average specific gravity during 
childhood is 1 -050 to 1 -055. 

Haemoglobin. — The percentage of haemoglobin is highest in the blood 
of the newly born, and falls rapidly during the first few days a f ter birth. 
Throughout childhood it is considerably lower than in adult life. The 
haemoglobin is lowest between the third month and the second year; 
after the second year it gradually increases up to puberty. The usual 
range in young children, as measured by the adult standard, is between 
65 and 85 per cent, 65 per cent being a low limit in healthy children. 

Red Corpuscles. — The number of red corpuscles is highest in the 
newly born. At this time it is from 4,350,000 to 6,500,000 in each cubic 
millimetre. In infancy it is from 4,000,000 to 5,500,000 ; in later child- 
hood, from 4,000,000 to 4,500,000 (Hayem). In size a much greater 
variation is seen in the red cells of the newly born than in those of older 
children and adults. In the blood of the foetus there are present nucle- 
ated red corpuscles or normoblasts (Plate XV, A). These diminish in 
number toward the end of pregnancy. They are always found in the 
blood of premature infants, but in infants born at term they are seen 
only in small numbers and disappear after a few days. In later infancy 
their presence is always pathological. 

856 



PLATE XV. 




A. 



B. 




Drawn by Dr. F. C. Wood. 



A. Blood of an Eight-Months' Fcetus. 
C. von Jaksch's Anjemia. 

1. Heel cells, normal. 

2. Red cells, normoblasts. 

3. Red cells, megaloblasts. 

4. Red cells, showing mitosis. 

5. Red cells, poikilocytes. 

6. Red cells, granular degeneration. 



B. Simple Anemia. 

D. Acute Lymphatic Leukaemia. 

7. Red cells, polychromatophilia. 

8. White cells, polynuclear neutrophiles. 

9. White cells, eosinophiles. 

10. White cells, lymphocytes. 

11. White cells, myelocytes. 

12. While cells, mast cells. 



DISEASES OF THE BLOOD. 857 

Normal White Cells. — According to Ehrlich, the following varieties 
are found in health : 

1. Lymphocytes. These are small cells about the size of a red blood 
cell. The protoplasm is small in amount, forming merely a narrow rim 
about the nucleus ; it stains with basic dyes rather more deeply than does 
the nucleus. The nucleus is relatively large, is centrally situated, and 
shows at times one or two nucleoli. The protoplasm may have a reticu- 
lar structure. These cells form in adults from 22 to 25 per cent of the 
white corpuscles, but in children they are often as high as 50 or 60 per 
cent. (Plate XV, B, 10). 

2. Large mononuclear leucocytes and transitional forms. These 
cells are two or three times the size of ordinary red cells (Plate XV, D, 
10). The oval nucleus is not so centrally situated as in the lymphocytes, 
and stains feebly but rather darker than the protoplasm, which is feebly 
stained by basic dyes. The protoplasm is homogeneous and relatively 
large in amount. 

The transitional forms occasionally contain a few feebly staining neu- 
trophilic granules ; their nuclei are bent or curved and stain more deeply. 

3. Polynuclear neutropltiles. These are smaller than the large leu- 
cocytes (Plate XV, B and C, 8). The nucleus consists of three to four 
parts, usually connected by narrower portions, and stains darkly. The pro- 
toplasm stains with acid dyes and shows a great number of granules which 
stain only with neutral dyes. In adults these cells form about 70 per 
cent of the white cells; but in children they are less numerous, the in- 
crease in the lymphocytes being at the expense of the neutrophiles. 

4. Eosinophiles. These are about the same size as the neutrophiles 
(Plate XV, C, 9) ; they have deeply staining nuclei, usually divided 
into two parts. The protoplasm has many large granules that stain 
deeply with acid dyes, and often a narrow outer layer staining more 
deeply than the rest. They form from 2 to 4 per cent of the total number 
of white cells. 

5. Mast cells. They are only occasionally found, their proportion 
being about 0.5 per cent of the white cells; they are mononuclear or 
polynuclear cells whose granules stain only with basic dyes, not at all 
with tri-acid; often they are metachromatic (Plate XV, C, 12). 

Pathological White Cells. — Of these there are two principal forms : 

1. Myelocytes. They have neutrophilic granules and a single rounded 
nucleus (Plate XV, C, 11). Ehrlichias myelocytes differ from those of 
Cornil in that the cells as a whole are smaller, the nuclei are more cen- 
trally situated and stain more intensely. 

2. Mononuclear eosinophiles. These resemble the polynuclear eosin- 
ophiles, except for the round undivided nucleus. Pathologically, the 
leucocytes may undergo acute or chronic degeneration, with swelling and 
fragmentation, nuclear changes, hydropic degeneration, etc. 



858 DISEASES OP THE BLOOD. 

The number of leucocytes in the blood of the newly born, according 
to Kieder, is at birth from 14,200 to 27,400; from the second to the 
fourth day, from 8,700 to 12,400; after the fourth day, from 12,400 to 
14,800. The variations in infancy are from 9,000 to 14,000, and in later 
childhood from 6,000 to 12,000. 

LEUCOCYTOSIS. 

By leucocytosis is meant an increase in the white corpuscles of the 
blood. This may relate to all or any of the varieties; although it is 
chiefly of the polynuclear neutrophiles, there is seen in children a greater 
tendency than in adults to an increase in the lymphocytes. 

It is customary to distinguish between physiological leucocytosis, 
such as that which follows a full meal, exercise, cold baths, or that which 
occurs in the newly-born infant, and pathological leucocytosis which 
occurs principally in inflammatory and toxic conditions, but may be seen 
also in malignant disease and after serious haemorrhage. 

Digestive leucocytosis, that which occurs after feeding, is especially 
pronounced in children, the increase frequently amounting to 33 per 
cent of the total number of leucocytes present. Leucocytosis of the 
newly born has already been mentioned. 

Leucocytosis is present in a great variety of pathological conditions. 
In many of them its significance is not yet fully understood; further 
study of it has not fulfilled the expectations of those who had hoped 
to obtain from it exact information regarding many pathological pro- 
cesses. 

The form of leucocytosis which is chiefly important in children is the 
inflammatory. This is most marked in acute pneumonia, diphtheria, 
and in inflammations attended by the formation of pus. It is also fre- 
quently present in pertussis, scarlet fever, erysipelas, acute rheumatism, 
septic and cerebro-spinal meningitis, and in severe forms of rickets. 
Of the purulent inflammations, it is especially important in appendicitis, 
peritonitis, empyema, pyaemia, septicaemia, osteo-myelitis, and all acute 
abscesses. In the conditions above mentioned the increase is chiefly or 
exclusively in the polynuclear neutrophiles. 

There are other conditions, especially hereditary syphilis, scurvy, and 
certain diseases of the spleen, in which the proportion of the lympho- 
cytes may be increased ; but under these circumstances the other white 
cells are generally diminished. 

The eosinophiles are principally increased in leukaemia; but an in- 
crease may also be present with intestinal parasites, especially tapeworm 
(Buckler), and in some forms of chronic skin disease. As a rule, leuco- 
cytosis is absent in typhoid fever, measles, malaria, influenza, and in 
tuberculous inflammations. D'Orlandi found it wanting in twenty cases 
of gastro-enteritis in infants. 



LEUCOCYTOSIS. 859 

Leucocytosis may be regarded as the reaction of the organism to the 
toxins in the blood elaborated by the bacteria concerned in the inflam- 
mation or infection, or to the bacteria themselves. It thus depends 
upon two factors: the severity of the infection, and the amount of re- 
sistance of the individual, the latter being the more important. A 
severe infection with a high degree of resistance produces the most 
marked leucocytosis, while with very feeble resistance and the same in- 
fection the leucocytosis would be slight or possibly absent. 

The degree of leucocytosis is also influenced by the nature of the in- 
flammatory process, it being less marked in serous inflammations, more 
pronounced in suppurative processes. In inflammations it is usually 
greatest during the active stage of exudation. 

The Diagnostic Value of Leucocytosis. — The following are the prin- 
cipal diseases in which a leucocyte count may be of clinical assistance : 

Appendicitis. — A marked leucocytosis may assist in distinguishing 
suppurative from catarrhal appendicitis, and usually points to the exist- 
ence of an abscess. 

Pneumonia. — A marked leucocytosis is a characteristic feature of 
this disease; the exceptions are very mild cases or very severe infection 
with little or no reaction. The increase begins shortly after the onset 
and continues during the stage of exudation, generally reaching its 
maximum shortly before the crisis, when it declines rapidly. The usual 
number of white cells in an average case of pneumonia in a young child 
is from 15,000 to 30,000, but it is not rare for the count to run up to 
40,000 or even 50,000. I have seen it over 100,000. The absence of leu- 
cocytosis in a strong child who is acutely ill is always strong presumptive 
evidence against pneumonia. A well-marked leucocytosis is of much 
value in differentiating pneumonia from typhoid fever, tuberculosis, in- 
fluenza, and bronchitis. 

Empyema. — A rapid increase in the leucocytes in the active stage of 
a pneumonia or after defervescence, in the absence of physical signs 
pointing to an extension of the pneumonic process, almost invariably 
indicates empyema. 

Typhoid Fever. — Leucocytosis is regularly absent in typhoid; its 
presence in an undoubted case indicates complications. 

Pertussis. — Leucocytosis is of considerable value in the diagnosis of 
this disease; it is considered in that connection. 

Meningitis. — As a rule, leucocytosis is present in acute simple and 
cerebro-spinal meningitis; in tuberculous meningitis it is not constant, 
and if present is generally less marked than in the other forms. 

Tuberculosis. — Leucocytosis is regularly absent in unmixed tuber- 
culous infections. 

In surgical diseases the presence of leucocytosis is considered a reli- 
able guide as to the existence of acute suppuration, although not always 



860 DISEASES OF THE BLOOD. 

as to its degree. An increasing leucocyte-sis is usually an indication for 
operative interference in cases where operation is admissible. This 
applies particularly to appendicitis. 

The Prognostic Value of Leucocytosis. — As the leucocyte count de- 
pends largely upon the resistance of the individual, it is generally true 
that in the diseases usually accompanied by leucocytosis a high count is 
a favourable sign. This is generally the case in pneumonia, unless the 
attack is a very mild one. On the other hand, in a severe attack a low 
count is very unfavourable. The following' case may be cited in illustra- 
tion : A delicate child, twelve months old, on the eleventh day of a severe 
lobar pneumonia had 24,500 leucocytes. Two days afterward a critical 
fall in the temperature occurred and resolution followed. The same 
child two weeks later was attacked with pneumonia in the opposite lung. 
On the second day the leucocyte count was 18,000; on the fourth day, 
9,900; on the sixth day, 7,300. Death occurred the following night. 

The value of the leucocyte count in diphtheria and its bearing upon 
prognosis are discussed under that disease. 

SIMPLE ANEMIA. 

This consists in an impoverishment of the blood, especially the red 
cells, and a corresponding diminution in the specific gravity and in the 
amount of haemoglobin. It is essentially a secondary anaemia, and occurs 
apart from, disease of the blood-making organs. Infancy and childhood 
are themselves strong predisposing causes of anaemia, on account of the 
great demands made upon the blood in the rapid growth of the body. 

Etiology. — The causes of anaemia embrace a wide range of patholog- 
ical conditions. A child born of a delicate mother or of one suffering 
from tuberculosis or syphilis may show marked anaemia at birth. It may 
follow any severe haemorrhage or occur in any of the blood dyscrasiae, 
purpura, scurvy, etc. ; also, loss of albumin from the blood as in prolonged 
suppuration, chronic nephritis, large serous effusions, many forms of 
diarrhoea and in malignant disease. Anaemia is often of toxic origin, 
sometimes being due to mineral poisons — lead, mercury or potassium 
chlorate; more frequently it arises from auto-intoxication, the result of 
absorption of the products of intestinal putrefaction. Certain of the 
specific infections, notably diphtheria, malaria, tuberculosis and rheu- 
matism, produce a marked degree of anaemia, as one of their effects; also 
some of the intestinal parasites, particularly varieties of the tapeworm. 

Much more frequent in young children than any of the above are the 
anaemias due to improper feeding and unhygienic surroundings. How 
important these causes are and how severe a grade of anaemia may be 
produced by them, is not usually appreciated. The physician is often 
led to suspect some serious organic or constitutional disease where none 
exists and to overlook such common conditions and obvious causes as 



SIMPLE ANAEMIA. 861 

those mentioned. Anaemia is seen where lactation is nnduly prolonged. 
It is a frequent result of the long-continued use of milk or infant foods 
as the sole diet, given, as these often are, throughout the second or third 
year, for the reason that the child will take no solid food, because he 
is allowed to have the bottle. Lack of fresh air, confinement to over- 
heated rooms and the crowding of young children in hospitals and insti- 
tutions are common and important causes of anaemia. 

Symptoms. — Anaemic children usually exhibit many symptoms of mal- 
nutrition. Their tissues are flabby; they are generally below average 
weight and suffer from digestive disturbances and chronic constipation. 
The associated nervous symptoms are many : headaches, indefinite pains, 
insomnia or disturbed sleep, general irritability and a high degree of 
nervousness, often ending in chorea. There is easy fatigue, shortness 
of breath on exertion, and sometimes fainting attacks. The peripheral 
circulation is poor ; hands and feet, often cold. The pulse may be slightly 
irregular. Anaemic murmurs are heard over the base of the heart or the 
large vessels, and may be so loud even in infancy as to be mistaken for 
organic disease. A venous hum is sometimes heard in the neck. Epis- 
taxis is not uncommon. The urine is scanty, sometimes pale, and fre- 
quently contains an excess of uric acid. There may be enuresis. (Edema 
is rare in older children, but in severe anaemias of infancy it is often 
marked. In a certain number of cases, even of moderate severity, the 
spleen is much enlarged. Pallor of the skin and mucous membranes is 
present in most cases, but is not an accurate guide as to the degree of 
anaemia. This can only be determined by an examination of the blood. 

The Blood. — There is a reduction of the number of red cells and to 
a still greater degree in the haemoglobin. In a case of moderate severity 
the red cells are from 4,000,000 to 4,500,000, and the haemoglobin from 
50 to 60 per cent. In severe cases the red cells may fall to 2,000,000 or 
2,500,000 or even lower, and the haemoglobin to 20 or 30 per cent. These 
figures are not uncommon. The lowest I have seen is a reduction of the 
haemoglobin to 15 per cent and of the red cells to 1,400,000. The red 
cells are pale. There is usually poikilocytosis ; and, especially in infancy, 
a few normoblasts and megalocytes may be found (Plate XV, B). 

There is generally a slight leucocytosis. The differential count of 
the white cells shows an increase in the lymphocytes, chiefly the small 
variety; the polynuclear cells are relatively reduced in number. 

Prognosis. — The course and termination of anaemia depend upon its 
cause. If this is one that can be removed, as in cases depending upon 
improper feeding and surroundings, very rapid improvement often takes 
place and prompt recovery. In the most severe cases death may occur, 
rarely from the anaemia, usually from some complicating disease. 

In making a prognosis in a given case the general symptoms and the 
cause of the anaemia arc much more important than the examination of 
56 



862 



DISEASES OF THE BLOOD. 



the blood. If the digestive organs are in good condition and good sur- 
roundings can be secured, often, though the haemoglobin and red cells 
are very greatly reduced, the prognosis is good. But in unfavourable 
surroundings and with a greatly disordered digestion, the outlook is 
much more serious. 

Typical blood examinations of a moderate and of a severe case of 
secondary anaemia in a young child are as follows : 

Moderate Anemia. 



Severe Anaemia. 

Haemoglobin 20 per cent. 

Red blood cells 2,500,000 

White cells 12,000 

Polynuclear 30 per cent. 

Small mononuclear 45 per cent. 

Large mononuclear 25 per cent. 

Other forms 5 per cent. 



Haemoglobin 50 per cent. 

Red blood cells 4,000,000 

White cells 10,000 

Polynuclear 40 per cent. 

Small mononuclear 25 per cent. 

Large mononuclear 20 per cent. 

Other forms 5 per cent. 



The treatment of all the forms of anaemia will be considered together 
at the close of the chapter. 

CHLOROSIS. 

Chlorosis is a primary or essential anaemia which usually occurs in 
young girls about the time of puberty. It is characterized by a peculiar 
greenish-yellow tint of the skin, and is not accompanied by emaciation. 
The changes in the blood consist in a very great reduction in the haemo- 
globin without a corresponding diminution in the red corpuscles. 

Etiology. — The exact cause of chlorosis is not yet understood. The 
disease rarely occurs in males; it is usually seen in girls between the 
fourteenth and seventeenth years, and more often in blondes than 
in brunettes. Heredit}^ appears to be a factor in some cases. Other 
causes are occupations deleterious to health, such as employment in 
factories or confinement in ill- ventilated rooms; insufficient food or 
clothing; psychical disturbances, like grief, care, or fright; excessive 
mental or physical strain; and disorders of menstruation — although the 
latter are perhaps more frequently a result than a cause of the disease. 
Virchow first called attention to the fact that chlorosis might depend 
upon a congenital narrowing of the aorta, sometimes associated with a 
small heart. It is difficult to reconcile this etiology with the rapid recov- 
ery under appropriate treatment which is seen in most of the cases. 
Andrew Clark has advanced the view that the chief cause of chlorosis 
is constipation and the resulting absorption of toxic materials from the 
intestine. 

Lesions. — Chlorosis is rarely fatal. In the few fatal cases the lesions 
noted have been dilatation of the right heart with hypertrophy of the left 
ventricle, a small aorta, small uterus and ovaries, and occasionally round 
ulcer of the stomach. Under the microscope there may be found a very 



PSEUDO-LEUK.EMIC ANJSMIA OF INFANCY. 863 

marked degree of fatty degeneration of the heart muscle, and sometimes 
of the inner coat of the blood-vessels. 

Symptoms. — The general symptoms of chlorosis are very much like 
those of simple anaemia. There are observed shortness of breath upon 
exercise, palpitation, syncope, attacks of vertigo, disturbances of diges- 
tion, amenorrhea, and almost invariably constipation. The appetite is 
capricious, it being a peculiarity of these patients to crave all sorts of 
indigestible articles. Instead of the usual pallor of anaemia, the skin 
has a yellowish-green tint, from which the term " green-sickness " has 
arisen. Occasionally patches of pigmentation are seen. Anaemic car- 
diac murmurs may be heard in various situations, most frequently a 
systolic murmur at the base of the heart, and usually loudest over the 
pulmonic area. There may be a venous hum in the neck. In some 
marked cases there is evidence of slight cardiac dilatation, especially 
of the right heart, and there may be hypertrophy of the left ventricle. 
The pulse is weak and soft, oedema of the feet is frequent, and some- 
times there is slight albuminuria. In some cases there is fever. Nerv- 
ous disturbances, such as vague, indefinite pains, attacks of migraine, 
supra-orbital neuralgia, various hysterical manifestations, and chorea, 
are common. Ulcer of the stomach is sometimes seen as a complication. 

The blood. — The specific gravity is reduced in proportion to the loss 
of haemoglobin. The characteristic feature of chlorosis is a loss of haemo- 
globin which is out of proportion to the reduction in the red cells. The 
haemoglobin in an ordinary case is frequently as low as 35 or 40 per cent, 
while the red cells may be 3,500,000 to 4,000,000, or even higher. 

Morphologically the cells are pale with a wide central clear area. 
Poikilocytosis may be present, but is not marked; rarely normoblasts 
may be found. The presence of megalocytes is disputed. The leuco- 
cytes are usually unchanged in number and proportion, but the lympho- 
cytes may be relatively increased. 

Prognosis. — The course of the disease is essentially a chronic one, 
often lasting for a year. Kelapses are quite frequent. Except when de- 
pendent upon congenital malformations of the heart and blood-vessels, 
these cases regularly recover when proper treatment can be carried out. 
A small number prove fatal by the development of tuberculosis or the 
occurrence of gastric ulcer. 

Diagnosis. — The diagnosis is in most cases easily made from the eti- 
ology, the functional derangement of the heart, the colour of the skin, 
and a positive diagnosis always by an examination of the blood. 

PSEUDO-LEUK^MIC ANEMIA OF INFANCY. 
This form of anaemia was first described by Von Jaksch in 1889, and 
is by him believed to be peculiar to infants and young children. It is 
characterized by marked leucocytosis, marked reduction in the number 



864 DISEASES OF THE BLOOD. 

of red cells and m the haemoglobin, a great enlargement of the spleen, 
and sometimes a moderate enlargement of the liver and the lymphatic 
glands. This disease is not to be confounded with the pseudo-leukaemia 
of adults, or Hodgkin's disease, which is purely a disease of the lym- 
phatic glands with secondary anaemia, but without any leucocytosis. 

The existence of pseudo-leukaemic anaemia as a distinct disease is 
denied by several authorities on diseases of the blood, who maintain that 
all such cases are to be classed as secondary anaemia, pernicious anaemia, 
or leukaemia. 

Etiology. — Of the cases thus far recorded the majority have been 
between the ages of seven and twelve months. Of twenty cases col- 
lected by Monti and Berggrtin, sixteen showed evidences of rickets and 
one was syphilitic. The exact cause of the disease is still unknown, and 
its essential nature is a matter of some doubt. Monti believes that it 
may develop from the more severe cases of anaemia which are accompa- 
nied by leucocytosis, as he has observed this condition before the devel- 
opment of pseudo-leukaemia and during its subsidence. 

Lesions. — The most characteristic change is found in the spleen, 
which is very much enlarged, often forming an abdominal tumour of con- 
siderable size. It is firm, hard, and there may be evidences of perisple- 
nitis. The microscope shows a simple hyperplasia. Enlargement of 
the liver is less constant, it being normal in more than half the cases. 
There is no relation between the size of the spleen and that of the liver. 
The hepatic cells are unchanged. Enlargement of the lymph glands has 
been noted in about half the reported cases, the swelling affecting the 
cervical, axillary, or inguinal glands ; but it is rarely great. Changes in 
the bone-marrow have been described by Luzet, these being usually most 
marked about the epiphyses. 

Symptoms. — The Hood. — The number of reported cases is as yet too 
small to make positive statements possible upon all points. The main 
features noted thus far are the following (Plate XV, C) : 

The specific gravity is lowered, the usual range being between 1 "035 
and 1 -044. The reduction of the haemoglobin is very great ; in many of 
the cases it has been as low as 30 per cent, and in a few below 25 per 
cent. 

The red cells are always diminished ; in 6 of 20 cases they were below 
1,600,000 (Monti and Berggriin). There is also great inequality in their 
size and shape. Nucleated red cells are found in considerable numbers ; 
as a rule, these are chiefly normoblasts, but when the anaemia becomes 
more severe, it is usually the megaloblasts that predominate. The leu- 
cocytes vary from 20,000 to 50,000. They may show an increase in the 
mononuclear or in the polynuclear forms. The eosinophiles are usually 
increased, but not to the extent to suggest leukaemia. All varieties of 
cell degeneration are found. 



PERNICIOUS ANEMIA. gfl5 

The general symptoms of the disease develop slowly and with the 
usual signs of anaemia. In some cases the infants continue to be plump 
and well nourished. Pallor is usually very marked. Enlargement of the 
spleen is so great that it can hardly be overlooked if the abdomen is ex- 
amined. The glandular enlargements are not marked, and in many cases 
are wanting altogether. 

The course of the disease is essentially chronic. Cases have been seen 
in which pseudo-leukaemia developed from an ordinary severe simple 
anaemia in the course of a few weeks. The symptoms and blood changes 
generally come on slowly in the course of weeks or months, and some- 
times remain nearly stationary for as long a period as several months, and 
then slowly improve. In other cases they grow gradually worse. In 
the cases going on to recovery, there is noticed improvement in the gen- 
eral symptoms coincident with a diminution in the size of the spleen, a 
reduction in the number of leucocytes, an increase in the red cells, the 
haemoglobin, and the specific gravity, and a gradual disappearance of the 
nucleated red cells. 

Prognosis. — In Monti's list of twenty cases four proved fatal; one 
recovered, in which the proportion of leucocytes to the red cells had 
been 1 to 12. The prognosis should be guarded, for, although improve- 
ment may take place, many patients die from intercurrent disease. 



PERNICIOUS ANAEMIA. 

This is the most severe form of anaemia known. Its cause and essen- 
tial nature are as yet very imperfectly understood. It is characterized by 
quite uniform blood changes and by the general symptoms of a very 
marked anaemia, and it tends to go on from bad to worse, terminating 
fatally in the great proportion of cases. 

Etiology. — Pernicious anaemia is a rare disease in childhood, and es- 
pecially rare in infancy. In the cases which have been observed in early 
life the following etiological factors have been noted : It has been associ- 
ated with hereditary syphilis and with severe rickets, especially when ac- 
companied by a marked enlargement of the spleen. It has followed 
other diseases, especially grave disturbances of nutrition. Sometimes 
simple anaemia, when severe and of long standing, has gradually de- 
veloped into the pernicious type. In a few instances parasites, partic- 
ularly tapeworms, have been the cause. Pernicious anaemia has in 
some instances occurred in patients where no cause whatever could be 
assigned. 

Many theories have been advanced in explanation of pernicious anae- 
mia. The one which at present appears to have most in its favour is that 
the disease consists in a great destruction of the red blood-cells, particu- 
larly in the liver, and that this is brought about through the agency of 



866 DISEASES OF THE BLOOD. 

some poison or poisons taken up from the intestine by the portal circula- 
tion. This has been advanced by Hunter and others in explanation of 
the peculiar deposit of iron found in the hepatic cells. 

Lesions. — There is found a very high grade of anaemia in all the in- 
ternal organs, fatty degeneration of the heart and blood-vessels, and 
sometimes also of the liver and kidneys, with numerous capillary haemor- 
rhages in the various organs. The most characteristic post-mortem 
change, however, according to Hunter, consists in the deposit of iron in 
the hepatic cells. Its distribution is peculiar and unlike that seen in 
any other disease. 

Symptoms. — The Blood. — The specific gravity of the blood in perni- 
cious anaemia is constantly and considerably reduced, and its coagulability 
is feeble. The haemoglobin is always reduced, usually it is as low as from 
20 to 30 per cent. The red cells are always much diminished in number 
and generally to a degree greater than the reduction in the haemoglobin. 
Their number is seldom greater than 2,000,000, and frequently less than 
1,000,000. Megalocytes are present, often in great numbers, and a pre- 
ponderance of them is regarded essential to the diagnosis. Microcytes 
are rare. It is characteristic of pernicious anaemia that owing to the 
relatively high haemoglobin the red cells stain well, usually deeper than 
in normal blood. A striking feature of these cases is the presence of 
extreme poikilocytosis. Nucleated red cells are also present, megalo- 
blasts in greater numbers than normoblasts. The red cells do not col- 
lect to form rouleaux. 

The total number of leucocytes is markedly diminished, but the lym- 
phocytes may be relatively increased. An occasional myelocyte may be 
found. 

The general symptoms are those of a most intense anaemia. There 
is marked pallor of the skin and mucous membranes, with great weak- 
ness and prostration. Various anaemic heart murmurs are heard. There 
is dyspnoea, and usually the urine is scanty and of low specific gravity. 
There may or may not be emaciation. The late symptoms are haemor- 
rhages from the nose and other mucous membranes, subcutaneous ecchy- 
moses with dropsy of the feet and ankles, and sometimes of the large 
serous cavities of the body, but without albuminuria. In many cases 
fever is present. This may be so high as to lead to the suspicion of some 
acute infectious process. 

The course of the disease is, as a rule, more rapid than in adults, the 
duration being in most cases several months; it is marked by periods of 
exacerbation and remission. During the exacerbations all the symptoms 
are intensified, and as a rule some fever is present. During the remis- 
sions marked improvement may take place in all the symptoms and an 
increase in the haemoglobin and red cells occur. In general, the progress 
of the disease is downward and sometimes the loss is very rapid. The 



TREATMENT OF ANEMIA. 867 

only exceptions are the cases in which the disease depends upon some 
intestinal parasite, where improvement and even recovery may occur. 

Treatment of the Different Forms of Anaemia. — In secondary anosmia 
the thing of the first importance is to discover and treat the primary 
condition upon which the anemia depends. In infancy, special atten- 
tion should be given to diet and hygiene, particularly with reference to 
an abundant supply of fresh air. The whole manner of life of these pa- 
tients must be carefully studied and managed according to the direc- 
tions laid down in the chapter upon Malnutrition, with which condition, 
especially in infancy, a very large number of these cases are associated. 
The general treatment referred to is often more important than the 
administration of the preparations of iron, which, however, should never 
be omitted. 

The preparations of iron available for infants are the albuminate, 
pepto-manganate, ovoferrin, haemaboloids, bitter wine, sweet wine, 
saccharated carbonate, malate, and citrate. The dose should be regu- 
lated according to the age of the child. Older children may take 
the same preparations as adults, especially reduced iron and Blaud's 
pills. Much benefit is seen from combining arsenic with iron, or from 
alternating the two. Arsenic should be used in conjunction with iron 
when there is enlargement of the spleen or lymphatic glands. In addi- 
tion to these remedies, cod-liver oil should be given if the condition of 
the digestive organs will permit. 

In chlorosis more decided results are seen from the use of iron than 
in any other form of anaemia. Blaud's pills are here the favourite 
method of administration, and are advantageously combined with small 
doses of nux vomica and aloin to overcome the tendency to constipation. 
Arsenic is useful in these cases also. Great benefit in chlorosis results 
from change of air and change of scene, thus removing the patient from 
all sources of nervous excitement or disturbance. The general condition, 
diet, and habits of life should also receive careful attention, particularly 
the condition of the bowels. 

Oxygen is a valuable adjuvant in the treatment of all anaemias not 
yielding to iron alone. It is important that the administration of iron 
should be continued for several months after the disappearance of all 
symptoms, on account of the tendency to relapse. 

In the pseudo-leukasmic anosmia of infants, arsenic is decidedly the 
most valuable drug, but should be given in combination with iron. 
Fowler's solution is the best preparation for infants; the dose should 
rarely be more than one drop, which should be repeated four or five times 
daily after feeding, and continued for a long time. The general treat- 
ment of these patients is the same as in cases of simple anaemia. When 
rickets is present cod-liver oil and phosphorus should be added. 

In 'pernicious anosmia, arsenic offers a much better prospect of im- 



868 DISEASES OF THE BLOOD. 

provement than iron. Beginning with small doses, the amount should 
be gradually increased up to the point of tolerance, very much as in cases 
of chorea. 

In every case of anaemia the most careful attention should be given to 
the general condition, particularly guarding against exposure to cold and 
dampness. The feeble circulation of these patients renders them pecul- 
iarly susceptible. Caution should also be given against much muscular 
exercise. With a severe grade of anaemia very active exercise should be 
prohibited, and many of these patients do best when complete rest in 
bed, either for the entire time or for a considerable part of each day, is 
insisted upon. This applies to children of all ages. 

LEUKEMIA. 

This is a disease in which the essential feature is a great increase in 
the number of leucocytes, with a moderate reduction in the number of 
red corpuscles, and the presence in the blood of cellular forms not found 
in health. 

Etiology. — Leukaemia is a rare disease in childhood, but has been seen 
even in early infancy. Its greater frequency in males holds good even in 
childhood. In a small number of cases heredity seems of some impor- 
tance as an etiological factor. Leukaemia may follow syphilis, rickets, 
malaria, or even simple anaemia, or it may occur as a primary disease in 
children previously healthy. In the great majority of cases the cause is 
unknown. 

Lesions. — The essential lesions of leukaemia are found in the spleen, 
the lymphatic glands, and the bone-marrow. In rare cases the most im- 
portant changes are in the lymphatic glands, giving rise to the lym- 
phatic form of leukaemia. In such cases the changes in the spleen or 
marrow may be slight or absent. Changes in the spleen and marrow are, 
however, usually associated, giving rise to what is known as the spleno- 
myelogenous form of the disease, which is the most frequent variety. 
The spleen is usually enormously enlarged, sometimes filling half the 
abdominal cavity. In the early stage it is soft, vascular, and of a dark- 
red colour ; in the late stages it is firm and hard,, and usually deeply 
fissured at its margin. There may be perisplenitis. On section, light- 
gray patches of lymphoid tissue may be seen scattered throughout the 
organ, and in some instances there may be wedge-shaped infarctions. 
The microscope shows thickening of the trabecular and deposits of lym- 
phoid tissue, especially about the arteries. In the lymphatic form any 
of the external glands of the body may be affected, the cervical, axil- 
lary, and the inguinal, or the mesenteric, tracheo-bronchial, the tonsils, 
and even the lymph nodules of the tongue, pharynx, and intestines. The 
changes in the glands are generally those of a simple hyperplasia. The 
liver is enlarged in very many of the cases, chiefly from an infiltration 



LEUKEMIA. 869 

with lymphoid tissue, which may be diffuse or may occur in patches. 
Less frequently similar. lymphoid masses are seen in other organs. 

Symptoms. — The Hood (Plate XV, D). — The colour is lighter than 
normal and its coagulability usually diminished. Generally' the red 
cells are much reduced in number, although not to the extent seen in 
pernicious anaemia. The most important feature is the great increase 
in the leucocytes, which vary in form according as the type is spleno- 
myelogenous or lymphatic. The red cells are usually of normal size and 
a moderate number of normoblasts is found ; the haemoglobin is dimin- 
ished. 

In the spleno-myelogenous form the white cells may be from 100,000 
to 500,000, but, especially under the influence of arsenic, a marked tem- 
porary diminution may occur, so that their number may be scarcely above 
the normal ; both Ehrliclr's and CorniPs myelocytes are present, and the 
presence of a large number of these is pathognomonic. The number of 
pohmuclear neutrophiles is greatly increased, although their proportion 
is diminished. The eosinophiles are very much increased in number, 
mononuclear forms being present. The number of lymphocytes is in- 
creased, but they vary according to the type and stage of the disease; 
this is true also of the large mononuclear leucocytes. Mast cells are 
much increased in number, this being the most reliable diagnostic sign. 

In the lymphatic form the lymphocytes alone are increased, so that 
the other white cells are relatively diminished. The increase is usually 
in the small lymphocytes which form from 80 to 90 per cent of the leuco- 
cytes present. Myelocytes and mast cells are either present in small 
numbers or absent altogether. 

The other symptoms of leukaemia in children resemble those in 
adults, with the difference that, as a rule, the progress of the disease is 
much more rapid in early life. In most of the cases the early symptoms 
are latent. A sudden and alarming haemorrhage is sometimes the first 
thing to call attention to the serious condition. In other cases there are 
only the symptoms of general weakness and anaemia. Sometimes the 
splenic tumour or the enlargement of the lymphatic glands is first no- 
ticed. In the early part of the disease, the usual symptoms of anaemia 
are present — digestive disturbances, shortness of breath, weak and rapid 
pulse. Haemorrhages may occur as an early or late symptom ; they are 
most frequently from the nose, but severe haemorrhages may occur from 
the stomach, the mouth, the intestines, or there may be ecchymoses upon 
the skin. The enlargement of the spleen may be sufficiently marked to 
form an abdominal tumour, so as to attract the attention even of the 
parents. The swelling of the liver is not so great. The lymphatic glands 
are enlarged only to a moderate degree, and in many cases this symptom 
is absent altogether. They are painless, movable, and usually several 
groups are affected. 



870 DISEASES OF THE BLOOD. 

The late symptoms are dropsy of the feet or general anasarca, haemor- 
rhages, diarrhoea, headaches, general weakness, and attacks of fainting. 
Fever is quite constant in the late stages of the disease, and the tem- 
perature may be from 101° to 103° F. The urine may contain albumin 
and casts. Vision is sometimes disturbed by the formation of leukaemic 
plaques in the retina. It is rare that there are any symptoms referable 
to the bones, although expansion and tenderness of the flat bones have 
been observed. 

Course and Prognosis. — The course of leukaemia is chronic, and in 
most cases slowly progressive, but not always so. The prognosis is very 
bad, the great proportion of the cases in children proving fatal within a 
year from the first symptoms, in infancy sometimes in two or three 
months. There has been described by Epstein and others an acute form 
of the disease, proving fatal in a few weeks. The usual causes of death 
are exhaustion, haemorrhages, and broncho-pneumonia. 

Diagnosis. — This, in children, has to be made chiefly from simple 
anaemia with leucocytosis, and pseudo-leukaemic anaemia. Without a 
blood examination this is impossible. The chief reliance is to be placed 
upon the enormous increase in the leucocytes, and especially upon the 
presence of numerous mast cells and myelocytes. 

Treatment. — The general treatment of leukaemia should be the same 
as that of anaemia. Of the drugs now in use, arsenic has altogether the 
most testimony in its favour. It must be given in large doses and for a 
long period. Next to this in value come iron and cod-liver oil. Leu- 
kaemia, however, is in most instances very little influenced by treatment. 
The reported cures must be taken with some allowance, for most of these 
were published before the time when leukaemia was sharply differentiated 
from simple anaemia with leucocytosis and from the pseudo-leukaemic 

anaemia of infancy. 

HAEMOPHILIA. 

Haemophilia is an hereditary disease, in which there is a tendency to 
profuse or even uncontrollable bleeding from slight wounds, or some- 
times even spontaneously. In many cases there is associated an inflam- 
mation of the joints. Persons so affected are known as " bleeders." 

Etiology. — The hereditary tendency of the disease is very strongly 
marked, and it has often been traced through seven or eight generations. 
Males are much more frequently affected than females, the proportion 
being about twelve to one. In the matter of inheritance, the disease is 
most often transmitted through the mother, who may, however, herself 
escape. Patients suffering from haemophilia have nothing else about 
them that is abnormal. The exact nature of the disease is unknown. 
It has no connection with either purpura or scurvy. Although generally 
classed among the diseases of the blood, it has not been established that 
there are any constant changes either in the blood or in the blood-vessels. 



PURPURA. 871 

Symptoms. — The first manifestations of haemophilia are not often 
seen before the second year. The haemorrhages of the newly born have 
no relation to this condition. The discovery of the disease is generally 
quite accidental. The first haemorrhage may be traumatic or spontane- 
ous. In traumatic haemorrhages there may be very severe bleeding after 
so slight a wound as the drawing of a tooth; sometimes a large hema- 
toma forms between the muscles as the result of a moderate contusion. 

The following is the relative frequency of spontaneous haemorrhages 
in 334 cases collected by Grandidier: bleeding from the nose in 169, 
mouth in 43, intestines in 36, stomach in 15, urethra in 16, lungs in 17. 
There may be haemorrhage from the skin or from any mucous membrane 
of the body. The attacks of spontaneous haemorrhage are often periodi- 
cal, and may be accompanied by arthritic symptoms resembling rheuma- 
tism. The severity of the haemorrhages varies much in the different 
cases. From a slight wound a patient may bleed until he is exsangui- 
nated, and even until death occurs. Such a result from the first haemor- 
rhage, however, is rare. In some cases the disposition to bleed is out- 
grown in later life. Grandidier states that, of 152 boys, over one half 
died before reaching the seventh year. It is striking that when the dis- 
ease affects females there is no tendency to excessive bleeding at men- 
struation or parturition. 

Treatment. — The indications at the time of bleeding are, to arrest 
the haemorrhage by the use of the ordinary surgical means — compres- 
sion, styptics, etc. (For epistaxis, see page 488). Little benefit is to be 
expected from drugs. In convalescence after attacks of haemorrhage, 
iron and general tonics should be given. In all patients who are bleed- 
ers everything which might by any means excite haemorrhage should be 
avoided. Marriage should be discouraged in girls who inherit the 
disease. 

PURPURA. 

The term purpura is used to designate a condition in which there is 
a tendency to spontaneous haemorrhages beneath the skin, from the vari- 
ous mucous membranes, and in some cases into the internal organs. 
The term purpura simplex is applied to those cases in which the haemor- 
rhages are limited to the skin; purpura Jwemorrhagica to those in which 
there is in addition bleeding from the mucous membranes or visceral 
haemorrhages. It is impossible to draw a line sharply between these two 
classes of cases, as the chief difference between them seems to be one of 
degree. Purpura is sometimes known as morbus macalosus or as Werl- 
hofs disease. 

Symptomatic Purpura. — This occurs in quite a variety of conditions, 
the haemorrhages generally being limited to the skin, but not always so, 
These cases may be grouped in the following classes: 



872 DISEASES OP THE BLOOD. 

1. Infectious. — This form of purpura is very constantly seen in ma- 
lignant endocarditis, in the haemorrhagic forms of the various eruptive 
fevers — measles, scarlet fever, variola, vaccinia, and typhus — also in 
epidemic meningitis and occasionally in diphtheria, pyaemia, and septicae- 
mia. The occurrence of haemorrhages in these cases appears to depend 
upon an altered condition of the blood, which is a direct result of the in- 
fection, and it is a bad prognostic sign. 

2. Cachectic. — Purpura occurs late in the course of many protracted 
and exhausting diseases, especially in infancy. It is most frequently met 
with in broncho-pneumonia, empyema, tuberculosis, ileo-colitis, in both 
the tuberculous and the simple forms of meningitis, and in malignant 
disease. It also occurs from apparently similar causes in several of the 
diseases of the blood, particularly in leukaemia and pernicious anaemia. 
In most cases of cachectic purpura the haemorrhagic spots are small, not 
very abundant, and occur either upon the abdomen or the lower extrem- 
ities. This form is quite common in hospital practice, and is almost 
invariably indicative of a fatal result. In cachectic purpura the haem- 
orrhages are usually limited to the skin. The condition is undoubtedly 
dependent upon a deterioration in the blood, possibly also upon the 
condition of the minute blood-vessels. 

3. Toxic. — Certain drugs, such as phosphorus, quinine, potassium 
chlorate and sometimes others, may in rare cases produce haemorrhages 
when long continued or in large doses. The haemorrhage of jaundice 
may also be considered in this group. 

4. Mechanical haemorrhages, such as those occurring in pertussis or 
epilepsy, are sometimes classed with purpura. In convalescence from 
protracted illness there are sometimes seen, when patients first stand or 
walk, purpuric spots on the lower extremities. They may occur after 
confinement of a limb in bandages or splints. In both these cases the 
cause is partly mechanical and partly due to the weakened condition of 
the blood-vessels. 

5. Neurotic. — These cases are occasionally seen in diseases of the 
spinal cord and sometimes in hysteria in young adults, but very rarely 
in children. 

Primary Purpura. — This occurs in children of all ages, being not un- 
common in infancy. Haemorrhages of the newly born have not gener- 
ally been included in this class, although there are some reasons why they 
might well be. The age at which primary purpura is most frequently 
seen is from two to ten years. The sexes are about equally affected; 
of Steffen's 56 cases, 27 were males and 29 females. The disease may 
occur in children who are cachectic, rachitic, or anaemic, and in those 
whose surroundings are poor, but it has not, like scurvy, any close rela- 
tion to diet. It may follow any acute disease, being associated most fre- 
quently with derangements of the stomach and bowels. Quite frequently 






PURPURA. 873 

the disease develops abruptly, without any assignable cause, in children 
previously healthy. 

Lesions. — The external haemorrhages may occur upon any part of the 
body. There are smaller or larger ecchymoses or an infiltration of the 
tissues with blood, which undergoes gradual absorption with the usual 
changes. With the haemorrhages, various forms of inflammation of the 
skin may be associated, especially erythema and urticaria, with some- 
times more or less oedema. Haemorrhages from the mucous membranes 
are more frequent, because of the feebler resistance of the tissues. 
There are seen ecchymoses upon the visible mucous membranes which 
resemble those upon the skin. At autopsy they are occasionally seen 
in the trachea or bronchi, but more often in the digestive tract. In 
the colon, and occasionally in the small intestine, ulcers may be found; 
but they are rarely if ever seen in the stomach. They may be super- 
ficial or deep, and have even been known to cause perforation. 

Intracranial haemorrhages are rare, and are usually meningeal. 
These may be sufficient to cause severe symptoms. In 1893 a case 
occurred in the New York Infant Asylum in an infant six months old, 
with an extensive meningeal haemorrhage covering a large part of the 
brain. In Steffen's paper several such cases are mentioned. 

Pulmonary haemorrhages are not frequent. Ecchymoses are found 
beneath the pericardium; but endocarditis and pericarditis are extreme- 
ly rare, probably occurring only in the rheumatic cases. The spleen is 
occasionally enlarged, but by no means uniformly so, and it may be the 
seat of haemorrhages. 

While haematuria is one of the most frequent of the visceral haemor- 
rhages, severe nephritis is rare. Acute degeneration of the renal epithe- 
lium of the tubes is quite common. There may be punctiform haemor- 
rhages, and occasionally larger ones beneath the capsule or in the mu- 
cous membrane of the pelvis of the kidney. The suprarenal capsules 
may be the seat of extensive and even fatal haemorrhage. There may 
be effusions of a sero-sanguineous fluid into any of the large serous 
cavities, most frequently into the peritonaeum. The articular lesions 
of purpura may be of a rheumatic character, with which purpura occurs 
as a complication; or there may be haemorrhages into the tissues about 
the joint, or even into the joint itself — usually the knee or elbow. 

Thus far no constant or essential changes have been demonstrated in 
the blood, other than those which are due to haemorrhages — viz., a mod- 
erate reduction in the haemoglobin and the red corpuscles, with occa- 
sional irregularities in size and the appearance of nucleated red cells. In 
the most severe cases there is a moderate degree of leucocytosis. 

Pathology. — Why it is that under certain circumstances the blood- 
vessels will not hold their contents, it is difficult to understand. There 
have been described by Cassel, Riehl, Wilson, and others, changes in the 



874 DISEASES OF THE BLOOD. 

small blood-vessels, usually a form of endarteritis, but it is not 
necessary to assume a lesion in the blood-vessels, since we know that 
diseased blood may pass through even normal vessels. Henoch has 
suggested the vaso-motor origin of purpura, in which there is first a 
paralytic distention of the small vessels, followed by stasis, haemorrhage, 
or oedema. In certain forms, as in malignant endocarditis, it is well 
established that the cause is an infectious thrombosis. Although the 
bacteriological examinations made thus far in purpura are not numerous 
enough to settle the question positively, there is little doubt that infec- 
tion is the essential factor in some forms of the disease, particularly in 
the cases characterized by sudden onset, high temperature, and cerebral 
symptoms, and which run a rapidly fatal course. At the present time the 
exact pathology of purpura is unknown. There are, no doubt, now in- 
cluded under this term, several diseases quite distinct from one another. 

The clinical types. — 1. The ordinary form. — In the mild cases the 
haemorrhage is confined to the skin (purpura simplex), or it is accom- 
panied by slight bleeding from the mucous membranes. There is usually 
some general indisposition of an indefinite character for a day or two be- 
fore the purpuric spots are noticed; most frequently a disturbance of 
digestion with vomiting, diarrhoea, and sometimes slight fever. The 
haemorrhages appear as small petechiae, varying in size from a pin's 
head to a pea; usually first upon the lower extremities. There may be 
only a few widely scattered spots or the body may be covered. The col- 
our is first a bright red, then purple, gradually fading in the course of a 
few days. New spots come as the old ones disappear, so that the amount 
of eruption may not diminish. They do not disappear upon pressure. 

The course of these cases is generally favourable, recovery taking 
place in from one to four weeks under the influence of general tonic 
treatment. Eelapses are, however, very frequent, and such attacks may 
come at intervals of a few weeks or months for a considerable period. 
One must be guarded in giving an absolutely favourable prognosis even 
in cases of such severity, for it occasionally happens that in a patient, 
who for several days has had symptoms of mild purpura, there suddenly 
develop those of the most severe type with a rapidly fatal termination. 

2. The severe form. — Such cases are characterized by haemorrhages 
from the mucous membranes (purpura haemorrhagica) from the outset. 
These may even appear before the spots upon the skin. In severe attacks 
the petechial spots are more likely to appear suddenly, and large ecchy- 
moses, varying in size from a pea to the palm of the hand, are more fre- 
quent. There may be bleeding from the nose, gums, mouth, or pharynx, 
and ecchymoses may be seen upon these mucous membranes, also upon 
the conjunctivae. Vomiting of blood and bloody discharges from the 
bowels are quite frequent symptoms. The urine may contain enough 
blood to give it a bright-red colour. Less frequently there are seen haem- 



PURPURA. 875 

orrhages of the retina or choroid and from the female genitals. In one 
of my own cases there was almost continuous bleeding from one ear. Cu- 
taneous ecchymoses are increased by slight injuries, such as the pressure 
from a bandage or from scratching. Epistaxis may be copious enough to 
necessitate plugging of the nares. The amount of blood vomited is not 
often large; its source may be the stomach, the mouth, or the pharynx. 
The blood in the stools is usually dark coloured, but there may be some 
bright-red blood even when there are no ulcers present. In one of my 
cases so much blood was lost by the bowels as to produce the symptoms of 
a very marked cerebral anaemia. In certain cases the gastro-intestinal 
symptoms are very prominent, and there may be slight icterus. The dis- 
charge of blood from the stomach or intestine may be accompanied by 
very severe attacks of colic and tenesmus. In some of these cases there 
are pains and slight swelling of the joints. Eenal symptoms are generally 
present. These attacks of pain with purpura and the discharge of blood, 
may come on paroxysmally every few days for a period of several weeks. 
They have been ascribed to thrombosis of the intestinal vessels. This is 
sometimes known as " Henoch's purpura." 

Constitutional symptoms are present in most of the severe cases. 
There is usually fever, from 101° to 103° F., and sufficient prostration to 
keep the patient in bed. If the amount of blood lost is large, there are 
the usual symptoms of severe anaemia. The loss of blood may be suffi- 
cient to cause death, particularly in infants. Cerebral symptoms may 
depend upon anaemia or upon meningeal haemorrhage. They are not 
frequent in this form of the disease. (Edema, especially of the face 
and feet, may exist without albuminuria, and albuminuria may be pres- 
sent in cases in which there is no renal haemorrhage. 

In some of the cases beginning with severe general symptoms, and 
occasionally when the onset is mild, the patients after a few days pass 
into a typhoid condition with low delirium, great prostration, weak and 
irregular pulse, dry, cracked tongue, and high temperature. Such cases 
are almost always fatal. They are not to be confounded with ordinary 
typhoid fever complicated by purpura. 

The course varies much in the different cases. It lasts from one to 
six weeks, the symptoms slowly subsiding, but often showing a strong 
tendency to recurrence. The prognosis depends upon the age of the 
patient, the extent of the haemorrhage, and the presence or absence of 
septic symptoms. 

3. The hyper-acute form (purpura fulminans). — This is a rare form, 
especially in young children. Its development is usually sudden with a 
chill, vomiting, marked prostration, and high temperature. The pur- 
puric spots come out with great rapidity, and in the course of a few 
hours or a day they may be very extensive. In addition to the ordinary 
subcutaneous haemorrhages, bloody vesicles may form upon the skin. In 



8^6 DISEASES OF THE BLOOD. 

many cases the haemorrhages are limited to the skin, the mucous mem- 
branes and the viscera escaping altogether. There is no tendency to 
gangrene. Cerebral symptoms are invariably present and usually promi- 
nent; there may be delirium, dulness, stupor, and finally coma. The 
spleen is apt to be enlarged. The urine is nearly always albuminous. 
This form of purpura has all the characteristics of a general infectious 
disease, and it is almost invariably fatal. 

4. The gangrenous form. — Sloughing is not common in purpura, but 
it is most often seen in the mucous membranes. Osier refers to two 
cases affecting the uvula. I once saw a slough which caused perforation 
of the soft palate. Wickham Legg reports a case with gangrene of the 
prepuce. Gangrene of the skin is even less frequent, although cases 
have been reported even in young children. Charron's case was only three 
years old, and several others in children are collected in Gimard's mono- 
graph upon this subject. The gangrene may involve the skin only, or 
the subcutaneous tissues and even the muscles. It has been seen upon 
the upper and lower extremities and even upon the face, and may extend 
over quite a large surface. In some of the milder forms of purpura, gan- 
grene results from some slight injury, such as a blow, the pressure from 
a bandage, or in the nose, from the pressure of a tampon. These cases 
are almost invariably fatal. Those in which the sloughing is confined to 
small areas of the mucous membrane of the mouth often recover. 

5. The rheumatic form. — The term " rheumatic purpura " (peliosis 
rheumatica) is applied to cases, not so common in children as in older 
patients, in which subcutaneous haemorrhages, and sometimes bleeding 
from the mucous membranes, are associated with painful joint swell- 
ings. These are to be regarded as cases of rheumatism complicated by 
purpura. The joints most frequently affected are the knee and the 
ankle. The arthritic symptoms are usually less severe than in attacks 
of acute rheumatism. There may be present erythema exudativum or 
erythema nodosum or urticaria. Usually there are throat symptoms 
and fever, and frequently oedema of the face and eyelids with albumi- 
nuria. The spleen may be enlarged. The usual duration is from one 
to three weeks, and although relapses may occur, the cases usually 
recover. 

Joint symptoms, particularly articular pains, are not infrequent in 
the course of milder attacks of purpura without the febrile symptoms 
mentioned. In severe cases extravasations of blood have been reported 
as occurring in the tissues about the joints, and even in the joints them- 
selves, these being cases of true arthritic purpura. It is probable that, 
in the past, some cases of scurvy have been included in this group. 

Diagnosis. — The rapid acute cases may be confounded with the haem- 
orrhagic forms of the various eruptive fevers. The ordinary subacute or 
passive forms are chiefly to be diiferentiated from scurvy. The diagnosis 



LYMPHATIC GLANDS. 877 

is not difficult and the mistake need not be made if the essential features 
of scurvy are borne in mind — its dietetic cause, bleeding gums, hyperes- 
thesia, and deep rather than subcutaneous haemorrhages which are usu- 
ally near the joints. 

Prognosis. — This depends very much upon the form of the disease. 
Of 128 cases of all varieties occurring in children in Steffen's collection, 
there were 40 deaths. In 12 cases of severe primary purpura reported by 
G-imard, there were 3 deaths and 9 recoveries. Purpura simplex is rarely 
fatal; cases of purpura haemorrhagica usually recover unless marked 
febrile symptoms are present. The forms classed as typhoid, gangre- 
nous, and purpura fulminans are almost invariably fatal. The tendency 
to relapses exists in all varieties. 

Treatment. — The treatment of symptomatic purpura should have ref- 
erence to the cause of the disease. The mild cases of primary purpura 
usually recover promptly under a tonic plan of treatment. The more 
severe cases require confinement in bed, absolute quiet, and care to avoid 
exposure and even the slightest injury or extra pressure upon any part. 
Drugs do not seem greatly to influence the course of the disease. Those 
most frequently employed are supra-renal extract, hydrastis, hama- 
melis, aromatic sulphuric acid, the vegetable acids, ergot, and gallic acid. 
Whether or not it is true, as claimed by some, that all hsemorrhagic dis- 
eases are related to scurvy, the striking improvement seen in this disease 
from the use of fresh fruit and vegetables, suggests their employment in 
purpura. In some cases very decided benefit seems to follow their use in 
the acute stage, but more particularly in convalescence. For hyperacute 
and gangrenous cases, little can be done except to treat the symptoms. 
Surgical means of arresting the haemorrhage are rarely successful. Iron 
and arsenic and alcoholic stimulants should be used in all cases during 
convalescence. 



CHAPTER II. 

DISEASES OF THE LYMPH NODES {LYMPHATIC GLANDS). 

It is characteristic of infancy and childhood that the lymphoid tis- 
sues — tonsils, adenoids, external and internal lymph glands, and many 
smaller lymph nodules throughout the body — are prone to swelling and 
hyperplasia. While this tendency belongs to all children, in certain indi- 
viduals it is so marked as to deserve a place as a distinci diathesis. It- 
was formerly classed as one of the manifestations of " scrofula " or 
"struma"; but the proof that most of the manifestations once called 
"scrofulous" are really forms of local tuberculosis, makes it undesirable 
to use that term any longer to designate the condition under discussion. 



878 DISEASES OF THE LYMPH NODES. 

In robust children, infections processes of the nose, pharynx, or 
bronchi, cause acute swelling of the lymph nodes in the neighbourhood, 
which rapidly subside when the cause is removed. In others, in whom 
this vulnerability of the lymphoid tissues exists, the hyperplasia in the 
lymph nodes is out of proportion to the exciting cause and continues after 
the cause has ceased to operate. Certain children have at birth an ex- 
cessive development of lymphoid tissue, particularly in the region of the 
throat in the form of enlarged tonsils, adenoid vegetations of the 
pharynx, etc. 

The influence of heredity in causing this condition is too often seen 
to be passed over as a coincidence. Frequently the parents, when chil- 
dren, suffered from the same condition, and often every member of a 
large family of children is affected. They may be in other respects 
healthy, reared amid good surroundings, and show no evidence of any 
other constitutional disease. Any disease in the parents in consequence 
of which children are born with tissues having less than normal resist- 
ance, may be regarded in the light of a remote cause. 

The condition is seen to perfection in children reared in institutions 
and in crowded tenements. It is more common in cities than in the coun- 
try. Anything which produces malnutrition or lowers the general vitality 
of the tissues may be ranked as a cause. Eickets is often associated; 
sometimes it is to be reckoned as a cause, and sometimes both conditions 
depend upon the same causes. 

During infancy,, the lymphoid structures most frequently affected are 
those connected with the gastro-enteric and the bronchial mucous mem- 
branes; in later childhood it is those which are connected with the 
pharynx and tonsils. 

The degree of enlargement of the lymph nodes which is sometimes 
found in the different situations has often led to a misinterpretation of 
them, particularly by those who only seldom see autopsies upon infants 
or young children. They have often been connected with pathological 
conditions or clinical symptoms with which they have really nothing 
to do. 

Enlargement of the mesenteric glands and of the solitary follicles 
of the large and small intestine is very frequently seen in infants who 
have died from marasmus, and has been regarded as the cause of the 
wasting; while in reality it was only the consequence of the chronic 
intestinal indigestion which is an almost constant accompaniment of that 
condition. 

As age advances we usually see retrograde changes in the different 
groups of glands unless they become the seat of tuberculous infection. 
Those connected with the digestive tract generally begin to diminish 
after the second year, and by the fifth or sixth year the enlargement has 
almost disappeared; while the tonsils, adenoid growth* of the pharynx, 



STATUS LYMPHATICUS. 879 

and enlarged cervical glands are usually stationary after the seventh or 
eighth year and undergo quite a marked atrophy about the time of 
puberty. The presence of these enlarged lymph nodes and the catarrhal 
condition of the mucous membranes with which they are associated, are 
important in relation to all acute infectious diseases which affect these 
mucous membranes. They bring about an increased susceptibility to 
scarlet fever, measles, diphtheria, diarrhceal diseases, and most of all to 
tuberculosis. 

STATUS LYMPHATICUS. 

This condition is known also by some writers as " lymphatism " ; 
while in its marked form it is quite distinct from that just described, the 
two have many points of resemblance, have often been confounded, and 
in fact, shade into each other. The term " status lymphaticus " is ap- 
plied to a very definite pathological condition which is associated with 
clinical manifestations, less constant and not characteristic. The rela- 
tion between the lesions and the symptoms is little understood, and 
almost nothing is known of the etiology or pathogenesis. The most strik- 
ing part of the lesion is the great enlargement of the thymus gland, with 
which is found a hyperplasia of the lymphoid tissues throughout the body, 
more marked than is seen in any other condition in childhood. The two 
most frequent symptoms are convulsions and attacks of asphyxia. 

Etiology. — The status lymphaticus is most often seen between the 
sixth and twelfth months, but may be met with in children of any age. 
Enlargement of the thymus to a degree sufficient to be regarded as patho- 
logical, is not an infrequent condition, being present according to the 
observations of Bovaird and Xicoll in about 12 per cent of the autopsies 
in the Xew York Foundling Hospital. How frequently the condition 
exists in cases not fatal it is impossible to say; but it certainly is not 
rare. An association with rickets is often observed, but it is doubtful 
whether this is anything more than a coincidence. 

Lesions. — Since the large thymus is so important a lesion it is desir- 
able to know what may be regarded as normal. The most extensive ob- 
servations upon this point have been made by Bovaird and Xicoll, who 
weighed the thymus in -195 consecutive autopsies in children under five 
years. They found that the weight was greatest at birth, the average 
being 7.7 grams. After this time the change in weight was very slight 
for the period of five years, the average for the entire 495 observa- 
tions being 5.9 grams, which was about the same as the average 
for each of the years taken separately. Excluding cases in which the 
organ was bo large as to be considered abnormal (10 grams or over) 
the average weight at birth was 6.5 grams; during infancy and early 
childhood, 4 grams. The results of these observations do not differ 
essentially from those of Friedlcben, which have been so extensively 



880 



DISEASES OF THE LYMPH NODES. 



misquoted. Of 141 observations up to the age of five years, he found 
the average weight to he 7.4 grams ; excluding cases in which the enlarge- 
ment might be considered pathological, the average was 3 grams. It may 
therefore be assumed that the average weight of the normal thymus at 
birth is from 6 to 7 grams ; from birth to five years from 3 to 4 grams. 
Anything over 10 grams may be considered distinctly abnormal. 

In the status lymphaticus the thymus is often from five to ten times 
larger than normal. In the marked cases its weight is from 30 to 40 




Fig. 172.— Enlarged thymus. 

The lungs, heart, and thymus are shown in the picture. The lungs have been turned 
back showing the two lateral lobes of the thymus overlapping the heart; the central lobe, 
above, covers the trachea. 

History. — Breast fed, male child, nine months old, well developed; ill less than twenty- 
four hours; dyspnoea, slight cyanosis, with death by asphyxia. T. 103° F. 

Autopsy. — Besides the large thymus there were present the general lesions of the status 
lymphaticus to a marked degree; lungs deeply congested. 



grams; in the less marked cases from 10 to 20 grams. The appear- 
ance of the enlarged thymus is well shown in the accompanying illus- 
tration (Fig. 172). A thymus of the size shown weighs about 45 grams, 
or 1J ounces. In this instance it was nearly as large as one of the lobes 



STATUS LYMPHATICUS. 881 

of the lung. In general appearance, the enlarged thymus is rather more 
vascular than normal, but other than hyperplasia shows no constant or 
essential changes, either by gross or microscopical examination. 

The lymph nodes of the tracheo-bronchial region are greatly enlarged, 
often to the size of a small cherry, and are found in great clusters. Those 
of the mesenteric region may be still larger. Peyer's patches are very 
prominent, and the solitary follicles of the small intestine appear like 
mustard seeds upon the folds of the mucous membrane. Those of the 
colon are also very prominent. The lymphoid tissues about the pharynx 
and all the lymph nodes of the body are greatly hypertrophied. The 
spleen is usually enlarged with prominent follicles. There are no other 
constant changes. Those present are usually accidental, depending upon 
the cause of death. 

Symptoms. — In very early infancy this is one of the explanations of 
sudden death occurring after slight causes, and in some cases without 
any apparent cause. 

Death may be attributed to overlying, to asphyxia from food, or to 
some other condition affecting respiration, or infants are simply found 
dead in their cribs. 

Even in those who live until they are several months, sometimes several 
years, old, there may be nothing in the child's condition to indicate the 
presence of the status lymphaticus until something acute occurs. This 
may be in the nature of a slight accident, a surgical operation of a 
trivial character, the administration of an anaesthetic, or some acute dis- 
ease, frequently one affecting the respiratory tract. The symptoms asso- 
ciated with this condition are most frequently of a nervous character, 
usually attacks of convulsions, or they affect the respiration, causing 
paroxysms of dyspnoea, cyanosis, and even asphyxia. A frequent history 
is somewhat as follows : A child previously regarded as healthy, often well 
nourished and perhaps entirely breast fed, is taken with convulsions fol- 
lowed by high fever, preceding which there may have been some pul- 
monary symptoms suggesting a commencing broncho-pneumonia. The 
convulsions recur at short intervals; the temperature remains steadily 
high; the signs in the lung are few and not proportionate to the other 
symptoms; and death occurs in from twelve to thirty-six hours often in 
convulsions. 

In other cases convulsions are absent and the prominent symptom is 
asphyxia, which comes in paroxysms and may be so complete as to Lead 
to the suspicion of laryngeal obstruction. If intubation or tracheotomy is 
performed, no relief follows. The child may die in the first severe attack, 
which may be preceded for a few hours by moderate dyspnoea, or may 
come on almost without warning. It is more frequent, however, for the 
first attack to be less severe, the child perhaps being resuscitated with 
some effort, after which he may breathe almost as well as usual. In a 



882 DISEASES OF THE LYMPH NODES. 

few hours the attack of asphyxia is repeated ; after several of these, each 
one growing more severe, death occurs. In these cases the elevation of 
temperature is usually slight and may be wanting. 

Symptoms similar to the above but of less severity and resulting in 
recovery would suggest this condition, although the diagnosis cannot be 
established. 

The cause of the symptoms is not definitely known. The asphyxia 
has been ascribed to pressure of the large thymus upon the lungs, the 
trachea, the pneumogastric nerves, or the auricles of the heart. Pres- 
sure would certainly seem to be one factor in the production of the 
dyspnoea. Further evidence in support of this is obtained by the relief 
afforded by an operation in which the anterior mediastinum is opened 
and the thymus raised and fixed to the sternum. This has been done 
in two or three instances with striking, but not always permanent, benefit. 

In other cases, although the thymus may be quite as large as in those 
just described, the evidences of obstructive dyspnoea are much less and 
may scarcely be noticed. 

There is another group of cases, perhaps the largest of all, in which 
there are no symptoms distinctly referable to the status lymphaticus, and 
yet this condition appears to be the factor which determines the fatal 
outcome of what was apparently an infection or an inflammation of only 
moderate severity. What is seen here is simply a greatly diminished re- 
sistance to disease. In these cases it is only the autopsy which reveals the 
explanation. 

Diagnosis. — The diagnosis of the status lymphaticus is very uncer- 
tain. In some cases of marked enlargement it is possible to make out 
the enlarged thymus by percussion, but this is always difficult on account 
of its proximity to the lungs and trachea. We may suspect this con- 
dition during life ; we can hardly do more. Marked enlargement of the 
tonsils and the adenoid tissue of the pharynx exists so frequently without 
thymus enlargement, that this can hardly be regarded as suggesting 
the condition. The hyperplasia of the tracheo-bronchial or mesenteric 
lymph nodes or of the follicles of the intestine produces no especial 
symptoms. 

Prognosis. — While this condition apparently may exist for an in- 
definite time without producing any symptoms, it undoubtedly often 
determines a fatal outcome of what might otherwise have been a mild 
illness or a trivial accident. It is especially important in connection with 
acute bronchitis and broncho-pneumonia, with attacks of convulsions, 
with the shock of slight operations, and with the administration of 
anaesthetics, particularly chloroform. It is one of the most frequent 
explanations of unexpected death from slight causes, such as an explor- 
atory puncture or the injection of antitoxine. 

At present no known treatment has any influence upon the condition. 



SIMPLE ACUTE ADENITIS. 



883 



Table showing the Situation and the Drainage- Areas of the Various 
Groups of Lymph Nodes of the Head and Neck.* 



10 






Name of the 
group. 



Sub-occipital 
Mastoid. 

Parotid. 



Submaxil- 
lary. 

Supra-hyoid. 

Superficial 
cervical. 



Deep cervi- 
cal, upper 
set. 



Deep cervi- 
cal, lower 
set. 

Sub-hyoid. 



Retro-phar- 
yngeal. 



Number and situation. 



One or two ; at nape of neck. 
Four or five small ones ; in 

mastoid region. 
Five to ten ; on the surface 

and in the substance of 

the parotid gland. 

Twelve to fifteen ; along base 
of jaw, beneath cervical 
fascia. 

One or two ; median line be- 
tween chin and hyoid bone. 

Five or more ; along external 
jugular vein, beneath pla- 
tysma, but superficial to 
the sterno-mastoid. 

Ten to sixteen ; about bifur- 
cation of common carotid 
and along internal jugular 
vein. They are just above 
upper border of thyroid 
cartilage and on a level 
with hyoid bone. 

A chain in the supra-clavicu- 
lar fossa. 



A few small glands below 
hyoid bone and near me- 
dian line. 

Two small glands in front of 
spine and upon preverte- 
bral muscles. 



Organs or areas from which they receive 
lymphatics. 



Scalp, posterior portion. 

Eeceive efferent vessels from group 1, 

and through them from part of scalp. 
Scalp, frontal and parietal portions; 

orbit, posterior part of nasal fossa, 

upper jaw, posterior and upper part 

of pharynx. 
Mouth, lower lip, gums. 



Chin and middle portion of lower lip. 

Auricle, part of scalp, skin of face 
and neck, and some efferent ves- 
sels from groups 1 and 2. 

Lower part of pharynx, larynx, palate, 
tonsils and part of tongue, part of 
nasal fossa, deep muscles of head 
and neck, and from inside the crani- 
um. Receive also efferent vessels 
from groups 3 and 4. 

Connect with axillary group by a chain 
along axillary artery; also with 
glands of mediastinum and with 
groups 7 and 9. 

Communicate with group 8, and may 
connect below with chain of bron- 
chial glands. 

Pharynx and part of nasal fossa. 



SIMPLE ACUTE ADENITIS. 

This is an acute inflammation of the lymph nodes which in infancy 
frequently terminates in suppuration. A certain amount of inflamma- 
tion of the lymph nodes occurs in children in all acute processes affect- 
ing the mucous membranes, especially when they are severe or prolonged. 
Those in connection with the various internal organs are considered with 
the diseases of the organs. Acute inflammation of the external nodes 
is of sufficient frequency to require separate consideration. While this 
is probably always secondary to some pathological process in the skin 
or mucous membranes, the primary condition may be so slight as to be 
overlooked, and the adenitis may be the more important condition or may 
even assume the appearance of a primary disease. It is particularly in 



* Modified from Treves after Curnow in the Lancet, 1879, vol. i, p. 397. 



884 DISEASES OF THE LYMPH NODES. 

infants that this is seen, and it depends upon the unusually active absorp- 
tion and upon the susceptibility of the lymphoid tissues at this age. The 
cervical glands are frequently affected, and occasionally those of the axil- 
lary and inguinal regions. 

Etiology. — Acute adenitis occurs in children of all ages in connection 
with diphtheria, scarlet fever, measles, and influenza. In such cases it is 
often severe, and after scarlet fever, occasionally terminates in suppu- 
ration. With the simple acute catarrhal processes of the pharynx and 
rhino-pharynx adenitis also occurs, but it is usually mild and rarely 
ends in suppuration. In infancy, on the other hand, acute adenitis 
from simple catarrh is not only very common but often severe, and fre- 
quently terminates in suppuration. Ulcerative stomatitis, carious 
teeth, eczema of the scalp or traumatism, may excite adenitis in chil- 
dren of all ages. Axillary adenitis may result from vaccination; ingui- 
nal adenitis, from vaginitis. 

Of 109 cases of acute adenitis from my records, not including any 
associated with diphtheria, measles, or scarlet fever, more than three 
fourths occurred in the first two years, and half of them in the first year 
of life. This susceptibility of infants is very striking. The disease oc- 
curs frequently in those who are in other respects perfectly healthy, 
and often when the evidences of disease of the mucous membrane are 
slight. This is true not only of the cases of cervical adenitis, but also 
of others in which the inguinal glands are involved. The inflammation 
is excited in most of these cases by the absorption of pyogenic germs, 
usually staphylococci or streptococci, from the mucous membranes or 
skin; in some cases, as in diphtheria, probably by the action of toxins. 

Lesions. — The changes taking place in the glands are acute conges- 
tion, with swelling, oedema, and active hyperplasia of the lymphoid ele- 
ments. The process may terminate in resolution or in suppuration ac- 
cording to the intensity of the infection and the susceptibility of the tis- 
sues. When severe enough to cause suppuration, the adenitis is accom- 
panied by considerable inflammation of the surrounding cellular tissue. 

In the series of 109 acute cases to which I have referred, not includ- 
ing the specific infectious diseases, 96 were cervical, 9 were inguinal, 
and 4 axillary; 62 per cent terminated in suppuration, the latter being 
nearly all in infancy. Suppurative otitis was present in 16 per cent of 
the cases. Suppurative retro-pharyngeal adenitis (retro-pharyngeal 
abscess) was seen in several cases. 

In infancy the disease is usually unilateral, or, if bilateral, the 
glands of one side are more severely affected than those of the other. 
Suppuration is nearly always of one side, and usually the abscess starts 
from a single gland. 

Symptoms. — The symptoms and course of the adenitis of the specific 
infectious diseases belong to their clinical history. Suppuration is infre- 
quent, except after scarlet fever. It is very rare after diphtheria, and 



SIMPLE ACUTE ADENITIS. 



885 




when present usually signifies mixed infection ; I have seen it occur but 
twice. 

The typical cases of acute adenitis are those which occur in infancy. 
There are present the symptoms of the original disease, — usually catarrh 
of the nose or rhino-pharynx, mouth, 

or ear, which may not be very severe, HHkh^. 

and sometimes is overlooked. The # 

glands most frequently affected are 
the deep cervical group. The tumour 
appears just below the angle of the 
jaw at the anterior border of the 
sterno-mastoid muscle (Fig. 173). 
The swelling during the acute catarrh 
is not rapid or great, but continues 
after the original process has sub- 
sided until it reaches the size of a 
walnut or even larger. In the most 
acute cases there is marked inflamma- 
tion of the periglandular cellular tis- 
sue, with pain, tenderness, and extra 
heat. If suppuration occurs, it is gen- 
erally evident in the latter part of the 
second week, but sometimes it may 
be as late as the third or even the 
fourth week. In the axillary or inguinal region (Fig. 174) the symptoms 
of adenitis are essentially the same as in the neck. In the inguinal cases 
the degree of catarrh of the mucous membrane is often very slight. 

Most cases run their course with 
slight fever and few general symp- 
toms ; but in young infants the con- 
stitutional symptoms are often severe 
and the physician may be in doubt 
whether the local process is suffi- 
cient to explain them. The temper- 
ature may be from 102° to 104° F. for 
several days, with considerable pros- 
tration, which is much increased if 
there is complicating otitis. After 
suppuration, if freely opened at the 
proper time, the abscess heals rapidly 
and permanently, a sinus being rare. 
Occasionally infection extends from 
one gland to another, and a succession 
of these glandular abscesses occurs. 



Fig. 173. — Acute suppurative adenitis in an 
infant one year old, showing the most fre- 
quent situation of the tumour in the cervi- 
cal region. 




Acute suppurative adenitis (in- 



guinal) in an infant three months old. 



886 DISEASES OP THE LYMPH NODES. 

In the non-suppurative cases the swelling may be even greater than 
in those which suppurate ; but it is less diffuse and apparently limited to 
the gland. It subsides slowly in the course of from four to eight weeks, 
often leaving a small tumour which may be apparent for several months. 
In susceptible children recurrent attacks of acute inflammation may lead 
to chronic enlargement which may last indefinitely. These glands do 
not become cheesy, except from subsequent tuberculous infection. 

The acute cases in infancy in which suppuration occurs, appear to 
recover about as promptly and quite as completely as those terminating 
in resolution, although in the former the constitutional symptoms are 
more severe. 

Diagnosis. — This is usually easy if it is remembered that, with the ex- 
ception of the specific infectious diseases, and occasionally local causes 
like eczema of the scalp, carious teeth, etc., acute suppurative adenitis is 
essentially a disease of infancy. I have often seen it mistaken for mumps 
when the swelling was severe, but on close examination there is but little 
resemblance between the conditions. The disease is essentially acute, and 
has nothing in common with tie slow suppuration seen in later childhood 
from the breaking down of tuberculous glands. 

Treatment. — Prophylaxis requires that in all acute catarrhs the mu- 
cous membrane should be kept as clean as possible by the use of nasal or 
pharyngeal sprays, or by syringing with simple solutions like DobelPs or 
Seller's, or one of common salt. 

In the stage of acute inflammation very hot applications or an ice- 
bag may be used for the relief of pain. It is very doubtful whether 
either of these means has much influence in preventing suppuration. If 
abscess forms, incision should be deferred until pointing has taken place. 
If this plan is followed, refilling is rare. A simple free incision with 
proper aseptic treatment is all that is required. Curetting may be 
done if there is much broken-down tissue present, but it is not usually 
necessary. In most of the cases the abscess promptly heals and a perfect 
cure takes place. In cases which do not suppurate, absorption may be 
promoted by the internal use of the iodide of potassium in full doses — 
gr. x daily to an infant of one year. I confess rarely to have seen any 
benefit from painting with iodine or from inunctions of iodine ointment 
or the oleate of mercury. If adenitis is secondary to carious teeth, 
eczema, or ulcerative stomatitis, these conditions should receive appro- 
priate treatment. Such cases do not usually suppurate, but subside rap- 
idly when the primary cause is removed. 

SIMPLE CHRONIC ADENITIS. 
This consists in a simple hyperplasia of the lymph nodes. There are 
considered here only the external glands, but those of the cavities of the 
body are affected in a similar way, in diseases of the mucous membranes 
with which they are connected. 






SYPHILITIC ADENITIS. 887 

Simple chronic adenitis is not nearly so frequent as the acute form 
even in infants and young children, and it is rare after the fifth year. It 
may follow one or more attacks of acute adenitis, or it may result from 
subacute or chronic inflammations of the skin or of the various mucous 
membranes, infection from which causes the acute form. The most fre- 
quent subjects are children who have the diathesis described as " lym- 
phatism." 

Symptoms. — The glands upon both sides of the neck are usually 
involved, and more often a group than a single gland. The degree of 
swelling is not generally great, being much less than in acute adenitis, 
and usually less than in the tuberculous form. There are no constitu- 
tional symptoms. Hypertrophy of the tonsils and adenoid growths of 
the pharynx are frequently present. There is no tendency to suppura- 
tion or caseation. The swelling usually increases slowly for one or two 
months, then remains stationary for about the same length of time, after 
which it slowly subsides. A subacute course is more frequent than a 
very chronic one. 

Diagnosis. — These cases are especially to be distinguished from those 
of tuberculous adenitis. The most important points for differentiation 
are, that they occur most frequently in children under three years, a 
period when tuberculous adenitis is not common; some definite exciting 
cause is usually present; caseation and suppuration do not occur; the 
glands do not become adherent to the skin or to the deeper tissues; 
they enlarge much more rapidly than do the non-caseating tuberculous 
glands; and they are influenced to a much greater degree by constitu- 
tional treatment. 

Treatment. — Operative measures are not called for in simple ade- 
nitis; but as there are some cases in which a positive diagnosis from 
tuberculous adenitis is impossible, operation is to be considered in all 
doubtful cases if a thorough trial of other measures for two or three 
months has been without benefit. Local causes usually found in the 
pharynx, nose, or mouth should be removed if possible. Often more can 
be accomplished by removal to a climate in which the child's catarrhal 
symptoms are relieved than by ail else. Little benefit is seen from local 
applications. The most useful internal remedies are, the syrup of the 
iodide of iron (twenty drops three times l day to a child of four years), 
guiaquin (one grain three times a day), and arsenic (two or three drops 
of Fowler's solution three times a day). Cod-liver oil should be given 
except during warm weather. 

SYPHILITIC ADENITIS. 

It is quite rare that a marked degree of glandular enlargement is 
seen as a symptom of hereditary syphilis ; indeed, it is so rare that it is 
often forgotten that chronic multiple glandular enlargements are ever 



888 DISEASES OF THE LYMPH NODES. 

due to this disease. In the few examples that have come under my ob- 
servation, this has been a late symptom of hereditary syphilis. The 
glandular enlargements were cervical and multiple, and the degree of 
swelling was often marked. They may be associated with disease of the 
bones or of the mucous membrane of the throat or of the nose, or with- 
out signs of such disease. The diagnosis of syphilis rests upon the asso- 
ciation of other late manifestations of the disease — keratitis, periostitis, 
deformities of the teeth — and the prompt improvement under anti- 
syphilitic treatment. In their local appearance they resemble tubercu- 
lous glands. 

TUBERCULOUS ADENITIS. 

Synonym: Scrofula. 

Tuberculous disease of the lymph glands of the cavities of the body 
is discussed elsewhere; only that of the external glands is here consid- 
ered. This condition presents some striking peculiarities: it is rela- 
tively rare in infancy, although a frequent form of tuberculosis in 
older children; it often exists as the only tuberculous lesion in the body. 
In the great majority of cases it is the cervical glands which are affected. 

Etiology. — The age at which tuberculosis of the cervical lymph glands 
is usually seen is from three to ten years. In my experience with tuber- 
culosis in infancy, the external glands are rarely involved, while the 
bronchial glands are almost invariably the seat of infection. 

Local conditions favouring infection are adenoid growths of the 
pharynx, chronic pharyngitis, and hypertrophied tonsils ; less frequently 
chronic otitis, chronic conjunctivitis, and pathological processes of the 
skin or the mouth, such as eczema of the face or scalp, ulcerative stoma- 
titis, carious teeth, etc. That the pharynx is the most frequent seat of 
primary infection, is shown by the fact that the deep cervical glands are 
generally first affected. The question often arises whether the process 
is at first a simple one, and later becomes tuberculous, or whether it is 
tuberculous from the outset. My own belief is that in most cases the 
process is a tuberculous one from the beginning. 

Children who are by inheritance predisposed to tuberculosis and those 
also who are prone to glandular enlargements — two conditions which are 
by no means identical — are the ones most liable to be affected. Attacks 
of acute infectious diseases, particularly measles, scarlet fever, and influ- 
enza, frequently play the role of exciting causes. 

The age of those affected corresponds very closely with that at which 
children are most often seen with hypertrophied tonsils and adenoid 
growths of the pharynx. The subsidence of symptoms about the time of 
puberty, is also characteristic of both conditions. 

Lesions. — It has been already stated that in the great majority of 
cases the cervical lymph nodes are involved, and generally they are the 



TUBERCULOUS ADENITIS. 889 

only ones affected. In 155 cases of tuberculous glands in the series re- 
ported by Treves,* those of the neck were the seat of disease in 145 and 
the only seat in 131 ; those of the axilla were involved in 17, but alone 
only in 4; the groin in 8, and alone in 6. This indicates the close asso- 
ciation of the disease with infection through the upper respiratory tract. 
The nodes first affected are most frequently the upper set of the deep 
cervical group; sometimes, however, it is the superficial nodes of the 
submaxillary, or the parotid group, and occasionally the submental or 
the pre-auricular. f The chain of deep cervical nodes which is involved, 
follows the carotid artery, and often extends some distance below the 
clavicle. These deep nodes are sometimes connected with the bronchial 
group. 

The process in all tuberculous glands is essentially a chronic one, but 
pathologically the cases may be divided into two groups, corresponding 
somewhat to the forms of disease seen in the lungs. In one group the 
process is more rapid, and tends to early caseation and softening; the 
products of inflammation are mainly cellular, and the amount of fibrous 
tissue is small. In another group the course is slower, and fibrous tissue 
predominates, caseation and softening being infrequent. 

In the first group the glands in the early stage are swollen, of a pale 
pink colour, and homogeneous ; later they become more firm, and show, 
as the first gross evidence of tuberculous deposits, small grayish-white 
spots, which are generally numerous and scattered through the affected 
gland; these spots enlarge, and may coalesce to form one large gray 
mass, involving nearly the whole gland. Subsequently there is caseation 
and then softening, usually beginning in the centre of the caseous area. 
Inflammation within the gland is followed by that of the surrounding 
tissues, which may result in adhesions or in the formation of a periglan- 
dular abscess. The first change in the gland is the production of epithe- 
lioid and giant cells, about which there is a zone of small round cells; 
cheesy degeneration then begins in the centre. The caseous masses may 
become encapsulated by the production about them of fibrous tissue ; or 
softening may occur at one or more foci, and an abscess form. Such an 
abscess contains curdy material but very little true pus, the contents 
being chiefly detritus from the broken-down node. Tubercle bacilli are 
usually more numerous in the early stages of the process, but are often 
difficult of detection in broken-down tissues, and the curdy pus is some- 
times sterile. As the glands soften, the process gradually extends from 
the centre to the surface, and they become adherent to the surrounding 
structures — blood-vessels, nerves, or the fascia — they fuse together and 
form large knotty masses, and when they ultimately break down they 
lead to the formation of an abscess in the cellular tissue, finally involv- 

* Scrofula and its Gland Diseases. Smith, Elder & Co., London, 1882. 
f Nicoll, Glasgow Medical Journal, January, 1896. 



890 



DISEASES OF THE LYMPH NODES. 



ing the skin. In the form of suppuration which occurs in and about 
tuberculous nodes, an important part is often played by other bacteria, 
usually the staphylococcus or the streptococcus. 

In the second group of cases, where the process goes forward more 
slowly, the changes are not quite the same, the essential difference being 
that the amount of fibrous tissue is much greater. These nodes are not 

so vascular; they are tough and hard, ap- 
pearing like small fibrous tumours. The 
capsules are greatly thickened, and under 
the microscope is seen fibrous tissue ar- 
ranged in concentric layers, often inclosing 
small caseous masses. These nodes less fre- 
quently form adhesions to the surrounding 
tissues, and consequently are freely mov- 
able, while suppuration is quite exceptional. 
Although the separate tumours are much 
smaller than in the first group, the glandu- 
lar mass is often a large one, because of the 
number of glands involved. 

It is seldom in either group of cases that 
the process is limited to a single node or 
even to two or three nodes. Very often an 
entire chain is involved (see Fig. 175). The 
pathological process under such circum- 
stances usually varies in degree according 
to the distance from the main focus of in- 
fection; the nodes nearest show the most 
advanced changes; those at a distance, the 
early stages of the disease. 

Tuberculous infection of the lymph 
nodes may terminate in resolution, encap- 
sulation, calcification, or suppuration. The 
inflammation may subside before caseation 
has taken place and the inflammatory prod- 
ucts undergo absorption. After caseation 
has occurred the masses may become encap- 
sulated and contract to small fibrous nod- 
ules. Calcification of the glands in this 
location is rare. In other cases caseation 
is followed by breaking down, liquefaction, 
and an external abscess. The course which the local disease takes will 
depend upon the intensity of the infection and the general vigour and 
resistance of the child. There is seen in most cases a tendency of the 
inflammation to subside spontaneously about the time of puberty. Cure 




Fig. 175. — Posterior cervical chain 
of tuberculous lymph nodes. 

The upper one showed giant cells 
and extensive cheesy degeneration; 
one at the middle showed early 
tuberculous changes— cell infiltra- 
tion, giant cells, and a small area 
of cheesy degeneration ; the lowest 
node showed one small tubercle 
with a cheesy centre. Child two 
and a half years old. (Dowd.) 



TUBERCULOUS ADENITIS. 891 

has sometimes followed an acute attack of intercurrent disease, such as 
erysipelas of the face, and even scarlet fever. 

Symptoms. — In the early part of the disease there are no symptoms 
hut the glandular swelling, and this "begins very gradually. In most 
cases "both sides are involved, but as the disease progresses the advanced 
changes are usually confined to one side. The enlargement is seldom 
continuous; it often increases for a time and then remains stationary 
or even diminishes, to take a new start from the stimulus of some fresh 
infection of the mucous membrane with which the glands are asso- 
ciated, such as an attack of measles or influenza, or simply from a 
deterioration in the patient's general health. During exacerbations, the 
glands may be painful and tender, and show the usual signs of local in- 
flammation. 

The whole course of the disease varies from several months to as 
many years. Treves gives three and a half years as the average dura- 
tion where suppuration occurs. The glands first affected are usually 
those situated near the bifurcation of the common carotid artery. Such 
tumours usually make their appearance just in front of the sterno-mas- 
toid muscle — sometimes behind it — and at the level of the upper border 
of the larynx or the hyoid bone. In the more rapid cases the tumours 
usually attain a considerable size in three or four months, sometimes in 
half that time. The usual size reached is from that of an almond to an 
English walnut. At first the tumours are movable and preserve their 
distinct outline ; later they become adherent, first to the deeper tissues 
and to each other, finally to the skin, and there is formed an irregular 
nodular mass in which it is sometimes difficult to make out the individ- 
ual glands. As the process approaches the surface there are small spots 
of softening ; then there is distinct fluctuation ; the skin becomes discol- 
oured and finally gives way, and there is a discharge of thick, curdy pus, 
which may continue for an indefinite time, until the whole of the broken- 
down gland has been thrown off. This course is repeated with each suc- 
cessive gland which breaks down. In cases progressing more slowly the 
glands become adherent chiefly to one another, and suppuration is less 
frequent. 

In what proportion of tuberculous lymph nodes suppuration occurs, 
it is difficult to say. Like other tuberculous lesions in the body, this one 
is more frequent than was once supposed ; and in the past most of those 
which did not break down were not classed as tuberculous. It is probable 
that of the cases allowed to run their course about one half terminate in 
suppuration. Two forms of suppuration occur in connection with tuber- 
culous glands — one an abscess of the gland proper, the other outside of 
and usually over it. In a typical case of the first variety, the gland is 
distinctly outlined and often superficial, there is very little inflammation, 
the spot of softening and fluctuation is small, and the pus discharged is 



892 



DISEASES OF THE LYMPH NODES. 



always curdy. In the second variety the abscess is preceded by a more 
diffuse swelling, and the outline of the gland may not be made out; the 
signs of inflammation are more marked, the area of fluctuation is larger, 
and the pus is more like that of any ordinary abscess. Often the two 
varieties are combined; as when a gland beneath the deep fascia breaks 
down and there is formed directly over it an abscess in the cellular tissue, 
which communicates through a narrow opening with the gland beneath. 
In such cases the sinus continues open for a very long time, until the 
whole of the gland has been discharged. If healing occurs before this, 
the cicatrix soon breaks down. 

Where abscesses are allowed to open spontaneously, large, irregular, 
and usually very intractable ulcers form. The skin is undermined for a 




Fig. 176.— Cicatrices following a neglected case of tuberculous adenitis, in a girl seven years 
old. There is also a tuberculous patch upon the skin of the cheek in a very frequent 
location. 



considerable distance, and it has an unhealthy appearance. Such ulcers 
sometimes continue for many months in spite of all treatment, particu- 
larly if the patient's general health is poor. The scars left after them 
are large and unsightly, and sometimes positively deforming (Fig. 176). 
Their appearance is quite characteristic. They often have many tabs 
of skin attached to them; they may form prominent ridges which un- 
dergo contraction like those after burns; they are of a purplish-red 



TUBERCULOUS ADENITIS. 893 

colour, and adherent to the deeper tissues. They are often sensitive 
and painful. As time passes they atrophy and become less conspicuous, 
though they remain through life. 

The general health of children with tuberculous glands may be much 
or little affected, and not a few remain in good condition throughout the 
whole course of the disease, particularly when suppuration does not 
occur, but sometimes even when it is protracted. 

Prognosis. — Tuberculosis of the external lymph nodes is seldom if 
ever the direct cause of death; although the course is often very pro- 
tracted, ultimate recovery can usually be predicted. As previously 
stated, it is surprising that this process is so frequently the only tuber- 
culous lesion in the body. Treves states that the percentage of those 
who die from general tuberculosis is so small that this danger is not to 
be considered an argument for operation. Poore * reports that of 58 
cases treated by operation, only 2 were known to have died from tuber- 
culosis. Dowd f has collected reports of 309 cases treated by removal 
more or less complete, whose histories were followed for several years 
after operation. Of these, 202, or 65 -4 per cent, were apparently cured; 
57, or 18 *4 per cent, were living, though suffering from either local or 
general tuberculosis; 50, or 16*2 per cent, died of tuberculosis. These 
statistics surely do not support the hopeful views of the writers first 
quoted, but they are, I think, more in accord with general experience. 

Diagnosis. — The diagnostic features of tuberculous glands are the 
age of the patient — usually from three to ten years — the site of the pri- 
mary swelling, the indolent course, the trifling original cause, and most 
of all the disposition to slow caseation, softening, and abscess. The 
cases of simple hyperplasia are usually in children under three years, 
their progress is much more rapid, there is often some definite cause, and 
in most cases they nearly or quite disappear in the course of three or 
four months. They suppurate, if at all, during the first month. Syphi- 
litic disease is to be recognised mainly by discovering the evidence of 
syphilis elsewhere, and by the effect of treatment. In Hodgkin's dis- 
ease, glandular groups in other parts of the body are involved simulta- 
neously or in rapid succession. There are no signs of inflammation or 
caseation; and the swellings are accompanied by very marked and defi- 
nite constitutional symptoms — anaemia, emaciation, and general prostra- 
tion. Malignant growths are very rare; they increase rapidly, often at- 
taining a great size in a few months. 

Treatment. — The general treatment of tuberculous glands is to put 
the child under the very best surroundings possible. The seaside has a 
great reputation for such cases, and no doubt the majority do very well 
there; but some are benefited even more by a dry, mountain climate. 

* New York Medical Journal, June 23, 1892. f Annals of Surgery, May, 1899. 

58 



894 DISEASES OF THE LYMPH NODES. 

At all events, a child from the city should be sent into the country when- 
ever this is possible. Internally the only remedies which have any spe- 
cial virtues are cod-liver oil and the syrup of the iodide of iron. The 
latter should be given in full doses — i. e., twenty or thirty drops, three 
times a day, to a child of six years. Arsenic and iron are useful as gen- 
eral tonics. Local applications are of little value and most of them posi- 
tively harmful ; painting with iodine and poulticing should be discarded 
altogether. The parts should be protected against cold, and should be 
rubbed or handled as little as possible. 

It is important in every case to remove from the nose and throat all 
sources of local irritation. Hypertrophied tonsils should be excised, and 
the adenoid tissue of the pharynx removed even when not very exten- 
sive, since these are the two regions which most frequently harbour the 
tubercle bacilli. Any pathological conditions in the nose, such as hyper- 
trophy of the turbinated bodies, should receive attention ; so also should 
chronic otitis, chronic conjunctivitis, carious teeth or ulcers in the mouth. 
All these, if they do no more, keep up a constant glandular irritation, 
and produce conditions which are most favourable for the activity of the 
tubercle bacillus. 

Operative measures. — These are indicated if, after two or three 
months of constitutional treatment, the glands affected continue to in- 
crease in size and number, or if softening occurs. The advantages of 
operation over leaving the case to Nature are, that it leaves a clean scar 
instead of a large, irregular one; that it shortens the disease and pre- 
vents the long, tedious suppuration of cases left to themselves; that it 
is a radical measure ; and that it avoids the danger of general infection 
by removing the tuberculous focus. 

The radical operation which aims at removal of all the diseased nodes 
through a free incision, is steadily growing in favour in New York. The 
best results follow this operation when it is done early before the skin 
is involved or the glands have softened or have formed extensive adhe- 
sions to the great vessels and neighbouring structures; also where a 
chain of glands is involved and where the inflammatory process is slow 
or indolent. In most cases operation requires a free incision and a pro- 
longed and careful dissection, for the purpose is the removal not merely 
of two or three large glands which were evident before the incision was 
made, but the entire chain of fifteen or twenty smaller ones (see Fig. 
175), some of which may not be larger than a pea, and are just begin- 
ning to be affected. If performed early a thorough operation by a good 
surgeon in the majority of cases will result in a permanent cure. How- 
ever, the operation is not contra-indicated in cases which have gone on to 
a later stage, although the results may not be quite so satisfactory. 

Other less radical operations are curetting, cautery puncture, and 
injections. Curetting is adapted to single large glands which have 



HODGKIN'S DISEASE. 895 

softened and are adherent to the skin. It may be done at any time except 
during a period of acute inflammation. Cautery puncture is an opera- 
tion much done in Europe, though but little in this country. It is not 
applicable to glands smaller than a cherry. This operation is done with 
a small cautery point, which is thrust through the skin into the gland, 
and then in two or three directions through it, after which some soothing 
dressing is applied. The substances chiefly used for injection are iodo- 
form emulsion, chloride of zinc, and carbolic acid. Injections and cau- 
tery puncture are to be advised only when the general or the local condi- 
tion contra-indicates the radical operation. 

Glandular abscesses should in all cases be opened as soon as pus 
forms, to prevent the extensive undermining of the skin, which is so 
likely to occur. The opening should be a small one, and all squeezing of 
the gland or surrounding tissues avoided. 

HODGKIN'S DISEASE (ADENIE). 

This is a rare disease in which there is a general hyperplasia of the 
lymphatic glands throughout the body, with growths of lymphoid tissue 
in the spleen, liver, and other internal organs. It is accompanied by 
marked anaemia, is progressive in its course, and usually terminates fa- 
tally. The cause is unknown. It is much more common in males than 
in females. Its occurrence in childhood is exceedingly rare. 

The changes in the glands consist in a simple hyperplasia, which may 
be extreme. Suppuration and caseation are very rare, if indeed they ever 
occur. Any of the external or internal groups of lymph glands may be 
affected, and in severe cases the disease may involve almost every chain 
of glands in the body. Of the external groups, the cervical and the axil- 
lary are usually most affected ; of the internal groups, those of the medi- 
astinum and the retro-peritoneal region. The spleen and the liver are 
moderately enlarged, and lymphoid growths, varying in size from a pin's 
head to a grape, are usually scattered throughout their substance. There 
may be changes in the bone-marrow. 

Symptoms. — The disease develops very gradually, often insidiously. 
The external glandular swellings are usually the first noticed, but some- 
times it is the anaemia which first attracts attention; occasionally it is 
the local symptoms resulting from the pressure of internal glands, which 
may give rise to oedema, pain, cough, or dyspnoea. The progress is gen- 
erally slow but steady, and the glands may reach an immense size. The 
blood changes are inconstant. As a rule, there is a relative increase in 
the lymphocytes, while the total number of white cells is generally less 
than normal, although sometimes increased. 

Treatment. — This i> very unsatisfactory. Arsenic in full dosesappears 
to benefit some patients. The use of the X rays lias produced striking, 
though in most cases only temporary improvement in the external glands. 



DISEASES OP THE SPLEEN. 

CHAPTEE III. 

DISEASES OF THE SPLEEN. 

Weight. — From one hundred and forty observations made at the New 
York Infant Asylum the following were the weights recorded at the dif- 
ferent ages : 

Weight of the Spleen in Infancy and Early Childhood. 



Age. 


Ounces. 


Grammes. 


Birth 


i 
* 

f 

1* 


7-7 


Three months 


15-5 


Twelve " 


23-2 


Two years 


38-5 


Three " 


46-4 







Position and Methods of Examination. — The normal position of the 
spleen is close against the diaphragm, its external surface being opposite 
the ninth, tenth, and eleventh ribs. Its anterior border comes as far for- 
ward as the middle axillary line, its posterior border being usually near 
the vertebral column. In infancy it is practically impossible to outline 
the spleen by percussion, unless it is enlarged. During full inspiration 
the spleen is often depressed enough to be felt at the free border of the 
ribs, but at other times it can not be felt unless it is enlarged or pushed 
downward by some pathological condition in the chest. Normally, the 
long axis of the spleen is nearly parallel with the ribs, but when the 
organ is much enlarged, its axis corresponds nearly with a line drawn 
from the axillary line at the border of the ribs to the middle of Pou- 
part's ligament. 

The thin abdominal walls of young children render palpation of the 
spleen much easier than in adults; and this is a much more satisfactory 
method of examination than is percussion. In fact, the results from per- 
cussion are so uncertain and misleading that in most cases one may dis- 
pense with it, and rely on palpation to determine the size of the spleen. 
For satisfactory palpation it is necessary that the abdominal walls 
should not be tense. It is therefore important that the child should be 
quiet, and that the examination be made as gently as possible, and no 
force or undue pressure used. The child should lie upon its back with 
the thighs flexed and the skin, of course, bared. The physician, always 
having taken the trouble to warm his hands, should stand upon the left- 
side of the patient and make pressure with the tips of the fingers, which 
are semiflexed. The pressure should be at first light, and gradually in- 
creased, the fingers being then held stationary during two or three re- 
spiratory movements. It is sometimes better to use the fingers of one 



ENLARGEMENT OF THE SPLEEN. 897 

hand for palpation, and make pressure with the other directly over the 
first. Palpation should be made in the axillary line. If the examination 
is satisfactory, and in the great majority of cases it is so if the child is 
quiet, the spleen can easily be felt when it is sufficiently enlarged to be of 
any diagnostic importance. With a little practice one can readily detect 
even slight degrees of enlargement. 

When moderately enlarged, the lower border of the spleen is an inch 
or so below the free border of the ribs ; when greatly enlarged, it forms 
a tumour which may nearly fill the left half of the abdomen. A tumour 
in the left hypochondriac region is recognised to be the spleen, by the fact 
that it is freely movable laterally and at its lower border or extremity, 
while it is attached above ; also its inner border can usually be felt to be 
thin and sharp, and marked about its middle by quite a deep notch. 

ENLARGEMENT OF THE SPLEEN. 

In Acute Disease. — The spleen is most frequently and most constantly 
enlarged in malarial and typhoid fevers, but it is occasionally so in all 
the acute infectious diseases. 

In most of these cases the enlargement is chiefly from congestion, but 
there may be acute hyperplasia and an increase in size of the Malpighian 
bodies. It may contain small haemorrhages, and in extremely rare cases 
the spleen may rupture. In appearance it is generally dark-coloured, 
soft, and somewhat friable. In the cases which recover, the splenic swell- 
ing subsides with the original disease. 

In Chronic Disease. — Like the lymph nodes, the spleen is much more 
often enlarged in children, particularly young children, than in adults. 
Enlargement is seen at times in almost all the chronic diseases of early 
life; but it occurs most frequently in rickets, syphilis, malaria, tubercu- 
losis, the blood diseases, and in amyloid degeneration. Besides, it may 
be the seat of a primary growth, either benign or malignant. 

Rickets. — The splenic enlargement which accompanies rickets is gen- 
erally seen during the first year ; at this period it is very frequent. The 
swelling is usually moderate, but occasionally it is so great that the lower 
border is three or four inches below the ribs. It belongs to the most 
severe forms of the disease. 

Syphilis. — Enlargement of the spleen is one of the most constant 
lesions in congenital syphilis. It is present with great uniformity in chil- 
dren born with syphilitic lesions, and very frequently during the active 
period of the disease in early infancy. It is seen at a later period during 
infancy or childhood, associated with other late symptoms. The degree 
of enlargement is often great. In several cases I have seen it sufficient to 
form a large abdominal tumour. The liver also is increased in size, but 
not to such a degree. The pathological changes in the spleen in syphilis 
are considered with that disease. 



898 DISEASES OF THE SPLEEN. 

Malaria. — The swelling in these cases may be very great. The liver 
is not so often enlarged as in syphilis. There is usually a history of ex- 
posure in a malarial district. 

Tuberculosis. — It is rare to find anything more than a moderate 
swelling of the spleen in tuberculosis. In the most acute cases this may 
be due to the fever and general infection ; in those which are less rapid, it 
depends either upon tuberculous deposits or passive congestion from 
venous obstruction, the result of the pulmonary disease. 

The blood diseases. — Marked enlargement of the spleen is found in 
many cases of simple anaemia accompanied by moderate leucocytosis. 
This is quite peculiar to infancy and early childhood. The spleen is con- 
stantly swollen, and usually greatly so, in the pseudo-leukaemic anaemia 
of infants, in leukaemia, and in Hodgkin's disease. In the last two dis- 
eases the liver is also enlarged, but to a much less degree than the spleen ; 
in the others it is but slightly changed. 

Amyloid degeneration. — The causes of this condition and its general 
symptoms are mentioned in connection with amyloid disease of the liver 
(page 463). The spleen is constantly involved, and the enlargement of 
this organ, as well as that of the liver, may be very great. The changes 
resemble those found in the liver. 

Cardiac disease. — In all forms of cardiac disease, and in other con- 
ditions in which there is obstruction to the systemic venous circulation, 
the spleen is enlarged. It is seen in congenital as well as in acquired 
cases. The liver is usually enlarged to about the same degree as the 
spleen, and there may also be dropsy of the feet. 

New-growths, tumours, etc. — It is seldom in early life that the spleen 
is the seat of new-growths; these are usually varieties of sarcoma, but 
carcinoma has also been reported. 

Primary spleno-megaly. — The rare cases of immense primary en- 
largement of the spleen have been variously interpreted. By some wri- 
ters the condition has been regarded as lymphoma. Bovaird * has re- 
ported two cases in children, sisters, one of which was carefully studied 
microscopically, and the conclusions reached that the process was an 
endothelial hyperplasia. The condition was first described by Gaucher. 
Clinically the disease is characterized by a slowly progressing enlarge- 
ment of the spleen which begins in early childhood and may continue for 
from five to twenty years ; the size attained is very great, it often nearly 
filling the abdomen. In one of Bovaird's cases the weight was twelve 
and a half pounds. The other symptoms are a simple anaemia, inflam- 
mation of the gums with haemorrhages from the nose, gums, and some- 
times beneath the skin, and finally secondary symptoms due to the ab- 
dominal tumour. The course is very chronic, and thus far no known 
treatment has been of any avail. 

