SAUNDERS' MEDICAL HAND-ATLASES. o+o. THE series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, compactness, and cheapness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, . . /des numer- ous illustrations in the text. The colored plates have been executed by the most skilful German ld Man. PLATE 2. Skulls of a Newborn Infant, of a Six-year-old Child, and of a Man. PLATE 3. Fig. 1. The Upper and Lower Jaws of a Child during the Second Dentition. Fig. 2. Complete Set of Milk Teeth. Pi, ATI: 1. Congenital Umbilical Hernia. Pi. A IK 5. Ophthalmoblennorrhca of the Newborn. PLATE 0. Fig. 1. Bony Development. Fig. 2. Normal Border between Bone and Cartilage. PLATE 7. Rachitis at the Junction of the Bony with the Cartilag- inous Portion of a Rib. PLATE S. Fig. 1. Fetal Chondrodystrophia. Fig. '_'. -Rachitis of a Flat Cranial Bone. Craniotabes. PLATE 9. Barlow's Disease. PLATE 10. Purpur.i Ilemorrhagica. Pi. ATI-: 11. Papular Rash of the Nates and Labia Majora in Hereditary Syphilis. PLATE 12. Fig. 1. Diphtheria of the Uvula. Fig. 2. Syphilitic Infiltration of the Liver. PLATE K'>. Syphilitic Changes in the Kidneys. Pi, ATE 14. Fig. 1. Congenital Syphilis of the Intestines. Fig. 2. Syphilitic Osteochondritis. PLATE 15. Congenital Tuberculosis. PLATE !(>. Scrofula. PLATE 17. Acute Disseminated Tuberculosis of the Lungs. Pi.\ii:lS. Kii.-. 1. Chronic Tuberculous Peritonitis. Fig. 2. Umbilical Fungus. PLATE 10. Acute Tuberculous Basilar Meningitis. PLATE 20. Tuberculosis of the Knee-joint. 8 LIST OF LITHOGRAPHIC PLATES PLATE 21. Early Symptoms of Measles. PLATE 22. The Eruption of Mea.slesTwo Days after its First Appear- ance. PLATE 23. The Eruption of Kubella One-half Day after its Apjxsir- ance. PLATK 24. The Exanthem of Scarlet Fever (Third Day). PLATE 25. Fig. 1. Scarlatinal Angina (Third Day). Fig. 2. Lacunar Angina. PLATE 26. Normally Developed Vaccine Pustules on the Plight h I >ay after Vaccination. PLATE 27. The Eruption of Varicella on the Fourth Day. PLATE 28. Fig. 1. Diphtheria of the Lips following Measles. Fig. 2. Diphtheria of the Pharynx. PLATE 29. Diphtheria Gravis ( Gangrenous, Septic Diphtheria). PLATE 30. Diphtheria of the Conjunctiva. PLATES 31, 32. Tracheotomy. PLATE 33. Low Tracheotomy. PLATE 34. Fig. 1. Confluent Bronchopneumonia. Fig. 2. Bronchitis and Beginning Bronchopneumonia. PLATE 35. Fig. 1. Aphthous Stomatitis and Beginning I'lrerative Stomatitis. Fig. 2. Thrush of the Oral Cavity. PLATE 3(5. Noma of the Cheek. PLATE 37. Fig. l.--The Stool of Melena Neonatorum. Fig. 2. Dyspeptic Stool of a Breast-fed < 'hild. Pi, ATE 38. Fig. 1. The Stool of Intestinal Catarrh. Fig. 2. The Stool of Infectious Colitis. PLATE 39. Prolapsus Recti. PLATE 40. Universal Seborrhea (Cutis Sebacea, Congenital Ichtliy- osis). Pi, \ ri: 41. Pemphigus Neonatorum. PLATE 42. Pemphigus Syphiliticus (Exanthema Pipulo-vesioo-pustu- losum). PLATE 43. Chronic General Eczema. PLATE 44. Crusta Lactea. PLATE 45. Impetigo Contagion. Pi.vn: 1 1'. Krythema Exudativum Multiforme. Pi. ATK 17. Lichen Scrofulosorum. PLATE 48. Scabies. CONTENTS PAGE ANATOMIC PECULIARITIES 17 The Fetal Circulation 17 The Skeleton . . .... 18 Internal Organs 23 PHYSIOLOGIC PECULIARITIES 28 Growth in Length . . 28 Skull and Chest Measurements 29 Increase in Weight 30 Digestion 37 NOURISHMENT 39 Natural Feeding 39 Artificial Feeding 44 Freeing Milk of Foreign Material and Bacteria 45 Equalizing the Chemicophysical Differences According to Various Methods 46 KXA.MIN.VTIOX AND II I STORY 49 Anamnesis 50 The Proper Method of Examining a Child 51 Inspection 55 Palpation 58 Auscultation 63 Percussion 63 Mensuration 66 Secretions and Excretions 67 GEXERXL MANAGEMENT OF I)ISKASK IN CHILDRKX 68 Dietetic Treatment 68 Ilydrotherapy 69 Medicinal Treatment 71 DISEASES OF THE NEWBORX 75 General Loss of Vitality and Premature Birth 75 Diseases of the I'nibilicus 81 9 10 CONTENTS DISEASES OF THE NEWBORN. Diseases of the Umbilicus. PAGE Treatment of the Normal Umbilicus M Congenital Umbilical Hernia 81 Acquired Umbilical Hernia 81 Umbilical Hemorrhage 84 Umbilical Fungus. Umbilical Growths 84 Infection of the Umbilicus 85 Sepsis of the Newborn 8G Blennorrhea Neonatorum, Ophthalmia Neonatorum .... 88 Tetanus Neonatorum 90 Melena Neonatorum 93 Acute Hemoglobinuria 94 Blood-tumor of the Head. Cephalhematoma 94 Mastitis Neonatorum 95 Malformations 96 Malformations from Arrested Development, Monstra per Defectum 96 Deformities of the Extremities 108 CONSTITUTIONAL, DISEASES 114 Rachitis 114 Symptoms 114 Direct Results of Disease of Skeleton !-<> Phenomena which are Not Directly Due to Di>ea.-f <>t' Skeleton l'J<> Etiology I! Normal Ossification 1-- Pathologic Anatomy 1-1 Diagnosis 1-7 Treatment l'J9 Congenital Disturbances in Bone Development K!') Barlow's Disease 137 Diseases of the Thymus Gland 138 Struma 138 Basedow's I !<;!* l.'J'.i Hypothyroidism 139 Dysthyrnidisin 139 Obesity 146 Hemocrhagic IHntln-sis. Ptirpura 146 Siinj)le Purpiira 146 Rheumatic Purpura (Peliosis) 147 CONTENTS 11 CONSTITUTIONAL DISEASES. Bemorrhagic Diathesis. Purpura. PAGE Hemorrhagic Purpura 147 Abdominal (Henoch's) Purpura 147 Fulminating Purpura . . 148 Treatment of Purpura 148 Anemia 149 Chlorosis 150 Treatment of Anemia and Chlorosis 150 Splenic Anemia : Infantile Pseudoleukemia 151 CHRONIC INFECTIOUS DISEASES 152 Hereditary or Congenital Syphilis : Heredosyphilis .... 152 Tuberculosis 168 Peculiarities . 170 Symptoms of General Tuberculosis 172 Tuberculosis of the Bronchial Nodes 173 Scrofula 174 Treatment of Tuberculosis and Scrofula 178 Tuberculosis of the Lungs 180 Tuberculous Pleurisy 183 Tuberculous Pericarditis 184 Abdominal Tuberculosis . . . , 184 Tuberculous .Meningitis 187 Tuberculosis of the Bones and Joints 194 Spina Ventosa 196 Spondylitis. Tuberculous Caries of Vertebrae .... 196 Coxitis 198 Tuberculosis of the Knee-joint 201 Tuberculosis of the Joints of the Feet 203 Tuberculosis of the Elbow 203 I >i< i :ASES OF THE NERVOUS SYSTEM 204 Diseases of the Brain and its Membranes 204 Cerebrospinal Meningitis 204 Purulent Meningitis 206 Serous Meningitis. Meningismus 207 Thrombosis of the Cerebral Sinuses 207 Circulatory Disturbances of the Brain 208 Hyperemia 208 Anemia 209 Chronic Ilydrocephalus 209 Encephalitis 217 12 CONTENTS DISEASES OF THE NERVOUS SYSTEM. I >iscases of the Brain and its Membranes. PAGE Cerebral Infantile Palsy 217 Tumors 224 Diseases of the Spinal Cord 225 Spinal Infantile Paralysis 225 Transverse Myelitis 229 Friedreich's (Hereditary) Ataxia 230 Spastic Spinal Paralysis 230 Functional Nervous Diseases 230 Eclampsia 230 Tetany ' 233 Pseudotetanus 236 Laryngospasrn 236 Spasmus Nutans 239 Salaam Convulsions 239 Congenital Myotonia 239 Peripheral Paralyses . 240 Chorea Minor 240 Epilepsy 212 Nervousness 2 1 "> Neurasthenia 2 1"> Hysteria 2-16 Night Terrors 248 Masturbation '-is Psychoses 249 Imbecility 249 Amaurotic Idiocy of Families 249 Moral Insanity 250 Juvenile Insanity 250 Primary Progressive Myopathy 250 AcrrK INFECTIONS DISEASES 2~>2 General Discussion . 252 Measles 256 Rubella 261 Srarlet Fever 2(12 Small-pox .267 Varicella 27:! Diphtheria 27.'. Typhoid Fever 292 Influenza . . 294 CONTENTS 13 ACUTE INFECTIOUS DISEASES. PAGE Whooping-cough 296 Mumps 299 DISEASES OF THE CIRCULATORY APPARATUS 303 General Considerations 303 Congenital Heart Disease 305 Pericarditis 307 Endocarditis 309 Myocarditis 311 Fatty Degeneration of Heart Muscle 311 Diseases of the Blood-vessels 312 Lymphadenitis '. 3J2 DISEASES OF THE RESPIRATORY ORGANS 315 General Discussion 315 Acute Rhinitis 315 Chronic Rhinitis and Ozena 316 Acute Laryngitis and Pseudocroup 318 Papilloma of Larynx 322 Foreign Bodies in the Air-passages 322 Hyperplasia of the Thymus Gland 323 Nervous or Bronchial Asthma 323 Acute Tracheitis and Bronchitis 324 Chronic Bronchitis 326 Capillary Bronchitis 326 Bronchopneumonia 328 Croupous Pneumonia 333 Chronic Pneumonia 335 Pleurisy 337 DISEASES OF THE DIGESTIVE ORGANS 342 Diseases of the Mouth and Pharynx 342 General Discussion '.\\'l Bednar's Aphthae 342 Stomatitis 342 Thrush 345 Noma . - 346 Angina 347 Hyperplasia of the Lymph-tissue of the Pharynx . . . 349 Retropharyngeal Abscess 353 Gastro-intestinal Diseases 354 General Discussion 354 Dyspepsia 360 14 CONTEXTS DISEASES OF THE DIGESTIVE ORGANS. Gastro-intestiual Diseases. PAGE Intestinal Catarrh 361 Cholera Infantum 362 Intestinal Inflammations 363 Chronic Anections 365 Atrophia Infantum 366 Atony of the Stomach and Intestines 374 Appendicitis 375 Congenital Stenoses and Atreshe of the Gastro-intestinal tract 375 Intestinal Imagination 380 Intestinal Parasites 380 Diseases of the Liver . . . 383 Icterus 383 Acute Peritonitis . - 383 Chronic Peritonitis 383 DISEASES OF THE GENITO-URINARY TRACT 385 Diseases of the Kidneys 385 General Discussion 385 Albuminuria 385 Hematuria and llemoglohinuria . . 387 Acute Parenchymatous Nephritis 388 Chronic Nephritis 390 Urinary Concretions 391 Pyelitis 394 Hydronephrosis :>!."> Diseases of the Bladder and Sexual Organs o'.i~> Pollakiuria and Enuresis 395 Cystitis 396 Preputial Epithelial Adhesion 398 Phimosis 398 Ilypospadias. Epispadias 400 I udescended.Testes 400 Hydrocele 402 Cellular . Atrt-sia of the Vulva ... .403 Vulvovaginitis. Gangrene and PhU-gmasia of the Vulva . 404 DISEASES OF THE SKIN 406 . General Discussion 406 Nevi 406 Seborrhea 408 CONTENTS ] 5 DISEASES OF THE SKIN. PAGE Ichthyosis 411 Pemphigus Neonatorum 414 Dermatitis Exfoliativa - 415 Scleroma Neonatorum 417 Eczema .' 419 Prurigo 425 Erythema Exudativum Multiforme and Erythema Nodo- sum 426 Lichen Urticatus 428 Urticaria 428 Lichen Scrofulosorum 429 Herpes 430 Scabies 431 Pediculosis Capillitii 432 Herpes Tonsumns 433 Folliculitis Abscedens 433 INDEX . 437 DISEASES OF CHILDREN GENERAL PART THE fact that certain diseases are peculiar TO infants and that many of the disea-es of' adult lite assume an altogether different eharaeter in children, depends lc-s upon differences in causation than upon the difference in the region attacked by the disease process. A thorough knowledge of the construction and function of the infan- tile body is absolutely necessary in order to understand the diseases of children. In general, the body of a child is characterized by its diminutive sixe. by its diminished re-i-tanee. and the consequent hypersensitiyeness of the organs, by increase in growth and alterations in form, together with the associated variations of the physiologic functions and reactions of the organs. ANATOMIC PECULIARITIES THE FETAL CIRCULATION The blood circulates through the fetus a< follows: From the placenta through the umbilical vein ; the latter divides into two branches at the liver, one empties into the portal vein and the other, as the dnctus venosns Arantii, into the inferior vena cava. This vessel in turn empties into the right auricle, whence the blood is guided by means of the Kustaehian valve through tin* foramen ovale directly into the left auricle. The blood then Hows into the left ventricle, the aorta, the major circulation, and in part through the hvpogastrie and umbilical arteries, to be aerated in the placenta. The blood from the superior 18 ANATOMIC PECULIARITIES FIGURE i Circulation in the Fetus. 1. Umbilical veiu. 2. Branches <>f the portalvein. 3. Ductus veuosus Arantii. 4. Inferior vena cava. 5. Aorta. 6. Hypogastric arteries. 7. Umbilical arteries. 8. Superior venu <-ava. 9. Pulmonary artery. 10. Ductus arteriosus Botalli. vena cava flows into the right auricle, and passing the blood current from the inferior vena cava, enters the right ventricle and the pulmonary artery ; from here only a small portion of the blood enters the lungs, while the greater portion passes through the ductus arteriosus Botalli into the aorta. Thus the fetus receives none but mixed blood, for together with the blood from the umbilical vein, the liver also receives blood which has already been used from the portal vein. The liver, the head, and the upper extremities are supplied with blood richly laden with oxygen, while the lower half of the body receives blood poor in oxygen. The blood in the lungs is purely venous. After birth the expansion and congestion of the lungs causes the pressure in the left auricle to lessen and to equal that of the right auricle, on account of which the foramen ovale closes. The ductus arteriosus Botalli receives less blood, and the change in the position of the lungs causes it to become constricted, thrombosed, and obliterated. The three umbilical vessels and the duetus Arantii likewise become obliterated on account of ce>acrum, as well a- the forward growth of the promontory of the sacrum. Vertebrae. Aside from the promontories the subsequent Tab. I Tab. 2 THE SKELETON 21 curvatures of the spine are still absent or only indicated, and the vertebra appear to form a straight line. The final shape of the spine is due to the weight of the body and the traction of the muscles. Voluntary raising of FIG. 3. Thorax of an adult man. The sternum and ribs have descended ; the upper aperture is hent downward ; the sternum is nearer the spinal column. (Preparation from the Anatomic Institute in Munich.) the head in from two to three months forms the cervical curvature ; the standing posture at about the twelfth month, the traction of the erector muscles of the trunk, 22 ANA TO MIC PECULIA RITIES and the weight of the abdominal organs tend to increase the lumbar curvature. The weight of the body in sitting, the traction of the shoulder and the rectus muscles, help to form the dorsal curvature. FIG. 4. Thorax of an adult woman. The descent of the anterior wall of the thorax is even more pronounced than in man. ( From a clmrt in the Anatomic Institute in Munich.) Extremities. Aside from the undeveloped state of the neck of the humerus, there are no great differences in form ; the foot, which originally is poor in fat, later, in INTERNAL ORGANS 23 the crawling and walking period, becomes encased in fat, showing the same skeletal structure as in the adult (Spitzy). The epiphyses of the long cylindric bones, the hand, and the tarsal bones are still cartilaginous ; their ossification is not completed until nearly the sixteenth year (Rauber, von Ranke). The body surface is much greater than in adults ; to each kilogram [2.2 Ibs.] of body weight there are 810 sq. mm. [12.5 sq. in.] of surface in the newborn, 620 sq. mm. [9.6 sq. in.] in infants six months old, 450 sq. mm. [6.9 sq. in.] in seven-year-old children, and 320 sq. mm. [4.9 sq. in.J in adults. INTERNAL ORGANS The Thymus Gland. This organ, occurring only in children, lies in the anterior mediastinum and is con- cerned in the formation of blood. Its size varies in individuals of the same age ; it is from 2 to 7 cm. [.8-1.4 in.] in width and from 5 to 10 cm. [2-4 in.] in length, and weighs in the newborn on an average 12 gm. [191 gr.]. The gland continues to grow during the first year of life, after which it diminishes in size on account of atrophy of the glandular substance, which is replaced by connective tissue, and disappears at the time of puberty. The Liver. This organ is relatively larger and heavier than in adults. It weighs in newborn and nursing infants one-twentieth of the body weight, whereas in adults it weighs only one-fiftieth of the total weight of the body. The lower edge runs obliquely from the crest of the right ilium above the umbilicus toward the left to the region of the ftindus of the stomach. The left lobe reaches the left anterior axillary line. The Kidneys. These are tabulated and comparatively large. The histologic structure of the liver, kidneys, and pancreas at the time of birth is still in a transitional stagr of the process concerned in the formation of a definite structure. The liver and kidneys probably still possess for a time after birth the fetal blood-producing function. 24 ANATOMIC PECULIARITIES FIG. 5. Median sectiou of a newborn infant. Aside from a slight promontory curvature, the vertebrae still form an almost perfVctly straight line. (From a preparation in the Munich Gynecologic Clinic.) FIG. 6. A median frozen section through the body of a six-year-old boy. The vertebral column shows a slight cervical and dorsal curvature and a fairly well-developed promontory. The spine is, however, still quite straight, especially in the lower dorsal and lumbar portion. A physio- logic lumbar lordosis is distinctly marked in life (J. Symington). FIG. 7. Median section through the skeleton of an adult man. The curvatures of the spinal column are fully developed ; the anterior wall of the thorax has descended and the pelvis tilted. (Preparation in the Anatomic Institute of Munich.) The Stomach. The stomach occupies a more vertical position, the fundus is but slightly formed, and the musculature, especially about the cardia, is but poorly developed. The normal position and shape are developed in the course of the first year. The mucosa, with its rich blood supply, is more sensitive to thermal and chemic irritants, which together with the position of the organ, the small fundus, and weakness of the cardia, all explain the tendency of the infant to vomit. The capacity of the stomach is increased from about 40 ccm. [1.3 oz.l at the time of birth to from 300 to 400 ccm. [10-13.5 oz.] at the end of the first year of life. The Intestines. The length of the intestines in nursing infants is six times that of the body, whereas in adults it is only four and a half times the body length. The ca- pacity in the new born is 5000 ccm. [10 pints], in twelve- year-old children 9000 ccm. [18| pints], and in adults only 4000 ccm. [13 pints] to 1 kilogram of body weight. The mucosa is sensitive and contains incompletely de- veloped glands. The weakness of the musculature favors constipation and explains the frequent tendency to dilata- tion and enteralgias. The intestines possess a great absorptive capacity, but relatively deficient digestive power. The colon runs without an hepatic flexure par- allel to the edge of the liver obliquely from the right iliac crest upward toward the left. The Nervous System. The dura is attached to the cranium. The brain is large and heavy and equals 13 to Flu. 5. FIG. 6. 26 FIG. 7. 27 28 PHYSIOLOGIC PECULIARITIES 14 per cent, of the body weight, in contradistinction to 2.7 per cent, in adults. It grows very rapidly during the first year, at the end of which time it reaches one- half of its permanent weight. The convolutions are but slightly differentiated and there are but few medullatcd nerve-fibers. The psychomotor subcortical inhibitory centers are but slightly excitable, as are also the per- ipheral sensory and motor nerves during the first six weeks (Soltmann, Westphal). The musculature is relaxed, pale, watery, and is readily fatigued. The adipose tissue is present in large amounts. In the cheeks, where it possesses distinct anatomic boundaries, it forms a cushion of fat, and is of assistance in the act of sucking (von Ranke). When the baby begins to walk about he loses much of this fat ; that of the cheek is the last to disappear. Female Genitals. These are not closed. The labia minora, hymen, and urethra are visible, and therefore the infant is predisposed to vulvovaginitis and cystitis. PHYSIOLOGIC PECULIARITIES GROWTH IN LENGTH The average length of a newborn infant is 50 cm. E20 in.], in boys 51 cm. [20.2 in.J and in girls 49 cm. 19.8 in.]. The length of the body at various ages, according to E. von Lange, is as follows : Age in) months) Birth. I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Body ) length > 49.5 55.2 f.1.0 r,3.o 64.7 66.2 67.5 68.8 69.9 71.0 njo 73.0 (cm.) 1 Body ) length > 19.8 22.0 23.4 24.4 25.2 25.8 26.4 27.0 27.9 28.4 28.8 29.4 (in.)] j The increase in the length of the body is practically the same for both boys and girls during the first two years, but from then until the thirteenth year the female child grows more slowly. After the thirteenth year, SKULL AND CHEST MEASUREMENTS 29 however, because of their earlier period of puberty, girls grow more rapidly and overtake the gain made by the males previous to that time. After its fifteenth year, however, the female child grows less in length than the male. During the first year the child grows about 23 cm. [9.2 in.] ; in the second year, about 10 cm. [4 in.] ; in the third year, 8 cm. [3.2 in.], and in the fourth year, 7 cm. [2.8 in.]. In four years it has doubled its growth and in four- teen years trebled it. Body Length, According to E. von Lange Age in years. Boys. Girls. Age in years. Boys. Girls. 1 73.0 73.0 10 130.7 130.0 ) 83.1 83.1 11 135.0 134.6 3 91.5 91.3 12 139.2 140.3 4 99.0 98.7 13 1438 147.6 5 106.4 105.0 14 149.7 153.8 6 111 -1 110.7 15 156.7 157.3 7 116.5 116.0 16 163.5 159.0 8 121.5 120.9 17 167.6 159.7 9 126.2 125.6 18 169.4 159.9 i SKULL AND CHEST MEASUREMENTS Of the skull measurements the fron to-occipital periph- ery is to be measured over the most prominent portion of the frontal and occipital bones. Aside from this measurement, in the case of cranial disease, the following distances are to be measured : The bitemporal from one external ear to the other; the fronto-occipital diameter from the glabella to the occipital protuberance; the biparietal, from one parietal protuberance to the other. The circumference of the chest is taken midway between inspiration and expiration while the arm- are held in a horizontal position. The circumferences of the skull and chest increase symmetrically until about the fifth year, but after that 30 PH TSIOLOQTC PECULIARITIES time the chest grows more rapidly. It is to be noted that the circumference of the chest usually exceeds one- half of the body length by from 9 to 10 cm. [3.6-4 in.]. Head and Chest Measurements (Heubner) Age. 1 month 35.4 cm. 6 months 42.7 1 year 45.6 2 years 48.0 4 years 50.0 5 years 50.0 8 years 51.3 12 years 52.3 Circumference of head. 14.1 in.l 17.0 18.4 19.2 20.0 20.0 20.5 20.9 Circumference of chest- 34.2 cm. 41.0 46.0 47.3 49.0 52.0 58.0 65.0 13.6 in.] 16.4 18.4 18.9 19.6 '20.8 : 23.2 r 26.0 INCREASE IN WEIGHT The average weight of a newborn infant is 3250 gm. (extremes 2500-4000 gm. and over), boys weighing a little more than girls. The physiologic loss of weight during the first three or four days equals about 200 gm. This depends upon the lack of proportion between ingestion and excretion ; discharge of meconium and urine, excre- tion through skin and lungs, and the small amount of nutritive material ingested. In from five to eight days the original weight is usually regained. The weight of the body increases steadily or intermit- tently with diminishing rapidity. The daily increase in weight is originally 30 gm. ; but after a year only about 10 gm. There is, as a rule, a loss of weight during the ninth month of life (dentition, change of nutrition) and in the first year of school life. At the -end of five months the weight is about double the original weight ; after a year, three times ; after six years, six times ; and after the thirteenth to the fourteenth years, twelve times the weight at birth. Bottle-fed infants weigh less than breast-fed children up to nine months of age, but after that time soon regain this loss and later show no difference. INCREASE JN WEIGHT Tables of Weights, According to Heubner 31 (a) First year oflife (breast-fed infants). Gm. Original weight 3433 End of 4th week .... ... 4008 End of 8th " 4907 End of 12th "... 5600 End of 16th " 6294 End of 20th " 6824 End of 24th " 7289 End of 28th ' 7774 End of 32d 8175 Kixl of 36th ' ... 8655 Knd of 40th ' 8855 End of 44th ' 9232 End of 48th " 9589 End of 52d " 10141 (fc) Between 2 and 18 years of age. Boys Girls. At the end of 2 years 132 b tr 120 ke At the end of 3 years 154 ?' 14.0 " At the end of 4 vears 168 157 " At the end of 5 vears 193 175 " At the end of 6 years . . . At the end of 7 years .... 21.1 23.0 19.0 " 207 " At the end of 8 vears 249 225 " At the end of 9 years ... . . 268 249 " At the end of 10 vears 294 264 " At the end of 11 yea re ... At the end of 12 vears .... 32.1 34.9 29.1 " 337 " At the end of 13 years At the end of 14 vears 38.2 426 37.9 ' 426 ' At the end of 15 vears .... 51 472 ' At the end of 16 years 57 1 482 ' At the end of 17 veal's 62 7 49 2 ' At the end of 18 years . ... 660 500 ' The increase in length and weight are not proportion- ate. During the period of active body growth the in- crease in height exceeds that of the weight (Axel Key). During the summer there is usually a decided increase in height, but only a slight increase in weight, whereas during winter the reverse holds true (Mailing, Hansen). 32 PHYSIOLOGIC PECULIARITIES Table of the Average Height, Weight, Head Circumfer- ences, and Chest Measurements of American Boys and Girls. (From Koplik.} Years of age. Sex. Height. Weight. Head circum- ference. Depth of chest. Breadth of chest. Chart expan- sion. In. Cm. Lbs. Kg. In. Cm. In. Cm. In. Cm. In. Cm. ^\ / Bovs 41.7 105.9 41.6 18.9 20.1 51.2 4.9 12.3 7.1 18.1 1.:; 3.4 * ; 1 Gir'ls . 41.3 104.9 40.7 18.5 19.7 50.2 4.8 12.3 7.0 17.7 1.4 3.5 K , j 'Boys . . 43.'i 111.9 45.2 20.5 20.2 51.5 5.0 12> 7.2 18.4 l.C, 4.2 bi ' 1 Girls . . 13.3 109.0 43.4 19.5 19.8 50.3 4.9 12.3 7.0 17.7 1.6 3.8 Boys . . i46.0 116.8 49.5 22.5 20.4 51.9 5.1 12.1) 7,1 18.9 1 .8 I 5 "1 . Girls . '45.7 116.0 47.7 21.6-20.0 50.9 1.9 12.5 7.2 18.4 1.8 1.6 01 Boys . 48.8 123.9 54.5 21,1 211.5 52.2 5.1 12.h T.ti 19.4 2.3 5.9 8J . . Girls . 47.7 121.1 52.5 2:;.s 211.2 51.2 4.9 125 7,1 18.9 2.0 5.0 Boys . 50.0 127.0 :>!)/> 1:7.1 1 2(l.ii 62.4 5.2 13.2 7.8 19.7 2.5 6.5 9J Girls . 49.7 126.2 57.4 26.0 20.4 51.9 5.1 13.1 7.0 19.3 2.2 5.6 Bovs . 51.9 131.8 (M.4 29.5 20.6 52.6 5.2 13.21 8.0 20.2 2.7 7-n 10J . . Girls . 150.7 131.3 62.9 2s.:> 20.5 52.0 5.1 Kin 7.s 19.8 2.4 6.0 nT Boys . . 53.6 136.1 70.7 32.2 20.8 52.9 5.4 13.8 8.2 2(1.'.) 2.8 7.3 2 Girls . . 53.8 136.6 69.5 ! 31.5 20.7 52.5 5.2 13.1 8.0 2ii.;; 2.6 6.6 1O1 Boys . j 55.4 140.7 i 76.9 34.9 21.0 53.3 5.6 14.1 8.5 21.5 3.0 7.8 24 .. Girls . r>6.1 1425 78.7 35.7 20.9 53.0 5.4 13.8 8.4 21.0 2.4 ti.2 Boys . . 57.5 146.0 84.8 38.5 21.1 53.5 5.6 14.3 8.7 22.1 3.2 8.2 13J . . ; Girls . 58.5| 148.6 88.7 40.3 21.0 53.5 55 14.1 8.7 22.1 2(1 6.6 I Boys . . 60.0 1W.3 95.2 43.2 21.3 54.1 5.9 15.0 8.9 22.7 3.3 8.4 14 * ' i Girls . . i.n 1 153.4 98.3 44.6 21.3 54.1 5.7 14.5 9.0 22.!) 2.7 6.8 TCI \ Boys . . 62.9 159.7 1(17.4 48.8 21.4 54.5 6.3 KI.II 9.3 23. 6 3.3 8.4 15 *' ' \jGirls . 61.6 156.4 106.7 48.5 21.5 54.6 60 i:, :: 9.5 23.8 2.8 6.5 Table of Weight, Length, Head Circumference, and Girth of Chest from Birth to the End of the Fourth Year. (From Koplik.) Age. Sex. Length. Weight. Head circumfer- ence'. Chest girth. In. Cm. l.l.s. Kg. In. Cm. In. Cm. Birth i Boys . . 19.7 500 7,1 3.45 13.8 35.1 12.6 32.0 Girls . . 19.3 19.0 7.1 13.1 33.4 11.8 30.0 6 months . j Boys . . Girls 25.4 25.0 64.8 16.0 15.5 '72 70 16.0 16.4 41.7 15.7 15.2 :;'.i ;i 88.6 12 months . j /j; 1 ^ 29.5 28.7 73.8 73.2 21.5 21.0 9.8 9.6 17 - 18.2 16 :: lfi.3 17.8 19.0 48.8 f RnvQ '* voars < * 33.8 84JS 30.3 13.8 19.3 19.0 20.0 32.9 82.8 29.2 13.3 18.0 45 C. 18.0 IS.II o ,,_, JiBoys 1 Girls 37.0 M.8 92.6 907 34.9 33.1 16.9 16.0 19J 10.0 49.0 18.4 20.1 19.8 51.1 4 years . . j Boys . . Girls . . 39.3 38.8 98.2 97.0 37.9 36.3 17.2 16.5 19.7 19.5 60.8 49.6 20.7 20.5 .V2.8 52.2 INCREASE IN WEIGHT 33 Daily Increase In \\'<'ih " (see Strophulus infantum). [It is very doubtful whether all these symptoms are produced by dentition. We would grant that local discomfort and general rest- lessness-might occur at this time. It does not seem in accord with modern pathologic conceptions to assume that convulsions, cough, vomiting, diarrhea, etc., can re- sult from, teething. These for the most part acute con- ditions disappear very shortly under appropriate treat- ment, though the process of dentition still continues. ED.] The resorption of the milk teeth begins with the dis- appearance of the last deciduous teeth by the crowding onward of the permanent teeth. The latter lie almost completely developed back of and underneath the milk teeth, and on account of insufficient space are frequently pushed upward or downward. Thus the particularly large canine tooth is displaced as far as the infra-orbital foramen. DIGESTION The oral apparatus of the suckling functionates only as a pump ; chewing and salivation are impossible on ae- count of the weak muscles of mastication, the lack of teeth, and the insufficiency of saliva. The oral cavity of a newborn child is dark red in color and dry. Only traces of the diastase ferment are present, but appear in appreciable quantities after the second month. The in- fant can, therefore, ingest nothing but liquids. Pepsin, hydrochloric acid, and rennin are secreted in the stomach. The casein of the milk is precipitated, and the free hydrochloric acid becomes united with the casein, which is partially dissolved. From the sugar of milk 38 PHYSIOLOGIC PECULIARITIES lactic acid is formed. Aside from the above action hydro- chloric acid has a bactericidal one also. The nutriment leaves the stomach of artificially fed children in from three to four hours, while in breast-fed children it paf- ont in from one and a half to two hours, that organ serv- ing only as a collecting and preparatory station. The fate of the food in the intestines through which it pa-.-cs in six to eight hours is as follows : The pancreatic juice and the bile alter its reaction and color; the albumin digestion continues ; the casein becomes peptonized ; the fats are split up, saponified, and absorbed ; the sugars and dissolved salts are absorbed, as are also the albumins. In the large intestine the water and the remaining unabsorbed dissolved substances are absorbed. The bac- teria, which are normally present in the large and small intestines (Bacillus acidophilus Moro; B. coli and B. lactis aerogenes Escherich), are important for the pur- pose of proteid digestion, fermentation of mi Ik -sugar, protection against invading pathogenic micro-organisms, and to excite peristalsis. The undigested portions of the food and the residue of the digestive juices pass out as feces and eventually form pathogenic products. The stools of the first few days the meconium are blackish green in color, odorless, acid, and composed mainly of the digestive agents excreted by the intestines. Microscop- ically they contain cylindric epithelium, mucoid bodies, fat globules, cholesterin, and minute hairs. Next follow transitory stools, which partake of the color of meconium and milk stools. The normal luva-t stool is golden yellow in color, of the consistency of soft paste, frequently somewhat nodular, almost odorless, and slightly acid in reaction. The normal stool of babies fed on cows' milk is paler and of a lighter yellow color, it possesses the consistency of paste, and is formed. As a rule it has an acrid odor, slightly acid or alkaline .in reaction, and is discharged in larger quantities. Alter the ingestion of a meal, especially cereal foods, the stools become brownish in color. The constituents of the stools are 85 per cent, water, casein, fatty acid salts, mucus, NATURAL FEEDING 39 sodium chlorid, cholesterin, and bilirubin. A microscopic examination shows micro-organisms, fat, epithelial cells, and vegetable debris. NOURISHMENT NATURAL FEEDING The only form of nutriment which is fully adequate for the nourishment of a child's body is that derived from its mother's milk. Such nourishment should be attempted in every case, excepting when the mother is suffering from pronounced tuberculosis, for it is also of advantage to her (favors prompt involution of the genitals, protec- tion against conception, and has a tendency to improve the nourishment of her own body). When there is really insufficient milk, artificial feeding should be accompanied by at least several attempts to feed from the breast, as this mixed feeding is of greater value to the child than a purely artificial diet. Constituents of Human Milk. Water, albuminoids, fat, sugar, and salts. Aside from these elements, human milk contains also unknown antitoxins and immune bodies, as well as a number of ferments (Escherich, Moro), which are of importance for internal metabolism. After a period of nursing the following characteristics are noted : Colostrum is the name given to the milk during the first eight days. It is richer in albumin and salts, but poorer in fat, and contains larger amounts of the so-called colos- trum bodies z. e., fatty degenerated mammary epithe- lium (see Fig. 8, 6). The milk of the first two months shows an increase of albumin, salts, and colostrum bodies, and gradually comes to resemble the permanent milk. Permanent milk remains nearly constant as to its con- stituents during the whole period of lactation ; it no longer contains colostrum bodies, and the fat globules 40 NOURISHMENT l&S (Stoo JQ * 3Shj5 e^K-- m&. FIG. 8. (a) Maternal milk. The fat globules are of varying size, but show, as a rule, equal subdivision ; no colostrum bodies. (b) Colostrum. The fat globules are unequally divided, agglutinated in certain areas, and show marked differences in si/.c tlar-i Cat varunlrsi ; the colostrum bodies may be recognized as pale gray areas partially cov- ered with fat. are of varying size, but nearly similar in form (see Fig. 8, a). ' NATURAL FEEDING 41 Comparison of Various Milks (Heubner and others) 100 gm. milk contain in grams : Other nitro- Source. Albumin. Fat. Sugar. Salts. gen-contain- ing and unknown bodies. Human ... .... 9 3.52 6.75 0.197 0.6 Cow 3.0 3.55 4.51 0.7 0.3 Goat 2.8 3.40 3.80 0.95 Mare 1.9 1.00 6.33 0.45 0.5 Ass 1.63 0.93 5.60 036 The portion of milk which is first drawn is more watery than that which is obtained at the end of a nursing. The number of meals daily during the first few weeks should be seven ; later, six or five. The size of the individual meals, according to Feer, Weeks. 2. 4. 8 12. 16. 20. Average amounts .... Maximal amounts .... Capacity, according to Pfaundler .... 90 140 110 160 90 140 215 100 150 240 110 160 260 125 170 270 140 The difference between the capacity and the amount of milk ingested is due to the fact that the milk passes into the duodenum during nursing. During the first two days only a very small amount is drunk. The amount of milk taken daily increases in the first few weeks from 10 gm. to 400 to 500 gm., and then continues to increase. The amounts drunk by a breast-fed child, according to Bendix and others, are : 42 NOURISHMENT At the end of 1st week of life 250 grams. At the end of 2d " 500 At the end of 3d " 550 At the end of 4th " 600 At the end of 8th " 800 At the end of 12th " 850 At the end of 16th " 860 At the end of 20th " 930 At the end of 24th ' " 1000 " The amount of food required by a nursling, as has been recently determined, depends upon the energy which such food can produce (Heubner). The number of calories, per 1 kg. of body weight, which are obtained from the food are indicated as the " energy-quotient " (Heubner). This energy-quotient during the first half year equals 100. According to Rubner the number of calories produced by various forms of nourishment are as follows : In 1 liter. Human milk (depending upon the amount of fat present) from 614-724 calories. Cows' milk from 690-724 Two-thirds milk (according to Heubner) from 480-724 One-third milk with sugar from 340-724 Buttermilk (according to de Jager) . . from 698-724 Liebig extract (according to Keller) . from 808-724 A llenbury's milk mixture from 546-724 Asses' milk (from Dresden) from 502-724 Flour soup (5 percent. from K i u It -i i i.-i tin's mi-id ) from 195-724 " The following example shows the manner of figuring out the amount of food required : A child weighing 7 kg. requires 700 calories ; the amount of human milk required (see table) = ^-jf-g- gm. (1.07 liters). The amount of cows' milk required = ^- gm. (1.01 liters). For practical purposes it should be remembered that a healthy child must receive daily during the first three months about one-sixth, and during the second and third months about one-seventh, of its body weight of human milk (Heubner). In other words, the amount of food ingested daily NATURAL FEEDING 43 during the first week of life should be 10 percent, of the body weight ; in the second to fourth week, 16 per cent.; in the second month, 17 per cent. After this period the percentage is about 1 per cent, less every month (Oppen- heimer). Breast Feeding. The breasts should be prepared during the pregnancy by washing and massage of the nipples. The child is applied to the breast for the first time on the first or second day. In case it is hungry and the milk has not yet appeared a teaspoonful of camomile tea may be given [warm water answers the same purpose]. If the nipples are hard to grasp a nipple-shield or breast- pump may be employed. At the beginning the child should be put to the breast every two hours, later, every three hours. The child should become accustomed to feed at regular intervals. It is best to confine the nursing to one breast until satisfied. The rest following nursing should continue for from four to five hours. The beginning of menstru- ation, or slight disturbances in the health of the child, should not interrupt the nursing. The mother should be given no special diet, but should continue her accustomed food as long as the appetite remains good. She may take as much milk as possible, but without compulsion. Alcohol must be avoided, her occupation regulated, and she must take regular exercise in the open air. The child should not be weaned until the sixth month and, if possible, not during the hot season. It should be prepared gradually throughout the course of weeks by the administration of artificial meals (milk mixtures, broths, and, under certain circumstances, bouillon). Indications for Weaning. Pregnancy, acute febrile dis- eases of the mother, insufficient milk (the child's weight failing to increase and the occurrence of constipation), unsuitable milk (the presence of colostrum bodies in the permanent milk, fat corpuscles, bacteria), and chronic dyspepsia of the infant. When there is a relative in- sufficiency of milk the mixed feeding should be continued as long as possible. 44 NOURISHMENT When the mother is unable to nurse the child, artificial feeding should be resorted to, and not until this fails should a wet-nurse be obtained. The requirements of a good wet-nurse are: Good health ; it is especially important that she should be free from tuberculosis and syphilis, of other acute or chronic diseases, and be capable of producing a large amount of good milk. Her condition may also be judged by the health and body weight of her own child, and by a careful observation of the increase in weight and the amount of milk taken by the child to be nursed. A chemic examination of the milk is of value. Pressure upon the glands should cause the milk to appear in several streams. As regards the quality of milk, the age of the gestation period is of little significance, yet it is advisable for safety's sake not to accept a wet-nurse previous to six weeks after confinement, and for social reasons, not after three months. The offspring of the wet-nurse should not be brought into the house. [There are several reasons why a wet-nurse should be permitted to have her own baby with her: (1) The moral question of consigning her own baby to an institution, probably to its death. To this there can be only one answer. (2) The wet-nurse's baby frequently stimulates the breasts and keeps up the supply of milk. (3) If she does not care for her own baby, it is doubt- ful if she ought to be trusted with another's baby. (4) She is more contented and in a better mental state, in consequence her milk is more likely to be normal. She will have no valid excuse to make visits or absent herself from her charge. For this reason she is at home when she is needed, and her food and morals are under control. ED.] ARTIFICIAL FEEDING Artificial feeding, even under the most favorable cir- cumstances, is not an absolute satisfactory substitute for the mother's breast. For this purpose cows' milk is the FREEING THE MILK OF FOREIGN MATERIAL 45 best, partly because the milk of other animals is too ex- peusive and partly because of a difference in constituency. Cows' milk differs from human milk in the following respects : The presence of dirt and bacteria ; it contains three times the quantity of albumin ; by the chemic union of the albuminoid bodies; by the comparatively larger amounts of dissolved albumin (relation of casein to albu- min in cows' milk = 10 : 1, in human milk 10 : 12); larger amounts of salts and less sugar; larger curds of casein ; greater acidity, on account of which less hydro- chloric acid is set free in cows' milk to prevent fermen- tation. The casein of cows' milk is not more indigestible than that of human milk (Heubner, Bendix). In preparing an infant's food an attempt is made to compensate for these differences by obtaining milk, if possible, which is clean and free from bacteria, and con- verting it both chemically and physically to correspond to human milk, and thus obtain perfect equalization. FREEING THE MILK OF FOREIGN MATERIAL AND BACTERIA To obtain clean milk : Judicious feeding and care of the animals ; exclusion of diseased cows, and cows tested with tuberculin ; mixed milk is better than the milk from one cow, because of the greater dilution of the injurious substances. The cows should be milked under clean and sanitary circumstances. The milk-slime should be separated by means of a centrifuge or an aseptic filter. The milk is to be rapidly cooled and kept cool until delivered ; cen- trally located model milk establishments for the distribu- tion of milk. When it is impossible to obtain raw milk free of bacteria, the latter should be destroyed either by simply boiling in covered vessels, set aside to cool rapidly and kept cool, or by steam sterilization at home in a So.rli/cf j>f children up to four years of age. (According to tliu exact cadaver meas- urements of Trumpp.) and employ the time asking the most important questions, and in observing the child with as little annoyance as possible. PROPER METHOD OF EXAMINING A CHILD 53 Note : A ceaseless drawing up of the legs with loud cries and painful distortion of the face in sleep indicates pain in the abdomen ; rubbing the head on the pillow points toward craniotabes or otitis media ; in the latter case, there is usually high fever. The failure of volun- tary motion when the child is awake is a sign of weak- ness, stupor (opiates), or imbecility. Characteristic appearance of the face in meningitis (sickly, painful, squint) ; in whooping-cough (puffiness in the neighbor- hood of the eyes, protrusion of eyeballs) ; in vegetative adenoids (somewhat stupid, open mouth, obliteration of nasolabial folds). After the pulse and respiration have been controlled, inspection, which plays a very important role in children, is undertaken. This is followed by thermometry, palpa- tion, auscultation, percussion, mensuration, and examina- tion of the excretions. The respiration can only be studied when the child is asleep or absolutely quiet. We note its frequency, depth, regularity, and character, which i< snorting in case of vegetative adenoids, impeded in tonsillitis, gurgling in retropharyngeal abscess, contraction of the jugulars in stenosis of the upper, and contraction of the costal arch in stenosis of the lower, air-passages. The pulse is likewise best observed when the child is asleep. It is to be noted that a considerable increase in the rate may follow the slightest cause, even in healthy subjects. The observation includes mainly the frequency, regularity, tension, and size. The pulse is slower than normal at the commencement of meningitis, during the convalescence from infectious diseases, and in weakening conditions. The pulse is accelerated in fever, in excite- ment, and in the terminal stage of meningitis. The pulse is irregular (also unequal) in certain intestinal diseases influenza, diphtheria, myocarditis, and in meningitis, even at the beginning. While the child is still in bed the temperature is taken. This is always done, without exception, per rectum, and is determined by passing, high up into the. rectum, the thermometer which has been cleansed with alcohol and 54 EXAMINATION AND HISTORY lubricated with fat, soap, or water. This act may be accomplished with greater ease by drawing the legs of the INSPECTION 55 child tightly against the abdomen. So-called "minute" or " half-minute " thermometers are to be employed, and the first result controlled by a second test. For further examination it is absolutely necessary to remove the child, undressed, from the bed. The infant is held cither on the lap of its mother or on an upholstered table with its face toward the light. INSPECTION We next note the general appearance and state of nutrition, expression of the face, posture, and abnormal movements. In inspecting the skin observe the peculiar cyanotic pallor of pneumonia ; the pale to dirty yellow, somewhat shiny color in hereditary syphilis ; the sickly and dry condition in diseases of the thyroid gland ; the cyanosis of laryngeal stenosis, miliary tuberculosis, and heart failure ; the edema in nephritis ; minute extravasa- tions of blood as unfavorable prognostic signs in certain diseases, especially in those of the intestines, in diphtheria. Various diseased states must be distinguished from insect bites, which are red with central points, sudamina, and the erythema which follows applications. The skin and the pad of fat in the region of the anus point to the general state of nutrition ; intertrigo in severe diarrhea ; rhagades in chronic constipation and in syphilis. Papules in eczema and syphilis. Also observe the general form of the body and of its different parts (deviation of the vertebra?, deformities, contractures), and also the posture and gait. Inspection of the oral cavity is not to be neglected in any case, but should be delayed until the end of the examination. It is to be performed with the infant in the lap or arms of the mother. The physician stands either in front of or behind the child and presses the tongue with a spatula or spoon until a swallowing movement occurs, which brings the posterior pharynx into view. If it is impossible to open the mouth because of the 56 EXAMINATION AND 1IISTORY FIG. 11. Inspection of the oral cavity of a small child. The hands are firmly fixed. The physician's left hand holds the head and guides it toward the light. The inspection may also be performed as in Fig. 12, the nurse holding the infant on her lap. strong resistance offered by the child, we should patiently try to enter the mouth back of the molar teeth. Hold- ing the nose shut in order to force the child to open its INSPECTION 57 FIG. 12. Inspection of the oral cavity with the physician standing back of the child. This position is a better protection against the cough, but requires more practise to see. 58 EXAMINATION AND HISTORY mouth is of no avail. It will only serve to excite the child, who can finally, even without opening the mouth, breathe through the tooth spaces. During the short time which is at our disposal, we note the color and any erup- tion that may be present on the hard and soft palates, the condition of the tonsils and posterior wall of the pharynx, and any deposit which may be on these parts. The presence of a tonsillar or retropharyngeal al << must not be overlooked under any circumstances. If it is suspected, the oral cavity must be palpated. Inspec- tion of the teeth with reference to their number, develop- ment, form, and position should take place either before or after viewing the pharynx. PALPATION By passing the flat hand over the surface of the body a superficial idea may be obtained of its temperature (but only the thermometer should be trusted). The skin is tested as to its moisture or dryness. It is moist when a fever is on the decline, dry in profuse watery diarrhea, in disease of the thyroid gland, and in increasing fever. If on inspection any discoloration or change in form is noticed, it is further examined by palpation. Edema and papular exanthems can only be determined positively in this manner; erythema and roseola can only be distin- guished from hemorrhages by their disappearance upon pressure. Then follows a systematic palpation of the whole body from the head downward. From the large fontanels, where the size of the opening, the degree of tension, and the character of the borders are noted, the hand passes to the occiput. The latter is grasped in both hands and with pressure exerted by the fingers we detect softened areas (craniotabes). The fingers passing over the two lateral fontanels exert pressure upon the tragus and the posterior auricular region, to exclude severe affections of the ear (otitis media, mastoiditis). Next the palpating hand examines the lower jaw, the posterior and lateral cervical region, as well as the two PALPATION 59 60 HISTORY AND EXAMINATION FIG. 14. Palpation of the liver from above. The organ may he pressed downward with light pressure exerted by the ball of the hand Palpation may also be performed from below. supraclavicular fossae and the lymph-nodes which arc found in that neighborhood. Note : Acute enlargement of the glands in diphtheria, scarlet fever, stomatitis, and abscesses ; chronic enlargement in scrofula, eczema of the head, caries of the teeth. Enlarged supraclaviculur nodes are of importance in latent tuberculosis. FlG. 15. Bimanual palpation of the spleen from below upward. Counterpressure is exerted upon the spleen with the left hand. In the thorax the borders of the cartilages of the ribs are felt and physiologic enlargement distinguished from the rachitic swelling. In palpating the abdomen the child should lie upon its back. The hand, which should be relaxed and held as flat as possible, is slowly and gently pushed inward. The abdomen is retracted in atrophic and cachectic conditions and in meningitis ; it is enlarged in rachitis and in many diseases of the intestines. Tender- ness exists in the region of the colon and in inflammatory processes of the lower section of the intestines. The ileocecal area should always be examined for tenderness and resistance. Ileocecal gurgling is a frequent phenom- enon in children. To detect free liquids in the abdominal PALPATION 61 FIG. 14. 62 HISTORY AND EXAMINATION cavity gently tap with the right middle finger and the wave with the point of the left finger. The spleen is palpated in two ways (compare Figs. 13 and 15). Be careful not to mistake the lower ribs for that organ. The same conditions hold true for palpation of the liver. Finally, the extremities are palpated for swellings, bony exostoses, tenderness, abnormal or dimin- ished motility, paralyses, spasms, etc. FIG. 16. Auscultation with the double stethoscope. Advantages: The area to be auscultated is visible, the child is less disturbed, and there is greater magnification of the sounds. Disadvantages: Neighboring sounds are more distinctly heard, and it is necessary to renew the tubes in the course of time. AUSCULTATION 63 AUSCULTATION It is desirable that the child be kept as quiet in this pro- cedure as in percussion, but it is not an absolute necessity. The crying is of use in determining the vocal resonance and fremitus. The respiratory murmur itself can in that case only be heard during the short inspiration. Whether auscultation precedes percussion or vice versa, depends upon which is the most unpleasant to the child. (It is wise to proceed gradually with the least pleasant exami- nations.) Auscultation of the lungs may be performed in various ways:- At first with the bare ear for thus the sounds are purer and clearer and then, to control the results of that method, by means of a stethoscope. The binaural stethoscopes are almost exclusively used in this country, and are to be recommended (Fig. 16). It is to be noted that normal bronchial breathing is heard on either side of the spinal column, and that frequently crepitant rfdes are heard at the beginning of the exami- nation on account of the forcing of air into parts which were previously atelectatic. Auscultation of the heart should always be performed with the stethoscope, for it cannot very well be outlined or localized in any other way. (For the normal relation- ship of a child's heart, see Diseases of the Heart.) PERCUSSION Either finger or hammer-pleximeter percussion. The latter is to be done only with a light Curschmann's hammer. Various forms of finger percussion are distin- guished, all of which are best employed one after the other. Direct Percussion of Bones. The point of the middle finger percusses anteriorly the clavicles at symmetric points, and posteriorly the spines of the scapulae. Palpatory Percussion. The four fingers of the right or left hand percuss directly the posterior wall of the thorax in symmetric areas. These two methods of percussion are useful in making a rapid examination. 64 HISTORY AND EXAMINATION The Usual Method of Percussion, Finger on Finger. This is not performed as in adults with relaxed wrist- FIG. 17. Manner of holding and fixing a child in anti'rinr ]ierriis>ii>ii. The same holds true for percussion of the back. The body should be in as symmetric a posture as possible. joint and with an clastic and hammering movement but with light pressure of the percussing fingers and, as in pal- PERCUSSION 65 pation, with the middle finger of the left hand applied closely and as lightly as possible, palpating at the same FlQ. 18. Percussion of the back while the child is held in the arms of the nurse. Position as symmetric as possible. time. Heavy blows include too large portions of the body in the resonance and must be absolutely avoided. . 66 HISTORY AND EXAMINATION For }>ercussion the child's body must be held as sym-. metrically as possible, since slight asymmetries of ]<- ture cause changes in the sound elicited. The finger which acts as the pleximeter must be always placed on symmetric parts. Since in children the sounds are de- cidedly influenced by the respiration, it is impossible to always percuss both sides during at least one whole res- piratory period. It should be borne in mind that the lower border of the right lung is higher because of the liver, which is not rarely mistaken for pulmonary dulness. On the left .-i< It- remember the close proximity of gastric tympany to the edge of the lungs. Examination of the axillary regions is of the greatest importance ; bronchopneumonic foci are frequently detected. Finger-nail upon finger-nail for very light percussion, especially for the spleen and thy m us. Auscultatory percussion by the simultaneous application of the stethoscope or phonendoscope. MENSURATION For weighing the child, either a decimal or one of the so-called "infant's scales," fitted with a bowl, is employed. The spring scales, to which the child is hung in a bag, are expensive and unreliable. The spring kitchen scales are useless. Infants should be weighed once every week, larger children, every month. For the physician the scales are indispensable in estimating deviations from normal development. Linear Measurement. Infants are held stretched on a table in the dorsal position and measured from heel to crown. Large children are measured standing against a wall or with a vertical measuring staff, which is supplied with a movable transverse arm. The linear measure- ment is also of value in determining normal and abnor- mal development, especially in rachitis, hypothyroidism, hereditary syphilis, etc. THE SECRETIONS AND EXCRETIONS 67 THE SECRETIONS AND EXCRETIONS The secretions from the conjunctiva? are examined for diphtheria bacillus and gonococci ; the secretion from the a (>.<, for influenza or diphtheria bacilli. With a platinum wire, which has been previously brought to a red heat, minute drops are secured from the secretion and rubbed upon the cover-glass ; the sputum (removed with a cotton swab or aspirated) is examined for its macroscopic characteristics, and microscopically for elastic fibers, influ- enza, diphtheria, and tubercle bacilli. Deposits in the ntdnflt or pharynx are removed in minute particles, either with a platinum rod which has been passed through a flame, with sterile forceps, or with a small cotton tampon. For these as well as for the succeeding examinations proceed as follows : At first examine the unstained prep- aration mixed with a drop of water and then dry and stain it. The urine is examined for its amount, specific gravity, color, reaction, cloudiness (bacteriuria, cystitis, phospha- turia), albumin, sugar, blood, biliary coloring-matter, indican, and the diazo-reaction. It is obtained from infants either with specially constructed vessels 1 or by means of catheterization (especial care is required in the case of boys). It may be obtained from a sleeping male child by simply catching it in an ordinary reagent glass. For determining the exact quantity of urine excreted the apparatus of Bendix and others may be employed. The feces are examined macroscopically for the amount, color, consistence, odor, reaction, abnormal ingredients, mucus, serum, pus, blood, and remnants of food; micro- scopically for bacteria, pus-corpuscles, fat, starch (colored blue with Lugol's solution), fungi, tissue cells, amebae, parasites and their ova. The cerebrospinal fluid is examined as to color, reaction, specific gravity, amount of albumin, sugar, bacteria, and pus-corpuscles. It is obtained by means of Quincke's lumbar puncture. The child lies upon its side or 1 Compare Diseases of the Kidneys. 68 MAXAUKMKST OF DISK. \ .S7-; 7.V r////./>/;/-;.\ assumes the sitting posture ; the spinal column is curved forward as much as possible ; a sterile needle about 7 mi. [2.8 in.] long is introduced with the point turned slightly upward in the middle line between the 4th and 5th or the 3d and 4th lumbar vertebra? to a depth of from 2 to 4 cm. [.8-1.6 in.], until the point of the needle is freely FIG. 19. Quincke's lumbar puncture. A line drawn from one iliac crest to the other will cross the spine between the 4th and ">th lumbar vertebrae. The puncture may be performed while the child is in tin- -it- ting posture. movable. The pressure of the spinal fluid is measured by connecting the needle by means of a thin rubber tube to a manometer. The normal pressure equals that of from 40 to 130 mm. [1.6-5.2 in.] of water. The opera- tion is free from danger if it is performed in an antiseptic manner. GENERAL MANAGEMENT OF DISEASE IN CHILDREN DIETETIC TREATMENT The most important factor is careful attention to the diet and hygiene. Breast-fed children when siek should continue to receive nourishment from the breast if practicable. Hand-fed children should in acute ruses have their diet reduced. In disturbances of dige.-timi 69 some bland fluid should be given which practically requires no digestion, such as water, dilute tea, or a very thin cereal water ; albumin-water (the white of one egg beaten up and stirred in ^ liter of cool water, then strained and sugar added) ; watery flour broths ; 5 to 10 per cent, solutions of nutritive sugar. Drinks for sick children are cold water, with or without fruit juices, toast- water (toasted wheat bread over which hot water is poured, with the addition of sugar and, if desired, lemon-juice), sugar-water, almond-water, aiid cold teas. As a non-irritating diet are recommended : Milk diluted or with the addition of other elements, flour broth, infant's food soups. For larger children give vegetable and potato broths, jellies, fresh minced meat, buttermilk, zwieback, soft eggs, light pastry, fruit, gelatin, and gruels. As a diet capable of giving strength in chronic sick- ness give foods rich in fat and sugar, cream, cereals, minced chicken, squabs, veal, ham, sausage, calves' brains, broths, beef-tea, eggs, chocolate, extract of malt, cocoa, and cold oatmeal gruel. In case of weakness give com- pressed meat juice, meat jellies, beef-tea, strong bouillon, tea, champagne, wine, and port wine. To stimulate the appetite give undiluted Valentine's meat juice, meat gravies, caviar, and sardines. Of medicines give wine of cinchona, the compound tincture of cinchona, and ichthalbin. The remaining hygienic directions, which in general are like those observed in adult life, are best given in greater detail, for especial attention should be paid to cleanliness of the mouth, eyes, nose, and skin ; preventing wetting of the bed; the clothing; the temperature (15 to 18 C. [59-64.5 F.]). HYDROTHERAPY Sick children are treated with hydro therapeutic pro- cedures to meet the following indications : To reduce the 70 MANAGEMENT OF DISEASE IN CHILDREN fever, to increase the conductivity of the skin, to regu- late the circulation, and to increase absorption. Water is employed as a counter-irritant, especially for the nervous system, respiration, and pulse ; and also as a sedative. The following baths are recommended : Hot baths (37 to 40 C. [98.6-104 F.]) as a prelude to sweating processes, to increase the temperature of the body (as an analeptic in diseases of the intestines), and to relieve the action of the heart. Warm baths (33 to 35 C. [91.4-95 F.]) for cleanli- ness; at the beginning of febrile diseases; for a sym- metric distribution of heat, and as a sedative. Cool baths (31 to 27 C. [87.8-80.6 F.]) to diminish fevers ; to stimulate and deepen respiration ; in nervous diseases, especially with simultaneous vigorous rubbing. The most useful additions to baths are : Aromatic solu- tions of camomile, fennel (1 to 2 handfuls in a linen sac over which hot water is poured) ; wheat-bran, oak-bark as an astringent (3 to 5 handfuls boiled in a sac); salt or brine (cooking salt or sea salt, 200 gm. to a pail of water) ; mustard as a strong stimulant (5 teaspoonfuls of black mustard in a linen bag over which boiling water is poured. and allowed to stand for several minutes); sublimate (0.5 to 1.0 gm. per bath); peat soil or peat salt ( 1 "> kg. of the former and 30 to 40 gm. of the latter) ; sulphur (1 5 to 25 gm. sulphuret of potash dissolved with hot water in a bag). Applications. Cooling applications made of linen cloth and covered by a larger woolen cloth, without interposing an impermeable layer. These are applied most frequently to the chest and trunk, more rarely to the whole body, for the purpose of diminishing the temperature, as a sedative and to increase conduction ; care must be taken not to let them remain in place longer than from one-half to two hours. A satisfactory antipyretic action is obtained at the beginning by changing the application every quarter hour and, later, every half hour. Hydropathic j>/!<-(ifions are made with linen, water- tight material, or woolen cloth. The action is a sedative to pain and resorbent ; they may remain in place from MEDICINAL TREATMENT 71 three to ten hours. The water used in all of these appli- cations has a temperature of from 16 to 20 11. [70- 77 F.] " room temperature." Hot Stupes. Linen cloths boiled in water, removed with spoons, wrung out in a second linen cloth, and then rapidly applied, covered with a woolen cloth and left in place from a quarter of an hour to an hour. These are employed in sepsis and diseases of the heart and kidneys. Mustard Poultices. One liter of boiling water poured on i- pound of powdered mustard, stirred until the mustard odor arises, soak a linen cloth in the mustard- water which has been poured off the above mixture, and apply it to the body, allowing it to remain in place one- half hour. Follow it by washing with cool water, and later by applying cool applications. A vigorous counter- irritant in bronchopneumonia. Cold sprays of 18 to 22 K. [72-81.5 F.] are used upon the neck and chest, usually a warm or cool bath, for the purpose of stimulation, especially of the respiratory center; also used independent of a bath in hysteria, epilepsy, and enuresis. Cold-water bathing, also bathing sometimes with brandy or eau de Cologne, are of use to refresh the body and to stimulate metabolism. To stimulate perspiration employ either hot baths or dry hot packs, or pack the whole body ; the latter is done by placing three or four jugs containing hot water in the bed wrapped in wet cloths. This treatment is supplemented by the administration of hot lemonade or tea. MEDICINAL TREATMENT Medicinal treatment is to be resorted to only to meet exact indications. The most convenient form is either the liquid or powder, although small pills, capsules, and gran- ules uay be used. Tablets must be crushed before use. The taste is always to be considered, and to disguise it give simple syrup or sugar-water to each individual dose. Bad-tasting medicaments must not be given in the food, for the latter will thus partake of the disagreeable taste; 72 MASA<;KMENT OF DISEASE iy (.