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THE
CASE HISTORY SERIES
CASE HISTORIES IN MEDICINE
BY
Richard C. Cabot, M.D.
Second edition, revised and enlarged
CASE HISTORIES IN PEDIATRICS
BY
John Lovett Morse, M.D.
Second edition, revised and enlarged
ONE HUNDRED SURGICAL PROBLEMS
BY
James G. Mumfofd, M.D.
CASE HISTORIES IN NEUROLOGY
BY
E. W. Taylor, M.D.
lCASE histories
IN
PEDIATRICS "!
A COLLECTION OF HISTORIES OF ACTUAL PATIENTS SE-
LECTED TO ILLUSTRATE THE DIAGNOSIS, PROGNOSIS
AND TREATMENT OF THE DISEASES OF INFANCY
AND CHILDHOOD, WITH AN INTRODUCTORY
SECTION ON THE NORMAL DEVELOP-
MENT AND PHYSICAL EXAMINA-
TION OF INFANTS AND
CHILDREN
JOHN LOVETT MORSE, A.M., M.D.
Associate Professor of Pediatrics, Harvard Medical School ; Associate Visiting Physician
at the Infants' Hospital and at the Children's Hospital, Boston.
SECOND EDITION
BOSTON
W. M. LEONARD, Publisher
1913
I °n3
Copyright^ igij,
By W. M. Leonard.
TO
THOMAS MORGAN ROTCH. M.D..
THE FATHER OF PEDIATRICS IN NEW ENGLAND.
THE ORGANIZER OF
THE DEPARTMENT OF PEDIATRICS
IN THE
HARVARD MEDICAL SCHOOL
AND THE
FOUNDER OF MODERN SCIENTIFIC INFANT FEEDING.
PREFACE TO THE FIRST EDITION
The author has found this method of case teaching so useful in
the instruction not only of undergraduates but also of graduate
students, who, although older and wiser than in their undergraduate
days, are still students in the best and widest sense, that he felt
that there was need for the utilization of this method for the
presentation of the subject of pediatrics to the practitioner.
Case teaching, which had been in use for a number of years in
the Harvard Law School, was introduced into the Harvard Medical
School in 1900 at the suggestion of Prof. W. B. Cannon, then a
student in the school. The author believes that this method of
teaching is far superior to recitations, quizzes, and conferences.
One of its greatest advantages is that it compels the student to
think for himself. It is almost as valuable as the clinical lecture,
in which the patient is shown, and, except in special instances, is
more instructive than the didactic lecture. It is surpassed only
by bedside instruction to small groups of students.
PREFACE TO THE SECOND EDITION
The number of case histories has been doubled in this edition in
order to cover the subject of Pediatrics more fully. An intro-
ductory section on the Normal Development and Physical Exam-
ination of Infants and Children has been added, because it was
believed that the readers would be able to study and analyze the
cases better, if they were familiar with the normal development
and methods of examination. Several reviewers of the first edition
found fault because the diagnosis was not given at the head of each
case, not realizing, apparently, that it was omitted in order that
the reader might study it out for himself. The main object of the
book is to present a series of problems to be solved by the reader.
This object would be defeated, if the diagnosis was given in the
beginning. Several reviewers have complained that there was
nothing to show whether or not the diagnoses and prognoses were
correct. It never occurred to the writer that any one would sup-
pose that they were not. Consequently, nothing was said about
it. As a matter of fact, the diagnoses are correct in every instance
in which a positive diagnosis is made. In a few, in which a prob'
able diagnosis only is made, the children are still alive. The prog-
noses are all absolutely correct, except in a few chronic cases in
which, the children being still alive, it is impossible to give exact
data as to the duration of life. The treatment recommended in
the text was that actually employed.
TABLE OF CONTENTS
Page
The Normal Development and Physical Examination of Infants ;
and Children 11-62
Diseases of the New-born.
Case 1. Prematurity 63
2. Cystic Hygroma of the Neck 66
3. Congenital Malformation of the Intestine 68
4. Congenital Obliteration of the Bile Ducts 70
5. Encysted Hydrocele of the Cord 72
6. Cephalhematoma 74
7. Obstetric Paralysis 76
8. Hematoma of the Sternocleidomastoid Muscle 79
9. Congenital Atelectasis 81
10. Congenital Laryngeal Stridor . 84
11. Congenital Malformation of the Esophagus 86
12. Physiological Engorgement of the Breasts 89
13. Icterus Neonatorum 90
14. Sclerema Neonatorum 92
15. Granuloma of the Navel 94
16. Prolapse of Meckel's Diverticulum 96
17. Hemorrhagic Disease of the New-born 98
18. Hemorrhagic Disease of the New-born 102
19. Septic Infection of the New-born 105
20. Omphalitis and Septic Infection of the New-born 108
21. Septic Infection of the New-born no
22. Erysipelas of the New-born 112
Diseases of the Gastro-enteric Tract.
Case 23. Organic Stricture of the Esophagus 118
24. Spasm of the Pylorus 121
25. Infantile Pyloric Stenosis 124
26. Nervous Vomiting 127
27. Recurrent Vomiting 129
28. Acute Gastric Indigestion 133
29. Chronic Gastric Indigestion 136
30. Chronic Gastric Indigestion 140
31. Congenital Dilatation of the Colon 143
32. Intussusception 146
^. Intussusception 149
34. Intussusception 152
35. Incontinence of Feces 155
36. Constipation 157
37. Constipation of the Spasmodic Type. Fissure of the Anus 160
38. Acute Duodenal Indigestion 163
39. Acute Duodenal Indigestion 166
40. Chronic Duodenal Indigestion 168
41. Acute Intestinal Indigestion of the Fermentative Type .... 171
42. Chronic Intestinal Indigestion 174
43. Chronic Intestinal Indigestion 177
44. Chronic Intestinal Indigestion 181
45. Intestinal Indigestion from an excess of Proteids in the Breast
Milk 185
46. Acute Gastric and Intestinal Indigestion 187
47. Indigestion from an Excess of Fat in the Food 189
7
8 CONTENTS
Diseases of the Gastroenteric Tract (Continued). Page
Case 48. Indigestion from an Excess of Proteids in the Food 192
49. Appendicitis 195
50. Appendicitis 198
51. Infectious Diarrhea 201
52. Cholera Infantum 204
53. Pin-worms 206
54. Round Worms 208
55. Tape Worm 210
Diseases of Nutrition.
Case 56. Malnutrition from an Insufficient Supply of Food 213
57. Malnutrition from an Insufficient Amount of Proteid in the Food 217
58. Malnutrition from an Insufficient Amount of Breast Milk . . . 220
59. Rickets. Atelectasis of the Lung 223
60. Rickets and Secondary Anemia 226
61. Late Rickets 230
62. Scurvy 234
63. Scurvy 238
64. Infantile Atrophy 240
Specific Infectious Diseases.
Case 65. Tubercular Peritonitis 243
66. Tubercular Peritonitis 247
67. Tubercular Peritonitis 250
68. Pulmonary Tuberculosis 253
69. Pulmonary Tuberculosis 255
70. Pulmonary Tuberculosis 257
71. Chronic Diffuse Tuberculosis 259
72. Tubercular Meningitis 262
73. Tubercular Meningitis 266
74. Tubercular Meningitis 269
75. Cerebrospinal Meningitis 272
76. Cerebrospinal Meningitis 275
77. Typhoid Fever 278
78. Typhoid Fever 281
79. Typhoid Fever with Enlargement of the Mesenteric Glands . . 284
80. Diphtheritic Rhinitis 287
81. Laryngeal Diphtheria 289
82. Influenza 292
83. Malaria 294
84. Periosteitis. Osteomyelitis 296
85. Periosteitis and Osteomyelitis 298
86. Syphilitic Rhinitis 300
87. Syphilitic Epiphysitis 304
88. Syphilitic Osteoperiosteitis 307
89. Chicken-pox 310
90. Measles 312
91. German Measles 314
92. Scarlet Fever 317
93. Scarlet Fever 320
94. Mumps 323
95. Whooping-cough 325
Diseases of the Nose, Throat, Ears and Larynx.
Case 96. Adenoids 329
97. Adenoids 331
98. Catarrhal Laryngitis 333
99. Retropharyngeal Abscess 335
100. Laryngismus Stridulus 338
101. Otitis Media 341
102. Otitis Media 344
103. Otitis Media 346
CONTENTS 9
Diseases of the Bronchi, Lungs and Pleura. Page
Case 104. Bronchitis 349
105. Bronchitis 351
106. Bronchitis 353
107. Foreign Body in Bronchus 355
108. Asthma 357
109. Asthma 360
no. Bronchopneumonia 363
in. Bronchopneumonia 366
112. Pneumonia 369
113. Pneumonia 372
114. Pneumonia 376
115. Serous Pleurisy 379
116. Purulent Pleurisy 383
117. Encapsulated Empyema 387
118. Interlobar Empyema 390
119. Pneumothorax 394
120. Sarcoma of the Lung and Liver 396
Diseases of the Heart and Pericardium.
Case 121. Congenital Heart Disease 399
122. Congenital Heart Disease 402
123. Congenital Heart Disease 404
124. Functional Heart Disease 407
125. Acute Endocarditis 410
126. Malignant Endocarditis 413
127. Chronic Valvular Disease of the Heart 416
128. Myocarditis 419
129. Pericarditis with Effusion 422
130. Pericarditis with Effusion 425
131. Chronic Adhesive Pericarditis 429
Diseases of the Liver.
Case 132. Fatty Liver 433
133. Cirrhosis of the Liver 436
134. Malignant Disease of the Liver 439
Diseases of the Kidneys and Bladder.
Case 135. Orthostatic Albuminuria 441
136. Hematuria 444
137. Acute Nephritis 446
138. Pyelitis 452
139. Pyelitis 455
140. Sarcoma of the Kidney 457
141. Chronic Parenchymatous Nephritis 459
142. Nocturnal Enuresis 462
Diseases of the Blood.
Case 143. Secondary Anemia 465
144. Secondary Anemia 468
145. Secondary Anemia with Splenic Tumor 471
146. Pernicious Anemia of the Aplastic Type 475
147. Lymphatic Leukemia 479
148. Lymphatic Leukemia 482
149. Anemia with Splenic Tumor 484
150. Pseudoleukemia 488
151. Band's Disease 491
Diseases of the Nervous System.
Case 152. Habit Spasms 495
153. Pavor Nocturnus 498
154. Epilepsy 500
IO CONTENTS
Diseases of the Nervous System (Continued). Page
Case 155. Epilepsy. Chorea 503
156. Reflex Convulsions 507
157. Pseudomasturbation 510
158. Microcephalic Idiocy 513
159. Amaurotic Idiocy 515
160. Mongolian Idiocy 518
161. Chronic Internal Hydrocephalus 521
162. Chronic Internal Hydrocephalus 524
163. Chronic Internal Hydrocephalus 527
164. Tetany 530
165. Cerebral Hemorrhage 533
166. Cerebral Paralysis 536
167. Influenza Meningitis 538
168. Pneumococcus Meningitis 540
169. Serous Meningitis 542
170. Encephalitis 544
171. Infantile Paralysis 548
172. Infantile Paralysis 550
173. Infantile Paralysis 553
174. Diphtheritic Paralysis 556
175. Erb's Paralysis 558
176. Cerebellar Tumor 561
177. Hysterical Paralysis 564
178. Sarcoma of the Brain and Skull 566
179. Amyotonia Congenita 568
Unclassified Diseases.
Case 180. Sporadic Cretinism 571
181. Enlargement of the Thymus 574
182. Enlargement of the Thymus 578
183. Status Lymphaticus 581
184. Cervical Adenitis 585
185. Bronchial Adenitis 588
186. Purpura 591
187. Idiopathic Dropsy 595
188. Idiopathic Dropsy 598
189. Angioneurotic Edema 601
190. Erythema Multiforme 604
191. Antitoxin Poisoning 606
192. Diabetes Mellitus 608
193. Diabetes Mellitus 611
194. Diabetes Insipidus 614
195. Osteogenesis Imperfecta 617
196. Still's Disease 619
197. Acute Arthritis of Infants 623
198. Difficult Dentition 625
199. Noma 627
200. Cyst of the Mesentery 629
SECTION I.
THE NORMAL DEVELOPMENT AND PHYSICAL
EXAMINATION OF INFANTS AND CHILDREN.
A careful and complete physical examination is of even
greater value in diagnosis in early life than in adult life,
because the baby and young child can tell little or nothing
as to their subjective symptoms. In fact, except in the
diseases of the gastroenteric tract, the diagnosis must be
made almost entirely on the findings of the physical exami-
nation. It is, moreover, easy to misinterpret these findings,
unless the normal development at different ages is known,
because what is normal at one age is abnormal at another.
Unless due attention is paid to these differences, mistakes
are almost certain to arise. While the methods of exami-
nation employed are the same at all ages, the relative value
of these methods varies with the age of the patient, and
due allowance must be made for these differences. These
methods also have to be modified in many ways before they
are applicable to infants and young children. The attempt
has been made in the following pages to give the chief
points in relation to the normal regional anatomy and
development of children and to describe the proper methods
of examination.
Growth in Height and Weight. The rate of growth is very
rapid in the beginning, especially in the first year. It is still
rapid, but less so, up to six years. It is then comparatively
slow until the prepubertal acceleration, which begins in girls
at about eleven years and in boys at about thirteen years,
and lasts several years.
The rate of growth in height and weight are not synchro-
nous during childhood, but show marked seasonal differences.
Growth in height is most rapid during the spring and the first
half of the summer and is often associated with an actual
ii
12
CASE HISTORIES IN PEDIATRICS.
loss of weight. It is least rapid during the latter part of the
summer and autumn. Growth in weight is most rapid
during the late summer and autumn and least rapid during
the late spring and early summer. In fact, there is often a
loss of weight during this period which is equal to, or greater
than, the gain during the winter and early spring.
Growth during First Five Years. The average weight of
American babies at birth is between seven and seven and
one-half pounds, the boys averaging a little heavier than the
girls. The average length of American babies at birth is
about twenty and one-half inches, the average length of the
boys being somewhat greater than that of the girls. There
are numerous statistics as to the rate of growth during the
first two years, but very few as to that during the next three
years. The average growth in length during the first year
is eight inches, and during the second year four inches. In
general, the birth weight is doubled at five months and nearly
trebled at a year. The only reliable figures as to the rate of
growth of American children during the third, fourth and
fifth years are those of Holt (Diseases of Infancy and Child-
hood, 1906, p. 20) which are based on observations on between
375 and 500 children. They are given in the following table.
TABLE I. — GROWTH IN HEIGHT AND WEIGHT DURING FIRST
FIVE YEARS.
Age.
Birth..
1 year.
2 years
3 years
4 years
5 years
Height.
Boys.
Inches.
20.6
29.O
32. S
35-0
38.O
4i-7
Cm.
52. 5
73-8
82.8
96.7
106.0
Girls.
Inches.
20.5
28.7
32.5
35-°
38.0
41.4
Cm.
52.2
73-2
82.8
89.1
96.7
i°5-3
Weight.
Boys.
Pounds.
7-55
20.5
26.5
31.2
35°
41.2
Kg.
3-43
9.29
12.02
14.14
iS-87
18.71
Girls.
Pounds.
7.16
19.8
25-5
30.0
34-0
39-8
Kg.
3.26
8.84
11.56
13.60
15-41
18.06
The heights and weights in this table are net; i.e., without shoes or clothes.
Growth from Five to Fifteen Years. There are several
large series of observations as to the growth of American
children after the first five years. Boas (Science, 1895, N. S.,
Vol. 1, p. 402) has calculated a table of heights from all the
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 3
available American material, comprising 45,151 boys and
43,298 girls, while Burk (American Journal of Psychology,
1897-8, Vol. 9, pp. 262-3) has calculated one of weights from
about 68,000 children. Their results are combined in the
following table.
TABLE II. — GROWTH IN HEIGHT AND WEIGHT FROM 5 TO
17 YEARS.
Age at last birthday.
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
Height.
Boys.
Inches. Cm.
41 -7
43-9
46.0
48.8
50.0
5i-9
53-6
55-4
57-5
60.0
62.9
64.9
105 -9
in. 5
116. 8
123.9
127.0
131-8
136. 1
140.7
146.0
i52-4
159-7
164.8
Girls.
Inches.
4i
43
45
47
49
5i
53-8
56.1
58. 5
60.4
61.6
62.2
Cm.
104.9
no. 1
116. o
121. 1
126.2
I3I-3
I36.6
142.4
148.5
153-4
I56-4
157-9
Weight.
Boys.
Pounds.
41.0
45-2
49-5
54-5
59-6
65.4
70.7
76.9
84.8
95-2
107.4
121 .0
Kg.
18.6
20.5
22.5
24.7
27.0
29-5
32.1
34-9
38.5
43-2
48.8
55-o
Girls.
Pounds
39
43
47
52
57
62
69
78
88
98
106
Kg.
18.0
19.7
21.6
23-8
26.0
28.5
31-5
35-7
40.3
44.6
48.5
5i .0
The heights in this table are without shoes.
The weights are with indoor clothes. These make up for boys approxi-
mately 8%, and for girls 7%, of the gross weight.
The term, " age at last birthday," is liable to give a wrong impression,
because the figures given are really average figures taken from all the children
from that birthday to the next. A more accurate term is the succeeding
half-year, i.e., 55 years instead of 5 years, the age at the last birthday.
Relative Growth of Extremities and Trunk. It is well
known that at birth the legs make up a much smaller pro-
portion of the total length of the body than they do in the
adult. There are, however, very few observations as to the
relation between the length of the legs and that of the body
at different ages. Holt (Diseases of Infancy and Childhood,
1906, p. 21) states that the distance from the anterior superior
spine of the ilium to the sole of the foot is 43% of the total
length at birth, 54% at five years, and 60% at sixteen years.
Vierordt (Gerhardt's Handbuch der Kinderkrankheiten,
Vol. 1, p. 77) quotes Zeising to the effect that the distance
from the crest of the ilium to the sole of the foot is at birth
50% of the total length of the body, 52.2% at one year,
14
CASE HISTORIES IN PEDIATRICS.
54-3% at two years, 56.1% at three years, 58.5% at five
years, 60.3% at eight years, 61.8% at thirteen years and
63.1% at sixteen years.
Head. The head is relatively large at birth, its circum-
ference being greater than that of the chest. It increases in
size very rapidly during the first year. The rate of growth
then becomes progressively slower and is very slow after five
years. Excepting in rare instances, such as marked hydro-
cephalus, the absolute size of the head is of less importance
in determining whether the head is of normal size or not than
the relation between that of the head and chest. The chest
grows faster than the head and surpasses it in size sometime
during the third year. The following table, copied from Holt
(Diseases of Infancy and Childhood, 1906, p. 20), shows the
relations between the head and chest at different ages.
TABLE III. — CIRCUMFERENCE OF HEAD AND CHEST.
Age.
Birth
6 months .
1 year. . .
2 years. .
3 years. .
4 years . .
5 years. .
10 years. .
15 years. .
Head.
Boys.
Inches.
9
Cm.
35-5
Girls.
Inches.
13-5
16.6
17.6
18.6
19.0
19-5
20.2
20.7
21-5
Cm.
345
42.2
44.6
47.2
48.4
496
51-3
52.8
54-8
Chest.
Boys.
Inches.
13-4
16. s
18.0
19.0
20.1
20.7
21-5
25.8
30.0
Cm.
34-2
42.0
45-9
48.4
Si- 1
52.8
54-8
65.6
76.6
Girls.
Inches.
13.0
16. 1
17-4
18.5
19.8
20. s
21.0
24.7
3°-3
Cm.
33-2
41.0
44-4
47.0
5°-5
52.2
53-5
63.0
76.8
The circumference of the head is the occipitofrontal.
The circumference of the chest is at the level of the nipples, midway be-
tween inspiration and expiration.
Babies are usually able to hold up the head alone, if the
back is supported, when they are eight or ten weeks old.
Shape of Head. Deformities resulting from compression
during labor are often present at birth, but disappear within
the first two to four weeks. The head is then rounded and
symmetrical. Flattening of the back or side of the head
from constant lying in one position is common and is easily
overcome by changing the position. Marked asymmetry
of the head may be present at birth. It usually disappears
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 5
during the first five or six years. The most common ab-
normalities in the shape of the head are caused by rickets
and hydrocephalus. Those due to rickets are the result of
overgrowth at the centres of ossification in the frontal and
parietal bones. These overgrowths form prominences on the
forehead and sides of the head which are often called "bosses."
When they are large and are associated, as they usually are,
with flattening of the top of the head, the so-called "square
head" of rickets results. The hydrocephalic head, on the
other hand, is rounded and enlarged symmetrically, while
the whole forehead overhangs.
Fontanelles. The posterior fontanelle is between one-
quarter and three-eighths of an inch (i cm.) in diameter at
birth. This fontanelle closes at six weeks.
The anterior fontanelle is smaller at birth than a few days
later, when the head has come into shape. It is then approxi-
mately one inch (2.5 cm.) in length and seven-eighths of an
inch (2.2 cm.) in width. It apparently increases somewhat
in size with the growth of the head during the first six to nine
months. There is some doubt, however, as to whether there
really is an absolute increase in size. It then gradually
diminishes in size and closes at about eighteen months.
Early closure may be due to a small brain or may be an
individual peculiarity. Delay in closure is usually due to
rickets, but may be the result of hydrocephalus or merely
an individual or family peculiarity. The level of the anterior
fontanelle is that of the surrounding bones or a little below
it. Bulging of the fontanelle means an increase in the intra-
cranial pressure. When chronic this is usually due to chronic
internal hydrocephalus; when acute, to meningitis. Depres-
sion of the fontanelle means a decrease in the intracranial
pressure. This is usually due to a diminution in the amount
of fluid in the brain as the result of general loss of fluid in
diarrhea or malnutrition.
Sutures. Separation of the cranial bones after birth is
abnormal, except that the frontal suture may be open in its
upper part for a few days or weeks. Mobility usually per-
sists for six months and sometimes for nine months, at which
time bony union is usually fairly firm. Overlapping of the
1 6 CASE HISTORIES IN PEDIATRICS.
bones at the sutures is very common in early infancy as the
result of malnutrition.
Softening of the bones of the skull, craniotabes, is usually
due to rickets but sometimes to syphilis. It usually appears
first along the sutures, about the anterior fontanelle and in
the occipital bone. The parietal bones are often involved;
the frontal and temporal, relatively rarely. The best method
of determining craniotabes is by placing the heels of the
hands on the forehead and then pressing on the head with
the tips of the fingers. Imperfect ossification of the bones of
the skull at birth is a manifestation of delayed or imperfect
development and is not due to rickets or syphilis.
Superficial Veins of Scalp. The superficial veins of the
scalp are usually visible if the hair is not too thick. They are
always enlarged in chronic internal hydrocephalus and fre-
quently so in disturbances of nutrition, especially rickets.
Enlargement of the veins of the scalp without evident cause
should always suggest the possibility of syphilis.
Macewen's Symptom. Macewen's symptom is the change
in the cranial percussion note as the result of certain gross
changes in the intracranial contents. It is best elicited by
listening, with the bell of the stethoscope placed on the middle
of the forehead or over the occipital protuberance, while the
skull is lightly percussed with the finger tip. The resonance
is increased and somewhat tympanitic in character when
there is an accumulation of fluid in the lateral ventricles and
there is sometimes dullness over a tumor, if it is situated near
the surface.
Hair. The first hair is sooner or later replaced by a new
growth. It sometimes begins to come out in the first few
weeks and sometimes is retained for several months. The
new hair may come in quickly or slowly, so that some
babies always have a considerable amount of hair, while
others are bald for a long time. Loss of hair on the back of
the head is sometimes due to rickets but is more often merely
the result of too soft a pillow, of turning the head from side
to side in order to see, or of lying too much in one position.
Coarse hair should always suggest an insufficiency of the
thyroid gland.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 7
Face. The face is relatively small and the cranium rela-
tively large at birth, the relation at that time being about
I to 8, while at five years it is I to 4 and in the adult 1 to 2.
If the part of the head below the orbital arches is designated
as the face and that above them as the cranium, the relation
of the face to the cranium at birth is approximately 1 to 1,
and in the adult approximately 2 to 1. The shortness of the
face is due principally to the rudimentary condition of the
jaws and teeth. The face is relatively much broader in
relation to its length at birth than in the adult, the relation
of the breadth to the length at birth being as 10 to 4 and in
the adult as 9 to 8.
Nose. The nose is relatively small in infancy and early
childhood and the bridge rudimentary and relatively wide.
It is especially wide in cretinism and Mongolian idiocy. A
depression at the root of the nose in infancy is never due to
syphilis, but may be in later childhood.
A nasal discharge is not uncommon in infancy and child-
hood. This is, in the vast majority of instances, due to a
simple rhinitis and not to diphtheritic rhinitis or syphilis. A
thin, irritating discharge, especially if tinged with blood,
suggests diphtheritic rhinitis, while a muco-purulent or
purulent discharge, especially if bloody, suggests syphilis.
Smell. It is probable that the sense of smell is present in
a rudimentary condition in the newly-born. It develops
slowly, however, and the ability to detect fine differences in
odors is not acquired until late in childhood.
Motion of the alae nasi in respiration points toward some
disease of the respiratory tract, which is not necessarily
pneumonia, as is often supposed. It is often present in
infancy, however, when there is no trouble in the respiratory
tract and is, therefore, of relatively little importance.
Lips. Fissures and rhagades are usually manifestations
of syphilis, but may be due to malnutrition and infection
from any cause.
Mouth. The examination of the mouth and throat is best
left until the last, because infants and young children are
often much disturbed by it. If it is done first they are very
likely to become frightened and resist further examination.
1 8 CASE HISTORIES IN PEDIATRICS.
The mouth is normally kept closed. An open mouth is
usually due to obstruction in the nose or nasopharynx. The
most common cause of this obstruction is adenoids. It must
be remembered, however, that babies and young children are
very likely to open their mouths, if they are interested.
Idiots are also very likely to keep their mouths open.
A rounded swelling is often visible on each side of the mouth
between the jaws during infancy. These swellings are the
so-called "sucking pads," which are collections of fat, enclosed
in a capsule, lying outside the buccinator muscles. They
become much smaller after infancy, but are often visible
throughout childhood.
The roof of the mouth is, as a rule, flatter in infancy than
in childhood, the arching becoming more marked as the
alveolar ridges develop. The normal variations in the arch
of the hard palate are, however, very great. An excessive
degree of arching is in most instances the result of inter-
ference with the nasal respiration, this interference usually
being due to adenoids. It is sometimes,' however, a stigma
of degeneration. The soft palate is more horizontal in in-
fancy than later, while the uvula is very small.
One or more small white or yellowish-white nodules are
often visible in the median line of the hard palate at or near
its junction with the soft palate during the early weeks or
months of life. These are accumulations of epithelial cells
and are known as Epstein's Pearls. A small protuberance
is often visible on each side of the soft palate. These are
the tips of the hamular processes of the sphenoid bone. The
mucous membrane over these processes is very thin, and, as
the result of mechanical injury, erosions and ulcerations often
occur in these areas. These lesions constitute the condition
known as Bednar's Aphthae, and are not manifestations of
syphilis or tuberculosis, as is often supposed. Similar lesions
also frequently occur over and about Epstein's pearls.
The mouth is relatively dry during early infancy, because
but little Saliva is secreted during the first three or four
months. The secretion then increases rapidly in amount.
A considerable proportion runs out of the mouth at first,
however, because the baby does not know enough to swallow
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 9
it. When he learns how, drooling ceases. There is no
etiological connection between drooling and dentition. They
merely appear coincidently.
Koplik's spots, which are pathognomonic of measles, are
situated on the buccal mucous membrane. They are rose-
red spots, the size of the head of a pin, or somewhat larger,
with a pearly white spot, the size of the point or shaft of a
pin, in the centre.
Tongue. The tongue is lightly coated, especially pos-
teriorly, during the early months. This coating is due to the
fact that, owing to the deficiency of the salivary secretion,
the desquamating epithelium is not washed away as it is later.
Enlargement of the tongue in infancy may be a congenital
malformation, but is more often a manifestation of cretinism.
The tongue is also enlarged in Mongolian idiocy in childhood,
but not in infancy.
Ulceration of the under surface of the tongue at or near the
frenum is not very uncommon as the result of the irritation
of the lower incisor teeth or infection (Riga's or Fede's
Disease). It does not necessarily indicate whooping-cough
as is sometimes taught.
Taste. The sense of taste is well developed at birth.
Teeth. Infants are sometimes born with teeth. The first
tooth usually appears at six or seven months. The teeth
usually erupt in groups with considerable regularity. There
are so many normal variations, however, that it is difficult
to lay down any hard and fast rules. In a general way the
first, or temporary teeth, erupt as follows:
2 middle lower incisors, 6-8 mos.
4 upper incisors, 8-10 mos.
2 lateral lower incisors,
4 anterior molars,
4 canines, 18-20 mos.
4 posterior molars, 24-30 mos.
20
Delay or irregularity in cutting the teeth may be due to
rickets or may be merely an individual or inherited peculiarity.
12-15 m°s.
20 CASE HISTORIES IN PEDIATRICS.
It is not wise to attribute delay in dentition to rickets, unless
there are other signs of the disease present. Disturbances
of nutrition, other than rickets, seldom delay dentition.
They often result, however, in an imperfect development of
the enamel and a tendency to early decay. Syphilis never
produces any characteristic changes in the first teeth, its
action being the same as that of other disturbances of nutri-
tion. The first of the second, or permanent, teeth are the
so-called "six-year old" molars, which appear at this time
behind the posterior molars of the first dentition. The
permanent teeth then begin to replace the temporary teeth,
the bicuspids taking the place of the temporary molars, after
which the permanent molars erupt posteriorly. The per-
manent teeth erupt in a general way as follows, the lower
teeth usually preceding the upper:
4 first molars, 6 years
4 middle incisors, 7 years
4 lateral incisors, 8 years
4 first bicuspids, 9 years
4 second bicuspids, io years
4 canines, 12-13 years
4 second molars, 12-15 years
4 third molars, 17-25 years
32
The permanent teeth often show, in the same way as the
temporary, an imperfect development of the enamel and a
tendency to early decay, if the nutrition has been disturbed
during early childhood. They also show the typical lesions
of syphilis, the so-called "Hutchinson teeth."
Projection of the upper teeth, like crowding together of
the upper teeth, is usually the result of imperfect nasal
breathing, ordinarily due to adenoids, and not of thumb-
sucking as was formerly supposed.
Throat. It is impossible to obtain a satisfactory view of
the throat unless the child is held properly. It must, in the
first place, be held so that the light shines into its throat,
that is, facing a window or a light. It should be held in the
Method of holding infant for examination of the throat.