* American Journal of the Medical Sciences, October, 1900. 






ACUTE ARTHRITIS OF INFANTS. 899 

CHAPTEE IV. 

DISEASES OF THE BONES AND JOINTS. 

ACUTE ARTHRITIS OF INFANTS. 

The terms acute purulent synovitis, acute epiphysitis, pycemia of bone 
and acute osteo-myelitis, have all been applied to this condition. The dis- 
ease is really a form of pyaemia. The causes and lesions may differ consid- 
erably in the different cases, bnt clinically they all have certain features 
in common, viz., an acute joint inflammation with suppuration. 

The acute arthritis of infants is essentially a disease of the first year, 
and is much more frequently seen in the first six months. The inflam- 
mation may begin in the joint, at the epiphyseal junction, or in the 
medullary canal; but however it may start, the joint is soon invaded. 
The nature of the arthritis varies somewhat with the exciting cause. 
When it is due to the gonococcus, it is usually confined to the joint ; there 
is in most cases a superficial inflammation involving the synovial mem- 
brane, but rarely leading to destructive changes in the cartilage, liga- 
ments or bone. When it is due to the streptococcus or staphylococcus, it 
may begin elsewhere than in the joint, which, however, is usually soon 
involved, and complete disorganisation may follow. It may also result 
in a diffuse osteo-myelitis, in a subperiosteal abscess, or separation of the 
epiphysis. As a late result there may be a pathological dislocation or a 
" flail joint " ; less frequently there is ankylosis. 

Etiology. — The cause of acute arthritis in infants is the entrance 
of pyogenic organisms into the circulation. In my own cases the organ- 
ism most frequently found was the gonococcus; next to this the strepto- 
coccus and staphylococcus ; very rarely, the pneumococcus. In most cases 
occurring during the first two months of life, the portal of entry is 
probably the umbilical cord. Less frequently infection takes place 
through the skin, conjunctiva, genital tract, or the mouth. In the cases 
developing later it is often difficult to determine the point of entry, espe- 
cially when the cause is the gonococcus. During the last few years 
twenty-six cases of acute gonococcus arthritis have been observed in the 
Babies' Hospital, only two of which, occurring during the first month, 
could be classed as infections of the newly born. The cases were ob- 
served during a hospital epidemic of gonococcus vaginitis, and yet nine- 
teen were in male children, in no one of whom was there any genital 
lesion, and in only one was there conjunctivitis. Of the seven cases 
occurring in girls, only two had vaginitis. The portal of entry in these 
cases could not be definitely determined. 

I once saw acute arthritis following pneumonia in an infant, in which 
the pneumococcus was obtained in the pus from the shoulder. 

Symptoms. — The general symptoms often precede the local ones. In 



900 DISEASES OF THE BONES AND JOINTS. 

the most acute cases the temperature is high and widely fluctuating, 
accompanied by other symptoms of a severe infection. The earliest local 
symptoms are pain and tenderness, soon followed by swelling, which may 
develop quite rapidly in a single joint, or in several joints simultaneously. 
In those superficially situated there is redness of the skin, and fluctuation 
may be evident in three or four days. In cases coming on more grad- 
ually the temperature may be only from 100° to 102°, and suppuration 
may not occur for two or three weeks. In the most severe cases the 
progress is rapid, one joint after another being involved, with general 
symptoms of pyaemia, and death may occur in a week or ten days, usually 
from some visceral inflammation, pneumonia, pericarditis, or meningitis. 
This very severe course is less frequent than the more protracted one 
where symptoms last from two to four weeks. Unless the pus is evac- 
uated extensive burrowing may take place. 

In Townsend's collection of 73 cases, the joints were involved in the 
following order: hip, in 38; knee, in 27; shoulder, in 12; wrist, in 5; 
ankle, in 4; elbow, in 4; small joints, in 4. In three- fourths of these 
cases only a single joint was affected. No bacteriological examinations 
were reported. In my own 26 gonococcus cases, the localisation was as 
follows: finger or metacarpus, in 20; ankle, in 18; knee, in 17; wrist, in 
12; toe or metatarsus, in 10; shoulder, in 9; elbow, in 5; temporo- 
maxillary, in 1 ; hip, in 1. The average number of joints involved was 
four or five, the largest number being eight. The tendency of the gono- 
coccus infections to involve the small joints is rather striking. 

Diagnosis. — When several joints are involved, the disease has often 
been mistaken for rheumatism, which, however, at this age is so rare it 
may be ignored. Syphilitic epiphysitis resembles it in the localised ten- 
derness and disability; but the rapid swelling and the severe constitu- 
tional symptoms are lacking. 

Treatment. — Cold applications or wet dressings may be useful in 
relieving the symptoms. In some cases, most frequently when the cause 
is the gonococcus, the inflammation subsides without suppuration. In 
infections due to other organisms, suppuration almost invariably occurs 
and early free incision should be practised, followed by fixation of the 
joint. The results depend in no small degree upon the promptness with 
which the pus is evacuated. In the gonococcus cases there may be com- 
plete recovery. In most of the others the functions are impaired. 

THE TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 

The chronic forms of tuberculous bone-disease, on account of their 
insidious onset and the frequency with which they simulate other dis- 
eases, more frequently fall, in the early stage at least, into the hands of 
the physician than into those of the general or orthopaedic surgeon. All 
that will be attempted in this chapter will be to outline in a general way 



TUBERCULOUS DISEASES. 901 

the most important forms — viz., disease of the vertebrae, hip, and knee — 
dwelling particularly upon the early symptoms and diagnosis. For 
their fuller discussion, particularly as to the details of treatment, the 
reader is referred to text-books on general or orthopaedic surgery. The 
causes are the same, and the lesions are very similar in all forms, and 
will therefore be considered together. 

Etiology. — The age at which tuberculosis of the bones most frequent- 
ly begins, is from the third to the eighth year, it being comparatively rare 
before the end of the second year. The sexes are affected with about 
equal frequency. Tuberculous bone disease may occur in a child who has 
previously been in apparent health, but more often in one who has been 
reduced by some previous illness, especially the infectious diseases; of 
these, it most frequently follows measles and whooping-cough. 

A family history of tuberculosis is present in a large number, but 
by no means in a majority of the cases. Like tuberculosis of the cervical 
glands, it is rarely preceded by other tuberculous processes, although it 
may be followed by them. It usually appears as an example of primary 
infection; but it seems very improbable that such should actually be the 
case. It is more likely that there has previously been a latent focus of 
tuberculosis elsewhere in the body. In many cases, antecedent disease of 
the bronchial glands has been demonstrated by autopsy. Infection from 
these or from other tuberculous lymph glands is the most probable 
explanation of the origin of infection in cases of bone disease. However, 
by some writers, notably Baumgarten, tuberculous disease of bone is 
regarded as due to direct inheritance, and is to be compared to the bone 
lesions which occur as late manifestations of hereditary syphilis. 

Traumatism is often an exciting cause, and it may determine the 
site of the disease. 

Lesions. — The tuberculous joint diseases of childhood are, as a rule, 
secondary to disease of the bones. Hip-joint disease usually begins in 
the head of the femur, and knee-joint disease in one of the condyles; 
ankle-joint disease in the lower epiphysis of the tibia, etc. 

The frequency with which disease is seen in the different locations is 
shown by the following table, which gives the number of cases of each 
form applying for treatment at the Hospital for Ruptured and Crippled, 
New York, during ten years: 

Spine 2,145 cases, or 37'5 per cent. 

Hip 1,937 " " 34-0 " 

Knee 1,222 " " 215 " 

Ankle or tarsus 255 " " 45 " 

Elbow 71 " "1-2 " 

Wrist 50 " " 0-9 " 

Shoulder 24 " " 0-4 " 

Total 5,704 1000 



902 DISEASES OF THE BONES AND JOINTS. 

The character of the bone disease upon which chronic joint disease de- 
pends is generally a primary ostitis, which affects the articular extremities 
of the long bones usually beginning near the epiphyseal line ; in the short 
bones it is a central ostitis. The stages in the process are first congestion, 
swelling, and cell infiltration, followed by caseation, and frequently by 
softening and suppuration. In the early stage, the bone is slightly en- 
larged, and on section one or more yellowish foci of disease are seen. The 
disease may be arrested in this stage, encapsulation of the inflammatory 
products taking place ; or it may continue until there is a more or less 
extensive breaking down or disintegration of the affected bone. As the 
disease extends there are involved, the periosteum, the articular cartilage, 
and finally the joint itself. Abscess may form in the joint or in the soft 
parts surrounding the bone. The process is quite analogous to tuberculous 
disease of the lung. As the disease advances ligamentous attachments are 
loosened, and displacement of the parts occurs with the production of 
deformity, due partly to muscular contraction and partly to the weight of 
the body. The inflammatory process with its resulting disintegration 
generally goes on to a certain point, where it is arrested. Gradually the 
broken-down bone substance is separated and thrown off in small particles 
in the discharge, and a reparative process begins, with the formation of 
healthy bone. Where joint structures have been destroyed, cure takes 
place by bony ankylosis. Sometimes the disease finds its way to the 
surface without involving the joint ; at other times the disease may be 
arrested, and its products become encapsulated within the bone. Inflam- 
mation of the joint may occur by a gradual extension of the inflammatory 
process, or by a sudden perforation of the articular lamella. As a result 
of extensive disease, all the joint structures may be affected, — the synovial 
membrane, ligaments, articular cartilages, and the cellular tissue surround- 
ing the joint. The process of disintegration and that of repair are both 
very chronic and measured by months or years. The entire course of the 
disease is from one to ten years, three years being about the average dura- 
tion. In the great proportion of cases but one joint is involved, although 
it is not infrequent in hospitals to see two, three, and sometimes four of 
the large joints affected in the same patient. 

Secondary lesions. — Abscesses form in a considerable proportion of 
the cases, and often burrow a long distance before they reach the surface. 
Amyloid degeneration of the liver, spleen, and kidney, and sometimes of 
the villi of the intestines, occurs as the result of the prolonged suppura- 
tion, chiefly in connection with disease of the hip or spine, occasionally 
with that of the knee. General or localized tuberculosis, particularly 
tuberculous meningitis, may develop at any time and prove fatal. 

Caries of the Spine — Pott's Disease. — This consists in a chronic 
inflammation of the bodies of the vertebrae, usually beginning in the cen- 
tral portion and extending to the periosteum, ligaments, cartilages, and, 



CARIES OF THE SPINE. 



903 






in fact, to all the contiguous structures. Secondarily it involves the mem- 
branes of the cord, the roots of the spinal nerves, and even the cord itself. 
The number of vertebrae usually affected is from two to five. The gross 
appearance of the lesion in a well-marked case is shown in the accompany- 
ing cut (Fig. 177). After the bodies of the vertebrae have become soft- 
ened and partially broken down by disease, the pressure from the super- 
incumbent weight of the body causes them to fall together and produces 
a backward displacement of the spinous processes, giving rise to the de- 
formity known as kyphosis, which in its ex- 
treme form is popularly known as " hunch- 
back." 

Any part of the vertebral column may be 
affected; but the disease is most frequent in 
the dorsal region, as shown by the following 
statistics from the Hospital for Euptured and 
Crippled : of 2,143 cases, 72*5 per cent affected 
the dorsal region, 15*3 per cent the lumbar 
region, and 12*2 per cent the cervical region. 

Symptoms.— The onset is gradual, often in- 
sidious, and the early symptoms are frequently 
overlooked or misinterpreted. The case may 
go on for weeks or even months before the 
true nature of the disease is recognised, which 
is often not until deformity has occurred. In 
nearly all cases, however, the early symptoms 
are sufficiently characteristic to enable a care- 
ful observer to make a diagnosis before the 
stage of deformity. 

The most constant early symptoms are : (1) 
pains caused by the irritation of the nerve 
roots and referred to various parts of the body, 
following the distribution of the spinal nerves ; 
(2) rigidity of the spine from muscular spasm, 
this being an attempt to prevent motion at 

the seat of disease ; and (3) the assumption of various postures calculated 
to relieve pressure upon the diseased vertebral bodies. Sometimes the first 
symptoms are those of pressure-paralysis (page 829) ; at others they are 
the local signs of abscess. In addition to the local symptoms mentioned, 
there is usually disturbed sleep, often accompanied by moaning. 

Cervical disease. — The pains are often felt above the point of disease, 
frequently in the form of occipital neuralgia ; sometimes they are referred 
to the front or the side of the neck. They may be so frequent and so 
severe that the face assumes a constant expression of anxiety or distress. 
In other cases pain is excited only by an attempt at movement. The 




Fig. 177. — Pott's disease of the 
upper dorsal region ; a ver- 
tical section of the spine, 
showing disintegration of the 
bodies of the vertebne and 
encroachment upon the spinal 
canal. ( From a patient dying 
in the Hospital for Kuptured 
and Crippled.) 



904 DISEASES OF THE BONES AND JOINTS. 

muscular spasm most frequently takes the form of slight torticollis, some- 
times of slight opisthotonus ; sometimes there is simply a fixation of the 
head by a tonic spasm of all the muscles of the neck ; both active and 
passive motion is resisted, and any movement may be so painful that the 
child involuntarily steadies its head with its hands. These symptoms 
come on gradually and are persistent. Sometimes they are overlooked, and 
the first thing to attract attention is a progressive weakness in the lower 
extremities, which proves the beginning of paraplegia. Occasionally the 
first marked symptoms are those due to the formation of a retropharyn- 
geal or a retro-cesophageal abscess. 

The deformity from cervical disease develops much later than when 
the disease is located elsewhere. Usually the neck appears broadened or 
thickened in a nearly uniform way, and often the head seems to have 
settled downward upon the shoulders. In the lower cervical region, a 
kyphosis is not infrequent.; but in the middle and upper regions there is 
more often an anterior prominence, which may be felt in the posterior 
wall of the pharynx. 

Dorsal disease. — The referred pains are now below the seat of disease, 
and take the form of intercostal neuralgia or pain in the epigastrium or the 
abdomen. They are often ascribed to cold, malaria, indigestion, or worms. 
There is a disposition to assume the prone position while sleeping, and 
also to lean across a chair or the lap of the nurse. The child walks care- 
fully, holding the spine erect and very stiffly, and exhibits great caution 
in getting into or out of bed, or in rising from a recumbent position. In 
the beginning there may be a slight lordosis, or forward curve at the seat 
of disease, instead of the usual kyphosis or backward projection, but the 
latter soon takes its place, and with it is seen the compensatory lordosis in 
the lumbar region. 

Lumbar disease. — The first symptoms here are often pain and lame- 
ness, referred to one of the lower extremities. This frequently leads to 
the suspicion that the hip is the seat of disease. In addition to the lame- 
ness there may be a tilting of the pelvis to one side, and sometimes quite 
a distinct lateral curvature of the spine. Eeferred pains are not so fre- 
quent nor so severe as when the upper part of the spine is affected ; they 
may be felt in the groin, in the loin, in the thigh, in the buttock, or in 
the hypogastrium. The gait and attitude are very characteristic : throw- 
ing the shoulders well back, the patient walks stiffly with short steps, 
holding the spine with the greatest care. He rises from the floor awk- 
wardly and with difficulty. Deformity is not usually so early or so 
marked as when the disease is dorsal, and often before it is visible there 
are symptoms due to the formation of psoas abscess, — lameness, flexion of 
one thigh, and a tumour deep in the iliac fossa or at the upper and 
inner aspect of the thigh ; in both locations it has often been mistaken 
for hernia. 



CARIES OF THE SPINE. 905 

Physical examination. — Whenever any of the above symptoms are 
present, the child should be stripped and submitted to a thorough exami- 
nation, the purpose of which should be to determine, first, the existence of 
any deformity ; secondly, the mobility of the spine ; thirdly, the presence 
of any secondary lesions, such as abscesses or paralysis. The mobility of 
the spine is best determined by studying the attitude, gait, and posture of 
the child, and the manner of stooping or rising from the floor. The gait 
has already been described with the symptoms of lumbar disease. As it 
has been aptly put, " the child walks with its legs but not with its back." 
In stooping, the same disinclination to bend or move the spine is seen. 
It is often impossible to induce the child to stoop at all, and when it does 
so, to pick up some object, there is acute flexion at the knee and hip, but 
as little bending of the spine as possible. In rising from the recumbent 
position the same thing is seen. The posture and attitude of the child 
will be modified by the position of the disease, and somewhat by the ac- 
tivity of the process at the time ; however, by comparing the movements 
referred to with those of a healthy child, the great difference will at once 
be apparent. If the symptoms point to cervical disease, a digital explora- 
tion of the pharynx for deformity or abscess should be made, and the 
extremities should be examined for paralysis. If the disease is in the 
lumbar region, deep palpation of the iliac fossa should be made to discover 
a psoas abscess, and the passive movements of the thigh should be carefully 
tested to determine whether there is any resistance to extreme extension, 
this often being present before the psoas tumour. No matter how clearly 
the lameness may be at the hip, it should be remembered that this often 
results from disease of the lumbar spine. If the thigh is flexed and freely 
movable except in extension, the symptoms are probably the result of 
psoas irritation, for in hip-joint disease the other movements of the joint 
are also resisted. 

The deformity of Pott's disease is often spoken of as " angular " curva- 
ture of the spine. While this is a true description of the disease at an 
advanced stage, there is often in the early stage only a general curve. 
Later a slight knuckle is seen from the unnatural projection of a single 
spinous process. This deformity may increase and finally involve five or 
six vertebrae. It is usually greatest in the upper dorsal region. A slight 
prominence, which does not disappear on suspending the patient, is always 
suspicious. 

Tenderness upon pressure over the spinous processes and increased 
sensitiveness to heat and cold, are rarely present. Pain may sometimes 
be produced by downward pressure upon the head or shoulders in the axis 
of the spine. This symptom is not necessary for diagnosis, and the at- 
tempt to elicit it is strongly condemned by Gibney, who has seen serious 
harm follow such a test. 

Course of the disease. — Caries of the spine is a very chronic disease, its 



906 DISEASES OF THE BONES AND JOINTS. 

course being measured by months or years, but marked, as in all chronic 
diseases, by periods of remission and exacerbation. An exacerbation may 
follow traumatism, and is often accompanied by the formation of an ab- 
scess. After the disease has lasted from one to three years, the destruc- 
tive inflammation usually ceases and repair begins, a cure being finally 
effected by a process of consolidation of the fragments of the diseased 
vertebra?, and the production of ankylosis. Eelapses are easily excited 
by traumatism, by improper treatment or by discontinuing the use of 
mechanical supports before the disease is arrested. 

Abscesses. — The frequency with which abscesses occur depends some- 
what upon the treatment. Townsend states that of 380 cases, abscess was 
present in 20 per cent. They are rarely seen earlier than three or four 
months from the beginning of symptoms, and usually belong to the sec- 
ond year of the disease. They sometimes form with acute symptoms, but 
more frequently they appear as typical cold abscesses. Those connected 
with cervical disease are retro-pharyngeal or retro-cesophageal, or they 
may open externally, usually just above the clavicle, in front of the sterno- 
mastoid muscle. Those with disease of the lower cervical and upper dorsal 
vertebras, are apt to burrow along the spine, appearing in the lumbar re- 
gion ; rarely they may rupture into the oesophagus or the pleural cavity. 
Those with disease of the lower dorsal or lumbar vertebras, may open just 
above the iliac crest posteriorly, or burrow anteriorly between the abdomi- 
nal muscles, but the usual course is for them to follow the psoas muscle, 
appearing in the groin just above Poupart's ligament or at the upper and 
inner aspect of the thigh. 

Paralysis occurs in about one half the cases in which the disease affects 
the lower cervical and upper dorsal vertebrae, but it is rare when the dis- 
ease is below the middle dorsal region (see Compression Myelitis) . 

Prognosis. — The actual mortality of Pott's disease is difficult to state, 
so many of the consequences of the disease being remote and not fully 
appreciated until adult life is reached. The general mortality from all 
causes is from ten to twenty per cent. The causes of death are exhaus- 
tion from prolonged suppuration, amyloid degeneration, myelitis, general 
tuberculosis, and tuberculous meningitis. Sudden death occasionally oc- 
curs from pressure upon the cord in the upper cervical region, or from the 
pressure effects of abscesses in the posterior pharynx or in the posterior 
mediastinum. 

The prognosis as to the amount of permanent deformity, will depend 
upon the seat of the disease, the time at which treatment is begun, and 
upon the thoroughness with which it is carried out. The best results as 
to deformity are obtained when the disease is below the middle dorsal re- 
gion. With improved methods of treatment begun early, a large number 
of these patients recover with an insignificant amount of deformity, and 
some with none whatever. 



HIP-JOINT DISEASE. 907 

Diagnosis. — The spinal deformity resulting from Pott's disease may be 
confounded with rachitic kyphosis or with rotary lateral curvature. Rachitic 
curvatures (page 261) are usually seen in children under eighteen months 
of age, a time when Pott's disease is rare ; there are other signs of rickets 
present, and instead of rigidity there is usually undue mobility of the spine. 
What is true of rickets may be said of all curvatures depending upon mal- 
nutrition. Rotary lateral curvature is seen about puberty, rarely in young 
children except in connection with rickets. A slight lateral deviation of 
the spine, sometimes seen in the early stage of caries, may resemble a case 
of incipient rotary curvature. The latter is not attended by pain or rigidity, 
and is most frequent in young girls from eleven to fourteen years of age. 

Other abscesses may be mistaken for those dependent upon vertebral 
caries. This difficulty is likely to exist in the cases attended by very 
little spinal deformity. These abscesses are most frequently in the iliac 
fossa or in the lumbar region, and may be due to perinephritis or ap- 
pendicitis. The latter are more acute than those depending upon bone 
disease and usually accompanied by fever. Tumours of the vertebrae or 
of the spinal cord may give rise to symptoms almost identical with those 
resulting from compression myelitis due to Pott's disease, but both of 
these are extremely rare. 

Treatment. — The treatment of Pott's disease is both general and local, 
and neither should be neglected. The constitutional treatment should be 
similar to that employed in other forms of tuberculosis. 

The indications for local treatment are to put the diseased parts at 
rest, by immobilizing the spine and removing the superincumbent weight 
of the body. With the great advances made in orthopaedic surgery it is 
no longer necessary to confine these patients in bed, as was formerly prac- 
tised, to secure this result. It may be accomplished either by plaster-of- 
Paris, or some other form of jacket, or a properly fitting steel brace. A 
head-support should be attached to all forms of apparatus, if the disease 
is above the middle dorsal region. The closest attention to details and 
much experience in the use of apparatus are required to secure the best 
results. In perhaps no class of cases has the beneficial results of mod- 
ern scientific treatment been more apparent than in those of Pott's dis- 
ease. For the details in regard to the mechanical treatment and the 
different forms of apparatus, the reader is referred to works on general 
or orthopaedic surgery. 

Articular Ostitis of the Hip — Hip-Joint Disease — Morbus 
Coxarius. — In early childhood this generally begins as a chronic ostitis 
in the head of the femur, starting near the epiphyseal line. Exception- 
ally, and according to Gibney, oftener in older children, it begins in the 
acetabulum. The pathological process, as well as the clinical history, is 
generally described as consisting of three stages. In the first stage — that 
of ostitis — the lesions are limited to the bone ; in the second stage — that 



908 DISEASES OF THE BONES AND JOINTS. 

of arthritis — all the joint structures are involved, and in this stage sup- 
puration usually occurs; in the third stage there is breaking down and 
absorption of the head and sometimes of the neck of the femur, which, 
with destruction of the ligaments, leads to marked displacement of the 
parts from muscular contraction. The disease may be arrested in the 
first or in the second stage, or it may continue through all three stages. 

Symptoms. — Clinically, the usual duration of the first stage is three or 
four months ; it may last only for a few weeks, it may extend over two 
or three years, and the disease may be arrested in this stage. The onset 
is usually very gradual, and the symptoms are often considered of trivial 
importance until they have continued for some weeks. Generally the first 
thing noticed is slight lameness, due to stiffness of the joint. In the 
beginning this may be seen only in the morning, wearing off during the 
day. It may be accompanied by some tenderness about the hip and a dis- 
inclination to walk. A little later the child complains of pain, which is 
most frequently referred to the front of the knee or the inner aspect of 
the thigh, but only in rare cases to the hip itself. This is slight at first, 
but gradually increases in frequency and severity, and soon there are 
added the " starting pains " at night, which are one of the most character- 
istic features of early hip-disease. These pains are produced by a sudden 
spasm of the muscles during sleep. The child often cries out sharply 
without waking, sometimes wakes with a cry; this is often repeated sev- 
eral times during the night. Soon restlessness and fretfulness during the 
day are present. The lameness, which at first was slight and occasional, 
or noticed only in the morning, comes to be a constant symptom, and 
week by week increases in severity. The evolution of these symptoms 
may take only a few weeks, but sometimes they come and go in the most 
inexplicable manner during a period of several months, or even one to 
two years, before they are fully developed. 

Physical examination. — Every child with a suspicious lameness, or 
with pains like those mentioned, should be stripped and submitted to a 
thorough examination. The first points to be observed on inspection re- 
late to the general contour of the hip ; every prominence and depression 
should be carefully noted. Then the attitude and gait should be studied ; 
and finally all the functions of the joint should be carefully tested, and 
the limbs measured, to determine the existence of shortening or atrophy. 
At every step a comparison should be made with the sound limb. The 
contour of the hip is changed quite uniformly : there is broadening and 
flattening of the whole gluteal region ; the trochanter is unnaturally 
prominent; the gluteal fold is shortened, and often single instead of 
double. There is no characteristic position of the limb in this stage. 
There is atrophy of the thigh and often of the calf. In Fig. 178 is shown 
the appearance of a typical case in the full development of the first stage. 
In walking, the child favours the diseased side, throwing the weight as 



HIP-JOINT DISEASE. 



909 



/ 



.L 



much as possible upon the sound limb ; but all these symptoms are of 
much less importance for diagnosis than is an examination of the func- 
tions of the joint. 

For this purpose the child should be placed upon a table upon its 
back, and the various movements of the hip — abduction, adduction, flexion, 
extension, and rotation — should be executed, first with the sound limb 
and then with the suspected one, the two being 
carefully compared at every point to determine 
the degree of motion allowed. It is not neces- 
sary that force should be employed or pain in- 
flicted. If the symptoms have existed for some 
weeks, there is generally a limitation of motion 
at the hip in all directions, but first usually in 
abduction, rotation, or extension. In more ad- 
vanced cases, no motion whatever may be per- 
mitted at the joint, the pelvis tilting with the 
slightest movement of the femur. This fixation 
of the hip is due to tonic muscular spasm. 
Crowding the articular surfaces together, by 
pressure upon the heel or trochanter, produces 
pain, which is usually referred to the joint. 
This test should be carefully made, lest injury 
be inflicted. Gibney cautions against examina- 
tions under ether, since in this way serious in- 
jury may be done unconsciously. 

Second stage.— This has been called the stage 
of arthritis. Its existence may be assumed when 
the limb takes the position of marked perma- 
nent deformity, which is due at this period to 
muscular action, not to destructive bone changes. 
The transition from the first to the second stage 
is in most cases a gradual one, and the line be- 
tween the two can not be sharply drawn ; some- 
times, however, it is rapid, and marked by a 
sharp exacerbation of all the symptoms. This 
may indicate a sudden perforation of the joint, 

and the rapid development of suppurative arthritis. Such is the usual 
result when an abscess which has been slowly forming in the bone, opens 
into the joint; or acute joint inflammation may be lighted up without 
so evident a cause. Sometimes the pus reaches the surface below the 
capsular ligament, and the joint remains intact. An acute exacerba- 
tion is indicated by increased pain, excessive tenderness about the hip, 
often by inability to walk, or even to bear any weight upon the limb, and 
frequently by fever. The position assumed by the limb is now fairly 



Li 



Fig. ITS. — Hip-joint disease, ut 
the end of the first stage, 
showing muscular atrophy, 
prominence of the trochan- 
ter, flattening of the gluteal 
region, and a single gluteal 
fold. 



910 DISEASES OF THE BONES AND JOINTS. 

characteristic. The foot is generally everted, the thigh slightly flexed and 
rotated outward, and the limb apparently lengthened. There may be 
infiltration anywhere about the hip, due to the formation of an abscess. 
The muscular spasm is so great that the joint is locked, — no motion 
whatever being allowed. Abscesses may form at any point about the 
hip ; they are especially frequent at the upper and outer aspect of the 
thigh, and may burrow long distances before reaching the surface. The 
duration of the second stage also is indefinite, but it usually lasts from a 
few months to a year, or the disease may be arrested in this stage. 

Third stage. — There is now marked deformity, which is the result of 
muscular contraction after absorption of the head and sometimes the 
neck of the femur, and destruction of the ligaments. The position of 
the limb is a very constant one, and resembles that present in dislocation 
upon the dorsum of the ilium. There is shortening of from one to four 
inches ; the thigh is strongly flexed, adducted, and rotated inward, and 
the foot is inverted ; the trochanter lies against the outer surface of the 
ilium, and is above Nelaton's line. In this position the joint may be- 
come ankylosed. The displacement usually comes on gradually, but it is 
sometimes so sudden as to be mistaken for a true dislocation, although 
the latter is exceedingly rare in the course of hip-disease. 

There is now marked atrophy of all the muscles of the limb, and the 
thigh may be two or three inches smaller than its fellow. No motion at 
all is usually allowed at the hip, but this is compensated for to some degree, 
by the exaggerated mobility of the lumbar spine. The spinal curvature — 
lordosis — is very marked both upon standing and walking. The duration 
of this stage may be several years. From time to time exacerbations oc- 
cur, often excited by falls, and accompanied by the formation of new ab- 
scesses. In protracted cases, all the soft parts about the hip may be seamed 
with cicatrices from old sinuses. After the disease has gone on to the 
third stage, cure can take place only by ankylosis. 

Diagnosis. — The important point in the early diagnosis of ostitis of 
the hip, is the gradual evolution of the symptoms, the most characteristic 
of which are lameness, " starting pains " at night, and impairment of all 
the functions of the joint. Mistakes in diagnosis most frequently arise 
from a failure to obtain a careful history, and from relying too much 
upon the symptoms of lameness and deformity. The essentially chronic 
character of the disease should constantly be borne in mind. In the vast 
majority of cases, with a careful history, and a thorough examination, 
there can be but little doubt as to the diagnosis except at the very outset. 
The proportion of obscure and irregular cases to those following the 
regular course, is small. 

In the early stage, hip- joint disease maybe confounded with a strain of 
the joint, with muscular rheumatism, poliomyelitis, periostitis of the shaft 
of the femur, phlegmonous inflammation in the neighbourhood of the 



KNEE-JOINT DISEASE. 911 

joint, or with caries of the lumbar spine. In the second stage there is 
even less difficulty in diagnosis, although abscesses resulting from perine- 
phritis or appendicitis have been mistaken for those arising from hip-dis- 
ease. In the third stage, a mistake is almost impossible. 

Prognosis. — This is to be considered both with reference to life and 
limb. The records of the Hospital for Ruptured and Crippled show the 
mortality of hospital patients with hip-disease to be nearly 25 per cent. 
This includes deaths directly or indirectly traceable to the disease. The 
causes are nearly the same as in caries of the spine, — exhaustion from pro- 
longed suppuration, amyloid degeneration, and general tuberculosis or 
tuberculous meningitis. 

Under the most favourable conditions, the disease may be arrested in 
the first stage, and recovery occur without lameness or any noticeable im- 
pairment of the joint functions. This result, however, is not often ob- 
tained, because the disease is usually well advanced before it is recognised, 
or because of the difficulty in the way of carrying out all the details of 
treatment in the best possible manner. If the disease has advanced to the 
second stage, and suppuration has occurred, there always results some im- 
pairment of the joint functions ; usually there are decided lameness and 
marked muscular atrophy, but very little shortening or deformity, provided 
the limb has been kept in the proper position. If the disease has ad- 
vanced to the third stage, there are always marked shortening, deformity, 
and lameness. 

Treatment. — The indications for constitutional treatment are the same 
as in caries of the spine. The purpose of local treatment is to secure con- 
stant and complete rest for the diseased parts, and to prevent deformity. 
Rest is secured by overcoming the muscular spasm by means of extension, 
by immobilizing the joint, and by transferring the weight of the body, in 
walking, from the hip to the perinaeum. All these indications are now 
met, while the patient is up and about, by the use of the most approved 
apparatus. Formerly, rest and immobilization could be secured only by 
keeping the patient in bed, with the use of the weight and pulley. The 
general opinion of orthopaedic surgeons at the present day is against 
excision, except in cases where, in spite of treatment by apparatus, the 
disease has advanced to the third stage, and in cases where life is threat- 
ened from prolonged suppuration and exhaustion. Under these con- 
ditions, excision should be performed ; but early excision gives results 
very much inferior to those obtained by mechanical and constitutional 
treatment. 

Articular Ostitis of the Knee — Knee-Joint Disease — White 
Swelling. — Ostitis of the knee usually begins in one of the condyles of 
the femur, the inner much oftener than the outer one; less frequently it 
begins in the head of the tibia. The pathological process is very much 
like that at the hip. There is in the first stage a central ostitis accom- 



912 DISEASES OF THE BONES AND JOINTS. 

parried by infiltration and expansion of the part of the bone affected. 
The disease may remain limited to the bone, the inflammatory products 
becoming encapsulated, or softening and breaking down may occur, with 
the formation of an abscess. Gradually the process extends outward, and 
the periosteum and the soft parts are involved. The disease may invade 
the joint itself in a destructive inflammation, or pus may escape externally 
without seriously involving the joint structures. The degree to which the 
joint is involved, varies much in different cases ; there may be only a sim- 
ple synovitis, a suppurative arthritis, or a destruction of the cartilages 
and articular ends of the bones, synovial membrane, and ligaments, so 
that in the advanced stage all traces of a joint structure are lost. 

If the process remains limited to the bone, recovery may take place 
with very little impairment of the joint functions. If suppuration in the 
joint has taken place, there will be more or less stiffness and fibrous or 
bony ankylosis. When there is destruction of the ligaments and articu- 
lar ends of the bones, the limb assumes a characteristic position — the 
joint is flexed, the tibia is displaced backward and rotated outward, and 
there is marked over-riding of the femur. Bony ankylosis in this posi- 
tion is often seen. 

Symptoms. — The earliest symptoms of disease at the knee are usually 
a slight stiffness of the joint, with a disposition to flexion and slight 
lameness. At first these symptoms are noticed only occasionally ; finally 
they become constant and there is pain, which is usually referred to the 
knee. In some cases there are " starting pains " at night, although these 
are less constant and less severe than in hip-disease. Swelling is noticed 
early, as the diseased parts are so superficial. At first this is chiefly of 
the bone itself ; the condyle, usually the inner one, is enlarged and elon- 
gated, often to a marked degree, before there is any infiltration of the soft 
parts. Later there is a general fusiform swelling, involving the entire 
joint and effacing all the normal outlines. Some tenderness upon pres- 
sure over the bone affected is present quite early, and there may be atrophy 
of the muscles of the thigh and calf. The knee is flexed and slightly 
rotated outward, the position which secures the most complete relaxation 
of the joint structures. In some cases there is seen the characteristic 
swelling due to distention of the synovial membrane. Abscesses may 
form anywhere about the joint ; very frequently they burrow beneath the 
tendon of the quadriceps extensor as far as the middle of the thigh. 
Gradually the deformity increases until the leg may be flexed at a right 
angle, and rotated outward over an arc of twenty or thirty degrees. 

The course of the disease resembles that of ostitis of the hip and the 
spine. During periods of remission, pain and tenderness often subside for 
several months so completely as to lead to the supposition that the disease 
has been arrested. An exacerbation is often excited by a fall or a strain 
of the joint, or it may follow an attack of acute illness. The disease may 



TUBERCULOUS OSTEO-MYELITIS. 913 

then progress rapidly and abscess after abscess form, with extensive de- 
struction of all the joint structures and the production of permanent 
deformity. 

Prognosis. — The danger to life is considerably less than in disease of 
the hip or spine. Death, however, results from the same causes — exhaus- 
tion, amyloid degeneration, and general tuberculosis or tuberculous men- 
ingitis. 

With an early diagnosis and proper treatment the disease may, in a 
considerable proportion of cases, remain limited to the bone, and the 
resulting lameness and deformity be very slight ; but otherwise a certain 
amount of lameness results from the stiffness of the joint. This may be 
due either to fibrous thickening or to bony ankylosis. Nearly all patients 
are able to walk without crutches, and if proper treatment has been carried 
out there is neither marked shortening nor deformity, although there is 
always great muscular atrophy. 

Diagnosis. — The important symptoms for diagnosis, are the gradual 
onset, the early swelling which is due to enlargement of the bone, and the 
constant lameness and deformity. The disease may be confounded with 
rheumatism, with synovitis, and even with scurvy. In all these cases the 
resemblance exists only during the period of exacerbation. A careful his- 
tory, however, will usually clear- up the diagnosis. 

Treatment. — The general treatment is the same as in other forms of 
joint disease. The indications for local treatment are the same as in hip- 
disease, — viz., to immobilize the affected limb and prevent deformity. 
This is accomplished by a form of apparatus which transfers the weight 
of the body from the joint to the perinaeum, and which overcomes the 
muscular spasm which produces flexion and inward rotation of the joint. 
As in hip-disease, the results with mechanical and constitutional treat- 
ment are decidedly better than from early operative measures ; but late 
operations are indicated under the same conditions. 

Tuberculous Osteo-Myelitis. — This disease is rarely seen except in 
the short tubular bones, most frequently those of the hand and fingers. 
From this fact it is often called scrofulous or tuberculous dactylitis. It 
is described by many writers under the name of spina ventosa. Unger * 
gives the following figures showing the frequency with which the different 
bones were affected : fingers in 43, toes in 3, metacarpus in 41, metatarsus 
in 14, radius in 2, ulna in 2, tibia in 3, jaw in 3. The first phalanx of the 
index finger is the bone which is most frequently the seat of disease. In 
the majority of cases the process is confined to a single bone, although it 
is not rare to see five or six affected. In such cases the disease is seldom 
symmetrical. The process is a chronic inflammation, beginning in the 
centre of the bone with the deposit of tuberculous material. The swelling 

* Archiv fur Kinderheilkunde, Bd. ii, 233. 



914 DISEASES OF THE BONES AND JOINTS. 

which follows causes an expansion of the bone and thinning of the shaft, 
until a mere shell may remain. The later changes are, inflammation of 
the periosteum and the soft parts, the formation of abscesses and sinuses, 
necrosis, the exfoliation of sequestra, etc. The entire disease lasts from 
one to three years, and causes in most cases marked deformity. 

Tuberculous dactylitis is essentially a disease of early childhood, being 
seen most frequently during the second and third years. In a consider- 
able proportion of the cases there is a family history of tuberculosis. The 
disease frequently appears to be the only tuberculous lesion in the body, 
but tuberculosis of the hip, knee, ankle, or spine may be associated. 

Symptoms. — Tuberculous dactylitis usually begins as a painless en- 
largement of one of the phalanges, most frequently the first one of the in- 
dex finger. It may be two or three months before it is of sufficient size to 

■n— 




Liacty litis oi tne nrst pi 



attract much attention. Exceptionally the inflammation is a more active 
one, and is accompanied by both pain and tenderness. The swelling is 
quite characteristic ; it is smooth, hard, uniform, and generally spindle- 
shaped, involving the entire phalanx of the affected finger. The appear- 
ance of a severe typical case is shown in Fig. 179. Later there is discol- 
ouration of the skin, and usually there is suppuration. The abscess 
generally opens at the side of the finger, and a curdy pus is evacuated. If 
the opening is enlarged by an incision there is found a cavity partly filled 
with caseous matter, and dead bone is felt, and perhaps a loose sequestrum. 
The cavity is surrounded by a thin shell of new bone, which is formed 
from the periosteum. If no operation is done the discharge continues for 
weeks or months, other abscesses often form, and finally several small 



SYPHILITIC DISEASES OF BONE. 915 

sequestra are exfoliated, — sometimes a single large one, which is the shell 
of the diseased phalanx almost entire. 

In some cases the disease is arrested before necrosis occurs, but in the 
majority this is not so. After the wounds have all healed the finger 
remains shortened, deformed, and often useless. In some cases the disor- 
ganization is so extensive that amputation is necessary. 

Diagnosis. — The recognition of dactylitis is usually easy, but as symp- 
toms identical in almost every particular may be seen in a syphilitic in- 
flammation, it is often difficult to tell with which of the two forms one 
has to deal. The tuberculous form is very much more frequent ; it may 
occur in a patient with tuberculous antecedents, or it may be associated 
with other tuberculous lesions. Syphilitic cases are distinguished by the 
fact that the lesion is more frequently multiple, that it is often symmetri- 
cal, and that other manifestations of syphilis are generally present. It is 
affected by anti-syphilitic remedies, which is not the case in the tubercu- 
lous variety. 

Treatment, — Painting with iodine and like measures are useless. The 
diseased part should be kept at rest, — if a finger, by the application of a 
splint. Every means should be taken to build up the patient's general 
health, as this is the most effective way to influence the local process. The 
general verdict of surgeons is against early excision as a means of arresting 
the disease. Abscesses should be opened early and freely, all diseased 
bone removed, the finger kept in proper position, and the wound treated 
according to general surgical principles. Under almost any treatment the 
disease is a protracted one, and rarely lasts less than a year. 

THE SYPHILITIC DISEASES OF BONE. 

The bone lesions of hereditary syphilis are not infrequent, but were 
long unrecognised, and have only within comparatively recent times been 
fully understood.* They may be divided into two groups, — those occur- 
ring with the early symptoms, and those which belong to the late manifes- 
tations of the disease. 

Acute Epiphysitis. — This is the most frequent variety of bone dis- 
ease in early hereditary syphilis. It may begin even in intra-uterine life, 
and it forms one of the most characteristic lesions of the disease. To some 
degree it is almost invariably present in syphilitic foetuses and in syphilitic 
infants who are still-born. 

In the early stage, there is an increase in the cartilage cells and delayed 
ossification. Later, a line of softening forms at the epiphyseal junction, 
which may cause loosening of the cartilages and ultimately complete 
separation of the epiphysis from the shaft, by the formation of granula- 

* See Taylor, Bone Syphilis in Children, New York, 1875 ; also G. Wegner, Vir- 
ehow's Archives, Bd. 1, Heft 3. 



916 DISEASES OP THE BONES AND JOINTS. 

tion tissue between them. In cases receiving proper treatment, recovery 
may take place with good union, perfect function, and without any de- 
formity. In other cases degenerative changes continue, and infection 
with pyogenic germs may be added. -The periosteum and the soft 
parts in the neighbourhood are now involved, with the formation of 
external abscesses; or the disease extends to the medullary cavity, giv- 
ing rise to acute osteo-myelitis, which may lead to necrosis; or the con- 
tiguous joint may be invaded, causing an acute suppurative arthritis. 
This last result is more likely to occur where the epiphysis joins the shaft 
within the joint cavity. The large joints are usually affected, and the 





Fig. ISO. — Syphilitic bone disease in a boy four years old. The lower end of the radius of both 
arms is enlarged as a result of former epiphysitis ; there are sinuses leading to dead bone 
over the metacarpal bone of the right thumb, and over the upper extremity of the left ulna. 
The last two are recent lesions. 

lesions are frequently symmetrical. Acute suppurative arthritis may oc- 
cur independently of changes at the epiphysis ; but even when these are 
seen in syphilitic infants they are to be regarded as of pyaemic rather 
than of syphilitic origin. Secondary to the changes at the epiphysis, there 
is periostitis and inflammation of the soft parts. Periostitis of the shaft 
is rare in early infancy, 

The bones most frequently the seat of acute epiphysitis are the 
humerus, radius and ulna, although any of the long bones may be 
affected. 

Symptoms. — The early symptoms are usually quite acute, and appear 
during the first six weeks of life ; they may precede any other mani- 
festations of syphilis. In some cases there is first noticed an inability on 



SYPHILITIC DISEASES OF BONE. 917 

the part of the child to move the limb, which may easily be mistaken for 
paralysis. It is, in fact, often described as " syphilitic pseudo-paralysis." 
The limb lies perfectly motionless, and any attempt at passive movement 
causes evident pain. There is tenderness on pressure and soon swelling is 
seen, both being most marked at the epiphyseal line. If the bone affected 
is superficially situated, as the lower epiphysis of the humerus, radius, or 
tibia, swelling is very apparent, while it may be scarcely perceptible at the 
upper epiphysis of the humerus. The swelling is usually cylindrical and 
moderate in degree, being limited to the extremity of the bone. In the 
more severe cases it may involve a great part of the limb. Abscess may 
form and separation of the epiphysis take place, so ttait crepitation may 
be obtained by moving the limb. Separation of the epiphysis not infre- 
quently occurs even when there has been no suppuration. 

In the milder cases, or those which have been subjected to active 
treatment, both the swelling and the tenderness subside rapidly without 
suppuration ; and even though the epiphysis has separated from the shaft, 
it speedily unites. Where pseudo-paralysis has been the chief symptom, 
very rapid improvement occurs under treatment, and usually complete 
recovery of function in two or three weeks. If the disease extends to the 
joint, or if osteo-myelitis develops, the case is almost certainly fatal. 

Diagnosis. — This is usually easy, from the age of the patient — gener- 
ally under three months — the early prominence of pain and apparent loss 
of power, with the later appearance of swelling and signs of inflamma- 
tion at the epiphyseal junction. In all these respects the disease closely 
resembles scurvy ; but the latter is rare before the eighth or tenth month, 
there is usually a history of the long-continued use of some proprietary 
infant food, and it is cured by dietetic treatment alone. 

The apparent loss of power may lead to the diagnosis of birth palsy, 
especially of the upper-arm type (page 112). The presence of acute pain 
and tenderness, the absence of the characteristic deformity, and the prompt 
recovery under constitutional treatment, usually make the distinction be- 
tween the two conditions an easy one. 

Treatment. — This is the same as in all early syphilitic manifestations, 
for which see the article on Syphilis. Locally, the part requires in the 
early stage only protection and rest. Should suppuration occur in the 
neighbouring joint, or should osteo-myelitis develop, these conditions 
should be treated surgically as they are when due to other causes. 

Chronic Osteo-Periostitis. — This is the usual form of bone disease 

which is seen in late hereditary syphilis, and it is one of the most frequent 

and most characteristic lesions of that stage of the disease. Occurring 

in adults, this would be classed as a tertiary symptom. Chronic syphilitic 

osteo-periostitis is rarely seen before the third year, and most of the cases 

occur between the fifth and fourteenth years. The most frequent seat of 

disease is the tibia, and next to this the bones of the forearm and the 
59 



918 DISEASES OF THE BONES AND JOINTS. 

cranium. The following is the frequency with which the different bones 
were affected in the series of cases reported by Fournier : * tibia in 91 
cases, ulna in 22, radius in 15, cranium in 16, humerus in 12, all others in 
37. The process may result either in a diffuse or a localized hyperplasia 
of bone or in necrosis. 

The typical changes are seen in the tibia. The shaft of the bone is 




Fig. 181. — Syphilitic disease of the tibia, showing the sabre-like deformity, in a boy 

nine years old. 

principally or solely affected. There is often produced a very characteris- 
tic deformity, consisting of a forward curve of the anterior border of the 
tibia, which has been compared to a sabre blade (Fig. 181). In some 
cases the bone is bent inward at its lower third, resembling somewhat a 
rachitic curvature (Fig. 182). Sometimes the entire shaft of the bone is 
affected, and it may be enlarged to nearly twice its normal dimensions. 

* Syphilis Hcrcditaire Tardive, Paris, 1886. 



SYPHILITIC DISEASES OF BONE. 



919 



At other times the swelling is chiefly near the epiphysis, where large 
bosses may form of sufficient size to interfere with the functions of the 
joint. Instead of affecting the bone uniformly, the disease often affects 
only certain parts, leading to the formation of large nodes which are more 
likely to be followed by necrosis than are the other lesions. In most of 
the cases the process is purely a hyperplastic one, leaving the bone per- 
manently enlarged. Less frequently, there occur gummatous deposits 




Fig. 182. — Syphilitic disease of both tibiae. The left shows a general enlargement of the bone, 
the characteristic curve of its anterior border, with ulcers due to necrosis. The enlarge- 

, ment of the right tibia is less marked, and there is a pseudo-rachitic curve at its lower 
third. Cicatrices near the knee mark the site of former ulcers. (After Fournier.) 

in or beneath the periosteum, which may soften, suppurate, and lead to 
superficial necrosis, with the formation of sinuses that remain open until 
the sequestrum is exfoliated (Fig. 183). Syphilitic deposits sometimes 
take place in the interior of the bones, generally near the articular ends ; 
these may soften and break down with abscesses, sinuses, etc., very much 
after the manner of a tuberculous inflammation (Fig. 180). 

The lesions of the other long bones are essentially the same as of the 
tibia. They are nearly always symmetrical and often multiple. In a case 
recently under observation in a boy of four years, the disease involved 
both tibiae, both radii, the right ulna, the left metatarsus, and the meta- 
carpal bone of the left thumb. The course of syphilitic osteo-periostitis 



920 



DISEASES OF THE BONES AND JOINTS. 



is very chronic, and some permanent deformity is the rule, unless 
come very early under treatment. 

When affecting the bones of the cranium the disease usually takes the 
form of a gummatous periostitis, which leads to the formation of large 
nodes. These may remain as permanent deformities, or they may break 
down and suppurate, with necrosis of one or both tables of the skull. 

This may be followed by inflammation 
of the dura, the pia, and even of the 
brain itself. 

Symptoms. — When the long bones 
are affected, the symptoms are pain, 
tenderness and deformity. These come 
on very gradually, and often the de- 
formity is noticed before either pain or 
tenderness is sufficiently marked to at- 
tract attention. The pain is regularly 
worse at night, and often felt only at 
that time ; it may be mild and occa- 
sional, or so severe as virtually to pre- 
vent sleep. There is tenderness on 
pressure over the bones affected, the 
acuteness of which will depend upon 
the activity of the process. When sup- 
puration occurs, it comes very slowly, 
and never with symptoms of acute in- 
flammation. Sinuses usually continue 
to discharge until a sequestrum is ex- 
foliated. The course of the disease is 
very tedious, and the whole duration is 
usually several years. 

When the cranium is affected, there 
are seen the irregular nodes, especially 
upon the frontal and parietal bones. They are from one to two inches 
in diameter, and project from one eighth to one fourth of an inch above 
the general outline of the skull. There may be pain, tenderness, soften- 
ing, suppuration, and necrosis, as in the long bones. 

Diagnosis. — It is so very rare that disease of the bones of the cranium 
is due in childhood to any other cause than syphilis, that this disease may 
always be assumed to exist if traumatism can be excluded. The bosses 
upon the cranium in rickets (page 262) are always large, smooth, and 
regular in position, and belong to infancy. 

Syphilitic disease of the long bones is recognised by the nocturnal 
pain, the tenderness and peculiar deformity, and by the association of 
other late manifestations of syphilis, — i. e., the peculiar notched teeth, 




Fig. 183. — Syphilitic necrosis of the tibia, 
showing moderate enlargement of the 
bone and a sinus. (From the same pa- 
tient as Fig. 180.) 



SYPHILITIC DISEASES OF BONE. 



921 



the interstitial keratitis, the enlarged epitrochlear glands, etc. Tuber- 
culous disease generally affects the articular ends of the bones; syphilis 
nearly always the shaft. The diffuse hyperplasia of the tibia and the 
sabre-like deformity of its anterior border are rarely if ever due to any 
other cause than sj'philis. 

The deformities of the long bones have in some cases a certain resem- 
blance to those due to rickets, but on close examination there are seen 
striking differences. The epiphyseal enlargement at the wrist in rickets 
affects both bones (Plate V, page 258) ; in syphilis it is usually of one 
bone only (Fig. 180). The differences between rachitic curvatures of the 
tibia and the deformities from syphilis may be readily seen by comparing 
Figs. 48, 49, and 50 (pages 263-2G5) with Fig. 182. 




i : 




Fig. 184. — Multiple syphilitic dactylitis, In a child two years old. The disease affects the first 
phalanges of both thumbs, both little fingers, and the index finger of the left hand. 

Treatment. — The constitutional treatment of these lesions is the same 
as that of the other late manifestations of syphilis, — mercury and the 
iodide of potassium; for details, see the chapter on Syphilis. Surgical 
treatment is required in cases which terminate in necrosis, whether of the 
cranium or the extremities. They are to be managed like the same con- 
ditions in adults. 

Syphilitic Dactylitis. — This belongs to a somewhat earlier period 
of syphilis than the disease just described, and is usually seen in children 
under five years old. It is not a frequent manifestation of syphilis, and 
as compared with tuberculous dactylitis it is rare. It was first fully de- 
scribed by Taylor (New York). The symptoms closely resemble the tuber- 
culous form. It may begin as a periostitis but more frequently as an 
osteo-myelitis. Like the tuberculous form it usually goes on to suppura- 
tion and necrosis. According to Taylor, dactylitis is more often single 
than multiple, but in my own cases several phalanges have generally been 



922 DISEASES OF THE SKIN. 

involved, and the lesions have often been symmetrical (Fig. 184). In one 
case, the first phalanx of every finger of both hands was affected. This 
occurred in a child nine months old who was under observation for over 
two years, and who presented during this period almost every lesion of 
hereditary syphilis. 

The symptoms and course of syphilitic dactylitis are essentially the 
same as in the tuberculous form. The differential diagnosis is considered 
with the latter disease. The prognosis is much the same in the two vari- 
eties, with the exception that in the early stage the syphilitic cases may 
often be arrested by constitutional treatment. This is the same as in 
other late lesions of syphilis. The same local treatment should be em- 
ployed as in the tuberculous cases. 



CHAPTER V. 
DISEASES OF TEE SKIN. 

The skin at birth is covered with a whitish sebaceous secretion, the 
vernix caseosa. The skin itself is of a deep purplish colour, which changes 
to a bright red over the face and trunk in a few minutes, with the estab- 
lishment of normal respiration, and in a few hours the whole body has 
the same tint. This excessive redness slowly fades during the first month, 
at the end of which time the skin has assumed the pale pink of infancy. 
On the third or fourth day there are usually seen the first signs of icterus ; 
this generally fades by the end of the second week. 

The epidermis which is present at birth soon loosens and is thrown 
off. This normal desquamation usually begins upon the fourth or fifth 
day, and is completed in ten days or two weeks. If the skin is frequently 
oiled and properly bathed, desquamation is scarcely noticeable unless a 
close examination is made. In some infants, especially those who are deli- 
cate and cachectic, it is very much more marked, and closely resembles 
that seen in scarlet fever. Ritter has described an exfoliative dermatitis 
of the newly born, appearing generally during the second and third weeks, 
a condition which is regarded by Kaposi as simply an exaggeration of 
normal physiological desquamation. This process may be mistaken for 
that due to hereditary syphilis ; the latter, however, is rarely general, ap- 
pears later, and is much more prolonged. 

Perspiration is rarely present before the end of the fourth month, and 
is then seen only upon the forehead. In healthy infants it is scarcely 
noticeable during the first year. Copious perspiration is most frequently 
a symptom of rickets ; less marked perspiration may occur with any gen- 
eral weakness or during acute illness. 



CONGENITAL ICHTHYOSIS. 



923 



CONGENITAL ICHTHYOSIS. 

Congenital, or more properly foetal, ichthyosis, sometimes known also 
as diffuse keratoma, is a rare disease, characterized by the formation, usu- 
ally all over the body, of a thick, horny epidermis resembling parchment. 
This is divided by fissures or shallow furrows into irregular patches; 
sometimes these are two or three inches wide, at others as small as a pin's 
head. The disease begins in the early months of foetal life, and is an 
abnormality in the development of the skin, there being an excessive pro- 
liferation of the layers of the epidermis. 

Symptoms. — In the gravest form of the disease the child often lives but 







Fig. 185.— Congenital ichthyosis in a child ten months old. The large scaly patches are well 
shown on the lower part of the right chest and abdomen, and the constricting bands upon 
the legs. (From a photograph by Dr. Cabot.) 

a few hours, and rarely more than a week. The openings of the nostrils 
and the ears may be occluded by the excessive production of epithelial cells. 
The eyes are in a condition of ectropion, and there are often deformities 
of the mouth and other orifices due to the contractions of the skin. The 
nails and hair are usually imperfectly developed. The body seems in- 
cased in a hard, horny covering, and looks as if it had been varnished or 
covered with collodion. The skin cracks or splits and the edges curl up, 
an appearance which has been aptly compared to the skin of a boiled 
potato. 

In the milder form, the duration of life is indefinite, depending upon 



924 DISEASES OF THE SKIN. 

the degree of development of the disease ; but even in such cases there 
are frequently seen the deformities at the orifices of the body, and there 
may also be a continued exfoliation of the epidermis in large irregular 
patches. After this has separated, the skin beneath appears red and moist, 
but gradually becomes dry, hard, and shining, slowly contracting until it 
splits in various directions. In a case recently under observation in the 
Babies' Hospital,* a picture of which is shown in the accompanying illus- 
tration (Fig. 185), it was stated by the mother that during the first ten 
months of life complete exfoliation of the skin had occurred in the course 
of every two or three months. 

The outlook is bad in all cases; in most of the severe forms death 
occurs in infancy, but in some of the milder ones, life may be prolonged 
throughout childhood. The " alligator boy " of the Dime Museum is an 
example of this class. 

Treatment. — The indications are to keep the skin moist and soft by 
the use of oils, continuous baths, etc., and to prevent infection by perfect 
cleanliness. Although a certain amount of improvement usually follows 
these measures, a cure is not to be expected. 

MILIARIA. 

The term miliaria is applied to an obstruction of the sweat glands, 
which may occur either with or without inflammation. The non-inflam- 
matory form is known as sudamina, the inflammatory forms as miliaria 
rubra, miliaria vesiculosa, and miliaria papulosa. 

Sudamina. — In this form there is no inflammation. The sweat ducts, 
according to Crocker, are blocked by an accumulation of epithelial cells 
while no perspiration is going on ; and when the process is restored the 
fluid, being unable to escape, accumulates in the form of tiny vesicles. 
These appear like small pearly bodies very closely set, and disappear in 
the course of a few days by absorption. Fresh crops may appear from time 
to time. Sudamina may be seen in any of the continued fevers or ex- 
hausting diseases. It requires no treatment. 

Miliaria Rubra. — This condition, also known as red gum, strophulus, 
etc., is a sweat rash, usually seen in young infants as the result of excess- 
ive clothing. It is most frequently observed upon the cheeks and neck, 
often upon the side of the face upon which the infant sleeps, or the side 
held against the mother's body while nursing, if this is done upon only 
one breast. The eruption consists of scattered red papules, sometimes 
with tiny vesicles. Miliaria rubra is an inflammation about the sweat 



* This case has been fully reported by Cabot, New York Medical Record, July 6, 
1895. For fuller description of the disease, see Ballantyne, Diseases of the Foetus, voL 
ii, 1895 ; also Archives of Paediatrics, April and June, 1894. 



MILIARIA. 925 

glands, the result of which is a retention of their secretion. There is 
generally little or no itching. The treatment consists in the removal of 
the cause, and the application of some absorbent powder, such as boric 
acid and starch. 

Miliaria Papulosa (Lichen Tropicus, Prickly Heat, etc.). — This is the 
most common and most important variety of miliaria. There is in this 
disease an obstruction of the sweat glands by inflammatory products. The 
lesion consists in the formation of bright-red papules, which are very 
closely set, the summits of some of them being surmounted by tiny vesi- 
cles, and here and there in severe cases even small pustules may be seen. 
If not interfered with by scratching, the vesicles dry up without rupture, 
and are followed by a slight desquamation. Where there is much scratch- 
ing, an eczematous condition may result. Miliaria papulosa comes out 
with great rapidity, especially upon the neck, forehead, back, and chest. 
It is accompanied by an almost intolerable itching and stinging sensa- 
tion. Over other parts of the body profuse perspiration occurs. The 
disease is produced by very hot weather and excessive clothing. Although 
the duration of a single attack is but two or three days, in susceptible 
patients it may keep recurring for weeks, being exceedingly intractable. 
Where there is much scratching the resulting eczema is very troublesome. 
It is not infrequently followed by furunculosis. 

The diagnosis of miliaria rubra and miliaria papulosa is usually easy. 
They are distinguished from eczema by the suddenness with which they 
appear, by the associated sweating of other parts of the body, by the tran- 
sitory character of the eruption, and by the fact that the rash never occurs 
in circumscribed patches. Prickly heat sometimes resembles the rash of 
scarlet fever, but the fact that the tiny papules are in some places crowned 
by vesicles and that constitutional symptoms are absent, usually make the 
distinction an easy one. 

Treatment. — Prickly heat is to be prevented by light clothing, fre- 
quent bathing, and the plentiful use of a good toilet powder, such as boric 
acid and starch. During an attack, the bowels should be freely opened by 
calomel or a saline, and secretion of the kidneys stimulated by the use of 
citrate of potassium or the sweet spirits of nitre. The skin should be 
protected against the irritation of flannel undergarments by the interposi- 
tion of silk or linen. When the inflammation is at its height, relief is 
obtained by the application of a calamine and zinc lotion (page 933), or by 
a dilute solution of the acetate of lead ; carbolic acid may be added to 
either, where the itching is intense. In some cases powders are preferable 
to lotions. One of the best is the stearate or the oxide of zinc, twelve 
parts ; bismuth, three parts ; powdered camphor, one part ; or equal parts 
of starch and boric acid may be used, or simply rice flour. All of these 
must be very freely applied. The diet should be light and fluid, and if 
milk is the food it should be considerably diluted. 






926 DISEASES OF THE SKIN. 

SEBORRHEA. 

Seborrhoea is considered by dermatologists generally, as a functional 
disease of the sebaceous glands ; although Unna regards all such cases as 
inflammatory, and classes them as seborrhoeic eczema, which is of para- 
sitic origin (page 929). The disease may affect almost any part of the 
body, and children of any age, but the most frequent form is that which 
is seen upon the scalp in young infants. This is the most important 
variety, and the only one which will be here considered. 

Seborrhoea of the scalp is characterized by the formation upon the 
vertex, of dirty-yellow crusts, which are soft, greasy, and friable. They 
are composed of epithelial cells, fat-globules, and granular masses, to which 
is always added dirt. In neglected cases the hairy scalp is nearly covered 
by a dense crust, which may be as thick as heavy pasteboard. If the 
crusts are removed the underlying scalp may be found perfectly healthy, 
but more frequently, in cases of long standing, it is eczematous. The 
eczema is set up by the decomposition of the exudation, or by the efforts 
to remove the crusts by such means as the fine-toothed comb, commonly 
employed in domestic practice. There is little tendency to spontaneous 
improvement or recovery, and the condition often lasts for months. Every 
seborrhoea should be treated, for when neglected it furnishes a favourable 
soil for the development of eczema. 

Treatment. — Only local measures are required. The crusts are first to 
be softened with oil, and then removed by washing thoroughly with warm 
water and soap, after which an ointment of resorcin (resorcin, gr. x ; ungt. 
aquae rosse, § j) or sulphur (precipitated sulphur, 3 j ; lanoline, § j) 
should be applied. The oil and soap and water are repeated every few days, 
or as often as the crusts form. In the meantime the scalp is kept cov- 
ered with the ointment. 

ECZEMA. 

Eczema may be defined as a catarrhal inflammation of the skin. It 
is the most frequent and altogether the most important disease of the skin 
in early life. The scope of the present work permits only a discussion of 
such features and varieties as are peculiar to infants and young children. 
The eczema of older children does not differ in any essential points from 
that of adults. 

Etiology. — The conditions in infancy which predispose to eczema are, 
first, that the skin is extremely delicate, and hence more easily affected by 
external irritauts and micro-organisms ; secondly, its more intense glandu- 
lar activity. While all children are susceptible, there are certain ones 
in whom the susceptibility is very marked, and in them the slightest 
amount of external irritation, or the most trivial disturbance of diges- 
tion may produce a severe eruption. It was formerly the fashion to class 






ECZEMA. 927 

eczema of the face and scalp among the manifestations of infantile 
" scrofula." We can not connect eczema with any single diathetic con- 
dition; but it is much more often seen in children with gouty antece- 
dents than in others ; or to state it differently, the most frequent mani- 
festation of gout during infancy is the tendency to eczema. Children of 
rheumatic families are also prone to the disease. Eczema of the face is 
common in fat, healthy-looking infants, both in those who are nursing 
and in those who are artificially fed. It also occurs in poorly nourished 
children, but rarely in those suffering from marasmus. 

The exciting causes of eczema may be external or internal. Of the 
former the most important are heat, cold dry air, and winds — as in the 
familiar chapping of the face — the use of hard water or of strong soaps 
in bathing. The disease may be due to the irritation of clothing, to want 
of cleanliness, or to irritating discharges from mucous surfaces, as in 
the eczema of the upper lip, thighs, or buttocks. It accompanies most 
of the parasitic skin diseases, particularly pediculosis, scabies, and ring- 
worm. 

What part is played by micro-organisms in the etiology of eczema has 
not yet been fully determined. The observations of Gilchrist and others 
seem to indicate that as a primary factor they are not of the first impor- 
tance. Secondary infection, however, occurs in most of the cases, and is 
a factor of the greatest importance in keeping up the disease. 

The internal causes of eczema are chiefly associated with deficient 
elimination from the kidneys and bowels, and digestive disturbances. It 
often accompanies chronic constipation where there is intestinal torpor 
and the white stools of deficient biliary secretion ; and it is seen where the 
urine is scanty and concentrated because children partake too largely of 
solid food. The latter is true both in the first and second years. 

Eczema may be produced by any form of digestive disturbance, but it 
is especially frequent in the intestinal indigestion which results from 
overfeeding, or the too early or excessive use of farinaceous food, or from 
breast milk in which the percentage of fat is very high. From personal 
experience in the post-mortem room, I can confirm the observation of 
Bohn regarding the frequency with which fatty liver occurs in very fat 
infants. Enlargement of the liver may sometimes be made out during life. 
It is highly probable that the interference with the hepatic functions which 
accompanies these fatty changes has much to do with the production of 
eczema in such subjects. In children fed upon cow's milk the excessive 
fat may be the cause, or it may be due to excessive proteids. Of farina- 
ceous articles, the two which are most often to be blamed are potato and 
oatmeal. Although eczematous patients usually appear to be well nour- 
ished, it is rare that some symptoms of indigestion are not present. 

Eczema is often due to some form of reflex irritation. Such are the 
cases which accompany dentition, and the rare ones due to genital irrita- 



928 DISEASES OF THE SKIN. 

tion. By many writers the eczema caused by disorders of the stomach or 
intestines is regarded as reflex. The stronger the predisposition, the more 
trivial is the reflex irritation which will induce an eruption. 

Simple Chronic Eczema— Eczema Rubrum. — This is the most frequent 
form of eczema occurring in infants and young children, and is usually 
seen upon the face. It affects by preference the cheeks, forehead, and 
scalp, not infrequently the ears and neck, and may occur upon any part 
of the body. Upon the trunk and extremities the eruption is usually in 
patches, but in rare cases may cover nearly the entire body. The disease 
generally begins upon the cheeks with the formation of small red papules ; 
later these coalesce, and there is a moist, red surface exuding serum or 
sero-pus. The secretion dries and forms thick, gummy crusts, which may 
be so hard as to form a mask for the face. From the scratching caused 
by the almost intolerable itching, the surface bleeds freely, and the dried 
blood gives to the crusts a dirty-brown colour and adds to the distressing 
appearance. The skin is often much swollen. After the removal of the 
crusts there is seen, in acute cases, a red, inflamed, granular surface, dis- 
charging pus or serum and bleeding readily. When the process is less 
active, there is redness, thickening, induration, and scaliness of the skin, 
and marked itching. In the same case these stages may alternate, exacer- 
bations occurring whenever the exciting cause is particularly active. 
From the cheeks the disease spreads to the forehead, ears, and scalp, and 
here similar lesions are seen. Upon the trunk and extremities thick crusts 
rarely form, but the skin is red, thick, and scaly. The parts most often 
affected are the forearms, chest, elbows, knees, abdomen, and back ; occa- 
sionally the eruption is general. 

Swelling of the lymph nodes in the neighbourhood of the eruption is a 
constant feature of eczema of the face and scalp ; these may reach the 
size of a chestnut or walnut, and occasionally they suppurate. Intense 
itching is a characteristic feature of all cases of eczema of the face or 
scalp. It causes restlessness and loss of sleep, and usually it is only in 
this way that the disease affects the general health of the patient ; but in 
most cases the health remains good. With eczema of the occipital region 
of the scalp, pediculosis is usually associated. 

Eczema of the face is very chronic, easily improved, but cured only 
with great difficulty. There is a strong tendency to relapses, brought on 
by neglect of local treatment or by any digestive disturbance. 

The predisposition to eczema often ceases with the second year ; those 
who have suffered from it almost constantly during infancy may be free 
from it during the remainder of childhood. This is in part to be ex- 
plained by the loss of fat in consequence of more active exercise and a 
diet which is more largely nitrogenous. Where the disease continues 
through the third and fourth years, the associated infantile condition — 
obesity — is not infrequently present. 



ECZEMA. 929 

Seborrheic Eczema. — This form of eczema has been brought into 
prominence by the writings of Unna, according to whom not only are all 
the cases usually classed as seborrhoea to be regarded as eczematous, but 
also many others classed as ordinary eczema. Instead of seborrheic 
eczema being a form of disease in which the fat-producing glands are 
involved in the inflammatory process, Unna believes it to be parasitic and 
due to a certain " mulberry coccus " which he has described. Although his 
investigations have not yet been corroborated, there are many arguments 
in favour of the pathology which he has advanced for this disease. Elliot, 
who accepts Unna's views, defines seborrheic eczema as follows : " An 
inflammatory disease of the skin, catarrhal in nature, due to micro-organ- 
isms — a parasitic dermatitis — characterized by its primary seat being upon 
the scalp, whence it tends to spread downward, involving by preference 
the middle portion of the face, the sternal and interscapular spaces, axilla, 
and inguinal regions, but may affect any part of the body." * The lesions 
upon the scalp may be of the nature of a dry seborrhoea with yellow 
greasy crusts, or like pityriasis. Upon the body, the eruption is scaly, with 
red macules or papules, or it may be accompanied by greasy crusts like 
those seen upon the scalp. The skin is not usually thickened and the 
lesions are not elevated. Itching in most cases is only moderate, and it 
may be absent ; but in some of the most severe cases it is marked and ac- 
companied by tingling. An extensive weeping surface is never seen. All 
the crusts are soft and contain fatty matter. The lesions are not deep, 
and the disease frequently shifts from one part of the body to another, 
often coming out very rapidly. In most cases the patches are rather 
sharply defined and have rounded borders. 

Pustular Eczema of the Scalp. — This condition, often called "simple 
impetigo," is less frequently seen in infants than in children from two to 
five years old. There are usually present from half a dozen to fifty 
greenish-yellow crusts, matting the hair, usually discrete, but sometimes 
coalescing to form a mask over half the scalp. There is very little itch- 
ing, in some cases none at all. The lymph glands are invariably enlarged. 
There is frequently continued auto-infection, and in this way the disease 
may be prolonged indefinitely. It is possible, too, that infection may 
spread to other children. 

Intertrigo. — This term is rather indiscriminately applied to any erup- 
tion which develops upon two moist surfaces, which are in contact. It 
is often regarded as a form of eczema, although, as Elliot has well 
pointed out, there are seen several processes which are quite distinct 
from one another. The most frequent is a simple erythema ; in other 
cases there is an eczema resulting from traumatism or the decomposition 

* Morrow's System of Genito-Urinary Diseases, Syphilology, and Dermatology, 
vol. iii, D. Appleton & Co., 1895. 



930 DISEASES OF THE SKIN. 

of secretions, or a seborrheic inflammation. Intertrigo is seen in the 
folds of the groin, between the scrotum and the thighs, between the but- 
tocks, about the anus, in the axillae, in the neck, or behind the ears. Its 
essential causes are moisture, friction, want of cleanliness, and sometimes 
infection. The disease is generally seen in its worst form about the 
thighs, genitals, and buttocks; it sometimes covers the sacrum and ex- 
tends down to the middle of the thighs. There is an intense uniform 
redness, and in some cases the epidermis is denuded over large areas, and 
the surface is moist. There is no thick crusting and little or no itching. 
Intertrigo is usually easy to control except in very poorly nourished or 
marantic children, among whom it is especially frequent. 

Diagnosis of Eczema. — This is usually quite an easy matter. In the 
majority of cases, the disease affects the face or the scalp, and its appear- 
ances are typical. Eczema of the body or extremities may be confounded 
with scabies or syphilis, and occasionally with other forms of skin disease. 
Scabies resembles eczema in its intense itching and multiform lesions; 
but in the former, one may often find evidences of its presence in other 
members of the family ; the parts most frequently affected are the flexures 
of the wrists, the elbows, the skin between the fingers, the margins of the 
axillae, the lower part of the abdomen and back, and, in boys, the penis ; 
and by careful examination with a lens some of the characteristic burrows 
are certain to be discovered. 

Syphilis is likely to be confounded with papular eczema of the but- 
tocks. The latter affects the parts near the anus, and the irritation may 
lead to the development of spots closely resembling mucous patches. The 
local appearances may at times be indistinguishable from syphilis, and the 
diagnosis is to be made only by the other symptoms present. In syphilis 
the characteristic eruption is seen usually upon the face, hands, legs, and 
sometimes the palms and soles ; there is no itching and very little evi- 
dence of inflammation ; the eruption is dark-coloured, and occurs as small 
circumscribed spots; there are usually present other symptoms, such as 
the coryza, the syphilitic cachexia, and enlargement of the spleen. 

The diagnosis from pediculosis and ringworm of the scalp, rarely pre- 
sents any difficulties. 

Prognosis. — All cases of chronic eczema are tedious. There is only a 
slight tendency to spontaneous improvement, and very little to spontane- 
ous recovery during infancy. In a given case, the prognosis' depends upon 
the duration of the disease, its severity, and very much upon the co-opera- 
tion of the mother or nurse. The results obtained depend not only 
upon the particular line of treatment adopted, but upon how well it is car- 
ried out. Usually it must be continued for several months. Eczema of 
the face is especially intractable when occurring in children suffering from 
chronic indigestion and constipation. Intertrigo is in most cases easily 
cured, unless the patient is suffering from marasmus. 



ECZEMA. 931 

Treatment. — It is never dangerous to cure an eczema, and always de- 
sirable to do so, in spite of the strong prejudice to the contrary, which 
still exists in the minds of the laity and in some members of the medical 
profession. The general tendency is to treat the eczema rather than 
the patient who is suffering from it. A judicious combination of gen- 
eral and local measures is necessary for the best results. One should 
first seek to discover and correct what is wrong with the child's diges- 
tion, assimilation, and elimination; unless nutritive disturbances can 
be removed, local treatment will give only temporary relief. External 
causes also must be investigated. The local measures employed must be 
chosen with reference to the condition present ; stimulating applica- 
tions should not be ordered for an acutely inflamed skin, nor sedative 
applications in very chronic conditions. 

Diet. — A thorough investigation into the food is necessary, not only 
as to its character, but as to quantity and preparation, the manner and 
frequency of feeding, etc. If the patient is a nursing infant, an examina- 
tion of the nurse's milk is indispensable to intelligent treatment. If the 
child is very fat and well nourished, it is generally the case that the fat of 
the milk is too high and must be reduced according to the rules given 
elsewhere (page 173), the most important thing being to exclude from 
the nurse's diet malt liquors and alcohol in all forms, and reduce the 
amount of meat. In a smaller number of cases the trouble is with the 
proteids of the milk ; there will then be other signs of indigestion, such 
as colic, the appearance of curds in the stools, etc. The amount of food 
should be reduced by lengthening the period between the nursings, and 
shortening the time which the child is allowed to remain at the breast 
at one nursing. Plain water, or better, some alkaline water, should be 
given freely between the nursings. In children fed upon cow's milk, the 
trouble may be with the sugar, the proteids, or the fat. The physician 
should try the effect, first of giving a milk which is low in proteids and 
moderately high in fat (e. g., formula G- or H, page 209) afterwards, one 
in which both fat and proteids are low (e. g., formula II or III, page 
194). These and other changes are to be made in the manner described 
in the chapter on Infant Feeding. During the latter part of the first and 
the entire second year, the usual error is that of overfeeding with in 
most cases an excessive use of solid food, especially farinaceous articles. 
The diet should then be much reduced, and the amount of farinaceous 
food restricted, potatoes and oatmeal being absolutely prohibited. The 
diet which suits most children best is one composed of milk, beef juice, 
broth, fruit, eggs, and a little red meat, with the addition in some cases 
of rice, wheat, or barley. In severe and obstinate cases, however, as com- 
plete a change in diet as possible is sometimes the best prescription. Any 
form of indigestion which exists is to be managed according to the spe- 
cial indications in each case. 



932 DISEASES OP THE SKIN. 

The diet of older children needs to be watched no less closely than 
that of infants. The general rules laid down elsewhere for feeding after 
the second year should be observed. The great majority of cases do best 
upon a diet which is largely fluid, and composed principally of milk or 
some of its substitutes — kumyss or matzoon. 

Elimination by the kidneys should be stimulated by the very free use 
of water, to which it is well to add — especially in cases with a gouty tend- 
ency — the citrate,* or acetate of potassium, from ten to twenty grains 
daily. 

Attention to the condition of the bowels is of the greatest impor- 
tance. To overcome the tendency to constipation is in many cases 
to cure the eczema. Suggestions under this head will be found in 
the chapter on Chronic Constipation. Special importance is to be at- 
tached to the occasional use of a purge of calomel, one half to one grain 
being given every third or fourth night. The best effects from this 
are seen in over-fed children. It has a favourable effect upon the 
kidneys as well as upon the bowels. The bowels must not only be 
opened, they must be kept freely open by the daily use, if necessary, of 
some of the milder laxatives, such as phosphate of sodium, rhubarb, or 
cascara. Sometimes nothing acts so well as castor oil, which may be 
given in from half a teaspoonful to teaspoonful doses every night for two 
or three weeks at a time. It should be administered in emulsion. 

When the disease occurs in flabby, anaemic, or poorly-nourished chil- 
dren, iron and bitter tonics are required, and occasionally alcohol and 
cod-liver oil. In other words, the child's general condition should be 
treated just as if no eczema existed. Arsenic is indicated in a chronic or 
recurring form of eczema with dry, scaly eruption. It is in no sense a 
specific remedy, but sometimes of great value. 

The general management of cases is important. The skin must be 
carefully protected by an ointment whenever the child is in the open air ; 
if the weather is very cold, or there are high winds, children with active 
eczema should not go out, but take the fresh air indoors. Never should 
an eczematous surface be washed with plain water, and much less with 
castile soap and water, so frequently employed by the ignorant. Where 
washing is necessary, it may be done with bran water, milk and water, 
or starch and water, to which borax (a teaspoonful to the quart) may be 
added. The clothing should not be so excessive as to keep the child con- 
stantly in a perspiration. Napkins should not be washed in strong soda 
solutions, nor, in case of eczema of the buttocks, should they ever be 
used a second time after being simply dried. 

* While the citrate can not be depended upon as a diuretic, unless dispensed from 
a newly opened bottle, it is generally to be preferred, as being more easily admin- 
istered. 



ECZEMA. 933 

In eczema of the face it is absolutely necessary to prevent the child 
from scratching the parts. The use of a mask is not always sufficient, 
nor the wearing of mittens ; nor is the local application of anti-pruritic 
lotions or ointments invariably successful. In severe cases mechanical 
restraint is absolutely indispensable. The most satisfactory method is to 
surround the arms at the elbows by pasteboard splints, and hold them in 
place by bandages. This allows free use of the hands, but makes it abso- 
lutely impossible for the child to reach the face. 

Local treatment. — Local treatment is always necessary, for not only 
are the causes sometimes entirely external, but the condition may persist 
after the original internal cause has been removed. There are several 
indications to be met by local treatment at different stages in the disease : 
(1) To remove crusts and other inflammatory products ; (2) to allay con- 
gestion and acute inflammation ; (3) to relieve itching ; (4) to protect the 
delicate new skin which is forming ; (5) to prevent infection ; (6) to stimu- 
late the skin in the chronic stages of the disease. 

Preparatory to the use of any application, the scales, crusts, and other 
products of inflammation must be softened and removed in order that the 
diseased surface may be reached. In most cases it is sufficient to soften 
the crusts by the use of olive oil for twelve or twenty-four hours, and then 
remove them by soap and warm water. If the crusts are very hard and 
thick, they can be softened by a poultice. During the stage of acute in- 
flammation only sedative applications should be used. Oue of the best of 
these is a lotion of zinc and calamine : 

3 Pulv. calaminae preparatae 3 ij 

Zinci oxidi § ss. 

Glycerinae § j 

Liquor calcis § ij 

Aquae rosae 5 V AJ« 

A piece of muslin should be dipped in this solution, and applied to 
the affected part, being kept in place by a bandage. If there is much 
itching, one per cent of carbolic acid may be added. 

Another plan of treatment, where there is much secretion, is to keep 
the surface covered with equal parts of boric acid and starch or dolomol 
powder. An application which is often successful in allaying the in- 
tense burning and itching is black wash. This is applied several times a 
day in full strength or diluted and allowed to dry on, after which a pro- 
tective ointment is used. 

A soothing application in general eczema is one composed of equal 
parts of lime water and sweet-almond oil ; sometimes this may be advan- 
tageously followed by smearing the body with a thick starch paste and 
allowing it to dry on. 

As a simple protective ointment, one containing starch, zinc oxide, or 
bismuth, either alone or in combination, may be used. An excellent for- 
mula is Lassar's paste : 



934 DISEASES OF THE SKIN. 

9 Acidi salicylici g r - x 

Zinci oxidi 3 ij 

Amyli 3 ij 

Vaseline I J 

Later, when the inflammation is less acute and the itching severe, 
nothing is so generally useful as a combination of tar and zinc, as in 
the following: 

^ Ungt. picis liquidse 3 iij 

Zinci oxidi • 3 iss. 

Ungt. aquae rosae 3 vi 

For more chronic cases, the amount of tar may be increased. All 
ointments used should be spread upon muslin, and kept in close contact 
with the inflamed part by means of a bandage or mask. Little or noth- 
ing is accomplished by simply rubbing the ointment upon the affected 
part. Where it is difficult to keep a mask applied, or in situations 
where it is impossible to use the ointment, Pick's paste may be tried : 

5 Pulv. tragacanthse 3 j 

Glycerinae . . 3 iss. 

Aquas rosae I iv 

To this may be added zinc oxide gr. xl and carbolic acid gr. v, or tar TT[ x. 
A similar basis for ointments, made from gum tragacanth has been sug- 
gested by Elliot and is known as bassorin paste. It may be combined 
with tar, zinc, salicylic acid, or resorcin. 

The methods of treatment above mentioned are especially applicable 
to eczema of the face and scalp. For pustular eczema of the scalp the 
best application is the white-precipitate ointment, which should be com- 
bined with three or four parts of vaseline. This is excellent also for small 
eczematous patches upon the body, but it is not to be used over a large 
surface. 

In intertrigo, the treatment should have reference to the pathological 
condition which is present. Cases of simple erythema usually yield 
promptly to cleanliness and the free use of absorbent antiseptic powders, 
such as boric acid and starch in equal parts, or if the skin is very sensi- 
tive, aristol or dolomol with aristol may be used. If there is an acute 
dermatitis, the calamine and zinc lotion may be used, and later some 
protecting ointment. When infection has been added, lotions of resor- 
cin or ichthyol, one half or one per cent strength, should first be applied, 
and the skin then covered with one of the powders mentioned ; both are 
to be repeated as often as the parts are wet by urine or soiled by fasces. 
It is important in all cases that the diseased surfaces should be kept 
separated, which is best done by starch or aristol and absorbent cotton. 
All napkins should be immediately removed when soiled. 

In cases of chronic eczema, where the skin remains thickened, red, 



FURUNCULOSIS. 935 

scaly, and itching, stimulating applications are to be used, such as the 
tincture of green soap or stronger preparations of tar than those men- 
tioned. They should be applied every three or four days. 

In the seborrhceic form of eczema, whether affecting the face, scalp, 
or bod}', nothing is so generally useful as resorcin : 

5 Resorcin gr. x 

Ungt. aquaB rosae 1 j 

This may also be advantageously combined with bassorin paste. 

FURUNCULOSIS, 

A furuncle, or boil, is a circumscribed inflammation of the subcuta- 
neous cellular tissue, usually beginning in a hair follicle, and usually 
ending in suppuration. When severe, it may result in necrosis of the 
follicle, which forms the " core," or the necrotic process may extend to 
the surrounding tissues for a variable distance. The ordinary boil need 
not be described, as it presents nothing peculiar in early life. The con- 
dition, however, which is characteristic of young children is the forma- 
tion of small ones in great numbers. It is to this more especially that 
the term furunculosis is applied. The principal location of these small 
abscesses is, in nearly all cases, the scalp, face, and shoulders, although 
they may be found upon any part of the body. They are sometimes 
numbered by hundreds, and appear in crops for a period of several 
months. In size, they usually vary from a pea to an almond, and they 
rarely contain a core. Infants are much more often the subjects of this 
disease than are those who have passed the second year. In the great 
majority of cases the condition is not serious, yet, occurring, as it often 
does, in infants who are already suffering from extreme malnutrition 
or marasmus, whose tissues possess but little resistance, the process may 
develop into a gangrenous dermatitis, which may prove fatal. 

Furunculosis is seen in children who are in other respects apparently 
healthy, even robust ; but the majority are in a more or less debilitated 
condition, and often are the subjects of digestive disturbances. The dis- 
ease is quite frequent in syphilitic infants; but these simple abscesses 
are to be sharply distinguished from those which result from the break- 
ing down of gummata of the skin. Want of cleanliness of the skin is a 
factor of some importance in producing the disease. Furunculosis may 
be associated with eczema. The exciting cause in all cases, as shown by 
all recent investigations, is the entrance of the staphylococcus pyogenes 
aureus, sometimes with other organisms, into the follicles of the skin. 

Treatment. — The internal treatment is to be directed toward any dis- 
turbance of digestion or general nutrition which is present. General 
tonics are indicated in most cases, particularly iron, arsenic, and the com- 
pound syrup of the hypophosphites. But little reliance can be placed 



936 DISEASES OF THE SKIN. 

upon internal remedies, such as sulphide of calcium, for the purpose of 
arresting this disease. Local treatment should have for its first object 
thorough cleanliness of the skin. This is best secured bj frequently bath- 
ing the parts affected, with a saturated solution of boric acid. Single 
furuncles may often be aborted by the frequent application of spirits of 
camphor, or a few applications of tincture of iodine, or by touching them 
with pure carbolic acid. The last mentioned, although efficient, can hardly 
be intrusted to the hands of a mother or nurse. A remedy which has been 
used with considerable success is a plaster of salicylic acid. In my ex- 
perience the best plan of treating the multiple small furuncles, is to delay 
incision until they have pointed, then to incise freely and empty the follicle 
completely by compression. It is then washed out thoroughly with a 
solution of bichloride (1 to 2,000), and small pledget of absorbent cotton 
applied till the bleeding has ceased. After this the part should be covered 
with simple collodion or that in which iodoform has been dissolved. Where 
the abscesses are of large size and upon the scalp, it is wise to make com- 
pression by applying a snug bandage for a day. It is very exceptional for 
abscesses so treated to refill. When the suppuration is more diffuse and 
there is necrosis of the cellular tissue, ichthyol, either in the form of an 
ointment or lotion (one to five per cent strength), is one of the best appli- 
cations. Early and free incisions must be practised in all such cases. 



GANGRENOUS DERMATITIS. 

This is not a frequent disease, and is seen almost exclusively in in- 
fancy. It may be primary or it may follow other diseases, and hence has 
been described under many different names — viz., varicella gangrenosa, 
ecthyma gangrenosa, pemphigus gangrenosa, etc. 

The lesion consists in small, discrete areas of inflammation of the skin, 
ending in necrosis. In the primary cases there is usually first seen a vesi- 
cle, about as large as a pea, with a dusky areola ; it increases in size and 
becomes a pustule. Crusts form which are quite adherent, and on re- 
moving them a loss of tissue is seen. The ulcers usually have sharp but 
not undermined edges, often presenting a " punched-out " appearance. 
By the coalescence of several small ones, ulcers an inch or more in diame- 
ter are sometimes formed. 

The primary form of gangrenous dermatitis occurs in wretched, 
poorly-nourished infants, and is most often seen upon the buttocks. In 
this location it may be mistaken for syphilis. The secondary form 
is more common, and usually follows varicella, less frequently vaccinia, 
measles, or pemphigus. My own experience with this disease has been 
confined to cases following varicella. In such, the lesion is usually seen 
upon the upper half of the body, especially upon the neck and chest. It 
follows the ordinary lesions of varicella and continues usually, in spite 



IMPETIGO CONTAGIOSA. 937 

of treatment, from one to four weeks, in most cases ending fatally. The 
disease always occurs in infants of poor vitality, often in those suffering 
from marasmus, and is seldom seen outside of institutions. It may be 
accompanied by fever, and other severe constitutional symptoms. 

For the production of the disease, two factors are necessary : first, the 
constitutional condition referred to ; and, secondly, the entrance of pyo- 
genic germs, usually the streptococcus pyogenes. 

Treatment. — Every means possible should be employed to build up the 
general health of the infant by tonics, fresh air, careful feeding, etc. Lo- 
cally, strict cleanliness and antiseptic applications are necessary. The best 
application is a solution of bichloride (1 to 5,000), or an ointment of ich- 
thyol or iodoform. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is a disease characterized by the formation of dis- 
crete vesiculo-pustules, occurring most frequently upon the hands and 
face. Cases are usually seen in groups affecting several children in one 
family or institution. It may be communicated from one person to 
another, and spread by auto-inoculation from one part of the body to 
another. 

One rarely has an opportunity to see the disease until vesicles have 
formed. These are usually from one fourth to one half an inch in diame- 
ter, and are flaccid, never distended. Later, their contents become slightly 
yellowish ; then they rupture and dry, forming thick yellow crusts, which 
have the appearance of being " stuck on," the surrounding skin being 
quite healthy. After the crusts fall off, a small red patch remains, which 
slowly fades. The true skin is not involved, except in poorly-nourished, 
cachectic subjects, as a result of continued local irritation, like scratching. 
Under such conditions ulceration may occur. Instead of the small vesic- 
ulo-pustules described, bullae from one to two inches in diameter may 
form, filled first with serum, afterward with sero-pus. Very little inflam- 
mation is seen about these patches, and in most cases the intervening skin 
is normal. 

The favourite seat of the eruption is the face, especially about the chin, 
next the hands, the neck, the feet and legs, the forearms, and the scalp ; 
it is rarely seen upon the abdomen, and never upon the back. There may 
be only half a dozen vesiculo-pustules, or from thirty to forty may be 
present. The smaller ones sometimes coalesce and form others of consid- 
erable size. Itching is never a prominent symptom, and in most cases it 
is absent altogether. 

The usual duration of impetigo contagiosa is two or three weeks; it, 
however, runs no regular course, and by continued auto-inoculation may 
last much longer than this. 

The studies of Gilchrist (Baltimore) point to a streptococcus of low 
virulence as the cause of this disease. European investigators, however, 



938 DISEASES OF THE SKIN. 

have with considerable uniformity found the staphylococcus pyogenes 
aureus in the vesicles. Impetigo contagiosa may occur in any child, 
but is seen most frequently in one who is poorly nourished. 

The diagnosis is not often difficult, and is made by the following fea- 
tures — viz., the occurrence of several cases together, the isolated vesiculo- 
pustules situated upon the face and hands, the slight itching, and the 
prompt cure by local measures only. The bullous form, however, is fre- 
quently confounded with pemphigus ; many cases in which the diagnosis 
of pemphigus is made are examples of impetigo. 

Treatment. — This is simple and usually very effective. The crusts 
are to be softened and removed by thoroughly washing the part with soap 
and water or a bichloride solution, after which the white precipitate oint- 
ment, combined with three parts of vaseline, should be applied. 

URTICARIA. 

Urticaria is a frequent disease in early life, and presents some features, 
particularly in infants and young children, which are quite different from 
those seen in adults. This is due to the fact that papules and vesicles, 
and occasionally pustules, are associated with the wheals. As the wheals 
quickly subside, it frequently happens that the other lesions mentioned 
are the only ones present. This fact has given rise to considerable con- 
fusion in names, and the urticaria of infancy has been called lichen 
urticatus, urticaria papulosa, strophulus, etc. It is now pretty generally 
agreed that the clinical picture, which is a familiar one, belongs to a single 
disease, and that this is urticaria. 

The initial lesion is the wheal, but on account of the extreme suscepti- 
bility of ihe skin in young children, the process is more intense than in 
older patients, so that it may result in the formation of an inflammatory 
papule or a vesicle. In a few hours the wheals may subside, and only the 
papules or vesicles remain, and without a good history the disease may be 
a very obscure one. The papules and vesicles occur with greatest fre- 
quency upon the hands and feet, particularly the palms and soles. The 
more severe form of the disease in poorly nourished children is sometimes 
accompanied by a -pustular eruption, and there may even be deep ulcera- 
tion (ecthyma). The usual appearance of the eruption is a number of 
small inflamed red papules whose tops are covered with scabs, the result of 
scratching. The eruption may be limited to the extremities or it may be 
general. It is as a rule more severe in regions accessible to scratching. 

There is usually severe itching, which leads to loss of sleep, and often 
in this way the disease affects the general health of the child. The urti- 
caria of older children does not differ essentially from the same disease in 
adults. 

The character of the eruption in urticaria and even its distribution 
strongly suggest scabies ; and unless one has had an opportunity to witness 
the development of the lesions, a differential diagnosis may be very difficult, 






SCABIES. 939 

as almost every lesion, except the wheal, may be identical in both diseases. 
Other cases may resemble varicella. 

Urticaria in early life is most frequently the result of some disturbance 
in the digestive tract. Almost any sort of derangement may produce it, 
the exciting cause varying with the patient. Exceptionally, it may result 
from other forms of irritation, such as dentition or intestinal worms, and 
it has been ascribed to malarial poisoning. 

Treatment. — The milder forms of urticaria usually respond quickly to 
treatment ; but when it is severe and has existed for several weeks, it is 
one of the most troublesome and intractable skin diseases of childhood. 
The treatment is to be directed primarily toward the condition of the 
digestive organs. Children should be put upon a milk diet, and even 
milk may need to be partially peptonized. The bowels should be kept 
freely open by calomel, a nightly dose of castor oil, or a morning dose of 
magnesia. If the urine is excessively acid and scanty, alkaline diuretics 
should be given. The drugs most useful for the indigestion with which 
urticaria is associated are salicylate of soda and nitro-muriatic acid, each 
of which is to be given after meals. 

All local causes of irritation, such as rough flannel underclothing, 
should be removed. The sleep may be so much disturbed as to require 
the use of trional or bromide and chloral. The two remedies which are 
of most value for the disease itself are antipyrine and atropine ; they may 
be used separately or in combination, and should be administered in mod- 
erately large doses. 

The local irritation and itching may be relieved by a lotion of menthol 
'(gr. ij, water § j), by a very dilute solution of the subacetate of lead or 
carbolic acid, or by a mixture of vinegar, or the fluid extract of hamamelis, 
and water. Where pustules are present, the white-precipitate ointment 
may be used, combined with four parts of vaseline ; in the papular and 
vesicular forms, an ointment of ichthyol or naphthol, one per cent strength. 
In many cases the improvement in the general health by the use of tonics, 
change of air, etc., will accomplish more than any measures directed 
especially to the relief of the urticaria. 



SCABIES. 

Scabies is a contagious disease due to the burrowing into the skin of 
the female acarus, with secondary lesions which result from scratching. 
This disease is not a common one in New York, even among dispensary 
patients, while among the better classes it is extremely rare. 

The burrowing of the acarus is usually where the skin is thinnest — 
viz., between the fingers, on the flexor surfaces of the wrists, the axillae, 
and, in males, the genitals. It is not seen upon the face, except in infancy, 
when it may be infected by contact with the breasts of the mother. 



940 DISEASES OF THE SXIN. 

The lesion excited by the acarus is usually a papule or a vesicle, some- 
times a pustule. In some cases no evidences of inflammation are present, 
but in infants and young children they may be marked — pustular erup- 
tions being frequent and often extensive, especially upon the hands and 
feet. The characteristic burrow is from one fourth to one half inch in 
length, and appears as a fine brown or black line, at the end of which the 
acarus may be discovered as a small white speck. The burrows are often 
difficult to find in infants. They are generally to be seen along the inner 
border of the hand and between the fingers. The intensity of the in- 
flammatory lesions varies greatly in different cases ; in some they are very 
few, while in others, particularly in delicate, cachectic, and neglected chil- 
dren, they are sometimes very severe, so that the skin of the affected 
part is nearly covered with pustules. These secondary lesions are due to 
infection by the streptococcus or staphylococcus. A pustular eruption 
upon the hands should always suggest scabies. The lesions which result 
from scratching may be found on any accessible portion of the body. 
There are usually at first linear, bloody marks, but after a time these 
may not be visible. In little children urticaria is often associated. 

The diagnosis of scabies is usually quite easy, as several children in a 
family are likely to be affected, particularly if they occupy the same bed. 
The diagnostic features of the eruption are the presence of papules, vesi- 
cles, or pustules, especially upon the hands, wrists, and genitals. A care- 
ful examination with a lens will usually disclose some of the character- 
istic burrows, or even the acarus. In infancy, scabies may be easily con- 
founded with the vesicular form of urticaria, unless the development of 
the lesions has been observed. 

Scabies may always be cured, provided sufficient precautions are taken 
to prevent re-infection. This necessitates boiling or baking, not only the 
patient's clothes, but all the bedding as well. 

Treatment. — This should always be begun by a hot bath, in order to 
soften the epithelial scales about the burrows. The body should be thor- 
oughly scrubbed with soap and water, preferably with a nail-brush, the 
bath being continued for at least half an hour. It is well to do this at 
night. After the bath, the body is anointed with the parasiticide, which 
should be thoroughly rubbed into the skin, clean clothing applied, and 
the child put into a perfectly clean bed. In the morning the ointment 
may be washed off, but none of the clothing previously worn should be 
put on. This treatment is to be repeated on two or three successive 
nights, and if thoroughly done it will effect a cure. The ordinary sulphur 
ointment is too irritating for use in little children, and one of the fol- 
lowing may be substituted : naphthol, 15 parts ; creta preparata, 10 parts ; 
vaseline, 100 parts (Kaposi) ; or, precipitated sulphur, 1 part ; balsam of 
Peru, 1 part ; vaseline, 8 parts ; or the simple balsam of Peru may be ap- 
plied without dilution. After the use of the parasiticide there is generally 



TINEA TONSURANS. 941 

required for a few days, some soothing application like those mentioned 
in the chapter upon Eczema. 

TINEA TONSURANS— RING-WORM OF THE SCALP. 

Eingworm of the scalp is a very frequent disease in institutions for 
children, often occurring as an epidemic. According to Crocker, the 
primary lesion consists in a red papule surrounding a hair, which soon 
increases to a small circular patch ; this spreads at its outer margin, 
gradually increasing in size until it is from one to two inches in diameter, 
but rarely larger than this. Sometimes several of the patches coalesce. 
These affected areas always have rounded borders, and are sharply out- 
lined. Here the hairs are very brittle, and often broken off close to the 
scalp, so that it may appear to be bald. Where they have not fallen off, 
the hairs have lost their lustre. The stumps of the broken hairs point in 
all directions. 

The fungus which produces the disease is the trichophyton tonsurans. 
It penetrates the shaft of the hair, both the spores and the mycelium 
being seen under the microscope. The spores are present in great num- 
bers in the hair, but the mycelium is most abundant in the scales. The 
amount of inflammation found in the diseased areas varies much in the 
different cases. There may be only a scaliness of the scalp, or a formation 
of pustules in the hair follicles, the hairs loosening and falling out in con- 
sequence. In young infants where the hair is scanty and thin, the dis- 
ease resembles tinea circinata — i. e., it is superficial, and the hair follicles 
are often not involved. Children of all ages are liable to tinea ton- 
surans. It flourishes particularly in those who are dirty and poorly 
cared for. 

The diagnostic feature of the disease is the presence of scaly patches, 
with loss of hair. The patches are usually circular, and by examination 
with a lens the stumps of broken hairs are seen all over the diseased 
area. By a microscopical examination the fungus is discovered. In 
typical cases the diagnosis is easy if the process is at all advanced, but 
there are many atypical forms and many mild cases where the recogni- 
tion of the disease is difficult. The symptoms are often masked by the 
inflammatory conditions present. The disease may be confounded with 
seborrhcea ; but in the latter the lesion is diffuse, never sharply defined ; 
there is general thinning of hair over the scalp, and never the stumpy, 
broken hairs. Psoriasis has points of resemblance, but it is usually found 
on other parts of the body, especially the knees and elbows, and upon the 
scalp the patches are more numerous and smaller. In eczema the loss of 
hair in circumscribed patches is never seen, nor are the broken stumps. 

Tinea tonsurans is always curable, provided the patient can be kept 
under close surveillance, and treatment thoroughly carried out. There is 
no tendency to spontaneous recovery. In a recent case, treatment must 



942 DISEASES OF THE SKIN. 

usually be continued for one or two months, and in chronic cases, from 
six months to one year, with the closest watchfulness. 

Treatment. — The great difficulty in treatment is to get the parasiticide 
deeply enough into the scalp to reach the fungus, since this is often at the 
very bottom of the hair follicles. As a first step, the hair should be cut 
short all over the patch and for at least an inch beyond it ; this is neces- 
sary in order to get at the diseased part and to detect new foci of infection 
early — if possible before the fungus has extended deeply into the follicles. 
The parasiticide should be applied not only upon but around the patch, 
and the entire scalp should be washed thoroughly two or three times a 
week. To prevent the disease spreading, all the scales are to be kept soft- 
ened by the use of carbolic soap. The hair should not be brushed, as this 
tends to scatter the spores and spread the disease. All patients while 
under treatment, should wear a cap of muslin or oiled-silk, or one lined 
with paper, in order to prevent infecting others. In institutions, affected 
children should invariably be isolated. 

To destroy the fungus almost every germicide on the list has been 
advocated at one time or another, which proves that the disease is a very 
obstinate one, an'd that no one application is invariably successful. Those 
which have the sanction of the widest use are the tincture of iodine, the 
bichloride, white precipitate, and oleate of mercury, kerosene, creosote, 
and croton oil. As a vehicle for ointments, lanoline is greatly to be pre- 
ferred to vaseline or lard ; according to Crocker, the addition of three 
parts of lanoline to one part of olive oil is much better than lanoline 
alone. Most of the germicides mentioned are used in the strength of one 
to five per cent, according to the age of the child and the irritability of 
the scalp. In an epidemic of ring-worm in the New York Infant Asylum 
the following combination of bichloride and kerosene proved extremely 
satisfactory : ten grains of the bichloride were dissolved in alcohol, and 
to this were added two and a half ounces each of olive oil and kerosene. 
This was applied every day, being thoroughly rubbed into the diseased 
patches, and the whole scalp saturated with it. Considerable irritation 
usually resulted, and every few days the parasiticide was omitted and some 
simple emollient applied until the irritation had in a measure subsided. 
In some of the cases, the tincture of iodine was alternated with the bichlo- 
ride and kerosene. Twenty-six cases were treated after this plan and all 
cured, the average duration of treatment being eight and a half weeks.* 

Epilation is necessary in many cases as an accessory to the application 
of germicides, particularly in older children. 

* A full report of these cases was made by C. G. Kerley, M. D., in the New York 
Medical Journal, October 10, 1891. 



ACUTE OTITIS. 943 

CHAPTEE VI. 

ACUTE OTITIS. ■ 

Otitis is a frequent affection during infancy and early childhood, at- 
tacks usually occurring in the cold season. Of all the inflammatory con- 
ditions which may be met with in early life, there is perhaps none which 
more frequently gives rise to obscure febrile symptoms than this. 