-UILDHEX insoluble powders may be given in a thick gruel or cocoa ; bromid or iodid solutions in cold milk ; qiiinin in slightly sweetened cocoa ; brornqform in the yelk of an egg : castor oil heated in a warm spoon or dusted with sugar, or in bouillon or raspberry juice. Dosage. As a general rule, give as many twentieths of the average adult dose as the child is years old (Neu- mann). Measurements. One coffeespoon = 5gm.; 1 children'.- spoon = 8 to 10 gm.; 1 tablespoon == 15 to 20 gni. ; the most useful are the graduated medicine-glasses. In the use of different remedies (narcotics), especially during the nursing age, great foresight must be practised, and it is always safest to first give a small tcst- to 10 leave.- boiled lor one-half minute); Barber's sagrada tablets; the neutral salts. MEDICINAL TREATMENT 73 Astringents. Alumin. acetic, internally, .5 per cent. ; externally, 2 to 4 per cent. ; silver nitrate, .04 per cent., internally ; 3 per cent, decoctions of calumba roots ; bis- muth salicylate, 3 to 5 per cent. ; tannigen, 0.05 to 0.5 per dose ; tannalbin, 0.25 ; tincture of veratrum, 0.1 : 5.0 ; diluted spirits, 3 to 10 gtt. every hour ; 5 per cent, decoc- tions of the leaves of uva ursi ; 5 per cent, infusion or the fluidextract of the leaves of jambul. Emetics. A coffeespoonful of the infusion of the root of ipecacuanha, l.Oto 2.0 : 50.0, every ten minutes ; powdered ipecac, 1.0 to 2.0 : 50.0; syrup of althaea; apomorphin hydrochloratc, 0.0008 to 0.003, subcutaneously. Narcotics. Aquae amygdalae amarse, 1.0 : 100.0; co- dein phosphate, ^ to ^ mg., for nursing infants, later 0.005 to 0.05; heroin hydrochlorate, ^ to ^ mg. per dose; tincture of opium, not before the third month ; at one year, ^ drop per day ; at two years, 1 gtt. ; from two to four to ten years, 1 to 2 to 5 drops per dose; morphin hydrochlorate should not be given until after the third year, 0.001 per dose ; chloral hydrate, 0.1 to 0.5 by mouth, 0.2 to 1.0 by rectal injections; extract of bella- donna, 0.001 to 003 per dose ; bromoform, 1 to 6 drops three times daily ; atropin sulphate, 0002 to 0.0003, subcutaueously. Nervines. Potassium bromid, 0.3 per day, depending upon the age (it is best to combine this with sodium and ammonium bromid and sodium bicarbonate ; the latter is given in double doses). Erlenmayer's bromid water, 4 to \ to 1 bottle daily ; Sandow's effervescent bromid salts ; the muriate of quinin, 0.1 to 0.3 ; tincture of vale- rian, 20 to 40 gtt. per day. Alterants. Iron (see Anemia, p. 145) ; arsenic (ibid.); iodin, externally, as tincture of iodin ; iodovasogen, potassium iodid ointment, for internal use (see Scrofula) ; mercury i sec Congenital Syphilis). Stimulants. Liquor ammonii anis., 2 to 5 gtt.; sweet spirits of niter, same dose; camphor, 0.01 to 0.03, inter- nally ; camphor and ether, subcutaneously ; wine, cham- pagne, and inhalations of oxygen. 74 MANAGEMENT OF DISEASE IN CHILDREN Diaphoretics. Pilocarpiu, ^ to 3 mg., subcutaneous! v, in double doses internally. Diuretics and Cardiants. Calcium acetate, 1 to 2 per cent. ; diuretin, 0.05 per dose ; infusion of the leaves of digitalis, 0.3 : 100.0, from 1 teaspoonful to 1 children's spoonful every three hours ; tincture of strophanthus, 1 to 3 drops ; caffein, 0.1 per dose. For the remaining remedies refer to the different dis- eases. Psychic Treatment. This is not a very practical thera- peutic remedy ; suggestion, advice, persuasion, deception, and threatening have some effect. These are of practical value in chorea, enuresis, during the convalescence of whooping-cough, hysteria, and disturbances of speech. Mechano-electric Therapeutics. General and local for stimulation of metabolism, to strengthen diseased or paralyzed muscles, to mobilize joints, and to scatter an exudate. The galvanic and faradic currents are employed for the same indications ; also for nerve stimulation, as in enuresis and hysteria. DISEASES OF THE NEWBORN GENERAL LOSS OF VITALITY AND PREMATURE BIRTH . LACK of development in size, weight, and function of the body at the time of birth usually exists in prematurely born infants, but may also occur in full-term babies whose parents are unhealthy, or who themselves are already diseased. Symptoms. Abnormally small and underweight chil- dren show prematurity in the nails, skin, and genitalia ; their respiration and pulse can hardly be detected; they sleep constantly ; react slowly to external stimulation ; nurse little or none at all ; the temperature varies between 30 and 28 C. [86 and 82.4 F.J; the umbilical stump is slow in healing. The face is small and weazened, the voice weak, and the body very sensitive to every change in temperature. Such infants usually die from scleroderma, pneumonia, or asphyxiation. The possibility of life exists only when the weight at birth is at least 1000 gm. ; by means of careful nursing it is possible then to save one-half, and when the weight at birth is greater, 80 per cent, of such children continue to live. Treatment. The application and maintenance of heat. The infant is wrapped in wool, surrounded by hot- water bottles, and kept in a warm room at a temperature from 18 to 20 R. [72.5-77 F.]. The following specially prepared brood chambers may be employed : A chest with movable glass covers, which is lined with peat moss and heated bricks placed underneath or upon the floor; a bath-tub with double walls between which hot water flows (Crede) ; thermophore ; incubator with appliances 75 76 LOSS OF VITALITY AND PREMATURE BIRTH FIGURE 20 I.-V. Incubator Room for Three to Five Infants. Escherich-Pfaundler System. (Original in the Clinic of Pfauudler.) Explanation: The framework of the incubator room is constructed of iron ; the sides and roof are lined with plates of cork, while the remainder is simply glazed. The walls are coated on both sides with enamel paint. The size of the room is large enough to accommodate a nurse or attendant. so the infants need never be removed and exposed to the injurious effects of a different temperature. The heat is obtained from a system of cast- iron tubes (I., a), which are of solid capacity. These tubes are connected with the hot-water pipes of the house. An extra stove (A) is set up in the wash-room as a reserve. The temperature of the room is regulated as may be desired between 28 to 34 C. [82.4-93 F.] by means of the ventilation apparatus (FJ ; an electric contact thermometer registers the gross temperature changes. The fresh air enters the room through a shaft (B) from without the building (Park), passes through a cotton filter over the heating pipes, and finally over a moistening apparatus which can be regulated two basins with oblique floors filled with water). By filling the latter to a certain height, the atmosphere in the room may be so regulated that it will hold a relative moisture of 60 per cent. The psychrometer shows then the difference between the temperature of the two thermometers to be 5 C. [9 F.]. The bed shared in common by the infants rests on a perforated metallic plate (G), which is surrounded by a railing. The floor of the room and of the incubator is composed of xylolith. The other arrangements of the room are shown on the plan (I.). for regulating warmth and moisture, and supplied with an apparatus for heating and for discharging the air which is breathed (Lion, Rommel, and others); the tem- perature in the incubator should be about 30 C. [86 F.]. The incubator which offers the greatest hygienic advan- tages is that invented by Escherich and Pfaundler, which, however, is only adaptable for hospitals. Children with poor vitality should be frequently moved and repeat- edly carried about every day in order to prevent atelectasis. [Specially improvised rooms and cabinets are in use as incubators for premature children. The details of their construction need not be gone into here. ED.] Feeding. Mother's milk, which is squeezed from the breasts, is administered with a spoon through the nose. If such milk is unobtainable, give the milk mixtures of Backhaus, Voltner, Biedert, etc., [modified milk with a low per cent, of fat, sugar, and proteids, e. //., fat, 0.25 percent. ; sugar, 4 per cent. ; proteids, 25 to 50 per cent.]. INCUBATOR ROOM 77 I GROUND PLAN -- FrskAir 78 LOSS OF VITALITY AND PRXMATl'HE BIRTH INCUBATOR ROOM 79 HI Electric confatt thermometer, ringing a-t ^ in jf~ Psychromtr Floor. 'f. {Moistening to cfljfcrtUtiv* "J o Humidity IV SECTIOIV THROUGH WINDOW PARAPET. Fresh/Air K^^IXytoa V GROUND PLAN OF CIRCULATION SYSTEM. to Hot Water Boiler, 80 LOSS OF VITALITY AND PREMATURE BIRTH PLATE 4 Congenital Umbilical Hernia. The hernial sac is filled with intes- tines and a portion of the liver. The amniou is discolored and is becom- ing gangrenous. It shows thickened folds at the junction with the abdominal walls. (Escherich's Clinic, Vienna.) Tab. \ ACQUIRED UMBILICAL HERXlA 81 DISEASES OF THE UMBILICUS TREATMENT OF THE NORMAL UMBILICUS It is best to allow only a short portion (1^- to 2 cm. [.6-.8 in.]) of the umbilical cord to remain. The stump is covered with a dry sterile dressing, which is permeable to the air and which does not cause any tension ; apply no ointment. Authorities have not yet agreed as to whether the child should be bathed daily excepting the first bath or not until after the cord has fallen off. At any rate, the greatest cleanliness must be observed in bathing the infant. In the case of premature births and weak chil- dren, on account of their susceptibility to septic infection, it is wisest to postpone bathing until the umbilical cord has healed. CONGENITAL UMBILICAL HERNIA Funicular Umbilical Hernia, Omphalocele. The abdom- inal wall around the umbilicus is the last to close. If any cause hinders this, the abdominal cavity does not become enclossd by the union of the walls, but only by closure of the peritoneum and the sheath of the umbilical cord, that is, the amnion. This thin covering is pressed for- ward by the viscera and forms an umbilical hernia. The umbilical cord is inserted at the apex of the hernial sac. Within the protruding mass, which varies in size from a walnut to a child's head, may be seen the intestines, and frequently also the liver and kidneys ; at the point where the abdominal walls pass into the amnion a swollen ring of tissue is formed. Small hernias may be cured with an ointment and bandage, which cause the amnion to become gangrenous. Larger hernias require surgical interven- tion. ACQUIRED UMBILICAL HERNIA This form of umbilical hernia does not occur until after the cord has dropped off and the wound healed. Favoring this condition are insufficiency of fat in the abdominal walls, too great intra-abdominal pressure when crying, or difficult micturition (phimosis) and meteorism. 6 82 DISEASES OF THE NEWBORN The thin umbilical scar succumbs to the pressure, the umbilical ring stretches, and the hernia is produced. At first it is temporary and occurs only when the child cries and presses downward, later, however, it becomes perma- nent The hernia, which usually contains a loop of small intestine, varies in size from that of a pea to an apple ; larger hernias are elongated, pendulous, and possess a FIG. 22. A mild form of acquired umbilical hernia. dark pigmented tip. Umbilical hernias are usually easily replaced and only rarely become incarcerated. Small hernias frequently heal spontaneously in the course of the first or second year of life by contraction of the umbilical ring. Treatment. Encourage spontaneous cure by relieving the pressure upon the umbilical ring by means of strips of adhesive plaster; the reduced hernia is pressed down- ACQUIRED UMBILICAL HERNIA 83 wan I by two folds of the skin, one from either side, which are kept in place with a wide strip of adhesive plaster (5 cm. [2 in.]) in such a manner that their surfaces touch each other. This strip reaches from one hypochondrium to the other. If the plaster, which remains in place when bathing, is protected during the first few days by a cloth binder, it should last for from one to three weeks. When changing binders it is advisable to clean the skin FIG. 23. Band of adhesive plaster over an acquired umbilical hernia. The plaster is tensely drawn and applied and fastened over the ribs on both sides, so that a longitudinal fold of the abdominal wall is drawn over the hernia. with ether. In place of this dressing a small plate made of folded adhesive plaster, or a cork plate, may be employed ; it must be at least 1 cm. [^- in.] larger in diameter than the hernial orifice. It is held in place by means of two crossed strips of adhesive plaster. The treatment may usually be discontinued after several weeks or a month, yet healing may be hoped for after even several years. Hernia-bandages or circular rubber her- nia-bands should be rejected. In case the hernia resists this treatment or when the opening is too large, an oper- ation is necessary, that is, a radical operation or the more recent paraffin injection method (Escherich). The par- 84 DISEASES OF THE NEWBORN affin (melting-point 39 C. [102.2 F.]) is injected into the hernial sac after the hernia has been reduced, after which the contents of the sac are again allowed to pro- trude, and covered for a short time with an ice compress. The latter causes the paraffin to harden, and it in turn pushes the hernia inward. A sterile dressing is applied for several days. UMBILICAL HEMORRHAGE We distinguish two forms of umbilical hemorrhage : One which occurs immediately after birth from a torn, poorly tied, and insufficiently thrombosed umbilical cord ; and the other from the umbilical wound, which does not occur until after mummification or after the cord has fallen off. The latter form occurs in sepsis, syphilis, and acute fatty degeneration. The hemorrhage is of a par- enchymatous character, and arises suddenly or gradually ; it is not always continuous and leads, after a few hours or days, with symptoms of severe anemia, to death. The pale red blood shows no tendency to coagulate. Treatment. The first form of hemorrhage is usually controlled by early ligation, but the second form is usually fatal. The treatment consists in instituting the following procedures : Tampons of chlorid of iron ; digital com- pression ; suture of the umbilicus (Dubois) ; filling the umbilical groove with plaster of Paris (Hill) ; clamping of the umbilicus with forceps (Fischl) ; gelatin externally and subcutaneously ; and adrenalin (1 :1000) subcutane- ously. [The local treatment by chlorid of iron and digital compression is unavailable in most cases. Suture and plaster of Paris have been recommended. Gelatin has been recently reported on favorably. Adrenalin has also given favorable results applied locally. ED.] UMBILICAL FUNGUS. UMBILICAL GROWTHS An umbilical fungus is due to an excessive develop- ment of the granulation tissue, which occurs normally in conjunction with the healing of the wound. These are INFECTION OF THE UMBILICUS 85 little red growths which reach the size of a cherry and situated in the depths of the umbilical groove, or they rise in a fungus-like manner above its sides, and always discharge a little secretion (see Plate 18, Fig. 2). Treatment. Apply caustic ; in case of larger growths tear off or remove with a pair of scissors. [Treat by solid nitrate of silver or, if large, may be tied off with fine silk. ED.] INFECTION OF THE UMBILICUS The umbilical wound may become infected through un- clean hands, dressings, instruments, etc. The virus in- fects either the umbilical wound itself and then leads to suppuration, ulce ration, and gangrene, or it spreads to the surrounding tissue and there causes a phlegmonous in- flammation (periomphalitis). Then again it may travel through the Whartonian jelly in the walls of the umbilical blood-vessels, preferably the arteries, where it sets up severe inflammation (periarteritis). The phenomena which arise are : Pyorrhea of the Umbilicus. Dried secretion collects at the reddened entrance of the umbilicus, an odorless pus flows forth from the umbilical wound, and a suppurative granulation occurs at the base of the wound. There are but slight constitutional symptoms. Omphalitis and Periomphalitis. These are marked by swelling and reddening of the umbilical fold, painful phlegmonous swelling and bulging forth of the area sur- rounding the umbilicus, and the appearance of enlarged lymph-vessels uport the abdominal wall. This condition terminates in spontaneous healing, abscess formation, gan- grene, and fatal peritonitis ; under certain circumstances a superficial ulceration of the umbilical wall results. It is always accompanied by fever. Gangrene of the Umbilicus. The swollen or phlegmon- ous area turns bluish black, the discoloration spreads rapidly, and the tissue softens and sloughs off, leaving a discolored and foul-smelling ulcer. As a rule the proc- ess spreads over the peritoneum and the symptoms of 86 DISEASES OF THE NEWBORN peritonitis develop. The patient gutters from abdominal pain and distention of the abdomen. Death follows from sepsis or peritonitis. Umbilical Arteries. Local phenomena are frequently absent. The patient becomes restless and develops fever, intestinal disturbances, slight icteric coloring of the skin, temporary erythema or punctiform hemorrhages in the skin, or we notice, proceeding from within outward, the signs of a septic omphalitis. Occasionally it is possible, by squeezing from below upward, to force pus out of the umbilicus. Bacteria are found in the venous blood. The result is usually death after a few days from peritonitis and collapse. Anatomically both arteries (the vein is rarely involved) are, as a rule, observed to be thickened and discolored grayish brown; the lumena are filled with pus or semi- solid thrombi, the intima is softened and ulcerated, and the surrounding tissue is infiltrated and discolored green. Aside from these disturbances there occur in nearly all cases ecchymoses and degenerative changes in the organs of the chest and abdomen, pulmonary infarcts and con- solidation, multiple abscesses, and enlarged spleen. Treatment of Infection of the Umbilicus. The prophyl- axis consists in the careful observation of asepsis iu treat- ing the umbilicus, especially in premature births and weakly infants. Mild cases are cauterized and covered with a dry antiseptic powder. In severe cases make applications of aluminum acetate or lysol (1 to -| per cent. ) ; pus should be removed with sterile swabs. In ease .if suppurative phlegmon make warm applications, and later incise. Feeding must receive careful attention and, if possible, the child should receive nourishment from its mother's breast. SEPSIS OF THE NEWBORN Etiology. The newborn infant shows a special predis- position to septic infections because of the undeveloped state of its protective mechanism (skin, mucous membranes, lymph-nodes, spleen). The causal agents of infection are SEPSIS OF THE NEWBORN 87 the various pus, inflammatory, and putrefactive bacteria. The infection occurs before or, as a rule, after birth. It develops inutero through infected liquor amnii or by trans- mission through the placenta. After birth it is caused by micro-organisms, some of which were deposited in the body itself (auto-infection), while others are introduced from without (hetero-infection). The most important points of entrance for the infection are existing inflam- mations or loss of substance of the umbilicus, the skin, the oral cavity, the lungs (Fischl), the intestinal canal, the bladder (Escherich, Trnmpp, Epstein), the ears, the eyes, and, finally, apparently uninjured skin and mucous membrane. Everything which comes in contact with the child's body in the course of its care may serve as the source of infection, including the hands, bath-water, clothes, sponges, thermometer, the air, incubator, etc. Morbid Anatomy. If the toxin has entered the circu- lation and caused blood intoxication, we find parenchym- atous degeneration of the internal organs, ecchymoses in the mucous membranes, and thin sterile blood. In case of blood infection degenerations and ecchymoses are also found, together with multiple abscesses, pneumonia, in- flammation of the serous membranes, ulceration of the mucous membranes, and a rapidly developing foul-smell- ing putrefaction. Symptoms. There is no regularity in the symptom- atology, for, on the contrary, it assumes many forms and, indeed, in some cases is quite indefinite. The symptoms develop immediately or in a few days after birth, and consist in a loss of appetite, high fever, a choleraic diarrhea, great acceleration of pulse and respiration rate, somnolence, and a rapid loss of strength. Hemorrhages occur in the dirty icteric and, later, cyanotic skin. Rest- lessness, tremor, and convulsions are noted. The high temperature falls to or below normal, and in many cases symptoms of pneumonia, peritonitis, pleuritis, meningitis, multiple inflammation of joints, embolism, and suppurative processes of the skin develop. The primary focus may be apparently absent or it appears as a suppurative, phleg- 88 DISEASES OF THE NEWBORN monous, ulcerated or gangrenous process of one of the previously mentioned points of entrance. The course is nearly always unfavorable ; healing in very mild cases or an early limitation of the process is possible. Diagnosis. This is not easy when the external local- ization is absent. Designating the indefinite and unclear constitutional condition as a septic one is made easier by the ophthalmoscopic finding of a retinal hemorrhage or by discovering pus-germs in the aspirated venous blood or in the cerebrospinal fluid. Treatment. Prophylaxis consists in insisting upon thorough cleanliness in the care of the pregnant woman and of the child, especially as regards the linen, the treatment of the umbilicus, the bath, the thermometer, the feeding apparatus, the preparation of the milk, hygiene of the milk, hygiene of the room, etc. Rhagades or injuries occurring during birth must be treated anti- septically. The treatment of the condition itself consists in supporting the child's strength, the administration of mothers or hot cows' milk, stimulants, meat broths, wine, and infusions of normal salt. To combat the fever give baths, cold pack, and quinin (0.1 gm.). Abscesses should be opened. BLENNORRHEA NEONATORUM, OPHTHALMIA NEONATORUM Blennorrhea neonatorum is a directly transmissible inflammation of the conjunctiva of newborn infants caused by the gonococcus of Neisser. A large percent- age of all cases of total blindness is due to this condition. The infection occurs either immediately after birth, during which the infected genital secretion enters the eyes, or later through infected fingers or toilet articles. Symptoms. The symptoms develop usually within the first week, but in later infection they do not appear until after that period. The eyelids are red and swollen and a bloody, serous secretion flows from the palpebral fis- sure. The swollen lids increase in size during the next one or two days and form, especially the upper lid, a BLENNORRHEA AND OPHTHALMIA NEONATORUM 89 vaulted eminence. The secretion becomes converted into a yellowish-red pus. The conjunctiva of the lids is swollen and greatly reddened. When the lids are inverted the transitional folds bulge forward as tense, shiny red eminences. The conjunctiva of the eyeball is also swollen and congested. If the secretion is not con- stantly removed it may erode the cornea ; in that case a minute speck develops in the middle of the cornea, which rapidly enlarges, turns yellow, and its superficial portion undergoes destruction. The resulting suppurating ulcer shows a great tendency to spread and to perforation. The complications of this infection of the cornea may be central macula, anterior capsular cataract, prolapse of the iris, staphyloma, or panophthalmia. After a number of days the secretion becomes thicker, yellowish green, and excreted in such profuse amounts that it oozes from the palpebral fissure as often as the lids are opened. In the course of several days the swelling of the eye diminishes, the palpebral conjunctiva becomes granular, and the secretion gradually lessens. In from two to three weeks the conjunctiva becomes pale, and finally nothing is noticed excepting a little mucopurulent secretion at the inner canthus. Course and Prognosis. The total duration is from three to five weeks or even longer. The later the disease develops the more favorable the prognosis. It is unfavor- able in the newborn and in weakly and sickly children. Even in infants otherwise healthy the prognosis should always be guarded. Treatment. As a prophylactic measure drop a 2 per cent, solution of nitrate of silver in both eyes after birth (Crede). It is usually impracticable to protect the healthy eye in newborn infants, and furthermore both eyes are infected, as a rule, from the very beginning. In the acute stage the treatment should be as mild as possi- ble, in order to avoid injuring the conjunctiva, The pus as it collects should be regularly and as frequently as possible removed from the conjunct! val sac, preferably by rinsing with a mild solution (sodium chlorid, 0.6 per 90 DISEASES OF Till-: .Y/-;U7>'o/;.Y PLATE 5 Ophthalmoblennorrliea of the Newborn. (From Haab's External Diseases of ihe Eye.) cent ; boric acid, 4 per cent; dilute solution of potas- sium permanganate). It is allowed to flow every quarter or half hour from a low height into the eye, which is held open with the fingers. During the intervals apply cool compresses made from one of the above-mentioned solutions (employ no ice compresses, which may increase the damage already done to the cornea). Not until the swelling has lessened and pseudomembranes no longer develop should a caustic be employed. For this purpose. 1 use a 3 per cent, silver nitrate solution, which should be neutralized later with normal salt. The treatment is the same when the cornea is involved. When perforation is threatened the intra-ocular pressure may be relieved by pilocarpin. In order to encourage the child to open its eyes spontaneously the room should be darkened and the eyes slightly cocainized. In cases running a slow course a 20 per cent, protargol salve should be employed .(Sal- zer). TETANUS NEONATORUM This condition consists of tonic spasms of the general musculature, which begin in the muscles of mastication and which increase in severity in paroxysms. Tlie-e spasms are brought about by the toxin of the bacillus of tetanus. Etiology. The bacillus of tetanus, which is quite prevalent in garden earth and wood, is transmitted to the umbilical wound through carelessness in the care of the infant. In this location, from which oxygen is excluded, it finds conditions favorable to its development and travels from there into the body. The bacillus may be demonstrated in the blood or in the umbilical wound. Symptoms. In from five to six days after prodromal symptoms, consisting of restlessness, crying out in sleep, and tremor of the jaw, the child becomes unable to take food because of the tonic spasm of the muscles of masti- Tab..-> TETANUS NEONATORUM 91 cation. Infants fed from the breast show the first indi- cation of the disease by biting the nipples, and when Fiu. 24. Teiamih ueouatoruiu. The body is rigid ; the expression of the 1'acr and the position of the arms and logs are charartiTistic. (Esche- rich's Clinic, Vienna.) liquids are administered they flow out again. The cheeks become hard as a board. Extension of the spasm to the 92 DISEASES OF THE NEWBORN remaining muscles of the face, the muscles of the neck, trunk, and extremities presents a typic picture. The mouth is puckered as if about to whistle or laugh, the forehead and eyebrows are wrinkled, the eyes, are closed, and deep furrows extend from the nose to the lower jaw. The head is held drawn stiffly backward, the neck and back are in a state of opisthotonos, the arms flexed and pressed against the body, the hands clenched, the legs and feet extended, and the abdomen has a board-like hardness. The whole body of the child when lifted feels like a stiff wooden doll. Involvement of the pharyngeal and respiratory muscles causes difficulty in swallowing and breathing. The spasm is not continuous, but lessens in severity to a certain degree for a short period of time and then is followed by a convulsive tremor of the whole body. The intervals of quietude last at the beginning for a few minutes, but later only for a few seconds. The spasms are exacerbated by external mechanical irritation, moving the body, the administration of food, etc. The whimpering of the child indicates the severity of the pain. The temperature is high (40 to 42 C. [104- 107.6 F.] ), especially toward the end, and the pulse is small and weak. The child dies in a few days or, at th*e most, in a week, from exhaustion or respiratory failure. In the rare cases of recovery the symptoms gradually disappear one after the other. The diagnosis is easily made when the disease is pro- nounced. Whenever newborn infants refuse nourishment the musculature of mastication should be examined. Treatment. As a means of prophylaxis the mother and child should receive the most rigid aseptic treatment. The results from the use of Behring's tetanus antitoxin cannot be depended upon yet, and the treatment is there- fore mainly symptomatic. Rest is absolutely necessary ; feeding is carried on by means of a tube through the nose. Narcotics and repeated chloroform inhalations are neces- sary until sleep sets in (Heubner). Chloral should be administered by means of enemata twice daily in 0.5-gm. doses, and potassium bromid is given in the same manner MELENA NEONATORUM 93 in from 1.0- to 1.5-gra. doses daily. Finally, an attempt should be made with the antitoxin as soon as possible. MELENA NEONATORUM Helena neonatorum is a rare disease which is character- ized by hemorrhages into the gastro-intestinal tract, ac- companied by bloody stools and the vomiting of blood. The real cause is unknown. It occurs in connection with septic processes, Buhl's disease, syphilis, and trauma. Morbid Anatomy. The stomach and intestines are filled with black blood, the source of which are minute erosions and round ulcers in the intestinal and gastric walls, or a diffuse hyperemia of the mucous membrane (diapedesis), thrombosis, or bacterial emboli. The remaining organs are anemic. Symptoms. This condition has a sudden onset during the first few days of life. The stools contain blackish blood-clots, which when deposited on the swaddling cloths are distinguished from the meconium by a dark red halo (see Plate 37, Fig. 1). The child also vomits bloody masses, but not in all cases. Collapse sets in early, the extremities become cold, the pallor increases, and the fea- tures have a death-like appearance. The child may develop the symptoms of hydrocephalus and die in from one to two days, or the hemorrhage ceases and recovery slowly sets in ; in that case the stools continue to have a tea-like character for one or two days. Local symptoms, pain, etc., are absent. If sepsis develops the character- istic phenomena of that condition are also present. The mortality rate is 50 to 60 per cent. Diagnosis. The characteristic collapse and the anemia fail to appear in melaia xj>in-ia, which consists in vomiting and passing per rectum blood that has been swallowed from the mother's nipple or from the nose and pharynx of the child itself. Treatment. Inject subcutaneously 1 5ccm. of a 2 to 5 per cent. (Merck's) solution of gelatin (Zuppinger). Give 1 drop of liquor ferri sesquioxid in 1 spoonful of gruel. In every case an ice-bag should be applied to the abdomen 94 DISEASES OF THE S and heat supplied to the rest of the body. [The reports from gelatin injections are not uniformly favorable. The editor has observed -symptoms of collapse in children who have received these gelatin injections. He believes the gelatin should be administered by mouth. Other medic- inal treatment should consist of the administration of 1- or 2-drop doses of adrenalin solution. ED.] ACUTE HEMOGLOB1NURIA OF THE NEWBORN ( WinckePs Disease) Acute hemoglobinuria of the newborn is, on the whole, a rare disease, occurring endemic-ally and sporadically, and is associated with cyanosis, icterus, and hemorrhages from the various organs. Death occurs, as a rule, in thirty-two hours. Anatomically we find swelling of Pyer's patches and of the mesenteric glands, dark red discoloration of the kidneys (the pyramids of which show dark hemo- globin striation), and fatty degeneration of the liver and other organs. The urine contains hemoglobin, casts, bacteria, and detritus. Treatment is useless. BLOOD-TUMOR OF THE HEAD. CEPHALHEMATOMA A cephalhematoma is a collection of blood between the cranial bones and the periosteum, either external (between the periosteum and the skull) or internal (between the dura and the skull); as a rule it is a combination of both varieties. It is caused by laceration of blood-vessels and loosening of the periosteum during birth. The external cephalhematoma appears a> a fluctuating and elastic growth, varying in size from that of a hazel- nut to that of an apple, which is usually situated over one of the parietal bones. It is joined to the edges of a bone and never extends over a suture or a fontanel. The skin is movable and somewhat bluish. After several days a wall is formed at the periphery of the growth, which is at first soft, but later as hard as bone. This wall is caused by ossification of the loosened periosteum. The growth MASTITIS NEONATORUM 95 increases in size during the first four days, it then remains stationary, and after the second week grows smaller. On palpation, crepitation is felt because of the deposition of bony substance in the upper layer of the tumor. The swelling disappears in about twelve weeks and the prog- nosis is favorable. Diagnosis. A cephalhematoma is to be distinguished from the edema of the head occurring during labor, which is doughy in consistency and extends over the sutures, by its distinct limitation to one bone, growth after birth, fluctuation, and bony wall. The absence of inflammatory and constitutional symptoms differentiates it from abscesses. A cephalhematoma may be mistaken for cerebral hernia, but this error may be avoided by remembering that a cerebral hernia occurs between the bones, that it is redu- cible, pulsates, and is enlarged by crying and coughing. Treatment. This may be expectant and consists in applying a simple protecting bandage, followed in eight days by aseptic puncture and aspiration, or making an in- cision and applying a light pressuredressing(von Winckel). [The expectant plan of treatment is all that is required, as the condition tends to spontaneous recovery. ED.] MASTITIS NEONATORUM The physiologic swelling of the colostrum-secreting mammary glands of the newborn may lead, through in- fection from without, to inflammation. It is caused by unnecessary squeezing of the gland with unclean fingers. When the abscess, which is usually one sided, is not incised at the proper time, it discharges externally and causes permanent disturbance of individual portions of the gland. Treatment. Prophylaxis consists in forbidding the squeezing out of the milk in the breasts of the newborn. If inflammation is present apply aluminum acetate ; in case of an abscess apply poultices. [Wet dressings of boric acid or hot boric-acid solutions may be used. ED.] Then make radial incision and dress with aluminum acetate. 96 MALFORMATIONS MALFORMATIONS Double monstrosities are of no practical interest. Of the single monsters only the most important will be con- sidered here. Malformations arise, as a rule, from ex- ternal or internal causes. The latter are chiefly typic forms, which are due to heredity or primary pathologic variations in the embryo. The former are due to any form of external injury which disturbs the embryonal rudiment in the course of its development ; the atypic types are usually of this class. MALFORMATION FROM ARRESTED DEVELOPMENT, MONSTRA PER DEFECTUM ( Incomplete Closure of the Cerebrospinal Canal) Anomalous fontanels occur as osseous lacunse in the mesial plane of the vault of the cranium. They are most frequently found in the region of the glabella and in the middle of the sagittal suture. Dermoid spaces within the cranial bones themselves are most common in the parietal bones. The prognosis is good. If they persist until the walking period, the child must wear a cap with leather or metal plates. The formation of clefts or fissures in the region of the cerebrospinal canal is due, according to von Reckling- hausen, to primary agenesis and hypoplasia of the em- bryonal medullary ridge. If the arrest of the develop- ment occurs in the cranial portion of the canal it results in fissure formation of the cranium. Cranioschisis or acrania is a congenital defect of the skull, which is accompanied either by total absence of the brain total anencephalus or by partial absence partial anencephalus. The contents of the skull fre- quently protrude through the fissure, which acts as the orifice of a hernial sac. If only the cerebral membranes and fluids enter the sac the condition is called a menin- gocele, but if it also holds cerebral substance, an en- cephalocele is formed. MA LFORMA TI()X FfiOM ARRESTED DEVELUTMKXT 97 An encephalocele occurs in various degrees, that is, small and large, and can be detected when it is small only by a very careful examination. The hernial sac is com- posed of either the dura and arachnoid, or both of these together with the soft cranial plates, or the latter alone. FIG. 25. Acrania, partial anencephalus (insufficient brain), encephalo- cele. The swelling is elastic, it communicates with the in- terior of the skull and is situated between the bones (a cephalhematoma lies directly upon the bones) ; its presence may finally be decided by a cautions puncture. Cerebral hernias are most frequently found in the occiput, less often 98 MALFORMATIONS in the frontal region and at the base of the skull. Partial hernias of moderate degree are accompanied by pain and also convulsions when the swelling is pressed upon ; Fio. 20. Craiiioschisis aiid encej>halocele of mild grade; double rlul>- foot. various nervous symptoms also occur. Characteristic of the severe cases are the bulging eyes and the whole ex- pression of the face toad's head. Only the very mild I-'IIOM ARRESTED DEVELOPMENT 99 cases continue to live and may heal spontaneously. The treatment consists in wearing a protecting cap or an opera- tion. In most cases this condition is associated with other malformations, such as hare-lip, club-foot, etc. Sacral spina bifida. (von Ranke's Clinic, Munich.) Rachischisis is partial or complete failure in closure of the spinal canal. When the cranial cavity is also ex- posed the condition is called craniorrachischisis. Of prac- tical importance are the partial fissure formations, which lead to a hernia of the spinal cord spina bifida. Three varieties are distinguished : 100 MALFORMATIONS Spinal Meningocele. This hernia consists of a pro- truded portion of the pia, which is filled with cerebro- spinal fluid. FIG. 28. Cervical spiua bifida. (Escherich's Clinic, Vienna.) Myelomeninffocele, in which the hernial sac contains also the nerve roots or a portion of the spinal cord. MALFORMATION FROM ARRESTED DEVELOPMENT 101 FK;. 2!. Hair-lip, assooiaU-d with t'ncenlmlo. left perodactylus, and chili-toot. Infant livi'days old. wliich dii'd in ritxht days. 102 MALFORMA TIONS Myelocystocele, which is a protrusion of the pia due to a cystic enlargement of the central canal. Spina bifida is an elastic, fluctuating, usually elongated tumor in the lumbar, sacral, and rarely in the cervical portion of the spine. It reaches the size of a child's head and may be made smaller by pressure (stretching of the fontanels and eventually convulsions). Fia. 30. Double cleft of the lip, jaw, and palate, with a rudimentary intermaxillary bone, which is a continuation of the frontal pn-rs*. Preparation of the Munich Pathologic Institute.) The skin over the swelling is normal or thin and livid. The second and third forms are usually associated with paralytic phenomena in the region supplied by the in- volved spinal nerves. The small spinal bifidas may undergo spontaneous cure, but the prognosis for the larger ones, especially the second and third forms, is hopeless. MALFORMA TION FROM ARRESTED DEVELOPMENT 103 The treatment involves the use of protective appliances, puncture, or operation. Facial Defects. The face is formed by the union of the paired processes from the visceral and branchial arches with the frontal process, which is single. Disturbances in this union lead to a more or less marked deformity of the face. \* KM;. 31. Double fissure of the jaw and the palate, with a rudimentary intermaxillary hone projecting from the frontal process. (Preparation of the Munich Pathologic Institute.) The lowest degree of deformity is represented by an indentation or scar-liko line in the upper lip or a forked division of the uvula. A stage further is the Jinre-fij) (labium leporinnm^, a lateral fissure of the upper lip, which is frequently combined with a cleft alveolar proc- 104 MALFORMA TIONS FIG. 32. Microcephalus, involving mainly the skull. (Escherich's Clinic, Vienna.) ess. Next comes the cleft palate (palatum fissum), which consists of a fissure of the hard palate, and is usually MALFORMATION FROM ARRESTED DEVELOPMENT 105 associated with hare-lip and occurs either on one or on both sides. At times the intermaxillary bone rests as a nodular process in the median line. These deformities result in difficulty in sucking, varying according to the depth of the cleft; in case of defects of the alveolar process and the hard palate, sucking is impossible, and feeding must be performed with a spoon while the head is held up. The treatment is exclusively operative. [Owing to the fact that infants bear operations poorly, they should be deferred until at least the third month of life. ED.] Microcephalus is a condition in which a skull is abnor- mally small in all dimensions or only in the cranial por- tion. It follows premature synostosis of the cranial bones or arrest in the growth of the brain because of encephalitic and meningitic processes. It is accompanied by a flat receding forehead, pointed head, a low cranium, and protrusion of the jaws (prognathism). As a rule the patient is an imbecile, varying in degree from the lowest to the highest grade. Congenital Cervical Fistula. This follows failure in union of the second branchial arch (Striibing). The ex- ternal orifice of this fistula lies between the two sterno- mastoid muscles near the clavicle, and ends either blindly or opens in the pharynx. It secretes a-mucoid fluid. The treatment should consist in an attempt at total extirpa- tion. Congenital Hygroma of the Neck. This is a serous cyst, possessing multiple compartments, which lies beneath the inferior maxilla or over the clavicle. It penetrates deeply into the connective tissue of the neck and mediastinum and may grow to a considerable size. The treatment in- volves extirpation or incision, followed by iodoform tampons. Hypertrophy of the Tongue, or Macroglossia. The tongue may be congenitally enlarged because of an overgrowth of interstitial tissue or of the muscular tissue itself. This enlargement causes the tongue to protrude (prolapsus lingua?) and to interfere with speech and the ingestion of 1 06 MALFORMA TIOXS food. In mild cases the tongue is treated by applying alum or by painting it with a weak solution of iodin; in severe cases excise a wedge-shaped section or eauteri/e Ranula. This is a tumor on the floor of the mouth, due to cystic degeneration of the sublingual gland or its excretory ducts. Its walls are thin and transparent ; it contains liquid and grows as large as a pea or a walnut. It interferes to a certain extent with swallowing by . DEFORMITIES OF THE EXTREMITIES 113 The pelvis sinks downward and scoliosis develops. In case of double luxation the child develops a duck-like, waddling gait, pronounced lumbar lordosis, and protrusion of the abdomen. Since these phenomena are also possible in rachitic deformity of the neck of the femur (coxa vara), FIG. 37. Congenital siipracotyloid luxation of the left femur. Radio- gram, taken in dorsal posture, of girl two arid a half years old. The lu-ud of tlie femur lies at the upper border of the socket. (From Liming and Schulthess, Atlas of Orthopedic Surgery.) the diagnosis should be made in every case by means of a Rontgen photograph. Orthopedic treatment (girdle, blood- less reduction) offers permanent cure, provided it is in- stituted before the fifth year of life. CONSTITUTIONAL DISEASES RACHITIS RACHITIS is a condition characterized by an insufficient deposit of calcium salts in the bony tissue. As direct results of this insufficiency of lime are an abnormal degree of softness, abnormal hypertrophy, and a lack of longi- tudinal growth of the bones, while the weight of the skeleton as well as the tension of the muscles cause a large variety of deformities of the soft and flexible bones. Rachitis occurs usually between the ages of one and two years, yet it may develop in very young infant- <>r even at birth. As a rule rachitis of the skull appears during the earlier periods of life. SYMPTOMS The Skull. The large fontanel is more patulous than it should be at that age, and remains open until the second or third year (normally it closes in from the twelfth to the fourteenth month). Its edges are soft, and being thick- ened they rise above the surface of the scalp. The small fontanel, which should be closed at birth, is still open and its edges are likewise soft. The portions of the temporal and occipital bones adjacent to it show isolated and soft- ened thin areas called craniotabcs? which give a parchment- Jike crepitus on pressure. The sutures gape. Swelling of the frontal and occipital tuberosities give the skull a square appearance caput quadrdtinn. As a result the whole head seems enlarged and may sometimes be mis- taken for hydrocephalus. 1 The examination for craniotabes is performed with the third and fourth fingers of both hands, which are placed flat upon the sides of the skull. 114 SYMPTOMS 115 FIG. 38. Craniotabes. Eachitic decalcification of the right paretal hone ; gaping sagittal and lambdoidal sutures. One-year-old child. (Preparation in the Pathologic Institute of Munich.) FIG. 39. Rachitic teeth. Boy nine and a half years old. The teeth are poorly developed, considerably eroded and grooved. Their position is very irregular ; the lower incisors occupy a frontal position (not in the arch of the jaw) and the inferior maxilla makes an angular turn at the canine teeth. 116 RACHITIS FIG. 40. Bachitic boy of three years. A large and some what angular head. The typic posture of a rachitic child, with the arms supported at his side. Curvature of the clavicles and the spine (see Fig. 41) causes the neck to appear short. Contraction of the lateral diameter of the thorax ; abdomen protrudes ; curvature of the bones of the forearm. The superior maxilla is lengthened in the sagittal diameter, on account of which its middle portion is nion- prominent. The inferior maxilla makes an angular turn in the neighborhood of the second incisor teeth, and 117 therefore appears to be flattened in front. The teeth, whose eruption is delayed and occurs at irregular inter- vals, are considerably displaced on account of deformity of the alveoli in which they are inserted. Their occlud- ing surfaces do not coincide, the canine teeth meeting in a sagittal line and the lower incisors in a frontal line. Fir,. -11. Each i tic boy (lateral view of Fig. 40). Bachitic rounded kyphosis (perfectly compensated when lying upon the abdomen) ; swell- ing of the epiphyses of the bones of the forearms and at the junction of the cartilaginous with the bony portions of the ribs. The surface of the teeth is usually prematurely dis- colored a dirty yellow, and presents fossae in close prox- imity to the gums. Later they are striped, grooved, notched, undergo decay, and crumble away. 118 RACHITIS FIG. 42. Extinct rachitis. A six-year-old ^ir!, showing decided curva- tures of the bones, which have now become hard. (Escherich's Clinic, Vienna.) SYMPTOMS 119 Thorax. Either all or only individual bones are en- larged at their cartilaginous extremities, and in some eases plainly knobbed " rachitic rosary." The weight of the arms, the traction of the diaphragm, and the atmospheric pressure cause flattening and retrac- tion of the lateral thoracic walls, a diminution of the transverse diameter, and an increase of the sagittal diameter (rachitic chicken-breast). The lower portion of the thorax over the liver, spleen, and stomach bulges outward. FIG. 43. Severe rachitis ; osteomalacic form with enormous deformities of all extremities. (Escherich's Clinic, Vienna.) Vertebrae. Posterior curvature of the lower portion of the thoracic spine is one of the most frequent phenomena. This rachitic form of kyphosis, contrary to the type met with in spondylitis (Pott's disease), disappears when the subject lies on its stomach (provided ossification has not set in) and is not painful. A vicarious lumbar lordosis is frequently present. The other forms of scolioses do not develop, as a rule, until later in life, and from other causes. Pelvis. The weight of the body presses the iliac bones outward, the sacrum and promontory forward, and elevates the os pubis. As a consequence the true conjugate diam- eter is shortened and the transverse diameter is increased. Extremities. The changes in the extremities, as a rule, occur later in the disease than those of the skull. They consist of a nodular swelling of the lower epiphyses of 120 RACHITIS the radius, ulna, tibia and fibula, and, more rarely, the humerus and femur. Furthermore, traction of the mus- cles and their weight cause curvatures or even greenstick fractures of the shafts of these bones ; as a rule the radius and ulna are bent convexly on their extensor surfaces, the humerus forward and the tibia and fibula outward. The fre- quent deformities of the joints, like genu valgum and genii varum, have their origin in the rachitic thickening of the epiphyses, the abnormal relaxation of the ligaments, the traction of the muscles, and the weight of the body. These various phenomena are not well marked in every case and may frequently occur singly. DIRECT RESULTS OF DISEASE OF THE SKELETON In craniotabes, rubbing of the head upon the pillow causes profuse sweating of the head ; the cranium is ex- tremely sensitive to palpation. Disease of the teeth in- terferes with mastication and salivation, thus at times con- tributing to the gastro-intestinal disturbances so frequently met with in rachitis. Disease of the ribs is manifested by pain when the child is lifted and by a decrease in the thoracic volume. The walls of the thorax being yielding permit the muscles of the chest to expand it sufficiently, excepting in certain parts where the intrathoracic space is diminished. An inspiratory retraction occurs in the neighborhood of the insertion of the diaphragm. Dis- ease of the vertebral column and of the extremities make it impossible for the child to sit up, to stand, or to walk at the proper period of life. Frequently the subjects forget what they have already learned as regards walk- ing or standing. The continuous insufficient ventilation of the lungs results in a decided predisposition to bron- chial catarrh and bronchopneumonia. PHENOMENA WHICH ARE NOT DIRECTLY DUE TO DISEASE OF THE SKELETON Characteristic of rachitis is its pronounced tendency to disturbances of digestion. The dyspepsia is manifested COURSE AND PROGNOSIS. 121 either in constipation or by the discharge of foul-smelling alcoholic stools. Meteorism, which is nearly always present, causes the characteristic enlargement of the abdomen, forces the diaphragm upward, and helps to diminish the intrathoracic space. Anemia is only rarely absent. In some cases the number of red blood-corpuscles is reduced to two or three millions and the leukocytes are increased. The skin as well as the subcutaneous tissue and the musculature undergo atrophy, and become relaxed and flabby in the course of time. Enlargement of the spleen is a frequent symptom, but not constantly present ; enlargement of the liver occurs even less frequently. In a large number of cases there is a certain excitability of the nervous system which shows itself, as a rule, by rest- lessness, peevishness, and crying, and in some cases by more serious phenomena, such as laryngospasm, spasm of the glottis, tetany with its latent and manifest symptoms, and attacks of eclampsia. (Concerning these symptoms, refer to their respective sections.) The course of rachitis is prolonged and extends, with intervals of improvement and exacerbation, over months and even years. Although the various phenomena fre- quently arise within a few weeks, their disappearance is gradual, inasmuch as a normal growth of bone must first set in. The large amount of osteoid tissue which is present becomes impregnated with lime salts, thus devel- oping unusually hard and compact bones " ossaeburnea." The primarily soft state of the bones is thus followed, after a certain period of time, by an abnormal firmness. A large number of the deformities, even the pronounced ones, are corrected without artificial aid by the traction of the muscles, provided they have not previously under- gone ossification. The well-established deformities, how- ever, such as chicken-breast, pronounced bow-legs, thick- enings of the cranium, and changes in the pelvis, remain unaffected throughout life. If craniotabes only is present it may heal without the appearance of other symptoms. The prognosis of the disease itself is favorable. The association, however, of rachitis with any other disease is 122 RACHITIS a serious complication, as is especially true of pneumonia and intestinal diseases, which are frequently followed by death. ETIOLOGY We are still in the dark as to the real cause of rachitis. Although the infectiousness of this disease has been fre- quently referred to, yet it has never been proved ; hered- itary influence, however, seems to play a very important part. In favor of this claim is the existence of rachitic and non-rachitic families living under similar unfavor- able hygienic conditions (Siegert). Etiologically, two factors which influence the general health are of prime importance, namely: 1. Long-continued living in foul air (small, dark rooms, overcrowded rooms, damp floors, or cellars). 2. Improper feeding, in which the special form of nourishment is of less importance than the indi- vidual digestive ability of the child. Artificially fed children are more frequently diseased than breast-fed infants ; the latter are, however, by no means immune to rachitis. In order to understand the morbid anatomy of rachitis it is of importance to understand the processes concerned in NORMAL OSSIFICATION We distinguish between bones preformed in cartilage (primary) and bones developed from a connective-tissue (secondary) foundation. Each type presents a different form of development : Bones Preformed in Cartilage. This type presents three main processes of bony development : Absorption of the cartilage and its substitution by bony tissue endochondral o.w ifu -at ion. Deposition of newly formed bony tissue at the periph- e ry per iosteal oss ifica tion. The reabsorption of fully developed bone, which is of importance in the building and nourishing of bone. This constant bony growth from without and destruc- tion from within occurs alike in all bones, and causes a NORMAL OSSIFICATION 123 decidedly active local metabolic process during the period of development. Endochondral ossification is only seen at the epiphyses of the long bones where longitudinal growth occurs, whereas the diaphysis, which is likewise originally preformed in cartilage, is already ossified (endo- chondral), and continues to grow only in width through periosteal ossification. The transit of cartilage into bone is performed within two narrow zones : 1. An upper pale blue and slightly swollen layer, the zone of cartilage proliferation. 2. Below it a thinner whitish layer, the zone of provisional calcification. Endochondral ossification occurs as follows : In the upper zone the cartilage cells become swollen and arrange themselves in rows and columns. Next the soft cartilaginous ground substance begins to harden by impregnation with calcium salts, the cartilage cells become enclosed, and their further growth is arrested. Blood- vessels accompanied by a large number of cells (osteo- blasts) now extend from the medullary space of the di- aphysis l into the cartilage prepared as above, which absorb the calcified cartilaginous ground substance, and causing the disappearance of the cartilage cells, build primary medullary spaces. Each column of cartilage cells represents a medullary space ; the latter are sepa- rated from each other by undisturbed processes of calci- fied cartilaginous ground substance. The osteoblasts now settle everywhere on the walls of these trabeculae and begin the development of the bony ground substance, which is free of cells the osteoid tissue. The osteo- blasts become gradually surrounded by this tissue, cease to build bone, and become permanent bone-cells. Simul- taneously the osteoid tissue takes up the lime salts and is converted into completed bone-tissue. While the primary medullary space- become filled in this manner with bone- tissue, a simultaneous absorption of the newly built bone again is brought about by the activity of a certain group of large cells the osteoclasts. Thus are formed the definite medullary spaces of the spongiosa. Isolated remnants 1 Or from llu- tissue lying beneath the peiichondriom, 124 MACHITIS PLATE 6 FiG.l. Bony Development. Portion of a longitudinal section through the inetacarpal bone of a five-mouths' -old embryo. Magnified 50 times. The figure shows the border of the endochoudral ossification zone and the changes the cartilage passes through before it is absorbed. K\ter- iially at the perichondrium is a layer of perichoudral bone. 1. Endo- chondral bone. 2. Cartilage. 3. Zone in which cartilage cells form columns. 4. Zone of enlarged cartilage cavities with temporary ealeiliea- cation of the ground substance. 5. Rudiments of calcified ground substance. 6. Marrow. 7. Periosteal bone. 8. Giautcells (osteoclastsi. (From Sobotta's Atlas of Histology.) FIG. 2. Normal border between bone and cartilage of the upper epiphysis of the femur of a seven-months' -old fetus (premature birth due to trauma to mother). Magnified 6 times. The border between the bone and cartilage runs as a slightly curved but regular and <-//- ilid. These are brownish-red, lentil- or mustard-seed- si/ed specks, which are especially likely to occur on the eyebrows, chin, nasolabial folds, soles, and the palms. The spots are considerably elevated and show a tendency to exfoliate and form crusts. A papular efflorescence is especially likely to occur in the anal and genital regions. Maceration of the secretion causes the development of multiple fissured and weeping excoriations at the angles 154 CHROXIC INFECTIOUS of the mouth and at the anus. In .addition to these specific exanthems we also meet with eczematoiis and psoriasis-like varieties. Diffuse Syphilitic Infiltration of the Skin (Hochsinger). The skin of the palms, the soles, nates, genitalia, and folds of the groin are decidedly red, dense, thickened, and shiny, as if varnished. That of the face is tense and gives a mask-like appearance. Splitting of the stretched skin causes the formation of fatty rhagades covered with crusts, which radiate from the edge of the lips to the nose and chin ; later they become converted into scar-ti. n<-, which remains visible for many years. Paronychia fol- lows infiltration of the matrix of the nails. The charac- teristic loss of hair from the scalp and eyebrows depends likewise upon a diffuse infiltration of the involved areas of the skin. The skin usually has a livid and at times dirty yellow and slightly shiny color [Trousseau's color]. The associated hemorrhages in the skin and mucous mem- branes (see Hemorrhagic Syphilis) are caused by a septic infection, which usually extends from the umbilicus. Liver. Children in whom the syphilitic symptoms arc not very pronounced develop icterus in the course of two or three months, accompanied by bile in the urine and acholic stools; there is also an enlarged and resistant liver, splenic tumor, and ascites. Kidneys. Involvement of the kidneys is manifested (chiefly at the close of life) in the form of an ordinary acute nephritis with albumin and granular casts; or as a true hemorrhagic inflammation. Lymph-nodes. Swelling of the lymph-nodes, espe- cially in the cervical, axillary, cubital, and inguinal regions, is rarely present. [Swelling of the cervical lymph-nodes occurs if there be an ulcerating lesion in the mouth, nose, etc. ED.] Bones. Painful, pale, ring-shaped swelling of one of the lower epiphyses of the humerus or femur. This is accompanied by a slight "voluntary" paralysis of the aifected side, without the signs of degeneration and with- out involvement of the joint Parrot's pseudoparalysis. HEREDITARY OR CONGENITAL SYPHILIS 155 Syphilitic Phalangitis (Hochsinger). This consists of a painless swelling, primarily of the first phalanges, sec- ondarily of the middle and distal phalanges of the fingers and toes, which causes the former to assume the shape of a bottle, the latter the shape of a tenpin. There is no tendency for the swelling to rupture externally or to in- volve the soft parts. Both affections of the bones are FIG. 55. Parrot's pseudoparalysis of the loft forearm and the hand in hereditary syphilis. Child four months old. Specific loss of hair from the scalp, eyebrows, and eyelashes. (A uiaculopapular exanthem had disappeared, hut the splenic tumor and coryza still persisted.) (Clinic of von Kanke, Munich.) caused by au osseous inflammation which has spread from the zone between the cartilage and bone (see Pathologic Anatomy). Syphilitic paralyses without involvement of the bones are due to a gumma or arteritis of the brain. These processes present the symptoms of paralysis of 156 CHRONIC INFECTIOUS DISEASES PLATE ii Papular Rash of the Nates and Labia Majora in Hereditary Syphilis. This girl (seven and a half months old) presents on the skin of the labiamajora and in the region of the anus a large number of effloiv.-rrnt papules. These are twice the size of a lentil, pale blue in color, umhili- cated, and excrete a slight discharge. This rash is accompanied by a non-specific eczema with dark red, elevated, and vesicular papules, which are also efflorescent (Eczema erythematosnm, papnlosnin. and vesicti- losum). Other symptoms manifested in this case were a palc-yello\v, slightly shiny skin, splenic tumor, and saddle-nose. Cure in six weeks by means of iodid of mercury. the upper and lower plexuses of nerves, and also prob- ably play an important part in many cases of Little's dis- ease, polio-encephalitis, idiocy, congenital hydrocephalus, etc. Occasionally specific infiltrations and ulcers are found in the larynx, intestines, testes, and various other organs. Syphilis Tarda. Children whose parents have undoubt- edly had syphilis occasionally develop, after the fifth year of life, certain phenomena which conform exactly with the tertiary manifestations of acquired syphilis. It has not yet been determined whether we have to do in that case with delayed manifestations of a case of true hered- itary syphilis, with the continuation of an overlooked early syphilis, or with the tertiary stage of syphilis acquired in early life. Chief Symptoms. Periostitis of the hyperplastic, gum- matous, and ulcerative type. As a result of this process we have chiefly a painful scabbard-like swelling of the tibia and the formation of the saddle-nose. A tor- pid, usually symmetric swelling of the knee-joints, which causes ankylosis. Gummata occur in the skin of the face and on the legs, arranged in groups, which heal slowly; also in the mucous membranes, especially in the mouth, where they undergo radiating cicatri- zation ; perforation of the palate ; cicatricial stenoses in the larynx. Indolent swellings of the lymph-nodes of the cervical, axillary, cubital, and inguinal regions. There is fre- quently considerable swelling of the liver and spleen, and, notwithstanding the absence of other pronounced symp- Tub lir.Ill'.DlTARY OR CO\(;i-:.