Method of holding child for examination of the throat.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 21
upright position; otherwise it is impossible to properly
extend the head. The person that holds the child should
look after the body and extremities. The examiner then
holds the head with his left hand and takes the spoon or
depressor in his right. If the examiner wishes to use both
hands, as in taking a culture, the head also can be held by
the person holding the child, or, if it is too strong to be held
in this way, by a third person.
If the child refuses to open its mouth it can usually be made
to do so by working the spoon or depressor in gradually from
the side, by pushing it in when it cries, or by pinching the
nose.
The throat cannot be properly examined unless the child
is made to gag. This can be done by placing the spoon or
depressor on the back of the tongue and pressing downward
and forward. It is useless to press on the front or middle of
the tongue. This merely pushes the back of the tongue
upward and obscures the view of the throat.
Inspection of the throat is not sufficient, if there are any
symptoms of obstruction to either respiration or deglutition.
In such instances a digital examination of the throat should
always be made, as it is perfectly possible to miss a retro-
pharyngeal abscess if reliance is placed on inspection alone.
A gag should never be used when the presence of a retro-
pharyngeal abscess is suspected, because sudden death
sometimes results if the jaws are widely separated in this
condition.
The tonsils are relatively larger throughout childhood than
in adult life and normally increase in size at the time of the
eruption of the molars.
The epiglottis is visible in infancy and early childhood
when the tongue is depressed and the patient made to
gag.
Esophagus. The distance from the gums to the cardia
in the new-born is seventeen cm. (6f inches) ; from the
incisor teeth to the cardia at three years, twenty-three to
twenty-four cm. (9~9f inches) ; and at six years, twenty-
seven cm. (iof inches). After swallowing a gurgling sound
is normally heard at the left of the spinous processes as far
22 CASE HISTORIES IN PEDIATRICS.
down as the eighth dorsal spine. In childhood the squirt-
ing sound of liquids passing through the cardia into the
stomach is heard in the epigastrium about five seconds after
swallowing.
Nasopharynx. The nasopharynx is very low at birth, but
relatively long from before backward. It increases rapidly
in height during the first six months, but very slowly during
the rest of infancy. It changes gradually toward the adult
type, but is relatively low during the whole of childhood.
Adenoid tissue is present in the nasopharynx at birth and
may even then be sufficient to cause obstruction.
It is impossible to examine the nasopharynx with the mirror
until the child is old enough to assist. This is usually not
before it is eight years old. Prior to this time the examina-
tion must be made with the finger. This is somewhat
difficult in infancy because of the small size of the parts, but
can almost always be done if the examining finger is not too
large. Care must be taken not to use force and thus tear
the soft palate. The best way to examine is to stand behind
the patient, holding the mouth open with the left forefinger
or a gag, according to the age of the child, and introducing
the right forefinger into the mouth. When held in this
position the child is unable to get away.
The maxillary antrum is present at birth and the ethmoidal
cells develop at about three years. The frontal sinuses are
not developed until seven years.
Ear. No physical examination is complete in infancy and
early childhood, unless some satisfactory explanation of the
symptoms has been found elsewhere, without an examination
of the middle ear. Disease of the middle ear cannot be ruled
out, as is so often done, because there is no discharge. The
absence of pain, of putting the hand to the ear and of tender-
ness over the mastoid, do not at this age by any means
exclude the presence of disease of the middle ear. In fact,
these symptoms are more often absent than present. The
ear must be examined with the speculum. In this way only
can the condition of the middle ear be determined. A smaller
speculum than comes with most sets is needed to examine a
young infant's ears.
Method of examination for Adenoids
Showing mouth-breathing and funnel chest as a result of Adenoids.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 23
In infancy the external auditory canal runs downward
and inward. The ear must, therefore, be pulled downward
and a little forward to straighten the canal instead of upward
and backward, as in older children and adults. It must also
be remembered that the drum is more horizontal at this age
than later.
Hearing. Infants hear little or nothing during the first
few days of life, probably because of the swelling of the
mucous membrane of the tympanum and the absence of air
in the middle ear. The hearing rapidly improves, however,
and in a short time becomes very acute.
The mastoid antrum is present at birth, but the mastoid
cells are usually not developed. They are, however, fairly
well developed at three years.
Eyes. The eye is anatomically developed at birth.
Vision is, however, probably very feeble. A strong light
evidently causes discomfort during the first few weeks. The
baby does not usually fix its eyes until it is at least six
weeks old and coordination is not well developed until three
months or later, at which time it seems to recognize objects.
It is, therefore, of little use to attempt to test the accommoda-
tion in young infants. The pupils react to light almost
immediately after birth, and this test can, therefore, be used
at once. It is best performed by bringing a light from above
the head downward in front of the eyes.
The function of the lachrymal glands is not developed at
birth. Tears are shed, as a rule, at about three months.
Neck. The neck is relatively short during infancy, because
of the large size of the head and its tendency to fall forward,
the high position of the sternum and the large amount of
fat tissue. The neck is also short and thick in cretinism.
Spine. The spine is largely cartilaginous at birth, ossifi-
cation not being complete until the thirtieth year. It is,
therefore, extremely flexible during infancy and early child-
hood. The infant is usually not able to sit up alone until he
is about eight months old. The lumbar curve is less marked
in the infant when sitting than in the child and adult. When
infants are forced to sit up before they are able, or when
infants and young children are feeble from any cause, they
24 CASE HISTORIES IN PEDIATRICS.
usually sit with a marked general kyphosis, most marked in
the lower dorsal region, the so-called "curve of weakness."
This disappears when they lie down. It is important not to
mistake this condition for the kyphosis due to disease of the
spine, which is localized and does not disappear on lying
down.
It is very difficult to count the spinous processes in the
infant and young child, though it is easy to do so in older
children. The first dorsal spine, not the seventh cervical, is
usually the most prominent in infancy. Failure to appreci-
ate this fact is likely to lead to error. The spine of the fourth
lumbar vertebra is at the level of the highest point of the
crest of the ilium at all ages. This fact is of importance in
relation to the operation of lumbar puncture. In this con-
nection it is important to remember that at birth the spinal
cord extends to the third, and after one year to the second,
lumbar vertebra.
Spina bifida with meningocele is obvious; it is easy, how-
ever, to overlook spina bifida occulta. Pigmentation of the
skin or an unusual growth of hair is very common over the
site of this malformation and should suggest its presence.
Chest. The relative sizes of the chest and head at dif-
ferent ages have already been discussed and are given in
Table III.
The shape of the chest in infancy and early childhood is
materially different from that in older childhood and adult
life, the chest being rounder and shorter. The relation of
the antero-posterior diameter to the lateral diameter of the
interior of the thorax at birth is as two to three, while in the
adult it is as one to two and one-half or one to three. The
ribs bend much less backward than in the adult and are more
nearly horizontal. The top of the sternum is higher and the
lower angle of the ribs more obtuse. The change from the
infantile to the adult type of thorax is nearly complete,
however, at five years.
The sternum is narrow and almost entirely cartilaginous at
birth, while the front of the chest is almost entirely made up
of the costal cartilages, the ribs themselves being relatively
much shorter than in later life. The chest is, therefore, more
Position of Rosary.
•
^r^ *<*rjui^li. "^
tiir ^
^
Extreme deformity of the chest in Rickets.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 25
compressible and elastic in infancy and early childhood than
later. Deformities of the chest, such as bulging of the
precordia over an enlarged heart, are, for the same reason,
more easily produced. When the intrathoracic pressure is
increased, as in pleural effusion, the whole chest wall yields
for the same reason before the intercostal spaces bulge.
Engorgement of the breasts with the secretion of a fluid
resembling colostrum in appearance is not uncommon in the
newly-born of both sexes. It usually appears from the third
to the fifth day and persists for several weeks. It is a phy-
siological, not a pathological, condition. The secretion is
true milk and contains between 2.5% and 3% of fat, about
2.5% of sugar and from 2.5% to 3.5% of proteids.
Deformities of the chest are not at all uncommon in infancy
and early childhood and at this age are in the vast majority
of cases due to rickets. In later childhood they are most
often due to tubercular disease of the spine, disease of the
pleura or weakness of the muscles.
The most common abnormality in the chest caused by
rickets is the "Rosary." This is caused by an overgrowth
of tissue at the junction of the ribs with their cartilages, which
results in the formation of a series of prominences resembling
beads. These, on account of the relative shortness of the
ribs at this age, are situated farther out from the median line
than is usually supposed. The line of junction of the ribs
and their cartilages is always palpable in thin babies and it
is sometimes difficult to distinguish this normal condition
from a beginning rosary. It is a safe rule not to call anything
a rosary unless a prominence can be felt at the sides of the
junction of the ribs and cartilages as well as on the anterior
surface. The beading usually appears first on the lower
ribs.
The deformities of the chest in rickets are due primarily
to the softening of the bones in this disease, which renders
them unable to resist the pressure of the atmosphere and the
pull of the muscles. Interference with free respiration, as by
adenoids, increases the degree of the deformities. The most
common deformity is a flattening of the sides of the chest.
When this is localized and rather sharply defined, it is known
26 CASE HISTORIES IN PEDIATRICS.
as "Harrison's groove." The flattening of the sides of the
chest is usually accompanied by a flaring of the lower ribs,
presumably due to the resistance of the large liver and the
distention of the abdomen, so common in this disease. The
flattening of the sides of the chest results in an increase in the
antero-posterior diameter with a consequent prominence of
the sternum. This, when marked, is known as "pigeon
breast" or "chicken breast." A depression of the sternum
resulting in the so-called "funnel chest" sometimes develops
in rickets, but is more often a congenital anomaly.
Diaphragm. The central point of the diaphragm is
probably somewhat higher in relation to the spine in infancy
than in later childhood. The evidence on this point is,
however, not very conclusive. The diaphragm reaches the
adult position at five or six years, or a little later.
Position in Examination of the Chest. The best position for
the examination of the front of the chest of an infant or small
child is lying on its back. It is less likely to be frightened
when lying on someone's lap than on a bed or table. An
older child can be examined equally well when sitting up.
The best position for the examination of the back of the chest
of an infant or small child is in the nurse's arms with its arms
around her neck. In this position there is no interference
with respiration and the air can enter both sides alike, while
the baby feels at home and is less likely to be frightened.
If the baby is too sick to be taken up it may be turned on
its face. This is less satisfactory, however, because the
weight of the body on the soft front of the chest interferes
with full respiration. The back should never be examined
when the baby is lying on its side, because the weight of the
body on the elastic chest wall interferes materially with the
entrance of air into the lower side and therefore diminishes
the respiratory sound on this side, which may lead to errone-
ous conclusions. It is unwise to examine an older child
when lying on its side, but the chances of error are less than
in infancy. Older children are best examined when sitting
up or lying on their faces.
It is usually wiser to examine the back of the chest of
infants and small children before the front as, in this way they
Pigeon Breast.
Retraction of the chest at the insertion of the diaphragm.
Method of holding baby for examination of back of chest.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 2J
are less likely to be frightened. It is also wiser to auscult
before percussing, partly because ausculation is less likely
to frighten the babies than is percussion and partly because
at this age the results obtained by auscultation, are, as a rule,
more reliable than those obtained by percussion.
Stethoscope. The stethoscope is, on account of the small
size of the parts, far preferable to the naked ear in the exami-
nation of infants and young children. It is very important,
moreover, to use a stethoscope with a small bell; one with
a diameter of three-quarters of an inch (2 cm.) is amply large
enough. It is impossible to get a larger bell down on the
chest of a thin baby, and a large bell transmits the sounds
from too large an area and makes it impossible to locate their
source accurately. The bell of the phbnendoscope will, for
example, cover nearly the whole of an infant's heart.
Heart. The volume and weight of the heart relatively to
the body weight are greatest in the new-born, sink rapidly in
the first and second years, increase again for a time, are
smallest in the years before puberty and increase rapidly
during puberty, reaching the adult relation.
The cardiac physical signs vary materially at different
periods of infancy and childhood, because of the varying
rapidity of the growth of the heart, thorax and other organs.
In infancy, the comparatively large heart is placed more
horizontally in the narrow thorax and is covered to a less
extent by the lungs than it is later, giving, therefore, a set
of physical signs materially different from those found in
later childhood and adult life. The physical signs gradually
approach the adult type with the development of the organ-
ism. The infantile form of thorax is replaced by the adult
type between four and five years, while the diaphragm
reaches the adult position at five or six years, or a little later.
The lungs are not fully expanded forward until six years or
later. The thymus modifies the signs in infancy and possibly
for two or three years longer.
Cardiac Impulse. The cardiac impulse is rarely visible
and frequently not palpable in early infancy. Later it is
more distinct than in adults. Owing to the anatomical
conditions already mentioned, it is at first higher up and
28 CASE HISTORIES IN PEDIATRICS.
farther out than in later life. In infancy it is in the fourth
space about one cm. (f inch) outside the nipple line and from
five cm. (2 inches) to six cm. (2§ inches) from the median line.
As the result of the anatomical changes due to growth, it
gradually moves downward and then inward, being in the
fifth space in the nipple line at seven years, and always inside
the nipple line by the thirteenth year.
Cardiac Area. The area of the relative cardiac dullness,
because of the anatomical peculiarities already mentioned,
is relatively larger than in adult life, and relatively larger in
infancy and at puberty than at other periods of childhood.
The area of absolute dullness — that part of the heart
uncovered by lung — is relatively larger than in adults until
the lungs are fully expanded at six years. On account of the
small size of the parts it is impossible to determine accurately
the area of absolute dullness in infancy. The usual mistake
is in making the area too large. The right border is at the
left sternal border throughout the whole of childhood.
Fortunately the knowledge of this area is of relatively little
importance. It is comparatively easy, however, to deter-
mine the area of relative dullness, which is the important one.
In the first two years the dullness of the thymus may interfere
with the determination of the upper border of the heart, but
it can usually be made out by the aid of strong percussion.
In infancy, the upper border of relative dullness is at the
lower border of the second costal cartilage or in the second
space. The left border is one cm. (f inch) outside the nipple
line, or from five cm. (2 inches) to six cm. (2§ inches) to the
left of the median line, the right border at, or just inside, the
right parasternal line, or two cm. (f inch) to the right of
the median line.
At six years, the upper border of relative dullness is at
the upper border of the third rib, the left border just outside
the left nipple line, or seven cm. (2| inches) to the left of the
median line, the right border two and one-half cm. (1 inch)
to the right of the median line.
At twelve years, the upper border of the relative dullness
is at the third rib, the left border one cm. (f inch) inside
the left nipple line, or eight cm. (3! inches) to the left of the
Area of cardiac dullness in infancy.
Area of cardiac dullness at six years. Area of cardiac dullness at twelve years.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 29
median line, the right border three cm. (i£ inches) to the
right of the median line.
Heart Sounds. In early infancy the first sound lacks the
booming quality heard later and is much more like the second
sound, so that the sounds often resemble the "tic-tac" heart
of the foetus. The first sound acquires the normal booming
character during the second year. The first sound at the
apex is relatively much louder in comparison with the first
sound at the base in infancy and early childhood than in
later life. The second pulmonic sound is louder than the
second aortic throughout the whole of childhood. For this
reason great care must be exercised in diagnosing an accentua-
tion of the second pulmonic sound. Reduplication of the
second sound is not uncommon under normal conditions.
When this occurs alone, it is, therefore, not necessarily
pathological.
Pulse Rate. The rate of the pulse is very irregular in
infancy, even under normal conditions. It varies markedly
as the result of exertion, excitement or any slight disturbance.
The rhythm is very easily disturbed. The pulse also becomes
irregular from very slight causes in early childhood. Irregu-
larity of the pulse is, therefore, of comparatively little sig-
nificance in infancy and early childhood. It is impossible,
for these reasons, to give more than approximate figures as
to the pulse rate at these ages.
Early weeks, 120-140
First year, 1 10-120
Second year, 1 00-110
Two to five years, 90-100
Five to ten years, 80- 90
The pulse rate increases very markedly from slight causes
in infancy and early childhood, and a very high rate may be
quickly reached. Increased frequency of the pulse is, there-
fore, of less significance at this age than later.
Blood Pressure. The blood pressure in childhood varies
with age, but not with sex. The general condition makes a
great difference in infancy, the pressure being much lower in
feeble or premature infants. It is lower when sleeping than
30 CASE HISTORIES IN PEDIATRICS.
when awake, when quiet than when moving or crying, and
before than after feeding.
Under six months, 60-90 mm. of mercury
Two to three years, 80-95 mm- °f mercury
Five to six years, 100 mm. of mercury
Nine to ten years, no mm. of mercury
It must not be forgotten that venous hums are as common,
or even more common, in infancy and early childhood as in
later life. A systolic, most often late systolic, murmur is
heard very frequently at the pulmonic area, and is functional
in origin. Systolic murmurs are often heard also in the great
vessels of the neck and are likewise functional. A systolic
murmur is often heard under the manubrium in infancy.
This is increased on extension of the head. In fact, it can be
elicited in almost every infant by hyperextension of the head.
This murmur is probably due to the pressure of the thymus
on the vessels, the antero-posterior diameter of the upper
opening of the thorax in infancy being only two cm. in diam-
eter. This murmur is not due to enlargement of the bronchial
lymph nodes, as was at one time supposed. It has no patho-
logical significance.
Lungs. Percussion. Percussion of the lungs gives, in
infancy and early childhood, less reliable information than
auscultation. They have the same relative value in later
childhood as in adult life. Finger percussion should always
be employed. It is necessary to percuss lightly, because of
the small size of the parts. Strong percussion is likely to set
more than one organ in vibration and thus produce mixed
sounds, which lead to confusion. It is very difficult to make
out the lung borders accurately in infancy because the plex-
imeter finger often covers a rib and a space, or even two ribs
and a space, while the tip of a large finger is almost as large
as the superficial cardiac area. It must be remembered that,
owing to the compressibility of the chest, the resonance is
impaired on the under side, if an infant is laid on its
side.
Resonance. The lower border of the lungs in infancy is,
owing to the somewhat higher position of the diaphragm,
Position of lobes of lungs in front.
Position of lobes of lungs behind.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 3 1
about one rib higher than in later life. The lower border
of the lung resonance is, therefore, at the fifth rib in the right
mammillary line, the seventh rib in the midaxillary line and
the tenth rib in the scapular line. The lower border in the
left midaxillary and scapular lines is about one space lower
than on the right. There is no pulmonary resonance under
the sternum during infancy, because the anterior borders of
the lungs do not extend under the sternum at this age. The
lung does not extend as far over the heart at this time as later,
but the parts are so small that percussion of the lung-heart
border is practically impossible. The adult relations are
attained at about six years.
The relation of the lobes to the chest wall is essentially the
same in infancy and childhood as in adult life. The line
between the upper and lower lobes starts in the median line
of the back at the level of the spines of the scapulae, runs
through the fourth rib in the midaxillary line and reaches the
border of the lung at the sixth rib in the mammillary line on
the left and the parasternal line on the right. The line
between the upper and middle lobes on the right side diverges
from the line between the upper and lower lobes at the outer
border of the scapula, runs through the third rib in the mid-
axillary line and reaches the border of the lung in front at
the fourth costal cartilage.
The percussion note is normally more resonant during
infancy and childhood than in later life. Under normal
conditions there is always a tympanitic element added at the
left base, because of the proximity of the stomach. When
the abdomen is distended with gas this tympanitic element
is greatly exaggerated on the left side and may be present on
the right side also.
Percussion of the apices in infancy and early childhood
is impossible because of the small size of the parts. The
percussion note is not higher pitched at the upper part of the
right lung, as it is in adults. On the contrary, there is an
area of impaired resonance under the inner third of the left
clavicle up to nine or ten years, although it is difficult to
elicit it in infancy. This area of dullness is due to the pres-
ence of the great vessels and the esophagus on this side, and
32 CASE HISTORIES IN PEDIATRICS.
the fact that the left lung does not extend as far forward as
the right.
Grocco's sign is found in infancy and childhood under the
same conditions as in adult life and is of the same significance.
A very important point in the examination of the chest in
infancy is the Sense of Resistance, meaning by this term
the resistance felt when tapping the chest with the ends of
the fingers, not that felt on ordinary percussion. Much can
be told as to the conditions within the chest in this way at
this age, because of the thinness of the chest walls. This
method of examination is of especial importance in the
diagnosis between pleural effusions and consolidation of the
lung, because the sense of resistance is much greater over an
effusion than it ever is over a solid lung.
Respiration. The respiratory rhythm is often very irregu-
lar under normal conditions during the first two years. It
is not uncommon for infants to hold their breath for a long
time during auscultation. This is always strong evidence
that there is no serious disease of the respiratory system.
The respiration is predominantly diaphragmatic in type
during the first years, the thoracic element not being markedly
developed until the seventh year. The variation in the type
of respiration according to sex does not manifest itself until
the tenth year. An inspiratory recession of the epigastrium
is physiological in the early months of life. It is very difficult
to give figures as to the rate of respiration at different ages,
because it varies so much in different individuals and accord-
ing to whether the child is asleep or awake, quiet or active.
The following figures are approximately correct when the
children are quiet.
At birth, 4°~45 Per minute
During the first two years, 25 per minute
At six years, 20 per minute
At ten years, 18 per minute
The respiratory sound is normally higher pitched up to
late childhood than in adult life; that is, it is slightly changed
from the vesicular toward the bronchial. This modification
of the respiration is usually spoken of as puerile. It is
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 33
often mistaken for bronchial respiration, especially when the
respiratory sound is diminished on one side, the mistake
being due to the fact that proper attention is not paid to the
difference between the quantity and quality of the respiratory
sound. It will not be mistaken for bronchial respiration if
it is remembered that when the character of the sound is the
same on both sides, back and front, it cannot be bronchial.
If there is any doubt as to whether respiration is puerile or
bronchial, it can always be settled by comparing it with the
respiratory sound heard over the trachea or at the root of
the lungs, which is, of course, always bronchial.
Bronchial respiration is heard normally over a wider area at
the root of the lungs in the back in infancy and early child-
hood than in late childhood and adult life. It is almost
always heard in the interscapular space and may extend a
little beyond the inner borders of the scapula?. It is important
to remember that bronchial differs from vesicular respiration
in two particulars : the character of the sound and the greater
length of the expiration. In infancy, owing to the normal
variability in the relative length of inspiration and expiration,
the character of the sound is of more importance than the
relation between inspiration and expiration. The character
of the respiratory sound is the same at both apices in infancy
and early life, and the expiration is not prolonged at the right
apex.
An area of dullness and bronchial respiration is often found
in the left back between the scapula and the median line at
about the level of the angle of the scapula when there is an
effusion into the pericardium or when the heart is much
enlarged. This area is due to the compression of the lung.
The respiratory sound is often so feeble in infancy, espe-
cially if there is disease of the lungs, that it is impossible to
determine its character. In such instances the baby must
be made to cry and thus to take a long breath. In this way,
and in this way only, can a satisfactory examination be made.
It is important to remember also that the respiratory sound
is diminished on the lower side if the baby lies on its side.
Failure to appreciate this fact often leads to a mistaken
diagnosis of pneumonia on the upper side, the normal puerile
34 CASE HISTORIES IN PEDIATRICS.
respiration being mistaken for bronchial because of the
greater intensity of the sound on the upper side.
Pneumonia. Certain points as to the respiratory sound
in pneumonia in early life are worthy of mention. A diminu-
tion in the respiratory sound, without change in its character,
is often the earliest sign. It is the character, not the inten-
sity, of the respiratory sound which is of importance in
distinguishing between bronchial and vesicular respiration.
Satisfactory conclusions cannot be drawn unless the baby is
made to breathe deeply. Bronchial respiration is often heard
first high up in the axilla. The examination is not complete
unless the axillae are examined. Loud bronchial respiration
does not prove the presence of pneumonia and rule out a
pleural effusion, because loud bronchial respiration is often
heard when there is an effusion. Conversely, diminution
in the respiratory sound, even when bronchial, does not
exclude pneumonia, because the respiration is often dimin-
ished on the affected side in this disease.
Voice Sounds. What has been said regarding the char-
acter and intensity of the respiration applies equally well to
the voice sounds. Reliance has to be placed, of course, in
infancy, on the cry, not on the spoken voice. A change in
the character of the voice sounds is often noticeable before
there is any change in the respiratory sound, when there is
beginning solidification of the lungs.
Tactile Fremitus. The fremitus, like the voice sounds, has
to be determined in infancy from the cry rather than from
the spoken voice. It is comparatively hard to distinguish
any but marked variations in the fremitus at this age, and,
owing to the elasticity of the chest wall, the fremitus is often
transmitted unimpaired, even when there is a large collection
of fluid in the chest. It is, therefore, of relatively little
importance in infancy.
Rales. The character, varieties and significance of rales
are the same in early infancy as in adult life. They often
sound louder at this age, however, because of the thinness of
the chest walls, and, for the same reason, are more often
palpable. Rales made in the nose or nasopharynx are often
transmitted to the chest in infancy and are often mistaken
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 35
for bronchial rales. They can, however, be easily distin-
guished. Bronchial rales are not audible over the cheeks
and trachea and are never exactly the same on both sides
and on the front and back. Rales made in the nose and
nasopharynx are usually audible over the cheeks, always
audible over the trachea, and sound exactly the same over
the trachea and over both lungs, both back and front.
Pleural Friction Sounds. These sounds are, for some
unknown reason, almost never heard in infancy, although
inflammation of the pleura is common enough at this age.
They are heard in childhood as frequently, and under the
same conditions, as in adult life. v
Thymus. The thymus may normally extend a little above
the sternum. Practically, it is not palpable under normal
conditions. If it is palpable, it is almost certainly enlarged.
It is claimed that by light percussion the thymus gives in
infancy the area of dullness shown in the accompanying
diagram.
Dullness of Thymus.
Some claim that there is a zone of vesicular resonance
between the lower border of the dullness of the thymus and
the upper border of the cardiac dullness; others, that they
are continuous. This dullness is said to gradually diminish
and to be gone at six years. The author has found it ex-
tremely difficult to map out the normal thymus. When he
finds dullness in this area it means to him enlargement of
the thymus or some other pathological condition.
Abdomen. The abdomen in infancy, on account of the
large size of the liver and the small size of the pelvis, is shaped
36 CASE HISTORIES IN PEDIATRICS.
like an egg with the small end down. There is, therefore, no
waist. The liver becomes relatively smaller as the child
grows older, while the pelvis remains relatively small for
several years. Its cavity is deep and the projection of the
sacro- vertebral angle is less marked. The pelvis gradually
increases in size, so that at puberty it presents, in both
sexes, the characteristics of the adult male pelvis. It acquires
its proper sexual characteristics after puberty. The shape
of the abdomen changes with the changes in the relative size
of the liver and pelvis.
When the normal infant is lying on its back, the sides of
the abdomen form nearly a straight line from the costal
border to the pelvis. Bulging outward shows enlargement
of the abdomen and laxness of its walls. The level of the
abdomen in infancy and early childhood, when the child is
lying on its back, is normally somewhat above that of the
thorax. It is on a level with the thorax, or somewhat below
it, in later childhood. The lower abdomen is normally more
prominent in early childhood than in later childhood and
adult life. The lower portion of the abdomen is especially
prominent in chronic duodenal indigestion and when there
is prolapse of the abdominal organs. In this condition the
child stands with an exaggerated lumbar curve and the
shoulders thrown back.
The circumference of the abdomen at the navel is through-
out infancy about the same as that of the chest. From this
time on the chest is larger than the abdomen. The absolute
circumference of the abdomen at the navel is of little impor-
tance, because of the normal variations in the size of different
children and in the relative size of the abdomen in different
children. The relation between the size of the abdomen and
that of the chest is of more importance, but not of much,
unless the variation from the normal is marked, because the
relation between the abdomen and chest varies so widely
under normal conditions in different children. Comparative
measurements of the abdomen in the same child are, however,
often of very great importance.
Enlargement of the abdomen is very common in infancy
and early childhood as the result of disturbances of digestion.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 2)7
Enlargement, while usually due to this cause, may, however,
be due to more serious conditions, such as ascites and tuber-
cular peritonitis. Enlargement of the abdomen in infancy
should always suggest the possibility of sarcoma of the kidney
as its cause. The signs of free fluid in the abdomen are the
same throughout infancy and childhood as in later life. It
is very easy, however, in infants and young children, when
the abdominal walls are lax, to mistake liquid feces in the
intestines for fluid in the peritoneal cavity, because under
these conditions the liquid feces gravitate to the dependent
portions of the abdomen. The presence or absence of a small
amount of free fluid in the peritoneal cavity can often be
determined, if the patient is an infant or young child, by
holding it up with the face downward and percussing from
underneath. The fluid, under these circumstances, will
gravitate to the region of the navel. It must not be forgotten
that both general and localized enlargements of the abdomen
may be due to paralysis of the abdominal muscles.
The sunken abdomen is almost invariably due to lack of
intestinal contents. It may, however, be due to contraction
of the intestines, as in colitis. Contraction of the intestine
from lead colic and hysteria is practically never seen in child-
hood. The abdomen is often sunken in meningitis. If it is,
the depression is almost invariably due to the lack of intes-
tinal contents, not to spasm of the abdominal muscles.
Spasm of the abdominal muscles is of the same significance
in infancy and childhood as in later life. It is impossible,
however, to determine whether spasm is present or not if
the child is crying. It must be quieted in some way, there-
fore, if there is any possibility of the presence of some disease
of the abdomen likely to be complicated by spasm.
Diastasis of the recti muscles is not at all uncommon in
thin babies and in those whose abdomen is enlarged. It is
much more common above than below the navel. It almost
never persists into later childhood.
Epigastric herniae are not at all rare in infancy and early
childhood. They rarely disappear spontaneously.
Navel. The level of the navel is usually for a short time
after the separation of the cord that of the abdomen. The
38 CASE HISTORIES IN PEDIATRICS.
navel soon puckers in, however, forming a depression.
Granulomata, accompanied by a thin purulent discharge,
are common at this time. It is important not to confuse
them with the so-called "mucous polyp," which is a pro-
trusion of the mucous membrane of the intestine. The dis-
charge in this condition is thin and serous. A fecal discharge
from the navel at this time means patency of Meckel's
diverticulum, while a discharge of urine means patency of
the urachus. Hemorrhage from the navel is not at all
uncommon in the first week after birth, and is usually a
manifestation of hemorrhagic disease of the new-born.
Inflammation in or about the navel, as the result of infection
of the skin or of the vessels, is not infrequent. It must not
be forgotten that infection through the vessels may occur
without any superficial inflammation.
Umbilical hernia is not infrequent in infancy.
Stomach. The empty stomach is completely covered by
the liver during infancy and early childhood. Even when
filled, it extends but a short distance into the triangle formed
by the edge of the liver and the left costal border. The
transverse colon passes in front of it at this age. Percussion
of the stomach is extremely difficult and the results obtained
are unreliable. It is safe to say, however, that under normal
conditions the lower border never extends to the navel. The
boundaries of the stomach in late childhood are the same as
in adult life.