Etiology. — Acute otitis is, as a rule, a secondary disease, and is gen- 
erally preceded by some infectious process in the rhino-pharynx. The 
usual avenue of infection is through the Eustachian tube. Downie 
(Glasgow) gives the following statistics of 501 cases of tympanic involve- 
ment : 

Originated during measles 131 cases, or 26*1 per cent. 

scarlet fever 63 " " 12'6 " 

" " whooping-cough 15 " " 3-0 " 

" " mumps 3 " " 06" 

" simple catarrh 147 " " 29-4 " 

dentition 101 " " 200 " 

Syphilitic 8 " " 1-6 " 

Doubtful...' 33 " " 6-7 " 

501 100-0 

The most severe forms of otitis usually follow scarlet fever, epidemic 
influenza, measles, diphtheria, or pneumonia. The entrance of fluids 
through the Eustachian tube from the nasal douche or nasal syringing 
may cause acute otitis. It sometimes results as an extension of inflam- 
mation from meningitis, especially the cerebro-spinal form. 

The micro-organisms concerned in the production of acute otitis 
vary with the condition of which it is a complication. With scarlet fever, 
measles, influenza, or simple catarrh, the streptococcus, the pneumo- 
coccus, or the staphylococcus may be found either separately or together, 
inflammations associated with the organism last mentioned being usu- 
ally of a milder character than with the other two. In cases complicat- 
ing diphtheria, the Klebs-Loeffler bacillus may be found with any of the 
forms mentioned, or may occur alone. In chronic cases any of the 
pyogenic organisms may be present, and not very infrequently the tuber- 
cle bacillus. 

Lesions. — The ordinary course of events in the pathological process is, 
first, acute hyperemia and swelling of the mucous membrane of the 
rhino-pharynx, which extends into the Eustachian tube, causing ob- 
struction more or less complete. The inflammatory process may be lim- 
ited to the tube, or it may extend to the mucous membrane lining the 
middle ear. 

There are two varieties of acute inflammation of the middle ear: (1) 



944 



DISEASES OF THE EAR. 



The catarrhal form, which usually accompanies simple catarrh of the 
rhino-pharynx or complicates measles. This is an inflammation of the 
mucous membrane merely, and its products are serum and mucus or 
muco-pus. It is not usually accompanied by great pain or followed by 
serious consequences. It is generally confined to the lower part of the 
tympanic cavity, and is the form more frequently seen in infants. (2) 
The phlegmonous form, which affects older children principally. This 




Fig. 186. — Temperature chart of acute otitis following influenza, in a child three years old. 

is a much more serious inflammation, and is often excited by the in- 
fectious catarrh of scarlet fever, diphtheria, or epidemic influenza. In 
this variety micro-organisms find their way into the middle ear in great 
numbers, and set up an inflammation of a more or less virulent type, 
which may involve not only the mucous membrane lining the tympanum, 
but also the cellular tissue in the upper part of the tympanic cavity. 

The catarrhal form of inflammation frequently subsides in a few days 
with proper treatment, the only result being a slight deafness, which 
is temporary. The phlegmonous form causes a stoppage of the Eusta- 
chian tube, rupture or sloughing of the tympanic membrane and dis- 
charge of the products of inflammation, or rarely pus finds an outlet by 
burrowing between the cartilages. The inflammatory process may ex- 
tend to the bones, causing necrosis of the ossicles or the bony walls of 
the tympanum. The remote results are periostitis and necrosis of the 
petrous bone, pachymeningitis, infectious thrombosis of the lateral 
sinus, general purulent meningitis, and cerebral abscess. These will be 
considered under Complications. 

Symptoms. — These are usually few in number, but present great varia- 
bility as regards their combination and intensity. The two most con- 
stant symptoms are pain and fever. In a typical case in an infant, there 
is generally at the beginning some discharge from the nose, slight con- 



ACUTE OTITIS. 



945 



§ 



1 



gestion of the pharynx and tonsils, and a temperature of 100° to 102° F. 
There is nothing characteristic about this catarrh. After two or three 
days the objective symptoms subside, but the infant continues to be rest- 
less, worries much of the time, wakes frequently at night with a start, 
nurses poorly, and if the thermometer is used, it is found that the tem- 
perature remains elevated, usually from 100° to 103° F. (Fig. 1S6). The 
infant seems decidedly ill, and yet no very definite symptoms are pres- 
ent. Sometimes there is marked tenderness about the ear, and the child 
refuses to lie upon the affected side, or shows signs of pain when the ear 
is touched. After a week or ten days a discharge is found in the auditory 
canal, and usually there follows a rapid subsidence of the constitutional 
symptoms. In some cases there is seen only a high temperature, ranging 
from 101° to 104° F., which persists for several days without outward 
evidences of pain or other signs of inflammation, the discharge being the 
first symptom which leads the physician to suspect disease of the ear. 
In other cases there is marked dulness, apathy, anorexia, and sometimes 
nausea and vomiting, but for several 
days no evidence of pain; the tempera- 
ture may be but little elevated. Thus, 
in most of the attacks seen in infancy, 
pain is not very marked, and it is this 
which so often leads to the great ob- 
scurity of the symptoms. 

In older children the symptoms are 
more characteristic. Pain is usually 
sharp and severe, and is complained of 
early in the attack. The temperature is 
nearly always elevated two or three de- 
grees, and occasionally it is 103° or 104° 
F. (Fig. 187), with severe headache, ex- 
treme restlessness, and even delirium 
or convulsions, so that meningitis may 
be suspected. 

The inflammation does not neces- 
sarily go on to suppuration and rupture. 
There are even more frequently seen, 
accompanying ordinary head-colds or 
mild attacks of influenza, cases in 
which the pain is quite severe for 

twenty-four or thirty-six hours, and accompanied even by a moderate 
elevation of temperature, and yet which rapidly subside without further 
symptoms. In these cases the pain is too constant and too prolonged to 
be an attack of neuralgia. They are simply cases of a mild form of in- 
flammation. 



%m 



Fig. 187 



Temperature chart of acute 
otitis aborted by early paracentesis. 
Boy nine years old ; attack followed 
a mild catarrh ; severe pain in both 
ears began in afternoon of second 
day. Both drum membranes found 
acutely congested and bulging ; in- 
cision followed by free haemorrhage 
and immediate relief of pain. Ears 
syringed with bichloride solution; 
no suppuration occurred ; patient well 
on fifth day. 






946 DISEASES OF THE EAR. 

In infants suffering from severe malnutrition or marasmus, otitis 
often comes on without any objective symptoms, the first thing noticed 
being the discharge. 

Of all the symptoms, fever is the most constant, and is present in 
all except the cases just mentioned. The usual range of temperature 
is from 100° to 102° F.; exceptionally it may be from 103° to 105° F. 
The course of the temperature is irregular. After spontaneous rupture or 
incision of the drum membrane the temperature usually falls, but often 
not immediately. Pain is more marked in older children than in infants : 
first, because in the latter the drum membrane is not so firm, yields 
more readily, and ruptures earlier; and, secondly, because the inflam- 
mation is usually of the catarrhal and not the phlegmonous type. Ten- 
derness is sometimes elicited by pressure just in front of the external 
auditory meatus; there may be increased sensitiveness of all parts of 
the ear and even of the whole side of the head. Children often complain 
of noises in the ear. One little girl with obscure symptoms and high 
temperature, first called attention to her ear by the remark, that she 
" heard pussy in the room." Cerebral symptoms are infrequent, and 
occur chiefly in cases not receiving proper early treatment; they may 
indicate meningeal congestion, or less frequently localised meningitis or 
thrombosis. 

In secondary otitis, especially when complicating severe scarlet fever, 
diphtheria, measles, or typhoid fever, all subjective symptoms are fre- 
quently wanting; unless the ears are examined the disease may be over- 
looked until rupture has taken place. 

The local appearances in the early stage — provided a view of the 
tympanic membrane can be obtained — are marked redness and conges- 
tion; later there is distinct bulging. If perforation has taken place, its 
site may or may not be visible, but its existence may be assumed if bub- 
bles of air are seen deep in the canal, and if much mucus or pus is present, 
as inflammation of the external canal seldom causes much discharge. 
The pus sometimes burrows between the cartilages and opens externally 
behind or at the side of the ear. In the catarrhal form, the discharge is 
at first sero-mucus and quite profuse, later it is purulent. In the phleg- 
monous form it is always purulent, and liable to a sudden arrest with an 
increase in the constitutional symptoms. 

Diagnosis. — Otitis in infancy is frequently obscure, because the pa- 
tient is too young to direct attention to the seat of pain, or because the 
pain is slight or absent. The temperature is almost invariably elevated, 
and the usual problem presented is to discover a cause for this fever. In 
the absence of definite otoscopic signs, one must rely upon the presence 
of faucial congestion, a history of a previous acute catarrh, restlessness 
and the absence of signs in the throat, lungs, or digestive tract, which 
might explain the fever. Local tenderness, deafness, or noises in the 



ACUTE OTITIS. 



947 



ears are of much significance when present. Otitis is so common a cause 
of high temperature in infants during the cold season, that one should 
always have it in mind. 

Complications and Sequelae. — Eemote consequences are most likely 
to be seen in cases following scarlet fever, probably because of their 
severity, particularly when early treatment has been neglected. 

Mastoiditis. — This is the most frequent complication of acute otitis. 
In infancy the mastoid process is small and contains but a single cavity. 
the mastoid antrum, which communicates directly with the vault of the 
tympanum. It is probable that in every severe case of acute suppurative 
otitis there is some pus in the antrum. This is usually discharged into 
the middle ear after the t} r mpanic membrane is incised or ruptures spon- 
taneously. The principal cause of mastoid involvement is want of proper 
early treatment in acute otitis, particularly the practice of allowing these 
cases to take their natural course instead of securing early drainage by 
incision of the drum membrane. 

The important s} T mptoms of acute mastoiditis are fever, mastoid 
tenderness, and swelling. If mastoiditis develops rapidly after acute 
otitis the temperature may be high 
—103° to 105° F.; if it develops 
gradually and appears late the tem- 
perature may be scarcely above 100°. 
Abrupt cessation of an ear dis- 
charge should always arouse sus- 
picion. It is always difficult to 
determine the presence of a slight 
amount of mastoid tenderness, but 
persistent tenderness of one side 
only is significant. It is often most 
marked close behind the auricle 
just over the antrum. The early 
swelling is due to oedema; later there 
may be an accumulation of pus. 
Post-auricular abscess causes a very 
characteristic swelling, the ear 
standing out from the bead (see 
Fig. 188). It is usually due to 
spontaneous rupture through the 
outer bony wall jusl over the antrum 
no discharge from the ear. II is a frequent resuH of severe cases of acute 
mastoiditis not operated upon, especially in young children. 

The characteristic otoscopic appearances of acute mastoiditis, accord- 
ing to Bacon, are, bulging of Shrapnell's membrane, and drooping of the 
upper posterior wall of the external meatus. 




\ 




Fig. 188. — Post-auvicular abseesH following 

acute otitis. 

it mav occur where there lias been 



948 DISEASES OF THE EAR, 

Meningitis. — This may be a cause of death in young children. There 
may be a localised pachymeningitis with the formation of pus — an epi- 
dural abscess — or less frequently general purulent meningitis. It may 
be secondary to other lesions, such as thrombosis of the lateral sinus, 
or the rupture of a cerebral abscess, but is usually due to infection 
through the roof of the tympanum, or along the internal auditory 
meatus. Meningitis may occur either with acute or chronic cases. Its 
symptoms are those of a severe acute secondary meningitis ; its duration 
is short; its termination, almost invariably in death. 

Cerebral Abscess. — This is due to a direct extension of the infec- 
tion from the bone, veins, or dura mater. In about two thirds of the 
cases the abscess is in the temporo-sphenoidal lobe. The next most 
frequent seat is the lateral lobe of the cerebellum. Korner states that 
disease of the mastoid and middle ear leads to cerebral abscess, and dis- 
ease of the labyrinth to cerebellar abscess. Abscesses may be compli- 
cated by thrombosis or by meningitis. They are often latent until just 
before death, which more frequently occurs from the development of puru- 
lent meningitis than from any other cause. They are rare except in 
otitis of long standing. 

Thrombosis of the lateral sinus may be simple or septic. In the 
former there is occlusion of the vessel by a fibrinous clot; in the latter 
there are in addition micro-organisms. 

Simple thrombosis causes no important symptoms. Septic thrombosis 
is relatively infrequent and causes very marked and severe symptoms. It 
follows operation upon the mastoid, and occurs as a complication of mas- 
toiditis quite apart from operation. The temperature is usually of a high 
and widely fluctuating type, and there may also be chills. In some cases 
the constitutional symptoms, except fever, may not at first be severe 
but may suddenly become very grave. Marked cerebral symptoms often 
develop rapidly, and death may follow in from twelve to twenty-four 
hours. At autopsy there may be found a soft broken-down^ clot in the 
sinus, which may extend into the jugular. It may be followed by sec- 
ondary lesions of a general pyaemia, or by localised or general meningitis. 

The labyrinth is not frequently involved, although cases are recorded 
by Pye, Phillips, and others, in which the necrosis and discharge of the 
entire labyrinth has occurred after scarlet fever. In most of these cases 
the deafness was complete, and in several vertigo was present. 

Facial paralysis rarely occurs in the acute cases, but accompanies a 
considerable proportion of the chronic ones. It is due to an extension 
of the inflammatory process from the bone to the seventh nerve, where 
it passes through the canal. The symptoms are those of ordinary peri- 
pheral facial palsy. 

Treatment. — Something may be done in the way of prophylaxis. It 
is of the first importance to secure a normal condition of the mucous 



ACUTE OTITIS. 949 

membrane of the naso-pharynx by the removal of enlarged tonsils, ade- 
noids, etc. The occasional attacks of earache accompanying these condi- 
tions are pretty sure to be followed by more serious trouble unless they 
are relieved. Whether during attacks of measles or scarlet fever, much 
can be done to prevent otitis, is still a mooted question. Personally I 
believe the risks of infection of the middle ear when judicious nasal 
syringing is employed are less than when nothing is done to cleanse the 
naso-pharynx. 

The medical treatment of acute otitis aims at the relief of pain and 
arrest of the inflammation. If the case is seen in the early stage, the 
inflammation may sometimes be cut short by local blood-letting, the use 
of heat, and free catharsis. Blood-letting is not to be advised in the case 
of infants, but may be used in older children. Either leeches or wet cups 
may be employed. They should be applied just in front of and close to 
the tragus. Dry heat is to be preferred to moist heat, both as a means 
of arresting inflammation and of relieving pain. It may be applied by 
means of a bag of hot water, salt, or bran, or by a hot brick or soap- 
stone. These may be placed beneath a thin pillow, upon which the 
child's head rests. If the child will not lie upon his hot pillow, a small 
bag of salt or hot water may be bound over the ear, which has been first 
covered by cotton. Neither oil nor laudanum should be dropped into the 
ear as is so often done in domestic practice ; but there is no objection to a 
few drops of a four-per-cent solution of cocaine, or a five-per-cent solu- 
tion of carbolic acid, either of which may relieve intense pain. Frequent 
irrigation with a warm boric-acid solution is often useful. If the child 
is not soon comfortable, an opiate should be given which may not only 
relieve pain, but may have a favourable influence upon the inflammation. 

A continuance of pain in spite of these measures, with an increasing 
temperature, calls for operative interference. If in addition there is 
mastoid tenderness immediate paracentesis of the drum membrane is 
imperative. An early incision is usually followed by a discharge of blood 
only ; but tension is relieved, pain disappears, and the inflammation often 
quickly subsides without the formation of pus. (See Fig. 187.) Much 
suffering is thereby avoided; the wound rapidly heals, and much less 
damage is done than by allowing the disease to go on to a spontaneous 
rupture. Later operation may be required either for the relief of pain 
or for the evacuation of pus to prevent, if possible, the disease from 
spreading to the bony parts. The advantages of early paracentesis in 
acute otitis can hardly be overstated. Properly performed, it is free from 
risk, causes little or no shock, and should be advised in many cases even 
in which the indications are not so clear as those above described. I 
favor incising the drum membrane in cases of doubt rather than waiting 
for more definite indications with the attendant risks of delay. 

In the secondary otitis of scarlet fever, measles, and diphtheria, the 
61 



950 DISEASES OF THE EAR. 

indications for paracentesis are usually to be derived from the appear- 
ance of the drum membrane alone, other symptoms being absent or 
masked by the primary disease. 

After incision or spontaneous rupture of the drum membrane the 
ear should be syringed every two or three hours with a warm solution of 
bichloride (1 to 5,000 ), or a saturated solution of boric acid, or simply 
with boiled water. A bulb ear-syringe of soft rubber is the most satis- 
factory instrument for general use. A further rise in the temperature 
usually means that drainage is imperfect; if it is accompanied by pain, 
a second incision may be necessary. If the temperature remains high, 
one should be on the lookout for mastoid disease or other complications. 

In most cases the discharge ceases in from one to three weeks ; should 
it continue longer, some measures for checking it may be used. Dench 
advises as better than other applications, the use of a few drops of a 1-to- 
3,000 solution of bichloride in 65 per cent alcohol, after syringing. It 
should be applied with a medicine dropper. Where the discharge has 
become fetid, syringing once a day with a solution of peroxide of hydro- 
gen (1 to 2) is often useful. A persistent discharge often depends upon 
the fact that the child's general condition is poor, and improvement in 
this is more important than any variation in local treatment. 

Mastoiditis. — When symptoms pointing to acute mastoiditis are pres- 
ent, early free incision of the drum membrane is indicated, even though 
there may be no bulging, and a mastoid ice-bag should be applied con- 
tinuously for thirty-six or forty-eight hours. In addition, in older chil- 
dren, the artificial leech may be placed over the antrum or mastoid tip. 
With these measures the inflammation often subsides. Eegarding opera- 
tion upon the mastoid, my own belief is that it is now performed too 
frequently and with insufficient indications, especially in infancy and 
early childhood. The operation is a serious one, and at this age its 
immediate risks are considerable. I have personally known of a number 
of deaths directly connected with it, and of others occurring at a later 
period, where the child was worn out by the long after-treatment, dying 
perhaps from some intercurrent disease or from exhaustion. On the other 
hand, the dangers to which patients are exposed who are not operated 
upon have, I think, been greatly exaggerated. In my own experience, 
meningitis, sinus thrombosis, and cerebral abscess do not occur in any- 
thing like the proportion of cases that the surgeons would have us 
believe.* 

* The records of the New York Foundling Hospital, with a resident population of 
about 800 infants and young children, showed 573 cases of acute otitis in five years (1900 
to 1904 inclusive). During this period there were three extensive epidemics of measles 
with a total of 1,034 cases ; 166 cases of scarlet fever ; 578 cases of diphtheria ; and 
1,505 cases of pneumonia, many of which complicated influenza. With the 573 cases 
of otitis, acute mastoiditis was recognised and recorded in but 17 patients. It is not 






ACUTE OTITIS. 951 

While I fully appreciate the value of the operation, and am quite 
sure that lives are often saved by its timely performance, I would in- 
sist that it be done only with very positive and clear indications. In 
infants, localised tenderness is difficult to determine; and fever after 
acute otitis may be due to many other conditions. In very young patients 
we should therefore insist upon other symptoms before deciding to oper- 
ate. The risks of waiting for clearer indications are, I believe, much 
less than those attendant on unnecessary operation. Often the cause 
of the temperature is found in the lungs; and not very infrequently a 
moderate pulmonary congestion or bronchitis becomes a pneumonia as 
a consequence of the prolonged anaesthesia necessary for the operation. 
With infants therefore in case of any doubt, as to diagnosis or the progress 
of the case, one should invariably decide against operation, or at least 
for postponement. With older children, however, conditions are some- 
what different ; diagnosis is easier and the operative risk much less. 

The treatment of chronic otitis and of the associated conditions is 
largely surgical, and belongs to the specialist; but it is extremely im- 
portant that the general practitioner should be familiar with their symp- 
toms, and realize the danger from these neglected cases, not only to the 
function of hearing, but also to life itself. The essential thing in treat- 
ment is to operate sufficiently to secure free drainage, and to permit 
thorough cleansing of the parts. Too much can not be said against the 
expectant treatment of these cases, or against the practice of prolonged 
poulticing. 

improbable that other mastoid inflammations were overlooked. In this institution, 
however, nearly every fatal case comes to autopsy, and if an unrecognised mastoiditis 
had led to a fatal result the autopsy records should show. In the five-year period, 
900 autopsies were made. There was no instance recorded of abscess of the brain fol- 
lowing otitis. There were but two examples of acute meningitis following otitis with 
mastoiditis ; but there were 14 cases of acute meningitis secondary to other conditions 
— pneumonia, 10; to pericarditis, 2; to empyema, 1; to diphtheria, 1. During the 
period mentioned there were 11 mastoid operations performed in the hospital, with 6 
recoveries and 5 deaths, all from causes directly connected with the operation. 

If mastoiditis follows otitis, complicating the acute infectious diseases of early 
childhood as often as has been claimed, we must admit that a very large proportion 
of the patients may get well without operation. 



SECTION IX. 
THE SPECIFIC INFECTIOUS DISEASES. 

Accurate classification of the infectious diseases is at the present 
time impossible, but there are two quite distinct groups into which, with 
one or two exceptions, those here considered may be placed. 

The first group includes scarlet fever, measles, rubella, varicella, and 
pertussis. The nature of the specific poison in each of these is as yet 
unknown. They are, strictly speaking, contagious; for it is practically 
certain that any of them may be contracted by proximity to a person 
suffering from the disease, without actual contact. In no one of these 
diseases is the poison given off in a single definite discharge, and in no 
one is there a characteristic visceral lesion. Mumps resembles the mem- 
bers of this group in all points except the one last mentioned. These 
peculiarities, together with the fact that thus far the poison of each of 
these diseases has resisted all attempts at isolation, render it not improb- 
able that these poisons are some other variety of micro-organisms than 
bacteria. 

In the second group may be placed diphtheria, typhoid fever, and 
tuberculosis, in each of which the specific poison is a known form of bac- 
terium. Each of these diseases is associated with definite and character- 
istic visceral lesions. The poison is discharged from the body in a certain 
well-understood manner from the tissues which are affected by the dis- 
ease, and in no other way. These diseases can not be contracted by prox- 
imity to a diseased person, but only by receiving into the body the specific 
germs, either by contact with a person suffering from the disease or con- 
tact with something upon which the special germs of the disease have 
been discharged. In other words, though communicable, they are not, 
strictly speaking, contagious. 

Syphilis, influenza, and malaria have not been included in either of 
the above groups. Syphilis must still be placed in the doubtful class, 
although its general characteristics ally it with the second group. In its 
communicability, influenza resembles the first group, although there is 
now little doubt that it is due to a form of bacterium — Pfeiffer's bacil- 
lus. Malaria belongs in a class by itself, differing in nearly all its essen- 
tial features from the other diseases of this general group, as its specific 
cause is a form of protozoon. 

952 



SCARLET FEVER. 953 

CHAPTER I. 
SCARLET FEVER. 
Synonym : Scarlatina. 

Scaklet fevek is an acute, contagious, self-limited disease, one 
attack usually protecting the individual through life. The period of in- 
cubation is usually from two to six days ; that of invasion, from twelve 
to twenty-four hours; that of eruption, from four to six days; that of 
desquamation, from three to six weeks. The disease may be communi- 
cated at any time from the first symptom of invasion throughout des- 
quamation, and sometimes even during the existence of purulent dis- 
charges from the nose or other mucous membranes. It is usually ushered 
in by vomiting, high fever, and sore throat, and is characterized by an 
erythematous rash appearing first upon the neck and spreading rapidly 
over the entire body. Its chief complications are otitis and membranous 
inflammations of the pharynx, which frequently extend to the nose, more 
rarely to the larynx. The most important sequelae are otitis and ne- 
phritis. 

Etiology. — Analogy leads to the belief that scarlet fever is due to a 
micro-organism, but as yet its nature has not been discovered. The 
complications are usually associated with the development of a streptococ- 
cus. Some have gone so far as to claim that this germ is the cause of the 
disease. From present knowledge, however, it appears rather to play 
the role of a secondary or accompanying infection, for the development 
of which the mucous membranes of a person suffering from scarlet fever 
seem to afford most favourable conditions. To the streptococcus may be 
ascribed the membranous inflammations of the tonsils and pharynx, the 
otitis, the inflammation of the lymph nodes and the cellular tissue of 
the neck, and probably also the nephritis, endocarditis, pneumonia, and 
joint lesions. In many of the above conditions the streptococcus is as- 
sociated with other pyogenic germs, and in some cases with the diph- 
theria bacillus. 

Predisposition. — The susceptibility of children to the scarlatinal 
poison is much less than to that of measles ; still, it is much greater than 
that of adults. Billington (New York) records observations made in 
twenty-six families living in tenements where little or no attempt at 
isolation was made. In these families there occurred 43 cases of scarlet 
fever; but 47 other children, although unprotected by previous attacks 
and constantly exposed, did not contract the disease. 

Johannessen reports that of 185 children under fifteen years who 
were exposed, 28 per cent contracted the disease; while of 314 adults, 
only 5 per cent contracted the disease. It may be stated that, approxi- 



954 THE SPECIFIC INFECTIOUS DISEASES. 

mately, not more than one half of the children exposed take the disease. 
The susceptibility is not great in early infancy, but it increases until 
about the fifth year, after which it steadily diminishes. Both sexes are 
equally liable to scarlet fever. Epidemics are more frequent in the fall 
and winter than in summer, and cases occurring in the cold months are 
apt to be more severe. Whitelegge, in 6,000 cases, found the highest 
mortality in the month of October ; and in Caiger's report of 1,008 cases 
this was also the month showing the greatest mortality. 

Incubation. — Of 113 cases * in which the period of incubation could 
be accurately determined, it was as follows : 

24 hours or less 6 cases, 

2 days 

3 " 



15 


u 


9 


28 


it 


11 


25 


u 


14 


6 


u 


21 


15 


ii 




8 


a 





days , 2 cases. 

5 " 

, 1 case. 

1 " 

1 " 



113 



Thus in 87 per cent of these it was between two and six days, and 
in 66 per cent between two and four days. The incubation is rarely 
over a week ; it is particularly short in surgical cases, a well-authenticated 
instance being on record in which it was but six hours. Speaking gener- 
ally, if, after exposure, a week passes without symptoms, the chances of 
infection are very small. A short incubation is more frequently seen in 
severe than in mild cases. 

Mode of infection. — The chief source of infection is the patient him- 
self. It is somewhat doubtful whether the poison of scarlet fever can 
be conveyed by the breath, but it may be by discharges from the mucous 
membranes involved, from the scales during desquamation, and prob- 
ably from all the excretions of the patient — urine, faeces, and perspira- 
tion. Infection often takes place from the carpets or furniture of the 
sick-room, and from the clothing of the patient. In a city the bed- 
clothing, while airing in the window, has been known to convey the dis- 
ease to an adjoining house. Instances are recorded of the spread of scar- 
let fever by the washing of infected with other clothing. Toys or books 
may be carriers of the disease. A bouquet of flowers sent from a sick- 
room to an institution, in one instance proved a vehicle of infection. 
Cats, dogs, and other domestic animals are known to have conveyed the 
disease. Scarlet fever is sometimes spread by food, particularly by milk 
(page 141). It is possible, under these circumstances, that a disease 
resembling scarlatina existed in the cows; but that this was identical 
with scarlatina, as seen in man, was not demonstrated. 

* Part of these are from personal observation, but the great majority are isolated 
cases scattered through medical literature, occurring under circumstances which made 
it possible to determine the exact length of the incubation. 






SCARLET FEVER. 955 

The transmission of the disease through a third person is not fre- 
quent, but numerous instances of it are on record. The persons most 
likely to carry it are the nurse and the physician. Physicians have in 
many cases carried scarlatina to their own children, but only when there 
had been pretty direct contact with the patient, and where the interval 
before seeing the second child was short. The clothing of the nurse 
may be almost as infectious as that of the patient. The transmission of 
the disease by one who, although living in the house, does not come in 
contact with the patient is extremely improbable. An instance is re- 
corded in Allbutt (ii, 129) where scarlatina was transmitted through 
two healthy persons. 

Duration of the infective period. — There is no evidence to show that 
the disease is communicable during the period of incubation. It is 
slightly contagious from the beginning of invasion, before the rash 
appears. Infection appears to be most active at the height of the 
febrile period — from the third to the fifth day — and, next to this, dur- 
ing the stage of active desquamation. 

In simple cases, the average duration of the contagious period may 
be placed at six weeks, or until desquamation is complete. However, 
physicians generally have been accustomed to place too much stress upon 
the danger from the scales, and too little upon that from the discharges 
from the mucous membranes. Early infection comes chiefly from the 
throat, nose, or possibly the breath. Late infection may arise from a 
purulent otitis, rhinitis, chronic pharyngitis, suppurating glands, 
eczema, empyema, and possibly also from the urine in nephritis. The 
infectious nature of these purulent discharges has not been sufficiently 
recognised. It is possible for them to convey the disease during a period 
of several months. One case is recorded in which scarlatina was com- 
municated through a purulent nasal discharge after eleven weeks; an- 
other in which the opening of a post-scarlatinal empyema in a surgical 
ward was followed by an outbreak of scarlet fever. 

In winter especially, a chronic pharyngeal catarrh may long contain 
the germs of infection. Ashby found, on careful investigation, that from 
two to four per cent of patients discharged from a scarlet-fever hospital 
subsequently conveyed the disease. There is particular danger from a 
child who has recently had the disease sleeping with other children. 
Line records a case in which this was the means of conveying the disease 
after fourteen weeks, and when the patient had been considered per- 
fectly well for three weeks. It is impossible to say that at any specified 
time absolute safety exists. All patients before being discharged from 
a hospital or released from quarantine in private practice, should be care- 
fully examined as to the condition of the mucous membranes, and quar- 
antine continued as long as catarrhal inflammations are present. The 
poison of scarlatina clings more tenaciously to clothing, upholstery, and 






956 THE SPECIFIC INFECTIOUS DISEASES. 

apartments than that of any other contagious disease, possibly except* 
ing tuberculosis. Authentic cases are on record in which more than a 
year had elapsed between the first and second cases, where the source of 
infection seemed certain. 

Lesions. — The only characteristic lesions of scarlatina are those of 
the skin and the mucous membranes of the mouth and throat. The skin 
is the seat of an acute dermatitis of variable depth and intensity. There 
is first acute hyperemia, followed by an exudation of serum and cells in 
the corium, especially about the blood-vessels and hair follicles. There 
results a death of the epidermis which is thrown off in the desquamation. 
The mucous membrane of the mouth, tongue, and throat is the seat of 
a catarrhal, membranous, or gangrenous inflammation which rarely in- 
vades the larynx, but very frequently the middle ear and nose. The entire 
oesophagus is often the seat of an intense congestion. From the ear the 
infection may extend to the mastoid cells, the meninges, or the brain, 
and from the nose to the accessory sinuses, particularly the antrum of 
Highmore. All the lymph nodes about the neck may be involved, the in- 
fection ending in cell-hyperplasia, suppuration, or necrosis. The cel- 
lular tissue of this neighbourhood may also become infiltrated, this being 
followed sometimes by suppuration and occasionally by gangrene. 

The most constant change throughout the body, according to Pearce 
(Albany), is hyperplasia of the .lymphoid tissue, which is seen every- 
where. The other lesions are degenerations due to the scarlatinal poison 
alone, or in conjunction with the various forms of secondary infection, 
or to the latter alone. The most important are : fatty degeneration of 
the heart; areas of focal necrosis in the liver; acute degeneration of 
the kidney or acute diffuse nephritis; proliferation of the cells of the 
Malpighian bodies of the spleen; broncho-pneumonia, gangrene, or ab- 
scess of the lung; pleurisy, which is often purulent; endocarditis, peri- 
carditis ; abscesses in the cellular tissue and inflammation of the joints. 
These visceral changes will be considered more fully under Complica- 
tions. 

Symptoms. — Invasion. — As a rule, the invasion of scarlet fever is ab- 
rupt, the symptoms at the onset usually being directly in proportion to 
the severity of the attack. In the majority of cases there is vomiting, 
a rapid rise in temperature, and soreness of the throat. Often the vomit- 
ing is repeated ; it is frequently forcible, and without nausea. In severe 
cases the rise in temperature is very rapid, to 104° or 105° F. ; in the 
mildest cases it may not be above 101°. A child may complain of sore- 
ness of throat, or the throat symptoms may be entirely objective. In 
most severe cases, there is a uniform erythematous blush covering the 
pharynx, tonsils, and fauces, but on the hard palate there are minute 
red points. The appearance of this is usually coincident with the rise 
in temperature. Occasionally membranous patches may be seen upon the 



SCARLET FEVER. 957 

tonsils the first day, but not generally before the third or fourth day. In 
mild cases the throat shows only a very moderate congestion. Severe 
cases are sometimes ushered in by convulsions, especially in very young 
children. Diarrhoea is not uncommon in summer. There is general 
prostration, which is directly proportionate to the height of the fever. 

Eruption. — This usually appears from twelve to thirty-six hours after 
the first symptoms of invasion ; exceptionally, not until the third or even 
the fifth day. A later appearance than this is somewhat doubtful, for 
the rash not infrequently recedes and reappears, having been overlooked 
in the first instance. In 108 cases observed in the New York Infant 
Asylum, the duration of the rash was as follows : 

Two days or less 5 cases. 

Three to seven days 81 " 

Eight to eleven days 16 " 

Over eleven days 4 " 

Recurring 2 " 

These statistics are confirmed by the observations of most writers, 
that the rash lasts from three to seven days. The full development of 
the rash is generally seen in from twelve to twenty-four hours from its 
first appearance, and not infrequently the whole body is covered in the 
course of four or five hours. Very rarely its extension is so slow that 
it is two or three days before the body is covered. Its first appearance 
is almost invariably upon the neck and chest. In the cases of moderate 
severity the typical rash is seen. Its colour is red rather than scarlet, and 
on close inspection it is seen to be made up of very minute points upon 
a reddish ground, giving the appearance of a uniform blush. The rash 
covers the entire body, including the face. There is often a peculiar 
pallor about the mouth, which is quite characteristic of the disease. 

Variations in the eruption are very frequent, and often extremely 
puzzling. In the mild cases the rash is not seen upon the face ; it is often 
faint upon the body, and may be present only upon certain parts ; when 
the rash is faint or scanty it is usually most marked in the groins and 
axillae, or over the buttocks and back of the thighs; it may last only one 
day, and sometimes may be so slight as to escape notice altogether. It 
may be absent in some very mild cases, in certain others where the throat 
symptoms are severe, and in malignant cases. In the very severe cases 
many irregularities are seen, both as to the time of the appearance of 
the eruption and its character. Sometimes it occurs as large, irregular 
patches; again, it is macular, closely resembling the rash of measles; 
occasionally it is of a dark purplish colour ; and very rarely it is hemor- 
rhagic. Not infrequently an eruption of fine vesicles is seen, especially 
on the chest and abdomen; this may be so pronounced as to make the 
diagnosis difficult. It is seen both in mild and severe cases. Much 
importance is attached by the laity to the early disappearance of the 
62 



958 THE SPECIFIC INFECTIOUS DISEASES. 

rash, an especial danger being believed to exist because the disease has 
" struck in." A well-developed bright rash indicates strong heart action, 
and a sudden recession of the rash is a sign of heart failure. Often a 
rash which is faint and doubtful in character, may be brought out fully 
by a hot bath. 

With the eruption at its height, there is intense itching or burning 
of the skin, and in severe cases considerable swelling, chiefly noticeable 
upon the hands and face. 

Desquamation. — Shortly after the rash has faded, about the eighth 
day, there begins an exfoliation of the dead epidermis, known as des- 
quamation. This is even more characteristic of the disease than the 
rash. It is usually first seen upon the neck and chest, where it appears 
as fine flakes. The desquamation of the trunk is completed in from 
one to three weeks. If baths and inunctions are being used, it is scarcely 
perceptible. It continues longest where the epidermis is thickest — viz., 
upon the hands and feet — and here it lasts from four to seven weeks, and 
not infrequently eight weeks. The appearance of the fingers and toes 
during desquamation is characteristic. The finger tips usually peel first, 
and the new epidermis is pink and fresh-looking, while that which has 
not yet separated is of dull gray colour and loosened at the margin. Oc- 
casionally the epidermis of a considerable part of a finger may be loos- 
ened at once, so that a partial cast may be thrown off like the finger of 
a glove. Sometimes the patient comes under observation for the first 
time during desquamation, the history of the early symptoms being 
doubtful or absent. Such desquamation as has been described, occurring 
both upon the hands and feet, may be regarded as conclusive evidence of 
scarlet fever, no matter what the history may be. 

1. The mild cases. — The symptoms may be so slight as to be entirely 
overlooked, nothing being noticed until desquamation occurs. Usually, 
however, there is a rather abrupt invasion, with vomiting and a tempera- 
ture from 100° to 103° F. The tonsils and pharynx are congested, while 
the palate shows a punctate redness somewhat like the cutaneous erup- 
tion. The papilla? of the tip and borders of the tongue are enlarged. 
Nearly always within twenty-four hours the rash makes its appearance, 
generally first upon the neck and chest. Very often it is not seen upon 
the face, but is abundant on the rest of the body. The rash fades on 
the third or fourth day, and has disappeared by the fifth day. There is 
very little prostration, the child often being with difficulty kept in bed. 

The highest temperature is coincident with the full eruption, and 
is usually seen during the first thirty-six hours of the disease. It grad- 
ually falls to normal by the third or fourth day. Some examples are 
shown in Fig. 189. In the mildest cases the temperature may never be 
above 100° F. 

Desquamation is often faint over the body, but is unmistakable over 



SCARLET FEVER. 



959 



the hands and feet. It begins about the end of the first week, always 
being most marked where the eruption has been most intense. 

The mild cases are usually uncomplicated, but the possibility of otitis 
and of late nephritis should always be kept in mind, as these may occur 
even with the mildest attacks. The difficulties in diagnosis in mild 
attacks of scarlet fever are often great. It should be remembered that 
these cases are just as contagious as severe ones, and that from a mild 



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Fig. 189. — Mild scarlet fever. 



Ill 



Three cases occurring successively in the same family. Diagnosis not made until the 
third case developed, at which time the first one was found to be desquamating in a typical 



attack a severe one is often contracted. It is frequently by these mild 
cases that this disease is spread in schools. In dispensaries I have often 
seen patients desquamating from scarlet fever, who had been attending 
school regularly up to the time when they were brought for treatment 
for nephritis or some other disease. 

2. Cases of moderate severity. — The onset is sudden with vomiting, 
which is usually repeated, rarely with convulsions. The temperature 
rises rapidly, and by the end of the first twenty-four hours has reached 
104° or 105° F. The rash usually appears within the first twenty-four 
hours, and its intensity is directly proportionate to the severity of the 
attack. Appearing first upon the neck or chest, it extends rapidly, cov- 
ering the entire trunk and extremities, often in a few hours. It is usu- 
ally typical in appearance, being made up of minute points, but giving 
the appearance of a uniform blush, which has been compared to a boiled 
lobster. Little change takes place in the rash for four or five days. 
After this it fades quite rapidly, and disappears by the sixth or 
seventh day. 

The throat resembles that of the mild form, except that the redness is 
more intense and there is slight swelling of the tonsils, fauces, and uvula, 
and often pain upon swallowing. Occasionally small yellowish patches 
are seen upon the tonsils by the second or third day, but these can be wiped 



960 



THE SPECIFIC INFECTIOUS DISEASES. 



off and are not distinctly membranous. There is usually a moderate 
discharge of a sero-purulent character from the nose. The lymph glands 
at the angle of the jaw are swollen and quite tender. The tongue 
may be coated in the centre and show bright red points at its borders 
and tip, or it may be quite red and show the prominent papillae every- 
where^ — the " strawberry tongue"; while not exclusively seen in scar- 
latina this is of some diagnostic value and may continue several days 
or even weeks. 

During the height of the fever there is restlessness, thirst, and not 
infrequently slight delirium. The temperature reaches the maximum by 
the second or third day, and usually falls gradually after the fourth or 



nour. 




X 


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101° 
100° 


































































































































































































































































































































































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Fig. 190. — Typical temperature curve of uncomplicated scarlet fever of moderate severity; 

girl three years old. 



fifth day, but even in uncomplicated cases the fever often lasts from ten 
to fourteen days (Fig. 190). The pulse in the early part of the disease 
is rapid and full, but later it may be weak. There is much prostration, 
frequently followed by quite a marked degree of anaemia. 

This form of the disease rarely proves fatal apart from complications, 
but it may do so in very young infants. The complications seen most 
frequently in this form of scarlet fever are broncho-pneumonia or pleuro- 
pneumonia and otitis, the latter being usually double and occurring be- 
tween the sixth and the fourteenth days. Nephritis is the only common 
sequel. 

3. The severe cases. — The severe type of scarlet fever usually declares 
itself from the beginning. The incubation is short, and the full rash may 
be seen within a few hours after the initial symptoms. It usually covers 
the entire body, even including the face. The severity of the infection is 
shown by the fact that the temperature is higher and continues for a longer 
period, and by the frequency and severity of the complications, particularly 
those of the throat. For the first two days the throat may present nothing 
different from what is seen in the milder cases. By the third or fourth 
day, however, membranous patches often appear on the tonsils, and spread 
to the soft palate, uvula, and pharynx, sometimes to the nose and through 



SCARLET FEVER. 



961 



the Eustachian tube to the ear, rarely involving the larynx. The mucous 
membrane of the mouth is intensely congested, and often partly covered 
by membrane; there are sordes on the lips and teeth, and there may be 
superficial ulcers, which bleed readily. The glands of the neck swell 
rapidly, often to a great size, and the cellular tissue about them is infil- 
trated. The head is thrown back to relieve the dyspnoea which the pres- 
sure from this swelling occasions. There is an abundant discharge from 
the nose and mouth; the breath is offensive, often fetid. The general 
symptoms are those of a severe septicaemia. The temperature is steadily 
high, usually between 103° and 105° F., for about a week, after which in 
cases ending in recovery it slowly falls unless complications develop 
(Figs. 191, 193, 194). But even in uncomplicated cases the fever some- 
times continues for three weeks. In fatal cases the temperature may be 
steadily high till death (Fig. 192), or it may fluctuate widely. The 
pulse is rapid, weak and irregular. There is complete anorexia; both 
food and stimulants have to be coaxed or forced down. There is low 
delirium or apathy, and sometimes all the symptoms of the typhoid 
condition are present. 

Signs of a broncho-pneumonia are often found in the chest, and by 
the end of the first week or early in the second the ears may begin to dis- 



par 

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Fig. 191. — Typical temperature curve of severe scarlet fever ending in recovery. 

Prolonged course due to severe throat symptoms lasting from second to sixth day, other- 
wise uncomplicated ; boy twelve years old. 

charge. The urine is rarely free from albumin, but the amount present is 
not usually great; there may be hyaline and epithelial casts, and some- 
times blood. In some cases the throat symptoms predominate ; in others, 
those of general sepsis, but more frequently the two are combined and are 
directly proportionate to each other. In still other cases, instead of the 
membranous inflammation, it may be of a gangrenous character, and ex- 
tensive sloughing may take place in the throat, and even in the cellular 
tissue of the neck. 

The duration of the symptoms in fatal cases is from six to fourteen 
days. There is general increasing prostration and finally a septic stupor, 



962 



THE SPECIFIC INFECTIOUS DISEASES. 



with death from exhaustion, from heart failure, or from some compli- 
cation — broncho-pneumonia, pleurisy, nephritis, haemorrhages follow- 
ing sloughing, laryngitis, pericarditis, or endocarditis. In cases which 



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' Fig. 192.— -Severe scarlet fever, septic type ; death on fourteenth day. 

Intense angina; otitis; nephritis; necrotic inflammation of cervical lymph glands* girl 
seven years old ; death from heart failure. 

recover, the acute symptoms nearly always continue for a full month; 
and after escaping the dangers of sepsis and the early complications, the 
child has still to run the gauntlet of all the late complications — nephritis, 
pneumonia, endocarditis, pyaemia, etc. A case may prove fatal as late 
as the end of the seventh week; nearly all such results are due to nephritis 
or to its complications. 

4. Malignant or cerebral cases. — These are rare cases which are more 
frequently described than seen, in which death takes place usually within 
the first forty-eight hours. The system is overpowered by the scarlatinal 
poison. Such cases are seldom seen except in severe epidemics. Under 
other circumstances, many cases are diagnosticated malignant scarlet 
fever which have no connection with this disease. 

The onset is sudden and 1 violent, usually with convulsions, the child 
passing in a few hours into a condition of deep stupor, with great prostra- 
tion and hyperpyrexia, the temperature ranging from 105° to 107° F. 
Sometimes, however, the temperature does not go above 100° F. The 
rash appears irregularly, late, or not at all. It may be haemorrhagic. 
There are frequently repeated convulsions, cyanosis, and invariably a 
fatal termination. The autopsy often gives no satisfactory explanation 
of these cases. Death occurs apparently from scarlatinal toxaemia, with- 
out any characteristic local evidences of disease. 

5. Surgical scarlet fever. — The existence of a special form of scarlet 
fever occurring in patients with recent wounds or those who have been 
subjected to surgical operations, while stoutly maintained by several 






SCARLET FEVER. 963 

writers, has been vigorously denied by others. The question is one dif- 
ficult of solution on account of the close similarity at times existing be- 
tween the symptoms of scarlet fever and sepsis, and the necessity of 
deciding in an undoubted case whether the infection with scarlet fever 
was dependent upon or coincident with the wound. 

Hamilton * has recently studied the question anew and analysed cases, 
some 174 in number, that have been reported more or less in detail, with 
the following conclusions : That proof of the existence of a special form 
of scarlet fever rests upon the reports of cases usually meagre, and 
careful analysis of these would lead one to consider them rather as septic 
than as scarlatinal infections; that when there was undoubted evidence 
of scarlet fever, there was no proof that it was in any way due to the coin- 
cident wound, and that there is as yet no convincing proof in the litera- 
ture that surgical scarlet fever is anything more than scarlet fever in the 
wounded. 

Relapses, Recurrences, and Second Attacks. — As a rule, one attack of 
scarlatina gives immunity through life. The exceptions are very few, but 
some of them are well authenticated. Kinnicutt (Xew York) observed 
two attacks within eight months in a boy of five years; Pritchard (Glas- 
gow) reports the case of a patient who had three attacks in the same hos- 
pital within two years; such cases are certainly extremely rare. I have 
never yet seen an undoubted instance of a second attack in the same 
individual. 

Relapses or recurrences within a brief period after the first attack are 
more frequent. There are to be excluded the cases of pseudo-relapses in 
which the rash, having temporarily subsided for two or three days, reap- 
pears; also those where the rash varies in intensity from time to time; 
and, lastly, the cases in which, occurring late in the disease, it is due to 
septicaemia or pyaemia. True relapses are usually due to auto-infection, 
sometimes to a new accession of poison from without. They are analo- 
gous to the relapses of typhoid fever. They occur most frequently during 
desquamation, between the seventh and twenty-fourth days. There may 
be not only a new eruption but a rise of temperature, sore throat, and 
vomiting, just as in the initial attack. These recurrences are sometimes 
shorter and milder than the first attack, but this is by no means uniform, 
since Korner mentions eight cases where the second attack proved fatal. 

In considering the subject of second attacks, the liability to errors in 
diagnosis must be borne in mind and only cases included which have pre- 
sented typical symptoms. 

Special Symptoms, Complications, and Sequelae. — Temperature. — 
The temperature curve <>[' thi> disease is quite characteristic. There 
is usually seen an abrupt rise, the maximum being reached on the sec- 

* American Journal of the Medical Sciences, July, 1904. 



964 THE SPECIFIC INFECTIOUS DISEASES. 

ond day; there follows a period of variable duration, generally lasting, 
according to the severity of the case, from two to five days, in which the 
fluctuations are very narrow; then a gradual decline to normal, which 
is reached in the milder cases in about a week ; in those which are more 
severe, in about two weeks. This typical curve (Figs. 190 and 191) is 
seen in the great proportion of uncomplicated cases which end in recov- 
ery. Deviations from it, therefore, are important as indicating that 
some complication exists. The explanation is usually to be found in the 
development of otitis, nephritis, pneumonia, etc. Severe throat symp- 
toms prolong the temperature but do not usually modify its course. In 
very severe cases ending fatally the high temperature is prolonged. In 
any case a rise after the fifth day is unfavourable. 

Throat. — Three distinct forms of angina are seen in scarlatina : sim- 
ple or erythematous, membranous, and gangrenous. 

1. Erythematous angina. — This can hardly be ranked as a complica- 
tion, as it is nearly as constant as the scarlatinal rash. Usually there is 
only the general blush over the entire pharynx with the fine red points 
upon the hard palate; but there may be seen upon the tonsils grayish- 
yellow spots resembling those of follicular tonsillitis, which can be wiped 
off, leaving a clean surface. This simple angina is at its height with the 
maximum temperature, and fades as the temperature falls. It does not 
often extend to adjacent mucous membranes. 

2. Membranous angina. — These cases were formerly classed as scarla- 
tinal diphtheria, and whether this process was identical with primary 
diphtheria or not, was for a long time a subject of much discussion. Cul- 
tures have shown that the great majority of these inflammations are not 
true diphtheria, but are due to the streptococcus. 

The lesions of this form of angina are considered in the chapter on 
Pseudo-Diphtheria. Usually on the second or third day of the disease 
an exudation appears upon the tonsils, and in the milder cases it covers 
only the tonsils. In the most severe form it may be seen within twenty- 
four hours of the onset, sometimes before the eruption appears. Be- 
ginning upon the tonsils, the membrane rapidly spreads to the entire 
pharynx, the mucous membrane of the nose, the mouth, the Eustachian 
tube, and even to the middle ear. In colour it may be gray, greenish, or 
almost black. There is so much swelling of the throat that swallowing 
becomes difficult. The infiltration of the cellular tissue of the neck and 
the enlarged lymph glands produce great external swelling, which may 
extend like a collar from ear to ear. The breath has a foul odour, the 
nasal discharge is thin and fetid, and nasal respiration is obstructed, so 
that the mouth is open constantly. It is surprising that the larynx is so 
seldom invaded. 

These local changes are accompanied by constitutional symptoms of 
great severity, which are due to a general streptococcus septicaemia; 



SCARLET FEVER. 965 

broncho-pneumonia and nephritis are very frequent, otitis is almost con- 
stant, and suppuration of the lymphatic glands is not uncommon. The 
eruption is often irregular and late in appearing. 

The frequency with which diphtheria coexists with scarlatina depends 
much upon circumstances. In some epidemics, thirty per cent of the 
throats showing membrane have contained the diphtheria bacillus; in 
others the proportion is much smaller. There are some clinical features 
by which the two types may sometimes be distinguished. The streptococ- 
cus angina is usually seen at the height of the disease; true diphtheria 
may occur at any time, even during convalescence. The streptococcus 
angina is characterized by much swelling, redness, and oedema of tonsils 
and fauces, and by great external infiltration, showing a marked tendency 
to invade the ears, but very little to invade the larynx. In true diphtheria 
the evidences of inflammation are usually much less, while there is a 
great tendency to invasion of the larynx. Very little reliance is to be 
placed upon the appearance of the membrane. The only positive means 
of differentiation is by cultures, which should invariably be made from 
the throat of every patient admitted to a scarlet-fever hospital, and of 
every case in private practice showing any exudate upon the tonsils. If 
the first culture is negative and the throat symptoms increase, repeated 
cultures should be made. 

3. Gangrenous angina. — This is seen only in the worst cases of scarlet 
fever. The process may be gangrenous from the outset, or preceded by a 
membranous inflammation. It is sometimes insidious in its develop- 
ment. There is a fetid odour to the breath, an irritating discharge from 
the nose and mouth, with very great glandular swelling. The tonsils are 
gray or grayish-black in colour, and large masses of necrotic tissue may be 
removed with the forceps from the tonsils, uvula, fauces, or pharynx, and 
sometimes sloughing occurs in the cellular tissue of the neck. Blood- 
vessels of considerable size are sometimes opened, and serious or even fatal 
haemorrhage may result. Little or no tendency to a reparative process is 
seen. The constitutional symptoms are those of great asthenia, prostra- 
tion, and profound cachexia, followed almost invariably by a fatal ter- 
mination. 

Lymph nodes. — These are swollen in all cases accompanied by severe 
angina. The inflammation may be simply an acute hyperplasia, or it may 
go on to suppuration or necrosis. Abscess does not often occur at the 
height of the disease, but may come at any time during convalescence. It 
may be confined to the glands or be complicated by suppuration in the 
cellular tissue of the neck. Disease of these glands is not an infrequent 
cause of torticollis. 

Cellulitis of the neck. — This usually occurs toward the end of the first 
week, and is associated with grave throat symptoms. Rapid and exten- 
sive infiltration occurs, the skin becomes tense and brawny, the head is 



THE SPECIFIC INFECTIOUS DISEASES. 



held back, and there may be considerable dyspnoea. The infiltration may 
be only in the neighbourhood of the lymph glands or it may be diffuse. 
Unless relieved by early incision, the diffuse form may result in suppura- 
tion and extensive sloughing, which may be deep enough to lay bare the 
large vessels of the neck. This is a complication of the gravest pos- 
sible import. Death may occur from septicaemia before or after slough- 
ing or from haemorrhage due to opening by ulceration of the external 
carotid or some of its branches; or there may be associated thrombosis 
of the jugular vein, leading to thrombosis of the lateral sinus, menin- 
gitis, or pyaemia. 

Ears. — The otitis is due to direct extension of the infection from 
the rhino-pharynx. It is the most frequent complication of scarlatina, 



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Fig. 193. — Severe scarlet fever; otitis; mastoiditis; death. 

Typical symptoms and temperature curve until fourteenth day ; secondary rise of tem- 
perature from otitis ; double paracentesis on the fifteenth day ; mastoid operation on the six- 
teenth day ; death twelve hours later from septicaemia ; boy five years old. 

and in doubtful cases may have some diagnostic importance. As a rule, 
the younger the child the greater the liability to otitis. It is more fre- 
quent in winter than at other seasons, and is closely connected with the 
severity of the throat symptoms. In an epidemic occurring in the New 
York Infant Asylum in the spring and summer of 1889 there were 73 
cases of scarlatina and not one of otitis. In a fall and winter epi- 
demic in the same institution two years later, of 43 cases 20 per cent 
had otitis. Of 4,397 cases reported by Finlayson, otitis occurred in 
10 per cent, and of 1,008 cases reported by Caiger, in 13 per cent. In 
Burkhardt's statistics the proportion was as high as 33 per cent. Of 
cases accompanied by severe throat symptoms otitis is present in fully 
75 per cent. 

As a rule, both ears are affected. Otitis is most frequent early in the 
second week, but may occur at any time, even during convalescence. In 
the cases where it develops at the height of the disease there are in some 



SCARLET FEVER. 



967 



cases no new symptoms ; in others there is pain and deafness and a rise 
in the temperature, which may fall after paracentesis or rupture of the 
drum membrane, or there may be rapid extension to the mastoid (Fig. 
193). The otitis is often overlooked unless the ears are regularly ex- 
amined. The form of inflammation may be catarrhal or phlegmonous, 
the latter being often accompanied by necrotic changes. 

Bezold makes the following report upon 185 cases showing the results 
of scarlatinal otitis : "In 30 there was entire destruction of the mem- 
brana tympani, with loss of one or more bones ; in 59 the perforation com- 
prised two thirds or more of the membrane; in 13 there were smaller per- 
forations; in 44 there were granulations or polypi; in 15 there was total 
loss of hearing on one side, and in 6 of the cases upon both sides; in 77 
of the cases the hearing distance for low voice was less than twenty 
inches." 

As a cause of permanent deafness and deaf-mutism, no disease of 
childhood compares in importance with scarlet fever. May (New York) 
has collected statistics of 5,613 deaf-mutes, of whom 572 owed their con- 
dition to otitis following scarlet fever. 

Kidneys. — Albuminuria accompanies nearly all the severe cases of 
scarlet fever. In many this is simply the ordinary febrile albuminuria 
due to acute degeneration of the kidneys. In those with severe throat 
complications, and in nearly all the septic cases, there is often an acute 
diffuse nephritis with interstitial changes especially marked. This 
occurs at the height of the febrile process and is rarely accompanied 
by dropsy; but albumin, casts, and even blood may be found in the 
urine. The most severe and the most characteristic renal complication, 




Fig. 194. — Scarlet fever of moderate severity followed by fatal nephritis. 

Early symptoms typical and uncomplicated; twenty-first day vomiting; twenty-fifth day 
ursemic convulsions; death twenty-sixth day. No dropsy; urine never below 10 ounces in 
twenty-four hours ; girl ten years old. 



and that generally designated as post-scarlatinal nephritis, is a diffuse 
nephritis, with changes in the glomeruli as the most striking feature. 
It usually develops during the third or fourth week of the disease, and 
may follow mild as well as severe cases (Fig. 194). It is very often 



968 THE SPECIFIC INFECTIOUS DISEASES. 

accompanied by general dropsy ; the urine is scanty and not infrequently 
suppressed, and it contains a large amount of albumin, blood, and great 
numbers of casts of all varieties. It may cause death by the occurrence 
of acute uraemia, or it may be followed by permanent damage to the kid- 
neys. It is more fully described with the Diseases of the Kidney. 
, Joints. — Acute articular rheumatism may occur coincidently with the 
development of the scarlatinal rash, and occasionally during convales- 
cence in patients who have a predisposition to that disease. Acute swell- 
ing of the joints is sometimes of pyaamic origin. A case is reported by 
Henoch in which this was due to an infectious thrombus in the jugular 
vein, associated with cellulitis of the neck. In pyaamic arthritis the large 
joints are usually involved and the lesions are apt to be multiple. Joint 
disease may occur as a sequel of scarlet fever, where it is secondary to 
disease of the bone or to periarticular abscesses opening into the joint. 

The foregoing include but a small proportion of the joint complica- 
tions seen in scarlet fever. The most frequent and most characteristic 
form of inflammation is scarlatinal synovitis, often improperly called 
scarlatinal rheumatism. It occurs in different epidemics with varying 
frequency. Car slaw (Glasgow) in 533 cases of scarlet fever met with 
synovitis in 60 patients. It is seldom seen in children under three years 
of age, and is most frequent after five years. It may occur in mild as 
well as in severe cases. According to Ashby, it is more frequent when 
the febrile stage is prolonged owing to other complications. Synovitis 
develops quite uniformly toward the end of the first or the beginning of 
the second week. The symptoms are generally mild, and are followed by 
prompt recovery. Suppuration is rare. Any of the joints may be at- 
tacked, but those of the wrist, hand, elbow, or knee are most frequently 
affected. Demme (Berne) has reported a case in which every large joint 
in the body was involved. The symptoms are redness, moderate pain, 
swelling, which is usually due to synovial distention, and sometimes a 
slight rise in temperature. The duration is generally but three or four 
days, and in most cases there is spontaneous recovery. This disease is 
distinguished from rheumatism by several points: it is not more fre- 
quent in rheumatic patients; cardiac complications are rare as com- 
pared with those seen in patients with genuine rheumatism ; in some epi- 
demics it is very common, and in others seldom seen; there is little or 
no tendency to relapses; anti-rheumatic remedies are without striking 
benefit; it does not skip about from joint to joint, and usually fewer 
joints are involved. 

Lungs. — The pulmonary complications of scarlet fever are neither 
so frequent nor so important as those of measles. Broncho-pneumonia 
is usually found at autopsy in septic cases where death has occurred later 
than the third or fourth day, but it is not generally recognisable so early 
by physical signs. 



SCARLET FEVER. 969 

In septic cases pleuro-pneumonia sometimes occurs early in the dis- 
ease and at other times late, generally associated with nephritis, but 
occasionally without it. It is always a serious condition, and not infre- 
quently a direct cause of death. Empyema may follow pleuro-pneumonia 
or occur with pyaemia or nephritis, but with the latter, simple serous 
pleurisy is more common. (Edema of the lungs occurs chiefly with ne- 
phritis, in which it is the most common cause of death. 

Heart. — Cardiac murmurs are frequent at the height of the disease, 
but both endocarditis and pericarditis are rare. They are oftenest seen 
in septic cases, and with post-scarlatinal nephritis. Endocarditis may be 
simple or malignant, and may lead to embolism during convalescence. 
Some degenerative changes in the cardiac muscle are probably present 
in all the severe cases. Acute dilatation may result, which is sometimes 
a cause of death. 

Blood. — In all cases there is a rapidly progressing anaemia that lasts 
into convalescence. The reduction in the red cells in an average case is 
about one million. The chief interest, however, attaches to the number 
and character of the white cells. In mild cases there may be only a 
moderate increase in their number, usually to from 10,000 to 14,000. 
It is in cases of moderate severity that the characteristic changes 
are found. In these there is a decided leucocytosis which appears early, 
attains its maximum about the fourth day, and gradually declines until 
the normal is reached, which may be not until the third, fourth, or fifth 
week. The maximum is usually about 30,000 to 35,000 ; although it may 
be as high as 75,000. During the first week the polynuclear neutrophiles 
form from 90 to 95 per cent of these cells; the eosinophiles as well as 
the lymphocytes are diminished. After the fifth or sixth day, there is 
a rapid increase in the eosinophiles which attain their maximum, some- 
times 20 per cent of the total leucocytes, between the fourteenth and 
twenty-first days. After the third week they gradually diminish. Ex- 
ceptionally there is found in convalescence a relative lymphocytosis, which 
may be as high as 50 per cent. Complications, nephritis excepted, usu- 
ally show actual as well as relative increase in the polynuclear neutro- 
philes. In malignant and rapidly fatal cases there is usually a very 
small proportion of eosinophiles, and little if any leucocytosis, though 
exceptionally it may be high. 

Digestive system. — Functional disturbances are very frequent, and, in 
fact, are seen in most of the cases, but organic changes are rare. Vomit- 
ing is the mode of onset in the majority of cases, but rarely continues 
throughout the attack. Late in the disease it is a frequent symptom of 
uraemia. Diarrhoea may be associated with it under both conditions. 
The tongue is nearly always coated, and clears off in quite a characteristic 
way, which, with the prominent papillae, gives rise to the " strawberry " 
appearance. Catarrhal stomatitis is a very frequent complication, and 



970 THE SPECIFIC INFECTIOUS DISEASES. 

in many cases of severe membranous angina the same process is seen in 
the buccal cavity. 

Nervous system. — Nervous complications and sequelae are seen less 
frequently with scarlatina than with most of the infectious diseases of 
such severity. Convulsions are frequent at the outset, and generally in- 
dicate a severe attack, though not invariably so. Occurring late in the 
disease, they are usually due to uraemia, and may be a cause of death. 
Meningitis may occur as a complication of otitis, in pyaemic cases, and 
sometimes with post-scarlatinal nephritis. Paralysis from peripheral 
neuritis is rarely seen. Hemiplegia sometimes occurs from meningeal 
haemorrhage, or from embolism secondary to endocarditis and associated 
with nephritis. Chorea was noted as a sequel in only three of 533 cases 
reported by Carslaw. In a report of 187 cases of epilepsy, Wildermuth 
states that it followed scarlet fever in 12 cases. Insanity has been occa- 
sionally observed, the usual form being acute mania, with complete re- 
covery in a few weeks or months. 

Gangrene. — Cases of symmetrical gangrene after scarlet fever have 
been reported by Wilson and others. The parts generally affected are 
the buttocks, thighs, and arms, but it may occur almost anywhere. The 
pathology of these cases is obscure. The process usually begins in sev- 
eral places simultaneously, or in rapid succession, and advances steadily 
till death occurs. 

Other infectious diseases. — Diphtheria is most frequently seen, and 
may be present even when there is no distinct membrane. 

Scarlatina may also be complicated by measles, varicella, or ery- 
sipelas, and occasionally by variola or typhoid fever. The symptoms are 
often an irregular commingling of those belonging to the two diseases. 
They may begin simultaneously, or more frequently one develops as the 
other is subsiding. 

Diagnosis. — The characteristic symptoms of scarlet fever are the 
abrupt onset, usually with vomiting, the marked elevation of tempera- 
ture, the erythematous condition of the throat, the punctate eruption on 
the hard palate, and the enlarged papillae at the edges and tip of the 
tongue, with the appearance of the rash within twenty-four hours. The 
difficulties of diagnosis usually depend upon irregularities in the erup- 
tion. The variations are seen in the mildest and in the most severe cases. 
In the former the rash may be of short duration, often less than a day, 
and in consequence easily overlooked; or it may be present only upon 
certain parts of the body instead of being diffuse. In every doubtful 
case the groins, axillae, and loins' should be closely scrutinised for a punc- 
tate eruption. In very severe attacks also the rash may be uncertain. It 
may appear late or recede after being fully out, or be haemorrhagic or in 
irregular blotches instead of a uniform blush. In all cases, too much 
stress should not be placed upon the rash alone. 



SCARLET FEVER. 971 

Until we have some exact means of laboratory diagnosis as in typhoid 
fever, malaria, and diphtheria, an absolute diagnosis will in certain cases 
be impossible. Sometimes the diagnosis remains doubtful until the enfl, 
although occasionally confirmato^ evidence may be obtained even in 
convalescence. Thus, a patient may desquamate in a manner so typical 
as to leave no doubt as to the nature of the preceding illness; again, 
the occurrence of a characteristic sequel, such as nephritis in the third 
or fourth week, may testify strongly for scarlatina as the primary disease ; 
and, finally, the outbreak of undoubted cases among children who have 
been in contact with the patient is practically conclusive, always pro- 
vided other sources of infection can be excluded. Desquamation, how- 
ever, follows so many other eruptions that one should not rely upon it 
when slight or irregular as an evidence of scarlet fever, but only upon 
a typical exfoliation upon the hands and feet. It is a point of some prac- 
tical importance not to oil the skin of a patient when awaiting desqua- 
mation for diagnosis, as this alters very much the characteristic appear- 
ances. In some puzzling epidemics the length of the incubation may 
be of material assistance in the diagnosis; where this is regularly more 
than a week, one may be pretty sure that he is not dealing with scarlet 
fever. 

Scarlet fever with severe throat s} r mptoms and doubtful eruption 
can be distinguished from diphtheria only by cultures, which should be 
made early and repeated if the first result is uncertain. Measles is 
distinguished from scarlet fever by the length of the invasion, the 
catarrhal symptoms, and the slowly spreading eruption, but most of 
all by Koplik's spots. Much more difficult is it to distinguish between 
mild scarlatina and rubella. In rubella the important thing is that, 
although the rash may be well marked, often covering the body, the 
constitutional symptoms are few or entirely absent. In scarlet fever 
with an eruption of the same intensity there is almost invariably a con- 
siderable elevation of temperature, usually 102° or 103° F., and a bright 
red throat. 

There are so many skin eruptions which may resemble that of scarlet 
fever, that it is always hazardous to make the diagnosis of this disease 
from the eruption alone. This is especially true of sporadic cases occur- 
ring in infants; there is seen at this age a great variety of eruptions, 
usually associated with digestive disturbances, which closely simulate a 
scarlatinal rash; but most of them are of short duration. A scarlatini- 
form erythema is occasionally seen after diphtheria antitoxin, also in 
influenza, typhoid fever, and varicella, which may cause them to be mis-, 
taken for scarlet fever, or may lead to the conclusion that both diseases 
are present. The same is the case with the septic erythema occurring in 
surgical patients. Belladonna, quinine, and occasionally antipvrine, may 
produce eruptions more or less closely resembling that of scarlet fever. 



972 THE SPECIFIC INFECTIOUS DISEASES. 

This is also true of some cases of urticaria, and of several other forms of 
skin disease. There is little doubt that many of the cases reported as re- 
lapsing scarlatina are really examples of recurring erythema, particularly 
as some of the latter are followed by a desquamation which is very similar 
to that after scarlatina. In all doubtful conditions great importance is 
to be attached to the constitutional symptoms. 

Prognosis. — The mortality of scarlet fever varies much in different 
epidemics. In some, nearly all the cases are of a mild type, and the 
mortality may be as low as 3 or 4 per cent ; in others, a severe or malig- 
nant type prevails, and it may be as high as 40 per cent. The disease 
is, as a rule, more fatal in the youngest infants, becoming less so as age 
advances. This is well shown in two recent epidemics in the New York 
Infant Asylum. There were — 

Under one year 29 cases ; mortality, 55 per cent. 

From one to two years 37 " " 22 " 

" two " three " 28 " " 7 " 

Over three years 23 " " " 

In the first epidemic the general mortality was 12*5 per cent ; in the 
second it was 33 per cent, in the same class of children. 

The following are the mortality records from various European 

sources : 

Ashby, Manchester Hospital 681 cases ; mortality, 12*2 per cent. 

Koren, a single epidemic 426 " " 14'0 " 

Bendz, Copenhagen 22,036 " " 12*2 " 

Ollivier, three Paris hospitals for five years 893 " " 14*0 " 

Fleischmann, five epidemics 1,356 " " 10*0 " 

The general mortality of the disease may therefore be assumed to be 
from 12 to 14 per cent; it is, however, much higher than this among 
young children, as shown by the following figures : 

New York Infant Asylum.. . 116 cases under 5 years ; mortality, 20 per cent. 
Ashby, Manchester Hospital. 259 " " 5 " " 23 " 

Bendz not stated " 5 " " 13 

Heubner 136 cases " 7 " " 30 « 

Fleischmann not stated " 4 " " 43 " 

Under five years of age the average mortality from scarlet fever is, 
therefore, between 20 and 30 per cent. 

The fatal cases may be grouped in three classes : first, those due to 
late nephritis, in which the early symptoms of the disease are of mod- 
erate severity or even mild ; secondly, the septic cases, usually associated 
with severe throat symptoms and dying most frequently in the second 
week from exhaustion, or from some complication, such as diphtheria, 
pneumonia, pleurisy, meningitis, or nephritis; thirdly, the malignant 
cases, which are overpowered by the poison of the disease in the first 
two or three days of the attack. 



SCARLET FEVER. 973 

Prophylaxis. — Even the mildest cases should be isolated for four 
weeks, and all cases until desquamation is complete. If complications 
exist, such as otitis, rhinitis, pharyngitis, empyema, or suppurating 
glands, the quarantine should be continued until these conditions are 
cured. Patients should not be allowed to mingle with other children for 
at least a month after all symptoms have subsided, and should be for- 
bidden to sleep with other children for three months. Children in the 
house who have not been exposed to the disease should be immediately 
sent away ; and those who have been exposed, separately quarantined for 
at least a week. After recovery, the patient, before mingling with other 
children, should have at least two disinfectant baths, the entire body 
being scrubbed with soap and water and then washed in a solution of 
carbolic acid (1 to 50) or bichloride (1 to 5,000), and every particle of 
clothing changed. The hair and the scalp should be thoroughly washed 
and disinfected. 

The nurse should be quarantined with the patient, and should not 
mingle with other members of the family until a complete change of 
clothing has been made, and hands and face thoroughly disinfected. The 
nurse and all others in close contact with a severe case should use fre- 
quently an antiseptic gargle and a nasal spray. The room should be in 
that part of the house most easily quarantined, usually on the top floor; 
during the attack it should be stripped of upholstery, hangings, and 
carpet, and should be freely ventilated and kept as clean as possible. 
All dust should be removed with damp cloths which should afterwards 
be burned; the floor should occasionally be sprinkled with a bichloride 
solution (1 to 1,000). The presence in the room of vessels filled with 
antiseptic fluids is of little or no practical value. The same may be said 
of sheets wet in carbolic or other solutions and hung about the room. 
Carbolic-acid poisoning has been known to result from this practice. 
After an attack it should be remembered that the room is probably 
a greater source of danger than the patient. Smooth walls should be 
wiped with damp cloths wrung out of a bichloride solution (1 to 2,000). 
The wood-work should be washed in the same solution and the floor 
scrubbed with it. After a thorough cleaning, while the floor is still 
wet and walls damp, the apartment should be fumigated with sul- 
phur, or better with formalin. A simple method of using formalin 
is by Schering's lamp and tablets. If fumigation is to be efficient the 
room must be tightly closed, all cracks being stopped with cotton, and 
larger openings about doors, windows, and fire-places sealed by pasting 
paper over them. Bedding, cushions, pillows, carpets, etc., should be 
hung over chairs or upon lines strung about the room. Books should be 
suspended from covers so that the leaves are exposed. After fumigation, 
the room should remain closed for twelve hours. After a severe case, the 
walls should be painted or whitewashed, or if papered, the wall-paper 



974 THE SPECIFIC INFECTIOUS DISEASES. 

should invariably be renewed and the wood-work repainted. Simply- 
airing a room after an attack is of little or no benefit. An instance is on 
record of a patient contracting the disease in a room in which the win- 
dows had been open constantly for three months. The carpets, bedding, 
hangings, and upholstery are best disinfected by steam. Where this is 
impossible, after a severe case the mattress and pillows should be burned. 
Bedding, blankets, and other articles should be boiled, and afterward 
exposed to sunlight for a long time out of doors. 

The bedclothes, linen, and clothing removed from the patient during 
an attack, should be put at once into a solution of carbolic acid (1 to 20), 
or zinc sulphate four ounces, common salt two ounces, and water 
one gallon, and afterward boiled at least two hours in the same solution. 
Instead of handkerchiefs, pieces of old muslin, surgeon's gauze, or ab- 
sorbent cotton, should be used for cleansing the nose and mouth of the 
patient and burned immediately. 

The physician in attendance upon a case should leave his coat and 
overcoat in an anteroom, and put on a long gown or rubber coat, suffi- 
ciently large to cover all his clothing. This should always be worn in the 
sick-room, and boiled or disinfected when the case is finished. For a sin- 
gle visit the overcoat may be worn in the room, but the clothing should 
be changed before visits to other children are made. After every visit the 
physician's hands and face should be thoroughly washed with soap and 
then with a disinfectant solution. A physician in attendance upon scar- 
latinal patients should not attend obstetric cases or other patients with 
recent wounds. The great liability of such cases to contract scarlatina 
should never be forgotten. If, in emergencies, it becomes necessary to 
attend such patients, the physician should change all his clothing and 
disinfect his hands, face, hair, and beard, with the greatest thoroughness. 

Schools are the hot-beds for the spread of scarlet fever. The greatest 
sources of danger are the mild or walking cases in which the disease has 
not been recognised, and the clothing of patients who have had a severe 
form of the disease. As a rule, a child should be kept from school six 
weeks from the beginning of the attack, and the certificate of a physician 
should be required before re-admission, stating not only that the des- 
quamation is complete, but also that the child is suffering from no 
sequelae. Other children in the household should not be allowed to attend 
schools of any kind during the period of active symptoms; they should 
be kept at home on the average for a month. This precaution is neces- 
sary, first, because they might carry the disease from the child at home ; 
secondly, because otherwise they might themselves attend school while 
suffering from the disease in a very mild form or during the period of 
invasion. When the sick child is completely isolated, the danger from 
the first source is very slight. During severe epidemics it frequently 
becomes necessary to close all schools. 



SCARLET FEVER. 975 

During desquamation the spread of the disease may be in a measure 
prevented by the free use of inunctions and warm antiseptic baths. All 
the excreta from the patient should be disinfected throughout the disease, 
best by a carbolic solution (1 to 20). If cases of scarlet fever are to be 
transported, this should be done only in a vehicle which can be easily 
disinfected. Under all circumstances as few persons as possible should 
come in contact with the patient. 

In general, it is to remembered that the danger is first from the 
patient, secondly from the room, and thirdly from the nurse. Special at- 
tention should always be given to the complete and immediate isolation 
of the first case which appears in an institution or community, which 
should apply to mild as well as severe forms of the disease. 

Treatment. — There is as yet no specific for scarlet fever. The physi- 
cian's duty in the average case consists in ( 1 ) establishing proper quaran- 
tine and the carrying out of adequate means of disinfection; (2) the hy- 
gienic care of the patient; (3) directing the diet; (4) watching for com- 
plications, especially otitis and nephritis. It should be borne in mind that 
otitis is rarely accompanied by pain or tenderness, and is recognised only 
by an examination of the ears ; also that severe and fatal nephritis may 
follow mild as well as severe cases. 

Mild attacks require no medicine. Children should be kept in bed 
for at least a week after the fever has subsided, and upon fluid diet for 
a period of three weeks. This is an important matter in the prevention 
of nephritis. During the height of the eruption, the intense itching of 
the skin may be allayed by sponging with a weak carbolic-acid solution, 
or by inunctions with vaseline, or by the free use of rice powder. Plenty 
of fresh air should always be secured in the sick-room. As soon as the 
fever and rash have disappeared, daily warm baths with soap and water 
should be used, after which the entire body should be anointed with 
carbolised vaseline, or boric acid and vaseline, five-per-cent strength, 
with the two-fold purpose of facilitating desquamation and disinfecting 
the scales. In case the skin becomes irritated by this treatment, bran 
baths may be substituted for soap and water. 

The temperature does not usually require interference when it only 
occasionally rises to 104° or 104.5° F. But if there is hyperpyrexia, or a 
temperature which ranges from 104° to 105.5° F. or over, antipyretic 
measures are called for. Cold is much safer and more certain than drugs. 
Sometimes cold sponging is sufficient, but in the great proportion of cases 
the cold pack or bath is required. The use of cold in the reduction of 
temperature is especially indicated in septic cases with typhoid symp- 
toms, and in those with pronounced cerebral symptoms. 

The nervous symptoms are frequently better controlled by ice to the 
head and by cold sponging than by medication. Antipyretic drugs may 
be relied upon to control restlessness and promote sleep, and in mild 



976 THE SPECIFIC INFECTIOUS DISEASES. 

cases to effect a moderate reduction in temperature. Phenacetine is 
usually to be preferred. 

As soon as the pulse becomes weak or rapid and irregular, or the 
first sound of the heart feeble, stimulants should be given, no matter at 
what stage of the disease. In septic, or malignant cases, or in those ac- 
companied by severe angina, adenitis, or cellulitis, alcoholic stimulants 
should be used freely. Digitalis is especially valuable when the pulse is 
weak and the tension low. It may be given alone or combined with 
strychnine ; one minim of the fluid extract of digitalis, and gr. ^ 
of strychnine being the initial doses for a child of five years. 

The erythematous sore throat requires no treatment except the use 
of a mild antiseptic gargle. If there is a profuse nasal discharge, gentle 
nasal syringing (page 58) with a warm saline or boric-acid solution 
may be used with the hope of preventing infection of the middle ear. 
The local treatment of the membranous angina is the same as that of 
other cases of pseudo-diphtheria. 

Milder forms of adenitis require no local treatment. When severe, 
the glands should be covered with ichthyol, and an ice-bag applied con- 
tinuously. Poulticing almost invariably does harm. If an abscess forms, 
early incision should be practised. 

The ears of patients with severe throat symptoms should be examined 
daily in order that there may be no delay in performing paracentesis 
should this become necessary. Any rise in temperature should direct 
attention to the ears. The indications for the operation are the same 
as in other severe forms of otitis. 

The physician should be constantly on the watch for the development 
of nephritis, not only during the febrile period, but also during con- 
valescence. Eepeated examinations of the urine are absolutely necessary. 
These are much facilitated by having a rack of test tubes and the ordi- 
nary reagents for detecting albumin in the sick-room, so that the physician 
may himself examine daily a fresh specimen of urine. The nurse should 
be instructed to measure and record accurately the twenty-four hours' 
urine throughout the attack. The treatment of scarlatinal nephritis has 
been considered in the chapter devoted to Diseases of the Kidney. Dif- 
fuse cellulitis of the neck calls for free, early incision as the only means 
of preventing extensive sloughing. 

Sera prepared by means of several different varieties of streptococci 
have been produced and extensively used without any uniform or striking 
success. One has lately been produced by Moser (Vienna) concerning 
whose effects there is much more favourable evidence. Escherich, Bokay, 
and other reliable Continental observers in their reports, declare that its 
effects are not less striking than those obtained from diphtheria anti- 
toxin. It is not yet on the market. 

During convalescence, tonics, particularly iron and digitalis, are 



MEASLES. 977 

called for. The urine should be frequently examined for a long time ; 
antiseptic gargles and a nasal spray or syringe should be used as long 
as a purulent discharge from the nose or pharynx continues. 



CHAPTER II. 
MEASLES. 

Synonyms : Rubeola, Morbilli. 

Measles is an epidemic contagious disease, more widely prevalent 
than any other eruptive fever ; very few persons reach adult life without 
contracting it. One attack usually confers immunity. It is highly con- 
tagious even from the beginning of the invasion, and spreads with great 
rapidity from the patient to all susceptible persons exposed. The poison, 
however, does not cling so long to clothing or apartments as does that of 
scarlet fever. Measles has a period of incubation of from eleven to four- 
teen days; a gradual invasion of three or four days with symptoms of 
an acute coryza ; a maculo-papular eruption which appears first upon the 
face and spreads slowly over the body, and which lasts from four to six 
days. This is followed by a fine bran-like desquamation, which is com- 
plete in about a week. The mortality is low, except among infants and 
delicate children, in whom it may reach 30 or even 40 per cent. In 
institutions for infants and young children no disease is more to be 
dreaded than measles, not only on account of its severity, but from 
the frequency with which, in such subjects, it is complicated by broncho- 
pneumonia. 

Etiology. — The essential cause of measles is as yet unknown. It is 
generally believed to be due to a micro-organism, but, as in the case of 
scarlatina, all attempts to isolate it have thus far been unsuccessful. The 
poison is one which possesses remarkable powers of diffusion, but whose 
viability is much less than that of most of the pathogenic germs which 
are known. Only a short exposure is required to communicate the dis- 
ease, and even close proximity to a patient does not seem necessary. One 
instance has come under my own observation where measles was appar- 
ently conveyed by an exposure of half an hour across a hospital ward, a 
distance of at least fifteen feet. 

Predisposition. — Very young infants do not so readily contract mea- 
sles, but all other children are extremely susceptible. The disease broke 
out in a cottage of the New York Infant Asylum which was occupied by 
twenty-three children, nearly all of them being under two years old; 
only four escaped, all these being under five months old. In an epi- 
demic reported by Smith and Dabney, 110 unprotected children, between 
the ages of eight and eighteen years, were exposed and only two escaped. 



978 THE SPECIFIC INFECTIOUS DISEASES. 

In the Nursery and Child's Hospital, during the epidemic of 1892, there 
were 62 children over two years of age ; five were protected by a previous 
attack and escaped; of the remaining 57 children, 55 took the disease. 
There were also in the institution 113 children under two years old; of 
this number 78 per cent took the disease; but, although a number were 
exposed, not one child under six months old contracted measles. The 
age of the persons affected depends much upon the length of time since 
the last outbreak of the disease. In an epidemic occurring in the Island 
of Guernsey, where the disease had not prevailed for many years, all ages 
were affected, the youngest being twelve days old, and the oldest, a man 
and wife, each aged eighty years. Somer has reported an instance of 
an eruption of measles appearing in a child twelve hours after birth; 
the mother was suffering from the disease at the time. Gautier has col- 
lected six additional cases, where measles either existed at the time of 
birth or developed within a few hours after it. 

Except, then, in early infancy, the probabilities are very strong that 
every child exposed to measles will contract the disease. Occasionally, 
however, one is seen who seems insusceptible to the poison, no matter 
how close the exposure. 

Epidemics of measles are more frequent and more severe during the 
winter and spring months. They are least frequent and mildest during 
the autumn months. 

Incubation. — In 144 cases,* in which the period of incubation could 
be definitely traced, it was as follows: 

Incubation of less than nine days 3 cases* 

" " nine or ten days 22 " 

" " eleven to fourteen days 95 " 

" " fifteen to seventeen days 19 " 

" " eighteen to twenty-two days 5 " 

Thus in 66 per cent of the cases the incubation was between eleven and 
fourteen days, and in only one case was it less than a week. The con- 
stancy of the incubation period is strikingly shown in some epidemics. 
Thus in the one reported by Smith and Dabney in an institution in Vir- 
ginia, exactly eleven days after the rash appeared in the first case, the 
disease developed in twenty children — no cases having occurred in the 
interval. 

Duration of the infective period. — This is much shorter than in scar- 
let fever, and the average duration may be placed at three weeks. Haig- 
Brown discharged fifty-eight cases on or before the twenty-ninth day 
of the disease, and in no instance was measles spread by these children. 

* About twenty-five of these are taken from ray own records ; the remainder are 
mainly isolated cases, scattered through medical literature. The incubation is reck- 
oned from the time of exposure to the beginning of the catarrh. 



MEASLES. 979 

Ransom, however, records one instance in which it was communicated 
thirty-one days after the appearance of the rash. 

Measles is highly contagious from the beginning of the catarrhal 
symptoms. A case occurred in the Babies' Hospital under my own ob- 
servation, in which a child conveyed the disease four days before the rash 
appeared. Ransom reports another precisely similar. An instance has 
been related to me by Dr. S. W. Lambert, where, of thirteen little girls 
who were at a children's party, only one escaped measles, the source of 
infection being a child who showed no rash until the following day ; the 
child who escaped had previously had measles. The period of greatest 
contagion is still a matter of dispute, the general belief being that it is 
coincident with the highest temperature, the full eruption, and the most 
severe catarrhal symptoms. 

With the fading of the eruption and the subsidence of the catarrh, the 
communicability of measles diminishes rapidly. It is relatively feeble 
during desquamation, and soon after this period it usually ceases alto- 
gether. It is generally proportionate to the severity of the catarrhal 
symptoms, and where these are protracted it is probable that the disease 
may be communicated for a much longer period than that mentioned. 

Mode of infection. — Measles is usually spread by direct contagion, very 
infrequently through the medium of clothing, furniture, or a third person. 
Townsend (Boston) records an instance in which one family moved into 
a tenement house on the same day on which it was vacated by another 
family in which two children had suffered from measles, one of them 
fourteen and the other eighteen days previously. The apartments were 
not fumigated or disinfected, and, although there were two susceptible 
children in the incoming family, they did not contract the disease. 
Measles rarely if ever clings to apartments for weeks or months, as does 
scarlet fever. Many instances are on record in which the disease has been 
carried by a third person; but, after all, this rarely happens, unless the 
contact both with the sick and the well child is very close and the interval 
short. It is very seldom that measles is carried by a physician who takes 
even ordinary precautions. In a case reported by Girom, the clothing 
of a patient is stated to have conveyed the disease nineteen days after an 
attack, but this must be regarded as very exceptional. 

Lesions. — The only constant lesions of measles are those of the skin 
and the mucous membranes, chiefly of the respiratory tract. According 
to Neumann, the process in the skin is of an inflammatory character, but 
is more superficial than in scarlet fever. There is congestion, accom- 
panied by an exudation of round cells about the small blood-vessels, and 
also about the sweat and sebaceous glands, and the papillae. To this 
exudation and the oedema, the swelling of the skin is due. It occurs 
everywhere, but is especially noticeable upon the face. 

The changes in the mucous membranes are quite as much a part of 



980 THE SPECIFIC INFECTIOUS DISEASES. 

the disease as are those of the skin. There is a catarrhal inflammation 
affecting the conjunctivae, nose, pharynx, larynx, trachea, and large 
bronchi, which varies in intensity with the severity of the attack. In the 
most severe forms in infants and in young children, this inflammation 
extends with great uniformity to the small bronchi, and usually to the 
air vesicles, causing broncho-pneumonia. In severe cases, the lesion in 
the pharynx and larynx also, instead of being catarrhal, may be mem- 
branous ; the larynx being much more frequently involved, and the ears 
much less so, than in scarlet fever. Freeman has described areas of focal 
necrosis in the liver similar to those found in diphtheria; they were 
present in four of twelve cases examined. The lesions of the lungs and 
of other organs will be more fully considered under Complications. 

The bacteria which are associated with the lesions of the respiratory 
tract are the staphylococcus and the streptococcus, separately or together, 
and either form may be associated with the pneumococcus (see Bac- 
teriology of Broncho-Pneumonia, page 532) . The poison of measles pro- 
duces conditions in the mucous membranes of the respiratory tract which 
are especially favourable for the development of these bacteria. They 
are present in the mouth in great numbers ; they may cause pneumonia, 
otitis, and other local inflammations, and the pneumococcus or strepto- 
coccus may produce a general septicaemia. 

Symptoms. — Invasion. — As a rule, the invasion of measles is gradual, 
both the fever and catarrhal symptoms increasing steadily up to the ap- 
pearance of the eruption. The characteristic symptoms of the invasion 
are those of a severe coryza — suffusion of the eyes, increased lachryma- 
tion, photophobia, sneezing, and a discharge from the nose. The hoarse, 
hard cough indicates that the catarrhal process has involved the larynx 
and trachea, as well as the visible mucous membranes. Frequently the 
patient complains of some soreness of the throat, and on inspection there 
is seen moderate congestion of the tonsils, fauces, and pharynx. On the 
hard palate are frequently seen small red spots. Much more character- 
istic are the minute white spots upon the mucous membrane of the cheeks, 
known as Koplik's sign (see Diagnosis). The constitutional symptoms 
are indefinite, and may be met with in almost any disease. There is 
dulness, headache, pains in the back, and the usual symptoms of malaise; 
there is rarely vomiting or diarrhoea. Drowsiness is a frequent symptom, 
and is regarded by the laity as characteristic. 

The exceptional cases in which the invasion is abrupt are puzzling. 
There may be a sudden accession of fever with vomiting, and even con- 
vulsions, as in a case lately under my observation. Not infrequently, 
when the disease prevails epidemically, the invasion is sudden, with high 
fever and pulmonary symptoms which are so severe as to mask every- 
thing else until the rash makes its appearance, the case up to that time 
being often regarded as one of primary pneumonia or of influenza. The 



PLATE XVL 




****** 



Eruption of Measles. 

On the face and trunk the eruption is rather more confluent than is usual: on the 
upper part of the chest, on the lower part of the abdomen, but especially on the left arm, 
many haemorrhagic spots are seen. The eruption on the lower extremities and feet is 
typical in appearance. 



6 days 


20 case 


7 " 


6 " 


8 " 


2 " 


9 " 


2 " 


" 


1 case. 



MEASLES. 981 

duration of the stage of invasion — i. e., from the beginning of the ca- 
tarrh until the eruption — in 270 cases of which I have notes, was as 
follows : 

1 day or less 35 cases. 

2 days 47 " 

3 " 64 " 

4 " 64 " 

5 " 29 " 

From this table it will be seen that the length of the period of invasion 
varies considerably — more, I think, in infants and very young children 
(most of these were under three years old) than in those who are older. 
In the greater number of cases it lasts from two to four days. 

Eruption. — The rash usually appears on the third, fourth, or fifth day 
of the disease — in the largest number upon the fourth day. As a rule, it 
is first seen behind the ears, on the neck, or at the roots of the hair over 
the forehead. It appears as small, dark-red spots, which are at first few, 
scattered, and not elevated, resembling flea-bites. In twenty-four hours 
the macules are much more numerous, and many of them have become 
papules. They frequently group themselves in crescentic forms. They 
are usually separated by areas of normal skin, but where the rash is in- 
tense they are frequently coalescent. From the time of its first appear- 
ance to the full development of the rash on the face, is usually about 
thirty-six hours, but may be from one to three days. With a full erup- 
tion (Plate XVI) there is considerable swelling of the face, especially 
about the eyes, and the features are sometimes scarcely recognisable. On 
the second day of the rash it begins to appear upon the neck beneath the 
chin, the upper part of the chest and back ; on the third day the trunk is 
covered, and scattered spots are seen upon the extremities. The rash 
appears last upon the lower extremities, and by the time it is fully out 
upon them it has usually begun to fade from the face. In mild cases it 
remains discrete, but in severe ones it is frequently confluent upon the 
face and upon the extensor surfaces of the extremities. As a rule, it 
covers the entire body, even the palms and soles. 

The eruption fades slowly in the order of its appearance, and there is 
left behind, in typical cases, a slight brownish staining of the skin, which 
often remains for a week or more. The duration of the rash is from one 
to six days, the average being four days. 

There are many cases in which the rash does not follow the typical 
course described: (1) Instead of spreading gradually, the entire body 
may be covered in a few hours. (2) The rash may be haemorrhagic. 
This condition was present in about five per cent of my cases. The 
whole eruption may be haemorrhagic, or it may be so only upon certain 
parts — usually the abdomen or extremities. Under such circumstances 
small petechial spots take the place of the macules — the " black measles " 
63 



982 THE SPECIFIC INFECTIOUS DISEASES. 

of the older writers. It is in most cases a bad, but by no means a 
fatal symptom. I have seen it in several cases that were not especially 
severe. (3) The rash may be very faint, and of short duration, being 
scarcely elevated at all. (4) It may consist of very minute papules, 
closely resembling the rash of scarlet fever. It is to be remembered, how- 
ever, that the irregular eruptions of scarlet fever much more frequently 
resemble measles than vice versa. (5) It may be very scanty, and late in 
its appearance ; particularly in cases of great severity and hyperpyrexia — 
the so-called malignant cases. (6) Temporary recession of the erup- 
tion may occur at any time during the height of the disease, and is usually 
due to heart failure. A recurrence of the eruption after it has run its 
usual course is something which I have never seen; although such cases 
have been reported, I believe them to be very exceptional. 

During the first two days of the eruption, the local and constitutional 
symptoms increase in severity, both usually reaching their maximum at 
the time of the full development of the rash upon the face. The skin 
is swollen, and the seat of intense itching and burning. The eyes are 
very red and sensitive to light, and there is swelling of the conjunctivae 
with an abundant production of mucus or muco-pus, causing the lids to 
adhere. There is pain on swallowing, also swelling of the glands at the 
angle of the jaw or in the post-cervical region. The cough is frequent 
and very annoying. There is complete anorexia, and often diarrhoea. 
The tongue is coated, and may show at its margin enlarged papillae, 
somewhat resembling the " strawberry " appearance of scarlet fever. 
As the rash fades the temperature declines rapidly, often reaching the 
normal in two or three days. The catarrhal symptoms now subside, and 
soon the patient is convalescent. Within a day or two after the fever 
has ceased, the rash disappears. 

Desquamation. — This begins almost as soon as the rash has subsided, 
and is first noticed on the face and neck, where the eruption first ap- 
peared. The nature of the desquamation is invariably fine, branny scales, 
never in large patches, as in scarlet fever. It is often quite indistinct 
and may be overlooked. Its usual duration is from five to ten days. It 
may, however, be prolonged for two weeks. The amount of desquamation 
varies considerably in the different cases. It is most marked in those in 
which there has been an intense eruption. There is frequently noticed 
at this time an odour about the patient which is quite characteristic of 
measles. During this stage the cough often persists and the eyes remain 
weak and very sensitive to light, but in other respects the patient usually 
feels perfectly well. 

1. The mild cases. — The mildest cases are distinguished by low tem- 
perature, which at tne height of the eruption usually reaches 102° F., but 
rarely lasts more than four days. The eruption is often scanty, and is 
never confluent. The swelling, itching, and other cutaneous symptoms 



MEASLES. 



983 



are wanting, as is also the intense red colour of the skin. The rash is 
frequently obscure, and, without the other symptoms, hardly sufficient 
for diagnosis. The catarrhal symptoms are more uniform than the rash, 
but these are very mild as compared with the usual form. The duration 
of the rash is shorter, desquamation is scarcely perceptible, and there are 
no complications. 

2. The cases of moderate severity. — The course of measles is much 
more regular in children over three years old than in infancy. In the 



DAY 


1 


2 


3 


i 


5 


6 


7 


8 


s 

X 

z 
w 

BE 
X 
< 


106° 
105° 
104° 
103° 
102° 
101° 

ioo c 

99° 

98 ' 


M E 


V E 


M E 


M E 


V E 


M E 


M E 


M E 








X 
















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DAY 


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2 


3 


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6 


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8 


9 


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IU 

X 

z 
ui 
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106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 


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M E 


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M E 


V. E 


M E 


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Fig. 195. 



Fig. 196. 



Fig. 195. — Temperature curve in uncomplicated measles, showing the gradual rise and critical 
fall ; patient ten years old ; x = first eruption ; £ = full eruption on the face. 

Fig. 196. — Typical curve in uncomplicated measles, with gradual rise and gradual fall ; patient 
three years old. 

former, the sjnnptoms of invasion come on gradually, and the tempera- 
ture rises steadily until the appearance of the eruption, which is in most 
cases on the third or fourth day of the disease. Figs. 195 and 196 repre- 
sent the typical tempera- 
ture curve in average un- 
complicated cases. Such a 
curve was seen in 44 per 
cent of 173 cases in which 
careful observations were 
made. Sometimes the de- 
cline in the fever is very 
rapid, almost a crisis, as in 
Fig. 195, but more often it 
falls gradually, as in Fig. 



DAY 


1 


2 


3 


4 


i 


6 


7 


8 


9 


10 


11 


12 


1- 
111 

I 
Z 

a 

cc 

X 

< 

b. 

- 


106° 
■105° 
104° 
103° 
102° 
101° 

■100° 
1-99° 
98° 


M E 


M E 


M E 


M E 


V, E 


M E 


M E 


M E 


M E 


M E 


H E 


II E 














x 






















X 


X 


x 




















\ 


A 












\ 






A 


/ 


V 


r \ 












\ 






/ 


/ 






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v 




/ 


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./ 










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V 














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Fig. 197. — A not infrequent temperature curve in mea- 
sles, showing abrupt invasion, but subsequent course 
typical; uncomplicated case; patient nine months 
o'ld. 



196. In such cases the 
duration of the fever is 
from five to nine days, the 
average being about a week. The other symptoms follow very closely the 
course of the fever. The maximum temperature is nearly always coinci- 
dent with the full rash upon the face, at this time usually being in un- 



984 



THE SPECIFIC INFECTIOUS DISEASES. 



complicated cases from 103° to 104° F. in older children, and 104° to 
105° in infants and young children. 

A not very uncommon temperature curve is that of Fig. 197, where 
the onset of the disease is marked by a sudden rise to 102° or even 104° 
F., with a fall nearly or quite to normal on the second day, after which 
the fever rises gradually, as in the first group. This curve was seen in 
5 per cent of my cases. 

3. The severe cases. — In Fig. 198 is shown a type of the disease which 
is more frequent in infants than in older children, the important features 
being the late eruption and the continuance of the high fever for several 
days after the rash has begun to fade. Such a prolonged course and so 
high a temperature are almost invariably due to some complication, 
usually broncho-pneumonia. Where the pneumonia goes on to the pro- 
duction of areas of consolidation, the fever usually continues for three 
and sometimes for four weeks, even though terminating in recovery. 



DAY 


1 


2 


3 


I 


5 


6 


8 


9 


10 


11 


12 


13 


u 


15 


16 


17 


I 
Z 

IT 

I 
< 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 


M E 


M E 


M E 


M E 


M E 


MEM 
X 


E M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 










X 


X 


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v v 


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Fig. 198, 



■Measles with prolonged invasion ; continuance of high temperature after full erup- 
tion due to severe bronchitis and diarrhoea ; child two years old. 



Figs. 199 and 200 illustrate two types of the disease which are often 
seen when measles is complicated by pneumonia. In cases like that shown 
in Fig. 199 the onset is abrupt with high temperature, prostration, and 
pulmonary symptoms not unlike those of primary pneumonia. A tem- 
perature curve resembling this was seen in 28 of 173 cases. The rash is 
often late in appearance; it is faint and altogether irregular; it may 
recede after the first day and reappear after an interval of one or two 
days. The catarrhal symptoms are not marked, but the whole force of 
the disease seems to be expended upon the lungs. The diagnosis of these 
cases presents great difficulties, and very often it would not be made 
but for the fact that there are other cases of measles in the family or 
the institution. This form is usually seen in infants, and it is usually 
fatal. 

In other cases marked by a sudden severe onset, the system seems to 
be overpowered by the poison of the disease itself. There is profound 



MEASLES. 



985 



depression, and hyperpyrexia, and the patient may die from toxaemia with 
cerebral symptoms before the appearance of the rash or just as it is begin- 
ning to show itself. Sometimes the pulmonary symptoms are entirely 
wanting ; at others the rash, if it appears, is haemorrhagic. 

In still another group of cases the onset is not violent, and for the 
first two days the attack may appear to be of only average severity; but 
there may then develop, often quite sud- 
denly, pulmonary symptoms of such intensity 



DAY 


1 


2 


3 


i 


5 


G 


7 


8 


9 


10 


1- 
Ui 

I 

z 
u 

c 

X 

if 


•106 c 
105° 

•104° 
103° 
102 c 
10l"' 

•ioo c 

99 c 

98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 






X 












# 


f 






A 












J 




A 


/ 


\ 


^ 


J 


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v 


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i 















DAY 


1 


2 


3 


4 


5 


t- 

uj 

I 

z 
111 

a 

I 

2 


108° 
107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 


M E 


M E 


M E 


M E 


M E 








ill 


x 








\f\ 


1 










i 






/ 




i 






/ 


I 






A 


/ 








/ 








/ 


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/ 





















Fig. 199. 



Fig. 200. 



Fig. 199. — Fatal attack of measles, complicated by broncho-pneumonia; very severe symptoms 

from the onset ; patient eighteen months old ; death on tenth day. 
Fig. 200. — Fatal attack of measles, complicated by broncho-pneumonia ; early invasion mild, 

but rapid development of severe symptoms on fourth day ; rash on last day ; patient eight 

months old. 



as to cause death within twenty-four hours. The eruption, if seen at all, 
is faint and not characteristic (Fig. 200). 

A secondary rise in the temperature after it has once fallen to normal 
was seen in 8 of 173 cases, being due to the development of otitis, ileo- 
colitis, or pneumonia. 

Complications and Sequelae. — The most frequent and most important 
complication of measles is broncho-pneumonia, and next to this are ileo- 
colitis, otitis, and membranous laryngitis. Most of the others are in- 
frequent; all complications are relatively rare in children over four 
years old. 

Lungs. — The greatest danger in measles arises from pulmonary com- 
plications, and the frequency is greatest in children under two years of 
age. In two epidemics in the Nursery and Child's Hospital, em- 
bracing about 300 cases, nearly all in children under three years old, 
broncho-pneumonia occurred in about 40 per cent of the cases. Of those 
who had pneumonia, 70 per cent died. Fortunately, such a record as this 
is never seen outside of asylums or hospitals for young children. Of 
2,477 cases, embracing several epidemics of measles among children of 
all ages, pneumonia occurred in 10 per cent. My own experience in the 
post-mortem room fully bears out the statement of Henoch, that a cer- 



986 THE SPECIFIC INFECTIOUS DISEASES. 

tain amount of pneumonia is found in almost every fatal case. Pneu- 
monia is more frequent and its mortality is higher in spring and winter 
epidemics than in those occurring at other seasons. It may develop at 
any time from the beginning of invasion until convalescence, but it 
mostly frequently begins about the time of full eruption. 

Lobar pneumonia, although rare, occasionally occurs as a complica- 
tion in children over three years old. In some epidemics many of the 
cases of pneumonia are complicated by severe pleurisy, which adds much 
to the danger from the disease. This form is frequently followed by 
empyema. Pneumonia is always to be suspected when the temperature 
continues high after the full appearance of the rash. 

Bronchitis of the large tubes, always accompanied by tracheitis, is 
seen in every case of measles, possibly excepting a few of the very mild- 
est. This is so constant a feature as hardly to be ranked as a complica- 
tion. In nearly all of the severe cases the bronchitis extends to the me- 
dium-sized and smaller tubes. 

Larynx. — A mild catarrhal laryngitis accompanies almost every case 
of measles. Severe catarrhal laryngitis is present in about ten per cent 
of the cases ; it may give symptoms which closely resemble those of mem- 
branous laryngitis, and the two are no doubt often confused. (For the 
points of differential diagnosis see page 493). 

Membranous laryngitis is more often seen as a complication of 
measles than of scarlet fever. It is especially seen in the epidemics of 
institutions. As a cause of death in older children it ranks next to 
pneumonia. When it develops at the height of the disease, it is some- 
times due to the streptococcus; but when it develops at a later period, 
it is usually due to the diphtheria bacillus. The streptococcus inflamma- 
tion is in most cases associated with similar changes in the pharynx or 
tonsils, but not always. True diphtheria, occurring as a complication 
of measles, not infrequently begins in the larynx. The streptococcus in- 
flammation may be as serious in this, connection as is true diphtheria, 
from the probability, which amounts almost to a certainty, of the devel- 
opment of broncho-pneumonia. No complication is more to be dreaded 
than this. The diagnosis between the true and pseudo-diphtheria may 
sometimes be made by the time of development, but only with certainty 
by cultures. I once saw in measles, where no false membrane was pres- 
ent in the rest of the larynx, a necrotic inflammation with almost en- 
tire destruction of the vocal cords — a condition which may be compared 
to that seen in the tonsils or epiglottis in scarlatina. 