\ITAL SY I'll I US 157 loins, the patient frequently suffers from a contracted kidney. FIG. 56. Crater-like ulceration of the hone brought on by gum- niut'iiis and ulcerating periostitis and osteitis; congenital syphilis (relapse). Child one and a half years old. (Preparation from the Munich Pathologic Institute.) Involvement of the Nervous System. Headache, various forms of paralysis, infantile tabes, progressive paralysis, idiocy, etc., are caused by chronic endarteritis with local 158 CHRONIC INFECTIOUS DISEASES PLATE 12 FIG. 1. Diphtheria of the Uvula. Enlarged 300 times. 1. Swollen epithelium. 2. Vesicular spaces in epithelium. 3. Leukocytes. 4. Fibrin. 5. Nuclei of the destroyed epithelium in fibrin. (From Diirck, Atlas of General Pathologic Histology.) FIG. 2. Syphilitic Infiltration of the Liver in a Congenitally Syphil- itic Eight -months' Old Fetus, which was Dead when Born.^EnlarKcd 50 times. Beginning maceration. 1. Foci of small-cell infiltration. which are beginning to form a gumma. 2. Proliferation of hepatic parenchyma cells. 3. Thickening of the capsule of Glissou. 4. En- larged bile-ducts. areas of softening, chronic meningitis, and cerebral guraraa. Of the so-called " Hutchinson's triad" interstitial keratitis, central deafness, and peculiar deformity of the teeth only the first is of pathognomonic value. The second is rare and occurs also in other affections ; like- wise the third, the median excavation of the upper inner permanent incisor teeth. Recurrence. In about one-third of the cases apparent cure is followed within the first four years by one or several relapses of this disease. The recurrence repre- sents either a mild form of the first attack with maculo- papular exanthem, corvza, rhagades, etc., or multiple weeping mucous papule. 1 , broad condylomata at the anus, genitalia, and oral cavity the condylomatous stage of hereditary syphilis. The latter is accompanied by deep gummatous disease of the bones, the skin of the ex- tremities, and of the skull; the liver, spleen, kidneys, pancreas, and testes ; and endarteritic processes in the brain and spinal cord, together with polio-encephalitic, hemiplegic, and epileptic manifestations ; iritis and local- i/ed chorioretinitis. (See Haab, Atlas of Ophthalmosoopy, Plates 39-41.) Morbid Anatomy. Macroscopic changes do not set in until after the fourth fetal month, and from the fourth to the sixth month the chief changes consist in an osteo- chondritis and an enlarged spleen. The whole chain of the remaining manifestations do not appear until later. The post-mortem examination is not infrequently nega- Tah. *s*v v " vcvi "**.** ' *'*'*- > \qPvkiw ..:^"^vf"; ' ,^^Xt?*'^5fR^^^\.5 -'-^^v."' i<* :";'.* '. ".': >'i >^d'-?O i C 1 '^ i ' ^ii> '.'^^J* ' '?^|S^ : : '{ ,' jr^j- .-^-.ii, '-^'-AlT ' ii^i < ' -,; -aaV >;> ii3^^ 1 , ..-.-..v %"*" < *, * * . ~- / HEREDITARY OR CONGENITAL SYPHILIS 159 tive. The macerated " sanguinolent " condition of the fetal corpse presents in itself no characteristic change. Even children who during life showed the undoubted presence of syphilis, frequently fail after death to present any of the positive symptoms of that disease. 1 2 FIG. 57. Normal thymus of a healthy full-term child which died during birth. The organ is richly supplied with cellular tissue, but sparsely with thin connective-tissue septa. Enlarged 52 times. 1. Per- ipheral substance. 2. Marrow. 3. Connective-tissue septum. 4. Hassal's corpuscles. The most important gross anatomic changes are: En- la rgement, induration, and increase in weight of the large abdominal glands; thus the spleen weighs ^fa to -fa of the body weight in comparison with ^^ normally ; the liver, y 1 ^ instead of ^- 1 T > an( l the kidney, -fa instead of y^j. The weights only hold true for fetal syphilis and that of the early nursing period. Later the organs undergo atrophy under the influence of the cachexia, and hence lose in weight. An exception to this is the thymus, 160 CHRONIC INFECTIOUS DISEASES PLATE 13 Syphilitic Changes in the Kidneys of a Stillborn Congenital Syph- ilitic (eight to nine months). Magnified 42 times. Beginning marcra- tion. 1. Thickened and partly obliterated peripheral arteries, whose walls and surrounding tissues show small-cell infiltration. 2. Perivascular small-cell infiltration. 3. The cortex is increased in width and under- going retrogressive development. 4. Young glomeruli. which in fetal syphilis weighs almost constantly less than normal, on an average j\-$ of the body weight instead of the normal ^-. Also note that aside from an increase in weight the liver is more elastic than normal (a piece held between the fingers may be snapped away like a cherry stone) ; it is dark in appearance, and on cross-section the surface varies from a brownish-violet to a slightly shiny yellow color ; the capsule is thickened and opaque. Syphilitic osteochondritis is the most frequent of the earliest and the longest in duration of the symptoms of congenital syphilis. Gummata varying in size from a miliary tubercle to that of a hazel-nut, as well as overgrowth of connective tissue and gross cirrhotic processes, are found in all the organs, especially the liver, spleen, lung (interstitial pneumonia), pancreas, thymus, and likewise in the rose- red discolored placenta. Deserving special mention is the so-called " white pneumonia " of a syphilitic fetus, in which the enlarged firm lung appears grayish white on cross-section ; it is generally combined with the interstitial pneumonia. An- other condition to be referred to is a rare chcrry-si/ed abscess of the thymus (so called by Dnbois), which may be easily mistaken for the normal tissue softening in the fetal thymus. The histologic changes of hereditary syphilis are uni- form in so far as the chief alterations are alike in every organ. Circumscribed small-cell infiltration, especially in the neighborhood of the large blood-vessels, which has a tend- ency to undergo central necrosis. This miliary syphiloma may be regarded as the beginning stage of a gumma (see Plate 12, Fig. 2). rt,. ?* $ ' * ',.-. ' it v : '''- ' -< (Hi CONGENITAL M77///./X 161 7)///".sr cellular infiltration, consisting of irregularlv distributed round cells throughout the whole parenchyma. Dtffu&e and circumscribed connccfirc-tixxm' jn'n/if< ration, representing the beginning of cirrhosis (see Plate 12, Fig. 2). FIG. 58. The thymus gland in heredosyphilis of an almost full-term dead child. The connective-tissue septa are more numerous and tliick- ened ; the glandular structure is shriveled and persists only in certain areas in small foci. The corpuscles of Hassal lie closely crowded together and are notably large. Magnified 52 times. 1. Glandular substance. 2. Connective-tissue septa. 3. Corpuscles of Hassal. Abnormal t'jiiflic/ial proliferation collections of epi- thelium in the liver and, rarely, in the lungs and kid- neys. Individual organs are especially characterized by certain peculiarities: The kidneys of the fetus show cel- lular infiltration of the walls and neighboring structures 11 162 CHRONIC INFECTIOUS DISEASES of the smallest peripheral arteries, enlargement of the epithelial marginal zone, and decrease in the size of the glomeruli (see Plate 13); nurslings suffer from acute degenerative nephritis. The spleen undergoes infiltra- tion of the middle and larger sized blood-vessel sheaths. In the thymus there is a thickening of the interlolwlur septa, with compression and shrinking of the acini (see Fig. 58). The alveoli of the lungs, which are the seat ^HWJv m V ''*.*- 1 1 1 Fio. 59. Umbilical cord of a healthy newborn child, showing unequal thickening of the vessel walls. Magnified 11 times. 1. Arteries. 2. Vein with thrombus. of white pneumonia, are filled with desquamated and fatty epithelium. The umbilical cord is infiltrated and the venous and arterial vessel walls are thickciu-d almost sufficiently to cause obliteration. Syphilitic Ofteochondritis (Wegner) (see Plate 12, Fig. 1), which attacks chiefly the epiphyses of the long bones, is marked by enlargement of the provisional /one of calcification, and a serrated border between the cartilage HEREDITARY OR CONGENITAL SYPHILIS 163 FIG. 60. Umbilical cord of a full-term syphilitic child which lived to be five days old. Arteritis and phlebitis obliterans. The walls of all throe vessels are considerably thickened ; proliferation of the intima. The lumen of the vein is much reduced in size ; pus ill one of the arteries. Magnified 11 times. 1. Vein. 2. Arteries. FIG. 61. Umbilical cord of a syphilitic newborn infant. Small-cell infiltration of the media of both arteries. Magnified 8 times. 1. Vein. 2. Arteries. 164 CJIROSIC INFECTIOUS DISEASES and bone; the notches of this border when palpated are felt to be hard and brittle. The bluish and swollen cartilaginous zone of prolife ration is diminished in size. Necrosis rapidly sets in, and finally there is inflammation, softening, and sequestration of the calcified and insuf- ficiently nourished tissue, with resulting separation of the epiphysis. 3 FIG. 62. Syphilitic interstitial pancreatitis in a dead-born infant from seven to eight months of age. Enormous growth of interstitial connective tissue; inflammatory thickening of the walls of the blood- vessels and excretory ducts. Magnified 25 times. 1. (ilandular struc- ture, with beginning proliferation of interstitial tissue. -J. Proliferating interstitial tissue. 3. Rudimentary glandular substance. 4. Thickened arteries. 5. Thickened excretory ducts. Histologically the process consists of a hardening (see Plate 14, Fig. 2, and Plate 6) of all the bone-building tissues (Heubner). The calcification progresses in an irregular manner into the cartilage, involving not only the cartilage but also the columns of cartilaginous cells and the cells of the bone-marrow. Inasmuch as the portion HEREDITARY OR CONGENITAL SYPHILIS 165 of the medullary space which lies next to the cpiphysis is filled with granulation tissue in which osteoblasts are absent, there is no deposit of osteoid tissue on the calcified bony trabeculse. Temporary calcified cartilage and med- ullary spaces, filled witli degenerated granulation tissue, are therefore arranged atypically side by side. In place of permanent bone there is a development of extensively calcified cartilage; this is more easily fractured, especially in the sheath, where it is interrupted by medullary spaces. Here also occurs the epiphyseal separation. Healing depends upon the fact that the medullary spaces are cap- able of forming osteoblasts; as a result, permanent bone is built up and the calcified cartilage disappears. Osteochondritis and Rachitis. In both conditions an interference with bony development is the cause, only in rachitis there is a defect in the development of inorganic and in syphilis of organic constituents of bone. That is, in rachitis there is an insufficient deposition of calcium salts with the undisturbed formation of osteoid tissue, while in syphilis there is no interference with the excre- tion of lime, but an insufficient development of young bone tissue. Diagnosis. In children born dead, without pronounced symptoms of syphilis, the detection of osteochondritis and increased body weight is of significance. Microscopic examination of the kidney for the presence of perivascu- lar infiltration is recommended because maceration of that organ is late in development ; likewise examine the thy mus. Infiltration must be differentiated from the phys- iologically rich supply of cells in youthful tissue, espe- cially in the liver, kidneys, and lungs. Care must be ob- served in the preservation of macerated preparations, which are stained with difficulty. In living children note the chief symptoms : SnufHes, pemphigus, enlargement of liver and spleen, and in- sufficient body weight as early manifestations ; latey maeulopapular exanthems, diffuse infiltration of the skin, and rhagades of the nose, mouth, and anus. Of signifi- 166 CHRONIC INFECTIOUS DISEASES PLATE 14 Fro. 1. Congenital Syphilis of the Intestines. Cross-section of the small intestine of a seven-months'-old syphilitic child which was dead when born. Magnified 60 times. A circumscribed specific infiltration, which may even be detected macroscopically, lies between the miicosa and submucosa ; it has resulted in loosening of the former. 1. Thick- ened peritoneum. 2. Muscular coat. 3. Submucosa. 4. Syphilitic infil- tration. 5. Loosened mucosa. 6. Normal mucosa. 7. Intestinal con- tents. FIG. 2. Syphilitic Osteochondritis. Longitudinal section of the distal epiphysis of the femur of a case of congenital syphilis in a seven- months'-old infant born dead. Magnified 6 times. The border between the bone and cartilage is serrated. The zone of temporary calcification of the cartilaginous ground substance is wider than normal, and extends into the diaphysis as well as into the cartilage. 1. Resting cartilage. 2. Cartilage cells arranged in columns which have been compressed be- tween the calcified cartilage tissue and crowded proliferating cartilage. 3. Large vesicular cartilage cells, in process of beginning ossification. 4. Calcified cartilage ground substance. 5. Primary medullary space, filled with granulation tissue. 6. Calcified cartilage surrounded by gran- ulation tissue. cance in doubtful cases, as during the intervals between recurrences, are numerous deaths in the family, lack of body weight, radiating scars on the lips, splenic tumor, yellowish, dirty skin, and swollen cubital lymph-nodes. Following are the conditions for which syphilis might be mistaken : Pemphigus vulgaris. Development after the first week of large soft vesicles, which do not involve the palms nor the soles. Snuffles are absent. The j>/ii/*- iologic desquamation and paronychia on the fingers and toes appear in from two to three weeks, and the other symptoms are absent. Simple coryza, a thin abundant secretion. Congenital hypertrophy of the nasal mnctmx membrane, adenoid vegetations. Other syphilitic >ymp- toms are not present. The glossy reddening of the soles of atrophic children, the denseness and desquamation of dif- fuse specific plantar infiltration. Papular eczema of flu- anus t the palms and the plantar surfaces of the i' t remain free ; also found in the neighborhood of true eczematous parts ; the other specific symptoms are absent. Spina rentosa (in comparison with specific phalangitis), children older in age, rarely multiple on one hand, fail to localize on the first phalanges, skin also involved, tend- ency to external rupture, of spheric and cylindrie shape. 3-4 '' I />//. y. HEREDITARY OR CONGENITAL SYPHILIS 167 Prognosis. The severe cases die in utcro, and only the mild forms are born. The prognosis is more favorable the later the symptoms develop after birth, and the slower they follow each other. The outlook is bad in the pres- ence of pemphigus and visceral syphilis which originated during fetal life. Relapses occur in about 30 per cent, of all cases, and almost exclusively within the first years of life. A weakening of the general system cannot be pre- vented even in the most favorable forms. Death is due to marasmus, septic, enteritic, nephritic, or pneumonic processes. Syphilis tarda usually terminates favorably. Breast-fed children have better prospects than bottle-fed children, yet careful artificial feeding may also offer good residts. Treatment: Prophylaxis, Marriage is not permissible until at least four years have elapsed since the infection and two years after the last relapse, during which time a thorough course of treatment must have been instituted. When syphilis has been manifestly acquired, the parent should receive energetic treatment. "When a mother has been infected during pregnancy, the general treatment should be combined with the local use of mercury by means of vaginal suppositories. Nourishment. Whenever possible, feeding should be maintained by means of the mother's milk, at least throughout the acute stage. According to Colics' law the mother is not endangered herself. No wet-nurse should be employed even in a doubtful case. If necessary, milk obtained artificially from the wet-nurse may be used. If human milk is not obtainable, then resort to careful indi- vidual artificial feeding, including artificial preparations, Xjifflfii' Treatment u'ith J/r/v///-// ,nnl Inant : Internally. 1'rotoiodid of mercury, 0.005 to 0.01 gin. twice daily; or in combination with saccharated ferri carbonate, 0.1 gm. ; calomel in like doses, or with opium, 0.003 gm. K.rfernatfy. Sublimate baths, 1.0 to 1.5 gm. to a bath. Caution should be used in ease of excoriated skin. Wel- ander's sacks (6 to 10 gm. of mercury and chalk mixture smeared on the woolen side of a piece of lint 20 X 40 1 68 TUBERCUL OSIS PLATE 15 Congenital Tuberculosis. In the atelectatic lungs of a child which died a few hours after birth was found a single cherry-sized caseous focus surrounded by a connective-tissue capsule ; tubercle bacilli were found in this focus. The connective tissue in the neighborhood of the focus was distinctly increased. Other tuberculous processes could not be found. Such a focus might have remained latent throughout life, or it might have been disseminated through an infectious disease, traumatism, etc., and a general tuberculosis caused. (Preparation in the Munich Pathologic Institute.) cm. [8 X 16 in.], which is folded, sewed together, and tied in place), which are to be renewed, as in the case of the commercial "mercolint aprons," after from four to six days. Wrap all four extremities at intervals of six days with mercury plasters. Locally. Apply calomel to condylomata ; 3 per cent, silver nitrate or 10 per cent, chromic acid solution to rhagades; red precipitate or 1 per cent, silver solution to nose. Duration of treatment is about six weeks, in any case for fourteen days after the disappearance of the last symptom. In case of gumma or retarded syphilis give sodium iodid, 1.0 to 2.0 gm. per day, until the dis- ease is influenced. To combat cachexia give arsenic, levico, etc. TUBERCULOSIS Frequency. Next to disease of the digestive tract, tuberculosis is the most frequent cause of death in children (13 to 20 per cent.) ; nearly 30 per cent, of all children possess latent tuberculosis. Of all deaths due to tuberculosis, 30 per cent, are in children. Transmission. Tuberculosis is either congenital or acquired. Congenital tuberculosis is met with but rarely, and is transmitted usually from a mother who is suffering from a severe form of tuberculosis by way of the placenta, which is also, as a rule, diseased. 1 Transmission of the 1 The bacilli enter the fetal blood-vessels or the amniotic sac, where the fetus may swallow them with the liquor amnii (SchmolTj congen- ital gastro-intestinal tuberculosis. lab. TRANSMISSION <>F TUBERCULOSIS 169 tubercle bacillus by means of the human ovum or the spermato/oon has never been determined ; the first is possible when tuberculous peritonitis exists, the latter, however, highly improbable (Gartner). 1 Congenital tuber- culosis represents either a general infection of the fetal body shortly after birth (tuberculous bacillemia), or it assumes the form of tuberculous foci disseminated in the organs. Acquired tuberculosis is the usual form, even in very young children. Caseous foci are rarely seen before the third or fourth month, yet this period of life favors the development of such foci. The infection is transmitted products containing tubercle bacilli, either from the parents' or the child's surroundings. The infection enters the body as follows : By inhalation of dried tuberculous sputum or of fine drops of sputum which have been coughed into the air; the latter occurs only when a person is constantly near the patient. The primary affection lies in the lungs them- selves, especially if a bronchitis or bronchopneumonia al- ready exists, or in the peribroiichial and mediastinal glands, in which case the bacilli travel through the lungs with- out injuring them. Occasionally the first deposition of the bacilli occurs in the pharyngeal or palatine tonsils. Inhalation represents the commonest mode of entrance for tuberculosis. By the introduction of material containing tubercle bacilli into the gastrointestinal tract, by placing utensils, toys, and dirty fingers (tubercle bacilli have been demonstrated in the dirt of the finger-nails) in the mouth, and by the ingestion of raw milk or meat from tuberculous cows. Here also the bacilli may pass through the intestinal walls, and collect in the regional lymph-nodes of the mesentery and peritoneum. It is difficult to determine whether the disease is due purely to the ingestion of in- fected food for tuberculosis of the intestines and mesen- 1 The number of tubercle bacilli in the spermatic fluid is very in- sisjnificant in comparison with the enormous number of spermatozoa, and no spermatozoa have ever t>een found to contain tubercle bacilli. 170 TUBERCULOSIS teric nodes may be secondary to infection through the lymph-channels from bronchial nodes or to the swallow- ing of tuberculous sputum. From the mucous membrane of the mouth, pharynx, nose, and genitals, as well as the external skin, when these tissues are damaged or even when they remain uninjured, provided they come in intimate contact with the bacteria (Cornet). The lips, tonsils, and carious teeth are espe- cially prone to admit the infection. PECULIARITIES OF TUBERCULOSIS IN CHILDREN Tuberculosis of childhood is nearly always a general disease which involves numerous organs and occurs rarely before the third month, reaching its maximum in from two to four years. Characteristic of infantile tuberculosis is the early and constant involvement of the lymph-nodes, especially the peribronchial, and also the cervical, abdom- inal, and inguinal nodes. Disease of the lymph-nodes is frequently the only manifestation of tuberculosis latent tuberculosis. In nurslings the lesions usually met with are tuberculous disease of the bronchial nodes, with caseous pneumonia of the neighboring pulmonary tissue or a generalized tuberculosis. The following varied mani- festatians of tuberculosis do not occur until later in child- hood : Affections of the bone-marrow, serous membranes, meninges, peritoneum, pleura, tendon-sheaths, and joints. As children grow older the symptoms assume the character of adult tuberculosis. Predisposition. This is either congenital, on account of a weak constitution, consisting of certain anatomic peeii- liarities of the skin, mucous membranes, and lymphatics, which are inherited from parents suffering from some dyscrasia, or it is acquired through unhealthy conditions of life, poor nourishment, or wasting diseases. Latent tuberculosis is frequently made active and manifest by febrile diseases, especially measles, whooping-cough, in- fluenza, and inflammation of the lungs. Paths of Dissemination. The inhaled tubercle bacillus is deposited on the pharyngeal or palatine tonsils, which PECULIARITIES OF TUBERCULOSIS IN CHILDREN 171 arc primarily infected, or penetrated to reach the regional lymph-nodes; or it travels to the finer bronchial tubes, where it begins the primary affection with a caseating bronchitis, peribronchitis, and bronchopneumonia ; or even more frequently it pierces the bronchial walls and reaches the lymph-nodes by way of the lymph-channels. Here it causes the formation of minute tubercles, which, becoming confluent, form larger ones; these become swollen and undergo chronic inflammation, and finally, necrosis with caseation, softening, and calcification. Here under certain circumstances the process comes to a stand- still latent tuberculosis. Tuberculosis may extend from the bronchial nodes in the following ways : By contiguity to the neighboring lung tissue peri- glandular caseous pneumonia. By way of the lymph-channels to various parts of the lungs lymphogenic tuberculous peribronchitis or also to distant structures (abdominal lymph-nodes, bones, and joints). Rupture of a calcified and softened nodular focus into a bronchus. Dissemination of tuberculous material by aspiration tuberculous caseous bronchopneumonia. Rupture of such a focus into the esophagus infection of the (/astro-intestinal tract (this may also follow swallow- ing of infected sputum). Rupture into the circulation, either by way of a pulmo- nary artery or a vessel leading to the heart (vein, artery, thoracic duct). In the first case disseminated pulmonary tuberculosis results, and according to the position of the vessel the whole lung or only part of it is involved ; in the latter case (rupture into a vein, etc.) dissemination throughout the whole body leads to generalized tubercu- losis. A particular manifestation of this form is acute miliary tuberculosis, which develops when a large; amount of the infective material is discharged into the circulation at one time, or when vital organs like the basilar meninges are attacked by tuberculous meningitis. In both cases the resulting miliary foci have not sufficient time to develop into larger disseminated nodules. 172 TUBERCUL OSIS Certain phenomena of tuberculosis are possibly not caused by live bacilli, but by the dead bacilli or their soluble products. Thus experimental investigation has shown that general marasmus, cold abscesses, and ca>ea- tion are due to dead tubercle bacilli or their extracts. SYMPTOMS OF GENERAL TUBERCULOSIS Subacute and chronic general tuberculosis are manifested anatomically by foci in process of caseation, varying in size from a hemp-seed or lentil to a hazel-nut, which arc spread throughout the lungs, spleen, kidneys, and brain (solitary tubercles), accompanied by primary older foci in the bronchial or mesenteric nodes. The clinical signs are loss of appetite, apathy, cough, sweats, and gastro- intestinal disturbances. The objective symptoms, if any are present, consist of dark circles surrounding the eyes, a slight or hectic fever which, in spite of its persistence, is unaccompanied by febrile disturbances ; swelling of the small subcutaneous lymph-nodes (micropolyadenopathy) ; chronic bronchitis; indications of the involvement of the bronchial lymph-nodes ; pneumonic infiltration ; enlarge- ment of liver and spleen ; nodules in the skin, varying in size, or dirty grayish-brown elevated specks which are dry and subdivided ; and, more important than all, a progressive emaciation. Other significant manifestations are : A caries encir- cling the teeth (Neumann); small semisoft nodules on the face which resemble incompletely developed furuncles, without a tendency either to suppuration or to resolution (Heubner) ; considerable growth of hair between the scapula? (Heubner). Acute general tuberculosis (miliary tuberculosis) is charac- terized anatomically by minute gray nodules in nearly all of the organs of the chest and abdomen, the meninges, etc. It is accompanied by marked constitutional disturb- ances, a high fever, diarrhea, meteori.sm, splenic tumor, slight cyanosis, dyspnea, and fremitus over both lungs without pronounced pneumonic symptoms. If the brain TUBERCULOSIS <>! Till'. BRONCHIAL .\()DKS 173 cove-rings are also involved, meningitis predominates the disease picture from beginning to end. Diagnosis. Only an approximate diagnosis can be made in case of latent glandular tuberculosis and chronic general tuberculosis. The detection of the tubercle bacilli in young children is difficult, even in the mucus which is removed from the mouth, for the absence of ulcerative processes hinders the appearance of the bacilli in the expectoration. The tuberculin-test presents a harmless and sure method for diagnosis (Sehlossmann). [This last statement is not generally accepted. There are a sufficient number of cases on record where an active tuberculosis has been lighted up from a latent one by the injection of tuberculin. Enough so to make clinicians cautious in the use of this test. ED.] TUBERCULOSIS OF THE BRONCHIAL NODES When tuberculosis of the bronchial nodes is well developed, a symptom-complex results, which is more likely to be characterized by the appearances of a consti- tutional disease than by pathognomonic local symptoms. Morbid Anatomy. Enlargement of the normal nodes lying at the bifurcation of the bronchi and behind the sternum, to a size varying between that of a bean and a walnut ; the nodes are joined into clumps. In the dif- ferent nodes the following individual stages of the tuber- culous process may be recognized side by side: Building of tubercles, infiltration, caseation, softening, calcification, and connective-tissue induration. Symptoms. A peevish or apathetic disposition; pallor; arrested or gradual loss of body weight, without any real disturbance of the appetite and the intestinal functions; inconstant fever; slight dyspnea (without any evident pulmonary lesion). Enlargement and induration of the cervical nodes, and especially the supraclavicular ones, which join under the clavicles and form a garland of nodes, from which extension into the thoracic cavity may naturally be expected. Small areas of dulness are found at one side of the sternum, and at the sternal end 174 TUBERCULOSIS of the first and second intercostal spaces, and in severe cases also posteriorly between the scapula;; the respira- tory murmur is exaggerated in these areas. FIG. 63. Chronic swelling (tuberculous) of the thoracic and abdominal lymph-nodes. A frontal frozen section of a bey four and a half years old, showing the close relationship of the glands to the large blood-ves- sels, also the position and size of the thoracic and abdominal viscera. 1. Trachea. 2. Lymph-nodes. 3. Aorta. 4. Pulmonary artery. (After J. Symington.) SCROFULA 175 Symptoms which arc caused by the pressure of the clumps of nodes upon nerves, blood-vessels, and air-pas- sages : Paroxysms of cough similar to whooping-cough, but without the inspiratory whoop; hoarseness; increased frequency of the pulse (paralysis of the recurrent and vagus nerves); prominence of the engorged veins of the fare, neck, and thorax; clubbing and slight cyanosis of tin: terminal phalanges of the hand (compression of the large venous trunks) ; signs of stenosis with respiratory retraction and whistling respiratory murmurs (pressure upon the trachea and bronchi). Painfulness of several spinous processes between the second and seventh dorsal vertebrae (spinalgia) is claimed to be characteristic (Petruschky). Although these symptoms are not pathognomonic in themselves, yet they become suspicious when present in children who possess a predisposition to tuberculosis, or in those who have recently passed through an attack of measles, whooping-cough, or influenza, or in those suffer- ing from some other form of tuberculosis or scrofula. SCROFULA Scrofula is a combination of chronic swelling of the lymph-nodes with certain inflammatory affections of the skin and mucous membranes, which are characterized by their obstinacy, tendency to relapses, their combined appearance, and their occurrence almost exclusively in childhood. TUBERCULOSIS AND SCROFULA Scrofula is closely related to tuberculosis and in certain respects identical. Corroborating this view are : Scrofu- lous manifestations are very often associated with genuine tuberculous affections, tuberculosis of the bronchial nodes, lupus, caries of the bones, exostoses, and joint disease, in all of which either tuberculosis or scrofula are primary. Simple glandular swelling is frequently observed to de- velop into true tuberculosis of the lymph-nodes. Post- mortem examinations of scrofulous children always 176 TVBERCVLOSrS PLATE 16 Scrofula. Boy six years old. Chronic rhinitis with excoriations and thickened upper lip; chronic right blepharoconjuuctivitis, chronic left kcratitis; the facial expression shows sensitiveness to light. reveal tuberculosis of the bronchial nodes (Heubner). The majority of scrofulous subjects, including those with- out evident glandular swelling, react positively to tuber- culin (Heubner). Primarily the tubercle bacillus, which because of its minute size can pass through the skin and mucous membranes without causing any damage, enters a bronchial; cervical, or mesenteric node, and sets up a true chronic tuberculosis. The resulting impairment of the general health lessens the resisting power of the body, which, together with the fact that in certain children the permeability of the skin and mucous membranes ("ex- ternal barrier ") to bacteria is already increased, offers but little resistance to the entrance of pus-exciting micro- organisms and tubercle bacilli. The scrofulous catarrh of the mucous membranes, eczema, etc., in which some- times pyogenic cocci and at other times tubercle bacilli are found, may therefore be, but not necessarily, tubercu- lous. Likewise the swelling of the lymph-nodes (" inner barrier"), depending upon the affection of the region they drain, may be of a pyogenic or a tuberculous character. The presence of a tuberculosis of the internal glands must be excluded. Symptoms. General Manifestations. At first the gen- eral appearance is still fresh, but later it is nearly always pale; as a rule, there is no emaciation, rather a certain increase of fat; the body and mind are easily fatigued ; dull and often irritable temperament; loss of appetite: headache ; shooting pains in the chest. Typic facial expression : Thickened nose, which is excoriated at' the nostrils by the secretion; thick, protruding upper lip; reddened, thickened eyelids, which are spasmodically contracted on account of photophobia. Lymph-nodes. Swelling is at first localized in the superficial nodes of the neck, lower jaw, and angle of the 7'tib.it SCROFULA 177 jaw. By contiguity the process spreads to neighboring nodes, and at times also by retrograde infection of bron- chial nodes from blocking of the lymph-stream. The size of the nodes varies between a lentil, a hazel-nut, or a walnut. Perinodular inflammation causes a number of nodes to form large clumps. At first the nodes are movable underneath the skin, but later they are adherent. Characteristic of this condition are painlessness, gradual increase in growth, and a tendency of the nodular hyperplasia to undergo necrosis ; unless resorption oc- curs, caseation, calcification, or softening and suppuration set in. If suppuration exists, the surrounding connec- tive tissue is infiltrated, the skin becomes thinner, and an abscess is formed, which ruptures externally unless incised. The abscess contains granular pus, shows but little tendency to heal after evacuation, and often leads, after the existence of fistula for a long time, to the for- mation of radiating sears. Not every case of lymphadenitis is scrofulous ; the secondary glandular involvement of eczema, dental caries, angina, stomatitis, etc., are usually distinguished without difficulty by their acute course, while lymphomatous tumors are recognized by their persistency. Skin. The following are the various scrofulous affec- O tions of the skin : Subcutaneous Infiltrations which develop slowly, unac- companied by manifestations of pain or inflammation, in various parts of the body; these infiltrations lead, in the course of time, to indolent ulcers which have serrated edges (scrofuloderma). Chronic impetiginous eczema of the face, seal]), ear, and surroundings. L'-f/iifin>t j>iifi(les on the lower half of the body, with deep-seated ulcers. Lichen xcrofiilostix, which is probably railiary tubercu- losis of the skin. Mucous Membranes. Eye*. Blepharoeonjunetivitis, thickening of the eyelids, peripheral phlyetenula. accom- panied by photophobia and blepharospasm, tendency of 12 178 TUBERCULOSIS the infiltrated tissue to undergo ulceration, keratitis. iritis, and finally, more or less permanent corneal opacity (leukoma). Nose. Obstinate rhinitis with tough, pus-like secre- tion, which forms crusts and excoriates the nostrils, lead- ing to nasal obstruction and thickening of the nose and upper lip ; in severe cases there is a destructive atrophic ozena. Pharynx. Hypertrophic pharyngitis, chronic inflam- mation, and hyperplasia of the palatine tonsils, and espe- cially the pharyngeal tonsil, with all the consequences of those affections. (See Adenoids.) Ear. Fetid, pus-like, and perforative otitis media, usually double, followed by extension, mastoiditis, etc. Other phenomena noted are caries encircling the neck of the tooth and a persisting gastro-intestinal and bron- chial catarrh. Course and Prognosis. The course is always chronic, yet it varies according to the individual's strength, the degree of extension, and, above all, the possibilities as to treatment and attention. In favorable cases, although of long duration, complete cure may be achieved ; in others the condition is made worse by the advent of bone caries, lupus, pulmonary and general tuberculosis, and meningitis. The prognosis, therefore, is always some- what doubtful, especially when caseous foci already exist. Diagnosis. Although the occurrence of glandular swelling, catarrh of the mucous membrane, and eczema is met with in other conditions than scrofula, yet they point toward the latter by their simultaneous occurrence, their persistence, and tendency to recurrence. Of diag- nostic importance is the general habitus and the facial expression. Positive tuberculin reaction would support the diagnosis. THE TREATMENT OF TUBERCULOSIS AND SCROFULA Prophylaxis. Institute careful nursing and feeding; instruct parents as to the hygienic care of their children; TBEA TMENT OF TUBERCULOSIS AND SCROFULA 1 79 careful hardening of the body against changes in tempera- ture and disease ; encourage a certain amount of physical laziness ; use pure milk. Discourage marriage between tuberculous individuals ; proper ventilation of dwellings ; much time to be spent in the open air. Preventing Infection of Susceptible Children. Forbid all association with tuberculous subjects ; separate from tuberculous parents, and raise in children's sanitaria ; when this is not possible the closest attention must be paid to prevent infection. Children should be taught cleanliness frequent washing of the hands, care of the mouth and nose, and disinfection of utensils and toys. Guard against diseases which predispose to tuberculosis, such as measles, whooping-cough, etc. General Hygienic and Dietetic Treatment. Light, well- ventilated dwellings ; sojourn in mountainous regions or at the sea ; careful supervision of air- and sun-baths ; keep the skin in good condition and give alcohol rubs ; salt- or peat-baths (see Rachitis), also sand-baths. Institutional treatment in children's sanitaria and sea hospitals ; abundant fatty foods : milk, cream, whipped cream, kefir, butter, and infants' meals ; together with chopped meat and pressed meat juice. As a rule give a mixed diet, but constantly alternate with green vegetables, salad, fruit, and compote. Special Treatment. Soft-soap Cure. Dilute the tinct- ure of green soap with a little warm water and rub it daily into the skin of the trunk and the extremities, and wash it off in ten minutes. To combat the glandular swelling make hydropathic applications with gruel, mud, or decoctions of oak bark. Also smear the body with potassium iodid ointment or iodovasogen, also in combina- tion with equal parts of soft soap, covered with cotton and allowed to remain over night. Large masses of lymph- nodes are extirpated before softening sets in. Adenoid vegetations and hyperplastic tonsils should be removed. Medication. One child's spoonful, twice daily, of brown or light cod-liver oil alone or combined with 1 to 3 per cent, creosote carbonate (creosotal). Cod-liver oil 180 TUBERCULOSIS PLATE 17 Acute Disseminated Tuberculosis of the Lungs. Bronchojienic form bronchiolitis nodosa. The bronchial luruina may be recognized iis points within the miliary foci. Chronic caseous tuberculosis and partial softening of the tracheal and bronchial lymph-nodes. Two-year-old child. Duration of disease, four weeks. Clinical history : Remitting fever, dyspnea, cyanosis, no evident dulness, and emaciation. may be substituted for lipanin or Mehring's chocolate. Tasteless guaiacol carbonate ("duotal"), 0.1 to 0.3 gm. per dose. Guaiacol valerianate (" geosot "), 4 to 8 drops three times a day ; thiocol, sufficient to cover a knife- point, three times a day. Sirolin or sulfusot syrup, 1 coffees poon ful three times a day. Syrup of the iodid of iron with simple syrup, of each 8 to 20 drops ; or the iodid of iron with malt extract, iodoferratose. To stim- ulate the appetite give the compound tincture of cinchona in 1-drop doses, or wine of iron and quinin in coffeespoon- ful doses after meals. To Combat the Phlyctenular Keratoconjunctivitis. Yel- low mercuric oxid ointment, 1 to 3 per cent. ; for obsti- nate infiltrations, dust with calomel; for the photophobia, hold the head in cold water. Treat the nasal infection with douches of warm salt-water and apply white precip- itate salve. (For treatment of the Eczema, see the section on that subject.) The therapy of acute generalized tuber- culosis consists in supporting the patient's strength, com- bating the fever with hydrotherapeutic measures of medi- cation, and relieving the pain with narcotics. TUBERCULOSIS OF THE LUNGS Excepting the bronchial glands, the lungs represent the part of the infantile body most frequently affected by tuberculosis. Morbid Anatomy. The following are the forms of pul- monary tuberculosis which occur in children. They may occur singly or in combination : Acute Disseminated 7V>ovWox/.s- (MiUarif Tuberculosis). This type may be either hematogenous or bronchial Tab. I. TUBERCULOSIS OF THE LUNGS 181 in origin, according to whether the caseous focus ruptures into a blood-vessel or a bronchus. When only isolated portions of the lungs are involved the course is slower and larger nodules are formed subacute and chronic dis- seminated tuberculosis. The hematogenous miliary tuberculosis consists of minute nodules scattered throughout the lungs and pleura, not involving the smallest bronchi ; hyperemia and con- solidation of the lung tissue. It is usually a part of gen- eral miliary tuberculosis. In the bronchogenic form the nodules lie in the walls of the smallest bronchi bron- chiolitis nodosa which finally spread to the neighboring pulmonary tissue. Caseous peribronchitis is due to extension from old foci along the lymph-vessels of the bronchi, and is accom- panied by caseous thickening of the bronchial wall and consolidation in the neighborhood. ( \iseous pneumonia is either perinodular, by direct extension of the tuberculous process (frequent in nurs- lings), or by confluence and spreading of peribronchial foci. The aifected area is tense, on cross-section has a yellowish-red to yellowish-white color, and appears granulated because of the exudate from the alveoli. Secondary tuberculosis develops from pre-existing infil- trations which follow r catarrhal or croupous pneumonia. These various forms may develop into chronic phthisis, with the formation of cavities, connective tissue, indura- tion, calcification, etc. This, the true "consumption of the lungs," attacks the bases of the lungs, as a rule, and is rarer in children than in adults. Symptoms. These vary according to the nature of the process. The manifestations of general tuberculosis are always demonstrable, and very frequently before the appearance of the disease itself, in the form of primary glandular tuberculosis. Acute miliary tubercu- losis, frequently the termination of other tuberculous affections, usually begins acutely with a high temperature, which later runs the course of a constant or cachectic fever, with increased respiration (40 to 60) of a 182 TUBERCULOSIS character, increased pulse-rate, cyanosis, anemia, and increasing emaciation throughout the course of the dis- ease. There is an irritable cough, usually without expec- toration (because the tubercles are mostly extrabronchial); in general the system may be looked upon as being in the typhoidal state. Objectively the lungs present no change or only a dry catarrhal capillary bronchitis ; the spleen and liver are swollen at times, and frequently older tuber- culous foci are found in the lungs and other organs. Death follows the development of diarrhea, convulsions, and weakening of the heart. The subacute and chronic forms of disseminated bronchial, hematogenic, and lymphogenic tuberculosis present a more gradual onset, a hectic fever, anemia, and emaciation ; mild dyspnea, vari- able areas of dulness, which are localized with difficulty ; the respiratory murmur is increased from vesicular to bron- chial ; whistling and small vesicular rales are heard ; yet clinically the picture of bronchopneumonia is not present. Caseous Pneumonia. A persistent lobar or lobular pneu- monia, especially after measles, whooping-cough, or influ- enza, accompanied by emaciation and loss of appetite ; a recently elevated or hectic fever; or primarily the symp- toms of a progressive bronchopneumonia with dulness, rales, bronchial breathing, to which are added the symp- toms of the general disease. The expectoration is pus- like and contains abundant tubercle bacilli (obtain by removing with cotton swabs). The dulness, which fre- quently spreads from the spine toward the apices or to the region of the scapula, often remains unaltered for many months. Course and Prognosis of Pulmonary Tuberculosis. The acute and subacute disseminated tuberculosis always ends unfavorably, usually after a few days or weeks. Cure is possible in the mild cases of caseous pneumonia, but never in the severe types. Death follows cardiac weak- ness, generalized tuberculosis, or meningitis. Chronic disseminated tuberculosis, like true pulmonary phthi-is, is more hopeful in children than in adults, and permanent cure is comparatively frequent. TUBERCULOUS PLEURISY 183 Diagnosis. The following are the characteristics of a pulmonary disease which is tuberculous in nature : The obstinacy of the condition ; the disproportion between the comparatively few local and the severe general symp- toms; general habitus; emaciation; anorexia; cyanosis; the existence of other tuberculous affections ; chronic swelling of the lymph-nodes, especially the supraclavicular group ; the discovery of the tubercle bacillus ; positive tuberculin reaction. Treatment. As to prophylaxis, predisposed children should be carefully watched after the acute infectious diseases, and sent, if possible, to the country. In the undoubted presence of pulmonary tuberculosis begin the treatment with rest in bed, followed by the open-air cure (protected against the wind). No sea-baths ; on the con- trary, the child should be sent to a mountainous region. Medication. Cod-liver oil, creosote, guaiacol. Stimu- late the appetite with the compound tincture of cinchona. To allay expectoration give codein and the extract of bel- ladonna (aa 0.01 to 0.05 gm. a day). To combat the fever make cold applications and give quinin internally ; acetic acid for the sweats ; or 1 per cent, menthol or spirits of the salicylates. Gelatin internally or injected for hemoptysis, or liquor ferri chloridi, 1 to 2 drops. TUBERCULOUS PLEURISY This is usually secondary; when it occurs as a mani- festation of miliary tuberculosis the pleura usually con- tains minute tubercles ; when a complication of pulmo- nary tuberculosis, it is usually of the dry form, witli the formation of fibrous indurations and caseating infiltra- tions. If a watery exudate exists, the pleurisy is of the serous or serosanguineous type; it is purulent in form when a cavity ruptures into the pleura, and in that cage the pus contains mononuclear leukocytes. Symptoms. The onset is insidious, difficult to recog- nize, and accompanied by the phenomena <>f general tuberculosis. Local subjective symptoms are absent. 184 TUBERCULOSIS At first there are slight pains, fever, and dyspnea. Later there is dulncss, pleural friction-rub, diminished breath sounds and fremitus, lessened excursion of the diseased side, etc. This process leads quite frequently to empy- enia. (For treatment, see that of Tuberculosis and Pleurisy.) The diagnosis is of importance because pleu- risy is frequently the first manifestation of tuberculosis. TUBERCULOUS PERICARDITIS This follows extension of the pulmonary process to the pericardium. If it involves both the parietal and visceral pericardium, they become intimately united. The symptoms are similar to those of ordinary pericarditis. Dry pericarditis in children is always suggestive of tuberculosis. The pharyngeal as well as the palatine tonsil* may become diseased primarily by aspiration, that is, dirt infection, and secondarily through the expectorated sputum. In the first form nodules are usually found lying deep in the glands, and in the other type superfi- cial latent ulcerations are found. ABDOMINAL TUBERCULOSIS Intestines. Origin. It follows the swallowing of tuberculous material (also congenital), or generalized tuberculosis by way of the blood, and from tuberculous mesenteric glands by way of the lymph-channels. Morbid Anatomy. The solitary follicles and Peyer's patches in the lower small and the large intestines are infiltrated, and breaking down, form ulcers, the edges of which are irregular, undermined, and infiltrated. These ulcers spread in a transverse direction in the intestinal walls ; they are often circular in outline and are sur- rounded by minute tubercles. A resultant local peritoni- tis, with adhesions of the involved section of the intes- tine and encapsulation of the exudate frequently occur. Symptoms. This condition develops either primarily with a gradual onset, or it arises secondarily to already existing tuberculous disease. An intractable diarrhea ABDOMINAL TUBERCULOSIS 185 sets in, alternating at times with constipation. Vague abdominal pain, with raeteorism, nausea, and loss of appetite. Aside from these the following constitutional symptoms exist : Emaciation, sweats, and irregular ele- vations of the temperature. Course and Prognosis. The course is always pro- tracted throughout months and years. The outlook is unfavorable because of the increase of the diarrhea and cachexia. Treatment. Observe general hygienic and dietetic principles. Preserve and increase the body strength; hydropathic applications ; feed as in case of catarrh of the large intestine. Of the astringents give : Bismuth subcarbonate, subnitrate, subgallate ; silver nitrate (0.05 to 100.0 gm.) ; calumba, tannigen, etc. [In persistent cases opium must be used in sufficient quantity to con- trol diarrhea. ED.] Mesenteric Nodes. Tuberculous disease of the mesen- teric nodes arises primarily by the entrance of the bacilli through the intact intestinal walls, or secondarily from an already existing tuberculosis of the intestines or peri- toneum. As in the case of the bronchial nodes, tubercu- losis of the mesenteric nodes may arise as an independent disease tabes mesenterica. The swollen nodes form large masses, which are packed closely together. Symptoms. Those of the general condition, together with a rounded dome-shaped abdomen, the apex of which is at the umbilicus; dilated abdominal veins, enlarged inguinal glands, and abdominal pain. If the glands are palpable (which is not always the case), they may be felt as movable tumors deep in the abdomen near the umbil- icus. The diagnosis, because of the possibility of feenl musses, can only be established after the intestines are evacuated. The course is usually unfavorable. Treatment. Hot applications, inunctions witli soft soap ; otherwise like that of tuberculosis of the bronchial glands. Peritoneum. Origin and Morbid Anatomy. Tubercu- lous peritonitis arises either secondarily to general tuber- 186 TUBERCULOSIS PLATE 18 FIG. 1. Chronic Tuberculous Peritonitis. Semidome-shaped abdo- men. Flattened, chronically infiltrated, and pigmented periomphalitis. Four-year-old girl. (Clinic of Escherich, Vienna.) FIG. 2. Umbilical Fungus. (See text, p. 84.) culosis or it is lymphogenic iu origin, following tubercu- lous ulcerations of the intestines, abdominal glands, vertebrae, genitalia, lungs, etc. In the first case miliary and submiliary nodules are distributed on both visceral and parietal layers, the presence of which are unrecognizable clinically. In the second case true tuberculous peritonitis there is at first the secretion of a thin serous fluid, this is followed by a serofibrinous, pus-like, sanguineous, or ichorous (in intes- tinal perforation) exudate. Next, fibrinous and caseous deposits are formed ; the intestinal coils adhere to each other and to the abdominal wall, and encapsulated abscesses are formed. Occasionally the peritonitis is of the dry form, accompanied by extreme thickening and wrinkling of the omentum. A fatty or cirrhotic liver or an amyloid liver and spleen are often met with. Symptoms. As a rule the onset is gradual, but occasion- ally it presents the picture of an acute and, later, chronic peritonitis. Chief Symptoms. Gradual increase in the size of the abdomen, which presently assumes an oval or semi dome shape, in marked contrast to the emaciation of the rest of the body. The abdominal skin is tightly stretched, and through it the veins are visible. The umbilicus, instead of being flattened, may protrude and be infiltrated peri- nmbilical inflammation. Usually the presence of free fluid is demonstrable (light percussion and palpation). At times a dense resistance, and the shape of exudative tumors are palpable. There is but slight tenderness to pressure, but considerable intermittent abdominal pain. Sometimes a respiratory friction-rub is heard over the spleen and liver. The stools are clay-like, acid in reac- tion, and fatty. Otherwise it presents the picture of the general disease. / f/O.M. TUBERCULOUS MENINGITIS 187 Course and P/-or/o.s/N. The disease lasts for months and years, with intervals of improvement or of arrest, during which time the exudate may be increased or decreased. Sometimes abscesses may rupture at the umbilicus or into the intestines, an event which does not favorably influence the course of the disease. Death may occur through a progressive marasmus, acute perito- nitis, general tuberculosis, or meningitis. In milder cases spontaneous healing gradually occurs, with perma- nent encapsulation ; the latter makes recurrence of the condition possible. The prognosis is, therefore, always doubtful, and is less hopeful in the presence of caseous products or other tuberculous affections. Diagnosis. Of significance is the enlargement of the abdomen while the rest of the body undergoes emacia- tion ; symptoms of general involvement, the subsequent development of tuberculous processes, and the discovery of solid or fluid exudates. Treatment. That of the general disease. Rest in bed, a non-irritating but strength-producing diet, milk, infant meals, eggs, bouillon, chopped meat, meat juice, somatose, and fruit jellies. For the pain, make warm applications, opium. To absorb the exudates anoint with soft soap or vasogen. Internally give creosote, guaiacol. If thev deep sighs. The apathy increases and the next stage is entered. The apathy and 190 TUBERCULOSIS drowsiness lead into a state of perpetual somnolence, from which, however, the patient may be aroused ; the child is still able to answer questions, recognize its sur- roundings, but soon falls asleep again. The eyes are then usually only half closed. Sleep is interrupted by rest- less tossing, mild delirium, or shrill outcries " cri hydrencephalique " while the pulse and respiration still maintain the above changes. Development of Symptoms of Cerebral Irritation. Converging strabismus, which may disappear again ; also nystagmus. Dilatation and undulation of the pupils, that is, contracted when exposed to the light and imme- diate dilatation in spite of the presence of light. By . FIG. 64. Tuberculous basilar meningitis. Five-year-old boy. St;i- of stupor. Marked emaciation ; contracted abdomen ; tonic spasm of botli lower extremities; spasm of right hand in pronation. The left arm was paralyzed. Spasms and palsies were uot permanent, but alter- nated with each other. ophthalmoscopic examination choked optic disk and choroidal tubercles are detected. Loud gnashing of the teeth ; movements of mastication. A wandering move- ment of the hands ; twitching of the lips and skin. Oscillatory movements of the extremities, which are lifted widely apart. Kern it fx *////*.- The leg when flexed at the hip and knee cannot be extended in the sitting posture. The tendon and skin reflexes are increased. Tar/ie cerebrales: Drawing the finger-nail over the skin is followed by dark red stripes, which continue for some time (Trousseau). The abdomen gradually undergoes a scaphoid retraction on account of lack of nutrition and contraction of the TUBERCULOUS MENINGITIS 191 FIG. 65. Tuberculous busihir meningitis. Boy three and a quarter years old. Stain- of stupor. Eyelids only partly closed, Coniecearo beginning to dry up. Ptosis of the right eyelid. Converging strabis- mus. The lower jaw hangs relaxed ; the nasohibial folds have disappcari-d (paralysis of the labial and maxillary muscles). Dry lips and tongue. (Clinic of Eschcrich. Vienna.) intestines (irritation of the vagus, Heubner). Rigidity 192 TUBERCULOSIS of the neck is usually not very pronounced. The influ- ence of light upon the eyes lessens and soon ceases entirely. The somnolence is changed into stupor. The patient becomes wholly unconscious and fails to respond even to the strongest stimulation. Final Stage. At times there is a short return to con- sciousness just before death. Eyes half closed ; cornea insensible ; palpebral fissures absent ; flakes of mucus in the eyes ; loss of sight and hearing. The pulse begins to grow more rapid, and its frequency may reach 200 or even higher (cardiac weakness); its rhythm becomes regular. The respiration is of the Cheyne-Stokes type, with long pauses, which may last fifty seconds. In con- sequence of the cardiac weakness and the insufficient oxidation we plainly see cyanosis, peaked nose, thin lips, and cold extremities. Excessive emaciation until the body is no more than a skeleton ; paralysis in the regions supplied by the cranial nerves, including ptosis, facial palsy, hemi- and monoplegic palsies, which may again disappear, and be replaced by chronic or epileptiform con- vulsions and extreme tremor. Complete anuria ; incon- tinence of feces. Death often sets in after days of coma. The fever presents no characteristic curve ; it is higher at the beginning than during the rest of its course ; it remits irregularly and rises in the evening, and is always of a moderate degree, but as the end approaches it frequently rises abnormally high 41 or 42 C. [105.8- 107.6 F.J (paralysis of the heat-moderating center, Henoch). Vomiting and constipation may be absent. Course and Prognosis. The prodromata last several weeks or months ; the duration of the disease itself from the first vomiting attack is three weeks on an average, but it may be shorter or as long as eight weeks (Monti). The somnolent stage is the longest. The development of cerebral irritation marks about the middle of the disease itself. The increase in frequency of the pulse begins about two and a half or, at the most, four days before death. The prognosis is hopeless. The cases are rare in which the patients recover from the first attack TUBERCULOUS MENINGITIS 193 and live long enough to experience a second attack, to which they are sure to succumb. Didf/no*!*. Chief characteristics : }'utn!t!nr/, independ- ent of the ingestion of food ; headache and comtipation in a child whose general health and state of nourishment have been disturbed for several weeks. Abnormally slo\v and unequal pt.il*e and irregular respiration. Grad- ual mental failure, languor and drowsiness, apathy, som- nolence, and stupor. Tuberculosis in the child itself or in its ancestors strengthens the diagnosis. The detection of the tubercle bacillus in the cerebrospinal fluid (by centrifuge) makes the diagnosis positive. Lumbar punc- ture shows increased pressure of the cerebrospinal fluid, which at the beginning is clear, but later cloudy, as' if a fine dust were held in suspension ; the fluid also contains a high and constantly increasing percentage of albumin (1 to 6 per cent., instead of 0.2 to 0.4 per cent, normally) and mononuclear leukocytes. POSSIBLE ERRORS. Typhoid fever: Typic elevation of fever, splenic tumor, roseola, bronchitis, meteorism, diarrhea, presence of typhoid bacillus in a drop of the blood, or a positive Gruber-AVidal reaction. Dygpcptia or constipation : Absence of prodromata and influence of therapy. Intestinal paraxitc* with cerebral irritation: Examination of stools ; administration of anthelmintics. Hereditary syphilitic cerebral processes: Cory/a, syphilids, and other specific symptoms. Uremia: Examine urine. DIFFERENTIAL DIAGNOSIS BETWEEN VARIOUS FORMS OF MENINGITIS. Epidemic Cercbroxpinal Jfeningitis. Acute onset without long prodromal stage, more intense headache, pronounced and painful stiifness of the neck and spinal column, hyperesthesia of the skin, ,'urly somnolence, no abnormal slowness or irregularity of the pulse. The oerebrospinal fluid is made turbid by the presence of pus and contains the Meningococcus intracellularis. High albumin-content (3 to 6 per cent.). Purulent ,l/ caseation, and form large caseous infiltrations in the spongiosa with isolated frag- TUBERCULOSIS OF THE BONES AST) JOISTS 195 ments of necrosed bone. These foci soften and become converted into cavities lined with granulation tissue and filled with caseous pus, in which the bony sequestra lie free. Simultaneous proliferation of the periosteum causes a thickening of that membrane. Local tuberculous infec- tion of the periosteum results in superficial or deep caries, in the formation of caseating periosteal nodules, or in the development of cold abscesses. These usually rupture externally by means of fistulae, either at the site of their origin or, tunneling through the tissue, they appear in an altogether different location. \J FIG. 66. Spina ventosa of the right thumb and left middle finger of a three-year-old child. In the joints we note the eruption of disseminated tubercles on the synovial membrane; the latter is con- verted into a hyperemic, infiltrated, or soft grayish-ivd granulation tissue, which is permeated with tubercles arthritis fungosa; a eerofibrinous or pus-like exudatc fills the articular cavities. The surrounding soft parts are ederaatous and infiltrated, the skin pale, smooth, ami shiny tumor - Gnulual stiffening 1 of the spinal column, which is espe- cially noticable at an early stage when picking an object up from the floor. Localized pressure tenderne-s when the spinous proees.-e-; are palpated ; a gradual or rapid 198 TUBERCULOSIS FIG. 68. Spomlylitis of the upper dorsal vertebrae. Sharp-angled kyphosis. This eight-year-old girl showed phenomena of transverse myelitis (spastic paraplegia of the legs with increased reflexes], which under orthopedic management disappeared, with the cure of the spondy- litis. (Clinic of von Eanke-Herzog, Munich.) development of any one of these symptoms. Formation of a more or less pointed hump, which does not disappear when the patient lies on the abdomen. As the process progresses the symptoms of the general disease gradually arise. In severe cases extension of the inflammation or compression of the spinal cord leads to manifestations of myelitis, which varies according to the height of the dis- eased area. In cervical spondylitis disturbances of swallowing and speech als6 co-exist. Results. Cure, with a remaining large or small hump; death due to exhaustion, amyloid disease, peritonitis, general tuberculosis, myelitis, or meningitis. The treat- ment should strive to relieve pressure and to set the spinal column at rest by means of extension beds and orthopedic corsets ; also general hygienic management. Osteomyelitis and periostitis of the long bones, of the malar bones, of the temporal bones, orbital, etc., are manifested by chronic swellings, cold abscesses, fistulous tracts, and caries. Treatment. Where possible, make alcoholic applica- tions, maintain rest, inject iodoformol. COXIT1S Coxitis is a tuberculous inflammation of the hip-joint, which is usually an extension from the bony portions of the joint.. Symptoms. At first there is a slight dragging, later a pronounced favoring of the diseased leg and over use of the healthy leg voluntary limping ; pressure tenderness at the trochanter ; pains in the knee; diminished mobility of the hip-joint. The leg is held contracted, at first in abduction, flexion, and external rotation, with apparent elongation ; later in adduction, flexion, and internal rota- tion, with apparent shortening. When an attempt is TUBERCULOSIS OF THE RONES AND JOISTS 199 Fn;. 