The Pylorus is situated in infancy about midway between
the tip of the ensiform and the navel in the median line or a
little to the right. It is covered by the liver. It is not
palpable when normal. If enlargement of the pylorus is
suspected, the examination should be made both when the
stomach is full and when it is empty, and with the abdominal
walls relaxed. Relaxation of the walls can usually be easily
obtained by making the child vomit or by washing out the
stomach. Visible peristalsis is often present when there is
stenosis or spasm of the pylorus. It is, of course, not present
unless the stomach is full. If it does not appear after filling
the stomach, the epigastrium should be flicked with a towel
or the finger or rubbed with a piece of ice.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 39
Gastric Capacity. The measurements ordinarily given for
the gastric capacity at different ages are practically useless,
because those based on experiments on the cadaver are
obtained under abnormal conditions, while those based on
the amount of food taken at a feeding neglect the fact that
the pylorus opens and lets food through, even while it is being
taken. It is safe to say, however, that the capacity of the
stomach at birth is approximately one ounce. It is also true
that the growth of the stomach is very rapid in the first three
months, slow in the second three months, and more rapid in
the fourth quarter than in the third.
Breast fed babies of the same age take in a general way
about the same amount of food in twenty-four hours, but
the amount taken at individual feedings varies tremendously
according to the appetite at the time and the interval between
the feedings. While these facts are true, experience shows,
nevertheless, that artificially fed babies, if fed at regular
intervals, take, on an average, about the following amounts:
Three months, 4 ounces (120 cc.)
Six months, 6 ounces (180 cc.)
Nine months, 8 ounces (240 cc.)
One year, 9 to 10 ounces (270 to 300 cc.)
Colon. The ccecum, in infancy and early childhood, lies
wholly or in part between horizontal lines drawn parallel with
the crest of the ilium and the anterior, superior spine. It
gradually works downward, so that in later childhood it is in
the adult position. This fact is of some importance in rela-
tion to the probable location of the appendix at various ages.
Owing to the high position of the ccecum and the large liver,
the ascending colon is relatively short in infancy and early
childhood. The lower border of the transverse colon is, in
infancy, just above the navel. It gradually gets higher, so
that in late childhood it is about two-thirds of the distance
from the ensiform to the navel.
Rectum. The attachments of the rectum to the surround-
ing structures do not extend as high up in the pelvis in infancy
as later and the lower third is more vertical. These facts,
taken iii connection with the peculiar shape of the infantile
40 CASE HISTORIES IN PEDIATRICS.
pelvis, predispose to prolapse. Malformation of the rectum,
at or above the anus, should always be looked for, if the
newly-born infant does not pass meconium.
Anus. Fissure of the anus is common in infancy and is
usually overlooked unless the examination is careful and the
folds are stretched. Hemorrhoids are rare at this age.
Mucous patches may be found in this region at any age.
Liver. The upper border of the liver flatness is, on account
of the slightly higher position of the diaphragm in infancy,
somewhat higher at this age than later. It is at the fifth rib
in the right mammillary line, at the seventh in the mid-
axillary and at the tenth in the scapular line. It gradually
descends, reaching the adult position at about six years. The
large size of the liver and the wide angle of the ribs in infancy
more than counterbalance the higher position of the dia-
phragm, so that the lower border of the liver extends below
the costal border. It extends at this age from one cm.
(f inch) to three cm. (if inches) below the costal border in
the mammillary line and from two cm. (f inch) to six cm.
(2? inches) below the tip of the ensiform. There are no exact
data as to when the adult relations are attained. The liver
is, however, usually not palpable in the mammillary line after
three years, although it probably may be felt normally up to
eight years.
It is very difficult to percuss out the lower border of the
liver in infancy and early childhood, because of the thinness
of its edge. It is, on the other hand, very easy to palpate
the lower border, since the abdominal wall is comparatively
thin. Palpation, therefore, gives much more accurate results
at this age than percussion. If there is any discrepancy in
the results obtained by palpation and percussion, those
obtained by palpation should always be accepted. It is
important, on account of the thinness of the abdominal wall,
not to palpate too deeply. It is very easy to miss the edge
if too much force is used and the palpation is too deep.
Striking palpation is of very little value at this age, ordinary
palpation giving far better results.
Gall Bladder. The examination of the gall bladder is
very unsatisfactory in infancy and early childhood. It is
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 4 1
extremely difficult to determine whether it is enlarged or
not. As a matter of fact, it very seldom is enlarged at this
age.
Spleen. The position of the spleen is the same at all ages.
It lies between the ninth and eleventh ribs and the anterior
border does not extend beyond the costo-articular line, that
is, the line drawn between the left sterno-clavicular articula-
tion and the tip of the eleventh left rib. Percussion of the
spleen is very difficult during the first few years of life,
because of its small size. It is seldom more than five cm.
(2 inches) long and three cm. (if inches) wide at this time,
being smaller more often than larger, while its thickness varies
between one-half a cm. (TV inch) and one and one-half cm.
(f inch). The normal spleen is not palpable unless the
abdominal wall is unusually thin and lax. It is easily pal-
pable, however, in infancy and early childhood if enlarged,
even if the enlargement is slight. It is wiser, therefore, to
trust to palpation than to percussion at this age. It is safe
to conclude that if the spleen is palpable it is enlarged and
that if it is not palpable it is normal? It is important imt to
press in too deeply while palpating, as, on account of the
thinness of the abdominal wall and the superficial position
of the spleen, it is very easy to push it out of the way by deep
palpation.
Kidneys. The kidneys are proportionately much larger
in infancy than in later life, the relation of the weight of the
kidneys to that of the body being in the infant as 1 to 120 and
in the adult as 1 to 240. The kidneys are lower in relation
to the vertebrae and iliac crests in the infant than in the adult,
partly because of their relatively large size and partly because
of the relatively small lumbar spine. The right kidney is
said to be situated somewhat lower than the left, but there is
some doubt as to this point. The adult relations are attained
by middle childhood.
It is impossible to percuss out the normal kidney either in
infancy or childhood. It is not possible to feel the normal
kidney unless the patient is very thin, and then only occa-
sionally. If the kidney is palpable, the presumption is,
therefore, that it is in some way abnormal.
42 CASE HISTORIES IN PEDIATRICS.
Floating kidneys are very uncommon in either infancy or
childhood, and, if present, are usually congenital in origin.
Tumors of the kidney make their appearance in the lumbar
region, in the side or in the antero-lateral portion of the
abdomen. They do not move with respiration. The colon
is in front of them.
Bladder. On account of the small size of the pelvis, the
relatively large size of the rectum and the greater obliqueness
of the pelvis in infancy, almost the whole of the bladder lies,
at this age, above the pubic crest. When the bladder is dis-
tended, practically the whole of the distention is upward into
the abdomen. The distended bladder is ovoid in shape, the
larger end being downward. There is no marked fundus.
The tendency is for the bladder, when distended, to lie close
to the anterior abdominal wall. Very little of the anterior
surface is covered by peritoneum. When the child begins
to stand and walk, the weight of the urine gradually changes
the shape of the bladder. The shape of the pelvis also
changes, so that by middle childhood the relations of the
bladder are essentially the same as in the adult. The bladder
at birth holds from two to four drachms (7.5 cc. to 15 cc),
while at six months its capacity is about one ounce (30 cc).
It is impossible to give any figures as to its capacity after
this time, because of its great distensibility.
The relatively high position of the bladder in infancy and
early childhood must always be borne in mind, as otherwise
it is easy to mistake it for a new growth or for fluid in the
peritoneal cavity. The bladder should always be emptied
by a catheter in every instance in which there is a question
of an abdominal tumor or of free fluid in the abdomen.
Some very awkward mistakes will be avoided in this way.
The groins should always be carefully examined, because
hernia is common and hydrocele of the cord not uncommon
in this region. Inguinal adenitis is also common. An in-
completely descended testicle is not infrequently found in this
region and sometimes a misplaced ovary.
External Genitals. The routine examination of the new-
born infant should always include that of the external
genitals. The most common abnormalities are: in females,
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 43
more or less extensive adhesions of the nymphae; in males,
failure of or partial descension of the testicles and hypospa-
dias. The labia minora are relatively large in infancy and
early childhood and project beyond the labia majora. The
prepuce is normally adherent to the clitoris throughout
infancy and probably even longer. A bloody discharge from
the vagina, probably the result of local congestion during
labor, is not uncommon during the first few days of life. It
must not be confused with hemorrhage from the vagina,
symptomatic of hemorrhagic disease of the new-born.
The glans penis is almost invariably completely covered
by the prepuce and in the vast majority of instances the
prepuce and glans are bound together by light adhesions.
This is the normal condition and is different from phimosis,
which is the condition in which the prepuce is so narrowed
that it cannot be retracted over the glans.
Extremities. The infant begins to reach out and grasp
things purposefully when three or four months old. It
begins to creep at about nine months, stands with help at
ten or eleven months and walks alone at about fifteen months.
These are, of course, average figures. Many infants do these
things earlier and many others are tardy about standing and
walking.
Deformities of Extremities. Deformities of the extremi-
ties in infancy and early childhood are, in the vast majority
of instances, due to rickets. The most common of these
deformities is enlargement of the epiphyses at the wrists and
ankles, the wrists being affected more often than the ankles.
When both are affected, the enlargement is usually more
marked in the wrists. It is important not to confuse these
enlargements of the epiphyses due to rickets with the en-
largements due to syphilis. The enlargements of rickets
occur in the epiphysis and at the epiphyseal line, while the
enlargements due to syphilis occur at the lower end of the
diaphysis at its junction with the epiphyseal line.
The next most common deformity of the extremities is
bowing of the long bones. This occurs much more often in
the lower than in the upper extremities and in them results
in bow-legs and knock-knees. Knock-knees are, however,
44 CASE HISTORIES IN PEDIATRICS.
probably more often due to an overgrowth of the inner
condyles of the femora than to bowing of the bones. The
best method of examination as to the presence or absence
of bow-legs and knock-knees is with the child on its back and
the legs extended. It is important not to confuse the normal
bowing of the legs in infancy with pathological bowing. The
normal bowing is of two types: a slight outward bowing of
the lower third of the tibiae, present during the first few months
of life, and a general outward bowing of the legs, which
persists through the first year and sometimes longer. This
latter bowing is apparent rather than real and is due to the
fact that at this age complete extension at the knees is rarely
possible. Unless care is taken to avoid outward rotation
of the thighs, the lines of the partly flexed legs are compared
instead of the inside lines of the legs. These lines are, of
course, bowed and are often the cause of an erroneous diag-
nosis of bow-legs.
The sabre-like deformity of the tibias in syphilis is often
confused with the similar deformity caused by rickets. The
deformity due to rickets appears in infancy, while that due
to syphilis develops between three and ten years. When
due to syphilis, it is associated with other signs of syphilis;
when due to rickets, with other signs of rickets. When due
to syphilis, it is usually the only bony deformity; when due
to rickets, it is always associated with other gross deformities
of the bones.
It is important to notice whether the legs are of the same
length. This is most satisfactorily determined by extending
the legs while the child lies on its back. If they are not of
the same length, the discrepancy is due to an actual difference
in size or to congenital dislocation of one hip. If the shorten-
ing is due to congenital dislocation of the hip, the trochanter
will be found above N61aton's line, the line drawn from the
anterior superior spine of the ilium to the tuberosity of the
ischium on the same side. In congenital dislocation of the
hip the leg can be pulled down into the normal position.
Double congenital dislocation of the hip is very unusual, but
does sometimes occur. It is always well, therefore, to
determine whether or not the trochanters are in the proper
Congenital dislocation of the hips.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 45
position and whether the legs can be pulled down from their
usual position.
Size of Extremities. The circumference of the arms and
legs on the two sides is normally alike during infancy and
childhood. Differences in size, if they are present, are usually
due to wasting on one side, not to hypertrophy. It is very
important, in testing for differences in size, to measure both
extremities in exactly the same place. This can only be done
by taking the measurement at some fixed distance from some
bony landmark on both sides. No attention should be paid
to differences of less than one cm. (f-inch), because such
differences are within the limits of error in measurement.
The shafts of the bones should always be examined for
swelling, tenderness and fractures. The contour of the
joints should also be noted. In a general way, swelling and
tenderness over the long bones in infancy are most often due
to scurvy, next to periosteitis ; in childhood, to periosteitis.
Acute swelling of the joints in infancy and early childhood is
most often due to septic arthritis; in later childhood, to
rheumatism. Chronic swelling of the joints at any age is
most often due to tuberculosis; comparatively seldom to
syphilis.
Position of Extremities. Improper position of the extremi-
ties may be due either to permanent contractures or to
temporary spasm. It must be remembered that in early
infancy and in emaciated infants there is a normal hyper-
tonicity of the muscles, most marked in the flexors, which
prevents the complete extension of the extremities. The
results of this normal hypertonicity must not be mistaken for
permanent contractures. It is important to notice the char-
acter of temporary spasm; whether, for example, the hands
and feet are in the position of tetany or the hands clenched.
It is not safe to assume that there is no spasm because when
the child is quiet the extremities are in the normal position.
Passive motions of the extremities should always be made to
determine whether there is or is not any spasm. If resistance
is encountered, it must be determined whether it is due to
voluntary opposition or involuntary spasm. It is also
important to determine whether the spasm is due to pain or
46 CASE HISTORIES IN PEDIATRICS.
not. It is important to remember that the spasm in cerebral
paralysis in early infancy is often first shown by opposition
to abduction of the thighs.
Paralysis. If the child is unconscious, the presence or
absence of paralysis must be determined by the way in which
the extremities drop when they are let fall and by the amount
of resistance which is encountered on passive motion. If
conscious, older children will attempt to make the various
motions as directed. Infants, however, will not do this.
The power in the arms must be tested by offering them
things to play with or showing them their bottle; that in
the legs by tickling their feet or pricking them with a pin.
It is important to distinguish failure to use the extremities,
because of the pain which motion causes, from real paralysis.
Knee-jerks. The response to tapping the ligamentum
patellae normally varies widely in infancy. It is often very
hard to elicit the knee-jerk in infancy, because of the baby's
failure to relax. It cannot be determined, however, unless
the leg is relaxed, and on this account great patience is often
required. The best method of eliciting the knee-jerk in
infancy is to place the hand under the lower part of the thigh
when the baby lies on its back, lifting it a little from the bed.
A response can sometimes be obtained if the angle of the leg
on the thigh is varied, the ligament being tapped repeatedly
as the knee is moved up and down. The knee-jerk is best
elicited in childhood by having the child sit up with the leg
hanging down, as in adult life.
Abdominal Reflex. This reflex is very inconstant in
infancy and early childhood.
Cremasteric Reflex. This reflex is lively in infancy, but
much less so during childhood. Neither the abdominal nor
the cremasteric reflexes are of much importance, however,
unless they are different on the two sides.
Plantar Reflex. The plantar reflex in infancy is more often
shown by extension than by flexion of the toes. Babinski's
Phenomenon, which is the simultaneous extension of the big
toe with flexion of the other toes when the sole of the foot
is scratched, is, therefore, of no diagnostic importance in
infancy. It is of the same value in childhood as in later life.
Method of eliciting Knee-jerk in infancy.
Kernig's sign.
Neck sign.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 47
Babinski's phenomenon shows some irritation or affection of
the pyramidal tract.
Kernig's Sign. Under normal conditions the leg can be
extended on the thigh to an angle of 1350 or more when the
thigh is at a right angle with the trunk. Kernig's sign
consists in the inability to extend the leg on the thigh, when
it is at a right angle with the trunk, to as much as 1350. This
sign is best tested with the child lying on its back. It makes
no difference whether the thigh is flexed to a right angle on
the trunk and the attempt then made to extend the leg or the
leg extended on the thigh, with the thigh extended, and the
attempt then made to bring the thigh to a right angle with
the trunk. Kernig's sign is an involuntary manifestation and
may or may not be accompanied by pain. The physiological
hypertonicity of young and emaciated infants may be mis-
taken for Kernig's sign, if it is not borne in mind. Kernig's
sign is strong, but not positive, proof of meningitis in infancy
and early childhood.
Neck Sign. Under normal conditions flexion of the head
forward, when the child is lying on its back, causes no motion
of the extremities. Under certain conditions, however,
passive flexion of the neck forward, while the child is lying
flat on its back, the chest being held stationary, causes
flexion of the legs at the hips and knees, but sometimes only
at the hips. This sign is known as Brudzinski's neck sign.
It is sometimes present on one side and not on the other. It
is present in many cases of meningitis and is almost never
found in any other condition.
Contralateral Reflex. Under normal conditions passive
flexion of one leg causes no motion on the other side. In
meningitis, and sometimes in other conditions, passive flexion
of one leg causes a concomitant reflex of the leg on the other
side — the identical contralateral reflex. Sometimes, how-
ever, the motion of the other leg is extension instead of
flexion — the reciprocal contralateral reflex.
Trousseau's Symptom. Pressure on the nerve trunks of
an extremity normally causes no reaction. In the spasmo-
philic diathesis, however, pressure on the nerve trunks of an
extremity not only brings on the typical spasm of tetany in
48 CASE HISTORIES IN PEDIATRICS.
that extremity but also in the others. This reaction is known
as Trousseau's symptom.
Chvostek's Symptom or the Facial Phenomenon. Under
normal conditions mechanical irritation of the facial nerve
produces no contraction. In the spasmophilic diathesis,
however, irritation of the facial nerve, either by striking it
or rubbing something quickly across it, causes contraction
of the facial muscles on that side, especially of those of the
lips.
Sensation. Sensation to touch and pain can be made out
even in infancy, although it is not very active during the first
few months. Sensation to differences in temperature cannot,
of course, be determined until the child is old enough to know
hot from cold and to talk. Sensation is, in general, the same
throughout childhood as in adult life.
Vasomotor Disturbances. Superficial vasomotor disturb-
ances of the skin are not at all uncommon in infancy and
childhood in many pathological conditions. The taches
cerebrales, are, therefore, of no importance in the diagnosis
of cerebral diseases.
Lymph Nodes. Local enlargement of the lymph nodes is
of the same significance throughout infancy and childhood
as in adult life. General enlargement of the peripheral lymph
nodes occurs in infancy, however, in all disturbances of
nutrition. At this age, therefore, it does not point to tuber-
culosis, syphilis or some blood disease. The epitrochlear
and occipital lymph nodes are often enlarged in disturbances
of nutrition. Enlargement of these glands, therefore, does
not at this age point toward syphilis. General enlargement
of the peripheral lymph nodes in later childhood is of the
same significance as in adult life. It is important to re-
member that there is no anatomical or physiological con-
nection between the lymph nodes of the neck and those of
the chest.
The physical signs of enlargement of the tracheo-bronchial
lymph nodes, while theoretically very definite, are practically
very unreliable. The earliest, and probably most reliable,
sign is the bronchial voice sound over the upper four or five
dorsal spines, this normally not being heard below the seventh
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 49
cervical spine. When the enlargement is greater, the res-
piration also is bronchial in this region. If the glands are
much enlarged, they may cause dullness in the interscapular
region and under the manubrium and upper portion of the
gladiolus. This latter dullness may as well, however, be due
to an enlarged or persistent thymus. Bronchial breathing
between the scapula? is also a sign of bronchial adenopathy.
Murmurs under the manubrium, which are louder when the
head is extended, are often attributed to enlargement of the
tracheo-bronchial lymph nodes. They are undoubtedly due
to this cause in some instances, but, since they can be pro-
duced in any baby by extending the head, are of no importance
in diagnosis. If the lymph nodes are much enlarged, they
may by pressure cause a difference in the amount of the
respiratory sound on the two sides, distention of the cervical
veins, edema of the face, atalectasis of the lung, hoarseness
and aphonia. Expiratory dyspnea is also a sign of enlarge-
ment of these nodes.
Development of Faculties. It is often of great importance
to determine whether or not a baby is normally developed
mentally. This must be decided by comparing its develop-
ment with that of the normal baby of the same age. To do
this it is necessary to know what the normal baby should be
able to do at a given age. Babies differ so much in their
mental development under normal conditions, however, that
it is impossible to give more than average figures. In a
general way, the baby smiles at from four to five weeks, and
laughs at from five to six months. He begins to notice
objects at from six to eight weeks, and probably knows his
mother or nurse from other people when about three months
old. He shows signs of fear at six months, or even younger,
and shows plainly his likes and dislikes at a year. He
enunciates single words at from ten to twelve months, and
forms short sentences by the middle or end of the second year.
He makes purposeful gestures at eighteen months. He should
control his sphincters by two years. This point is of com-
paratively little value, however, as the development of the
control of the sphincters depends very largely on the baby's
training.
50 CASE HISTORIES IN PEDIATRICS.
Skin. The skin should always be examined for eruptions,
ecchymoses, -desquamation and scars. Its color should also
be noticed. The color of the nails and of the mucous mem-
branes is a far better index of the condition of the blood,
however, than the color of the skin. It must not be forgotten
that many pale children are pale because of the small size
of the skin capillaries and the thickness of the skin, not
because of anemia.
Bluish or bluish-black spots in the sacral and gluteal
regions occur in 90% of Asiatic children and in those with
negro blood. They are known as Mongolian spots and are
also sometimes seen in white children. They gradually
disappear and are almost always gone before the close of
infancy. They are due to a deposit of pigment in certain
cells of the corium. They are, moreover, not a sign of an
admixture of negro blood, but merely of the persistence, in
a rudimentary form, of a functional layer of pigment cells
in our ancestors, the monkeys.
Three conditions of the skin which are liable to be confused
are edema, sclerema and angioneurotic edema. Edema
may occur at any age, appears first in the eyelids, on the
dorsa of the feet and in dependent portions, is not hard, pits
on pressure, is not associated with rigidity and is pale or
waxen in color. Sclerema occurs in the new-born, or in very
feeble infants. It usually develops first in the cheeks, back
or posterior surfaces of the legs, but may appear anywhere,
except in the prepuce, scrotum, palms and soles. It is hard,
does not pit on pressure, is accompanied by rigidity of the
extremities and is of a normal or slightly bluish color. An-
gioneurotic edema may be general, but is usually circum-
scribed. It may appear in any position. It is usually
somewhat pinkish in color, does not pit on pressure and is
often accompanied by itching.
The function of the Sweat glands is usually not developed
at birth. Babies ordinarily begin to perspire when they are
from three to five weeks old.
THE URINE. The Urine in the Newly-born. The first urine
is acid, almost always clear and but little colored. During the
first four or five days it is usually more or less cloudy from the
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 5 1
presence of epithelial cells from the urinary passages and uric
acid crystals. The specific gravity averages about 1012.
Small amounts of albumin are almost always present, but
rarely last longer than ten days. The sediment always
contains epithelial cells, various forms of uric acid crystals,
and now and then hyaline casts. The amount of urine is
small. It increases rather rapidly on the fourth day, 20 to
50 cc. being passed in the first three days and about 100 cc.
on the fourth day. It averages between 200 cc. and 300 cc.
in the second week.
The Urine in Infancy. The odor is slight, the color pale.
It is usually clear, sometimes slightly opalescent and not
infrequently turbid from mucus. Turbidity should always
suggest the possibility of an infection of the urine with colon
bacilli. If the turbidity is not cleared by heat, a micro-
scopic examination should always be made. The reaction
is feebly acid. The specific gravity varies from 1003 to 1008
in the first six months, and from 1006 to 1012 up to two
years. It does not contain albumin, and sugar is absent
with the ordinary reagents. Sugar is not infrequently found
in the urine of healthy infants during the first two months,
and may be made to appear in the urine by increasing
the amount ingested. According to Gr6sz, lactose appears
in the urine when more than three or four grams per kilo
of body weight are given, the limits of tolerance for other
sugars being higher, that for glucose being five grams and
that for maltose nearly eight grams per kilo. The sedi-
ment is slight and consists entirely of cells. The amount
of urine is relatively large, the infant passing from five to
six times as much urine per kilo of weight as the adult.
It varies between 200 cc. and 500 cc. from the first to the
seventh month, and between 250 cc. and 600 cc. up to
two years. The characteristics of the urine in childhood
are essentially the same as in the adult. The quantity,
however, is three or four times as large per kilo of weight
as in the adult. It is impossible, however, to give anything
more than approximate figures as to the amount passed
at different ages, because of the variations dependent on the
amount of fluid ingested. Holt has combined the figures
52 CASE HISTORIES IN PEDIATRICS.
of a considerable number of observers and arrived at the
following results:
Two to five years, 500- 800 cc.
Five to eight years, 600-1200 cc.
Eight to fourteen years, 1 000-1500 cc.
The specific gravity is on the whole somewhat lower in
childhood than in adult life. It is impossible to give any
figures as to the specific gravity at different ages, because
of the normal variations according to the amount of fluid
ingested.
The Blood. Hemoglobin. The percentage of hemoglobin
varies between 100 and 125 during the first three or four days
of life. It then rapidly drops to the minimum of about 60%
in three weeks, after which it gradually rises to about 70%
at six months. It remains at this point during the rest of
the first two years, after which it slowly rises, reaching the
adult standard at about six years. The normal variations
in the percentage of hemoglobin in different children and at
different times in the same child are very marked. The
percentage of hemoglobin averages somewhat higher in boys
than in girls.
Red Corpuscles. The number of red corpuscles per cubic
mm. during the first two or three days of life varies between
6,000,000 and 7,500,000. The large number of red cells at
this time is probably due to a combination of loss of fluid
and starvation. The number of red cells then rapidly falls
to the normal infantile limit, which it reaches at about two
weeks. The number of cells during infancy ranges between
5,500,000 and 6,000,000. The number gradually diminishes
during early childhood, reaching the adult standard at
approximately six years.
Variations in the size and shape of the red cells develop
much more quickly in infants and in young children than in
older children and adults. Nucleated red cells are normally
present in small numbers during the first six days. They
appear with less provocation during infancy than later.
White Corpuscles. There is a marked increase in the
number of leucocytes during the first few days, this increase
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 53
sometimes reaching as high as 36,000. The number rapidly
drops to from 12,000 to 14,000, where it remains during the
first six months. The normal limits during the rest of
infancy are between 10,000 and 12,000 per cubic mm. The
number of leucocytes from this time on is approximately the
same as in adults.
The digestive leucocytosis is very inconstant and irregular
in infancy. Leucocytosis develops more quickly and is
usually more marked in infants and young children than in
older children and adults. The type of leucocytosis is also
less constant at this age, a considerable increase in the number
of mononuclear cells being not uncommon. The percentage
of polynuclear cells is high at birth, rises during the first
twenty-four hours to 70% or a little more, then quickly drops
to the normal infantile relation at the end of the first week
or ten days. The relations of the different normal forms of
leucocytes throughout infancy are roughly as follows:
Small mononuclear,
40% to 50%
Large mononuclear and transitional
forms,
10%
Polynuclear neutrophils,
35% to 45%
Eosinophiles,
1% to 5%
Mast cells,
1%
The mononuclear cells vary much, not only in the size of
the cell as a whole but also in the size of the nucleus and in
the amount of protoplasm. The percentages of the large
mononuclear and transitional forms and of the eosinophiles
remain about the same to middle childhood, while that of the
small mononuclear cells gradually diminishes and that of the
polynuclear neutrophiles increases until the adult relations are
reached at from five to six years.
Myelocytes are not normally present in the infant's blood.
They appear, however, on relatively slight provocation and
sometimes in considerable numbers. Their presence is,
therefore, of much less significance at this age than later,
a percentage of from five to six, or even more, not being very
unusual at this age in secondary anemia.
An increase in the number of eosinophilic cells is not
54 CASE HISTORIES IN PEDIATRICS.
uncommon in infancy and early childhood and seems to be
of but little significance. The percentage may be as high
#as ten without any evident cause. A high percentage of
eosinophiles should, however, always suggest the presence
of intestinal parasites.
In considering the blood changes in infancy and early child-
hood certain points must be borne in mind: Blood changes
develop more easily and more frequently as the result of
morbid conditions and diseases than in older children and
adults. All the changes seen in later life as the result of
disease are aggravated in infancy. The tendency is always
to revert to a younger or to the fcetal type of blood. As the
result of the tendency to aggravation of changes and to
reversion to a younger type of blood, the red corpuscles show
much greater variety in size and shape and many more
nucleated forms are seen than under similar pathologic con-
ditions in the older child and adult. In general, the most
characteristic features of all the blood diseases of infancy are
the relatively low percentage of hemoglobin, the relatively
large number of non-granular cells and the marked mor-
phological changes in the red corpuscles.
The Stools in Infancy. The characteristics of the stools in
infancy are so different from those of children after they have
begun to take an ordinary mixed diet that they deserve
special description. The characteristics of the stools of
children are the same as in the adult.
The stools differ normally according to whether the infant
is taking human milk or cows' milk, and whether starches or
other carbohydrates are added to the cows' milk.
The Stools of Breast-fed Infants. The breast-fed infant
has, during the first few weeks or months of life, three or four
movements daily of the consistency of pea soup, of a peculiar
golden-yellow color, with a slightly sour or aromatic odor, and
with a slightly acid reaction. The number of stools diminishes
later to two or three in the twenty-four hours and the con-
sistency becomes more salve-like, the other characteristics
remaining the same. The golden-yellow color is due to
bilirubin, which passes unchanged through the intestinal
tract because of the rapidity of the passage, the relatively
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 55
low proteid content of the milk and the low reducing power
of the infant's intestine. The odor is due to a combination
of lactic and fatty acids. The acid reaction is due to the
relative excess of fat over proteid in the milk.
It is not uncommon, even when babies are doing well on
the breast, for them to have a larger number x>( stools of
diminished consistency and of a brownish color. In such
instances examination of the breast milk usually shows that
the proteids are high. It is also not unusual to find numer-
ous soft, fine curds and sometimes mucus in the stools of
healthy breast-fed babies. While such stools are undoubtedly
abnormal, it is unwise to pay too much attention to them
if the baby is gaining and seems well.
The Stools of Infants fed on Cows* Milk. Infants that are
thriving on cows' milk mixtures have, as a rule, fewer move-
ments in the twenty-four hours than breast-fed babies and
these movements are of firmer consistency. Slight con-
stipation is not uncommon after the first few months and is
not of pathological significance. The color of the stools is a
lighter yellow, probably because of the relatively larger
amount of proteid, and because some of the bilirubin is
converted into hydrobilirubin. When the relative propor-
tions of fat and proteids in the mixtures are approximately
those of breast milk, the odor and reaction of the stools are
essentially the same as when the infant is taking breast milk.
When infants are given whole cows' milk or simple dilutions
of cows' milk, so that the proteids are equal to or greater than
the fat, the odor is slightly modified toward the fecal or cheesy
because of the action of bacteria on the casein. The reaction
becomes alkaline for the same reason.
Skimmed Milk Mixtures. When infants are fed on
skimmed milk or on mixtures very low in fat and high in
proteids, the stools have a slightly brownish-yellow color, a
slightly cheesy or foul odor, and a strongly alkaline reaction
because of the longer stay of the casein in the intestine and
the consequently greater opportunity for bacterial action
and for the change of bilirubin to hydrobilirubin. In some
instances the stools have a peculiar salve-like appearance like
those from buttermilk.