Throat. — A catarrhal angina is part of the disease, and is as charac- 
teristic of measles as is the eruption upon the skin. There is acute con- 
gestion and swelling of the tonsils, uvula, palate, and pharynx. In a 
certain proportion of cases, very much less frequently than in scarlatina, 
the development of membranous patches is seen upon the tonsils and ad- 



MEASLES. 987 

jaceni mucous membranes. These occur in two or three per cent of the 
cases. They are to be regarded in the same light as similar conditions 
complicating scarlet fever, with these differences, that in measles there 
is much greater likelihood of the extension of the disease to the larynx, 
while extension to the nose and ears is much less probable. True diph- 
theria, however, may complicate measles, and cases of membranous in- 
flammation of the tonsils or pharynx developing late in measles are 
usually due to the Klebs-Loeffler bacillus. 

Although in most cases the inflammations of the pharynx and tonsils 
which accompany measles are not serious when they are due to the strep- 
tococcus, they are sometimes quite as severe as any that accompany scarlet 
fever. They may cause death from general sepsis apart from any affec- 
tion of the larynx. 

Digestive System. — Gastric disorders are not more common than in 
other febrile diseases ; but diarrhoea is very frequent, and in summer it 
may be even more serious than the pulmonary complications. All forms 
of diarrhoea are seen, from that which results from simple indigestion to 
the severe types of ileo-colitis. This complication is most often seen in 
children under two years old. The most severe intestinal symptoms are 
not usually seen at the height of the primary fever; but, beginning at 
this time, they often increase in severity, and are most marked in the 
second and third weeks of the disease. 

Catarrhal stomatitis is present in almost every case of measles ; less 
frequently the herpetic form is seen. Ulcerative stomatitis is not uncom- 
mon, particularly in institutions. One of the worst complications of 
measles, but fortunately a rare one, is gangrenous stomatitis, or noma. 
This usually occurs in inmates of institutions, or in children with bad 
surroundings who were previously in wretched condition. It is nearly 
always fatal. 

Gangrenous inflammations of other parts of the body are sometimes 
seen after measles, especially of the ear, the vulva, or the prepuce. 

Nervous System. — I have seen convulsions at the onset of measles in 
but a single case. During the progress of the disease they are not so rare, 
and may occur in connection with otitis, meningitis, or severe broncho- 
pneumonia — chiefly in infants. 

Meningitis is rare, but either the simple or the tuberculous form may 
occur, more often, however, as a sequel than as a complication. Insanity, 
usually of a temporary character, occasionally follows measles. In the 
epidemic of 108 cases reported by Smith and Dabney, insanity was noted 
three times, all the cases terminating in recovery. Epilepsy and chorea 
are rare sequelae. 

Ears. — Otitis is a frequent complication in some epidemics ; in others 
it is seldom seen. In one hospital epidemic it was noted in 14 per cent 
of the cases. This epidemic occurred in early spring and affected very 



988 THE SPECIFIC INFECTIOUS DISEASES. 

young children, both of which circumstances are favourable for the devel- 
opment of otitis. Usually both ears are affected, but the otitis of measles 
is, as a rule, less serious than that of scarlet fever. 

Eyes. — Simple catarrhal conjunctivitis accompanies nearly every case 
of measles. In the severe form there is a muco-purulent catarrh, which 
may attain any degree of severity. In neglected cases, and among chil- 
dren who are poorly nourished, especially in asylums, the disease is apt to 
extend to the cornea. Chronic conjunctivitis often persists after measles, 
particularly in the class of children just mentioned. 

Lymph nodes. — Swelling of the lymphatic glands of the neck is fre- 
quent, but not generally severe, and rarely terminates in suppuration. 
Chronic enlargement may continue for months, and sometimes the glands 
may become tuberculous. Similar changes and similar consequences 
may occur in the glands of the tracheo-bronchial group. 

Kidneys. — The infrequency of renal complications in measles is in 
striking contrast to scarlet fever. Transient febrile albuminuria is not 
uncommon, but a serious degree of nephritis, either clinically or at au- 
topsy, I have never seen, and literature furnishes but few cases. 

Heart. — Both endocarditis and pericarditis have occurred in the 
course of measles, but they belong to the rare complications. The same 
may be said of changes in the muscular walls of the heart. 

Shin. — As complications, erysipelas, furunculosis, impetigo, and pem- 
phigus have been noted; but all are rare. 

Hemorrhages. — Associated with the hemorrhagic type of the erup- 
tion, severe and even fatal haemorrhages may occur from the mucous 
membranes, and the latter are sometimes seen without the hemorrhagic 
eruption. 

Blood. — There is a leucocytosis of 15,000 to 30,000 beginning soon 
after infection, even before the invasion, and increasing for four or five 
days. The number of leucocytes then falls gradually to normal or below 
during the eruption. A marked leucocytosis at any time points to a com- 
plication, but its absence during eruption does not exclude one. The dif- 
ferential count shows the increase to be in the polynuclear neutrophiles. 

Other infectious diseases. — Measles in institutions is often compli- 
cated by diphtheria. Scarlet fever or varicella occasionally occurs during 
measles, though it is rare that the two eruptions are exactly simultaneous. 
Epidemics of measles and whooping-cough frequently occur together or 
follow each other. The relation of measles to tuberculosis seems to be 
particularly close. In some cases general or pulmonary tuberculosis 
follows directly in the wake of measles, which seems to furnish, espe- 
cially in the lungs, conditions which ar"e favourable for the develop- 
ment of latent tuberculosis. As a late manifestation the most com- 
mon one is tuberculosis of the bones, occurring as hip- joint disease, 
caries of the spine, etc. An attack of measles in a child with tuber- 



PLATE XVII. 



Fig. 1. 



Fig. 2. 





Fig 8. 



Fig. 4. 





The Pathognomonic Sign of Measles (Koplik's Spots). 



Fig. 1. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated 
rose-red spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

FlG. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches 
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin 
is at. this time generally fully developed. 



Fig. 4. — Aphthous si omatitis apt to be mistaken for measles spot s 
Minute yellow points are surrounded by a red area. Always discrete. 



Mucous membrane normal in hue. 



MEASLES. 989 

culous antecedents should, therefore, always be looked upon with appre- 
hension. 

Diagnosis. — A sign of the greatest diagnostic value is the buccal erup- 
tion. Although it appears that this was described many years ago by 
Flindt, of Denmark, it is to Koplik, of New York, that the credit belongs 
of its independent discovery and publication in 1896. It is generally 
known as " Koplik' s sign." The unit of the eruption is a bluish-white 
speck upon a red ground; only a few of these may be present or the 
mucous membrane may be fairly peppered with them (Plate XVII). 
Often they are not seen except by careful search for which strong sun- 
light is necessary ; artificial light is not satisfactory. The spots are best 
seen on the inside of the cheeks opposite the molar teeth, and in most 
cases only there; but they may be present on almost any part of the 
buccal mucous membrane. Their diagnostic value is due to the fact 
that they are nearly always present, that they are not found in other 
diseases, and that they usually appear two or three days before the skin 
eruption. They generally disappear at the time of full eruption. 

I have recently had an opportunity to study the value of this sign 
in two epidemics of measles at the New York Foundling Hospital. Care- 
ful notes were kept in the second epidemic of 187 cases. Koplik's spots 
were unmistakably present in 169 cases, absent in 8, doubtful in 10. In 
78 cases, fever, rash, and Koplik's spots were all present at the first ob- 
servation. In 54 patients the sign was noted one day before the rash; 
in 25, two days before ; in 4, three days before ; in 3, four days before ; and 
in 2, five days before. In 2 the spots were not seen until after the skin 
eruption ; in one case they were present without any eruption. As this 
patient had been exposed and had a prolonged fever, it seems fair to 
regard the case as one of measles. In only one case was the buccal erup- 
tion seen before any elevation of temperature. 

These facts, amply confirmed by other observations, indicate that Kop- 
lik's sign is of value in enabling us to make a diagnosis from one to 
three days before it is possible by the skin eruption, also in furnishing 
a new means of distinguishing measles from the other eruptive fevers, as 
well as from rashes due to drugs, antitoxin, etc. 

Other important symptoms are the coryza, the gradual rise in tem- 
perature, and the eruption which appears first upon the neck and face, 
and slowly extends over the body. Cases which present the greatest diffi- 
culties in diagnosis are usually the very severe ones and those in infants. 

Prognosis. — This depends upon the age and previous condition of 
the patient, the character of the epidemic, and the season of the year. 
Except in children under three years of age, the deaths from measles are 
few; but in institutions containing young children, no epidemic disease 
is so fatal. 

The general mortality of the disease is from 4 to 6 per cent ; but in 



990 THE SPECIFIC INFECTIOUS DISEASES. 

epidemics in institutions for young children it has, in my experience, 
ranged from 15 to 35 per cent. The following table gives the figures of 
an epidemic in one institution in 1892: 

From six to twelve months 42 cases ; mortality, 33 per cent. 

" one to two years 51 "- " 50 " 

" two to three years 27 " " 30 

" three to four years 20 " " 14 " 

" four to five years 3 " " " 

In any single case the important symptoms for prognosis are the tem- 
perature and the character of the eruption. An initial temperature above 
103° F., or one which remains high until the eruption appears, is a bad 
symptom. So also is one which rises after a full eruption, or which does 
not fall as the rash fades. The following table shows the highest tem- 
perature and mortality in 161 hospital cases: 

Highest temperature not over 102° 6 cases; mortality, per cent. 

102° to 103-5°.... 14 " " 7 

104° "104-5°.... 49 " " 16 

105° " 105-5°.... 65 " " 40 

106° or over 27 " " 80 

A favourable eruption is one of a bright colour, covering the body, 
remaining discrete, and spreading gradually. It is unfavourable for the 
eruption to appear late, to be very faint, scanty, or hemorrhagic, or to 
recede suddenly, as this is usually due to a weak heart. 

Of 51 fatal cases, the cause of death was broncho-pneumonia in 45, 
ileo-colitis in 4, and membranous laryngitis in 2. More than half the 
deaths occurred during the second week, the earliest being upon the fifth 
day of the disease. 

The ultimate result of an attack of measles may not be evident for 
some time. Cases in which the temperature persists for two or three 
weeks without assignable cause after the disease is apparently over, 
should be watched with the greatest solicitude. The explanation of this 
is most frequently to be found in the lungs, althougrrUhe physical signs 
are often obscure. The condition may be either subacute pneumonia 
or pulmonary tuberculosis. Even though the attack of measles may not 
have been in itself severe, seeds are often sown the full fruits of which 
are not seen until long afterward. Chronic glandular enlargements which 
may or may not be tuberculous, chronic bronchitis, chronic laryngitis, 
subacute or chronic nasal catarrh, hypertrophy of the tonsils, and adenoid 
growths of the pharynx — all are frequent sequelae. 

Prophylaxis. — Measles is often regarded by the laity as so mild a 
disease that its prevention is thought of little importance, and no effort 
is made to limit its extension. The great probability that every person 
at some time in his life will have the disease, is no justification of un- 
necessary exposure. Although in older children measles is usually mild, 






MEASLES. 991 

this is not so in infants, who should be carefully protected from exposure. 
Special care should also be taken to avoid the exposure of delicate chil- 
dren or those with a strong tendency to pulmonary disease or to tubercu- 
losis. In institutions it is of the utmost importance to secure prompt and 
complete isolation of the first case which appears. 

The disease being usually spread by the patient and rarely from 
apartments, it follows that while early isolation is more important, 
there is not required the same thorough cleansing and disinfection which 
should follow every case of scarlet fever. In an institution, the ward or 
cottage from which a case has been removed should be quarantined for 
at least sixteen days after the appearance of the last case, and absolute se- 
curity can not be said to exist until the end of three weeks. The same 
rule should be applied in private families where children who have been 
exposed should be quarantined apart from the patient, but not sent away. 
Under ordinary circumstances the quarantine of a case of measles should 
last three weeks from the beginning of invasion. It should be contin- 
ued longer if there is pneumonia, otitis, or a nasal discharge. 

Thorough cleansing and disinfection of the sick-room should be done 
before it is again occupied by children, and it should remain vacant at 
least two weeks. Children should be kept from all schools while the dis- 
ease is in their homes, chiefly because they are otherwise liable to spread 
the disease while suffering from the early symptoms of invasion. 

Treatment. — Measles is a self -limited disease, and there are no known 
measures by which it can be aborted, its course shortened, or its severity 
lessened. The indications are therefore to treat serious symptoms as they 
arise, and, as far as possible, to prevent complications, which are the prin- 
cipal cause of death. 

The sick-room should be darkened, as the eyes are very sensitive to 
light. Every child with measles should be put to bed and kept there with 
light covering during the entire febrile period. There can be no possible 
advantage in causing a child to swelter by thick covering, under the delu- 
sion that the disease may be modified thereby. The food should be light, 
fluid, and given at regular intervals. If the conjunctivitis is severe, iced 
cloths should be applied to the eyes, which should be kept clean by the fre- 
quent use of a saturated solution of boric acid, the lids being prevented 
from adhering by the application of vaseline or simple ointment. The 
intense itching and burning of the skin may be relieved by inunctions of 
plain or carbolized vaseline. The cough, when distressing, may be allayed 
by heroin, small doses of opium, either in the form of codeine or the 
brown mixture. The restlessness, headache, and the general discom- 
fort which accompany the height of the fever may be relieved by an 
occasional dose of phenacetine or antipyrine. As soon as the rash has 
subsided, a daily warm bath should be given, followed by inunctions to 
facilitate desquamation and prevent the dissemination of the fine scales. 



992 THE SPECIFIC INFECTIOUS DISEASES. 

The important indications to be met in the severe cases are very high 
temperature, cardiac depression, and nervous symptoms — dulness, stu- 
por, sometimes coma, or convulsions. In some of the cases there is in 
addition dyspnoea and cyanosis, showing severe acute pulmonary con- 
gestion. For the nervous symptoms and high temperature, nothing is so 
reliable as the cold baths or packs (pages 49 and 50) and the nearly con- 
tinuous use of ice to the head. I do not think there is any evidence that 
the use of cold increases the liability to pneumonia ; but cold extremities, 
feeble pulse, and cyanosis, when associated with high temperature, call 
for the hot mustard bath, although ice should still be applied to the head. 
The indications for stimulants and the methods of using them are the 
same as in broncho-pneumonia, which is usually present in cases requir- 
ing them. 

To diminish the chances of pneumonia, it is necessary that every 
patient should be kept in bed during the attack, and care exercised to 
avoid exposure ; that the chest should be protected with flannel and rubbed 
daily with oil. But still more important is it in hospitals and institu- 
tions where most of the cases of pneumonia occur, to allow the patients 
plenty of air space, never crowding them together in small wards. If pos- 
sible, cases complicated by pneumonia should be separated from simple 
cases. The pneumococcus and the streptococcus are found in the mouth 
in such numbers that systematic disinfection of the mouth may prove of 
value. 

The danger of diphtheria as a complication may be greatly lessened 
if during epidemics of measles in institutions every case receives an im- 
munizing dose of diphtheria antitoxin. This plan has been followed at 
the New York Foundling Hospital for several years with most striking 
benefit. 

The bronchitis and broncho-pneumonia of measles should be man- 
aged as when they occur as primary diseases, since the coexistence of 
measles furnishes no new indications. The same is true of the diarrhoea, 
conjunctivitis, and otitis. Membranous laryngitis, pharyngitis, or ton- 
sillitis should be treated like other cases of pseudo-diphtheria. Should 
cultures show the presence of the diphtheria bacillus, the case should be 
treated like one of ordinary diphtheria in the same situation. 

During convalescence the eyes should be used very carefully for at 
least several weeks. Should the cough and slight fever persist, with or 
without physical signs in the chest, the patient should, if possible, be 
sent away to a warm, dry, elevated district, as the development of tuber- 
culosis is always to be feared. Cod-liver oil should be given continuously 
throughout the succeeding cool season, and iron, wine, and other tonics 
according to indications. The cough itself should be treated as when it 
follows an ordinary bronchitis, creosote being more generally useful than 
any other drug. 



RUBELLA. 993 

CHAPTEE III. 
RUBELLA. 

Synonyms : German measles ; rotheln. 

Rubella is a contagious eruptive fever which is rarely seen except 
when prevailing epidemically. It is characterized by a short invasion, 
with mild, indefinite symptoms, usually lasting but a few hours, and by 
an eruption which is generally well marked but of variable appearance. 
The constitutional symptoms are very mild, and the disease rarely proves 
fatal, not often being even serious. For a long time rubella was con- 
founded with measles and scarlet fever, as the eruption sometimes resem- 
bles one and sometimes the other disease. Its identity is now fully estab- 
lished, and, as Strumpell well says, its existence is doubted only by those 
who have never seen it. The following peculiarities have been stated 
by Griffith (Philadelphia), who has written more fully on rubella than any 
other American writer, and to whom I am indebted for many facts in this 
article : 

( 1 ) Rubella is a contagious, eruptive fever, and not a simple affection 
of the skin; (2) it prevails independently either of measles or of scarlet 
fever; (3) its incubation, eruption, invasion, and symptoms differ ma- 
terially from those of both these diseases ; (4) it attacks indiscriminately 
and with equal severity those who have had measles and scarlet fever and 
those who have not, nor does it protect in any degree against either of 
them; (5) it never produces anything but rubella in those exposed to its 
contagion; (6) it occurs but once in the same individual. 

Etiology. — Rubella is beyond question contagious, but is decidedly 
less so than either measles or scarlet fever; so that some observers have 
doubted its contagion altogether. It can be communicated at any time 
during its course, but is especially contagious during the early stage. 
Epidemics usually prevail in the winter or spring. As in the other 
eruptive fevers, a striking immunity is seen in infants under six months 
old ; but, with this exception, all ages are liable to the disease. 

The incubation of rubella varies considerably; the usual period is 
from fourteen to twenty-one days, although the limits are from ten to 
twenty-two days. 

Symptoms. — Invasion. — This is rarely more than half a day, and in 
many cases no prodromata whatever are noticed, the rash being the first 
thing to attract attention. In a few cases there are mild catarrhal symp- 
toms, with general malaise and slight fever. At other times there may 
be vomiting, convulsions, delirium, epistaxis, rigors, headache, or dizzi- 
ness; but all are to be regarded as very exceptional. 

Eruption. — Frequently a child wakes in the morning covered with 
the rash, no symptoms having been previously noticed. It generally ap- 



994 THE SPECIFIC INFECTIOUS DISEASES. 

pears first upon the face, and spreads rapidly to the whole body, the lower 
extremities being last covered. Less than a day is usually required for 
its full development. Exceptionally the eruption comes first upon the 
chest and back, and sometimes nearly the whole body is covered almost 
at once. The rash is occasionally observed in the roof of the mouth 
before it is visible on the face. In a considerable number of cases the 
entire body is not covered ; but the rash is more constantly seen upon the 
face than upon any other part of the body. 

Its character is subject to considerable variation. The eruption is 
most frequently composed of very small maculo-papules ; they are of a 
pale-red colour, and vary in size from a *pin's head to a pea. The spots 
are usually discrete, but may cover the greater part of the body where it 
is seen. On the face it is frequently confluent, and often appears here 
as large, irregular blotches of a red colour. From this description the 
rash will be seen to resemble that of measles more than that of any other 
disease. Very often, however, there is a tolerably uniform red blush 
which bears a close resemblance to the rash of scarlet fever ; but even in 
such cases there will nearly always be found upon some part of the body, 
usually the wrists, fingers, or forehead, some typical maculo-papules. 
Between these two extremes all variations are seen. The colour of the 
eruption is sometimes dark red, and rarely it has been noted to be haemor- 
rhagic. The degree of elevation above the surface is also variable ; some- 
times this is so marked as to give to the skin a " shotty " feel, while in 
others the elevation is scarcely perceptible. The duration of the erup- 
tion is usually three days. Occasionally it lasts only two days, and it may 
last but one ; it is rare for it to remain as long as four days. It fades 
in the order of its appearance, and more rapidly than the eruption of 
measles. A slight brown pigmentation of the skin sometimes remains 
for a few days after the rash. 

The highest temperature is coincident with the full eruption; this 
does not usually exceed 101°, and often it is only 100° F. As a rule, 
the temperature continues but two days, falling as the eruption fades. 
Very often the fall to normal is abrupt. Earely more severe cases are 
seen in which the fever lasts for two or three days, being 101° or 102° F. 
during the invasion, and rising to 103° F. or more during the full erup- 
tion. The other symptoms are in most cases even less marked than the 
fever. Occasionally catarrhal symptoms resembling a mild attack of 
measles are present, or a sore throat suggesting mild scarlet fever; bub 
more frequently all these symptoms are absent. The eruption is usually 
out of all proportion to the other signs of disease. 

Swelling of the post-cervical glands is one of the most constant fea- 
tures of rubella. In most epidemics it is seen in nearly all cases; but 
as a symptom for differential diagnosis it is not of great importance, as 
it is not uncommon in measles. The glandular swelling is most marked 



RUBELLA. 995 

at the height of the disease; it is never very great, and subsides slowly 
without suppuration. Vomiting and diarrhoea are rare. Swelling and 
itching of the skin are usually present and sometimes marked. There is 
no leucocytosis in this disease. 

Forchheimer * has described an eruption on the mucous membrane of 
the throat, or " enanthem," which he believes to be characteristic. It con- 
sists of minute, bright, rosy-red points, seen on the uvula and soft palate, 
rarely on the hard palate. It is present only in the first twenty-four hours. 

Desquamation. — This is exceedingly variable. It is sometimes en- 
tirely wanting ; writers who have observed some fairly typical epidemics 
have stated that it did not occur. In most cases, however, some des- 
quamation is present, though it may be so slight as to be discovered only 
by a close examination. It is usually in the form of fine scales over the 
body and extremities. In a few cases it is more pronounced, and may 
be in larger flakes or patches. 

Prognosis. — There are few diseases so free from danger as rubella. 
Complications and sequelae are very seldom seen, and when present are 
usually of the mildest character. 

Diagnosis. — The principal interest attaching to rubella is in its diag- 
nosis. This is a matter of extreme difficulty, and often it is an impossi- 
bility. The characteristic thing about the disease is a well-marked erup- 
tion with very few other symptoms. Cases so closely resemble mild 
scarlet fever that the differentiation by symptoms may be impossible; it 
must be made by the circumstances under which it occurs, especially a 
prevailing epidemic. Scarlet fever with a low temperature and abundant 
rash should always be regarded with suspicion; also an abundant rash 
with little or no desquamation. The longer period of incubation in 
rubella may be of assistance. Koplik's spots furnish a valuable means of 
distinguishing measles from rubella. These difficulties in diagnosis can 
be appreciated only by one who has seen epidemics of measles and scarlet 
fever in institutions, and has watched the mild course of undoubted 
cases of these diseases which have there occurred. 

It is never safe to make the diagnosis of rubella unless the disease is 
prevailing epidemically. Sporadic cases in which this diagnosis is made 
are, I believe, almost invariably instances of mild measles or scarlet fever. 
The first cases of rubella in an epidemic are usually overlooked. The 
continued absence in succeeding cases of the characteristic symptoms and 
complications of measles or scarlet fever should suggest to the physician 
that he is probably dealing with rubella. 

Treatment. — None whatever is required for the disease excepting iso- 
lation, which should be complete until the diagnosis is positively deter- 
mined. The individual symptoms and complications are to be treated as 
they arise. 

* Archives of Paediatrics, 1898, 721. 



996 THE SPECIFIC INFECTIOUS DISEASES. 

CHAPTER IV. 

VARICELLA. 

Synonym: Chicken-pox. 

Varicella is an acute, contagious disease, characterized by a cuta- 
neous eruption of papules and vesicles and by mild constitutional symp- 
toms, serious complications and sequela? being very rare. Although long 
confounded with varioloid, its existence as a distinct disease has been 
generally admitted for many years. 

Etiology. — It is well established that the contagium of the disease is 
contained in the vesicles, as it may be communicated by inoculation with 
their contents. The specific poison, however, has not yet been isolated. 
Varicella is contracted by exposure to another case or through the me- 
dium of a third person. It affects children of all ages, one attack being 
as a rule protective. It is very contagious, resembling measles in this 
respect. The period of incubation is quite uniformly from fourteen to 
sixteen days. 

Symptoms. — Slight fever and general indisposition may be noticed 
for twenty-four hours before the appearance of the eruption, but in most 
cases the eruption is the first symptom. It usually appears first upon 
the face or trunk, as small, red, widely-scattered papules. The papules in 
most cases come in crops, new ones continuing to appear for three or 
four days, even upon the same part of the body. The earlier ones have 
generally begun to dry up by the time the later ones appear, so that all 
stages of the eruption may be present at one time in the same region, 
this being one of its diagnostic features. The papules are at first very 
small, but gradually increase in size, and are surrounded by an areola 
from one fourth to half an inch in width. Many of them go no further 
than this stage, but the majority become vesicular. The vesicles are 
usually flat, and vary a good deal in size — the largest being about one 
fourth of an inch in diameter. The process of drying up generally be- 
gins at the centre, which causes a slight depression, giving the vesicle 
a somewhat umbilicated appearance. The areola is most distinct at the 
time of the fully-formed vesicle, and fades as the latter dries. Crusts 
now form, which fall off in from five to twenty days, depending upon 
the depth to which the skin has been involved. In the majority of cases 
no mark is left, but after the most severe attacks, where the true skin 
has been involved, scars remain, and occasionally there is quite deep 
pitting. Such marks are few in number, and are most likely to occur 
upon the face. 

Sometimes, especially upon hands and feet, the vesicle appears with- 
out having been preceded by a papule ; often there is no areola, and the 



VARICELLA. 997 

vesicle resembles a drop of water upon healthy skin. In most cases pus- 
tules are not seen, but they may develop in consequence of irritation or 
infection, the result of scratching, or in children who are poorly nour- 
ished. Under these circumstances deeper ulceration may occur, lasting 
for weeks. In rare cases there may be a necrotic inflammation about the 
site of the pock, a condition to which is sometimes given the name vari- 
cella gangrenosa. It is not peculiar to varicella, and is described else- 
where under the head of Gangrenous Dermatitis (page 936). 

The pocks are usually most abundant over the back and shoulders. 
In mild cases only twenty or thirty may be found upon the entire body, 
but in severe cases the skin in certain regions may be nearly covered. 
The eruption is never confluent. The pocks are usually seen on the 
hairy scalp, and often on the mucous membrane of the mouth or pharynx 
— a point of some diagnostic value. In the latter situation the appear- 
ance is first as a tiny vesicle, and later as a superficial ulcer resembling 
that of herpetic stomatitis. Marfan and Halle have described cases of 
varicella of the larynx. Croupy symptoms were present, and in one 
case which proved fatal from pneumonia a tiny ulcer was found on the 
vocal cords. 

The temperature is highest when the eruption is most rapidly appear- 
ing, this usually being the second or third day. In an average case it 
reaches only 101° or 102° F., and lasts but two days; in severe cases it 
may rise to 104° or 105° F., and lasts for four or five days. It falls grad- 
ually to normal as the rash fades. The other symptoms are mild and 
not characteristic. 

Complications. — The most important complication is erysipelas, 
which develops about the pocks, particularly when they are deep and at- 
tended with some ulceration. I have known of three fatal cases from this 
cause. Adenitis, either simple or suppurative, and abscesses in the cel- 
lular tissue, are occasionally seen. Nephritis is very infrequent, but a 
number of cases are recorded. It may occur at the height of the dis- 
ease, but more often at a later period, like the nephritis of scarlet fever. 
Varicella is quite frequently complicated by other infectious diseases. In 
the New York Infant Asylum epidemics of varicella and scarlet fever at 
one time occurred together, and in at least a dozen children both diseases 
were seen at the same time. 

Diagnosis. — The diagnosis of varicella is usually easy, provided the 
following points are kept in mind: first, that the eruption comes out 
slowly and in crops, so that papules, vesicles, and crusts may be seen upon 
the skin in close proximity; secondly, that the umbilication is due only 
to the mode of drying up of the vesicle, which begins at the centre; 
thirdly, the appearance of the pocks upon the mucous membranes, and 
the history of exposure. It is distinguished from urticaria and other 
forms of skin disease by the presence of fever. 
64 



998 THE SPECIFIC INFECTIOUS DISEASES. 

Treatment. — Although it is usually a trivial disease, isolation of cases 
of varicella should be enforced in schools and in institutions containing 
many infants. In the home, unless the other children are delicate or in 
poor condition, quarantine is unnecessary. The disease may probably be 
conveyed as long as the crusts are present, hence isolation should be 
maintained until they have fallen off. In most cases constitutional symp- 
toms of the disease are so mild as to require no treatment. 

Locally, the itching, when annoying, may be allayed by sponging 
with a weak solution of carbolic acid or the use of carbolized vaseline. 
When the crusts have formed, this ointment or vaseline containing two 
per cent ichthyol should be applied. Care is necessary to keep the skin 
clean, and, in the case of infants, to prevent scratching. In severe cases 
the urine should invariably be examined. 



CHAPTER V. 
VACCINIA— VACCINA TION. 

Vaccinia (cowpox) is a febrile disease induced in man by inocula- 
tion with the virus obtained either directly from the cow (bovine virus) 
or from a person who has been inoculated (humanized virus). The dis- 
ease is not contagious in the ordinary sense of the term, but is communi- 
cated by inoculation either accidental or intentional. 

The nature of the protection against smallpox which vaccination 
affords is even now but imperfectly understood. The fact, however, re- 
mains one of the best attested in medical history. Its effect when sys- 
tematically practised is graphically shown in the accompanying chart 
(Fig. 201). It is the imperative duty of the physician to see to it that 
every young infant is vaccinated. 

Re-vaccination. — Regarding the duration of the protective power of 
a single vaccination, positive statements are impossible. Nearly all 
writers are agreed that vaccination should be done in infancy, again at 
puberty, and a third time at about the age of twenty or twenty-five. 
Many also insist upon re-vaccination at about the seventh year. It is a 
safe rule when smallpox is prevalent to vaccinate every person who has 
not been successfully vaccinated within five years. 

Choice of Lymph. — The substitution of bovine for humanized virus 
is now well-nigh universal. It has precluded the possibility of trans- 
mitting syphilis and greatly lessened the chances of other forms of in- 
fection. A further advance has lately been made by the introduction of 
" glycerinated " lymph. As now prepared, the lymph is taken from the 
calves under the most rigid aseptic precautions and emulsified with 



VACCINIA— VACCINATION. 



999 



glycerin. The few saprophytic bacteria present soon die, so that when 
properly prepared the glycerinated virus is practically sterile.* It should 



PRUSSIA. 



WITH COMPULSORY VACCINATION, AND 

COMPULSE' RE-.'-CCINATION 
AT THE AGE OF 12. 



After the Law of 1874 
was passed. 



1808-1874 
Average 
yearly Deaths 
from small- 
pox In every 

100,000 
Inhabitants. 



Il.-lllllll.. 



Annual Deaths 

from small-pox 

in every 100,000 

Inhabitants. 



HOLLAND. 

WITH COMPULSORY VACCINATION OF CHILDREN 
BEFORE ENTERING A SCHOOL. 



After the Law of 1873 
was passed. 



1800-1872 

Average 

yearly Deaths 

from small. 

pox in every 

100,000 
inhabitants. 



iLii 



Annual Deaths 

from small-pox 

in every 100,000 

Inhabitants. 



AUSTRIA, 



_11D 



.100 



1808-1874 
Average 
yearly Deaths 
from small- 
pox in every 

100,000 
inhabitants. 



Annual Deaths 

from small-pox 

in every 100,000 

Inhabitants. 



4 

70 | 



1 
50Q 



_ 30 



Fig. 201. — Table showing the protective power of vaccination. (Carsten.) 

not be distributed until it has been carefully tested for pathogenic organ- 
isms of all kinds, particularly the tetanus bacillus. It is preserved and 
distributed in capillary tubes hermetically sealed; these are much safer 



* Reliable glycerinated lymph is prepared by the New York Health Department, 
Mulford & Co., and Parke, Davis & Co. For an excellent paper on Clinical Aspects 
of Vaccination, see Fielder, Medical News, March 30, 1901. On Vaccination Infec- 
tions, see Kubin, Medical Record, April 6, 1901. 



1000 THE SPECIFIC INFECTIOUS DISEASES. 

than quills or ivory points, which may easily become contaminated by 
handling. After the lymph has been taken, the calves are killed in order 
to make certain that they are free from disease. The practical advan- 
tages of glycerinated lymph are so great that it has been officially 
adopted by the Governments of the United States, Great Britain, Ger- 
many, and many other countries. 

Time for Vaccinating. — In selecting a time for vaccination, the child's 
age and general health must be taken into consideration. It is pretty 
well established that the constitutional disturbance is much less in in- 
fancy than in later childhood, and less in very young infants (under one 
month) than in those of five or six months. A good rule for general 
practice is to vaccinate every healthy infant as soon as its nutrition is 
established, this being in most cases during the first three months of 
life. In delicate infants or in those whose nutrition is a matter of 
great difficulty, those who are syphilitic, those suffering from eczema or 
any other form of active skin disease, vaccination should be deferred 
until the child is in good condition, unless it is likely to be exposed to 
smallpox. As a rule, vaccination should be avoided during dentition. 

Methods of Vaccinating. — In my experience it is better to vaccinate in 
one place rather than to make two or three inoculations. If more than 
one is made they should be at least an inch apart. Either the leg or the 
arm may be chosen ; in young infants it is usually easier to protect the 
vaccine sore upon the leg than upon the arm ; in children oldi enough 
to run about, the arm is to be preferred, as being more easily kept at rest. 
The point selected for inoculation should be either the outer aspect of the 
left calf, about the junction of the middle with the upper third of the leg, 
or, if the arm is chosen, the insertion of the left deltoid. The skin should 
be washed with soap and water, dried, and then washed with alcohol. 

The New York Health Department supplies with each tube of lymph, 
a needle, a bit of rubber tubing, and a tooth-pick with one flat end. The 
needle should be sterilised in an alcohol flame, and three or four small 
scratches made not more than one-eighth of an inch long, just deeply 
enough to draw blood. The ends of the capillary tubes are broken off, 
one end inserted in the rubber tube, and the lymph blown out of the 
tube upon the broad end of the tooth-pick, then applied to the scratched 
surface and rubbed in for a full minute. The wound should not be 
covered until dry ; this usually requires from fifteen to twenty minutes. 
It may then be covered with a sterilised bandage, or isinglass plaster 
moistened in boiled water. If thoroughly dried no dressing is neces- 
sary. The limb should not be washed for twenty-four hours. 

The Normal Course of Vaccinia. — The course of a proper vaccination- 
pock is quite uniform, and one which does not follow this course should 
not be considered protective. The wound heals and nothing is noticed 
until the third or fourth day, when a red papule makes its appearance. 



VACCINIA— VACCINATION. 



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1002 THE SPECIFIC INFECTIOUS DISEASES. 

Usually in twenty- four hours more a small vesicle appears which enlarges 
until the sixth or seventh day, reaching its full development about the 
ninth day. Its shape and size depend somewhat upon the inoculation 
(Fig. 202). The vesicle is usually from one-fourth to one-half inch 
in diameter; it is of a pearly-gray colour and has a depressed centre. 
During the next two days an areola forms about the vesicle extending 
from it a variable distance, usually one or two inches into the healthy 
skin. Its size depends upon the intensity of the infection. This areola 
is normally of a bright red colour and accompanied by some induration. 
It is generally at its height on the ninth or tenth day. The vesicle usu- 
ally dries down to a firm, dark crust which remains from one to three 
weeks and falls off, leaving a bluish scar which fades to white, becoming 
somewhat honey-combed. When the process is at its height some consti- 
tutional disturbance is usually present; there may be loss of appetite, 
fretfulness, and general indisposition, and the temperature is usually ele- 
vated from one to three degrees. The lymph nodes in the groin or axilla 
may be tender and swollen. These symptoms generally last for three or 
four days. 

If in a young infant the first inoculation is unsuccessful, at least 
three trials should be made with good virus, and in the event of further 
failure, after a year vaccination should be repeated. A failure to inocu- 
late does not mean insusceptibility to smallpox, as is often popularly be- 
lieved, but most frequently arises from the fact that the virus is inert. 
I have known one case in which the seventh, and another in which the thir- 
teenth, inoculation was successful after previous failures; occasionally 
there are seen children who can not be inoculated at all. 

Constitutional symptoms, as previously stated, may be absent in very 
young infants; but in others there is quite constantly present a fever 
which runs a fairly regular course. It usually begins on the fourth or 
fifth day, is remittent in type, and rises gradually, reaching its high- 
est point with the full development of the vesicle. At this time it varies 
from 101° to 104° F., falling gradually to normal. The duration of the 
fever in cases running the usual course is four or five days. Accompany- 
ing the fever there may be anorexia, restlessness, loss of sleep, slight in- 
digestion, and other symptoms of a general indisposition. 

Both the local and the general symptoms are sometimes more severe. 
This may depend upon the susceptibility of the child, the lymph being 
pure and the vaccination properly done. The original vesicle may be 
much larger than usual, and small secondary vesicles may form in the 
neighbourhood (Fig. 202). In very rare instances a generalized erup- 
tion of true vaccine vesicles occurs with marked fever and other general 
symptoms of corresponding severity. Single vesicles may be produced 
on distant parts of the body as a result of auto-inoculation, usually by 
scratching. Where eczema of the face is present, inoculation is not infre- 



VACCINIA— VACCINATION. 1003 

quently carried thither. Most of the very sore arms and legs, however, 
are due to infection from pyogenic bacteria contained in the lymph, or 
to their accidental introduction at the time of vaccination or subse- 
quently. In the milder cases, the swelling and other evidences of local in- 
flammation are more marked than in a normal vaccination; a drop or 
two of pus forms beneath the scab, and when the latter comes away an 
excavation is left which heals in two or three weeks. Or, the inflamma- 
tion may extend more deeply into the connective tissue, to be followed by 
more extensive suppuration or sloughing, leaving an ugly ulcer an inch 
or more in diameter which slowly fills by granulation in from five to eight 
weeks. Sometimes the period of incubation is unduly prolonged, so that 
the vesicle does not form until the twelfth or fourteenth day, although 
its subsequent course may be normal. In other cases, the incubation is 
shorter than usual, and the vesicle may appear as early as the third or 
fourth day. 

Much has been written about the so-called " raspberry excrescence " 
which not very infrequently takes the place of a proper vesicle. It is of 
a dark-red colour, elevated, smooth or slightly granular, not sensitive, 
having no areola and no constitutional symptoms. It generally per- 
sists for two or three weeks, and slowly disappears, leaving no scar. It is 
usually the result of virus of feeble activity, and if it gives any protection 
it is very slight. Such cases should always be re-vaccinated, and in my 
experience re-vaccination is usually successful. 

Complications and Sequelae. — Post-vaccine eruptions are many and 
of great variety. The most frequent is a general roseola, sometimes 
resembling scarlet fever, but much oftener measles, and usually occurring 
at the height of the local process. Other eruptions seen are urticaria, 
various forms of erythema, and, rarely, purpura. Other complications 
are chiefly from mixed infection. Syphilis and tuberculosis are practi- 
cally excluded by modern methods of procuring the lymph. Tetanus can 
result only from carelessness or neglect of suitable precautions in pre- 
paring the lymph; proper legal restrictions regarding its production 
should in the future make this impossible. The most common form of 
local infection is cellulitis, which may terminate in suppuration or 
sloughing at the site of vaccination, and sometimes may cause suppura- 
tion of the neighbouring lymph nodes. In rare cases, general septicaemia 
or pyaemia may follow. Impetigo contagiosa sometimes occurs. Ery- 
sipelas may develop at any time before the vaccine sore is entirely healed ; 
I saw it once as late as the sixth week. Pneumonia and nephritis may be 
associated with any of the more serious complications. Latent tubercu- 
losis may become active after vaccinia, and a child who is subject to 
eczema is liable to a recurrence. In a delicate child a condition of mal- 
nutrition is often intensified if the vaccinia is at all severe. 

The mortality of vaccination is stated by Voigt, from careful statis- 



1004 THE SPECIFIC INFECTIOUS DISEASES. 

tics drawn from German sources, to have been 35 in 2,275,000 cases, in- 
cluding both primary and secondary vaccinations. Of the deaths, 19 
were due to erysipelas, 8 to gangrene, 2 to cellulitis, 3 to " blood poison- 
ing," and 3 to other causes. The occurrence of tetanus after vaccinia has 
already been mentioned. With proper precautions in preparing lymph it 
will not occur. In fact, nearly all the deaths are from causes which are 
preventable. 

Treatment. — The whole purpose of treatment is to prevent infection. 
The first essentials are a clean limb, pure virus, and a clean needle ; the 
next, to allow thorough drying of the wound before the clothing touches 
it. After this nothing is necessary until the vesicle forms. Then the im- 
portant thing is to prevent scratching and the irritation of the clothing. 
All vaccine shields are objectionable. For an infant nothing is better than 
the sterilized bandage, which can be kept in place by sewing to the stock- 
ing or sleeve of the shirt. Any constriction of the limb is injurious. 
For older children the simplest dressing is a pad of sterile gauze fast- 
ened to the limb by two pieces of adhesive plaster. Should the vesicle 
rupture and discharge serum, it should be kept clean and dry by dusting 
daily with boric acid. When the local symptoms are at all severe the 
limb should be kept at rest. An infected vaccination wound, like any 
other infected wound, requires careful surgical treatment; disastrous 
results often follow the use of poultices and other applications much in 
vogue in domestic practice. 



CHAPTEE VI. 
PERTUSSIS. 

Synonym : Whooping-cough. 

Pertussis is a contagious disease which prevails epidemically and in 
most large cities endemically. Although it may affect persons of any 
age, it is generally seen in young children, and as a rule it occurs but once 
in the same individual. While in later childhood pertussis may be ranked 
as one of the milder infectious diseases, in infancy it is one of the most 
fatal. Its principal complications are broncho-pneumonia and convul- 
sions. Pertussis is characterized by catarrhal and nervous symptoms. 
The catarrh affects the mucous membrane of the respiratory tract, and is 
probably due to a specific form of infection. It is accompanied by a hy- 
peraesthetic condition of this mucous membrane. The most prominent 
nervous manifestation is a peculiar spasmodic cough which occurs in 
paroxysms, and from which the disease takes its name. The cough is no 
doubt of reflex origin, from an irritation which has been located by dif- 
ferent writers in various parts of the respiratory tract. In addition to 



PERTUSSIS. 



1005 



these conditions, there is present in pertussis a marked irritability of the 
nervous system, which in infancy often shows itself by convulsions. 

Etiology. — Everything that is known of pertussis suggests a micro- 
organism as its cause. Present evidence, moreover, points strongly to a 
bacillus, first described by Eppendorf, afterward more fully by Joch- 
mann and Krause. An important recent contribution to this subject 
has been made by Dr. Martha Wollstein from the laboratory of the 
Babies' Hospital. She not only confirmed previous observations as to 
the constant presence of this organism from a study of thirty cases of 
pertussis, but obtained characteristic agglutination reactions with the 
blood of children suffering from the disease. The bacillus belongs to the 
influenza group, and in many points resembles Pfeiffer's bacillus.* 

Proximity to a patient, is all that is required to communicate the 
disease, and even close proximity is not necessary. There seems to be no 
doubt that the disease may be contracted in the open air. 

Predisposition. — Fully one half the cases of pertussis occur during the 
first two years of life. The following are the statistics of Szabo (Buda- 
Pesth), showing the ages at which the disease was met with in 4,591 
cases, comprising the records of one clinic for thirty-four years : 



Under one year 1,028 cases. 

One to two years 1,008 " 

Two to three years 659 " 



Three to four years 904 cases. 

Four to seven years 803 " 

Over seven years 189 " 



Pertussis thus shows a stronger tendency to affect young infants than 
does any other contagious disease. A number of cases are on record in 
which it has occurred during the first month, and one has recently come 
to my notice where a child twelve days old was attacked, whose mother 
was suffering from the disease. The disease is nearly twice as frequent in 
the winter and spring as in the summer and autumn. Epidemics of per- 
tussis often occur at the same time with or follow those of .measles. 

The susceptibility to pertussis is very great, and is equalled only by 
that to measles. Biedert reports that of 401 children exposed during an 
epidemic in a certain village, 366, or ninety-one per cent, took the disease. 



* The bacillus is found in the mucus expelled after the typical paroxysm. This 
should be received in a sterile dish and washed several times in sterile or peptone 
water. Examined in smears, the organism appears as a short, plump, ovoid bacillus 
lying singly or in clumps between the pus and epithelial cells. It decolourizes when 
stained by Gram's method. It grows best on blood-agar plates. It is non-motile. 
According to Wollstein the bacillus agglutinates with the blood of pertussis patients 
in dilutions as high as 1-200, and occasionally 1-500. This reaction was not found 
until the third week of the attack and was present as late as three months. The 
bacilli were present in greatest numbers after the cough had continued for about two 
weeks, but were very numerous throughout the paroxysmal stage, being found as late 
as the eighth week of the disease. 



1006 THE SPECIFIC INFECTIOUS DISEASES. 

Infective period. — Pertussis may be communicated from the very be- 
ginning of the catarrhal stage ; it is more contagious at this period than 
later. There seems little doubt that it is contagious throughout the 
spasmodic stage and possibly longer. Quarantine is generally required 
for two months, and in many cases for a longer time. The usual source 
of the contagion is the patient, rarely the room or the clothing. While 
pertussis may be carried by a third person, this is very unlikely unless 
one has been in very close contact with the patient, and goes at once 
without change of clothing to another child. 

Incubation. — The very gradual onset of pertussis renders it impos- 
sible in the majority of cases to fix the exact date, and hence to establish 
the definite duration of the period of incubation. In cases where this 
could best be determined it has usually been from seven to fourteen 
days, or about the same as in measles. If, after an exposure, sixteen 
days pass without the development of a cough, the probabilities are very 
strong that the disease has not been contracted. 

Lesions. — The only constant lesion of pertussis consists in a catarrhal 
inflammation of varying intensity, which affects the mucous membrane 
of the larynx, trachea, and bronchi, and sometimes that of the nose and 
pharynx. If the child dies during a paroxysm, either with or without 
convulsions, the brain is found intensely congested and may be the seat 
of punctate haemorrhages, or even larger extravasations. The lungs 
always show emphysema if the attack has been severe or protracted. 
The other pulmonary lesions are due to complications, the most fre- 
quent of which is broncho-pneumonia. Catarrhal enteritis and colitis 
are not infrequent. 

Symptoms. — The symptoms of pertussis are usually divided into three 
stages — the catarrhal, the spasmodic, and the stage of decline. 

The catarrhal stage continues on the average for about ten days, al- 
though cases show considerable variation on this point. Some children 
whoop almost from the very beginning of the disease, while others may 
cough for three or four weeks before a typical whoop is noticed. The 
symptoms in the beginning are indistinguishable from those of an ordi- 
nary attack of subacute tracheo-bronchitis, and unless there has been an 
exposure to pertussis no suspicion is excited. After five or six days, how- 
ever, the cough, instead of abating as in an ordinary cold, gradually in- 
creases in severity and occurs in paroxysms. At first these are mild, 
and there are only two or three a day, but they gradually increase in 
frequency and severity until the typical whoop is heard which marks 
the beginning of the spasmodic stage. During the first stage there may be 
symptoms of a mild grade of catarrhal inflammation of the nose, pharynx, 
and larynx, and often there is a slight elevation of temperature. 

The spasmodic stage. — In a typical paroxysm of average severity the 
child, who can usually foretell it, will often run for support to the lap of 



PERTUSSIS. 1007 

the mother or the nurse, or seize a chair with both hands. There now 
occurs a series of explosive coughs, from ten to twenty in number, com- 
ing in such rapid succession that the child can not get its breath between 
them ; the face becomes of a deep red or purple colour, sometimes almost 
black; the veins of the face and scalp stand out prominently; the eyes 
are suffused, and seem almost to start from their sockets ; there follows 
a long-drawn inspiration through the narrowed glottis, producing the 
crowing sound known as the whoop; and then another succession of 
rapid coughs follows and another whoop. In a single severe paroxysm, 
which lasts two or three minutes, the child may whoop half a dozen 
times; with the final paroxysm a mass of tenacious mucus is usually 
brought up. In a young child vomiting is almost certain to follow, if 
food has been recently taken. Epistaxis sometimes occurs with nearly 
every severe paroxysm, but in most cases the bleeding is slight. After 
a severe attack the child is at times so exhausted as to be hardly able to 
stand; there is profuse perspiration; his mind is confused, and he may 
be completely dazed. In infants the attack may result in a degree of 
asphyxia requiring artificial respiration. Those old enough to describe 
their sensations tell of a sense of impending suffocation, the suffering 
from which is almost indescribable. 

The number of severe paroxysms or " kinks " in twenty-four hours 
varies, according to the severity of the case, from half a dozen to forty 
or fifty. There are always many more of a milder form. Paroxysms 
are often excited by eating or drinking anything cold, by a draught of air, 
or by imitation; they are usually more frequent during the night than 
the day, and in a close room than in the open air. 

In less severe cases no paroxysms of the grade above described may 
occur, and no typical whoop may be heard throughout the attack; but 
the paroxysmal nature of the cough which continues until the plug of 
mucus is expelled, the watery eyes, and the vomiting which follows a 
paroxysm, stamp the disease as pertussis. In young infants the whoop 
is frequently not marked. The child sometimes coughs until it is as- 
phyxiated, and yet no whoop occurs. The paroxysms are also modified 
by intercurrent disease, especially by attacks of pneumonia or severe 
bronchitis. At such times they usually become less frequent and less 
typical, and may be absent for several days, returning as the complica- 
tion subsides. 

The seat of the irritation which produces the cough has been various- 
ly located by different observers: some have thought it to be in the nose, 
others in the trachea, the bronchi, or the larynx. It is very probable that 
it may not always be in the same place and that the infectious catarrh, 
which is really the most important element in the disease, may vary in 
its intensity and location in different cases. The weight of evidence seems 
to be that in the great majority of cases the source of irritation is in 



1008 THE SPECIFIC INFECTIOUS DISEASES. 

the larynx or trachea. From laryngoscopic examinations made during 
the disease, Von Herff found the mucous membrane of the larynx to be 
swollen and congested, and occasionally the seat of small haemorrhages 
or superficial ulcers. He states that the frequency and severity of the 
paroxysms corresponded with the degree of laryngitis, and he found that 
a paroxysm could always be excited by irritating the mucous membrane 
between the arytenoid cartilages. During a paroxysm he observed that 
there was a collection of mucus on the posterior laryngeal wall, the re- 
moval of which had the effect of shortening the paroxysm. 

Rossbach made laryngoscopic examinations, with negative results so 
far as the larynx was concerned, but he states that a plug of mucus could 
always be seen in the lower trachea for one or two minutes before the 
paroxysm occurred. There is little doubt that this collection of mucus is 
the exciting cause of the paroxysm, as it is a familiar clinical fact that 
the paroxysm always continues until this is dislodged. 

The average duration of the spasmodic stage is about one month. It 
increases in intensity for the first two weeks, remains stationary for 
about a week, and then gradually diminishes in severity. The course and 
duration of this stage are, however, subject to wide variations. In mild 
cases it may last only a week; in severe cases, especially in the winter 
season, it may continue for three months, at times almost subsiding, but 
lighting up again with all its previous severity with every fresh attack of 
cold. After it has entirely ceased the whoop may return with an attack 
of bronchitis, and continue for a month or more. This is not to be re- 
garded as a true relapse of pertussis. The habit of the paroxysmal cough 
once established, it tends to recur with every slight bronchitis, often for 
months afterward. 

The stage of decline. — Gradually the severity of the paroxysms abates, 
the whoop ceases, and the cough resembles more and more that of ordi- 
nary bronchitis. This stage usually continues about three weeks, but 
may be prolonged indefinitely in the winter months. 

Complications. — Haemorrhages. — The haemorrhages of pertussis are 
mechanical, and depend upon the intense venous congestion which accom- 
panies the paroxysm. Epistaxis is the most frequent variety, and occurs 
in a considerable proportion of the severe cases, in a few with almost 
every severe paroxysm, but it is rarely severe enough to require local 
treatment. Haemorrhages from the mouth may have their origin either 
in the pharynx or the bronchi, the blood being brought up by the cough; 
such haemorrhages are usually small. Conjunctival haemorrhages are less 
frequent, and are usually slight, although I have seen the entire con- 
junctiva covered. In a case under my observation there was bleeding 
from both ears with every severe paroxysm, for more than a week. This 
child had previously suffered from scarlatinal otitis, with perforation of 
the drum membrane. Small extravasations into the cellular tissue be- 



PERTUSSIS. 1009 

neath the eyes are occasionally seen, giving an appearance somewhat 
like an ordinary " black eye." Intracranial haemorrhages are not fre- 
quent, but many examples have been recorded, and they may be severe 
enough to produce death. They are usually meningeal, very rarely 
cerebral; according to their extent and location they may produce 
hemiplegia, monoplegia, aphasia, facial paralysis, or disturbances of 
sight, hearing, or sensation; in addition, there may be convulsions or 
rigidity, but rarely complete coma. The extravasations are usually 
small, and the symptoms which they produce disappear at the end of a 
few weeks. Fatal cases with autopsies have been reported by Cazin, 
Marshall, and others. In almost every instance these haemorrhages have 
f- occurred as a direct result of the severe paroxysms. Purpura haemor- 
rhagica as a sequel of pertussis was twice seen at the New York Infant 
Asylum. 

Respiratory system. — The most serious complications of pertussis are 
connected with the lungs. By far the largest proportion of deaths is due 
to pulmonary complications, usually broncho-pneumonia. This is more 
frequent in winter and spring than in the summer months, and is espe- 
cially to be dreaded during infancy. In later childhood lobar pneumonia 
is occasionally seen. Pneumonia rarely begins before the second week 
of the disease, and most frequently develops at the height or toward the 
close of the spasmodic stage. The physical signs present no peculiarities ; 
the cough changes somewhat in character during the pneumonia, and 
the whoop may not be heard. The prognosis of the pneumonia is bad, 
because of the debilitated condition of the children at the time of its oc- 
currence. A great danger is from the supervention of convulsions, this 
being a frequent mode of termination. As there is always considerable 
emphysema the rapidity of breathing is frequently out of proportion to 
the temperature, which often is only moderately elevated. If the child 
escapes the dangers of the acute stage, death may still occur from ex- 
haustion, owing to the protracted course which the disease frequently 
runs (seepage 551). 

Bronchitis of the large tubes is present in almost all the severe 
cases, and is not of itself serious. Bronchitis of the small tubes has 
the same dangers and the same complications as broncho-pneumonia. 

Vesicular emphysema has been present, I think, in every case which 
I have seen upon the post-mortem table ; a certain amount of it, no doubt, 
occurs in every severe case. It is produced by the forcible cough of the 
paroxysm. In very severe cases interstitial emphysema is also found. 
Northrup has reported a remarkable instance of this complication. Rup- 
ture of the air-blebs which form on the surface of the lung may lead to 
emphysema of the cellular tissue of the mediastinum, and the air may 
find its way along the great vessels into the neck, and finally into the 
subcutaneous cellular tissue of the entire body. Cases of general sub- 



1010 THE SPECIFIC INFECTIOUS DISEASES. 

cutaneous emphysema have been reported by Croker and by Hodge, 
both of which ended fatally, one in three and one in eight days from 
the beginning of the emphysema. In the great majority of the cases 
vesicular emphysema is not permanent. 

Digestive system. — During the summer, infants with pertussis are 
almost certain to suffer from diarrhoea; it may be only an occasional 
symptom, or the attack may be severe and prolonged, resulting in the de- 
velopment of ileo-colitis. The intestinal complications may be almost 
as serious in summer as are those of the respiratory tract in winter. 
Vomiting is even more frequent than diarrhoea, and while it may be dis- 
tressing at any age, it is especially so in infancy. So frequently does the 
taking of food excite vomiting, that the nutrition of these patients often 
becomes a matter of the greatest difficulty, and in fact the most serious 
problem in the management of a case. Malnutrition and even marasmus 
may follow, or the general resistance of the child may become so reduced 
by lack of food that it falls a ready prey to pneumonia. 

Nervous system. — There may be convulsions, coma, paralysis, aphasia, 
disturbances of sight or hearing, and in rare cases even of the mental con- 
dition. The most serious of these complications are convulsions. They 
are much more frequent in infancy than later, and particularly in those 
who are rachitic, in whom they are often fatal. Convulsions are of 
course more common in severe attacks, but they may occur suddenly where 
there has previously been no cause for anxiety. They are especially to be 
dreaded if pneumonia is present. The attack of convulsions may be the 
culmination of the extreme degree of nervous irritability which accom- 
panies the paroxysm, it may be due to asphyxia, or to an intracranial 
lesion ; if the latter, there is usually meningeal haemorrhage. This is to 
be suspected if there are continued convulsions for several hours, with 
general rigidity or hemiplegia. 

Disturbances of sight are not infrequent in severe cases; usually 
these are transient, but there may be blindness lasting two or three 
days or even weeks. The transient symptoms depend most likely upon 
circulatory changes that occur in the brain during the paroxysm, 
while those which last for two or three weeks are probably due to 
meningeal haemorrhage. Disturbances of hearing are rare. The dif- 
ferent forms of paralysis occurring with pertussis may likewise be 
transient or permanent. They are to be explained in the same way 
as the disturbances of the special senses. The most common form is 
hemiplegia. 

Albuminuria is not infrequent, being found in 66 of 86 examinations 
by Knight. The quantity of albumin is rarely large, and it may be ac- 
companied by a few hyaline casts. Both are probably the result of circu- 
latory disturbances in the kidney. Other complications of pertussis are 
hernia, prolapsus ani, and ulcer of the frenum linguae. 



PERTUSSIS. 1011 

Diagnosis. — The only constant features of pertussis are the course of 
the disease and its communicability. In many cases the typical whoop is 
never heard. There are no symptoms by which a positive diagnosis can 
be made in the catarrhal stage; but a cough not accompanied by fever or 
physical signs, which steadily increases in severity for two weeks, in spite 
of treatment, and which occurs chiefly at night, is always suspicious. 
When, in addition, the cough begins to come in paroxysms, accompanied 
by suffusion of the face and occasionally by vomiting, there can be little 
doubt even though no whoop is heard. If the disease is prevalent the 
diagnosis is practically certain. Mild cases which do not go even as far 
as the symptoms mentioned are most puzzling. But if there is a history 
of exposure, if the cough continues from four to six weeks, little influ- 
enced by treatment, and if other cases follow, the disease must be per- 
tussis. Without evidence of communicability, however, one may be in 
doubt even after the disease is over. In early infancy any cough may 
have more or less of a spasmodic character, and a fairly typical whoop is 
often heard in the course of an ordinary bronchitis. I have several 
times seen abortive or very short attacks in one member of a family of 
children, the others having the disease in a typical form. Occurring by 
themselves such cases cannot be recognised. 

Irritation of the pneumogastric or recurrent laryngeal nerve from en- 
larged tracheal or bronchial lymph nodes, whether of a simple or tuber- 
culous character, may give rise to a spasmodic cough, which in certain 
cases may be indistinguishable from pertussis. The prolonged duration 
of these cases is sometimes the only diagnostic point ; but the paroxysms 
are usually not so severe as in true pertussis, and the course is generally 
less typical. 

The presence of leucocytosis may be an aid to diagnosis in some 
doubtful cases.* 

Prognosis. — The most important factor in the prognosis of the dis- 
ease is the age of the patient. After the fourth year it is indeed rare 
that either a fatal result or serious complications are seen; but during in- 
fancy, and particularly during the first year, there are few diseases more 
to be dreaded. This is especially true on account of the connection of 
whooping-cough with the three most fatal conditions of infantile life — 
broncho-pneumonia, diarrhoeal diseases, and convulsions. Fully two 
thirds of the deaths from whooping-cough occur during the first year of 

* Frohlich and Meunier first called attention to the leucocytosis accompanying 
pertussis, far exceeding that of any other afebrile disease of the respiratory tract. It 
appears in the early part of the convulsive stage, and disappears slowly with improve- 
ment. The count is usually between 15,000 and 25,000, although 51,000 has been 
recorded. The differential count shows an increase in the lymphocytes at the expense 
of the neutrophiles. The leucocytosis is little influenced by complications, and even 
during broncho-pneumonia the lymphocytes may continue to be in excess. 



1012 THE SPECIFIC INFECTIOUS DISEASES. 

life. The prognosis is very much worse in infants under three months 
than in those who are older and consequently have more resistance. It is 
better in the summer than in the winter, because broncho-pneumonia is 
then less frequent. It is particularly bad in delicate infants, in those 
who are rachitic, in those who are prone to attacks of bronchitis, in 
those who have suffered previously from pneumonia, and in those with 
a strong tendency to tuberculosis. 

The exact mortality of whooping-cough it is difficult to state in fig- 
ures. During the first year of life it is probably not far from twenty-five 
per cent, although it diminishes rapidly after this time. In foundling 
asylums and hospitals for infants it is to be ranked among the most fatal 
diseases, and in some epidemics the mortality in such institutions is as 
high as fifty per cent. 

Fully two thirds of the deaths during whooping-cough are from 
broncho-pneumonia ; the next most frequent cause is diarrhceal diseases. 
Convulsions may be the mode of death in either of the above conditions, 
or may occur apart from them. During the first year, death often results 
from marasmus, the child having been reduced by the prolonged disease. 
Occasionally death is due to asphyxia following a severe paroxysm, to 
intracranial haemorrhage, or to general emphysema. 

As a predisposing cause of tuberculosis, pertussis is second only to 
measles. In both diseases tuberculosis develops in much the same way 
and from practically the same causes. 

Prophylaxis. — Pertussis is a contagious disease, and a child suffering 
from it should be isolated from other children whenever this is possible. 
Children with pertussis should never be allowed to attend school, and 
needless exposure should always be avoided. 

Young infants, delicate children, and those with a predisposition to 
tuberculosis, should be most carefully protected against exposure, since it 
is in them chiefly that the disease is likely to be serious. As it is from 
the patient that the disease is nearly always contracted, there does not 
exist the same necessity for the fumigation and disinfection of apart- 
ments as after other contagious diseases. In institutions, however, this 
should always be practised, and in private houses if the room is subse- 
quently to be occupied by an infant. 

It is as undesirable as it is impossible to confine a child with pertus- 
sis to a single room during the attack; all those persons for whom expo- 
sure would be dangerous should therefore be sent away from the house. 
Quarantine should continue for at least six weeks, or until the spas- 
modic stage is over. 

Treatment. — We have as yet no specific remedy for pertussis. The 
important thing in most cases is the hygiene or general management of 
the case; fully half of the cases seen in practice require nothing more. 
Much harm is done by indiscriminate drugging. 



PERTUSSIS. 1013 

General measures. — Fresh air is important throughout the attack. It 
is almost invariable that the paroxysms are fewer while patients are out 
of doors, and more frequent when they are in close rooms. Older chil- 
dren with pertussis may go out even in winter except on stormy, raw, or 
windy days. With infants and delicate children, the outdoor treat- 
ment in cold weather so enthusiastically advocated by. some writers 
should be used with the greatest caution. It should certainly not be per- 
mitted if the patient has even the slightest amount of bronchitis. My 
own experience is that during the winter in a climate like that of New 
York or New England, the class of patients just referred to are better 
off indoors, taking their airing, if at all, in their rooms. In warm 
weather or in a mild climate all children should be kept in the open air 
as much as possible. 

A change of climate is desirable when the cough is unduly prolonged, 
also for delicate children in winter. A warm place at the seashore is 
one which is most likely to be beneficial. The improvement following a 
sea voyage is often very marked, surpassing even a residence at the sea- 
shore. 

The rooms occupied by children suffering from pertussis should be 
frequently changed, thoroughly aired, and occasionally fumigated. The 
daily use in the room of one of the small formalin lamps is of decided 
benefit. A change of rooms, clothing, bedding, etc., sometimes exerts a 
marked influence on the course of very prolonged attacks, the inference 
being that continued re-infection takes place. Such a change should be 
made twice a week, and it is of special importance in hospitals, where 
many children quarantined in a ward seem to cough interminably. 

Careful feeding and attention to the bowels are matters of the great- 
est importance; with infants particularly, chronic indigestion and ab- 
dominal distention have a very marked effect in increasing the frequency 
of the paroxysms. Feeding is difficult since vomiting occurs so easily. 
In most cases it is necessary to repeat the meal in a short time, if 
the first one has been vomited. Children over two years old should in 
all such cases be kept upon a fluid diet, chiefly of milk. For infants, milk 
should be diluted, and in many instances it should also be partially pep- 
tonized. Any medication which causes disturbance of the stomach 
should be omitted. In severe cases the child's strength should be kept 
up by the judicious use of alcoholic stimulants. 

Local treatment. — This may be effected by insufflations of powder into 
the nose, by local applications to the larynx, or by inhalations. 

The first two methods have been advocated, in the belief that the 
cough is due to an infectious catarrh having its seat in the nose or 
larynx. For insufflation, quinine or benzoic acid is preferred, mixed 
with some finely divided, inert powder, such as bicarbonate of sodium, 
talcum, or coffee; these are used with the powder insufflator once or 
65 



1014 THE SPECIFIC INFECTIOUS DISEASES. 

twice daily. Local applications to the larynx may be made by means 
of a spray or swab. Kesorcin and carbolic acid, each in a one-per-cent 
solution, are most used. These applications are made once or twice 
daily. I have never seen from any of the above methods the beneficial 
results claimed, and I believe them to have been exaggerated. The 
application of cocaine to the larynx should never be employed in young 
children on account of the danger of poisoning. 

Inhalations are of much more value. They are useful to modify the 
catarrh by allaying irritation, facilitating the expulsion of the mucus, and 
possibly as antiseptics. Those most employed are carbolic acid, creosote, 
and cresolene. In my experience creosote is the best. These subr 
stances may be used upon cotton in a respirator, or vapourized over an 
alcohol lamp (page 60). The possibility of absorption should not be 
forgotten, and the urine should be watched. Where the paroxysms are 
frequent and of great severity, chloroform may be used to ward off con- 
vulsions or prevent dangerous asphyxia. In such conditions O'Dwyer 
used intubation with striking benefit. The tube entirely overcomes the 
glottic spasm which is the chief cause of suffering and danger. O'Dwyer's 
plan was to have the tube worn constantly until the severity of the dis- 
ease had passed. With the rubber tubes now in use the difficulty in get- 
ting rid of the tube subsequently is not great. 

Internal medication. — Of the innumerable drugs which have been rec- 
ommended for this disease, four possess undoubted advantages over all 
others — viz., quinine, belladonna, bromoform, and antipyrine. Quinine 
should not be used for infants and seldom for young children on ac- 
count of its tendency to upset the stomach. For older children full 
doses are required to be of much benefit — i. e., twelve to fifteen grains 
daily to a child of five years. In giving belladonna it is important to 
begin with a small dose and gradually increase both its frequency and 
size until the physiological effects of the drug are produced. To an 
infant two years old, one fourth of a minim of the fluid extract may be 
given every four hours as an initial dose, gradually increasing to every 
two hours ; if atropine is used, gr. -g-J-Q ma y De given in the same way. Al- 
though belladonna usually has a decided influence in reducing both the 
frequency and the severity of the paroxysms, it causes many unpleasant 
symptoms, and its effects must be closely watched. 

Bromoform has considerable value, but it is by no means a specific. 
A convenient method of administration is to drop it upon sugar. When 
prescribed in emulsions or mixtures these should be carefully shaken 
before each dose, or the patient may be poisoned by getting the greater 
part of the drug in the last few doses. The dose at two years is from 
one to three drops, at &ve years two to four drops from three to five 
times a day. In full doses it must be used with caution. 

Antipyrine has been in my experience more generally useful than 



PERTUSSIS. 1015 

any other single drug. It may be given with safety, even to young in- 
fants, in considerably larger doses than are ordinarily employed. For a 
child six months old the initial dose may be one grain every three hours ; 
later this may be given every two hours. For a child two years old the 
initial dose may be two grains repeated every four to six hours, gradually 
increasing up to two grains every two hours. Should pneumonia de- 
velop, the antipyrine should be discontinued. 

Nearly all drugs which allay nervous irritability have a certain amount 
of effect in controlling the paroxysms of pertussis; codeine, chloral, and 
trional are useful where the night attacks are so severe as to prevent 
sleep. A combination of the bromide of sodium with antipyrine is often 
better than the latter given alone. Heroin, although in use but a short 
time, promises to be a valuable addition to our therapeutics. I do not 
believe that any form of internal medication or local treatment shortens 
pertussis; but, inasmuch as the disease is self-limited, great benefit to 
the patient results from the reduction of the number and the diminu- 
tion of the severity of the paroxysms. 

In establishing the value of any method of treatment, it should be 
remembered that the number of cases in which the disease is considerably 
shorter than the average is large, and also that almost any method of 
treatment if employed after the attack has reached its height will be 
thought beneficial, as the natural tendency is then to improve. The value 
of any particular line of treatment is to be judged in a given case only 
by its effect in reducing the number and severity of the paroxysms. This 
ought to be evident in the case of drugs within two or three days, and can 
only be determined by keeping a careful record of the number of severe 
paroxysms day and night. No drug succeeds equally well in all cases. 

In a mild case, where the number of paroxysms does not exceed 
eight or ten during the day, where there is no vomiting and the gen- 
eral health is not affected, it is not usually advisable to continue the 
administration of any drugs throughout the disease. A single dose of 
antipyrine or codeine at night may be all that is necessary. All cases 
in infants must be watched with great care and the parents warned of 
the possible dangers which may supervene suddenly, even in the course 
of mild attacks. For severe cases antipyrine should be given to diminish 
the frequency and the severity of the paroxysms, and inhalations of 
creosote used if much catarrh is present. All the fresh air possible 
should be allowed. For older children the same plan of treatment may be 
followed, or quinine or belladonna may be substituted for the antipyrine. 

As these drugs are given solely for the purpose of diminishing the 
frequency and severity of the paroxysms, their continuous use should be 
deferred until the symptoms are sufficiently severe to greatly disturb the 
child, the benefit at this period being more striking than if they are 
begun early and used continuously. 



1016 THE SPECIFIC INFECTIOUS DISEASES. 

CHAPTEE VII. 
MUMPS. 

Synonym : Epidemic parotitis. 

Mumps is a contagious disease characterized by swelling of the par- 
otid, and sometimes of the other salivary glands, with constitutional 
symptoms which are usually mild. Both severe complications and a 
fatal termination are extremely infrequent. The disease is not a very 
common one, and general epidemics are rare. 

Pathology and Lesions. — The contagious character, definite incuba- 
tion, and typical course, stamp the disease as a general one due to a spe- 
cific poison, probably a micro-organism, whose nature is as yet unknown. 
It is probable that infection takes place through the salivary ducts. 

The precise nature of the changes in the gland is still a matter of 
dispute, as opportunities for pathological examination are very rare. 
From existing evidence it would appear that the gland substance is first 
involved, and afterward the surrounding connective tissue. The gland 
is the seat of an intense hyperemia and oedema ; the walls of the salivary 
ducts are swollen, and the ducts are obstructed. While the primary dis- 
ease does not tend to excite suppuration, pyogenic germs may occasionally 
gain entrance and an abscess form; but this is to be regarded as a rare 
accidental infection. 

In the great proportion of cases the parotids alone are affected, al- 
though the same changes are occasionally found in the other salivary 
glands. There are no other essential lesions of the disease, those which 
are found depending upon complications. 

Etiology. — Mumps is spread by contagion, close contact being usually 
required to communicate the disease, although it is known to have been 
carried by a third person and even by clothing. The susceptibility of 
children to the poison of mumps is much less than is the case with the 
other contagious diseases, so that only a small number of those who are 
exposed take the disease. The greatest predisposition is between the 
fourth and fourteenth years. Infants are rarely affected, although a 
case in a child three weeks old is vouched for by so good an observer as 
Demme. 

Mumps is contagious from the beginning of the symptoms. Two cases 
have come under my notice in which the disease was communicated 
before any swelling was seen. It is impossible to fix with certainty the 
duration of the infective period. The disease is undoubtedly communi- 
cable for several days after the swelling has subsided; and for safety a 
case should be isolated for three weeks from the beginning of symptoms, 
or at least ten days after the swelling has disappeared. 



MUMPS. 1017 

Incubation. — In forty-eight collected cases in which the incubation 
was definitely determined, it varied between three and twenty-five days. 
It was less than fourteen days in only four cases, and in twenty-six of 
the forty-eight cases it was between seventeen and twenty days. In three 
cases of my own in which it could be definitely fixed, the incubation was 
nineteen days in one case and twenty days in two cases. The average 
period of incubation, then, may be stated to be from seventeen to 
twenty days. 

Symptoms. — In the milder cases the local symptoms are the first to 
attract attention; in those which are more severe there are frequently 
prodromal symptoms of from twelve to forty-eight hours' duration — 
anorexia, headache, vomiting, pains in the back and limbs, and fever. 
Soltmann has reported a case ushered in by convulsions. The initial 
temperature in a mild attack is 100° to 101° F. ; in a severe one, from 
102° to 104° F. 

Of the local symptoms, the pain usually precedes the swelling; it is 
increased by movement of the jaws, by pressure, and sometimes by the 
presence of acid substances in the mouth. It is usually referred to the 
posterior part of the jaw just below the ear. The swelling may begin 
simultaneously in both parotids, but more frequently one side is involved 
a day or two in advance of the other. It usually reaches its maximum on 
the third day, often on the second, remains stationary for two or three 
days, and then subsides gradually. The degree of swelling varies with 
the severity of the attack. When it is marked, the patient may be so 
changed in appearance as scarcely to be recognisable; it fills the lateral 
region of the neck between the jaw and the sterno-mastoid muscle and 
extends forward upon the face to the zygomatic arch, so that the centre 
of the tumour is usually the lobe of the ear. The other salivary glands 
may swell simultaneously with the parotids, or several days later, even 
after the parotid tumour has disappeared. Occasionally swelling of the 
submaxillary or the sublingual glands occurs before that of the parotid, 
and in rare instances these may be the only glands affected. 

As a rule, the parotid of both sides is involved. Of 282 cases both 
sides were affected in 215. When one side alone is involved, it is the 
left a little more frequently than the right. The interval between the 
swelling of the two sides may be a week, or even five or six weeks, but 
usually it is only two or three days. 

The salivary secretion is usually very much diminished, and the dry 
mouth causes great discomfort. An exceptional instance has been re- 
ported by Simon, in which a distressing salivation occurred, the secre- 
tion amounting to six or eight ounces daily. 

Although as a rule the patient is not seriously ill, mumps may in rare 
cases produce most alarming and even dangerous symptoms. The tem- 
perature may for several days reach 104° F. or more, deglutition may be 



1018 THE SPECIFIC INFECTIOUS DISEASES. 

extremely difficult, pressure on the jugular veins may lead to venous 
hyperemia of the brain, causing headache and sometimes delirium ; there 
is sometimes great prostration and the symptoms of the typhoid condi- 
tion. These severe attacks are nearly always in children over twelve 
years old. 

The constitutional symptoms of mumps usually last from three to 
five days ; the swelling continues on an average a little less than a 
week. If the case has been a severe one, slight swelling may continue 
for two weeks or even longer. Relapses, in which the opposite side from 
the one first affected is involved, are quite frequent, occurring in about 
ten per cent of the cases. 

Complications and Sequelae. — In childhood the complications are few 
and usually unimportant ; but in adolescence they are occasionally seri- 
ous. Orchitis is exceedingly rare in childhood; of 230 cases observed by 
Rilliet and Barthez, this was seen in but 10, and only 3 of these cases 
were under fifteen years, and no case under twelve years old. When or- 
chitis occurs it is generally toward the end of the second or the beginning 
of the third week; it is usually marked by an accession of fever, sometimes 
by a chill; if severe, nervous symptoms may be present. The body of 
the testicle and not the epididymis is generally affected. The acute 
symptoms continue for three or four days, and the entire duration of the 
attack is about a week ; although the testicle is often enlarged for some 
time afterward, and atrophy of the organ may follow. 

In females, congestion and swelling of the breasts, ovaries, or labia 
majora may occur; and, although these complications are all very rare, 
most of them have been observed even in young children. 

Nephritis has in a few instances followed mumps, sometimes coming 
on as late as four or five weeks after the attack. Single cases have been 
reported by Croner, Isham, Henoch, and others. Nervous sequelae are 
more frequent, but even these are rare. Jaffrey has reported a case of 
multiple neuritis with typical symptoms, occurring three weeks after an 
attack. Facial paralysis three weeks after mumps has been reported by 
Hillier, apparently due to an extension of inflammation from the gland 
to the seventh nerve. 

Pearce * has collected an interesting series of forty cases of deafness 
following mumps, in which there was no sign of otitis, the symptoms 
coming on suddenly with vertigo, a staggering gait, and often with vomit- 
ing. In most of the cases the deafness was unilateral and the loss of 
hearing was permanent. The cause assigned was disease of the auditory 
nerve, the seat of the trouble being in the labyrinth. Toynbee has re- 
ported an instance of haemorrhage into the labyrinth. Otitis media is 
rarely seen. 

* Manchester Chronicle, 1885. 



DIPHTHERIA. 1019 

Suppuration of the parotid gland occurs in about one per cent of 
the cases, and is probably due to accidental infection. Gangrene and 
sloughing of the parotid were observed twice by Demme in 117 cases; 
both of these proved fatal. Pneumonia, meningitis, endocarditis, and 
pericarditis have been observed as complications of mumps, although 
all are extremely rare. 

Prognosis. — In the great proportion of cases mumps is a mild dis- 
ease, and terminates in complete recovery in a few days. In young chil- 
dren complications are infrequent, and those which occur are rarely 
severe. 

Diagnosis. — Mumps is most likely to be confounded with acute swell- 
ing of the cervical lymph nodes. In a parotid swelling, the lobe of the 
ear is near the centre of the tumour, which extends backward to the 
sterno-mastoid muscle and forward upon the face as far as the zygomatic 
arch, embracing the angle and ramus of the jaw. 

A swollen lymph node is usually entirely below the ear and behind 
the jaw, not extending upon the face. The tumour is generally smaller 
and more circumscribed if only a single node is involved, and it comes on 
much more slowly than does mumps. When only the submaxillary or sub- 
lingual glands are affected, the diagnosis from swollen lymph nodes is 
sometimes impossible except by the course of the disease. Mumps is 
characterised by the rapidity with which the swelling occurs, and by its 
relatively short duration. 

Treatment. — The disease is self-limited and the individual symptoms 
rarely distressing, so that in most cases very little treatment is required. 
If constitutional symptoms are present the patient should be kept in 
bed, and if there are none he should be confined to the house. The gland 
should be protected by cotton or spongio-piline, and if the pain is severe 
heat should be applied or the gland painted with belladonna. The diet 
should be liquid, on account of the pain produced by mastication. The 
mouth should be kept clean by the use of some antiseptic mouth-wash. 
The general symptoms and complications are to be treated according to 
the indications presented. Cases of mumps occurring in schools or insti- 
tutions should be quarantined for three weeks, and in private practice 
where there are susceptible persons. Fumigation and disinfection after 
an attack are unnecessary. 



CHAPTER VIII. 
DIPHTHERIA. 

Until within the last few years it was customary to class as diph- 
theria all diseases characterised by the production of a false membrane 
upon the mucous membranes of the throat or air passages. In the fol- 



1020 THE SPECIFIC INFECTIOUS DISEASES. 

lowing pages the term diphtheria will be limited to those cases in which 
the Klebs-Loeffler bacillus is present, the others being grouped under the 
head of false or pseudo-diphtheria. 

Diphtheria may then be defined as an acute, specific, communicable 
disease due to the bacillus of Klebs and Loeffler. It is usually charac- 
terised by the formation of a false membrane upon certain mucous mem- 
branes, especially those of the tonsils, pharynx, nose, or larynx. Like 
other pathogenic organisms, however, this germ acts with varying in- 
tensity, and may cause inflammation of all degrees of severity, from 
a mild catarrhal angina to the most serious membranous inflammation ; 
but to all alike the term diphtheria should be applied. In its mild form 
it may be almost without constitutional symptoms ; but in its severe form 
it is attended by great general prostration, cardiac depression, and 
anaemia, it is frequently complicated by pneumonia and nephritis, and 
it may be followed by localised or general paralysis; it then constitutes 
one of the diseases most to be dreaded in childhood. 

Etiology. — The Bacillus Diphtheria?. — This was first described by 
Klebs in 1883, and during the following year it was isolated by Loeffler 
and shown to be pathogenic. It varies considerably in size and shape 
even in the same culture. In a specimen it occurs singly or in pairs, 
sometimes in chains of three or four; the bacilli may lie parallel, but 
frequently two form an acute or an obtuse angle (Plate XIX, 3, 4, and 
5). They are straight or slightly curved, and sometimes branching; they 
may be swollen or club-shaped at their ends. 

Distribution and mode of communication. — In most large cities diph- 
theria prevails endemically, with periods in which outbreaks of con- 
siderable severity are observed. In the country it prevails chiefly as 
an epidemic. The disease is often introduced into remote districts in 
some inexplicable manner, and before its nature is recognised a large 
number of persons may be exposed, and an epidemic results.* 

Diphtheria does not arise de novo. Every case has its origin in a 
previous case either directly or remotely. The bacilli may enter the 
body through the inspired air; they may be taken into the mouth with 
toys or other articles upon which they have lodged, or by kissing, and 

* The following is an example of the way in which diphtheria may be introduced : 
In the country branch of the New York Infant Asylum, consisting of a somewhat 
isolated community of about five hundred persons, chiefly children, there had been 
no case of diphtheria for several years. The first case was one of membranous laryn- 
gitis, rapidly proving fatal in two days. The case was regarded at that time as 
evidence of the existence of a primary non-diphtheritic membranous croup. In the 
course of the next few weeks there developed a number of cases of typical diphtheria. 
On investigation, it was discovered that the nurse who had charge of the child first 
affected had been a few weeks before in attendance upon a case of diphtheria. During 
the five years following, cases of diphtheria occurred in the institution every year. 



DIPHTHERIA. 1021 

sometimes by accidental inoculation. As a rule, the bacilli first gain a 
foothold upon the mucous membrane of the tonsils, nose, or larynx. 

Direct infection is the cause in the great majority of the cases. 
There is no proof that the bacilli are contained in the breath of a person 
suffering from the disease. They are present in great numbers in the 
saliva and mucus from the mouth and nose, often being distributed by 
sneezing and coughing, and also in pieces of membrane which are dis- 
charged ; they are not present in the urine or faeces. The most contagious 
cases are those of pharyngeal diphtheria on account of the amount of dis- 
charge which accompanies them. The least contagious are those in which 
the membrane is limited to the larynx and lower air passages. 

Direct infection may occur from persons convalescent from diph- 
theria, whose throats still contain virulent bacilli, or from persons suf- 
fering from a mild form of the disease, which is not recognised as diph- 
theria. In the latter way it is often spread in schools. It has been 
repeatedly shown that a person may harbour virulent bacilli in his nose 
or throat, and may even communicate the disease to others, without him- 
self suffering from diphtheria at any time. 

The length of time during which a patient with diphtheria may con- 
vey the disease to others is somewhat uncertain. Transmission is possi- 
ble so long as virulent bacilli remain in the throat; these are frequently 
found two weeks after the membrane has disappeared and the patient is 
regarded as entirely well, and in a few cases they are found five or six 
weeks or longer after recovery. 

Indirect infection is not uncommon, and may occur from the bed or 
clothing of the patient, from the carpet, furniture, wall-paper or hang- 
ings of the room, from toys or picture-books, from dishes, feeding bottles, 
or drinking-cups, from swabs and brushes used for local applications 
to the throat, from spoons and tongue-depressors, and from surgical 
instruments with which tracheotomy or intubation has been done. 
Diphtheria may be carried by a third person, but rarely except by one 
who has been in close contact with the patient — either the physician or 
nurse. The frequency of diphtheria in physicians' families bears wit- 
ness to the great danger of infection in this manner. 

Bacilli may retain their virulence for an indefinite period. Both 
Park and Loeffler found cultures in blood-serum to be virulent after 
seven months; Roux and Yersin, bacilli in dried membrane to be viru- 
lent after twenty weeks ; and Abel, upon a child's toy after five months. 

Domestic animals may in rare instances be carriers of infection, and 
in the case of pigeons, at least, they may themselves suffer from the dis- 
ease. Diphtheria has been repeatedly spread by milk, but very rarely 
through the contamination of a water supply. 

Predisposing causes. — Local conditions in the throat influence very 
largely the occurrence of diphtheria. An important predisposing cause 



1022 THE SPECIFIC INFECTIOUS DISEASES. 

is the existence of a chronic catarrhal inflammation of the mucous mem- 
branes of the nose and throat, so frequently found in children suffering 
from adenoid growths of the pharynx or from enlarged tonsils. These 
adenoid growths, the tonsillar crypts, and the cavities of carious teeth, 
may harbour the bacilli for a considerable time both before and after 
an attack. The condition of the mucous membranes of the nose and 
pharynx in other acute infectious diseases furnishes a marked predis- 
position to diphtheria. This is most striking in the case of measles 
and scarlet fever; it is seen less frequently in typhoid fever and 
influenza. 

The two sexes are about equally liable to the disease. Children 
under ten are much more often affected than those who are older, the 
greatest susceptibility as regards age being between the second and fifth 
years. 

While diphtheria is seen throughout the year, it is more frequent 
during the cold than the warm months. 

The incubation of diphtheria is short. In most of the cases in which 
it could be definitely traced it has been between two and five days. The 
virulence of the bacillus varies much in different cases and in different 
seasons, and while it is frequently true that persons infected from a 
mild type of the disease have a mild attack, and those infected from a 
malignant one a severe attack, there is no certainty that such will be the 
sequence. Dr. W. H. Park informs me that, out of many hundreds tested 
in the laboratory of the New York Health Department, by far the most 
virulent bacillus was obtained from the throat of a boy who had what 
was clinically a very mild form of tonsillar diphtheria. 

The immunity conferred by one attack of diphtheria is of compara- 
tively short duration, amounting probably to a few months only. In- 
stances have recently been reported where a second attack occurred within 
two months of the first, although antitoxin was used. 

Lesions. — The essential lesions of diphtheria consist not in the pro- 
duction of a membrane, but, as long ago pointed out by Oertel, and more 
recently by Babes, Sidney Martin, and others, in certain acute degenera- 
tive changes in the cells of the body caused by the diphtheria toxins. 
These changes are seen particularly in the epithelial cells of the affected 
mucous membranes, the heart muscle, the kidney, the liver, the central 
and peripheral nervous system, the spleen, and the lymph glands; the 
most characteristic being those of the nerves and the liver. There are 
other lesions which are the result of the action of other organisms, espe- 
cially the streptococcus pyogenes and the pneumococcus, either alone, 
together, or in conjunction with the diphtheria bacillus. The most im- 
portant lesions due to these organisms are broncho-pneumonia and ne- 
phritis ; but there may be found in the blood, and in many of the organs 
of the body, the evidences of the invasion of these bacteria — i. e., a 



DIPHTHERIA. 



1023 



streptococcus septicaemia, less frequently a general pneumococcus in- 
fection. 

Distribution of the diphtheria bacillus in the body. — Unlike many 
other pathogenic organisms, the diphtheria bacillus is not in most cases 
widely distributed throughout the body. It is found in great numbers 
on the surface of the affected mucous membranes and in the false mem- 
brane itself, particularly in its superficial portion, but it does not invade 
deeply the subjacent structures. 

The frequency with which the diphtheria bacillus and other organ- 
isms are found in the blood and viscera is shown in a series of 209 autop- 
sies studied by Councilman, Mallory, and Pearce, of Boston, in 1901. 
The following table shows the percentage of cases in which the different 
bacteria were found by culture : 



Diphtheria bacillus 

Streptococcus 

Staphylococcus aureus. 
Pneumococcus 



Heart's blood. 



6 per cent. 
20 

2-5 " 
1-5 " 



Liver. 



20 per cent. 
30 

4 

2-5 " 



Spleen. 



12 per cent. 
27 

3 

1-5 " 



Kidneys. 



19 per cent. 
28 

8 

5 



In this series, 153 cases were pure diphtheria; 56 were complicated 
by measles or scarlet fever or both. The streptococcus was much oftener 
found in the viscera in the complicated cases ; otherwise there was little 
difference in the two groups of cases. 

The diphtheria toxins. — The wide-spread effects seen in diphtheria 
are due to the action of certain substances called toxins which the diph- 
theria bacillus produces during its growth on mucous membranes. They 
are very diffusible, readily entering the lymphatic circulation and the 
blood, and through these channels may affect the entire body. In sus- 
ceptible animals there may be produced by the injection of these toxins 
all the characteristic lesions of diphtheria except the membrane, as well* 
as the essential symptoms of the disease, even including paralysis. For 
the production of the membrane living bacilli are required. 

" Catarrhal " diphtheria. — The routine practice of making cultures 
from diseased throats has established the fact that catarrhal inflamma- 
tion may often be the only result of diphtheritic infection. Although 
to the naked eye there were only the ordinary changes of a simple in- 
flammation, Oertel found the characteristic degenerative changes in the 
epithelial cells, varying in degree with the severity of the process. 

The diphtheritic membrane. — The membrane in diphtheria is most 
frequently seen upon the mucous membrane of the tonsils, soft palate, 
uvula, pharynx, nose, larynx, trachea, and bronchi ; less frequently upon 
the mouth, lips, oesophagus, conjunctivae, middle ear, stomach, and geni- 
tal organs. It may also affect fresh wounds, notably a tracheotomy 
wound, or any abraded cutaneous surface. The gross appearance of the 



1024 THE SPECIFIC INFECTIOUS DISEASES. 

membrane varies greatly (Plate XVIII). It is most frequently of a gray 
or mouse-colour, but it may be pearly white, yellow, green, and sometimes 
almost black. It is composed of fibrin, cells, granular matter, and bac- 
teria. Its consistency varies with the relative proportions of the differ- 
ent elements. When made up chiefly of fibrin it is firm and retains its 
form, often being discharged as a complete cast of the nose, larynx, or 
trachea. When the amount of fibrin is small the membrane is soft, 
friable, and sometimes granular. It is more closely adherent upon the 
mucous membranes covered with squamous epithelium, as in the phar- 
ynx and upper air passages, than upon those covered with columnar and 
ciliated epithelium, as in the lower air passages. 

The microscopical examination shows the fibrin to be sometimes 
granular, but usually in the form of a network, inclosing in its meshes 
small round cells and epithelial cells in various stages of degeneration. 
On the surface and in the superficial layer there is usually found quite a 
variety of bacteria including diphtheria bacilli. Beneath this is a cellu- 
lar layer containing little or no fibrin, in which also the diphtheria ba- 
cilli are usually found. In the deepest parts of the false membrane and 
in the mucous membrane itself they are few in number or absent. 

Characteristic changes, which are similar in all the affected mucous 
membranes, are found in the epithelial cells, which undergo marked 
degeneration with fragmentation of their nuclei; the mucosa is infil- 
trated with leucocytes. The infiltration with small round cells is vari- 
able in degree in the different mucous membranes; in some it extends 
deeply into the submucous and even the muscular layers, while in others 
it is very superficial. Marked evidences of degeneration are seen also 
in the cells infiltrating the deeper layers. In places the epithelium is 
detached, in others the line between the false membrane and the gran- 
ular mucous membrane is scarcely distinguishable. 

The seat and the distribution of the membrane. — This varies some- 
what with the age of the patient, the season, and the peculiarity of the 
epidemic. 

My own records show that the larynx is involved in about 40 per cent 
of the cases in children under three years. In general the statement may 
be made that the younger the child the greater the liability of the disease 
to attack the larynx; also when the larynx is affected, the greater the 
tendency to spread to the trachea and bronchi. The larynx and lower 
air passages are rather more frequently attacked in winter than in 
summer. 

The tonsils are the most frequent and usually the earliest seat of the 
diphtheritic membrane; it may form here a tough, leathery patch, par- 
tially or completely covering and very adherent to them; or the disease 
may affect only the tonsillar crypts, so that the gross lesion may resem- 
ble that of ordinary follicular tonsillitis. There is in most cases only 



DIPHTHERIA. 1025 

moderate swelling, but it may be so great that the tonsils are in contact. 
The surrounding cellular tissue is infiltrated with inflammatory products. 

The membrane covering the pharynx and uvula is also usually very 
adherent and intimately blended with the mucous membrane. The 
uvula is swollen and cedematous. Membrane may be seen only upon the 
fauces and uvula, or the posterior and lateral pharyngeal walls may be 
covered down to the level of the cricoid cartilage, but generally not 
below this point. If the posterior pharyngeal wall is covered, the mem- 
brane is apt to extend into the rhino-pharynx, and may fill the entire 
pharyngeal vault, covering the posterior portion of the velum and ex- 
tending into the posterior nares. The adenoid tissue of the vault is fre- 
quently the part most affected. 

The nose may be involved secondarily to the rhino-pharynx, or infec- 
tion may be through the anterior nares; if the latter, it is not infre- 
quently the only part involved. Many cases classed as nasal are really 
rhino-pharyngeal. The membrane in the pure nasal cases is usually 
thick and tough and often separates en masse. Both sides are generally 
involved, but it may be unilateral. 

The observations of Councilman, Mallory, and Pearce have shown 
that it is very common for the accessory sinuses of the nose, especially 
the antrum of Highmore, to be involved in fatal cases. It seems highly 
probable that infection of these parts explains the remarkable persist- 
ence of diphtheria bacilli in the nose which is occasionally seen. 

The epiglottis is swollen to three or four times its normal thickness, 
and the aryteno-epiglottic folds are cedematous. The anterior surface 
of the epiglottis is rarely covered by membrane; but its lateral borders 
and posterior surface, and the aryteno-epiglottic folds are involved in 
most of the severe pharyngeal cases (Plate XVIII, C). This lesion is 
associated with pharyngeal rather than with laryngeal diphtheria. 

The lesions which extend most deeply are thus seen in the tonsils, 
uvula, pharynx, and epiglottis. But even here there is very rarely deep 
or extensive sloughing. 

The lesions of the larynx, trachea, and bronchi are similar to the 
above, although much more superficial. The interior of the larynx may 
be completely covered, the membrane coating the true and false vocal 
cords and lining the ventricles of the larynx. The membrane in the 
larynx is not usually very adherent, and it frequently separates and is 
coughed up in large pieces or even as a cast. That covering the epiglot- 
tis and the aryteno-epiglottic folds is very adherent, like that in the 
pharynx. Catarrhal laryngitis is not an uncommon complication of 
pharyngeal diphtheria. 

In a considerable number of cases the membrane stops abruptly at 
the lower border of the larynx. In the trachea it is generally loosely 
attached, and often it is found at autopsy entirely separated from the 



1026 THE SPECIFIC INFECTIOUS DISEASES. 

mucous membrane. It is almost invariably associated with membrane in 
the larynx. Usually the membrane in the bronchi is continuous with 
that in the trachea. Occasionally I have seen the trachea and larger 
bronchi passed over and found membrane only in the larynx and smaller 
bronchi. As a rule, the bronchi of both sides are affected, and to the 
same degree. I once saw a case of laryngeal diphtheria in which mem- 
brane was found only in the bronchi of one lung. The above exceptions 
are to be explained as accidents in the mechanical transportation of 
bacilli. 

The extent of the membrane varies greatly in different cases. It 
may stop at the bifurcation of the trachea or at the bifurcation of the 
primary bronchi; but if it goes beyond this point it is likely to extend 
to the minutest subdivisions. Exceptionally a very tough fibrinous 
membrane forms in the trachea and bronchi, of sufficient thickness and 
consistency to be expelled as a cast, reproducing almost the entire bron- 
chial tree. 

The inflammation of the mucous membrane of the larynx, trachea, 
and bronchi is very much less severe and more superficial in character 
than that of the pharynx, tonsils, and upper air passages. 

The buccal cavity is very seldom covered by the membrane; but 
in the worst cases of pharyngeal disease it may line the cheeks, cover 
the lips, gums, and more or less of the hard palate, but rarely the 
tongue. It usually occurs in patches rather than as a continuous mem- 
brane. In one case I saw the membrane on the lower lip, extending 
on to the face, though the buccal cavity was free. It is not common 
for the diphtheritic membrane to spread down the digestive tract. In 
127 autopsies studied by Councilman, Mallory, and Pearce, in which 
the extent of the membrane was carefully noted, it was found twelve 
times in the oesophagus, five times in the stomach, and once in the 
duodenum. The amount of membrane varied from small striations on 
the folds of the stomach or oesophagus to a complete covering. The 
accompanying changes consist in infiltration, haemorrhage, and cell 
degeneration. In the intestines there is often found a hyperplasia of 
the lymphoid elements — solitary follicles and Peyer's patches — with 
changes similar to those in the lymph nodes elsewhere in the body, but 
nothing else that is characteristic. 

The writers just referred to found otitis, usually double, in 60 per 
cent of 144 autopsies ; although in less than one third of the number was 
the complication recognised during life. Mastoid disease is infrequent. 
Otitis is usually the result of direct extension from the pharynx. It may 
be due to the diphtheria bacillus alone, to the streptococcus alone, or more 
frequently to both combined; occasionally the pneumococcus is found. 
Conjunctival diphtheria is rare and probably due to accidental infection 
rather than extension through the lachrymal duct. Before the advent of 



DIPHTHERIA. 1027 

antitoxin, it almost invariably resulted in destruction of the eye; but a 
number of cases successfully treated have now been reported, and one has 
recently come under my own observation. Diphtheria may attack any 
muco-cutaneous surface, especially the anus, prepuce, or female genitals ; 
any abraded cutaneous surface, or recent wound, most frequently the 
tracheotomy wound of the neck. The diphtheria bacilli have been found 
in pure culture in superficial abscesses. 

Visceral lesions. — The visceral lesions * of diphtheria are due partly 
to the action of the diphtheria toxins and partly to the invasion of the 
body with other organisms, especially the streptococcus. It is to experi- 
mental diphtheria that we owe our most accurate knowledge of the for- 
mer changes, for in human diphtheria the large proportion of all the 
fatal cases show infection with other organisms, particularly the strepto- 
coccus, to a less degree the pneumococcus or staphylococcus. The fre- 
quency with which these bacteria are found at autopsy in different 
organs has been already stated. 

The visceral lesions of diphtheria consist in wide-spread areas of cell 
degeneration similar to those which have already been described as oc- 
curring in the epithelial cells of the affected mucous membranes, to- 
gether with haemorrhages due to changes in the blood-vessels and pos- 
sibly in the blood itself. 

The lymph nodes of the cervical region are the most constantly and 
the most seriously affected. Similar but less marked changes are seen 
in the tracheo-bronchial and the mesenteric groups, and in the lymph 
nodules of the mucous membrane of the stomach and intestine. There 
are degenerative changes in the cells of the nodes most affected, with 
marked infiltration with leucocytes and frequently small haemorrhages. 
The cellular tissue in the neighbourhood of the cervical nodes is often 
extensively infiltrated with cells. The process in the lymph nodes usu- 
ally terminates in resolution, rarely in suppuration. 

The changes in the spleen are quite constant. The organ is swollen, 
sometimes very much so, and deeply congested. Haemorrhages are often 
seen beneath the capsule ; the spleen pulp is soft, the follicles are large, 
and cell degeneration is quite constantly observed similar to that which 
takes place in the lymph nodes. 

There are frequently small haemorrhages beneath the capsule of the 
liver, and sometimes these are seen throughout the organ. There are 
found scattered through the liver, areas of necrotic hepatic cells which 
are peculiar to this disease; some of these areas are infiltrated with 
leucocytes. 

* For an exhaustive study of the pathological anatomy of diphtheria, see mono- 
graph of Councilman, Mallory, and Pearce (Boston, 1901) ; being a study of 220 fatal 



1028 THE SPECIFIC INFECTIOUS DISEASES. 

The kidneys are involved in almost all fatal cases except where death 
occurs early from laryngeal stenosis, also in nearly every severe case 
which terminates in recovery. Acute degeneration of the epithelium 
of the tubes and the tufts is seen in less severe cases and those of 
shorter duration, and is the direct result of the action of the toxins in 
the blood. In the more severe and protracted cases there is acute dif- 
fuse nephritis of variable type and intensity. There is no form of in- 
flammation which is peculiar to diphtheria; in some cases the intersti- 
tial changes predominate, in others the glomerular changes. Welch 
mentions hyaline changes in the glomerular capillaries and small arter- 
ies as the characteristic feature of the nephritis of diphtheria. 

In children dying suddenly in the early stage of the disease, cardiac 
thrombi are occasionally found. They may form rapidly only a short 
time before death, or slowly during several days when the circulation 
is very feeble. Portions of these thrombi may be carried into the pul- 
monary or systemic circulation, causing embolism in any of the arter- 
ies of the extremities, the lungs, or other viscera. Even in the early 
fatal cases the heart muscle may be seriously affected; in the later ones 
this is almost constant. The changes consist in a toxic myocarditis, the 
left ventricle being most involved. 

Degeneration of the arteries, especially of the endothelial layer, is 
occasionally seen, and there may be infiltration of the adventitia. The 
arteries of any of the viscera may be the seat of hyaline degeneration. 

Lesions of the brain are rare; both haemorrhage and embolism may 
be met with. In the spinal cord and membranes multiple haemorrhages 
occasionally occur. The characteristic lesion, however, consists in de- 
generative changes which are found to some degree in nearly all the 
more severe cases which have been examined. These affect the ganglion 
cells of the anterior horns, the anterior and posterior nerve-roots, and 
sometimes the pyramidal tracts and columns of doll. In some cases of 
paralysis induced in animals, lesions practically identical with those of 
ordinary poliomyelitis have been seen. Some recent writers (Katz and 
Crosz) are of the opinion that the cord lesions are primary and the 
degeneration of the spinal nerves secondary. However, the general opin- 
ion still prevails that certainly the less severe cases of diphtheritic 
paralysis are due to peripheral rather than to central lesions. Degenera- 
tive changes have been found also in the pneumogastric, spinal acces- 
sory, hypoglossal, motor-oculi, and in the cardiac nerves. These nerve 
degenerations produced by the diphtheria toxin constitute one of the 
most striking lesions of diphtheria. (See Multiple Neuritis.) 

In infants and young children broncho-pneumonia is found at au- 
topsy in fully three fourths of the cases, and in a large proportion of 
these it is the cause of death. It is well-nigh constant in cases of diph- 
theritic bronchitis of the finer tubes, and is usually present where the 



DIPHTHERIA. 1029 

membrane has extended to the bifurcation of the trachea. The largest 
factor in the production of pneumonia is the aspiration of diphtheria 
bacilli and streptococci from the upper air passages; an important part 
is also played by the pneumococcus and the influenza bacillus. These 
organisms may be present in many combinations. 

With laryngeal stenosis, some emphysema is invariably present, and 
usually it is of the vesicular variety. In extreme or protracted cases of 
stenosis there may be interstitial emphysema. Eupture of some of 
these blebs may lead to the escape of air into the cellular tissue of the 
mediastinum or of the neck, which may result in the production of a 
general emphysema of the subcutaneous cellular tissue. 

Blood. — According to the studies of Ewing, Morse, Billings, and 
others, there is found in all severe cases of diphtheria a reduction in the 
number of red cells to the extent of 500,000 to 2,000,000. There is a 
nearly proportionate reduction in the haemoglobin, this amounting to 
from 12 to 28 per cent. While the haemoglobin falls coincidently with 
the number of red cells, it is regained much more slowly. Leucocy- 
tosis is generally present, and usually proportionate to the severity of 
the attack, but is occasionally wanting in the most severe as well as in 
some of the very mildest cases. The increase in the leucocytes is in the 
polynuclear forms. Engel has noted the frequent presence of myelo- 
cytes, especially in fatal cases, the proportion of these in some instances 
reaching 16 per cent of the white cells. In his observations, every case 
in which the myelocytes exceeded 2 per cent, proved fatal. 

Symptoms. — The clinical picture of diphtheria is one which presents 
wide variations, depending upon the principal location of the disease, its 
severity, and its complications. For practical purposes the following 
seems the simplest grouping that can be made : 

1. The mild cases, in which there is either no membrane, or the 
amount of membrane is small and limited to the tonsils or to the nose, 
with few or none of the constitutional symptoms which follow absorp- 
tion of the diphtheria poison. These cases partake essentially of the 
character of a local disease. 

2. The severe cases, which are of two kinds: first, those in which 
there are marked evidences of constitutional poisoning from diphtheria 
toxins; and, secondly, those with laryngeal stenosis. The first form 
is usually accompanied by an extensive formation of membrane in the 
pharynx and sometimes in the nose. The larynx may be involved 
secondarily to disease in the pharynx or nose, or it may be primarily 
affected. 