200 TUBERCULOSIS made to extend the flexed leg, with the patient in the dorsal posture, the spine is lifted and becomes lordoscd FIG. 69. Dorsal spondylitis. with the lornuition of an abscess at the summit of the hump. and the pelvis moves with the joint; when attempting to TUBERCULOSIS OF THE BONES AND JOINTS 201 flex the leg the pelvis is raised and the lordosis disap- pear*. Interference with posterior rotation of the affected leg is also of importance ; this is tested for by grasping the tip of the foot and rotating first one leg, then the other, while the patient is in the recumbent position. The process progresses with swelling of the hip and gin teal regions and with the development of burrowing abscesses, which commonly rupture at the posterior and outer side of the femur. Treatment. Rest by means of plaster-of-Paris cast ; permanent extension. As soon as possible institute such orthopedic procedures as will permit the child to walk, and yet correct the deformity and transmit the support of the body weight to the pelvis. The general disease is treated by sojourn in the open air and at the seacoast. The disease may be cured at any stage ; the prognosis in the early stages is the most favorable, while in the more advanced periods the cure is only relative and is accom- panied by deformities, aukylosis, and pseudo-arthrosis. TUBERCULOSIS OF THE KNEE-JOINT ("WHITE SWELLING" OF THE KNEE) Tuberculous disease of the knee-joint begins with stiff- ness, lessened mobility, and slight pains. Early swelling of the joint may be recognized by the disappearance of the two fossae at the sides of the patellar tendon, as well as by filling out of the popliteal space. Later the knee is flexed and becomes painful when moved, and also spon- taneously. The growing swelling assumes a spindle form, is elastic, and its skin covering is shiny and stretched ; there is fluctuation or pseudofluctuation ; the patella be- comes immobile. The de velopment of an abscess incr< ;!-.< the size of the swelling considerably and causes severe pain; the abscess ruptures in the region of the joint itself or in that of the femur or the tibia. Destruction of the joint leads frequently to subluxation and luxation of the tibia backward. Healing is possible in all stages, but, as a rule, connective-tissue overgrowth or true bony ankylosis results. 202 TUBERCULOSIS PLATE 20 FIG. 1. Tuberculosis of the knee-joint, which led to destruction of the joint and subluxation of the tibia. Tuberculous osteomyelitis and periostitis of the tibia, with multiple fistulous tracts. FIG. 2. Tuberculosis of the Knee-joint. Disappearance of the con- tour of the joint. Doughy swelling at the anterior aspect of the knee covered by tense, pale skin. Fistula formation. Subluxation of the tibia. Treatment. Place at rest in plaster-of-Paris cast in the position of flexion. Inject iodoformol ; later apply port- FIG. 70. Tuberculosis of the right ankle-joint, with doughy swelling of the joint and disappear- ance of the bony contours. FIG. 71. Tuberculous caries of the left tarsal bones, with the formation of a fistula. able apparatus, with the support at the tuberosity of the ischium. Fitf.1. />// 9. TUBERCULOSIS OF THE RONES AND JOINTS 203 TUBERCULOSIS OF THE JOINTS OF THE FEET (TUMOR ALBUS PEDIS) The ankle-joint is the one most commonly involved. It is accompanied by localized pain in front and at the sides of the foot on standing, which later may also occur spontaneously. The tissue in front and back of each bone is somewhat swollen and the bony contours are lost. Later a distinct and diffuse elastic .swelling is noted around the joint; suppuration, cold abscesses, fistula formation. Treatment. Put at rest. Alcohol applications.. lodo- formol. TUBERCULOSIS OF THE ELBOW Pain, interference with movement, and spindle-shaped swelling, which forms a marked contrast to the emaciated upper forearm. The forearm is flexed midway between pronation and supination. DISEASES OF THE NERVOUS SYSTEM DISEASES OF THE BRAIN AND ITS MEMBRANES CEREBROSPINAL MENINGITIS CEREBROSPINAL, meningitis is an epidemic and sporadic suppurative inflammation of the cerebrospinal meuinges, which attacks by preference young children and nursing infants ; its direct cause is the Meniugococcus intracellu- laris. This is similar to the gonococcus, inasmuch as it occurs in pairs, and is found in groups of twenty or more pairs within the cell. It is stained by methylene-bltie, but in the meningeal exudate it fails to stain by Gram's method, whereas it may be detected by means of Gram's stain in smear-cultures. It grows in glycerin-agar ; when it is injected intradurally into goats it sets up a typic case of meningitis (Heubner) ; the meningococcus has been demonstrated in the nasal discharge of patients suffering from meningitis. Morbid Anatomy. Hyperemia of the cranium and of the meninges of the brain and spinal cord. A gelatinous, serous, fibrous, or purulent exudate collects between the pia and arachnoid, preferably at the convexity between the convolutions, and at the posterior surface of the cer- vical and lumbar spine. The brain appears as if it were "smeared with butter." Inflammation and softening of the superficial portions of the brain. A cloudy, seropuru- lent exudate fills the ventricles. Symptoms. Its onset is sudden during the enjoyment of perfect health, or it begins after a short period of pro- dromal symptoms, consisting of weakness and loss of appetite, with a high fever, convulsions, vomiting, ex- treme pains in the neck and back, accompanied by loud sighing. Extreme hypersensitiveness to movement, light, and noise. The cardinal symptoms are : Intense stiffness 204 CEREBROSPINAL MENINGITIS 205 of the neck and of the spine opisthotonos. Spasms of the extensor muscles of the extremities, followed finally by tonic rigidity of the whole body. There is also an early clonic twitching and tremor in the various groups of mus- cles ; nystagmus (Kernig's symptom). Partial palsy of the lower extremities, of the muscles supplied by the facial nerve, and of the ocular muscles. Consciousness is soon lost and the patient enters a somnolent stage, which is interrupted by shrill cries and jactitation. The pupils are contracted and the abdomen retracted. Herpes racialis (in 50 per cent.), various erythemata, petechiae, and urticaria. The pulse and respiration rate are usually considerably increased. At times the former is irregular, and later in the course of the disease it. becomes slower than normal. The fever rises rapidly to 40 C. [104 F.] and over, and is irregularly remittent or intermittent. Course. Very acute cases are sometimes met with which run a course of only a few hours or days, accom- panied by a sudden loss of consciousness, convulsions, subnormal or hyperpyretic temperature, and apoplecti- form palsies. In contradistinction we meet abortive forms, presenting a headache, moderate cervical rigidity, and fever, which frequently cannot be recognized except during an epidemic. The average course is protracted over weeks and months and associated, as a rule, with remissions and fresh relapses. Convalescence sets in gradually and is considerably protracted; individual symp- toms may persist for a long time. ( Vivbral disturbance.-, deafness, blindness, hydrocephalus, and psychoses are frequently the after-effects of this disease. For this IVMM.II and on account of the high mortality rate (60 to 70 per cent.) the prognosis must be doubtful. Dead) occurs during coma, or on account of cardiac weakness, or because of complications, such as disease of the lungs, intestines, heart, kidneys, etc. Treatment. Absolute rest. Prevent external irrita- tions ; carefully selected, appeti/ing diet. Hot baths (35 to 40 C. [95-104 F.] ), with cold applications to the head once or twice a day.. To relieve the pivsMire 206 DISEASES OF THE BRAIN AND ITS MEMBRAXK* perform lumbar puncture ; repeat every few days. Apply ungiientum Crede to the neck, temples, and back. Sub- cutaneous infusions of sublimate (0.005 to 0.01 gm. per day) in the gluteal region, daily at the beginning, later, every two days (Dazia, Consalvi). Keep nose clean by bathing. PURULENT MENINGITIS ; SIMPLE MENINGITIS Purulent meningitis is a suppurative inflammation of the membranes of the brain caused by injuries to the skull, extension of suppurative processes in the middle ear, nose, etc. The direct cause is one of the various micro-organisms, especially the pneumococcus, strepto- cocci, and staphvlococci, the bacillus of influenza, colon bacillus, typhoid, and pyocyaneus. It attacks children at any age or of any constitution. Morbid Anatomy. The convexity of the brain is cov- ered, as if by a hood, with a yellowish-green, puru- lent, seropurulent, or fibrinous exudate, which lies in the subarachnoid space. The adjacent portions of the brain are inflamed and a turbid fluid is found in the ventricle's; the latter may, however, be absent. Symptoms. -Sudden onset; chills, vomiting; high fever (40 C. [104 F.] ) ; severe convulsions of a tonic and clonic character, which appear at intervals; loss of con- sciousness; expanded fontanels in nurslings; pupils con- tracted and unequal; staring eyes; torturing headache; great thirst ; rigidity of the neck ; Kernig's symptom ; temporary erythema. The pulse and respiration rate are extraordinarily rapid; incontinence of feoes and urine. Death, at the latest, at the end of a week. Very rarely the patient recovers after a prolonged convalescence, which is, however, nearly always followed by permanent sequelae. The prognosis is, therefore, serious. Diagnosis. Meningitis is differentiated from acute in- fections by the following symptoms: Expanded fonta- nels; severe headache; Keruig's symptom, and pupillary contraction. THROMBOSIS OF THE CEREBRAL SINUSES 207 Treatment. Prevent external irritation; ice-cokl or hot applications ; hot baths ; leeching ; laxatives (calomel, rhubarb); febrile diet; lumbar puncture to relieve the pressure. SEROUS MENINGITIS. MENINQISMUS Serous meningitis consists of an infiltration of the pia and the presence of a clear serous fluid in the ventricles, which is accompanied by the symptoms of meningitis. It occurs in tumors and injuries of the skull, as the termination of acute infections and gastro-intestinal dis- eases, and in otitis media. The symptoms are those of a meningitis, but show no specific characteristics ; some- times they simulate the epidemic form, sometimes the tuberculous or purulent meningitis. The course is, how- ever, usually favorable. Treatment. Repeated lumbar punctures. [It is doubt- ful if this form of treatment would receive unanimous approval from clinicians. True serous meningitis tends to spontaneous recovery. ED.] The spinal cord may be involved in every form of meningitis, and this extension may be recognized by the following manifestations : Rigidity of the spine, muscu- lar twitching in the extremities, hyperesthesia of the skin, and paralysis of the bladder and rectum. THROMBOSIS OF THE CEREBRAL SINUSES The following forms of thrombosis are distinguished : Inflammatory thrombosis, following extension from per- ipheral purulent processes, mostly from caries of the petrous portion of the temporal bone, head wounds, ami eczema. The petrous and transverse sinuses are most frequently involved, more rarely, the cavernous and longitudinal sinuses. Marantic thrombosis, following interference with the circulation by tumors of the skull and brain, or from slowing of the blood-current in exhausting diseases; the longitudinal sinus is the one most frequently involved. In many cases a bacterial phlebitis is also the eau-r. 208 CIRCULATORY DISTURBANCES OF THE BRAIN Morbid Anatomy. The diseased sinus is felt as a tense, thickened cord, which contains at a certain point an adherent thrombotic mass, whose appearance and con- sistency vary with age and cause ; thus it may be homogeneous or stratified, red, gray, or yellow ; hard or soft, also purulent. Not rarely there is also a thrombosis of neighboring veins, hyperemia, and also hemorrhages of the meninges and the brain. Symptoms. The characteristic symptoms are few. Manifestations of a cerebral disease, including convul- sions, muscle palsies, etc. Signs of general sepsis are often present. Of the local symptoms the following are important : Bulging of the previously sunken fontanels ; hemorrhagic condition of the spinal fluid which has been obtained by lumbar puncture ; extension of the throm- botic process to the jugular vein ; unilateral swelling of the eyelids and face ; protruding eyeballs (cavernous si mis), cyanosis of face and forehead (longitudinal sinus) ; one jugular less full of blood than the other, and swelling of the mastoid process (transverse sinus). The result is usually fatal ; cure with remaining defects is possible in marantic thrombosis (permanent disturbances of cere- brum). Operative treatment of otitic thrombosis some- times gives good results; other treatment consists in applying antiphlogistics and in depleting the part. CIRCULATORY DISTURBANCES OF THE BRAIN HYPEREMIA Active hyperemia follows increase of arterial blood- pressure in traumatism, sunstroke, at the beginning of the acute infectious diseases, in meningitis, alcoholic intoxications, psychic excitement, and dentition. Symptoms. Hot, flushed head, reddened eyes, head- ache, ringing in the ears, arterial pidsation, vomiting, excitement, delirium, somnolence, coma, and increased pulse rate. Treatment of Active Hyperemia. Antiphlogistics ; leech- CHRONIC HYDROCEPHALUS 209 ing back of the ear; ice-caps; depletion by purging with calomel or compound infusion of senna. Passive hyperemia is due to venous obstruction in pul- monary and cardiac diseases, struma, whooping-cough, spasm of the glottis, or holding of the head in bent position. Symptoms. Languor, drowsiness, cyanosis, weak ten- sion of pulse, and expanded fontanels. Treatment of Passive Hyperemia. Treat the causal con- dition ; administer stimulants camphor, alcoholics. ANEMIA Cerebral anemia occurs in acute loss of blood, in car- diac weakness, and as an associated phenomenon of the various forms of anemia. Symptoms. Pallor of the face ; tossing of the head to and fro, numbness ; eyes rotated upward ; cloudiness of corneae ; tonic contractures of the extremities which are usually in position of flexion; the fontanels are retracted (in contradistinction to hydrocephalus and meningitis) ; the pulse is small and very rapid ; the respiration is in- creased in rapidity and the temperature is low. A peculiar form of cerebral anemia is the hydrocepha- loid (Marshall Hall). This is a cerebral state which fol- lows the loss of considerable fluid in an exhausting intes- tinal catarrh, which is characterized anatomically by anemia and a watery condition of the brain without the collection of fluids in the ventricles. Treatment. External and internal stimulation ; infu- sion of normal salt solution hypodermically and by rectum. (See also Cholera Infantum.) CHRONIC HYDROCEPHALUS Chronic hydrocephalus is a condition due to the collection of an abnormal amount of fluids within the skull, either in the cerebral ventricles (hydrocephalw ////case (v. Ranke). There is faulty development or retrogression of the psychic function, resulting in various degrees of idiocy. Course. The course is chronic and progresses with an increase in the circumference of the skull and the various physical and mental changes. Death is brought on by eclampsia, collapse, or intercurrent diseases. More rarely Vu;. 7'i. 215 216 CIRCULATORY DISTURBANCES OF THE BRAIN FIG. 77. Chronic hydrocephalus which has run its coarse. Imbe- cility ; adenoid vegetations. Boy nine years old. Born prematurely, between seven and eight mouths. The head was observed to be too large immediately after birth ; the fontanels closed in three years. No convulsions. Was taught to walk when two years old, but lost the faculty (rachitis), and did not again learn to walk until the fifth year. Unable to talk correctly until six years. Much headache. The boy is now attending the first school class forthe second time, and is making but tolerable headway. Of a phlegmatic yet fearful disposition. The facial expression is somewhat stupid on account of the adenoid vegetations. The cranium is enlarged and its protuberances are prominent ; the mouth is held open ; mild convergent strabismus. Carious teeth (see Fig. 39) ; pointed palate. the disease may take the following courses: Spontaneous cure may occur, but only when the fluid which has col- CEREBRAL INFANTILE PALSY 217 lected is small in amount ; the condition may also remain at a standstill with a gradual further development of the intellect ; rupture externally, either through the nose, eyes, ears, or fontanels, may lead to a cure. Diagnosis, This is impossible in mild cases ; in doubt- ful cases it is important to take regular measurements of the head. Treatment. If syphilis is suspected, resort to specific treatment externally and internally, with mercury or potassium iodid. Lumbar puncture repeated every few weeks, with the removal of small amounts of fluid, about 30 cc. (Bokay). Puncture the lateral ventricles by way of the large fontanel to one side of the middle line by means of a trocar or aspirating needle and inject tincture of iodin (Pott, von Ranke, Phokas, Gross) ; paracentesis with drainage (Biedert) ; suitable training and methodic teaching ; carry out rules of general hygiene. ENCEPHALITIS The following forms of encephalitis may arise : Acute, non-suppurative encephalitis, with cerebral irrita- tion, convulsions, fever, etc. The prognosis is not unfavorable. Many of the favorable forms of cerebral irritation without paralysis belong to this division. Acute suppurative encephalitis (brain abscess) follows injuries to the skull, suppuration in the head, especially of the ear, and septieemia. The onset is sudden and is accompanied by fever and general meningitic symptoms, together with focal phenomena. The differentiation of brain tumor from meningitis is difficult, Treatment is operative when the exact site is known; otherwise it is that of meningitis. CEREBRAL INFANTILE PALSY This is no uniform disease process ; it represents a group of chronic disturbances of motility, the nature of which indicates the site of the lesion to be in the brain. 218 (1RCULATORY DISTURBANCES OF THE BSAIX FIGS. 78, 79. Case of heruiplegic type of cerebral infantile paral- ysis, which has run its course. Thirteen-year-old boy. Contracturcsof the flexors of the right upper and lower extremities, with typic atti- tude and slight atrophy of the whole right half of the body. No reac- tions of degeneration. Mentality slightly defective. Cerebral infantile palsy develops before birth or during the first three years of life. Morbid Anatomy. The primary pathologic changes are meningeal or cerebral hemorrhages, accompanied by a reactive inflammation of the adjacent portions of the brain, or encephalitic processes and thrombosis. As a result we find destruction of the section of the brain involved, including softening, fatty degeneration, and resorption, which lead to loss of brain substance, and the substitution of the latter by serous cysts or Ijyperostoses (porencephaly) and scar-tissue. Aside from the above changes a diffuse sclerosis (i. e., chronic inflammation of the supporting tissue) is met with ; there is frequently a secondary degeneration and atrophy of the pyramidal tracts. Etiology. Before Birth. Traumatism to the body or brain of the mother; congenital syphilis, and premature birth. During Birth. Continued asphyxiation during pro- tracted labor; premature discharge of the liquor amnii, and compression by the obstetric forceps (Little's dis- ease). After Birth. Injuries to the skull ; acute infectious diseases, such as scarlet fever, measles, influenza, and meningitis. Some cases present a certain neuropathic predisposition. Symptoms. Two types are distinguished, the hemi- plegic and the diplegic (Freud). Hemijdegic Type; Spastic Infantile Hemiplegia ; Acute PoKoencepnaRtu (Striimpell). This type begins suddenly, presenting the picture of an acute infectious disease with high fever, vomiting, delirium, and convulsions. In from a few days to weeks a one-sided flaccid paralysis of the body is found to be present, and it will be noted that FIG. 78. 210 220 CIRCULATORY DISTURBANCES OF THE BRAIN FIG. 80. Congenital spastic rigidity of the extremities (Little's dis- ease). Girl one and a half years old. The rigidity involves all four ex- tremities, as well as the musculature of the neck and face. The legs show the characteristic crossed position on account of marked involve- ment of the adductors. The left arm is more markedly allVrtrd than the right; mask-like appearance of the face. Farther course not known. the arms, legs, and face are involved to a variable extent. The palsy is partial or complete and improves in the course of time to a certain degree. In some cases only a slight helplessness and a tremor of one side are demon- strable. Resulting Phenomena. Flexor contractures of the involved extremities, which are held in a characteristic position : The arm is pressed against the trunk, the fore- arm is held semipronated and bent at right angles at the elbows, the hand is flexed and curved toward the ulna, while the fingers are flexed. The legs are slightly bent at the knee, the foot assumes the eqtiinovarus position, and the toes undergo dorsal flexion. The involved members show athetosis and choreic movements ; disturb- ances of speech exist, also aphasia and defective intelli- gence, which varies in grade from moral degeneracy to idiocy. Epilepsy develops in the later stages. The muscles are atrophied, but fail to show the reactions of degeneration ; the tendon reflexes are increased. The diplegic type includes all of the remaining large variety of forms of cerebral palsies, especially the con- genital spastic form of muscular rigidity ; the general form of infantile chorea and athetosis. Congenital spastic rigidity of the muscles (Little's dis- ease) represents a condition which is characterized by the development of marked stiffness and spastic contractures of the legs, with a peculiar gait, within a certain time after birth, usually at the time of mental development. The legs are rotated inwardly, strongly adducted, and often cross each other; the feet are in the position of equinovarus ; the upper portion of the body is rigid and bowed forward. The spasms, which are due to increased excitability of the reflexes, tend to disappear upon rest in bed. In mild cases they may only be elicited by CONGENITAL SPASTIC RIGIDITY 221 FIG. 80. 222 CIRCULATORY DISTURBANCES OF THE BRAIN FlGS. 81, 82. Alternating convulsive seizures of the I'acial muscula- ture following porencephaly in a child four days old, spontaneously born at full term. It presented respiratory disturbances from the first day on. The respiratory pauses lasted from one-half to one minute, were accompanied by marked cyanosis and a disappearing pulse, and alternated with periods of similar or shorter length of fleeting respiration. On the third day the whole right half of the face was seized with tonic spasms, which lasted several hours. On the fourth day similar spasms attacked the left half of the face. These convulsive seizures continued until the sixteenth day, when death occurred. First one side and then the other was involved, but more frequently the right. The necropsy revealed (Prof. Diirck} a loss of the superficial substance (porencephaly) in the re- gion of the lower surface of the pons and the cerebellum, together with connective-tissue and mucoid degeneration of the brain substance in the region of the defect. rapid passive movements. Reactions of degeneration are absent. The muscular rigidity may be confined to the CEREBRAL INFANTILE PALSY 223 legs, in which case the mentality remains intact ; or it involves all extremities, converting the children into rigid dolls, and causes cerebral disturbances, strabismus, and defects of intelligence. This general rigidity is usually congenital. FK;. 82. See page 222. General infantile chorea is distinguished from rheumatic chorea by its early appearance, its stationary course, and the development of cerebral manifestations. 224 CIRCULATORY DISTURBANCES OF THE BRAIN Athetosis may be recognized by the relaxation of the con tract u res, the presence of palsy-like signs, and the spontaneous movements. The fingers are almost con- stantly in motion, either spreading out, flexing, orgrasping. Diffuse sclerosis probably possesses its own morbid anat- omy (diminished size and dense consistence of the cere- bral cortex, later, also of the white substance ; prolifera- tion of the glia and degeneration of the ganglion cells), but presents few clinical characteristics, so that it is proper to classify it with the infantile palsies (diplegic type). Disseminated sclerosis, with its circumscribed dense foci in the brain and spinal cord, offers the same symp- toms as in adults. The prognosis of cerebral infantile palsies as regards recovery is, with rare exceptions, bad, but good as concerns life ; yet cases have been recorded in which death occurred during the convulsions. As a rule incomplete recovery follows with permanent contract- ures, athetosis, and defective intelligence. The outlook is much brighter when modern orthopedic surgery is re- sorted to. Diagnosis. This is impossible during the acute stages of the hemiplegic form. Of importance later in contra- distinction to encephalitis and meningitis are the absence of fever; in contradistinction to tumors, the absence of choked optic disk and the initial manifestations ; and in comparison with spinal infantile palsies, the hemiplegic or paraplegic and simultaneous spastic form of the paralysis, the typic contract tires, the associated movements, the increased reflexes, the strabismus, and the defective men- tality. Treatment. In the acute stages depletion and anti- phlogistics ; later, faradization, massage, dry heat, alcohol rubs, warm baths, and passive movements. (For treat- ment of the contractures, see Poliomyelitis; of deft-dive mentality, see Idiocy.) TUMORS By far the commonest tumors are tubercles, solitary and multiple, which are chiefly located in the cerebellum SPIRAL 1XFASTILK PARALYSIS 225 and pons ; they arc sharply outlined, quite dense, and vary in si/e up to that of a walnut. Other cerebral growths are sarcoma, glioma, gnnima, psainmoina, and those due to the cysticercus and echinococcus. The symptomatology and therapy present no peculiarities char- acteristic of childhood. The presence of cerebral tuber- cles may be suspected when tuberculosis exists elsewhere in the body, and when chronic meningeal manifestations and symptoms of cerebral foci arise. DISEASES OF THE SPINAL CORD SPINAL INFANTILE PARALYSIS (Acute Anterior Poliomyelitis) This is a degenerative paralysis of single extremities, which has an acute onset, runs a subsiding course, and is probably due to an infectious myelitic process in the anterior horns of the cord. The most frequent subjects with this condition are children from one and a half to four years. Morbid Anatomy. In recent cases the substance of the anterior horns is softened ; microscopically the multi polar cells are seen to be degenerated and the interstitial tissue inflamed. In older cases we note atrophy and sclero.-is of one anterior horn, with disappearance of all ganglion cells, secondary degeneration of the anterior motor roots and of the nerves, muscles, and tendons supplied by them. [According to the researches of Marie and Gold- scheider, it is shown that the anterior horns are supplied by the anterior branches of the spinal arteries. The areas supplied by these branches have been found necrosed and softened, the vessels blocked, and the nerve-cells com- pletely destroyed. ED.] Symptoms. The disease may be divided into four stages (Fischl) : Inftiaf Sldijc. It begins in the midst of perfect health, apparently as an acute infectious disease, including high fever, headache, slight somnolence, and, more rarely, con- 15 226 DISEASES OF THE SPINAL CORD vulsions and stupor. The duration is from thirty-six to forty-eight hours. Stage of Fully Developed Paralysis. The acute symp- toms disappear and a flaccid paralysis remains, which in- volves several extremities. As a rule the paralysis affects both legs and one arm, an arm and a leg on opposite sides, both legs, or all four extremities. The excitability of the muscles to the faradic current rapidly lessens and the paralysis reaches its highest point of development. The duration of this stage is from one to at the most two weeks. Stage of Abatement of Paralysis. The paralyses im- prove by degrees, and the improvement affects a whole member or only individual muscle groups. The para- lyzed parts show beginning reactions of degeneration, and the diseased muscles react to the galvanic current with sluggish vermicular twitchings; the An.Cl.C. exceeds the Ca.Cl.C. The improvement ceases after one, two, or more months, and the following stage is reached : Stage of Completed Paralysis and Sequela'. The paral- ysis of a leg or an arm or both legs now becomes perma- nent. Of the upper extremities, the deltoid and shoulder muscles, the extensors or flexors of the forearm are most frequently involved, while in the lower extremities the extensors and peroneal muscles are mostly attacked. The usual sequelae are : Atrophy and fatty degeneration of the muscles and tendons ; sometimes these are thick- ened because of increased fatty growth ; bony growth is delayed or bony absorption takes place. The paralyzed extremities are wasted, loose at the joints, the muscles are pale and withered, the tendons are thin and relax. The shoulder, when attacked, appears flattened and the finger can be introduced between the acrnmion and the humerua The skin temperature is subnormal and the affected extremities are cyanosed. Muscular reaction to electric stimulation is lessened or wholly absent. The tendon and skin reflexes are absent, but sensation remains nor- mal. Deformities result from the action of antagonistic muscles, from the weight of individual parts and of the SPINAL ISFAST1LE PARALYSIS 227 FIG. 83. Spinal infantile paralysis in t!n> Ma ire <>f fully developed palsy. Tlirrr-yf'ur-old K'rl- Tin- flaccid paralysis nf the rijilit leu is shared by the (|iiadrice]is. peroneal. and extensor conuiiiinis di^itonini muscles. The nse of the lei; was restored by periosteal tendoii tnins- plantatioii (F. Lange). 228 DISEASES OF THE SPINAL CORD whole body. These include paralytic club- foot and talipes equinus and, more rarely, talipes ealcaneus and club-hand. After the formation of these deformities spontaneous cure is hopeless and the disease has reached its termina- tion. Prognosis. Complete cure as well as an unfavorable ending are rare. As a rule the disease leads to some permanent deformity. By means of timely and subse- quent treatment, especially by resorting to modern ortho- pedic methods, it is possible to secure functional improvement and cure. In the third stage the condi- tion of the muscles as regards electric reactions is of prognostic significance. Diagnosis. This cannot be established in the acute stages. Indicative of this disease are : The flaccid par- alysis, which at the beginning is widely spread, but later limited and stationary, and which, accordingly, runs a retrogressive course ; the degenerative atrophy ; the loss of reflexes; the retained sensibility and sphincter function. A conclusion as to what muscles are paralyzed and to what extent they are affected may be reached by deter- mining what movements are possible by palpation of the contracted tendons (F. Lange). Treatment. In the acute stage resort to an antiphlogis- tic regimen, deplete through the bowels, and keep at rest in bed for. several weeks. If the paralyses are evident and the fever has disappeared, use electricity over a long period of time, also massage, passive movements, and gymnastics. At the beginning apply a weak current of electricity by passing the cathodal electrode over the paralyzed muscle, while the anodal pole is held over the part of the spinal cord which represents the affected area. Later employ stronger stimulation by means of the faradic current (at first every other day, later, daily). Prevent contractures by the application of splints, which fix and hold the member in a correct position. (The splints are only worn at night.) Corrective manipulation is also recommended ; periosteal transplantation of ten- dons, with the insertion of silk tendons, according to the TRANSVERSE MYELITIS 229 recent simplified operative methods (Lange) ; fix loose- joints by means of arthrodesi-. TRANSVERSE MYELITIS Transverse inflammation of the spinal cord is especially likely to follow a spondylitis the so-called comprewtoti myelitis. It is then due to the direct pressure of the caseous exudate, the deformed vertebrae, to disturbance of the circulation, or it is an extension of the inflam- matory process. Aside from these etiologic factors it may also develop as a termination of an acute infectious disease, or it may be caused by traumatism, exposure to wet, or syphilis. Morbid Anatomy. In recent cases there is a slight discoloration and softening of the cord, while in older cases the spinal cord is smaller and harder than normal. Microscopically we note a small-celled infiltration and swelling of the axis cylinders and of the connective tissue; degeneration of the medullary sheaths and gang- lion cells; fatty granules; later the connective tissue and glia show proliferation ; ascending and descending degen- eration of the spinal tracts. Symptoms. Transverse myelitis may be sudden or gradual in onset. Paresthesise, pains, and, later, hyper- esthesiu} and anesthesia?. Spasmodic twitchings of the extremities. Paralysis of that portion of the body innervated by the spinal cord, varying according to the location of the affection. In diseases of the lumbar cord, flaccid paralysis of the lower extremities with atrophy, reactions of degeneration, loss of reflexes, disturbances of sensation, paralysis of the rectum, and deeubitns. AVhen the dorsal cord is involved, spastic paraplegia with increased reflexes, unaccompanied by atrophy and reac- tions of degeneration ; otherwise the symptoms are the same. In involvement of the cervical cord, paralysis of the arms is added to the symptoms of disease of the dorsal cord. The so-called " Brown-Sequard paraly-k" or unilateral lesions, consisting of motor palsy and in- creased reflexes on the diseased side and sympathetic 230 FUNCTIONAL NERVOUS DISEASES palsy on the sound side, occurs in disease of one side of the spinal cord (crossing of sensory fibers after entering the cord, straight course of the motor fibers). The prognosis is usually unfavorable, excepting in cases following syphilis or infectious diseases. The course is chronic and is dependent upon the causal condition. Treatment. If due to spondylitis or syphilis, direct treatment for those diseases. In case of syphilis and also in other forms of myelitis which are not tuberculous, administer potassium iodid internally and paint the site externally with iodin. Massage and electricity for the muscles. Careful nursing in order to avoid decubitus, which is so frequent, and the disturbances of the bladder with their sequelae. FRIEDREICH'S (HEREDITARY) ATAXIA This is a family disease occurring before puberty, which is caused by degeneration of the posterior columns of the cord. It is characterized by ataxic movements of the arms and legs, nystagmus, muscular disturbance of speech, loss of knee-jerks, extremely chronic and an incurable course. SPASTIC SPINAL PARALYSIS This is a disease of later childhood, consisting of a gradually developing spastic paralysis of the legs accom- panied by contractures of the adductors of the femur and of the muscles of the calves, crossing of the legs, pes equinus, increased reflexes without atrophy, reactions of degeneration or cerebral manifestations. (Little's dis- ease occurs congeuitally, or it arises during the first period of childhood.) FUNCTIONAL NERVOUS DISEASES ECLAMPSIA (Convulsions; Spasms; Eclampsia Infantum) Clonie spasmodic cotiru/xionx accompanied by uncon- sciousness. These represent no distinct disease, but ECLAMPSIA 231 rather a symptom, the cause of which is still unknown in many cases. Etiology. Primary Reflex or Functional Eclampsia. The convulsions arise spontaneously or as the result of sensory disturbances (intestinal parasites, foreign bodies, injuries, psychic or sensory impressions). Of predispos- ing influence is the physiologic increased tendency to convulsions in children (spasmophilia), the cause of which, according to Soltmann, lies in the imperfect development of the psychomotor inhibitory center together with in- creased reflex excitability of the peripheral nerves. Eclampsia may also precede true epilepsy. Secondary symptomatic eclampsia occurs in diseases of the brain, meningitis, tumors, hydrocephalus, encephalitis, anemia, hyperemia (pertussis), and in otitis media. It may also be of hematogenic origin, that is, the convul- sions may follow the presence of toxins in the blood, or the poison of intestinal bacteria, or they may be brought on by fever, anomalies of metabolism, rachitis, affections of the gastro-intestinal tract, or overfeeding. Convul- sions have been known to occur at the onset of acute in- fectious diseases instead of the initial chill ; on account of carbonic-acid intoxication in laryngospasm or pneumonia ; in uremia or when the blood contains an insufficient amount of water. Eclampsia is also a frequent compli- cation of tetany and laryngospasm, especially during the first eighteen months of life. Symptoms. The attack begins suddenly, with pallor of the face, a vacant stare, and rolling of the eyes. The fol- lowing conditions arise simultaneously : Loss of con- sciousness, tonic rigidity of the head and of the extrem- ities ; flexion of the fingers, extension of the legs, and the pes equinus or talipes calcaneus position of the feet. After a few seconds we observe a clonic twitching around the angles of the month, distorted facial expression, tightly set jaws; in older children gnashing of teeth; tossing of the head to and fro ; rhythmic twitching of the extremities, as if electric shocks were given. Cyanosis around the mouth and nose, escape of froth and, fre- 2:J2 FUNCTIONAL NERVOUS DISEASES quently, bloody saliva; the pupils are dilated; the corneal reflex is lost, complete failure of reaction to all external stimulation; incontinence of urine and f< <<<. The respiration is shallow and interrupted by spasmodic pauses, while the pulse is irregular and unequal. Such an attack lasts but a few moments, after which the spasms successively disappear, the face becomes flushed and quiet, the child falls into a sleep, the beginning of which is interrupted by single twitchings. A single at- tack is very rare ; as a rule, on the contrary, the convul- sive seizures recur at longer or shorter intervals of days, weeks, or months. In some cases a series of convulsions occur in quick succession, even before the patient awakens from a previous attack. In the severest forms the patient is in a continuous convulsive state for several hours, which is only interrupted by short periods of sleep. Exhaustion and venous stasis, on account of in- hibition of respiration, may lead to death. The intensity of the attacks varies from the severest to the lightest, in which the turning of the eyes and the slight twitchings (as may also be seen in healthy nurslings when asleep) are barely noticed by the parents. Loss of consciousness is, however, constantly present. Diagnosis. Inasmuch as many diseases may begin with convulsions, the diagnosis of true eclampsia is difficult at the commencement. Careful examination of all organs will prevent errors and the further course of the disease will establish the diagnosis. Eclampsia is distinguished from organic brain disease by permanent tension of the fontanels, whereas in convulsions the tension is only dur- ing the attack ; long duration (more than twelve hours) of the attack, as well as prolonged unilateral convulsions, indicate cerebral affection. In favor of epilepsy are : The recurrence of attacks over a long period of time without any apparent cause ; the presence of an hereditary predisposition, and the late occurrence at the end of the M< -ond year of life. Prognosis. This should be guarded and not made until after long observation of the child, both during the TETANY 233 attack and the interval. The prospects are dependent upon the severity and frequency of the attacks, as well as the nature of the original causal condition. The reflex and hematogenic forms of convulsion run, as a rule, a favorable course. Death may occur during the attack because of asphyxiation or cerebral hemorrhage. Con- vulsions are not infrequently followed by paralysis, de- fective mentality, or true epilepsy. Treatment of the Attack. Remove clothing ; stimulate with cold water; chloroform inhalations, chloral enemata (1.0 gm. to 30.0 cc. milk, starch-water, for two injections) ; tepid baths with cold applications to the head. In hyper- em ia of the brain compress the carotids (Seitz) or apply leeches. After the attack deplete by way of the bowels (calomel) and skin (stimulation of the skin, heat). Low diet. Should the attacks frequently recur, give the bro- mids with or without chloral ; if rachitis exists adminis- ter phosphorus and resort to antirachitic treatment. [In those cases associated with high fever, antipyrin combined with bromids sometimes gives excellent results. In the cases of continuous or protracted convulsions small doses of morphin ^-^ to y^ gr. may be given hypodermic- ally. ED.] TETANY Tetany is a functional neurosis depending upon a hyper- excitability of the peripheral nervous system, which chiefly attacks the rachitic children of poor parents dur- ing the first two years of life, especially in the spring months. Etiology. Disturbances of the gastro-intestinal tract ; foul atmosphere, artificial (cows' milk) feeding (Finkel- stein). Morbid Anatomy. Thus far no uniform change has been noted. Symptoms. A symmetric tonic muscular contraction, beginning with the fingers, then the hands and toes, and which does not involve the arms and legs until after the lapse of considerable time; the musculature of the trunk is very rarely attacked. Characteristic position of the 234 FUNCTIONAL NERVOUS DISEASES hands the fingers are extended at the phalangeal joints and flexed at the metacarpal joints, while the thumb is turned in a volar direction obstetric hand (Fig. 85) ; the legs are extended and the toes flexed. These contractures FIG. 84. Persistent form of tetany in a girl a year and a half old. Tetanic contractures of the arms and legs; hands in the " obstetric" po- sition ; feet in plantar flexion. The convulsions lasted three days unin- terruptedly and disappeared after thorough purging. Trousseau's sign, the facial phenomenon, and the heightened electric excitability (Ca.Cl.C. 1.0 M. A. : Ca.O.C. 3.2 M.A.) remained demonstrable for a long time latent form. Etiology : Chronic constipation in a child living under un- favorable conditions of life. may continue as a permanent form of tetany (Escherich) or they disappear after a certain time intei'inittent form ; the latter type is most frequently observed. Dur- FIG. 8T>. The obstetric hand of tetany. (From Fig. 84.) ing the interval the hypersensitiveness persists and is manifested by the so-called latent symptoms. Those are, moreover, in some cases the only expression of the //f/,Y/r rn-figo or petit mal. These are characterized by temporary disturbance of consciousness, with a fixed expression and loss of memory; at times they last but a few seconds or they are not noticed at all, then again they may continue for a longer period of time, when they are accompanied by vertigo, a feeling of fear, and also by twitchings of the face. Jacksonian epilepsy is a term applied to attacks which consist only of clonic spasms of individual muscles 244 FUNCTIONAL NERVOUS DISEASES or of a distinct muscle group, as the face, arm, or leg of one side. The initial cry is usually absent and conscious ness is generally preserved at the beginning. Course and Prognosis. The course is always chronic and complete recovery is rare. The patient either remains normal mentally, and may develop to an extra- ordinary degree of intellectual power (Julius CVsir, Napoleon), or in the course of time the character is altered and the child becomes peevish, irritable, and ill humored. We may also observe moral insanity, with a tendency to telling falsehoods, adventures, stealing, violent acts ; or the mind may gradually decline until imbecility and complete idiocy are reached. The disease usually continues until death, and in many cases epilepsy is followed by other cerebral affections. The prognosis is the more favorable the earlier treatment is begun ; it is better in the reflex type than in the genuine form, which can be attributed to no recognizable cause. If recovery occurs, the attacks gradually decrease in frequency and in intensity, become converted into petit mal, and finally cease altogether. Diagnosis. Hysteric seizures almost always follow emotional disturbances, generally during the day, may last for hours, and are unaccompanied by the initial cry, biting of the tongue, incontinence of feces and urine, and are not followed by the somnolent state ; nor does complete loss of consciousness occur, The epileptic attack is very often independent of emotion, continues at the most for seven minutes, occurs frequently at night, and often leaves traces of blood on the pillow, due to biting of the tongue. Inquiry into the anam- nesis and a careful examination is important in every case. Treatment. Vegetable and easily digestible diet ; large quantities of milk and farinaceous foods; prohibi- tion of alcohol, tea, and coffee; wash with warm water and follow by cool douches ; tepid baths (25 to 22 R. [88.2-81.5 F.]). Avoid mental strain. The bromid cure : NEURASTHENIA 245 fy Sodium bromid, Potassium bromid, fia 1.0-2.0gm.; Ammonium bromid, 0.5 gm. M. Give this mixture daily in one dose, together with ^ to | pint of water, followed later by more water. If these preparations remain ineffectual, try the Flechsig cure (the results of which are indeed uncertain); for four or five weeks administer 0.005 gm. of opium twice daily, gradually increasing the dose until from 0.01 to 0.03 gm. are given, then follow immediately by a course of the above bromid mixture for two or three months. A portion of the salt of the food may be substituted by sodium bromid. If brornism develops, stop the bromids and give large amounts of alkaline waters. NERVOUSNESS. NEURASTHENIA. HYSTERIA Etiology of Nervousness. Inherited predisposition to nervous diseases of any kind, development of puberty, injuries, heat prostration, chronic intoxication from alcohol, coffee, tobacco, excessive use of meat, and follow- ing acute or chronic diseases ; affections of the brain and spinal cord. Bad example set by the parents or hysteria; strong mental impressions, fright, punishment, religious impressions; masturbation; improper training; physical and mental fatigue while at school. NEURASTHENIA Neurasthenia represents a state of physical and mental fatigue and irritability. Chief Symptoms. Drowsiness and weariness after slight exertion, poor memory, inability to concentrate the thoughts, sensitiveness to loud noises and strong light ; headache, which is already present upon awaken- ing and increases during the day, but improves toward night. Nervous asthenopia (Wilbraiid, Singer); nervous dyspepsia, with constipation or diarrhea, gastralgia, hyper- or anacidity, with normal appetite; disposition 246 FUNCTIOXAL NERVOUS DISEASES grows worse; tremor of the eyelids when the eyes are tightly closed (Roseubach's sign). HYSTERIA Hysteria is a condition characterized by an abnormally excitable temperature and sensitiveness of the body, which shows a pronounced tendency to respond to any occurrence or event with decided psychic and physical disturbances of varying intensity. Peculiar to hysteria of childhood is the occurrence of individual symptoms ; stigmata are met with. Frequently a former symptom of organic origin persists, that is, after the organic condi- tion has disappeared it remains as an hysteric symptom. For example, hysteric contractures after rheumatism or the habituation of the so-called " tubards " to the larvn- geal tube, even after the disappearance of the original stenosis ; in these cases the respiration is perfectly free when the tube is not employed during anesthetization. Characteristic of hysteria is the fact that the severest symptoms disappear in a short time, leaving no trace, and reappear in another place. Symptoms. The most significant of the manifold symptoms are : Continual change of disposition from one to the other extreme and morbid introspection ; absent- mindedness ; autosuggestibility, as, for instance, a perma- nent impression of the inability to walk, to lift the arms, or to speak after a single overexertion of the muscles involved ; a tendency to lie ; vague pains ; hyperesthesiffl : paralyses and spasms of the extremities, the voice, speech, and muscles of respiration, etc.; such palsies in contra- distinction to those following organic lesions occur un- systematically, and never lead to changes in the reflexes or to electric excitability ; spasms of yawning, laughter, crying, and shrieking. The affected child may jump about, dance, or throw itself upon the floor eAorea major ; it may make grimaces spasm of customary ex- pressions; atasia and abasia, that is, inability to stand or walk although all movements of the legs are active when the patient is resting in bed ; pronounced convulsive 247 seizures accompanied by more or less disturbance of consciousness for several hours or less, with partial or complete preservation of memory; catalepsy; outcries at night; somnambulism. The morning vomiting of school children is also hysteric, especially of ambitious children, and is usually brought on for the first time by emotion or worry over lessons. Course and Prognosis of Neurasthenia and Hysteria. Neurasthenia, which may stretch over a period of months and years, runs a variably intermittent course. The prog- nosis is dependent upon the severity of the individual case. The course in hysteria is likewise usually intermittent, and frequently one symptom is replaced by another. The prog- nosis, when external influence can be eliminated, is com- paratively good, especially in the presence of single symp- toms; severe and incurable cases are, however, met with. Diagnosis. To avoid error, before making the diagnosis of neurasthenia or hysteria a most careful and conscien- tious examination of the body must be made and all organic diseases excluded. By the term mental or psychopathic inferiority (Koch) is meant a lack of resistance of the general nervous system of children who inherit a neuropathic predisposi- tion to external influences, so that, on the one hand, these children are more likely to be affected by nervous disturbances; on the other, they do not possess sufficient strength to combat them. Patients of this class, who are often talented, suffer later from want of steadiness of character and purpose, and many commit suicide. Prophylaxis and Treatment of Nervousness. Prohibit or discourage marriage between neuropathic persons. Combat the predisposition by the proper physical and mental training. Treatment. Remove from the hysterogenic surround- ings and avoid any overexertion ; psychic treatment ; stimulate the child's will power and. under certain circumstances, do not pay any regard to the various manifestations; easily digestible diet and hydrotherapy. If indicated, give iron, quinin, and valerian. 248 FUNCTIONAL NERVOUS DISEASES NIGHT TERRORS Etiology. Anemia, hysteria, alcoholism, adenoid vege- tations, punishment, and dreams with excitable imagina- tions. Symptoms. The child awakens suddenly from a peace- ful sleep, showing great fear, cries out, sits up in bed, has hallucinations, fails to recognize its surroundings, and appears to be still dreaming. After a time he again lies down quietly, falls asleep, and the next morning remembers nothing, or only vaguely, of what transpired during the night. The attacks are repeated at shorter or longer intervals. Treatment. A non-irritating bodily food ; avoid any mental irritation. Horrible stories must not be told and the child should be raised amid peaceful surroundings. Alcohol and coffee should be prohibited. The bladder and rectum are to be emptied at the proper time. Treat the causal condition and attend to the hygiene of the bedroom and of the bed. In pronounced ' cases give the bromids. MASTURBATION Masturbation occurs in every phase of childhood, even during the nursing age. Etiology. Itching of the anus in eczema and oxaluria ; phimosis; balanoposthitis ; suggestion by example <>r reading. It is performed by a rocking or rubbing move- ment of the legs or by direct manipulation. It results locally in enlargement of the penis, reddening of the prepuce or of the labiae, and is finally manifested by nil possible forms of infantile neurasthenia. Treatment. Light, easily digestible vegetable diet, without alcohol, coffee, or tea. Sleep on a hard mattress. Emptying of bladder and rectum at proper intervals. Care of the body and skin. Careful prevention of all causes which give an opportunity, and institute psychic treatment. AMAUROTIC IDIOCY OF FAMIL/1 v 249 PSYCHOSES The causes are the same as for nervousness. In case of idiocy, old cerebral processes and defects of the brain are also to be considered. Other causes are: Premature closing of the fontanels and degeneration of the thyroid gland, either hypoplasia or aplasia. IMBECILITY Imbecility is due to a lack of development of the mind, and is marked by the inability to concentrate thought and to realize mental impressions. It mav he congenital or acquired and occurs in all stages, from weak mindedness to fully developed idiocy. Chief Symptoms. The child learns to stand and walk- later than normally ; uncleanliness ; delayed and incom- plete development of speech ; limited in the ability to grasp and understand all complicated directions, whereas the simple mechanics can be learned ; undeveloped dis- position. Inclination to lie, to steal, and to outbursts of passion and acts of violence. Slow response to mental impressions; shows a blunt confidence in strangers; active, early analgesia (Thiemich). An idiot shows a lack of intellect from the very beginning or he reaches the intel- lectual height of a child from one to two years old, where a standstill mentally is reached. Idiotic expression; babbling speech with a sobbing tone; nncleanliuess. Apathetic as well as active and cheerful idiots are met with. Imbeciles and idiots may live to old age, but in the severer types death occurs much earlier, due to pneu- monia, eclampsia, or intestinal disease. THE AMAUROTIC IDIOCY OF FAMILIES Amaurotic idiocy is a family disease which appears as early as the first year of life, and is accompanied by flae- cidityof the muscles and disturbances of sight. Ophihal- moscopic examination reveals white specks with red centers near the macula. Death occurs generally in two years. 250 PSYCHOSES Treatment of Idiocy. Institutional treatment, which may afford considerable relief in the mild cases ; courses in conversation ; schools for the weak minded. In case of myxedema and idiocy administer thyroid tablets. MORAL INSANITY Degenerate tendencies, with defect of the intellect. It begins as " naughtiness " and " ill temper." The child is inclined to lie and is guilty of cruelty, cunning, and craftiness. He has a tendency to commit crimes, such as stealing and arson, and to do bodily harm. Every form of training is powerless. JUVENILE INSANITY (Hcbephrenia) This represents a state of weakened intellect which develops during puberty and runs a progressive course. It begins with excitement, depression, and hallucinations, and as it progresses it enters a katatonic state (negativism, stereotypy, automatism, etc.) and passes gradually, with marked mental deterioration, into weak mindedness. PRIMARY PROGRESSIVE MYOPATHY This is a chronic hereditary and family disease of certain muscle groups, occurring in childhood or at puberty, which is not of central, but of myogenic origin. It is accompanied by atrophy and simultaneous hyper- trophy of the muscles, with intact sensibility, but without reactions of degeneration and with loss of knee-jerks. Morbid Anatomy. The nervous system is normal. Pale, soft, or also hard muscles ; histologically there is proliferation of the connective tissue, compression of the muscle-fibers, and eventually degenerative changes and the deposition of fat in the latter. Symptoms. Pxeiuloliypcrtrophic Paralysis (Duchenne). It begins between the fifth and eighth year, generally in boys, with uncertainty in gait and in jumping ; wab- JUVENILE MUSCULAR ATROPHY. 251 bling gait with protruded abdomen and lordotic spinal column. The child shows characteristic movements when it raises itself from the floor; the body is supported with the hands, first on the floor, then on the knees and legs, and thus climbs slowly up on its own body. The di:-e;i>e begins always in the muscles of the trunk and the lower extremities. The muscles, especially the gluteal and those of the calves of the legs, are thickened and shape- less. The affection progresses slowly and also involves the upper extremities, and, gradually undergoing con- version into true atrophy, renders the patient helpless. Death in the course of years from intercurrent diseases. Erb's Form of Juvenile Muscular Atrophy. Gradually developing weakness and emaciation of certain muscle groups of the shoulders and arms without pseudohyper- trophy. The muscles uniformly involved are the pectorals, trapezius, latissimus dorsi, serratus anticus, and the rhomboidei (the shoulder-girdle type), to which are added the gluteal muscles, the quadriceps, and peroneal muscles (pelvic-girdle type). Both forms may coexist; very chronic course. Death is due to intercurrent affec- tions. Infantile form, with involvement of the facial muscula- ture (Duchenne, Landouzy, Dejerine). This form begins in the muscles of the face; the eyelids are closed; whist- ling, laughing, and speaking become difficult or impossible. Collapse of the cheeks and hanging down of the lower lip interfere with mimicking and form the typic stupid " myopathic " facial expression. Diagnosis. In differentiating the myopathic from the spinal muscular atrophy, note in the former the juvenile and family character, the typic localization and the non- involvement of the sternomastoid, the deltoid muscles, and, above all, the small muscles of the hand. Muscular twitchings and the reactions of degeneration are absent. Treatment. Avoid overexertion; massage and galvan- ism; gymnastics and food rich in proteids. ACUTE INFECTIOUS DISEASES GENERAL DISCUSSION THE acute infectious diseases which are accompanied by fever are caused by special micro-organisms which are transmitted directly from one diseased person or indirectly through a third person by means of infected articles of use or provisions. The portals of entrance for the bac- teria, of which we are as yet only acquainted with a small number, are the mucous membrane of the respiratory and digestive tracts and (rarely) the skin. If the bacteria find the condition at the point of entrance favorable for growth, and if for any reason the individual's general resistance is weakened, the invading virus may call forth disease symptoms, provided no congenital or acquired specific immunity exists. These symptoms depend upon the character of the specific germ, and are caused either by the bacterial body itself, which eventually enters the blood-stream (infection in a strict sense), or through their poisonous metabolic products with which the body is supplied from the point of invasion (intoxication). The disease symptoms are not noticed so long as the micro- organisms are engaged in combat with the varying number of natural immune bodies of the organism, and so long as a sufficient multiplication of bacteria or a sufficient accumulation of the specific disease poison does not occur. A certain period usually elapses from the time of infec- tion until the disease makes its appearance, which is called the period of incubation. The duration of the incubation and the disease symptoms vary according to the character of the specific germ, each of which creates a symptom-complex peculiar to itself; thus, the diphtheria 252 ACUTE INFECTIOUS DISEASE 253 bacillus causes only diphtheria and not scarlet fever or measles. If a second disease develops simultaneously with or after another one, it may be assumed that the causes of both diseases invaded the body at the same time or soon thereafter. This possibility is not so very- rare, for between certain infectious diseases a closer rela- tionship exists than that of the preparation of the soil by one disease for the other. Such a relationship i.\i>t"s between measles on the one hand and influenza and whooping-cough on the other. The course in each in- dividual form of acute infection is typic. In the acute exanthems we distinguish between an eruptive, a florid, and a desquamative stage, each of which (provided com- plications are absent) presents a fairly definite form of development and duration. In certain diseases the erup- tion of the exanthem is directly preceded by more or less characteristic manifestations the prodromal symptoms. The course of the disease is dependent upon the virulence of the micro-organism, the strength and the susceptibility of the patient to poisons, and, furthermore, upon the development of complications, which may be traced back to the secondary invasion of non-specific bacteria into the already weakened body. Many of the infectious diseases are complicated by nephritis, nervous and psychic disturbances, and frequently by pronounced anemia. If death does not occur, the disease is overcome by the action of specific immune bodies which, during the course of the disease, have developed within the body (every specific poison in the body calls forth a protective measure to destroy it), and which creates a permanent or, at least, temporary immunity against that disease. Much may be attained prophylactically by early isolation of the patient and personal attention, also by disinfection of the articles used the secretions and excretions and, later, of the sick room ; also by keeping brothers and sisters of the patient. as well as convalescents, from visiting school (the period of isolation in measles, rotheln, varicella, and mumps is three weeks ; in diphtheria and typhoid lever, five week- ; in scarlet fever, six weeks ; in pertussis, eight weeks; in 254 ACUTE INFECTIOUS DISEASES Exanthem. Initial fever- Eruptive fever. FIG. 87. The type of fever in measles (von Strumpell). Exantlirm. FIG. 88. The type of fever in scarlet fever (von Strumpell). ACUTE INFECTIOUS DISEASES 255 UitV Of diseases. V I 5 6. 7. 8 9. 10 11. 1E 13 1<< 15 16. 17 18 19 20 El Exantliera. Invasion fever. Suppuration fever. Desiccation fever. FIG. 89. The type of fever iu small-pox (Leo). .2. 3. ^. 