56 CASE HISTORIES IN PEDIATRICS.
Whey and Whey Mixtures. When infants are fed on whey
or whey mixtures low in fat, the stools have essentially the
same characteristics as those from skimmed milk, except that
they are usually browner.
Starch Mixtures. When starch is added to cows' milk
mixtures the color of the stools becomes distinctly brownish
and the reaction tends toward the acid. The odor is more
aromatic. Most starch flours contain small brownish specks
which are the remains of the husks. These specks pass
through the gastrointestinal tract unaffected and appear in
the stools.
Malt Sugar Mixtures. The addition of malt sugar to cows'
milk mixtures changes the color of the stools to a distinct
brown, tends to make the reaction acid and to increase the
acidity of the odor. When malt sugar or the malted foods
are given without milk the stools are dark brown, sticky,
acrid in odor and acid in reaction.
Buttermilk and Buttermilk Mixtures. The stools of in-
fants fed on buttermilk and buttermilk mixtures are of a
peculiar shiny, salve-like appearance, grayish-brown in color,
alkaline in reaction and have a very characteristic acrid odor.
Animal Food. When beef-juice or broth is added to the
infant's diet the color of the stools is changed to brown, while
the odor becomes fecal and the reaction alkaline from the
action of bacteria on the proteids.
The Starvation Stool. The starvation stool is made up of
bile, the intestinal secretions and bacteria and resembles the
meconium. It is usually small, sometimes constipated,
sometimes loose, brownish or brownish-green in color and
has, as a rule, a stale odor like that of starch or paste. In
some cases it has the odor of acetic acid as the result of the
action of microorganisms.
Reaction of the Stools. The reaction of the normal stool
depends on the relation between the fat and proteids in the
food. When there is a relative excess of fat the reaction is
acid; when there is a relative excess of proteid the reaction
is alkaline, the reaction depending, in the one case on the
products of the decomposition of fat, in the other on the
products of the decomposition of proteids. The carbo-
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 57
hydrates have no effect on the reaction of the normal stool.
When the carbohydrates are in excess, or when there is
fermentation of the carbohydrates as the result of bacterial
action, the acidity of the stools is markedly increased.
Stools which irritate the buttocks are invariably acid in
reaction, and in most instances this excessive acidity is due
to the decomposition of carbohydrates. Frothy stools are
usually acid in reaction, and due to the same cause, but some-
times the frothiness is caused by gases formed during the
decomposition of proteids. The reaction of the stools is,
however, of comparatively little importance from the clinical
side. It is best tested by placing wet red or blue litmus paper
on, not in, the stool.
Odor of the Stools. The odor of the stools depends on the
composition of the food, the rapidity of the absorption of the
products of digestion and the degree of the bacterial activity.
The fats give the odor of butyric or lactic acid to the stools.
The carbohydrates, if thoroughly utilized, do not affect the
odor; if not utilized, they give the odors of lactic, acetic or
succinic acids. The proteids give cheesy odors of various
sorts, sometimes those of skatol, indol and phenol.
The odor of the normal stool and the influence of variations
in the diet upon it have already been mentioned. The stools
of fat indigestion have a strong odor of butyric acid, those of
proteid indigestion various cheesy or putrefactive odors as
the result of the decomposition of the proteids by bacteria.
When several elements of the food are improperly digested
the odor is a combination of those resulting from the decom-
position of the various elements. The stools of cholera
infantum are almost odorless. Stools composed almost
entirely of mucus have a peculiar aromatic odor, resembling
that of wet hay. When there are deep ulcerative or gan-
grenous processes in the intestine, the stools have a putre-
factive or gangrenous odor.
Color of the Stools. The normal variations in the color
of the stools according to the composition of the food have
already been mentioned. Abnormalities in the color are very
common. The color of the stool must not be judged from
the outside, as it may change very rapidly from drying and
58 CASE HISTORIES IN PEDIATRICS.
exposure to the air. The stool must be broken up or smoothed
out and the inside examined.
Green. The most common abnormal color is green. The
shade of green may vary from a very delicate light grass-
green to a dark spinach green. In a general way, the darker
the green the greater its significance. A very light grass-
green color in a stool which is otherwise normal is of no
practical importance. The change from yellow to green after
the stool is passed is not abnormal. The green color is, in
the vast majority of instances, due to the change of bilirubin
to biliverdin. There is much doubt as to the cause of this
change. It is probable that it may be due to either excessive
acidity or alkalinity of the intestinal contents or to the pres-
ence of some oxidizing ferment. The green color is not
characteristic of any special type of disease. In some in-
stances it is due to the action of the bacillus pyocyaneus.
If it is due to bacterial action, the addition of nitric acid
decolorizes the stool. If it is due to biliverdin, the addition
of nitric acid gives the characteristic colors of Gmelin's
test.
Gray. The next most common abnormal color is gray.
This is due, as a rule, to the absence of bile and the presence
of some form of fat in the stool. It must be remembered,
however, that there may be bile in the stool even when it is
gray, the bile pigment being in the form of the colorless
leucohydrobilirubin. It is never safe, therefore, to conclude
that there is no bile in the stool without a chemical examina-
tion. The easiest and most satisfactory test is that with
corrosive sublimate. When the stools are gray at birth, or
become so within a few days after birth, the lesion is usually
a congenital obliteration of the bile ducts. When the gray
color appears later, and especially when it is associated with
large amounts of mucus, the trouble is usually in the duo-
denum.
White. The white stools are due to the presence of
undigested fat in the form of soaps. These may be soft,
looking much like curdled milk, or, more often, hard and
dry, resembling the stools of a dog which has been eating
bones.
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 59
Black. The black stool, while in rare instances due to the
presence of changed blood, is usually due to the action of
some drug, ordinarily bismuth, sometimes iron.
It is very common to see a pink stain on the diapers about
a stool which is otherwise normal, or nearly so. This pink
stain is of no especial significance and is due to some unknown
change in the bile pigment.
Abnormal Constituents. Curds. The most common ab-
normal constituents are curds. There are two kinds of curds,
one primarily composed of casein, the other composed mainly
of fat, mostly in the form of fatty acids and soaps. The
small amount of fat in the casein curds and the small amount
of proteid in the fat curds are merely incidents. The casein
curds vary in size from that of a bean to that of a pecan nut.
They are usually white, sometimes yellow, in color. They
are firm and tough, cannot be broken up by pressure and sink
in water. When placed in formalin they become as hard as
rocks. They are insoluble in ether. The fat curds are small,
varying in size from that of a pinhead to that of a small pea.
They vary in color from white to yellow or green, according
to the general color of the movement. They are easily
broken up by pressure, and, when shaken up in water, tend
to remain in suspension. They are soluble in ether to a
considerable extent after acidification and are unaffected by
formalin.
Mucus. Mucus can be detected in small amounts under
the microscope in the majority of normal stools, and is almost
invariably present in abnormal stools. It is never present
macroscopically in normal stools, but is very common in the
abnormal. It does not denote any special form of disease,
merely an excessive secretion of the mucous glands of the
intestine from some cause. When thoroughly mixed through-
out the stool it usually comes from the small intestine ; when
in combination with a clay-colored stool, from the duodenum;
when on the outside of a constipated stool, from the rectum.
Stools composed mainly or entirely of mucus and blood
indicate either severe inflammation of the colon or intussus-
ception. Undigested starch is often mistaken for mucus.
They can be distinguished by the addition of some preparation
60 CASE HISTORIES IN PEDIATRICS.
of iodine, which stains the starch blue, but does not affect the
mucus. The suspected material should be taken off the
diaper in order to avoid possible confusion from the presence
of starch on the diaper.
Blood. Blood on the outside of a constipated stool
indicates a crack of the anus. Blood mixed with mucus
indicates either severe inflammation of the large intestine or
intussusception. Blood in infancy is seldom due to hemor-
rhoids.
Pus. Pus indicates severe inflammation of the large
intestine. It is usually not present early in the disease, but
appears later. When the infants survive the acute stage it
persists into convalescence. Pus can be found with the
microscope in nearly every case of inflammation of the
colon, but is of no special significance unless visible macro-
scopically.
Membrane. Membrane indicates very severe inflammation
of the large intestine and is rarely seen, the patients usually
dying before membrane appears in the stools.
Other abnormal constituents are undigested masses of food,
foreign bodies which have been swallowed, and worms.
Microscopic Examination of the Stools. The macroscopic
examination of the stools affords data sufficiently reliable for
clinical work in the great majority of instances. It may,
however, lead to erroneous conclusions, especially with regard
to the amount of fat and undigested starch. Fatty and
starchy stools sometimes appear perfectly normal macro-
scopically, and only microscopical examination will prevent
mistakes. It is advisable, therefore, in all but the plainest
cases, to examine the stools microscopically as well as macro-
scopically. The microscopical examination of the stools is
not a difficult procedure and can be carried out in ten minutes
or less by anyone accustomed to it.
The feces, if hard, are first rubbed up with a little water.
Otherwise they are thoroughly mixed, and three different
portions examined. The first is examined in the fresh con-
dition. In this portion any undigested tissues or pathological
elements, such as blood, pus and eggs of parasites, can be
differentiated. A preliminary estimation of the amount of
NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 6 1
neutral fat, fatty acids, soaps and starches can also be
made.
The second portion is stained with Lugol's solution (iodine,
2; potassium iodide, 4; distilled water, 100) and examined for
starch. The starch granules stain blue or violet. Certain
microbes also stain blue. These, the so-called iodophilic
bacteria, are associated with faulty carbohydrate digestion,
and, when found alone without other symptoms, are sugges-
tive of an early disturbance in the digestion of the carbo-
hydrates. Before concluding that undigested starch is
present, all possibility of contamination with baby powders
must be eliminated.
The third portion is stained with a saturated alcoholic
solution of Sudan III. The neutral fat drops and fatty acid
crystals stain red. Soap crystals do not stain with Sudan III.
After this specimen is examined and the microscopic picture
is clear, a drop of glacial acetic acid is allowed to run under
the coverglass, is thoroughly mixed in, and then heated until
it begins to boil. This process turns the soap into neutral
fat and fatty acid which will appear as large stained drops
and upon cooling crystallize. They usually retain the red
stain. Any increase in the amount of fat after the addition of
acetic acid indicates the presence of a corresponding amount
of soaps. If there are any fat drops visible after the addition
of Sudan III and before the addition of acetic acid, another
specimen should be stained with a dilute solution of carbol-
fuchsin (carbolfuchsin sol., 1; water, 4 or 5). With this
solution the neutral fat is not stained, while the fatty acids
are stained a deep red and the soaps a dull rose-red. Without
this stain it is impossible to distinguish neutral fat from fatty
acids. An excess of neutral fat indicates that the digestion
of fat is not carried on normally; an excess of fatty acids
and soaps, that the digestion is normal, but assimilation is
abnormal.
It is well to examine the specimen first with a low-power
objective and later with a No. 7 objective in order to bring
out the detailed structure.
Bacteriologic Examination of the Stools. Our knowledge
of the bacteriology of the disturbances of digestion and of
62 CASE HISTORIES IN PEDIATRICS.
the various inflammatory diseases of the intestine is so
limited at present that no conclusions of clinical impor-
tance can be drawn from the microscopic examination of
the stools, the only exception being, possibly, the presence
of large numbers of iodophilic bacteria, which, as already
stated, point to disturbance of the digestion of the carbo-
hydrates.
Gown for premature infant.
Premature infant in gown.
SECTION II.
DISEASES OF THE NEW-BORN.
CASE i. Ruth S. was delivered at 6 a.m., April 6, by high
forceps, after a labor lasting twelve hours. The operation
was not a difficult one. She was expected May 9. She
gasped at once and breathed immediately, but did not cry.
She passed both urine and meconium soon after she was
born. Her parents were healthy, but frail. There was no
known cause for the premature labor. She was seen at
7.30 A.M.
Physical Examination. She was small but well nourished.
Her color was good, her skin clear and the surface of the body
warm. The heart was normal and the lungs fully expanded.
The lower border of the liver was palpable three cm. below
the costal border in the nipple line. The spleen was not
palpable. There were no deformities. She weighed five
pounds.
Diagnosis. The diagnosis is, of course, Prematurity.
Whatever may be the cause of the prematurity, it is certainly
not syphilis.
Prognosis. The prognosis should always be guarded in
premature babies. They ought not to be considered out of
danger until they are thriving under normal conditions.
Her chances are, however, better than the average, because
she is only a month premature, weighs five pounds, was born
after a short and easy labor and is not syphilitic.
Treatment. She ought not to be bathed, but should be
anointed with olive oil. She should be oiled in her crib every
other day. This will gradually clean the skin and keep it
in good condition. She should not be dressed, but should
be wrapped in absorbent cotton, or, better, in a quilted gown
with a hood. The gown is made by quilting cotton between
two layers of cheesecloth. This protects the baby as well as
63
64 CASE HISTORIES IN PEDIATRICS.
cotton alone, and makes the care much easier. Absorbent
cotton should be used at first instead of a diaper.
She should be placed in a padded bassinette or basket, the
temperature of which should be kept at 900 F., by electric
heating pads or hot water bags or bottles. The thermometer
by which the temperature of the basket is regulated should
be fastened to the front of the gown. Her rectal tempera-
ture should be taken two or three times daily. If it is above
99.50 F., the temperature of the basket should be lowered;
if it is below normal, it should be raised. The temperature
of the room should be kept at 8o° F. The air of the room
must at the same time, however, be kept fresh. The ther-
mometer by which the temperature of the room is regulated
must be hung near the basket, not on the wall many feet from
the baby. A sunny room with a fireplace, in which there is
a fire, is the best. A padded basket is much preferable to
an incubator, because an incubator does not provide a suffi-
cient supply of fresh air, and because the temperature of the
air which the baby has to breathe is too high. The baby's
vitality and its resistance to infection are lowered by the lack
of fresh air. The lack of fresh air increases the liability of
infection, and bacteria grow most luxuriantly at the tempera-
ture at which the incubator is usually kept.
She should be given a teaspoonful of warm water every two
hours until to-morrow morning. She ought not to be put to
the breast then, because she is not strong enough to suck well,
is not vigorous enough to be handled and is liable to be
chilled by the exposure consequent to being taken from her
basket. It is even more important, on account of their
undeveloped powers of digestion and absorption, for pre-
mature babies than for full-term babies to have breast-milk.
Their chances of survival are much better on breast-milk
than on any modification of cows' milk. She should, there-
fore, be given a drachm of a mixture of one part of breast-
milk and three parts of water every two hours, day and night.
If her mother has no milk, a wet nurse should be procured.
If breast-milk is not obtainable, she may be given instead a
modified milk containing 1% of fat, 5% of milk sugar, 0.25%
of whey proteids and 0.25% of casein. This amount of food
DISEASES OF THE NEW-BORN. 65
is entirely inadequate to cover her caloric needs. There is
great danger, however, of disturbing her digestion, if too
strong a mixture or too large a quantity is given at first, and
it will be very difficult to correct it, if it is disturbed. If she
takes and digests her food well, the strength and the amount
at a feeding should be rapidly increased, changes being made
every day, or even twice a day, if necessary. It must be
remembered that premature babies, on account of their small
size and their imperfect metabolism, require more calories
per kilo than full-term babies, and that, therefore, it is very
important to increase the strength and amount of her food
as fast as is possible without disturbing her digestion. She
is too small to take an ordinary nipple well and probably
too feeble to suck vigorously. The milk should, therefore,
be given to her in a "Breck Feeder," which is far better
than either a spoon or a dropper. The "Breck Feeder" is a
graduated glass tube open at both ends. On the smaller
end is a nipple, about the size of the rubber of a medicine
dropper. This is perforated and goes into her mouth. On
the other end is a large finger cot. By squeezing the finger
cot the milk can be forced into her mouth and efforts at
sucking be aided or induced.
She must not be handled any more than is absolutely
necessary. No one should be allowed to see her except those
who are taking care of her. It is not necessary to darken the
room or to be especially careful about noise, because light
and noise will not disturb her at present.
She does not require any stimulation.
66 CASE HISTORIES IN PEDIATRICS.
CASE 2. John M., the first child of healthy parents, was
born at full term after an instrumental labor. He was normal
at birth, except for a tumor in the neck. This tumor had
not increased in size. He had never been properly fed, had
had more or less disturbance of the digestion from the first
and had not gained in weight. He was admitted to the
Floating Hospital when six weeks old.
Physical Examination. He was fairly developed and
nourished. The hair was sparse. The anterior fontanelle
was three cm. in diameter and level. The posterior fon-
tanelle was still open. The pupils were equal and reacted to
light. The cervical spine was normal. The throat was
normal, as were the heart and lungs. The abdomen was full,
soft and tympanitic. The lower border of the liver was just
palpable in the nipple line, the upper border of dullness being
at the fifth rib in the same line. The spleen was not palpable.
The extremities showed nothing abnormal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's sign was absent. There was a slight general
enlargement of the peripheral lymph nodes. There was a
mass, the size of a small orange, in the left side of the neck.
The location is best shown in the accompanying photograph.
It was covered with normal skin and was neither hot nor
tender. Pressure on it caused no discomfort or diminution
in size. It was rounded, but had a definite and relatively
small base. It was somewhat fluctuant and evidently con-
tained fluid. The fluctuation was not as marked, however,
as would have been expected if the fluid was contained in a
single cavity. Several small masses could be felt indis-
tinctly, as well as a number of bands running through it.
The rectal temperature was 99.20 F. ; the pulse, 126; the
respiration, 30.
Diagnosis. The absence of heat, redness and tenderness
and the normal temperature show that the tumor cannot be
inflammatory in origin, even if this possibility was not
excluded by the fact that it was present at birth. The
absence of any defect in the cervical spine, the position of
the tumor, the absence of all signs of involvement of the
spinal cord and the fact that pressure on the tumor causes
John M. Case 2.
DISEASES OF THE NEW-BORN. 67
no discomfort or diminution in its size exclude a spinal
meningocele. The position of the tumor, posteriorly to the
sternocleidomastoid muscle, and the fact that it is evidently
multilocular rule out a branchial cyst. The only other con-
genital tumor which occurs in this position is the cystic
hygroma. This tumor is situated in the usual position of
these tumors, contains fluid and is multilocular. It corre-
sponds, therefore, in all its characteristics to those of a
Cystic Hygroma of the Neck, and undoubtedly is one.
Prognosis. The tumor will certainly not diminish in size
and is not likely to grow any larger. It may, however,
become infected and suppurate. It is in no way dangerous
to life, but, unless removed, will cause much discomfort and
inconvenience.
Treatment. The tumor must, of course, be eventually
removed. It will be wise, however, to delay until the baby
is older and stronger, because these tumors usually have
diverticulse which extend deep into the neck, the removal
of which often makes the operation a long and serious one.
68 CASE HISTORIES IN PEDIATRICS.
CASE 3. Mary C, the first child of healthy parents, was
born at full term, after a normal labor, at 9 p.m., Aug. 21.
She appeared normal at birth, except that her abdomen was
rather large, and weighed nine pounds. She passed no meco-
nium either during or after the labor. She began to vomit a
yellowish-green material soon after birth. The vomiting was
not explosive. It was, in fact, more like regurgitation than
vomiting, the vomitus often running out of the mouth with-
out any apparent effort. She took the breast well but con-
tinued to vomit everything taken. There having been no
movement of the bowels, she was given a high enema of a pint
of water early in the morning of Aug. 23. Two sticks of
smooth, dry, gray feces the size of the finger were obtained.
Two doses of castor oil, given that afternoon, were vomited.
The temperature remained normal and the abdomen lax
until the morning of Aug. 24, although the bowels did not
move and the vomiting continued. Distension of the
abdomen developed during the morning, however, the tem-
perature rose steadily all day and her general condition grew
progressively worse. Another dose of castor oil was vomited.
A high enema brought away a small amount of grayish
material of the same character as that obtained from the first
enema. She was seen in consultation at 5 p.m., Aug. 24.
Physical Examination. She had evidently lost much
weight. The face was drawn. There was no jaundice. She
was quiet unless disturbed, but every few minutes regurgi-
tated a small amount of yellowish-brown, watery material.
The fontanelles were depressed. There was no rigidity of the
neck and no neck sign. The pupils were equal and reacted to
light. The mouth and throat were not examined. The
heart and lungs were normal. The liver and spleen were
not palpable. The abdomen was much enlarged and so tense
that nothing could be determined by palpation. It was
everywhere tympanitic, but apparently not tender. The
superficial veins were distended. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and normal. Kernig's sign was absent. The
diapers were wet, but not stained by bile. The rectal tem-
perature was 102.80 F.; the pulse, 172.
DISEASES OF THE NEW-BORN. 69
Diagnosis. The absence of any physical signs of increased
cerebral pressure or meningeal irritation excludes all forms
of cerebral disease as the cause of the vomiting and obstipa-
tion. Disease of the brain would not, moreover, account for
the gray color of the feces. The distension and rise of tem-
perature are undoubtedly due to some complication of the
original condition, the symptoms of which are vomiting and
obstipation. The early onset and the persistence of the vom-
iting, taken in connection with the absence of meconium, the
small amount of intestinal contents obtained by enemata
and the absence of all signs of inflammation in the abdomen
and of fever until this morning show conclusively that there
is some congenital obstruction of the digestive tract. The
amount of the vomitus, the character of the vomiting, the
presence of bile in the vomitus, the absence of bile in the in-
testinal contents and the absence of jaundice and bile in the
urine prove that the obstruction is situated below the en-
trance of the common bile duct into the duodenum. The
fact that a soft rubber catheter could be passed well into
the intestine and that a pint of water could be injected at
one time shows that the obstruction must be located above
the large intestine. It is impossible, however, to determine
in what part of the small intestine below the duodenum the
obstruction is located. It is probable, however, judging
from the small amount of intestinal contents obtained, that
it is situated in the lower portion of the ileum. While it is
possible that the obstruction may be due to constriction by
a band or peritoneal adhesions, the chances are very much in
favor of a Congenital Malformation of the Intestine.
The distension and fever are almost certainly the result of
a complicating peritonitis as the result of infection.
Prognosis. The outlook is practically hopeless. There
is a small chance of finding some condition, like obstruction
from a band or adhesions, which can be relieved. Even so,
however, the complicating peritonitis will probably prove
fatal. In all probability, however, the obstruction is due to
some irremediable malformation of the intestine.
Treatment. There is no possible hope of recovery without
an operation. An exploratory laparotomy should, therefore,
be done at once.
70 CASE HISTORIES IN PEDIATRICS.
CASE 4. Martha R., the third child of healthy parents,
was born at full term after a normal labor and was apparently
normal at birth. She was seen when three and a half months
old. She was breast-fed entirely for two weeks, given one
part of whole milk and two parts of water in addition for two
months, then milk and water alone. Her weight at birth
was not known, but she had evidently gained a little. The
movements had been whitish in color from the first. Jaundice
was first noticed when she was ten or twelve days old and
had persisted, with a certain amount of increase, ever since.
It was thought that the urine was light-colored in the begin-
ning, but that it very soon became greenish and had so
continued. The abdomen was large at birth and had so
remained. The baby had seemed fairly well on the whole,
but had vomited occasionally and had had two loose white
movements daily. It was thought that she had had a little
fever from time to time.
Physical Examination. She was fairly developed and nour-
ished. There was marked jaundice of the skin, mucous
membranes and conjunctivae. The anterior fontanelle was
4 cm. in diameter and level. She was perfectly intelligent.
The mouth and throat were normal, and there were no snuf-
fles. There was no rosary. The heart and lungs were normal.
The upper border of the liver flatness was at the upper border
of the fifth rib in the nipple line. The lower border of the
liver was palpable, running from the right anterior superior
spine to the left costal border in the nipple line. The notch
was indistinctly palpable in the median line; the edge was a
little rounded, the surface smooth. The gall bladder was not
felt. The spleen was palpable, running out from beneath
the costal border in the anterior axillary line, downward to
the level of the navel, and backward and upward under the
ribs in the posterior axillary line. It extended 4 cm. below
the costal border and was 6 cm. wide. There was a moderate-
sized umbilical hernia. There were no signs of fluid in the
abdomen and no other masses were felt. The abdomen was
not distended, except by the enlarged liver and spleen.
Rectal examination was negative. The cervical lymph nodes
were slightly enlarged; the axillary and inguinal were not.
DISEASES OF THE NEW-BORN. Jl
There was a slight intertrigo about the buttocks and genitals,
but no lesions of scratching. There were no mucous patches
and no scars of any old eruption. The extremities were
normal. The weight was nine pounds.
The urine was greenish in color, of a specific gravity of
1,009, and acid in reaction. It contained no albumin but
considerable bile.
The stools were somewhat loose, grayish-white in color,
foul in odor. Examination by the corrosive sublimate test
showed a total absence of bile.
Diagnosis. The history, physical examination, urine and
stools together present such a characteristic picture of
Congenital Obliteration of the Bile Ducts that a
differential diagnosis is hardly necessary. The only other
things to be considered as possibilities are congenital syphilis
and duodenal indigestion. Enlargement of the liver and
spleen, sometimes accompanied by jaundice, do occur in
congenital syphilis. The absence of bile in the stools and of
other signs of syphilis, such as snuffles, mucous patches and
the scars of old eruptions, exclude it in this instance. Duo-
denal indigestion is extremely unusual at this age, the liver
but little enlarged, the spleen not at all. It can, therefore,
also be ruled out. An important point to be remembered in
this connection is the fact that there is a colorless form of
bile, leucohydrobilirubin. It is never safe, therefore, to con-
clude absolutely, without a chemical test, that a stool does
not contain bile, even if it is white or clay-colored.
Prognosis. The prognosis is absolutely hopeless. No case
has lived to be more than eight months old. Death occurs
from debility, secondary hemorrhage or intercurrent disease.
Treatment. There is no curative treatment. The patients
probably live longer and certainly digest better and are more
comfortable, however, if fat is eliminated from their food.
72
CASE HISTORIES IN PEDIATRICS.
CASE 5. Robert R., the first child of healthy parents, had
always been very well. He had been entirely breast-fed, had
never had a cough and had not cried more than a normal baby
should. When he was about three months old his mother
noticed a bunch in the right groin. She had not seen it
before, but could not say whether it had been there before or
not. She thought that it had increased a little in size since
she first discovered it. It apparently caused the baby no
discomfort. He was seen in consultation a week after the
discovery of the tumor.
Physical Examination. He was in splendid general con-
dition, large, fat and of good color. The fontanelle was level.
There was no rosary. The heart, lungs and abdomen were
normal. The liver was palpable 2 cm. below the costal border
in the nipple line; the spleen was not palpable. The extremi-
ties were normal. There was no spasm or paralysis; the
knee-jerks were equal and normal; there was no Kernig's
sign. There was no enlargement of the peripheral lymph
nodes.
There was a slightly elastic swelling, about the size and
shape of a catbird's egg, in the right inguinal region just
above the entrance to the scrotum. It was not tender, hot
or red. It could be pushed upward and downward en masse,
but could not be pushed into either the abdomen or the scro-
tum. It did not gurgle. The inguinal rings felt alike on both
sides, and nothing could be felt in them. Both testicles were
in the scrotum.
Diagnosis. The history is unimportant in this instance.
Babies often develop an inguinal hernia without cough or
excessive crying and the mother does not know whether the
swelling was present at birth or appeared later. The diag-
nosis must be made entirely on the physical examination.
A partially descended testicle can be ruled out because both
testicles are in the scrotum. The elasticity rules out a
hyperplastic lymph node. It is, moreover, very unusual to
find only one enlarged lymph node in the groin, and a large
lymph node is seldom so movable. The normal condition of
the inguinal ring rules out hernia. The absence of gurgling
and the irreducibility of the mass are corroborative evidence
DISEASES OF THE NEW-BORN. 73
against hernia. The shape, elasticity, mobility and irreduci-
bility are characteristic of an Encysted Hydrocele of the
Cord, which is the diagnosis.
Prognosis. There is, of course, nothing dangerous about
this condition. A single tapping usually cures it.
Treatment. The treatment is aspiration with a fine needle.
One tapping will probably cure it. If it does not, the tapping
may be repeated. An operation will almost certainly not be
necessary.
74
CASE HISTORIES IN PEDIATRICS.
CASE 6. Harriott H., the first child of healthy parents,
was born at full-term after a difficult forceps delivery, and
weighed eight pounds. She breathed at once and seemed
normal in every way except that her head was much swollen
and out of shape. The general swelling went down in twenty-
four hours and then a circumscribed swelling was noticed on
the right side of the head. This had diminished a little in
size and had apparently caused her no discomfort. She had
seemed normal in every way except for the swelling on the
head. She was seen in consultation when a week old.
Physical Examination. She was well developed and nour-
ished and of good color. There was a swelling, the size of a
duck's egg, over the right parietal bone. This swelling was
soft and fluctuating, but neither red nor tender. Pressure on
it caused no bulging of the anterior fontanelle and no dis-
comfort or signs of increased cerebral pressure. It did not
extend beyond the borders of the right parietal bone. The
pupils were equal and reacted to light. There was no rigidity
of the neck. The anterior fontanelle was level. The heart,
lungs and abdomen were normal. The liver was palpable
2 cm. below the costal border in the nipple line; the spleen
was not palpable. The extremities were normal; there was
no spasm or paralysis; the knee-jerks were equal and normal;
there was no Kernig's sign.
Diagnosis. This tumor corresponds in every way to a
Cephalhematoma and undoubtedly is one. The caput
succedaneum is hard, does not fluctuate and is not limited to
a single bone. It disappears in from twenty-four to forty-
eight hours. The swelling first noticed in this instance was
undoubtedly a caput. A meningocele protrudes through one
of the normal openings in the skull, a fontanelle or suture,
and is most often situated at the root of the nose or in the
occipital region. Pressure on it causes bulging of the anterior
fontanelle, discomfort and symptoms of increased cerebral
pressure, such as spasm or twitching of the extremities. An
abscess is hot, red and tender, and is accompanied by fever
and symptoms of general constitutional disturbance.
Prognosis. The prognosis is absolutely good if the tumor
is let alone. It is sure to disappear in from three to six weeks.
Harriott H. Case 6.
Multiple Cephalhematoma.
DISEASES OF THE NEW-BORN. 75
If it is aspirated or opened it may become infected and an
abscess result.
Treatment. The treatment is to let it alone. External
applications cannot hasten the absorption of the blood.
Aspiration will hasten the disappearance of the tumor, but
is unnecessary and carries with it the danger of infection.
An incision is unnecessary, will leave a scar and is very likely
to result in infection and the formation of an abscess.
y6 CASE HISTORIES IN PEDIATRICS.
CASE 7. William P. was the second child of healthy par-
ents. The position was 0. D. P. He was delivered by high
forceps and weighed eleven pounds. The physician in charge
pulled very hard on one shoulder, probably the right, during
the delivery, and thought that he felt something give way.