3. The cases of mixed infection or the septic cases. In very many 
of the cases of the two preceding groups streptococci are found in the 
throat, but they are not in sufficient numbers or of sufficient virulence 
to modify the course of the disease. In the cases to which the term 



1030 THB SPECIFIC INFECTIOUS DISEASES. 

mixed infection is applied, in addition to the constitutional symptoms of 
diphtheritic toxaemia and the local conditions which usually attend it, 
there are marked evidences of a general septicaemia, usually due to the 
streptococcus. In these cases the symptoms of inflammation are espe- 
cially prominent, not only in the pharynx but sometimes in the lymph 
glands and cellular tissue of the neck, which may be followed by sup- 
puration or sloughing. This form is frequently complicated by bron- 
cho-pneumonia even without laryngeal disease, and sometimes by severe 
nephritis. 

Cases without membrane. — During an epidemic of diphtheria in a 
family or an institution, cases are frequently seen which present the 
clinical evidences of only a catarrhal inflammation of the nose or phar- 
ynx, and yet cultures show the presence of the diphtheria bacillus. 
Such cases may be examples of simple catarrhal inflammation with the 
accidental presence of the diphtheria bacillus; or the inflammation may 
be caused by infection with the diphtheria bacillus, but not of sufficient 
intensity to lead to the production of a membrane. The latter is the 
view of pathologists, and the one to which clinicians must, it seems, 
inevitably come. However, a membrane has so long been regarded as a 
sine qua non of this disease that the existence of diphtheria without it, 
is something which the clinician finds it hard to grasp. 

Catarrhal diphtheria may be either pharyngeal or nasal. In the 
pharyngeal cases there are present the usual appearances belonging to 
a catarrhal inflammation of moderate severity, often accompanied by 
swelling and tenderness of the cervical lymph glands. 

The nasal cases, in my experience, have been most frequent in in- 
fants or very young children. Constitutional symptoms may be want- 
ing or so slight as to be overlooked. The only striking thing is a per- 
sistent nasal discharge which may be serous and frothy, purulent or 
bloody. It is usually copious, often excoriating the upper lip and 
sometimes continuing for three or four weeks before any other symp- 
toms are observed. I have known it to be mistaken for a syphilitic 
coryza. Such cases can be recognised with certainty only by cultures. 
Clinical evidence of their true character is sometimes afforded by the ap- 
pearance of visible membrane in the nose or pharynx, by the development 
of croup, or by the fact that they cause diphtheria in other children. 

Catarrhal diphtheria is not in itself serious, but it may be followed, 
particularly in young children, by laryngeal diphtheria, or, after it has 
existed for a time, pharyngeal diphtheria may develop in its usual form. 
Cases like those just described are to be distinguished from others in 
which bacilli, either of the virulent or the non-virulent variety, are 
found without any evidence of inflammation. 

Cases with a small amount of membrane. — Tonsillar diphtheria. — 
The exudation is usually limited to the tonsils (Plate XVIII, A), and 



PLATE XV11I. 



B 








**& 



^jf* ^ J f ' 



The Diphtheritic Membrane. 

A. Typical tonsillar diphtheria. 

B. Severe pharyngeal diphtheria (fatal case). 

C. Pseudo-diphtheria. The specimen is seen from behind, the larynx and trachea 
having been laid open, and shows an extensive membrane involving the epiglottis and 
the entire lower pharynx, but extending into the larynx only a short distance. It is 
also seen upon the posterior surface of the uvula and soft palate, the tonsils being only 
partially covered. The colour of the membrane is not characteristic of pseudo-diph- 
theria, as the same appearance is often seen in true diphtheria, particularly of the 
septic type. 



DIPHTHERIA. 1031 

may partake of the character of either follicular or croupous tonsillitis ; 
sometimes there is a slight extension to the faucial pillars or to the phar- 
ynx. These cases are quite common, and in some epidemics most of those 
seen are of this variety. They are more frequent in older children and 
adults than in infants and young children. 

The onset is accompanied by a little soreness of the throat; the ini- 
tial temperature is from 101° to 104° F. ; but the symptoms are often not 
severe enough to keep the patient in bed. If seen early, the throat 
shows slight redness, followed by a gray film, and later by a gray or 
white deposit upon the tonsils. It may start as a small patch which en- 
larges, or as small, isolated spots which coalesce or remain separate. 
Until it disappears the membrane generally remains of its original 
colour. It is generally quite adherent, and can not easily be removed 
with a swab ; usually it is sharply defined, but with a somewhat irregular 
outline. In many cases the patch is not larger than the finger nail. 
The inflammatory changes in the pharynx are slight; a faint red areola 
is frequently present at the border of the patch. The lymph glands 
behind the jaw may be slightly swollen. There is no nasal discharge 
and very little increase in the saliva or mucus from the pharynx. Some 
constitutional symptoms are present, but they are never severe. The tem- 
perature commonly continues above the normal while the membrane 
lasts, its usual range being from 100° to 102° F. The membrane re- 
mains from three to seven days — a shorter time if antitoxin is used. It is 
very often a matter of surprise that so small an exudate is so persistent. 
The urine is generally normal. The parents are loath to believe that 
strict quarantine is necessary in so mild an illness ; and where the mem- 
brane is only upon the tonsils, even after the disease has run its course, 
the physician may be lead to doubt the diagnosis of diphtheria. 

In many cases one with experience can usually make an accurate diag- 
nosis from the clinical symptoms alone; but there are many others in 
which the diagnosis from ordinary tonsillitis is impossible, even by the 
most practised observers, except by cultures. When diphtheria bacilli 
are found in these mild cases the question often arises whether they may 
not be the non-virulent form. Park tested forty such cases, and found 
the bacilli to be virulent in thirty-five and non-virulent in five. In 
twenty of the forty cases the clinical diagnosis was follicular tonsillitis.* 

Severe cases. — The clinical picture of diphtheria is so modified by 
the use of antitoxin that those who see it given regularly and early can 
have but little conception of the horrors of this disease when not thus 
influenced. The onset in severe cases may be gradual, even insidious. 

* From one of these mild cases was obtained a bacillus whose virulence so greatly 
exceeded that obtained from any other case of diphtheria, that its cultures were used 
for the preparation of toxins for injecting horses. It was by means of these powerful 
toxins that the strongest antitoxin was produced. 



1032 THE SPECIFIC INFECTIOUS DISEASES. 

There is then a slight indisposition for a day or two, and perhaps some 
soreness of the throat ; the temperature may be but little elevated, some- 
times less than 100° F. The symptoms may steadily increase in intensity 
for four or five days, until the maximum is reached. At other times the 
disease begins abruptly with vomiting, headache, chilly sensations, and a 
temperature of 103° or 104° F. Occasionally, the first thing to attract 
attention is the swelling of the cervical lymph glands, which may be so 
great that mumps is suspected. The abrupt onset is more often seen in 
young children than in those who are older. 

The membrane upon the tonsils resembles that of the mild form pre- 
viously described, but, instead of remaining limited to them, it gradually 
spreads to the fauces, the lateral wall of the pharynx, the uvula, the 
rhino-pharynx, and the posterior nares. The rapidity with which the 
membrane extends is in direct proportion to the severity of the attack. 
In some cases it may cover all the parts mentioned in twenty-four hours 
from its first appearance ; in others this may require several days. When 
the nose is first affected there is an abundant discharge of serum and 
mucus, occasionally tinged with blood, which may continue some days 
before any membrane is visible. 

When a severe case is fully developed there is a very abundant dis- 
charge of mucus from the mouth and nose. The tonsils, the entire fau- 
cial ring, and the pharynx are covered with membrane (Plate XVIII, B) 
which is at first gray and gradually becomes darker, often being of a 
dirty olive-green colour. Membrane is sometimes seen upon the lips, or 
in patches in the mouth. There is obstruction to nasal respiration from 
the swelling of the palate, the tonsils, and the tissues of the rhino-phar- 
ynx; the mouth is half open, the breathing noisy, the tongue dry, and 
the lips are fissured and bleed readily. Occasionally large nasal haem- 
orrhages occur which may necessitate plugging the nares. Both nostrils 
are generally blocked by the swelling and the false membrane; the dis- 
charge excoriates the upper lip, and frequently has a fetid odour. Dur- 
ing the second week there may be regurgitation of fluids through the 
nose, owing to paralysis of the palate. The lymph glands at the angle 
of the jaw swell rapidly; in severe cases they are very prominent, and 
there may also be extensive infiltration of the cellular tissue about 
them, although this is more characteristic of the cases of mixed in- 
fection. 

The constitutional symptoms usually increase steadily with the ex- 
tension of the membrane. In the most severe cases the system is over- 
whelmed with the poison, and all the evidences of intense toxaemia are 
present by the third day of the disease. This is shown by great muscu- 
lar weakness and prostration, by a feeble, rapid pulse, and a mental state 
of complete apathy or stupor, sometimes alternating with great rest- 
lessness. It is more frequent for the constitutional symptoms to develop 



DIPHTHERIA. 1033 

gradually, and not to reach their height before the fourth or fifth day. 
The pulse becomes rapid, weak, and compressible, sometimes irregular; 
and there is a great and steadily increasing anaemia. The course of 
the temperature is irregular, and bears no constant relation to the 
severity of the other symptoms. Its usual range is from 101° to 103°, 
but in some of the worst cases it may never go above 101° F. It 
fluctuates irregularly with the development of complications, and some- 
times without apparent cause. By the second or third day the urine 
regularly shows the presence of albumin, and by the end of the first 
week the quantity is often large. Granular and hyaline casts, and occa- 
sionally blood in small quantities, are also found. The amount of urine 
secreted is not noticeably diminished, and dropsy is rare. There is com- 
plete anorexia, and often vomiting and diarrhoea are present; in some 
of the cases they are prominent. Nervous symptoms are seen in all the 
very severe cases. There may be dulness and apathy, but more fre- 
quently, owing to the discomfort arising from local symptoms, there is 
extreme restlessness and excitement, sometimes followed by delirium. 

At any time during the first week, but not often after that time, 
symptoms may arise indicating that the disease has extended to the 
larynx. The first signs of laryngeal invasion usually appear from the 
second to the fifth day of the disease. These are at first hoarseness, a 
croupy cough, and slight dyspnoea. In the severe cases these symptoms 
steadily increase until all the signs of laryngeal stenosis are present. 
The symptoms of diphtheria of the larynx, whether it begins there or 
follows disease of the pharynx, have already been described in the chap- 
ter on Diseases of the Larynx. 

The local process in the pharynx seems to be a self-limited one, 
even when no antitoxin is used. It usually reaches its height by the fifth 
or sixth day, and after that the appearances do not change materially 
for two or three days. From the seventh to the tenth day, in favourable 
cases, the diphtheritic membrane begins to loosen and separate from its 
attachment. It hangs loosely from the palate or uvula, and can often be 
pulled away in large masses. The detachment is frequently rapid, and 
in two or three days from the time when the first improvement is seen, 
the tonsils and pharynx may be almost free from membrane. The mu- 
cous surface left behind is of a bright red colour and bleeds easily. The 
separation of the membrane in the nose and rhino-pharynx takes place 
more slowly. From the former it may disintegrate gradually or come 
away en masse. With the disappearance of the membrane the local symp- 
toms abate rapidly — the discharge ceases, the swelling of the lymph 
glands subsides, deglutition becomes easy and natural, and nasal breath- 
ing is re-established. When antitoxin is given the local process passes 
through similar stages, but much more rapidly. 

Simultaneously with these changes in the throat the constitutional 



J.034 THE SPECIFIC INFECTIOUS DISEASES. 

symptoms improve, but much more slowly. Convalescence is often pro- 
tracted. The anaemia and muscular weakness, and, most of all, the feeble 
heart action, may persist for weeks. 

Instead of the usual course just described, the diphtheritic mem- 
brane may persist for two or three weeks. In rare cases relapses occur, 
the membrane forming again after it has entirely or partially disap- 
peared. 

The early course of the disease in the fatal cases often does not dif- 
fer from that of the severe cases which end in recovery, except in the 
malignant form, which kills in twenty-four or forty-eight hours, and 
which is very rare. In very young children death is most frequently due 
to broncho-pneumonia, usually accompanying diphtheria of the larynx 
and bronchi. It may also be due to progressive asthenia the result of 
diphtheritic toxaemia, or to heart failure, which may come early or late ; 
rarely to nephritis. 

Pneumo gastric paralysis. — This usually follows severe types of infec- 
tion, and is seen not only in cases in which no antitoxin is given, but 
also when it is administered late or in too small doses. In such circum- 
stances the early toxaemia may be neutralised and the local disease in the 
larynx and trachea controlled; yet so susceptible are the nervous tissues 
to the action of the diphtheria toxin, that injury sufficient ultimately 
to produce death may still have been done. This is most frequently 
through the action of the toxin upon the pneumogastric nerves. 

Pneumogastric paralysis may come on at any time in the course 
of the disease, but seldom earlier than the end of the second week. By 
this time the throat has usually cleared off entirely, and the patient is 
considered convalescent. The physician has ceased his frequent visits 
and looks in only once a day to satisfy himself that all is going well. 
The symptoms relate to the stomach, the heart and the respiration. 
Usually the first thing to attract notice is that the patient refuses food 
and vomits occasionally, afterward persistently, without apparent cause. 
If the pulse is carefully observed it is found to be much slower than 
previously, being only 80 or 90 when it was formerly 120 or more. It 
is also weaker, compressible, and often somewhat irregular. The face 
is pale, often slightly cyanotic, and moderate dyspnoea may be noticed. 
There are frequent attacks of severe abdominal pain which comes in 
paroxysms, and is usually referred to the epigastrium. These symptoms 
in most cases gradually increase in severity for two or three days, but 
sometimes develop with such intensity that death occurs within twelve 
or twenty-four hours. The later symptoms are a continuance of the 
abdominal pain and vomiting; there is a feeling of great precordial 
oppression and distress accompanied by dyspnoea ; the respiration is shal- 
low and often rapid ; the face is either pale or cyanotic ; the extremities, 
cold; the pulse, slow, irregular and intermittent, becoming rapid on 



DIPHTHERIA. 1035 

the slightest exertion. The heart sounds are weak, the muscular quality 
is absent, and the rhythm much disturbed. There may be no murmurs. 
There is great restlessness, but the mind is entirely clear. Death usually 
results from syncope, which may come quite suddenly, often from so 
slight exertion as turning over in bed or attempting to take food. 

Not all the cases are so severe. In the milder forms of the condition 
there is some palpitation, an irregular pulse, slight dyspnoea, and occa- 
sional syncopal attacks, but of no great severity. Such symptoms may 
come and go for several days and then disappear; but more frequently 
they prove to be the beginning of the more serious form of the com- 
plication. 

The time of occurrence of pneumogastric paralysis varies consid- 
erably. It may be as late as the third or fourth week. The late cases 
are generally associated with some other form of post-diphtheritic par- 
alysis. 

Sudden heart failure may be seen late in diphtheria quite apart from 
the symptoms just described. It may occur with few or no premonitory 
symptoms; as when a child falls dead after walking across a room, or 
suddenly sitting up in bed, or from some other muscular effort, or pos- 
sibly as a consequence of passion or excitement. I knew of one little 
girl who was considered well enough to go coasting and who died suddenly 
after the effort. 

The explanation of heart failure during or after diphtheria is there- 
fore not always the same. When it occurs at the height of the disease 
it is sometimes due to cardiac thrombosis, probably always associated 
with changes in the muscular walls. When it occurs late and follows 
some sudden muscular effort or excitement without premonitory symp- 
toms of any sort, it is probably the result of changes in the muscular 
walls — a toxic myocarditis. When prodromal symptoms are present, and 
particularly when accompanied by vomiting, abdominal pain, and dis- 
turbed respiration, it is probably the result of a toxic neuritis affecting 
either the pneumogastric or the cardiac nerves, and is to be regarded as 
a form of post-diphtheritic paralysis. In many cases, no doubt, changes 
are present both in the nerves and in the myocardium. The other forms 
of diphtheritic paralysis which may result fatally, are discussed in the 
chapter on Diseases of the Peripheral Nerves. 

Cases of mixed infection or septic diphtheria. — The symptoms are 
usually severe from the outset. The exudation in these cases may be 
of a yellow, or dirty-gray, or olive colour, sometimes being almost black 
from the presence of blood. The membrane is usually extensive, cover- 
ing the entire pharynx, often extending to the nose and the middle ear, 
and occasionally spreading to the buccal cavity. There is great swelling 
of the tonsils and uvula, and it is often impossible to obtain a view of 
the pharynx ; all the evidences of inflammation are usually more marked 



1036 THE SPECIFIC INFECTIOUS DISEASES. 

than in the severe uncomplicated cases. Sometimes the inflammation is 
of a necrotic character, and there may be extensive sloughing of the 
tonsils, the uvula, or the soft palate. The nasal discharge is generally 
abundant, and often very offensive. There is marked swelling of the 
cervical lymph glands, and frequently extensive infiltration of the cellu- 
lar tissue of the neck, so that the head is thrown back to relieve the 
pressure upon the larynx and trachea. The swelling sometimes forms a 
distinct collar, reaching from ear to ear and filling out the whole space 
beneath the jaw. The pressure upon the jugular veins leads to conges- 
tion and swelling of the face and congestion of the brain. 

The general symptoms are those of a severe septicaemia. The tem- 
perature is usually higher than in simple diphtheria ; it follows no regular 
course, but is generally high and sometimes fluctuates widely from 102° 
to 106° F. In the cases characterised by such high temperature there is 
frequently found a general streptococcus or pneumococcus infection, usu- 
ally the former. The pulse is weak, rapid, and compressible. The periph- 
eral circulation is poor, the extremities are often cold, there is extreme 
muscular prostration, and both vomiting and diarrhoea are frequent. 
There may be excitement, restlessness, and active delirium, or dulness, 
apathy, and stupor. Nephritis is very frequent and is often severe ; the 
urine contains a large amount of albumin and casts of all varieties, but 
rarely blood. In a large proportion of the children under three years 
old broncho-pneumonia develops. Severe symptoms continue for from 
two days to a week ; the patient may die from the sudden invasion of the 
larynx, or there may be suppression of urine and uraemic convulsions; 
but more frequently the cause of death is asthenia or broncho-pneu- 
monia. Death usually occurs while the local disease is at its height. 
Occasionally it comes later from heart failure, after the signs of local 
improvement have begun. 

Those who manage to escape the dangers of the acute period have 
still others to encounter. Among the latter may be mentioned: ex- 
tensive sloughing in the throat or of the cellular tissue of the neck, 
which may be followed by severe or even fatal haemorrhage, diffuse sup- 
puration of the same region, late nephritis, pneumonia, or pleurisy, and 
finally paralysis of the heart or respiration. 

Complications and Sequelae. — Most of the complications of diph- 
theria have already been mentioned either under the head of Lesions or 
Symptoms. It only remains to consider their clinical association. 

Otitis occurs particularly in the rhino-pharyngeal cases, and is some- 
times due to the diphtheria bacillus alone, but more often to mixed in- 
fection. The type of inflammation is often a severe one, and it may be 
accompanied by necrotic changes in the drum membrane which resem- 
ble those of scarlet fever. 

Broncho-pneumonia is the most frequent complication in young chil- 



DIPHTHERIA. 1037 

dren. It occurs especially in laryngeal cases, and in those of a septic 
type whether the larynx is involved or not. Other pulmonary compli- 
cations are infrequent. Pleurisy with a serous effusion may occur in 
connection with severe nephritis, and empyema in septic cases. Emphy- 
sema is a complication of laryngeal diphtheria ; it is nearly always vesic- 
ular, sometimes interstitial, and may become general, extending into 
the cellular tissue of the neck and afterward that of the entire body. 
Pericarditis, endocarditis, and meningitis are all very rare and are seen 
chiefly in septic cases of the most severe type. Myocarditis is much 
more frequent, and is present to a greater or less degree in nearly all 
severe cases, although in but a small proportion of these does it give 
rise to distinct symptoms. It is closely connected pathologically with 
degeneration of the cardiac nerves, and it may be a cause of sudden 
death at any time during the acute period of the disease or during con- 
valescence. 

Thrombosis and embolism are among the less frequent complica- 
tions. If cerebral, they may cause hemiplegia, aphasia, and sometimes 
convulsions; if peripheral, they usually affect one of the lower extrem- 
ities, where they may cause sudden pain, numbness, and coldness of the 
limb, followed by partial paralysis, oedema, and sometimes even by gan- 
grene. Thrombosis of the pulmonary artery or of the heart may be a 
cause of sudden death, the symptoms being dyspnoea and praecordial dis- 
tress, with pallor or cyanosis. Both thrombosis and embolism are asso- 
ciated with a very feeble action of the heart, and generally they are pre- 
ceded by degenerative changes in its muscular walls. 

Haemorrhages are usually nasal, and while in most cases they are not 
serious, they may necessitate plugging of the posterior nares. Bleeding 
from any other mucous membrane may occur, but it is rare except from 
the mouth. Subcutaneous haemorrhages are infrequent, and are evi- 
dence of a very high degree of diphtheritic toxaemia. They usually 
occur as small petechial spots, but are sometimes extensive. They may 
be seen upon almost any part of the body, most frequently upon the 
abdomen and lower extremities; but the most extensive extravasation 
I have ever seen was in the neck, reaching from the clavicle almost 
to the ear and covering nearly one lateral half of the neck. 

Albumin is present in the urine of almost every case of moderate 
severity, usually depending upon acute degeneration of the kidneys. 
Acute nephritis is mosi frequently seen in septic cases. It then usually 
develops at the height of the LocaJ disease, but may come during con- 
valescence. Albumin and casts are found in the urine, but rarely is 
there dropsy or signs of uraemia. Loss frequently a more severe form 
of inflammation occurs, with dropsy, scanty urine, or even suppression, 
vomiting, and all the usual symptoms of acute uraemia. This complica- 
tion may be a cause of death. 



1038 THE SPECIFIC INFECTIOUS DISEASES. 

Functional disturbances of the stomach are present in most of the 
severe cases, but lesions of the mucous membrane are rare. While diar- 
rhoea is often seen without intestinal lesions, the -latter are of frequent 
occurrence. The most characteristic form of inflammation is a follicu- 
lar ileo-colitis, which, however, seldom goes on to ulceration. It is ex- 
tremely rare that the membranous form is seen, and then it is almost 
always associated with the presence of other bacteria, not with diph- 
theria bacilli. 

Diphtheria is usually followed by a severe and often persistent anae- 
mia which may continue for weeks. Pneumonia, nephritis, and cardiac 
disease may first show themselves during convalescence, and so be ranked 
as sequelae. The most important sequel of diphtheria, however, is post- 
diphtheritic paralysis, already discussed in the chapter on Multiple 
Neuritis. 

Diagnosis. — The diagnosis of diphtheria rests upon two kinds of evi- 
dence — clinical and bacteriological. In mild cases and in the early stage 
only bacteriological evidence can be relied upon. However, the clinical 
manifestations of the disease are important and should not be ignored. 
It is in most cases possible to say from clinical symptoms that a case 
is one of diphtheria; but it is never possible to say from symptoms alone 
that a case is not diphtheria. Cultures, therefore, are of the greatest 
assistance, and should if possible be made in every case. They are neces- 
sary in the mild cases in order that a correct diagnosis may be made and 
proper quarantine regulations enforced; otherwise a case might be dis- 
missed as simple tonsillitis and no precautions taken. 

The mere presence of diphtheria bacilli in the throat does not prove 
that a person has diphtheria any more than the presence of the pneumo- 
coccus in his saliva proves that he has pneumonia ; but where diphtheria 
bacilli are associated with clinical evidences of inflammation of the 
throat or nose the diagnosis may be regarded as established. Again, 
the case may be one of diphtheria and the bacilli not found at the 
first examination, although found subsequently. In using antitoxin 
one must, in perhaps the majority of cases, be guided by clinical 
symptoms alone, not waiting for the result of the bacteriological exami- 
nation. It is therefore important that both methods of diagnosis should 
be employed. 

1. The Clinical Diagnosis. — Not much importance can be attached to 
the mode of onset; for diphtheria may begin in many different ways. 
The presence of a nasal discharge, especially if abundant, ichorous 
and tinged with blood, the early development of the symptoms of croup, 
the rapid enlargement of the cervical lymph glands, and the early appear- 
ance of albumin in the urine — all point strongly to diphtheria. Later 
symptoms which are especially diagnostic are marked anaemia, pro- 
gressive asthenia, intense toxaemia often with a low temperature, very 



DIPHTHERIA. 1039 

feeble pulse which is sometimes slow, sometimes rapid, sudden attacks 
of syncope, nasal haemorrhages, nasal regurgitation from paralysis of 
the soft palate, contagion, and, finally, the development of paralysis of 
the muscles of the throat, eye, or extremities, with paralysis of the heart 
or respiration. 

The membrane of diphtheria generally appears first upon the tonsils, 
usually as a gray film which gradually becomes more dense and white, 
and often has the look of being plastered on. The colour of older mem- 
brane is gray, greenish-yellow, brown, sometimes black. Beginning as 
a small patch, it soon covers the tonsils. It frequently affects one tonsil 
twenty-four or thirty-six hours before the other, and occasionally it is 
confined to one side. In exceptional cases it begins in the c^pts of the 
tonsil and appears as isolated dots, which may coalesce to form a con- 
tinuous patch like that already described, or it may remain isolated like 
the exudate of an ordinary follicular tonsillitis. More important is 
the fact that the membrane spreads from the original seat, and also the 
manner of its spreading. If it extends beyond the tonsils to the walls of 
the pharynx, the faucial pillars, and the uvula, it is almost surely diph- 
theria. The same is true of doubtful patches on the tonsils or fauces 
followed by symptoms of croup. The rapidity of the spreading varies 
much in the different cases, depending upon the intensity of the infec- 
tion; but the gradual extension, as shown by observations made at in- 
tervals of six or eight hours, usually settles the diagnosis in the primary 
cases. However, if the throat symptoms complicate measles or scarlet 
fever the above rules do not apply. Most of the membranous inflam- 
mations of the throat seen in these diseases are not due to diphtheria. 
This is particularly true of those which occur at the height of the primary 
disease. Those which develop at a later period are often due to diph- 
theria. 

In pure diphtheria there is a notable absence of oedema of the fau- 
cial pillars and uvula, so common in throat inflammations due to cocci. 
In fact, whenever there are seen in the throat evidences of a very high 
degree of inflammation, it usually points either to mixed infection or to 
false diphtheria. 

Primary membranous inflammation of the larynx may always be 
safely regarded as diphtheria; but if there is no visible membrane, the 
diagnosis is rendered positive only by a bacteriological examination. 
This may be true of many nasal cases where the only symptoms are a 
discharge of the character previously described. Such cases may con- 
tinue for weeks with no symptoms other than the discharge, especially 
in infants. 

The most characteristic clinical differences between diphtheria and 
other inflammations accompanied by an exudation upon the throat or in 
the nose — i. e., pseudo-diphtheria — are shown in the following table: 



1040 



THE SPECIFIC INFECTIOUS DISEASES. 



DIPHTHERIA. 

1. Often a history of exposure, or preva- 
lence of an epidemic. 

2. Onset often gradual, with low tem- 
perature and slight constitutional symp- 
toms. 

3. Previous attacks rare. 

4. Often begins in the larynx. 

5. If pharyngeal, shows a strong tend- 
ency to extend to the larynx. 

6. Primary cases frequently severe. 

7. When it complicates measles or scar- 
let fever it often develops late — after 
the primary fever has subsided. 

8. Occasionally limited to the nose 
(croupous rhinitis). 

9. Albuminuria the rule, except in the 
mildest cases. 

10. Nasal regurgitation from paralysis 
of the palate in the second week or later. 

11. Toxic symptoms common ; asthenia, 
great anaemia after the fourth or fifth 
day ; later, sudden heart paralysis, respira- 
tory paralysis, or post-diphtheritic paraly- 
sis of throat, eyes, or extremities. 

12. Usually less evidence of inflamma- 
tion of mucous membrane and in sur- 
rounding parts. 

13. A membrane on the tonsils with 
patches on the uvula or elsewhere in the 
pharynx is usually diphtheria; doubtful 
patches on the tonsils followed by croup 
almost invariably diphtheria. 



PSEUDO-DIPHTHERIA. 

1. Usually none. 

2. Onset usually abrupt, with high tem- 
perature and quite marked constitutional 
symptoms. 

3. Often a history of repeated attacks. 

4. Seldom if ever does so when primary. 

5. This tendency is much less marked. 

6. Rarely severe unless secondary, par- 
ticularly to measles or scarlet fever. 

7. Usually occurs at the height of the 
primary disease, 

8. Doubtful if ever so. 

9. Rarely seen in primary cases, and 
sometimes not in the secondary form, 
even though the symptoms are severe. 

10. Never seen. 

11. Septic symptoms frequent, espe- 
cially when secondary, but the peculiar 
toxic symptoms are never seen. 



12. Often evidence of intense inflamma- 
tion. 

13. It is never possible to say by the 
appearance of the membrane alone that 
the case is not true diphtheria. 



It is seldom difficult to distinguish diphtheria from any other dis- 
ease; but the exudation upon the pharynx or tonsils may be confounded 
with thrush or herpes. The appearance of the tonsils on the second 
or third day after tonsillotomy has been performed, may easily be mis- 
taken for diphtheria by one who is unfamiliar with the appearance of 
the wound. 

Diphtheria of the mouth may be mistaken for herpetic or ulcerative 
stomatitis ; but, as a rule, it is seen only in the worst cases of pharyngeal 
diphtheria. Diphtheria of the mouth alone is so rare that it may be 
ignored. 

It is sometimes difficult to distinguish cases of scarlet fever in which 
the throat symptoms are severe and appear early, from cases of primary 
diphtheria. In many of these cases the eruption appears late, and is 



PLATE XIX. 









6 






v 

* x^ 






# 4 «^ * n 4 



9 








Diphtheria Bacilli and their Associates. 

1 and 2, colonies of diphtheria bacilli under a low and a high power ; 3, 4, 5, char- 
acteristic diphtheria bacilli x 1,000; 5, showing the short even-stained diphtheria 
bacilli ; 6, pseudo-diphtheria bacilli ; 7, streptococci from a serum culture ; 8, strep- 
tococci from a smear directly from the throat. (After Park.) 



DIPHTHERIA. 1041 

not characteristic. Much importance is to be attached, as pointing 
toward scarlet fever, to a prevailing epidemic, a history of exposure, a 
sudden onset with severe symptoms, vomiting, prostration, very high 
temperature, and to a very active inflammation in the pharynx. In all 
cases with a sudden onset, in which from the throat symptoms one is 
inclined to make a diagnosis of diphtheria, the possibility of scarlet 
fever should not be forgotten; and one should never omit to examine 
the patient thoroughly for an eruption. The diagnosis of primary diph- 
theria of the larynx has already been considered (page 495). 

2. The Bacteriological Diagnosis. — The technique. — In many cases 
an immediate diagnosis may be reached by the examination of a cover- 
glass smear from the throat. This method, although often valuable, is 
not adapted for general use, as bacilli directly from the throat are much 
less typical than those from cultures, and the chances of contamination 
are much increased. Furthermore, the mouth often contains bacilli which 
somewhat resemble the diphtheria bacillus. 

In taking a culture from the throat, the tongue should be depressed 
and the tonsils, pharynx, or other seat of visible membrane rubbed firmly 
with a swab, which is then rubbed over the surface of the culture-medium 
in the tube or on the plate. In laryngeal cases the culture should be 
taken from the posterior wall of the pharynx, and in nasal cases from 
the nostril. The tube or plate is then placed in an incubator for twelve 
or fourteen hours * and kept at a temperature of about 100° F. (37° C), 
at the end of which time the colonies (Plate XIX, 1 and 2) may be 
examined. Examination, in the great majority of cases, shows either a 
great number of diphtheria bacilli (Plate XIX, 3, 4, and 5) and a 
few cocci, or only cocci in pairs or short chains (7 and 8) ; exception- 
ally, the cocci and bacilli may be present in nearly equal numbers. 
A definite opinion should not be given without examining several 
colonies. 

The reliance to be placed upon bacteriological diagnosis. — The diph- 
theria bacillus will almost invariably be found: (1) if there is visible 
membrane in the pharynx ; ( 2 ) if the culture is made during the period 
in which the membrane is forming; (3) if no antiseptics have been 
applied shortly before using the swab; (4) if the culture has been made 
with sufficient care to avoid contamination. 

The diphtheria bacillus sometimes disappears early; hence cultures 
made while the membrane is loosening may be negative. If the mem- 

* In the laboratory of the Babies' Hospital we have found that the rapid method 
of staining cultures at the end of five or six hours can usually be depended upon, but 
that it is not always reliable where the result is negative. In every case it is wise for 
control to make an examination of individual colonies at the expiration of the usual 
time. However, the rapid method is of great advantage, as the saving of time is of so 
much importance in the administration of antitoxin. 



1042 THE SPECIFIC INFECTIOUS DISEASES. 

brane has disappeared, or if none has been present, it is not infrequently 
necessary to go into the tonsillar crypts with a probe or spoon to discover 
bacilli. It is therefore important in all cases to consider the duration 
of the disease before drawing a conclusion from a negative culture. If 
the case is one of laryngeal disease without pharyngeal exudation, an 
early culture is negative in nearly half the cases ; although a little later 
bacilli may be coughed up and found in the pharynx in abundance. A 
single negative culture should never be taken as conclusive. 

For diagnostic purposes, all bacilli present in suspicious throats, hav- 
ing the morphological and cultural characteristics of diphtheria bacilli, 
are to be regarded as virulent. 

Non-virulent bacilli resembling the diphtheria bacillus. — There may 
be found in throats a form which corresponds in every other character- 
istic with the diphtheria bacillus, but which lacks virulence as shown by 
animal tests. Also, another form, which, though in many particulars 
resembling the diphtheria bacillus, differs from it in being shorter, 
plumper, and more uniform in size, and in producing an alkali in broth 
cultures; to this the term pseudo-diphtheria bacillus* (Plate XIX, 6) 
has been given. It is more frequently seen than the form just described 
and like it is non-virulent. Both these forms are rare in throats where a 
suspicion of diphtheria exists. 

The presence of virulent bacilli in the throats of healthy persons. — 
That virulent bacilli may be harboured for an indefinite period in the 
throat or nose of a healthy person is proved by many observations. In 
Eschericrr's well-known case, the throat of an apparently healthy nurse, 
under whose care a number of cases of diphtheria had developed, was 
found to contain numerous virulent bacilli which remained for weeks. 
In a case observed by Park, virulent bacilli were found for months in the 
nose of an apparently healthy infant, and this child communicated diph- 
theria, it was believed, to two other members of the family, without itself 
ever suffering from the disease. These cases are to be regarded as very 
exceptional. However, the presence of bacilli in the nose or throat of a 
child who has recently been exposed to diphtheria is very common. The 
New York Health Department made observations upon forty-eight chil- 
dren in fourteen families in which one or more cases of diphtheria had 
occurred, and where no attempt at isolation had been made. In one 
half these cases bacilli were found, and animal tests showed them to be 
virulent in every one of six cases tested, although four of the children 
did not develop diphtheria. Of the entire number, forty per cent subse- 
quently developed diphtheria. My own experience in two institutions 
where diphtheria has been endemic, fully confirms the observation that 

* An unfortunate term, as this bacillus has nothing to do with the form of angina 
classed as pseudo-diphtheria, which is generally due to the streptococcus. 



DIPHTHERIA. 1043 

bacilli of all degrees of virulence are very frequently found in the noses 
or throats of such exposed children, although a large proportion of them 
never develop the disease. Outside of institutions and infected tene- 
ment houses, however, such a condition is extremely rare. 

Summary. — 1. The discovery in the throat of a case of suspected 
diphtheria, of bacilli having the appearance of the Klebs-Loeffler bacillus, 
may be regarded as conclusive evidence of diphtheria. 

2. Cultures may yield negative results late in pharyngeal cases, and 
often do early in laryngeal cases ; but in no instance is a single negative 
culture to be regarded as conclusive. 

3. Both the appearance of the throat and the stage of the disease 
should be considered in connection with the bacteriological report. 

4. Virulent bacilli are frequently found in the noses or throats of 
children exposed to diphtheria, apart from all throat lesions. Such a 
finding is not in itself evidence that these persons have diphtheria, but, 
inasmuch as they may infect others and as a considerable proportion 
of them subsequently develop diphtheria themselves, they should be 
regarded with suspicion and if possible kept under observation. 

5. Non-virulent bacilli are occasionally, and virulent bacilli are very 
rarely, found in the throats of healthy persons when there is no history 
of exposure to diphtheria. 

6. The presence of diphtheria bacilli, associated with marked evi- 
dences of catarrhal inflammation of the mucous membrane, is evidence 
of diphtheritic infection. 

Prognosis. — Many possibilities exist, and even the mildest case must 
be regarded as serious and carefully watched, since we can never know 
when unfavourable symptoms may develop. 

The factors to be considered in the prognosis of any given case are : 
the age and previous condition of the patient; the extent of the mem- 
brane and the rapidity with which it is spreading; the degree of diph- 
theritic toxaemia as shown by the condition of the pulse and the nervous 
symptoms; whether or not the membrane has invaded the larynx; and 
the presence or absence of complications, especially nephritis and bron- 
cho-pneumonia ; but of more importance than any or all these things is 
whether antitoxin is used and when it is administered. 

The following figures are from the Keport of the Health Depart- 
ment of Chicago of cases treated from October 5, 1895, to February 28, 
1899: 

Died. Mortality. 

Injected 1st day 355 1 • 27 per cent. 

2d day 1,018 17 167 

3dday 1,509 57 3*77 

4th day 720 82 11*39 

later 469 119 25-37 

Totals 4,071 276 6*77 



1044 THE SPECIFIC INFECTIOUS DISEASES. 

In all these cases the diagnosis of diphtheria was confirmed by 
cultures. 

Diphtheria mortality is highest during the first two years of life, 
from its strong tendency to invade the larynx and lower air passages, 
and from the frequency with which broncho-pneumonia occurs as a com- 
plication. Those whose experience with this disease does not antedate 
the introduction of antitoxin can scarcely appreciate the results previ- 
ously obtained. Of eighty-five consecutive cases under twenty-six 
months of age observed in the New York Infant Asylum, in a period 
extending over two years, the mortality was 68 per cent; in over two 
thirds of the fatal cases the disease involved the larynx. In diphtheria 
hospitals, where most of the mild cases included in the above statistics 
would probably not have been admitted, the mortality in children under 
two. years formerly varied from 60 to 80 per cent; in private practice it 
ranged for this age from 30 to 60 per cent. 

It can not be too often emphasised that the danger from diphtheria 
is not over when the throat has cleared. The most frequent causes of 
death after this time are broncho-pneumonia and cardiac or pneumo- 
gastric paralysis. 

Prophylaxis. — In no infectious disease, smallpox alone excepted, can 
so much be accomplished in the way of prevention as in diphtheria. 

Public funerals of children dying from diphtheria should invariably 
be prohibited. Schools should be closed whenever the disease is epi- 
demic. Children from families where diphtheria exists should not be 
allowed to attend school, nor mingle in any way with other children, 
for the reasons that they may, while healthy, be the carriers of the dis- 
ease; and, what is even more important, that they may be themselves 
suffering from diphtheria in an early stage or in a mild form. 

In every large city, hospitals for diphtheria patients should be estab- 
lished, not only for the poor, but with private rooms for cases develop- 
ing in hotels or other places where isolation is impossible. Every city 
should be provided with a steam disinfecting plant, where carpets, 
blankets, bedding, etc., can be sent from the sick-room for disinfection. 

Quarantine. — Not only every undoubted case of diphtheria, but every 
suspected case, should be immediately isolated. Quarantine for the lat- 
ter should continue until the diagnosis is settled either by a bacterio- 
logical examination or by the course of the disease. Positive and sus- 
pected cases should not be isolated together. The quarantine in every 
instance must be complete. If possible, cultures should be taken from 
the throats of all exposed children. Those containing diphtheria bacilli 
should be quarantined like cases of diphtheria, for they may be equally 
dangerous ; they should use gargles and sprays, and the nose and throat 
should be closely watched. 

Bacteriology has furnished some very definite data from which the 



DIPHTHERIA. 1045 

necessary duration of the period of quarantine may be determined. In 
this the physician is to be guided by the time that the bacilli remain in 
the throat, for the patient is to be considered as dangerous while they 
persist. This point was investigated by the Xew York Health Depart- 
ment in 605 cases : In 304 of these the bacilli had disappeared by the 
third day after the membrane was gone; and in 301 they persisted for a 
longer time — in 176, for seven days; in 64, for twelve days; in 36, for 
fifteen days ; in 12, for twenty-one days ; in 4, for twenty-eight days ; in 
4, for thirty-five days ; and in 2, for sixty-three days. Many of the cases 
in which the bacilli have persisted for an unusual time have been those 
of nasal diphtheria; in some of these it is doubtless owing to the fact 
that the nasal sinuses, especially the antrum, have been invaded. While 
it is unquestionably true that in a certain number of cases these persist- 
ent bacilli are non-virulent, the opposite has been frequently shown. Of 
15 cases in which the virulence was tested, virulent bacilli were found in 
9 at periods varying from eight to twenty-five days after the membrane 
was gone. Tobiesen found that of 46 patients leaving the hospital un- 
der ordinary rules, virulent bacilli were present in 24 at the time of 
their discharge. If no culture tests can be made, quarantine should be 
continued in mild cases for ten days, and in severe cases for three weeks, 
after the membrane has disappeared. The danger after this period in 
either instance is very slight; for even where virulent bacilli are found 
long after the membrane has disappeared, their number is usually small. 
The rules above given should be followed with children returning to 
school or mingling with other children, and adults who are thrown into 
close contact with children. 

Treatment of suspected cases. — During an epidemic of diphtheria, es- 
pecially in an institution, every sore throat and nasal discharge should 
be looked upon with suspicion, and isolated pending the result of a bac- 
teriological examination, even though no membrane is present. All 
such patients should be separated from the other inmates of the home or 
institution, and while waiting for the results of the bacteriological ex- 
amination or for positive symptoms, antiseptic gargles or sprays should 
be used. If there are patches on the tonsils or any other visible mem- 
brane, the case should be treated as true diphtheria, in order that no 
time may be lost. If the bacteriological examination shows the disease 
not to be true diphtheria, the patient may be released from quarantine 
in two or three days, provided the throat symptoms disappear. It is, 
of course, important that the conditions laid down with reference to bac- 
teriological diagnosis shall have been fulfilled. Should symptoms con- 
tinue, however, a second culture should be taken. 

Immunisation of persons exposed. — When a case of diphtheria occurs 
in a family or an institution, every child that has been exposed should 
receive an immunising dose of antitoxin. This rule is not followed in 

67 



104:6 THE SPECIFIC INFECTIOUS DISEASES. 

practice as regularly as it ought to be. There is no doubt that for a 
limited time — from three to four weeks — the serum confers almost com- 
plete protection. 

One need not hesitate to immunise persons of any age and in almost 
every condition, even newly born infants and pregnant women. 

The dose for immunisation is from 100 to 1,000 units, the former 
being that required for an infant under one month, and the latter for a 
child of twelve or fourteen years; for one from two to ten years the 
usual dose is 700 units. If the exposure is continuous, as in an institu- 
tion, the dose should be repeated every three or four weeks. A nurse 
in charge of a diphtheria case should receive 1,000 units. 

Diphtheria so often complicates scarlet fever and measles, particu- 
larly in institutions and in hospitals for contagious diseases, that special 
consideration should be given to such patients. It is practically impos- 
sible by cultures to separate with absolute certainty all cases in which 
diphtheritic infection is present, from others; the only safe rule is to 
immunise every child admitted to a scarlet-fever or measles hospital, 
and in institution epidemics of either of these diseases to immunise 
every child attacked. This rule has been followed for some years at the 
New York Foundling Hospital with the most striking benefit. 

Nurses and physicians. — As diphtheria is contracted, not from the 
breath of the patient or the air of the room, but by receiving the bacilli 
into the mouth or air passages, all possible means should be taken to de- 
stroy the bacilli discharged, and to secure absolute cleanliness in every- 
thing about the sick-room. Nurses should never be allowed to eat or 
sleep in the sick-room, and an antiseptic gargle should be used four or 
five times a day. The hands should be kept clean, and only such dresses 
worn as can be readily washed and disinfected. It is the nurse who is 
most likely to contract the disease, on account of the continued exposure. 

The physician should take the same precautions as in scarlet fever. 
A pocket tongue-depressor should not be used for the examination of the 
throat, but a spoon which is kept in a solution of carbolic acid, 1 to 40. 

The sick-room. — The carpets, hangings, upholstered furniture, every- 
thing in fact not necessary for the patient's welfare, should be removed, 
especially books, toys, cushions, etc. The room should be a large one, if 
possible with an open fireplace, well ventilated, and fresh air should be 
allowed in abundance. The floor should be washed once a day with a 
solution of bichloride, 1 to 2,000, and dusted often with cloths moistened 
in the same solution. All handkerchiefs, bed-linen, and clothing re- 
moved from the patient should be treated as in a case of scarlet fever. 
Pieces of membrane and other matters discharged from the patient 
should be put into a solution of carbolic acid, 1 to 20, or of bichloride, 1 
to 1,000. Old muslin or absorbent cotton should be used to cleanse the 
nose and mouth of the patient and burned immediately. All vessels for 



DIPHTHERIA. 1047 

the reception of expectoration or other discharges should contain bichlo- 
ride, 1 to 2,000. The bed-linen should be very frequently changed, and 
everything kept scrupulously clean. In the room should be a large 
bowl of carbolic acid, 1 to 40, or some similar solution for cleansing the 
hands, and a tray of the carbolic solution for spoons, syringes, or other 
things used in the treatment of the patient. All spoons, cups, or other 
dishes used by the patient should be carefully sterilised by boiling. No 
milk or other food should be allowed to stand about the room. There is 
no objection to the hanging of sheets moistened in carbolic, bichloride, 
or other disinfectant solutions before the door, but neither this nor 
hanging them about in the sick-room is to be regarded as having any 
value in disinfecting the air of the room. They create a false sense of 
security, and often lead to the neglect of thorough cleanliness. 

Disinfection of apartments after an attack should be done as after 
scarlet fever. 

Treatment. — General measures. — It is important in every case that 
there should be plenty of fresh air in the room throughout the attack. 
Where it is possible, it is desirable to have two rooms for the patient, so. 
that he can be changed from one to the other every day, giving time for 
thorough cleanliness and airing. Hospital patients should never have 
less than 1,000 cubic feet of air space, and if possible 1,200 should be 
allowed. Even in mild cases the patient should be kept in bed through- 
out the entire attack, and in severe cases this should be continued for 
some time during convalescence. 

Nursing infants may be fed on breast milk obtained by a breast 
pump, but should not be put to the mother's breast. The feeding of 
older children should be managed very much as in other cases of severe 
illness. Milk is the main reliance; it should usually be diluted, and 
for younger infants partially peptonised. The greatest difficulty in feed- 
ing is seen in the latter part of the disease, when the patients are septic 
and have a strong aversion to food, when vomiting is easily excited and 
when swallowing is difficult on account of the swelling and pain. It 
is then that gavage (page G4) is most valuable. This is much more 
successful with children under three years old than is rectal feeding. 
In older children the tube may be passed through the nose. 

Stimulants. — These should be begun as soon as the depressing effects 
of the poison of diphtheria are shown upon the pulse and general con- 
dition of the patient. In most cases, therefore, (hey are not needed 
until the third or fourth day; in a few they may be required from the 
outset, and in some they may not be required at all. The indications 
for alcoholic stimulants are marked prostration, a feeble pulse, and a 
weak first sound of the heart. In regard to the quantity, half an ounce 
of whisky or brandy in twenty-four hours is enough to begin with, for a 
child four years old. This should be diluted with at least eight parts of 



1048 THE SPECIFIC INFECTIOUS DISEASES. 

water. In very severe cases two or three times as much may be given; 
but more than this, except for a short period, is seldom wise. The ex- 
cessive doses often used surely endanger the kidneys. The method of 
administration should be the same as in other severe acute diseases 
(page 51). Other heart stimulants than alcohol, though inferior to it, 
are of value. Probably the most useful one is strychnine, which should 
be given as in pneumonia. Camphor and carbonate of ammonia are val- 
uable for rapid effect in syncopal attacks, and digitalis in other cases 
where the pulse is weak and arterial tension low, but it is not wise to 
give it in large doses. In cases of threatened heart paralysis occurring 
late in the disease or during convalescence, morphine and strychnine 
may be used hypodermically. Full doses must be given and repeated 
every two to four "hours, so that the child may be kept under their in- 
fluence. 

Except for stimulation or the control of special symptoms such as 
vomiting or diarrhoea, all internal medication should be omitted; for 
there is yet wanting proof that drugs influence the course or the result 
of the disease. 

Local treatment. — Since the introduction of antitoxin, opinion has 
undergone a decided change with reference to local treatment. While 
it should not be entirely abandoned, still it is of secondary importance; 
and under conditions where it can be carried out only with great diffi- 
culty and the use of force it is often wise not to attempt it systematically. 

The purpose of local treatment, it is now generally agreed, should be 
cleanliness, and not the destruction of bacilli. Cleanliness of the nose, 
mouth, and pharynx is important, inasmuch as one of the chief dangers 
of the disease is the aspiration of bacteria contained in the abundant 
secretions of these parts, into the larynx and bronchi. Our aim should 
therefore be to keep the parts as clean as possible without too severely 
taxing the strength of the child. 

For cleansing the nose and pharynx only syringing can be depended 
upon. Nasal syringing is indicated when there is much nasal discharge, 
whether membrane is visible in the anterior nares or not. In septic 
cases with a profuse fetid discharge it may be necessary to syringe the 
nose, no matter how strongly the child resists. Whether it shall be 
done, will depend upon the condition of the patient's strength and his 
pulse. The purpose in syringing is not so much to clear the nose, from 
which absorption is slow and imperfect, as to flush the rhino-pharynx, 
from which absorption is always very active. Only bland solutions 
should be employed, such as a common-salt solution, one per cent, or 
a boric-acid solution, one to four per cent strength. For some cases, the 
piston syringe and the method described on page 59 may be used; but for 
most cases a fountain syringe possesses manifest advantages, and it is 
rather more convenient for hospital purposes. Irrigation of the pharynx 



DIPHTHERIA. 1049 

is best done with the fountain syringe, and is of especial value where 
there is much swelling or abundant discharge. All solutions should be 
used as warm as can be borne, and in sufficient quantity to irrigate the 
parts thoroughly, a few such irrigations being much better than a great 
many partial ones. By a skilful nurse syringing can in most cases be 
done with comparatively little disturbance to the child. 

Slight nasal haemorrhages may necessitate less frequent syringing, 
and a free haemorrhage may require it to be discontinued. Astringent 
solutions of alum, supra-renal extract, lemon juice, etc., are often bene- 
ficial in such cases, but they must be used carefully. In children who 
are old enough gargles should be used. A solution of boric acid, lister- 
ine, or DobelPs or Seller's solution much diluted, may be employed. 

In cases with a moderate nasal discharge it is usually sufficient to 
syringe three or four times a day; but in severe septic cases, with very 
abundant discharge, syringing should be repeated as often as every two 
hours during the day and every four hours at night. 

External applications to the throat have practicaly no effect upon 
the disease, but are often useful to relieve pain and tension in the 
swollen lymph-glands. Poultices should never be employed. As a con- 
tinuous application, only cold is to be advised, generally by means of an 
ice bag well protected to prevent wetting the clothing. 

The treatment of pneumogastric and other forms of post diphtheritic 
paralysis has been considered in the chapter on Multiple Neuritis. 

The Serum Treatment. — This has been the outcome of a long series 
of experiments in which many men have had a share; but it is to Behr- 
ing pre-eminently that the credit belongs for the development of the 
principles of serum-therapy. 

Eegarding the nature of the antitoxin and its mode of action much 
is as yet unknown. It is produced by the cells of the body under the 
stimulus of the diphtheria toxin. It is intimately combined with the 
globulin of the blood, and is itself possibly a globulin. The action of 
the antitoxin is two-fold: it directly neutralises the toxin produced by 
the diphtheria bacillus which is present in the blood; it also has some 
effect upon the bacilli themselves the nature of which is not understood, 
but it induces a condition in the blood which inhibits the growth of the 
bacilli, and thus arrests the membranous inflammation which the bacilli 
excite. 

Properly prepared, it will keep without deterioration for from three 
to six months; but after one year it loses somewhat its antitoxic prop- 
erties. It should be kept in a cool, dark place, and after a bottle has 
been opened it should be used within a few days. Antitoxin is now 
prepared in a dry form, which is to be preferred only when it must 
be kept for a very long time. 

The strength of the serum is measured in antitoxin units, the unit 



1050 THE SPECIFIC INFECTIOUS DISEASES. 

being an arbitrary one, viz., the amount of antitoxin which will protect 
a guinea-pig weighing 250 to 300 grams against one hundred times the 
fatal dose of diphtheria toxin. The improvements in the production of 
the serum have thus far consisted in increasing its strength. Behring's 
serum first used contained but one unit in each cubic centimetre. At 
present there can be obtained from most manufacturers a serum con- 
taining 500 antitoxin units in each cubic centimetre. This concentration 
is of immense advantage and has to a large degree done away with the 
unpleasant symptoms, such as pain, localised oedema, etc., which were 
formerly so frequent. 

Method of administration and dosage. — In selecting an antitoxin 
syringe one should be chosen which holds at least 5 c. c, which can read- 
ily be disinfected by boiling and whose needles are not too large. The 
smallest needle through which the serum will flow is the best. Before 
making the injection, the skin should be thoroughly cleansed with alco- 
hol; the. needle should invariably be boiled and the whole syringe either 
boiled or rinsed with alcohol. Care should be taken to see that all air 
is expelled from the syringe. The seat of injection is not a matter of 
great importance; my own preference is for the cellular tissue of the 
abdomen. After the injection is made the puncture should be covered 
by adhesive plaster. 

The dose of antitoxin required in a given case is always somewhat 
problematical. It is desirable to give enough to neutralise the diph- 
theria toxin present in the blood, and that is always an unknown quan- 
tity, depending upon the stage of the disease, the severity of the attack, 
the extent of the membrane, and to some degree upon the age of the 
patient. Convinced now of the essential harmlessness of the serum, the 
tendency everywhere has been to use larger and larger doses, a practice 
which has been fully justified by the results obtained. For a child over 
two years old an initial dose for a severe attack, including all laryngeal 
cases, should not be less than 7,000 or 8,000 units ; repeated in from six 
to eight hours, provided no improvement is seen. Children under two 
years should receive from 5,000 to 6,000 units. Cases of exceptional 
severity, in older children, should receive from 10,000 to 15,000 units, 
to be repeated in from six to eight hours if the progress of the disease 
is unfavourable. Mild cases should receive from 3,000 to 5,000 units as 
an initial dose, a second being rarely required. 

In cases receiving antitoxin late, even though the symptoms may 
not seem particularly severe, the dose should be increased in proportion 
to the length of the illness — i. e., if three days ill, three times the ordi- 
nary dose should be given. 

Only serum from a trustworthy manufacturer should ever be used. 
The sera chiefly used in this country are those of the New York Health 
Department, Mulford & Company, and Parke, Davis & Co., all of which, 



DIPHTHERIA. 1051 

I believe, are reliable. The most concentrated serum which can be ob- 
tained should be selected. 

All experience shows that the results are greatly modified by the 
time of its administration. The serum can not undo the serious damage 
already done to the cells of the body, and this at the time of injection 
may be so great that death will result. In very mild cases, with older 
children, one may wait for the result of a bacteriological examination, 
but never in a severe case and never in a young child. In the group of 
severe cases should be placed every one which at the first visit shows a 
pharjoigeal exudate covering more than the tonsils, also all cases with 
symptoms of laryngeal invasion, and all with an exudate on the pharynx 
and a profuse nasal discharge. If in a doubtful case twelve hours' obser- 
vation shows that the membrane has spread from its original seat, no 
further delay is admissible. Experiments have shown that after a fatal 
dose of diphtheria toxin, an animal can usually be rescued if the anti- 
toxin is administered within forty-eight hours, but rarely after that 
time. In human diphtheria marked benefit usually follows injections 
made as late as the third day ; but after this time the value of the serum 
diminishes very rapidly, and although striking examples of benefit are 
sometimes seen after later injections, they can not be depended upon. 
On the other hand, in very severe or in malignant cases irreparable harm 
may be done during the first twenty-four hours of the attack. 

The effect upon the diphtheritic membrane is usually noticeable within 
twenty- four and often in twelve hours ; it first stops spreading, and soon 
begins to soften and loosen. The swelling of the mucous membrane 
subsides and the local disease abates, very much as when the disease 
runs its usual course. The striking thing after the use of antitoxin is 
the rapidity with which these changes take place, and the abrupt tran- 
sition from an advancing to a retrograde process. The subsidence of 
the inflammatory conditions in the larynx and trachea is quite as .marked 
as in the pharynx. The symptoms of stenosis, even when severe, often 
diminish in a few hours, making operation unnecessary in a very large 
number of cases where previously it seemed inevitable. The membrane 
loosens rapidly in the larynx and trachea, sometimes necessitating the 
frequent removal of the intubation tube, where operation has been per- 
formed. Improvement is also shown by the cessation of the nasal dis- 
charge, the re-establishment of nasal respiration, and the diminution in 
the swelling of the glands of the neck. 

The effect upon the constitutional symptoms is not less striking. In 
favourable cases there is seen, often in twelve hours, a fall in tempera- 
ture and improvement in the pulse and in the nervous symptoms. 

The limitations of antitoxin. — It is important that these should al- 
ways be kept in mind. The serum must be given early, for if given late 
it can not undo the mischief already done by the diphtheria toxin. 



1052 TH E SPECIFIC INFECTIOUS DISEASES. 

Cases of great severity often pass the period when recovery is possible, 
before the antitoxin is given. This period may in some cases be four 
days, in others it may be less than twenty-four hours. The tissues most 
susceptible to the diphtheria toxin are probably those of the nervous 
system, the heart, and the kidneys; and the consequences of its action 
may be seen in the production of nephritis, in heart failure at the height 
of the disease, or in later paralysis of the heart, respiration, or voluntary 
muscles, in spite of the fact that antitoxin is given at a period early 
enough to avert death from local disease in the larynx or bronchi. 
Again, antitoxin is of no value in cases of streptococcus septicaemia. 
The early arrest of the inflammation excited by the diphtheria bacillus 
is unfavourable to the spread of streptococcus infection, yet sometimes 
the latter gains such headway or is of such intensity as to involve al- 
most the entire body. Against the phlegmonous inflammation of the 
throat or the cellular tissue of the neck, broncho-pneumonia, and ne- 
phritis, antitoxin is powerless; and just in proportion to the severity of 
these inflammations are negative results seen. 

Eruptions and other unpleasant effects. — Some transient oedema usu- 
ally follows the injection. In a few hours there may be seen a general 
erythema; this, however, is rare and usually of short duration. The 
most important eruptions are seen between the eighth and fourteenth 
days. They follow from ten to twenty per cent of the injections made, 
and appear to be quite independent of the amount of serum used. The 
exact cause is not known. The most common eruption is urticaria. This 
is often intense, very annoying, and may nearly cover the body. It 
may be accompanied by a slight rise of temperature; it usually lasts 
for two or three days, however, it is rarely severe for more than twenty- 
four hours. Various forms of erythema are occasionally met with. In 
two or three instances I have seen haemorrhagic eruptions, generally in 
the neighbourhood of the large joints, and always in children suffering 
from extreme malnutrition. In a few cases a moderate swelling of some 
of the joints has been observed, and very exceptionally a transient albu- 
minuria. One occasionally meets with patients who seem unusually 
susceptible to serum injections, and in whom even small immunising 
doses cause headache, muscular pains and general malaise so that they 
feel quite wretched for several days. All of the above symptoms except 
the urticaria are rare, and should not for an instant deter one from using 
antitoxin when indicated. 

Real and alleged dangers from antitoxin injections. — In the few 
cases where sudden death has followed antitoxin injections, the evidence 
that antitoxin was the cause of death is not conclusive. In some of 
these patients the autopsy has revealed a status lymphaticus not before 
suspected. In this condition the shock of so slight a thing as a needle 
puncture might produce death. 



DIPHTHERIA. 1053 

That so very few alleged instances of serious harmful results have 
occurred among the great numbers of injections which have now been 
made, is sufficient to establish the fact that the serum itself is essentially 
harmless. 

The unfavourable effects upon the heart, the kidneys, and the blood, 
attributed to antitoxin, have not been proved. In a disease like diph- 
theria, where the heart and kidneys are often and seriously affected, 
and where cardiac and renal symptoms in many cases are suddenly mani- 
fested, it is impossible to say, even when such symptoms follow the in- 
jection of serum, that they are not due to the original disease. They 
were seen with great frequency before antitoxin was known. Observa- 
tions regarding the effect of the serum upon the blood were made by 
Billings, upon twenty-nine cases of diphtheria. He found the reduc- 
tion both in the haemoglobin and the red cells to be much less than the 
average found in cases of diphtheria of similar severity not treated by 
the serum. 

At the present time, no evidence has been adduced as to the danger 
or injurious effects of diphtheria antitoxin which should deter any one 
from its use. Those which have been reported are to be regarded in 
the light of accidents for which the antitoxin itself can not be held 
responsible. 

Results with antitoxin treatment. — Since 1895 the serum has been 
tested on so extensive a scale as the prevalence of diphtheria all over the 
world has made possible with results so uniformly good that it seems 
quite unnecessary any longer to cite statistics in proof of the value of 
this remedy. No tables of figures are so convincing to an individual 
as personal experience, and by this argument one by one the opponents 
of antitoxin have been converted. 

The beneficial effects of the remedy may be summed up in the fol- 
lowing statements: (1) The percentage mortality from diphtheria in 
hospitals both in Europe and in America has been reduced to a little 
more than one third the previous figure; (2) the proportion of cases 
now requiring operation for laryngeal stenosis has been reduced to about 
one half; (3) the mortality after tracheotomy has been reduced to one 
half, and that after intubation to about one third the former figure; 
(4) but even more convincing is the effect of the serum treatment upon 
the actual diphtheria mortality of cities and countries where it has 
been used. 

In the first of the subjoined tables is given for a period of years the 
actual number of reported deaths from diphtheria and membranous 
croup, irrespective of the growth in populaton ; in the second one the 
number of deaths in each 10,000 of population. These figures can not 
be open to the question which is sometimes raised concerning percentage 
mortality statistics. 
68 



1054 



THE SPECIFIC INFECTIOUS DISEASES. 



Table Showing Annual Deaths from Diphtheria and Croup, 
1887 to 1900 {inclusive). 



London 

Berlin 

Paris 

New York 

(Manhattan and Bronx) 

Chicago 

Boston 

Philadelphia 

Brooklyn 

Denver 

Germany 

(966 towns over 15,000) 

New York State. 
Massachusetts. . . 



1887 1888 1889 1890 1891 1892 1893 



1,579 

If! 

1,585 

3,056 

1,405 

410 

858 

1,453 

68 

10,970 

6,490 
1,628 



1,812 
1,195 
1,729 
2,553 

1,297 
589 
523 

1,885 

120 

10,142 

6,710 
1,831 



2,075 
1,210 
1,706 
2,291 

1,509 
683 
727 

1,467 

109 

11,919 

5,930 
2,214 



1,877 
1,601 
1,659 
1,783 

1,261 
462 
748 

1,283 

277 

11,915 

4,954 
1,626 



1,174 
1,106 
1,361 
1,970 

1,358 

285 

1,362 

1,180 

175 

10,484 

4,844 
1,218 



2,182 
1,342 
1,403 
2,106 

1,548 

481 

1,707 

1,137 

89 

12,365 

5,970 
1,455 



3,484 
1,637 
1,266 
2,558 

1,467 
546 

1,238 

878 

106 

16,557 

5,942 
1,394 



1894 

2,861 
1,416 

U 

2,870 

1,406 
878 
1,452 
1,660 
71 
13,790 

6,616 
1,801 



1895 1896 1897 1898 1899 1900 



2,479 
987 
435 

1,976 

1,632 
654 
1,398 
1,454 
40 
7,611 

5,696 
1,784 



2,793 
559 
444 

1,763 

1, 
572 

1,201 

1,310 

19 

6,262 

4,640 
1,677 



2,328 
546 
268 

1,591 

774 
456 
1,514 
998 
43 



4,115 
1.426 



1,842 
664 
256 
843 



185 
1,154 

745 

34 

5,220 

2,612 
706 



2,041 
655 



917 
304 
997 
744 
31 
5,111 

2,786 
*1,047 



1,558 
563 
291 

1,121 

797 

537 

1,064 

673 

14 



3,306 

tl,475 



Cases reported 1899, 7,134. 



+ Cases reported 1900, 12,641. 



Table Showing Average Annual Deaths from Diphtheria and Croup 
per 10,000 of Population. 



3-7 
1-3 
63 
50 

1-7 
96 



London, before antitoxin, 


1887- 


'93, 


4*8; since 


Berlin, 


M 


<; 




10-2; 


Paris, 


if 


M 




65; 


New York, 


« 


U 




14-5; 


Chicago, 


«( 


«( 




13-1; 


Denver, 


(( 


M 




12-9; 


Philadelphia, 


(( 


1890- 


•'94, 


11-9; 



Some explanation of these figures is necessary that they may be 
fully appreciated. The great reduction in the death-rate is seen only 
in those cities and countries where the serum treatment has been 
widely employed. Nowhere in Europe is this true to the same degree 
as in Paris, Berlin, and Germany generally; and probably nowhere 
in Europe has it been so little used and so slow in gaining favour 
as in London. In our American cities the effect of the serum treat- 
ment upon municipal mortality figures has been directly proportion- 
ate to the extent to which the health departments have believed in its 
efficacy and encouraged its use by furnishing it free to the poor, and 
sending their own inspectors to administer it. This is true par- 
ticularly of New York and Chicago; in Philadelphia, on the contrary, 
the authorities for a long time were openly opposed to the serum 
treatment. 

Summary. — 1. Behring's antitoxin is a specific remedy for experi- 
mental diphtheria in animals. 

2. Experience is now sufficient to justify the statement that it is so 
in man, and just to the extent in which we can fulfil the conditions 
which are essential in experimental diphtheria. 



DIPHTHERIA. 1055 

3. These conditions are, that the serum must be administered early, 
that the dose be adequate, and the case be one of pure diphtheria. 

4. Experience shows the serum to be much less efficacious in cases of, 
so-called mixed infection or septic diphtheria, and that it is valueless in 
membranous inflammations which are due to streptococci — i. e., pseudo- 
diphtheria. 

5. The serum itself is essentially harmless both when injected in 
healthy persons for immunization, or in those suffering from diphtheria. 

6. In a young child the serum should be injected upon a clinical 
diagnosis of diphtheria without waiting for bacteriological confirmation; 
in older children one may wait in a mild case, but never in a severe one, 
particularly a laryngeal case. 

7. For all patients, but especially for young children, the most con- 
centrated preparations of antitoxin that can be obtained should be 
employed. 

8. The actual mortality from diphtheria (including membranous 
croup) has been reduced in those cities and countries where it has been 
generally adopted by nearly 50 per cent; the mortality of intubated 
cases has fallen from 70 to less than 30 per cent; of tracheotomized 
cases from 60 to 33 per cent; the proportion of cases in which operation 
is required has been reduced fully 50 per cent. 

9. The evidence is conclusive that in laryngeal diphtheria the serum 
in sufficient doses largely prevents the extension of the membrane into 
the trachea and bronchi, thus preventing broncho-pneumonia. 

10. It is not yet possible to state to what extent the heart, the 
kidneys, and the nervous system are protected by the serum. It is, 
however, certain that such results can not be depended upon unless 
injections are made early and full doses given. 

11. For a period of from three to four weeks the protection con- 
ferred by immunization is practically complete. The serum should 
therefore be given to every child in an infected household or institution. 

12. Gratifying as were the earlier results with the serum treatment, 
they have been constantly improving, and there is every reason to be- 
lieve that, with larger experience both in its preparation and its use, 
still better results will yet be reached. Certainly there is no remedy 
for any disease that has more testimony in its favour than has antitoxin 
for diphtheria. 

Convalescence. — After a severe attack of diphtheria convalescence is 
always slow on account of the anaemia and the depressing effects of the 
disease. Patients should invariably be kept in bed for at least a week 
after the throat has cleared, and longer if any tendency to cardiac weak- 
ness is seen. The pulse should be carefully watched, and irregularity, 
intermission, dicrotism, or a weak first sound of the heart, should make 
one apprehensive. An abnormally slow pulse is generally more serious 



! 



1056 THE SPECIFIC INFECTIOUS DISEASES. 

than one which is rapid. Under such circumstances the patient should 
be kept recumbent and absolutely quiet, since sudden and even fatal 
syncope may be the result of a violation of these rules. 

The extreme degree of anaemia requires that iron be given for a con- 
siderable time during convalescence, to be followed by cod-liver oil, wine, 
and other tonics. 

Great difficulty is occasionally experienced in getting rid of the ba- 
cilli in the throat. The tonsillar crypts, the adenoid tissue of the rhino- 
pharynx, and the nasal sinuses are the places where the bacilli are most 
likely to remain. Inasmuch as it is now generally made a condition of 
release from quarantine that the throat shall have been shown by cul- 
tures to be free from bacilli, this becomes a matter of much importance. 
The most efficient means appears to be to syringe the nose gently three 
or four times daily with a solution of bichloride, 1 to 10,000, to which 
one eighth glycerin has been added, and to use the same solution as a 
gargle. For children under four years old a simple salt solution, or a 
dilute DobelFs solution, should be substituted and the gargle omitted. 

PSEUDO-DIPHTHERIA. 

Synonyms : False diphtheria, streptococcus diphtheria, scarlatinal diphtheria, 
diphtheroid inflammation, croupous tonsillitis. 

At the present time there are included under the term pseudo-diph- 
theria all inflammations of the throat and upper air passages character- 
ized by the production of a false membrane, in which the Klebs-Loeffler 
bacillus is not found. When these inflammations are primary they are 
rarely serious; but when they complicate scarlet fever or measles they 
may be very severe, and frequently prove fatal. 

Frequency. — Numerical statements regarding the relative frequency 
of this disease and true diphtheria signify very little, because of the 
variable conditions under which observations have been made. From 
the investigations of Park, Baginsky, Martin, Morse, and others, it 
would appear that in from twenty-five to thirty-five per cent of the 
cases formerly sent to hospitals with a clinical diagnosis of diphtheria,, 
the disease was pseudo-diphtheria. Most of these were mild, and were 
regarded by many physicians as simply cases of tonsillitis, the exceptions 
being those which were secondary to scarlet fever or measles. 

Of the membranous inflammations occurring in the diseases just 
mentioned, the great majority are examples of pseudo-diphtheria. Of 
seven cases of membranous angina in measles and three in scarlet fever, 
studied by Prudden, all were proved to be pseudo-diphtheria; of nine- 
teen occurring with scarlatina, studied by Park, only two were found 
to be true diphtheria; and of sixteen occurring with scarlet fever and 
three with measles, studied by Booker, none was true diphtheria. In 
1,000 cases of scarlatina observed by McCollom, only twelve per cent of 



PSEUDO-DIPHTHERIA. 1057 

those showing distinct membrane in the throat were true diphtheria. It 
has been the general experience of all writers that when it complicates 
other diseases, pseudo-diphtheria nearly always occurs at the height 
of the primary disease, while true diphtheria may occur at any time, 
even during convalescence. 

Etiology. — As was first shown by Prudden in 1888, and abundantly 
confirmed by others since that time, this inflammation is usually due to 
the streptococcus; it may be found alone, or associated with the staphy- 
lococcus aureus or albus, and occasionally the staphylococcus may be 
found alone. 

The streptococcus is very frequently found in the throats of healthy 
children, particularly in winter and in cities, and more often in those 
who live in tenements or who are inmates of hospitals or other institu- 
tions. The local conditions in the mucous membranes during an attack 
of measles, scarlet fever, and other infectious diseases, are especially 
favourable for the development of these germs, which at such times are 
very often present in great numbers even when no membrane is seen. 

This form of sore throat is more apt to occur in houses with bad 
drainage and other unsanitary conditions. From the fact that the strep- 
tococcus is so widely distributed, attacks of pseudo-diphtheria may 
occur in any place and at any time, irrespective of epidemic influences 
or even the occurrence of other cases. 

To what degree these cases are to be regarded as communicable, and 
what precautions regarding isolation and disinfection are required, are 
questions of much importance. The most extensive investigations upon 
these points are those made by the New York Health Department. As a 
result of observations upon 450 cases which were followed, the conclu- 
sion was reached that the disease was so slightly contagious, if at all, 
and usually so mild, that strict isolation and subsequent disinfection 
were unnecessary. Of 113 cases occurring in 100 families, in only 14 
was there a history of exposure to a similar case; and in only 9 was there 
another case in the same family. In many of the latter, a common origin 
appeared more probable than that one case was derived from another. 

They are probably more contagious in the presence of the poison of 
scarlet fever or measles. 

Lesions. — In the primary cases the membrane is generally confined 
to the tonsils or is chiefly there, there being only small deposits else- 
where. In the secondary cases, the entire pharynx may be covered and 
the disease may extend to the nose, the mouth, the middle ear, and occa- 
sionally to the larynx, trachea, and bronchi. 

The structure of the membrane resembles that of true diphtheria, 
and it is impossible by a microscopical examination alone always to 
separate the two diseases. In many cases the membrane is softer, more 
friable, and contains a relatively larger number of cells than does that 



1058 THE SPECIFIC INFECTIOUS DISEASES. 

of true diphtheria, but the structure of the latter varies so much that 
it is not safe to draw any positive conclusions. 

In the mild cases the inflammation of the mucous membrane is a 
superficial one and the pseudo-membrane is not very adherent. In the 
severe cases, chiefly the secondary ones, the process extends much deeper. 
Besides the pseudo-membrane upon the surface there is intense con- 
gestion, oedema, and cell-infiltration of all the lymphoid and cellular 
tissue of the pharynx. It affects the tonsils, soft palate, uvula, epi- 
glottis, adenoid tissue of the vault and the entire pharyngeal ring, and 
also extends to the external lymph nodes .and surrounding cellular tissue. 
The process both in the throat and externally in the neck may terminate 
in resolution, suppuration, or in necrosis. 

The streptococci are found in the false membrane, in the underlying 
mucous membrane, in the lymph spaces and in the lymph nodes. In the 
most severe cases there are present the lesions of a general streptococcus 
infection. The blood swarms with these germs, and they may set up in- 
flammations in any of the organs, but especially in the lungs and the 
kidneys, less frequently in the serous membranes. Small foci of sup- 
puration may be found in any of the viscera. 

Symptoms. — 1. The primary cases. — The onset is usually abrupt, 
with well-marked symptoms: there are frequently chilly sensations, head- 
ache, vomiting, general pains, and in most cases the child complains of 
soreness of the throat and pain on swallowing. There are first seen a 
general redness and swelling of the tonsils, sometimes of the entire 
pharynx; shortly afterward membranous patches appear upon the ton- 
sils. These vary greatly in appearance. In colour they are yellow or 
gray, often changing later to a dirty-olive tint. (Plate XVIII, 0.) The 
membrane seems loosely attached and can frequently be wiped off with a 
swab. It is soft and friable, very rarely thick, firm, or tenacious. It is 
often irregular in its outline, which is not sharply defined. The mem- 
brane usually remains but three or four days and disappears rapidly. 
As a rule, it is limited to the tonsils, and does not spread after it first 
forms. Occasionally, however, small patches are also seen upon the 
fauces or the pharynx. The oedema and other evidences of inflamma- 
tion in the throat are usually more marked than in true diphtheria, and 
the swelling of the lymph nodes behind the jaw is slight. The constitu- 
tional symptoms are generally more severe during the first two days, and 
the temperature may be 103° or 104° F., but by the third day it falls, 
and most of the symptoms subside. It is rare for the disease to extend 
either to the nose or the larynx. Generally there are no complications 
and no sequelae. 

2. The secondary cases. — Some of these are mild, and do not differ 
from those just described, but most of the severe cases are included in 
this group. The clinical picture of the latter is that of scarlatina angi- 



PSEUDO-DIPHTHERIA. 



1059 



nosa, as given by the older writers, and it does not differ in any essential 
particulars from the septic form of true diphtheria (page 1035). The 
local symptoms are those of severe pharyngeal diphtheria, and the con- 
stitutional symptoms those of septicaemia. 

When the disease complicates scarlet fever, the symptoms may pre- 
cede the eruption, but they usually begin at the height of the primary 
fever — i. e., from the second to the fourth day — and gradually increase 
in severity, reaching their maximum from the fifth to the eighth day of 
the disease. In measles the throat symptoms are somewhat later; they 
begin at the height of the primary fever, and often increase while the 
eruption fades. In most of the severe scarlatinal cases the disease in- 
volves the nose and the middle ear. In measles both these complications 
are less frequent, but there is a much greater tendency to involve the 
larynx, and if the larynx in a young child, the process is almost invariably 
complicated by broncho-pneumonia. In some cases the larynx is invaded 
when there is no membrane in the pharynx; but this is very infrequent 
unless the disease is true diphtheria. Catarrhal laryngitis in a young 
child may produce symptoms which are practically identical with those 
of the membranous form, and there is little doubt that many cases com- 
plicating measles in which the latter diagnosis is made are really exam- 
ples of catarrhal laryngitis, particularly if no membrane is visible in 
the throat. 



DAY 


1 


2 


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Fig. 203.— Pseudo-diphtheria following measles. The chart begins at the time of the full erup- 
tion in a severe case of measles. On third day temperature fell, with fading eruption, and 
child seemed convalescent. With secondary rise in temperature, the tonsils, which before 
had been only red, showed membranous patches, the exudation rapidly spreading until the 
entire pharynx was covered; throat symptoms very severe, with great swelling of cervical 
glands, but the membrane did not extend beyond the pharynx. From sixth to twelfth day 
a most profound septicaemia, so that life was despaired of. The patient was a vigorous child, 
and, escaping both nephritis and pneumonia, made B good recovery. Convalescence quite 
rapid; no sequela}. Repeated cultures were made from the throat, but all showed only 
streptococci. Patient a girl four years old. Case observed in private practice. 

Secondary cases as a class are characterized by high temperature 
(Fig. 203), rapid, feeble pulse, great prostration, and delirium, apathy 



1060 THE SPECIFIC INFECTIOUS DISEASES. 

or stupor, and often albuminuria. In fatal cases death usually occurs 
at the height of the disease, from asthenia, broncho-pneumonia, or 
nephritis, sometimes from laryngitis. If none of these complications 
develop, patients may withstand the toxic symptoms even when they are 
very severe. If the attack terminates in recovery, the local disease fol- 
lows very much the same course as in diphtheria. The subsequent anae- 
mia is, however, less severe, and none of the dangers of convalescence 
connected with cardiac or respiratory paralysis are present. 

There may be in connection with the local process in the throat, deep 
sloughing of the tonsils or adjacent structures, suppuration of the lym- 
phatic glands or in the cellular tissue of the neck, occasionally followed 
by serious haemorrhage. However, these complications are rare, and if 
the patient survives the danger of the acute stage of the disease, he 
usually recovers. 

Diagnosis. — The clinical features which distinguish pseudo-diph- 
theria from true diphtheria have already been considered (page 1040). 
It is impossible in any case to be certain of the diagnosis except by cul- 
tures; for, although by clinical symptoms alone one may in the great 
majority of cases be certain that a given case is one of true diphtheria, 
to say that any membranous inflammation of the throat is not diph- 
theria is impossible. The bacteriologists have taught us to be cautious 
in pronouncing too positively upon even mild cases, as it has been shown 
that some of them may be caused by most virulent diphtheria bacilli 
(page 1031). 

In the secondary cases the diagnosis by clinical symptoms is more ac- 
curate. A membrane which appears in the throat early in the course of 
measles or scarlet fever, or at the height of the primary disease, is usually 
due to the streptococcus; while one which develops late or after the pri- 
mary fever has subsided, is frequently due to the diphtheria bacillus. 

Prognosis. — There is no more striking contrast between true and 
pseudo-diphtheria than in their mortality when they are seen side by 
side. Of 117 primary cases of pseudo-diphtheria observed by Park in 
the Willard Parker Hospital, New York, the mortality was 3*5 per cent; 
of 127 cases of true diphtheria seen in the same institution at the same 
time, the mortality was 34*5 per cent. In a group of 154 hospital cases 
reported by Baginsky, there were 118 of true diphtheria, with a mor- 
tality of 38 '2 per cent, and 34 cases of primary pseudo-diphtheria, with 
a mortality of 5*5 per cent. From the same hospital, Philip has pub- 
lished a report upon 376 cases: 332 of these were true diphtheria, with 
a mortality of 37 per cent; 31 were cases of primary pseudo-diphtheria, 
with no mortality. The Bulletin of the New York Health Department 
contains a report upon 324 cases of pseudo-diphtheria in children, with 
a mortality of 9, or 2*8 per cent; 4 of the fatal cases complicated scarlet 
fever; of the primary cases, the mortality was but 1*5 per cent. These 



PSEUDO-DIPHTHERIA. 1061 

were not hospital cases. From the above data the deduction seems war- 
ranted that in a child previously healthy, primary pseudo-diphtheria is 
not a serious disease. 

Turning now to the secondary cases, we find very different condi- 
tions. From the best available statistics it would appear that the usual 
mortality of pseudo-diphtheria, when it is secondary to scarlet fever and 
measles, is from 15 to 20 per cent. However, when these diseases prevail 
epidemically in institutions, the mortality is often higher than this. 

Prophylaxis. — In primary cases strict quarantine is unnecessary after 
the question of diagnosis has been settled. Cases of pseudo-diphtheria 
occurring in measles or scarlet fever should certainly be separated from 
uncomplicated cases. By way of prevention, something can be done in 
these diseases by keeping both nose and throat as clean as possible during 
severe attacks by the use of an antiseptic mouth-wash or gargle, and a 
nasal spray. For young children only weak solutions should be em- 
ployed, such as a diluted DobelPs or Seller's solution, 1: 10,000 bichloride, 
or a one-per-cent solution of boric acid. 

Treatment. — Every child with a membranous patch on its throat re- 
quires close watching; if under three years old diphtheria antitoxin 
should be administered, pending the result of a bacteriological examina- 
tion. In all cases with doubtful diagnosis this should invariably be 
done. The primary cases require only the treatment of an attack of 
tonsillitis. 

In the secondary cases local treatment should be begun with the 
appearance of the first patch upon the tonsils. In mild cases the use of 
gargles and antiseptic throat sprays is sufficient. In the severe cases 
local treatment should be thorough and energetic, but not repeated too 
frequently. It is seldom necessary to disturb a very sick child for local 
treatment oftener than every two hours by day and every four hours by 
night. The nose should be syringed with warm, bland solutions but not 
too forcibly. For the pharynx stronger solutions may be employed as 
hot as can be borne. In order to clear the secretions from behind 
the swollen tonsils a short piece of a soft catheter may be attached to 
the tip of the syringe, which should be inserted well back behind the 
molar teeth. Where the swelling and oedema are great, benefit may 
result from frequent spraying with solutions containing supra-renal ex- 
tract, also from inhaling hot vapour impregnated with eucalyptol, ben- 
zoin, etc. For a local germicidal effect swabbing is most reliable; strong 
solutions should be used but not frequently repeated — e. g., 1: 500 bichlo- 
ride of mercury or a 10-per-cent solution of nitrate of silver, from one to 
three times a day. As an external application nothing is so beneficial as 
the ice-bag, which, whenever there is great adenitis and cellulitis, should 
be constantly used covered with thin flannel, and kept well up against 
the throat by a four-tailed bandage. 



1062 THE SPECIFIC INFECTIOUS DISEASES. 

The general management of these cases as to feeding, stimulants, 
etc., is the same as in diphtheria. Aside from stimulants no internal 
medication should be attempted with young children. Those who are 
older may take with advantage tr. f erri chlor., gtt. v to x, with glycerin, 
every three or four hours. The use of streptococcus antitoxin in these 
cases has thus far been attended with very little success, and can not yet 
be recommended. 



CHAPTEE IX. 
TYPHOID FEVER. 

Typhoid fevek is an acute infectious disease due to a specific germ 
— Eberth's bacillus. It may affect the foetus in utero, or the newly born 
child, and it is seen in infancy and throughout childhood. 

Foetal typhoid. — Morse * (Boston) has collected the evidence bear- 
ing upon foetal infection, from which the following conclusions seem 
warranted: Infection of the child from the mother is a frequent but not 
an invariable occurrence. The bacilli may pass directly from the ma- 
ternal into the fcetal circulation. The foetal form of the disease is a 
general blood-infection, since the intestines are not functionally active. 
The most common result is death of the foetus and consequent abor- 
tion; but the child may be born alive still suffering from infection, 
and die in a short time because of its feeble resistance. Whether a 
foetus may recover completely and be born alive and well, is not yet 
established. 

Infantile typhoid. — Much difference of opinion exists regarding the 
frequency with which typhoid fever occurs in infancy. Some clini- 
cians hold the opinion that the disease is of very common occurrence, 
but is often unrecognised because of the absence of many of the symp- 
toms which are characteristic at a later age. They regard every pro- 
tracted fever not malarial and not dependent upon a local inflammation 
as presumably typhoid. The symptoms from which we may regard the 
question of typhoid as established will be considered under Diagnosis. 
I have seen but two undoubted cases of typhoid under two years of age, 
and I believe it to be rare, at least in New York. No case recognised as 
typhoid occurred in a child under two years of age during my eight years' 
service in the New York Infant Asylum, where about ten thousand cases 
of acute illness were treated and over seven hundred autopsies made ; and 
but two in my sixteen years' service at the Babies' Hospital where about 
the same number of autopsies have been made. No case has been rec- 
ognised as typhoid, either in the wards or the post-mortem room of the 



* Archives of Paediatrics, December, 1900. 



TYPHOID FEVER. 1063 

New York Foundling Hospital during the past twenty-five years. Ty- 
phoid has been seen by Murchison at six months and by Ogle at four 
and a half months, the diagnosis being in both instances confirmed by 
autopsy; also by Griffith at seven months and by Taylor at eight 
months, with fairly typical symptoms. It is during epidemics that most 
of the infantile cases are seen; sporadic instances of infantile typhoid 
should always be regarded with suspicion, and I believe that most cases 
so diagnosticated are questionable. Even in epidemics it is surprising 
that so few infants are attacked. In that of Montclair, N. J., in 1894, 
of 115 cases, only 3 were under two years; in that of Stamford, Conn., 
in 1895, of 406 cases only 4 were under two years. 

Typhoid in childhood is by no means rare, but it is not until after the 
fifth year that it can be said to occur frequently. The following figures, 
embracing groups of cases reported by eight writers, represent the rela- 
tive frequency with which the disease is seen at the different ages: Of 
970 cases, 8 per cent occurred under five years, 42 per cent between five 
and ten years, and 50 per cent between ten and fifteen years. 

Typhoid fever is almost invariably contracted by drinking water or 
milk (see page 139) which contains the germs of the disease. The in- 
f requency of typhoid in infants is explained, in part at least, by the fact 
that most of the water and a large part of the milk taken is previously 
boiled, or heated in some manner. 

Lesions. — Typhoid in young children is so seldom fatal that oppor- 
tunities for a study of the lesions have been limited. In a general way 
they resemble those of adults except in severity. In a considerable 
number of the cases the pathological process in the intestines does not 
go on to ulceration; and when ulcers form they are seldom large or 
deep, and perforation is very rare. Montmollin gives the following 
facts concerning 23 autopsies, most of them, however, being in children 
over eight years old: ulcers were present in 17 cases; they were situ- 
ated in the lower ileum in 16, and in 10 they were only there; in the 
ascending colon in 9, and only there in one case; perforation occurred in 
3 cases, in every instance in the lower ileum. Autopsies made upon 
infants may show even less severe intestinal lesions than those men- 
tioned. In fact, some cases in which the clinical diagnosis was beyond 
question, have shown only moderate redness and swelling of Peyer's 
patches, the solitary follicles and the mesenteric lymph nodes — lesions 
which are exceedingly frequent in cases of simple diarrhoea. In a 
doubtful case such post-mortem findings do not establish the diagnosis 
of typhoid. Indeed, they prove nothing unless cultures from the intes- 
tinal contents, the mesenteric glands, or other organs, show the typhoid 
bacillus. Enlargement of the spleen is practically constant. The de- 
generative changes in the heart, the kidneys, and the liver are much 
less frequent and generally less severe than in adults. 



1064 THE SPECIFIC INFECTIOUS DISEASES. 

Symptoms. — The peculiar features of typhoid in early life are seen 
only in children under ten years old; for after this time the disease does 
not differ essentially from the adult type. In brief, the typhoid of early 
childhood may be described as a fever characterized more often by nerv- 
ous symptoms than by intestinal symptoms. 

Onset. — A sudden onset with well-marked symptoms — fever, pros- 
tration, vomiting, etc. — is not uncommon; in fact, it is quite as fre- 
quently seen as the insidious beginning with lassitude, headache, coated 
tongue, anorexia, and gradual rise in temperature. In cases developing 
abruptly it often appears as if an acute indigestion had been the means 
of precipitating the attack. The most frequent initial symptom is vomit- 
ing; a chill is rare. Epistaxis occurs as an early symptom rather less 
frequently than in adults. 

Condition of the bowels. — There is no constant relation between the 
severity of the intestinal lesions and the condition of the bowels. Tak- 
ing large groups of cases together, diarrhoea is present in about half the 
total number. It is rarely profuse, from two to four discharges a day 
being the average. The appearance of the stools is seldom character- 
istic; they are usually thin and fluid, often containing mucus. Consti- 
pation may be present at the beginning only, or throughout the attack. 
Tympanites is generally moderate, and is often entirely absent; it usu- 
ally accompanies constipation. Marked iliac tenderness and gurgling 
are infrequent. 

Spleen. — By the end of the first week this is almost invariably found 
to be enlarged to a sufficient degree to be recognised by palpation. 
Usually the spleen extends but an inch or an inch and a half below the 
ribs, but at times it may be three inches or more; persistent enlarge- 
ment always indicates that the disease is not at an end even though the 
temperature has reached the normal, and a relapse should be expected. 

Eruption. — It is the experience of nearly all who have seen much of 
typhoid in children that the eruption is less constant, less abundant, 
and less characteristic than in adults. Of 670 cases in Morse's * collec- 
tion, it was noted in but 60 per cent. The typical eruption consists of 
small, scattered, rose-coloured spots, which appear chiefly or solely 
upon the abdomen at the beginning of the second week. They come in 
successive crops, each one of which generally lasts three days, the whole 
duration of the eruption being about ten days. 

Prostration, emaciation, etc. — As a rule the prostration is quite suffi- 
cient to keep a child in bed after the first few days. The general weak- 
ness after this time is in direct proportion to the height of the tempera- 
ture. Loss of flesh is steady and usually marked; and in a prolonged 
attack there may be extreme emaciation. 

* Typhoid Fever in Childhood, with an Analysis of 284 Cases ; Boston Medical and 
Surgical Journal, February 27, 1896. 



TYPHOID FEVER. 



1065 



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Temperature. — In the cases with, a gradual onset, the typical tem- 
perature curve is one which rises steadily for from two to seven days, 
fluctuates within the limits of one to three degrees during the second 
week, and steadily declines during the third week, reaching the normal 
on the average at the end of the third week. In cases with an abrupt 
onset, the temperature rises at once to from 102.5° to 105° F., but sub- 
sequently may run the same course as in the first group. 

The following are the most important variations from the tempera- 
ture curve of adults: The initial rise is much more frequently rapid; 
during the second week 
the remittent character is 
less marked, this probably 
depending upon the fact 
that ulceration is less fre- 
quent and less extensive; 
the average duration is 
shorter. In young chil- 
dren the proportion of 
cases in which the fever 
lasts only from eight to 
fourteen days is quite 
large (Fig. 204). After the 
age of ten years the type 
of the fever is much like 
that seen in adults. The maximum temperature in the mild cases is 
103° or 104° F.; in the severe ones it often reaches 105° or 106° F., but 
rarely goes above this point. The range is usually higher than in adult 
cases of the same severity. At the beginning of convalescence a sub- 
normal temperature is very frequent, and by many writers is considered 
to be the rule. A secondary rise is most frequently due to errors in 
diet, but may occur from the development of complications. A sudden 
fall indicates either perforation or intestinal haemorrhage. 

Relapses were present in 8*4 per cent of 533 cases collected by 
Morse. They follow about the same course as in adults (Fig. 205). 

Nervous symptoms. — As a rule, these are more prominent in severe 
cases than the intestinal symptoms, and are directly proportionate to 
the height of the temperature. The extreme nervous symptoms be- 
longing to the typhoid state in adults are rare in childhood, except in 
patients over ten years old. Beadache and mild delirium at night are 
very frequent, the former being seen in the majority of cases. Young 
children are usually dull, apathetic, and often in a state of semi-stupor. 
Occasionally the disease may closely simulate meningitis. The nervous 
symptoms are usually most severe in the second, or early in the third 
week, and subside as the temperature declines. 



Fig. 204. — Typhoid fever of short duration in a child 
thirteen months old. Spleen enlarged : eruption typi- 
cal ; no diarrhoea and only moderate abdominal dis- 
tention. There were two other cases in the family, 
all being due to the same cause — infected milk. 
(After Northrup.) 



1066 



THE SPECIFIC INFECTIOUS DISEASES. 



Pulse. — This is increased in frequency, but not to the degree that 
is seen in most diseases of childhood with a similar elevation of temper- 
ature. The force and rhythm of the pulse are usually good, irregular- 
ity, very low tension, and dicrotism being rare as compared with adults. 



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Fig. 205.— Typhoid fever with relapse. Child two and a half years old ; early temperature high 
and symptoms typical ; natural fall on fourteenth day ; rise on seventeenth day apparently 
due to otitis ; relapse on twenty- fourth day, with fresh eruption and return of splenic swell- 
ing which had disappeared. Temperature was subnormal at the end both of primary and 
secondary fever. 

Urine. — A small amount of albumin is found in the urine of most 
of the severe cases at the height of the disease, and is due to acute renal 
degeneration; but a marked degree of nephritis is infrequent. In from 
one-fourth to one-third of the cases typhoid bacilli are found in the 
urine, generally in pure culture. They usually appear in the latter 
part of the disease, the second or third week, and may continue for 
months or even years. They are sometimes accompanied by evidence 
of cystitis or nephritis. Their number is in some cases so large as to 
render the urine turbid; in others they give no indication of their pres- 
ence. Ehrlich's diazo reaction is usually present at the height of the 
fever. 

Intestinal hemorrhage. — Of 946 collected cases, mainly from hospital 
reports, intestinal haemorrhage occurred in 30, or about three per cent; 
the majority of these were in children over ten years old. Of 24 col- 
lected cases of haemorrhage in children, 10 terminated fatally. The 
youngest case of this nature which has come under my own notice was 
in a child of four and a half years. 

Intestinal perforation. — This is even more rare than haemorrhage. 
In 1,028 collected cases, this accident occurred but twelve times, or in 
1*1 per cent. Eight of these proved fatal. Perforation is indicated by 
a sudden fall in the temperature, with collapse; usually there is vomiting 
and the rapid development of tympanites. 

Complications and Sequelae. — The complications of typhoid in early 
life are infrequent and usually mild. Bronchitis is present in most of the 
severe cases. Pneumonia has been noted in 9 per cent of the cases 
reported by various authors. Both serous and purulent effusions into 
the chest are occasionally seen, and sometimes abscess of the lung. 



TYPHOID FEVER. 1067 

Complications referable to the nervous system are not very frequent, 
but are of much interest. Meningitis is extremely rare. Morse has col- 
lected twenty-one cases of aphasia, in two of which it was clearly due to 
embolism; in the remainder, however, it apparently was not dependent 
upon any organic lesion. In two thirds of the cases it came on during 
convalescence, and in nearly all complete recovery occurred after an 
average duration of three weeks. Aphasia usually followed a severe 
type of the disease, and in most of the cases was not accompanied by any 
other paralysis or by mental disturbance. Insanity is a rare sequel of 
typhoid in children, the usual type being acute mania. Adams (Wash- 
ington) has reported two examples of this, both terminating in recovery. 
Chorea is seen rather oftener than after the other infectious diseases. 

Otitis is not an infrequent complication, occurring much oftener than 
in adults. It is principally seen in young children and during the cold 
season. Among the less frequent complications may be mentioned: paro- 
titis, which is usually suppurative and is seen in septic cases; abscess of 
the liver, examples of which have been reported by Bokai, Asch, and 
others; gangrenous inflammation of the mouth or genitals; pericarditis, 
endocarditis, and peritonitis, suppurative inflammations of joints, mul- 
tiple abscesses and furunculosis. Tuberculosis of the lungs or bones not 
infrequently follows typhoid. 

Diagnosis. — The diagnostic symptoms of typhoid are the Widal blood 
reaction, the discovery of the bacilli in the urine or faeces, the eruption, 
the course of the temperature, the enlargement of the spleen and the 
abdominal symptoms — diarrhoea, tympanites, intestinal haemorrhage, 
and perforation. 

The Widal reaction is present at some period in from 95 to 98 per 
cent of the cases, and thus becomes the most valuable single symptom 
for diagnosis. It is seldom obtained before the seventh day and fre- 
quently not until the tenth; it may not be present until convalescence 
or a relapse. Eepeated tests should always be made if the first reac- 
tion is negative or doubtful; and the tests should be made by an ex- 
perienced pathologist. The reaction is therefore of much less value for 
an early than for an exact diagnosis. A positive reaction may be present 
if the patient has previously had typhoid, something much less likely to 
be the case with children than with adults; in rare instances it has been 
obtained in other diseases or in health where no history of previous 
typhoid existed. Both these conditions, however, are very exceptional, 
and a positive reaction may as a rule be taken to establish the diagnosis. 

Typhoid bacilli, according to the observations of Park (New York), 
may be demonstrated in the stools by culture in about 40 per cent of 
the cases. They are found in the urine, usually in the latter part of 
the disease, in about one-third the cases. Their discovery in either of 
these discharges is conclusive evidence of previous or existing typhoid. 



1068 THE SPECIFIC INFECTIOUS DISEASES. 

An examination of both urine and faeces should, if possible, be made in 
all doubtful cases. 

The course of the temperature is an important aid to diagnosis, but 
alone is not to be depended upon. The characteristic feature is a fever 
which continues for two, three, or four weeks, and subsides sponta- 
neously. The variations from the adult type have already been men- 
tioned, also the frequency of the eruption, the enlargement of the spleen, 
and the abdominal symptoms. We are not warranted, I think, in making 
the diagnosis of typhoid, if repeated tests fail to show the Widal reac- 
tion or if the eruption and splenic enlargement are absent, and no bacilli 
can be demonstrated in the discharges, no matter what the course of the 
temperature may be. 

One should be very slow to make the diagnosis of typhoid in a child 
under two years old, unless the disease is epidemic. The great majority 
of sporadic cases reported as occurring in infancy are probably not 
typhoid. After the fifth year the disease is more frequent, and its 
symptoms in general resemble those of adults, except in severity. 

A differential diagnosis is to be made from malarial fever, ileo-colitis, 
meningitis, tuberculosis, and from other ill-defined continuous fevers 
of unknown origin. From malarial fever the diagnosis is to be made by 
the temperature curve, the organisms in the blood, and the effect of 
quinine. In most of the cases of malaria the temperature will be found 
to touch the normal at some time in the twenty-four hours. The admin- 
istration of full doses of quinine is a diagnostic test of much practical 
importance; an irregular or remittent fever which yields promptly to 
quinine is most certainly not typhoid. 

Ileo-colitis and typhoid fever are not often confounded. The former 
is chiefly seen in the first three years of life, a time when typhoid is 
rare. The intestinal symptoms of ileo-colitis are marked even though 
the temperature is not high, and they are altogether more severe than 
is usual in typhoid; while enlargement of the spleen, tympanites, and 
the eruption are not present. 

The cerebral symptoms of typhoid may be difficult to distinguish from 
meningitis, unless one has watched their development. Irregular respira- 
tion, a slow, irregular pulse, localized paralysis and complete coma are 
seldom, if ever, seen in typhoid, and a retracted abdomen very rarely^ 
while the enlarged spleen and the peculiar eruption are not seen in 
meningitis. In typhoid with pronounced nervous symptoms the tem- 
perature is usually higher than in meningitis. 

General tuberculosis very often resembles typhoid so closely that a 
differential diagnosis is almost impossible until local signs of tuberculosis 
have appeared, usually in the lungs. (See page 1090.) 

Prognosis. — Of 2,623 cases collected from the reports of twelve differ- 
ent writers, the mortality was 5*4 per cent. These are, however, almost 



TYPHOID FEVER. 1069 

all taken from hospital reports, where as a rule the mildest cases are not 
brought for treatment. The mortality of the disease in children over 
three years old probably does not exceed 3 or 4 per cent. Death seldom 
occurs from the disease itself, but usually from some accident or com- 
plication, the most frequent being pneumonia and intestinal haemor- 
rhage or perforation. Griffith's collection of cases occurring in infancy 
indicates a much higher mortality for this period. The death-rate for 
the first year reached nearly 50 per cent. 

Treatment. — The usually low mortality of this disease shows how 
successful all methods of treatment are likely to be considered. In the 
great majority of cases very litte active treatment is required. Every 
patient with typhoid should be put to bed and kept there during the 
febrile period, and a few days beyond it, no matter how mild the attack 
may be. A fluid diet should be prescribed in every case, sterilised milk 
or animal broths, which should be given regularly every three hours, but 
not pushed beyond the desire of the patient. Milk may be diluted or 
partially peptonised, and kumyss or matzoon may be substituted for it if 
the stomach is irritable. Plenty of water should be given. Solid food 
should not be allowed until the temperature is normal. 

Both the urine and faeces should be immediately and thoroughly dis- 
infected by a solution of carbolic 1 : 20. If the movements are in a cham- 
ber or a bed-pan they should be covered with this solution for at least 
six hours before they are thrown into the water-closet. If napkins or 
diapers are used, they should be soaked in some effective antiseptic so- 
lution for twelve hours and then thoroughly boiled. Sheets stained by 
discharges should be treated in the same way, and all bed-linen should 
be boiled for two hours apart from the washing of the family. The 
efficiency of urotropin in removing typhoid bacilli from the urine seems 
now to be well established. It should be given at the close of the attack 
in doses of three to five grains, three times a day, and continued for a 
week or ten days. 

Diarrhoea calls for treatment only when the movements exceed four 
or five in twenty-four hours. If no more than this number are present, 
they should not be interfered with. Opium and bismuth are undoubt- 
edly the best means for controlling excessive diarrhoea, but care 
should be taken that they are not pushed to the degree of inducing 
constipation. 

Constipation early in the disease may be relieved by calomel, followed 
by the salines, or castor oil, but all active purgation should be avoided. 
Later in the disease daily irrigation of the colon with tepid water is 
better than anything else. On the whole, constipation is more trouble- 
some to overcome than diarrhoea. 

Tympanites is rarely severe enough to require treatment; it may be re- 
lieved by turpentine stupes, by a glycerin suppository, or a small glycerin 



1070 THE SPECIFIC INFECTIOUS DISEASES. 

injection (one teaspoonful of glycerin to two ounces of water), or, better 
still, by the use of the rectal tube. 

Whenever the temperature remains above 103° F., antipyretic meas- 
ures are indicated. In mild cases cold or tepid sponging is generally 
sufficient. In those which do not yield to such measures, baths may be 
employed. Not all children bear baths well, and considerable discretion 
should be used in employing them. One should be guided quite as much 
by the effect upon the pulse and the nervous system as by the tempera- 
ture. The best method is usually the graduated bath ; the child is placed 
in the tub with the water at a temperature of 95° or 100° F. ; this is 
gradually lowered to 95°, 90°, or even 85° F., but seldom lower. The 
body should be actively rubbed while the child is in the bath, to prevent 
shock and cardiac depression. The cold pack (pages 49 and 50) may be 
substituted for the bath where circumstances make the latter imprac- 
ticable. The bath or pack should be repeated in an average case in 
from three to six hours. The method of applying cold which causes 
the least disturbance to the patient is the one which should always be 
selected. 

The milder nervous symptoms — headache, restlessness, sleeplessness, 
etc. — may be relieved by an occasional dose of phenacetine, either alone 
or in combination with the bromides, or by cold or tepid sponging; the 
more severe ones usually occur with high temperature, and are best con- 
trolled by the cold bath. 