5. 6. 7. 8. 9. 10. 11. 12. 13. 1V 15. 16. 17 Fastijrium. i;<-mis*ion. TVriniirition by ly>is. FIG. t)0. The type of fever in tlie (yplioid fever of childhood ((ierhardt- Beifferl '. 256 ACUTE JNFECTIOUS DISEASES PLATE 21 Early Symptoms of Measles FIG. 1. KoplikSpOts. These are seen two days before tlie eruption of the exanthem. The bnceal mucous membrane shows reddish specks in the region of the molars, in which area are also seen somewhat elevah-d injected spots of varying size (fraction of a millimeter) and of a rounded or oval form. FIG. 2. The Eruption of Measles on the Mucous Membrane One Day Before the Skin Eruption. Irregularly formed, small and la rye pale red spots with serrated edges on the mucous membrane of the soft palate, which is still pale. The edges of the velum palati, the uvula, and the tonsils are reddened. The tongue is covered with a thick grayish-white fur. other diseases the child should be kept home according to the discretion of the doctor). Especial care must be observed to guard young or weak children from infection. The best protection is a hygienic life ; in case of small- pox, vaccination ; in diphtheria, preventive inoculation by means of antitoxic serum. The most important measures in infectious diseases are of a hygienic-dietetic nature : Provide fresh air, preserve the body heat (rest in bed), careful attention to the skin and the mouth ; a non- irritating diet, which, in the presence of fever, should contain no meat. With respect to medicaments, tinw- are of less value than hydrotherapeutic measures. Of specific remedies we possess the diphtheritic antitoxin and the antistreptococcic serum. MEASLES (J/o billi) Measles is an acute febrile disease accompanied by a maeulopapular rash and catarrhal phenomena. The incubation period lasts eleven days and runsasymp- tomless course, or with the appearance of manifestations of a general character. Symptoms. Following the period of incubation the dis- ease begins with catarrhal symptoms (<-(ti normal and remains there, provided no complications arise. Simultaneously with the disappearance of the fever the remaining symptoms disappear. The duration of the disease in favorable cases is from three to four weeks. Particular forms of this exanthem are milinry, vesicular, variegated (appearance of isolated spots <>f varying size), papular, and hemorrhagic scarlatina. The pharyngeal lesion may also vary in different cases it may consist of scarlatina with angina or it may be scar- latinodiphtheroid. In the latter form the initial simple angina may be converted into a diphtheritic affection SCARLET I'KVER 265 with a strong tendency to tissue necrosis. It may run a violent or a more prolonged course and greatly endanger the patient's life. In differentiating from diphtheria note: The pultaceous (smeary) character of the depo.-it ; the marked swelling of the lymph-nodes' and tis.-nc necrosis, which is rarely so severe in diphtheria ; the slight tendency to spread to the larynx and trachea and the absence of paralysis. Aside from the above types of this disease, we also meet with a number of other severe forms ; in scarlatina gravissima the virus has a rapid paralyzing action upon the brain and heart; the typhoidal form of scarlet fever is characterized by a grave infection accompanied by typhoidal symptoms ; variable hemorrhagic and septic types, which are also observed, run a course whose character is dependent upon that of the secondary septic infection. Comph' cations and Sequelae. The most frequent compli- cations and resulting conditions following scarlet fever include otitis, nephritis, inflammatory diseases of the lungs, pleura, endocardium, and joints. The scarlatinal nephritis begins usually at the commencement of the third week. The scanty amount of urine excreted contains albumin, casts, and blood. The general health is deci- dedly disturbed. Partial edema, also smaMirca ; hyper- trophy and dilatation of the left ventricle result. The affection lasts from three to four weeks (usually gloinern- lonephritis). In unfavorable cases the course is prolonged and passes into chronic nephritis, or it progresses rapidly with all the symptoms of a severe intoxication uremia. The prognosis of scarlet fever, because of the constant danger of serious complications, before the cud of three or four weeks should be doubtful. The average mortal- ity rate is about 12 per cent. 'The diagnosis, when the cardinal symptoms exist, is casv. Treatment and Prophylaxis (see Introduction). -lu-t in bed for from three to six weeks; fever diet Without meat for three weeks. To relieve the heart, which is threatened 266 ACUTE INFECTIOUS DISEASES by the scarlatinal virus, give daily hot baths (40 C. [104 F.] ) ; anoint the body with soap. When nervous symptoms are prominent resort to neutral soap-baths (35 C. [95 F.] ), with cold rubbing while in bath. When pronounced weakness exists, substitute the baths for cold washing or the wet pack. Special Therapeutic Measures. In case of delayed erup- tion of the exanthem, resort to packing. To lessen itch- ing of he skin rub with thymol, 0.5 gm., carbolic acid, 2.0 gm., and vaselin, 50.0 gm., after bathing. In scar- latinal diphtheria : Priessnitz's compresses, gargle with carbolic acid solution (1 teaspoonful of 5 per cent, car- bolic acid solution to \ pint of water) ; cautious swabbing of the tonsillar deposit with 5 per cent, carbolic acid solution or tincture of ferric chlorid. Heubner recom- mends injecting a hypodermic syringeful of 3 per cent, carbolic acid solution into the tonsils and palate twice daily (for injection it is necessary to attach a Taube can- nula to a hypodermic syringe), spraying the oral cavity every two hours with katharol (3 per cent, solution of hydrogen peroxid), and bathing the nose with salt water or boric acid solution. To lessen the swelling of the lymph-nodes rub them with 10 per cent, iodovasogen or ichtnyol-vasogen ; in threatening abscess formation apply cataplasms. For scarlatinal otitis, ice suppositories or an ice-bag; inject 1 to 2 drops of 10 per cent, carbolic acid and glycerin ; when perforation is delayed resort to para- centesis, followed every one or two hours by injections of katharol. Treat scarlatinal rheumatism by immobil- izing the joint with cotton dressings (cardboard splints) and administer salicylates. In the nephritis of scarlet fever absolute rest in bed and milk-diet ; only in case of distaste for the latter, or long duration of the nephritis and the development of weakness, is it permissible to cautiously add vegetable .food ; sour lemonade, a Avine- glassful two or three times daily. To stimulate diapho- resis, hot baths followed by dry packs ; diuretin ; cafifcin. Control hematuria by adrenalin or gelatin, internally or subcutaneously. Prolonged and marked albuminuria SMALL-POX. VARIOLA 267 indicates a coffeespoonful of infusion of digitalis (0.5 gni. : 100.0) every two hours. If uremia is threatened resort to warm baths and dry pack ; venesection ; enemata of chloral ; ice-bag to the head ; stimulants. The Moser antistreptococcic serum is recommended in severe cases as specific treatment (not yet sold on the market). SMALL-POX. VARIOLA Small-pox is a febrile contagious disease accompanied by a pustular eruption and a course which is divided into several stages. The disease begins after an incubation period of nine days with a high continuous fever, severe nervous and dyspeptic manifestations, pains in the back, weakness, and occasionally a scarlatinal or a measles-like rash (initial exanthem). The eruption appears on the third or fourth day of the disease, at first on the throat and face, later, on the whole body (it being thickest on the face and hands), as well as in isolated patches upon the mucosa of the digestive, respiratory, and genito-urinary tracts, and not rarely on the conjunctive. The virus of small-pox causes exten- sive vascular changes in circumscribed areas of the skin or mucous membranes, which lead to hyperemia and edematous swelling, and later a marked inflammatory exudation and infiltration of the involved parts. At first roseola-like spots are seen to develop, which are rapidly converted into flat papules, and within two or three days after partial liquefaction into variously formed vesicles ; this is the stage of eruption. Following the inflammatory exudation, further con- version occurs (from the end of the first week on) of the approximately lentil-sized umbilieated vesicles which are of mother-of-pearl color into tense pustules on an infiltrated base, which are surrounded by a red bonier, filled with a seropurulent fluid, and occasionally tend to coalesce ; this is the stdX. VA RIOLA 269 of the appearance of the suppuration fever; in older children, from secondary septic infections which originate in ruptured or scratched pustules. Aside from the above-described moderate form of small- pox, we also meet with other severer and even milder types. To the former belongs the so-called black small- pox (Purpiira vuriolosa), which is accompanied by pro- nounced cerebral symptoms, marked cardiac depression, hemorrhages into the skin and mucous membranes, as well as from the mouth, nose, ear, stomach, intestines, and kidneys. Death sets in before the true eruption of small- pox has had time to appear. Another severe form is the variola hcemorrhagica pustu- losa, in which the hemorrhagic diathesis does not appear until the stage of development. Still another variety is the confluent variola, in which collapse and death occur as early as the ninth to eleventh day from extensive suppuration and marked general infection. The milder forms of small-pox include variola sine exanthemata, variola apyretica, variola abortiva, and varioloid. In the latter variety the symptoms of the invasion appear, but the suppuration fever fails to develop (attacks chiefly vaccinated individuals in whom the im- munity due to a former vaccination has worn off in the course of years). The diagnosis before the appearance of the vesicles may cause much difficulty. The prodromal erythema and the beginning skin eruption are distinguished from scarlet fever and measles by the absence of the enanthem, the typic scarlatinal angina, and the Koplik spots (the latter is also only present in measles in 80 per cent, of all cases). As the disease progresses the serious nervous symptoms may also be mistaken for meningitis. The prognosis is dependent upon the character of the epidemic, the age of the patient (most fatal in nursing children), and vaccination. Prophylaxis and Treatment. All persons who have come in contact with a patient suffering from small-pox should be immediately vaccinated or revaccinated. Infect rd 270 ACUTE INFECTIOUS DISEASES PLATE 26 Normally Developed Vaccine Pustules on the Eighth Day after Vac- cination. FIG. 96. The first vaccination. articles should be burned. Strict isolation of the patient and careful nursing. The therapy is eminently symp- tomatic. Lessen the inflammatory process by the contin- uous action of red light (red window-curtains or panes of red glass) ; tepid baths with cold sprays and as recom- SMALL-POX. VARIOLA 271 mended by Hebra the use of a water-bed, scrupulous cleanliness of all accessible raucous membranes. Treat the skin by painting it with a 2 to 3 per cent, silver solu- tion or apply nitrate of silver or ichthyol ointment (5 to 10 per cent.). Vaccination. Immunity is obtained against true small- pox by inoculating a human being with the infectious ma- terial after its virulence has been weakened by passage through the body of a lower animal ; this is known as vaccination. In- Germany vaccination is a hygienic measure which is required by law, and every healthy child between the ages of one to twelve years must be vaccinated. (The first vaccination may be postponed in children suffering from febrile and weakening diseases, anemia, rachitis, scrofula, and skin diseases). Animal glycerin-lymph is alone used as the inoculating material ; it is obtainable at the Central Vaccine Institutions or from druggists, enclosed in little capillary tubes. The first vaccination is performed on the right, and the re- vaccination on the left, upper arm. With a vaccination lance from four to six incisions at intervals of about 2 cm. [.8 in.] are made over the deltoid muscle, care being ob- served to only incise the superficial layer of the skin, so as not to draw blood. [In this country glycerinated lymph is furnished in capillary tubes or on ivory points. A vaccination abrasion | inch in diameter is all that is necessary. Care should be taken to merely remove the epi- dermis, not to cause bleeding. ED.] As the upper arm is grasped and held tense by the left hand of the phys- ician the incisions stand open and the lymph can be easily introduced. Normally, the skin at the site of the inocu- lation turns slightly red in two days, becomes infiltrated on the third ; from the fifth day on it is accompanied by a mildly remittent fever up to 20 per cent, of first vaccina- tions are associated with ulbuminuria (Falkenheim) and at times annoying itching; we observe the glos>y and mother-of-pearl-colored pustules, which roach their highest degree of development on the seventh or eighth day. At this time the pustules already show an oval central umbil- 272 ACUTE INFECTIOUS DISEASES ication which is darkly colored. Occasionally the pustules are only surrounded by a narrow inflammatory zone, in other cases the skin of the whole inoculated area is red- dened, swollen, and infiltrated. In the second week the pustular contents become turbid, then purulent, and turn yellow. The desiccation begins at the center, and a yellowish-, later, blackish-brown scab forms, which falls off in about twenty-three days after vaccination. White net-like or radial scars remain behind. Occasionally the eruptive stage is complicated by a measles-like, scarlatinal, or a vesicular vaccination rash, or, on account of scratch- ing, pustules appear on various parts of the body ; gen- eral vaccinia is, comparatively speaking, extremely rare. Worthy of note is the possibility of transmission to an individual suffering from some skin affection (eczema) who has not as yet been vaccinated. The normal course may be considered disturbed if the vaccine has become infected with a pathogenic micro- organism at the time of its manufacture or before its use, or if during the vaccination the wound becomes infected. The most frequent complications are erysipelas (which spreads from the site of inoculation soon after vaccina- tion) and impetigo contagiosa. An infection of the pus- tules may also follow rupture or scratching of them (Heubner). To avoid infection, vaccination must be per- formed under strict aseptic and antiseptic principles (cleanse area to be inoculated with soap and alcohol), and the site of inoculation and the developing pustules must be protected as much as possible against mechanical inju- ries and the advent of bacteria. Worthy of recommen- dation are sterile vaccine points which are enclosed in glass tubes. A bath may be taken after the vaccination is manifest, provided the area is carefully protected from wetting. If inflammation becomes excessive, dust with lycopodium and make applications of moist boric acid compresses. In case of vaccination-erysipelas, resort to sublimate compresses immediately. VARICELLA. CHICKEN-POX 273 VARICELLA. CHICKEN-POX Varicella is an acute febrile, vesicular exanthem, which runs a mild course. The period of incubation, lasting from two to two and one-half weeks, is, as a rule, symptomless. The eruption begins usually on the face and head, some- times also on the trunk or the upper arm, with the appearance of small red nodules, which rapidly increase to the size of a lentil ; the centers of these nodules form small water-colored vesicles after a few hours. The ves- icles rapidly enlarge and soon involve the whole papule, but retain, as a rule, a light red border. They contain but one chamber, at first fairly well filled, which, as it in- creases in size, becomes umbilicated. The contents con- sist of a clear serous fluid which becomes turbid later, on account of which the originally gray vesicles assume a yellow color. After one or two days the vesicular con- tents dry up and honey-yellow, transparent, thin crusts are formed, which later turn brown. These scabs, when they fall off, leave a red spot over which the skin rapidly grows ; in extremely rare cases of exceptional severity white contracted scars are left behind. The number of vesicles is very variable, as a rule, only a few dozen. They are found on all parts of the body, but are thickest on the back, breast, and the scalp. Ves- icles also develop in about one-third of the cases upon the conjunctival, oral, and pharyngeal mucous membranes; more rarely upon the genital mucosa. They soon lose their covering and are more likely to resemble aph- thous ulcers. The eruptions of varicella never arise at one time, nor are all ever converted into vesicles. They occur more often individually within the course of sev- eral days, being separated by intervals of time; and it will be observed that one portion is papular in form and undergoes resolution without entering the vesicular stage. Thus we may note the various stages in development of the eruption side by side at the same time; small red papules with or without miliary vesicles; also vesicles of 18 274 ACUTE INFECTIOUS DISEASES PLATE 27 The Eruption of Varicella on the Fourth Day. The second crop of the eruptiou consists of a few dozen vesicles, some of which are in process of development, while others are already beginning to suppurate. Of the first eruption nothing remains but little brownish scales and red spots. Mucous membranes not involved. (On the first day a number of pin-head-sized, grayish-yellow vesicles, surrounded by a red /one. appeared on the anemic palate.) Afebrile course. General health good ; excessive itching. No albuminuria. Duration of disease was eight days. varying size on an infiltrated or slightly altered base con- taining light or turbid contents ; finally, the various grades of desiccation and the remaining red areas of the skin. The duration of the disease varies from five to ten days, depending upon the number of relapses, while full restoration of the skin occurs in about three weeks. During the first few days and at the appearance of each new crop of vesicles a high fever develops. The general health is otherwise disturbed only by the itching of the skin. The scratching which is indulged in may lead to secondary infection, suppuration of the vesicular contents, or to the subsequent formation of furuncles and deep- seated skin ulcers. Variations in the eruption are designated as varicella confluens, bullosa vel hcemorrhagica. A mild form of nephritis develops in rare cases. The differential diagnosis consists in distinguishing varicella from lichen urticatus and true small-pox. The eruption of lichen urticatus selects by preference the lower half of the body, feels very dense, and never undergoes a vesicular change. Of significance in true small-pox are the severe prodromata, high fever, erysipe- latous swelling and reddening of the face and scalp, extensive coalescence of the vesicles and pustules, and the absence of the various stages of development of the eruption at one time, which is so characteristic of chicken- pox (Heubner). Treatment. Rest in bed for several days; non-irritat- ing diet (nephritis). Protect against secondary infection 7' t DIPHTHERIA 275 (in case of excessive itching use thymol ointment or dust with talcum powder or cornstarch). DIPHTHERIA Diphtheria is an acute infectious disease characterized by the formation of membranous deposits and toxic constitutional symptoms. The cause of diphtheria, the Klebs-Loffler bacillus, is deposited on the mucous membrane, preferably of the tonsils, of the nose, or of the larynx and trachea. In these regions it multiplies rapidly and after a variable period of incubation causes necrosis of the epithelium and marked alterations in the blood-vessels of the mucous membranes. These vessels are congested and at high tension and permit the blood-serum to leak out rapidly and in large quantities (fibrinom exudate). Coagulation of the exudate causes the formation of the fibrinous diphtheritic pseudomembrane (see Plate 10, Fig. 1). The latter is sometimes loosely attached to the mucous membrane which has been deprived of its epithelium (croupous\ but at other times it is adherent and extends deeply into the mucosa (diphtheritic). The diphtheria bacillus requires much oxygen and therefore spreads, as a rule, only on the surface of the mucous membranes, especially of the respiratory tract, and but rarely extends to the deeper tissues, as into the circula- tion and the internal organs. From this local focus the whole organism is supplied with the poisonous metabolic products, the diphtheria toxin. The latter rapidly enters the circulation and travels to the viscera, where, attack- ing the living cells, it causes the development of degen- erative manifestations, especially of the heart muscles (fatty, and at times, waxy degeneration or secondary interstitial processes), the kidneys (parenchymatotis nephritis), and the peripheral nerves (peripheral neuritis with inflammatory changes in the spinal cord). The activity of the bacillus of diphtheria may be influenced to a certain extent by a mixed infection with other pathogenic bacteria, especially the streptococcus. 276 ACUTE INFECTIOUS DISEASES PLATE 28 FIG. 1. Diphtheria of the Lips following Measles in a Child Two and a half Years Old. The upper and lower lips are greatly swollen and covered by thick greenish-yellow deposits (joined at the ends), which have spread inward to the oral mucosa. The pseudoinembrsne is firmly adherent and cannot be drawn off without causing hemorrhage and the loss of tissue (microscopic examination showed the presence of large numbers of the diphtheria bacillus). Fetor of the breath. The lances are dark red, but free of deposit. The deposit disappeared in six day.-, after local and specific treatment. (Clinic of von Kanke, Munich. ) FIG. 2. Diphtheria of the Pharynx One Day After Serum Injection. Uvula, tonsils, and posterior pharyngeal wall are reddened : the median surfacesof the palatine tonsils present symmetric, whitish-yellow, sharply outlined fibrinous deposits, which are surrounded by a fairly broad blood-red zone (demarcation of serum action i. Two days later the deposits had undergone softening, became smaller and smaller, and finally disappeared. The fever disappeared in three days. The symptom-complex is very variable and depends upon : The localization of the primary disease focus ; the reaction of the mucous membrane to the invasion of the bacilli; the quantity and quality of the bacterial poison on the one hand, the susceptibility of the individual to the poison on the other. The mucous membrane reacts in one case only with catarrhal manifestations, in another case with the formation of fibrinous exudates and necrosis. The organism reacts with a high ephemera] fever and mild albuminuria and at other times with grave phenomena : High fever, marked albuminuria, disease of the cardiac muscle, and paralysis. The local and general symptoms need not necessarily correspond to each other in severity, for insignificant pathologic changes in the mucous membranes may be accompanied by the gravest manifestations of intoxication and the reverse (Escnerich). The beginning and course of the diphtheria may be fulminant or insidious, and at one time the local, at an- other the general, symptoms predominate. (A character- istic type of fever does not exist.) There is constant danger of the local process extending to the deeper air- paages with the sudden appearance of toxic symptoms. The duration of the disease is fairly indefinite, depend- DIPHTHERIA 277 ing upon the severity of the case and the onset of com- plications. According to the localization of the process we distin- guish between pharyngeal, nasal, laryngeal, conjunctival, vulvar, and wound diphtheria. The most common is the pharyngeal diphtheria. The mucous membrane of the pharynx is reddened and swol- len and the tonsils and uvula are considerably enlarged. The tongue is heavily coated and the odor of the breath is fetid. Several small white fibrinous plaques are seen on one tonsil, more rarely on the uvula or posterior pharyngeal wall, which rapidly coalesce into an irregular continuous deposit. The latter may remain stationary or spread by contiguity or by bounds to symmetric parts of the opposite side. In the progressive form the isthmus of the fauces and, later, the posterior wall of the pharynx are soon covered with a thick layer of fibrinous exudate, and by ascending and descending processes the mucous membrane of the mouth, of the pharyngeal cavity, and of the larynx and trachea are also attacked. The deposit, which is originally white, soon becomes yellowish or yellowish gray in color ; it is sharply outlined, elevated, tenaciously elastic, and may be fairly easily removed from the reddened infiltrated mucous membrane in large sections, accompanied by the loss of blood and tissue sub- stance. The lymph-nodes are always infiltrated and hard. In severe eases the lips and nares are excoriated by a sero- sanguiuolent secretion ; the speech, because of the im- mobilization of the velum palati, is nasal and the respira- tion is rasping and snorting. The toxic manifestations are variable in nature ; when the process is very extensive they are usually quite pronounced, and consist of high fever, considerable albnminuria, and swelling of the spleen and liver; paralyses develop during the convales- cence. Aside from these typic forms of diphtheria, we also observe especially mild and particularly severe varieties. The mild type of diphtheria consists only of a severe 278 ACUTE INFECTIOUS DISEASES PLATE 29 Diphtheria Gravis (Gangrenous, " Septic " Diphtheria). ' 'The ton- sils on both sides are swollen to the circumference of a hazel-nut, their surfaces are irregularly fissured, have a foul odor, and a dirty, yellowish- brown color. On incision the parenchyma of the tonsils is found to have become gangrenous. The surrounding mucous membrane is decidedly reddened and swollen, the uvula is considerably thickened and gl<>.-s\. The surface of the tongue has a dirty brown color. The larynx is uot involved." (From von Bellinger, Atlas of Pathologic Anatomy.) and obstinate inflammatory catarrh of the pharyngeal mucous membrane ; as regards the presence of membran- ous deposits, these are confined to single disseminated, mostly lacunar deposits (angina diphtheritica, diphtheria punctata). The toxic symptoms are likewise mostly mild, but may exceptionally be severe and lead to death before typic local changes are noticeable (hypertoxic form). Diphtheria gravis (Heubner), formerly called "septic diphtheria," consists of extensive mucous-membrane in- volvement, accompanied by putrefactive processes and the gravest manifestations of intoxication. It is caused by extraordinary virulence of the micro-organism or by a high degree of individual susceptibility to the virus. The patients usually die soon from the double action of absorbed bacterial virus and the products of putrefaction or from pneumonia or pyemia. Laryngeal Diphtheria (Croup). This condition is usually an accompaniment to or a result of pharyngeal diphtheria ; the latter has a marked influence upon tire disease pic- ture. With the primary localization in the larynx we note at first the symptoms of a laryngotracheitis, which, however, grows steadily worse ; hoarse and finally toneless voice; a dry, irritating cough; difficulty in breathing. In beginning stenosis (inflammatory swelling diphther- itic deposit) the auxiliary muscles of respiration become active and an inspirator? retraction of all yielding parts of the thorax occurs. Inspiration and expiration become slower, labored, and accompanied by crackling rales, especially on inspiration. Occasionally attacks of as- phyxiation follow the collection of mucus and obstruction DIPHTHERIA 279 by loosened sections of membrane. If a severe form of increasing stenosis is not checked by an operation the process may even spread to the bronchial tubes, and the patients die from the double action of carbonic acid and diphtheritic intoxication. Nasal Diphtheria. This also is generally an accompani- ment of pharyngeal diphtheria. In nursing infants the nose is often the primary seat of the diphtheria, and in this case there is a constant tendency to septic complica- tions. We note the following symptoms : Swelling of the nose, obstructed, noisy nasal breathing, serosanguiuo- lent, flaky, and (later) purulent discharge. Rkinoscopic Picture. Reddening and swelling of the mucosa ; white fibrinous deposits, which are mostly con- fined to the posterior portions of the nose. Toxic symp- toms also arise, as in other forms of diphtheria. A febrile purulent coryza is suggestive of diphtheria. The term " rhinitis (pseudo)membranacea " is employed to des- ignate a benign form of nasal diphtheria with extensive membrane formation, but without disturbance of the gen- eral health. Diphtheritic Conjunctivitis. Diphtheria attacks the conjunctiva} rather rarely as a primary or a secondary condition. It arises gradually either in the croupous or the diphtheritic form (from an anatomic point of view), that is, deposits are formed which are easily pulled off, or a pseudomembrane, varying in color from bluish white to that of amber, develops on the conjunctiva, which can be loosened only at the expense of hemorrhage and loss of substance. The diphtheritic form may also involve the bulb and not rarely the cornea also. The serosangui no- lent secretion is converted into a blennorrhea during the healing stage. Toxic symptoms and resulting conditions may occur, as in any other form of diphtheria. Diphtheria of the Vulva. This is a rare localization of diphtheria which is associated with marked manifesta- tions of a severe intoxication. The mons veneris, the inner surface of the thighs, and the labijc ma j ores are considerably swollen and reddened and the neighboring 280 ACUTE L\FE('IK)US PLATE 30 FIG. 1. Dipntheria of the Conjunctiva in a Young Boy. "Tin- in- flammatory swelling and reddening of the upper lid is more pronounced than in blennoiThea neouatoruni ; the skin of the lower lid and in the region of the inner can thus has undergone purulent infiltration, and is partially eroded hy the discharge. FIG. 2. "The lower lid of the same case inverted, to show the depth to which the diphtheritic infiltration of the conjunctiva lias extended; it is discolored yellowish gray." (From llaab, Atlus of UK- J^-n-nml l>i.*- eaucs of the Eye.) lymph-nodes are markedly infiltrated. Multiple dissem- inated and sometimes coalescing ulcers, varying in size from a lentil to a bean, are seen on the vaginal mar- gins ; these ulcerations are covered by a grayish-white, closely adherent deposit. In some cases the whole vulva is covered by a connected dirty gray deposit, beneath which a deep-seated necrosis exists. Complications and Sequelae of Diphtheria. The com- monest complications are nephritis, bronchitis, and pneu- monia. The sequelae consist of cardiac weakness and paralyses. The danger of paralysis of the heart is ever present during the acute stage and in convalescence, and requires the greatest care in treatment. The heart loses its strength either gradually or death due to heart failure may arise suddenly. Both conditions are caused by alterations in the cardiac muscular fibril he, which, aceord- ing to Eppinger, are a direct sequel of a toxic edema due to the diphtheritic virus. The postdiphtheritie paralyses are a manifestation of peripheral neuritis whose course is unaccompanied by fever, pain, or paresthesia?. Recovery occurs almost without exception in from four to six .weeks. The velum palati and certain ocular niu>clcs are especially prone to become paralyzed ; more rarely the muscles of the trunk and the extremities. Threaten- ing life are paralysis of the larynx and pharynx, the abdominal musculature, and that of the diaphragm. The prognosis of diphtheria is dependent upon the age and strength of the patient (the older the patient the more favorable the prognosis), upon the character of the epidemic, and the time at which skilful scientific treat- Tab.30. 281 mcnt is obtained. The mortality rate, when serum therapy lias been employed, is only a small jK-rcentage (von liauchfuss, Bayeaux) ; in operative cases it equals about 36 per cent. (Siegert). Diagnosis. The greatest difficulty is met with in dis- tinguishing diphtheritic from non-diphtheritic angina, and laryngeal diphtheria from pseudocroup. In the micro- scopic and bacteriologic examination, which should be resorted to in every doubtful case, we must bear in mind that the discovery of single bacillus on the inflamed mucous membrane, when the diphtheria bacilli are spread widely over the mucous membrane of a healthy person, is not indicative of the diphtheritic character of the disease, for the latter only holds true when diphtheria bacilli are found in colonies. On the other hand, the diagnosis of diphtheria in a case which appears clinically to be such should not be rejected because the specific bacillus has been displaced by other bacilli or because it was not found by chance in the examined material. For micro- scopic examination remove a bit of the deposit with a pair of forceps, wash in distilled water, and spread be- tween two cover-glasses. Fix over a flame. Stain with LofHer's methylene-blue. The diphtheria bacilli are slender, slightly curved rods, about as long but twice as wide as the tubercle bacillus; the ends are often clubbed and assume a characteristic angular position. They stain intensely with methylene-blue and are peculiarly nucleated. Treatment. Specifto Treatment : Scrum Treatnio neutrali/es anv diphtheritic toxin which may be in the circulation at 'the time of injection. Failure to relieve is due to either a severe and irreparable toxic action before the time of serum injection or to a mixed infection, in 282 ACUTE INFECTIOUS DISEASES FIGURE 93 Microscopic findings in diphtheritic angina. Colonies of diphtheria bacilli, isolated cocci, and thready fibrin. Enlarged 510 times. FIGURE 94 Microscopic findings in lacunar angina which is non-diphtheritic in character. Diffused bacterial growth. Of the numerous varieties none seem to predominate. Spare fibrin threads. Enlarged 510 times. which case we can only expect the antitoxin to influence the specific and not the foreign virus. Irrespective of age the following injections should be made : In localized diphtheria, 1000 I. U. (Behring II.) ; in progressive diphtheria or with involvement of the larynx, 1500 I. U. (B. III.); in laryngeal stenosis or severe intoxication, 2000 to 3000 I. U. (B. D. IV -VI.) ; as a prophylactic inject 600 to 1000 I. U. (B. I. or II.). 1 [The above doses may be considered small. In a case of clinical diphtheria 3000 units at least should be given at the onset. This dose may be repeated at intervals of six hours until some effect is produced on the membrane. ED.] The serum may be injected with any syringe contain- ing 5 cc. and which can be easily sterilized. For the injection, a portion of the skin should he selected beneath which there is loose subcutaneous tissue, as, for instance, the side of the chest. [The gluteal region is easily accessible when the child is held on the lap of mother or nurse, and is a favorite site for these injections. ED.] The site is thoroughly cleansed ; a fold of the skin is seized in the fingers and the cannula introduced parallel to it to such a depth that the latter is freely movable in 'The curative serum is usually obtained from horses which, after careful preparation (repeated injections of gradually increasing Fig. 93. v ', Fig. 94. DIPHTHERIA the subcutaneous cellular tissue. Before withdrawing the cannula a piece of adhesive plaster should be applied to the point of in- jection to prevent the escape of the serum and the infection of the wound. Massage of the swollen area which results is unnecessary. Pains in the wound disappear within twenty-four hours. Occa- sionally within the first fourteen days after the injection we may note an increase of fever, con- stitutional disturbances, and the appearance of morbilliform, scar- latina- or urticaria-like rashes, and, in rare cases, articular pains. These ill effects of the serum in- jection disappear without leaving any traces behind within several hours or, at the most, within one or two days. The serum has no other untoward effect. Local and Constitutional Treat- ment. Cleanliness of the mouth ; nasal douches ; hydrotherapeutic measures ; neutral soap-baths (35 C. [95 F.] ), with cold rubbing. Light, stimulating diet. The nephritis and paralyses usually require no special treatment. Special Treatment. In nasal diphtheria douche the nose with weak antiseptic solutions or in- sufflations of powdered boric- acid or sodium sozoiodol. For diphthe- ria of the conjunctiva make warm FIG. 97. An easily strri!i/:ilil>' scrum syringe with a metallic piston (modified by Walcher). 283 284 ACUTE INFECTIOUS DISEASES FIG. 98. The injection of serum in the left axilla, t;. e anus being tightly supported on both sides, so that the patient cannot interfere with the operation. The cannula is introduced, parallel to the surface of the body, into the elevated fold of skin. Fio. 99. Intubation with elastic tubes. As the tube is being put into place it assumes the curvature of the introducer, which conforms in shape to the curvature of the tongue. After it has boon introduced it follows the curvature of the laryngotrachoal tube. (Note how the left index-finger, which lies at the cut ranee to tiie larynx, draws the epiglottis and root of the tongue forward and upward in onler to expose the entrance into the larynx as much as possible.) DIPHTHERIA 285 applications; apply disinfectants for diphtheria of the vulva; after cleansing, apply boric-iodoform powder. At the beginning of laryngeal stenosis order a hot bath, followed by sweat-stimulating packs ; energetic vapor treatment in order to reduce the inflammatory swelling and to hasten softening of the membrane. When the stenosis threatens life, resort to intubation (O'Dwyer) or tracheotomy. Intubation consists in introducing into the larynx by way of the mouth a small tube constructed of metal, hard rubber, or some elastic material, and allowed to remain in place until the local process has undergone resolution, which is about three days. The patient is wrapped from neck to feet in a sheet, and intubated while lying in bed or sitting on the lap of an assistant, who fixes with his thighs the child's legs, holds the mouth open with one hand and the head in a median position with the other. The tube is inserted by first introducing the left index- finger far into the pharynx to hold the entrance of the pharynx open by pressing the tongue as far forward and upward as possible and the epiglottis against the root of the tongue. During this operation the following precau- tions are necessary : The instrument must be introduced in the middle line to avoid entering one of the different lateral mucous fossie. The handle of the introducer should be raised after the epiglottis is passed, in order that the tube will not glide over the entrance of the larynx, which is half covered by the tongue, into the esophagus. After the tube is inserted into the larynx the handle should again be lowered to avoid injuring the anterior wall of the larynx by the tube. The operation should last only a few seconds. Accidents during the operation itself are rare, but, on the other hand, difficulty in swallowing, coughing the tube out, or obstruction of tin- tube, and' the more extensive formation of pressure ulcers are more or less serious accompaniments. [In the hands of experienced operators this procedure is not difficult, hence accidents are rare. In the inexperienced, 286 ACUTE INFECTIOUS DISEASES however, injuries to the mucosa of the larynx are more common than would be expected from the literature. Eli.] The cxtnbation is performed either by means of a pharyngeal forceps-like instrument or, better, by the use of a silk thread, one end of which is fastened to the head of the tube and the other end passing out of the FIG. 100. Intubation tubes. Metallic tubes : a. O'Dwyer's original tubes, b. Bauer's curved tubes, c. Bayeux' short tubes. Bobber tubes: d. O'Dwyer's ebony tubes, e. Trumpp's elastic tubes. mouth, which is fastened to the cheek by means of a piece of adhesive plaster. If the existing conditions prevent free respiration through the tube or if, for any reason, it is impossible to introduce the tube, the bloody operation must be siilxti- tuted, and the trachea opened above or below the isthmus of the thyroid. FIG. 101. Intubation (<> i>\vyrrs instrument, ebony tube). First operation : Introduction into the mouth. The handle of the introducer is depressed. 287 .- FIG 102.-l.,uumuon. Second opewtkni: IiisiTtioM into the larynx. Handle of the introducer is etevmted. 289 290 ACUTE INFECTIOUS DISEASES PLATES 31-33 Tracheotomy The plates show the various tissues of the neck which must be severed in tracheotomy. The incisions are so presented as to show simultaneously the important anatomic relationships in high and low tracheotomy. In practise the skin incision iu high tracheotomy is made 1 cm. [.4 in.] higher and in low tracheotomy 1 cm. \_A in.] lower than is shown in the figure. PLATE 31. The skin has been incised and the subcutaneous cellular tissue exposed. The hyoidbone, the thyroid and cricoid cartilages, the trachea, the thyroid, and thymus glands are traced in dotted lines for purposes of demonstration. In palpation remember that in small chil- dren only the hyoid bone and the cricoid cartilage can be plainly felt, and that the latter cartilage (not as in the case of an adult, the thyroid) represents the most prominent portion. PLATE 32, FIG. 1. The adipose tissue has been severed and the superficial cervical fascia with the branches of the inferior thyroid vein brought into view. The musculature with the liiiea alba is seen to shine through the fascia. FIG. 2. The superior cervical fascia has been incised and the sterno- hyoid muscles, which are joined in the median line by the liuea alba, exposed. FIG. 3. The musculature has been cut and the deep cervical fasHa exposed. FIG. 4. The superficial layers of the deep cervical fascia are incised. and we see exposed at the upper portion of the wound the isthmus, which is about 1 cm. [.4 in.] wide, and. to a certain extent, the lateral lobes of the thyroid gland, also the anastomosis of the inferior and superior thyroid veins. The thymus gland, which protrudes markedly upward, is seen at the lower end of the wound. Loose cellular tissue and the deep layers of the cervical fascia lie between the thyroid and thymus gland, also the anastomosis of the inferior thyroid with the anterior jugular vein. PLATE 33. Low Tracheotomy. -Cellular tissue and the deep layers of the cervical fascia are severed and the trachea exposed between tin- thyroid and thymus glands. To the left of the lower portion of tin- wound is the innominate artery, which is in a high position. (The in- nominate, as a rule, occupies a high position in children dnrinii the first year of life, also as is not rarely the case during the second and third years. This must be remembered to avoid injuring it.) The patient is wrapped in a sheet (as in case of intuba- tion), placed on a table, and in order to obtain full extension of the neck a bottle wrapped in cloth is pl;iccd underneath it. An assistant attends to the anesthetiza- tion (which in profound carbonic-acid intoxication is unnecessary) and watches the neck of the child during the operation, in order to prevent lateral movement or I lib. Tab. DIPHTHERIA 291 displacement. The same asepsis is necessary as in any other bloody operation. The incision of the skin as well as that of the other tissues should be exactly in the median line. The opening in the skin should be at least 5 cm. [2 in.] long and reach, in case of superior tracheot- omy, to the chin ; in the case of inferior tracheotomy, to the sternum. The subcutaneous tissue is retracted by means of two artery forceps; next the superficial fascia and beneath it the glistening tinea alba of the sternohyoid muscles are severed on a grooved director. The next step differs in high and low tracheotomy. In the former, a transverse incision is made through the deep cervical fascia, w y hich lies exposed beneath the muscles, to the lower edge of the cricoid cartilage. It is then loosened by blunt dissection and drawn upward together with the enclosed thyroid gland to expose the trachea. In low tracheotomy the cervical fascia is incised in a longitudinal direction, layer by layer, on a grooved direc- tor until the thyroid gland is reached. After the deepest layer has been severed, the trachea, which lies partially exposed, is caught by two sharp hooks and drawn up- ward and freed by blunt dissection of any loose cellular tissue which may still adhere. A sharp-pointed knife is now forced through the trachea until the hissing sound of the escaping air informs us that the tracheal lumen has been opened ; the incision is then sufficiently enlarged with a probe-pointed bistoury to permit the entrance of the canmila, that is, from 1 to 1.5 cm. [.4-.6 in.]. Not until the breathing has become absolutely free is the ean- nula (with a movable shield, as recommended by Liier or Hagcdorn) introduced and fastened to the neck with a simple band. The wound is well dusted with iodoform and covered with a piece of lint or gauze to receive the expelled tracheal secretion, and also with a piece of gutta- percha or a piece of cambric. Difficulty may be encountered in performing this operation by the presence of an abnormally large thyroid gland, or it's close union with the trachea, a lar^e thymus, numerous congested venous branches, and (in rare cases) 292 ACUTE INFECTIOUS DISEASES arterial anomalies. The after-treatment is complicated by the presence of post-operative hemorrhages, dvsphagia, obstruction of the cannula, and decubitus. For the sake of cleanliness the cannula must be changed on the third day. To do so, retract the soft parts which are still ununited with hooks and pass a catheter, with a large opening, through the cannula into the trachea and employ it as a conductor for the removal of the old and introduction of the new cannula. In one or two days a speech-cannula is inserted, and by closing the same the permeability of the larynx may be tested. If the child passes through a night well and sleeps undisturbed the closed speech-cannula may be removed and the wound allowed to heal. TYPHOID FEVER Typhoid fever is an infectious disease which is primarily localized in the intestines and accompanied by swelling of Peyer's patches and of the spleen. It occurs in chil- dren, especially after five years of age, almost as frequently as in adults. The morbid anatomy as well as the symptom-complex is, on the whole, the same in older children as in adults, but in younger children there is a decided difference. In the latter the upper portions of the intestine are chiefly in- volved and the morbid process is not as deeply seated, accordingly necrotic eschars, extensive typhoidal ulcers, and intestinal perforation are rare in children. Clinically, we frequently note in place of the typie diarrhea (pea-soup stools) an obstinate constipation, with partly pappy and partly hard nodular stools. In other respects the disease picture represents the mild typhoid of adults (gastric fever] : Dyspepsia, headache, remittent fever, slight swelling of the spleen, and sometimes rose- ola. The manifestations are frequently so slightly characteristic of typhoid that the diagnosis remains doubtful, and is only made possible by severe relapses or by etiologic relationship with other undoubted cases of typhoid fever. Sometimes the condition passes into TYPHOID FEVER 293 a form of moderate severity which is accompanied by an initial pseudornembranous angina, epistaxis, cerebral irritation, diarrhea, dry bronchitis, and marked loss of strength. The severe type of typhoid in children does not differ much cither in its course or complications from that disease in adults; children, however, complain more frequently of abdominal pain, the nervous symptoms are more prominent, and the whole duration of the disease is, in general, shorter. Day of disease. 2. 3. A. 5. 6. 7. 8. 9. 10. 11. 12. 13. 1V 15. 16. 17. 39 38 l 37 36 \ Fastigium. Typic defervescence of a remission by lysis. FIG. 103. The type of fever in typhoid fever of childhood (Gerhardt- Seiffert). The diagnosis is made from the characteristic step- ladder-like ascent of the fever, the roscolur rash, enlarge- ment of the spleen, absence of leukocytosis (Baginsky) (leukocytosis in pneumonia), diazo-reaction of the urine, Grnber-Widal reaction (agglutinating action of diluted blood-scrum from a typhoid patient upon the typhoid bacillus). 294 ACUTE INFECTIOUS DISEASES The prognosis in children is, on the whole, more favor- able than in adults. Treatment. The strictest observation of all hygienic measures, especially as regards cleanliness of the mouth. Baths from three to six times daily at a temperature of from 30 to 35 C. [86-95 F.] and of five to ten minutes' duration, during which the child is energetically rubbed and finally douched with water which has been cooled off by means of ice. The number and temperature of the baths depend less upon the degree of fever than upon the severity of the attack (Heubner). In case of very high fever and severe diarrhea make cold applica- tions to the chest and abdomen, which are changed every fifteen minutes. Give large quantities of liquids and limit to a milk or carbohydrate diet. INFLUENZA Influenza in children is characterized by attacks of high fever, an initial retropharyngitis, and toxic constitu- tional symptoms which are especially referable to the gastro-intestinal canal, the nervous system, and, to a less extent, the respiratory organs. The bacillus of in- fluenza seems to attack by preference the mucous mem- brane of the postpharyngeal wall, from whence, after an incubation period of from one to eight days, it dis- tributes its poisonous metabolic products throughout the whole organism. Prodromal manifestations are usually absent. Symptoms. The disease begins with the development of pronounced weakness, headache, sometimes chills, and a high remittent fever which often lasts but two or three days. Inspection of the pharynx discloses a diffuse red- ness of the dry mucosa, a retropharyngitis (Soltmann). Pain develops in the neck, back, joints, and head, where it is very severe. The appetite is lost, the pulse is small, rapid, and at times arhythmic. Not rarely symptoms of cardiac weakness and mild cyanosis are met with. The remaining symptoms depend largely upon the age of the INFLUENZA 295 child. In older children as well as in adults the phe- nomena of a descending catarrh of the respiratory tract exist ; frequently also an influenzal croup (descending croup with exceptionally tenacious expectoration). On the other hand, in younger children the dyspeptic or enteritic (Baginsky, Schlossmann) and cerebral symptoms predominate (diarrheic, mucous stools of a foul odor, sometimes the typhoidal state, slight enlargement of the spleen, coma, delirium, meningitic symptoms or true primary influenzal meningitis, due to infection of the blood by the bacillus of influenza). The bronchial and pulmonary phenomena in influenza show a remarkable and characteristic resistance toward the ordinary therapeutic measures. They are, in general, not of a serious character ; however, cases of broncho- pneumonia are met in which the confluence of lobular foci lead to consolidation of whole lobes, and death may even occur, due to abscess or necrosis. Influenza fre- quently involves the tympanic cavity, in which case hemorrhagic inflammation of the tympanum and suppura- tion of the middle ear almost always develop (Hartman, Heubner). Conjunctivitis and extreme photophobia are not rare complications (Spiegelberg, Comby). In about 12 per cent, we note the development of a measles-like, roseolar, or scarlatinal eruption (Schlossmann), and, more rarely, nephritis. The duration of the disease is from three days to as many weeks and, rarely, longer. The prognosis is, on the whole, more favorable than in adults. The diagnosis may be made in questionable cases from catarrh, bronchitis, pneumonia, and meningitis by t he- detection of the bacilli of influcn/a. The latter are minute rods, usually occurring in pairs, which lie in large groups between the pus-corpuscles and frequently al-> within the cells. Doubt as to the influenzal nature of Castro-intestinal symptoms may be settled by the as- sociated joint and muscle pain ami headache. Treatment. Symptomatic (at the beginning of the 296 ACUTE INFECTIOUS DISEASES disease procedures which increase perspiration may he indicated). Give as many decigrams of quinin twice daily as the patient is old in years. WHOOPING-COUGH. PERTUSSIS Whooping-cough is a catarrhal affection of the upper air-passages occurring in epidemics, which is character- ized by marked irritation of the respiratory mucous membrane, and especially by attacks of coughing, accom- panied by a prolonged crowing inspiration which occurs frequently at night. The laryngoscopic and pathologic findings consist of a catarrh of the upper air-passages extending into the large bronchi, accompanied by redness, swelling, and softening of the mucous membrane, with the excretion of an extremely tenacious discharge, which is rich in mucin and contains varying quantities of pus-cells. The great- est degree of reddening is noted in the interarytenoid space and at the bifurcation of the trachea. Laryngo- scopic examination shows these areas to be particularly irritated, and that the passage over them of the tenacious mucus flakes causes the typic spasmodic attacks of cough- ing. The characteristic changes in the lungs consist of ecchymoses of the pulmonary cortex, acute distention of the apices, emphysema, and distention of the bronchioles. The latter contain a thick, creamy pus, which at times finds its way into the alveoli, these, through violent in- spiration of the secretion (into the formerly collapsed alveoli), become dilated to the size of a pin head or pea (Fauvel, Ziemssen). Dilatation and hypertrophy of the right heart is nearly always present (due to increased pres- sure in the pulmonary circulation). The clinical manifes- tations at the beginning and during the stage of decline show little that is characteristic. We distinguish between an initial catarrhal stage, a catarrhal convalescent stage, and the interval between them, or the convulsive stage. The period of incubation lasts from three to ten days and is symptomless. WHOOPING-COUGH. PERTUSSIS 297 Symptoms. The initial cataivhal stage is marked by the symptoms of a febrile laryngo-tracheo-bronehitis, which resists the treatment of an ordinary catarrh. Toward the end of the initial stage the catarrhal symp- toms gradually disappear, and the cough, which is at times loose and at other times dry, assumes a peculiar metallic tone. It occurs more frequently at night and becomes more spasmodic. The initial and frequently high fever sinks after a few days, as a rule, to normal, and the constitutional symptoms lessen in severity. In about two weeks after the commencement of the first symptoms of the disease the attacks of cough de- velop less often, but are of a convulsive character con- nifxive stage. The convulsions are preceded for several seconds or a minute by an aura in the form of a tickling sensation or burning of the throat, a feeling of oppres- sion, great restlessness, nausea, and tracheal rattling. The cough, which has been vainly held back, then breaks forth ; numerous expiratory coughs follow each other, interrupted only now and then by a laborious, sighing, and crowing inspiration, which follows at times a short period of rest. This is continued until the main attack and two or three after-attacks (Reprise, Baginsky) have forced out a tenacious plug of mucus, which frequently fails to occur until one to five minutes after a vomiting spell. During the attack, in which the child is frequently close to asphyxiation, the venous stasis causes the lips and eye- lids (the latter is often present even after the attack) to swell and the face to become red and finally cyanosed. The pulse is very rapid, in many cases hemorrhages un- noted from the nose and ear or into the conjunctiva and, in rarer cases, into the brain, accompanied by the symp- toms of cerebral pressure and even death. (A series of venous complications of whooping-cough is attributed by Neurath to toxic inflammation of the meninges.) The child soon recovers after the attack, and in uncomplicated cases feels perfectly well during the interval. Examina- tion of the lungs is negative or discloses a lew dry rales. The duration of the interval is most variable. In 298 ACUTE INFECTIOUS DISEASES mild cases only about a dozen and in severe cases several dozen attacks occur within twenty-four hours. In the latter case the child, especially when raised under unfavorable circumstances of life, fails in general health, its sleep is disturbed by the frequent attacks, and the repeated vomiting interferes with nutrition. After the convulsive stage has lasted two or three and sometimes eight or ten weeks, the attacks begin to become less frequent and lessen in severity. The cough gradually loses its spasmodic nature and becomes looser, and the disease passes into the terminal catarrhal stage, the dura- tion of which depends upon external hygienic and climatic conditions. Relapses during convalescence be- cause of neglect are quite frequent. The prognosis of pertussis in small, weakly, especially rachitic children, is very dubious, because of the fre- quency of severe complications, such as eclampsia, capil- lary bronchitis, bronchopneumonia, and sometimes puru- lent meningitis. Danger of asphyxiation during an attack is especially likely to threaten nurslings, for in them the seizures are less noisy and frequently the crow- ing inspiration is replaced by a sneezing sound (at times also in older children [Hagenbach] ), and not rarely decided air hunger already exists before attention is attracted to the child's condition. Older children present an obstinate catarrh of the respiratory organs, bronchiec- tasis, and, as a frequent sequel, tuberculosis ; less rarely, otitis and nephritis. A doubtful prognosis is always made in mixed infection, as in the occurrence of measles, rotheln, scarlet fever, and diphtheria. The diagnosis is easily made if a typic coughing spell is heard ; in some cases it is possible to artificially excite such an attack by pressure upon the root of the tongue or on the larynx (pressure upon the vocal cords by means of the index-finger introduced through the mouth [Variot] ). Of diagnostic significance is a bloated face with the presence of a doubtful cough, also the existence of ulcerations upon the frenum of the tongue, due to the wedging of that organ between the teeth during an attack. MUMPS. EPIDEMIC PAROTITIS 299 The urine is of high specific gravity and the amount of uric acid is increased (Hippius-Blumenthal). Finally, the anamnesis of the patient is of assistance in reaching a diagnosis. Treatment. Provide fresh, not too cold or dry, and, above all, dust-free air. For this purpose the child should live alternately in two rooms during the febrile initial stage when rest in bed is necessary, as well as later throughout the course of the disease when the weather is unfavorable. These rooms must be constantly well ventilated and properly heated (the two-room treat- ment of Wertheimber). To supply the air with the proper degree of moisture employ cloth hangings which have been immersed in a carbolic acid solution; and the floor should be wiped repeatedly each day with the same solution. If the out-door air presents the necessary requirements (later a change of climate) the warmly dressed child should spend as much time outside of the house as possible. Aromatic baths (hayseed, camomile). Hardy children should receive daily baths at a tempera- ture of 35 C. [95 F.], followed while in the bath by cold rubbing. An easily digestible diet with prohibition of dry and strongly sweetened food. In case of frequent vomiting give small portions of food in the form of gruel every half hour or every hour. Medicaments. Quinin, etiquinin (expensive), antitussin, pertussin, bromoform, and for older children use extract of belladonna together with codein or morphin. In- halations of oil of cypress (Soltmann) or of a 2.5 per cent, solution of carbolic acid. Administer alkaline waters. The bromids in large doses and cnemata of chloral are indicated for eclampsia. MUMPS. EPIDEMIC PAROTITIS Mumps is an acute febrile and contagious swelling of the parotid glands and surrounding structure-. The incubation period lasts from one to three week- and is symptomless. 