The baby was somewhat white at birth, did not respond to
artificial respiration, and mouth-to-mouth insufflation was
necessary. He then cried and seemed perfectly normal
except that it was noticed at once that there was some
trouble with the face and the right arm. He did not close
the right eye and there was no motion of the right side of
the face. The right arm hung limp at the side and was used
but little. There had been some improvement in the condi-
tion of both face and arm. He was seen in consultation when
one week old. He was not nursed, but took the bottle well
and had no disturbance of digestion.
Physical Examination. He was well-developed and nour-
ished. His color was good. The fontanelle was 3 cm. in
diameter and level. The head was of good shape. There
was no rigidity of the neck. There was a hemorrhage into
the right conjunctiva. The pupils were equal and reacted
to light. The left eye could be closed entirely; the right
only partially. The mouth was drawn to the left when he
cried. There were forceps scars on the left forehead, but none
on the right. The heart and lungs showed nothing abnormal.
The level of the abdomen was that of the thorax. The cord
was still on, but was healthy. The liver was palpable 3 cm.
below the costal border in the nipple line ; the spleen was not
palpable. The genitals were normal. The right arm hung
limply by the side, extended at the elbow and wrist, and with
the palm turned backward. He made no active motions
with this arm except at the wrist and with the fingers. His
grip was strong. Passive motions were not limited. The
arm was not tender, and there were no evidences of fracture
or dislocation. The left arm and the legs were normal and
showed no signs of spasm or paralysis. The knee-jerks were
equal and lively. There was no Kernig's sign. There was
no enlargement of the peripheral lymph nodes. The rectal
temperature was normal.
DISEASES OF THE NEW-BORN. 77
Diagnosis. The diagnosis of facial paralysis is evident.
The inability to close the eye shows that the upper branch
of the facial nerve is involved and that the paralysis is, there-
fore, peripheral in origin. It was undoubtedly caused by the
pressure of the forceps blade on the trunk of the nerve.
The hemorrhage into the right conjunctiva is presumably
also due to injury from the forceps blade.
The flaccidity of the right arm at once rules out cerebral
paralysis, in which the paralysis is spastic. Moreover, in
cerebral paralysis due to injury at birth, the paralysis is
never limited to one extremity, and if an extremity is affected,
it is always affected as a whole, not in part. If the baby was
older, infantile paralysis (poliomyelitis) might be considered,
but, as the paralysis was present at birth, this is an impossi-
bility. It corresponds perfectly to the so-called "obstetric
paralysis" of the upper-arm type, in which there is a paralysis
of certain muscles from injury to the brachial plexus during
labor. The stretching of the plexus caused by the pulling on
the shoulder was presumably the cause in this instance. The
characteristic position of the arm is due to the fact that only
certain muscles are involved, namely, the deltoid, biceps,
brachialis anticus, supinator longus, infraspinatus, supraspi-
natus and serratus magnus.
This baby, therefore, shows both the facial and arm types
of Obstetric Paralysis.
Prognosis. The prognosis of the facial paralysis is almost
absolutely good. Recovery almost invariably takes place in
a few weeks.
The prognosis of the paralysis of the arm is not as good.
There will certainly be a great deal of improvement, but
equally certainly some permanent disability. How great
this disability will be cannot be told for a year or two, after
which time little improvement can be expected.
Treatment. The facial paralysis requires no treatment.
The only treatment indicated for the arm at present is a
sling to take the weight of the arm off the shoulder muscles.
Massage and electricity may be begun in about three weeks.
The object of them both is to keep up the tone of the muscles
until the nerves regain their power. Faradism should be
78 CASE HISTORIES IN PEDIATRICS.
used, if the muscles react; if they do not, galvanism. If,
at the end of a year, there has been but little improvement,
operation on the nerve trunks will be worthy of consideration.
The results of this operation have been, in a number of
instances, very satisfactory. It is, however, a delicate oper-
ation and should be performed only by those accustomed to
the surgery of the nerves.
Obstetric Paralysis. — Facial type. Case 7.
Obstetric Paralysis. — Arm type. Case 7.
DISEASES OF THE NEW-BORN. 79
CASE 8. Marion S. was the first child of healthy parents.
There had been no miscarriages. She was born at full term,
after a moderately hard forceps delivery, and weighed seven
pounds. Nothing abnormal was noticed about her at birth.
She was not nursed, but was at once given modified cows'
milk, on which she had done very well. A lump was noticed
in her neck when she was four and one-half weeks old. Both
her mother and the nurse were positive that there had been
no lump there before. There had been no evidence of pain
or tenderness in the neck and the swelling apparently caused
her no inconvenience. She was seen when five weeks old.
Physical Examination. She was well developed and
nourished and of good color. The posterior fontanelle was
closed; the anterior, three cm. in diameter and level. She
held her head straight and moved it freely in all directions
without pain. There was a hard, non-tender bunch, the size
of an almond, in the lower third of the sternal portion of the
right sternocleidomastoid muscle, and the lower third of the
clavicular portion was thickened and hard, but not tender.
The swellings were not red or hot. The skin and subcutane-
ous tissues were freely moveable over them. The mouth and
throat were normal. The heart, lungs, abdomen and ex-
tremities were normal, as were the deep reflexes. The liver
was palpable two cm. below the costal border in the nipple
line. The spleen was not palpable. There was no enlarge-
ment of the peripheral lymph nodes. There was no nasal
discharge and no eruption on the skin. The rectal tempera-
ture was normal.
Diagnosis. The tumor and thickening are distinctly within
the sheath of the sternocleidomastoid muscle. They cannot,
therefore, be due to enlarged cervical lymph nodes or con-
nected with the thyroid gland, as was supposed by the former
attendant. Tumors and thickening of the sternocleidomas-
toid muscle in early infancy are almost invariably the result
of a hemorrhage into the muscle during labor. Other causes,
such as syphilis and malignant disease, are so extremely
unusual that it is not necessary to consider them. The
physician in charge did not notice anything abnormal at
birth, however, and the mother and nurse affirm that the
80 CASE HISTORIES IN PEDIATRICS.
tumor did not appear until the baby was more than four weeks
old. These statements do not appear consistent with the
diagnosis of hematoma of the sternocleidomastoid muscle, a
condition which develops at birth. It is easy to explain them,
however, when it is remembered that the effusion is at first
liquid and very easily overlooked unless there is tenderness.
The tumor is usually overlooked, therefore, until it becomes
hard from the organization of the clot and the formation of
scar tissue, unless the unusual position of the head, which is
turned a little downward and toward the affected side, calls
attention to it. In this instance the mother and nurse were
probably also poor observers. The statements as to the late
appearance of the tumor do not, therefore, invalidate in any
way the diagnosis of Hematoma of the Sternocleido-
mastoid Muscle.
Prognosis. The lesions in this instance are relatively slight
and there is no deformity or limitation of motion. It is
practically certain, therefore, that resolution will gradually
take place and that there will not be sufficient retraction of
the newly-formed tissue to cause torticollis. It will probably
be a year before the swelling will entirely disappear.
Treatment. Passive motion of the head to prevent con-
tracture of the muscle should be made regularly. Massage
of the thickened areas will probably hasten resolution.
DISEASES OF THE NEW-BORN. 8 1
CASE 9. Catherine E. was delivered at full-term by low-
forceps after a long labor, and weighed nine pounds. Her
mother had been married twice. Her only pregnancy by
her first husband had resulted in a miscarriage at two or
three months, after an accident. She thought that he had
not had syphilis and had had no symptoms of it herself.
Her second husband denied having had syphilis. The
patient was the first child by the second husband. She is
said to have cried vigorously immediately after birth. The
nurse noticed, a few hours later, however, that she did not
breathe naturally. The trouble with the breathing continued.
When quiet, she breathed quickly and her color was fair.
If disturbed, or if she made any exertion, she usually became
very cyanotic. Sometimes she at first became very pale and
then cyanotic. She seldom cried. The respiration was never
noisy. She usually kept her mouth shut and was able to
suck. She had apparently never had any fever and had never
had any disturbance of the digestion. She was seen in con-
sultation when about five weeks old.
Physical Examination. She was fairly developed and nour-
ished. When quiet, she breathed quickly but quietly. The
alae nasi did not move, she kept her mouth shut and her
color was good. There was, however, moderate retraction of
the epigastrium and of the sides of the chest. When dis-
turbed, the respiration became more rapid and labored, but
not noisy. She kept her mouth open and was evidently
distressed. She tried to cry but was unable to make much
noise. She became very cyanotic, and the retraction of the
epigastrium and sides of the chest was much increased. A
probe was easily passed through both nostrils. There were
no snuffles. The throat was normal both to inspection and
palpation and no adenoids were felt with the finger. There
was no increase of the thymus dullness, and the thymus
could not be felt in the suprasternal notch. The cardiac
impulse was indistinctly palpable in the fourth left space
5$ cm. to the left of the median line. The right border of
dullness was 2 cm. to the right of the median line. The action
was regular; the rate varied between 140 and 180 according
to the difficulty in breathing. The sounds were normal in
82 CASE HISTORIES IN PEDIATRICS.
character and there were no murmurs. There was marked
dullness and diminished broncho-vesicular (much nearer
vesicular than bronchial) respiration, with an occasional
medium moist rale in the left front down to the cardiac area
and in the upper left axilla, and over the whole right back
except at the apex. There was hyperresonance and exagger-
ated vesicular respiration over the rest of the lungs, and
numerous fine moist rales were heard. The abdomen was
normal. The liver was palpable 2 cm. below the costal border
in the nipple line; the spleen was not palpable. The ex-
tremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and normal. There was no en-
largement of the peripheral lymph nodes. There was no
eruption and no scars of any old eruption. There were no
mucous patches about the anus. The rectal temperature
was normal.
Diagnosis. The problem is to find the cause of the diffi-
culty in respiration and cyanosis. This cause is the diagnosis.
The physical examination rules out obstruction in the nose,
nasopharynx, pharynx and larynx, as well as pressure from
an enlarged thymus. The heart shows nothing abnormal.
Sometimes, however, the examination of the heart shows
nothing abnormal in congenital heart disease even when
there are marked symptoms. The signs in the lungs are so
definite in this instance, however, that it is not necessary to
take refuge in this explanation. The signs in the lungs show
partial solidification. The possible explanations of this
solidification are resolving pneumonia, syphilis of the lung
and congenital atelectasis.
Resolving pneumonia is mentioned merely because this
was the diagnosis of another consultant. It can at once be
ruled out because there was never any fever and the symptoms
appeared within a few hours after birth. Syphilitic involve-
ment of the lung sufficient to give such marked physical
signs is very unusual and is found only in the severest cases
in which there are many other signs of the disease. The
negative family history and the lack of any other signs of
syphilis rule it out in this instance. The early appearance
and the persistence of the symptoms without fever are most
DISEASES OF THE NEW-BORN. 83
characteristic of atelectasis. The only point against it is
that the baby is said to have cried vigorously at birth. This
may have been an error of observation, but, if true, does not
rule out atelectasis, because it is perfectly possible for a
baby to cry loudly and yet not completely expand the lungs.
The diagnosis is, therefore, Congenital Atelectasis. The
fine moist rales heard over the rest of the lungs are undoubt-
edly due to edema.
Prognosis. The prognosis is very grave. There is very
little chance of expansion of the atelectatic areas after five
weeks, and the child cannot live long in its present condition.
Treatment. There is no direct treatment for the atelecta-
sis. The best that can be done is to feed the baby carefully,
give it plenty of fresh air, administer oxygen when there is
cyanosis, and stimulate it, if necessary.
84 CASE HISTORIES IN PEDIATRICS.
CASE io. Roger S. was seen in consultation when three
months old. He was the fifth child and was born at full
term after a normal vertex labor. He was perfectly normal
at birth, but when he was two days old it was noticed that
he had some difficulty in breathing. This difficulty gradually
increased for about three weeks, since when it had remained
about the same. Inspiration was always noisy, whether he
was awake or asleep. It was noisier when he was excited and
when he was lying down, especially if he lay on his face.
Expiration was quiet. He never became blue and never
held his breath. His cry was always clear and he almost
never coughed. He had at times a little difficulty in taking
food. He was partly breast- and partly bottle-fed. His
digestion had always been perfect and he had gained steadily
in weight.
Physical Examination. He was well developed and nour-
ished, but a little flabby. He was somewhat pale, but not
at all cyanotic. Inspiration was always accompanied by a
crowing sound, which was more marked when he was fright-
ened or excited. This noise was louder when he was lying
down than when he was sitting up. He seemed uncomfortable
when lying on his face. Expiration was perfectly quiet.
His mouth was usually open, but the crowing sound was no
louder and respiration was no more difficult when it was
closed. His cry was perfectly clear. There was slight
retraction of the epigastrium with almost every inspiration.
This was more marked and was accompanied by marked
retraction of the suprasternal and supraclavicular spaces
when the crowing was louder. He was not at all cyanotic
even when the crowing sound was the loudest. The anterior
fontanelle was 4 cm. in diameter and level. The shape of the
head was good. There was no craniotabes. The fauces,
pharynx and nasopharynx showed nothing abnormal on
either inspection or palpation. The thymic dullness was not
increased and the thymus could not be felt in the suprasternal
notch. The heart and lungs were normal. The chest was
slightly flattened on the sides and the sternum was a little
prominent. There was a moderate rosary. The abdomen
was rather large, but otherwise normal. The lower border of
DISEASES OF THE NEW-BORN.
S5
the liver was palpable 2 cm. below the costal border in the
nipple line; the spleen was not palpable. The extremities
showed nothing abnormal. There was no spasm or paralysis.
The knee-jerks were equal, but not very lively. Kernig's
sign was absent. There was no enlargement of the peripheral
lymph nodes. Trousseau's sign and the facial phenomenon
were absent.
Diagnosis. Laryngismus stridulus can be excluded at
once because the crowing sound is continuous. Other less
important points against laryngismus stridulus are the early
onset and the absence of other signs of increased nervous
irritability (Trousseau's sign, facial phenomenon, exaggerated
reflexes). Obstruction in the nose, nasopharynx and pharynx
is excluded by the physical examination. Obstruction from
pressure on the trachea by enlarged bronchial glands, new
growths in the mediastinum or an enlarged thymus is ex-
cluded by the fact that the interference is entirely with in-
spiration. The sound resulting from obstruction in this
locality is, moreover, not crowing in character. It cannot be
due to obstruction within the larynx from inflammation or
new growths, because the cry is clear and there is no cough.
The obstruction must be, therefore, at the entrance of the
larynx. The anatomical malformation which can produce
this obstruction is a narrowing of the epiglottis with laxness
of the ary-epiglottidean folds. This condition was found by
laryngoscopic examination in this patient. The result of this
condition, noisy inspiration, is known as Congenital
Laryngeal Stridor.
Prognosis. The prognosis is good, both as to life and
recovery. The deformity disappears with the growth of the
parts and the crowing gradually diminishes and finally ceases
toward the end of the second year.
Treatment. Nothing can be done to hasten the growth of
the parts. It is important, however, to avoid, as far as
possible, catarrhal processes in the respiratory tract.
86 CASE HISTORIES IN PEDIATRICS.
CASE II. Marjorie D. was seen in consultation when four
days old. She was the second child of healthy parents, was
born at full term after a normal, rapid labor, and weighed
seven and one-quarter pounds. The older child was well
and there had been no miscarriages. She seemed normal at
birth, except that there was much mucus in the nose and
throat, which was removed with considerable difficulty.
There continued to be a profuse discharge of mucus, which
at times accumulated and caused severe suffocative attacks,
relieved only by the mechanical clearing of the nose and
throat. There was a constant rattling in the nose and throat
between these attacks. Her cry was somewhat feeble and
a little hoarse. Her mother's milk had appeared on the
third day and seemed sufficient in quantity. She took the
breast well, but was liable to have an attack of suffocation
come on while nursing. At times she vomited during or im-
mediately after nursing; at others, she retained several
successive feedings without vomiting. The stools were
still composed entirely of meconium. She passed urine,
but infrequently and in small amounts. The rectal
temperature had been normal. She had lost one pound in
weight.
Physical Examination. She was fairly developed and
nourished. She was slightly jaundiced, but there was no
cyanosis. There was no bulging of the fontanelles. She
was sleeping quietly, but with a little rattling in the nose.
Closing the mouth did not interfere with breathing or wake
her up. A probe was easily passed through both nostrils.
When the tongue was depressed a large amount of yellowish-
white liquid, mixed with mucus, came up in the throat.
When this was cleaned out and the operation repeated more
of the same material appeared. Palpation of the throat
showed nothing abnormal. Her cry was a little hoarse, but
strong. There was no retraction anywhere. The heart,
lungs and abdomen were normal. The stump of the cord
was healthy. The lower border of the liver was palpable two
cm. below the costal border in the nipple line. The spleen
was not palpable. The extremities were normal. There
was no spasm or paralysis. The knee-jerks were equal and
DISEASES OF THE NEW-BORN. 87
normal. Kernig's sign was absent. She took the breast
well, swallowed without difficulty, nursed about five minutes
and did not vomit.
Diagnosis. The suffocative attacks are undoubtedly due
to the collection of mucus in the nasopharynx. Why does
this mucus collect and why was it present in such large
quantities at birth? Is it because there is an excessive
secretion as the result of some local irritation or is it because
the secretion is not swallowed? A strong point against the
existence of an excessive secretion from local irritation is the
fact that the mucus was present in large amounts at birth.
On the other hand, the child swallows milk, and, if it swallows
milk, ought to be able to swallow mucus also. The material
which comes up in the throat when the tongue is depressed
looks like colostrum or thin pus, mixed with mucus. It is
hard to believe it pus, when it is taken into consideration that
the baby is only four days old, shows no evidences of infection
and has always had a normal temperature and that there are
no signs of an abscess from which the pus can come. It
hardly seems possible, on the other hand, that it can be colos-
trum, because she nurses and swallows well, and, according
to the history, has at times taken several successive feedings
without vomiting. It is possible, however, that she may not
have taken as much at these feedings as was supposed, that
although she swallows well she gets but little and that this
little does not reach the stomach but accumulates in the
esophagus. The persistence of the meconium-like stools
also points to some obstruction to the entrance of milk into
the gastrointestinal canal. A reasonable explanation of the
symptoms is, therefore, that there is a malformation of the
esophagus which does not interfere with swallowing but
prevents the passage of mucus and milk into the stomach,
that the suffocative attacks are due to the accumulation of
mucus in the pharynx, that not as much milk is taken as was
supposed, that several small feedings accumulate in the upper
esophagus, that the accumulated material is forced up when
the tongue is depressed and vomited when the reservoir is
overfilled. It is easy to prove whether this explanation is
correct or not by examining the material which comes up in
88 CASE HISTORIES IN PEDIATRICS.
the throat, and, if it proves to be milk, by passing a soft
rubber catheter into the esophagus.
The material from the throat contains many colostrum
corpuscles, much mucus and no more leucocytes than are
normally found in the colostrum. The catheter is easily
introduced into the esophagus but meets an obstruction about
four inches from the gums and can be passed no further.
There is no doubt, therefore, that the symptoms are due to a
Congenital Malformation of the Esophagus. This
malformation is situated at about the junction of the upper
and middle thirds, and is, judging from the usual condition
in these cases, presumably an obliteration of the esophagus
at this point. There is, for the same reason, probably an
opening between the trachea and the lower portion of the
esophagus.
Prognosis. The prognosis is absolutely hopeless. The
baby will die of starvation in a few days no matter what
method of treatment is pursued.
Treatment. The condition is irremediable. Surgical in-
tervention is impossible. Life may be prolonged a little by
rectal feeding and the subcutaneous injection of salt solution,
but these measures can only postpone the fatal outcome a few
days or possibly a week.
DISEASES OF THE NEW-BORN. 89
CASE 12. Eleanor S. was the fourth child of healthy
parents. She was born at full term, after a normal labor, was
normal at birth and weighed eight pounds. She was entirely
breast-fed and had done well in every way, except that she
had rather too many movements. Enlargement of the
breasts began when she was four or five days old and increased,
so that when she was ten days old they were much enlarged.
There having been no diminution in the size of the breasts,
she was brought on that account when three weeks old.
Physical Examination. She was well developed and nour-
ished and of good color. The posterior fontanelle was still
open; the anterior fontanelle was level. The mouth was
healthy. The heart, lungs and abdomen showed nothing
abnormal. The navel was normal. The lower border of the
liver was palpable one cm. below the costal border in the
nipple line. The spleen was not palpable. The extremities
were normal. There was no spasm, paralysis or disturbance
of the deep reflexes. There was no enlargement of the pe-
ripheral lymph nodes. Both breasts were markedly swollen,
the area at the base being about that of a fifty-cent piece and
the shape that of the engorged breast in the adult. They
were not red, hot or tender. A milky fluid could be easily
expressed from them. The rectal temperature was 990 F.
Diagnosis. The normal temperature and the absence of
heat, redness and tenderness prove that there is no inflamma-
tion of the breasts. The condition ought not, therefore, to
be called "mastitis," as it usually is. It is simply a Physio-
logical Engorgement of the Breasts, presumably due to
the passage into the fetus of some of the hormones circulating
in the blood of the mother. These stimulate the production
of milk in the child as well as in the mother.
Prognosis. The secretion of milk will gradually cease and
the enlargement of the breasts subside. There is no danger
of the development of mastitis if the breasts are let alone.
If they are handled or squeezed, they may become inflamed.
Treatment. The treatment is to let the breasts entirely
alone.
90 CASE HISTORIES IN PEDIATRICS.
CASE 13. Sidney K. was the first child of healthy parents.
There was no history of syphilis and there had been no mis-
carriages. He was born May 28, about a week premature.
He weighed six pounds and was put at once on a weak
modified milk. Jaundice developed on the second day and
became very marked. He took his food well and had not
vomited. The movements consisted at first of meconium;
later the bowels were very constipated, but the movements
were yellow and smooth. The temperature was normal or
slightly subnormal. The urine had not stained the diapers.
He was seen in consultation June 5, when eight days old.
Physical Examination. He was small and somewhat emaci-
ated, having lost a pound. There was cleep jaundice of the
skin and conjunctivae. He did not seem especially feeble.
The fontanelle was level. The mouth and throat were nor-
mal. The heart, lungs and abdomen were normal. The
umbilicus was healed. The liver was palpable 2 cm. below
the costal border in the nipple line. The spleen was not
palpable. The extremities were normal; there was no
spasm or paralysis; the knee-jerks were equal and normal.
The genitals were normal. There were no ulcerations about
the anus. There was no eruption or enlargement of the periph-
eral lymph nodes. The rectal temperature was normal.
The urine was not examined, but the diapers were not
stained by it.
The movements were small, constipated, brownish-yellow
and well-digested.
Diagnosis. When jaundice develops during the first few
days of life it is always a temptation to call it icterus neona-
torum and to dismiss it without further consideration. There
are other causes of jaundice at this age, however, and while a
snap diagnosis of icterus neonatorum will be correct in the
vast majority of cases, it will occasionally be wrong, and
wrong often enough to justify a careful differential diagnosis
in every instance. The diseases to be considered are, septic
infection of the newborn, congenital obstruction or oblitera-
tion of the bile ducts, acute duodenal indigestion, congenital
syphilis and congenital icterus.
The early appearance of the jaundice, the presence of deep
DISEASES OF THE NEW-BORN. 91
jaundice without cyanosis, the good general condition and
the absence of fever and of enlargement of the liver and spleen
rule out septic infection of the newborn. The absence of
enlargement of the liver and spleen and of bile in the urine,
together with the presence of bile in the stools, rule out
congenital obliteration of the bile ducts. Acute duodenal
indigestion is very uncommon at this age. It is excluded by
the absence of bile in the urine and the presence of bile in the
stools. Congenital syphilis is suggested by the prematurity.
There are, however, other causes for prematurity than syphi-
lis. The good family history and the absence of miscarriages
are against it. The normal size of the liver and spleen,
together with the absence of all signs of syphilis, rule it out.
Congenital icterus is an extremely rare condition and is
excluded because the jaundice was not present at birth and
the spleen is not enlarged. The diagnosis by exclusion is,
therefore, Icterus Neonatorum. The development of the
jaundice on the second day, the good general condition,
the presence of bile in the stools, its absence in the urine,
the normal temperature and the absence of enlargement of
the liver and spleen are all consistent with this diagnosis.
Prognosis. Icterus neonatorum does not affect the general
condition. The jaundice will probably not increase in in-
tensity, but will not disappear entirely for several weeks.
Treatment. No treatment is indicated. Icterus neona-
torum is a physiological condition and is due to the mere
mechanical difficulty which the bile encounters in passing
through the bile capillaries. There is, therefore, no object
in giving cathartics. Cleaning out the intestine cannot
affect the conditions in the bile capillaries. It has been shown
that calomel, like the other so-called " cholagogues," does
not increase the flow of bile. If it did, it would be contra-
indicated rather than indicated in this condition. There is
no indication for changing the food, because sufficient bile
to carry on digestion enters the intestine, only the excess
passing into the circulation.
92 CASE HISTORIES IN PEDIATRICS.
CASE 14. Robert M. was the third child of healthy
parents. The other children were well and there had been
no miscarriages. He was born at full term, after a normal
labor, and appeared normal at birth. He was given at first
a weak mixture of condensed milk and water. This did not
agree with him and he was then given barley water for a few
days, and after that a number of proprietary foods in rapid
succession, all of them being prepared with water. He had
vomited a great deal from the first and the stools, although not
increased in number above the normal, had always been green
and usually undigested. He had lost weight steadily. He had
several convulsions October 9. Two days later he suddenly
became very feeble and since that time had taken almost no
nourishment. He was admitted to the Children's Hospital,
October 14, when six weeks old.
Physical Examination. He was poorly developed and
emaciated. The skin was pale, with slight cyanosis of the
lips and nails. The surface of the body was cold. He was
extremely feeble, was unable to cry aloud and seldom opened
his eyes. The anterior fontanelle was two cm. in diameter
and depressed; the posterior was closed. The bones of the
skull overlapped. The mouth and pharynx were dry. The
respiration was very shallow. The cardiac impulse was
neither visible nor palpable. The cardiac area was normal.
The action was irregular and the sounds feeble. There were
no murmurs. The lungs showed nothing abnormal. The
abdomen was full and tympanitic, but otherwise normal.
The liver and spleen were not palpable. The genitals were
normal. Both cheeks were somewhat indurated. There was
marked induration of the whole of the back and of both upper
and lower extremities, except that the palms and soles were
not involved. There was no pitting on pressure. The color
of the indurated areas was slightly yellowish. He was
so rigid that when he was lifted from the bed by a hand
placed under his back there was no change in his position.
He did not move his extremities, but a certain amount
of passive motion could be elicited with some difficulty.
The character of the knee-jerk could not be determined,
because of the rigidity. The rectal temperature was
DISEASES OF THE NEW-BORN. 93
94.20 F., the pulse could not be obtained, the respiration
was 50.
Diagnosis. The diagnosis of Sclerema Neonatorum is so
evident in this instance that it is hardly necessary to consider
any other condition. The distribution of the induration, the
color of the indurated areas, the absence of pitting on pres-
sure and the sparing of the palms, soles and external genitals
are all characteristic of this condition and distinguish it from
edema, in which the color is pale, there is pitting on pressure
and the palms, soles and genitals are involved. The low
temperature is also characteristic of sclerema neonatorum. It
is seldom much below normal in edema.
Prognosis. The prognosis is practically hopeless. He
will probably not live more than twenty-four hours.
Treatment. He should be wrapped in cotton, placed in a
padded crib or basket and surrounded by heaters or, better,
electric heating pads. In fact, the same measures should be
used to keep up his temperature as are employed in the case
of premature infants (see Case 1). The best food for him
is human milk, diluted with an equal amount of water and
given with a dropper or Breck feeder. He will probably not
be able to take more than half an ounce every one and one-
half hours. If human milk is not obtainable, a modification
of cows' milk, containing 1% of fat, 5% of milk sugar, 0.50%
of whey proteids and 0.25% of casein, with lime water 25% of
the milk and cream in the mixture, may be substituted.
He should also be given -g-g-g- of a grain of strychnia every
three hours, supplemented, if necessary, by caffeine-sodium
benzoate or salicylate in doses of one eighth of a grain.
94 CASE HISTORIES IN PEDIATRICS.
CASE 15. Ursula M., the first child of healthy parents,
was born at full term, September 23, after a normal labor,
and was normal at birth. She had been breast-fed and, ex-
cept for considerable colic, had done well. The cord came
off on the sixth day. The navel was healthy and continued
dry until October 3. There had been since then, however,
a thin, purulent discharge from the navel. She was seen
October 6.
Physical Examination. — She was small, but was developed
and nourished, and of good color. The fontanelle was level.
The mouth was healthy. The heart and lungs were normal.
The liver was palpable two cm. below the costal border in
the nipple line. The spleen was not palpable. The abdo-
men showed nothing abnormal, except at the navel. There
was a tumor, the size of a small pea, at the bottom of the
navel, which was normally sunken. This tumor looked like
a mass of granulation tissue. There was a small amount of
thin purulent discharge from it. Careful examination with
a probe failed to disclose any canal in it. The extremities
were normal. There were no mucous patches about the anus
and there was no eruption on the skin. There was no en-
largement of the peripheral lymph nodes. The rectal tem-
perature was 990 F.
Diagnosis. The absence of a central canal in the mass at
the navel and the fact that the discharge is purulent, rather
than thin and watery or fecal, shows that it cannot be a
prolapse of Meckel's diverticulum. Patency of the urachus
is almost never accompanied by the presence of a tumor.
The absence of a central canal and of a discharge of urine
from it shows that this mass cannot be connected with the
urachus. The good family history and the absence of all
other evidences of syphilis show that it cannot be syphilitic
in nature. It is undoubtedly merely a mass of granulation
tissue, which has formed as the result of the imperfect healing
of the navel ; that is, it is a Granuloma of the Navel.
Prognosis. If it is untreated, it is likely to persist for
several weeks, or even months, and will very probably in-
crease in size. It will disappear in a few days, however, if
properly treated.
DISEASES OF THE NEW-BORN. 95
Treatment. It will undoubtedly dry up and disappear in
one or two weeks, if it is kept dry and powdered with aristol.
It will dry up much quicker, however, if it is touched daily
with a stick of nitrate of silver. If it does not dry up in a
few days under treatment with the nitrate of silver stick, a
small ligature should be tied about its base, or it may be
snipped off with the scissors and the base treated with nitrate
of silver or the actual cautery. Ligation is, however, the
simpler and therefore the preferable procedure.
96 CASE HISTORIES IN PEDIATRICS.
CASE 1 6. Catherine G. was born at full term after a
normal labor. She was normal at birth, except for a pro-
jecting red mass, about the size of the cord, at the navel.
This mass was left after the cord came off and had not
changed in size since then. It bled freely when irritated,
and there was a dark-colored, foul-smelling discharge from
it. She had been breast-fed, had had no disturbances of
digestion, had gained steadily in weight and had seemed
perfectly well except for the mass at the navel. She was
admitted to the Infants' Hospital when a month old.