Stimulants in most of the cases are not called for. They are to be 
given according to the indications afforded by the pulse, the first sound 
of the heart, and the child's general condition. They are seldom needed 
earlier than the middle of the second week; they should be well diluted. 
Brandy or whisky is to be preferred to wines, and, unlike the milk, they 
may be given at frequent intervals whenever the patient will take them 
best. Intestinal haemorrhage calls for absolute quiet, morphine hypoder- 
mically, and an ice-coil to the abdomen, nothing being given by mouth 
except stimulants, turpentine, and possibly opium. Intestinal perfora- 
tion is successfully treated only by early laparotomy. 



CHAPTEK X. 
TUBERCULOSIS. 

Tubeeculosis is an infectious communicable disease, due to the 
bacillus tuberculosis of Koch. It may be local or general, and may in- 
volve any organ and almost any structure in the body. 

Etiology. — Frequency. — Miiller, in 500 autopsies upon children in 
Munich, found tuberculosis in 40 per cent of the cases; in 30 per cent 



TUBERCULOSIS. 1071 

death was due to tuberculosis, and in the remaining 10 per cent tubercu- 
losis was found at autopsy in patients dying from other diseases. I do not 
think it is so frequent in this country, for, of 726 consecutive autopsies in 
the New York Infant Asylum, tuberculosis was found in only 58, or 8 per 
cent of the cases ; 6 per cent of the deaths were due to tuberculosis, and in 
2 per cent the children died from other diseases. Of 319 consecutive autop- 
sies in the Babies' Hospital, tuberculosis was found in 44, or 14 per cent. 

Predisposing causes. — The predisposition to tuberculosis is general or 
local. General predisposition may be inherited directly from parents who 
have themselves suffered from tuberculosis, or from those who, in conse- 
quence of syphilis, alcoholism, or any other constitutional vice, have trans- 
mitted a feeble constitution to their children. Inherited predisposition is 
exceedingly common, and really signifies a diminished resistance of the 
cells of the body to tuberculous infection. It should be distinguished 
from the very exceptional condition of congenital tuberculosis, where in- 
fection takes place before birth. General predisposition includes the 
child's surroundings, in so far as they affect the constitution and lower 
the general vitality. Children reared in the city, either in institutions 
or in crowded tenements, are more frequently affected than those who 
have had the advantage of the best surroundings, not only because of their 
increased chances of exposure, but also from their feebler resistance. 
Marasmus, intestinal diseases, and, in fact, any debilitating general or 
local disease, may predispose to tuberculosis. 

A local predisposition is created by any pathological condition of the 
mucous membranes or organs most exposed to infection. The most im- 
portant are repeated attacks of bronchitis, broncho-pneumonia, or pleurisy, 
and chronic catarrhal inflammation of the mucous membrane of the nose or 
pharynx, so frequently associated with enlarged tonsils or adenoid growths 
of the pharynx. Much less frequently the local predisposition is the result 
of some previous disease of the intestines. 

The role played by other diseases in the development of tuberculosis is 
an important one, and until recently but little understood. In a very 
large number of cases tuberculosis develops as a sequel of one of the 
acute infectious diseases, particularly measles, pertussis, or epidemic in- 
fluenza. In such cases there has probably existed previously a latent tuber- 
culosis, usually in the bronchial lymph nodes. This process, sometimes 
long quiescent, under the stimulus of a new infection may be awakened to 
activity. It is to be noted that it is the infectious diseases that are in- 
timately associated with pulmonary complications, which are liable to be 
followed by tuberculosis. 

Age. — No age is exempt from tuberculosis. It was formerly believed 
that the disease was rare in infancy, but recent observations have shown 
that, although its form is somewhat different, it is more frequent in in- 
fancy than at any period of later childhood. Statistics, taken chiefly from 



1072 THE SPECIFIC INFECTIOUS DISEASES. 

two institutions where children up to four years of age are received, give 
the following results, the diagnosis being confirmed by autopsy in nearly 
every case under two years old : 

Under three months 5 cases 

From three to six months 21 " 

" six to twelve months 31 " 

" twelve to eighteen months. 29 " 

" eighteen to twenty-four months 10 " 

" two years to five years 32 " 

Over five years 15 " 

Total 143 " 

It will be seen that the first year furnished 57 cases, the second year 
39, and the succeeding three years but 32 cases. 

Intra-uterine infection, or the direct transmission of tuberculosis, 
although rare, has been established by the report of at least seven com- 
plete and well authenticated cases. Tuberculosis of the placenta is still 
more frequent, there being according to Wollstein * now twenty cases 
on record. In most of the cases of congenital tuberculosis the mother 
has been suffering from the disease in an advanced form, and the child 
is either still-born or dies soon after birth. Besides tuberculosis of the 
placenta, there are found tubercle bacilli in the organs of the child, and 
when life is prolonged, there are generalised lesions showing infection 
through the blood. In some cases cheesy nodules in the umbilical cord 
have been observed. 

Intra-uterine infection is highly probable in many of the cases of chil- 
dren born of tuberculous mothers, who develop the disease during the 
first few months of life, although they may show no evidence of it at 
birth. Among my own cases there were five which died of tuberculosis 
during the first three months. One of these children was but twenty 
days old. It was born prematurely of a mother who at the time was suf- 
fering from advanced tuberculosis, and died from that disease shortly 
after the child. Besides other lesions, the autopsy showed, in the case of 
the mother, tuberculosis of the endometrium. In this instance the infec- 
tion of the child certainly took place before birth. 

In another case, a child died of general tuberculosis, with wide-spread 
lesions, at the age of seven weeks. The mother of this infant died from 
tuberculosis eleven days after the birth of the child. Intra-uterine infec- 
tion must, however, be considered rare in comparison with the frequency 
with which infection takes place after birth, instead of being, as was 
formerly supposed, very common. 

Tuberculosis may be communicated by direct inoculation, as in the 
case of a bite from a person suffering from the disease, several instances 
of which are on record. The rite of circumcision performed by a rabbi 

* See Archives of Paediatrics, May, 1905, for literature on congenital tuberculosis. 



TUBERCULOSIS. 1073 

suffering from tuberculosis is also known to have caused the disease. One 
of the most striking instances of direct infection is that reported by 
Keich.* In a town of about 1,300 inhabitants, the obstetric practice was 
divided between two midwives. Within fourteen months no less than 
ten infants, who had been delivered by one of these women, died of tuber- 
culous meningitis. In none of these families was there a history of tuber- 
culosis. This midwife was found to be suffering from pulmonary tuber- 
culosis, and died from that disease. It was her custom to remove the 
mucus from the mouth of the newly-born infants by direct mouth-to- 
mouth aspiration, and then to establish respiration by blowing into the 
nose. In the practice of the other midwife, who was healthy, no cases of 
tuberculosis occurred, although she treated the newly-born infants in the 
same fashion. 

The following instance of infection has recently come to my notice : 
Two little girls were much in the room and about the bed of a young 
woman who was suffering, it was afterward discovered, from pulmonary 
tuberculosis. Within three months of that time, and within six weeks of 
each other, both died of tuberculous meningitis. 

Examples might be multiplied indefinitely of cases where children 
have contracted the disease from a close exposure to nurses or other per- 
sons in the household. More frequently, however, the mode of infec- 
tion can not be traced, the exposure doubtless being in most of these 
cases long antecedent to the development of symptoms. 

Aside from accidental inoculation already mentioned, the tubercle 
bacilli may gain an entrance to the body either through the respiratory or 
the alimentary tract or the skin — the last, however, being so very rare that 
it need only be mentioned. In infancy and early childhood, infection is 
most frequently through the respiratory tract. This is indicated by the 
situation of the primary lesions (pages 411 and 1076). The source of 
the bacilli in the inspired air is mainly the sputum of patients suffering 
from pulmonary tuberculosis, which dries and becomes part of the dust 
of the street, of the railroad car, the home, or the hospital. Bacilli may 
be taken into the alimentary tract with milk from tuberculous cows or 
tuberculous women. Infection in this way I believe to be niro.f Unless 

* Berliner klinische Wochenschrift, No. 37, 1878. 

f In this connection the following incident is interesting as bearing upon the other 
side of the question : Near a large American city was a fancy stock farm of registered 
Jersey cows, which supplied milk for table use and infant feeding to a large number 
of lamihes in the wealthiest part of the city, for a period of over ten years. At the 
end of that time the tuberculin test was used for the first time, and 45 per cent of 
these cows were found to be tuberculous, and were killed by order of the State Board 
ol Health. The diagnosis was confirmed by autopsies upon the animals in every 
instance. An investigation was instituted among the children who had been fed 
upon this milk, but in only one case of many hundreds could it be learned that tuber- 
culosis had developed, and in this instance it was by no means established that the 



1074 THE SPECIFIC INFECTIOUS DISEASES. 

the udder is the seat of disease, the number of bacilli in cow's milk is so 
small that the chances of infecting a child after these bacilli have passed 
the stomach are exceedingly small. Its possibility even is questioned by 
many good authorities. The same may be said regarding the transmis- 
sion of tuberculosis through the milk of a nurse. Infection from the 
meat of tuberculous animals is doubtless a possibility, but hardly more. 
Bollinger's experiments in feeding animals with the expressed juice of 
such meat gave negative results. 

The Various Paths of Infection adopted by the Tubercle Bacillus. — 
The tubercle bacilli which enter the body with the inspired air are ar- 
rested upon the mucous membrane of the upper or the lower respiratory 
tract ; upon which one of these, is largely determined by local conditions 
in the various mucous membranes. Both clinical experience and animal 
experiments indicate that the bacilli may pass through a mucous mem- 
brane without inducing in it a tuberculous disease, but that penetration 
is much easier if the mucous membrane is the seat of a catarrhal inflam- 
mation, or if the epithelium has been injured. The bacilli are taken up 
by the lymphatics from the surface of the mucous membrane upon which 
they have lodged, and are carried to the nearest lymph nodes, where, 
for a considerable time at least, they are arrested. It has long been a 
familiar clinical fact that the great majority of children who suffer from 
tuberculosis of the cervical lymph nodes escape general tuberculous in- 
fection, so eminent an authority upon this subject as Treves considering 
this to be a very exceptional result. 

It is not infrequent, in autopsies both upon children and adults dying 
from various non-tuberculous diseases, to find tuberculosis limited to the 
bronchial lymph nodes. In a series of 125 autopsies at the New York 
Foundling Asylum upon children with tuberculosis, Northrup* found 
13 such cases, these being children who had died from acute non- 
tuberculous diseases. Many confirmatory reports have been published 
by Bollinger (Munich) and others. I have myself seen it in a number 
of instances. 

H. P. Loomis f (New York) made inoculation experiments with the 
bronchial lymph nodes taken from the bodies of thirty persons dying by 
violence or from acute disease, in whom no evidence of tuberculosis in any 
other part of the body could be found at autopsy. From eight of the cases 
he produced tuberculosis in animals by inoculation. Arnold has shown 

milk had been the source of infection. It should be stated that this was before the 
days of sterilizing milk for infant feeding. Besides the families who took the milk 
in the manner mentioned, the employees at the farm were accustomed to drink the 
skimmed milk in large quantities daily as a beverage in the place of water. Many of 
them continued to do this for years, and yet not one of them developed tuberculosis. 

♦ New York Medical Journal, February 21, 1891. 

f The Medical Record, December 20, 1890. 



TUBERCULOSIS. 1075 

by experiments with dust inhalation in animals, that in a short time the 
bronchial lymph nodes were filled with dust, though the bronchi and 
alveoli were free ; but, however prolonged the inhalation, dust was never 
found in the lymphatic vessels beyond the nodes. 

Arriving at the lymph node, the bacilli light up a tuberculous inflam- 
mation of varying degrees of intensity, depending upon their number 
and upon local conditions. This inflammation may pass through the 
usual changes of tuberculous glands — congestion, swelling, cell prolifera- 
tion and caseation ; or the process may be arrested at any point, and the 
products of inflammation become encapsulated by a proliferation of fibrous 
tissue, in which condition they may remain latent in the body for an in- 
definite number of years — possibly for a lifetime. This is what occurs in 
older and more vigorous children, and it is consistent with every outward 
sign of health ; but it is a smouldering ember which at any time may be 
fanned into flame under the stimulus of an inflammation excited by some 
other cause. 

In infants and young children, the tendency is always for the bacilli to 
lodge first in the bronchial lymph nodes, probably on account of the 
favourable conditions for entrance existing in the bronchi and lungs. In 
those who are delicate and have but little resistance, the process in the 
lymph nodes is likely to go on to caseation and softening, and secondarily 
to this process in the glands, the lung may become infected. Of 91 cases 
observed by Northrup, in which the mode of infection could be pretty 
accurately traced, in 88 it was primarily in the bronchial lymph nodes. 
The manner of the extension of the disease to the lung is not always easy 
to trace ; but in many instances it has been shown to be the result of 
the softening of one of these small tuberculous lymph nodes, which then 
ulcerates through the wall of one of the small bronchi or a blood-vessel, 
in this way distributing its bacilli through the lung. 

Although this is the course usually taken by bacilli when they are in- 
haled, it is not always the case. Lesions in the lungs are occasionally 
found where the lymph nodes are not involved ; and there are other cases 
in which advanced changes exist in the lung, while only the earlier ones 
are seen in the lymph nodes. In these cases, which perhaps are to be 
considered as exceptional, the tuberculous process probably begins in 
the walls of the small bronchi, the alveoli, or in the connective-tissue 
septa. 

Tubercle bacilli entering the alimentary tract rarely cause lesions of 
the gastric mucous membrane, or through it reach the lymphatic circula- 
tion. In the intestines, however, more favourable conditions exist. It is 
possible for the bacilli to reach the mesenteric lymph nodes without caus- 
ing disease of the intestinal mucous membrane, but I believe it to be ex- 
ceedingly rare; for by careful search I have seldom failed to find intes- 
tinal ulceration where the lymph nodes were manifestly tuberculous. 



1076 



THE SPECIFIC INFECTIOUS DISEASES. 



Lesions, — In the following table are given the different lesions of tu- 
berculosis as they were found in 119 autopsies, of which I have notes. 
These represent the lesions of infancy and early childhood, 66 per cent of 
these children being two years old or under. There are introduced for 
comparison, the statistics of 131 autopsies from the Pendlebury Hospital 
Keports (Manchester, England). Very few of the cases in this series were 
under three years, the hospital admitting only older children : 

Frequency of the Different Visceral Lesions of Tuberculosis. 



Organs. 



Lungs 

Pleura 

Bronchial lymph nodes. . 

Brain , 

Liver 

Spleen , 

Kidneys 

Stomach , 

Intestines 

Mesenteric lymph nodes. 

Peritonaeum 

Pericardium 

Endocardium 

Thymus 

Suprarenal capsules 

Pancreas 



Personal cases ; 

119 autopsies (chiefly under 

three years). 



117 

69 

108 

40 

77 

88 

46 

5 

40 

38 

10 

7 

1 

3 

2 

3 



99*0 per cent. 

58-0 " 

960 " 

37-0 " 

65-0 " 

75-0 " 

39-0 " 

4-0 " 

37-0 " 

350 " 

90 " 

6 •" 

0-8 " 

2-5 " 

1-7 " 

25 " 



Pendlebury Hospital Reports ; 


131 autopsies (chiefly over 


three years). 


122 


93 • per cent. 


100 


76-0 " 


91 


70-0 " 


60 


46-0 " 


86 


65-0 " 


76 


58-0 " 


54 


41-0 " 


1 


0-8 " 


65 


50-0 " 


77 


59-0 " 


37 


28-0 " 


4 


3-0 " 






2 


1-6 " 



The varieties of tuberculosis seen at different ages. — During the first 
two years of life, tuberculosis, with great uniformity, involves first the 
bronchial lymph nodes and the lungs. It is most frequently the pul- 
monary process which is the cause of death, and next to the lungs, death is 
due to tuberculosis of the brain. It is rare for any other local tuberculous 
process to be fatal at this time of life. Of 72 cases of tuberculosis in the 
first two years of life, in which the exact nature of the lesions was deter- 
mined by autopsy, the lungs were extensively involved in all ; but death 
was due to meningitis in 13, in only one to tuberculous peritonitis, and in 
one to haemorrhage from a tuberculous ulcer of the intestine. During 
infancy, meningitis is rare except when associated with pulmonary tuber- 
culosis ; but after the second year, meningitis is relatively more frequent. 
Of the deaths from tuberculosis during the third year, meningitis was 
present in over one half the number. After this time it frequently exists 
with few and sometimes with no lesions in the lungs, it being often sec- 
ondary to tuberculosis of the bones or lymph nodes. 

Beginning with the third year, tuberculosis of the bones, cervical and 
mesenteric lymph nodes, peritonaeum, and intestines, becomes more frequent, 
and in any of these organs it may occur as the principal lesion, although 
at autopsy the lungs, even at this age, are rarely found free from infection. 



TUBERC ULOSIS. 1077 

Pulmonary Lesions. — As compared with adults, the pulmonary tuber- 
culosis of children is more widely diffused, and the predominance of cases 
in which the lesion is at the upper lobes, though less marked, still exists. 
The peculiarities are principally seen in children under two years. In 
those who have passed the sixth or seventh year, the pathological processes 
resemble those of adult life. In my own autopsies the oldest lesions were 
found 69 times in one of the upper lobes (left 35, right 34) ; 23 times in 
the right middle lobe, and 35 times in one or other of the lower lobes 
(left 24, right 11). Although localized tuberculous processes are frequently 
met with in patients dying from other diseases, those who die from tuber- 
culosis usually show wide-spread lesions of the lungs, and the younger the 
child the more diffuse they are. 

1. Miliary tuberculosis of the lungs. — In nearly every case of pulmo- 
nary tuberculosis, miliary tubercles are found in some part of the lung ; 
usually they are seen upon the surface and in scattered areas in the 
vicinity of some older process. Occasionally in older children, but 
very rarely in infants, they are distributed through nearly the whole of 
both lungs. 

In some places the lung, with the exception of these gray granulations, 
appears quite normal ; in others it is congested, and shows between the 
tubercles the lesions of simple broncho-pneumonia in its various stages. 
There is also an acute bronchitis of the middle-sized and smaller bronchi. 
The microscope shows that the tubercles usually develop in the walls of 
the small bronchi or the blood-vessels, or very close to these structures. 
In their gross appearance, the lungs in these cases resemble those in ordi- 
nary acute broncho-pneumonia, with the exception that everywhere upon 
the surface and throughout the substance of the lung are seen the small 
gray granulations, and in most cases some small yellow tuberculous nod- 
ules. The pleura is usually normal except for the presence of the tuber- 
cles. This form of the disease represents the rapid dissemination of 
tubercle bacilli throughout the lungs, the miliary tubercles being the 
result of the inflammation excited by their presence. 

2. Tuberculous broncho-pneumonia. — This is the most frequent and 
the most characteristic form of tuberculosis in infants and young chil- 
dren, and it is the one which at this age usually causes death. In this 
form of disease there are produced in the lung, caseous nodules, or larger 
caseous areas, some of which have usually undergone softening by the 
time the case comes to autopsy. The process generally runs a somewhat 
subacute course. With the lesions mentioned there are always associated 
those of simple broncho-pneumonia. 

The pleura is involved in almost every case. There may be simply 
dense connective-tissue adhesions which bind the lung firmly to the chest 
wall, or the pleura may be greatly thickened and contain caseous deposits. 
Occasionally empyema is seen, but it is almost always sacculated and small. 



1078 THE SPECIFIC INFECTIOUS DISEASES. 

Both lungs are usually involved, but one to a much greater degree than 
the other. There are found large areas of consolidation which some- 
times involve an entire lobe, but more often areas are seen in several lobes. 
These portions of the lung appear much firmer and harder than in ordi- 
nary pneumonia. The upper lobes are more often affected than the 
lower, and especially that part of the lobe which is near the root of the 
lung, on account of its frequent association with tuberculosis of the 
bronchial glands ; the disease very often extends forward from this point 
to the middle lobe of the right, or the corresponding part of the left lung. 
On section the affected part of the lung usually shows many caseous 
nodules varying in size from a pin's head to a walnut, which appear of a 
pale yellow colour, and resemble caseous lymph nodes. They contain giant 
cells and are usually filled with bacilli, those which have softened con- 
taining yellow pus. There is nearly always seen in some part of the 
lung a large caseous area; and not infrequently there may be diffuse 
caseation of almost an entire lobe (Fig. 206). Sometimes no spot of 
softening is seen even in these large areas, but in the great majority 
of them there are found cavities of variable size with ragged but not 
dense walls. 

Softening and excavation represent the final stages of the process in 
tuberculous pneumonia. It has been shown by Prudden that these changes 
are chiefly or entirely due to other pathogenic organisms — usually the 
streptococcus or staphylococcus — and not to the tubercle bacillus. Soften- 
ing usually begins in the centre of a caseous part, often at several points 
at the same time. Areas of excavation large enough to deserve the name 
of cavities were present in thirty-five of seventy two autopsies upon tuber- 
culous patients, two years old and under. They are found in the great 
majority of the cases in which continuous pulmonary symptoms have been 
present till death. They vary in size from a cherry to a hen's egg, and 
sometimes a much larger one is seen (Fig. 207). They are usually rather 
deeply seated, and partially or entirely filled with caseous masses or pus, 
but very seldom perforate the pleura, causing pneumothorax or pyopneu- 
mothorax. It is rare in a young child to find cavities surrounded by dense 
fibrous walls such as are seen in older children or in adults; for in infancy 
the process of softening once begun usually advances steadily until the 
death of the patient. 

It is very frequent to find at autopsy small cavities surrounded by 
larger areas of caseous pneumonia, and these in turn surrounded by a 
zone of simple pneumonia through which are scattered many miliary 
tubercles. Often the lesions mentioned will be present in one lobe, while 
the other lobe or the opposite lung will show only the changes of a simple 
pneumonia. 

The bronchial lymph nodes are in these cases invariably found to be 
tuberculous, and not only those at the root of the lung, but if a dissection 



TUBERCULOSIS. 



1070 



is made, a chain of these tuberculous glands will be found to follow the 
larger bronchi for some distance into the lung (Fig. 210). Sometimes 
one may discover one of these which has softened and ulcerated through 
into a small bronchus, and in this way has spread the infection through- 
out that part of the lung. 

Microscopical examination of these cheesy nodules shows that they 
most frequently begin as tuberculous deposits in the walls of the small 





Fig. 206. 



Fig. 207. 



Fig. 206. — Tuberculous pneumonia. A vertical section through the middle of the right lung 
of a child thirteen months old. The greater part of the upper lobe is uniformly caseous— a 
diffuse tuberculous pneumonia; near the centre the commencement of a cavity is seen ; he- 
low it has the appearance of a consolidation from simple pneumonia. The part of the Lower 
lobe shown is normal. 

Fig. 207. — Cavity from breaking down of tuberculous pneumonia; another view of the sarae 
lung, the section bein<^ made very near the posterior border of the lung. The cavity occu- 
pies at this point nearly the whole of the upper lobe. At autopsy this cavity contained nu- 
merous loose caseous masses, the largest being the size of a marble. The lower lobe is 
normal. (For history, see Fig. 213.) 

bronchi, either in the mucous membrane, the fibrous coal, ot I lie lymphat- 
ics; sometimes, however, they begin in the walls of a small vein or artery. 
Cell proliferation takes place, separating the coats of the bronchus or 
blood-vessel, and partly or entirely obstructing its lumen. Softening may 



1080 



THE SPECIFIC INFECTIOUS DISEASES. 



take place and the contents be discharged into the bronchus or blood- 
vessel. About this focus other changes of an inflammatory character 
occur, as a result of which each cheesy nodule is surrounded by a zone 




Fig. 208. — A small tuberculous nodule surrounded by lung tissue which shows only slight 
inflammatory changes. The centre of the nodule is necrotic ; at its periphery is shown in- 
filtration with round cells and several giant cells. (From Karg and Schmorl.) 

of simple broncho-pneumonia (Fig. 208) which tends, in a measure at 
least, to limit the tuberculous process. The larger caseous areas are 
formed by an extension of this process to the zone of pneumonia 
which surrounds it; but in its further growth it is still preceded by 
a simple pneumonia (Fig. 209). The rapidity with which the lesions 
advance differs much in the different cases, and is greatly modified by 
the patient's age; in infants the progress is apt to be continuous until 
the death of the patient; in older children it is usually slower, and is 
often interrupted by longer or shorter intervals of arrest and even of par- 
tial retrogression. Such periods are marked by the absorption of the sim- 
ple inflammatory products in the zone of pneumonia surrounding the 
tuberculous nodule, accompanied by improvement in the symptoms and 



TUBERCULOSIS. 



1081 



often by a disappearance of some of the physical signs. During these times 
of quiescence there is an opportunity for the organization of the cells in- 
filtrating the alveolar walls and septa into a more or less resistant fibrous 
wall which acts as a barrier against the advance of the pathological pro- 
cess. 

Not infrequently one sees in the post-mortem room one or two caseous, 
or less frequently calcareous, nodules encapsulated by firm, organized con- 
nective tissue where a most careful search fails to show any other tubercu- 



B- 




Fio. 209. — Pulmonary tuberculosis, showing areas of tuberculous pneumonia and conglomerate 
tubercles. In the greater part of the specimen the air vesicles are tilled with the products 
of simple pneumonia. The larger dark areas, A A J, are spots of tuberculous pneumonia, 
while at B B only single air vesicles or groups of two or three are affected by the tuber- 
culous process. Tin- specimen shows a comparatively early stage of the process, of which 
the late Stage is represented by Fig. 2<>s. I'ntient, a child three months Ola; the symptoms, 
those of simple acute pneumonia. Then: were conglomerate tubercles scattered through 
both lungs, and large areas of cheesy pneumonia in the left lower lobe. 



lous lesion in the lung. If, however, the nodules are widely scattered 
through the lung, such an arrest of the process is not to be expected. 
3. Chronic pulmonary tuberculosis, chronic phthisis. — With thepatho- 



1082 THE SPECIFIC INFECTIOUS DISEASES. 

logical process as it is seen in adults, we have nothing to do in infants 
and very young children. In those who have reached the age of eight 
or ten years the disease is essentially the same as in adult life, and need 
not be described here. 

In little children the nearest approach to this condition is seen in the 
cases of tuberculous broncho-pneumonia, which run a slow, irregular, 
and somewhat chronic course. The essential features of the process in 
these patients is a chronic interstitial broncho-pneumonia with tubercu- 
lous nodules which rarely undergo softening, but usually become encap- 
sulated. 

The gross lesions closely resemble those of simple chronic broncho- 
pneumonia (page 583). There are the same generalized pleuritic adhe- 
sions and the shrunken cicatricial condition of the part of the lung most 
affected, with bronchiectasis, compensatory emphysema, etc. The tuber- 
culous nodules are old and for the most part converted into dense fibrous 
tissue in the centre of which, however, some softened, caseous areas are 
often seen. Lesions like those described, which may be regarded as a 
form of recovery, are usually found in patients who have died of other 
diseases ; sometimes in those who have died of other forms of tuberculosis 
— of the brain, bones, or peritonaeum ; at other times they are associated 
with a recent process in some other part of the lung. The bronchial 
glands may be somewhat enlarged and contain encapsulated caseous 
masses, or they may be calcareous. 

Bronchial lymph nodes {bronchial glands). — The prominence of the 
lesions of the lymph nodes is one of the most striking features of tuber- 
culosis in infancy and early childhood. Those which are most frequently 
affected are connected with the bronchi. The lymph nodes, to which the 
term " bronchial glands " is generally applied, consist of three groups : 
the first of which surround the trachea; the second are situated at the 
bifurcation of the trachea and surround the primary bronchi ; while the 
third follow the course of the bronchi into the lung, being found, accord- 
ing to anatomists, as far as the fourth division. The anatomical relation 
of the different groups should be borne in mind, since upon them the 
symptoms principally depend. The first group, or the peri-tracheal lymph 
nodes, are in relation with the superior vena cava, the pulmonary artery, 
the pneumogastric and recurrent laryngeal nerves ; the second group, at 
the bifurcation of the trachea, with the oesophagus, pneumogastric nerve, 
and aorta; the third group, with the bronchi and the branches of the 
bronchial and pulmonary arteries and veins. 

All the groups are usually involved at the same time, but in varying 
degrees, and in most cases those belonging to one lung to a greater extent 
than the other ; in my own cases those of the right side have more often 
been involved than those of the left. There may be simply two or three 
tumours as large as a hazelnut, or there may be a mass two or three inches 



PLATE XX. 




Tuberculosis of the Tracheobronchial Lymph Nodes. 

From a fairly nourished child, four months old, who was under observation for 
three weeks, with slight fever and a most severe, teasing, dry COUgh, which was almost 
constant, and upon which no treatment seemed to have the slightest effect. At, first 
there were no signs of disease; in the lungs; later there were a few coarse scattered 
rales. 

There were small tuberculous deposits throughout both lungs, with quite a large 
area of cheesy pneumonia in the right middle lobe, and scattered miliary tubercles in 
other organs. 



TUBERCULOSIS. 



10S3 



in diameter, which is made up of ten to twenty of these nodes fused 
together by inflammatory products, completely surrounding the trachea 
and both the large bronchi. It is rare that the individual glands are 
more than an inch in diameter, and most of them are smaller than this. 







/ £ 




Fig. 210. — Tuberculous bronchial lymph nodes. Section of the lung of an infant through 
cheesy bronchial lymph nodes at the root of the lung, and adjacent cheesy masses, Beveral 

lung otherwise normal ; lite-si 



of which have softened at the centre 
Northrup.) 



tin 



size. (After 



A well-marked but nol unusual example of this condition is shown in 

Plate XX. There is usually found a chain of these tuberculous ^land- 
following the course of the large bronchi for some distance into the lung; 
sometimes these are almost as large as the external group ( Fig. 210) ; at 
other times they are not noticed unless a somewhat careful dissection is 



1084 THE SPECIFIC INFECTIOUS DISEASES. 

made. The process is not infrequently more advanced in these deeply- 
seated glands than in those situated at the root of the lung ; and lesions 
here are also more important, as it is very frequently through them that 
the lung becomes infected. 

The pathological changes through which these glands pass as a 
result of tuberculous infection, are very similar to those already described 
with reference to the cervical glands. Suppuration is less frequent 
than in the region of the neck, while calcific degeneration is much more 
so. This applies especially to children over three years old. In infancy 
suppuration is not infrequent in the bronchial glands, while at this age 
calcification is extremely rare. Infection of these lymph glands is not 
always followed by general tuberculosis or even by infection of the lung. 
Although the process has gone on to caseation, these inflammatory prod- 
ucts with bacilli may become encapsulated, and may remain innocuous 
for an indefinite period. The bacilli may die or may exist here, living, for 
years. At any time the old process may be lighted up, and a more or less 
rapid dissemination of tubercle bacilli take place through the lungs or 
through the whole body. Latent tuberculosis more frequently exists in 
the bronchial lymph nodes than in any other structure in the body. 

Secondary lesions may be produced by these lymph nodes. The 
pneumogastric and recurrent nerves may be surrounded by one of these 
cheesy masses which causes pressure and irritation. The oesophagus, the 
trachea, or the bronchi, may be compressed or opened by ulceration. The 
superior vena cava usually suffers only compression, but this or any of the 
other large vessels may be opened. Ulceration may also take place into 
one of the large or small bronchi or the trachea. If the gland has soft- 
ened and broken down, and if the bronchus is a small one, the only result 
of this may be a, rapid spreading of tuberculous infection throughout the 
lung. If sudden rupture occurs, a large caseous mass may escape into the 
trachea, or a large bronchus, with a result similar to that produced by any 
other foreign body. If suppuration occurs, the abscess may rupture into 
the surrounding cellular tissue, causing mediastinal or retro-cesophageal 
abscess. This may open externally at the suprasternal notch, or in the 
first or second intercostal space, or may ulcerate into any of the large 
vessels, the oesophagus, or the pericardium, or may burrow downward 
into the peritoneal cavity. 

Pleura. — This is rarely normal in any case of tuberculosis. In acute 
general tuberculosis the only lesion may be a deposit of miliary tubercles 
upon the visceral pleura. In most of the other cases there are found 
fibrous adhesions over the part of the lung involved, binding it to the 
pericardium, the diaphragm, or the chest wall. The amount of thicken- 
ing of the pleura varies a good deal, but is rarely great. In about one 
fifth of my own autopsies tuberculous nodules were found in the pleura ; 
with these lesions there is usually considerable thickening. Pleurisy with 



TUBERCULOSIS. 1085 

a hemorrhagic exudation is very rare in the tuberculosis of early child- 
hood. Empyema is also rare, being seen in but five per cent of my 
cases, and then it was small and sacculated. Pneumothorax and pyo- 
pneumothorax are very rare in children under three years of age ; they 
were not seen in any of my cases. 

Heart. — It is exceptional for the pericardium to be affected even in 
the most generalized forms of miliary tuberculosis. In such cases the 
usual lesion is a deposit of a few gray tubercles upon the visceral surface. 
In chronic cases other lesions analogous to those of the pleura may be 
seen, but all are rare in childhood. In a single instance I have seen 
miliary tubercles upon the endocardium. They are extremely rare, and 
the development of cheesy nodules in the heart is almost unknown in 
early life. 

Brain. — Tuberculosis of the brain is not uncommon during infancy, 
being then associated in nearly all cases with general tuberculosis, and 
especially with tuberculous pneumonia; but it is relatively twice as fre- 
quent after the second year. There may be found miliary tubercles alone, 
or these may be accompanied by inflammatory products — tuberculous 
meningitis — or there may be caseous nodules. Miliary tubercles are fre- 
quently found in small numbers in cases which have presented no symp- 
toms. The lesions of tuberculous meningitis have already been described. 
Cheesy nodules are rare in infancy, being noted in but 2.5 per cent of my 
own autopsies, which were mainly on children under three years old; 
while in the Pendlebury Hospital cases, including those between four and 
twelve years old, they were noted in 24.4 per cent. These nodules vary 
in size from a pea to a child's fist ; they are usually associated with tuber- 
culous meningitis, but they may exist alone. When they are large they 
rank as cerebral tumours, being most frequently seen in the cerebellum. 
They rarely soften, but may be the seat of calcareous deposits. 

Liver. — This is frequently involved in general tuberculosis, although it 
is doubtful if it is ever the seat of primary infection except in the con- 
genital cases. Usually the only lesion is the presence of miliary tubercles 
on its surface and in its substance, and in most cases these are not numer- 
ous. They are found in about two thirds of the cases. In a smaller 
number there are tuberculous nodules of various sizes. In nearly every 
protracted case the liver is markedly fatty. In very late cases of tubercu- 
losis of the bones, it is frequently the seat of amyloid degeneration. 

Spleen. — This is more frequently affected than the liver, but in very 
much the same way. In most of the cases of general tuberculosis, miliary 
tubercles are present in the spleen, these being usually numerous, both 
upon the surface and throughout the organ. Not infrequently small tuber- 
culous nodules are also seen, but there are rarely any which are larger than 
a pea. The size of the spleen is not altered if only miliary tubercles are 
present; but with the tuberculous nodules it may be much enlarged. 



1086 THE SPECIFIC INFECTIOUS DISEASES. 

Amyloid degeneration is found under the same conditions as in the 
liver. 

Stomach. — Tuberculosis of the stomach is one of the rare lesions ; both 
its contents and its acid reaction seem to protect it against direct infection 
from the mouth. Tuberculous ulcers were seen in five of my autopsies, 
which is a larger proportion than is usually noted. 

Intestines. — These are less seriously affected in infancy than in older 
children, which is rather surprising when we consider how susceptible are 
the intestines of infants to other forms of infection. The explanation of 
this difference seems to me to be this : Intestinal infection is nearly always 
secondary to disease of the lungs ; primary lesions being extremely rare. 
Infants usually die from the more rapid tuberculous processes in the 
lungs or brain before there has been time or opportunity for intestinal 
infection to occur. The opportunities for such infection depend upon the 
number of bacilli which are coughed into the pharynx and swallowed. In 
infancy this number is small, because of the many who die of tuberculous 
pneumonia or meningitis before extensive softening in the lungs has taken 
place. In older children the slower course of the pulmonary disease gives 
ample time for intestinal infection, while the more extensive softening and 
excavation are accompanied by the discharge of a much larger number of 
bacilli. The intestinal lesions and those of the mesenteric lymph nodes 
with which they are almost invariably associated, are described on page 411. 

Peritonaeum . — In infancy the peritonaeum is not often involved even 
in general tuberculosis, and at this age it is very rare for it to be the seat 
of the principal tuberculous process. This occurred but once in my own 
119 autopsies. In older children it is more frequent; of the 131 Pendle- 
bury Hospital cases, the peritonaeum was involved in 37, or twenty-eight 
per cent. In most cases of general tuberculosis there are only deposits 
of miliary tubercles; less frequently there are tuberculous nodules with 
other inflammatory products. The lesions in these cases are described 
with Diseases of the Peritonaeum. 

Thymus gland. — In three of my cases tuberculous nodules were found 
in the thymus body, the size varying from a small pea to a hazelnut. 
Some of the largest nodules had undergone softening at the centre. All 
these were cases showing widely disseminated tuberculous lesions. 

Pancreas. — In three of my cases this organ also was the seat of small 
tuberculous nodules, all of them being cases of general tuberculosis. 

Uro-genital organs. — Serious tuberculosis of any part of the urinary 
tract is very rare in children. Miliary tubercles were found in the kid- 
neys in about one third of my autopsies on tuberculous patients. They 
are generally few in number. Tuberculous nodules of the kidney I have 
seen but once in a young child. They are very rare before the fourteenth 
year (page 670) . In two of my autopsies tuberculous nodules were found 
in the suprarenal capsules, Tuberculosis of the testicle has been observed 



THE CLINICAL FORMS OF TUBERCULOSIS. 1087 

in rare instances among children, although not in one of my own series. 
Koplik (New York) has reported several cases. 

Tuberculosis of the bones and of the external lymph nodes have al- 
ready been described. 

THE CLINICAL FORMS OF TUBERCULOSIS. 

I. General Tuberculosis. — Cases of tuberculosis present a wide 
variety in their symptomatology. Almost every case possesses some pecul- 
iar features which depend upon the constitution of the patient, the source 
of infection, the rapidity with which the bacilli are disseminated through 
the body, or the numbers in which they enter. The general symptoms 
usually precede the local ones, but in probably the majority of cases they 
are masked and unrecognised. It is not often possible to recognise tuber- 
culosis until the process is quite well advanced in some one organ. The 
early symptoms in most cases are very indefinite and susceptible of many 
explanations. 

1. Cases Resembling Infantile Marasmus. — In early infancy, tubercu- 
losis often gives at first and for a long time only the symptoms of maras- 
mus. Infants are pale and thin, they do not gain in weight, and finally 
become emaciated. There is nothing characteristic about these symp- 
toms, and it should be remembered that they depend much more fre- 
quently upon simple marasmus than upon tuberculosis. There may be no 
cough and no fever sufficient to attract attention, and the case may even 
go on to a fatal termination without any symptoms except those of in- 
fantile marasmus. This I have seen at least a dozen times in cases that 
came to autopsy. 

More frequently, however, there are developed toward the end of the 
disease both the symptoms and signs of pulmonary disease and fever. 
These are generally found together, as the process in the lungs is the cause 
of the rise of temperature. The febrile symptoms are often not seen until 
the last two or three weeks of life. The course of the temperature is ir- 
regular. It is never of the hectic type and rarely high. The usual range 
is between 100° and 102° F. The pulmonary symptoms are generally few 
and not very well marked. There is usually some cough, but it is rarely 
severe. The breathing is more rapid than would be explained by the 
temperature alone. Severe dyspnoea and cyanosis are rare, and are seen 
only at the close of the disease. The physical signs are those of either 
localized bronchitis or of broncho-pneumonia. 

The other symptoms usually relate to the digestive tract. There may 
be indigestion, with occasional vomiting and green undigested stools, or 
there may be diarrhoea. The intestinal symptoms depend on the general 
condition of the child and the constitutional disease, rarely upon a tuber- 
culous process in the stomach or bowels. 

If the casft has gone on to the development of constant fever and rec- 



1088 THE SPECIFIC INFECTIOUS DISEASES. 

ognisable physical signs which slowly spread, the infant's fate is sealed. 
The progress of the case from this time is steadily downward, and the 
child can live at most but a few weeks. Death generally occurs from pro- 
gressive asthenia without the development of any new symptoms. Occa- 
sionally toward the close, cerebral symptoms rapidly develop, and the 
child is carried off in a few days by tuberculous meningitis ; sometimes 
there is a rapid spreading of the disease in the lungs, and death occurs 
with symptoms of simple acute pneumonia. 

Diagnosis. — The difficulty in diagnosis is chiefly during the first year 
of life. Every circumstance in the patient's surroundings and family 
history which bears upon the development of tuberculosis must be 
weighed to establish the fact of inheritance or of exposure to contagion. 
In simple wasting, the usual history is that the infant was plump and well 
nourished at birth. A sufficient cause for its condition can in most 
cases be found in improper or insufficient nourishment or the want of 
proper care. (See causes of marasmus, page 238.) Often the wasting 
follows some acute disease of infancy, most frequently some form of gas- 
trointestinal disease. 

In tuberculosis, the infant may show all the signs of malnutrition at 
birth, but in most cases they are of later development. They either come 
without adequate cause, or are associated with pulmonary disease or they 
follow measles or pertussis. No explanation of the wasting can be dis- 
covered in the food, the surroundings, or in the condition of the digestive 
organs. Diarrhoea and vomiting more frequently follow than precede it. 
The above facts are sufficient to warrant a suspicion only that tubercu- 
losis is present until some local manifestation occurs, usually in the lungs. 
The early wasting without adequate cause, followed by the gradual devel- 
opment of low fever, and finally the appearance of signs of subacute 
broncho-pneumonia, form the most characteristic features of general tu- 
berculosis in early infancy. Yet all these symptoms are occasionally met 
with in cases in which the autopsy shows none of the lesions of tubercu- 
losis, for simple broncho-pneumonia frequently occurs in patients suffer- 
ing from marasmus ; but in such cases fever is usually slight and it may 
be absent. 

The wasting and cachexia of hereditary syphilis sometimes resemble 
tuberculosis, but the early history in syphilis is usually so characteris- 
tic, and other symptoms of the disease are so rarely wanting, that the 
mistake is not likely to be made if a patient is submitted to a careful ex- 
amination. In the absence of definite syphilitic symptoms the chances 
are greatly in favour of tuberculosis. 

2. Cases in Older Children with Symptoms Besembling a Continued 
Fever. — Before the development of fever in these cases, there is usually 
quite a protracted period of very indefinite symptoms, each one of which 
alone is unimportant, but all of which taken together should excite sus- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1089 

picion. Such children are usually delicate ; they are persistently anaemic 
without sufficient reason ; they often show a loss in weight ; there is a 
marked cachexia, sometimes a capricious appetite, and a digestion easily 
disturbed. In some of them a change in disposition is observed, and 
they become peevish or fretful and are disinclined to muscular exertion. 
All these symptoms indicate a gradual decline in the general health. 

This clinical picture may be due to many causes, but it should always 
arouse in the mind of the physician a suspicion of incipient tuberculosis, 
particularly in a child who by surroundings or inheritance is predisposed 
to that disease. After these indefinite symptoms have lasted a few weeks 
fever is added. Sometimes the prodromal symptoms are absent or 
unnoticed and fever is the first evident symptom. This fever is peculiar 
in that it comes without evident cause and without any local manifesta- 
tions of disease. The temperature is not often high, but it is continuous. 
The tympanites and the rose-coloured spots are not present, but the gen- 
eral aspect of the patient is strikingly like that belonging to typhoid 
fever. 

After the fever has lasted from one to three weeks there develop some 
signs of localized tuberculosis, generally in the lungs, or the fever may 
decline gradually, and although the patient improves he does not get 
well. He is still weak and does not gain in weight, and the thermometer 
shows the existence of a very slight amount of fever. Before long he 
may grow rapidly worse and the course of the temperature becomes irreg- 
ular, with alternate exacerbations and remissions. Such an irregular and 
inexplicable fever sometimes puzzles the physician for three or four weeks 
before the characteristic features which stamp the process as tuberculous 
are present. One general symptom is almost invariably associated with 
the fever, viz., wasting. This may not be rapid, but is progressive. The 
tuberculous cachexia is frequently unmistakable ; but in most of the cases 
one must wait for the process to advance far enough in some one of the 
organs to give local signs or symptoms before he can be sure of tuberculo- 
sis. In four cases out of five this is in the lungs. Less frequently it is 
in the peritonaeum, the brain, or a general infection of the lymph glands 
throughout the body. If in the lungs, the process manifests itself as a 
broncho-pneumonia whose tuberculous character may be suspected from 
its localization — the apex or the middle of the lung in front — but chiefly 
from the fact that the general symptoms, fever and wasting, have for so 
long a time preceded the local signs of disease. From this time, the 
course of the disease may be that of a typical tuberculous broncho- 
pneumonia. 

If the tuberculous process is localized in the brain, we have dulness, 
vomiting, headache, apathy, irregular pulse, irregular respiration, and 
finally convulsions and coma — in short, the symptoms of tuberculous 
meningitis; if in the peritonaeum, we have abdominal distention from 



1090 THE SPECIFIC INFECTIOUS DISEASES. 

gas or fluid, tenderness, pain, diarrhoea, or constipation ; if in the lymph 
glands, there is a general enlargement of those situated in the neck, and 
sometimes those of the axillary and inguinal regions, with symptoms indi- 
cating similar changes in those at the root of the lung. 

Diagnosis. — In distinguishing general tuberculosis from typhoid fever, 
very great stress is to be laid on the family and previous history of the 
patient and the surroundings, as favouring tuberculosis. On the other 
hand, the prevalence of typhoid fever in the family, the neighbourhood, 
or the institution in which the case occurs, is important. The extreme 
infrequency of typhoid in children under two years old should always 
lead the physician to scrutinize very carefully every case in which he is 
disposed to make such a diagnosis at that time of life. In typhoid, the 
course of the fever is more regular than in tuberculosis, but less so than 
in the typhoid of adults, and the spleen in nearly every case is sufficiently 
enlarged to be easily felt below the ribs. The rose spots are usually pres- 
ent. But the most conclusive evidence is that afforded by the blood 
reaction in WidaPs serum-test ; without this, by the gradual cessation 
of the fever in the third or fourth week and complete recovery of the 
patient. 

In tuberculosis, on the contrary, the fever is less regular. It common- 
ly shows wider fluctuations, the spleen is not usually enlarged, and there 
are no rose spots. Tympanites and abdominal tenderness are sometimes 
seen, but the fever shows no disposition to stop after the third week, 
and the wasting is continuous. The signs in the lungs, at first few, in- 
crease from day to day. In most cases one must wait for ten days at 
least, and in many three weeks, before a positive diagnosis can be made. 

II. Tubekculous Bkoncho-Pneumonia. — This occurs clinically un- 
der the following conditions : (1) It may begin in the lungs or extend to 
the lungs from the bronchial glands, the symptoms in either case being 
essentially pulmonary from the outset. (2) It may follow either form 
of general tuberculosis described — that resembling marasmus in infants, 
or that resembling a continued fever in older children. In both of these 
the pulmonary symptoms develop gradually in the course of the general 
symptoms of the disease. (3) It may occur in the course of any of the 
forms of local tuberculosis, — of the bones, peritonaeum, intestines, external 
lymph glands, or skin. In such cases the invasion of the lungs frequently 
marks the last stage of the process. (4) It may follow any of the infec- 
tious diseases, especially measles or pertussis, even though they are not com- 
plicated by broncho-pneumonia, but more frequently when they are. (5) 
It may follow single or repeated attacks of simple bronchitis or pneumonia. 

Clinically the cases may be divided into three groups : First, the most 
rapid ones, lasting from one to three weeks ; secondly, those running a 
more protracted course, with a duration of from three weeks to three 
months ; thirdly, those which are more or less chronic. In the first two 



THE CLINICAL FORMS OF TUBERCULOSIS. 1091 

groups the progress is nearly always steadily downward, and a fatal ter- 
mination the almost inevitable result ; in the third form the course is more 
irregular, and marked by a series of exacerbations and remissions. 

1. The Most Rapid Cases. — In this form of the disease there are found 
scattered through certain portions or nearly the whole of both lungs, mili- 
ary tubercles and minute tuberculous nodules, the intervening parts of 
the lung being involved more or less seriously in a simple inflammation. 
In most of the cases the clinical picture is that of simple acute broncho- 
pneumonia, for it is to the accompanying broncho-pneumonia, and not to 
the scattered tuberculous deposits themselves, that the symptoms and the 
physical signs are due. The development of the disease, although acute, 
is not usually abrupt. There are present, fever, cough, dyspnoea, acceler- 
ated respiration, prostration, and sometimes cyanosis. The temperature 
in these cases is never hectic, but its course is a somewhat irregular one 
the usual range being between 100° and 104° F. In most of the cases it 
differs in no respect from the temperature of simple broncho-pneumonia. 
Sometimes it is seen that the general symptoms are severe and the phys- 
ical signs wide-spread, and yet the range of temperature is not high. To 
be sure, this is occasionally seen in a simple broncho-pneumonia, but it is 
more frequent in tuberculosis. The cough early in the disease is slight, 
but later becomes severe and often distressing. In infants and young 
children it may be of a paroxysmal character, resembling pertussis. Ex- 
pectoration is wanting in infancy, and is not often seen in those under 
seven years, so that bacilli in the sputum is a symptom of only a small 
number of cases. Bloody expectoration, likewise, is rare in children. 

The conditions in the lungs which give physical signs are bronchitis 
of the smaller tubes, with areas of complete or partial consolidation. In 
character, these signs are identical with those of simple broncho-pneu- 
monia (page 547). They may be scattered throughout the whole of both 
lungs; but when localized they are more frequently in the upper than in 
the lower lobes, and rather more .frequently in front than behind. Al- 
though both lungs are involved, they are usually not affected to the same 
degree. The patient may die before signs of complete consolidation are 
present; more often there are during the last few days small areas of 
partial consolidation, as shown by broncho- vesicular breathing, exagger- 
ated voice, and slight dulness. These signs may be due to the simple 
broncho-pneumonia, and are often found in the lower lobes behind. 
Large areas of complete consolidation, with pure bronchial breathing, 
bronchial voice, and marked dulness are infrequent. 

From the beginning of acute symptoms the progress of the disease is 
Bteadily downward, death resulting from the same causes as in simple 
broncho-pneumonia. The end is marked by cyanosis, great dyspnoea, 
weak pulse, and extreme prostration. In a few cases there develop shortly 
before death cerebral symptoms, indicating tuberculous disease of the 



1092 



THE SPECIFIC INFECTIOUS DISEASES. 



brain. Such symptoms may be the first to lead the physician to suspect 
the process to be a tuberculous one. In these cases death may occur in 
convulsions in two or three days from the first cerebral symptoms. In 
other cases the course is slower, with the typical symptoms of meningitis. 
2. The More Protracted Cases. — In this form of the disease there are 
found in the lungs caseous nodules, with larger areas of caseous pneu- 
monia, and usually some spots of softening. The process is not usually so 
generalized as in the cases just described, but as in them there is always 



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Fig. 211.— Tuberculosis following measles. Child sixteen months old, inmate of an institu- 
tion. Chart begins on fifth day of a severe but uncomplicated attack of measles, and shows 
a natural decline to normal. Fever then returned and continued till death, twelve weeks 
later. Eecord for the period which is omitted was much like that which immediately pre- 
cedes and follows. Early symptoms not acute, only slow wasting, slight cough and' fever, 
with scattered rales throughout chest. Signs of consolidation not distinct till eighth week, 
then present in right upper lobe. Toward the end, rapid emaciation, marked pulmonary 
symptoms, and signs of cavity at right apex. Autopsy showed a large cavity, extensive 
tuberculous deposits throughout both lungs and in nearly all abdominal organs. 

associated a certain amount of simple pneumonia. This is the most fre- 
quent and most characteristic form of pulmonary tuberculosis in infancy 
and early childhood. Its usual duration is from one to three months ; its 
course is then steady and uninterrupted. In its slower or subacute form 
it lasts from three to six months, and its course is then more irregular. 

The mode of onset will depend upon the conditions under which the 
disease develops. When the general symptoms of tuberculosis — fever and 
wasting, — have preceded those in the lungs, the evolution of the latter 
is gradual, with cough, rapid breathing, dyspnoea, increased prostration, 



THE CLINICAL FORMS OF TUBERCULOSIS. 



1093 



etc. When the pulmonary symptoms are present from the beginning, they 
are the same as in simple broncho-pneumonia, with the exception that they 
usually come on less acutely. The latter is true of cases which are second- 
ary to some other form of tuberculosis in the bones, peritonaeum, etc. 

When pulmonary tuberculosis follows measles (Fig. 211) or whooping- 
cough which has been complicated by simple pneumonia, the early symp- 
toms may present no unusual features. After two or three weeks the tem- 
perature gradually falls, and the physical signs improve, but neither quite 
disappears. The cough continues, though its severity somewhat abates. 
In the course of a few weeks the child, who has meanwhile improved some- 
what in his general condition, becomes distinctly worse, often without any 
assignable cause. The temperature rises to 102° or 103° F. ; the cough 
increases, and an extension of the disease in the lungs is evident by the 
physical signs. In other cases the progress of the disease after the pneu- 
monia which complicated measles is without an intervening period of 
apparent improvement. It sometimes happens that the attack of measles 
or whooping-cough is not accompanied by any serious pulmonary symp- 
toms, and the case goes on to apparent recovery, except that there remain 
anaemia, a slight cough, and fever. The temperature, although not high, 
persists ; but it may be two or three weeks before there are present definite 
symptoms and signs of disease in the lungs. 

Fever is a constant accompaniment of all active tuberculous processes 
in the lungs in the child as in the adult, it being absent only during the 
periods of remission which occur in the cases of slow and irregular prog- 



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Fig. 212.— Tuberculous pneumonia, general tuberculosis. Patient eleven montbs old, and under 
observation at the time he was taken sick. Chart of entire illness is given. Disease began 
as an acute pneumonia in lower part of left axilla and spread to entire lower lobe. Early 
Bigna of consolidation; at end of two weeks, flatness bo marked thai a needle was inserted, 
fluid being Buspected, Vomited frequently, and had loose discharges from bowels through- 
out the illness; abdomen much swollen for last two weeks. Autopsy showed elieesy pneu- 
monia of part of the upper and the entire left lower lobe, where wire two small cavities. 
Recent tubercles found throughout righl Lung, and extensive deposits in abdominal organs 
with peritonitis, intestinal ulcers, etc. 



ress. 



It is a very important guide to the progress of the disease. The 
early fever depends chiefly upon the coexisting broncho-pneumonia, 
and its course resembles that of simple pneumonia of the protracted 
variety. There is no typical curve. The fever is not often steadily high, 
and in many cases it is never high (Fig. 212). It frequently runs for 



70 



1094 



THE SPECIFIC INFECTIOUS DISEASES. 



several days between 99° and 102° F., and then, without evident cause, 
rises to 104° F. or over; again, it may be scarcely over 100° F. for days 
together. In infants the morning temperature is frequently subnormal, 
although the evening temperature may be 102° or 103° F. Even toward 
the close of the disease, when softening and breaking down are actively 
going on, the regular hectic temperature of adults is rarely seen in a 
young child (Fig. 213). While the presence of fever is of great signifi- 



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Fig. 213. — Tuberculous pneumonia, with extensive softening and excavation. A delicate child, 
thirteen months old ; weight, 10 pounds ; came under observation four weeks before death, 
with consolidation at apex of right lung. Signs increased in intensity, and extended in area 
until there were heard, from clavicle to below the nipple, exaggerated bronchial voice and 
breathing and many moist rales ; percussion note was flat ; behind, the same signs at ex- 
treme apex. No distinct signs of a cavity ; no hectic fever ; no sweating. Autopsy showed 
large cavity (Fig. 207) at right apex partly filled with caseous masses ; diffuse caseous pneu- 
monia (Fig. 206) of the rest of right upper lobe, with scattered deposits in the other lobes, 
the opposite lung, and a few in the abdominal organs. 

cance, its course has almost no diagnostic importance in early life. Espe- 
cially should one beware of drawing the conclusion that, because the fever 
is not hectic, there is no breaking down of the lung. 

Sweating belongs only to the late stage of the disease, and is usually 
associated with the hectic type of fever ; both these are regular symptoms 
in children over seven years old, but not in very young children. 

Wasting, like fever, is characteristic of all active tuberculous processes. 
Whenever they are associated, tuberculosis should always be suspected, 
no matter how obscure the other symptoms may be. The wasting is not 
always rapid, but it is usually continuous while fever lasts. During the 
periods of temporary improvement, children may not only cease to lose, 
but may actually gain in weight. In the early stage of the disease, wast- 
ing is especially suggestive when it continues without apparent cause 
after measles or pertussis, or when it persists under other circumstances 
in spite of a good appetite and apparently good digestion. It may at 
first be so slight as not to be noticed unless the scales are employed. In 
obscure cases thi's steady loss of weight is a point of much diagnostic 
value, and is frequently overlooked. Toward the close of the disease there 
is rapid and frequently extreme emaciation. 

Cough, although almost invariably present, shows no peculiarities. It 
may be hard, dry, or suppressed ; it sometimes occurs in paroxysms re- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1095 

sembling pertussis, which may or may not depend upon the presence of 
enlarged bronchial glands. 

Expectoration is absent in infants, the matters coughed up being 
swallowed. In children over seven years old, we often get a profuse muco- 
purulent expectoration, but it is very exceptional below this age. 

Haemoptysis is a rare symptom, but not unknown even in young chil- 
dren. Henoch has reported a case of fatal haemoptysis in a child ten 
months old, where the haemorrhage was due to the rupture of an aneurism 
in the wall of a cavity. Herz, in 247 clinical cases of tuberculosis in chil- 
dren, records 8 of haemoptysis — 4 of them under five years, and the young- 
est only eighteen months old. The records of 131 autopsies on tubercu- 
lous children in the Pendlebury Hospital, show that haemoptysis was four 
times a cause of death ; two of these patients were under five years, and 
one was only twelve months old. I have never met with a case of haemop- 
tysis under five years old. As in adults, fatal haemoptysis is usually due 
to the opening of a large vessel by ulceration in the wall of a cavity, which 
is sometimes in the lung and sometimes in one of the bronchial glands. 

The respiration in all cases of tuberculous pneumonia is accelerated, 
and usually out of proportion to the rise in temperature. As the lung 
becomes more and more extensively invaded there is constant dyspnoea. 
The pulse is rapid in the early stage, and continues so throughout the 
disease ; toward the end it becomes weak and irregular. Irregular respi- 
ration and a slow, irregular pulse, may occur at any time from the develop- 
ment of cerebral complications. 

Pleuritic pains in the chest are not frequent in children. Gastroin- 
testinal symptoms, such as indigestion, vomiting, diarrhoea, etc., are gen- 
erally present, but are not peculiar in this disease. They usually depend 
upon the patient's general condition, only exceptionally upon tuberculous 
disease of the stomach or intestines. The characteristic symptoms of 
intestinal tuberculosis — abdominal pain, tenderness, uncontrollable diar- 
rhoea, and intestinal haemorrhage — are not often met with in children 
under five years. With such symptoms, and sometimes when they are 
doubtful or absent, careful palpation of the abdomen may disclose the 
presence of enlarged mesenteric glands. When these are not readily felt 
through the abdominal walls, they may sometimes be discovered by a rec- 
tal examination after the method of Carpenter (London). 

The spleen is often enlarged, sometimes very much so, but this does 
not occur with sufficient frequency to be of much diagnostic value. It 
may be due to tuberculous deposits, to causes connected with the lungs or 
heart, or to fever. The liver is never enlarged from tuberculous deposits, 
but may be so from amyloid or fatty degeneration, or from obstructed 
circulation, as in the case of the spleen. 

Dropsy is rare and seen only toward the close of the disease. It may 
depend upon anaemia, upon complicating nephritis, especially amyloid de- 



1096 THE SPECIFIC INFECTIOUS DISEASES. 

generation, upon cardiac or pulmonary conditions leading to interference 
with the return circulation, or upon pressure of tuberculous retro-perito- 
neal or mesenteric glands upon the inferior vena cava. Clubbing of the 
fingers is occasionally seen in cases running a very protracted course, and 
is due to obstructed circulation. 

Anaemia is commonly associated with wasting, and it is of special im- 
portance where the latter is slight or absent. It is a frequent sequel of 
acute disease in infancy when not dependent on tuberculosis ; when, how- 
ever, it is associated with low fever, cough, and persistence of rales in the 
chest, it should always excite apprehension. 

3. Chronic Tuberculous Pneumonia. — In young children this is a chronic 
interstitial pneumonia associated with tuberculous deposits. These cases 
have usually had their beginning in one of the more acute forms just de- 
scribed. The primary attack runs a tedious, protracted course; there is 
a slow convalescence and apparent recovery, although this is not complete. 
Often a slight cough remains, or returns from the slightest exposure or 
other exciting cause. The child does not regain his former weight or 
vigour, and careful examination of the lungs shows that some abnormal 
signs remain. There are frequently present feeble breathing and slight 
dulness over the affected part of the lung, and occasionally friction- 
sounds may be heard. 

After a few months, possibly, the child has another attack resembling 
the first and running the same tedious course. It is accompanied by fever, 
cough, and perhaps there is a fresh consolidation of some part of the lung, 
generally in the neighbourhood of the old disease. All active symptoms 
finally subside, and most of the signs of recent disease disappear ; but it is 
usually found then that the lung is not quite in so good condition as it 
was before this second illness. The acute attacks may be repeated several 
times and pass under the name of bronchitis, broncho-pneumonia, or 
pleurisy. They may extend over a period of two or three years or even 
longer. The general health in the interval is not good, there being present 
in most cases anaemia, with the usual symptoms of malnutrition ; the chil- 
dren are regarded as being very delicate. 

The course of this disease thus differs in no essential particulars from 
that of simple chronic broncho-pneumonia (page 583) ; the physical signs 
likewise are identical in character, although they may differ in their loca- 
tion. They are generally found in the same situations as are the signs in 
the more rapid forms of pulmonary tuberculosis in early childhood. A 
fatal result in these cases is usually brought about in one of three ways : 
(1) by the development of acute tuberculous pneumonia or miliary tuber- 
culosis of the lungs, occurring with the symptoms of one of the previous 
exacerbations which has come on without apparent cause or perhaps has 
followed an attack of measles or whooping-cough ; (2) by tuberculous 
meningitis ; (3) by a simple acute broncho-pneumonia. 



THE CLINICAL FORMS OF TUBERCULOSIS. 1097 

Physical Signs of Tuberculous Pneumonia. — Speaking generally, there 
is no difference in a young child between the signs of a tuberculous and 
those of simple broncho-pneumonia except in their position ; for cavities, 
although they are present at autopsy in most of the cases, are very rarely 
of such size and so situated as to be recognised during life. In children 
over seven or eight years old, and sometimes in those of five or six, the 
signs are essentially like those in adults. 

By reference to the description of the lesions (page 1077) it will be 
noted that the upper lobes are the seat of the most advanced disease twice 
as frequently as the lower lobes, and the right lung rather more frequently 
than the left. When the disease is in the upper lobes it is rarely at the 
extreme apex, and when it is in the lower lobes it is very exceptional to 
find it at the base, posteriorly. The region most often involved is the 
middle zone of the lung. If the signs appear first behind they are, in the 
great majority of cases, in the interscapular space ; if in the lateral part 
of the chest, they are in the middle or upper part of the axilla ; if in 
front, they are in the mammary region, more frequently above than below 
the nipple, but rarely extending quite to the clavicle. In other words, it 
is near the root of the lung that the disease most frequently begins, spread- 
ing thence forward more often than backward. The explanation of this 
is found in the fact that the disease in infants and young children so often 
extends from the lymph nodes at the root of the lung to the lung itself. 
The physical signs themselves may be grouped under four heads, corre- 
sponding to the pathological conditions existing in the various stages 
of the disease — viz., (1) localized bronchitis; (2) partial consolidation; 
(3) complete consolidation ; (4) excavation. The early signs in the first 
two stages are identical with those described in broncho-pneumonia, those 
of the third stage being the signs of the persistent form. As a rule, how- 
ever, the transition of the signs from one stage to another is much slower 
in tuberculous than in simple broncho-pneumonia. 

As stated in the description of the lesions, cavities are found in the 
lungs in the majority of cases of infants dying from tuberculosis of the lungs. 
It is, however, rare that they can be recognised in children under three 
years old. From three to eight years they give more positive signs, and 
after eight years practically the same signs as in adults. The reason why 
in infancy cavities are so seldom recognised during life is because they 
are generally small, often centrally located, nearly always filled with thick 
pus or cheesy matter, and rarely communicate freely with the bronchi. 
On the other hand, it is very common to find signs in young children 
which, if heard in adults, would be regarded as almost positive evidence of 
a cavity, although none is present. These Bigns are cracked-pot reso- 
nance and cavernous breathing. They are not usually due to bronchi- 
ectasis, since this condition belongs to chronic cases, and especially to 
older children ; but most frequently to consolidation about a large bron- 



1098 THE SPECIFIC INFECTIOUS DISEASES. 

chus superficially situated — viz., below the clavicle, high in the axilla and 
in the interscapular region. The wide area over which this broncho-cav- 
ernous breathing is heard, is one of the most striking points of difference 
from the signs of a cavity. 

Course, Duration, and Termination. — Whatever may be the evolution 
of the symptoms, and the variations are almost endless, the cases fall readily 
into two groups, — those in which the progress is rapid and steady and those 
in which it is slow and intermittent. The duration of the first group is 
from four to eight weeks. Fever is constant, wasting progressive, and the 
physical signs show a steady advance of the disease in the lungs. Dyspnoea 
becomes severe and constant ; the pulse grows more and more rapid and 
feeble ; and death occurs from exhaustion, pulmonary oedema, or syncope, 
less frequently from meningitis. 

In the second group the duration is from two to twelve months. The 
course can not better be described than as a succession of attacks of 
broncho-pneumonia, sometimes separated by an interval of several weeks, 
at other times one coming on before the first is fairly over. During 
exacerbations the symptoms resemble those of the first form, there being 
marked fever, wasting, cough, and dyspnoea. The child may seem hope- 
lessly ill when, without any special reason, a change for the better occurs, 
the acute symptoms abating and the signs of consolidation in great meas- 
ure disappearing. Toward the end of the disease the pulmonary and 
constitutional symptoms become constant, and frequently there are added 
symptoms due to extension of the tuberculous process to other parts of 
the body — the brain, peritonaeum, intestines, mesenteric glands, etc. 
These cases die, as do the more acute ones, from the local disease in 
the lungs or from general infection. 

Diagnosis. — The evidence upon which a diagnosis of tuberculosis is 
made, is of two kinds — that which relates to the patient and that which 
relates to the local disease. In any case, a diagnosis is reached by weigh- 
ing the evidence as a whole rather than by relying upon the presence of 
particular symptoms or physical signs. One should investigate the family 
history, surroundings, and previous condition of the patient; also the 
mode of onset, and course of the disease, and consider the evidence 
afforded by the examination of the patient. 

A careful examination of the family history should be made to deter- 
mine, first, the existence of phthisis in the parents or in other members 
of the family, near or remote. Children more often inherit a predis- 
position from the mother than from the father, and are more likely to 
contract it from her, owing to the closer contact. It is not enough sim- 
ply to investigate the question of phthisis. Inquiry should be made re- 
garding meningitis, disease of the cervical glands, spine, hip, knee, or 
ankle, especially in the other children of the family. These points are 
important not only to establish the fact of heredity but also the probable 



THE CLINICAL FORMS OF TUBERCULOSIS. 1099 

chances of exposure. Other conditions favourable for acquiring the dis- 
ease should be considered, such as, in a private family, exposure to nurses 
or other members of the household; also whether the surroundings have 
been such as would give opportunities for infection, as in cases where 
a child has been reared in a tenement house, or has been long an inmate 
of a hospital or other institution. In the child's previous history, it is 
important to know whether there have been other manifestations of 
tuberculosis in the cervical glands, spine, hip, knee, or ankle, or the 
skin; also whether he has been liable to attacks of severe or protracted 
bronchitis or broncho-pneumonia. If he has had measles or pertussis, 
it is important to know whether they were severe, accompanied by pul- 
monary complications, or followed by a protracted cough or obscure fever. 
The child's general constitution should be considered, whether he is 
delicate, narrow-chested, poorly nourished, or anaemic. 

In its symptoms and course it is with simple broncho-pneumonia that 
tuberculous disease is likely to be confounded. The onset of simple 
pneumonia is usually rapid and often abrupt; tuberculous pneumonia 
more frequently develops gradually with constitutional symptoms pre- 
ceding the local ones by several days or even weeks. When tuberculosis 
develops rapidly, the pulmonary symptoms and the physical signs may 
be identical in the two conditions. One is often struck during the acute 
stage with the disproportion between the general symptoms — loss of 
flesh, prostration, and temperature — and the local evidences of pulmo- 
nary disease. When the patient dies in the early acute stage the disease 
is rarely recognised, nor, indeed, can it be diagnosticated with certainty. 
Usually it is not until the time for resolution to occur that the course 
of the disease suggests something different from broncho-pneumonia. 
The question then arises whether we have to deal with a case of per- 
sistent broncho-pneumonia or with tuberculosis. It should be remem- 
bered that it is not infrequent for simple broncho-pneumonia to resolve 
slowly or to go on to the development of chronic interstitial pneumonia; 
and that local conditions as determined by physical signs, which in adults 
would 1)" regarded as certainly tuberculous, very often in children are 
simple processes. 

Often the course of the disease, after the first acute period lias passed, 
furnishes further evidence to clear up the diagnosis; but not necessarily, 
for in tuberculosis it may be steadily downward, or it may be marked by 
periods of remission and exacerbation, and the same is true of simple 
pneumonia. Fever is a more constant symptom in tuberculosis, and it 
is usually higher than in persistent broncho-pneumonia; bul the excep- 
tions are so many and the variations so wide thai it is not safe in young 
children to lay very much Btresa upon the temperature curve. Anosmia 
and wasting are more marked in tuberculosis, and in most eases pro- 
gressive. A copious muco-purulent expectoration is seen almost as fre- 



1100 THE SPECIFIC INFECTIOUS DISEASES. 

quently in pneumonia as in tuberculosis; but in neither disease is it 
common under five years. The presence of the bacillus tuberculosis in 
the sputum is, of course, positive evidence of tuberculosis. 

With infants and young children the only satisfactory method of 
obtaining the sputum for examination is to pass the stomach-tube well 
into the oesophagus, and stain the mucous which adheres to it when with- 
drawn. This procedure, first employed I think in the Babies' Hospital, 
has been in constant use by us in that institution for several years with 
the most satisfactory results. 

Simple broncho-pneumonia may affect any part of the lungs, but by 
preference the lower lobes posteriorly. The signs of tuberculosis may 
likewise be found anywhere, but most frequently in the anterior part of 
the lung, the mammary region, the axillary margin, or the apex; if pos- 
terior, the signs are usually at the apex or in the interscapular region. 
From the character of the physical signs, no inference can be drawn un- 
less a cavity can be positively made out; but when the process has 
advanced to that stage, the diagnosis is generally plain from the general 
symptoms. 

Tuberculin with older children is quite as useful for diagnosis as with 
adults. With infants and very young children, on account of the well- 
marked fever which is usually present, it is less frequently applicable. 

Meningitis developing during a pulmonary disease of doubtful char- 
acter, is generally tuberculous, and its occurrence is usually to be inter- 
preted as establishing the tuberculous nature of the process in the lungs. 
The development of cheesy lymph glands in the neck, the groin, or axilla, 
or the presence of symptoms pointing to enlargement of the bronchial 
glands, or those of chronic peritonitis with or without ascites, or intes- 
tinal haemorrhage — all point strongly to tuberculosis. 

If the acute symptoms begin during measles and persist, they may be 
due either to broncho-pneumonia or to tuberculosis. If, however, they 
begin insidiously during convalescence from measles, they are very prob- 
ably due to tuberculosis. If the symptoms begin acutely during per- 
tussis, they may be due to simple broncho-pneumonia or a tuberculous 
process; but if they develop gradually and insidiously after pertussis, 
the disease is probably tuberculosis. It should not be forgotten, however- 
that it is not uncommon for simple broncho-pneumonia occurring with 
pertussis, to persist two or three months, or until the attack of pertussis 
has subsided. 

If the child was previously healthy and living in good surroundings, 
and if the disease began with acute symptoms, the process is simple 
pneumonia in nine cases out of ten, no matter how irregular its course, 
how prolonged its duration, or what the physical signs. Still, after all 
has been said, the diagnosis is in all cases difficult, and in some, par- 
ticularly the more chronic ones, a positive diagnosis is impossible, as 



THE CLINICAL FORMS OF TUBERCULOSIS. 1101 

no one knows so well as he who has an opportunity to follow his cases 
to autopsy. 

III. Chronic Phthisis. — This form of tuberculosis, with its chronic 
hectic fever, slow cavity formation, progressive emaciation, night sweats, 
etc., is very rarely seen before the fifth year, and it is not at all frequent 
until the tenth or twelfth year. In its symptoms, course, termination, 
and physical signs, it resembles the same disease in adults, and need not 
be described at length here. 

IV. Tuberculosis of the Bronchial Lymph Nodes (Bronchial 
Glands). — This condition is usually associated with some form of pul- 
monary tuberculosis, but it may exist as the most important and some- 
times as the only tuberculous lesion. 

Its symptoms are usually associated with those of pulmonary or gen- 
eral tuberculosis ; but they may occur when the pulmonary changes are 
too few to be recognised either by symptoms or physical signs. From the 
great frequency with which this lesion is found in infants and young chil- 
dren, it might be expected that local symptoms would be common in such 
patients. They are, however, in my experience, quite exceptional. Most 
of the cases in which well-marked symptoms occur are in children over 
two years old, and it is between the third and tenth years that they are 
usually seen. In infancy, although these glands are almost invariably 
affected, death in the great majority of cases occurs from the pulmonary 
disease, before the later changes in the glands have had time to develop. 

General symptoms indicating a tuberculous cachexia may or may not 
precede the local ones. The latter are chiefly mechanical, and depend 
upon the size of the glands and upon their anatomical relations, and very 
little or not at all upon the nature of the changes in them. The most 
important relations, so far as the production of symptoms is concerned, 
are those which they bear to the pneumogastric and recurrent laryngeal 
nerves, the superior vena cava, the trachea, and bronchi ; those less impor- 
tant are to the aorta, pulmonary artery, and oesophagus. 

Pressure upon or irritation of the pneumogastric or recurrent nerves 
produces cough, dyspnoea, and sometimes a change in the voice. The cough 
is hoarse, persistent, and teasing, and frequently occurs in paroxysms which 
in many respects resemble those of pertussis, but it lacks the characteristic 
whoop, and is not accompanied by the expectoration of the mass of tena- 
cious mucus. These paroxysms are severe and often prolonged, but careful 
observation shows distinct differences from those of pertussis, though by 
an unfamiliar ear the two are easily con founded. The dyspnoea, like the 
cough, is paroxysmal, and sometimes strongly resembles ordinary spas- 
modic croup; at other times it is Like a severe attack of asthma. Such 
symptoms may come and go, but they are frequently prolonged, and usu- 
ally in the interval between the severe seizures the patient is not wholly 
free from dyspnoea. Although the chief cause of dyspnoea is no doubt 



1102 THE SPECIFIC INFECTIOUS DISEASES. 

nerve irritation, it may be due in part to pressure upon the trachea or one 
of the large bronchi. In dyspnoea from pressure on the trachea the head 
is usually thrown back, and the obstruction is more frequently on expira- 
tion than on inspiration. 

After such symptoms as those mentioned have existed for a few days 
or weeks, and in some cases without any warning, there may occur a sud- 
den attack of asphyxia which may prove fatal. This is generally due to 
ulceration of a caseous gland into the trachea or a large bronchus and the 
escape of a large mass into the air passages, where it produces the same 
effects as any other foreign body. 

Loeb has collected fifteen cases of this description, a summary of 
which gives a good idea of the circumstances under which this accident 
usually occurs : In four cases death took place in the first attack of suffo- 
cation, the only previous symptom having been cough; in three there 
had been a number of milder attacks extending, in two of the cases, over 
a considerable period before the occurrence of the fatal one; in three, 
death occurred in the first attack, in children who had no previous cough 
and who were apparently healthy ; in one, the fatal attack came on during 
pertussis. In the majority of the cases, death followed in from five to ten 
minutes from the first symptom ; in a few the patients lived for an hour. 
In rare cases after ulceration into the trachea, the patient has coughed up 
a large quantity of foul pus, and recovered. 

Pressure upon the superior vena cava is usually associated with spas» 
modic dyspnoea and cough, and causes cyanosis of the face and blueness 
of the lips. There is frequently a puffiness of the face, and there may be 
marked oedema. The coexistence of cyanosis with such oedema, when the 
urine is free from signs of renal disease, should always lead one to suspect 
pressure at the root of the lung. In some rare cases the interference with 
the return circulation has been so marked that meningeal haemorrhage 
has resulted. By a process of ulceration set up by these glands they may 
open, not only into the air passages, but into the pericardium, the oesopha- 
gus, or any of the large vessels. The last mentioned is usually followed 
by instant death. Aldibert reports two cases in which the pulmonary 
artery was opened, death occurring from haemoptysis, as there was also a 
communication with one of the large bronchi. In Vogel's case the sub- 
clavian vein was perforated, and death resulted from the entrance of air. 
If ulceration takes place into the surrounding connective tissue, a medias- 
tinal abscess may result, producing any of the pressure symptoms noted 
above, and, in addition, dysphagia from pressure on the oesophagus. Such 
an abscess may point in the supra-sternal notch ; it may open through the 
chest anteriorly between the ribs or at the xiphoid cartilage ; or it may 
burrow along the oesophagus to the peritoneal cavity. As a rule, however, 
patients die of general tuberculosis before the local conditions have ad- 
vanced so far. 



THE CLINICAL FORMS OF TUBERCULOSIS. 1103 

Physical Signs. — In order to produce physical signs, the mass of tuber- 
culous lymph nodes must be large enough to form a mediastinal tumour, 
or so situated as to produce pressure on the trachea or bronchi. As a rule, 
the signs are more characteristic behind than in front. Percussion may 
give dulness anteriorly over the first piece of the sternum or posteriorly 
along one or both sides of the spine from the second to the fifth dorsal 
vertebra; the dulness is rarely complete. Auscultation posteriorly may 
give in the most marked cases amphoric or cavernous breathing, or exag- 
gerated bronchial breathing with prolonged expiration, in those which 
are less pronounced. Large, moist rales are sometimes heard. The aus- 
cultatory signs are so like those of a cavity that it is often difficult to 
believe that a cavity does not exist. The sounds heard appear to be those 
produced in the trachea and bronchi transmitted to the ear with great 
exaggeration by the mass of lymph nodes which surrounds them and 
fills the space between them and the chest wall. When the head is thrown 
back a venous hum may sometimes be heard. If one of the primary bron- 
chi or one of its lobar divisions is compressed, there may be very feeble 
respiration over one lung or one lobe ; if the pressure is sufficient to pre- 
vent the entrance of air, or if one of these large tubes has been plugged 
by a caseous mass, there is an absence of respiratory murmur over a single 
lobe or an entire lung. This sign is of great diagnostic value, but it is 
not often present. 

Diagnosis. — Enlargement of the bronchial glands to a sufficient degree 
to produce symptoms, may occur in syphilis, in Hodgkin's disease, and in 
various forms of malignant disease of the mediastinum. A certain amount 
of swelling is seen in nearly all cases of simple bronchitis or pneumonia, 
especially in those running a subacute or chronic course. Whether this 
simple hyperplasia is ever sufficient to cause such symptoms as those men- 
tioned is exceedingly doubtful. I have myself never known it to pro- 
duce anything more marked than a spasmodic cough. The great infre- 
quency of other forms of enlargement to a sufficient degree to be of 
clinical importance, usually warrants us, from the symptoms mentioned, 
in making the diagnosis of tuberculosis. The development in a child of 
a chronic abscess in the anterior mediastinum, is almost always due to 
tuberculous glands ; and so is one in the posterior mediastinum, provided 
Pott's disease can be excluded. 

The most important points for diagnosis are the association of a spas- 
modic cough with paroxysms of dyspnoea resembling asthma or croup, 
and oedema or congestion of the face. More stress is to be laid upon 
the symptoms than upon the physical signs ; the latter are at most only 
confirmatory. The chief difficulty in diagnosis is found in those cases 
which present few or no other signs of tuberculosis, and which come first 
under observation with attacks of dyspnoea or asphyxia resembling laryn- 
geal stenosis. In many such cases tracheotomy has been done without 



1104 THE SPECIFIC INFECTIOUS DISEASES. 

finding any cause for the dyspnoea, the autopsy showing it to be due to 
ulceration and impaction of a caseous gland. 

General Prognosis of Tuberculosis. — The outlook for a young child 
with general or pulmonary tuberculosis is always bad. So long as the 
disease remains confined to the lymph nodes, the child is not usually in 
danger, except from accidents connected with their softening and ulcer- 
ation, which after all are raro. Spontaneous cure may occur in these 
glands in the same way as in others in the body— viz., by encapsula- 
tion, calcification, etc. Such a result is no doubt a very frequent one ; 
exactly how often it occurs it is impossible to say. But when once the 
disease has gained any headway in the lung itself, its steady advance is 
almost certain in a young child. In those who are older and have more 
resistance the chances of an arrest of the process are much greater. 

If the bacilli have gained entrance into the body in any considerable 
numbers, even though they are shut up in an encapsulated, caseous, 
bronchial gland, the patient is never free from the danger of general 
infection. 

Prophylaxis. — The prevention of tuberculosis must have constant ref- 
erence to its cause. The first essential is the destruction of the tubercle 
bacilli wherever they exist. Since most of the germs existing in the air 
are derived from the sputum of patients affected with pulmonary tuber- 
culosis, it should be insisted upon, everywhere and at all times, that the 
sputum from such cases should be collected in special cups or cloths and 
destroyed either by germicides or by fire. The next point is to avoid 
needless exposure. A tuberculous mother should on no account nurse 
her child nor kiss it upon the mouth. A wet-nurse likewise should be 
free from any tuberculous taint. No nurse or other care-taker should 
ever be employed about children who has, or ever has had, pulmonary 
tuberculosis. It is wise to exclude also those who suffered when children 
from tuberculosis of the bones or the cervical glands, although the dan- 
ger from such persons is extremely slight. If active tuberculosis exists in 
any member of the family, a young child should be kept away from the 
room, and if possible should not reside in the house. On no account 
should infected persons be allowed to kiss children or sleep in the same 
bed with them. The danger from drinking-cups and other dishes should 
not be forgotten. A tuberculous person should either have his special 
dishes, or the utmost care should be taken to boil all those which he has 
used. Cows whose milk is used for children should be under regular veteri- 
nary inspection and should have passed the tuberculin test. In any case 
where the slightest doubt regarding the health of the cows exists, or where 
the source of the milk is unknown, the milk should be heated to a tem- 
perature of 155° F. for thirty minutes. The danger of infection through 
the alimentary canal is very much less than through the respiratory tract, 
and consequently the precautions first mentioned are much more impor- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1105 

tant than those relating to the food, although the latter should on no 
account be neglected. 

In the case of delicate children and those of tuberculous parents or 
with other tuberculous relatives, everything possible should be done to 
fortify them against the disease. They should be kept under more or less 
constant medical supervision as regards their clothing, manner of life, 
etc., and should take cod-liver oil every winter. Every attack of bron- 
chitis or broncho-pneumonia should be watched with the greatest solici- 
tude. Exposure to measles or pertussis should especially be avoided. The 
country rather than the city should be chosen for residence, and the child 
should spend the winter and spring in some warm, dry climate, such as 
that of southern California, the interior of South Carolina or Georgia, 
or Lakewood, X. J. Parents should be distinctly taught that watchful- 
ness and care do not mean coddling or the keeping of children in the 
house the greater part of the time. Such children should live as much 
as possible in the open air, and every form of sport encouraged which 
tends to keep them there. Overheated houses are one of the most pro- 
lific agencies, in perpetuating a delicate condition of health. Plenty of 
fresh air in sleeping apartments should always be insisted upon. All 
catarrhal troubles of the nose and pharynx should receive early and 
prompt attention, especially should hypertrophied tonsils and adenoid 
growths of the pharynx be removed, since these are conditions which 
form a most favourable nidus for the growth of tubercle bacilli. 

Treatment of General and Pulmonary Tuberculosis. — If fresh air and a 
proper climate are necessary for the cure of this disease in adults, they are 
tenfold more necessary in the case of children. Without them there is 
little hope for a child with active pulmonary tuberculosis. Nowhere do 
these cases do so badly as in a hospital located in a city, and no class of 
hospital cases do worse than these. The same regions that are beneficial 
for adult cases usually agree with children, with the exception that the 
latter, as a rule, do better in a warm than in a cold climate. Plenty of 
fresh air and sunshine are essential. A child must be where he can be 
kept in the open air for at least several hours each day, in spite of 
fever, cough, or other acute symptoms. 

For the most acute cases where the children are confined to the bed, 
the largest, best-ventilated, and sunniest room available should be secured, 
and a window should be open the greater part of the time. The general 
management of such cases is the same as for those with acute pneumonia. 
No specific remedy for tuberculosis has as yet stood the test of expe- 
rience. The diet is a matter of the utmost importance. Tuberculous 
patients must be fed like most other sick children, care being taken not to 
disturb the digestion by the unnecessary use of drugs. For a staple article 
of diet, milk is the best, and where this is not well borne some of its sub- 
stitutes — kumyss, matzoon, etc. — may be tried. Cream is almost as use- 



H06 THE SPECIFIC INFECTIOUS DISEASES. 

ful as cod-liver oil, and should be given in one form or another whenever 
the child can take it. 

The two drugs which are most useful are creosote and cod-liver oil. 
Creosote may be given both by the stomach and by inhalation, as in cases 
of pneumonia. By the stomach there may be used for older children, the 
shellac-coated pills containing one or two drops of creosote; for those 
who are younger, it may be given in combination with the liquid pepto- 
noids or in an emulsion with cod-liver oil. Cod-liver oil is usually best 
given in a fresh emulsion, although some children bear the pure oil bet- 
ter than any other preparation. Inunctions of this or other oils are of 
some value when it is not well tolerated by the stomach. Arsenic, iron, 
and the compound syrup of the hypophosphites are all useful as general 
tonics, but as specifics their action is very questionable. 

When symptoms pointing to tuberculosis of the bronchial glands are 
present, the syrup of the iodide of iron should be used in the same way as 
in disease of the cervical glands. When they ulcerate into the trachea 
or larger bronchi, they generally cause death, no matter what is done. 



CHAPTEE XI. 
SYPHILIS. 

Syphilis is a communicable disease due to a specific poison. Of the 
various micro-organisms which have been associated with this disease 
the only one which deserves mention is the spirochceta pallida of Schau- 
dinn. Although but recently published, many confirmations of his work 
have already appeared. The organism is an elongated spirillum. It has 
been found in the adult in the primary lesion and in inguinal lymph 
glands; in cases of congenital syphilis, in the cutaneous lesions and in 
the liver and spleen. It has not yet been cultivated. 

In infancy and childhood both the acquired and the hereditary forms 
of syphilis are seen. 

ACQUIRED SYPHILIS. 

While acquired syphilis is very much less frequent than the heredi- 
tary variety, it is by no means a rare disease in early life. It is not im- 
probable that some of the manifestations of syphilis in later childhood 
which are usually denominated "late hereditary syphilis," are really 
due to the acquired form. 

Etiology. — An infant may be infected by its mother during parturi- 
tion; but this is extremely rare and can take place only when there 
are lesions upon the mother's genitals. Infection is more likely to 



HEREDITARY SYPHILIS. 1107 

be from a mother who contracts syphilis subsequently to the birth of 
the child, and may occur through nursing or accidental contact by 
kissing, etc. In either of these ways children may be infected by wet- 
nurses, or from a venereal sore upon the nipple. Whether syphilis can 
be communicated through the milk when the nipple is perfectly healthy 
and free from fissures, is somewhat doubtful. 

Syphilis may be communicated directly from a syphilitic child to one 
who is healthy by kissing, sexual contact, or indirectly by means of bot- 
tles, spoons, cups, clothing, etc. The latter mode of infection is most 
likely to occur in institutions. Vaccination was formerly a not infre- 
quent mode of communicating syphilis, but since the general introduc- 
tion of bovine virus this is very rarely seen. Cases have been recorded 
by Taylor, Hutchinson, and others where the disease has been conveyed 
by the rite of circumcision, either from the mouth or the instruments of 
the operator. 

The relative frequency of the different sources of infection is shown 
by Fournier's statistics of forty cases : The source of infection was the 
parents in nineteen ; nurses, in eight ; servants, in four ; sexual contact, 
in four ; vaccination, in two ; other children, in two ; a physician, in one. 
The ages at which the disease was acquired in this series of cases were as 
follows : during the first year, nineteen ; during the second year, ten ; 
during the third and fourth years, seven ; from the fifth to the fourteenth 
years, six. 

Symptoms. — The symptoms of acquired syphilis in children are in all 
respects similar to the same disease in the adult. A primary sore is pres- 
ent at the site of infection, which is most frequently the lips, the mouth 
or some part of the face ; very rarely is it seen on the genitals. There 
are very few individual symptoms belonging to hereditary syphilis which 
may not also be present when the disease is acquired. Its course, how- 
ever, is very much milder in the latter and a fatal termination is rare. 
Fournier states that of his forty-two cases only one died of marasmus. 
This marked contrast to hereditary syphilis is due chiefly to the fact that 
in the acquired variety the infant is rarely affected during the early 
months of life, a time when hereditary syphilis is so very fatal. 

Tertiary symptoms may appear at any time from three to twenty years 
after the original infection. 

The treatment is the same as in hereditary syphilis. 

HEREDITARY SYPHILIS. 

Etiology.— A child may inherit syphilis from both parents or from 
either separately. If botli parents are syphilitic, the child is usually but 
not invariably so. The symptoms, however, are not more severe than 
when the inheritance is from one parent only. The likelihood of trans- 
mission depends upon the stage of the disease in the parents. If both 



1108 THE SPECIFIC INFECTIOUS DISEASES. 

are suffering from secondary symptoms, transmission is almost certain. 
If active treatment has been employed for several months, if the child is 
born at a period when no active symptoms are present, or if the symptoms 
are of a tertiary character, the offspring will probably escape. First-born 
children are more likely to suffer severely from syphilis than the later 
ones, provided infection of the parents has taken place prior to the birth 
of all the children. 

Infection from the father. — Syphilis may be inherited from the father 
alone. In this case the disease is probably communicated directly from 
the semen to the ovum. It is more likely to be transmitted from the 
father than from the mother, as the child is frequently syphilitic when 
the mother has few or no active symptoms. Of twenty cases observed by 
Meyer in which the father alone was syphilitic, the foetus was discharged 
macerated in eleven cases, and nine children were born with congenital 
syphilis, all but one dying soon after birth. It is possible, though rare, 
for the father to convey syphilis when he is free from symptoms, or when 
he is suffering from tertiary symptoms only. 

Infection from the mother. — It is certain that syphilis may be trans- 
mitted when the mother alone is diseased, as is shown by cases where 
women who have acquired syphilis while wet-nursing infected children, 
have subsequently borne syphilitic children, the father remaining healthy. 
If the mother only is syphilitic the probabilities of transmission to the 
child appear to be considerably less than if the father alone is affected. 
If the mother's symptoms are tertiary the child will probably escape. 

Both parents healthy at the time of conception and the mother infected 
during pregnancy. — Under these conditions the child may or may not be 
syphilitic. Transmission to the child is much less likely to occur if the- 
mother is infected during the last two months of her pregnancy than 
earlier, although, as Hutchinson's cases conclusively show, there is no cer- 
tainty that the child will escape. Diday states that if the mother is in- 
fected before the fourth week and proper treatment is instituted, the 
child will usually escape on account of the relation of the embryo to the 
maternal circulation during this early period. 

Can a healthy mother bear a syphilitic child? — In 1837 Colles enun- 
ciated the following proposition, the truth of which has been abundantly 
verified since his time : " A new-born child affected with inherited syphi- 
lis, even although it may have symptoms in the mouth, never causes 
ulceration of the breasts which it sucks if it be the mother who suckles it, 
although continuing capable of infecting a strange nurse." 

Caspary inoculated with syphilis a woman, apparently healthy, who 
had aborted with a syphilitic child ; the result was negative. A similar 
experiment was made by Neumann, with a like result. Widal reports a 
case of an apparently healthy woman who had a syphilitic child by an 
infected husband ; later, by a second husband who was free from syphilis, 



fiEREDlTAfcV SYPHILIS. 1109 

she had a syphilitic child. The conclusion seems irresistible that the 
carrying of a syphilitic child gives immunity to the mother against the 
disease and that this immunity is due to the fact that she herself suffers 
from syphilis, or a modification of that disease. According to Hutchin- 
son, the modified syphilis acquired by a woman under the circumstances 
mentioned, bears to syphilis acquired from a chancre a somewhat similar 
relation to that which vaccinia bears to smallpox. The mother under 
these circumstances can not be inoculated, either by her syphilitic nurs- 
ing-infant or artificially. 

The communicdbility of hereditary syphilis. — That hereditary syphilis 
is contagious is conclusively shown by a number of recorded instances 
in which a healthy wet-nurse has been infected by a syphilitic infant. 
However, such examples of contagion are very rare, and many writers 
of large experience state that they have never seen it. It is certainly 
true that the danger of spreading infection from a case of hereditary 
syphilis has been exaggerated, and that it differs so much in this respect 
from the acquired form of the disease that this peculiarity is of some 
value in differential diagnosis. 

Lesions. — Death may be due to syphilis, and yet the autopsy may re- 
veal no characteristic anatomical changes, and in fact there may be no 
demonstrable changes in any of the organs. 

Bones. — In the case of a syphilitic foetus, a stillborn child, or one 
dying soon after birth, the changes in the bones are more uniformly 
present than are any other lesions. They are in fact rarely wanting, and 
it is by them usually that syphilis is recognised post mortem. The long 
bones are principally affected, the most important changes being found 
at the junction of the shaft with the epiphyseal cartilage. The lesion 
i- termed an epiphyseal osteo-chondritis or acute epiphysitis. There is 
in the early stage congestion, swelling, and cell proliferation, which may 
be followed by separation of the epiphysis, suppuration in the neighbour- 
ing joint, osteomyelitis, and necrosis. These changes are more fully 
considered under Diseases of the Bones. 

Liver. — This is probably more frequently involved in the foetus and 
newly-born infant than any other organ. The syphilitic lesions of the 
liver have been studied very fully by Hudelo. He describes as present 
in the youngest infants an interstitial hepatitis, a gummatous hepatitis, 
and a combination of the two varieties. 

In the interstitial form, which is most frequent in infancy, there is 
first a congestion and swelling of the organ, with the exudation of leuco- 
cytes in groups. The liver is enlarged, frequently very much so, but pre- 
sents few other gross changes. Later there is increased exudation be- 
tween the liver cells, new connective tissue forms, and atrophy of the liver 
cells takes place, with obliteration of some of the portal and hepatic 
vessels. This process may be diffuse, but it is usually in patches. Groups 
11 



1110 THE SPECIFIC INFECTIOUS DISEASES. 

of miliary syphilomata may also be found. If the process is diffuse, the 
liver is large, firm, and of a grayish-yellow colour. If it is localized, the 
affected areas are yellow or gray and the other parts are normal. 

The gummatous form is not frequent in early infancy, but belongs to 
a little later period. In this there may be miliary syphilomata with in- 
terstitial changes, and in addition the formation of small or large gum- 
matous tumours, which may be softened at the centre. They are sur- 
rounded by zones of new connective tissue and the liver cells are atro- 
phied. Amyloid changes may be present. 

In the late form of hereditary syphilis, usually seen in children over 
four or five years old, the liver is rarely affected. Hudelo was able to 
collect but forty-seven such cases. The lesions resemble those of the 
congenital variety. There are found cirrhotic changes, which may be 
diffuse or circumscribed, and gummatous deposits, which vary from a 
minute size to that of a cherry ; there may be amyloid degeneration. 

Spleen. — This is almost invariably enlarged in newly-born children 
with syphilis and in syphilitic foetuses, but nothing characteristic is found 
under the microscope (Birch-Hirschfeld). In older children the enlarge- 
ment of the spleen is apt to be greater than at birth ; the organ may be 
the seat of interstitial changes, and sometimes there may be gummatous 
deposits. These changes are rare in children under two years of age. 

Respiratory system. — In syphilitic infants which are stillborn and in 
those which die soon after birth, there is frequently found in the lungs 
what is known as " white pneumonia." This process consists, according 
to Hillier, in fatty changes in the epithelium of the air vesicles ; with this 
there is associated a certain amount of interstitial pneumonia, which is 
chiefly peri-bronchial. In older cases the interstitial pneumonia is ex- 
tensive, and the lungs may be the seat of gummatous deposits, which 
soften and form small cavities. Accompanying these changes there 
may be bronchiectasis, emphysema, and the usual secondary lesions 
which follow chronic interstitial pneumonia. In syphilitic infants there 
is a strong tendency for all inflammations of the lungs to become chronic. 

The trachea and bronchi are in rare cases the seat of stenosis, which 
results from cicatrization following the softening of gummatous deposits 
in their walls. Lesions of the larynx (page 507) are also infrequent. 
There is usually perichondritis, which more often involves the epiglottis 
than any other part, and sometimes there is the formation of papilloma- 
tous masses ; but ulceration and stenosis are both rare. 

The nasal mucous membrane in the early stage of the disease is very 
constantly the seat of a chronic catarrhal inflammation, which may be 
accompanied by superficial ulceration. In the late cases there is deeper 
ulceration, from the breaking down of gummata, with extension to the 
periosteum, cartilages, and bones, causing perforation of the septum, ne- 
crosis of the bones, etc. 



HEREDITARY SYPHILIS. 1111 

Nervous system. — Syphilitic lesions of the brain and cord are rare in 
children as compared with adults, and they are especially so in infancy. 
The most characteristic cerebral Lesion of the newly-born child is hydro- 
cephalus which may depend upon ependymitis, as in two cases reported 
by D'Astros, the disease proving fatal in the second month. Syphilitic 
meningiti- is exceedingly rare under two years. There is occasionally 
>(^n in young infants a chronic basilar meningitis of syphilitic origin. 
Chronic pachymeningitis associated with gummata has been observed as 
early as the fourth year. Money (London) has reported a case with 
-vmptoms beginning at eleven months, in which there was chronic men- 
ingitis with great thickening of the dura mater and cerebral sclerosis. 
A few other cases of a similar nature have been recorded. 

Nearly all the syphilitic lesions of the nervous system which are seen 
in adult life have been observed in childhood, but infrequently, and in 
young children they are extremely rare, although Barlow's patient with 
multiple gummata at the base was only fifteen months old. 

Heart and arteries. — These may be affected even in young infants. 
Adler (New York), of four cases examined, found two in which well- 
marked lesions were present in infants under four months. There was 
endarteritis of the coronary arteries accompanied by the early changes 
belonging to interstitial myocarditis. Chiari has reported syphilitic 
endarteritis of the brain at fifteen months-, followed by thrombosis and 
softening. 

Digestive system. — Chronic catarrhal pharyngitis is almost a constant 
symptom of the early cases. Later there is seen superficial or deep 
ulceration of the pharynx, tonsils, or fauces, which may lead to perfora- 
tion of the soft palate or to the formation of condylomata. 

There are no important lesions of the stomach or intestines either 
with early or late syphilis. The rectum is occasionally the seat of ulcera- 
tion, and condylomata may form even in young children. 

Organs of special sense. — Otitis is a frequent accompaniment of the 
early syphilitic pharyngitis. It is very likely to become chronic, and in 
many cases results in a permanent impairment of hearing. Iritis is rela- 
tively rare in children, but it may occur even in intra-uterine life, as 
shown by the presence of adhesions in newly-born children. It is usually 
seen in infants four or five months old, and is always serious. Interstitial 
keratitis occurs frequently as a late manifestation of syphilis. Choroid- 
itis and optic neuritis are both occasionally seen, but they are rare. 

Genito-urinary organs. — Nearly all these may be affected, but gener- 
ally in the late period of the disease. There may be chronic intersti- 
tial nephritis and more rarely gummatous deposits in the kidney, intersti- 
tial changes in the suprarenal bodies, and orchitis, which usually affects 
the body of the organ, rarely the epididymis; it is generally an inter- 
stitial inflammation, with or without gummatous deposits. 



1112 THE SPECIFIC INFECTIOUS DISEASES. 

Among the less frequent visceral lesions may be mentioned, abscesses 
of the thymus, which are usually small and multiple; enlargement of the 
pancreas, with an increase of connective tissue and glandular atrophy; 
and chronic peritonitis. The lesions of the mucous membranes will be 
considered under Symptoms. 

Symptoms. — As the result of syphilis, abortion may take place at any 
period of pregnancy, with the discharge of a dead or macerated foetus, or 
the child may be stillborn at term, or it may be born alive prematurely, 
but with so feeble a vitality that it survives but a few hours. Under 
these circumstances it is often difficult and sometimes impossible to decide 
positively with reference to the existence of syphilis. Maceration of the 
foetus or peeling of the skin is no proof, and even the examination of the 
internal organs may not be conclusive. Lomer examined 43 foetuses, all 
dying before the thirtieth week of pregnancy ; he found the spleen and 
liver enlarged in all, and marked bone changes in 21. Birch- Hirschf eld 
examined 108 newly-born syphilitic infants ; he found the spleen invaria- 
bly enlarged ; typical bone changes were present in 35, but in many cases 
the bones were normal. Mervis, from an examination of 92 syphilitic 
foetuses, states that no eruption upon the skin was found earlier than the 
eighth month. 

Symptoms are present at birth in only a small number of cases. In 
such there is usually a very severe degree of infection, and the infants 
do not often live more than a few days. Upon the skin there may be 
seen an eruption of pustules, papules, or bullae. The bullae are usually 
upon the soles and palms, but may be found upon other parts of the body. 
The name " syphilitic pemphigus " is often given to this condition. Pem- 
phigus in the newly born, however, is not invariably due to syphilis, but 
may be present in other conditions of low vitality. The bullae are at first 
small, and then coalesce and form larger ones two inches or more in 
diameter. They contain a turbid serum which is sometimes tinged 
with blood, and sometimes yellow from pus. Pustules, when present, are 
usually seen upon the face or scalp. The general appearance of these in- 
fants is wretched in the extreme. The body is wasted, the skin wrinkled, 
and temperature subnormal. The spleen is usually enlarged and often 
the liver also. They suck feebly or not at all, and usually die from inani- 
tion within two weeks. 

In the great majority of cases the infant appears healthy at birth, and 
continues so for a variable time before the manifestation of the character- 
istic symptoms of syphilis. As a rule, the more intense the infection, the 
earlier the symptoms make their appearance. The earliest symptoms are 
generally seen between the second and the sixth weeks. If three months 
pass without evidence of syphilis, the child may be considered safe, the 
exceptions to this rule being very few. Miller (Moscow) gives the fol- 
lowing statistics of the time of beginning of symptoms in 1,000 cases: 



HEREDITARY SYPHILIS. 1113 

Symptoms appeared during the first week 85 cases. 

" second week 138 " 

" third week 240 " 

" " " " fourth week 177 " 

" fifth week 86 " 

" " " sixth week 54 " 

" " " " seventh week 50 " 

" eighth week 30 " 

After the eighth week 140 " 

Sometimes the constitutional symptoms — wasting, cachexia, etc. — are 
noticed before the local ones, but usually this is not the case. Generally 
the first symptom is the coryza or " snuffles," which resembles an ordinary 
cold in the head, except that it persists. It is accompanied by a hoarse 
cry, indicating that the larynx participates in the catarrhal inflamma- 
tion. Soon the eruption makes its appearance, being generally first seen 
upon the hands, feet, and face. Fissures and mucous patches may be 
seen upon the lips, about the anus, etc. There is often slight fever, from 
99° to 101° F. There may also be observed excessive tenderness and 
swelling about the shoulders, elbows, wrists, or ankles, due to acute epi- 
physitis, which may cause the child to cry from the slightest amount of 
handling, and the limbs may be moved so little that paralysis is sus- 
pected. 