300 ACUTE INFECTIOUS DISEASES FIG. 104. Epidemic parotitis. Second day. The picture shows the uniform swelling in the region of the left ear, which baa spread to the face and the subiuaxillary areas; also the characteristic elevation of the auricular lobule. The filling of the fossa between the mastoid process and the ranius of the lower jaw is unfortunately not visible. (See Fig. 107, cervical lymphadenitis.) The prodromal phenomena consist of general uneasiness which in a few days leads to a local disturbance. The child experiences a painful drawing sensation in the region of the ear, and finds that chewing and swallowing are somewhat interfered with. Simultaneously with these symptoms a swelling is noted below the lobule of the ear, which rapidly spreads forward to the region of the par- otid gland. Sometimes collateral edema involves the neighborhood, including the whole side of the face as far as the nose and orbits, and the neck as far as the di-tal end of the clavicle. The swelling causes a characteristic elevation of the auricular lobule and distortion of the face, which increases decidedly in width. In from two to four days the affection also spreads frequently to the other parotid gland, in which case the extensive swelling of both sides meet below the jaws and give the face a comical, pear-shaped appearance. The skin over the swollen portions of the gland remains pale, although occasionally it may be slightly reddened. The parotid, the sublingual, and submaxillary glands, as well as those at the angle of the jaw (which may likewise be involved), are sensitive to pressure and may be plainly felt through the swelling (which is elsewhere fairly soft and doughy) as dense nodules. The painfulness of the inflamed glands and the pres- sure of the swelling upon the deep-lying soft parts represent the chief disturbances. Movement of the head is limited ; troublesome swallowing and ear-ache are present. As a rule, an initial fever of 38.5 C. [100.9 F.] occurs; only rarely is the temperature higher; frequently lacunar angina and fetor of the breath coexist. The swelling begins to diminish after two or three days and disappears in about eight days. Recovery EPIDEMIC PAROTITIS 301 \ Fie,. UU. 302 ACUTE INFECTIOUS DISEASES is decidedly delayed in involvement of both the parotid glands. It is worthy of note that in exceptional cases in place of involvement of the parotid the submaxillary glands are alone involved submaxillary mu/i/jix. Mumps is not rarely complicated by middle-ear dis- ease, which may restdt in complete and incurable deaf- ness; also by nephritis. Metastasis to the testes and ovaries occurs only exceptionally in children. Diagnosis. Parotitis must be differentiated from lymph- adenitis when it exists in the region of that gland. The swelling is similar in both conditions at the begin- ning, excepting that in case of lymphadenitis it is not localized so exactly between the mastoid process and the angle of the lower jaw, it grows more slowly and pre- sents, as it becomes more .tense, reddening of the skin. and, finally, fluctuation if an abscess forms (suppuration is rare in epidemic parotitis). The displacement of the auricular lobule, which is so characteristic of parotitis, is also absent in lymphadenitis. Inspection and digital examination of the oral and pharvngeal cavities precludes the possibility of mistaking parotitis for the secondary edematous swelling of stomatitis, alveolar periostitis, and retropharyngeal abscess. The prognosis is favorable provided no complications arise. Treatment. Rest in bed during the fever and confine- ment to the room until the swelling has completely disappeared. Cleanliness of the mouth is important, as is also a liquid or semiliquid, non-irritating diet, because of difficulties in swallowing and of the danger of neph- ritis. Depletion by way of the intestines. The swelling is covered with zinc powder or rice flour and protected with cotton. In case of pain resort to rubbing with heated oil of hyoscyamus, and with potassium iodid ointment or 6 per cent, iodovasogen if resorption is de- layed. DISEASES OF THE CIRCULATORY APPARATUS GENERAL CONSIDERATIONS DISEASES of the arteries in childhood are very rare, but, on the contrary, pathologic changes in the heart, especially after the fifth year of life, are quite frequent. Such alterations are mainly due to infections or to toxic influences (atheromatous processes do not occur in chil- dren). [Atheroma is found in congenital syphilis.] As causal conditions we have the acute infectious diseases and, above all, acute articular rheumatism (which is known to attack children even during the nursing period), also rheumatic conditions, which are apparently of a mild type, such as angina, for which reason the heart should always be examined in those diseases. The congenital anomalies of the heart, which are not very numerous, are attributed to disturbances in de- velopment which alone affect the circulatory apparatus, or more frequently but simultaneously, also other organs (deformities of all varieties, hare-lip, situs inversus, etc.). Such anomalies may also follow fetal endocarditis (the transmission of the infectious micro-organisms from the maternal blood to the fetal circulation), which frequently causes permanent changes in the heart valves, and may be associated by a certain genetic relationship with mal- formations of the heart due to arrested development. The symptomatology of cardiac diseases in children presents fewer characteristics than in adults. On account of the more efficient supply of blood to the heart mus- culature and the physiologic tachycardia \ve note that: Disturbances of compensation occur more rarely and later, and that, therefore, dropsy and secondary changes 303 304 CIRCULATORY DISEASES in the liver, kidneys, spleen, and lungs are only rarely observed. Congenital as well as acquired affections of the heart may exist for a time without influencing in any way the heart dulness, so far as percussion can detect. These reasons, together with the better nourishment of the heart, probably contribute in making the prognosis of acquired heart disease during childhood more favorable than in later life (Hochsinger). The knowledge of certain peculiarities of the infantile heart is requisite in establishing a diagnosis of cardiac disease in children. The apex-beat during the first or second year of life lies about 2 cm. [.8 in.] outside of the left rnammillary line in the fourth interspace, and moves during the course of years to the right and downward, so that after the fourth year it is located in the fifth inter- space, at first in the mammillary line, but later within that line. The absolute cardiac dulness in the first year 'of life reaches above to the lower border of the third rib, to the left mammillary line, and to the left border of the ster- num. While the outer and inner borders of the heart remain stationary, the upper edge extends at the age of four years to the upper edge of the fourth rib, and in the twelfth year to the lower edge of the fourth rib. The relative cardiac dulness reaches in the first year above to the second rib, to the left somewhat beyond the apex-beat, to the right as far as the right parasternal line. The upper border moves gradually downward until the twelfth year to the third rib, and its inner border moves during the same time to the right sternal border. In auscultating note that, first, up to the second year the first sound is normally accentuated everywhere ; second, in easily excitable children the first 15 to 20 heart-beats at the beginning of the examination are ac- companied by the so-called "cardiac-pulmonary mur- mur" (jerky exaggeration and weakening of the inspira- tory murmur in the medial pulmonary cortex caused by CONGENITAL HEART DISEASE 305 the rhythmic movements of the heart, with which they are synchronous ; most evident when the heart's action is vigorous and rapid and the respiration rate is increased in frequency); and third, the so-called awidcntdl, iu<>r;/y pain or disturb- ance of the general health. The resolution is equally 314 CIRCULATORY DISEASES slow and frequently accompanied by suppuration, ease- ation, and induration. Chronic lymphadenitis is usually a sign of syphilis and tuberculosis, and the node is not rarely the point of origin of tuberculosis in other organs. Particularly suspicious of tuberculosis is the development of numerous small hard lymph-nodes in the occipital region (micropolyadenitis). Treatment. This is symptomatic. Employ iodin prep- arations. When tuberculosis is suspected the glands should be extirpated as soon as possible. [Favorable results are reported in the treatment of tuberculous lymph-nodes by the use of the arrays. A full diet and out-door life is advisable in these cases. ED.] (For further discussion, see Scrofula.) DISEASES OF THE RESPIRATORY ORGANS GENERAL DISCUSSION THE upper air-passages the nose, mouth, and pharynx possess certain protective agencies in order to preserve the extremely sensitive mucous membrane of the true respiratory organs from injurious influences. The mucous membrane of -the respiratory portion of the nose is sup- plied with ciliated epithelium which retains bacteria and dust and provides a bacteria-destroying secretion. The gland-like structures at the isthmus of the fauces and roof of the pharynx, the palatine and pharyngeal tonsils, may likewise be looked upon as a sort of bacteria-filter. Thus, the inhaled air is filtered before its entrance into the larynx and moistened and warmed by means of the rich blood supply to the nasal mucous membrane. Dis- turbances of these protective agencies lead, as a rule, to disease of the air-passages. Even breathing through the mouth, which offers but little protection when the nose is obstructed, results in irritation and inflammatory catarrh. Most marked, however, are the disturbances noted when a patient breathes through a tracheal cannula, in which case the air, without any prophylactic measures, passes with all its injurious elements directly into the trachea and bronchial tubes. Hence we must attach more im- portance to diseases of the upper air-passages, especially in the case of sensitive children, than we are wont. ACUTE RHINITIS (Coryza; Snuffles) A catarrhal condition of the nasal mucous membrane, accompanied by swelling, redness, and increased secre- tion, is quite frequent in children and even in infants. It is always due to an infection ; primarily through 315 316 RESPIRATORY DISEASES various forms of bacteria and secondarily in various in- fectious diseases through the specific etiologic factor. In primary rhinitis, thermic, mechanical, and chemic irri- tants act as predisposing factors. The affection, which is at first accompanied by a watery mucoid and, later, thick yellowish-green secretion in large quantities, causes in young children, especially in nurs- lings, decided constitutional disturbances, interference with nourishment and respiration (orthopnea, Henoch), and finally a high fever. There is danger of involvement of the Eustachian tube when the process extends backward to the nasopharynx. (For Acute Pharyngeal Angina, see that condition.) It is of diagnostic significance that the course of the dangerous primary nasal diphtheria is also accompanied by the symptoms of a febrile corvza. Treatment. Apply wet compresses, over which are drawn thick woolen compresses ; hot pack to the head ; increase perspiration in order to rapidly abort the condi- tion. Insufflation of boric acid powder by means of a paper cylindric tube or a powder insufflator. (Do not blow upward.) Nasal douche : By means of a coffee- spoon or individual nasal glass pour into each nasal ori- fice a little cleansing fluid while the patient's head is held slightly backward. As a cleansing fluid employ : Boric acid, sodium chlorid, and glycerin, of each, 2.5 gm. : 250.0 of water. Later, paint with lukewarm almond oil. In case of orthopnea instil 1 drop of a 1 per cent, cocain solution, followed by a douche of physiologic salt solution, or the application of a menthol ointment, con- sisting of menthol 0.2 gm., unguentum of boric acid 35.0 gm., liquid paraffin 10.0 cc. If necessary, admin- ister nourishment with a spoon. CHRONIC RHINITIS AND OZENA Chronic rhinitis develops gradually as a result of fre- quent recurrences of acute catarrh or on account of con- tinued sojourn in a dusty, damp, and foul atmosphere. It may also occur as an accompaniment to hereditary < -minx 1C R1IIMTIS AND n/j-:.\.[ 317 318 RESPIRATORY DISEASES syphilis or tuberculosis. Diseases of the pharyngeal lymphatics, adenoid vegetations, and nasal polypi are frequently concomitant conditions. The nasal mucous membrane is considerably reddened, swollen, and elevated in a cushion-like manner; the secretion is greenish yellow and purulent. Nasal breath- ing is decidedly interfered with and involvement of the Eustachian tube frequently causes difficulty in hearing. The stage of inflammatory hyperplasia is followed after a longer or shorter time by atrophy of the mucous mem- brane and of the nasal stroma. The pale mucous mem- brane of the dilated nostrils is seen to be coated with grayish-green scabs. In ozena the origin of which, aside from association with syphilis and tuberculosis, is unknown the atrophied mucosa presents a decidedly thickened epithelial layer (pavement instead of ciliated epithelium), the desquamated cells of which undergoing putrefaction impart to the nose the characteristic < \- tremely foul odor. Treatment. When possible remove the causal condi- tion. Nasal douches ; introduction of boric acid and zinc ointment tampons. In ozena, regular and conscien- tious spraying with katharol and, finally, employ the yeast-cure. ACUTE LARYNGITIS AND PSEUDOCROUP Catarrhal inflammation of the laryngeal mucous mem- brane arises from the same causes as acute rhinitis (ex- posure to cold, specific or non-specific infection), but frequently occurs only as a sequel to a catarrhal condition of the nasopharyngeal space. Symptoms. The disease begins with manifestations of catarrhal irritation of the nose, conjunctiva, and with a tickling, burning sensation in the throat and a great in- crease in temperature. A short, dry cough and slight hoarseness soon set in. Laryngoscopic exam i nation shows the mucous membrane of the larynx and adjacent trachea to be reddened and swollen. In severe cases the HI!>- ACUTE LARYNGITIS AND PSEUDOCROUP 319 mucosa of the upper portion of the larynx may also be involved (genuine croup of measles), likewise the sub- chorda 1 region (pseudocroup). Narrowing of the lumen of the larynx and the collection of secretion causes sten- otic disturbances. The latter occur in poeudocrovp in attacks and only during sleep. The child, which for- merly showed only mild catarrhal symptoms, awakens suddenly during the night with a high fever, a barking cough, and hoarseness (which is never so severe as to result in aphonia), and presents all of the signs of as- phyxiation, which for several minutes appear to threaten life. The attack, however, soon passes over and the child rapidly recovers ; the attack may repeat itself during the same night or during the following night. Only rarely does death follow asphyxiation during an attack. The explanation of the rapid and frequent development of threatening laryngcal stenosis in children is found in the peculiar anatomic construction of the child's larynx. The latter is of a very delicate and yielding structure, not only absolutely but also relatively smaller than in the adult, especially in the sagittal diameter. The glottis is short, the interarytenoid space is especially small, and is furthermore lined with a mucous membrane rich in blood- vessels and glands, the swelling of which may easily cause closure of the respiratory glottis. Such a swelling, because of the sensitiveness to irritation of the infantile laryngeal mucosa, occurs very frequently. It may be assumed, especially in pseudocroup, that the collection of the large quantities of tough secretion during sleep excites a reflex glottic spasm with the sudden development of stenosis, The differential diagnosis offers difficulty not only dur- ing the interval, but also in an attack (see the following subject), particularly because in highly excitable ehihlivu it is usually impossible to make a laryngoscopic examina- tion. Such an examination tends only to increase the stenosis. Inspection of the pharynx offers the same picture in pseudocroup as in laryngcal diphtheria (without 320 RESPIRATORY DISEASES Flo. 109. Multiple papillorua of the larynx. Girl two and a half years old. Since the first year of life increasing hoarseness, othei un- healthy. Treatment for the suspected laryngitis was inelTectual. At the beginning of the second year adenotomy was performed, but without influence upon the condition. In a short time the hoarseness inci<;i-cd to complete aphonia. Attacks of asphyxiation occurred at times. Lar- yngoscopic examination was frustrated by the patient's restlessness and by the rapid development of stenosis which the operation excited. In- tubation was then performed. The tube was easily .introduced, but was soon coughed out. This was followed by considerable relief, the cyanosis disappeared, and a certain amount of phonation was possible. The child recovered and treatment ceased. Four weeks later death occurred suddenly at night in an attack of suffocation. Necropsy : The superior portion of the larynx was rilled with a white papillomatous mass. A narrow central canal, which could have been occluded by a floating por- tion of a growth which was attached to the median portion of the larynx. pharyngeal deposits), namely, redjiess and swelling of the mucous membrane and thickening of the ulcerated epiglot- tis. We are, therefore, dependent upon the history in making this distinction which is of so much importance therapeutically. In favor of diphtheria are gradually but steadily developing catarrhal symptoms and stenosis, together with increase of hoarseness, until complete aphonia sets in. The patient recovers only partially after the attack, continues to be dyspneic, and its restless sleep is repeatedly disturbed by fresh attacks of a-phyxia- tion. In favor of pseudoeroup are the sudden and unex- pected development of severe symptoms, a clearer tone to the cough, and the absence of aphonia. After the attack the patient usually falls asleep and only the symptoms of a severe laryngotracheai catarrh persist. Treatment. In simple laryngitis, rest in bed, Priess- nitz's compresses, and hot drinks to stimulate sweating. For phlegmonous swelling, mustard and water and hot pack to encourage perspiration. During the attack of pseudoeroup give hot drinks, apply a hot sponge to the neck, administer an emetic, and in case of a high-grade stenosis, resort to intubation. [During an attack of acute laryngitis, sedatives, such as sodium bromid or camphor- ated tincture of opium, are of great service in quieting the child, diminishing the paroxysms of cough, and lessening the local congestion. ED.] FK;. Kid. 38] 322 RESPIRATORY DISEASES PAPILLOMA OF THE LARYNX Papilloma represents the commonest tumor of the larynx in childhood (von Rauchfuss). It may be congen- ital or follow continued inflammatory affections of the larynx. According to its location, size, and number it may gradually produce a stenosis or a valve-like closure of the larynx. Permanent hoarseness arises unaccom- panied by fever. The prognosis is, as a rule, unfavorable. As a therapeutic measure resort may be had to intubation with a heavy metallic tube (or curetment with O'Dwyer's fenestrated tube). A laryngotomy may be performed, the growth excised, and a tracheotomy tube inserted. FOREIGN BODIES IN THE AIR-PASSAGES The entrance of a foreign body into the air-passages of children is a very frequent and nearly always fatal occurrence. It may be aspirated by way of the mouth through an involuntary violent inspiration in laughing, coughing, and fright. The body then causes a mechan- ical obstruction to breathing, either on account of its size or on account of its sharp edges ; a stenosis indirectly, by piercing the mucous membrane and exciting a laryngeal edema. If the body enters a bronchial tube and cannot be removed by means of the bronchoscope, it leads to consecutive complications like bronchitis, pneumonia, atelectasis, abscess, gangrene, and, finally, death. Diagnosis. Of diagnostic significance is the sudden de- velopment of choking and dyspnea in a child previously healthy. In the course of time frequently repeated at- tacks of pneumonia occur at the same site, and soon symptoms arise of cavity formation, empyema, and pneu- mothorax. Characteristic is the rapid change of the phenomena (Fronz, Hecker). Secure a skiagram of the larynx and bronchus. The treatment is operative. After removal of the for- eign body the most serious pulmonary processes, even gangrene, undergo resolution and recovery. STRUMA (see page 138). NERVOUS OR BRONCHIAL ASTHMA 323 HYPERPLASIA OF THE THYMUS GLAND Extraordinary increase in .size of the thymus gland, especially in case of true tumors of that organ (leukemia and lymphosarcoma), may lead to chronic stenosis of the trachea or bronchus (stridor thymicus, Hochsinger). Fur- thermore, hyperplasia of the thymus tends to cause laryngospasm, and is an important concomitant symptom of the constitutional anomaly called " status lymphaticus " (Paltauf, Escherich), which may lead to sudden death. Percussion reveals at both sides of the manubrium especially to the left an increased amount of dulness, which passes downward into the cardiac dulness. The diagnosis is verified by skiagraphy. The treatment consists in trying organotherapy (tablets of thymus-gland substance) or displacement of the gland by operation. NERVOUS OR BRONCHIAL ASTHMA A pure essential bronchial asthma, which is a reflex neurosis accompanied by spasmodic attacks of dyspnea (spastic contracture of the bronchial musculature), occurs with the well-known symptoms in children of all ages. Hereditary influence plays an important role. It is fre- quently also caused by nasopharyngeal disease (Bagin sky), especially adenoid growths (nasal asthma, the usual ex- citing cause is an acute catarrh) or indigestion (dys- peptic asthma). During the first two years of life asthma (cardiac) is frequently at first superimposed upon a congenital defect of the heart. Eczetnatoofl patients are not rarely subject in later life to asthma (Feer). Treatment. As prophylaxis avoid exposure to cold and judicious hardening of the body. Change of scene; so- journ at the sea or at mountain resorts of moderate height. Operative procedures for nasal asthma ; emetics for dyspeptic asthma. During and after the attack give every two hours a ooffeespooniul or a child's spoonful of 324 RESPIHATOllY DISEASES sodium bicarbonate or potassium iodid, of each 2.0 gm. to 100.0 cc. (Neumann). Hot pack to stimulate sweat- ing. Vapor inhalations ; emetics. During the intervals give arsenic. ACUTE TRACHEITIS AND BRONCHITIS Acute tracheitis and bronchitis arise from the same causes as acute laryngitis, and frequently at the termina- tion of a catarrhal disease of the upper air-passages. Morbid Anatomy. The mucous membrane of the tra- chea and the large bronchial tubes is reddened, swollen, relaxed, and after long duration of the disease becomes pale gray and atrophied. The secretion covering the mucous membrane is generally tenacious, glossv, and contains air-bubbles, but at a later stage it becomes thicker, mucopurulent, yellow, or greenish yellow. Symptoms. The disease begins with a dry, painful, and spasmodic cough, increased respiration rate, fever, loss of spirit and appetite. Young children usually swallow the excretion ; the expectoration of older chil- dren shows the above-described characteristics. Palpa- tion reveals rales over the whole thorax. Percussion is negative. On auscultation at the beginning, when the mucous membrane is simply swollen, we near dry rale>, but as the serous secretion increases, moist large and small vesicular rales are heard. The intensity of the tone of the rales depends upon the distance between tin- disease focus and the body surface. The respiratory murmur is vesicular, accentuated, and sometime- inter- rupted by the noise of the rales. In catarrh of the bronchi, both lungs, especially the lower lobes, are in- volved. After several days' duration the fever falls by lysis, all symptoms lessen in severity, and the cough be- comes looser and disappears gradually in one or two weeks. In weak children living in an unhealthy atmo- sphere and in neglect of the acute symptoms the a fleet ion becomes chronic and lays the foundation for tuberculosis of the bronchial nodes. The prognosis is, therefore, ACUTE TRACHEITIS AND BRONCHITIS 325 dubious under the conditions mentioned. (For differen- tiation from Pertussis, see that disease.) Treatment. Attempt to abort the disease during the development by hot packs or baths, in order to increase perspiration. Provide fresh air, keep the body warm, and rest in bed in case of fever. Priessnitz's compres-. - ; hot drinks to excite expectoration and perspiration. Moisten the inhaled air by means of an inhaler or croup FIG. 110. Vapor apparatus for moistening the air to be inhaled in diseases of the respiratory tract. The kettle is filled with 1 liter [I qt.] Of boiling water. Camomile and other preparations arc placed in the upper portion of the apparatus. The current of steam which travels for about 1} meters [4 ft.] is directed against .the face of the patient. T<> obtain a inure pronounced action (especially in croup or pseudocroup) a primitive steam room may be arranged by spreading linen sheets over the bed. kettles. Internally give a coffeespoonful of the infusion of ipecacuanha, 0.3 gm. to 120.0-150.0 cc., every two hours. To this may be added the extract of belladonna, eoilein, or aqua amygdala 1 amarae, in order to lesson the irritation of the cough, and liquor amm. anis. or (according to Fischl) potassium iodid, 0.3 to 1.5 gm., to stimulate expectoration. In very young children administer a child's spoonful, every two hours, of syrup of ipecacuanha with syrup of senega or althea. 326 RESPIRATORY DISEASES CHRONIC BRONCHITIS In chronic bronchitis the persistent cough is looser and of a catarrhal character ; the secretion is sometimes more profuse, more frequently, however, it is less in quantity, while the sputum is grayish yellow and appears in lumps. On palpation mucous rales are felt, and on auscultation vesicular breathing and coarse rales are heard. The res- piration rate is not increased. The affection, provided it is not of a tuberculous nature, is not accompanied by fever or marked disturbances of the general health, although in some cases asthmatic symptoms arise. (With reference to the development of Bronchiectasis, see that condition.) Treatment. Provide as hygienic a life as possible. So- journ at the sea or in the mountains. A non-irritating and, preferably, vegetable diet. If the secretion is pro- fuse, inhale oil of turpentine; if it is scanty, inhale silt water. Internally give potassium iodid and alkaline and muriatic waters. CAPILLARY BRONCHITIS If the inflammatory process spreads from the large and moderate-sized bronchial tubes to the smaller and minute bronchi, we have a capillary bronchitis, the most danger- ous disease of the respiratory passages. When this region is once involved, the process extends rapidly to a large section of the bronchial tree. Morbid Anatomy. The mucous membrane of the bron- chial tubes even in the smallest branches is intensely red, swollen, and covered with a tenacious, glossy, and (later) mucopurulent secretion. The bronchioles are in some areas completely obstructed by the swelling and secretion, and not rarely the associated alveolar portion collapses after the absorption of the air and becomes ;ite- lectatic. The atelectatic lobules are bluish red, relaxed, hyperemic, and diminished in volume. On section, slight pressure will cause a large amount of pus to ooze from the medium- and smallest-sized bronchial tubules. CAPILLARY BRONCHITIS. 327 The disease picture is a very severe one. The inflam- matory swelling of the mucous membrane tends to cause a dangerous stenosis in the infantile bronchi, for the nar- row bronchial lumen easily becomes obstructed by the tenacious secretion. The direct result is defective aera- tion of the lungs, that is, insufficient entrance of oxygen and discharge of carbon dioxid. The indirect results are an increased activity and a decrease of the heart's ability to work. Symptoms. Clinically these changes make a distinct impression. When very extensive they begin with high fever, dyspnea, and cyanosis. The respiration is super- ficial, irregular, and rapid; in the case of nursing infants it is increased to 60 and 100 per minute. On inspiration the ribs are retracted. The ala3 nasi move with the res- piration. The expiration is prolonged, accentuated, and sighing. The cough is frequent, short, painful, and therefore suppressed as much as possible. Great rest- lessness and symptoms of indigestion. The skin is pale and the mucous membrane slightly cyanosed. The pulse is small and has a rate of 120 to 180. The temperature averages between 39 and 39.5 C. [102.2 and 102.7 F.l, it is irregular, remittent, and frequently increases with extension of the process. Examination of the lungs gives the same results in capillary bronchitis as in acute bronchitis, only we find in several areas, especially at the bases posteriorly, fine vesicular rales which frequently drown the puerile vesicular breathing, and are only dis- tinguished from the crepitant rales of pneumonia by the fact that they are also audible on expiration. The res- piratory murmur is often completely absent over por- tions of the lungs where the bronchi are obstructed. With gradual disappearance of all symptoms the patient may completely recover in the course of a week. It fre- quently causes death (especially in rachitic children) or it may lead to atelectasis and pneumonia. The prognosis is always doubtful, especially in weak and rachitic children or in those predisposed to tubercu- losis. It is unfavorable when the process extends sud- 328 RESPIRATORY DISEASES denly to the whole bronchial tree. In many instances the inflammation involves the pulmonary tissue also. Diagnosis. The passing of a bronchitis into the capil- lary type is marked by the sudden development of high fever, increased irritation of the cough; shortened respi- rations, and a sighing expiration. After the preliminary symptoms only a few febrile catarrhal manifestations exist. Capillary bronchitis is distinguished from pneumonia by the absence of bronchial breathing, bronehophony, and dulness. The differentiation may, however, be impossible when the pneumonia is not extensive and it is impossible to determine the presence of pneumonic consolidation by physical signs. The treatment is that of bronchopneumonia. BRONCHOPNEUMONIA (Lobular Pneumonia. The Pneumonia of Children) If the inflammatory process spreads to the pulmonary tissue the alveoli become filled with inflammatory prod- ucts (serous or serofibrinous exudate, pus-corpuscles, and desquamated alveolar epithelium). The involved portion of the lungs is thus congested and unable to perform its function, and we have the condition known as broncho- pneumonia. The inflammation travels longitudinally along the bronchial tubes to the alveoli or it penetrates the bronchial wall and attacks the peribronchial tissue. In both cases we note circumscribed, either lobular or peribronchial foci, which coalesce and, enlarging, finally involve a whole lobe, the so-called " pseudolobar form." This type of pulmonary disease is characterized by the fact that it originates in a disease of the bronchial tree. The direct cause of the condition may be of a specific or non-specific nature. To the first class belong the micro- organisms of measles, whooping-cough, diphtheria, and influenza, and to the second class the various pneumo- coccic bacteria (bacillus of Friedlander, Frankel-Weich- selbaum diplococcus) and pus cocci. Occasionally the pneumonia follows the aspiration of particles of food or BRONCHOPNEUMONIA 329 mucus by children when in a stuporous stale or when a tracheotomy has been performed foreign-body or aspira- tion pni'ii/noititf. Morbid Anatolny. The diseased lung tissue is already recognizable macroscopically by its increased volume, dark discoloration, and its hard, nodular consistency. The pleura in the region of the disease process is at times covered with a thin fibrinous deposit and isolated hemor- rhages. Section shows a varied picture ; side by side are seen pale normal air-containing lung tissue and brownish-red, prominent, airless, and dense inflammatory foci of varying size, the centers of which are sometimes faded ; aside from which we always note bluish-red, soft, airless, and somewhat retracted atelectatic areas. The inflamed foci show a smooth surface which when con- siderable fibrin exists is granulated. Pus can be squeezed out of the inflamed bronchi and a turbid yellow- ish fluid from the diseased portions of the lungs. The air-content is decidedly diminished. In peribronchitis the bronchial wall is thickened. The pulmonary cortex is frequently emphysematous and atelectatic. Prolonga- tion of the disease leads to cylindric ectasia of the small- est bronchi, hyperplasia of the bronchial nodes, fatty degeneration of the heart muscle, and dilatation of the right heart. Microscopically we find round-cell infil- tration and pronounced congestion of the alveolar borders, and, later, of the peribronchial tissue also. The alveoli are filled with a mass of cells which have undergone partial fatty degeneration and an inflammatory extidate, which sometimes contains but a small amount of fibrin and at other times a large quantity. This peculiarity of the bronchopneumonic exudate, which is only rarely of a purely eatarrhal nature, is characteristic of the pneumonia of children, and is also noticeable in the clinical course of the disease. Noteworthy is the frequent occurrence of giant cells in the pneumonic infiltrated alveoli in diphtheria and measles. (Concerning characteristic changes in the Pneumonia of Whooping-cough, see that disease.) 330 RESPIRATORY DISEASES PLATE 34 FIG. 1. Confluent Bronchopneumonia in a Child Two Years Old. The inflammation has existed for several weeks. Enlarged 52 times. The microscopic picture of a fully consolidated pulmonary lobe offers a uniform appearance. The alveoli are filled with an exudate which con- sists of fibrin (retracted on account of the hardening process), degenerated alveolar epithelium which stains with difficulty, and a few leukocytes, while in some areas only pus-corpuscles are present. 1. Exudate com- posed of fibrin, degenerated epithelium, and a few leukocytes. 2. Puru- lent exudate. 3. Alveolar borders showing round-cell infiltration. FIG. 2. Bronchitis and Beginning Bronchopneumonia in a Child One Year Old. Died of enteritis. Enlarged 52 times. The picture shows the extension of the bronchopneumonia from a bronchitis. The inflam- matory process, which was primarily confined to the bronchial mucous membrane, has penetrated the whole bronchial wall and caused infiltra- tion of the peribronchial tissue. The manner in which two peribronchitic foci have become confluent may be seen. The freshly infiltrated tissue is hyperemic. 1. Lumen of a bronchus. 2. Desquamated bronchial epi- thelium. 3. Catarrhal bronchitic exudate. 4. Bronchitic exudate with a large amount of exfoliated bronchial epithelium. 5. Beginning broncho- pneumonic exudate. 6. Confluent infiltrate. 7. Dilated blood-vessels. 8. Normal lung tissue. Symptoms. Bronchopneumonia can often be distin- guished clinically from capillary bronchitis only by the changes in percussion. As soon as the congested foci have, through confluence, reached a certain extent, pro- vided they are not too deeply seated, they may most frequently be demonstrated by percussion in the region of the axilla and parallel to the spine. Auscultation dis- closes, aside from loud catarrhal and at times bronchial murmurs, fine vesicular rales, and, if the afferent bron- chial tubes are not obstructed, bronchial breathing and bronchophony. Vocal fremitus is increased when the process is extensive. The course of the disease and the general and local symptoms vary from case to case, ac- cording to the extent of the anatomic process and the character of the exudate. When large pneumonic areas become confluent and a cellular and fibrinous exudate occurs, the symptoms resemble those of fibrinous and croupous pneumonia, so that it is impossible to distinguish between these two forms. On account of frequent relapses the intensity of the symptoms may also vary consider- ably in individual cases. The disease frequently runs a course of many weeks, ; j i ., jo V V I . ;: ".4^i-" - - * K-* BRONCHO PNEUMONIA 331 although in favorable cases it may end in one or two. Resolution sets in, with the gradual disappearance of the dulness, fall of the fever by lysis, and improvement of all remaining symptoms and the general condition. Death may follow from weakness or from carbonic-acid-poison- ing. Lobular pneumonia passes into the chronic form, not rarely by caseation of the alveolar contents or inflam- mation of the interstitial tissue. It is quite often pri- marily of a tuberculous character or it terminates in a miliary tuberculosis. Frequent complications are pleu- risy, gastritis, and otitis media. Diagnosis. The lack of physical signs of changes in the pulmonary parenchyma at the beginning and the prev- alence of some causal disease frequently leads to a mistaken diagnosis. In favor of bronchopneumonia are : Sudden and marked rise in temperature during the course of a bronchitis or the persistence of a high fever beyond the usual febrile period of a causal disease (measles). Lessening and painfulness of a formerly vigorous cough. Difficult and rapid breathing. Activity of the accsssory muscles of respiration. Movement of the alae nasi in breathing. Physical signs of pulmonary consolidation. Occurrence on both sides. In favorable cases resolu- tion is gradual, the fever falls by lysis, without regard to critical days and slow convalescence. In atelectasis the percussion-note is not so dull and is usually accompanied by a tympanitic note. Bronchial breathing and bronchophony are absent, only suberepi- tant inspiratory r&les are audible, which disappear with deep respiration. In croupous pneumonia the disease is a primary condition which begins on one side; the catarrhal rales are absent, the consolidation involves pirt of a lobe, the fever is higher and ends nearly always by crisis. In pleurisy the dulness is more resistant, of a characteristic form and extent. The vocal fremitus is lessened. The anamnesis gives valuable information in caseating tuberculous pneumonia. The loss of strength 332 RESPIRATORY DISEASES is disproportionately rapid. The course is suspiciously long. Symptoms of cavity formation and the develop- ment of tuberculous affections in other organs frequently arise. The prognosis in weak, rachitic, or scrofulous children is always doubtful. The disease is far more dangerous than croupous pneumonia and is more fre- quently followed by permanent changes in the respiratory tract. Treatment. Treat the original causal disease. Observ- ance of general dietetic and hygienic principles as in acute bronchitis. Frequent change of position in the bed to avoid hypostasis (infants should be carried about at inter- vals). At the beginning of the disease relieve the bronchi by an emetic. Give for this purpose powdered ipecac, 0.5 to 2.5 gm., with syrup of althea, 40.0 cc., of which a coffeespoonful is given every ten minutes until effect is produced. Later, for thermic stimulation of the nerves, to combat the fever, to deepen the respiration, and to ex- cite expectoration, resort to hydropathic measures : Baths at a temperature of 25 to -35 C. [77-95 F.], varying with the fever and the patient's strength, followed by short cold douches. (If influenza, pertussis, or rachitis are simultaneously present, the body heat must not !><> lowered too vigorously.) In case of subnormal tempera- ture or difficult breathing on account of carbonic-ox id in- toxication, subject the occiput and neck to a stream of water as cold as possible. As many as ten streams fol- lowing each other maybe applied, at intervals of -from ten to twenty seconds, and each stream should meas- ure about 1 cm. [.4 in.J in diameter (Jiirgensen). In place of baths employ cold and moist packing, leaving the head, arms, and legs exposed ; to increase the radia- tion of heat renew the pack every ten minutes. If the condition becomes worse and the surface of the body cold, use mustard pack. The internal medication consists of enemata of quinin (0.3 gm. to 20.0 cc.) ; infu- sion of ipecac, 0.3 gm. to 100.0 cc. ; together with liquor ammonii anisatus, 1 to 1.5 gm., or, as stimulants, tritu- rates of camphor and benzoic acid, of each 0.015 gm., CBOUPOUS J'.\i-:i'M.\/.( 333 every one or two hours. For delayed resolution admin- ister a child's spoonful of potassium iodid (2 to 3 gin. to 100 ce.) every two hours j oxygen for dyspnea. Cham- pagne, euuiphor, or injection of ether for threatening heart failure. Venesection for threatening asphyxiation. CROUPOUS PNEUMONIA (Fibrinous Pneumonia; Lobar Pneumonia) Aside from bronchopnenmonia with its atypic exu- date we also find fairly frequent in children, especially during the first five years, cronpous pneumonia, which begins with a high fever, runs an acute course, and is ac- companied by a purely fibrinous and slightly cellular exudate. The micro-organisms mentioned in the last disease are the etiologic factors. The irritation caused by these bacteria involves directly and at one time a large surface of the alveolar epithelium, so that, unlike bnm- chopncumonia, instead of the small inflammatory foci which gradually spread, a large area, usually a whole lobe, is involved at once. The disease is more prevalent in cold and wet weather, and is brought on by those fac- tors which lessen the resisting forces of the organism, as circulatory disturbances. Croupous pneumonia of chil- dren presents no special etiologic, anatomic, or clinical differences from the same disease in adults. The pre- viously described micro-organisms are present; anatom- ically the stages of inflammatory engorgement exist, that is, hepati/ation and purulent infiltration, also a locali/cd fibrinous pleurisy. The clinical symptoms consist of a sudden onset, with vomiting, chilly sensations, rarely convulsions ; a high, continuous fever, dyspnea with pain in the side, cough, and a rust-colored sputum. Percus- sion reveals slight diilncss. A tympanitic sound is elic- ited on deeper percussion over a whole lobe or a large portion of it. On auscultation crepitant rales, exagger- ated or weakened, and indefinite breathing are heard. Later there is pronounced dnlncss, bronchial breathing, bronchophony, and increased vocal fremitus. In favor- 334 RESPIRATORY DISEASES able cases resolution is accompanied by disappearance of the symptoms in the same order as in their development. The fever disappears by crisis rarely by lysis on the fifth to the ninth day (exceptionally earlier or later), usually with continued severe perspiration. Character- istic of croupous pneumonia in childhood is the beginning in young children with vomiting, convulsions, and a slight chilliness, instead of the marked chills of adults ; also a pulse and respiration rate corresponding to the height of the fever, the development of symptoms of cerebral irritation, and a more rapid convalescence than in adults. When lobar pneumonia occurs at the close of an acute infection, absence of reaction on the part of the organism interferes with the typic course, and the exu- date fails to undergo the usual resolution. This type is more likely to be protracted and terminates frequently in death or in caseation or connective-tissue new growth (Ziemssen). The primary form of pneumonia in young children may also offer diagnostic difficulties. The sub- jective symptoms are absent, usually the characteristic sputum also, and, as mentioned above, the initial chill. Cough, shortness of breath, and pain in the side are fre- quently pronounced. The diagnosis is especially difficult when the pneumonia is of central origin. For example, in pneumonia of the upper lobes, in which case the phys- ical signs usually do not develop until the fourth or fifth day, and the presence of cerebral manifestations may lead to suspicion of a cerebral or meningeal affection. The following facts are of assistance in making the diagnosis of croupous pneumonia: Leukocytosis, acetonuria,diace- turia, herpes labialis (less common in children than in adults), and disappearance of the patellar tendon reflex (not until after the third year of life Pfaundler). Differential Diagnosis. In capillary bronchitis, atelec- tasis, and bronchopneumonia the child is pale and cyanotic, whereas in croupous pneumonia the initial stage is accom- panied by marked redness of the cheeks. In the first disease the pulse is small and soft, but in croupous pneu- monia, full and hard. Bronchopneumonia progresses CHRONIC PSKrUDSlA 335 with the gradual development of catarrhal symptoms, the ureas of d ulness are smaller, and the temperature is nor- mal or of a moderate height. (For the characteristics of Caseous Pneumonia, see that disease.) The dyspnea is less, the temperature rarely rises as high as incroupous pneumonia, and shows an irregular morning rise, or the ti/pltns inversus. Croupous pneumonia accompanied by cerebral symptoms is distinguished from meningitis by the mildness and lack of constancy of the nervous manifestations, the regular and rapid pulse, the simulta- neous development of symptoms of a pulmonary disease, and, finally, the loss of patellar reflex (which is increased in meningitis). The temperature of meningitis does not show the influence of critical days. Prognosis. Croupous pneumonia, as a rule, runs a favor- able course in children previously healthy and strong and who have been brought up under favorable conditions of life. Death may follow pulmonary edema when the in- flammation is very extensive, or a complicating pleurisy, pericarditis, or meningitis (otitis, nephritis). Tubercu- lous infection of the exudate in weak scrofulous individ- uals may also cause death. Treatment. General hygienic and dietetic measures as .in bronchitis and bronchopneumonia. Of especial im- portance is a strengthening liquid diet. Cleanliness of the mouth. Regular bowel movements. Cold pack ; baths, with cool douches and subsequent vigorous rubbing (omit all hydrotherapeutic procedures at the time of crisis). In case of heart failure and somnolence give camphor, ether, or champagne. For extreme dyspnea, in- halations of oxygen. Employ the ice-bag for severe nervous phenomena. In ease of delayed resolution, nmist warm pack and iodin preparations. CHRONIC PNEUMONIA (Bronckieetasi* i The passing of a pneumonia into the chronic stage (bronchieetasis) occurs more frequently in catarrhal than in croupous pneumonia. It is marked by inspissation of 336 RESPIRATORY DISEASES the alveolar contents and proliferation of the interstitial connective tissue with consecutive contraction of the parenchyma. The child is anemic, emaciated, and sal- low; every exertion is accompanied by shortness of breath and cough is constant. A remittent or intermittent fever with afebrile intervals exists ; also dyspepsia and profuse sweats. Locdl/y : Dulness, indefinite or bronchial breath- ing and rales ; mucopurulent expectoration. The affected side of the thorax is contracted when the lung shrinks. Bronchiectasis may not only follow pulmonary contrac- tion, but may also be due to continued increased inspira- tory or expiratory pressure. The latter occurs when the inflammatory process in chronic purulent bronchitis pene- trates the bronchial. wall and, involving the surrounding tissue, causes the bronchial wall to become gradually thin, soft, yielding, and its elasticity damaged. This is especially likely to develop in the course of the pneu- monia developing in diphtheria, whooping-cough, and measles. A severe, troublesome, and spasmodic cough, which arises chiefly in the morning and evening, brings up a thin, purulent, greenish expectoration which has a foul odor ; this discharge not rarely gushes forth from the nose and mouth and forms layers in the vessel in which it is collected. Characteristic of this condition are the changes in percussion and auscultation as the cavity-like dilated bronchus becomes filled. The symp- toms of a cavity are presented when a large expansion of the bronchus occurs superficially. A cure is impos- sible in indurated interstitial pneumonia and bronchieo- tasis. The resorption of an inspissated cxudale may, however, occur after a period of weeks, provided case- ation or tuberculosis do not develop. The treatment of this chronic disease of the lungs must preferably be hygienic and dietetic. Breathe air which is free from dust ; sojourn at the sea, mountains, or winter resorts. Woolen underclothing. A strengthen- ing diet which is rich in fats. Cod-liver oil. Tepid baths. Priessnitz's compresses. Turpentine inhalations for bronchiectasis. PLEURISY 337 PLEURISY Pleurisy occurs quite frequently in children, especially at the middle period of childhood", and, as a rule, second- ary to or as an associated manifestation of disease else- where in the lungs or to a constitutional condition. In exceptional cases pleurisy is primary in origin, due to cold or trauma. Pleurisy develops as in adults in the dry, fibrinous, or exudative form ; the latter type is des- ignated according to the character of the exudate. Serous or serofibrinous pleurisy is accompanied by the excretion of a clear, yellowish fluid, which is poor in cellular elements and chiefly composed of serum contain- ing more or less fibrin. Purulent pleurisy, or empyema, is associated with an abundant cellular purulent exudate, which may become decomposed by the entrance of putrefactive bacteria and give forth a fetid odor (ichorous empyema). Hemorrhagic pleurisy is characterized by a serous fluid which is colored reddish or brownish red by the admix- ture of red blood-cells. The development of a pleurisy is due, on the one hand, to the entrance of large masses of pathogenic bacteria or their virus, and on the other, to alterations in the pleura through disease processes of neighboring organs, trauma, exposure to cold, diseases of tin blood, and disturbances of circulation. The entrance of bacteria or their toxins follows either from the blood or lymph-vessels or directly from the diseased neighbor- ing organs. In the first case the pleurisy is an expression of a constitutional infection ; in the second, it is usually the result of pulmonary diseases. Pleurisy is alain-<-x play the most important role. Breast-fed children may also suffer from this con- dition when they receive too much food, or when the 356 GASTRO-1NTESTINA L DISEASES FIG. 116. Hirschsprung's disease before treatment. (Clinic of Escherich.) For description, see p. 358. ETIOLOGY 357 FIG. 117. Ilirschspriziifj's disease six months after treatment. (Clinic of Escherich.) For description, see p. 358. 358 G ASTRO-INTESTINAL DISEASES FIGS. 116, 117. Hirschsprung's disease. Boy three years and nine months old. Since birth suffered from constant intestinal catarrh, obsti- nate constipation, alternating with diarrhea and increasing abdominal distentioii. On examination the abdomen measured in circumference 77 cm. [30.8 in.] and the body length 87 cm. [34.8 hi.]. The diaphragm was situated abnormally high, the thorax short and noticeably enlarged at the base, abdominal walls abnormally distended and presenting dilated veins. Active peristaltic movements visible, extending toward the left side. Deficient abdominal pressure. Percussion : Distention of the ab- domen by intestines filled with air. Auscultation : Splashing and gurg- ling sounds. Palpation: Liver, spleen, and kidneys plainly palpable, abnormally movable, the spleen enlarged and hard. Examination of the rectum : Abnormal dilatation of the lower section of the large intestine, which has been con verted into a smooth-walled cavity measuring 20 cm. [8 in.] in diameter, whose anterior and upper walls are not palpable. Irrigation was followed by the discharge of foul-smelling flatus and par- tially liquid, partially clay -like, well-digested stools. Appetite good. Treatment : Regular irrigation with solution of thymol ; massage ; fara- dization; binder to the abdomen. The child died in six months fol- lowing surgical intervention. mother's milk has been injuriously influenced by gross errors of diet during the nursing period, or by the admix- ture of bacteria (staphylococci) from the ducts of the mammary glands (staphylococcus enteritis, Moro). Arti- ficially fed children are more frequently threatened with gastro-intestinal diseases, especially when they are given a diet unsuitable to their age, as, for example, overabun- dance of starchy foods before the end of the third month (insufficient diastasic ferment). The infantile digestive- functions may also be disturbed to a certain extent when fed with cows' milk, although the latter simulates in com- position the nutritive elements of woman's milk, yet it is poorer in easily digestible constituents; furthermore it cannot be drunk immediately at its source, for it must first receive special preparation, on account of which its digestibility is lessened and often becomes contaminated by bacteria. Owing to the ability of the digestive tract of normally developed infants to functionally respond even after a short time to these dietetic changes, a diet which is digested with difficulty may be assimilated pro- vided the amount of food ingested is not disproportionate to the digestive strength. Overfeeding which is unfor- tunately so common leads to exhaustion of the intestinal and glandular epithelium with gradually increasing fail- ETIOLOGY 359 ure of assimilation of the food, which, stagnating in the stomach and intestines, undergoes abnormal putrefactive changes (Biedert's "injurious food remnant"). The products of this process (fermentation of sugar-albumin- ous putrefaction) create local irritation and symptoms of general intoxication (Escherich, Heubner). Still another cause of disturbances of digestion is the ingestionof food which has undergone chemic or bacterial decay. The gross impurities of cows' milk or infection with a specific pathogenic germ (tubercle bacilli, etc.) are less common, as these dangers are nowadays generally avoided, since it has become the custom to examine and boil the milk. On the other hand, the lapse of time be- fore cows' milk can be administered tends to increase the action of lactic acid bacteria and other saprophytes. If the milk has been preserved in a low temperature it simply turns sour on account of fermentation and causes only local symptoms of intestinal irritation (Marfan, Escherich), whereas, if the milk has been preserved for a long time in a high temperature, as during the hot months, multiplication of those bacteria dependent upon heat will be noted, and the milk will receive certain toxic properties from their metabolic products which when in- gested will cause pronounced manifestations of intoxica- tion (cholera infanttim). A certain number of gastro-intestinal diseases are either directly or indirectly attributable to the influence of improper nursing. Indirectly they are due to impure and damp air, dark dwellings, lack of cleanliness and warmth, together with improper feeding, all of which rapidly ex- haust and overcome the inherited resisting forces and with them the ability of the intestines to perform their func- tions. Directly, inasmuch as unhygienic conditions of life favor the development of true intestinal disturbances. These infections are similar in the beginning and course to the specific intestinal infections, such as typhoid, dys- entery, and Asiatic cholera. They are caused by various forms of infectious germs (streptococci and bacilli similar to the colon bacillus), which enter the intestines by way 360 GASTRO-INTESTINAL DISEASES PLATE 37 FIG. 1. The Stool of Helena Neonatorum. Blackish-red coagulated mass of blood with slight admixture of tueconiuin. Dirty red areola. FIG. 2. Dyspeptic Stool of a Breast-fed Child. Remnants of milk, whitish-gray and green colored fat and soap remnants enclosed in yellow liquid masses of mucus. Dirty yellow areola. Odor and reaction strongly acid. (Drawn by Dr. Moro, Escherich's Clinic.) of the mouth or anus, through the air, by transmission from driukiug-cups, etc. Here inflammatory changes are affected under certain circumstances, metastasis occurs through the injured intestinal walls, and general infection results. Streptococcic enteritis, described by Escherich, may be mentioned as a type of intestinal infection depend- ent upon the nutrition ; a disease which tends to spread in hospitals and foundling asylums (Epstein, Rossi, Fin- kelstein, Escherich). Symptomatology. The manifold etiologic factors by no means indicate a similar variety of clinical symptoms, for, on the contrary, diseases of digestion in infants are usually accompanied by a comparatively uniform symptomatol- ogy. The preventive measures of the organism, consist- ing in vomiting, increase of peristalsis, watery and mu- cous stools, by means of which' the action of the injurious intestinal contents is shortened or at least weakened, vary but slightly and according to the character, intensity, and duration of the injurious influences and the resisting forces of the individual. Even grave organic changes of the intestinal canal manifest themselves by only a f'r\\ variable symptoms. It must not be forgotten also that the local changes observed at necropsy are frequently, in a certain sense, contrary to the severity of the symptoms during life and offer no satisfactory explanation for them (Heubner). Sharply defined disease pictures of intes- tinal conditions in childhood depend less upon the pecu- liarity of the symptoms than upon their characteristic grouping. DYSPEPSIA Dyspepsia is a result of injurious effects upon alimenta- tion or disturbances of digestion and absorption due to organic weakness. /\/7>/7.Y.i/. r. r/'. i /;/// 361 Dyspepsia following disturbances of fermentation (in bot- tle-fed children) : Regurgitation and vomiting of non- coagulated milk, even if the vomiting does not occur until a certain time after feeding. Constipation follows the collection of undigested masses; formation of gas (enteralgia). A S7,,,,/ X . p a ] e y e ll OW) shaped in small or large firm nodules, which contain remnants of food and have a stale or foul odor. Marked insufficiency of fat digestion ; fat diarrhea (Bie- dert) : Excretion of abnormal amounts of fat in the stools. A state of chronic diarrhea usually exists. Emaciation.. Stools. White, fatty, mucoid; containing abundance of soaps, fatty crystals, fat-drops, and fat-plaques. Acid-fermentation dyspepsia in breast- and bottle-fed infants ; acid eructations, vomiting, and a sour odor from the mouth. The stools, which are increased in number and contain large masses of undigested or decompo.-ed remnants of food, are passed with loud flatus and much restlessness on the part of the child. An abnormal amount of gas and acid formation takes place in the stomach and intestines with resulting distention of the abdomen, enteralgia, loss of appetite, and a standstill or loss of body weight. The course is afebrile. Sfaofx, At the beginning these possess a strong acid reaction and odor (butyric acid) ; at first they are yellow in color, then vary between milk white and green (or brown when amylaceous food is eaten). Yellowish-white flakes and remnants, consisting of fat, alkaline soaps, and epithelium, imbedded in bacterial masses are found mixed with mucus in gruel-like stools. Microscopic examina- tion discloses remnants of milk, fatty detritus, and single epithelial cells. INTESTINAL CATARRH Intestinal catarrh may be a sequel to dysjwpsia or a prelude to inflammatory processes. Symptoms. The intestinal mucous membrane is liyper- emic, swollen and relaxed, and a portion of the epithe- 362 6' ASTRO-INTESTINAL DISEASES PLATE 38 FIG. 1. The Stool of Intestinal Catarrh. Aside from tlie lumpy, thread-like, yellowish-brown masses of mucus, we also see isolated gray- ish-green dyspeptic flakes and shreds. The whole is surrounded by an extensive pale, dirty green, sharply outlined zone. Acid reaction. FIG. 2. The Stool of Infectious Colitis. lu the partly dark green, partly ochre colored, and partly colorless lumps of mucus are seen scat- tered hemorrhagic points and several large drops of blood as well as whitish (lakes of pus. Narrow, greenish areola. Foul odor. Alkaline reaction. Hum is destroyed ; it may excrete a watery fluid and mucus. The follicles are swollen and the mesenterio nodes are injected. Severe local symptoms are accom- panied by general toxic manifestations. These include vomiting, frequent and copious watery and mucous stools, decrease of urinary secretion, increased thirst, and active peristaltic movements in the abdomen, which is sensitive to pressure. The urine frequently contains albumin. A rapid decline, and at times clonic-tonic twitchings and toxic dyspnea are noted. Fever develops, especially when the stomach is markedly involved. Stools. These are passed in spurts, with much noise, and are at first similar to those of acid dyspepsia, yet contain a marked increase in water and mucus. Later they become less feculent and assume a more brownish appearance. The reaction is usually acid. Microscopic- ally they show an abundance of mucus, a large amount of intestinal epithelium, and a large number of acidophilic bacilli, which stain by Gram's method in contradistinction to the normal intestinal bacteria, which react negatively to Gram's stain. CHOLERA INFANTUM Cholera infantum is a very acute condition accompanied by the symptoms of severe collapse, vomiting, and diar- rhea, brought on by the ingestion of milk which has undergone eotogenio degeneration on account of preserva- tion in too high a temperature (Escherich). It occurs most frequently in the summer months, infants between five and seven months of age are most prone to develop 'I'.lb -. INTESTIXA L ISI'L . I .MM A TIONS 363 it, and that, too, of a severe type (Schlossmann). In the majority of cases death ocetirs in from OIK- 'to -i\ days in consequence of excessive loss of water and seven- intoxication (the heart weakens, acute course, cvaim-i- ; later, sclerema and hydrocephalus). A most unfavorable prognostic sign is the vomiting of coffee-ground masses (blood). Stools. Greenish-yellow, watery stools, throughout which are interspersed colorless flakes of mucus. In some cases they consist only of a colorless and odorless liquid. Alkaline reaction. INTESTINAL INFLAMMATIONS Intestinal inflammations are diseases of the intestines which follow catarrhal and dyspeptic processes, or they may be primary. Morbid Anatomy. Swelling, inflammation, and, finally, suppuration and ulceration. Swelling of the mesenterie and inguinal glands. The stools are considerably increased in -number and contain mucus, blood, and pus. If only isolated port ions of the intestines are involved, practically normal stools may be passed alternating with those of a pathologic na- ture. As a result of the excessive watery discharges per rectum, the secretion of urine is diminished and the thirst increased. If gastric catarrh or edema of the cere- bral meninges is also present, vomiting develops. Symp- toms of cerebral irritation are frequently present. The loss of body juices, loss of sleep, and spreading of the infection leads to a rapid decline. Complete care does not occur even in favorable cases until after several weeks. Sequelae. Thrush is favored by constitutional weak- ness; intertrigo is due to the irritation of the frequent stools and the concentrated urine; metastatico-septic proc- esses are also met with. Secondary infections include ecthyma, furunculosis, phlegmasia, pneumonia, otitis, cys- titis, nephritis, and pyelonephritis. 364 GASTRO-1NTESTINAL DISEASES PLATE 39 Prolapsus recti of a moderate degree, due to straining and pressing during evacuation' of the bowels. Secondary erythema of the nati-s. (Clinic of Escherich, Vienna.) Other forms of intestinal inflammation to be consid- ered are : Gastro-enteritis, which usually represents only an ex- acerbation of dyspeptic or catarrh a 1 disea-e, is especially likely to attack the small intestine. Not until a later stage is the large intestine involved. The copious stools are watery and discharged in spurts ; and contain at the beginning only remnants of food, but consist later of an odorless or foul-smelling green or gray- ish-yellow mucoid fluid, with which are mixed blood and pus. The reaction is usually alkaline. The abdomen is frequently distended and tense, but the umbilicus not ob- literated. Colitis, a primarily localized inflammation of the large intestine, is frequently an expression of a true intestinal infection which develops at times in limited epidemics (Widcrhofer's follicular enteritis). The discharges con- tain colon-like bacilli (Rossi, Finkelstein, Escherich, Celli), and more recently dysenteric bacilli of the Shiga- Kruse as well as of the Flexner type were found by American authors and Jehle (clinic of Escherich). Ac- cordingly this disease seems to bear a close etiologic rela- tionship to epidemic dysentery (" colitis dysentcriformis," Concetti). The disease always has an acute onset and is usually accompanied by a high irregidar and remittent fever. The general health is unfavorably influenced by colic, troublesome tenesmus, and sleeplessness, and the symp- toms of collapse set in rapidly. The abdomen i> ret meted and the thickened descending colon may be palpated as a Baasage-Bhaped tumor which is tender upon pressure. Prolapsus recti develops frequently, owing to straining and pressing during stools. The stool*, which are accompanied by tenesmus, con-i-t CHRONIC AFFECTIONS 365 exclusively of a little serous fluid and bile-stained gelati- nous or colorless frog-spawn-like mucus, which is inter- mingled with more or less pus and fresh red blood in traces or in large amounts. The number of stools is enormous, sometimes as many as forty or fifty are passed per day. The amount of each discharge at the beginning ~ is considerable, but rapidly lessens, so that finally only a small trace of mucus sprinkled with blood appears. The reaction is alkaline and the odor at the beginning is stale ; later, however, when putrefaction of the albumin-contain- ing intestinal secretion sets in, it becomes foul. CHRONIC AFFECTIONS Chronic affections frequently follow the foregoing con- ditions, but at times they are caused by the continued action of injurious factors (errors in diet and unhygienic dwellings). The mucous membrane of the intestines is frequently catarrhal, relaxed, and anemic throughout its whole extent, or it shows residue of a preceding inflam- mation. The follicles, Peyer's patches, and mesenteric glands are swollen. As an acute form of intestinal in- flammation passes into the chronic stage all of the violent symptoms disappear without recovery. Accompanied by intervals of exacerbation and temporary improvement the course may stretch over several months, with resulting marked emaciation and loss of strength. The prospects for recovery lessen with the duration of the disease. The stools are discharged at irregular intervals and vary considerably in quality and quantity. The abdomen is often distended as a result of fermentation and putre- factive processes in the intestine;-, vet it is nevertheless soft, and the umbilicus is not obliterated. The appetite varies and vomiting occurs occasionally. Development of thrush is a frequent occurrence. Fever arises only when complications set in. Furthermore, we note all the results of disturbed absorption and nourishment and the loss of body juices ; these include anemia, emaciation, and fatty degeneration of the organs a/rojiliia infantum. 