Physical Examination. She was well developed and
nourished and of good color. The posterior fontanelle was
almost closed, the anterior was three cm. in diameter and
level. The mouth and throat were normal. There was no
rosary. The heart and lungs were normal. The level of the
abdomen was a little above that of the thorax. It showed
nothing abnormal except a tumor at the navel. This tumor
protruded from the umbilical ring, was one inch long and
one-half inch in diameter. Its surface was covered with
mucous membrane, which was bleeding from many small
points. The centre of its apex was occupied by a canal, also
lined with mucous membrane, which admitted a probe two
inches. There was a small amount of thin grayish-yellow
discharge, with a slightly fecal odor, from the opening.
There was no evidence of inflammation about the navel.
The lower border of the liver was palpable two cm. below the
costal border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no spasm or
paralysis. The knee-jerks were equal and normal. Ker-
nig's sign was absent. There was no enlargement of the
peripheral lymph nodes.
Diagnosis. This tumor is too large to be a granuloma.
It is, moreover, covered with mucous membrane and has a
central canal, conditions not consistent with a granuloma.
The discharge from the central canal is certainly not urine.
Patency and protrusion of the urachus can, therefore, be
excluded. The characteristics of the discharge are those of
the contents of the small intestine. The facts that the
surface of the tumor is covered with mucous membrane,
DISEASES OF THE NEW-BORN. 97
that it has a central canal and that there is a discharge of
material from it resembling the contents of the small intes-
tine, justify the diagnosis of persistence, protrusion and
eversion of the omphalomesenteric duct. This condition is,
however, more often spoken of as Prolapse of Meckel's
Diverticulum.
Prognosis. This condition is not dangerous to life. It
is, however, a source of annoyance and there is always the
possibility of infection of the mucous surface. There is little
probability of recovery without an operation.
Treatment. The only rational treatment, when the pro-
trusion is as marked as in this instance, is the removal of
Meckel's diverticulum at its origin from the intestine and
extirpation of the navel.
98
CASE HISTORIES IN PEDIATRICS.
CASE 17. John B. was the first child of healthy parents,
except that his mother had always been anemic. There had
been no miscarriages. His father denied syphilis and showed
no signs of having had it. There had never been any " bleed-
ers " in either family. He was delivered at 6 a.m., August 4,
at full term, by low forceps, after a short labor, and weighed
nine pounds. He was normal except for a slight abrasion on
the right cheek and another on the back of the neck, and
breathed at once. He was put to the breast that afternoon,
took hold well, but got nothing. The next morning he was
ordered one-half ounce of a mixture containing 1% of fat,
5% of sugar, 0.25% of whey proteids and 0.25% of casein
every two hours, but as this was vomited it was stopped
after three feedings. Since then he had had only boiled
water. Oozing of blood began about midnight, August 5,
from both abrasions, and a hematoma, the size of half a
walnut, appeared at the site of each of them. The oozing
continued and he lost about half an ounce of blood during
the night. The bleeding was then controlled by pads soaked
in a 1-10,000 solution of adrenalin chloride. Several small
hemorrhagic areas appeared in the roof of the mouth and one,
the size of a dime, on the back that morning, August 6.
He had not vomited blood or had any blood in his movements.
The highest rectal temperature was 990 F. He had been given
10 ccm. of fresh rabbit's serum at 3.30 p.m., August 6. He
was seen in consultation at 5 p.m.
Physical Examination. He was well developed and nour-
ished, but moderately pale. The respiration was a little
rapid. He seemed uncomfortable and was inclined to moan.
The fontanelle was level. There was no rigidity of the neck.
There were slight ecchymoses in the right eyelids. There
were several ecchymotic areas, varying in size from that of a
split pea to that of a twenty-five cent piece, on the upper
part of the right cheek. There was an abrasion, about 2 cm.
long and 1 cm. wide, over the largest ecchymosis, where there
was also some swelling. It was scabbed over and not oozing.
There was an ecchymotic area, the size of a twenty-five cent
piece, on the back of the left neck, where there was also a
scab, but no oozing. There was an ecchymotic area, the size
DISEASES OF THE NEW-BORN. 99
of a ten-cent piece, on the lower back, and half a dozen ecchy-
motic areas, the size of a pinhead or a little larger, in the
roof of the mouth. The heart and lungs were normal. The
abdomen was negative. There was no bleeding from the
stump of the cord. The liver was palpable 3 cm. below the
costal border in the nipple line; the spleen was not palpable.
The extremities were normal ; there was no spasm or paraly-
sis; the knee-jerks were equal and normal; Kernig's sign was
absent. There was no enlargement of the peripheral lymph
nodes. There was no bleeding from the point where the
rabbit's serum was injected.
The movements which were seen were loose, dark-green
and contained considerable mucus, but no blood.
Diagnosis. The diseases to be considered here are congeni-
tal syphilis, hemophilia and hemorrhagic disease of the new-
born. Syphilis can be excluded on the negative family his-
tory, the absence of miscarriages, the good general condition,
the absence of all signs of syphilis, such as enlargement of
the liver and spleen and eruptions, and the fact that hemor-
rhage occurs only in the severest cases which show many
other signs of the disease. Hemophilia can be excluded on
the family history and the fact that the tendency to bleed in
hemophilia almost never appears before the end of the first
year. Larrabee, writing in 1906, was able to collect but
thirty-six cases of hemorrhage in the newborn due to hemo-
philia, and in all but two of these there was a family history
of the disease. The diagnosis is, therefore, Hemorrhagic
Disease of the New-born.
Prognosis. The condition is, in general, a very serious one.
Sixty per cent, or more, of the patients die, one half of them
in the first twenty-four hours after the onset of the bleeding.
If they survive a week they almost invariably recover. The
symptoms cease in the first five days in two thirds of the
cases that recover. The cases in which there is hemorrhage
from the gastro-intestinal tract and in which there is a high
temperature are more serious than those in which there is
no gastro-intestinal hemorrhage and in which the tempera-
ture is low.
The following prognosis seems justified in this instance.
IOO CASE HISTORIES IN PEDIATRICS.
The baby has a very serious disease. It is impossible to say
whether or not the hemorrhages will recur or others appear.
The outlook is, however, fairly good because he has already
lived seventeen hours, there has been no hemorrhage for
several hours, the bleeding is all external where it can be
reached, and the temperature is normal. Every day that he
lives increases his chances materially. There is no reason to
fear recurrence in after years because this is a self-limited
condition and not the disease hemophilia.
Treatment. It is very difficult to know just how to treat
the condition known as hemorrhagic disease of the newborn,
because it is probably not a definite disease, but merely a
combination of symptoms due to a variety of causes, the most
common of which is presumably sepsis. The only definite
point in the pathology is that the blood coagulates very slowly,
or not at all. It is very probable, too, that the delay in the
coagulation is due to the lack of something in the blood and
not to the presence of some inhibitory substance.
Most of the methods employed in the past in the treat-
ment of this disease have recently been proved to be useless.
Ergot and iron cannot, of course, have any effect in increasing
the coagulability of the blood. Adrenalin has practically no
action unless given intravenously. Its action is then general
and not local, and the increase of the blood pressure would
tend to increase rather than to diminish the bleeding. Gelatine
does not increase the coagulability of the blood either in
vitro or in viro. There is no lack of calcium salts in the blood
in these cases and, therefore, the administration of calcium
salts can do no good.
A more rational treatment is the subcutaneous injection of
fresh animal serum, preferably rabbit's, which contains all
the ferments of the blood. Theoretically it would seem as if
this could not do any good, because the blood contains anti-
ferment enough to much more than neutralize the ferment
contained in the ordinary doses of serum before it can be
utilized in coagulation. Practically, it has seemed very
useful in a considerable number of cases.
The most rational method of treatment is transfusion,
which not only replaces the lost blood but stops the hemor-
DISEASES OF THE NEW-BORN. I0I
rhage by supplying new material for the production of the
fibrin ferment. It has proved most satisfactory in the few
cases in which it has been used. Before performing trans-
fusion, however, it is necessary to be sure that the donor's
blood does not produce hemolysis. Transfusion is a serious
operation for both parties, and should not be undertaken
lightly but only as a last resort. It must not on this account,
however, be delayed too long.
This baby has already had an injection of rabbit's serum.
If the hemorrhage recurs, it should be repeated in six or eight
hours and again at the same interval, if necessary. If the
serum fails to restrain the hemorrhage in these doses, or if at
any time the baby's condition is becoming at all critical,
transfusion should be done. The preferable donor is the
father.
Locally, the adrenalin solution should be continued in
connection with pressure. If this fails to stop the bleeding,
the strength of the solution may be increased to 1-1,000, or
the dry powder used. If this is not effective, Monsel's salt
and pressure may be tried.
The baby should be given one to two teaspoonfuls of a
mixture of one part of breast milk to three parts of water, or
whey, every hour.
102 CASE HISTORIES IN PEDIATRICS.
CASE 1 8. Joanne W. was the second child of healthy
parents. The other child, a boy, was well. Her father had
never shown any symptoms of hemophilia, except that on
one occasion, when he had had several teeth extracted, the
gums oozed for three or four hours. Two of his brothers
had, however, died within the first two or three days of life
from hemorrhages of some sort, and the first child of his
sister, a girl, had died of hemorrhages when two days old.
Joanne was born at noon, December 16, after a normal labor,
seemed normal at birth and weighed nine and one-quarter
pounds. She had three movements, consisting of meconium,
in the first thirty-six hours after birth and passed urine freely.
She took the breast well during the night of December 18.
At 7.30 a.m., December 19, she vomited about half a teaspoon-
ful of bright blood, and at 9.30 a.m. a little more than half a
teaspoonful of bright blood. At 11.20 a.m. she had a move-
ment from the bowels which soaked through three napkins,
her nightgown and on to the bed. This movement was mostly
black, but contained a little bright blood and a few clots.
At 12.30 p.m. she vomited a little more blood and again at
1.30 p.m. She was given 15 cc. of rabbit's serum subcutane-
ously at 3 p.m. At 3.45 p.m. she had a discharge of dark
blood from the bowels, which wet through two napkins. She
was given 15 cc. of rabbit's serum subcutaneously at 4.15
p.m., and during the afternoon and early evening took three
ounces of a thin gelatin solution by mouth. At 9.15 p.m. she
had a movement from the bowels, consisting mostly of bright
blood, which wet through several diapers and her nightgown.
She had not seemed affected by the loss of blood before this
last movement. Since then, however, she had begun to look
pinched and a little blanched, and her pulse had gone up to
160. Her cry remained strong, however, and there was no
sighing or restlessness. She was seen in consultation at
10.45 P.M.
Physical Examination. She was well developed and nour-
ished, but had evidently lost weight. She looked pinched
about the mouth and was a little pale. Her cry was strong.
The anterior fontanelle was level. There was no rigidity of
the neck. The mouth and throat showed no bleeding point.
DISEASES OF THE NEW-BORN. IO3
The heart was normal. The lungs were normal in front. The
back was not examined. The liver was palpable two cm.
below the costal border in the nipple line. The spleen was
not palpable. The stump of the cord was healthy. The
rectal temperature was 99. 5° F. ; the pulse, 156. The ex-
tremities were not examined. She had another movement,
consisting of about two tablespoonfuls of dark blood, during
the examination.
Diagnosis. Hemorrhage from congenital syphilis can be
excluded on the good family history, the good general condi-
tion and the absence of all other evidences of syphilis. Hem-
orrhage from general sepsis can be excluded on the practically
normal temperature, the good general condition and the
absence of jaundice, cyanosis and other signs of sepsis. The
two conditions which must be seriously considered are hemo-
philia and hemorrhagic disease of the new-born. The history
of the death of a child of an aunt and of two of the father's
brothers from hemorrhage during the first few days of life
and of the somewhat prolonged bleeding from the gums in the
father suggests hemophilia. The bleeding from the gums in
the case of the father was comparatively slight, however, and
had never been considered unusual until this baby began to
have hemorrhages. There are only thirty-six cases on record
of hemophilia in which the symptoms appeared in the first few
days of life. It seems far more probable, therefore, that the
father's brothers and his niece died of hemorrhagic disease of
the new-born than of hemophilia. The fact that hemophilia
almost never occurs in the female makes it still more probable
that the girl died of hemorrhagic disease of the new-born.
Further points against hemophilia in this instance are that
the disease is transmitted through the female, not through the
male, and that the baby is a girl, not a boy. The hemor-
rhages in hemophilia seldom occur, moreover, spontaneously,
while the hemorrhages in hemorrhagic disease of the new-
born are almost invariably, as in this instance, spontaneous.
The diagnosis of Hemorrhagic Disease of the New-born
seems, therefore, justified.
Prognosis. There is no medicinal treatment which offers
any prospect of relief. Rabbit's serum has not been of any
104 CASE HISTORIES IN PEDIATRICS.
benefit. The chances of the spontaneous cessation of the
hemorrhage are practically nil. She will almost certainly
die within the next thirty-six hours unless a transfusion is
done.
Treatment. The treatment is immediate transfusion.
The most available donor is the father, since it is hardly wise
to subject the mother to a long and serious operation and
inadvisable to call on anyone else, because of the danger of
hemolysis. The points already detailed in discussing the
diagnosis seem sufficient to prove that he is not a hemophiliac
and that it is safe to use his blood. (See Case 17.)
DISEASES OF THE NEW-BORN. 105
CASE 19. William S. was the first child of healthy parents.
He was born September 7. His father denied having had
syphilis and there was no reason to suspect that his mother
had had it. There had been no miscarriages. He was
delivered at full term by high forceps, was normal at birth
and weighed seven and three-quarters pounds. His mother
had plenty of milk. He nursed well until September 1 1 , after
which he took the breast very poorly. He did not vomit.
The stools consisted of meconium during the first three days,
since when he had had three or four brownish-yellow stools,
containing many small soft curds and a little mucus, daily.
The cord came off September 13, leaving a healthy navel.
His temperature rose to 1030 F. on September 10, and had
ranged between 1020 F. and 103. 50 F. ever since. His mouth
became sore September 12, and he had been more or less rigid
since then. He had had no convulsions. He had lost weight
and strength very rapidly during the last few days. He was
seen in consultation September 15, when eight days old.
Physical Examination. He was considerably emaciated
and his face looked pinched. The anterior fontanelle was
sunken and the bones of the skull overlapped. The pupils
were equal and reacted to light. The tongue, lips and mouth
were much reddened and in places covered by a thin pseudo-
membrane. The heart, lungs and abdomen were normal.
The navel was healthy. The lower border of the liver was
palpable two cm. below the costal border in the nipple line.
The spleen was not palpable. The genitals were normal.
The extremities were normal. There was moderate rigidity
of the neck and extremities, with slight retraction of the head.
There was no rigidity of the lower jaw. The knee-jerks were
equal and exaggerated. Kernig's sign was absent. There
was no enlargement of the peripheral lymph nodes. The tips
of the ears, the end of the penis and the heels and elbows were
excoriated. There was also a profuse pustular eruption on
the neck, as well as an occasional pustule on the body. The
skin about the anus was normal. The rectal temperature
was 103.20 F.; the pulse, 180; the respiration, 48.
Cultures from the throat showed the staphylococcus aureus
as the predominating organism and no Klebs-Lceffier bacilli.
106 CASE HISTORIES IN PEDIATRICS.
Diagnosis. The diagnosis in this instance lies between con-
genital syphilis and septic infection of the new-born. Tetanus,
which is suggested by the general rigidity, can be excluded on
the normal condition of the navel, and on the absence of rigidity
of the jaw and of convulsions. Cerebral hemorrhage, as the
result of injury at birth, and meningitis are also suggested by
the rigidity. The former can be ruled out on the persistent
high temperature, the sunken fontanelle, the late develop-
ment of the rigidity and the local evidences of septic infection,
while the sunken fontanelle and the evidences of local infec-
tion make the latter most improbable. Rigidity of the neck
and extremities is, moreover, a very common symptom in the
new-born whenever they are seriously ill, no matter what the
trouble, and is presumably merely an exaggeration of the
normal congenital muscular hypertonia. It is of no assist-
ance, therefore, in the diagnosis between congenital syphilis
and septic infection. The sore mouth and the skin lesions
suggest syphilis. The lesions of the mouth and skin are,
however, in no way characteristic of syphilis. There are no
mucous patches about the anus and the palms and soles are
clear. The family history is good, there have been no mis-
carriages, the baby was born at full term, there is no enlarge-
ment of the liver and spleen, the genitals are normal and the
temperature is higher than would be expected in syphilis. It
seems justifiable, therefore, to exclude syphilis as the cause of
the illness. There is nothing about the history and physical
examination which is inconsistent with a septic infection ; in
fact, they are both most characteristic of it. A positive
diagnosis of Septic Infection of the New-born is, there-
fore, justified.
Prognosis. The prognosis is practically hopeless. He
will almost certainly die within the next forty-eight hours.
Treatment. The treatment can be only symptomatic.
His mouth must be kept clean by swabbing it with a 4%
solution of boracic acid or with a wash prepared with 5 parts
of borax, 20 parts of glycerin and 80 parts of water. He
should be fed every one and one-half hours with from two to
four drachms of a mixture of equal parts of his mother's
milk and water, given with a Breck feeder or a dropper. He
DISEASES OF THE NEW-BORN. lO'J
should also be given toV<f of a grain of strychnia every three
hours and, if necessary, caffeine-sodium benzoate, in doses of
yq of a grain, in addition. A dressing of boracic acid oint-
ment should be applied to the excoriated areas and boracic
acid powder to the neck.
108 CASE HISTORIES IN PEDIATRICS.
CASE 20. Frederick G. was the second child of healthy
parents. He was born at full term, December 29, after a
rapid labor at which, in the absence of both physician and
nurse, the grandmother officiated. He was normal at birth
and weighed seven and one-half pounds. The cord came off
January 3. Reddening and thickening about the navel,
accompanied by a foul, thin, glairy discharge, was noticed
January 9. There had been but little change in the local
condition since then, although the physician in charge had
pulled a slough, an inch long and as large around as a slate
pencil, from the navel, January 16. He had taken the breast
well until January 15, since when he had been given small
quantities of his mother's milk, diluted with water, from
the bottle. He began to vomit January 18, the vomitus
being green. He had had ten or twelve loose, green stools,
containing small curds and mucus, daily since January
10. The rectal temperature had ranged between 1020 F.
and 1030 F. since January 17; it had not been taken before.
He had lost weight and strength very rapidly during the
last forty-eight hours. He was seen in consultation Jan-
uary 19.
Physical Examination. He was considerably emaciated.
The skin was pale with a decided yellow tinge. He looked
and acted very sick. The anterior fontanelle was depressed
and the bones of the skull overlapped. The tongue was con-
siderably coated and the whole mouth reddened. The heart
and lungs were normal. There was a round and tender
swelling, about the size of one-half of an English walnut,
about the navel. There was an opening, the size of a slate
pencil, in the centre, from which a foul, glairy material could
be squeezed. A probe could be run about, parallel with the
surface, for an inch in all directions, but no opening into the
deeper tissues or abdomen could be found. The abdomen
showed nothing else abnormal. The lower border of the liver
was palpable two cm. below the costal border in the nipple
line. The spleen was not palpable. The extremities were
normal and there was no enlargement of the peripheral lymph
nodes. The rectal temperature was I02.6°F.; the pulse,
180; the respiration, 48.
DISEASES OF THE NEW-BORN. 109
Diagnosis. The diagnosis of Omphalitis and Septic In-
fection of the New-born is plain. There is no evidence of
a direct extension of the inflammatory process into the abdo-
men or along the vessels to the liver. The infection must be,
therefore, a general one.
Prognosis. The outlook is practically hopeless. There is
not one chance in one hundred of recovery. He will prob-
ably not live more than two or three days.
Treatment. The inflammatory area at the navel should
be opened up, cleaned out and dressed with a 5^00 solution
of corrosive sublimate. He should be given one-half an ounce
of a mixture of two parts of his mother's milk, one part of
lime water and one part of water every one and one-half
hours. He should also be given two °f a £ram oi strychnia
every three hours. This may be helped out from time to
time, if necessary, by caffeine-sodium benzoate, in doses of
one-sixteenth of a grain, given subcutaneously.
110 CASE HISTORIES IN PEDIATRICS.
CASE 21. Baby G. was born at full term after a normal
labor. He seemed healthy at birth but was not carefully
examined. He was taken care of by a woman ignorant of the
ordinary rules of cleanliness. The cord came off on the
seventh day. The navel was healthy and at no time, before
or after, was there any redness or inflammation about it.
He was breast-fed and did very well until he was five days
old, when he began to vomit a little and act as if he had pain
in the abdomen. The vomiting and pain continued and
increased in severity. He also began to have two or three
loose yellow movements, containing fine curds and having a
foul odor, daily. When he was nine days old a swelling, which
seemed tender, was noticed in the epigastrium. The swelling
in the epigastrium increased and by the twelfth day the
whole abdomen was distended. He had apparently begun
to have fever on the eighth day, but the temperature had not
been taken. He was seen in consultation when two weeks
old.
Physical Examination. He had evidently lost much weight
and his color was pasty. His face bore an expression of
suffering. The fontanelle was depressed. There was no
rigidity of the neck. The pupils were equal and reacted to
light. The tongue was dry and covered with a brownish
coat. The heart and lungs were normal. The upper border
of the liver flatness in the nipple line was at the fourth rib;
the lower border was not palpable. The spleen was not
palpable. The navel was healthy and there was no redness
about it. The abdomen was generally considerably dis-
tended, but distinctly more so in the epigastrium. It was
everywhere tympanitic, except over an area, the size of a
silver dollar, in the median line midway between the tip of
the ensiform and the navel. There was a marked sense of
resistance in and about this area, but no definite muscular
spasm. Tenderness was general throughout the abdomen,
but much more marked over the resistant area in the epigas-
trium. There was no dullness in the flanks and no fluid
wave. The legs were drawn up on the abdomen and exten-
sion caused additional pain. It was impossible to determine
the presence or absence of the knee-jerks or Kernig's sign
DISEASES OF THE NEW-BORN. HI
because of the baby's resistance. There was no enlargement of
the peripheral lymph nodes. The rectal temperature was
1040 F., the pulse 160, the respiration 60.
Diagnosis. The trouble is undoubtedly located in the
abdomen. The liver is displaced upward. The fact that the
baby is breast-fed and the mildness of the symptoms of in-
digestion in comparison with the high temperature, poor
general condition and marked local symptoms show that the
trouble is outside the gastro-intestinal tract. The situation
of the local symptoms and the age of the baby make ap-
pendicitis very improbable. The two possibilities are an
inflammatory process, probably a localized abscess in the
epigastrium, or a general peritonitis. The localization of the
physical signs in the epigastrium and the absence of general
muscular spasm and free fluid in the abdomen are much
against general peritonitis and in favor of a localized abscess.
A white count was not made because it could not help in the
diagnosis, since both conditions are associated with leucocy-
tosis. An inflammatory process in the upper or middle abdo-
men at this age is almost invariably due to infection through
the navel. The navel in this instance shows no signs of
inflammation at present, and has shown none in the past.
This does not rule out infection through the navel, however,
as it is not uncommon for this to occur without causing any
local manifestations. The known ignorance and the unclean-
liness of the woman who took care of the baby make an
infection through the navel seem even more likely. The
most reasonable diagnosis is, therefore, a localized inflam-
matory process, probably an abscess, in the epigastrium, as
the result of an infection through the navel, i. e., a Septic
Infection of the New-born.
Prognosis. The prognosis is hopeless without an operation,
practically hopeless with one.
Treatment. The only treatment which offers any chance
of recovery is an immediate laparotomy.
112 CASE HISTORIES IN PEDIATRICS.
CASE 22. Constance H. was born January 5 at full term,
after a normal labor, and was normal at birth. Her mother
had an uneventful convalescence, without any signs of sepsis,
and had a plentiful supply of milk. There had been no irri-
tation of the nipples or inflammation of the breasts. She
did perfectly well until January 24, when she did not take the
breast well, but did not seem sick in other ways. She was
seen by her physician the next morning. He found nothing
abnormal on physical examination, but a rectal temperature
of 1020 F. She took the breast well again during that day.
The next morning, the twenty-sixth, her upper lip was con-
siderably swollen and reddened. The swelling extended to
the lower lip during the day, and during the night to the
right cheek. The whole of the right cheek was involved on
the twenty-eighth, but the swelling of the lips had dimin-
ished so much that she was able to nurse again without
difficulty. The swelling extended during the twenty-ninth
to the right ear and side of the head. The rectal temperature
had ranged between 102. 50 F. and 104.50 F. She had not
vomited and had had normal movements. She was seen in
consultation at 5 p.m., January 29.
Physical Examination. She was well developed and nour-
ished and of good color. Her cry was strong. The anterior
fontanelle was level. There was no rigidity of the neck.
The pupils were equal and reacted to light. There was no
nasal discharge. The mouth was healthy. Both the upper
and lower lips were slightly swollen, but not reddened. The
whole of the right side of the face was somewhat swollen and
slightly reddened. The right ear was much swollen and
reddened, as was also the lower part of the right side of the
head. The edge of the swelling about the ear and side of the
head was raised and easily distinguishable by its induration
and color from the surrounding tissues. The swelling was
not especially tender. The heart, lungs and abdomen were
normal. The liver was palpable two cm. below the costal
border in the nipple line. The spleen was not palpable.
The navel was healthy. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. Kernig's sign was absent. There was no en-
DISEASES OF THE NEW-BORN. II3
largement of the peripheral lymph nodes. The rectal tem-
perature was 104.50 F. ; the pulse, 160; the respiration, 36.
Diagnosis. The progressive extension of the swelling, the
improvement in the parts first affected and the elevated and
sharply defined edge are so characteristic of Erysipelas, that
there can be no doubt that this is the diagnosis.
Prognosis. At least 90% of young babies affected with
erysipelas die, erysipelas at this age being almost invariably
migratory in character. Babies that survive the acute stage
of the disease are, moreover, very likely to die, apparently
from weakness, within the next one or two weeks. The
chances are, therefore, very much against recovery in this
instance, in spite of the baby's good general condition at
present.
Treatment. There is no local treatment which has much,
if any, effect on the progress of the disease. Ichthyol has as
much, if not more action than any of the others. A 30%
ointment of ichthyol, prepared with vaseline, should be ap-
plied every three or four hours to the affected areas. There
is no drug which has any effect whatever on the local condi-
tion. In the more chronic cases vaccines sometimes seem to
be of assistance. If the process continues to extend in this
instance, it will perhaps be advisable to use vaccines after
another week. The most important methods of treatment
are regulation of the diet and hygienic surroundings. The
baby is now on the breast. This food cannot be improved
upon. Great care must be taken, however, to prevent in-
fection of the mother's nipples and breasts. She should be
given all the fresh air and sunlight possible. No stimula-
tion is required at present.
SECTION HI.
DISEASES OF THE GASTRO-ENTERIC TRACT.
The classification which follows is a slight modification of
that adopted by the Department of Pediatrics of the Harvard
Medical School, and, while open to many objections, seems
to the author more satisfactory than any other. It is given
in order that the terms used later may be intelligible.
The author is in the habit of roughly dividing the diseases
of the gastro-enteric tract, associated with diarrhea, in the
following manner. He realizes that this division is arbitrary
and open to much criticism, but it seems to him reasonably
satisfactory from a clinical standpoint and as a basis for
treatment.
When there is merely an increase in the number of move-
ments, with a diminution in the consistency, no fever and
practically no other symptoms, he describes the condition as
nervous diarrhea and attributes it to causes acting directly
or indirectly on the central nervous system.
Under normal conditions there is an equilibrium between
the work to be done and the power to do it, that is, between
the food which is to be digested by the intestinal secretions
and the secretions. If there is a disturbance of this equi-
librium, either from an increase in the amount of work to be
done, as occurs when the amount or strength of the food is too
great, or from a diminution in the amount or digestive power
of the secretions, as occurs when the child is depressed from
any cause or is suffering from some other disease, the con-
dition designated as intestinal indigestion due to disturb-
ance of equilibrium develops. This condition may be
either acute or chronic. Bacteria play no part in its
etiology. The stools are increased in number and, as a
rule, diminished in consistency, but usually not changed
in color. They also show evidences of incomplete digestion
115
Il6 CASE HISTORIES IN PEDIATRICS.
of the food. Under this head are included those disturbances
due to an excess of one or more elements of the food, fat,
carbohydrates or proteids, as the case may be. The character
of the stools in such instances naturally varies according to
what element or elements of the food are in excess. The
term, malnutrition resulting from an excess of fat, carbo-
hydrates or proteids in the food, describes the condition more
satisfactorily, perhaps, than does that of chronic intestinal
indigestion.
If fermentation or decomposition takes place in the in-
testinal contents as the result of bacterial action, new symp-
toms develop. The stools are usually changed in color and
odor and show more marked disturbance of digestion. Other
symptoms, such as fever, may appear as the result of toxic
absorption. This is the class of cases known as intestinal
indigestion of the fermentative type. It is more often acute
than chronic. It is assumed that in pure cases there is no
inflammation of the intestine and no entrance of bacteria
into the circulation.
If the bacteria cause inflammatory changes in the intestinal
wall there is usually a further change in the character of the
stools, which become very numerous and are composed
mainly of mucus and blood. The temperature is usually
moderately and constantly elevated, and the constitutional
symptoms are much more marked. It is probable that in
many instances bacteria traverse the intestinal wall and enter
the circulation. This condition is called infectious diarrhea
of the dysenteric type.
Cholera infantum, in which there is a very large number
of profuse watery movements, is presumably a variety of
infectious diarrhea.
Since the diagnosis between the various diseases of the
gastro-enteric tract is of relatively more importance than
that between these and other diseases, the cases illustrative of
them are given together and follow.
DISEASES OF GASTRO-ENTERIC TRACT.
117
Non-Infectious
Gastric.
Developmental Malpositions.
Malformations — Pyloric stenosis.
Non- Infectious Functional.
Nervous vomiting.
Recurrent vomiting.
T ,. . ( Acute.
Indigestion j Chronic.
Mechanical.
Contraction.
Dilatation.
Ulcers — peptic.
New growths.
Gastritis — corrosive.
Infectious Gastritis.
Enteric.
Developmental Malpositions.
Malformations.
Mechanical.
Dilatation of colon.
Volvulus.
Intussusception.
Hernia.
Fissure.
Prolapse.
Polypi.
Hemorrhoids.
New growths.
Functional.
Incontinence.
f Atonic.
Constipation •{ Spasmodic.
^ Mechanical.
Nervous diarrhea.
Indigestion
Acute.
Chronic.
Acute.
t Chronic.
(^Fermentation.
Proctitis.
Appendicitis.
Fistulae.
T r .. ,. , ( Dysenteric type.
Infectious diarrhea j c^olera infantum>
Animal Parasites.