In a severe case, as these local symptoms develop, the infant's gen- 
eral nutrition suffers. It loses steadily in weight; it becomes extremely 
anaemic; it whines and frets almost continually, but especially at night. 
The features have a pitiful, drawn expression; and the face is wrinkled, 
giving the infant a very old appearance. The skin has a peculiar sal- 
low colour, which has been well described as cafe au lait. The symp- 
toms may continue until a condition of extreme marasmus is reached, 
or death occurs from some intercurrent affection of the lungs or diges- 
tive organs. 

In the milder forms of infection the severe constitutional symptoms 
described are not seen, although the local evidences of disease are well 
marked. The severity of the symptoms is also much modified by treat- 
ment, especially when this is begun early. 

The mosl importanl local Bymptoms are the coryza, eruption, fissures 
about the mouth and amis, mucous patches, painful swellings at the ex- 
tremities of the long hones, pseudo-paralysis, and onychia. 

Coryza. — In most of the cases this is tin- first symptom. Beginning 
like an ordinary catarrh, it is distinguished by its severity and its per- 
sistence. There is ;i copious discharge of mucus and scrum, often tinged 
with blood. Thick crusts form, which produce the usual symptoms of 
nasal obstruction; there is greal difficulty in aursing; the infant breathes 
through the mouth, and the mucous membrane of the mouth is dry, caus- 



1114 



THE SPECIFIC INFECTIOUS DISEASES. 



ing great discomfort. If untreated, the process, which at first involves 
the mucous membrane only, may extend to the submucous tissue, causing 
ulceration; but the cartilages and the bones of the nasal fossae are not 
involved till a later period in the disease. 

The nasal catarrh is associated with more or less laryngitis, causing 
hoarseness or aphonia, and rarely there may be laryngeal stenosis. Dillon 
Brown has reported one case in an infant six weeks old, which recovered 
after intubation. 

Eruption. — This usually occurs after the coryza has lasted about a 
week; but the two may come at the same time; or the coryza may be 
absent or so slight that the rash appears to be the first symptom. 

Occasionally there is seen a diffuse blush or roseola, but more fre- 
quently the eruption is macular, occurring in small, dark-red spots about 
the size of the infant's finger nails, usually circular and often slightly 

elevated; there is no surrounding inflammation, 
and rarely any itching. It is usually most 
abundant upon the face, the neck, and the ex- 
tensor surface of the upper and lower extremi- 
ties, especially the hands and feet, sometimes 
extending over the entire body, although it is 
generally scanty over the chest and abdomen. 
At first the colour is bright, but gradually be- 
comes of a dusky-red or coppery hue. After a 
little time very fine scales may be seen upon 
the surface of the red macules. The rash 
comes out slowly, usually requiring from one 
to three weeks for its full development. It 
fades gradually, leaving a coppery discoloration 
of the skin, which continues for a long time. 
The duration of the eruption is from three to 
eight weeks; less if active treatment is em- 
ployed. 

A papular eruption is rarely seen alone, but 
is usually associated with the macular variety. 
The papules are of a brownish colour and 
are hard. They are seen most frequently upon the palms and soles. 

A squamous eruption is frequently seen upon the palms and soles, but 
very rarely elsewhere. In a few cases this scaliness forms the most dis- 
tinctive feature of the cutaneous lesion (see Fig. 214). 

Fissures and mucous patches. — These are among the most diagnostic 
features of early hereditary syphilis. Fissures are most frequently seen 
on the lips and about the anus, but they may occur about the nostrils and 
occasionally elsewhere. The fissures of the lips are really linear ulcers, 
and are distinguished by their persistence in spite of local treatment. 




Fig. 214. — Syphilitic scaling 
of the foot. From an in- 
fant eight weeks old. 



HEREDITARY SYPHILIS. 1115 

They are multiple, deep, painful, and bleed easily. Those at the angle 
of the mouth are especially troublesome. 

Mucous patches may develop from fissures, but more frequently from 
papules which are situated in regions where they are exposed to constant 
moisture and friction. They are very common upon the muco-cutaneous 
surfaces and wherever the skin is especially thin. They are most apt 
to be seen about the lips, anus, scrotum, and vulva, but they may also be 
found behind the ears, between the toes, in the folds of the groin, axillae, 
or buttocks. They vary from an eighth to half an inch in diameter, are 
whitish in colour, and are raised rather than excavated. 

Ulcers may be present upon any of the mucous membranes, fre- 
quently in the mouth or on the genitals; they are seldom symmetrical, 
and while they may be broad they are never deep. 

Hcemorrhages. — They are generally associated with the lesions of the 
mucous membranes, especially of the nose. In young infants with severe 
infection, bleeding may occur from the bullous eruption upon the skin, 
or from the fissures at any of the orifices, particularly the mouth and 
anus. Fischl has reported seven cases of multiple haemorrhages in the 
newly born, associated with other symptoms of congenital syphilis. 
Mracek noted haemorrhages in thirty-three per cent of 160 autopsies on 
syphilitic stillborn infants or those dying soon after birth. Examination 
of the blood-vessels in some of these cases showed infiltration of their 
walls and narrowing of their lumen. The vascular changes were thought 
to be the cause of the bleeding. 

Nails. — The nails present several peculiarities in syphilitic infants. 
There may be a disease of the matrix resulting in suppuration and exfo- 
liation of the nail; frequently the dorsum is much arched, and the nail 
appears as if it had been pinched by a pair of forceps — i. e., claw-shaped; 
this is an early symptom of some diagnostic importance. The hair and 
eyebrows frequently fall out completely. This symptom is not usually 
present in very early infancy. 

Pseudo-paralysis. — This is due to acute epiphysitis, and it may be 
the first symptom of hereditary syphilis to attract attention. It is usu- 
ally noticed when the infant is a few weeks old that one or sometimes 
both arms are not moved, and that the parts are tender when handled. 
Tlie arm is very frequently held in marked inward rotat ion with the palm 
looking outward, resembling the position in BrVs palsy; but careful ex- 
amination makes it evident that the loss of power is only apparent, and 
that it is due either to the pain which motion produces or to epiphyseal 
separation. A history will usually he obtained that loss of power did 
not exist at birth, bui developed subsequently. The electrical reactions 
in these cases are normal, and the rapid improvement under mercurial 
treatment i- diagnosl ic. 

The only visceral symptoms of importance relate to the spleen, which 



1116 THE SPECIFIC INFECTIOUS DISEASES. 

is almost invariably much enlarged in the active stage of hereditary 
syphilis. 

Late Hereditary Syphilis. — These symptoms may come on at any 
period during childhood or about the time of puberty, but very rarely 
at a later time than this. They are seen both in those who have had the 
usual symptoms of hereditary syphilis in early infancy, and in others 
where the most careful examination into the history fails to disclose any 
symptoms whatever of early syphilis. It is fair to assume in such cases 
either that early symptoms were absent or that they were of trivial im- 
portance. It is still a matter of dispute whether these late symptoms 
should be regarded as hereditary, tertiary syphilis, which has not pre- 
viously given signs, or as the late stage of ordinary syphilis in which 
the early symptoms have been overlooked. It is certain that the symp- 
toms are quite as apt to be severe when there is no history of early 
syphilis as when this has been typical. It is quite possible that some of 
these may be the late manifestations of the acquired syphilis not recog- 
nised in the early stage. 

Late hereditary syphilis shows itself by symptoms which in acquired 
disease would be classed as tertiary. The most characteristic are the 
affections of the teeth, the bones, gummatous deposits in the solid vis- 
cera, the skin, or mucous membranes, the breaking down of which may 
lead to ulceration. 

Teeth. — There are no peculiarities in the first teeth of syphilitic chil- 
dren except their proneness to early decay. They are rather more likely 

to appear early than late. 

The characteristic teeth of syphilis are those 

of the second set. In estimating the diagnostic 

value of these changes, only the upper central 
Fig. 2iZ— Typical "Hutch- incisors are to be relied upon; these are the test 
mson's teeth." (After teeth. Although changes are frequently seen in 

other teeth, they are not always diagnostic. Typi- 
cal syphilitic teeth, according to Hutchinson, have each a single notch 
in the centre of the edge (Fig. 215). The notch is usually shallow and 
more or less crescentic in shape. The enamel is generally deficient in 
the centre of the notch, and the tooth here is apt to be discoloured. The 
teeth in other cases are variously dwarfed and deformed. (See Fig. 216.) 
They often taper regularly from the base to the edge, giving rise to the 
term " screw-driver teeth." The teeth are not so flat as the normal in- 
cisors, but often rounded and peg-like. They are not properly placed, 
but incline either toward or away from each other. They are seldom 
large enough to touch the adjacent teeth on both sides. 

Although Hutchinson's teeth may generally be taken as conclusive 
evidence of syphilis, they are not invariably so, as Keyes and others have 
shown. It is to be remembered in this connection that the absence of 




HEREDITARY SYPHILIS. 



1117 




Fig. 216.— Syphilitic teeth; boy- 
eight years old ; under observa- 
tion several years with various 
syphilitic manifestations. 



changes in the teeth is of no importance whatever as evidence that 
syphilis is not present. Hutchinson states that they are wanting in 
more than half the cases. 

Bones. — The form of disease which is usually seen at this period is 
an osteo-periostitis, affecting principally the shaft of the long bones and 
the cranium. It has already been de- 
scribed elsewhere. 

Lymph nodes. — They are much less fre- 
quently affected than in adults, and in 
early infancy they are seldom involved. 
In most cases after the first year there 
may be found a moderate degree of en- 
largement of the post-cervical and epi- 
trochlear glands, swelling of the latter 
having considerable diagnostic value. They 
are situated just above the internal condyle 
of the humerus, and under normal condi- 
tions can scarcely be felt. In syphilitic 
children they may be as large as a pea or 
a small bean; sometimes two or three of 
them can be distinguished. They are so 
rarely enlarged from other constitutional conditions that, provided no 
local cause for the swelling exists, they should always create a suspicion 
of syphilis. The post-cervical glands are frequently affected, but are not 
so diagnostic. The degree of enlargement is rarely great. Occasionally 
there are seen in the neck large masses of swollen lymph glands which 
resemble tuberculous swellings. They are, however, very rare. 

Special senses. — The most frequent affection of the eye in late syphilis 
is interstitial keratitis, the close connection of which with hereditary 
syphilis was firsi pointed out by Hutchinson. It is usually found asso- 
ciated with the typical notched teeth. The diagnostic value of keratitis 
in syphilis i- denied by Fournier, who states that, while often syphilitic, 
il is not infrequently dm- simply to malnutrition. Both eyes are usually 
affected, and in all degrees of severity, from a slight haziness of the 
cornea to complete opacity. However, with an early diagnosis and prompt 
treatment, recovery may he expected in most cases. 

Chronic otitis may be a result of the acute 1 process seen in early 
infancy. There is nothing peculiar about the inflammation in these 
cases. A form of deafness occurs in older children, which Hutchinson 
states is almost invariably due 1<> syphilis. lis onsel is quite sudden, 
without pain and frequently without discharge. The loss of hearing is 
apt to be permanent, and if it occurs early in childhood it is a cause of 
deaf-mut ism. 

Skin. — The most important of the later manifestations of syphilis 

72 



1118 THE SPECIFIC INFECTIOUS DISEASES. 

consists in the formation of subcutaneous gummata. In the early stage 
they are indurated, elastic, of a grayish colour, with red borders. Under 
treatment they disappear quite rapidly by absorption; but when neglected 
they break down, leaving large deep ulcers. These ulcers are quite char- 
acteristic in appearance, but may be confounded with those due to tuber- 
culosis. The syphilitic ulcer has rounded, thickened, indurated borders, 
and a base which is depressed and has the appearance of being scooped 
out. It is sometimes covered by hard crusts and is surrounded by a red 
areola. It leaves a smooth white scar. The most frequent situation is 
upon the face and upper part of the legs or thighs. Tuberculous ulcers 
have usually soft, flat edges, and do not extend so deeply; they are more 
irregular in outline; the cicatrix left is of a purplish colour, which be- 
comes red and slowly fades. Tubercle bacilli may be found. Sometimes 
it is only by the effect of treatment that the diagnosis can be made be- 
tween these two lesions. 

Nose and palate. — Disease of these parts generally begins as the 
breaking down of gummatous deposits in the mucous membrane. The 
nose may in consequence be the seat of a protracted fetid discharge 
(ozaena). The disease may take on a destructive form of ulceration which 
is at times phagedenic, and may cause rapid destruction of the nasal car- 
tilages and bones, perforation of the septum, and occasionally of the floor 
of the nasal fossae. There may be necrosis of the turbinated bones, the 
vomer, or the ethmoid. In the most severe forms the nose may be almost 
destroyed in the course of a few weeks. There may be at the same time 
deep ulceration of the soft palate, leading to perforation. In a young 
person this is almost invariably due to syphilis. In many particulars 
these ulcerations of the nose and palate resemble lupus; they are dis- 
tinguished by the rapidity of their progress, syphilis often doing as 
much damage in weeks as is done by lupus in years (Hutchinson). 

Other symptoms. — Syphilitic disease of the larynx and bronchi is rare 
in childhood. The former (page 507) may give rise to hoarseness or 
aphonia and occasionally to stenosis; the latter to a chronic cough and 
asthmatic attacks. There are no characteristic symptoms belonging to 
syphilis of the lungs. The different lesions of the central nervous sys- 
tem which may be due to syphilis are all quite rare. The forms have 
already been mentioned, and their symptomatology is discussed in Dis- 
eases of the Nervous System. 

The only visceral changes which aid much in diagnosis are those of 
the liver and spleen. The liver is often enlarged, sometimes to a marked 
degree, and occasionally there is ascites, but very seldom jaundice. 

Enlargement of the spleen is a very frequent symptom — in fact, it is 
almost constant during active syphilitic disease. I have several times 
seen it so swollen as to form an abdominal tumour of considerable size. 
In one case, in a boy three years old, the spleen extended five inches be- 



HEREDITARY SYPHILIS. 1119 

low the free border of the ribs, quite to the crest of the ileum. It was 
associated with moderate enlargement of the liver, as is usually the case. 

In addition to the local symptoms of late hereditary syphilis enumer- 
ated, there are others of a general character which are quite as important. 
The body is usually undersized; the constitution is delicate, and shows 
but little resistance to all forms of disease; puberty is frequently delayed, 
and the development of the breasts and the genital organs often imper- 
fect; anaemia is usually present, and the skin has a sallow appearance. 
Mentally, many of these children are somewhat deficient, and in a few 
instances they become idiotic, epileptic, or the subjects of dementia. 

Diagnosis. — The diagnosis of early syphilis in most cases is not diffi- 
cult. The coryza, eruption, labial fissures, mucous patches about the 
anus and genitals, enlarged spleen, and general cachexia — all form a 
picture which it is difficult to mistake. In irregular cases the diagnosis 
is easy just in proportion to the number of the foregoing symptoms which 
are present. Special care should be taken not to confound the moist 
papules of simple intertrigo upon the buttocks or thighs with those of 
syphilis. 

In late syphilis the following symptoms are the most reliable for diag- 
nosis: notching of the teeth, falling in of the bridge of the nose, intersti- 
tial keratitis, deafness not traceable to ordinary otitis, enlargement of 
the spleen and epitrochlear glands, ulceration of the palate or nose, the 
sabre-like deformity of the tibia, and nodes upon the tibia or cranium. 

It becomes at times important to distinguish hereditary from ac- 
quired syphilis. While this is not always possible, it is often so. Visceral 
lesions in acquired syphilis are not common and belong to the late period 
of the disease; in the hereditary form they are well-nigh constant and 
occur early, often being present at birth. The acute epiphysitis, some- 
times accompanied by pseudo-paralysis, seldom if ever occurs in acquired 
syphilis, though frequent in the hereditary form. Symptoms due to 
defects in development, like the misshapen finger-nails, are seen only in 
hereditary syphilis. The early symptoms of the mucous membranes and 
muco-cutaneous surfaces — coryza, hoarseness, haemorrhages, labial fis- 
sures, etc. — so characteristic of hereditary syphilis, have no place in the 
acquired form, while the single primary lesion sometimes found in the 
acquired form does not exist in the hereditary disease. Finally, heredi- 
tary syphilis is very slightly, whereas the acquired form is highly con- 
tagious. 

Prognosis. — Generally speaking, the prognosis is much worse in infan- 
tile syphilis than in that of adults. In infancy it is much worse when 
hereditary than when acquired, for the reason that often the child who 
is the subject of hereditary syphilis lias been affected by the poison from 
the very beginning of its existence, and this has modified its entire devel- 
opment. 



1120 THE SPECIFIC INFECTIOUS DISEASES. 

The results of 206 syphilitic pregnancies observed by Jullien (Paris) 
were as follows : abortion occurred in 36, stillbirths in 8, and 69 children 
died soon after birth, making a total mortality of 55 per cent ; 50 were 
living and syphilitic ; only 43 living and in good health. Still worse were 
the results in cases observed by Le Pileur : of 154 pregnancies in syphi- 
litic women, there were 120 abortions or stillbirths, 26 children died soon 
after birth, and only 8 survived. The statistics of the Foundling Asylum 
in Moscow for ten years showed that of 2,038 syphilitic infants the mor- 
tality was over 70 per cent. 

Such a mortality as that indicated in the above statistics is seen only 
in institutions where little or no previous treatment has been employed. 
In private practice certainly nothing approaching it occurs. 

In addition to those who die early as the result of syphilitic infection, 
there must be added many whose constitutions are so impaired by syphilis 
that they fall an easy prey in infancy to pneumonia, diarrhoea or other 
forms of acute disease. The remote effects of syphilis in infancy it is 
hard to estimate ; it exerts a modifying influence upon the constitution in 
childhood and even throughout the life of the individual. 

The prognosis in an individual case depends upon the age at which 
the symptoms develop, the time when treatment is begun, upon its thor- 
oughness, and upon the surroundings and mode of nourishment of the 
child. The outlook is better the longer after birth the first symptoms 
appear; it is also better in infants who are nursed than in those who 
are artificially fed. 

As compared with syphilis of the adult, relapses are rare, and when 
they occur early they are nearly always the result of insufficient treatment. 
If proper early treatment is carried out, the severe late symptoms are rare ; 
patients are usually free from all symptoms until six or seven years old, or 
until near the time of puberty — two periods when they are likely to develop. 

The prognosis is better in the later children of syphilitic parents than 
in the earlier ones, provided infection has preceded the birth of all the 
children. This fact illustrates the general tendency of the syphilitic 
poison to diminish in virulence as time passes, even without treatment. 
The following instance cited by Bertin well illustrates this point : 

In the first pregnancy, the mother aborted with a dead child at the 
sixth month; in the second, at the seventh month; in the third, at seven 
and a half months; in the fourth the child was born at term, and lived 
eighteen days; in the fifth it lived six weeks; in the sixth the child lived 
four months, without treatment. 

Prophylaxis. — No infected person should be allowed to marry until 
at least two years have passed after the initial sore, steady treatment 
being continued meanwhile; nor if there are any active symptoms, no 
matter how long a time has elapsed since infection. There is no cer- 
tainty in any case that the child will escape. 



HEREDITARY SYPHILIS. 1121 

The mother should be treated during her pregnancy : (1) if she is 
syphilitic, whether the disease was acquired at the time of concep- 
tion or subsequently; (2) if the father is known to be suffering from 
syphilis, whether the mother has symptoms or not ; (3) if the mother has 
previously shown signs of syphilis, but has had no active symptoms for 
a considerable period. In all these conditions if efficient treatment is 
carried on throughout pregnancy there is a strong probability, but in no 
case a certainty, that the child will escape. The third condition mentioned 
is the one in which treatment is most likely to be neglected, especially if 
the mother has previously borne a child who was not syphilitic. Syphilis, 
however, shows a strong tendency to reappear and become active during 
pregnancy, even though it has been long quiescent, as the following case 
cited by Diday shows : 

A woman who had lost seven children from syphilis was put under 
treatment during the eighth pregnancy; result — child born healthy, and 
continued so. In the ninth pregnancy treatment was continued with a 
like result ; in the tenth pregnancy, no treatment, child syphilitic, dying 
when six months old ; in the eleventh pregnancy, treatment repeated, 
child healthy. 

The danger of infection during labour is slight. If there are upon 
the genitals of the mother either a chancre or syphilitic ulcers, they 
should be thoroughly cauterized before labour. 

As the greatest danger of infecting a child after birth is from its parents 
or a wet-nurse, syphilitic parents should be duly warned of the danger to 
their children, and especially should be cautioned against kissing them 
or sleeping in the same bed with them. The utmost care should be ex- 
ercised to prevent a healthy child from being infected by a syphilitic 
nurse. A nurse should never be accepted without a thorough examina- 
tion, no matter how clear a history may be given. As a syphilitic child 
in the household may be the means of infecting other children, the 
same precautions should be taken as in the case of other contagious 
diseases. The chief danger to other children comes from kissing or 
from using bottles, spoons, or cups which have been infected ; as the 
syphilitic infant is chiefly dangerous on account of the lesions in the 
mouth. Trouble most frequently occurs because of ignorance regard- 
ing the nature of the disease* It is possible for a syphilitic child to nurse 
a healthy woman without communicating syphilis, if the child's mouth 
is treated and the nipple not allowed to heroine fissured; bul it is an ex- 
periment which should never be tried. 

Treatment. — This should always be begun as soon as the first positive 
symptoms of syphilis appear. Under certain circumstances it may be 
advisable not to wait for symptoms; as, for example, where both parents 
have recently Buffered from active symptoms, where previous children 
have died soon after birth, or where, with marked symptoms in the par- 



1122 THE SPECIFIC INFECTIOUS DISEASES. 

ents, the child exhibits the cachexia of syphilis, but no definite local 
symptoms. Such anticipatory treatment need not be continued longer 
than six weeks unless symptoms appear. 

The indirect treatment, designed to reach the child through the 
mother's milk, has fallen into deserved disuse, as it is very uncertain and 
altogether unsatisfactory. 

Mercury is as much a specific for hereditary as for acquired syphilis. 
There are many ways of introducing it into the system : it may be given 
by inunctions, by the mouth, by fumigations, by baths, or hypodermically. 
In most cases inunction is the manner to be preferred in young infants. 
Gr.x of mercurial ointment, diluted with the same amount of vaseline, may 
be rubbed daily into the palms, soles, axillae, or the inner surface of the 
thighs. It is advisable to change the place of inunction from day to day ; 
and if this is done, it is extremely rare that erythema is produced. If for 
any reason inunctions are objectionable, as they may be where the family 
are to be kept in ignorance of the treatment, either the gray powder or the 
bichloride may be given by the mouth. The usual dose of the gray powder 
should be gr.j four times a day; that of the bichloride gr. -fa four times a 
day, always well diluted. It is rare that larger doses are advisable. When 
the symptoms are urgent, it is often best to substitute calomel for a few 
weeks, as the system can usually be brought more rapidly under the influ- 
ence of mercury by this than by the other preparations mentioned ; gr. ^ 
four times a day is the usual dose required. Other methods of administra- 
tion and other preparations offer no advantages, and have some very ob- 
vious disadvantages. 

The iodide of potassium is to be used, either alone or in combination 
with mercury, whenever such lesions exist as are classed among adults as 
tertiary. This includes all the late manifestations, and the earlier ones 
whenever the bones or viscera are affected. The iodide is usually well 
borne by children, and may be given in almost any desired dosage. In 
infancy it is rare that more than twenty grains daily are required, but 
in older children the necessary amount may be from one to two drachms 
daily. It should always be given largely diluted. 

The duration of mercurial treatment should be at least one year. The 
doses during the last six months may be reduced to one half or one third 
those employed while active symptoms are present. Treatment should be 
longer than a year if symptoms exist. It is often better not to give the 
mercury continuously, but with short periods of intermission. 

The tonic treatment of syphilis is important and should not be neg- 
lected. After specific treatment has been carried on for a time, particu- 
larly if rapidly pushed, the child often becomes anaemic, and suffers greatly 
from general malnutrition. Under such circumstances also it is often 
wise to discontinue mercury altogether for a time, or at least to reduce 
the dose very much, and administer cod-liver oil, iron, wine, and other 



INFLUENZA. 1123 

tonics. Such a change is frequently found to act most beneficially, even 
when lesions are present, which perhaps have been very little or not at all 
affected by the specific remedies employed. A judicious combination of 
specific and tonic treatment is required in every case, whether the reme- 
dies are given simultaneously or alternately. 

Local treatment. — Ulcerative lesions of the skin require cleanliness, 
dusting with calomel or iodoform, or bathing with the black wash. Mu- 
cous patches should be dusted with equal parts of calomel and bismuth. 
Fissures and ulcers of the mucous membranes should be treated by nitrate 
of silver. Phagedenic ulcers of the palate or nose should be cauter- 
ized with nitric acid or the acid nitrate of mercury. The late syphilitic 
ulcers of the skin, due to the breaking down of gummata, should be 
treated with iodoform. 



CHAPTEE XII. 

INFLUENZA. 
Synonym : La grippe. 

Influenza is an infectious, communicable disease, which is now 
generally admitted to be due to the bacillus described by Pf eiff er in 1892. 
It is serious in children chiefly from its tendency to complications of 
the respiratory tract, in which respect it closely resembles measles. 

Etiology. — The influenza bacillus is found chiefly in the sputum and 
nasal discharge; it is also present in the lower air-passages, and has occa- 
sionally been found in the exudation of otitis, empyema, and meningitis 
accompanying the disease, but rarely in the blood. It is not easily de- 
tected in the sputum, repeated examinations often being necessary; but 
in typical attacks if carefully sought it is found with great uniformity. 
In acute cases it may disappear very early; in protracted cases its pres- 
ence is some! i nits detected for weeks or even months. Besides the bacil- 
lus of IM'eitTer, there are frequently found, either associated or separate- 
ly, in the organs of patients dying from influenza, the streptococcus and 
the diplococcus pneumoniae, for the development of which influenza 
creates conditions in the highest degree favourable. 

Influenza is highly contagious; the poison may be carried by cloth- 
ing or fomites and clings For some time to infected apartments. The 
disease prevails epidemically, and after epidemics it may be endemic 
for a number of years. In New York the disease lias probably been 
present for many years, although it attracted little attention under the 
name of influenza until the great epidemic of 1891. Epidemics prevail 
chiefly in winter and spring. All ages are liable to the disease, infants 



1124 THE SPECIFIC INFECTIOUS DISEASES. 

under one year least so, and in some epidemics they may escape alto- 
gether. The disease has, however, been observed in infants only a few 
days old, where the mother was suffering from it at the time of delivery. 
The children most frequently affected are those from two to ten years 
of age. 

The period of incubation is uncertain. It is usually short, being gen- 
erally believed to be from one to seven days. Little if any immunity 
seems to be afforded by one attack; recurrences and second attacks are 
not uncommon in the same epidemic, and a patient who has once had 
influenza seems to be more susceptible to the disease in consequence. 

Lesions. — There are no characteristic lesions of influenza; those 
which are most frequently found are due to catarrhal inflammation of 
the respiratory or the digestive tract. In some cases only the upper 
respiratory tract is involved, in which case the disease often spreads to 
the middle ear; in others, only the lower respiratory tract, this in in- 
fancy usually spreading rapidly to the lungs, and resulting in broncho- 
pneumonia. Inflammation of the stomach and intestines is much less 
frequent and, as a rule, less severe. This will be considered more fully 
under Complications. 

Symptoms. — The symptoms of influenza are due to the systemic effects 
of a general poison, and to certain local congestions and inflammations 
which are regarded as complications. The two classes of symptoms — the 
general and the local ones — are found in all possible combinations. 

1. The mild, uncomplicated variety. — This lasts from two to five days, 
occasionally a week. The onset is usually abrupt, with chilliness, mus- 
cular pains, and sometimes vomiting. The temperature ranges from 101° 
to 103° F. Even though the fever is not high, the prostration is consider- 
able, and children are often ill enough to remain in bed for several days. 
The usual general symptoms which accompany fever are present. After 
the fever has subsided, the child is left weak and anaemic; convalescence 
is frequently protracted, and it may be three or four weeks before the 
general health is regained. This is the most common variety seen, the 
essential symptoms being fever and prostration without evidences of 
local inflammation. Often there is in addition a mild coryza at the 
outset and a slight but persistent cough. 

2. Uncomplicated cases of the severe type. — These are not very frequent 
in children. They are characterized by high temperature, severe toxic 
symptoms, and great prostration. They often resemble cases of pneu- 
monia, except that the local symptoms and physical signs in the chest 
are wanting. The onset is usually abrupt with vomiting and headache, 
sometimes even with convulsions. The temperature ranges from 100° 
to 106 -5° F. It seldom remains steadily high, but often fluctuates widely. 
I have repeatedly seen a temperature over 106° F. in uncomplicated 
influenza. Marked nervous symptoms are usually present; there may 



INFLUENZA. 



1125 



be headache, photophobia, delirium, stupor, opisthtotonus, and convul- 
sions — all strongly suggesting meningitis, but not so continuous as in 
that disease. In other cases the tongue has a brown coating, the lips 
are dry and parched, the pulse is weak and rapid, and other symptoms of 
the typhoid condition are present. The usual duration of these severe 
attacks is from two to five days; but even where no complication devel- 




Fig. 217. — Temperature chart of nnoomplicated influenza; infant fourteen months old. No 
local signs of disease; repeated blood examinations lor malaria negative; the wide fluctu- 
ations of the temperature independent of therapeutic measures. Prompt cessation of fever 
on removal from the city. (Patient seen with l)r. L. E. La F^tra.) 

ops severe sj mptoma may last for two weeks and sometimes longer until 
a change of climate La made. (Sec Fig. 217.) Although the symptoms 
are very alarming, except in young infants, the attacks arc seldom fatal 
unless pneumonia develops; bul ii may lie a long time before the full 
effects of -mil an illness have entirely disappeared. 

3. Cases complicated />>/ catarrhal inflammation of the tipper respira- 
tory tract. — Tn this group there are added to the general symptoms of the 
mild uncomplicated variety, a Bevere coryza, with pharyngitis and often 
stomatitis. The catarrhal symptoms differ from ordinary catarrh of 
these mucous membranes chiefly in severity. They are also likely to be 
more prolonged, and there is a greater tendency t<> involve the ears and 
the cervical lymph nodes. 'The usual Bymptoms of acute rhino-pharyn- 
gitis arc presenl with its serous, sero-mucous, or muco-purulent dis- 
charge. The whole pharynx may be the seat of an acute, erythematous 



1126 THE SPECIFIC INFECTIOUS DISEASES. 

blush, or the mucous membrane may present a granular or spongy appear- 
ance. The tonsils are red; occasionally there is follicular tonsillitis; 
rarely membranous patches. The nostrils and upper lip are often ex- 
coriated from the nasal discharge. The mouth may be the seat of a sim- 
ple or a herpetic stomatitis with superficial ulceration. These catarrhal 
symptoms are usually severe for three or four days, and gradually sub- 
side. In infants the temperature may be 104° or 105° F. at the outset, 
but continues high only for a day or two. In older children the tempera- 
ture ranges from 100° to 102° F. 

There are two complications which in infancy are very frequent— 
otitis and cervical adenitis. Otitis may be either catarrhal or purulent. 
It runs the usual course of otitis following simple catarrhal processes of 
the pharynx, and usually terminates in complete recovery. Exceptionally 
these cases may go on to the development of chronic otitis, or the disease 
may extend to the mastoid cells. In addition to the severe cases, there 
are frequently seen attacks of catarrhal deafness from inflammation of 
the Eustachian tube. Pain in this form is less severe, and may be ab- 
sent; there is no increased fever. Deafness is the chief symptom, and 
in most cases it disappears spontaneously. 

The adenitis usually involves either the lymph nodes situated below 
the ear and behind the angle of the jaw, or those of the retro-pharyngeal 
region. The inflammation runs the usual course of such inflammations 
when associated with other diseases. 

4. Cases with broncho-pulmonary complications. — A moderate amount 
of inflammation of the mucous membrane of the larynx, trachea, and 
large bronchi occurs in most of the cases of influenza. In the more 
severe forms, broncho-pneumonia or lobar pneumonia often develops. 
Sometimes the pulmonary symptoms do not appear for two or three days, 
or even a week; at other times they are coincident with the development 
of the fever and other constitutional symptoms, and, except for the prev- 
alence of influenza, this would not be considered a factor in these cases. 
A striking feature in these attacks is that the temperature, prostration, 
and cerebral symptoms are out of all proportion to the pulmonary signs 
and symptoms. 

The broncho-pneumonia complicating influenza may not differ essen- 
tially from the ordinary types, except that the proportion of cases which 
do not go on to the development of areas of consolidation is larger than 
is seen under most other conditions. If lobar pneumonia develops, it 
frequently runs its regular course. But besides these two varieties of 
pneumonia, quite a large number of cases of an irregular type are seen 
with influenza. These are often of short duration, but accompanied by 
extremely high temperature (Fig. 218). In many cases there is an ex- 
cessive amount of pleurisy, so that the process is really a pleuro-pneu- 
monia. In an epidemic occurring in the New York Infant Asylum in 



INFLUENZA. 



1127 



the winter of 1891 and 1892 nearly every pneumonia was of this type, 
and in a few weeks there were about twenty cases, all of a very severe 
form. This is often followed by empyema. 

5. Cases with g astro-enteric complications. — Vomiting and diarrhoea 
are frequent at the beginning of influenza, and in some cases, especially in 
infants, they may be the predomi- 
nant symptoms of the attack. The 
stools may be large and fluid, or 
they may contain mucus and even 
blood, and be passed with pain and 
tenesmus — the symptoms being 
those of an acute gastritis or of 
ileo-colitis of moderate severity. 
The duration of these attacks is 
usually three or four days, and 
except in very young or delicate 
children they are rarely fatal. In 
older children there may be initial 
vomiting, abdominal pain, tym- 
panites, protracted diarrhoea, and 
other symptoms strongly suggest- 
ive of typhoid fever. 

6. Influenza in very young in- 
fants. — The severe cases in infants 
under six months old often pre- 
sent peculiar features. The tem- 
perature may be very high, or it may be only two or three degrees above 
the normal, but the prostration is extreme. The eyes are sunken, the 
face is pale, there is marked apathy, and food is often refused altogether. 
In other cases there is cyanosis and very rapid respiration, indicating 
acute congestion of the lungs, although no abnormal signs are present, 
except very feeble breathing sounds. Nearly always there is a disturb- 
ance of digestion, with vomiting and undigested stools. Death may 
occur in two or three days; sometimes it is postponed for a week, the 
chief symptoms being gradually increasing prostration, and finally col- 
lapse, without the development of any marked local evidences of dis- 
ease. The system seems in these cases to be overpowered by the intensity 
of the poison. In other cases pneumonia develops, and from this death 
occur-. 

7. Protracted cases. — There lias long seemed to be sufficient clinical 
ground foi the opinion thai influenza poisoning may sometimes assume 
a chronic or persistent form, and IMVill'er and others have demonstrated 
the presence of the influenza bacillus for months in the secretions of 
such patients. The protracted cases in my experience have almost in- 




Fig. 218. — Acute broncho-pneumonia, abor- 
tive type, complicating influenza, in an 
infant six months old. The entire left 
lung posteriorly, was involved. 



1128 THE SPECIFIC INFECTIOUS DISEASES. 

variably been preceded by a well-defined acute attack, after which there 
is improvement but not recovery, and an irregular low fever follows, 
which may drag on indefinitely. The temperature is not high, seldom 
above 102*5°, often not above 101-5° F. The patients are not sick 
enough to remain in bed; there is in most cases neither cough nor other 
catarrhal symptoms, only the general symptoms of a chronic poisoning — 
poor appetite, coated tongue, anaemia, headache, lassitude, irritability, 
and occasional pains. The cases are often called malaria, or chronic 
intestinal poisoning, and not infrequently tuberculosis is suspected. 
But the special features of all these diseases are wanting. In the cases 
I have seen the symptoms have been controlled by change of climate, 
but without this they have usually continued until the following warm 
season. 

Complications and Sequelae. — The most frequent ones — pneumonia, 
otitis, acute adenitis, and gastro-enteritis — have already been considered. 
Cutaneous eruptions are not infrequent, and are often very puzzling. 
There may be a general eruption resembling urticaria, or an erythema 
which sometimes simulates measles, but more frequently scarlet fever. 
These eruptions are irregular in their course and often in their distribu- 
tion, and are not followed by desquamation. In most of the cases with 
high temperature the urine contains albumin; although nephritis is rare, 
one should be on the watch for it even in young children. I once saw 
acute pyelitis as a complication. The nervous sequelae of adults — men- 
tal disturbances, multiple neuritis, etc. — are extremely rare in child- 
hood, although they have been observed. One of the most frequent se- 
quelae is anaemia; this may be very severe, and in one case I have known 
it to continue to a fatal termination. Following the inflammation of 
the mucous membranes, there may be enlarged tonsils, adenoid growths 
of the pharynx, or chronic enlargement of the cervical lymph glands. 
Attacks of influenza bear the same relation to the development of 
tuberculosis as do those of measles. 

Convalescence after influenza is usually very slow, and it is often 
many months before the full effects of a severe attack have disappeared. 
A recurrence of the symptoms before complete recovery is not uncom- 
mon, and often second attacks during the same season are seen. For a 
long time the mucous membranes are in an extremely sensitive condition. 
Relapses are often brought about by slight exposure before the symp- 
toms have quite disappeared, and I have often seen them occur simply 
from airing an infant in the room. 

Diagnosis. — This is usually easy when the disease is epidemic. The 
sporadic cases often present great difficulties, particularly early in the 
disease. It is often impossible to tell for two or three days whether the 
case is one of pneumonia, malaria, or influenza. In most of the severe 
cases I have seen, pneumonia has been the diagnosis first made; it is 



INFLUENZA. 1129 

only by the course of the disease and the absence of any physical signs, 
as shown by careful and repeated examinations, that influenza can be 
distinguished from pneumonia. From malaria, influenza is differentiated 
by the fact that the fever is not materially affected by quinine, there 
are no organisms in the blood, and the spleen is not usually enlarged. 

The cerebral symptoms are less continuous than in meningitis and 
are usually in direct proportion to the fever. In the protracted cases, the 
temperature may bear some resemblance to typhoid, but the other char- 
acteristic symptoms of that disease are wanting. Measles is distin- 
guished by Koplik's spots. In its mode of onset, and sometimes in its 
eruption, influenza often resembles scarlet fever, but the course of the 
symptoms usually clears up the doubt. In general, influenza is charac- 
terized by severe constitutional symptoms without evidence of local dis- 
ease of sufficient importance to explain the temperature. 

From ordinary catarrh, influenza differs only in its high communica- 
bility, its severity, and the frequency with which it is complicated by 
otitis, adenitis, and pneumonia. Mild cases when not epidemic can not 
be distinguished from simple catarrh of the respiratory tract. 

Although in most cases the bacilli may be found by staining the 
sputum or nasal discharge, or may be cultivated from either of these, 
the difficulties in the way are such that this method of diagnosis has been 
as yet but little employed. In many cases the bacilli disappear early, 
and in others careful and repeated examinations are necessary to dis- 
cover them. In general, therefore, the other symptoms of influenza must 
be relied upon for diagnosis. Since none of these is wholly characteris- 
tic, exact diagnosis is by no means easy, and in some cases it may be 
impossible. A probable diagnosis is made by excluding the other dis- 
eases mentioned; the probability is greatly increased if influenza is prev- 
alent, especially if there are other cases in the same house. The tend- 
ency in practice is to call a great many other kinds of infection by the 
name of influenza, particularly when the disease is epidemic. 

Prognosis. — As a rule, the type of influenza seen in children is milder 
than that which occurs in adults. In the case of children previously 
healthy, few die except from pulmonary complications, while the great 
majority of attacks are mild and recovery is prompt. In infants the 
tendency to pulmonary complications is much greater than in older chil- 
dren. Uncomplicated eases are seldom fatal, except in infants under six 
months old; and even though the temperature is very high and the symp- 
toms severe, ncoverv may usually he predicted as long as there is no 
evidence of serious complications. The prognosis of the pneumonia of 
influenza is rather worse than that of simple hroncho-pneumonia, and 
depends chiefly upon the age of the patients affected. In a word, in- 
fluenza is particularly serious in the very young, or when there are pul- 
monary complications, hut rarely otherwise. In infants the constitu- 



1130 THE SPECIFIC INFECTIOUS DISEASES. 

tional depression which results may be the beginning of a condition of 
malnutrition which goes on to the development of marasmus; or a child 
falls an easy victim to some other form of acute disease. The remote 
effects of influenza may therefore be serious, even though the attack 
itself is not especially severe. 

Treatment. — The communicability of the disease makes it desirable 
that cases of influenza should be isolated whenever practicable, and par- 
ticularly that delicate children, or those prone to pulmonary disease, 
should not be exposed. The fumigation of apartments after attacks 
should be regularly practised, preferably with formalin gas; this with 
isolation will do much to control house epidemics. 

The disease usually runs its course, when uncomplicated, in from 
three to seven days. As there is no specific for influenza, the indications 
are to sustain the patient, to make him comfortable during the attack, 
and to prevent so far as possible the occurrence of complications. Every 
child with influenza should be put to bed and kept there during acute 
symptoms. At the outset the bowels should be opened by castor-oil or 
calomel, and free perspiration induced by the use of hot drinks, the hot 
pack, or small doses of Dover's powder in combination with phenacetine. 
A very high temperature should be relieved by cold sponging or the cold 
pack, precisely as in pneumonia, but large doses of antipyretic drugs are 
to be avoided. The nervous symptoms — restlessness, pain, headache, and 
other disturbances — are best controlled by phenacetine in combination 
with codeine — e. g., to a child of one year, phenacetine gr. j, codeine gr. 
^V, every three or four hours. Double the dose may be given to a child 
of four years. Alcoholic stimulants are required whenever the pulse 
shows signs of weakness, as it does in most of the severe cases, and in 
most young infants. They should be given according to the same rules 
as in pneumonia. Next to alcohol, strychnine is the most valuable heart 
stimulant. 

In older children there is a decided advantage in the use of moder- 
ately large doses of quinine — e. g., gr. ij, four or five times a day, to a 
child five years old; but in infants this should be omitted, on account 
of its tendency to upset the stomach. The cough which so often persists 
after influenza is best controlled by cod-liver oil and creosote, used as 
after acute bronchitis. With persistent bronchitis which resists ordinary 
remedies, a patient should be sent to a warm, dry climate. The compli- 
cations of influenza are to be treated as they arise, in the same manner 
as when they occur under other conditions. In all cases careful feeding 
in accordance with the general rules laid down for feeding in acute dis- 
eases, good nursing, and care to avoid exposure during convalescence, 
are essentials in treatment. One should be particularly anxious about 
patients who have a strong tendency to tuberculosis, and such cases 
should be watched with the greatest solicitude. 



MALARIA. 1131 

In prolonged or constantly recurring attacks nothing is of much 
avail except a change of air. If this is impossible, a child should be fre- 
quently removed from one apartment to another, as re-infection often 
appears to take place from the sick-room. 



CHAPTER XIII. 
MALARIA. 

Malaria is a general infectious disease due to the presence in the 
blood of a specific organism often called the Plasmodium, but more ex- 
actly the hcematocytozodn malaria. It manifests itself in children by the 
ordinary acute febrile attacks which are seen in adults and by chronic 
malarial poisoning. Both of these forms may present certain peculiar 
symptoms dependent upon the age of the patient. 

Etiology. — The malarial organism was discovered by Laveran in 1881; 
it is a parasite of the blood and belongs to the group of protozoa. It is 
now well established that the parasite enters the blood through the bite 
of certain forms of mosquito, those belonging to the genus Anopheles, 
and probably in no other way. For this knowledge we are indebted 
chiefly to the work of Ronald Ross, in India, in 1897. For a general 
discussion of the malarial parasite, its methods of staining, etc., the 
reader is referred to works on clinical medicine. 

Malaria affects all ages, even the newly-born infant. We must accept 
with some allowance the statements made by the older writers upon the 
subject of intra-uterine infection, but in the following case occurring in 
the practice of my former associate, Dr. Crandall, there seems little 
doubt that the disease was contracted in utero: For ten days before de- 
livery the mother had suffered from a tertian intermittent of moderate 
severity. Eighteen hours after birth the child was noticed to have cold 
hands and feet, blue lips and nails, and a pinched face. These symptoms 
lasted about half an hour and were followed by a distinct fever. Upon 
the following day the paroxysm was repeated. Examination of the blood 
of both mother and child was made by Dr. Walter James, who found the 
malarial organisms in both cases. 

Malaria is more frequently overlooked in young children than in later 
life, from the fact that its forms are more irregular, and this has led to 
the belief that young children are less liable than adults to the disease. 
I believe, however, the opposite to be the case. In a large number of in- 
stances where families have been exposed to malaria] poisoning I have 
noted that the young children were frequently the first to show the 
symptoms of the disease. 



1132 THE SPECIFIC INFECTIOUS DISEASES. 

Malaria is an endemic disease prevailing in certain localities. Exact 
knowledge regarding the mode of infection has cleared up many obscure 
points in the etiology of this disease. The role of the mosquito explains 
the greater liability to contract malaria after sunset and during the 
night, the danger from stagnant ponds and pools of water, the peculiar 
susceptibility of infants and young children, and the greater frequency 
of the disease in the spring and summer. Malarial attacks may, however, 
occur at any season, since the poison may be latent in the body for an 
indefinite time; how long it is impossible to say, but there seems to be 
conclusive proof that it may be for many months. Attacks of malaria 
very often occur when the general health has been reduced by some other 
cause, particularly by disturbances of digestion. 

Lesions. — Opportunities for a study of the peculiarities of the lesions 
of malaria in children are infrequent, especially in New York, as fatal 
cases are extremely rare. I have myself seen but two. As observed by 
others, the lesions do not differ in any marked way from the adult form 
of the disease. The most important changes are the destruction of the 
red corpuscles of the blood, enlargement, and in chronic cases hyper- 
plasia with pigmentation of the spleen; less frequently pigmentation of 
the liver, kidneys, and brain. Pneumonia and gastro-enteritis are occa- 
sional complications. 

Symptoms. — The clinical forms of malarial fever in children from six 
to ten years old, do not differ essentially from the same disease in adults. 
Both intermittent and remittent forms occur, the former being the type 
usually seen. Of the different varieties of intermittent fever, the quo- 
tidian (Fig. 219) is the most common, although the tertian (Fig. 220) is 
fairly frequent, but in this locality the quartan is extremely rare. The 
stages of the paroxysm are generally well marked. The cold stage begins 
with a chill or vomiting, with headache, lassitude, and general pains. 
The hot stage is usually characterized by a higher temperature than in 
adults, and this is followed by the sweating stage, which is generally 
marked. The paroxysm may be repeated every day or every other day 
until controlled by quinine, or the stages may become less and less dis- 
tinct as the disease progresses until a more or less remittent type of fever 
develops. Less frequently the fever is remittent from the beginning and 
the constitutional symptoms are of greater severity. In this form there 
is marked prostration, the tongue is thickly coated, there are often ten- 
derness and pain in the region of the liver, and occasionally there is 
slight jaundice. 

In infants and very young children peculiar types of malaria are 
seen. A well-marked intermittent fever with distinct stages is often 
absent, many cases assuming more of a remittent type or an irregular 
form of intermittent (Fig. 221) . The onset is usually abrupt with vomit- 
ing, a well-marked chill being rare. Malarial chills are not often wit- 



MALARIA. 



1133 



nessed in children under five years old. They are replaced in infants by 
cold hands and feet, blue lips and nails, sometimes slight general cyano- 
sis, pallor, drowsiness, and prostration. Vomiting has been present in 
two thirds of my own cases. Several times have I seen a malarial attack 
ushered in by convulsions. 

The fever is relatively higher than in adults, rising rapidly to 104° or 
105° F., occasionally to 106° or 106-5° F. This continues from four to 
twelve hours and gradually falls, usually to normal. The other constitu- 
tional symptoms of the febrile stage are much less severe than in most 



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preceded Dy a chill. It will be noticed that the temperature rose higher with each suc- 
ceeding paroxysm ; x marks the time when quinine was begun. 



diseases with the same elevation of temperature. The sweating stage 
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After the first paroxysm the patient may be quite well for several 



1134 



THE SPECIFIC INFECTIOUS DISEASES. 



hours or even for a day, when the second paroxysm occurs. This is gen- 
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Fig. 220. — Typical malarial temperature, tertian type, in a boy five years old. Onset with 
vomiting and drowsiness, but no chill. This was an anticipating intermittent, the first 
paroxysm occurring at 3 p.m., the second at 12 m., the third at 10 a. m. ; x marks the time 
when'quinine was begun. 

and later becomes intermittent, but it is very rare under any circum- 
stances that the temperature does not touch the normal point at some 
time in the twenty-four hours. In infants the quotidian has been in my 
experience very much more frequent than any other type, the tertian 
being rare and the quartan almost unknown. 

Enlargement of the spleen is present in the great majority of cases, 
and usually to a sufficient degree to be readily appreciated by exam- 
ination. The most satisfactory method of examination is by palpation. 
A spleen which can be easily felt below the ribs (except in the rare 
cases in which the organ is displaced downward by some condition in 
the thorax) is enlarged. When it is not sufficiently enlarged to be 



MALARIA. 



1135 



readily felt by a practised observer under favourable conditions for ex- 
amination, it is not large enough to be of any diagnostic importance. 
None of the other symptoms occurring in malarial fever are character- 
istic; they are quite similar to those which are seen in almost all febrile 
attacks. They are anorexia, coated tongue, constipation, and restlessness. 

Masked or Irregular Forms of Malaria. — These are quite frequent in 
young children, and are due to the presence of certain special or uncom- 
mon symptoms which may readily lead to a mistake in diagnosis. They 
are more often seen than cases of true malarial cachexia. 

Among the most frequent of the irregular forms are those relating 
to the nervous system. Headache is exceedingly common and is usually 
frontal. When severe and associated with continuous drowsiness, vomit- 
ing, and constipation, it may lead to a strong suspicion of tuberculous 
meningitis. Vertigo is not a frequent symptom, but it is sometimes very 



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Fie. 221. —An irregular malarial temperature in a child nine months old. The paroxysm on the 
fourth day wraa accompanied by an attack of acute pulmonary congestion which came near 
being fata] ; x marks tne time when quinine was begun. Although the course of the tem- 
perature is irregular, it touched the normal line both on the second and fourth days. 



prominent. Pains in various parts of the body are very common. A 
sharp severe pain a1 the epigastrium is frequent at the beginning of a 
paroxysm. It is often associated with tenderness, but has no relation to 
meals. Less frequently, pain is localized in the region of the spleen 



1136 THE SPECIFIC INFECTIOUS DISEASES. 

or liver. Trifacial neuralgia of malarial origin is rare in childhood. 
Aching or dragging pains in the muscles of the lower extremities are 
frequent symptoms during acute attacks, but they are of short duration, 
disappearing with the fever. They are to be distinguished from the 
acute lancinating pains of multiple neuritis, which is occasionally seen 
as a result of malarial poisoning. I have seen the latter in young chil- 
dren in three cases, and it has been observed by others. The pain is 
accompanied by tenderness of the muscles and nerve trunks, and by loss 
of power, which is usually partial. 

Spasmodic torticollis (page 731) I have seen in eight cases, in which 
the condition seemed very clearly to depend upon malaria. This was 
shown by the fact that the spasm was intermittent, coming on every after- 
noon, but being absent in the morning; that it was accompanied by a 
slight rise in temperature, and usually by enlargement of the spleen; and 
that it was immediately controlled by quinine. This combination of 
symptoms seemed to be conclusive evidence of the malarial origin of the 
affection, although these cases were observed before the time when blood 
examinations were made. 

Accompanying the paroxysm of malaria there is occasionally seen, 
more often in infants than in older children, acute pulmonary congestion 
(Fig. 221), which may give rise to obscure and often very alarming 
symptoms. There is an acute onset with vomiting and prostration, high 
temperature, cough, rapid respiration, and often slight cyanosis. On ex- 
amination of the chest there is found feeble or rude respiration over one 
lung, or over both lungs behind, and sometimes coarse moist rales; these 
signs and symptoms may disappear in the course of a few hours with the 
fall in temperature, to return with the next paroxysm, or if quinine is 
given they may disappear entirely.* This group of symptoms has often 
led to the mistaken opinion that the disease was pneumonia, which had 
been aborted by the administration of quinine. 

* The following case is a good example of this condition in its more severe form, 
and illustrates the difficulties in the diagnosis of malaria in infancy : A fairly nour- 
ished child, nine months old, who had been under observation in an institution for 
two weeks, was suddenly taken with vomiting and fever (Fig. 221). A cathartic was 
followed by a large undigested stool, and as the temperature then fell to normal, the 
attack was regarded as one of indigestion. On the third day the temperature was 
again high and accompanied by cough ; coarse rales were found throughout the chest, 
and fine rales at the right base ; it was then thought that pneumonia was developing. 
On the fourth day all the symptoms were so much improved that the infant was regarded 
as convalescent. At 6 p. m. the temperature was normal, and the infant went to sleep 
quietly. At 9.30 p. m. he awoke with a temperature of 104°, extreme restlessness, and 
marked dyspnoea. In half an hour his symptoms had increased to a point where he 
seemed likely to die. He became cyanotic, the respirations were of a panting char- 
acter and rose nearly to one hundred a minute, and he coughed with almost every 
breath ; the pulse was scarcely perceptible. The severe symptoms continued for about 



MALARIA. 1137 

Subacute or Chronic Forms of Malaria. — The most constant symptoms 
are anaemia, enlargement of the spleen, and slight fever. The anaemia is 
usually marked, often being extreme. The enlargement of the spleen is 
distinct, easily made out by palpation, and sometimes is very great. 
The fever is often so slight as to be discovered only when the tempera- 
ture is taken five or six times in the twenty-four hours. The other 
symptoms are of a very indefinite character; there may be slight oedema 
of the lower extremities, general muscular weakness, so that the child 
is easily fatigued, loss of appetite, coated tongue, constipation, headache, 
muscular pains, and often cough from a slight bronchitis. These symp- 
toms may depend upon many conditions other than malaria, even when 
they are seen in a malarial district. The only positive evidence of mala- 
ria in such cases is the presence of the malarial organisms in the blood. 
Even the swollen spleen, anaemia, and slight fever, which are often looked 
upon as diagnostic, may be present in cases of anaemia with which mala- 
ria has nothing whatever to do. 

Diagnosis. — The positive diagnosis of malaria rests upon the demon- 
stration of the malarial organisms in the blood. They will be found in 
nearly all the cases provided a careful examination is made during the 
paroxysm, and also that no quinine has been administered. When their 
number is small they may be missed at the height of the fever, although 
they may readily be found just before the temperature begins to rise. 
Blood from the spleen is more certain to show the organisms than that 
from the finger; and if possible the examination should be of fresh blood 
as well as of stained specimens. While a positive result is conclusive, a 
negative one is not always so because of the impossibility of fulfilling all 
the above conditions. This fact and lack of experience in blood examina- 
tions make it necessary for a large part of the profession to make the 
diagnosis by the other symptoms. These, in order of their importance, 
I would place as follows: Prompt curability (especially in cases of fever) 
by quinine; distinct periodicity in the symptoms; enlargement of the 
spleen; and a history of an exposure in a district known to be malarial. 
Particular importance is to be attached to the therapeutic test. Eecent 
experience emphasizes more and more strongly the fact that quinine has 
very little influence upon fevers which are not malarial, and, conversely, 
that a fever immediately and permanently controlled by quinine is pretty 
certain to be malarial. The combination of all the above symptoms, even 

an hour, then passed away gradually, and at the end of two and a half hours they 
had completely disappeared, and the child was in a quiet sleep which continued until 
morning. Malaria was now suspected, and the diagnosis established by the discovery 
of the plasmodium in the blood. The spleen was at this time much enlarged; the 
signs in the chest were those only of bronchitis of the large tubes. Quinine was now 
begun in full doses, and immediately controlled the temperature and the pulmonary 
symptoms. 



1138 THE SPECIFIC INFECTIOUS DISEASES. 

in the absence of an examination of the blood, may be regarded as suffi- 
cient to establish the diagnosis of malaria. 

The cachexia and course of the temperature in septicaemia, pyaemia, 
broncho-pneumonia, tuberculosis, and empyema, may easily cause them 
to be mistaken for malaria. The fever and recurring chills of pyelitis 
are often attributed to malaria; as are also the heaviness, lethargy, head- 
ache, coated tongue, and slight fever of chronic intestinal indigestion. 
Many conditions accompanied by an enlarged spleen may be confounded 
with malaria, especially simple anaemia, leukaemia, rickets, and syphilis. 
While malaria may be multiform in its manifestations, the physician can 
fall into no more serious error than to regard all ailments with obscure 
or indefinite symptoms as malarial, neglecting careful physical and blood 
examinations, by which means alone an accurate diagnosis is reached. 

Prognosis. — Although it is seldom fatal in itself, an attack of malaria 
in an infant may so undermine the constitution that the child may suc- 
cumb to some other acute disease, usually of the lungs or intestines. 
Cases are often difficult to cure while the patient remains in the malarial 
districts, and while a constant absorption of the poison continues. Under 
other circumstances the prognosis of malaria is good. 

Treatment. — Prophylaxis. — More exact knowledge regarding the eti- 
ology of malaria makes it possible for much to be done in the way of 
prevention. Besides the general measures proposed for the extermination 
of the mosquitoes concerned, emphasis should be laid upon the necessity, 
in the case of young children, of protecting them against the bites of 
mosquitoes in localities which are or which may possibly be malarial. 
This can be done by a more thorough use of mosquito netting and by using 
upon exposed parts of the body lotions or ointments containing menthol, 
pennyroyal, turpentine, or other substances which keep these pests away. 
The general treatment is symptomatic, and is to be conducted as in all 
acute febrile diseases. In the cold stage, stimulants or a hot bath may 
be required; in the hot stage, ice to the head and frequent sponging. 
The bowels in all cases should be freely opened, preferably by calomel. 

Methods of administration of quinine. — For infants my own prefer- 
ence is to give the bisulphate in an aqueous solution, one or two grains 
to the teaspoonful, according to the age of the patient. Most infants 
take such a solution with less difficulty and vomit it less frequently than 
the combinations with the various vehicles supposed to cover its taste. 
In the event of failure by this method, the same solution may be given per 
rectum through a catheter. It should then be more largely diluted with 
some bland fluid such as gruel, and in double the dose. This is necessary, 
not only because absorption is less certain and complete, but also be- 
cause a rectal dose can seldom be repeated oftener than every five or 
six hours. There is sometimes an advantage in giving part of the quinine 
by the mouth and part of it by the rectum; should both fail it may be 



MALARIA. 1139 

given hypodermically. For this purpose the bimuriate of quinine and 
urea, the hydrochlorosulphate, the hydrobromate, or the bisulphate may 
be used. The salts first mentioned have the advantage of greater solu- 
bility. But all are more or less irritating and there usually follows some 
induration at the site of the injection, which may last a long time. While 
the hypodermic use of quinine is sometimes invaluable it should not be 
employed in infants except in serious attacks and when we are tolerably 
certain of our diagnosis. In a number of instances both in hospitals and 
private practice I have seen ugly sloughing follow the use of nearly all 
the preparations generally employed. The occurrence of abscess points 
to infection at the time of injection; but necrosis I believe may be due 
simply to the irritation of the quinine upon tissues having a lowered 
vitality, as in the case of young or delicate infants. I have seen this 
happen when the strictest precautions against infection were observed. 
The frequent repetition of the hypodermic injections should be avoided; 
in most cases, one or two good doses are sufficient, the effect being con- 
tinued by quinine given by other methods. 

For children from two to seven years old the taste of quinine must 
be concealed. An aqueous solution of the bisulphate may be mixed with 
the syrup of sarsaparilla, orange, or yerba santa; or the sulphate may be 
given in suspension in the same vehicle, the mixture being made just 
before the dose is taken; otherwise the partial solution of the drug will 
render the whole dose exceedingly bitter. When the dose required is not 
large, as in the milder cases, the lozenges of the tannate of quinine com- 
bined with chocolate answer the purpose admirably, for these are so 
nearly tasteless that children will take them without difficulty. Each 
lozenge usually contains one grain of the tannate, which is equivalent to 
about one third of a grain of the sulphate of quinine. A similar lozenge 
containing one grain of the sulphate may be made, which is often taken 
by children without the slightest objection. The bisulphate may be given 
in solution by the rectum, or, better, at this age, in the form of supposi- 
tories; but, as in infancy, with very urgent symptoms, it is better to resort 
at once to the hypodermic method in case of failure by the stomach. 

For children over seven years old, the same methods of administra- 
tion may usually be employed as in adults. It is always preferable to 
give quinine in solution, or if not so, in capsule, but never in pill form. 

In a case with well-marked paroxysms the quinine should if possible 
be given in the interval, with the largest dose about four hours before 
the expected paroxysm. With infants this plan is sometimes imprac- 
ticable, as frequent small doses are usually better borne by the stom- 
ach than a few large ones. In them also vomiting seems less likely 
to occur when it is given on an empty stomach. For this reason it 
is advantageous to give the drug al regular two- or three-hour intervals 
during the night, and omit all medical ion during the day. I have never 



H40 THE SPECIFIC INFECTIOUS DISEASES. 

succeeded in getting the physiological effects of quinine by inunction, 
though there are good observers who claim this result. It is certainly a 
very uncertain way of introducing quinine into the system. 

Dosage. — Eelatively much larger doses of quinine are required for 
young children than for adults. Except for its tendency to disturb the 
stomach, quinine is borne remarkably well by little patients. Generally 
too small doses are given. An infant of a year with a sharp attack of 
malarial fever will usually require from eight to twelve grains of the 
sulphate (ten to fourteen grains of the bisulphate) daily. Occasionally 
I have found it necessary to give double the quantity referred to, and I 
have seen no unpleasant cerebral symptoms. It is useless to expect to 
control an acute attack of malaria by such doses as one grain three or 
four times a day. Children from five to ten years old require almost as 
large doses as do adults. None of the substitutes for quinine are to be 
relied upon in acute cases. 

In chronic cases, arsenic and iron are usually required in combination 
with smaller doses of the quinine than those mentioned. For children 
over seven years old, Warburg's tincture may be employed. In most 
chronic cases a cure can be effected only by a change of climate. 

The marked and irregular manifestations of malaria are to be treated 
in the same manner as cases of malarial fever. 



SECTION X. 
OTHER GENERAL DISEASES. 

CHAPTER L 
RHEUMATISM. 

The rheumatic diathesis manifests itself in children by quite a differ- 
ent group of symptoms from those seen in adults ; for this reason the 
disease was formerly supposed to be a rare one in early life. It is only 
within recent years that its frequency and its peculiarities have come to 
be appreciated. For our present understanding of the subject we are in- 
debted largely to the work of English physicians, especially Cheadle,* 
who has brought out more fully than any one else the close connection ex- 
isting between many conditions formerly not regarded as rheumatic. One 
who has in mind only the adult types of articular rheumatism, and regards 
arthritis as a necessary symptom for a diagnosis, will overlook in early life 
many manifestations which are clearly the result of the rheumatic poi- 
son. There is seen at this period a group of clinical phenomena, which 
often occur in combination or in succession, whose association was not 
understood until they were all discovered to be related to rheumatism. 
Sometimes one member of the group and sometimes another is first seen, 
but when one has appeared others are likely soon to follow. 

Rheumatism in childhood, then, is manifested not alone by arthritis 
with acute or subacute symptoms, but by a large number of other condi- 
tions which are not to be regarded in the light of complications, but rather 
as forms of the disease. 

Etiology. — It is not in the province of this work to discuss the various 
theories regarding the nature of rheumatism and its exciting cause. The 
drift of medical opinion to-day is strongly toward the view that acute 
rheumatism is an infectious disease, probably of microbic origin. Al- 
though the character of the micro-organism is not yet determined, the 
latesl observations of I'oynton and Paine \ point lo a diplococcus. The 
excessive formation of acids in the system may be regarded as a result 
of the infection, or possihly as a condition necessary for the activity of 
the specific poison. Under five years of age articular rheumatism is not 
common, and in infancy it is extremely rare. I once saw, however, in 
a nursing infant, a typical attack of rheumatic fever with multiple joint 

* See the Hantaan Lectures, 1889. f Lancet, May 4, 1901. 

73 1141 



1142 OTHER GENERAL DISEASES. 

lesions; and undoubted cases have been reported at as early an age as 
two months. In 1899 Miller (Philadelphia) could find in medical litera- 
ture but nineteen cases under one year. The condition is therefore so 
exceptional that one should be cautious in making the diagnosis of rheu- 
matism in infancy. Most of the cases so regarded are examples of scurvy. 
After the fifth year both the articular and the other manifestations of 
rheumatism become very common, and occur with increasing frequency 
up to the time of puberty. 

Heredity is a very important etiological factor, and in fully two 
thirds of the cases that have come under my care, a rheumatic family 
history was obtained. Of the other important causes, the most frequent 
are living in damp dwellings, direct exposure to cold and wet, poor 
hygienic surroundings, and insufficient food. While seen among all 
classes, rheumatism is more common among those who are badly housed. 
Attacks of rheumatism occur at all seasons, but are much more frequent 
in the spring months. One attack strongly predisposes to a second, and 
in most cases there is a history of a large number of attacks of greater 
or less severity. Among my own patients, girls have been affected with 
greater frequency than boys. 

Symptoms. — The general and articular manifestations. — The clinical 
types of rheumatism in children present very notable contrasts to those 
seen in adults. A typical attack of acute articular rheumatism such as is 
seen in adult life, with a sudden onset, high temperature, severe inflam- 
mation of several joints, profuse acid perspiration, and occasional delir- 
ium, is rarely seen in a child under eight or ten years old. In most of 
the attacks in childhood the onset is not very acute, the temperature is 
but slightly elevated — only 100° or 101-5° F. — the swelling and pain are 
moderate, and the redness is often absent. The number of joints involved 
is generally small, those most frequently affected being the ankles, the 
knees, the small joints of the foot, the wrists, or the elbows. These symp- 
toms are often not severe enough to keep the patient in bed, and only the 
pain in the joints of the lower extremities prevents him from walking. 
The duration of these attacks is from one to three weeks, and in the 
course of a month most of them recover even without treatment. 

Not infrequently the symptoms are limited to a single joint, usually the 
hip, knee, or ankle. Possibly the joints of the upper extremity are affected 
oftener than would appear, but disease here is much more likely to be 
overlooked than when lameness is present. The swelling is moderate and 
may not be evident except on a close examination ; in some cases there is 
none. There is stiffness of the joint, as shown by lameness, and there may 
be so much pain and soreness that the child refuses to walk altogether. 
Muscular spasm about the affected joint is often marked, and may be the 
most striking objective symptom. The tenderness is sometimes local- 
ized, but it may affect the ligaments, tendons, and even the muscles. 
These symptoms may persist for two or three weeks and lead to the 



RHEUMATISM. 1143 

suspicion of incipient tuberculous disease of the joint. Rheumatism is 
distinguished by its more acute onset and usually by the presence of 
slight fever ; some elevation of temperature being the rule, though it is 
not often much over 100° F. A family history of rheumatism, or a his- 
tory of previous similar attacks in the patient affecting the same or other 
joints, or other manifestations of rheumatism, are also of assistance in the 
diagnosis. Occasionally all doubt is removed by the disease extending to 
other joints, or by the development of endocarditis. In some cases the 
symptoms are less in the articulation than in the muscles, and they are 
dismissed as simply " growing pains," having nothing characteristic about 
them except their occurrence in damp weather. 

Cardiac manifestations. — These may occur where the articular symp- 
toms are very mild, and in some cases where they are entirely absent. 
The most frequent is endocarditis. This is much more often seen in the 
acute rheumatism of children than of adults, and probably occurs in the 
majority of all severe cases ; if it does not come in the first attack, it is 
likely to be seen in the later ones. It frequently occurs with a mild rheu- 
matic arthritis, often being unnoticed until valvular disease of considerable 
severity has developed. Sometimes there is only high fever with severe 
constitutional symptoms of an indefinite character, but no arthritis, and 
no suspicion that the attack is rheumatic until endocarditis is discovered. 
Such cases are not infrequent. If the patients are kept under observation, 
articular symptoms are almost certain to develop later, and often there are 
other manifestations of rheumatism, especially chorea. 

Pericarditis is less frequent than endocarditis, and usually occurs in 
children over seven years old. It is often associated with endocarditis. 
The most characteristic form of inflammation in early life is a subacute, 
dry, fibrous form, often resulting in great thickening with extensive adhe- 
sions, and frequently in obliteration of the pericardial sac. When once 
started it shows a strong tendency to recurrence and persistence. 

The heart is so frequently affected in the rheumatism of childhood 
that it should be closely watched whenever articular symptoms are present, 
no matter how mild they may be ; and not only in these cases, but in all 
the conditions hereafter enumerated with which rheumatism is likely to be 
associated. 

Inflammations of other serous membranes — the pleura, peritonaeum, 
and pia mater — were much more frequently ascribed to rheumatism in the 
past than now. There is little doubt that on rare occasions any one of 
these may be due to rheumatism. The pleura is most often involved, but 
even this is rare in young children. 

Torticollis when it occurs acutely is frequently rheumatic. This form 
is characterized by its sudden development, continuous spasm, the great 
amount of muscular soreness, the moderate pain, and the fact that it usu- 
ally disappears spontaneously after a few days. It is often seen in con- 



H44: OTHER GENERAL DISEASES. 

nection with a rheumatic sore throat. Other manifestations of muscular 
rheumatism are less characteristic and usually affect the muscles of the 
extremities. 

Anosmia is almost invariably seen in rheumatic patients, both during 
and between the attacks. The effect of the rheumatic poison upon the 
blood resembles that of malaria. The presence of anaemia is so evident 
and its degree often so marked, that one may have great difficulty in dis- 
tinguishing cardiac murmurs which are haemic from those due to endo- 
carditis. 

Chorea. — In the article upon Chorea I have already discussed the asso- 
ciation of that disease with rheumatism and expressed my own belief in 
a very close relationship existing between them. Not very infrequently 
chorea is the first manifestation of the rheumatic diathesis, to be followed 
soon by articular symptoms or by endocarditis without such symptoms. 
In other cases chorea and acute endocarditis occur together without 
articular symptoms, or all three may be associated. Whichever of the 
three conditions is first seen, the physician should always be on the look- 
out for the others. The frequency of rheumatism in choreic patients has 
been variously estimated by different observers; in my own cases over 
fifty-six per cent gave unmistakable evidence of the rheumatic diathesis. 

Tonsillitis. — The association of tonsillitis and pharyngitis with rheu- 
matism appears in many cases to be a close one. Children who are the 
subjects of frequent attacks should be regarded as possibly rheumatic, 
and closely watched for other signs of that disease. Acute tonsillitis 
often ushers in an attack of rheumatic arthritis, and occasionally acute 
endocarditis without articular symptoms. Eheumatism may be associated 
with any form of tonsillitis, but its connection with quinsy seems closest. 
The nature of the relationship is not yet fully explained; by many the 
tonsils are regarded as the structures through which the rheumatic 
poison is absorbed. Packard (Philadelphia), however, regards the ton- 
sillitis as non-rheumatic, and the endocarditis as of septic origin. 

Subcutaneous tendinous nodules. — General attention was first drawn 
to these as a manifestation of rheumatism by Barlow and Warner, in 
1881, who described them as " oval, semi-transparent, fibrous bodies like 
boiled sago grains." They are most frequently found at the back of the 
elbow, over the malleoli, at the margin of the patella; occasionally on 
the extensor tendons of the hands, fingers, or toes, or over the spinous 
processes of the vertebrae or the scapulae. They are composed of fibrin, 
cells, and fibrous tissue, and vary in size from a large pin's head to a 
small bean, sometimes being as large as an almond. The nodules may 
come in crops, lasting for a few weeks and then disappearing, or they 
may last for months. An eruption of nodules is usually coincident with 
other rheumatic manifestations. These nodules are better felt than seen, 
although, as Cheadle observes, they are visible if the skin is tightly 
drawn. They are certainly not common in this country; and although I 



RHEUMATISM. 1145 

have made it a rule to examine rheumatic patients for them, I have seen 
them but seldom, and they have been prominent in only two or three 
cases. This, I think, has also been the experience of most observers in 
New York. From published reports, however, they appear to be much 
more frequent in England. There can be no doubt regarding the con- 
nection of these nodules with rheumatism. 

Erythema. — The connection between rheumatism and the various 
forms of erythema — marginatum, papulatum, and nodosum — has been 
very clearly shown by Cheadle. None of these are frequent conditions in 
childhood, but when seen they should always suggest rheumatism. 

Purpura. — The association of purpura with rheumatism is so often 
seen that there can be little doubt of the close connection between the 
two conditions. Rheumatic purpura, however, is quite distinct from the 
other forms of purpura, and is a much less frequent disease. 

Diagnosis. — In order to recognise rheumatism in a child, one must 
free his mind from preconceived notions of the disease drawn from its 
manifestations in adults, as very few cases correspond to the adult type of 
acute rheumatism. In early life the disease is recognised not by any one 
or two special symptoms, but by the association or combination of a num- 
ber of conditions which may appear unrelated. In determining whether 
or not any given set of symptoms is due to rheumatism, one should con- 
sider : (1) The family history, since in early life heredity is so important 
an etiological factor; (2) the previous history of the patient, not only as 
regards articular pains and swelling, the slight joint-stiffness without 
swelling, the indefinite wandering pains of damp weather, and the so-called 
growing pains, but also the previous existence of chorea, frequent attacks 
of tonsillitis, torticollis, or erythema ; (3) the examination of the patient, 
which should include a careful search for tendinous nodules, as well as a 
thorough examination of the heart for signs of endocarditis or pericar- 
ditis, and, in cases which are at all acute, the temperature. In doubtful 
cases with mon-articular symptoms much importance is to be attached 
to the presence of slight fever, the abrupt onset, and tenderness of the 
neighbouring muscles and tendons, — all occurring without a history of 
traumatism. Rheumatism is more often overlooked than confounded 
with other diseases ; although in childhood multiple neuritis and tubercu- 
loid and syphilitic hone disease are often mistaken for it, and in infancy 
the same is true of sourvy. The extreme infrequency of rheumatism 
during the first two years of life should always make one skeptical regard- 
ing it. In an infant, when the symptoms are confined to the legs and 
are not accompanied by fever, they are almost certain to be due to scurvy 
even though the gums are normal and ecchymoses haTO not yet appeared. 
Multiple gonococcua arthritis has often been diagnosticated rheumatism. 

Prognosis. — Rheumatism in a child is in itself seldom if ever danger- 
ous to life. In the grea.1 majority of cases the articular symptoms soon 



1146 OTHER GENERAL DISEASES. 

disappear, even without special treatment. The danger from the disease 
consists in its cardiac complications. One attack of rheumatism is almost 
certain to be followed by others, and when once the heart has been af- 
fected its lesions are likely to increase with each recurrence of the disease. 

Treatment. — Eheumatism in children derives its chief importance 
from its relation to cardiac disease. Cardiac complications are so fre- 
quent and so serious that everything possible should be done to avert 
rheumatism from those who by inheritance are especially predisposed to 
it, to prevent its recurrence in a child who has once had the disease, and 
during an attack to prevent the heart from becoming involved. The rela- 
tion of diet to rheumatism is very imperfectly understood; but it is cer- 
tainly a fact that rheumatic children do much better upon a diet com- 
posed largely of nitrogenous food, where starches are restricted in 
amount, than the reverse. Milk should be freely given in all cases. The 
underclothing should be of flannel during the entire year, in summer the 
lightest weight being worn. The feet should be carefully protected, and 
exposure in damp weather avoided. In-door occupations should be 
chosen for rheumatic boys. 

The tendency to recurrence is so strong in this disease that a child of 
rheumatic antecedents, who has shown in the various ways mentioned a 
marked predisposition to rheumatism, and who has had an attack, even 
though a mild one, should, if possible, spend the winter and spring in 
some warm, dry climate, or even remain there permanently. Otherwise in 
most such children, it is only a question of time when, with the repeated 
attacks, the heart will become involved. 

To avert the danger of cardiac complications during an attack of rheu- 
matism, or to limit their extent, there are two things which should invari- 
ably be insisted on : first, to confine to the house and in a warm room every 
child with rheumatic pains, no matter how mild ; secondly, if fever is also 
present, to keep the child in bed while it continues, even though it may 
never be above 100° F. Absolute rest and the equable temperature thus 
secured are unquestionably of more importance than anything else in pro- 
tecting the heart during a rheumatic attack. With these precautions must 
be combined an early diagnosis. In very many, perhaps in most cases, the 
harm is done before the true nature of the disease is suspected, the symp- 
toms being dismissed as of slight importance because the articular mani- 
festations are not very severe. Children who have once had rheumatism 
should be closely watched during chorea and other diseases related to 
rheumatism, the heart should be frequently examined, and the physician 
should be on the alert for the first articular symptoms. 

Aside from the measures just mentioned, the treatment of rheumatism 
in childhood is to be conducted very much like that of adult life. In the 
most acute attacks either salicylate of soda, oil of wintergreen, or salicin 
should be given ; as the majority of cases are not very acute, marked im- 
provement is by no means always obtained by these drugs. Alkalies 



DIABETES MELLITUS. 1147 

should be given in all cases, but particularly in those in which, there is 
hyperacidity of the urine. Either the acetate or citrate of potassium or 
the bicarbonate of sodium may be used, a sufficient quantity being admin- 
istered to render the urine alkaline. 

Quite as important as these drugs is the use of general tonics, particu- 
larly iron and cod-liver oil. These should be given not only between 
attacks to fortify patients against their recurrence, but also in subacute 
cases which are sometimes influenced very little or not at all either by 
salicylates or alkalies. 



CHAPTER II. 
DIABETES MELLITUS. 

In this chapter will be attempted only a description of the peculiar 
features which diabetes presents when affecting young patients. It is a 
very infrequent disease in children. Of 1,360 cases of diabetes collected 
by Pavy, only eight were under ten years of age. In a series of 700 cases 
collected by Prout, only one case was under ten years. In a series of 380 
cases collected by Meyer, only one case was under ten years of age. 

Etiology. — Stern, in a series of 117 collected cases of diabetes in chil- 
dren, states that 47 were females and 31 males, the sex in the other cases 
not being given. Although extremely rare, cases have been observed 
during the first two years, and even during the first year of life. Sta- 
tistics on this point are not altogether trustworthy, since some cases of 
temporary glycosuria have certainly been included. 

Among the etiological factors, heredity is one of the most important. 
Pavy reports the case of a child dying of diabetes at two years in whose 
family the disease had existed for three generations. Inherited gout, 
insanity, and nervous diseases generally, may be looked upon as factors 
in the production of diabetes. Several of the cases reported in children 
have been preceded by injuries received upon the head. In a number 
of my own cases the disease has followed the consumption of large quan- 
tity ■- of sugar for a long time. Often no adequate cause can be found. 

Symptoms. — The most important early symptoms are thirst, polyuria, 
and wasting; their development is often quite rapid. The thirst is in- 
tense, often leading children to drink four or five pints of fluid a day. The 
amount of urine passed varies from one to eight quarts daily. The specific 
gravity is from 1,026 to L,040, and the usual amount of sugar is from 
three to five per cent, rarely more. Albumin is not infrequently present. 
Incontinence of urine is an important symptom, and often one of the 
earlie-t to be noticed. Tin 4 wasting is usually quite rapid, so that a child 
may lose as much as six or eight pounds in a month. It is generally ac- 



1148 OTHER GENERAL DISEASES. 

companied by anaemia. The appetite may be poor ; at times, however, it 
is voracious. Other symptoms of less importance are a dry mouth, scanty 
perspiration, irregular sleep, occasional epistaxis, furuncles and abscesses, 
decayed teeth, and genital irritation. 

The course of the disease is much more rapid in children than in 
adults, and, as a rule, the younger the child the more rapid its progress. 
The majority of cases prove fatal in from two to four months from the 
time the symptoms are sufficiently marked to make the diagnosis possible. 
Very few last more than six months ; occasionally, however, one of the 
milder type may be prolonged from one to two years. 

The progress of the disease is marked by continuous wasting, which 
may result in a marked degree of marasmus, and prove fatal. Some are 
carried off by intercurrent pneumonia or tuberculosis, but the majority 
die comatose. When coma develops, the case may be considered hopeless, 
and death is likely to be postponed but a few days. The cause of diabetic 
coma has not yet been satisfactorily explained, but it is usually believed to 
be due to acetonaemia. 

Diagnosis. — Diabetes is apt to be overlooked, because of the common 
neglect of urinary examinations in children. The prominent symptoms — 
thirst, polyuria, and wasting — when associated, should always attract at- 
tention. Incontinence of urine, accompanied by marked wasting, is always 
suspicious. In some cases genital irritation may be the most prominent 
early symptom. A positive diagnosis is made only by an examination of 
the urine. 

Prognosis. — In few diseases is the prognosis so bad as in diabetes in 
children. So high an authority as Senator declares that diabetes in chil- 
dren is hopeless and all treatment is useless. From a study of seventy- 
seven cases, Stern reaches the same conclusion. There are, however, 
cases on record in which recovery is believed to have taken place. The 
cases which I have seen have all terminated unfavourably. In a given 
case the prognosis, as to the duration of the disease, is rendered much 
worse by the presence in the urine of diacetic and oxybutyric acids. 
This condition is even more serious than is a high percentage of sugar; 
that the patient will then live more than three months is highly im- 
probable. 

Treatment. — The indications for treatment are the same in children 
as in adults: first, diet; secondly, general hygienic measures; and, finally, 
the use of drugs, of which at the present time the favourites are codeine, 
salicylate of soda, and the bromide of arsenic. 



INDEX. 



Abdomen, examination of, 39 ; growth of, 
24 ; in rickets, lit..".. 

Abscess, alveolar, 279 ; cerebral, 780 ; 
symptoms, 781 ; treatment, 782 ; cere- 
bral, in acute otitis, 948 ; ischio-rectal, 
457 ; mammary, 11G ; hepatic, 460 ; peri- 
toneal, 407 ; peritonsillar, 310 ; peri- 
typhlic (see appendicitis), 439; psoas, 
in spinal caries, 906 ; retro-oesophageal, 
316; retro-pharyngeal, in Pott's disease, 
298. 906 ; retro-pharyngeal, of infancy, 
295 : subphrenic, 477. 

Abscess, multiple, in malignant endocar- 
ditis. 626 : multiple, in newly born, 85. 

Acetonemia in diabetes mellitus, 1148. 
nuria, 651. 

Achondroplasia (see Chondrodystrophy), 
810. 

Acid, hydrochloric, increased by lavage, 
hydrochloric, in gastroenteric in- 
toxication, -"-Tit: hydrochloric, in stom- 
ach digestion, 320; lactic In stomach 
digestion, 320. 

Adenie (sec HODQKIIf'S DlSBASfi), 805. 

Adenitis, acute, 831 : acute axillary, 
S85 : acute cervical", 885 : acute In- 
guinal, 885 : cervical, in diphtheria, 
louT : Id Influenza, 1125; In measles, 
969; retro-cesophageal, 316; retro- 
pharyngeal, 295; simple acute, sv -"> i 
simple chronic, B86; ayphllitic, 887; 
tuberculous, 888 ; treatment, 893. 

Adenoid vegetations of pharynx, 290, 481 ; 
symptoms, 301 : treatment, 303; asthma 
from, 524 ; causing acute nasal catarrh, 
• s ' ; chronic laryngitis with, 508 i in 
rickets, 268; removal advised in tuber- 
culous adenitis, 894 ; with adenitis, 887. 

Adenoma <>f umbilicus, 114. 

Agenesis, cortical, 7no. 

Airing, when allowed out of doors, 8. 

Air space required by Infants, 10. 

Alalia. 7 10. 

Albinism, stigma of degeneration, 81R. 
Albumin water, preparation of. 887. 
Albuminuria, functional or cyclic, 644 j In 

chronic cardiac disease. 630: In chronic 

nephritis. »;<;!»; | E influenza, 1128; In 



in pertussis. 1010 ; in 
967 ; in typhoid fever, 



measles, 988 
scarlet fever, 
1066. 

Alcohol, as stimulant, 51 ; as tonic, 52 ; 
effect on breast milk, 174 ; use of, in 
diet of nurse, 138. 

Amaurotic family idiocy, 807. 

Amyloid degeneration, in chronic bone dis- 
ease, 902 ; of the intestines, 410 ; of the 
liver, 410 : of the spleen, 410. 

Anaemia, cardiac murmurs in, 637 ; follow- 
ing diphtheria, 1029 : pernicious, 865 ; 
pseudo-leukaemic. of infancy, 863 ; treat- 
ment, 867 : simple. 860 : treatment, 867 ; 
with adenoids, 303 : in malaria, 1137 ; 
in malnutrition, 232 ; in marasmus, 
241 : in rheumatism. 1144 : in rickets, 
267 : in scurvy, 248 ; in tuberculosis, 
1096 : preceding tuberculosis, 1089. 

Anaesthesia, partial, in multiple neuritis, 
849. 

Anaesthetics, those best for children, 68. 

Anasarca, general, in acute diffuse nephri- 
tis, 664 : in chronic cardiac disease, 630. 

Aneurism, 639. 

Angina, catarrhal, in measles, 986; in 
scarlet fever, 964. 

Anglo-Swiss food, 166. 

Ankle, enlarged epiphyses in rickets, 264. 

Anodynes. 53. 

Antipyretic drugs, 50. 

Antipyretics, 48 ; in acute broncho-pneu- 
monia. 559. 

Antlpyrine, in chorea, 727 ; in catarrhal 
croup, 491 : in pertussis, 1014; scarla- 
tlnlform rash from, 971. 

Antitoxin, in the treatment of tetanus. 92: 
eliminated by human milk. 189; results 
without, in membranous laryngitis, 497 : 

with, lor,:: (see Diphtheria Anti- 
toxin} i streptococcus, 1062. 

Anuria. 652 

Anus, fissure of the. 454 : imperforate, 
117. 

Aorta, abnormal origin of, 612; aneurism 
of. 639 : atheroma of, 639 ; congenital 
narrowing of. In chlorosis. 862; hypo- 
plasia of. 639 ; thrombosis of, 640. 



1149 



1150 



INDEX. 



Aortic insufficiency, 633 ; stenosis, 632. 

Aphasia, functional, 740 ; in acquired 
cerebral paralysis, 802 ; after typhoid 
fever, 1077 ; motor, in cerebral tumour, 
.785, 786. 

Aphonia, hysterical, 735 ; in diphtheritic 
paralysis, 852. 

Appendicitis, 438 ; lesions, 438 ; symp- 
toms, 440 ; diagnosis, 443 ; leucocyte 
count an aid in, 444 ; treatment, 444. 

Arm, paralysis of, at birth, 111. 

Arnold sterilizer, 156. 

Arsenic, as a tonic, 52 ; dosage in chorea, 
727. 

Arteries, hypogastric, in fcetal circulation, 
606 ; hypoplasia of, 639 ; umbilical, in 
foetal circulation, 606. 

Arthritis, acute, of infants, 899 ; acute 
suppurative, syphilitic, 916 ; gonococcus, 
686, 691, 899 ; rheumatic, 664. 

Arthrogryposis (see Tetany), 716. 

Artificial feeding, 182 ; versus wet-nurs- 
ing, 170. 

Ascaris lumbricoides (see Worms, Intes- 
tinal), 448. 

Ascites, 476 ; detection of, 476 ; chylous, 
476 ; in acute diffuse nephritis, 664 ; in 
cirrhosis of liver, 462 ; rare with amy- 
loid liver, 463 ; with chronic peritonitis, 
469 ; with tuberculosis of the perito- 
naeum, 471. 

Asphyxia, death from, in young children, 
46 ; from overlying, 44 ; from aspiration 
of food, 45 ; from enlarged thymus, 45 ; 
in convulsions, 706 ; in retro-pharyngeal 
abscess, 297 ; in the newly born, 69 ; 
from tuberculous bronchial lymph 
nodes, 1102 ; methods of resuscitation, 
72 ; sudden, from tongue-swallowing, 
278 ; sudden, in retro-oesophageal ab- 
scess, 317. 

Aspiration of chest in empyema, 602. 

Asthma, 523 ; etiology, 524 ; symptoms, 
524 ; diagnosis, 526 ; prognosis, 526 ; 
treatment, 526 ; catarrhal, 525 ; with 
adenoids, 302 ; long uvula, cause of, 
295 ; simulated by tuberculous bronchial 
glands, 1101. 

Astigmatism, stigma of degeneration, 819. 

Ataxia, Friedreich's, 841 ; in multiple 
neuritis, 849. 

Atelectasis, acquired, 588 ; from compres- 
sion, 588 ; from obstruction, 588 ; in 
delicate infants, 589 ; causing sudden 
death, 45 ; congenital, 74 ; in marasmus, 
239. 

Atheroma, 639. 

Athetoid movements, 728 ; in acquired 
cerebral paralysis, 802 ; in birth para- 
lysis, 799. 

Athetosis, 728. 

Athrepsia (see Marasmus), 238. 

Atomizer, 57, 61. 



Atresia ani, 352. 

Atrophy, infantile (see Marasmus), 238; 
muscular, facial type, 846 ; in multiple 
neuritis, 849 ; juvenile form, 846 ; pro- 
gressive muscular, hand type, 843 ; 
peroneal type, 844. 

Atropine, hypodermically in cholera in- 
fantum, 384. 

Aura of epilepsy, 710. 

Autopsies, principal lesions found in, 41. 



Babcock's centrifugal machine, 147. 

Bacillus of diphtheria, 1020, 1041 ; dis- 
tribution in the body, 1023 ; in milk, 
142 ; in healthy throats, 1042 ; in laryn- 
geal diphtheria, 495 ; non-virulent, 
1042; of dysentery (Shiga) in ileo- 
colitis, acute, 385 ; in gastro-intestinal 
intoxication, acute, 365 ; of Eberth, in 
typhoid fever, 1062 ; of Friedlander, in 
acute broncho-pneumonia, 532 ; Klebs- 
Loeffler (see B. Diphtheria), 1020; 
lactis aerogenes, 322 ; of Pfeiffer, in in- 
fluenza, 1123 ; pseudo-diphtheria, 1042 ; 
of tuberculosis, 1070 ; in acute broncho- 
pneumonia, 533 ; in empyema, 597 ; 
paths of infection, 1074. 

Backwardness, 808. 

Bacteria, etiology of diarrhoea, 365 ; in 
human milk, 139 ; in cow's milk, 141- 
146, 153, 157 ; means of excluding from 
cow's milk, 145 ; intestinal, 322. 

Bacterium coli commune, 322 ; in appen- 
dicitis, 438 ; in gastro-enteric intoxica- 
tion, 368 ; in peritonitis, 466. 

Bacterium lactis aerogenes, 322. 

Balanitis, 686. 

Band, abdominal, 1, 3. 

Barley water, directions for making, 165 ; 
use during first year, 206. 

Barlow's disease (see Scorbutus), 244. 

Bath, at birth, 1, 2 ; cold, 50 ; in acute 
broncho-pneumonia, 559 ; in asphyxia of 
newly born, 72 ; evaporation, 50 ; hot, 
56 ; hot air, 56 ; vapour, 56 ; mustard, 
56 ; bran, 57 ; tepid, 57 ; shower, 57 ; 
cold sponge, 57 ; hot, in asphyxia, of 
newly born, 72 ; in typhoid fever, 1070. 

Bed-wetting, 692. 

Beef, broth, 164 ; extracts, 163 ; juice, ex- 
pressed, 163 ; juice, without cooking, 
163 ; preparations of, 163 ; raw scraped, 
164. 

Belladonna, 53 ; elimination of, in milk, 
139 ; scarlatiniform rash, 971. 

Bile, physiological action of, 321. 

Bile-ducts, congenital malformations of, 
77. 

Birth paralyses, 107 ; cerebral, 107 ; 
spinal, 107 : peripheral, 107. 

Bladder, control acquired, 693 ; exstrophy 
of, 685 ; haemorrhage from, in newly 



INDEX. 



1151 



born, 105 ; stone in, 698 ; training to 
control, 4. 

Bleeders, 870. 

Blindness, hysterical, 734 ; stigma of de- 
generation, 819 ; transient, in pertussis, 
1010. 

Blisters, 54. 

Blood, circulation of, in early life, 606 ; 
corpuscles, red, 856 ; corpuscles, white. 
857 ; diseases of, 856 ; haemoglobin, 
856 ; in chlorosis, 863 ; in diphtheria, 
1029 ; in empyema, 600, 859 ; in leukae- 
mia, 869 ; in measles, 988 ; in pernicious 
anaemia, 866 : in pertussis, 1011 : in 
pneumonia, 859 ; in pseudo-leukaemic 
anaemia, 864 ; in scarlatina, 969 ; in 
simple anaemia, 861 ; leucocytes of, 
varieties of, 857 : leucocytosis, 858 ; 
Plasmodium malariae in, 1137 : specific 
gravity, 856 : blood letting, local, 55. 

Blood-vessels, diseases of, 639 : aneurism, 
639 ;. arterial hypoplasia, 639 ; athe- 
roma, 639 ; embolism, 640 ; thrombosis, 
640. 

Boil (see Furunculosis), 935. 

Bone-marrow in leukaemia, 868. 

Bones, diseases of, 899 ; in hereditary 
syphilis, 1109 : in late syphilis, 1117 ; 
lesions of, in rickets, 254 ; microscopical 
changes of, in rickets, 255 ; syphilitic 
diseases of, 915 ; tuberculous diseases 
of, 900 ; etiology. 901 ; lesions, 901. 

Bothrioeephalus latus, 447. 

Bottles, nursing, choice and care of, 204. 

Bowels, haemorrhages from (see II.kmok- 
bhaqe, Intestinal) ; movements of, 
i i regularity in times for, 424 ; training 
to control movements, i. 

Bow-k'Ks in rickets, 263. 

Bradycardia, 638. 

Brain, discuses of, 7 17: abscess of. 780; 
atrophy and sclerosis of, 7'.»7 ; atrophy 
and sclerosis of, in acquired cerebral 
paralysis, 800; cysts <>f. in Infantile 
cerebral paralysis, 7'.»7 ; malformations 

of. 747; tuberculosis of, 1085; tumour 

of. 7^.;: trater on the, 770 ; weight of, 

I', ran bath, .".7. 

Breast, abscess "f, in newly born, 116. 

Breasl feeding, 171; schedule for, 1 tj. 

Breast milk (see Milk, Woman's). 

Breath, offensive, in ulcerative stomatitis, 
j^ i. 

Breathing, noisy, with adenoids, 801 : 
Btrldulous, in diseases "i the larynx, 
100, 108, 196 : in retro oesophageal ab- 

1 1 1 7 . 

Brlght's disease (see Nsphbitis), 660. 
Bromides, elimination of. in milk, 189. 

Bronchi, catarrhal spasm of, 526 : diph- 
theria of. 1025; foreign bodies in. 508; 

lesions of. In acute broncho pneumonia, 



533 ; lymph nodes of, in tuberculosis, 
1074. 1082 ; tube casts of, 521. 

Bronchial glands (see also Lymph Nodes, 
Bronchial), enlarged, cause of asthma, 
524 ; in acute broncho-pneumonia, 540 ; 
reflex cough from, 523. 

Bronchitis, acute catarrhal, 512 ; symp- 
toms, 513 ; diagnosis, 515 ; treatment, 
516 ; prophylaxis, 516 ; asthma follow- 
ing, 525 ; capillary (see Broncho- 
pneumonia, Acute), 531, 542; attacks 
of asthma resembling, 524 ; chronic, 
521 ; etiology, 521 ; symptoms, 521 ; 
diagnosis, 522 ; treatment, 522 ; chronic, 
bronchiectasis in, 522 ; chronic, in 
rickets, 258 ; diphtheritic, broncho-pneu- 
monia in, 552 ; fibrinous, 520 ; treat- 
ment, 520 ; in pertussis, 1009 ; in 
typhoid fever, 1066; spasmodic (see 
Asthma), 523. 

Bronchiectasis in chronic bronchitis, 522 ; 
in broncho-pneumonia, chronic, 582. 

Broncho-pneumonia, acute, 531 ; bacteri- 
ology, 532 ; complications, 553 ; com- 
plicating influenza, 1126 ; diphtheria, 
1028 ; measles, 985 ; pertussis, 1009 ; 
pseudo-diphtheria, 1060 ; rickets, 258 ; 
diagnosis, 554 ; etiology, 531 ; lesions, 
533 ; associated, in the lung, 540 ; 
physical signs, chart of, 548 ; protracted 
or persistent form, 550 ; secondary 
pneumonia with measles, 552 ; ileo- 
colitis, 553 ; influenza, 553 ; pertussis, 
551 ; diphtheria, 552 ; prognosis, 555 ; 
protracted cases, 550 ; symptoms, 541 ; 
temperature charts of, 545 ; termina- 
tions, 539 ; treatment, 557 ; prophylaxis, 
557 ; summary of, 561. 

Broncho-pneumonia, chronic, 582 ; lesions, 
583 ; symptoms, 583 ; physical signs, 
58 1 ; treatment, 585. 

Broncho - pneumonia, tuberculous, 1077, 
1090 ; rapid cases, 1091 ; protracted 
cases, ll<)2 (see also Tuberculous 
Pneumonia). 

Broths, directions for making, 164. 
Bubo, with gonorrhoea! urethritis, 686. 
Buhl's disease, <.).;. 
Buttermilk, 162. 

Calamine lotion. 938. 

Calculi, biliary. 4<>4 ; renal, 677; pyelitis 

with, 678 : vesical, 698. 
Calomel Fumigations, 497. 

Calomel, how best given, 48. 

Calories, required daily by healthy in- 
fants. 182; method of calculating, 182; 
value of different food stuffs in. 129. 

Cancrum oris (see Stomatitis, can- 

0BBNOU8), 290. 
Carbohydrates, function of, in diet, 127. 
Carcinoma of brain, 783; of kiduey, 671; 

of stomach, 850. 



1152 



INDEX. 



Cardiac cough, 523. 

Carnrick's soluble food, 166. 

Casein, 149, 185 ; in the faeces, 323 ; stools 
in difficult digestion of, 415. 

Caseinogen, 149. 

Casts in urine of chronic nephritis, 668. 

Catarrh, Eustachian, in hypertrophy of 
tonsils, 312 ; foetid (see Rhinitis, 
Atrophic), 485; gastric, 340; nasal 
acute, 478 ; prophylaxis, 480 ; chronic, 

481 ; with adenoid growths, 301 ; for- 
eign bodies in nose, 481 ; nasal polypi, 

482 ; rhinitis, simple chronic, 482 ; hy- 
pertrophic, 484 ; atrophic, 485 ; syph- 
ilitic, 485 ; rhino-pharyngeal, with ade- 
noids, 301. 

Catheters, sizes required for infants, 642. 

Cellulitis of abdominal wall with perito- 
nitis, 466 ; of neck, in scarlet fever, 
965. 

Centrifugal machine, 135, 147. 

Cephalhaematoma, external, 97 ; internal, 
97 ; symptoms, 98 ; diagnosis, 98 ; treat- 
ment, 99. 

Cereals, 165 ; allowed from third to sixth 
year, 222. 

Cerebellum, abscess of, 780 ; tumours, 783. 

Cerebral paralysis, 795 ; from haemor- 
rhage, 107 ; etiology, 107 ; lesions, 108 ; 
symptoms, 109 ; prognosis, 110 ; treat- 
ment, 110. 

Cerebro-spinal meningitis (see Menin- 
gitis, Acute Cerebro-spinal), 754. 

Cerebrum, abscess of, 780 ; tumour, 783. 

Chest, circumference of, 20 ; development 
of, 24 ; " funnel " chest, 24 ; in rickets, 
261 ; lateral depressions of, in adenoids, 
301 ; lateral furrowing of, in rickets, 
258. 

Cheyne-Stokes respiration in cerebro-spinal 
meningitis, 762 ; in tuberculous menin- 
gitis, 773. 

Chicken-pox (see Varicella), 996. 

Chloral, dosage and administration, 53. 

Chlorosis, 862 ; etiology, 862 ; lesions, 
862 ; symptoms, 863 ; blood in, 863 ; 
prognosis, 863 ; diagnosis, 863 ; treat- 
ment, 867. 

Cholera infantum, 364 (see also Intoxi- 
cation,, Acute Gastro-enteric), 381. 

Chondro-dystrophy, 810. 

Chorea, 721 ; acute endocarditis in, 624 ; 
diagnosis, 725 ; endocarditis in, 725 ; 
etiology, 721 ; following birth paralysis, 
799 ; typhoid fever, 1067 ; habit, 727 ; 
heart murmurs in, 725 ; prognosis of, 
726 ; hysterical, 735 ; with adenoids, 
302 ; in rheumatism, 1144 ; pathology, 
723 ; post-hemiplegic, 729 ; in cerebral 
palsy, 799 ; prognosis, 726 ; relation to 
rheumatism, 722 ; speech in, 725, 740 ; 
symptoms, 724 ; treatment, 726 ; urine 
in, 725. 



Circulation, changes in, at birth, 606 ; 
foetal, 606 ; in early life, 606. 

Circulatory system, diseases of the, 606. 

Citrate of Soda, use of, with difficult feed- 
ing cases, 211. 

Claw-hand, 843. 

Cleft palate, 274. 

Clothing at birth, 2 ; in summer, 3 ; at 
night, 3 ; in summer diarrhoea, 375. 

Club-foot with spina bifida, 822. 

Codeine, doses of, 53. 

Cod-liver oil as tonic, 52. 

Cold, as an antipyretic, 49 ; ice cap, 49 ; 
sponging, 49 ; pack, 49 ; bath, 50 ; irri- 
gation of the colon, 50 ; in the head, 
with adenoids, 301 ; therapeutics of, 55.. 

Cold sores, 275. 

Colic, habitual, from excessive proteids,. 
203 ; intestinal, 420 ; renal, 678. 

Colitis, acute (see Ileo-colitis, Acute),. 
385 ; amoebic, 409 ; membranous, 398 ;. 
membranous gastritis with, 339. 

Collapse, in acute broncho-pneumonia, 
treatment of, 500 ; in acute peritonitis, 
467 ; in appendicitis, 442 ; in corrosive 
gastritis, 341 ; in ulcer of stomach, 350. 

Collapse, pulmonary (see Atelectasis,, 
Acquired), 588. 

Colles's law, 1108. 

Colon, abnormal position of, 353 ; con- 
genital atresia of, 117 ; cysts of mucosa, 
405 ; dilatation of, 428 ; in rickets, 265 ; 
follicular ulcers of, 389 ; hypertrophy 
of, 428 ; irrigation of, 50, 65 ; in gastro- 
enteric intoxication, 378 ; in intestinal 
indigestion, 419 ; membranous inflam- 
mation of, 391 ; transverse, dilatation 
of, in chronic ileo-colitis, 407 

Colostrum, 130 ; corpuscles of, 130 ; com- 
position of, 130. 

Coma, in tuberculous meningitis, 773 ; in. 
diabetes mellitus, 1148. 

Compression-myelitis (see Myelitis), 829.. 

Condensed milk, cause of rickets, 251 ; 
composition of, 159 ; dilution of, for in- 
fants, 159 ; fresh, 159. 

Congenital, ichthyosis, 923 ; myotonia,. 
730 ; rickets, 258 ; syphilis, 1112 ; tuber- 
culosis, 1072. 

Conjunctiva, catarrhal inflammation in 
measles, 982 ; haemorrhage from, in 
newly born, 106. 

Constipation, a cause of chlorosis, 862 ; 
causes of, in rickets, 265 ; chronic, 422 ;: 
dilatation of colon in, 428 ; anal fissure 
from, 454 ; early symptom of rickets, 
259 ; from deficient fat in food, 201 ;. 
in appendicitis, 440 ; in intestinal indi- 
gestion, chronic, 414, 416 ; in intus- 
susception, 434. 

Contractures, hysterical, 734. 

Convulsions, 701 ; symptoms, 703 ; diag- 
nosis, 704 ; prognosis, 706 ; treatment,. 



INDEX. 



1153 



706 ; attributed to dentition, 280 ; caus- 
ing death without other symptoms, 46 ; 
chloral in, 707 : epileptic, 710 : hyster- 
ical, 735 : in acquired cerebral para- 
lysis, 801 : in cerebral haemorrhages, 
109 ; in congenital atelectasis. 75 : in 
pertussis, 1010 : in rickets, 207 ; mor- 
phine in, 707 ; in status lymphaticus, 
881. 

Cooley creamer. 152. 