366 GASTRO-ISTESTINAL DISEASES ATROPHIA INFANTUM (Pedatrophia) Atrophia infantum represents a general wasting disease which arises whenever, for any reason, the digestive, the absorptive, and the assimilative power become inefficient Pedatrophia may accordingly develop as a sequel to a previous acute gastric catarrh, or primarily in congenital weakness of the digestive function, or in improper feed- ing, in which cases the gastro-intestinal diseases are not the cause but the result of this condition (Escherich, Con- cetti). Since the digestive apparatus works at a great loss, the amount of absorbed and assimilated nutriment FIG. 118. Pedatrophia. Five-month's-old child which emaciated to a skeleton from gastro-intestinal disease (weight, 3350 gm.). Movements of defense were barely noticeable (spasmodic seizures of the extremities) ; the skin is of a dirty color, dry, sallow, andean be lifted in folds. 1'an- niculus adiposus almost completely disappeared. The face presents a wizened expression. The abdomen is retracted and soft. Thrush. Intertrigo of glutcal region. necessary to meet the requirements of nutrition are no longer satisfied. The organism receives sparse and insufficient compensation for the body material consumed; at any rate not the supply necessary for body growth. The body is finally compelled to attack the supply of energy daily necessary to life which is preserved in its fat deposits /. e., it gradually wastes away (Heubner). If this disturbance of metabolism continues for a long period of time the following series of symptoms arise in the order they are given, which may, however, vary : Emaciation, loss of vital activity of the organs, and therefore height- ATROPHIA INFANTUM 867 ened predisposition to secondary diseases of the skin, the mucous membranes, the lungs, the kidneys, and of the nervous system; gradual starvation and, finally, death. Stools. These depend upon the origin of the chronic affection, and in some cases hardly differ from the normal (so in primary atrophy), whereas in other cases are noted the characteristic dyspeptic, catarrhal, and enteritic stools which rapidly alternate with each other. During the final stage they are brownish, homogeneous, and soup-like* Prophylaxis of Gastro-intestinal Diseases. An attempt should be made to prevent the development of gastro- intestinal diseases whenever possible by providing the infant with natural nourishment, that is, the mother's breast milk, otherwise a proper substitute for it by means of fresh cows' milk, which is secured in clean stalls and prepared according to accepted scientific methods. Pro- tect the child from overfeeding or insufficient feeding, and observe the rule that the amount of food administered equals in the first quarter year one-sixth, in the second quarter, one-seventh, in the third quarter, one-eighth of the body weight. (See Nutrition, p. 42.) Weekly determi- nation of the body weight by means of scales is impor- tant. We should inform ourselves accurately as to every detail of nursing, ventilation, light, warmth, rest, :ml cleanliness (also as to the personality of the nurse). In- testinal infection and sepsis may be easily prevented in private practice by observation of the simplest hygienic principles. Wherever a large number of infants and younger children must live in a single room, as in chil- dren's hospitals or orphan asylums, the above-mentioned conditions are more likely to occur, and for their preven- tion far more energetic and expensive measures must be undertaken. A glance at Fig. 119 shows how in modern times it is possible, and with excellent results, to prevent infection by contact by means of the Heubner, Finkel- stein, Schlossmann, and other maternity hospitals. ^ The individual beds are isolated by glass walls (" box. >." par- tially open cells). The material necessary for the nurs- ing of each individual child is usually kept prepared in 368 G ASTRO-INTESTINAL DISEASES m ATROPHIA INFANTUM 369 the same enclosed room (individual drinking, washing, bathing, and night utensils, individual thermometers and other instrumentarium, and individual examination coat for the physician, etc.). The treatment of gastro-intestinal diseases is causal, and it is, therefore, necessary to remove the etiologic fac- tor. In the first place the protective functions of the body must be supported. The organism seeks in the va- rious dyspeptic, catarrhal, and inflammatory affections to discharge injurious ingesta from the stomach and intes- tines by means of vomiting, increased intestinal excretion, and by peristalsis. We assist nature in recent and acute cases by cleansing the stomach and colon and by means of lavage, 1 and the small intestine by the administration of castor oil (| coffees poon fill every two hours). Secondly, as nature requires reft for the diseased organ, anorexia sets in. Accordingly, therefore, depending upon the severity of the case, foocl is given only at intervals varying between six and forty-eight hours (in cholera in- fanturn intervals of several days); on the other hand, the increased demand for liquids should be satisfied after one- half- to two-hour pauses with smaller or larger amounts of weakly sweetened cold teas or alkaline mineral waters (Schlossmann). 1 Oastric Lfivage. The instrumentarium consists of a Ni'laton cath- eter (No. 18 to 20), a 50-cm. [20-in.] long rubber tube (both united by means of a glass tube), and a glass funnel having a capacity of 30 ccm. [1 fl. oz.]. The child lies with its hips raised upon its mother's lap, who rests her right foot upon a footstool and the left foot upon the floor. The physician introduces the Nelaton catheter by exerting light downward pressure upon the tongue, and passes it for 25 cm. [10 in.] into the esophagus (the alveolar border is 15 to 23cm. [f>-9.4 in.] distant from the cardia at the age of one year). After the gastric contents have been removed the stomach is washed clean with a .<> percent, sodium chlorid solution at a body temperature. Intesti)il L\ Instrumentarium the same as above, but in place of the Nelaton catheter an intestinal tube, 1 meter [32 in.J long, and in place of the funnel, a graduated irrigator, arc employed. The child lies. with its pelvis raided, on its side or on its abdomen. The lubricated in- testinal tube is introduced with a gentle pushing movement (<> such a height in high enemata that (lie fluid will again pass out beside the tube. The length of the large intestine during the first year of life is :.() to 100 cm [20-40 in.]. 24 370 G ASTRO-INTESTINAL DISEASES Thirdly, we must bear in mind, when normal feeding is again resorted to, that the functional activity of the di- gestive apparatus has become limited by the effects of the FIG. 120. Gastric lavage in infants. foregoing diseases and, therefore, only a very small amount of nourishment should be given at the beginning. Ac- cordingly, only minute quantities of food are given after ATROPHIA INFANT I'M 371 as long intervals of time as possible. During the inter- vals administer tea or mineral water to satisfy thirst. In the regulation of did we must next consider whether the affection concerned is associated with acid or alkaline fermentation (albuminous putrefaction). In the first case the diet is begun with egg-albumin-water, thin boiled rice, and rolled oats ; later, veal broth may be given. In the case of albuminous putrefaction (e.g., pu- trefaction of the intestinal secretions) give a carbohydrate diet (Soxhlet's nutritive sugar, infants' foods) or weak cream mixtures. After recovery sets in resort is again had to simple, fresh-milk nourishment. In cholera infantum the supply of liquid necessary for life is main- tained by subcutaneous infusion of normal salt solu- tion, 1 and when it is possible to again take liquids per os they must be administered at first in very minute quantities. It is of the greatest importance in pedatrophy to obtain a diet which requires the least amount of digestive energy, and which will be more easily assimilable than the pre- vious form of nourishment. Aside from women's milk, the looked-for results have been attained in mild cases by the use of buttermilk (Texeira de Mattos) or cream mix- tures. M~ey means of a curved infu-ion needle, a tube, and funnel, or it is injected by means ofa la r-c syringe. of the tumor caused by the injected lluid. 372 G ASTRO-INTESTINAL DISEASES Treatment of Constipation. If the constipation is a re- sult of muscular weakness the symptomatic use of sup- positories or enemata is recommended, also light abdom- inal massage to strengthen the musculature. In case the FIG. 121. Abdominal massage in infants. I Massage of the descend- ing colon. Rotary movements of the hand, with simultaneous move- ment of the abdominal walls; pressure being increased in a longitudinal direction over the colon. II. Manage of the ileocecal region. i Same a* I.) III. Massage of the small intestine. The band placed flat upon the abdomen in the region of the umbilicus performs movements by prona- tion and supination, and pressure is exerted upon the abdomen ut our time with the tips of the fingers and at another time with the ball of tlie hand. Finally, the center of the abdomen is tapped with piano-playing- like movements. IV. Stroking the colon throughout the whole constipation is due to dyspepsia good results can only be obtained from as thorough a change of diet as is possible. If it be due to spastic conditions small doses of opium frequently act very promptly. Rhagades of the anus re- ATROPHIA INFANTVM 373 quire applications with the silver stick. In enlarged colon (Hirschsprung's disease) complete cure may be ob- tained by means of methodic introduction of oil. Treatment of Prolapsus Recti. In Mild Cases. Adhe- sive straps placed like tiles over the nates, which are FIG. 122. Adhesive-plaster dressing for prolapsus recti. tightly pressed together. The plaster must extend over the perineum. In Revere Caw*. Fixation of the rectum by means of longitudinally directed injections of paraffin. Thi> is performed aoVordine to the method described by Spit/y (Children's Clinic at Graz) : Melted hard paraffin (melt- 374 GASTRO-INTESTINAL DISEASES ing-point 50 to 55 C. [122-131 F.J) is drawn into a sterilized and heated syringe, which is covered witli a rubber tube to prevent the rapid dissipation of heat, and supplied with a straight, not too narrow, hollow needle which measures 8 to 12 cm. [3.4-4.8 in.] in length. The needle is inserted between the coccyx and rectum ; the left index-finger is introduced into the rectum and guides the syringe as high up as possible. While the needle is slowly withdrawn about 5 ccm. of the paraffin arc in- jected. The injected material hardens rapidly and when cooled forms an irregular longitudinal ridge which per- manently prevents inversion of the rectum without caus- ing any constipation. When carefully performed one injection is sufficient. Ill results are not noticed. The effect is more certain in action and less formidable than the methods formerly practised. ATONY OF THE STOMACH AND INTESTINES Atony of various sections of the digestive tract are of great practical interest. In the stomach such a condition is represented by gastric paresis (usually due to overfeed- ing or improper feeding, and is acquired during the first year of life Pfaundler). In the intestines, where it is known as " intestinal atony," this condition plays an im- portant role in the digestive disturbances of childhood. Anemic and weak girls who are approaching puberty are especially likely to suffer frequently from anorexia and obstinate constipation. The latter may be accom- panied by a whole series of toxic and nervous symptoms (migraine, periodic vomiting, intermittent albuiuiuiiria, arhythmia of the pulse, and skin eruptions). Treatment. Scientific massage of the abdomen, certain exercises (performed on home u'vnmastic appliances), moist applications and douches upon the abdomen, liira- di/ation of the atonic portions of the intestines; later, baths and a vegetable diet. The abuse of purgative- is to be guarded against. Gastric paresis in infants responds rapidly and favorably to limitation of diet and intervals i VNGENIT. 1 /, STKXOSES AND A TRESIsK 375 between feeding. In obstinate cases the gastric contents present after two and a half hours should be removed systematically (without lavage). APPENDICITIS Disease of the appendix and its vicinity in children is practically analogous to that in adults. However, greater difficulty in diagnosis is frequently met with in childhood. Of assistance in the diagnosis are : The re- sults of a bi manual examination by way of the rectum and the abdominal wall (painful tumors in Douglas' pouch) ; examination of the blood (leukocytosis in pus formation); the " facies abdominalis"; the constipation and the detection of an appendiceal tumor by symmetric palpation and percussion of the abdomen. In typic cases this tumor lies midway between the umbilicus and the an- terior superior spine of the ilium ; frequently, however, it lies deeper in the pelvis at the fundus of the bladder, to the right or even to the left of the median line. In such cases dysuria, which may lead to the mistaken diag- nosis of cystitis, is a characteristic symptom. Treatment. Early operation during the intervals. Treat the attack as in adults. CONGENITAL STENOSES AND ATRESI^E OF THE GASTROINTESTINAL TRACT Many fatal cases traceable to physical and digestive weaknesses are caused by stenosis of the pylorus. Etiology. Closure of the pylorus (incomplete) may be due to acquired hypertrophy of the muscularis, more fre- quently, however, it is due'to functional spasmodic nar- rowing of the opening (Pfaundler). Spontaneous im- provement and. finally, complete recovery occur in many cases in spite of most alarming symptoms, including vom- it in-r after each meal and frightful loss of body weight. Recovery may be hastened by high enemata (for the ex- isting constipation). Cataplasm to the abdomen and atropin internally or subcutaneously. 376 GASTRO-INTESTINA L DISK ASKS On the whole, the prognosis is unfavorable in and atresia of the intestines, excepting atresia of the anus (absence of communication between the blind end of the large intestine and the external cuticular covering), which is so favorably situated in many cases that it can be easily corrected by operative intervention (see Deform itii-i. Congenital constriction or obliteration of the intestines is due to the development of peritonitis during embryonal FIG. 123. Congenital hypertrophy of the pylorus. Enlarged 30 times. The child presented si nee birth the following symptoms of pylorio stenosis : Vomiting always after the ingestion of food ; diminished stools and excretion of urine ; protruding and peristaltic contractures of the dilated stomach; finally, a small growth was palpable in the region of the pylorus. Temporary improvement followed. IVgnin milk and ex- tract of belladonna. Gastric lavage was useless. Death occurred in four weeks due to inanition. . Post-mortem examination showed circular thickening and hardening of the pylorus, whose lumen was about :> mm. [i in.] in diameter. 1. Mucosa. 2. Submucosa. 3. Hypertrophy of the muscularis. life, also twisting and strangulation of the intestines (Epstein), as well as volvulus (Kohts) in a congenital ab- normally long colon. This defect develops most com- monly in the duodenum, at the end of the iletim, and where the descending colon passes into the S loop. In atresia, continuous vomiting (of food, bile, and blood) sets in as early as the first day of extra-uterine life, followed by death. In permeable stenoses the term of life de- pends upon the degree of constriction. Dilatation of the CONGENITAL STENOSES AND ATRESI& 377 I'ppor third of the duo- 1 denum. Location of the ut resin in the- dor- sal wall of the diiudo 1H1111. I'ylorus/ culon. FIG. 121. Congenital infrapapillary atresia of the duodenum. Twin child lour days old. Premature birth (seven and a half months). After birth the child had two passages of traces of in coninin, since then no stool. Nutrition decidedly disturbed ; bloody discharge from the nose, leterus, sclcrema. lobnlar pneumonia. Albtiminuria. Death fourteen hours after consultation. AVm;>s//. Abdominal cavity : Enormous dila- lation of the stomach and upper duodenum : a rin.n-shaped constriction between the two (pyloric valve). The middle section of tlieduodenum is converted intoa white, fibrous, solid cord, in the upper end of which the papilla of Yatcr projects into the duodenum, which is bere barely open. From this point a probe may bo easily passed through the common duct and that of Wirsunir. From th<- point of constriction downward the intestine is completely collapsed and empty. G ASTRO- INTESTINAL DISEAWX FIGS. 125, 126. Congenital gastric and intestinal stenosis and congen- itiil displacement of the colon in an infant five months old. Tin- abdo- men was markedly distended since birth; vomiting; meeoninm was passed only after intestinal lavage. Breast fed. Curdled milk was not passed until the tenth day and then only after lavage. About every f.-nr weeks spontaneous, at first diarrheic and then gruel-like formed, stools were noted, and in the course of a few days the obstinate constipation was renewed, with vomiting at intervals. The spontaneous stools were preceded for several hours by violent pain. In the performance of in- testinal lavage the tube met an nnsurmountable obstruction about -'Mem. [8.8 in.] above the anus. Careful general and local treatment managed to keep the child in a fairly good state of nourishment for four weeks. but after that the health began to steadily fail. The child, who had lie- come extremely weak through chronic inanition, died in five months CONGENITAL STENOSES AND ATRESI& 379 FIG. 126. (See description under Fig. 125.) intestine above the stenotic area always sets in primarily ; later, hypertrophy of the musculature and, finally, paral- ysis of the latter and perforative peritonitis develop. The clinical symptoms are obstinate in spite of all treat- ment directed to the constipation, and death occurs often surprisingly quick under the symptoms of peritonitis or intercurrent diseases. Laparotomy may be attempted. from acute enteritis. Necropsy, Abdomen : No signs of peritonitis. 'I lu: culi in \vas abnormally elongated and presented an abnormal course ; at first it extended downward into the true pelvis and then, with ft doable loop, it passed laterally toward the right pelvic crest and upward. It stretched, markedly distended, in a uniform curvature from right to left along the lower border of the thorax and pushed the liver backward and down ward, the stomach backward and upward, and made a semirotation on its long axis. Where the colon pusses into the S flexure it was fixed by a peritoneal covering, and decidedly constricted by a complete turning on its axis. In the region of constriction the folds of half of the circum- ference of the intestines were arranged longitudinally. The pylorus wasalniost vertical in position ; the stomach was elongated and constricted in two places : Directly before it enters the duodenum : at the border be- tween the ventricle and the pylorus, especially upon (beside of the great- est curvature. Ii>. consequence of these stenoses the fiindus of the stomach was prematurely developed : the musculature was hypertrophied, and especially so at the stenotic areas The three divisions of the stom- ach maybe easily recognized fiindus. body, and pylorus. 380 GASTRO-INTESTINAL DISEASES INTESTINAL INVAGINATION Invagination of the intestines is rather frequently ob- served in children, especially during the first year of life. It consists in the invagination of a contracted section of the intestines into a neighboring relaxed portion ; the cause is unknown. The ileocecal region represents the site of predilection. Symptoms. The cardinal symptoms of this constantly serious disease are : Constipation ; vomiting ; passage of blood and collapse. The intussusceptum is frequently palpable as a movable hard tumor in the left and, less rarely, in the right side of the abdomen. The child usually dies from peritonitis. Spontaneous resolution oc- curs occasionally and, rarely, recovery follows sloughing of the necrosed intussusceptum. The so-called arasiti-s. unms 389 It is noteworthy, depending uj)on the nature, the in- tensity, and* duration of the injurious factor, that in one case a certain tissue element, while in another a different element, is attacked with especial severity. Thu-, in scarlet fever, changes in the blood-vessels* particular! v of the glomerali, predominate, while in diphtheria the epithelium of the uriniferous tubules is most markedly involved, and processes of a septic nature are mainlv characterized by inflammatory foci in the interstitial tissues (Heubner). Symptoms. Symptoms referable to nephritis are a result of a disturbance of circulation interfering with the func- tional activity of the kidneys, which in mild cases, how- ever, are overshadowed by the symptoms of the primarv disease. They are frequently limited to a moderate fever, gastric phenomena, moderate edema of the i'aee and knuckles, and the characteristic findings in the urine. The amount of urine is diminished. It is discharged after much straining in small quantities, is cloudy, dark, and, on account of the admixture of blood, cither of a meat-juice color, brownish red, or blackish. The reaction is acid, the specific gravity high, and it always contains albumin, blood-cells, and an abundance of casts (granular, hyaline, epithelial, and blood-casts), renal epithelium, and fatty detritus. The less common serious forms are accompanied bv chills and a fever as high as 40 C. [104 F.], headache, vomiting, severe pain in the renal region, olignria vary- ing in amount from 150 to 100 cem., and even anuria, edema of a more or less marked degree, and the collection of exudates in body cavities, together with dyspnea. The pulse is of high tension, diminished in frequency, and may be arhvthmic. The skin has a wax-like pallor. Course. Improvement and recovery with increased ex- cretion of urine and disappearance of albuminuria may gradually set in, even in the severest types, after a dura- tion of weeks and after repeated relapses. Life may. how- ever, be threatened by extensive circulatory interference, and by the retention of the urine and it< poi-onou- ineta- 390 DISEASES OF THE KIDNEYS bolic products in the collecting tubules. Such disturb- ances include dilatation and hypertrophy of the left ven- tricle, edema of the glottis, lungs, and brain, and al-o uremia (coma and convulsions). Prognosis. Inasmuch as cases which are mild at the beginning may rapidly change to severe forms of nephritis, the prognosis must always be dubious, yet it is, in general, more favorable in children (excepting infants) than in adults. The conversion of acute into chronic forms is fairly rare. Possible complications are pneumonia, plcu- ritis, endo- and pericarditis, and meningitis. The diagnosis can only be made with certainty when the urine constantly contains a marked amount of albumin and when the sediment presents an abundance of ea-t-; also when the amount of urine is diminished simulta- neously with the occurrence of albumin and blood in the urine, with the subsequent development of dropsy. The single symptoms, like dropsy, albuminuria, and hematuria, occur also independently of nephritis, as in heart and pulmonary disease and in anomalies of the blood. Treatment. Rest in bed; diet should consist largely of milk ; increase diuresis with lemonade and mineral water, and diaphoresis by means of hot baths and other sweating procedures. For the uremia cause depletion by way of the intestines ; ice-cap to the head, enemata of chloral, lumbar puncture (Seiffert), and, if necessary, vene- section (Baginsky) followed by infusion of normal :-alt solution (Leube). In hemorrhagic nephritis, ice-cap to the renal region. A child's spoonful of the infusion of ergot (2 : 100) every two hours. CHRONIC NEPHRITIS The various tyjws of chronic parenchymatous nephritic have occasionally been observed even in children. Its origin may sometimes be traced with a certain amount of surety to a preceding infectious disease, but in other cases the etiology is not clear and the course is so atypic that it is difficult to classify the condition under the known divi- URINARY CONCRETIONS 391 sions of renal diseases. Of the more characteristic forms, the interstitial type, contracted kid net/, is more common than the parenehymatons form, large white < >r ximllcn kidney. In the former case the urine is increased in amount, its specific gravity is lower than normal, and the amount of albumin is slight, whereas in the latter type of renal dis- ease the urine is sparse in amount, saturated with albumin, casts, and blood. Amyloid degeneration of the kidneys is comparatively rare in children (lardaccous kidney). It occurs in associ- ation with amyloid degeneration of the spleen and liver, prolonged suppuration of the bones, chronic pulmonary and glandular tuberculosis, and syphilis. The urine ob- tained by cathetcrization is pale and contains a large amount of albumin. Profuse diarrhea and persistent dropsy are usually present. The prognosis of the contracted and of the white kidney is absolutely fatal, but that of the amyloid kidney de- pends upon the duration of the causal condition. Treatment. A mild and not too strict dietetic regime. Avoid exposure to cold ; hot douches and warm baths. As diuretics, employ caffein, digitalis, potassium acetate, or camphor. URINARY CONCRETIONS Uric-acid infarcts in the newborn are frequent in the first days of life and usually disappear when sufficient fluid is 'ingested. This may become so excessive during the first days of life because of the .small amount of urine secreted that the collection of uric-acid salts and free- uric acid in the straight uriniferous tubules leads to the for- mation of uric-acid infarcts. The irritation due to the collection of nitrogen-containing excrementitious material causes the kidney to become hyperemic, and as a iv-nlt of the circulatory disturbances albumin is excreted (euo-lobulin). Examination of the urine, which is do- creased in amount, shows small quantities of albumin off and on during the first two weeks of life, few hyaline casts and epithelium, as well as yello\vish-red granular 392 DISEASES OF THE KIDNEYS portions of the infarcts, that is, uric-acid crystals. The organ presents the changes of hyperemia and yellowish- red striations in the pyramids. Nephrolithiasis. Renal sand, gravel, or calculus forms with esj)ecial frequency in children during the first year of life, and in the pelvis as well as in the parenchyma of the FIG. 129. Uric-acid infarcts in the kidney of a newborn infant. A freshly isolated uriniferous tubule from the medulla, which is partially filled with spheric and gland-like concretions. Enlarged -JM) times. (From Diirck, Atlas of General Pathologic Histology.) kidney. As etiologic factors we have over- and insuffi- cient feeding (especially with food rich in nitrogen), pro- fuse discharge of body juices, and marked loss of tinc vomiting and diarrhea, atrophy (Comby). The concre- tions consist mainly of free uric acid and uric-acid sails and, more rarely, of calcium oxalate, cystin, and phos- phates. Renal sand and gravel usually effect no mani- festations of disease, and the renal calculi only after they UJRISAJiY r^.\r/;/.77o.v.N 393 have 1 reached a certain size (lentil to bean size). Then they may call forth hemorrhages and inflammatory proc- esses in the renal pelvis or parenchyma (pyelitis, pyelo- nephritis) j or, in case of difficult passage through the ureter, renal colic and even hydro nephrosis may be caused. ( 'liicf Symptoms. Restlessness or pain upon micturi- tion. Pains in the region of the kidney radiating toward the bladder. Frequent discharge of small amounts of bloody urine containing an abundance of sediment. Passage of concretions. Treatment. A diet poor in nitrogen ; massage and gymnastics, carbonate and alkaline waters. For calcium- oxalate stone give sodium phosphate (2 to 10 per cent.), for phosphatic concretions administer citric acid. Hot applications to relieve colic. Vesical Calculi. Vesical calculi are equally as frequent as renal calculi, especially in boys up to ten years of age (40 per cent, of all cases of lithiasis). The nucleus of the stone is formed, as a rule, by uric-acid concretions washed out of the kidneys ; less rarely they are formed primarily in the bladder from the sediment of alkaline urine. The process is favored by mechanical obstruc- tions to the outflow of the urine, as in phimosis and similar conditions. The color, form, and size of the stones vary considerably ; in rare cases they may fill almost the whole bladder (the stones enlarge in the blad- der by the deposit in concentrically arranged layers of cystic urinary sediment). Symptoms. The disturbances caused by eystolithiasis arc partly mechanical and partly inflammatory in nature : Displacement of the neck of the bladder by a stone may lead to more or less severe disturbances of micturition. The irritation of the mucous membrane by the stone pro- duces vesical catarrh and inflammation. <'/if('i-t*f><> riienomcna. Temporary pains, radiating toward the perineum and glans penis, are caused mainly when the body is moved or shaken : frequent discharge of feces and urine; frequently sudden stoppage of the 394 DISEASES OF THE KIDNEYS urinary stream, after which the urine is passed only in drops or, indeed, it cannot be passed at all for hours or even days (emptying of the bladder is sometimes possible when the posture is altered or, if spasm of the bladder exists, in a hot bath) ; in some cases in place of retention we observe incontinence of urine. The condition of the urine : Sometimes clear, at other times turbid and containing cystic sediment, or also blood and fragments of concretions. Noteworthy in cystolithiasis of children is the frequent tendency to prolapsus recti and the incli- nation of boys to manipulate the penis (often elongated) during retention of urine (Henoch). Small concretions may obstruct the urethra, prevent the passage of urine, and produce painful infiltration of the perineum, scro- tum, and penis. The diagnosis is made certain by examination with the sound (metallic sound, clicking). The prognosis is doubtful. If of long standing, ma- rasmus results. The development of ascending nephritis is by no means a rare event and the danger of uremia may threaten life. Stones possessing a rough surface may occasion deep-seated ulceration of the vesical mucous membrane and, later, pericystitis and fatal peri- neal abscesses. Treatment. As in case of nephrolithiasis. Removal by operation as soon as possible. PYEL1TIS (Pyelonephritis) Inflammation of the mucous membrane of the pelvis of the kidney and of the renal pyramids followed by consecutive inflammation of the renal tissue is also observed in children, particularly as complications of cystitis (ascending nejthritix), nephrolithiasis, and after scarlet fever. The disease runs a course similar to that of adults. A serious sequel is the development of renal abscess. POLLAKIURIA AND ENURESIS 395 HYDRONEPHROS1S Renal concretions, anomalies in position of the kidney, anomalies in the formation of the ureters (abnormal length), or disease of neighboring organs may displace a ureter and prevent the flow of the urine into the bladder on the affected side. In consequence the urine is dammed back above the obstruction, the renal pelvis and the upper portion of the ureter become dilated, and marked com- pression of the kidney substance results. If the condi- tion is not relieved the renal pelvis may finally form a cyst the size of an adult's head (in congenital hydroneph- rosis birth is interfered with), in which only remnants of the kidney, which has been atrophied from pressure, can be found. When the hydronephrosis is extensive the lumbar region on the affected side presents an immovable fluctuating tumor over which the percussion-note is dull, and tympanitic if the colon lies above it. Dyspnea, con- stipation, and shooting pains in the legs develop as the condition progresses. As the healthy kidney assumes the duties of the diseased one no symptoms of general disturbance set in. Radical operations are followed by permanent recovery. If, however, the other kidney becomes diseased, death soon follows the development of edema and uremic symptoms. DISEASES OF THE BLADDER AND SEXUAL ORGANS POLLAKIURIA AND ENURESIS Two varieties of disturbances of the bladder are fre- quently observed early in life and during the years of puberty. In one, called jx>//-iim-i'..r< vps. 400 DISEASES OF BLADDER AND SEXUAL ORGANS clysuria and balanoposthitis. Excessive straining may lead to the development of hernia and prolapsus ani. Triad : Phimosis, umbilical hernia, hydroeele. Increased tendency to lithiasis and masturbation also exists. Con- genital phimosis of a moderate grade usually disappears spontaneously with the growth of the penis. On account of the sequela? a marked constriction requires an early operation. In cases in which a ring-shaped constriction occurs when the foreskin is drawn back, the outer and inner pre- putial membranes should be divided on a grooved director as far back as the retroglandular sulcus. Suture is unnec- essary. Dress with aluminum acetate solution and, after a few days, with airol paste. Elevate the penis to lesst n the postoperative edema which always develops. In all other cases the prepuce may be drawn br.ck without a bloody operation after a preliminary loosening, which is made especially easy in a hot bath or in narcosis (later stretch with dressing- forceps). Eczema of the prc- putial border is a contra-indication. HYPOSPADIAS. EP1SPADIAS Hypospadias and epispadias represent a congenital in- complete fissure formation either on the ventral or on the dorsal surface of the penis, in which the urethra is par- tially closed or present in a rudimentary form. The penis is usually very short and the glans fairly well devel- oped. The resulting disturbances of function may become troublesome in later years. The treatment is operative. UNDESCENDED TESTES Ectopia Testis. If for any reason during the sixth or seventh fetal month the beginning of the descent of the testes to the scrotum is prevented, they remain either above the inguinal ring i" the abdominal cavity or in the ring itself (if one-sided, we have monorchism ; if bilateral, FIGS. 135, 136. Hypospadias. Dorsal surface of penis. Boy one and a half years old. PenisScm. [.8 in.] long. Glans penis is disproportion- ately lar<;e. The urethra is an open groove 13 inm. [4 in.] long, which extends from the scrotum to the glans. Where this groove approaches the glans penis it flattens out. By means of a plastic operation the penis \v;i- made longer and the orifice of the urethra was formed at the tip of the glans. \ I FlG. 136'. Hypospadias. ventral surface of the \>er cent. aluminum acetate or .5 per cent, zinol. Beware of auto- infection (ophthalmoblennorrhea) and contact infection ! The non-specific form of vulvovaginitis after the cans. has been removed heals generally in a few days bv means of cotton tampons soaked in a solution of alum- inum acetate. Phlegmon and noma of the vulva and vagina which fol- low infection with pyogenic cocci develop at times in very badly neglected children, in trauma, and in infectious dis- eases which run a malignant course (scarlet fever, diph- theria, measles, and typhoid fever). The constitutional or local symptoms, as in phlegmonous or gangrenous in- volvement of any mucous membrane, are of a severe type. Energetic and antiseptic management and the ad- ministration of a strengthening diet are imperative. (For Diphtheria of the Vulva, see that disease.) DISEASES OF THE SKIN GENERAL DISCUSSION DISEASES of the skin are very common in children and, indeed, far more frequent in infants than in older children or adults. On the one hand, they are the expression of the extraordinary sensitiveness of the infantile skin toward various and to a certain extent trivial external injurious influences, and on the other hand, the manifes- tations of an existing dyscrasia, a result of disease of the digestive apparatus or of the nervous system. The treatment must, therefore, not be purely symptom- atic, and great stress should be placed upon the discovery of the causal disease. Furthermore, the tenderness of the infantile skin must be borne in mind and when possible only bland remedies are to be employed, which, when properly used, will prevent further injury to the skin and lead to a cure in most cases. NEVI Nevi, or mother's marks, are congenital anomalies of development. We distinguish between pigmentary and vascular nevi. Pigmentary nevi are referable to exr >- sive deposition of pigment in the rete Malpighii. Their color varies between light brown and black. The skin itself may remain unchanged and its surface smooth nevus spilus ; or the skin may be wart-like or rough and supplied with coarse hairs wrnx r< 'rrtu-osiix ; or :i pro- nounced tumor-like thickening of the skin exists covered thickly with hair nevitf pilomu. In rare cases the pig- mentary nevi involve a whole region of the body. Vascular iievi are due to abnormal blood-vessel growth and are congenital in origin or Mcquired at an early 406 FIG. 140. Nevus pilosus. Large grayish-black nevus nilostis which covers the body like a pail of swimming trunks. It is thickly covered in certain areas liy black hairs and a large number <>t' IxMiiirn nmwtlis (fibroma rnolhisctini!. There are aNn disseminated overlhe Imdy smaller and larger nevi. which are nearly all thickly covered with hair. (Clinic of vou Kanke, Munich.) 407 408 DISEASES OF THE SKIN period of life (proliferation and new formation of blood- vessel walls). This condition occurs mainly in the pap- illary and upper layer of the skin or the corium. The smooth or swollen skin presents specks, which may vary in color from a flaming red to bluish red nt't-uxjluimtit'iix or angioma simplex ; or elevated, swollen, and even pul- sating growths are seen, the skin of which, sometimes smooth and other times rough, allows the dilated vessels to shine through angioma oavcrnosum. Xc-vi increase in size during the early period of life, after which they gm- erally remain unchanged. A nevus flammcus may also disappear spontaneously. When an angiocavcrnoma grows to an excessively large size it may become danger- ous by pressure upon the surrounding organs. Treatment. Excision, cauterization, electrolysis, gal- vanocautery, and radium treatment. SEBORRHEA An 'increased activity of the sebaceous glands exists in the newborn child as in the fetus, consisting of the ex- cretion of epidermoid cells which have undergone fatty changes and an active regeneration of epidermis. If this function, which is physiologic in the newborn, should continue throughout the first few days ef life, and if the activity becomes abnormally increased, we have a dis- eased condition which is designated, according to whether it is spread generally over the body or whether it is limited to individual body areas, as universal or local seborrhea. The commonest situation for local seborrhea is the scalp. The products of this process, which are termed by the laity " scabs," consist of fat, dust, loosened epi- dermis, and hair; these substances form yellowish-brown or dirty colored, greasy masses, which are brittle like cheese or dry and possess in some cases a foul odor. This mass of material is spread over the whole scalp either in thin or thick layers or it is found only in certain foci. The scalp beneath this scab is pale and moist, as if SEBORRHEA 409 FIG. 141. Seborrhea of the head and face. Child seventeen months old. The sculp and upper half of the lace are coated with an uninter- rupted layer of thick, dirty sebum. (Clinic of Escherk-h, Vienna.) 410 DISEASES OF THE 6'A'AY ICHTHYOSIS 411 covered with oily drops of sweat, and not rarely it is in- flamed and eczematous from the macerating action of altered skin secretion. The portion of tiie scalp covered by hair is less damaged ; the hair loosens and falls out and disk-shaped areas of baldness result. Universal seborrhea of the newborn infant, also desig- nated as cutis sebacca and congenital ichthyosis, is due to a constant renewal of the rcniix caseosa (after-birth), which dries and covers the whole body with a horn-like sub- stance. The stiff coating of the skin varies from a yellowish- to a brownish- red color and possesses a varnish-like gloss (according to Hebra it resembles the skin of a half-roasted sucking pig). The body presents a statue-like immobility on account of the tightness and stiffness of this coating. If the mouth is involved the act of nursing is impos- sible ; yet the mouth, eyes, and anus usually remain unaffected. Deep tears in the covering on the face and at the joints show the lamellar structure of the dep.-it of sebum. It may be drawn off in these regions in large fragments. The skin underneath this coating is slightly red, shiny, and soon becomes covered again with ma---- of sebum. The child soon dies from inanition and lo-s of body warmth (Kaposi, Escherich). Treatment. The sovereign remedy in the treatment of seborrhea is sulphur, in the form of 10 per cent, sulphur and Lassar's paste or sulphur baths. The ma>-s <>\' sebum may be loosened ly means of warm oil, cod-liver oil, butter, or boric-acid ointment, and removed with lukewarm soap-water (glycerin soap). ICHTHYOSIS /V.v/i-sm/r 7)i'.-vn.-v) Ichthyosis is a skin disease transmitted by heredity, which coiiHsts of thickening of the corimn, together with a uniform hypertrophy of the papillary l.u br composed of a large number of small and large scales which have white borders. Recovery followed the usual treatment of seborrhea. (Clinic of von Winckel, Munich.) Symptoms. As a result of the interference with the function of the sebaceous glands the skin is dry, markedly scaly, wrinkled, and rough on account of the thickening and prominence of the normal furrows of the skin. In a more severe form of this disease w r e note, in place of the furrows, more or less deep painful fissures (especially in the region of the elbow-joint) ; as a result of this fis- suring, scaly, horn-like plates are formed, which are pig- mented a dirty grayish-brown to grayish-green color and have pale borders. Severe cases are accompanied by the formation of true horns. Active shedding of the horny mass occurs. The disease generally attacks almost the whole area of the body symmetrically, especially the extensor surfaces of the extremities; the face, genitalia, palms, and soles, however, remain uninvolved. On the other hand, in exceptional cases the arms and soles are alone affected ichthyosis palm arts et plantaris. Almost as rare is ichthyosis follicularis, in which the horny formation in- volves only the skin-follicles (Lesser). Ichthyosis gen- erally begins in the course of the first or second year of life and continues practically unchanged throughout life. The general health is only slightly disturbed. Diagnosis. Trophoneuroses may occasionally simulate ichthyosis, yet they are limited to narrow confines and do not arise symmetrically. Lichen pilaris may be mistaken for ichthyosis follicularis, yet is rarely met before pu- berty. Prognosis. Absolute cure is rare. Treatment. Warm soap-baths, followed by rubbing in of fat, soft-soap, or 5 to 10 per cent, sulphur ointment. ICHTHYOSIS m I 413 k 1 FIG. 143. Ichthyo.-is. (See text) 414 DISEASES OF THE SKL\ PLATE 41 Pemphigus Neonatorum. Child four weeks old. Vesicles appeared in the skin oiie day after birth. Parents and midwife healthy. Child emaciated, anemic, and weak. The vesicles are covered with a sallow skin all over the body. They are most abundant on the Jlexor sides of the lower extremities. Their color is whitish or grayish yellow and they vary in size from that of a lentil to a silver dollar. (The palms of the hands, as well as the soles of the feet, are free, excepting one large ves- icle on the left great toe.) The smaller vesicles are tense, whereas the larger ones are relaxed and their membranes wrinkled or torn and col- lapsed. The contents of the vesicles consist of a serum which is clear or turbid with pus (the bacterial findings showed the presence of the Staph- ylococcus pyogeues aureus). In many areas nothing but scabs remained or, where these have been removed, specks are noted which are red and weeping or covered with a delicate membrane surrounded by a white. epidermic ring. High septic fever. Death in four days after admission. (Clinic of von Eanke, Munich.) PLATE 42 Pemphigus Syphiliticus (Exanthema papulo-vesico-pustulosum). " Infant six days old. Papular and vesicular eruption to the si/e of a pea on the legs and soles of the feet which contained pus and surrounded by an inflammatory areola. On the following day the extensor surface of the lower extremities, nates, and back also became covered with a pro- fuse papular eruption. A vesicular and papular eruption occurred be- tween the papules. The nose remained uninvolved. Death on the seventeenth day from bronchopneumonia and gastro-intestinal catarrh. At necropsy, among other changes, infiltration of theliverand spleen was found to be present." (From Mrac"ek, Atlas of Syphilis.) Primary de- velopment of copper-colored papules and the secondary conversion of these into pustules. In pemphigus neonatorum, on the contrary, we note primarily the formation of vesicles. PEMPHIGUS NEONATORLM Pemphigus neonatorum is a contagious skin disease 1 which generally runs a favorable course and is accompanied by the formation of vesicles ; it develops sporadically and sometimes also endemically and epidemically. The vesi- cles are due to the exudation of a serous fluid into the rete which causes the production of vesicles. The eti- ology of the disease is unknown. Symptoms. A number of lentil- to pea-sized hemi- spheric vesicles develop in various parts of the body dur- ing the middle or at the end of the first week in children enjoying good health ; occasionally their appearance may be accompanied by a slight rise of temperature. The vesicles Tab, ,, f Tab.*2. DERMATITIS EXFOLIATIVA 415 are transparent, grayish red, or yellowish, surrounded by a narrow red areola, fairly tightly distended by serum, and easily ruptured. With the appearance of repeated crops we may finally note thirty to fifty vesicles of vary- ing size and stage of development. Large vesicles (as large as a twenty-five-cent piece) become flatter and more relaxed and are the last to rupture, after which the con- tents dry up. After the shell of the vesicle peels off the skin is seen to be slightly red, still moist, but alreadv covered with a delicate tissue and surrounded by a white ring of epidermis. The disease runs a favorable and afebrile course which terminates in two weeks, provided no septic complications set in. The malif/nant form occasionally observed is accom- panied by the formation of huge vesicles on previously reddened skin, runs a high febrile course, and usually ends fatally (Baginsky, Bloch). (For Differential Diag- nosis from Syphilitic Pemphigus, see that disease.) Treatment. Avoid mechanical injuries; prevent bac- terial infection ; favor desiccation of the vesicular con- tents with dusting-powders; when extensive exposure of the corium occurs resort to baths of oak bark decoction (1 pound boiled in 3 quarts of water for a bath). DERMATITIS EXFOLIATIVA An increase of the physiologic exfoliation of the skin and a diffuse serous infiltration of the rete Malpighii de- velops, occasionally without a known cause, in pivma- tmvlv born and unhealthy children during the first few days of life. This leads 'to relaxation and loosening of the skin to an extreme degree, and in certain area- t..a smooth vesicular elevation of the same (similar to lar-e relaxed pemphigus vesicles). Symptoms. the skin at first shows a rosy tint all over, after which it is speckled with an erythema-like red color. The horny layer of the skin gradually swells and appears finally as'if macerated. In this stage the pressure of a finder is sufficient to displace the superficial layer of the 416 DISEASES OF THE SKIN . x -r * 2 3 ^i ^ / . /. j: ^ -^ >> 0^3 " ~ ~ l/ " i- _^ Ox-. ** > /. -^ ~ ^ ' - * 3 a J E.f ^ " ** I ?- - - ~ = ' z - - SCLEREMA NEONATORUM 417 skin upon its base, and on account of its cohesive proper- ties it may be drawn off in large fragments. Beneath it is seen the red weeping corium. Such a displacement and tearing of the epidermis occurs with every move- ment of the patient, and hence we often see large sections of the superficial skin loosened and hanging down in large shreds or rolled up like a knot. Vesicular separa- tion of the skin is usually seen only in dependent re- gions and on the extremities, and not rarely to such an extent that the superficial layer of the skin represents a glove-like coating of the affected part, which may often be drawn off in toto (Escherich). The disease itself is not accompanied by fever or other marked disturbances of general health. The majority of the patients, how- ever, die from general sepsis. It may be possible to i-avc a life now and then when the epidermolysis is not too ex- tensive and when the outward conditions of life are favor- able. The specific treatment is that of acute pemphigus SCLEREMA NEONATORUM Sclerema neonatorum is a disease characterized by hard- ening of the skin and loss of body temperature, which may develop in the form of sclercma edematosum, sd- reina adiposum, or a combination of both forms. Sclerema edematosum is a result of weakened cardiac action and disturbance of heat production in sickly, pre- maturely born infants who a re suffering from myocarditis. nephritis, or syphilis, and who are victims of unfavorable and unhygienic circumstances of life. Slo\v capillary cir- culation and abnormal permeability of the blood-v. . I walls lead to edema of the subcutaneous tissue and, later, to dense infiltration of the skin and hardening of the panniculns adiposus. Symptoms. The disease begins generally in the lower extremities, with coldness, edema, and hardening of the calves and legs. It then spreads to the trunk and in the course of a few hours or days it becomes universal. The skin of the affected parH is tense, shiny, white, mottled. or reddish. At the commencement of the disease it i> 418 DISEASES OF THE SKIN still movable upon its base, can be lifted up in thick stiff folds, and pits on pressure. At a later stage the edema disappears from the primary foci, the skin becomes dry, stiff, immovable, and turns a dirty yellow or brownish color. The stiffening of the skin interferes with the body movements and with nursing and gives the face a peculiar senile appearance. The whole body feels cold and lies stiff, as if frozen. Sclerema adiposum, or fat sclerema, is a result of exces- sive loss of water and serum after exhausting diseases, especially cholera infantum. The consequent disturb- ances of circulation and lowering of the body temperature may, in conjunction with improper feeding and insuffi- cient application of external heat during the first week of life, lead to a finely granular coagulation and stiffen- ing of the subcutaneous adipose tissue (Knopfelmacher, Siege rt). Symptoms. The disease spreads rapidly, but spares, as a rule, the anterior surface of the neck and trunk. The skin is dry, without gloss, and dirty yellow in color ; it does not pit on pressure nor is it movable on its la.-c. The whole body is stiffened and immobile like a corpM . Both affections, the sclerema edematosum and the scle- rema adiposum, possess in common the constant and progressive falling of the body temperature about 2 to 3 C. [1.8-3.6 F.] daily, until 29 or 25 C. [84.2 or 77 F.J is reached ; also a rapid lessening of all other vital functions, which leads, as a rule, to death in a few days or, at the latest, in two or three weeks. Prophylaxis and Treatment. Children in danger of sclerema should be provided with the best possible cir- cumstances of life and, above all, the loss of energy through dissipation of heat must be prevented (wrap in flannels, cotton, hot-water bottles, or incubator). Jn ex- ceptional cases it is possible to save children suffering from sclerema by the application of hot moist packs, hot baths (30 to 32 R. [86-89.6 F.]), as well as by in- creasing the capillary circulation by massage, the cardiac activity by stimulants. ECZEMA 419 ECZEMA Eczema is the commonest skin disease of childhood. It is characterized by an itching polymorphous eruption, and anatomically by an exudative dermatitis which is chiefly confined to the uppermost layers of the skin. This dermatitis consists of a pronounced serous ex iidatin and cellular infiltration. The etiologic factor may be any skin irritant of a chemic, mechanical, thermic, or para- sitic nature. In many cases this irritation of the skin is only the exciting cause, the real factor being a dyscrasic constitutional anomaly or a disturbance of metabolism, as in scrofula, rachitis, status lymphaticus, obesity, pro- longed disturbance of digestion, and especially a> a con- sequence of overfeeding. Symptoms. Depending upon the nature and duration of the injurious influence and upon the individual predisposi- tion, eczema manifests itself in the form of a diffuse red- dening and painful edematous swelling of the skin, or in the form of pale or red itching nodules which become rapidly converted into vesicles or pustules (Eczema ///- thematosum, papulostiin, vesicnlostuii, pUBtuloswn). The-e manifestations may undergo resolution in a few days or rupture, and scratching of the vesicles and pustules causes the development of weeping eczema (Eczema madidan*), which heals with the formation of crusts and scabs, but not until several week< have elapsed (Eczema c/vx/o.v///, nuomoRum). Healing may, however, be considerably delaved by the continuation of exudation, which causes stasis of the pus-altered serum underneath the crusts [Eczema impdiginosum) or even purulent destruction of the tissue (ccthtnna). Eczema may also occur diffusely and spread over the entire body or remain confined to certain areas of predi- lection (scalp, mouth, lobule of the ear, cheek-, around the eyes nates, genitalia, and the inner surfaces of the anus). A -:cma is occasionally met with in which the described alterations occur in regular order over a course 420 DISEASES OF Till- .s'A '/.Y PLATE 43 Chronic General Eczema. Child a year and a half old, who sullVrcd since the first year of life from a skin eruption which began in t lie face and then spread over the whole body. Otherwise healthy and well nour- ished. The skin, especially of the back, is reddened and covered with numerous irregularly grouped yellowish-red to dark red small nodules of about the size of a pin's head, also honey-colored or brownish crusts and whitish scales. In certain areas the skin is markedly infiltrated. of from three to four weeks. More frequently, however, the disease spreads at the periphery and heals centrally, or through irregular recrudescences the disease appears in different parts of the body, presenting at one time this, and at another time that, pathologic change, and running a chronic course spread over several months. In acute localized eczema the general health is hut slightly influenced, excepting perhaps the effects of pro- longed itching. In general eczema and in east- of delayed healing the bodily nutrition suffers from fever, sleepless- ness, lack of appetite, and loss of serum. Complications to be considered are lymphadenitis, furunculosis, phleg- mon, and gangrene. Course and Prognosis. If the dermatitis remains super- ficial, as is the rule, recovery is complete and without destruction of tissue; otherwise superficial .-ear- remain (always in ecthyma). If the disease lasts for years, the disturbance in the nutrition of the skin leads to the for- mation of permanent tissue changes, including pigmenta- tion, thickening of the skin with degeneration of the hair-follicles, sweat, and sebaceous gland-. The prognosis depends upon the cause. If the derma- titis proceeds to gangrene and phlegmon, collapse and death may follow the development of eclampsia. Sudden death has been observed, even in the absence of the-e changes, in children who are encumbered with lymphatic constitutional anomalies c<-~.eann bandages permit free movement of the hands, but prevent Ili-xing of the arms and hence scratching of the face. They arc a No recommended in children who have undergone intubation, in order to prevent the removal of the tube by the thread to which it is fastened. skin thoroughly cleaned and avoid fresh injury. Attempt to assist and hasten the natural healing process with as 424 DISEASES OF THE SKIN bland remedies as possible. Avoid rubbing, pressure, or wetting of the eczematous areas. Hence prohibit the wearing of too tight or too warm clothing or such as will irritate the skin (wool). Remove as rapidly and as care- fully as possible from the diseased portions of the skin urine, feces, sputum, and vomitus by means of gentle swabbing with cotton (dry or soaked in sweet oil). Limit bathing and washing to the uninvolved portions of the body. If, however, occasional cleaning is necessary, employ cotton (do not use a sponge, which is cleaned with difficulty) and only boiled water to which has been added a little aluminum acetate or a 1 per cent, solution of boro- glycerin; dry by gentle swabbing and not by rubbing. Add to the baths wheat-bran or potassium permanganate solution until a rose-red color is obtained. The arm bandage of Eversbusch is employed to pre- vent injurious scratching and the diseased areas of the skin are protected by an ointment dressing or by zinc oxid adhesive plaster. The itching is lessened by wash- ing with alcohol or by the addition of menthol, carbolic acid, etc., and the use of dusting-powders, ointments, or pastes. To secure healing in children it is sufficient, as a rule, to remove the causal condition and avoid injurious factors. The following dermatotherapeutic measures are recom- mended : In case of eczema caused by the sweat, miliaria, and intertrigo use bland dusting-powders (/inc oxid, 5.0 gm. ; talcum venet., 30.0 gm., with or without to 1 per cent, menthol); macerated areas are first painted with a 2 to 3 per cent, solution of silver nitrate. In other acute forms of inflammatory eczema (papular, vesicular, pustu- lar) make cold moist applications with aluminum acetate (15:500). In the crusty impetiginous type of eczema resort to mechanical removal of the scabs after they have been previously softened with aluminum acetate applica- tions, ointments, or oil dressings; afterward apply alumi- num acetate until the inflammation has undergone reso- lution and, finally, use a drying paste (Lassar's paste). In isolated impetigo contagiosa remove the scabs, paint PRURIGO 425 with silver nitrate solution, and apply a pa.sk-. Ecthyma should be first treated with corrosive sublimate dressings and later with applications of aluminum acetate. Of value in squamous and chronic eczema is an ointment of sulphur or 1 part of liquor carbonis detergens with 9 parts of zinc paste. Occasionally very efficient results are obtained by altering the diet, and especially in the administration of buttermilk. PRURIGO Prtirigo is a chronic inflammatory affection of the skin which begins with an obstinate urticaria and a character- istic papular eruption at about the eighth to the twelfth month of life. The disease is accompanied by marked itching and persists, as a rule, throughout life. The anat- omic findings are similar to the papular and chronic forms of eczema. Symptoms. The minute papules, which do not develop generally until the second year of life, are pale or red, of a dense consistency, and occasion excessive itching. They appear chronically in the form of repeated eruptions and predominate on the extensor surface of the extremities, on the nates, in the sacral region, and at times in other local- ities, but they never appear on the flexor surfaces. The papules are generally scratched and covered with small bloody scabs, which remain in place even after the di.