Duodenal
C Disturbance
Intestinal < of equilibrium
Infectious
Il8 CASE HISTORIES IN PEDIATRICS.
CASE 23. Frank G., six years old, was the second child
of markedly neurotic parents. His brother, who was nine
years old, would not eat meat, milk or eggs. He was well up
to the age of two years when he had the whooping-cough, in
which he had frequent attacks of vomiting. Since then he
had had recurrent attacks of vomiting, lasting for weeks at a
time. At the beginning of an attack he would vomit solid
food, but would retain liquids. After a few days he would
vomit liquids and finally would retain nothing. He would
then gradually improve and get back to his usual routine.
He would never, however, even between attacks, swallow
hard solids, like meat, but swallowed bread, after chewing it
thoroughly, and soft solids without difficulty. The vomiting
always occurred immediately after taking food. If the food
was not vomited within a few minutes after it was taken, it
was retained. He never vomited any food which had been
taken some time before or which was decomposed. He never
had any pain. The bowels were constipated during the
attacks, but at other times the movements were normal.
He had been through a course of stomach washing six months
before he was seen in consultation. An adult stomach tube
was passed at that time without difficulty. There was no
evidence of gastric stasis and the stomach contents showed
no evidences of indigestion. His present attack was the
most severe that he had ever had. He had retained practi-
cally nothing for a number of days, although he had been very
hungry and had taken food eagerly. Even water had been
vomited immediately during the last few days. Thirst was
consequently extremely troublesome. He had been given
nutrient enemata for several days, but had, nevertheless, lost
rapidly in flesh and strength.
Physical Examination. He was thin and pale. He was
perfectly clear mentally. He was constantly asking for water.
He would take about two ounces eagerly, but would vomit
it up immediately with considerable retching. He would at
once take another two ounces and vomit it up and would
apparently have kept on doing this indefinitely. His tongue
was clean. The throat was normal to both inspection and
palpation. When water was swallowed gurgling could be
DISEASES OF GASTRO-ENTERIC TRACT. 119
heard to the left of the spinous processes as far down as the
sixth dorsal spine (normally it should be heard to the eighth
or ninth). Nothing could be heard entering the stomach.
An adult-sized stomach-tube was easily passed in seven
inches from the incisor teeth, where it met an obstruction
and could be passed no further. When a very little water
was poured in, it was promptly vomited and evidently did
not reach the stomach. The heart and lungs were normal.
There was no dullness under the manubrium or in the middle
back. The bronchial voice sound was not heard below the
seventh cervical spine. Air entered both lungs alike. There
was no evidence of pressure on veins or nerves within the
thorax. There was no murmur under the manubrium, and
the pulses were synchronous in both arms. The abdomen
was sunken and entirely negative. The liver and spleen were
not palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's sign was absent. There was no enlargement of
the peripheral lymph nodes.
The urine was high-colored, strongly acid, of a specific
gravity of 1030, and contained no albumin or sugar. The
sediment was abundant and composed of amorphous urates.
Diagnosis. There is undoubtedly a narrowing of the
esophagus about four inches above the cardia. This narrow-
ing cannot be due to pressure from the outside, because of
the duration of the symptoms and the absence of all signs of
inflammation, new growth, aneurism or enlargement of the
tracheobronchial lymph nodes. It cannot be due to cica-
tricial contraction, because there is no history of any injury
in the past. The duration and the intermittence of the
symptoms, as well as the relatively good general condition,
rule out a malignant growth, while these points in connection
with the absence of other evidences of syphilis exclude a
syphilitic growth. The facts that small quantities are
vomited immediately, that several feedings are never retained
and then vomited and that the vomitus is never decomposed
show that there is no marked dilatation above the narrowing
and no diverticulae. The narrowing may be due, then, to a
non-malignant constriction, to spasm, or to a combination
120 CASE HISTORIES IN PEDIATRICS.
of the two. The points in favor of an organic constriction
are the permanent inability to swallow solid food, the firm
resistance encountered by the stomach tube, the persistence
of the symptoms in the present attack and the tender age
of the patient. The points in favor of spasm are the neurotic
family inheritance, the fact that his brother has always
refused to eat certain kinds of food, the intermittence of the
symptoms and the fact that a stomach-tube could be passed
easily six months ago. The most reasonable explanation
seems to be that he has always had a certain amount of
organic constriction, that the obstruction has been exagger-
ated at times by spasm and that the organic constriction has
now increased so much that it practically obliterates the
lumen. This diagnosis ought, however, to be verified by an
examination with the Roentgen ray after the ingestion of
bismuth paste. The accompanying Roentgenographs show
the conditions found in this way by Dr. A. W. George. The
diagnosis of Organic Stricture of the Esophagus is, there-
fore, verified.
Prognosis. The prognosis is hopeless without surgical in-
tervention. He can, of course, be kept alive for a short time
by nutrient enemata and the subcutaneous injection of salt
solution. Death must, however, eventually result from starv-
ation. If the stricture is dilated, either from above or below,
the cure ought to be a permanent one and recovery complete.
Treatment. The treatment is, of course, the dilatation of
the stricture by the passage of bougies. It is possible that
he can be made to swallow a thread and that bougies can be
passed along it. This is a difficult procedure in a child,
however, and it will in all probability be necessary to do
a gastrotomy and pass the first bougie from below upward.
'Anteroposterior view.
Lateral view.
Frank G. Case 23.
DISEASES OF GASTRO-ENTERIC TRACT. 121
CASE 24. David R. was born at full term, February 16,
after a normal labor. He seemed normal at birth, but was
not weighed. The breast-milk came in quickly, was suffi-
cient in quantity and he took it well. When four days old
he began to vomit after nearly every feeding, the vomiting
occurring immediately after nursing. He usually cried at
the time of the vomiting and for ten or twenty minutes after
it, as if in pain. When two weeks old, condensed milk and
lime water and barley water and lime water were tried
in place of the breast-milk. Both were vomited and he was,
therefore, put back on the breast. The vomiting from this
time on was explosive. Beginning March 13, ten drops of
lime water and one teaspoonful of water were given before
each nursing. The vomiting had not been quite as severe
since then. The bowels had not moved spontaneously since
he was a week old. Suppositories were ineffectual, but a
movement had been obtained daily from castoria. These
had been very small, often being merely a dark brown stain
on the napkin. He had not been weighed, but was thought
to have lost weight steadily since he was a week old. He
was admitted to the Infants' Hospital, March 17, when a
month old.
Physical Examination. He was small, emaciated and
feeble, but his color was fair. The skin was not very dry,
but there was a little general rigidity. The anterior fon-
tanelle was two and one-half cm. in diameter and sunken.
The posterior fontanelle was still open. The bones of the
skull did not overlap. The mouth was clean and moist.
The heart and lungs were normal. The liver was just" pal-
pable in the nipple line. The spleen was not palpable. The
abdomen was sunken and nothing abnormal could be de-
tected in it when the stomach was empty. He was given a
bottle of whey and after he had taken an ounce the stomach
was distinctly palpable. When he had taken two ounces
the stomach felt hard, but there was no visible peristalsis.
By the time he had taken two and one-half ounces the pylo-
rus could be felt to contract and harden, being as large as the
last joint of the little finger. This was followed by marked
explosive vomiting of all that he had taken. The pylorus
122 CASE HISTORIES IN PEDIATRICS.
could then be felt to relax and finally entirely disappear.
This sequence recurred every time that the stomach was
filled. There was no visible peristalsis at any time. The
genitals were normal. The extremities showed nothing ab-
normal. There was no paralysis. The knee-jerks were equal
and lively. Kernig's sign was absent. There was no en-
largement of the peripheral lymph nodes. He weighed four
pounds.
The urine was pale in color, clear, slightly acid in reaction
and contained no albumin.
The stool was composed of bile and water with a very
little mucus.
Diagnosis. The slight general rigidity suggests, to a cer-
tain extent, some cerebral lesion as the cause of the vomiting.
The rigidity can be equally well explained, however, by the
age of the baby and the disturbance of nutrition, both of
which are often accompanied by muscular hypertonia. The
positive findings in the abdomen prove, moreover, that the
condition is a local one. Chronic gastric indigestion is very
uncommon in breast-fed babies. It can be excluded in this
instance by the explosive vomiting, the pain during and after
vomiting, the lack of milk remains in the movements, and
the presence of a palpable tumor at the pylorus. The diag-
nosis lies, therefore, between spasm of the pylorus and ste-
nosis of the pylorus.
The fact that the baby is breast-fed is a point in favor of
stenosis, while the pain during and after vomiting is in favor
of spasm. The explosive vomiting, the constipation and the
progressive failure are symptoms common to both conditions
and are, therefore, of no importance in differential diagnosis.
The presence of a tumor points strongly towards stenosis,
because a tumor is much more often palpable in stenosis
than in spasm. The intermittent contraction and relaxa-
tion of the tumor never occurs in stenosis, however, and is
most characteristic of spasm. The presence of this sign
justifies, therefore, a positive diagnosis of Spasm of the
Pylorus.
Prognosis. His general condition is fair under the cir-
cumstances; the disease is curable; he has had no rational
treatment. The outlook is, therefore, reasonably good.
DISEASES OF GASTRO-ENTERIC TRACT. 123
Treatment. He should be taken off the breast for the
present. The breasts must not be allowed to dry up, how-
ever, for he will probably be able to take breast-milk again
later. The most suitable food for him at present is one
which has but little stimulant action on the gastric secre-
tions and which will leave the stomach quickly in the liquid
form. Whey is such a food. The stomach becomes pal-
pable and hard from contraction when he has taken but an
ounce. He ought not, therefore, to be given more than half
an ounce at a time. If given such a small amount at a
feeding, he must be.fed at short intervals. Otherwise he will
not get enough food. He should, therefore, be given sixteen
feedings, at one and one-half hour intervals, of one-half an
ounce of whey. It has been claimed, and there is some evi-
dence to show that it is true, that rectal injections of salt
solution diminish the gastric secretions and hence gastric
spasm. It will be well, therefore, to give an ounce of physi-
ological salt solution with a rectal tube every four hours.
If it does not have this action, it will, at any rate, supply
needed water to the tissues.
If the whey is retained, as it probably will be, the amount
can be increased to 20 or 25 cc. at a feeding. The caloric
value of this food is, however, entirely insufficient to cover
his needs and must soon be increased. The following prin-
ciples must be remembered in strengthening his food: fat
delays the emptying of the stomach; carbohydrates leave
the stomach quickly; casein is coagulated by rennin, while
whey proteids are not; alkalies delay the action of rennin
and allow the passage of the milk into the intestine before it
is coagulated. A suitable modification for him will be, there-
fore, one containing 1% of fat, 7% of milk sugar, 0.75% of
whey proteids and 0.25% of casein, with lime water 50% of
the milk and cream in the mixture. If this is well borne he
may then be given a mixture containing 1.50% of fat, 7% of
milk sugar, 0.75% of whey proteid and 0.25% of casein, with
lime water 50% of the milk and cream or, better, equal parts
of breast-milk and a 7% solution of milk sugar.
124 CASE HISTORIES IN PEDIATRICS.
CASE 25. Robert M., the second child of healthy parents,
was born at full term after a normal labor. He was normal at
birth and weighed six pounds and twelve ounces. His mother
had a plentiful supply of milk and he was nursed regularly at
two-hour intervals. He vomited a little from the first, but
when two weeks old began to vomit much more. This was
at first attributed to indiscretions in diet on his mother's
part, but continued to increase after her diet was carefully
regulated. It was then thought that he got too much milk,
and the length of nursing was shortened to five minutes.
This made no difference in the vomiting. A half-teaspoonful
of lime water was then given with each nursing, but did not
affect the vomiting. The mother was a healthy, vigorous
woman, and it did not seem probable that the composition
of the breast-milk was at fault, although it had not been
examined. Whey, which was tried for twenty-four hours,
was vomited more than the breast-milk. The vomiting some-
times occurred immediately after nursing, but usually not for
an hour or more. Sometimes several feedings were retained
and then vomited together. The vomiting had recently been
explosive. The bowels had moved regularly, but the move-
ments had been small ; they were dark green in color and
composed largely of mucus with a few fine curds. He acted
hungry all the time and cried a great deal, apparently from
hunger. He gained slowly in weight during the first three
weeks up to seven pounds and twelve ounces. When seen in
consultation, when five weeks old, he had dropped back to
seven pounds and four ounces.
Physical Examination. He was well developed and nour-
ished and of good color. The fontanelle was level, and the
bones of the skull did not overlap. His tongue was clean and
moist. The heart and lungs were normal. The liver was
palpable 1 cm. below the costal border in the nipple line.
The spleen was not palpable. The extremities were normal.
There was no spasm or paralysis; the knee-jerks were equal
and normal. There was no enlargement of the peripheral
lymph nodes. The examination of the abdomen was at first
rather difficult because of the crying, and nothing abnormal
was detected. The stomach was undoubtedly empty, as he
DISEASES OF GASTRO-ENTERIC TRACT. I25
had vomited a great deal about an hour before and had taken
nothing since. It was thought that he would keep quieter if
his stomach was filled and that perhaps something might be
seen or felt then which could not be before. He was, there-
fore, given two and one-half ounces of water, which he took
greedily. The lower border of the stomach then reached to
the navel, and very marked waves of peristalsis, running from
left to right, appeared. A mass about the size of a marble was
felt indistinctly in the region of the pylorus. He then vomited
the whole of the water in one gush, the water striking the floor
about three feet from the baby. The tumor could then be
felt very distinctly while the baby was relaxed after the vomit-
ing. He had a small movement, consisting of about half a
teaspoonful of brownish mucus, during the examination.
Diagnosis. The history in this instance is so typical of
Infantile Pyloric Stenosis that it justifies, as far as any
history without physical examination can, a positive diagnosis
of this condition. The only other disease to be seriously
considered is chronic gastric indigestion. The appearance of
vomiting in a breast-fed baby after two weeks, in which there
had been only a little spitting up, the progressive increase of
the vomiting, the failure to respond to regulation of the
nursing, the explosive character of the vomiting and the small
meconium-like stools containing almost no fecal residue, are
not consistent with chronic gastric indigestion. A cerebral
lesion as the cause of the vomiting can be immediately ruled
out on the general condition, the level fontanelle and the
absence of spasm, paralysis and increased reflexes.
The physical examination verifies, of course, the diagnosis
made on the history. The enlargement of the stomach, the
visible peristalsis and the palpable tumor are proof positive.
The methods employed in the examination of the abdomen
are worthy of attention. No examination of the abdomen
can be considered complete, when there is a suspicion of
stenosis of the pylorus, unless it is made with the stomach
both full and empty. If peristalsis is not visible when the
stomach is full, it can often be produced by stroking the
epigastrium or flicking it with a towel wet in cold water, or a
piece of ice. The author believes that a positive diagnosis of
I26 CASE HISTORIES IN PEDIATRICS.
pyloric stenosis would have been justified in this case even if
a tumor had not been felt.
Prognosis. The prognosis without operation is hopeless;
with an operation by a competent surgeon the outlook is
very good, because of the baby's good general condition.
The operations for this condition are all so recent that there
are almost no data as to what happens to these babies in
after years. What data there are, however, go to show that
their digestive powers are not impaired, that they develop
normally and that their expectation of life is not altered.
Treatment. The only rational treatment in this instance
is immediate operation. The best operation is a posterior
gastro-enterostomy. It is a delicate operation, requiring
special skill. Slight variations in technic make the difference
between success and failure, life and death. No surgeon
who has not done it before, or who has not had much experi-
ence in operating on small animals, should attempt it.
DISEASES OF GASTRO-ENTERIC TRACT. 1 27
CASE 26. Mary M., three and a half years old, was in
the habit of having occasional attacks of vomiting, which
were usually of short duration. She was a well and vigorous
but nervous child. She was carefully fed. July I she ate
an unusually hearty supper of proper food at six o'clock and
then played very hard and was a good deal excited for about
half an hour. She went to bed soon after and quickly dropped
to sleep. She woke up and began to vomit at 9 p.m. The vom-
iting continued and finally there was much retching without
vomiting. Thevomitus at first consisted of the food taken at
supper, later of nothing but mucus. She was seen at 1 1 .30 P.M.
Physical Examination. She was well developed and nour-
ished and did not look or act ill. Her tongue was nearly
clean. The level of the abdomen was that of the thorax.
There was no muscular spasm or tenderness. The rest of a
careful physical examination showed nothing abnormal.
The rectal temperature was 98. 6° F.
Diagnosis. The absence of physical signs and the normal
temperature rule out at once all diseases outside of the diges-
tive tract. The only diseases of this tract to be considered
are nervous vomiting, acute gastric indigestion and the onset
of recurrent vomiting.
It is impossible to absolutely exclude recurrent vomiting
at this time, only two and a half hours after the onset, but
the history of similar attacks in the past, all of short duration,
makes it very improbable. The differentiation between
nervous vomiting and acute gastric indigestion is a rather
difficult and uncertain one, as the line between the two forms
is not very sharp. The absence of temperature and the prac-
tically normal condition of the tongue are against indigestion.
The fact that the vomiting developed after a meal of proper
food followed by undue exertion and excitement point strongly
to a nervous disturbance. The over-exertion and excitement
presumably inhibited digestion, and the undigested food
acted like a foreign body in the stomach and brought on the
vomiting by reflex action. The diagnosis is, therefore, Nerv-
ous Vomiting.
Prognosis. The prognosis as to life is, of course, good.
The stomach having been thoroughly emptied, as shown by
128 CASE HISTORIES IN PEDIATRICS.
the character of the last vomitus, the vomiting ought to
stop in a few hours or less, if nothing is done in the way of
medication to keep it up.
Treatment. Quiet and frequent sips of a solution of bi-
carbonate of soda, fifteen grains to a glass of water, are all
that is necessary. A mild laxative, such as two teaspoonfuls
of milk of magnesia, in the morning, to hurry along any undi-
gested food which may have passed into the intestine is
advisable. Broth and toast for breakfast, and a rather light
diet and quiet for the rest of the next day, complete the
treatment.
DISEASES OF GASTRO-ENTERIC TRACT. 129
CASE 27. Rosamond B. was seven and a half years old.
Her mother had valvular heart disease and was markedly
neurotic. Her mother's family was extremely neurotic and
several members had been insane. Her father's family was
rheumatic.
She was a decidedly neurotic child and was very fussy
about her diet, and had also been fed very carefully because of
the rheumatic family history. Her appetite was very good.
She had had no symptoms of indigestion except that her
bowels were always constipated. She had been taking cascara
regularly for more than a year.
She had had no unusual excitement, had not exerted her-
self unduly, and had done nothing unusual during November
28. She began to vomit at 5 a.m., November 29. She vomited
every few minutes during that day and night and about
every two hours during the 30th up to 9 p.m., when she was
seen in consultation. In all, she vomited fifty- two times
during this period. The vomiting was not explosive. The
vomitus at first contained a little of the food taken at supper,
but after this consisted of water mixed with a little mucus.
It did not contain bile. She had taken nothing by mouth
except water in small quantities and cracked ice, which had
been given because of the extreme thirst. Both had been
vomited immediately. The bowels had been moved freely
by enemata. The stools were normal in character. Her
temperature, taken in the axilla, had ranged between 990 F.
and ioo° F. She had been rather restless and had slept
but little. Bromide, given by enema, had quieted her
considerably. She had had no pain.
Physical Examination. She was tall and slight. Her color
was good. The pupils were equal and reacted to both light
and accommodation. There was no rigidity of the neck.
She was perfectly clear mentally. Her tongue was moist
and but slightly coated. Her breath had a slightly sweetish
odor. The heart, lungs and liver were normal. The level of
the abdomen was that of the thorax. There was no muscular
spasm and no tenderness. Palpation was easy and disclosed
nothing abnormal. The spleen was not palpable; the area
of dullness was normal. The extremities showed nothing
130 CASE HISTORIES IN PEDIATRICS.
abnormal. There was no spasm or paralysis. The knee-
jerks were equal and lively. Kernig's and Babinski's signs
were both absent. The cervical and axillary lymph nodes
were somewhat enlarged; the inguinal were not. The
rectal temperature was 990 F., the pulse 96, the respiration
20. She did not object to the examination, but gave the
impression that she was decidedly neurotic.
The urine contained neither albumin nor sugar, but gave
the tests for both acetone and diacetic acid.
Diagnosis. The conditions which may be reasonably
considered in this instance are meningitis, more likely tuber-
cular than cerebrospinal, intestinal obstruction, nervous
vomiting and recurrent vomiting.
Meningitis can be at once excluded on the combination of
the absence of all signs of meningeal irritation, the low tem-
perature and the excessive amount of the vomiting compared
with the other symptoms. It can be so positively excluded
that lumbar puncture is not justified as a method of diagnosis,
although this ought to be done in every case in which there is
a reasonable chance of meningitis because of the good which
can be accomplished by the serum treatment in cerebrospinal
meningitis, especially when the diagnosis is made early.
Intestinal obstruction can also be excluded on the char-
acter of the vomitus, the absence of physical signs in the
abdomen, the clean tongue, the free movements from the
bowels, the low temperature and the good general condition.
The neurotic family history and the neurotic disposition
of the patient are consistent with either nervous or recurrent
vomiting. So are the character of the vomitus, the absence
of physical signs, the clean tongue, the low temperature and
the good general condition. The excessive amount of the
vomiting and the absence of any cause for nervous vomiting
make this diagnosis very improbable. In fact, the whole
picture is characteristic of what is known as Recurrent
Vomiting. It may be said that it is incorrect to call the
condition " recurrent vomiting " when the child has never
had anything like it before. It must be remembered in this
connection, however, that there is always a first time for
everything. Since acid intoxication is probably one of the
DISEASES OF GASTRO-ENTERIC TRACT. I31
causes of recurrent vomiting, the sweet odor of the breath and
the presence of acetone and diacetic acid in the urine might
be thought indicative of this condition as against nervous
vomiting. This is not so, however, as the abstinence from
food for thirty-six hours will account for them equally well.
Prognosis. There is no danger as to life. The vomiting
will probably not persist more than forty-eight hours longer,
more likely a shorter than a longer time. The duration will
depend somewhat on whether the treatment is rational or
not.
Treatment. Before taking up the treatment it must be
remembered that recurrent vomiting is probably merely a
symptom-complex of manifold etiology. In most instances it
is a manifestation of some disturbance of metabolism. This
disturbance is sometimes an intoxication from the acetone
bodies (the so-called acid intoxication) and sometimes an
intoxication from uric acid. Most often the nature of the
disturbance is unknown. In some instances it is a manifesta-
tion of inflammation of the appendix. In this instance ap-
pendicitis can be immediately ruled out on the absence of all
signs of inflammation in this region. It is impossible to state,
however, what the nature of the disturbance of metabolism
is. The sweet breath and the presence of acetone bodies in
the urine suggest acid intoxication. They do not prove it,
however, because starvation will also account for them. It
is reasonable, however, to treat the condition on this basis.
Such treatment can do no harm if it does no good.
This treatment consists in the administration of bicarbon-
ate of soda. From one-half ounce to an ounce should be given
in twenty-four hours. The attempt should be made to give
it by mouth in teaspoonful or tablespoonful doses of a solu-
tion of bicarbonate of soda, one teaspoonful to a glass of water,
every fifteen to thirty minutes. It is well to persist, even if
the soda is vomited. High enemata of a solution of bicarbon-
ate of soda, two drams to six ounces of water, should be
given every four hours. The child should be kept perfectly
quiet, in a cool, dark room. No food should be given by
mouth. It will probably be necessary on account of the
excessive thirst to give small amounts of liquid, even if vom-
132 CASE HISTORIES IN PEDIATRICS.
ited. Water or carbonated water, in doses of from one tea-
spoonful to one tablespoonful, or cracked ice, may be given.
If she is restless or sleepless from vomiting, ten or fifteen
grains of bromide of soda may be given in the enemata of
bicarbonate of soda. If this is not effective, morphia, gr. -jg,
may be given subcutaneously. Food should not be given
until twelve hours after the vomiting has stopped. Whey,
cereal waters, or cereal waters with sugar, should then be
given, beginning with an ounce every hour and increasing
the amount if they are retained. These foods are given in-
stead of broths or albumin water because the carbohydrates
antagonize the acid intoxication and have more food
value.
DISEASES OF GASTRO-ENTERIC TRACT. 1 33
CASE 28. Ralph C, two years old, had always been well
except for an occasional attack of acute gastric or intestinal
indigestion. He had had nothing unusual for supper, but had
eaten a good deal hurriedly and had been a good deal excited
after supper. He began to vomit and to be feverish about
midnight. The vomitus consisted first of his supper and then
of water and mucus. He had apparently had no pain, and
had been clear mentally. The bowels had not moved. He
had no cough. He was seen at 5 a.m.
Physical Examination. He was well developed and nour-
ished, but a little pale. He vomited twice during the examina-
tion. He was perfectly clear mentally. There was no motion
of the alffi nasi and the respiration was quiet. There was no
rigidity of the neck. The pupils were equal and reacted to
light. The tongue was moist, moderately coated and not
reddened. The throat was normal. The heart and lungs
were normal. The abdomen was a little sunken and lax.
There was no tenderness, muscular spasm, tumor or dullness.
The liver was just palpable, the spleen was not. The extremi-
ties were normal. There was no spasm or paralysis. The
knee-jerks were equal and normal ; Kernig's sign and the neck
sign were absent. There was no rash. The membranae
tympanorum were normal. The rectal temperature was
103. 50 F., the pulse 130, the respiration 30.
Diagnosis. The sudden appearance of vomiting and fever
is consistent at this age with the onset of almost any acute
disease, and it is often impossible as early as this to make a
positive diagnosis. Certain diseases are more probable,
however, than others. These are, in the first place, acute
gastric indigestion, pneumonia and scarlet fever; in the sec-
ond place, tonsillitis, influenza, otitis media and meningitis,
especially of the cerebrospinal form.
The normal ear drums rule out otitis media; the absence
of reddening of the throat and enlargement of the tonsils,
tonsillitis. Meningitis, beginning with such acute symptoms
as in this instance, would almost certainly have shown by
this time some signs of meningeal irritation, none of which
are present. The relatively slow rate of the respiration in
comparison with the pulse practically rules out pneumonia.
134 CASE HISTORIES IN PEDIATRICS.
The absence of cough, of motion of the alae nasi and of
physical signs in the lungs, together with the quiet respira-
tion, are also against it, but not nearly as important as the
relatively low rate of the respiration. The absence of inflam-
mation of the throat and enlargement of the papillae of the
tongue is against scarlet fever, but does not rule it out, as
they might not have developed at this time. The rash would
not, of course, have appeared thus early. Scarlet fever is,
therefore, a possibility. Influenza is always a possibility
with this history, as its manifestations are so manifold.
The abdominal type is, however, much less common at this
age than the respiratory type. The history of attacks of
acute gastric indigestion in the past, the hurried and hearty
supper with the subsequent excitement, the absence of the
signs characteristic of other diseases and the fact that acute
gastric indigestion is very common while the other conditions
to be considered are relatively rare, make the diagnosis
of acute gastric indigestion altogether the most probable.
The final diagnosis is, therefore, Acute Gastric Indigestion,
with the bare possibility that it may be scarlet fever or
influenza. Twenty-four, or at most forty-eight hours, will
settle the diagnosis positively, either by the cessation of the
symptoms or the development of something more definite.
Prognosis. The prognosis as to life is, of course, absolutely
good. The vomiting will probably cease during the day.
He will, however, probably have more attacks unless his diet
and routine are very carefully regulated.
Treatment. The treatment should be on the basis of the
diagnosis of acute gastric indigestion. It will do no harm
if the true diagnosis proves to be scarlet fever or influenza.
The first thing to do is to cleanse the stomach. The quickest
and most effective way to do this is to wash out the stomach.
This is a very simple operation in a child of this age. A soft
rubber catheter, No. 16 American, is used. It should be
passed through the mouth and the stomach washed with
plain water, or a weak solution of bicarbonate of soda, until
the wash water returns clear. The stomach may also be
cleansed, but less quickly and effectually, by giving copious
drinks of water which will probably be immediately vomited.
DISEASES OF GASTRO-ENTERIC TRACT. I35
Food should be entirely withheld for from eight to twelve
hours. Whey or broth, in one or two-ounce doses, every one
or two hours, may then be given. A solution of bicarbonate
of soda, one-half teaspoonful to a glass of water, given in
teaspoonful doses every fifteen to thirty minutes, will prob-
ably help to quiet the stomach.
After the stomach has been cleansed and rested for an hour
or two, a dessertspoonful of castor oil should be given. This
may be vomited, but will probably be retained. If it is
vomited, one-half teaspoonful doses of milk of magnesia,
given at hour intervals, until three teaspoonfuls have been
given, will probably be retained.
Sponge baths of 95% alcohol and water, equal parts, at
900 F., will reduce the fever and make the child more com-
fortable.
I36 CASE HISTORIES IN PEDIATRICS.
CASE 29. Robert M. was the first child of healthy par-
ents. He was born at full term after a normal labor, and
weighed six pounds and ten ounces. He was nursed entirely
for a month, digested well, and went up to seven pounds and
fourteen ounces. The breast-milk then began to diminish
and was helped out by a home-modified milk which contained
3-5°% of fat, 6.00% of sugar and 0.70% of proteids. The
baby soon began to have the colic and lose weight, while the
stools contained large tough curds, showing casein indigestion.
The breast-milk then gave out entirely and he was given a
milk mixture prepared with Eskay's Food, which contained
3% of fat, 3.50% of sugar, 0.75% of proteids and 2% of
starch, alternating with barley water, containing 1.50% of
starch. Possibly because of the starch in the Eskay's Food
and barley water he ceased to pass the large tough curds, but
began to vomit and to lose weight steadily. When two
months old he was taken to a hospital, where he remained
until he was five months old. While there he was fed on
various milk mixtures and improved somewhat. He con-
tinued to vomit, however. His weight on leaving the hospital
was eight pounds and twelve ounces. He was then put on a
modified milk of unknown composition prepared with Mellin's
Food. This, of course, practically amounts merely to the
substitution of malt sugar for milk sugar in the milk mixture.
He gained at first to nine pounds, but soon began to refuse
his food, vomit and lose weight again. He was then given a
mixture of one-third gravity cream and two-thirds barley
water, which is equal to a mixture containing 5% or more of
fat, 1.50% of sugar, 1.15% of proteids and 1.00% of starch.
He gained again for a time, but soon began to vomit more
than before. A malted milk mixture was then given. This,
like the Mellin's Food mixture, amounted to little more than
giving malt sugar in place of milk sugar. He kept this down
and gained for a time, but soon began to vomit worse than
ever. The doctor then said that the baby " could not take
cow's milk," and put him on Allenbury's Food No. 1, pre-
pared according to directions. This was about a week before
he was seen. The composition of the mixture was, according
to the proprietor's figures, 3.33% of fat, 10.20% of lactose,
DISEASES OF GASTRO-ENTERIC TRACT.