Cord, spinal, diseases of, 820 ; malforma- 
tions of, 820 ; position of, 826 ; menin- 
gitis, 826 : myelitis, 827 ; pressure- 
paralysis of, 829 ; tumours of, 839 ; 
weight of, 699. 

Cord, umbilical, care of, 1 ; separation 
of, 2. 

Cornea, ulcers of, in chronic ileo-colitis, 
407. 

Corpuscles of blood, 856. 

Coryza, 478 ; early symptom of measles, 
980; syphilitic. 485, 1113. 

Cough, hysterical, 735: reflex. 522; from 
pharyngeal irritation, 522 ; elongated 
uvula, 522 : from pharyngeal mucus, 
522 : from aural irritation, 522 ; from 
cardiac disease, 523 : of puberty, 523 ; 
periodical, at night, 523 ; from Pott's 
disease, 523 : symptoms, 523 ; diag- 
nosis, 52:: : treatment, 523 ; spasmodic, 
in retro-eesophageal abscess, 317 ; in 
tuberculous bronchial glands, 1111 ; 
whooping (sec Pertussis), 1004. 
'Counter-irritants, 54. 

Cow's tnilk I Bee Mii.k ). 

Cranio-tabes, early symptom in rickets, 259. 

Cranium, syphilitic nodes <>n. 920. 

Cream, 150; to secure different percerit- 
ages <>\. i.". i . 152. 

< 'i'M in gauge, l 35, l 18. 

Crede's method of preventing ophthalmia 
neonatorum, i ; treatment <>i" ophthal- 
mia, 88 

Cretinism, sporadic, 813. 

Croup, bronchial, 520; catarrhal, 189; 
keti ie, 80 : membranous, 105 ; mem- 
branous, iu Bcarlel fever, 985; spas- 
modic, 489 : true, 495. 

Cry, causes ami varieties of. .". i ; In dis- 
: i : in colic, 121 ; iu retro- 
pharyngeal abscess, 298. 

( Iryptorcbidlsm, 685. 

cups, dry, Indicatloni for, 55; wet, con- 
demned, 55. 

Curds and u bey, 1 <'>2. 

Cyanosis. in acute broncho pneumonia. 
541, 548 ; in acute inanition. 228 : in 

chronic cardiac disease, 880; In congen- 
ital atelectasis, 7~> \ In congenital die 
ease of heart. 81 8 i In dlphtherH Ic pa 
ralysls, 852 ; In malaria, i i;;::. i i::«; ; 
of race, from pressure at root ,,f lung, 
l L02. 



Cyclic vomiting, 331. 

Cyst, of brain, 783 ; of brain in infantile 

cerebral paralysis, 797 ; of intestinal 

mucosa, 405. 
Cysticercus, 446. 

Dactylitis, scrofulous, 913 ; syphilitic, 
922 ; tuberculous, 913. 

Deaf-mutism, 819 ; stigma of degenera- 
tion, 819. 

Deafness following mumps, 1018 : with 
adenoids, 301 ; with hypertrophy of ton- 
sils, 312 ; sudden, in late syphilis, 1117. 

Death, most frequent causes of, at differ- 
ent ages, 43 ; sudden, causes of, 44. 

Deformities, hysterical, 734 ; in rickets, 
259. 

Degeneration, stigmata of, 818. 

Deltoid, paralysis of, at birth, 111. 

Dentition, 27 ; eruption of first teeth, 28 ; 
eruption of permanent teeth, 29 ; de- 
layed, 28 ; before birth, 28 ; difficult, 
279 ; in rickets, 266 ; in the etiology of 
diarrhcea, 356 ; often delayed in malnu- 
trition, 232. 

Dermatitis, exfoliative, of newly born, 
922 ; gangrenous, 936. 

Development, conditions interfering with, 
30 ; muscular, 25 ; of body, 15. 

Dew's method of inducing artificial res- 
piration, 72. 

Dextro-cardia, 613. 

Diabetes insipidus, 652. 

Diabetes mellitus, 1147. 

Diacetonuria, 651 . 

Diagnosis, general considerations in, 31. 

Diapers, 3. 

Diaphragm, hernia through, 118. 

Diarrhcea, general consideration of, 354 ; 
deaths from in New York in five years, 
354 ; prevalence during summer, 355 ; 
impure milk as a cause, 356 ; observa- 
tions of Rockefeller Institute on asso- 
ciation of feeding Impure milk and 
diarrhoea! disease, ^56 et scq. ; differ- 
ent varieties of, 359 ; inflammatory (see 
[lbo-colitis, Acute), 385; In chronic 
intestinal indigestion. 414; in intestinal 
tuberculosis, 412; summer, 364; my- 
cotic, 364. 

Diastatlc ferment of pancreas, 321; of 

bile, 321. 

Diathesis, lymphatic, with adenoids, 300. 

Diet i see also FEEDING), as cause of 

chronic constipation, 423; cause of 

rickets. 251 ; in acute gastroenteric in- 
fection. 375; i n acute gastric indiges- 
tion, .",::7 : in chronic constipation, 12 1; 
in chronic gastric Indigestion, 346; in 
eczema, !>27 ; In intestinal indigestion, 
418; in malnutrition. 235; in rickets, 
271 : in scurvy, 251 ; of nurse, effect on 
milk. 138. 



1154 



INDEX. 



Dietary of the infant, 129. 

Digestion, gastric, 319 ; duration of, 320 ; 
in infancy, 318 ; intestinal, 321. 

Digestive system, diseases of the, 274. 

Digitalis, dosage for infant, 683. 

Dilatation of the stomach, 347. 

Diphtheria, 1019 ; bacillus (see Bacillus 
of Diphtheria), 1020; broncho-pneu- 
monia in, 552, 1028, 1036 ; blood in, 

1029 ; cardiac failure in, 1035 ; cardiac 
thrombi in, 1028 ; catarrhal, 1023, 

1030 ; complications and sequelae, 1036 ; 
croupous bronchitis in, 520 ; diagnosis, 
1038 ; bacteriological, 1041 ; clinical, 
1038 : from pseudo-diphtheria, 1040 ; 
disinfection after, 1047 ; distribution 
and mode of communication, 1020 ; en- 
tero-colitis in, 1038 ; etiology, 1020 ; 
immunization, 1045 ; incubation, 1022 ; 
lesions, 1022 ; membrane, 1023 ; mem- 
branous gastritis in, 339 ; proctitis in, 
455 ; myocarditis in, 636, 1037 ; nasal 
syringing in, 1048 ; nephritis in, 1028, 
1037 ; of oesophagus, 315 ; otitis in, 
1036 ; paralysis after, 1034 ; paralysis 
in, 851 ; prognosis, 1043 ; prophylaxis, 
1044 ; quarantine, 1044 ; septicaemia in, 
1035 ; simulated after tonsillotomy, 
314 ; symptoms, 1029 ; thrombosis in, 
1037 ; toxins of, 1023 ; treatment, 
1047 ; local, 1048 ; serum, 1049 ; of 
children exposed, 1045 ; of suspected 
cases, 1045 ; supplementary to anti- 
toxin, 1056 ; false (see Pseudo-Diph- 
theria), 1056; laryngeal, 495, 1033; 
nasal, 1030, 1032 ; pseudo (see Pseudo- 
Diphtheria), 1020, 1056; scarlatinal 
(see Pseudo-Diphtheria), 1056; scar- 
latinal, 965 ; scarlatiniform erythema 
in, 971 ; streptococcus (see Pseudo- 
Diphtheria), 1056; tonsillar, 1030. 

Diphtheria antitoxin, dosage of, 1050 ; 
immunizing dose of, 1046 ; influence on 
mortality of cities, 1054 ; local and 
general effects of,' 1051 ; other treat- 
ment with, 1047, 1055 ; real and alleged 
dangers from, 1052 ; strength of, 1050 ; 
time of administration, 1050. 

Diplegia, in birth paralysis, 798 ; in 
meningeal haemorrhage, 109 ; spastic, 
795. 

Disease, peculiarities of, in children, 30 ; 
etiology, 30 ; symptomatology and diag- 
nosis, 31 ; pathology, 40 ; prognosis, 42 ; 
prophylaxis, 46 ; therapeutics, 47. 

Diverticulum, Meckel's, 114. 

Dover's powder, dosage of, 53. 

Dropsy (see also (Edema) ; in acute dif- 
fuse nephritis, 662, 663 ; in chronic car- 
diac disease, 630 ; in chronic nephritis, 
668 ; in newly born, 120 ; in tuber- 
culosis, 1095 ; without renal disease, 



Drugs, administration of, 48 ; antipyretics, 
50 ; elimination of, in breast milk, 139 ; 
well borne, 54 ; not well borne, 54. 

Duct, omphalo-mesenteric, 114, 118. 

Ductus arteriosus, closure of, 606 ; in 
foetal circulation, 606 ; patent, 612 ; 
venosus, closure of, 606 ; in foetal cir- 
culation, 606. 

Duodenum, catarrhal inflammation of, 
341 ; congenital atresia of, 117. 

Dura mater, haematoma of, 751 ; throm- 
bosis of the sinuses of, 778. 

Dysentery (see Ileo-colitis., Acute), 
385. 

Dysphagia, hysterical, 735 ; in retro- 
pharyngeal abscess, 296. 

Dyspnoea, evidence of, 36 ; from tubercu- 
lous bronchial lymph nodes, 1102 ; in 
acute catarrhal laryngitis, 493 ; in ca- 
tarrhal spasm of larynx, 490 ; in mem- 
branous laryngitis, 496 ; in chronic car- 
diac disease, 629 ; in retro-pharyngeal 
abscess, 296 ; inspiratory, in retr- 
oesophageal abscess, 317 ; pressure of 
abscess on pneumogastric, 317 ; spas- 
modic, in asthma, 524. 



Ear, anomalies of, as stigmata of degen- 
eration, 818 : haemorrhage from, in 
newly born, 106 ; middle, inflammation 
of (see Otitis), 943; in measles 987; 
in scarlet fever, 966. 

Ears, development of hearing, 26. 

Eberth's bacillus of typhoid fever, 1062. 

Ecchymoses in purpura, 874 ; in scurvy, 
245 ; in leukaemia, 869. 

Echinococcus of liver, 464. 

Eclampsia (see Convulsions), 701. 

Ecthyma gangrenosa, 936. 

Ectocardia, 613. 

Eczema, 926 ; etiology, 926 ; diagnosis, 
930 ; treatment, 931 ; exacerbations 
during dentition, 280 ; intertrigo, 929 ; 
pustular, of scalp, 929 ; rubrum, 928 ; 
seborrhoeic, 926, 929 ; simple chronic, 
928. 

Electrotherm, 12. 

Emboli, infectious, in malignant endo- 
carditis, 626. 

Embolism, 640 ; in diphtheria, 1037. 

Emphysema, 589 ; symptoms, 591 ; acute, 
in bronchitis of infants, 513 ; in acute 
broncho-pneumonia, 541 ; in pertussis, 
1009. 

Empyema, 596 ; lesions, 597 ; symptoms, 
599 ; diagnosis, 600 ; treatment, 602 ; 
tuberculous, 1077 ; in acute broncho- 
pneumonia, 540. 

Encephalocele, 747 ; symptoms, 748 ; 
treatment, 749. 

Endarteritis, syphilitic, of brain, 1111 ; 
tuberculous, 770. 



INDEX. 



1155 



Endocarditis, acute simple, 622 ; lesions, 
023 ; symptoms, 624 ; treatment, 625 ; 
acute simple, in chorea, 624 : chronic 
(see also Heart, Valvular Disease), 
627 ; foetal, 610 ; in chorea, 725 ; in 
rheumatism, 1143 ; malignant, 626. 

Enemata, 67 ; nutrient. 67 ; drugs by, 67 ; 
astringent, in chronic ileo-colitis, 408 ; 
in chronic constipation, 426 : in colic, 
422 : ice-water in cholera infantum, 
384 ; injuries to rectum from, 454. 

Enteritis follicularis (see Ileo-colitis, 
Acute), 385. 

Enterocolitis, in diphtheria, 1038 (see 
Ileo-colitis, Acute), 385. 

Enuresis, 692 : symptoms, 694 ; treat- 
ment. 694 ; stigma of degeneration, 819. 

Ependymitis, acute, in hydrocephalus, 
7<>l : following spina bifida, 825. 

Epidemic, haemoglobinuria, 92 : menin- 
gitis (see Meningitis, Acute). 

Epidermis, exfoliation of, in congenital 
ichthyosis, 924 ; exfoliation of, in newly 
born. 922. 

Epilepsy, 708 : diagnosis, 713 ; hysterical, 
7.;.~> : idiopathic, 708 : in acquired cere- 
bral paralysis, 802 ; in birth paralysis, 
798 : insanity following, 806 ; intestinal 
putrefaction in, 709 ; Jacksonian, in 
cerebral tumour, 784 ; mental condition 
in, 712: pathology, 709; prognosis, 
713 ; status epilepticus, 713 ; stigma of 
degeneration. 819 ; symptomatic, 712 ; 
symptoms, 710; treatment, 714. 

Epiphyseal separation in acute arthri- 
tis, 899 ; in scurvy, 248 ; in syphilis, 
915. 

Epiphyses, enlargement of, in rickets, 
263 . in syphilis. 917, 921. 

Epiphysitis, acute (see Arthritis, 
Acute), 899; syphilitic, 905, 1115. 

Epispadias, 684. 

Epistaxls, 487 : in ana?mia, 861 ; in per- 
tussis. 1008; in purpura, 874; in 
scurvy. L'JV 

Epltrochlear lymph nodes in syphilis, 
1117. 

i:ii>s paralysis, 1 12. 

Erj slpelas In newly horn. 85. 

Erythema, following diphtheria antitoxin, 
1052; in Influenza, 1128; Intertrigo, 
!)!•!> : in Intestinal Indigestion, 4 17 ; in 
rheumatism, 1145; of the buttocks in 
marasmus, 241 ; scarlatiniform, causes, 
971. 

Erythroblasts, 863, 

Est lander's operation, 605. 

Eustachian tube in acute otitis, 948 ; In- 
flammation of, in Influenza, 1126; ob 
structlon of, in hypertrophy of tonsils, 
312. 

Examination of sick child. 33; inspection, 
34; measurements, 85; vital signs. 35; 



respiration, 36 ; temperature, 36 ; local 
examinations, 37-40. 

Exercise, importance of. 7 : caution re- 
garding", in heart disease, 635 ; in anae- 
mia, 868. 

Expectorants in bronchitis, 518. 

Exstrophy of bladder, 685. 

Extubation, 503. 

Eye, anomalies of, as stigmata of degen- 
eration, 818 ; keratitis, interstitial, in 
syphilis, 1117 ; care of, at birth, 1, 3 ; 
diphtheritic paralysis of, 852 ; early 
use, 25 ; ectropion of, in congenital 
ichthyosis, 923 ; inflammation of, in 
newly born, 87 ; in measles, 988 ; 
nystagmus, 729. 



Face, asymmetry of, as stigma of degen- 
eration, 818 ; expression of, in disease, 
34 ; cyanosis and oedema of, from pres- 
sure at root of lung, 1102. 

Facial paralysis, at birth, 110 ; acquired, 
peripheral, 853 ; in otitis, 948. 

Faeces, 323 ; of milk diet. 323 ; of mixed 
diet, 324 ; incontinence of, 457. 

Fat. determination of, in milk, 135 ; in 
the faeces, 324 ; test for, 362 ; lack of, 
a cause of rickets, 251 ; lack of, caus- 
ing constipation, 423 ; in woman's milk, 
134 ; percentages of, in modification of 
cow's milk, 185, 190 ; symptoms from 
deficiency of, in food, 201, 202 ; symp- 
toms from excess in food, 201, 203 ; 
function of, in diet, 126. 

Fatty degeneration of the newly born, 93. 

Fauces, syphilitic, ulceration of, 1111. 

Feeding, artificial, fundamental principles 
of, 182 ; rules for, 196, 205 ; schedule 
for first year, 205 ; versus wet-nursing, 
170 ; breast, schedule for, 172 ; other 
than milk, first year, 205 ; difficult 
cases, first year, 206 ; summary of in- 
fant feeding, 216; daily dietary from 
fourteen to eighteen months, 220 ; for 
healthy infants, second year, 219 ; diffi- 
cult cases, second year, 221 ; from third 
to sixth year, 222 ; articles allowed, 
222; articles forbidden, 223: dietary, 
from third to sixth years, 222; during 
acute illness, 224 ; in infants, 224 ; 
older children, 225 ; during very hot 
days, 373 : by gavage, in acute illness, 
225 ; nasal. 64 : in acute gastro-enteric 
intoxication. 375; in acute intestinal 
indigestion. :',('..". : methods of. in etiol- 
ogy of diarrhoea, •".■"•<"> ; mixed, indica- 
tions for, 181 ; simple rules in, 224. 

Vvt't, anomalies of, as stigmata of degen- 
eration, 818. 

Feser's lactOSCOpe, 1 17. 

Fever, puerperal, of the child, 81 ; from 
Insufficient nourishment, 174; inanition, 



1156 



INDEX. 



120; toxic, in intestinal indigestion, 
417 (see also Temperatuke). 

Finger (see Dactylitis). 

Fingers, clubbing of, in chronic cardiac 
disease, 630 ; in congenital heart dis- 
ease, 614. 

Fissure of the anus, 454. 

Fistula, congenital, of the neck, 314. 

Flatulence, cause of colic, 420 ; in intes- 
tinal indigestion, 417. 

Foetal circulation, 606 ; endocarditis, 610. 

Fcetus, evidences of syphilis in, 1112. 

Follicles, solitary (see Lymph Nodules) ; 
solitary, of intestine, often enlarged in 
marasmus, 239. 

Follicular ulceration of intestine, 389. 

Fomentations, hot, 55. 

Fontanel, bulging of, in cerebro-spinal 
meningitis, 762 ; bulging of, in menin- 
geal haemorrhage, 109 ; bulging of, in 
tuberculous meningitis, 773 ; in hydro- 
cephalus, 792 ; closure of, 22 ; in 
cretinism, 815 ; in rickets, 258. 

Food, constituents, 125 ; proteids, 125 ; 
fats, 126 ; carbohydrates, 127 ; mineral 
salts, 128 ; water, 128 ; farinaceous, a 
cause of eczema, 927 ; in chronic indi- 
gestion, 346 ; second year, 219 ; im- 
proper in etiology of diarrhoea, 356 ; re- 
gurgitation of, causes and treatment, 
201. 

Food - fistula between oesophagus and 
larynx, 316. 

Food-diseases, 244. 

Poods, infant, 166; milk, 166; malted, 
166; farinaceous, 166; proprietary, dan- 
gers of, 124 ; cause of rickets, 251 ; 
cause of scurvy, 245 ; uses of, in chronic 
constipation, 425. 

Foramen ovale, closure of, 607 ; function 
of, In foetal life, 606 ; patent, 612. 

Fractures, green-stick, in rickets, 255, 263. 

Franco-Swiss food, 166. 

Freeman's pasteurizer, 154. 

Friedlander's bacillus in acute broncho- 
pneumonia, 532. 

Friedreich's ataxia, 841. 

Fruit, best time Cor giving, 220; during 
second year, 220; allowed during third 
to sixtli year, 22:',; forbidden during 
third to sixth year, 223. 

Furunculosls, 935; In diabetes mellitus, 
I I is 

•""• of the Pace, 290; of intestine, 
in Intussusception, 431 ; of lung, 586; 
in acute broncho pneumonia, 541 ; in 

m pneumonia, 564 ; in scarlet fever, 

mi measles. 987. 

' 384; in malaria, 1135; in 
ial carles, 904. 

ac , ::::7 ; etiology, 337; 

-Ptoms, 340; treat- 



ment, *341 ; chronic, 343 ; ulcers in, 
349; toxic (see Gastritis, Corrosive), 
339. 

Gastro-duodenitis, 341. 

Gastroenteric infection or intoxication 
(see Intoxication, Acute Gastro- 
enteric), 364. 

Gastro-enteritis (see Intoxication, Acute 
Gastro-enteric), 364; in newly born, 
84. 

Gavage, 64 ; in acute illness, 225 ; in 
acute inanition, 230 ; in diphtheria, 
1047 ; in premature infants, 14 ; in 
thrush, 289. 

Genital irritation, 697. 

Genital organs, diseases of, 683 ; ano- 
malies of, as stigmata of degeneration, 
818 ; care of, in newly born, 4 ; malfor- 
mations of, 683 ; female, gangrene of, 
290 ; female, diseases of, 688 ; haemor- 
rhage from, in newly born, 106 ; males, 
diseases of, 686. 

Gingivitis, hemorrhagic, in scurvy, 246, 
247. 

Glands, bronchial (see Lymph Nodes, 
Bronchial). 

Glands, lymphatic (see Lymph Nodes), 
877. 

Glioma of brain, 783 ; of spinal cord, 840. 

Glio-sarcoma of brain, 783. 

Glossitis, 277. 

Glottis, oedema of the, 505 ; spasm of, 
idiopathic, 719. 

Glycosuria, 647. 

Gonococcus, differentiation of, 690 ; in 
gonorrhceal stomatitis, 289 ; in specific 
urethritis, 686 ; in vulvo-vaginitis, 690. 

Gout, eczema in children, 927 ; uric-acid 
deposits in urine, 650. 

Granuloma of umbilicus, 113. 

Grippe (see Influenza), 1123. 

Growing pains, rheumatic, 1143. 

Growth, conditions interfering with, 30 ; 
of body, 15 ; extremities, 21 ; trunk, 21. 

Gumma, syphilitic (see Syphilis Le- 
sions), 1109; in syphilitic bone dis- 
ease, 919 ; of brain, 783. 

Gums, abscess of, 279 ; bleeding in ulcer- 
ative stomatitis, 285 ; inspection of, 38 ; 
lancing, 281 ; spongy and bleeding, in 
scurvy, 246, 248 ; in ulcerative stomati- 
tis, 285. 

Habit-chorea, 727. 

Habit-spasm, 727. 

Habits, injurious, 743. 

Ilaematemesis, 350. 

Ila^matoma of the sterno-mastoid, 96. 

Haematocytozoon malariae, 1131. 

Hematuria, 646; in newly born, 107; in 
purpura, 873 ; in pyelitis, 676 ; in 
scurvy, 248 ; in tumours of kidney, 672. 

Haemoglobin, 856. 



INDEX 



1157 



Hemoglobinuria, 647 ; epidemic, 92 ; par- 
oxysmal, 647. 

Haemophilia, 870. 

Haemoptysis in tuberculosis, 1095. 

Haemorrhage, from stomach, 350 ; in 
haemophilia, 871 : intra - alveolar, in 
acute broncho-pneumonia, 536 ; internal, 
causing sudden death, 44 ; intestinal, 
from tuberculous ulcer, 412 ; in typhoid 
fever, 1066 : meningeal, causing birth 
paralysis, 796 : in acquired cerebral 
paralysis, 800 ; in acute broncho-pneu- 
monia, 553 : in convulsions, 704 ; men- 
ingeal, in pertussis, 1009 : meningeal, 
in purpura, 873 : nasal, in diphtheria, 
1037 ; pulmonary, in cardiac cases, 
630 ; rectal, from ulcer, 456 ; in leu- 
kaemia, 869 : in measles, 988 ; in per- 
tussis, 1008 ; in pernicious anaemia, 
866 ; in purpura, 874 ; in the newly 
born, 95 : haematoma of the sterno- 
mastoid, 96 ; cephalhematoma, 97 ; vis- 
ceral, 99 ; in scurvy, 245, 249 ; sub- 
periosteal, in scurvy, 245 ; in syphilis, 
1115. 

Hemorrhagic disease of the newly born, 
100. 

Haemorrhoids, 457 : in chronic constipa- 
tion, 423. 

Hair, anomalies, stigmata of degenera- 
tion, 818. 

Hand, progressive muscular atrophy of, 
843. 

Hands, anomalies, stigmata of degenera- 
tion, 818. 

Harelip, 274. 

Hawley's food, 166. 

Hay fever, 525. 

Head, circumference of, 20 : closure of 
sutures, 22 ; closure of fontanels, 22 ; 
shape of, 23 ; in rickets, 259 ; examina- 
tion of, 37 ; hydrocephalic, characteris- 
tics of, 792 : rotary and nodding spasm 
of, 729 ; sweating of, in rickets, 250. 

Headache, frequent, with adenoids, 302 ; 
varieties, 737 ; diagnosis, 738 ; treat- 
ment, 738. 

Hearing, when developed, 26. 

Heart, diseases of. 606 : aneurism of, 637 ; 
aortic disease, congenital, 612; area of 
absolute cardiac dulness, 609 ; of rela- 
tive dulness, 608; auscultation of, 39; 
diphtheritic paralysis of, 852 ; examina- 
tion of, 60S ; hypertrophy of, in con- 
genital diseases, 615; hypertrophy of, 
in valvular diseases, 628; in measles, 
988; In scarlet fever. 969; malforma- 
tions of, 010 : peculiarities of, in early 
life, 606 : persistent foetal conditions, 
610; position of apex beat, 608; In 
infancy, 608 : size and growth of, 607 : 
sounds of reduplication, 610; sudden 
failure of, in diphtheria, 1035 ; throm- 
74 



bus of, ante-mortem, 640 ; transposi- 
tion of, 613 ; congenital anomalies of, 
610 ; functional disorders of, 638 ; mur- 
murs of, 631 ; anaemic, 637 ; in con- 
genital diseases, 614 ; in chorea, 725 ; 
in marasmus, 241 ; valves, aortic insuf- 
ficiency, 633 ; aortic stenosis, 632 ; 
mitral insufficiency, 631 ; mitral stenosis, 
632 ; congenital absence of valves, 613 ; 
tricuspid insufficiency, 633 ; valvular 
disease of (see also Endocarditis), 
622 ; chronic valvular disease of, 627 ; 
ventricle, left, signs of dilatation, 632 ; 
signs of hypertrophy, 631 ; right, signs 
of hypertrophy, 615. 

Hectic fever in tuberculosis, 1094. 

Height, 21 ; from birth to sixteenth year, 
20. 

Hemianopsia in cerebral tumour, 786. 

Hemichorea, 724. 

Hemiplegia in acquired cerebral paralysis, 
801 ; in birth paralysis, 797 ; in men- 
ingeal haemorrhage, 109 ; in cerebral 
tumour. 786 ; spastic, 795. 

Hermaphroditism, false, 684. 

Hernia, cerebri, 748 ; diaphragmatic, 118 ; 
umbilical, 115. 

Herpes, labialis, 275. 

Herpetic stomatitis, 282. 

Hiccough, 730 ; in acute peritonitis, 467 ; 
in appendicitis, 442 ; in hysteria, 735. 

Hip, articular ostitis of, 907. 

Hip-joint disease (see Hip, Articular 
Ostitis of), 907. 

History-taking, 32. 

Hives (see Urticaria), 938. 

Hoarseness with adenoids, 302 ; in ca- 
tarrhal spasm of larynx, 490 ; in syph- 
ilis, 1114. 

Hodgkin's disease, 895. 

Home modification of milk (see Milk, 
Modification at Home), 191. 

Horlick's food, 166. 

Hubbell's prepared wheat, 166. 

Hutchinson's teeth in late hereditary 
syphilis, 1116. 

Hydatids of liver, 464. 

Ilvdrencephalocele, 747. 

Hydrocele, 687. 

Hydrocephalus, 789 ; in chronic basilar 
meningitis, 776 ; with spina bifida, 791, 
822 ; acute (see Meningitis, Tuber- 
culous), 770-789; chronic external, 
789 ; internal, 789 ; shape of head, 792 ; 
congenital, 7.10 ; intra - uterine, 748 ; 
syphilitic. 1111. 

Hydronephrosis, 0"> ; traumatic, 679 ; 
with malformations of kidney, 658; 
with renal calculi, 678. 

Ilydromyelus, 840. 
Hygiene of infancy. 1. 
Hyperesthesia, general, in cerebro-spinal 
meningitis, 760 ; in infantile spinal 



1158 



INDEX. 



paralysis, 833 ; hysterical, 734 ; in mul- 
tiple neuritis, 849; in scurvy, 247; in 
spinal meningitis, 827. 

llvpermetropia, stigma of degeneration, 
819. 

Hypertrophy, of the tonsils, 312; muscu- 
lar pseudo-, 844. 

Hypodermic medication, 67. 

Hypospadias, 684. 

Hysteria, 733; etiology, 733; symptoms, 
734 : diagnosis, 736 ; prognosis, 736 ; 
treatment, 736. 

Hystero-epilepsy, 735. 

Ice, bag, 56 ; cap, 49, 56 : coil, 56. 

Ichthyosis, congenital, 923. 

Icterus, 459 ; in epidemic hemoglobinuria, 
92 : in gastro-duodenitis, 342 ; varieties 
in newly born, 77 ; in malformation of 
the bile ducts, 78 ; physiological or 
idiopathic, 78. 

Idiocy, 804 ; Mongolian, 806 ; amaurotic 
family. 807 ; cretinoid, 807. 

Ileo-colitis, acute, 385; etiology, 385 
lesions, 386 ; in catarrhal, 387 ; ii 
follicular, 389 ; in membranous, 391 
associated lesions, 393 ; symptoms, ca 
tarrhal form, 394 ; with follicular ulcer 
ation, 396 ; membranous form, 398 
diagnosis, 400 ; prognosis, 401 ; treat 
ment, 401 ; broncho-pneumonia compli 
eating, 553 ; following pertussis, 1010 
in influenza, 1127 ; in measles, 987. 

Ileocolitis, chronic, 404; lesions, 404 
symptoms, 406 ; diagnosis, 407 ; prog- 
nosis, 408 ; treatment, 408. 

Ileum, congenital atresia of, 117. 

Imbecility, 804. 

imperial granum, 166. 

impetigo, bullous, in newly born, 94; 
simple, 929 : contagiosa, 937. 

[nanltion, acute, 227. 

Inanition fever, 120. 

Incubator, 12; in marasmus, 243. 

Indican, In urine of chronic constipation. 
l_'l of intestinal indigestion, 418; test 
for. in urine. <;r>(). 

Indlcanurla, 650. 

Indigestion, acute gastric, 335; etiology, 
■"■•".•"-; symptoms, :'.:'>(•>: diagnosis from 
u'jistritis, :;;;<;•. treatment, 336; vomiting 
in. 829; chronic gastric, 343; etiology, 
•"•i". lesions, 343; symptoms, in in- 
fantS, 344 ; in older children, 345; prog- 
nosis, B45; treatment in infants, 345; 
with dilatation, 348; acute intestinal, 
•"■ ,; > ' etiology, 381 : symptoms, 361 : 
362 : prognosis, .".<;:: ; treat- 
ment, 363. 

Indigestion, chronic intestinal. 413; in 

young Infants, 118 : lesions, 414; symp- 

" ' ; diagnosis, 415 ; prognosis, 

treatment, H6 ; In older children, 



416 ; symptoms, 416 ; prognosis, 418 ; 
treatment, 418. 

Infant, care of newly born, 1 ; when 
premature or delicate, 10. 

Infant feeding, 168. 

Infant foods, 166. 

Infarctions, uric acid, in kidney, 658. 

Infectious diseases, the specific, 952. 

Influenza, 1123 ; etiology, 1123 ; lesions, 
1124 ; symptoms, 1124 : with broncho- 
pulmonary complications, 1126 ; with 
gastro-enteric complications, 1127 ; in 
very young infants, 1127 ; protracted 
cases, 1127 ; complications and sequelae, 
1128 ; diagnosis, 1128 : prognosis, 1129 ; 
treatment, 1130 ; broncho-pneumonia, 
553, 1126 ; epidemic, acute otitis in, 
943 ; scarlatiniform erythema in, 971. 

Inhalations, 60 ; in bronchitis, 518. 

Inheritance a factor in disease, 30. 

Injections, rectal, in ileo-colitis, 403 ; in 
intussusception, 437 ; subcutaneous, of 
saline solution in cholera infantum, 
384. 

Insanity, 816 ; etiology, 817 ; symptoms, 
817 ; prognosis, 818 ; following typhoid 
fever, 1067. 

Inspection of sick child, 34. 

Intermittent fever, malarial, 1132. 

Intertrigo, 929 ; treatment, 934. 

Intestinal obstruction in newly born, 117 ; 
acute, from intussusception, 428. 

Intestines, diseases of, 352 ; amyloid de- 
generation of, 410 ; bacteria of, 322 ; 
digestion in, 321 ; haemorrhage from, in 
newly born, 105 ; in typhoid, 1066 ; in 
tuberculosis, 412 ; length, 321 ; mal- 
formations of, 352 ; obstruction, con- 
genital of, 117 ; obstruction by omphalo- 
mesenteric duct, 118 ; perforation of, in 
tuberculous peritonitis, 473 ; in tuber 
culous ulcers, 412 ; in typhoid fever, 
1066; tuberculosis of, 410, 1086; eti 
ology, 411 ; lesions, 411 ; symptoms 
412 ; treatment, 413. 

Intoxication, acute gastro - enteric, 364 
etiology, 364 ; lesions, 366 ; symptoms, 
simple form, 368 ; relapses, 370 ; cases 
without diarrhoea, 371 ; diagnosis, 372 
prognosis, 372 ; prophylaxis, 373 ; treat 
ment, hygienic, 374 ; dietetic, 375 ; medi 
cinal and mechanical, 377 ; cholera in 
fantum, 381 ; etiology, 381 ; symptoms, 
381 ; prognosis, 383 ; treatment, 383. 

Intubation, 498 : advantages over trache- 
otomy, 503 ; retained intubation tubes — 
prolonged intubation, 504 ; in acute 
catarrhal laryngitis, 495 ; in syphilitic 
laryngitis, 508 : in pertussis, 1014. 

Intubation set, O'Dwyer's, 498. 

Intussusception, 428 ; etiology, 429 ; le- 
sions and mechanism, 430 ; symptoms, 
431 ; diagnosis, 435 ; prognosis, 435 ; 



INDEX. 



1159 



treatment, 436 ; laparotomy, 437 : in the 
dying, 429. 

Invagination of intestine in intussuscep- 
tion, 431. 

Iodides, elimination of, in milk, 139. 

Iritis, syphilitic, 1111. 

Iron, tonic preparations of. 52. 

Irrigation, intestinal, in chronic indiges- 
tion, 419 : as antipyretic, 50 ; of the 
colon, method of, 65. 

Ischio-rectal abscess, 457. 

Italians, rickets in, 252. 

Jacket, oil-silk, 61. 

Jaffe's test for indican, 650. 

Jaundice (see also Icterus), 459; ca- 
tarrhal, 341. 

Jaw, necrosis of, from alveolar abscess, 
279 : in gangrenous stomatitis, 291 ; in 
ulcerative stomatitis, 284. 

Jejunum, congenital atresia of, 117. 

Joints, diseases of, 899 : hysterical affec- 
tions of, 734 : in scarlet fever, 968 ; 
rheumatism of, 1142 ; suppuration of, 
in newly born, 84 ; swelling of, in 
scurvy, 248 ; ecchymoses about, in 
scurvy, 247 ; tuberculous diseases of, 
900. 

Junket, 162. 

Keller's malt soup (see Malt Soup). 

Kemp's tube, 65. 

Kernig's sign, 760. 

Keratitis, interstitial, in late syphilis, 
1111, 1117. 

Keratoma, diffuse, 923. 

Kidney, diseases of, 654 ; acute congestion 
of, 659 : acute degeneration of, 660 ; 
benign tumours of, 674 ; calculi in, 675 ; 
chronic congestion of, 659 ; contracted 
(see Nephritis, Chronic), 668; cystic 
degeneration of, 655 ; floating, 658 ; 
granular (see Nephritis, Chronic), 
668 ; haemorrhage from, in newly born, 
106 ; in scurvy, 246, 248 ; horseshoe, 
<;."."> ; hydronephrosis, 655 ; traumatic, 
679 ; malformations and malpositions 
of, 654 ; malignant tumours of, 671 ; 
nephritis, acute diffuse, 660 ; acute exu- 
dative, 660 ; chronic, 667 ; perinephritis. 
07!> : pyelitis, 674 ; pyelonephritis. 656 : 
pyonepbrosis, <J75 ; single. 655 : tubercu- 
losis of. 670, 1086: uric acid Infarction, 
658; waxy. 667; in diphtheria, 10'JH; 
in scarlet fever, 967. 

Klebs-Loeffler bacillus (see Bacillus or 
Diphtheria), 1020, 1041. 

Knee, articular ostitis of. 911 ; symptoms, 
912; treatment, 913: subluxation of. in 
infantile spinal paralysis. 835 : swelling 
of, in scurvy. 247 : white swelling of 
(see Knee, Articular Ostitis). 



Knee-jerk, in acquired cerebral paralysis, 
802 ; in birth paralysis, 799 ; lost, in 
diphtheritic paralysis, 852 ; in infantile 
spinal paralysis, 835 ; in multiple neu- 
ritis, 849. 

Knee-joint disease (see Knee, Articular 
Ostitis). 

Knock-knee in rickets, 263. 

Koplik's sign, in measles, 989. 

Kumyss, 160. 

Kyphosis in rickets, 261 ; treatment, 271 ; 
in spinal caries, 902. 

Lactalbumin, 133. 149, 153. 

Lactated food, 166. 

Lactation, care of breasts during, 171. 

Lactoglobulin, 133. 

Lactometer, author's, 135. 

Lactoscope, Feser's, 147. 

Landry's paralysis, 842. 

Laparotomy, in chronic peritonitis, with 
ascites, 470 ; in intussusception, 437 ; 
in tuberculous peritonitis, 475. 

Laryngismus stridulus, 719 ; in rickets, 
267 ; with tetany, 717. 

Laryngitis, acute catarrhal, 492 ; catar- 
rhal, in measles, 986 ; chronic, 506 ; 
with adenoid vegetations of pharynx, 
506 ; tuberculous, 506 ; syphilitic, 507 ; 

- with new growths of larynx, 508 ; mem- 
branous, 495 ; antitoxin, 497 ; intuba- 
tion, 498 ; spasmodic, 489 ; submucous 
(oedema of glottis), 505. 

Laryngotomy. for foreign body in larynx, 
509. 

Larynx, diseases of, 489 ; catarrhal spasm 
of, 489 ; from long uvula, 295 ; with 
adenoids, 303 ; diphtheria of, 495, 1033 ; 
foreign bodies in, 508 ; intubation of, 
498 ; in measles, 986 ; in pseudo-diph- 
theria, 1057, 1059 ; new growths of, 
508 ; stenosis of, simulated by tuber- 
culous glands, 1103 ; syphilis of, 507, 
508, 1110 ; tuberculosis of, 506. 

Lassar's paste, 933. 

Lavage (see Stomach Washing). 

Leptomeningitis, acute (see Meningitis), 
754. 

Leukaemia, 868. 

Leucocytosis, definition. 858 ; diagnostic 
value. 859 ; prognostic value. 860 ; in 
diphtheria, 1029 ; in acute meningitis, 
762. 

Lewi's method for examination of wom- 
an's milk. 1 35. 

Lichen urticatus (see Urticabia), 938; 

tropicus. 925. 

Lleblg'e food, 1(56. 

Limewater, in modification of cow's milk, 
187. 

Lip, eczema of. 276 ; perleche, 276 ; dis- 
eases of, 275 ; herpes of, 275 ; malfor- 
mations of, 274. 



1160 



INDEX. 



Lisping, 739. 

Lithuria, 649. 

Liver, diseases of, 458 ; abscess of, 460 ; 
acute yellow atrophy of, 460 ; amyloid 
degeneration of, 462 ; biliary calculi, 
464 ; cirrhosis of, 461 ; congestion of, 
460 ; enlarged, in congestion, 460 ; in 
abscess, 461; in cirrhosis (early), 462; 
in chronic cardiac disease, 630 ; fatty, 
463 ; fatty, in eczematous children, 927 ; 
in marasmus, 239 ; functional disorders 
of, 459 ; hydatids of, 464 ; in rickets, 
267; in syphilis, 1109, 1118; in tuber- 
culosis, 1085; lardaceous, 462; mal- 
formations and malpositions of, 459 ; 
size and position of, 39, 458 ; tubercu- 
losis of, 1095 ; waxy, 462 ; weight of, 
in infancy, 458. 

Loeffler's bacillus (see Bacillus of Diph- 
theria), 1020. 

Lumbar puncture, 764; tubercle bacilli in 
fluid, 775. 

Lung, diseases of, 509 ; abscess of, 585 ; 
abscesses of, in acute broncho-pneu- 
monia, 541 ; acute congestion of, in 
malaria, 1136; calcareous nodules in, 
1081 ; caseous degeneration of, 1078 ; 
collapse of, from compression, 588 ; 
from obstruction, 588 ; in acute broncho- 
pneumonia, 534 ; congenital atelectasis 
of, 74 ; emphysema of, 589 ; acute, in 
bronchitis of infants, 513 ; gangrene of, 
586 ; gangrene of, in lobar pneumonia, 
564 ; haemorrhages into, in newly born, 
99 ; inflation of, 73 ; miliary tubercu- 
losis of, 1077 ; peculiarities in disease, 
512 ; in infancy and early childhood, 
509 ; physical examination of, 510 ; 
structure of, 510. 

Lymph nodes, diseases of, 877 ; calcareous 
cervical, 890 ; bronchial, 1082 ; early 
infection in tuberculosis, 1074 ; enlarged 
in eczema, 929 ; in Hodgkin's disease, 
895 ; in malnutrition, 232 ; frequency of 
disease of, 41 : inflammation of (see 
Adenitis), 883; in late hereditary 
syphilis, 1117; in measles, 988; in 
pseudo - diphtheria, 1058 ; in scarlet 
fever, 965 ; simple hyperplasia of, 886 ; 
situation and drainage areas of the 
groups of head and neck, 883 ; syphilitic 
disease of, 887 ; tuberculous bronchial, 
1001; lesions, 1074, 1082; symptoms, 
1001; cervical, tuberculosis of, 888; 
mesenteric, 410, 1075; in diphtheria, 
1027 ; in rickets,' 266 ; in tonsillitis, 
310; epitrochlear, in syphilis, 1117; 
mesenteric, often enlarged, in maras- 
mus, 239; in typhoid fever, 1063; tu- 
berculosis of. 888; retro-pharyngeal, 
abscess of, 295. 

Lymph nodules of intestines, ulceration 
of, 389. 



Lymphadenoma of stomach, 350. 
Lymphangioma of tongue, 275. 
Lymphatism (see Status Lymphaticus), 

879. 
Lymphocytes, 857. 

Magendie, foramen of, in hydrocephalus, 
789. 

Malaria, 1131 ; etiology, 1131 ; lesions, 
1132 ; symptoms, 1132 ; diagnosis, 1137 ; 
prognosis, 1138; prophylaxis, 1138; 
treatment, 1138 ; quinine, methods of 
administration, 1138 ; acute pulmonary 
congestion in, 1136 ; contracted in utero, 
1131 ; spleen in, 898. 

Malformations as cause of sudden death, 
44. 

Malnutrition, 230 ; etiology, 231 ; symp- 
toms in infants, 231 ; symptoms in older 
children, 233 ; diagnosis, 234 ; prog- 
nosis, 234 ; treatment in infancy, 235 ; 
treatment in older children, 237. 

Malnutrition, marasmus, 238. 

Malted milk, 166. 

Malt extracts, use of, in diet of nurse, 
138. 

Maltose, substitute for milk sugar, 127. 

Malt soup of Keller, use of, with difficult 
feeding cases, 214, 218. 

Mania, 817; acute, following typhoid 
fever, 1067. 

Marasmus, 238 ; etiology, 238 ; lesions, 
239 ; symptoms, 241 ; complications, 
241 ; diagnosis, 242 ; from tuberculosis, 
242, 1088 ; prognosis, 242 ; treatment, 
243 ; fatty liver in, 464 ; general oedema 
in, 682 ; tuberculosis resembling, 1087. 

Massage, 68 ; in chronic constipation, 
425 ; in malnutrition, 236 ; of breasts 
to increase milk, 176. 

Mastitis in the newly born, 116. 

Mastoid disease, cerebral abscess follow- 
ing, 780 ; in acute otitis, 947. 

Masturbation, 744 ; a cause of epilepsy, 
709 ; of insanity, 817 ; of functional 
disorder of heart, 638. 

Matzoon, 161. 

Measles, 977 ; broncho-pneumonia compli- 
cating, 552 ; complications and sequelae, 
985 ; desquamation, 982 ; diagnosis, 989 ; 
digestive system, 987 ; diphtheria in, 

987 ; duration of infective period, 978 ; 
ears, 944, 987 ; eruption, 981 ; etiology, 
977 ; eyes, 988 ; gangrenous dermatitis 
in, 936; German (see Rubella), 993; 
haemorrhage in, 988 ; hsemorrhagic, 981 ; 
heart in, 988 ; ileo-colitis, 984 ; incuba- 
tion, 978 ; invasion, 980 ; kidneys in, 

988 ; larynx in, 986 ; lesions, 979 ; 
lungs, 985 : lymph nodes, 988 ; mode of 
infection, 979 ; mortality, 989 ; nervous 
system in, 984 ; other infectious diseases 
in, 988 ; otitis, 984 ; predisposition, 



INDEX. 



1161 



977 ; prognosis, 989 ; prophylaxis, 990 : 
pseudo-diphtheria in, 1059 ; quarantine 
in, 991 ; skin in, 988 ; symptoms, 980 ; 
throat, 986 ; treatment, 991 ; tubercu- 
losis following, 988. 

Meats, allowed from third to sixth years, 
222 ; forbidden from third to sixth 
years, 223. 

Meckel's diverticulum, 114, 353. 

Meconium, composition of, 323. 

Mediastinum, anterior, abscess of, 1103 ; 
tumour of, due to tuberculous lymph 
nodes, 1103. 

Mediastinitis, 618. 

Melancholia, 817. 

Melsena, 105. 

Mellin's food, 166, 167. 

Membrane, in diphtheria, 1023 ; in pseudo- 
diphtheria, 1057. 

Meningeal haemorrhage, 1, 751, 796. 

Meninges, diseases of, 747. 

Meningitis, acute, 754 ; cerebro-spinal, 
754 ; course, duration and termination, 
763 ; diagnosis, 764 ; etiology, 754 ; 
from acute otitis, 948 ; in newly born, 
84 ; in typhoid fever, 1067 ; purulent, 
in acute broncho-pneumonia, 553 ; le- 
sions, 755 ; leucocytosis in, 762 ; lum- 
bar puncture in, 764 ; symptoms, 759 : 
diagnosis, 764 ; prognosis, 763 ; treat- 
ment, 766. 

Meningitis, simple acute, 767. 

Meningitis, chronic basilar, 775 ; spinal, 
826: syphilitic, 1111. 

Meningitis, tuberculous, 770 ; lesions, 770 ; 
etiology, 771 : symptoms, 771 ; duration, 
774 ; diagnosis, 774 ; prognosis, 775 ; 
treatment, 775 ; lumbar puncture in, 
775. 

Meningocele of brain, 747 ; of cord, 821. 

Meningo-encephalitis, 796. 

Meningo-myelocele, 821. 

Menstruation, effect on nursing, 137. 

Mental defects, 804 ; classification, 804 ; 
diagnosis, 808 ; treatment, 809. 

Mercury, elimination of, in milk. 139; 
ulcerative stomatitis from, 284 ; in 
syphilis, 1122. 

Microcephalia, 750. 

Micro-organisms in cow's milk, 141 ; see 
also Bacteria. 

Micturition, difficult or painful. 0!»7 ; fre- 
quency of. 643. 

Miliaria, 924; papulosa, 925; treatment, 
925 ; rubra, 924. 

Milk, cow's, 140 ; average percentages of, 
185; bacteriological standard for, 144; 
handling and transportation of. 145, 
146; certified, 146, 147; composition of, 
146; average percentages in, from dif- 
ferent breeds, 146, 147; examination 
of, 147; coagulation of, in stomach, 
320; cream, 150; contaminated, cause 



of diarrhoea, 356 ; differences from hu- 
man milk, 149 ; diphtheria bacilli in, 
142, 154 ; essentials of, for infant feed- 
ing, 141 ; formulae from diluting, 192 
et scq. ; micro-organisms in, 141 ; modi- 
fication of, percentage or American 
method of, 184, 216 ; at home, 191 ; 
top-milk, 151 : formula? from top-milk, 
192 et seq. ; schedule of percentages for 
first year, 190 : schedule showing quan- 
tities and intervals of feeding, 205 ; 
rules for varying percentages, 197 ; 
modifications required by particular 
symptoms, 200 ; in difficult cases, 209 ; 
in summer diarrhcea, 375 ; in acute in- 
digestion, 363 ; in chronic constipation, 
424 ; pasteurization of, 154 ; proteids 
of, 125 ; sterilization of, at 167° F., 
154 ; sterilization of, at 212° F., 153 ; 
sterilized, scurvy ascribed to, 245 ; tu- 
bercle bacilli in, 1073 ; typhoid contami- 
nation of, 142; condensed (see Con- 
densed Milk), 159: peptonized, 158; 
peptonized, use of, 211 ; dangers from 
long use of, 211. 

Milk-laboratories, 188. 

Milk-sugar, uses of, as food, 127 ; solu- 
tion, how to prepare, 186. 

Milk, woman's, 129 ; physical characters 
of, 129 ; colostrum of, 130 ; daily quan- 
tity of, 131 ; average quantity at one 
nursing, 132 ; composition of, 133 ; pro- 
teids, 125, 133, 149 ; fat, 134 ; sugar, 
134 ; salts, 134 ; reaction, 134 ; specific 
gravity, 135, 136 ; average percentages 
of, 185 ; conditions affecting composi- 
tion of, 137 : menstruation, 137 ; diet, 
138 ; drugs, 139 ; pregnancy, 139 ; elim- 
ination of antitoxin and other protective 
substances, 139 ; nervous impressions, 
140 ; examination of, 134 ; variations 
in quality, 137 ; apparatus for examin- 
ing, 136 ; flow established, 129 : how to 
modify quantity and quality, 176, 177 ; 
indications of scanty supply, 174. 

Modified milk, from milk laboratory, 188 ; 
schedule for feeding from birth, 190 ; 
made at home (see Milk, Modification 
of, at Bomb). 

Mongolian idiocy. 806. 

Monoplegia, in birth paralysis, 797 ; in 
cerebral haemorrhage, 109 ; in cerebral 
tumour, 786. 

Morbllll (see MbASI.ES), 977. 

Morbus COXarlUB (see IIn>, ARTICULAR 
Ostitis of), 907. 

Morbus maculosus Werlhofti (see Pur- 
puba), 871. 

Morphine, dosage of, 58, i''- s : dosage in 
convulsions, 707 ; hypodcrinically in 
cholera infant iini, 384'i in u r ;ist ro-intes- 
tinal intoxication. 379. 

Mortality at different ages. 42. 43. 



1162 



INDEX. 



Morton's fluid, 826. 

Mouth, diseases of (see also Stomatitis), 
274, 281 ; applications to, 289 ; care of, 
at birth, 1, 3 ; haemorrhage from, in 
newly born, 105 ; haemorrhages from, in 
scurvy, 248 ; malformations of, 274 ; 
mucous patches, in syphilis, 1114 ; 
syphilis of, 289 ; " tapir," 846 ; syring- 
ing of, 59. 

Mouth-breathing, with hypertrophy of ton- 
sils, 312 ; with adenoids, 301 ; with 
retropharyngeal abscess, 296. 

Mucous membranes, frequency of involve- 
ment in childhood, 40 ; in rickets, 266. 

Mucous patches, syphilitic, 1114. 

Mumps, 1016 ; complications and sequelae, 

1018 ; diagnosis, 1019 ; etiology, 1016 ; 
incubation, 1017 ; pathology and lesions, 
1016 ; prognosis, 1019 ; quarantine in, 

1019 ; symptoms, 1017 ; treatment, 1019. 
Murmurs, cardiac (see Heaet Murmurs). 
Muscles, atrophy of, 842 ; in infantile 

spinal paralysis, 834 ; in multiple neu- 
ritis, 849 ; in myelitis, 828 ; contractures 
of, hysterical, 735 ; in acquired cerebral 
paralysis, 802 ; in birth paralysis, 799 ; 
development of, 25 ; flabbiness of, in 
rickets, 264 ; rigidity of, in birth para- 
lysis, 798 ; spasm of, about rheumatic 
joint, 1142. 

Muscular atony, as cause of chronic con- 
stipation, 423. 

Muscular atrophies, different types of, 
842. 

Muscular pseudo-hypertrophy, 844. 

Mustard bath, 56 ; paste, 54 ; pack, 54. 

Myelitis, 827 ; symptoms, 828 ; treatment, 
828 ; compression, from Pott's disease, 
829 ; diffuse, 828 ; transverse, 828. 

Myelocytes in leukaemia, 869 ; in diph- 
theria, 1029. 

Myocarditis, 636 ; aneurism in, 637 ; toxic, 
in diphtheria, 852, 1028 ; in scarlet 
fever, 969 ; in syphilis, 1111. 

Myopia, stigma of degeneration, 819. 

Myotonia, congenital, 730. 

Nail-biting, 747. 

Nails in syphilis, 1115. 

Neck, cellulitis of, in scarlatina, 965 ; con- 
genital fistula of, 314; wry (see Torti- 
collis). 

Necrosis of bone in syphilis, 916, 918. 

Negroes, rickets in, 252. 

Nematodes (see Worms, Intestinal), 
448. 

Nephritis, acute diffuse, 660 ; etiology, 
660 ; lesions, 661 ; symptoms, 662 ; 
prognosis, 664 ; treatment, 665 ; in 
broncho-pneumonia, 554 ; acute paren- 
chymatous type, 662. 

Nephritis, chronic, 667 ; etiology, 667 ; 
lesions, 667 ; symptoms, 668 ; of the 



parenchymatous type, 668 ; of the in- 
terstitial type, 669 ; prognosis, 669 ; 
diagnosis, 669 ; treatment, 670 ; chronic 
diffuse, with hydronephrosis, 656 ; 
chronic interstitial, syphilitic, 1111 ; 
in diphtheria, 1028 ; interstitial (see 
Nephritis, Chronic), 669; post-scarla- 
tinal, 967. 

Nerves, peripheral, diseases of, 846. 

Nervous impressions, effect of, on nursing, 
140. 

Nervous system, diseases of, 699 ; diseases 
of, functional, 701 ; general hygiene of, 
5 ; peculiarities of, in childhood, 700. 

Nestle's food, 166, 167. 

Neuritis, multiple, 846 ; after diphtheria, 
851 ; in malaria, 1136 ; optic, in acute 
meningitis, 761 ; in cerebral tumour, 
785 ; with cerebral abscess, 782. 

Newly born, diseases of, 69 ; acute infec- 
tious diseases of, 81 ; acute pyogenic 
diseases of, 81 ; atelectasis, congenital, 
74 ; asphyxia of, 69 ; blood in, peculi- 
arities of, 856 ; care of, 1 ; diseases or 
accidents at birth, 30 ; dermatitis ex- 
foliativa in, 922 ; facial paralysis in, 
110 ; fatty degeneration of, 93 ; haemor- 
rhages in, 95 ; haemorrhagic disease of, 
100 ; hyperpyrexia in, 120 ; inanition 
fever in, 120 ; icterus in, 77 ; infection 
of, 31 ; malformations of, 30 ; mastitis 
in, 116 ; ophthalmia of, 87 ; pemphigus 
in, 94 ; peritonitis in, 465 ; sclerema in, 
118 ; skin of, 922 ; ulcer of stomach in, 
349. 

Nightmare, 742. 

Night-terrors, 742. 

Nipples, care of, during lactation, 171 ; 
fissure of, hsematemesis from, 351 ; rub- 
ber, choice of, 204 ; care of, 204. 

Nodding spasm of head, 729. 

Nodes, lymph (see Lymph Nodes), 877. 

Nodules, subcutaneous tendinous, in rheu- 
matism, 1144. 

Noma of face (see Stomatitis, Gan- 
grenous), 290; of vulva, 692. 

Nose, diseases of, 478 ; deformities of, in 
hereditary syphilis, 485 ; difficulty in 
blowing, with adenoids, 301 ; diphtheria 
of, 1025 ; discharge from, with ade- 
noids, 301 ; foreign bodies in, 481 ; 
haemorrhage in, 487 ; in newly born, 
105 ; in scurvy, 248 ; in hereditary 
syphilis, 485, 1010 ; in late syphilis, 
1118 ; polypi in, 482 ; pseudo-diphtheria 
of, 1057 ; sprays for, 57 ; syringing, 
58. 

Nurse, effect of diet on milk of, 138 ; 
requisite qualities in, 10 ; wet (see 
Wet-nurse). 

Nursery, temperature, ventilation, 9. 

Nursing, at night, 172 ; when discontin- 
ued, 172 ; during acute illness, 224 ; 



INDEX. 



1163 



during first days of life, 171 ; hours for, 
in newly born, 172 ; during illness, 181 ; 
importance of good habits, 172 ; unsuc- 
cessful, symptoms of, 172 ; maternal, 
contra-indications for, 169. 

Nursing-bottles, choice of, 204 ; care of, 
204. 

Nutrient, enemata, 67. 

Nutrition, derangements of, 226 ; acute 
inanition, 227 ; malnutrition, 230 ; ma- 
rasmus, 238 ; faulty, diseases due to, 
244 ; importance in paediatrics, 124. 

Nystagmus, 729 ; in cerebral haemorrhage, 
110 ; in hydrocephalus, 794 ; in tuber- 
culous meningitis, 773 ; stigma of de- 
generation, 819 ; with tumour of crura 
cerebri, 786. 



Oatmeal water, 165. 

O'Dwyer's intubation set, 498. 

OEdema, in acute diffuse nephritis, 662, 
663 ; in anaemia, 861 ; in chronic ne- 
phritis, 668 ; in cardiac disease, 630 ; in 
delicate infants, 120 ; in leukaemia, 870 ; 
of face from pressure at root of lung, 
1102 ; general, in marasmus, 241 ; not 
from renal disease, 682. 

OEdema glottidis, 505 ; rare in acute ca- 
tarrhal laryngitis, 492 ; in corrosive 
oesophagitis, 316 : in quinsy, 311. 

CEsophagitis, acute, 315 ; catarrhal, 315 ; 
corrosive, 315. 

(Esophagus, diseases of, 314 ; abscess be- 
hind, 316; congenital narrowing of, 
314 ; congenital obstruction in, 314 ; 
diphtheria of, 1026 ; malformations of, 
314 ; pseudo-diphtheria in, 315 ; stric- 
ture of, 314 ; thrush in, 315 ; in scar- 
latina, 956. 

Oil enemata, 67. 

Oiled-silk jacket, 61. 

Omphalitis in newly born, 82. 

Omphalomesenteric duct, 118, 353. 

Onychia, syphilitic, 1115. 

Ophthalmia, gonorrhoeal, 87 ; in newly 
born, 87 ; treatment, 88. 

opisthotonus, cervical, 730; hysterical, 
736 ; in cerebrospinal meningitis, 758 ; 
in birth paralysis, 798 ; in meningeal 
haemorrhage, 109, 110; in chronic 
basilar meningitis, 776 ; in marasmus, 
242 ; in tuberculous meningitis, 773. 

Opium, elimination of, in milk, 139; in 
gastro - enteric intoxication, 379 ; in 
bronchitis, 518 ; preparations and dos- 
age, 53. 

Optic nerve, atrophy of, in cerebral tu- 
mour, 7H."i. 

Orange juice in scurvy, 260. 

Orchitis, in mumps, 1018; in specific ure- 
thritis, 686; syphilitic, 1111; tubercu- 
lous, 1086. 



Orthopnoea, in chronic valvular disease, 
629 ; in functional disorders of the 
heart, 638. 

Osteo - myelitis, acute (see Arthritis, 
Acute), 899; acute, syphilitic, 916; in 
newly born, 84 ; tuberculous, 913 ; 
symptoms, 914 ; diagnosis, 915 ; treat- 
ment, 915. 

Osteo-periostitis, chronic, syphilitic, 917. 

Osteotomy in rickets, 273. 

Ostitis, primary, followed by joint disease, 
902 ; simulated by scurvy, 249. 

Otitis, acute, 943 ; etiology, 943 ; lesions, 
943 ; symptoms, 944 ; complications and 
sequelae, 947 ; treatment, 948 ; cerebral 
abscess in, 780, 948 ; thrombosis of 
lateral sinus in, 948 ; facial paralysis 
in, 948 ; labyrinth in, 948 ; mastoid dis- 
ease in, 947 ; meningitis in, 948 ; 
chronic, in iate syphilis, 1117 ; reflex 
cough from, 523 ; frequent attacks of, 
with adenoids, 302 ; in influenza, 1126 ; 
in scarlet fever, 966 ; in syphilis, 1111 ; 
in typhoid fever, 1067 ; adenitis compli- 
cating, 885. 

Overlying, causing death by asphyxia, 44. 

Oxyuris vermicularis (see Worms, Intes- 
tinal), 450. 

Ozama in late syphilis, 1118 (see Rhi- 
nitis, Atrophic), 485; syphilitic, 485. 

Pachymeningitis, acute, 751 ; chronic (in- 
ternal), 751; syphilitic, 1111; menin- 
geal haemorrhage from, 800 ; hemor- 
rhagic, 751 ; pseudo-membranous, 751. 

Pack, cold, 49 ; hot, 56 ; mustard, 54. 

Palate, cleft, 274 ; deformities of, stig- 
mata of degeneration, 818 ; diphtheritic 
paralysis of, 851 ; hard, ulceration of, 
286; in late syphilis, 1118; soft, lesions 
of, in hereditary syphilis, 486. 

Pancreas, ferments of, 321 ; syphilis of, 
1112 ; tuberculosis of, 1086. 

Paracasein, formed from casein in stom- 
ach digestion, 149. 

Paralysis, ascending, 842 ; atrophic (see 
Paralysis, Infantile Spinal), 831 ; 
birth, 107, 796 ; atrophy and sclerosis 
following, 797 ; meningo - encephalitis, 
7!)(! ; secondary degenerations following, 
797 ; symptoms, 797 ; Erb'S, 111 ; facial, 
110, 853; in acute otitis, 948; hyster- 
ical, 73(5; in compression-myelitis, 830; 
in multiple neuritis, 848; in myelitis, 
828 ; Landry's, 842 : of face in newly 
born, 110; of the upper extremity in 
newly born, 111 : peripheral, 107 (see 
also Neuritis, Multiple), 846; post- 
diphtheritic, 1028 : pseudo hypertrophic, 
844; simulated by scurvy, l ( J7. 

Paralysis, infantile cerebral, 107, 7!>."» ; 
acute acquired, 79!); birth, 796; of 
intra-uterine origin, 795 ; varieties and 



1164 



INDEX. 



symptoms, 796, 797, 801 ; prognosis, 
802 ; diagnosis, 803 ; treatment, 804. 

Paralysis, infantile spinal, 831 ; etiology, 
832 ; symptoms, 833 ; course, 834 ; diag- 
nosis, 837 ; distribution of primary 
paralysis, 834 ; electrical reactions, 835, 
838 ; residual paralysis and deformity, 
835 ; prognosis, 838 ; treatment, 838 ; 
mechanical, 839. 

Paraplegia, Pott's (see Myelitis, Com- 
pression), 829; spastic, 795. 

Paregoric, dosage of, 53. 

Parotitis, epidemic (see Mumps), 916. 

Paste, mustard, 54. 

Pasteurized milk, 154. 

Pathology, general considerations of, 40. 

Pavor nocturnus, 742. 

Peliosis rheumatica, 876. 

Pelvis, deformities of, in rickets, 263. 

Pemphigus, gangrenosa, 936 ; syphilitic, 
1112 ; in newly born, 94. 

Pepsin in stomach secretion, 319. 

Peptonized milk, preparation of,- 158 ; par- 
tially, 158 ; completely, 158. 

Percentages of ingredients in milk formu- 
las, how to calculate them, 196. 

Pericarditis, 617 : acute, in broncho- 
pneumonia, 554 ; chronic, with adhe- 
sions, 621 ; diagnosis, 620 ; dry, 618 ; 
external, 618 ; in newly born, 84 ; in 
rheumatism, 1143 ; mediastinal, 618 ; 
prognosis, 620 ; purulent, 618 ; sero- 
fibrinous, 618 ; tuberculous, 618 ; with 
effusion, 618 ; with effusion of blood, 
618 ; with lobar pneumonia, 565 ; with 
pleuro-pneumonia, 580 ; with transuda- 
tion of serum, 617. 

Pericardium, congenital absence of, 613 ; 
tuberculosis of, 1085. 

Perinephritis, 679 ; acute peritonitis com- 
plicating, 466. 

Peritonaeum, diseases of, 465 ; hemor- 
rhage into, in newly born, 99 ; in tuber- 
culosis, 1086. 

Peritonitis, acute, 465 ; etiology, 465 ; 
lesions, 466 ; symptoms, 467 ; treatment, 
468 ; chronic, non-tuberculous, 469 ; 
with ascites, 469 ; foetal, cause of mal- 
formations, 353 ; in intussusception, 
435 ; in newly born, 83 ; in suppurative 
appendicitis, 439 ; pelvic, from gonor- 
rhoea, 690 ; tuberculous, 470 ; miliary, 
with general tuberculosis, 471 ; miliary, 
with ascites, 471 ; fibrous form, 472 ; 
ulcerative form, 473 ; with tuberculous 
mesenteric glands, 474 ; with intestinal 
ulcers, 412 ; with lobar pneumonia, 565. 

Perityphlitis (see Appendicitis), 438. 

Perleche, 276. 

Perspiration (see Sweating), 922. 

Pertussis, 1004; broncho-pneumonia in. 
551, 1000: complications, 1008: convul- 
sions, 1010; diagnosis, 1011; etiology, 



1005 ; haemorrhages in, 1008 ; incuba- 
tion, 1006 ; infective period, 1006 ; le- 
sions, 1006 ; paralysis in, 1010 ; pre- 
disposition to, 1005 ; prognosis, 1011 ; 
prophylaxis, 1012 ; symptoms, 1006 ; 
treatment, 1012. 

Peyer's patches, in typhoid fever, 1063 ; 
swollen, in acute ileo-colitis, 388 : tuber- 
culosis of, 411 ; ulceration of, in ileo- 
colitis, 390. 

Pharyngitis, acute, 293 ; uvulitis in, 294 ; 
chronic catarrhal, syphilitic, 1011. 

Pharynx, diseases of, 293 ; adenoid vege- 
tations of vault, 299, 481 ; with ade- 
nitis, 885 ; diphtheria of, 1025 ; diph- 
theritic paralysis of, 852 ; lesions of, in 
hereditary syphilis, 485 ; pseudo-diph- 
theria of, 1058 ; reflex cough from, 
522 ; retro-pharyngeal abscess, 295 ; 
syphilitic ulceration of, 1111 ; syringing 
of, 59. 

Phimosis, 683 ; reflex phenomena from 
684. 

Phlebitis, of dural sinuses, 779. 

Phosphorus in rickets, 271. 

Photophobia, in influenza, 1125 ; in mea- 
sles, 980 ; in tuberculous meningitis, 
772. 

Phthisis, chronic, 1081, 1101. 

Physical examination of the child, 33. 

Pick's paste, 934. 

Pigeon-breast in adenoids, 301. 

Pinworms (see Worms, Intestinal), 450; 
proctitis from, 454. 

Plasmodium malarise, 1131. 

Pleura, effusion into, in acute nephritis, 
664 ; tuberculosis of, 1077, 1084. 

Pleurisy, 591 ; dry, 592 ; in acute broncho- 
pneumonia, 540 ; purulent (see Empy- 
ema), 596; tuberculous, dry form, 592; 
with lobar pneumonia, 574 ; with serous 
effusion, 593. 

Pleuro-pneumonia, 579 ; pericarditis in, 
617, 619. 

Pneumococcus, in broncho-pneumonia. 530, 
532 ; lobar pneumonia, 563 ; peritonitis, 
566 ; diphtheria, 1027, 1029 ; empyema, 
596 ; acute meningitis, 767 ; malignant 
endocarditis, 623. 

Pneumonia, 527 ; anatomical varieties and 
classifications of, 527 ; broncho- (see 
Broncho - pneumonia, Acute), 531 ; 
catarrhal (see Broncho - pneumonia, 
Acute), 531 ; chronic interstitial (see 
Broncho-pneumonia, Chronic), 582; 
in newly born, 83 : in typhoid fever, 
1066 ; sources of infection, 530 ; varie- 
ties, classification, 530 ; hypostatic, 
582 ; in marasmus, 239 ; lobular (see 
Broncho - pneumonia, Acute), 531: 
pleuro- (see Pleuro-pneumonia), 579; 
syphilitic, 1110: tuberculous, 1079 
(see also Tuberculosis, Pneumonia) ; 



INDEX. 



1165 



course, duration, termination, 1098 ; 
diagnosis, 1098 ; physical signs, 1097 ; 
chronic, 1096. 

Pneumonia, lobar, 562 ; etiology, 562 ; fre- 
quency of, 569 ; complicating influenza, 
1126 ; complications, 574 : course, 565 ; 
abortive, 566 ; cerebral, 566 ; diagnosis, 
575 ; lesions, 563 ; lysis, frequency of, 
569 ; pathological differentiation from 
broncho-pneumonia. 528 ; physical signs, 
571 ; prognosis, 573 ; symptoms, 565 ; 
cerebral, 570 ; termination, 574 ; treat- 
ment, 578. 

Pneumothorax in pulmonary tuberculosis, 
1078. 

Pock, in vaccinia, 1002 ; in varicella, 
996. 

Poisons, gastritis from, 338, 339. 

Poisoning, stomach-washing in, 64. 

Poliencephalitis, acute, causing cerebral 
paralysis, 800. • 

Poliomyelitis, acute (see Paralysis, In- 
fantile Spinal), 831. 

Polydactyly, stigma of degeneration, 818. 

Polydipsia in diabetes insipidus, 653 ; 
mellitus, 1147. 

Polypi, nasal, 482 ; rectal, 452. 

Polyuria, 652 ; hysterical. 736 : in dia- 
betes insipidus, 653 ; mellitus, 1147. 

Porencephalies, 751. 

Pott's disease (see Spine, Caries of), 
902 ; cervical, causing torticollis, 732 ; 
reflex cough in, 523. 

Poultices, use and preparation of, 55. 

Powders for skin, 4. 

Prsecordia, bulging of, 608, 632. 

Pregnancy, effect on woman's milk, 137, 
139; effect on nursing child, 179. 

Premature infants, management of, 12; 
results with, 14. 

Prematurity, cause of marasmus, 238. 

Prepuce, adherent, 683. 

Prickly heat. 925. 

Proctitis, 454. 

Prognosis, general consideration of, 42. 

Progressive muscular atrophy, hand type, 
843 ; peroneal type, 844. 

Prolapsus ani (see also Rectum. Pro- 
i.ai-si: op), 452; from proctitis, 455 : in 
ileocolitis. ::!>.-): in membranous ileo- 
colitis. 399. 

Prophylaxis, general consideration of, 46. 

Protelds, determination of, in milk, 135; 
function in diet, 125; in the faeces, 
323; of woman's milk, 133; of cow's 
milk, 149 ; percentages of, in modifica- 
tion of cow's milk, 1!>4. 195. 1!»<; ; in 
feeding difficult cases, 209 et seq. : vege- 
table, 126. 

Pseudo-diphtheria, 1020, 1056; bacillus, 
1042; broncho - pneumonia in, 1059; 
communicability of. 1057 : diagnosis. 
1060 ; etiology, 1057; in measles. 1059; 



in scarlet fever, 1059 : lesions, 1057 ; 
mortality, 1060 ; prognosis, 1060 ; quar- 
antine in, 1061; streptococcus in, 1057; 
symptoms, 1058 : treatment, 1061. 

Pseudo-hypertrophic paralysis, 844. 

Pseudo - paralysis in rickets, 265 ; in 
scurvy, 247 ; in syphilis, 917, 1115. 

Psoas abscess in spinal caries, 906. 

Psoriasis of tongue, 276. 

Puberty, delayed, stigma of degeneration, 
819 ; in cretins, 815 : in syphilis, 1119 ; 
effect of, on heart in valvular disease, 
634, 639 ; reflex cough of, 523. 

Pulse, examination of, 35 ; in early life, 
607. 

Purpura, 871 : arthritic, 876 ; blood in, 

873 ; fulminans, 875 : gangrenous, 876 ; 
ha?matemesis in, 875 ; hemorrhagica, 

874 ; Henoch's, 875 ; primary, 872 ; 
rheumatica, 876 ; simplex, 871, 874 ; 
symptomatic, 871 ; cachectic, 872 ; in- 
fectious, 872 ; neurotic, 872 ; mechan- 
ical, 872 ; toxic, 872. 

Pyaemia, in newly born. 81 ; of bone (see 
Arthritis, Acute), 899. 

Pyelitis, 674. 

Pyelo-cystitis, 674. 

Pyelo-nephritis, 656, 674. 

Pylephlebitis, 460 ; cause of hepatic ab- 
scess, 460. 

Pylorus, atresia or stenosis of, 325 ; sten- 
osis, dilated stomach in, 348. 

Pyogenic diseases, acute, in newly born, 
81 ; general symptoms, 86 ; prophylaxis, 
86 ; treatment, 87. 

Pyo-nephrosis following pyelitis, 675. 

Pyo-pneumothorax in pulmonary tubercu- 
losis. 1078. 

Pyo-salpinx from gonococcus vaginitis, 
690. 

Pyuria, 650 ; in pyelitis, 676. 

Quartan intermittent fever. 1134. 

Quincke's lumbar puncture, 757. 

Quinine, dosage, 1139; methods of admin- 
istration, 1138; scarlatiniform rash, 
971. 

Quinsy. 310. 

Quotidian intermittent fever, 1134. 

Race, influence of, upon rickets, 252. 
Rachitis (see Rickets), 251. 

Reaction of defeneration, in Erb's para- 
lysis, 11.".: in facial paralysis. 111. 854 : 
in infantile spinal paralysis, 835, 838 | 
in multiple neuritis, 8 19. 

Rectal injections, astringent, 40.'', : in 
acute ileocolitis, 403 ; opium in, 403 : 
saline. 403. 

Rectum, diseases of. 452; administration 
of drugs by. <'»7 : atresia of, 352; con- 
genital obstruction of, 117; enemata, 



1166 



INDEX. 



67 ; feeding by, 67 ; haemorrhage from 
ulcers of, 456; inflammation of (see 
Proctitis), 454; malformations of, 
352 ; prolapse of, 452 ; ulcers of, 455. 

Red gum (see Miliaria Rubra), 924. 

Regurgitation of food, causes of, in young 
infants, 291 ; nasal, in diphtheria, 852, 
1032, 1040. 

Remittent fever, malarial, 1132. 

Renal calculi, 677 ; renal colic, 678. 

Rennet, ferment in digestion, 320. 

Respiration, artificial, methods of, 72 ; 
Cheyne-Stokes, in cerebro-spinal menin- 
gitis, 759 ; in meningitis, tuberculous, 
773 ; noisy at night with adenoids, 301 ; 
paralysis of, in diphtheria, 862 ; rapid- 
ity and characteristics, 510 ; in pulmo- 
nary tuberculosis, 1095. 

Respiratory system, diseases of, 478. 

Restlessness at night in rickets, 259. 

Rheumatism, 1141 ; symptoms, 1142 ; diag- 
nosis, 1145 ; treatment, 1146 ; chorea in, 
722, 1144 ; endocarditis in, 622, 1143 ; 
erythema in, 1145 ; purpura in, 876, 
1145 ; scarlatinal, 968 ; simulated by 
scurvy, 249 ; subcutaneous tendinous 
nodules, 1144 ; tonsillitis in, 310, 1144 ; 
torticollis in, 732, 1143. 

Rhiaitis, chronic, 482 ; simple, 482 ; hyper- 
trophic, 484 ; atrophic, 485 ; syphilitic, 
485 ; membranous, 487 ; hypertrophic, 
cause of asthma, 524. 

Rhino-pharyngitis, acute, 478 ; in influ- 
enza, 1125 ; with adenoids, 301. 

Rhino-pharynx, diphtheria of, 1025 ; re- 
flex cough from, 522 ; simple catarrh 
of, in acute otitis, 943. 

Ribemont's laryngeal tube, 73. 

Ribs, beading of, early symptoms in rick- 
ets, 252 ; resection of, in empyema, 
604. 

Rice water, 165. 

Rickets, 251 ; etiology, 251 ; pathology, 
253 ; lesions, 254 ; symptoms, 258 ; 
course and termination, 267 ; acute, 
268 (see also Scorbutus), 244; con- 
genital, 268 ; convulsions in, 701 ; diag- 
nosis, 268 ; from scurvy, 249, 269 ; prog- 
nosis, 269 ; treatment, 270 ; of deformi- 
ties, 271 ; dilatation of stomach in, 348 ; 
late, 268 ; spleen in, 897. 

Ridge's food, 166. 

Ringworm of scalp, 941. 

Robinson's patent barley, 165. 

Rotary spasm of head, 729. 

ROtheln (see Rubella), 993. 

Round worms (see Worms, Intestinal), 
448. 

Rubella, f)!).°> : complications and sequelae, 
!>!>r> ; diagnosis, !)!>-> ; eruption, 993 ; in- 
cubation, '.)!>:>,; symptoms, 993; treat- 
ment, !>!).-). 

Rubeola (see Measles), 977. 



Saccharomyces albicans in thrush, 287. 

Saint Vitus's dance (see Chorea), 721. 

Saline solution, as rectal injection, 403 ; 
subcutaneous injection of, in cholera 
infantum, 384 ; in acute inanition, 230. 

Saliva, 319. 

Salivation, in mumps, 1017 ; in ulcerative 
stomatitis, 285. 

Salts, inorganic, in modification of cow's 
milk, 187 ; mineral, function of, in diet, 
128 ; of cow's milk, 150 ; of woman's 
milk, 134. 

Sarcoma, of brain, 783 ; of kidney, 671 ; 
of spinal cord, 839 ; of stomach, 350. 

Scabies, 939. 

Scalp, pustular eczema of, 929 ; ringworm 
of, 941 ; seborrhcea of, 926. 

Scapula, angel-wing deformity of, 837. 

Scarlatina (see Scarlet Fever), 953; an- 
ginosa, 1058. 

Scarlatiniform erythema, causes of, 971. 

Scarlet fever, 953 ; albuminuria in, 967 ; 
angina in, 964 ; blood in, 969 ; complica- 
tions and sequelae, 964 ; desquamation, 
958 ; diagnosis, 970 ; diphtheria in, 

965 ; disinfection after, 973 ; duration 
of infective period, 955 ; eruption, 957 ; 
etiology, 953 ; heart in, 969 ; incuba- 
tion of, 954 ; invasion, 956 ; joints in, 
968 ; kidneys in, 967 ; lesions, 956 ; 
lymph nodes in, 965 ; mode of infection, 
954 ; mortality in, 972 ; myocarditis in, 
636 ; nervous system in, 970 ; other in- 
fectious diseases with, 970 ; otitis in, 

966 ; predisposition to, 953 ; prognosis, 
972 ; prophylaxis, 973 ; pseudo-diph- 
theria in, 964, 1059 ; quarantine in, 
973 ; relapses, recurrences, and second 
attacks, 963 ; symptoms, 956 ; surgical, 
962 ; throat in, 964 ; treatment, 975. 

Schultze's method of inducing artificial 
respiration, 72. 

Sclerema, 118 ; in cholera infantum, 383. 

Scorbutus, 244 ; symptoms, 246 ; treat- 
ment, 250 ; stomatitis in, 284. 

Scrofula (see Adenitis, Tuberculous), 
888; (see Tuberculosis). 

Scurvy (see Scorbutus), 244. 

Seborrhcea, 926. 

Seborrhceic eczema, 929. 

Senses, special, development of, 25. 

Sepsis in newly born, 81. 

Septum nasi, ulcer of, with haemorrhage, 
489. 

Serous membranes, frequency of disease 
of, 40. 

Serum diagnosis of typhoid fever, 1077. 

Serum-therapy of diphtheria, 1049. 

Sewer-gas, influence on sore throat, 1057. 

Shiga bacillus (see Bacillus of Dysen- 
tery), 365, 385. 

Shock in intussusception, 434. 

Shower bath, 57. 



INDEX. 



1167 



Sight, when developed, 25. 

Sigmoid flexure, length, 321. 

Singultus, 730. 

Sinuses of dura mater, thrombosis of, 
779 : lateral, in otitis, 948. 

Skin, diseases of, 922 ; anomalies of, as 
stigmata of degeneration, 818 ; of newly 
born, 922 ; care of, in newly born, 4. 

Skull, asymmetry of, in birth paralysis, 
799 ; sutures, separation of, in hy- 
drocephalus, 791 ; syphilitic nodes on, 
920. 

Sleep, disorders of, 740 ; disturbed, 7, 
740 ; with hypertrophy of tonsils, 312 ; 
in intestinal indigestion, 416 ; in rick- 
ets, 259 ; with adenoids, 301 ; excessive, 
443 ; inspection during, 34 ; proper 
periods of, 5. 

Sleeplessness, 740. 

Smallpox, protection against (see Vac- 
cination), 998. 

Smegma, 683, 686. 

Smell, sense of, when developed, 27. 

Snoring, with adenoids, 301 ; with hyper- 
trophied tonsils, 318. 

Snuffles, syphilitic, 485, 1113. 

Spasm, carpo-pedal (see Tetany), 716; 
of glottis, 719 ; habit, 727 : nodding, of 
the head, 729 : rotary, of the head, 
729 ; vesical, 697. 

Speech, disorders of, 738 ; when acquired, 
27. 

Spina bifida, 820 ; with congenital hydro- 
cephalus, 791. 

Spina ventosa (see Osteo-myelitis, Tu- 
berculous), 913. 

Spinal cord (see Cord, Spinal), 820. 

Spine, angular curvature of, in caries, 
905 : caries of, 902 ; symptoms, 903 ; 
physical examination, 887 ; diagnosis, 
907 ; treatment, 907 ; causing compres- 
sion of cord, 829 : curvature of, in hip 
disease, 910 ; hysterical affections of, 
735 ; in rickets, 261 ; lateral deviation 
of, 907 ; Pott's disease of (see Spine, 
Caries of), 902. 

Spiroehceta pallida, in syphilis. 1106. 

Spleen, diseases of, 896 ; amyloid degen- 
eration of, 898 ; enlargement of, 8!)7 ; 
in acute disease, 897 ; in chronic car- 
diac disease, 630 ; in chronic disease, 
897 : in cirrhosis of liver, 462 : in leu- 
kemia, 869; in malaria, 1134; in 
pseudo-leuksemic anaemia, 865 : In rick- 
ets, 258 ; in simple anaemia, 861 ; in ty- 
pboid fever, 1064 ; with amyloid liver, 
463; in diphtheria, 1027; in hereditary 
syphilis, ill*): in late syphilis, 1118; 
in tuberculosis, 1095; new growths and 
tumours of. 898 ; position and methods 
of examination. 896 ; weight, 896. 

Sponge bath, cold. 57. 

Sponging, cold, 49. 



Spotted fever (see Meningitis, Cerebro- 
spinal), 760. 

Spray, nasal, 57 ; steam, 61. 

Sprue (see Thrush), 286. 

Sputum, means of obtaining, for examina- 
tion, 1100. 

Stammering, 739. 

Staphylococcus, in pseudo - diphtheria, 
1057 ; in furunculosis, 935 ; in acute 
broncho-pneumonia, 532 ; in diphtheria, 
1023 ; in empyema, 597. 

Starch, in the faeces, test for, 324 ; objec- 
tions to, as food of young infants, 
128. 

Status lymphaticus, 45, 879. 

Stenosis, laryngeal, in acute catarrhal 
laryngitis, 492 ; in membranous laryn- 
gitis, 496 ; in syphilitic, 507 ; of pylorus, 
325 ; dilated stomach in, 348. 

Stercoraceous vomiting, in appendicitis, 
442 ; in intussusception, 432. 

Sterilization of milk, 153 ; changes pro- 
duced by, 153 ; at 212° F., 153 ; at low 
temperature, 154 ; indications for, 157 ; 
limitations of, 157 ; methods of, 155. 

Sterno-mastoid hematoma of, 96 ; spasm 
of (see Torticollis). 

Stigmata of degeneration, 818. 

Stimulants, alcoholic, 51 ; indications, 51 ; 
contra-indications, 51 ; administration, 
51. 

Stomach, diseases of, 318 ; absorption 
from, 321 ; bacteria of, 322 ; capacity 
of, 319 ; congestion of, in acute gastro- 
enteric intoxication, 366 ; development 
of, 319 ; digestion in, 347 ; dilatation of, 
347 ; in chronic gastric indigestion, 
343 ; in rickets, 265 ; haemorrhage from, 
350 ; in newly born, 105 ; in scurvy, 
248; inflammation of (see Gastritis), 
337 ; malformations and malpositions 
of, 324 ; round ulcer of, in chlorosis, 
862 ; thrush in, 288 ; tuberculosis of, 
1086 ; tumours of, 350 ; ulcer of, 349 ; in 
newly born, 349 ; from acute gastritis, 
349 ; tuberculous, 349 ; round, perforat- 
ing, 349. 

Stomach washing, in acute gastritis, 341 ; 
in acute indigestion, 338 : In chronic 
indigestion, 346 ; in .^astro-intestinal 
intoxication, 377 ; method, 62 ; indica- 
tions for. 63. 

Stomatitis, aphthous (see Hebpbtic Sto- 
matitis), 2kj ; catarrhal, 281; in 
measles. 987; diphtheritic, 289, ioin; : 

follicular (see BBRPBTIC STOMATITIS), 

282 : gangrenous, 2i)o ; gonococcus, 289 ; 

herpetic. 282; parasitic (see THRUSH), 
286; syphilitic. 289; ulcerative. 284 J 
vesicular (see Bbbpbtic Stomatitis), 
282. 
Stone, in the kidney, 677 ; in the bladder, 
698. 



1168 



INDEX. 



Stools, blood in, from ulcer of stomach, 
349 ; in catarrhal ileo-colitis, 394, 396 ; 
in membranous ileo-colitis, 397 ; in in- 
tussusception, 432 ; in purpura, 875 ; 
fat in, test for, 203, 362 ; green, expla- 
nation of, 362 ; in acute intestinal indi- 
gestion, 362 ; in cholera infantum, 382 ; 
in gastro-duodenitis, 342 ; in intestinal 
indigestion, chronic, 414, 416 ; in simple 
gastro-enteric intoxication, 369 ; indica- 
tion of improper feeding, 203 ; mucus 
in, in malnutrition, 233 ; undigested 
casein in, in chronic gastric indiges- 
tion, 345. 

Strabismus, in tuberculous meningitis, 
773 ; stigma of degeneration, 818 ; with 
tumour of crura cerebri, 786. 

Streptococcus, antitoxin, 1062 ; pyogenes, 
in acute broncho-pneumonia, 532 ; in 
complications of scarlet fever, 964 ; in 
dermatitis gangrenosa, 937 ; in diph- 
theria, 1023, 1027, 1036 ; in empyema, 
596 ; in peritonitis, acute, 466 ; in 
pseudo - diphtheria, 1057 ; in scarlet 
fever, 953. 

Stridor, in catarrhal spasm of larynx, 
490 : in acute catarrhal laryngitis, 493. 

Strophulus (see Miliaria Rubra), 924; 
(see Urticaria), 938. 

Struma (see Tuberculosis). 

Strychnine in acute broncho-pneumonia, 
558. 

Stupe, turpentine, 54. 

Stuttering, 739. 

Subcutaneous tendinous nodules in rheu- 
matism, 1144. 

Sucking, 318 ; as a bad habit, 743. 

Sudamina, 924. 

Sudden death, chief causes of, 44. 

Sugar, cane, derivatives in digestion, 321 ; 
substitute for milk-sugar, 127, 186 ; 
milk, determination of, 135 ; percentage 
of, in woman's milk, 134 ; milk, deriva- 
tives in digestion, 321 ; percentages of, 
in modification of cow's milk, 186 ; so- 
lutions, rules for making, 205 ; stools 
in difficult digestion of, 415 ; symptoms 
of excess of, in food, 201, 203. 

Summer diarrhoea, 364. 

Suppositories, in chronic constipation, 
426 ; medicated, 426 ; proctitis from 
long use of, 4">4. 

Suprarenal capsules, in syphilis, 1111; in 
tuberculosis, 1086; haemorrhage into, 

100. 

Sutures, closure of, 22; premature ossifi- 
cation of, 23 ; separation of, in hydro- 
cephalus, 7!>2. 

Sweating, in Infants, ( .)T1 ; of head in 
rickets, 259 ; in tuberculosis, 1094, 

Symptomatology, general considerations, 
:: '. 

Syndactyly, stigma of degeneration, 818. 



Synovitis, acute purulent (see Arthritis, 
Acute), 899; scarlatinal, 968. 

Syphilis, 1106; acute epiphysitis in, 915; 
acute osteo-myelitis in, 916 ; bone le- 
sions in, 915 ; chronic osteo-periostitis 
in, 917 ; dactylitis in, 921 ; of larynx, 
507 ; pseudo-paralysis in, 917 ; spleen 
in, 897 ; acquired, 1106. 

Syphilis, hereditary, 1107 ; adenitis in, 
887 ; bones, 1109 ; Colles's law, 1108 ; 
communicability of, 1109 ; diagnosis, 
1119 ; etiology, 1107 ; evidences of, in 
foetus, 1112 ; haemorrhages, 1115 ; le- 
sions, 1109 ; prognosis, 1119 ; prophy- 
laxis, 1120 ; pseudo-paralysis, 1115 ; 
rhinitis of, 485 ; spleen, 1010 ; symp- 
toms, 1112 ; at birth, 1112 ; treatment, 
1121 ; late hereditary, 1116 ; bones, 
1117 ; skin, 1118 ; spleen, 1118 ; teeth, 
1116 ; tertiary, chronic laryngitis in, 
507 ; intubation for, 508. 

Syringe, nasal, 58 ; for antitoxin, 1050. 

Syringing, nasal, 58 ; of mouth and 
pharynx, 59. 

Syringo-myelia, 840. 

Syringo-myelocele, 822. 

Tdche cerebrale in tuberculous meningitis, 
773. 

Tachycardia, 638. 

Taenia, cucumerina or elliptica, 446 ; flava 
punctata, 447 ; nana, 447 ; saginata or 
medio-canellata, 446 ; solium, 446. 

Tannic acid as rectal injection, 403. 

Tapeworms, 445. 

Tar ointment in eczema, 934. 

Taste, when developed, 27. 

Teeth, 27 ; eruption of first set, 28 ; per- 
manent, set, 29 ; presence of, at birth, 
28 ; care of, 3 ; decayed, cause of ade- 
nitis, 884 ; delayed, in rickets, 266 ; 
grinding of, in intestinal indigestion, 
416 ; Hutchinson's, in syphilis, 1116. 

Teething, reflex symptoms from, 279. 

Temperature, at birth, 36 : best taken in 
rectum, 36 ; in childhood, 36 ; subnor- 
mal, 36 ; raised by artificial heat, 36 ; 
variations of, in health, 36 ; general 
consideration of, 48 : of nursery. 9. 

Tenesmus, from proctitis, 455 ; in intus- 
susception, 434 ; in membranous ileo- 
colitis, 399 ; treatment of, 403. 

Tent for inhalation and vapourization, 60. 

Tertian intermittent fever, 1134. 

Testicle, retraction of, with renal calcu- 
lus, 678 ; syphilis of, 1111 ; tubercu- 
losis of, 1086 : undescended, 685. 

Tetanus, in the newly born, 89. 

Tetany, 716. 

Therapeutics, general consideration of, 47. 

Thirst, in diabetes insipidus, 653 ; mel- 
lltus, 1147 ; in hot weather, 373. 

Thomsen's disease, 730. 



INDEX. 



1169 



Thoracoplasty, 605. 

Thorax, description of, 509 : measure- 
ments of, 20, 24 ; causes of deformity 
of, 24. 

Threadworms (see Worms, Ixtestixal), 
450. 

Throat, diseases of (see Pharynx and 
Tonsils) ; importance of inspection of, 
38. 

Thrombosis, 640 : cachectic, of dural sin- 
uses, 778 : in diphtheria, 1028, 1037 ; in 
infectious diseases, 640 ; inflammatory, 
of dural sinuses, 779 ; of internal jugu- 
lar vein, 640 ; of lateral sinus in acute 
otitis, 948 ; of sinuses of dura mater, 
778 ; of the aorta, 640 : of the vena 
cava, 640 ; septic, of dural sinuses, 779. 

Thrush, 286. 

Thymus, abscess of, syphilitic, 1111 ; dul- 
ness due to, 511 ; enlargement of, caus- 
ing convulsions, 45 ; in status lym- 
phaticus, 879 ; tuberculosis of. 1086. 

Thyroid extract in cretinism, 815. 

Thyroid gland, congenital, absence of, in 
cretinism, 813. 

Tibia, deformities of, in rickets, 264 ; en- 
larged epiphyses in rickets, 254 ; sabre- 
blade deformity in syphilis, 918. 

Tinea tonsurans, 941 ; treatment, 941. 

Toes, clubbing of, in congenital heart dis- 
ease, 614. 

Tongue, diseases of, 274 ; bifid, 275 ; con- 
genital hypertrophy of, 275 ; epithelial 
desquamation of, 276 ; geographical, 
277 ; inflammation of, 277 ; malforma- 
tions of, 275 ; ulcer of frenum, 278. 

Tongue-sucking, 747. 

Tongue-swallowing, 278. 

Tongue-tie, 275. 

Tonics, 52. 

Tonsils, diseases of, 307 ; anatomy of, 
307; chronic hypertrophy of, 312; 
diphtheria of, 1024, 1031 ; hypertrophy 
of, cause ,of asthma, 524 ; hypertrophy 
of. in rickets, 266 : removal advised in 
tuberculous adenitis, 894 ; with ade- 
nitis, 887; pseudo-diphtheria of. 1058; 
membrane upon, in scarlet fever, 960. 

Tonsillitis, acute catarrhal, 307 : croupous 
(see I'sKino-niPHTiiKRiA t, 307. 10S8 ; 
ulcero - membranous, 308; follicular, 
309; in rheumatism, 1144: phlegmo- 
i 8, .^.10 ; acute otitis in, 943. 

Tonsillotomy. 313. 

Top-milk. 151. 

Torticollis. 731 : congenital. 732 : from 

- cervical Pott's disease, 7.' , .2, 904 ; from 
hoematoma of sterno-mastoid, 96 ; hys- 
terical. 735 ; in phlegmonous tonsillitis, 
311 ; in retro-pharyngeal abscess, 297 : 
malarial. 732 : rheumatic. 732 : spas- 
modic, 731. 

Touch, when developed, 26. 



Toxaemia, in intestinal indigestion, chronic, 
415 ; vomiting in, 329 ; in acute gastric 
indigestion, 336. 

Toxins, of diphtheria, 1023, 1052. 

Trachea, diphtheria of, 1025. 

Tracheotomy, for foreign body in larynx, 
509 ; in membranous laryngitis, 498 ; in 
retro-cesophageal abscess, 318. 

Trismus, in tetanus, 90. 

Trypsin, 321. 

Tubercle bacilli (see Bacillus 'of Tuber- 
culosis), 1074. 

Tuberculin test in herds, 144 ; in diag- 
nosis, 1100. 

Tuberculosis, 1070 ; age, 1071 ; anaemia, 
1096; bacillus of (see Bacillus of 
Tuberculosis), 1070; in milk, 141; of 
brain, 1085 ; bronchial lymph nodes in, 

1074 ; clinical forms of, 1087 ; broncho- 
pneumonia, 1077, 1090 ; chronic phthi- 
sis, 1101 ; chronic pulmonary, 1081 ; 
congenital, 1072 ; cases resembling mar- 
asmus, 1087 ; cases resembling a contin- 
ued fever, 1088 ; course, 1098 ; chronic, 
1081, 1096 ; diagnosis from marasmus, 
242, 1088 ; from typhoid, 1090 ; from 
broncho - pneumonia, 1098 ; etiology, 
1070; following measles, 988; follow- 
ing pertussis, 1012 ; frequency, 1070 ; 
haemoptysis, 1095 ; incipient, symptoms 
in, 1089 ; intestines, 410, 1086 ; intra- 
uterine infection, 1072 ; kidney, 670, 
1086 : lesions, 1076 ; diagnosis, 1103 ; 
physical signs, 1103 ; mesenteric, 410, 

1075 ; mode of infection, 1072 : of 
larynx, 506 ; of lymph nodes, cervical, 
888 ; paths of infection, 1074 ; pericar- 
ditis in, 619 ; physical signs, 1097 ; 
pleura in, 592, 1084 ; predisposing 
causes, 1071 ; prognosis, 1104 ; prophy- 
laxis, 1104; spleen, 898, 1085, 1095; 
sputum, means of obtaining, 1100 ; 
treatment, 1105 ; tuberculin in diag- 
nosis, 1100. 

Tuberculous, adenitis, 888 ; meningitis, 
770; nephritis, 070; ostitis. 900; peri- 
carditis, 618; peritonitis, 470; pleurisy, 
592 ; pneumonia, 1090. 

Tumour, abdominal, in intussusception, 
432; eerebral, is:; ; tuberculous. 1085; 
fatty, in cretinism, 815; of spinal cord, 
839 : mediastinal, tuberculous lymph 
nodes, 1101 ; of spleen. 897. 1118. 

Tunica vaginalis, hydrocele of. 687. 

Turpentine stupe, preparation of. 54. 

Tympanites in acute peritonitis, 167; in 
Intestinal Indigestion, 416; in rickets, 
265 : in typhoid fever. 1064. 

Typhlitis (sec APPENDICITIS), 436. 

Typhoid fever, 1062; bacillus of. In milk. 
142: complications and sequels, 1060; 

diagnosis, 1007 : etiology, 1062 : inf.-s 

tinal hemorrhage in. 1066; Intestinal 



1170 



INDEX. 



perforation in, 1063, 1060 ; lesions, 
1063 ; prognosis, 1068 ; scarlatiniform 
erythema in. 971 ; symptoms, 1064 ; 
treatment, 1069 ; urine in, 1066 ; 
Widal's test in, 1067. 

Ulcers, catarrhal, of intestine, 389 ; follic- 
ular, of intestine, 389 ; following tuber- 
culous adenitis, 892 ; of stomach, 349 ; 
tuberculous, of skin, 892, 1118 ; syph- 
ilitic, 1118; tuberculous, of intestine, 
411, 1086; typhoid, 1063. 

Umbilical vessels, arteritis in newly born, 
82 ; phlebitis in newly born, 83 ; fistula, 
114. 

Umbilicus, haemorrhage from, in newly 
born, 104 ; hernia of, 115 ; inflammation 
of vessels in newly born, 82 ; treat- 
ment of suppuration, 87 ; tumours of, 
113. 

Urachus, persistent, enuresis from, 692. 

Uraemia, acute, in scarlet fever, 968 ; in 
acute ephritis, 664 ; in chronic ne- 
phritis, 669. 

I'reter, dilatation of, 655 ; supernumerary, 
655. 

Urethra, haemorrhage from, in newly born, 
105. 

Urethritis, 686 ; gonorrheal, 686. 

Uric acid, in anaemia, 861 ; in chorea, 
725 ; in cyclic vomiting, 333 ; in mal- 
nutrition, 234 ; in early infancy, 643 ; 
infarctions, in kidney, 658 ; causing 
haematuria, 106. 

Urine, acetone in (see Acetonuria), 651 ; 
arrest of secretion (see Anuria), 652; 
albumin in, 644 ; blood in (see Hema- 
turia), 646; "brick dust" in, 649; 
composition of, 644 ; daily quantity of, 
ti-li' ; diacetic acid in, 651 ; examination 
of, 40 ; hyperacidity of, in rheumatism, 
1147; incontinence of, 692; with aden- 
oids, 300 ; in diabetes, 1147 ; in myelitis, 
SL'S : in typhoid, 1066; in vesical calcu- 
lus. 698; indican in, (see Indicanuria), 
650; in infancy and childhood, 642; 
methods of collecting, 40, 642; micro- 
scopical examination of, 643; physical 
character of, 64.",: pus in (see Pyuria), 
646; reaction of, 643; specific gravity 
"f. •'.J.".; sugar in. 644 (see also GLY- 
COSURIA), 647; urea in, 644; uric acid 

In, <; 1 1 i see also Lithubia), 649. 
Urogenital organs, tuberculosis of, 1086. 

DrO-genltal system, diseases of, 642. 

Urticaria, 988; following diphtheria anti- 
toxin, 1052; in Influenza, 1128; in in- 
teatinal Indigestion, 417 ; papulosa. 938 ; 
latiniform rash with. 972. 
Uvula, bifid, 275: diphtheria of, 1025; 
ligation of. 295; cause of asthma, 
I cough, 522 ; oedema of, 
1 Inflammation of. 29 1. 



Vaccination, 998 ; choice of virus, 998 ; 
methods of, 1000 ; revaccination, 998. 

Vaccinia, 998. 

Vaginitis, 688 ; simple, 688 ; gonococcus 
vaginitis, 689. 

Vapourizer, 60. 

Vapour bath, 56. 

Varicella, 996 ; symptoms, 996 ; diag- 
nosis, 997 ; gangrenosa, 936, 997 ; treat- 
ment, 998. 

Vegetables, allowed from third to sixth 
years, 222 : forbidden from third to 
sixth years, 223. 

Vegetations on valves in endocarditis, 626. 

Vein, internal jugular, thrombosis of, 
641 ; umbilical; 606. 

Veins, abdominal, dilated in cirrhosis of 
liver, 462 ; in thrombosis of vena cava, 
641. 

Vena cava, thrombosis of, 641. 

Ventricles, cardiac, relative thickness of, 
608. 

Vertigo, in cerebral abscess, 781 ; in cere- 
bellar tumour, 787 ; in functional dis- 
orders of heart, 638. 

Vesical, calculi, 698 ; spasm, 697. 

Viscera, abdominal, transposition of, 353 ; 
frequency of inflammations of, 41 ; 
haemorrhages of, in newly born, 99. 

Voice, hoarse or husky, with adenoids, 
302 ; nasal, with hypertrophy of ton- 
sils, 312 ; with adenoids, 301 ; in diph- 
theritic paralysis, 852. 

Volvulus, foetal, cause of malformations, 
353. 

Vomiting, 328 ; from overfilling the stom- 
ach, 328 ; in acute gastric indigestion, 
329 ; in acute intestinal obstruction, 

329 ; in peritonitis, 329 ; in nervous dis- 
eases, 329 ; at onset of acute infectious 
disease, 329 ; from toxic substances in 
the blood, 329 ; reflex, 330 ; from habit, 

330 ; chronic, 330 ; of blood, in ulcer of 
stomach, 349 ; stercoraceous, in appen- 
dicitis, 442 ; in intussusception, 432 ; 
cyclic, 331 ; symptoms, 331 ; treatment, 
334. 

Vulvitis, gangrenous, 688. 

Walking, causes which prevent, 25 : de- 
layed, in rickets, 264 ; late, in malnu- 
trition, 232 ; when attempted, 25. 

Wasting, in tuberculosis, 1094 ; simple 
(see Marasmus), 238. 

Water, function of, in diet, 128. 

Weaning. 179 ; time for. 180 ; indications 
for. 180; sudden, 181; percentages of 
milk required at, 197. 

Weather, hot, prophylaxis against diar- 
rhoea in, 373. 

Weight. 15: at birth. 16; curve during 
first few weeks, 16; curve of first year, 
17; from second to fifth year, 19; of 






INDEX. 



1171 



older children, 19 ; from birth to six- 
teenth year, 20 ; loss of, in acute inani- 
tion, 228 ; stationary, indications in, 
199 ; symptoms of unsuccessful nursing, 
173. 

Werlhof's disease (see Purpura), 871. 

Wet-nurse, in acute gastro-enteric intoxi- 
cation, 376 ; in acute inanition, 229 ; 
selection of, 178 ; dangers of syphilis, 
1121. 

Wet-nursing, 178 ; versus artificial feed- 
ing, 170 ; indications for, 170 ; disad- 
vantages of, 170. 



Wheal, in urticaria, 938. 

Whey, 162 ; whey mixtures, 210. 

White-swelling of knee, 911. 

Whooping cough (see Pertussis), 1004. 

Widal's test in typhoid fever, 1067. 

Winckel's disease, 92. 

Worms, intestinal, 445 ; tapeworm, 445 ; 

roundworm, 448 ; threadworms, 450. 
Wrist, enlarged epiphyses in rickets, 263. 
Wry-neck (see Torticollis), 731. 



Zoolak, 161. 



08) 



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