-:ip- pea ranee of the papules. Continued eczema causes st reaky excoriations and the secondary development of all the different varieties of eczema. Finally, the skin, especially on the legs, which are always most severely attacked, pre- sents brownish pigmentation, infiltration, thickening, and dry ness. The lymph-nodes, especially the crural, under- go indolent swelling and feel like Hat pebbles. The sleeplessness and the loss of body fluids cause a rapid de- cline in health and the child looks pale and haggard. Chief Characteristics. The skin of the extensor surt:ic< - of the extremities is covered with minute papules and scabs, and later with secondary eczema. The integument 426 DISEASES OF THE SKIN PLATE 46 Erythema Exudativum Multit'ornie. Girl fourteen years old. Little round decidedly red papules developed without a demonstrable cause upon the backs of both hands. They enlarged rapidly and upon spread- ing to the fingers occasioned itching and pain. The general health was otherwise undisturbed. The eruption, which covered nearly the whole back of the hands, coalesced into areas varying between a five-cent piece and a silver dollar; their wall-like elevated edges, which were joined by curved lines, were dark red in color, whereas their centers were some- what pale, bluish red, and presented in several areas brick-red spots (fresh papules beginning at the center erythema iris). Repeated occur- rence of fresh crops. Recovery in five weeks. (Clinic of Escherich, Vienna.) is scratched, pigmented, and infiltrated. The flexor sur- faces of the joints are always uninvolved. Glandular swelling. Continual itching. A chronic course marked by recurrences. Prognosis. A temporary improvement is all that may be hoped for. Recovery from the severe types is impos- sible. Treatment. Anoint with 1 to 3 per cent, naphtol ointment three times a week in the evening. Wash in bath with naphtol and sulphur soap. Cod-liver oil, regulation of the diet, and sojourn in the country. ERYTHEMA EXUDATIVUM MULTIFORME AND ERYTHEMA NODOSUM Erythema exudativum multiforme and erythema nodo- sum are inflammatory dermatoses which follow irritation of the vasmotor centers. The etiology is still UIH crtain ; they are influenced to a certain extent by diseases of the internal organs (auto-intoxication). Characteristic of the angioneurotic erythema is the development of red specks, whose periphery is dark red and whose center is colored a bluish red. The dark red color is due to active conges- tion with blood, and the central blue coloration is caused by consecutive relaxation hyperemia (stimulation and paralysis of the vasoconstrictors). The relaxation of the blood-vessel walls may also lead to the escape of hemo- globin, serum, and even red blood-cells, which cause dis- ERYTHEMA EXUDATIVUM MULTIFORME coloration and the formation of papules, nodules, vesicles, and hemorrhages (Kaposi). Erythema Exudativum Multiforme. This disease con- sists of simultaneous and symmetric development of dis- seminated, flat, or somewhat elevated red specks about the size of a pin's head on the backs of both hands and feet. as well as on neighboring jx)rtions of the forearms and legs. These spots rapidly enlarge to the size of a silver dollar and tend in many instances to coalesce. The centers of the larger specks appear bluish red, and when hemoglobin escapes from the vessels they present various colors, from blue to yellow, green, and brown. If fresh primary specks appear in the same areas they assume, on account of the hematin already present, a brick-red color (erythema iris). According to the grade of exudation we note the formation of papules, nodules, vesicles (ery- thema papulatum, nrticarium, vesiculosum, bullosiiin ; with a peripheral vesical border: herpes circinatus, herpes iris). The affection may, in the course of time, attack the skin of the whole body, and also the trachea 1 and laryngeal mucous membrane. It runs, as a rule, an afrit- rile course accompanied by moderate itching and termi- nating in from two to six weeks. Erythema Nodosum (Dermatitis Contusiformis). Cap- illary stasis in and beneath the skin of the backs of both feet and legs, more rarely of the thighs, nates, and upper extremities, leads to the formation of dense, painful swellings and nodules about the size of a hazel-nut. Their appearance is accompanied by gastric disturbances and swelling and painfulness of the joints. The skin covering the papules is ro-e red in color, but in^lroiii two to three days shows the gradual development of the same play of colors seen in the eruption of erythema exuda- tivum multiforme. The papules undergo resolution in from eiffht to fourteen days, yet the appearance of 1'n-h crops of eruption may prolong the disease over six weekfl or more. Treatment. There is no especial treatment for erythe- ma exudativnni multiforme. To allay the itching employ 428 DISEASES OF THE SKIN menthol or carbolic acid, 1.0 gm., to spiritus vini gullici, 150.0 cc. Erythema nodosum requires rest in bed, cool applications, and the administration of the salicylates for articular pains. LICHEN URTICATUS (Strophulus, Toolhr-rash) Lichen urticatus is an angioneurotic eruption accom- panied by much itching and developing frequently at the time of the first dentition ("tooth-rash"); in the latter case it is probably excited reflexly from the dental nerves. It occurs, however, also in children who are not teething, practically so only in the second period of childhood, from as yet unknown causes (in many cases it can be referred to an insect bite). Symptoms. Without any constitutional disturbance various parts of the body, especially the neck, lower extremities, soles of the feet, and the palms of the hands, become covered with red specks which rapidly grow into wheals the size of a lentil seed. Their centers fade and assume the appearance of wax-like vesicles (similar to varicella) ; they are, however, distinguished from vesicles by their extremely dense, horn-like con- sistency. The excessive itching causes the eruption to be scratched sore. The repeated occurrence of fresh eruptions may prolong the disease over weeks, months, and even years. Treatment. Anoint with remedies which will relievo the itching, such as 1 to 2 per cent, carbolic acid solution or menthol, 1.0 gm. ; glycerin, 3.0gm. ; spiritus vinigal- lici, 150.0 cc., and spiritus setheris, 15.0 cc. Apply bland dusting-powders to the areas which are still moist. In obstinate cases administer a laxative. URTICARIA Urticaria is a disease belonging to the angioneurotic forms of dermatoses and is characterized by the develop- ment of wheals. It develops suddenly, following certain internal and external forms of irritation, vaccination, LICHEN SCROFULOSORUM 429 insect bites, burns, dyspepsia, intestinal parasites, certain foods (strawberries), and psychic influence, and disap- pears rapidly in a few hours or days, accompanied by moderate scaling of the skin, and occasionally leaving yellow specks behind. Symptoms. The wheals, which are circumscribed eleva- tions of the skin due to the collection of a serous fluid in the rote, are white or rose red in color and surrounded by a red areola. They vary in size from a lentil seed to that of a twenty-five-cent piece, and tend frequently to coalesce into extensive irregular figures. The face and joints are attacked by preference (when localized in the orbital region no wheals develop, but the lids are red and edema- tons). The appearance of wheals is associated with itch- ing or burning, which increases when resting in bed. Fever is occasionally present. Recurrences are especially frequent in nervous subjects. Treatment. When possible remove the cause. Locally apply cooling lotions and the salicylates in the powder form. [Laxatives are indicated in the persistent forms.- Belladonna or atropin in minute doses brings relief. ED.] LICHEN SCROFULOSORUM Scrofulous children, especially at the age of puberty, occasionally develop gradually and unnoticeably an erup- tion which itches but slightly and consists of flat, pale red or yellowish-brown papules. The latter vary in size from a millet seed to a pin's head, are but slightly resistent, and possess a scaly summit. They are arranged in groups or in circles, chiefly upon the trunk, le-- rarely upon the extremities, and remain unaltered for months, after which they gradually fade and undergo resolution accompanied by moderate exfoliation. Anatomically the local process consists of a cellular infiltration and exuda- tion in the neighborhood of the orifices of the hair-follicles (Kaposi). The cause of this condition is srn.fula. and other symptoms of that disease an* always present, espe- cially marked lymphatic swelling. (Since the genetic 430 DISEASES OF THE SKIN PLATE 47 Lichen Scrofulosorum. A girl nine years old presented the typic symptoms of scrofula, including clirouic conjuiictival and nasal catarrh and swelling and hardening of the cervical and axillary nodes. An eruption is seen on the skin, chiefly on the trunk, which during the two months of its existence has undergone no noticeable change. Innumer- able pale, brownish, millet-seed-sized flat papules are seen irregularly grouped and partly arranged in continuous lines and crescents. Single papules are also noted on the skin of tho upper arms and thighs. Slow recovery followed the external and internal use of cod-liver oil. relationship between scrofula and tuberculosis has been more thoroughly studied there has been a tendency to also call lichen scrofulosorum miliary tuberculosis of the skin.) Chief Characteristics. Appearance of homogeneous, pale-red or yellowish-brown soft papules covered cen- trally by scales, which occur in groups or are arranged in circles. They attack, as a rule, only the trunk and per- sist for weeks and months without undergoing conversion into vesicles or pustules. Accompanied by symptoms of scrofula. Treatment. Oil the dry, papular skin with cod-liver oil two or three times a day. Treat as in case of scrofula. HERPES Herpes is an ephemeral eruption of a group of vesicles on the face or on the genitalia, and spreads independently of the course of the nerves. It is a frequent concomi- tant to febrile diseases, but arises also in healthy children without a demonstrable cause. Symptoms. Pin-head-si/ed vesicles which rapidly coa- lesce appear with a moderate burning sensation and itch- ing on a section of skin previously reddened. They are clear a.s water and are arranged cither in round or irreg- ularly formed groups. In one or two days they become turbid and purulent, followed by desiccation and the for- mation of scabs. Healing occurs within a week. The diagnosis is easily made, even when the vesicles coalesce 7',, A. 4 SCABIES 431 or when the scabs are lost (through maceration or scratch- ing), by the constant circular form of the eruption. Treatment. Bland dusting-powders ; for marked swelling make applications with aluminum acetate (1 tablespoonful to 1 pint of water). SCABIES (Itch) Scabies is an itching eruption caused by the presence of the itch-mite (Acarus scabiei), which, burrowing itself in the skin as deep as the rete, causes eczematous changes. The mite, which is transmitted by contact, attacks by preference the interdigital folds, the flexor surface of tin- wrist, elbow, and knee-joints, the gluteal and axillary folds, the prepuce, and in children also the palms of the hands and soles of the feet. The disea.se may spread further from these central sites, but the head always re- mains uninvolved. The burrows appear in the hands and feet as irregularly curved whitish lines dotted with dark points. In other regions they are represented ly long papular reddened elevations, the surface of which appears as if scratched with a needle. The point at which the mite enters the epidermis is marked by a small pustule or, after it has died, by a pear-shaped epidermal exfoliation. The mite lies at the end of the burrow ami may be recognized macroecopically as a whitish-yellow point glistening through the corneum. The dark ami almost black points in the burrows are the feces of tin- mite. The ec/ema (papular, vesicular, and pustular for- mation) is partly primary, due to the activity of the mite, and partly secondary, due to scratching on account of the intense itching. Chief Characteristics. Itching of the skin, which is increased by the warmth of the bed. A peculiar type ..f eczema which predominates in the areas of predilection. // Albumimiria, 385 cyclic, :'.S7 intermittent, 387 orthotic, 387 transitory, 387 Alimentary disturbances, 355 AJterante, 73 Amanrotic idiocy of families, 249 Amyloid degeneration of kidneys, 391 Anamnesis, 50 in diseases of digestive tract, 51 of metabolism, 50 of respiratory tract, 51 in hereditary syphilis, 50 in nervous diseases, "ill in rachitis, 50 Anatomic peculiarities, 17 Anemia, 149 cerebral, 209 feeding in, 150 hydrotherapy in, 151 splenic, 151 treatment, 150 Angina, 347 eatarrhal, 347 diagnosis, 348 lacunae, ."> 17 prophylaxis, 349 symptoms, 347 treatment, 349 ulcerosa, 344 Angioma cavemosum, 408 simplex, 408 Anomalies, congenital, of heart, ."><>:; Antitoxin treatment of diphtheria, 281 Anus, atresia of, in newborn, 107 Aphthae, Bednar's, 342 Aphthous stomatitis, 343 Appendicitis, 375 Applications, 70 Arteries, umbilical, 86 Arthritis fungosa, 195 Asearis Inmbricoides, 381 Aspiration pneumonia, 329 Asthma, bronchial, 323 nervous, 323 Astringents, 73 Ataxia, hereditary, 230 Friedreielf s, 230 Athetosis, 224 Atonv of stomach and intestine-. .-.71 Atresia, cellular, of vulva, In:', congenital, of gastro-inte-tinal tnct, ::75 of anus in newborn, 107 Atrophia int'antiim. .".''i'i constipation in, treatment, ''>'- diet in. .".71 gastn >-intestin:il di-.-a-e- in, prophrlaxifl, '' l >~ treatlnelll, "iti'l 438 INDEX Atrophia infantum, medication in. 372 prolapse of rectum in, treat- ment, 373 Atrophy, juvenile muscular, Erb's form of, 251 Auscultation, 63 of heart-sounds, 304 Auscultatoiy percussion, 66 BACTERIA in milk, freeing, 45 Balanoposthitis, 398 Barlow's disease, 137 treatment, 138 Basedow's disease, 139 Baths, cold-water, 71 cool, 70 hot, 70 warm, 70 Bednar's aphthae, 342 Biedert's injurious food remnant, 359 Birth, premature, 75 Black small-pox, 269 Bladder, diseases of, 395 ectopia of, in newborn, 107 inversion of, in newborn, 107 prolapse of, in newborn, 107 Blennorrhea neonatorum, 88 treatment, 89 Blood, 33 circulation, 33 Blood-tumor of head in newborn, 94 treatment, 95 Blood-vessels, diseases of, 312 Bloody operation in diphtheria, 286 Bone, apposition of, in rachitis, 124 connective-tissue, in rachitis, 125 development, congenital disturb- ances in, 130 Bones and joints, tuberculosis of, 194 direct percussion, 63 in hereditary syphilis, 154 preformed in cartilage in rachitis, 122 Brain abscess, 217 anemia of, 209 circulatory disturbances of, 208 diseases of, 204 Brain, hyperemia of, 208 active, 208 passive, 209 tumors of, 224 Breast feeding, 43 Bronchial asthma, 323 nodes, tuberculosis of, 173 morbid anatomy, 173 symptoms, 173 Bronchiectasis, 335 Bronchitis, acute, 324 morbid anatomy, 324 symptoms, 324 treatment, 325 capillary, 326 diagnosis, 328 morbid anatomy, 326 prognosis, 327 symptoms, 327 treatment, 328 chronic, 326 Bronchopneumonia, 328 diagnosis, 331 morbid anatomy, 329 symptoms, 330 treatment, 332 Brown-Sequard paralyse, 229 CALCULI, vesical, 393 diagnosis, 394 prognosis, 394 symptoms, 393 treatment, 394 Calories produced by various forms of nourishment, 42 Capillary bronchitis, 326. Set- a I si > Bronchitis, capillary. Caput quadratum, 114 Cardiac-pulmonary murmur, 304 Cardiants, 74 Caries, tuberculous, of vertebra-, 1 '.('. results, 198 symptoms, 197 treatment, 198 Caseous peribronchitis in pulmon- ary tuberculosis, 181 pneumonia in pulmonary culosis, 182 morbid ;in;it<>my, 181 Catarrh, intestinal, 361 Catarrha! angina, 347 INDEX Catarrlial stomatitis, 342 Cellular atresia of vulva, 403 Cephalhematoma of newborn, 94 Cerebnil anemia, 2<) ( .t infantile palsy, 217 diagnosis, 224 diplegie tvpe, 220 etiology, 218 hemiplegic type, 218 morbid anatomy, 218 symptoms, 218 treatment, 224 sinuses, inflammatory thrombosis <>f, 207 marantic thrombosis of, 207 thrombosis of, 207 Cerebrospinal canal, incomplete closure of, in newborn, 96 fluid, examination, 67 meningitis. 204 course, 205 epidemic, diagnosis, 193 treatment, 205 Cervical fistula, congenital, 105 Chest measurements, 29 Chicken-pox, 273. See also Vari- cella. Chlorosis, 150 feeding in, 150 hydrotherapy in, 151 treatment, 150 < 'liolera infantum, 362 Chorea, electric, 2 1 1 general infantile, 223 major, 246 minor, 240 course, 242 diagnosis, 242 etiology, 240 morbid anatomy, 240 muscle anarchy in, 241 prognosis. 212 symptoms, 2 1 1 treatment, 2 12 paralytic, 241 Chvostck's sign of tetany, 235 Circulation, fetal, 17 of blood, 33 Circulatory apparatus, di-eases of, 303 general considerations, 303 Cleft palate, 104 ( 'old sprays, 71 Cold-water baths, 71 Colicystitis, 396 treatment, 397 Colitis, 364 dysenteriformis, 364 Colics' law, 152 Colostrum, 39 Compression myelitis, 229 Concretions, urinary, 391 Confluent variola, '_''>'.) Conjunctiva, secretions from, ex- amination, 67 Conjunctivitis, diphtheritic, 279 Connective-tissue bone in rachitis, 124, 125 Constipation, habitual, 354 in atrophia infantum, treatment, 372 Constitutional diseases, 114 Convulsions, 230 salaam, 239 Cool baths, 70 Coryza, 315 Cox'itis, 198 treatment, 201 Craniorrachischisis, 99 Cranioschisis, 96 ( ran iota hes in rachitis, 114 ('retinism, sporadic, 140 Croup, 278 Croiipons pneumonia, 333 differential diagnosis, 334 prognosis, 335 treatment, 335 Crusta lactea, 421 ( 'rvptoivhism, 402 Cut is sebacea, 41 1 Cystitis :;'.". Chief characteristics, 397 treatment, 397 Cystolithiasis, 393 l>i: \FM:-S 35 Deformities of extremities in new- born, ins iVyencration, amvloid, of kidneys, :;'.U fatty, of heart, 311 symptoms, 312 440 INDEX Degeneration, fatty, of heart, treat- ment, 312 Dentition, 36 Dermatitis contusiformis, 427 exfoliativa, 415 symptoms, 415 treatment, 417 Dermoid spaces in newborn, 96 Desiccation fever of variola, 268 Diaphoretics, 74 Diarrhea, fat, 361 Diathesis, hemorrhagic, 146 Diet in atrophia infantnm, 371 in rachitis, 130 Dietetic treatment of disease in children, 68 Digestion, 37 fat, marked insufficiency of, 361 Digestive organs, diseases of, 342 tract, diseases of, anamnesis in, 51 Diphtheria, 275 and scarlet fever, differentiation, 265 beginning, 276 bloody operation in, 236 cause, 275 complications, 280 constitutional treatment, 283 course, 276 diagnosis, 281 extubation in, 286 fibrinous exudate in, 275 gravis, 278 intubation in, 285 laryngeal, 278 local treatment, 283 nasal, 279 of vulva, 279 pharyngeal, 277 prognosis. 280 septic, 278 sequela^, 280 serum treatment, 281 special treatment, 283 specific treatment, 281 symptom-complex, 276 symptoms, 276 tracheotomy in, 286, 290 treatment, 281 Diphtheritic conjunctivitis, 279 Dislocation, congenital, of hip- joint, 112 iliac, 112 supracotyloid, 112 and iliac, 112 Diuretics, 74 Diverticulum, MeckeFs, in new- bom, 107 Dosage, 72 Drinks for sick children, 69 Dry pleurisy, 338 Duchenne's paralysis, 250 Dulness, absolute cardiac, 304 relative cardiac, 304 Dyspepsia, 360 acid-fermentation, 361 following disturbances of fermen- tation, 361 Dysthyroidism, 139 EAK in scrofula, 178 Eclampsia, 230 diagnosis, 232 etiology, 231 functional, 231 infantum, 230 prognosis, 232 secondary symptomatic, 231 symptoms, 231 treatment, 233 Ecthyma, 419, 422 cachecticorum, 422 pustules in su-ot'ula, 177 Ectopia of bladder in newborn, 107 testis, 400, 402 Eczema, 419 chief characteristics, 1'JO chronic impetiginous, in scrofula, 177 course, 420 crustosum, 419 cyclic, 419 death, 420 erythematosum, 419 impetiginosmn, 419 inter! rigo, 421 madidans, 11'.' papulosnin, 419 prognosis, 420 piistiilosinn, 419 squamosum, 419 IMtKX 441 Eczema sudamcn, 121 symptoms, 419 treatment, I'J."> vcsiculosum, 419 Elbow, tuberculosis of, 203 Electric chorea, 241 Emetics, 7:! Empyema, 337 ichorous, 337 Encephalitis, 217 acute iio!i-snppiir;itive, 217 suppurative, 217 Endocanlitis, 309 diagnosis, 310 prognosis, 310 symptoms, 309 treatment, 310 Endochondral ossification in ra- chitis, 122, 125 Energy-quotient, 42 Enlargement of spleen and liver in hereditary syphilis, 153 Enuresis, 395 treatment, 396 Epilepsy, 242 course, 244 diagnosis, 244 etiology, 242 Jacksoninn, 243 prognosis, 244 reflex, 242 symptoms, 243 treatment, 244 Epileptic vertigo, 243 Epispadias, 400 Epithelial adhesion, prepntial, 39S Erh's form of juvenile muscular atrophy, 2">1 sign of tetany, 235 Ervthema and measles, differentia- tion. 260 exiidativiim nnihit'orme. 426, 427 treatment, 427 nodosum, 426, 427 treatment, 427 Eschericli's pseudotetanns, 236 Everslmscli's arm bandage in ec- zema, 424 Examination, 49 proper method, 51 Excretion of urine, 35 Excretions, 67 ExjKTtorants, 72 Extremities, anatomy, 'J'J deformities of, in newborn, 108 in rachitis, 119 Extulmion in diplitheria, 286 Eye- in scrofula, 178 Fu i \i. defect- in newlMirn, 103. nerve phenomenon of tetany, 2.'*" Fat content of milk, loss of, hi diarrhea. 361 digestion, marked insnlliciencvof, 361 Fatty degeneration of heart, 311 symptoms, 312 treatment, 312 examination, 67 IH-a-soup, in typhoid fever, 2'.2 Feeding, artificial, 4 1 breast, ll! in anemia and chlorosis, 150 natural, 39 premature children, 76 Feet, joints of, tuberculosis of, 203 Female genitals, 28 Fermentation, dyspepsia following disturbances of, :'>ll Fetal circulation, 17 myxedcma, 130, 136 rachitis, 130 Eibrinous pneumonia, ."".."> Finger-nail-on-tinger-nail nu-tlmd of percussion. 6H Finger-on-iinger method >f JHTCIIS- sion, 66 Fingers, abnormal numU-r of, in newborn, 108 Fish-scale disease, 411 Fistula, cervical, congenital, 1 0." ( Flat-foot in newborn, 1 12 Folliculitis abscedens 4:;:! treatment, !:'>! Fontanels, anomalous, 96 |'',.nd, amount of, required by nurs- ling 12 FniviL'ii Ixnlies in air-pa-.-i-e-, :;-J-J Fireitrn-lxHly pneumonia, :'-'' Friedrcich's ataxia. 2.">i> Fiilminatinir purpuni, 1 I s Fungus, umbilical. > I 442 INDEX GAN<;KKXK of umbilicus, 85 of vulva, 405 Gastric lavage,*369 ( iastro-enteritis, 364 Gastro-intestinal diseases, 354 etiology, 354 from improper nursing, 359 general discussion, 354 in atropbia infantum, prophy- laxis, 367 treatment, 369 symptoms, 360 tract, congenital atresia of, 375 stenoses of, 375 Genitals, female, 28 Genito-urinary tract, diseases of, 385 Gibbus, 196 Glandular fever, 313 Glottis, spasm of, 236 Gonorrheal vulvovaginitis, treat- ment, 404 Growth in length, 28 HABITUAL, constipation, 354 vomiting, 354 Hand, obstetric, 234 Hare-lip, 103 Head, blood-tumor of, in newborn, 94 treatment, 95 measurements, 30 Hearing, 35 Heart, congenital anomalies of, 303 disease, congenital, diagnosis, 305 treatment, 307 diseases of, 303 diagnosis, 304 symptoms, 303 dulness of, absolute, 304 relative, 304 fatty degeneration, 311 symptoms, 312 treatment, 312 murmurs, accidental inorganic, 306 Heart-sounds, auscultation of, 304 Ilrlirphrcnia, "I'M Keeker's urine vessel, 385 Hematuria, 387 Hemiplegia, spastic infantile, 218 Hemoglobinuria, 387 acute, of newborn, 94 Hemorrhage, umbilical, S} Hcmorrhagic diathesis, 146 pleurisy, 337 purpura, 147 rachitis, acute, 137 Henoch's purpura, 147 Heredosyphilis, 152 Hernia, umbilical, acquired, 81 treatment, 82 congenital, 81 funicular, 81 Herpes, 430 symptoms, 430 tonsurans, 433 treatment, 431 Heiibner's two-thirds milk mix- ture, 46 Hip-joint, congenital luxation, 112 iliac, 112 supracotyloid, 112 and iliac, 112 Hirschsprung's disease, 354 History, 49 Hot ba'ths, 70 stupes, 71 Hutchinson's triad, 158 llydrocele, 402 communicans, 402 Hydrocephaloid, 209 Hydrocephalus, acute, 187. See also Menin;/i!i.<, tuberculous. chronic, 209 course, 214 diagnosis, 217 disturbances of motion, 214 etiology, 211 morbid anatomy, 211 symptoms, 211 treatment, 217 externus, 209 interims, 209 iotrameningealk, 211 Hydronephrosis, .'I'. 1 ') Hydropathic applications, 70 Hydrotlicnipv. r,;t in anemia and chlorosis, 151 Hygroma, congenital, of neck, 105 of main, 208 INDEX 443 Ilyperemia of brain, active, 208 passive, 209 Hyperplasia of lymph-tissue of pharynx, 349 diagnosis, 353 treatment; 353 of thyinus gland, 322 Hypertrophy of tongue in new- born, 105 Hypospadias, 400 Hypothyroidism, 139 chronic benign, 139 treatment, 145 Hysteria, 246 course, 247 diagnosis, 247 prognosis, 247 symptoms, 246 ICHTHYOSIS, 411 congenital, 411 diagnosis, 412 folhcularis, 412 palmaris et plantaris, 412 prognosis, 412 symptoms, 412 treatment, 412 Icterus, 383 neonatonim, 33 Idiocy, amaurotic, of families, 249 treatment, 250 Imbecility, 249 Impetigo contagiosa, 421 Incubator room, 76 Infantilism, 140 Infarcts, uric-acid, in newborn, 391 Infectious diseases, acute, 252 general discussion, 252 period of incubation, 252 prodromal symptoms, _'">.'! chronic, 1">2 Inflammations, intestinal, chronic, 365 morbid anatomy, 363 sequehe, 363 Inflammatory thrombosis of cere- lira 1 sinuses. 'H)7 Influenza, 294 bronchial phenomenon in, 295 , diagnosis, 295 Influenza, duration. 295 prognosis, 295 pulmonary phenomenon in, 295 retropharyngitis in, '.".'I symptoms, 'JUl treatment, 295 Insanity, 250 moral, 250 Inspection, 55 Intermittent albuminuria, 387 Intestinal catarrh, 361 inflammation, 363 chronic, 365 morbid anatomy, 363 sequela?, 363 imagination, 380 lavage, 369 parasites, 380 diagnosis, 380 Intestines, anatomy of, 24 atony of, 374 tuberculosis of, 184. See also Tuberculosis of intestines. Intubation in diphtheria, 285 tubes, 286 Invagination, agonal, 380 intestinal, 380 Inversion of bladder in newborn, 107 Itch, 431 JACKSONTAN epilepsy, 243 Jaundice, 383 Joints and hones, tuberculosis of, 194 of feet, tuberculosis of, 203 KERATOCONJUNOTIVITIS. phi \cteii- ular, in scrofula, treatment. M 1 Keruig's sign, 190 Kidnevs, amyloid degeneration of, :;. 1 anatomy, 23 contracted, .".'.'1 diseases nf. I'i'v'i dia.u'iioMs, 385 in hereditary syphilis, 154 lardaceoiis, 391 larire white. :;'.'! swollen, :'.!> 1 Knee, while -.welling of, 201 444 INDEX Knee-joint, tuberculosis of, 201 treatment, 202 Koplik's spots, 257 LACUNAR angina, 347 Lardaceous kidney, 391 Laryngeal diphtheria, 278 Laryngismus stridulus, 236 Laryngitis, acute, 318 differential diagnosis, 319 symptoms, 318 treatment, 320 Laryngospasm, 236 course, 238 diagnosis, 238 of tetany, 235 prognosis, 238 symptoms, 236 treatment, 238 Larynx, papilloma of, 322 Lavage, gastric, 369 intestinal, 369 Laxatives, 72 Length, growth in, 28 Lichen scrofulosorum, 177, 429 chief characteristics, 430 treatment, 430 urticatus, 428 Little's disease, 220 Liver, anatomy, 23 diseases of, 383 enlargement of, in hereditary syphilis, 154 in hereditary syphilis, 154 Lobar pneumonia, 333 Lobular pneumonia, 328 Lungs, miliary tuberculosis of, 180 tuberculosis of, 180. See also Tuberculosis of linii/.t. Lymphadenitis, 312 acute, symptoms, 312 chronic, 313 treatment, 314 Lymph-nodes in hereditary syph- ilis. 154 in scrofula, 1 76 Lymph-ring, pharyngeal, "lii Lymph-tissue of pharvnx, hvper- plasia of, 349 diagnosis, 353 treatment, 353 MACROGLOSSIA in newborn, Id.") Malformations of newborn, 96 from arrested development, 9(5 Management, general, of disease in children, 68 Manns vara in newborn, 112 Mai-antic thrombosis of cerebral sinuses, 207 Mastitis neonatorum, 95 Masturbation, 248 Measles, 256 and erythema, differentiation, 260 catarrhal stage, 256 complications, 259 diagnosis, 259 eruptive stage, 257 exanthem, 257 incubation period, 256 Koplik's spots in, 257 noma i'acialis et vulva- in, 2-V.i prognosis, 259 symptoms, 256 Measurements, 72 chest, 29 head, 30 skull, 29 Mechano-electric therapeutics. 7 1 Meckel's diverticulum in newborn, 107 . Medicinal treatment, 71 Melena neonatorum, 93 spurious, 93 Mi-ningismus, 207 Meningitis, cerebroepinaL.204 course, 20. "> epidemic, diagnosis, 193 treatment, 205 purulent, 206 diagnosis, 206 differential diagnosis, 1 '.:', treatment, 207 serous, 207 differential diagnosis, 194 simple, 206 tulK-reulous, 187 course, 192 development of symptoms of cerebral irritation, 190 diagnosis, 193 differential diagnosis, I'.i:'> INDEX Mi ninyitis, tuberculous, final stage, 192 Kenny's sign nt'. I'.M) morbid anatomy, 188 prognosis, I'.'l^ symptoms, 188 tivatment, 194 Meningocelc, spinal, 100 Mensuration, 06 linear, 66 Mesenterie nodes, tuberculosis of, 185 Metabolism, diseases of, anamnesis in, 50 Microcephalus, 105 Miliaria, 421 Miliary tuberculosis, 172 of lungs, 180 Milk, 45 administration of, 47 chief danger, 47 albumin content, diminishing, 46 and human milk, difference* in, 15 ehemicophysical differences of, equalizing, 46 comparison of, 41 fat content, loss of, 46 freeing of foreign material and hacteria, 45 human, constituents of, 39 of first two months, 39 permanent, 39 mixture, Ilcubner's two-thirds, 46 overfeeding with, 47 pasteurization, \~> sterilization, 45 result of, 46 Milk-slime, -\~> Moiiorchism, 400 Monstra per defect mil, 96 Moral insanity, 250 Morl.illi, 256 " Morbus maculoBua Werlhofli, 147 Mother's marks, 4(Ml Mouth, deposits in, removal of, 67 diseases of, 342 Movements, 35 Mucous membranes in scrofula, 177 Mumps. I".!'. i. >ce also epidemic. Muniuu-s, cardiac-pulmonary, .".u I heart, accidental inorganic, :',*\~> Muscle anarchv in chorea minor, 241 Muscles, congenital spastic rigidity of, 220 Mi ocular atrophy, juvenile, fiirm of, 'J51 Musculature, 28 Mustard poultices, 71 Myelitis, compression, 'J'J'.l transverse, -- 1 .* treatment, 230 Myelocystoc(4e, 10'J Myelomeningocele, 100 Myocarditis, 31 1 diagnosis, 311 symptoms, 311 treatment, 311 Myopathv, primary 250 diagnosis, 251 morhid anatomy, 250 syni|)toms, 250 treatment, 251 Mvotonia. conirenital, 239 Myxedema, fetal, 130, 136 'infantile, 140 Myxidiotie, 140 N \i;coTics. 73 Nasal diphtheria, 279 Nephritis, acute parenchymaiou>, 388 coiirsOj 389 diayno'sis, 390 morliid anatomy, 388 prognosis, 390 symptoms, 389 treatment, 390 ascending, ''' I chronic, .">'.>(> prognosis, :>'.'! treatment, :'.'.'! Nephrolitliiasis. .",'.i-J svinptoms, 393 treatment. :'.'.':', Nervine-. ~'-'- Nervous asthma, 323 446 INDEX Nervous diseases, anamnesis in, 50 functional, 230 system, anatomy, 24 diseases of, 204 involvement of, in hereditary syphilis, 157 Nervousness, 245 etiology, 245 prophylaxis, 247 treatment, 247 Neurasthenia, 245 course, 247 diagnosis, 247 prognosis, 247 Rosenbach's sign of, 246 symptoms, 245 Nevus, 406 flammeus, 408 pilosus, 406 spilus, 406 treatment, 408 vascular, 406 verrucosus, 406 Newborn, abnormal attachment of tongue in, 106 number of fingers in, 108 acute hemoglobinuria of, 94 atresia of anus in, 107 blennorrhea of, 88 blood-tumor of head in, 94 treatment, 95 cephalhematoma of, 94 deformities of extremities in, 108 dermoid spaces in, 96 diseases of, 75 ectopia of bladder in, 107 facial defects in, 103 flat-foot in, 112 general loss of vitality in, 75 hypertrophy of tongue in, 105 incomplete closure of cerebro- spinal canal in, 96 inversion of bladder in, 107 macroglossia in, 105 malformations of, 96 from arrested development, 96 manus vara in, 112 mastitis of, 95 Meckel's diverticulum in, 107 melena of, 93 Newborn, ophthalmia of, 88 pes cak-uiK'iis in, 112 equinus in, 112 valgus in, 112 varusin, 112 polydactylism in, 108 prolapse of bladder in, 107 ranula in, 106 sepsis of, 86 treatment, 88 syndactylism in, 108 tetanus of, 90 treatment, 92 Night terrors, 248 Noma, 346 facialis et vulvas in measles, 259 of vulva, 405 Nose in scrofula, 178 secretions from, examination, 67 Nourishment, 39 calories produced by various forms of, 42 Nursing, improper, gastro-intesti- nal diseases from, 359 OBESITY, 146 Obstetric hand, 234 O'Dwyer's tubes, 286 Omphalitis, 85 Omphalocele, 81 Ophthalmia neonatorum, 88 Ossification, endochondral, in ra- chitis, 122, l-j:> normal, in rachitis, 122 periosteal, in rachitis, 122, 124, 125 Osteochondritis in hereditary syph- ilis, 165 morbid anatomy, 162 Osteogenesis, imperfect, 130, 132 Overfeeding with milk, 47 Oxynris vermicularis, 380 treatment, 381 Ozena, 316 PALATE, cleft, 104 Palpation, 58 of spleen, 62 Pulpatory percussion, 63 Papilloma of larynx, 322 Paralysis, Brown-Sequard, 229 f\in-:x 447 Paralysis, cerebral infantile, 217. See also ('./,/ infantile palsy. Duchcmie's _'"'< i peripheral, 240 paeudohypertrophic, ! spastic spinal, 2."> ( > spinal infantile, 'I'll. See also Spinal infantile paralysis. Paralytic chorea, 241 Parasites, intestinal, 380 diagnosis, 380 of skin, 435 Parotitis, epidemic, 299 diagnosis, 302 incubation period, 299 prodromal phenomena, 300 prognosis, ."02 submaxillary, 302 treatment, 302 Pasteurization of milk, 45 Pea-soup stools in tvphoid fever, 292 Pedatrophia, 366 Pediculosis capillitii, 432 IVliosis, 147 Pelvis anatomy of, 20 in rachitis, 119 Pemphigus in hereditary syphilis, 153 neonatorura, 414 malignant form, 415 symptoms, 414 treatment, 415 Percussion, 63 auscultatory, 66 direct, of hones, 63 tiiiL'vr-nail-on-tinsrer-nail method, 66 finger-on-finger method, 64 palpatory, 63 Peribronohitis. caseous, in pulmon- ary tuberculosis, 181 Pericarditis, 307 diagnosis, 308 treatment, 308 tuberculous, 184 PeriompbaJitis, 85 Periostea! ossification in rachitis, l'2'2. 124. !_>.-) Peripheral paralyses, 240 Peritoneum, diseases of, 383 Peritoneum, tuberculosis of, ]-', /l/.W.i '/ j, I ('/'- III ll.llt. Peritonitis, acute, 383 chronic, 383 treatment, 384 Perspiration, stimulation, 71 Pertussis, 2! f, convulsive -ta.irr, 'J'.'T diagnosis, 298 initial catarrhal stage, % _".i7 laryugoscopic findings in, 2'.n; pathologic finding i- prognosis, 298 syiii]itoms, 297 treatment, 299 Pes calcaneus in newborn, 112 cquinus in newUrn, 112 valgns in newliorn, 112 varus in newborn, 112 Phalangitis, syphilitic, in hered- itary syphilis, 155 Pharyngeal diphtherli, 277 lympli-ring, 349 Pharynx, deposits in, removal, 67 diseases of, 342 in scrofula, 178 lymph-tissue of, hyperplasia of, 349 diagnosis, 353 treatment, 353 Phimosis, 398 treatment, 400 Phlegmon of vulva, 1<>"> Physiologic pi-ciiliariti' I'leiiri-y, .".:'.7 and pneumonia, dilleivntiation, 340 course, 339 diagnosis, 339 dry, 338 hemorrhagic, 337 purulent, ::.".7 result, :::'.'. i lihrinous, 337 serous, 337 svmptoms, 338 treatment. :'.ll tiiU-rciilous, 183 Pbenmonia, and ph-uri^y, ditlereiitiatioii, .".11 448 INDEX Pneumonia, aspiration, 329 caseous, in pulmonary tubercu- losis, 182 morbid anatomy, 181 chronic, 335 treatment, 336 croupous, 333 differential diagnosis, 334 prognosis, 335 treatment, 335 fibrinous, 333 foreign-body, 329 lobar, 333 lobular, 328 white, 160 Polioencephalitis, acute, 218 Poliomyelitis, acute anterior, 225 Pollakiuria, 395 treatment, 396 Polydactylism in newborn, 108 Porrigo larvalis, 421 Pott's disease, 196 Poultices, mustard, 71 Premature children, 75 feeding, 76 Preputial epithelial adhesion, 398 Prognathism, 105 Prolapse of bladder in newborn, 107 of rectum in atrophia infantum, treatment, 373 Prurigo, 425 chief characteristics, 425 prognosis, 426 symptoms, 425 treatment, 426 Pseudocroup, 318 Pseudofurunculosis, 433 Pseud()liyjHTtn>]iliic paralysis, 2">0 Pseudoleukernia, infantile, 151 1'seiidotetanus, 236 Psychic treatment, 74 Psychoses, 249 I'lirpura, 146 abdominal, 147 fulminating, 148 hemorrhagic, 147 Ht-nocli's, 147 rheumatic, 1 17 simple, 146 treatment, 148 Purpura variolosa, 269 Purulent meningitis, 206 diagnosis, 2iMi differential diagnosis, 193 treatment, 207 pleurisy, 337 Pustules, ectliyma pustules in, 177 I'yelitis, :;;ii Pyelonephritis, 394 Pyorrhea of. umbilicus, 85 RACHISCHISIS, '.i',i Rachitic rosary, 119 Rachitis, 114 " acute hemorrhagic, 137 anamnesis in, 50 apposition of bone in, 124 bones preformed in cartilage in, 1-22 connective-tissue bone in, 124, 125 course, 121 craniotalx.-s in, 114 diagnosis, 127 differential, 127 diet in, 130 direct results, 120 endochondral ossification in, 122, 125 etioli >gy, 1 22 extremities in, 119 fetal, 130 in hereditary syphilis. l'i"> macroscopic change* in. 121 medication in, 130 microscopie ehangrs in. 12") normal ossification in. 122 pathologic anatomy, 124 pelvis in, 119 periosteal ossification in. 122. 12 I. 125 phenomena not directly due to, 120 prognosis. 121 skull in, 1 1 I symptoms, 1 1 1 thorax in, 1 1'.' treatment, 129 vertebra- in, 119 Kannla in newborn, 106 INDEX 449 Rectum, prolapse of, in atrophia infantum, treatment, 373 taking temperature in, 53 Reflex epilepsy, L'42 primary, 231 Respiration, 34 Respiratory organs, diseases of, 315 anamnesis in, 51 Retropharyngeal ;ilct->, 353 Retropharyngitis in influenza, 294 Rheumatic purpura, 147 Rhinitis, acute, 315 treatment, 316 chronic, 316 treatment, 318 membranacea, 279 llo>ary, ruchitic, 119 Hosenbach's sign of neurasthenia, 246 Rubella, 261 symptoms, 261 SALAAM convulsions, 239 Scabies, 431 treatment, 432 Scabs, 408 Scalp, seborrhea of, 408 Scarlatina gravissima, 2l>~> Scarlet fever, 262 and diphtheria, differentiation, 265 complications, 265 diagnosis "l^'i heraorrhagic type, 265 prognosis, 265 prophylaxis, 265 septic types, :><;:> sequela-. 1'ii") special therapeutic measure-. 266 treatment, 265 typhoidal form, 265 Selerema adiposum, 418 edematosum, 417 neonatorum, 417 prophylaxis, 418 symptoms, 417 treatment, 418 Sclerosis, diffused. 224 disseminated, '224 Scorbutus, infantile, 137 29 Scrofula, 175 course, 178 diagnosis, 178 ear in, 178 ecthynia pustules in, 177 eczema in, 177 eyes in, 178 general hygienic and dietetic treatment, 179 lymph-nodes in, ITU medication in, 179 mucous membranes in, 177 nose in, 178 pharynx in, 178 phlyctenular, keratoconjiinctivi- tis in, treatment, 180 preventing infection of sus*v|>- tible children, 179 prognosis, 178 prophylaxis, 178 skin in, 177 soft-soap cure, 179 special treatment, 179 subcutaneous infiltrations in, 177 symptoms, 176 treatment, 178 tuberculosis and, 175 Seborrhea, 408 of scalp, 408 treatment, 411 universal, 411 Secretions, 67 from conjunctiva, examination, 67 from nose, examination, 67 S. | >s is of newborn, 86 treatment, 88 Septic diphtlicri : Serofibrinous pleurisy, 337 Serous meningitis, 207 differential diagnosis, 194 pleurisy, 337 Serum treatment of diphthriia. 281 Sexual organs, dNea-e of. :'.'.'"> sinuses, cerebral, inflammatory thromJxis of, 207 manintie tliromKoMs of, 'Ju7 thromU>sis of, "Jit" Skeleton, IS Skin, condition of, 33 450 INDEX Skin, diffuse syphilitic infiltration of, in hereditary syphilis, 154 diseases of, 406 general discussion, 406 treatment, 406 in hereditary syphilis, 153 in scrofula, 177 parasites of, 435 Skull, anatomy, 18 in -rachitis, 114 measurements, 29 Sleep, 34 Small-pox, 267. See also V Colics' law of, 152 connective-tissue proliferation in, 161 diffuse cellular infiltration in, 161 syphilitic infiltration of skin in, 154 enlargement of spkvn and liver in, 153 involvement of nervous system in, 157 kidneys in, 154 liver in, 154 lymph-nodes in, 154 macular and papular BqoamooB syphilid in, 153 mercury and iodin in, 167 morbid anatomy, 158 nourishment in, 167 osteochondritis in, 165 morbid anatomy, 162 INDEX 451 Syphilis, hereditary, pemphigus in. 153 prognosis, 167 prophylaxis, 167 rachitis in, 165 recurrence of, 158 skin in, 153 snuffles in, 153 symptoms, 153 syphilitic phalangitis in, 155 transmission of, 152 treatment, 167 white pneumonia in, 161 tarda, 156 Syphilitic phalangitis in hereditary syphilis, 155 TACHK ce're'brale, 190 Temperature, 34 taking of, in rectum, 53 Tenia rnediocanellata, 381 solium, 381 treatment, 381 Terrors, night, 248 Testes, undescended, 400 treatment, 402 Tetanus neonatorum, 90 treatment, 92 Tetany, 233 Chvostek's sign of, 235 course, 235 diagnosis, 235 Erb's sign, 235 facial nerve phenomenon of, 235 intermittent form, 234 laryngospasm of, 235 latent, 234 prognosis, 235 treatment, 235 Trousseau's sign, 235 Thomson's disease, 239 Thorax, anatomy, 20 in rachitis, 111) Thrombosis of cerebral sinuses, 207 inflammatory, 207 marantic, 207 Thrush, 345 diagnosis, 345 symptoms and course, 345 treatment, 346 Thymus gland, anatomy, 23 diseases of, 138 byperplana of, 324 struma of, 138 Tongue, abnormal attachment of, in newborn, 106 hypertrophy of, in newborn, 105 Tooth-rash, 428 Tracheitis, acute, 324 morbid anatomy, 324 symptoms, 324 treatment, 325 Tracheotomy in diphtheria, 286, 290 Transverse myelitis, 229 treatment, 230 Trichocephalus dispar, 381 Trousseau's sign of tetany, 235 Tuberculosis, 168 abdominal, 184 acquired, 169 and scrofula, 175 congenital, 168 frequency of, 168 general, acute, 172 chronic, 172 diagnosis, 173 hygienic and dietetic treat- ment, 179 subacute, 172 symptoms, 172 latent, 170 medication in, 179 miliary, 172 of lungs, 180 of bones and joints, 1!< of bronchial nodes, 173 morbid anatomy, 173 symptoms, 173 of elbow, 2o:; of intestines, 184 course, 185 morbid anatomy, 184 prognosis, 1 s ! symptoms, 184 tivatiiu-nt, 185 of joints of feet, 203 of knee-joint, 201 treatment, 202 of lungs, 180 acute cii-seminated, 180 452 INDEX Tuberculosis of lungs, caseous peri- bronchitis in, 181 pneumonia in, 182 morbid anatomy, 181 course, 182 diagnosis, 183 morbid anatomy, 180 prognosis, 182 secondary tuberculosis in, 181 symptoms, 181 treatment, 183 of mesenteric nodes, 185 of peritoneum, 185 course, 187 diagnosis, 187 morbid anatomy, 185 origin, 185 prognosis, 187 symptoms, 186 treatment, 187 paths of dissemination, 170 peculiarities of, 170 phlyctenular keratoconjunctivi- tis in, treatment, 180 predisposition to, 170 preventing infection of suscep- tible children, 179 prophylaxis, 178 secondary, in pulmonary tuber- culosis, 181 special treatment, 179 transmission of, 168 treatment of, 178 Tuberculous meningitis, 187. See also Meningitis, tuberculous. pericarditis, 184 pleurisy, 183 Tumor albus, 195 pedis, 203 Tumors of brain, 224 Typhoid fever, 292 diagnosis, 293 morbid anatomy, 292 pea-soup stools in, 292 prognosis, 294 symptom-complex, 292 treatment, 294 Typhus inversus, 335 ULCERATIVE stomatitis, 344 diagnosis, 345 Ulcerative stomatitis, symptoms, 344 treatment, 345 Umbilical arteries, 86 fungus, 84 growths, 84 hemorrhage, 84 hernia, acquired, 81 treatment, 82 congenital, 81 funicular, 81 Umbilicus, diseases of, 81 gangrene of, 85 infection of, '85 treatment, 86 normal, treatment, 81 pyorrhea of, 85 Undescended testes, 400 treatment, 402 Uric-acid infarcts in newborn, 391 Urinary concretions, 391 Urine, examination, 67 excretion, 35 Urticaria, 428 symptoms, 429 treatment, 429 VACCINATION against variola, '271 Vapor apparatus, 325 Varicella, 273 confluens, 274 bullosa vi-1 tuemorrhagica, '-74 differential diagnosis. L'7 1 duration, 274 eruption, 273 period of inrubation. '_'7.i treatment, 274 Variola, 267 black, 269 confluent, 269 desiccation fever of, 268 diagnosis, 269 hemorrhagica pnstnlosa, 269 incubation period, 2C>7 prognosis, '_'!'.> prophylaxis, 269 stage of desiccation, 268 of eruption, 267 of suppuration, _'<'> 7 suppuration fever. L'l'iS symptom-complex, 268 INDEX 453 Variola, treatment, 269 vaccination against, 271 Vascular nevi, 406 Vertebrae, anatomy, 20 in rachitis, 119 tuberculous caries of, 196 results, 198 symptoms, 197 treatment, 198 Vertigo, epileptic, 243 Vesical calculi, 393 diagnosis, 394 prognosis, 394 symptoms, 393 treatment, 394 Vision, 35 Vitality, general loss of, in new- born, 75 Vomiting, habitual, 354 Vulva, cellular atresia of, 403 diphtheria of, 279 gangrene of, 405 noma of, 405 phlegmon of, 405 Vulvovaginitis, 404 gonorrheal, treatment, 404 symptoms, 404 WARM baths, 70 Weaning, indications for, 43 Weighing child, 66 Weight, increase in, 30 White kidney, large, 391 pneumonia, 160 swelling of knee, 201 Whooping-cough, 296. 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Cloth, 3.00 net. DEALING WITH THE SURGICAL ASPECT This new atlas covers one of the most important subjects in the entire domain of medical teaching, since these hernias are not only exceedingly common, but the frequent occurrence of strangulation demands extraordi- narily quick and energetic surgical intervention. During the last decade the operative side of this subject has been steadily growing in importance, until now it is absolutely essential to have a book treating of its surgical aspect This present atlas does this to an admirable degree. The illustrations are not only very numerous, but they excel, in the accuracy of the portrayal of the conditions represented, those of any other work upon abdominal hernias with which we are familiar. The work will be found a worthy exponent of our present knowledge of the subject of which it treats. PERSONAL AND PRESS OPINIONS Robert H. M. Dawbarn, M. D.. Proftsior of Surgery and Surgical Anatomy, New York Poly clime. " I have spent several interested hours over it to-day, and shall willingly recommend it to my classes at the Polyclinic College and elsewhere." Boston Medical and Surgical Journal " For the general practitioner and the surgeon it will be a very useful book for reference. The book's value is increased by the editorial notes of Dr. Coley." They have already appeared in thirteen different languages SAUNDEKS' MEDICAL HAND-ATLASES ^ Bruhl, Politzer, and MacCuen Smith's Otology Atlas and Epitome of Otology. By GUSTAV BRUHL, M. D., of Berlin, with the collaboration of Professor DR. A. POLITZER, of Vienna. Edited, with additions, by S. MACCUEN SMITH, M. D., Professor of Otology in the Jefferson Medical Col- lege, Philadelphia. With 244 colored figures on 39 lithographic plates, 99 text-illustrations, and 292 pages of text. Cloth, 3.00 net. This excellent volume is the first attempt to supply in English an illus- trated clinical handbook to act as a worthy substitute for personal instruction in a specialized clinic. This work is both didactic and clinical in its teach- ing, the latter aspect being especially adapted to the student's wants. Clarence J. Blake, M. D.. Professor of Otology, Harvard University Medical School, Boston. " The most complete work of its kind as yet published, and one commending itself to both the student and teacher in the character and scope of its illustrations." Grunwald and Newcomb's Mouth, Pharynx, Nose Atlas and Epitome of Diseases of the Mouth, Pharynx, and Nose. By DR. L. GRUNWALD, of Munich. Edited, with additions, by JAMES E. NEWCOMB, M. D., Instructor in Laryng- ology, Cornell University Medical School. With 200 illustra- tions on 42 colored lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, $3.00 net. Journal of Ophthalmology, Otology, and Laryngology "A collection of the most naturally colored lithographic plates that has been pub- lished in any book in the English language. . . . Very valuable alike to the student, the practitioner, and the specialist." They are offered at a price heretofore unapproached in cheapness 8 SAUNDERS' MEDICAL HAND-ATLASES Sobotta and Huber's Human Histology Atlas and Epitome of Human Histology. By PR. DR. J. SOBOTTA, of Wiirzburg. Edited, with additions, by G. CARL HUBER, M. D. , Professor of Histology and Embryology, Univer- sity of Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 text-cuts, and 248 pages of text. Cloth, $4.50 net. This work combines an abundance of well chosen and most accurate illus- trations with a concise text, and in such a manner as to make it both atlas and text-book. The colored lithographic plates have been produced with the aid of over thirty colors, and particular care was taken to avoid distortion and assure exactness of magnification. Boston Medical and Surgical Journal " In color and proportion they are characterized by gratifying accuracy and litho- graphic beauty. . . . May be highly recommended to those who are without access to his- tologic collections." Haab and deSchweinitz's Operative Ophthalmology Atlas and Epitome of Operative Ophthalmology. By DR. O. HAAB, of Zurich. Edited, with additions, by GEORGE E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in the University of Pennsylvania. With 30 colored lithographic plates, 154 text-cuts, and 377 pages of text. Cloth, 3.50 net. RECENTLY ISSUED This new volume forms an admirable conclusion of the series of atlases on the Eye prepared by Professor Haab. Operations are described with all the fidelity and clearness that thirty years' conscientious practice in eye work naturally brings. The colored illustrations exhibit the same perfection of art and accurate-ness of detail which are found only in this invaluable series of atlases. Unsurpassed for accuracy, pictorial beauty, completeness, cheapness SAUNDERS' MEDICAL HAND-ATLASES 9 Haab and deSchweinitz's Ophthalmoscopy Atlas and Epitome of Ophthalmoscopy and Ophthal- moscopic Diagnosis. By DR. O. HAAB, of Zurich. From the Third Revised and Enlarged German Edition. Edited, with additions, by G. E. DESCHWEINITZ, M. D., Professor of Oph- thalmology, University of Pennsylvania. With 152 colored lithographic illustrations; 85 pages of text. Cloth, $3.00 net. Not only is the student made acquainted with carefully prepared oph- thalmoscopic drawings done into well-executed lithographs of the most important fundus changes, but, in many instances, plates of the microscopic lesions are added. It furnishes a manual of the greatest possible service. The Lancet, London " We recommend it as a work that should be in the ophthalmic wards or in the library of every hospital into which ophthalmic cases are received." Haab and deSchweinitz's External Diseases of Eye Atlas and Epitome of External Diseases of the Eye. By DR. O. HAAB, of Zurich. Edited, with additions, by G. E. DESCHWEINITZ, M. D., Professor of Ophthalmology, University of Pennsylvania. 98 colored illustrations on 48 lithographic plates and 232 pages of text. Cloth, $3.00 net. SECOND REVISED EDITION RECENTLY ISSUED In this thorough revision the text has been brought up to date by the addi- tion of new matter, including references to some of the modern therapeutic agents. There have also been added eight chromolithographic plates. The Medical Record, New York " The work is excellently suited to the student of ophthalmology and to the practising physician. It cannot fail to attain a well-deterved popularity." (Review of previous ed.) They are convenient in size and uniformly bound 10 SAUNDERS' MEDICAL HAND-ATLASES Durck and Hektoen's General Pathologic Histology Atlas and Epitome of General Pathologic Histology. By PR. DR. H. DURCK, of Munich. Edited, with additions, by LUDVIG HEKTOEN, M. D., Professor of Pathology, Rush Medical College, Chicago. 172 colored figures on 77 lithographic plates, 36 text-cuts, many in colors, and 453 pages of text. $5.00 net. JUST ISSUED This new atlas gives the accepted views in regard to the significance of pathologic processes. All the illustrations have been made from original specimens without combining different microscopic fields. Extraordinary care has been taken to reproduce them as near perfection as possible, in many cases twenty-six colors being required. Durck and Hektoen's Special Pathologic Histology Atlas and Epitome of Special Pathologic Histology. By DR. H. DURCK, of Munich. Edited, with additions, by LUDVIG HEKTOEN, M. D., Professor of Pathology, Rush Medical College, Chicago. In Two Parts. Part I. Circulatory, Respira- tory, and Gastro-intestinal Tracts. Part II. Liver, Urinary and Sexual Organs, Nervous System, Skin, Muscles, and Bones. 243 colored figures on 122 plates, and 350 pages of text. Per part: Cloth, $3,00 net. William H. Welch, M. D.. Profetsor of Pathology, Johns Hopkins University, Baltimore. " I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very useful book for students and others. The plates are admirable." They represent the best artistic and professional talent SAUNDERS* MEDICAL HAND-ATLASES n Lehmann, Neumann, and Weaver's Bacteriology Atlas and Epitome of Bacteriology : INCLUDING A TEXT- BOOK OF SPECIAL BACTERIOLOGIC DIAGNOSIS. By PROF. DR. K. B. LEHMANN and DR. R. O. NEUMANN, of Wiirzburg. From the Second Revised and Enlarged German Edition. Edited, with additions, by G. H. WEAVER, M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical College, Chicago. In two parts. Part I. 632 colored figures on 69 lithographic plates. Part II. 511 pages of text, illustrated. Per part: Cloth, $2.50 net. INCLUDING SPECIAL BACTERIOLOGIC DIAGNOSIS This work furnishes a survey of the properties of bacteria, together with the causes of disease, disposition, and immunity, reference being constantly made to an appendix of bacteriologic technic. The special part gives a complete description of the important varieties, the less important ones being mentioned when worthy of notice. The lithographic plates, as in all this series, are accurate representations of the conditions as actually seen, and this collection, if anything, is more handsome than any of its predecessors. As an aid in original investigation the work is invaluable. OPINIONS OP THE MEDICAL PRESS American Journal of the Medical Sciences " Practically all the important organisms are represented, and in such a variety oi forms and cultures that any other atlas would rarely be needed in the ordinary hospital laboratory." The Lancet, London " We have found the work a more trustworthy guide for the recognition of unfamiliar species than any with which we are acquainted." There have been 82,000 copies imported since publication 12 SAUNDERS* MEDICAL HAND-ATLASES Schaffer and Edgar's Labor arid Operative Obstetrics Atlas and Epitome of Labor and Operative Obstetrics. By DR. O. SCHAFFER, of Heidelberg. From the Fifth Revised and Enlarged German Edition. Edited, with additions, by J. CLIFTON EDGAR, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 14 lithographic plates in colors; 139 other cuts; in pages of text. $2.00 net. The book presents the act of parturition and the various obstetric opera- tions in a series of easily understood illustrations. These are accompanied by a text that treats the subject from a practical standpoint. Dublin Journal of Medical Science, Dublin Schaffer & Edgar's Obstetric Diagnosis and Treatment Atlas and Epitome oi Obstetric Diagnosis and Treat- ment. By DR. O. SCHAFFER, of Heidelberg. From the Sec- ond Revised German Edition. Edited, with additions, by J. CLIFTON EDGAR, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 122 colored fig- ures on 56 plates; 38 other cuts; 315 pages of text. 3.00 net. This book treats particularly of obstetric operations, and, besides the wealth of beautiful lithographic illustrations, contains an extensive text of great value. This text deals with the practical, clinical side of the subject. New York Medical Journal " The illustrations are admirably executed, as they are in all of these atlases, and the text can safely be commended, not only as elucidatory of the plates, but as expounding the scientific midwifery of to-day. These are the famous " Lehmann medicinische Handatlanten " SAUNDERS' MEDICAL HAND-ATLASES 13 Mracek and Stelwagon's Skin Atlas and Epitome of Diseases of the Skin. By PROF. DR. FRANZ MRACEK, of Vienna. Edited, with additions, by HENRY W. STELWAGON, M. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With 77 colored plates, 50 text-cuts, and 288 pages of text. Cloth, $4.00 net. JUST ISSUED NEW (2d) EDITION This volume, the outcome of years of scientific and artistic work, con- tains, together with colored plates of unusual beauty, numerous illustrations in black, and a text comprehending the entire field of dermatology. The illustrations are all original and prepared from actual cases in Mracek' s clinic. American Journal of the Medical Sciences " The advantages which we see in this book and which recommend it to our minds are : First, its handiness; secondly, the plates, which are excellent as regards drawing, color, and the diagnostic points which they bring out. We most heartily recommend it." Mracek and Bang's Syphilis arid Venereal Diseases Atlas and Epitome of Syphilis and the Venereal Dis- eases. By PROF. DR. FRANZ MRACEK, of Vienna. Edited, with additions, by L. BOLTON BANGS, M. D., late Prof, of Genito- Urinary Surgery, University and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, $3.50 net: According to the unanimous opinion of numerous authorities, to whom the original illustrations of this book were presented, they surpass in beauty anything of the kind that has been produced in this field, not only in Ger- many, but throughout the literature of the world. Robert L. Dickinson, M. D., Art Editor of " The American Text- Book of Obstetrics." " The book that appeals instantly to me for the strikingly successful, valuable, and ter of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' praphic charac : know of nothing in this country that can compare with it." The lithographs, all made in Germany, are unrivalled 14 SAUNDERS* MEDICAL HAND-ATLASES Schaffer and Webster's Operative Gynecology Atlas and Epitome of Operative Gynecology. By DR. O. SCHAFFER, of Heidelberg. Edited, with additions, by J. CLARENCE WEBSTER, M. D. (EDIN.), F. R. C. P. E., Professor of Obstetrics and Gynecology in the Rush Medical College, in affili- ation with the University of Chicago. With 42 lithographic plates in colors, many text-cuts, a number in colors, and 138 pages of text. Cloth, #3.00 net. RECENTLY ISSUED The excellence of the lithographic plates and the many other illustrations in this atlas render it of the greatest value in obtaining a sound and practical knowledge of operative gynecology. Indeed, the artist, the author, and the lithographer have expended much patient endeavor in the preparation of the water-colors and drawings. They are based on hundreds of photographs taken from nature, and they reproduce faithfully and instructively the various situations. The text closely follows the illustrations, and is fully as accurae. Shaffer and Morris' Gynecology Atlas and Epitome of Gynecology. By DR. O. SHAFFER, of Heidelberg. From the Second Revised and Enlarged German Edition. Edited, with additions, by RICHARD C. NORRIS, A. M., M. D., Gynecologist to Methodist-Episcopal and Philadelphia Hospitals. With 207 colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. The value of this atlas will be found not only in the concise explanatory text, but especially in the illustrations. The large number of colored plates, reproducing the appearance of fresh specimens, will give the student a knowl- edge of the changes induced by disease that cannot be obtained from mere description. Bulletin of Johns Hopkins Hospital, Baltimore " The book contains much valuable material. Rarely have we seen such a valuable collection of gynecological plates." Thet books *re next Lett to actual clinical work S A UNDER S' MEDICAL HAND- ATLASES 15 Jakob and Eshner's Internal Medicine & Diagnosis Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By DR. CHR. JAKOB, of Erlangen. Edited, with additions, by AUGUSTUS A. ESHNER, M. D., Professor of Clin- ical Medicine in the Philadelphia Polyclinic. With 182 colored figures on 68 plates, 64 illustrations in black and white, and 2 59 pages of text. Cloth, #3.00 net. In addition to an admirable atlas of clinical microscopy, this volume describes the physical signs of all internal diseases in an instructive manner by means of fifty colored schematic diagrams. As a means of instruction its value is very great ; as a reference handbook it is admirable. British Medical Journal " Dr. Jakob's work deserves nothing but praise. The information is accurate and up to present-day requirements." Grunwald and Grayson's Diseases of the Larynx Atlas and Epitome of Diseases of the Larynx. By DR. L. GRUNWALD, of Munich. Edited, with additions, by CHARLES P. GRAYSON, M. D., Clinical Professor of Laryngology and Rhinology, University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2.50 net. This atlas exemplifies a happy blending of the didactic and clinical, such as is not to be found in any other volume upon this subject. The author has given special attention to the clinical portion of the work, the sections on diagnosis and treatment being particularly full. The Medical Record, New York " This is a good work of reference, being both practical and concise. ... It is a valu- able addition to existing laryngeal text-books." For " Special Offer " regarding these atlases see page I 16 SAUNDERS 1 MEDICAL HAND-ATLASES Hofmann and Peterson's Legal Medicine Atlas of Legal Medicine. By DR. E. VON HOFMANN, of Vienna. Edited by FREDERICK PETERSON, M. D. , Clinical Pro- fessor of Psychiatry, College of Physicians and Surgeons, N. Y. 120 colored figures on 56 plates, 193 text-cuts. #3.50 net. The Practitioner, London " The illustrations appear to be the best that have ever been published in connection with this department of medicine, and they cannot fail to be useful alike to the medical jurist and to the student of forensic medicine." Jakob and Fisher's Nervous System and its Diseases Atlas and Epitome of the Nervous System and its Diseases. By PROF. DR. CHR. JAKOB, of Erlangen. From the Second Revised German Edition. Edited, with additions, by EDWARD D. FISHER, M. D., Professor of Diseases of the Nervous System, University and Bellevue Hospital Medical College, N. Y. 83 plates and copious text. Cloth, #3.50 net. Philadelphia Medical Journal "We know of no one work of anything like equal size which covers this important and complicated field with the clearness and scientific fidelity of this hand-atlas." Golebiewski and Bailey's Accident Diseases Atlas and Epitome of Diseases Caused by Accidents. By DR. ED. GOLEBIEWSKI, of Berlin. Edited, with additions, by PEARCE BAILEY, M. D., Consulting Neurologist to St. Luke's Hospital and Orthopedic Hospital, N. Y. 71 colored illustrations on 40 plates, 143 text-cuts, 549 pages of text. Cloth, $4.00 net. Medical Examiner and Practitioner " It is a useful addition to life-insurance libraries, for lawyers, physicians, and for every one who is brought in contact with the treatment or consideration of accidents or diseases growing out of them, or legal complications flowing from them." The "Atlas of Operative Surgery" has been adopted by U. S. Army SAUNDERS' MEDICAL HAND-ATLASES Atlas and Epitome of External Diseases of the Eye. By DR. O. HAAB, of Zurich. Edited, with additions, by G. E. DE SCHWEINITZ, M.D., Professor of Ophthalmology in the University of Penn- sylvania. Second Revised Edition. With 98 colored illustrations on 48 plates and 232 pages of text. Cloth, $3.00 net. " The work is well done, and is valuable to physicians in general, as well as to ophthal- mologists. I shall take pleasure in recommending it." JOHN E. WEEKS, M.D.. Clinical Professor of Ophthalmology, University of Bellevue Hospital Medical School, N. Y Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By DR. CHR. JAKOB, of Erlangen. Edited, with addi- tions, by AUGUSTUS A. ESHNER, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. With 179 colored figures on 68 plates and 259 pages of text. Cloth, $3.00 net. " Dr. Jakob's work deserves nothing but praise. The information is accurate and up to present-day requirements." British Medical Journal. Atlas of Legal Medicine. By DR. E. VON HOFMANN, of Vienna. Edited, with additions, by FREDICRICK PETERSON, M. D., Clinical Pro- fessor of Psychiatry, College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates and 193 half-tone illustrations. Cloth, $3.50 net "It is rare indeed that so large a series of illustrations are found which demonstrate so well and so accurately the conditions which they are supposed to represent." Boston Medical and Surgical Journal Atlas and Epitome of Diseases of the Larynx. By DR. L. GRUNWALD, of Munich. Edited, with additions, by CHARLES P. GRAYSON, M.D., Clinical Professor of Laryngology and Rhinology in the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. . Cloth, $2.50 net. " Excels everything we have hitherto seen in the way of colored illustrations of disease! of the larynx." British Medical Journal. Atlas and Epitome of Operative Surgery. By DR. O. ZucKERKANDL, of Vienna. From the Second Revised and Enlarged Ger- man Edition. Edited, with additions, by J. CHALMERS DACosTA, M.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. Second Edition, Revised and Greatly En- larged. With 40 colored plates, 278 text-cuts, and 410 pages of text. Cloth, 3.50 net. " It may be said that few, if any, books of this description are so comprehensive in their scope." Philadelphia Medical Journal. Atlas and Epitome of Syphilis and the Venereal Dis- eases. By PROF. DR. FRANZ MRACEK, of Vienna. Edited, with ad- ditions, by L. BOLTON BANGS, M.D., late Professor of Genito-Urinary Sur- gery, University and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, J>3-5O net. "A glance through the book is almost like actual attendance upon a famous clinic." Journal of the American Medical Association. Atlas and Epitome of Skin Diseases. By PROF. DR. FRANZ MRACEK, of Vienna. Edited, with additions, by HENRY W. STELWAGON, M.D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With 77 colored plates, 50 half-tone illustrations, and 288 pages of text. " The illustrations are very well executed, and the coloring remarkably accurate ; they will serve as substitutes for clinical observation." Medical Record, New York. Atlas of Bacteriology and Text-Book of Special Bac- teriologic Diagnosis. By PROF. DR. K. B. LEHMANN and DR. R. O. NEUMANN, of Wiirzburg. From the Second Revised and Enlarged German Edition. Edited, with additions, by G. H. WEAVER, M.D., As- sistant Professor of Pathology and Bacteriology, Rush Medical College, Chicago. Two volumes. Part I. 632 colored figures on 69 plates. Part II. 5 11 pages of text, illustrated. Per volume: Cloth, $2.50 net. " The illustrations . . . are works of art ; they are true in color and relationship and are much superior to the usual photographic reproductions." Buffalo Medical Journal, University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. Biomedical Librar Biomedical Library JUN 1 2 1991 JUN 101991 2 WEEK RECEIVED CAT NO 24 161 KK- ln LCtS. cin, _350 net. eau- - the don. to< idi- Tie's ext- ~net. >the -iical B' : >red t. iet. ibl* t -u 1 et- rised Dfes- tool. "net. nical nd fond C. nell ,38 net. rtific its /A/ ions, tern, ites; net. by E. Unive 215 p: 'the^ne *"""" Mtdicint. of Ophthalmoscopy and pphthal- lOSiS By DR. O. HAAB, of Zunch. From the TkirdKansea ana enlarged Gtrman Edition Edited with ^ditiow, by G E DESCHWKINITZ, M.D., Professor of Ophthalmology in th versity of Pennsylvania. With 152 colored figures; 82 pages ot text. Nowb.e SAUNDERS' MEDICAL HAND-ATLASES Atlas and Epitome of Otology. lin, with the collaboration of PRO" 7 ^~ with additions, by S. MxcCuEN the Jefferson Medical College, PI \1\\\\\\\\\\\\\\\\\P W\ " ""- , -, Q lithographic plates, 99 text-cuts, a. QOO ^ " ~~ uel< Atlas and Epitome of Abdc . .ornias. By PRIVATDO- CENT DR. GEORG SULTAN, of Gottiugen. Edited, with additions, by WIL- LIAM B. COLEY, M.D., Clinical Lecturer on Surgery, Columbia Univer- sity, N. Y. 119 illustrations, 36 in colors; 277 pages of text. Cloth, 13.00 net. Atlas and Epitome of Traumatic Fractures and Dislo- cations. By PROF. DR. H. HELFERICH, of Greifswald. Edited, with additions, by JOSEPH C. BLOODGOOD, M.D., Associate in Surgery, Johns Hopkins University, Baltimore. With 216 colored figures on 64 litho- graphic plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. CO S CD Atlas and Ep i4- * rk! ~~>~*+u M/MI, DHarvrt*. o9 and NOP <% Revised at JAMES E. University plates, 41 Atlas anc scop with V7S200 Embr . . figures H4498. 1907 Atlas a SCHA iecker, Rudolf. STUR, AtlaF and epitome of diseases of colog' Chica childre n. figures Atlas By PR LUDVI Chicaj ures, i Atlas j DR. C ITZ, \ 30 col Atlas of I MEDICAL SCIENCES LIBRARY Prof 44 1 UNIVERSITY OF CALIFORNIA, IRVINE Atlas R. 1 IRVINE, CALIFORNIA 92664 lege W. B.