137
1.00% of albumin and 1.12% of casein. He had a great deal
of gas after beginning this and continued to vomit. The
bowels, which had been somewhat constipated, became loose,
and the movements, which had been of good character, were
undigested and contained a good deal of mucus. He was
taking seven or eight feedings of from four to four and one-
half ounces of the Allenbury's Food mixture, at two and one-
half-hour intervals, when he was seen in consultation, when
seven months old.
Physical Examination. He was bright and happy. He was
small and poorly nourished, but of good color. The skin was
in good condition. The fontanelle was 3 cm. in diameter and
level. There was no rigidity of the neck. He had no teeth.
The mouth, tongue and throat were normal. The heart and
lungs were normal. The abdomen was large but not tense.
The liver was palpable 3 cm. below the costal border in the
nipple line. The spleen was not palpable. The lower border
of the stomach did not reach to the navel. The stomach was
not visible even after taking his bottle, and there was no
visible peristalsis. The abdomen was negative. There was
a small umbilical hernia. The extremities were normal.
There was no spasm or paralysis; the knee-jerks were equal
and lively; Kernig's sign was absent. There was no enlarge-
ment of the peripheral lymph nodes. The weight was nine
pounds and four ounces.
Diagnosis. The physical examination shows nothing ab-
normal except the signs of malnutrition. The diagnosis must
be made, therefore, on the history. The continued vomiting
shows that the gastric digestion was disturbed. The normal
character of the movements up to the last change in the food
shows that the intestinal digestion was not affected until the
very end. The tendency to constipation was presumably due
to the facts that much of the food was vomited and that the
portion which passed into the intestine was so small that
little residue was left to form feces. The diagnosis is, there-
fore, Chronic Gastric Indigestion.
It is very difficult in this instance to draw any very definite
conclusions as to what element or elements of the food were
at fault. In general, the percentages of the fat were not
138
CASE HISTORIES IN PEDIATRICS.
excessive, most of the time being below 3.50% and only once
above 4%. The proteids were usually both absolutely and
relatively high. The sugars were at times excessive, espe-
cially in the last mixture, which contained over 10% of lactose.
The increase in the amount of gas at this time and the change
for the worse in the character of the movements suggest that
sugar was not well borne. The food at times contained more
starch than many babies of this age can digest. The symp-
toms were no more marked at such times, however, than they
were when there was no starch in the food. The only con-
clusions which can be drawn are that the baby is unable to
digest large amounts of sugar, and, by exclusion, that the
somewhat excessive amounts of starch in the food may pos-
sibly have played a part in the production of the trouble.
Prognosis. Chronic gastric indigestion is always a serious
condition, one never to be regarded lightly. In this instance,
however, the comparative mildness of the symptoms and the
baby's reasonably good condition justify, barring accidents,
a favorable prognosis.
Treatment. The best food for this baby, as for all babies
suffering from chronic gastric indigestion, is good human
milk. With it recovery is certain to be rapid. It is not a
necessity in this instance, however, and the baby will prob-
ably recover in time without it. The best substitute for it is
some modification of cow's milk. A doctor has said, however,
that this baby " can't take cow's milk." Is this statement
true in this instance, or is it ever true? The author believes
that it is extremely unusual for a baby to be born with an
idiosyncrasy against cow's milk. He also believes that the
improper use of cow's milk may develop a temporary, but not
a permanent, intolerance for cow's milk. There is nothing in
this baby's history, however, to show that it cannot digest
cow's milk, if properly modified to suit its digestive capacity,
most of the modifications which it has had in the past having
been unsuitable in some way or other.
The only definite indications to be drawn from the history
of this baby as to the regulation of the food are to keep the
sugar comparatively low and not to give starch. On general
principles, it is advisable to keep the fat a little low when
DISEASES OF GASTRO-ENTERIC TRACT.
139
babies are vomiting. It is wiser, therefore, not to give this
baby more than 2% of fat at first. In chronic gastric indi-
gestion the food should, if possible, be so regulated as to
diminish the work of the stomach and throw it on the intestine.
The addition of an alkali to the food retards the coagulation
of casein by rennin and allows the liquid milk to pass into the
intestine, thus throwing the work of digestion from the stom-
ach on to the intestine. If the lime water, the alkali most
often used, is equal to 50% of the milk and cream in the mix-
ture, it practically prevents the coagulation of the casein and
throws all the work on the intestine. If the lime water is
25% of the milk and cream, it throws a proportionate part of
the work on the intestine, and so on. It is evident that as the
important relation is between the casein and the lime water,
and as the milk and cream are the only substances in the
mixture containing casein, the amount of lime water to be
added must be calculated in relation to the milk and cream
and not in relation to the total quantity of the mixture, which
is made up largely of water, or to whey, which contains no
casein. Lime water is indicated in this instance, therefore,
and in the proportion of 25% of the milk and cream in the
mixture. Whey proteids are not acted on by rennin, leave
the stomach quickly and throw but little work upon it. They
are, therefore, indicated in this instance. The following
formula meets these indications:
Fat, 2.00%
Milk sugar, 5-5°%
Whey proteids, 0.75%
Casein, 0.25%
Lime water, 25.00% of the milk and cream.
Four ounces is as much as he should have at a feeding.
Eight feedings, at two and one-half hour intervals, gives
103 calories per kilo, and 2.3 grams of proteid per kilo, which
covers both the caloric and proteid needs.
If whey mixtures are not satisfactory, pancreatization of
suitable milk and cream mixtures may be tried.
No drugs are indicated. The symptoms at present are
hardly severe enough to require lavage.
I40 CASE HISTORIES IN PEDIATRICS.
CASE 30. Frances M. was an only child. Her parents
were neurotic and her father was a chronic dyspeptic. She
was breast-fed and was perfectly well during infancy and until
she was six years old. Since then she had had more or less
disturbance of the digestion. Her appetite was usually
good, but she ate hurriedly, did not chew her food and was
in the habit of washing it down with water. Her diet was a
reasonably good one. Her tongue was often coated and her
breath foul. She had hiccoughs frequently and often belched
gas and gaped. She was occasionally nauseated and at times
vomited. Her mother had noticed no definite relation be-
tween these symptoms and the time of taking food. Her
bowels moved regularly and the stools appeared normal,
except that they were often a little loose. She did not go
to school or play with other children, because her mother
feared that she might contract some disease. She had some
home lessons, however, and was out of doors much of the
time. She had no rest in the middle of the day, but went to
bed at seven and slept well. She was rather excitable. She
had lost a little weight. She had had no other illnesses.
She was seen when nine years old.
Physical Examination. She was tall and slim. Her color
was good and her skin in good condition. Her tongue was
nearly clean. Several of her teeth were decayed. The
throat, heart and lungs were normal. Nothing abnormal
was detected in the abdomen. The liver and spleen were not
palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
Her weight without her clothes was fifty pounds and six
ounces, which is equal to about fifty-four pounds with her
clothes and is about three pounds below the average for her
age. Her height without her shoes was fifty and one-half
inches, which is about one inch above the average.
The urine was normal in color, clear, acid in reaction, of
a specific gravity of 1020 and contained no albumin or sugar.
Her stool was of medium size, soft, homogeneous, brown,
foul and alkaline in reaction. Microscopically it showed no
starch, a few meat fibres and a very little fat in the form of
DISEASES OF GASTROENTERIC TRACT.
141
soaps. The meat fibres and soaps were, however, not in
excess of the normal limits.
Diagnosis. The symptoms of indigestion are gastric rather
than intestinal. The stool shows no evidence of intestinal
indigestion. The diagnosis of Chronic Gastric Indiges-
tion is, therefore, warranted. The neurotic inheritance, the
bad example of the father, the lack of companionship and
occupation, the failure to chew her food properly and the
washing it down with water have probably all played a part
in its causation.
Prognosis. The symptoms are not very marked, her
general condition is but little impaired and many of the
causative factors are remediable. The outlook for a speedy
recovery is, therefore, very good.
Treatment. There are no very definite indications as to
what food elements will or will not agree with her. She
should, therefore, be given a simple, easily digested diet.
It will be well, on general principles, to keep the fat very
low, as fat tends to delay the stomach digestion. The
following list is a reasonable one for her:
Skimmed milk.
Soft boiled eggs.
Dropped eggs.
Scrambled eggs.
Lamb chop.
Mutton chop.
Beef steak.
Roast lamb.
Roast mutton.
Boiled mutton.
Roast beef.
Roast chicken.
Boiled chicken.
Broiled chicken.
Boiled fish.
Broiled fish.
White bread.
French bread.
Plain crackers.
Educators.
Milk toast.
Strained oatmeal.
Cream of wheat.
Wheat germ.
Germea.
Ralston.
Farina.
Rice.
Hominy.
Cracked wheat.
Baked potato.
Plain macaroni.
Butter — very little.
String beans.
Asparagus.
Spinach.
Beet greens.
Peas.
Summer squash.
Stewed celery.
Grapes.
Orange juice.
Junket.
Baked custard.
Corn starch pudding.
Bread pudding.
Rice pudding.
Plain blanc mange.
It will, in all probability, have to be modified somewhat in
the future to fit her individual case. Careful observation of
her symptoms and repeated examinations of the stools in
connection with a complete record of the food taken will show
I42 CASE HISTORIES IN PEDIATRICS.
what these modifications should be. She will require about
1350 calories daily to cover her caloric needs. She should
have three meals and no lunches. She must be made to eat
slowly and to chew her food properly. She must not be
allowed to wash her food down with water or other liquids.
There is, however, no objection to her drinking water with
or after her meals. She must be encouraged to drink water
between her meals.
It will be well for her to go to school half a day in order that
she may have occupation and companionship. She must also,
and for the same reason, be allowed to play with other
children. It will be wise for her to rest an hour after her
dinner.
There is nothing about the symptomatology to suggest
gastric hyperacidity and the symptoms are not severe enough
to point to sufficient hypoacidity to call for the administra-
tion of hydrochloric acid. Pepsin is always present if there is
hydrochloric acid and pancreatin is destroyed in the stomach.
Her appetite is good. There is, therefore, no indication for
the administration of drugs.
She should have her teeth filled.
DISEASES OF GASTRO-ENTERIC TRACT. 1 43
CASE 31. Edward C, six years old, was the third child of
healthy parents. The two other children were living and well
and there had been no miscarriages. There was a history of
tuberculosis in his father's family, but he had had no known
exposure to it. He was born at full term, after a normal
labor, was normal at birth and weighed seven pounds. He
was constipated from birth. The physician, who attended
him at this time, said that there was a growth about a finger's
length up the bowel. The mother said that with her little
finger she could just reach something which felt like a ring.
An attempt was made to dilate this constriction by the intro-
duction of the finger, first by the physician and then by the
mother, once or twice a week during the first year. Nothing
of the sort had been done since then. The constipation had
continued up to the present time. Variations in the diet had
no effect upon it. All sorts of drugs had been tried, but none
of them had worked as well as enemata. He never had a
movement without help. The stools were usually small in
diameter, dark-colored and well digested. They were some-
times in very small pieces, like sheep dung, but never in the
form of large balls. There was sometimes a little mucus on
the outside of the stools, but never any blood. The only
time in his life that he had had loose movements was once
when he had eaten a great many pears. He had had attacks
of vomiting ever since he was weaned, when six months old,
which were apparently due to blocking up of the bowels, as
they always ceased when the bowels moved. His abdomen
began to enlarge when he was two and one-half years old.
It had, on the whole, grown steadily larger, although it varied
in size from day to day. The swelling was at first most
marked in the lower portion, but recently the upper portion
had seemed the larger. There was at times visible peris-
talsis. He very seldom had any pain, but often passed a
great deal of gas from the anus. He had developed well in
other ways. He cut two teeth when he was four months old,
walked at sixteen months and talked early. He was active
and was able to run about and play with the other boys,
although he became short of breath if he exerted himself
much.
144 CASE HISTORIES IN PEDIATRICS.
Physical Examination. He was tall and thin. The lips
and nails were of good color. He was perfectly normal
mentally. The tongue was clean, the teeth poor. The
abdomen was enormous, the chest and extremities appearing
like appendages to it. The heart was of normal size, but it
was displaced a little upward and to the left. The sounds
were normal. The lungs were normal. The upper border
of the liver flatness was at the upper border of the fifth rib.
The lower border of the liver dullness was two cm. above the
costal border. The spleen was not palpable. The abdomen
was enormously distended, the distention being greatest
in the upper portion. The distention was at times uni-
form; at others, slight waves of peristalsis were visible with
deep sulci between them. The abdomen was everywhere
tympanitic. There was no tenderness or muscular spasm
and no tumors were felt. The following measurements were
taken:
Circumference of chest at nipples, 61 cm.
Circumference of abdomen at navel, 64 cm.
Circumference of abdomen at level of anterior superior
spines, 55 cm.
Greatest circumference of abdomen, 74 cm.
The extremities were normal except for their small size. The
knee-jerks were equal and normal. Kernig's sign was absent.
There was no enlargement of the peripheral lymph nodes.
A stool, which was seen, was smooth, dark-colored and
about the size and shape of the finger.
Diagnosis. The distention of the abdomen is unquestion-
ably due to dilatation of the intestines. It is reasonable to
believe that this dilatation is due primarily to a congenital
narrowing of the rectum, and that the large intestine only is
involved. It is possible that there was also some other con-
genital malformation of the large intestine, but the late
development of the enlargement of the abdomen makes this
improbable. It is not quite proper, therefore, to speak of
this as a Congenital Dilatation of the Colon or Hirsch-
sprung's Disease, in which the condition is primarily a
congenital malformation of the whole or a part of the large
Edward C. Case 31.
DISEASES OF GASTROENTERIC TRACT. I45
intestine. Whatever the origin, however, the present con-
dition is now the same as in the typical cases of this type.
Prognosis. His general condition is better than would be
expected from the duration of the disease and the size of the
abdomen. There is no possibility of spontaneous improve-
ment. Drugs and enemata are merely palliative measures.
Ulceration of the intestine or marked toxemia from reten-
tion of the intestinal contents is almost certain to develop
eventually and to finally cause death. There is a possibility
of cure by operation. The operation, is, however, a serious
one and more than likely to result fatally.
Treatment. He can be kept alive and fairly comfortable
for a considerable time by the combined use of enemata and
massage of the abdomen. Sooner or later, however, these
measures will prove ineffectual and it will be necessary to
operate upon him or to let him die without operation. The
operations possible are the making of an artificial anus and
the removal of the large intestine. The former operation is
merely palliative, not curative, and, if successful, is a source
of great discomfort. The removal of the colon is a very
serious operation and very likely to prove fatal. If success-
ful, however, it results in a cure.
146
CASE HISTORIES IN PEDIATRICS.
CASE 32. Mary D., five and one-half months old, had
always been a perfectly well, breast-fed baby. About 6 a.m.,
September 6, she suddenly began to cry and to put her hands
on her abdomen. The crying continued for half an hour or
more. At about this time she had three movements con-
sisting almost entirely of bright blood. After this she vomited
two or three times. The character of the vomitus was not
noticed. Judging from the story, she evidently was somewhat
collapsed for a short time after the onset of the pain. She
was seen about 7.30 A.M. by her physician, who examined the
abdomen but found nothing abnormal. He did not consider
the condition an important one, although he watched the
case very carefully afterward. She continued to have seven
or eight small movements daily, which consisted entirely of
mucus and blood. The amount of blood, however, had
steadily diminished. The movements contained no fecal
matter. A bismuth mixture, which was ordered at the first
visit, was vomited. There was no more vomiting until the
noon of the 8th, since when she had vomited almost con-
stantly. She continued to take the breast well. She had had
no very sharp attacks of pain, but had slept very little, moan-
ing most of the time. She did not seem very sick until the
8th and had noticed things and played a little that afternoon.
The temperature had been taken morning and evening, but
had never been over ioo0 F. The mother thought that she
felt a bunch in the abdomen the evening of the 7th, but both
the mother and the doctor failed to find it the next morning.
She was given two teaspoonfuls of castor oil the morning of
the 8th, which were vomited, and also several large injections
of salt and water, which brought away nothing but mucus and
blood. She was seen in consultation at 9 p.m., September 8,
sixty-three hours after the onset.
Physical Examination. She was well developed and nour-
ished. There was slight pallor. Her face was drawn and
anxious. She noticed a little. The fontanelle was nearly
level. The tongue was slightly dry, but not coated. The
heart and lungs showed nothing abnormal. The liver was
palpable 3 cm. below the costal border in the nipple line.
The spleen was not palpable. The level of the abdomen was
DISEASES OF GASTRO-ENTERIC TRACT.
147
somewhat below that of the thorax. An indefinite resistance
was felt in the left lower quadrant. There was no muscular
spasm, but a little tenderness in this region. The rest of the
abdomen was negative. Rectal examination showed more
resistance in the left half of the abdomen than in the right,
but nothing at all definite. The extremities showed nothing
abnormal. There was no enlargement of the peripheral
lymph nodes. The rectal temperature was 100.40 F., the
pulse 180.
Diagnosis. The diagnosis of Intussusception is so plain
in this instance that it is hard to understand how it could
have been mistaken for infectious diarrhea, as was done.
The sudden onset of severe abdominal pain with partial
collapse, the vomiting and the passage of bright blood are
pathognomonic of intussusception and entirely different
from the slow onset of infectious diarrhea. The further
course of the disease, with continued abdominal pain and
numerous stools of mucus and blood without fecal matter, is
most characteristic. Pain is uncommon, except at the time
of defecation, in infectious diarrhea at this age, and some of
the movements always contain fecal matter. The physician
was undoubtedly misled by the facts that the baby nursed
well and did not appear very ill. It is, however, not at all
uncommon for babies with intussusception to take their food
well almost to the end, and the general condition is often not
much affected during the first thirty-six hours or so. He was
also probably further misled by the moderate temperature.
This, again, is characteristic of intussusception, high fever
being very unusual. He should have paid more attention to
the mother's story of a bunch in the abdomen and not have
trusted so much to his own negative examination, for it often
happens that the tumor can be felt at one time and not at
another. The failure to obtain fecal matter from the injec-
tions should also have suggested intussusception. The castor
oil was, of course, very bad treatment. If it had been re-
tained, it would have merely made the intussusception
tighter.
The physical examination, as often happens in intussuscep-
tion, aids but little in the diagnosis. The strained and anxious
I48 CASE HISTORIES IN PEDIATRICS.
face are suggestive of intussusception, but not inconsistent
with infectious diarrhea. The indefinite resistance and slight
tenderness in the left lower quadrant and the increased
resistance in the left half of the abdomen on rectal examina-
tion are corroborative of the diagnosis of intussusception, but
without the history would not be of much importance.
Prognosis. The prognosis is very grave. It is almost
certain that during the sixty-three hours since the onset ad-
hesions have formed so that the intussusception cannot be
reduced. The circulation has been interfered with so long
that the gut is almost certainly gangrenous. A resection will
undoubtedly have to be done. There is not one chance in
ten for recovery.
Treatment. The only possible treatment is immediate
operation.
DISEASES OF GASTRO-ENTERIC TRACT. 149
CASE 33. Sophie M., nine months old, was the child of
healthy parents. She was born at full term after a normal
delivery and had always been well. She had been nursed
irregularly, but had had no other food except occasionally a
little zwiebach.
She woke up from a nap crying, evidently from pain in the
abdomen, about noon, April II. She was pale for some time
after she ceased crying. She had nursed well since then but
had vomited everything taken, including a number of cathar-
tics, almost immediately. The vomitus consisted of the food
taken, with a little water and mucus; it was never greenish or
brownish. She had had no fecal movement of the bowels,
although numerous enemata had been given. Once she had
passed " a small glassful of clear blood." She had apparently
not been much feverish and had apparently not had any pain
since the onset. She had passed very little urine. She was
seen at noon, April 13, forty-eight hours after the onset.
Physical Examination. She was well developed and nour-
ished and a little pale. She was moderately prostrated, but
her face was not pinched and her eyes were clear. The an-
terior fontanelle was slightly depressed. The pupils were
equal and reacted to light. There was no rigidity of the neck
or neck-sign. The tongue was rather dry, but not red or
coated. The throat was normal. The heart and lungs were
normal. There was no rosary. The liver was just palpable.
The spleen was not palpable. The level of the abdomen was
a little below that of the thorax. There was no definite
muscular spasm, but the whole abdomen was held a little
rigidly, especially in the right lower quadrant. There was
no tenderness or dullness. Nothing at all definite could be
made out in the right lower quadrant, but it seemed as if
there was a little more resistance there than on the other side.
Rectal examination showed nothing abnormal. The rectum
was empty. There was no blood on the examining finger.
The extremities were normal. There was no spasm or pa-
ralysis; the knee-jerks were equal and normal; there was no
Kernig's sign.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was 98. 6° F., the pulse 136.
150 CASE HISTORIES IN PEDIATRICS.
Diagnosis. The diagnosis in this instance lies between
acute gastric indigestion, with secondary constipation, and
intussusception. The points in favor of intussusception are
the sudden onset in a breast-fed baby, the continued vomiting,
the absence of fecal movements, the history of the movement
of blood, and the slight rigidity and sense of resistance in the
right lower abdomen. The points against intussusception are
the character of the vomitus, the slight amount of prostration,
the absence of an abdominal tumor, the negative rectal exami-
nation and the low temperature. It may also be argued
that the history of the passage of " a small glassful of clear
blood " was probably untrue, and that if the baby had passed
blood once it would certainly have passed it again if the con-
dition was intussusception. The small amount of urine is, of
course, of no importance, merely meaning that very little
fluid was retained.
There is no question as to the validity of the objections
to the diagnosis of intussusception. They are, however, all
unimportant compared with the almost pathognomonic com-
bination of the sudden onset of abdominal pain in a breast-fed
infant, the constant vomiting, the obstipation and the passage
of blood. These are positive symptoms ; the others are merely
negative. The absence of fecal vomiting can be explained
on the ground that the reverse peristalsis is not very active;
the absence of frequent movements of blood and mucus, on
the ground that the constriction is not very tight, and that
consequently there is not much congestion or exudation into
the bowel, and not much peristalsis set up. The absence of a
tumor can be explained by the absence of a very tight con-
striction or of marked swelling, or by the deep location of the
tumor; the absence of a tumor on rectal examination, by the
high position of the intussusception; and the low tempera-
ture by the absence of absorption.
These signs are so characteristic of Intussusception that it
is hardly necessary to attempt to rule out other forms of intes-
tinal obstruction. Some other form is, however, a possibility.
Fortunately, the treatment is the same in any instance.
Prognosis. The chances for recovery are about even in this
instance, with a good surgeon, if operation is done at once.
DISEASES OF GASTRO-ENTERIC TRACT. 151
The absence of fecal vomiting and frequent movements, the
good general condition, the low temperature and the short
duration of the intussusception are all favorable points.
Treatment. The only rational treatment for intussuscep-
tion at any stage is immediate operation as soon as the
diagnosis is made. Attempts at reduction by inflation of the
bowel with water or air are in rare instances successful. In
the vast majority of cases, however, they are unsuccessful,
they waste time and use up the child's vitality. It is impos-
sible, moreover, to know at once whether the intussusception
has been reduced or not by these measures, so that on this
account still more time is wasted. An early' operation is
usually successful, because at this time the intussusception
can be easily reduced, while the dangers from opening the
abdomen are slight in skilled hands. When the operation is
delayed, the intussusception can usually not be reduced
because of adhesions, and the bowel is irreparably damaged.
A resection has to be done or an artificial anus made. Under
these circumstances the baby almost invariably dies.
152 CASE HISTORIES IN PEDIATRICS.
CASE 34. Virginia P., seven months old, had always
been a perfectly well, breast-fed baby. She began to vomit
about 6 p.m., November 4. She had a perfectly normal
movement from the bowels at 7 p.m. When seen by her
physician, at 7.30 p.m., she was somewhat stupid, but not at
all -collapsed. The physical examination was negative, ex-
cept for a little more resistance in the left lower abdomen
than elsewhere. The rectal temperature was normal. She
was very restless all night, apparently from pain in the
abdomen. She vomited both of two nursings and also water
which was given her from time to time. She had seven
movements, consisting entirely of mucus and blood, during
the night. Irrigation of the bowels at 9 a.m., November 5,
brought away nothing but a little blood. She was seen in
consultation at 12 m., November 5. She had not vomited
since 5 a.m., although she had taken water freely, and the
bowels had not moved since the irrigation.
Physical Examination. She was very fussy, but appar-
ently not in pain. The mouth was dry, the tongue clean.
The anterior fontanelle was level. The heart and lungs
were normal. The lower border of the liver was just pal-
pable in the nipple line. The spleen was not palpable. The
level of the abdomen was below that of the thorax. Exam-
ination of the abdomen was very difficult because of the
constant crying, but it was finally decided that there was no
tenderness, spasm or tumor. Rectal examination showed
nothing abnormal, but the withdrawal of the finger was
followed by the discharge of a teaspoonful of dark reddish-
brown water. The extremities showed nothing abnormal.
The rectal temperature was 100.20 F. ; the pulse, 116.
A positive diagnosis of intussusception was made and
immediate operation advised. When the surgeon saw her,
an hour later, she was asleep and a careful examination of
the abdomen showed nothing abnormal. When she awoke
she was bright and happy and acted like a normal baby.
She seemed so well that he thought that the intussusception
had probably been reduced by the irrigation, or spontaneously
during the ride to the hospital, and declined to operate
unless further symptoms developed.
DISEASES OF GASTROENTERIC TRACT. 1 53
She was seen again in consultation at 4 p.m. She had
taken water freely and had not vomited. She had had no
food since 5 a.m. The bowels had not moved; neither had
she passed gas. She had had no pain and had slept a little.
She was smiling and playing in the nurse's arms and looked
well, but a little tired. The abdomen was soft, there was no
tenderness, spasm or tumor. A gush of dark reddish-brown
water followed the introduction of a suppository. The rectal
temperature was 102. 2° F. ; the pulse, 118.
Diagnosis. There is no doubt that she had an intussus-
ception. The question is whether it is still present or has
been reduced. The points in favor of its having been re-
duced are the cessation of the vomiting and bloody move-
ments, the absence of pain and tumor, the negative rectal
examination and the marked improvement in the general
appearance. The arguments in favor of the intussusception
being still present are as follows: Reduction by a simple
irrigation is very unusual. Spontaneous reduction, while it
may occur, takes place so rarely that it is wiser to take it for
granted that it never happens. Remissions in the subjec-
tive symptoms are very common, especially in the first
thirty-six hours. Pain is seldom present after the onset.
The tumor cannot be felt if it is situated high up under the
diaphragm or liver. Rectal examination is always negative
unless the tumor is low down. There have been no fecal
movements. The cessation of vomiting is due to the absti-
nence from food. The temperature is rising in spite of the
apparent improvement in the subjective symptoms. It may
be said in rebuttal, however, that there has not yet been
time for feces to appear and that the rise in temperature is
due to starvation and fatigue. It is evidently impossible
to be absolutely sure whether the intussusception has been
reduced or not. The question must be decided by weighing
the chances on the two sides. The relative frequency of
remissions in the subjective symptoms must be balanced
against that of spontaneous reduction and reduction from
simple irrigation. The other points can be explained either
way and are, therefore, of no importance. Remissions are
infinitely more common than spontaneous reduction or re-
154 CASE HISTORIES IN PEDIATRICS.
duction from simple irrigation. The chances are, therefore,
very much in favor of the persistence of the intussusception,
so much so that the diagnosis of an Unreduced Intussus-
ception is justified.
Prognosis. The prognosis without an operation, if the
diagnosis is correct, is hopeless. She is in good condition;
the intussusception occurred less than twenty-four hours ago;
the symptoms are not very acute. It is probable, there-
fore, that the intussusception can be reduced and that a
resection of the bowel will not be necessary. The chances for
recovery are, therefore, better than even.
Treatment. She should be operated on immediately. It
is true that the operation may be found to be unnecessary.
There is very little risk, however, in an exploratory lapa-
rotomy, while she is certain to die if not operated upon, if the
intussusception is still present.
DISEASES OF GASTROENTERIC TRACT. 1 55
CASE 35. Walter R., eight years old, had always been
well, except for whooping-cough when three years old. He
was very constipated until he was four years old, the stools
being made up of masses of hard "bullets." These little
bullets would often slip out into his trousers when he was
running and playing. During this time he was given enemas
constantly, many of them being high. Since then the stools
had been formed, but not hard, the only abnormality about
them being their large size. He was, however, often unable
to hold them when playing, although he never dirtied him-
self when quiet or asleep. His lapses were not due to care-
lessness, because he always felt very badly about them and
punishment had made no difference. The attempt had been
made to prevent these accidents by forcing him to have a
movement directly after breakfast. He rarely succeeded,
however, and the straining in the attempt to have a move-
ment apparently made matters worse, because he almost
always had an involuntary movement soon after. The fre-
quency of the accidents varied. Sometimes he went several
weeks without one; at other times they occurred almost
every day, while during the previous summer he went sev-
eral months without trouble. His appetite was good, his diet
admirable and he had no symptoms of indigestion. He lived
an ideal out of doors life in the country, was not overstimu-
lated mentally and showed no signs of nervousness.
Physical Examination. He was well developed and nour-
ished and of good color. He seemed of average intelligence
and not at all nervous. His tongue was clean, his mouth
and throat normal. The heart and lungs were normal. The
level of the abdomen was that of the thorax; nothing
abnormal was detected in it. The liver and spleen were not
palpable. The genitals were normal. The prepuce was com-
pletely retractible and there was no local irritation. The ex-
tremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and normal. Kernig's and Babin-
ski's signs were absent. There was no disturbance of the
sensation. The peripheral lymph nodes were not palpable.
Rectal examination showed nothing abnormal. The tone
of the sphincter seemed normal.
I56 CASE HISTORIES IN PEDIATRICS.
Diagnosis. The trouble is, of course, Incontinence of
Feces. The important question is its cause. It is evidently
not due, as in some instances, to distention of the rectum
with hard feces. Judging from his good general condition
and apparently stable nervous system, it is not due to de-
bility or lowered nervous tone. There are no signs of local
irritation. It is probably due, therefore, to delayed develop-
ment of the normal control of the sphincter ani. It is pos-
sible, however, that the constipation during the early years
and the continued use of enemas may have played a part in
its production by interfering with the normal processes of
defecation.
Prognosis. The prognosis is good with time. The condition
is, however, a disagreeable and annoying one, which should
be stopped as soon as possible.
Treatment. There is nothing about his diet or daily rou-
tine which needs to be changed. There is no indication for
tonics or nerve stimulants or sedatives, as his general condi-
tion is good and there is no evidence of any general dis-
turbance of the nervous system. The treatment must be
directed toward the development of the control of the sphinc-
ter muscle. This can best be done by teaching him to con-
tract and relax the sphincter at will and by practice in doing
it. There ought not to be much difficulty in teaching him
to do this, as he is eight years old and of normal intelli-
gence. It is possible that the application of the faradic cur-
rent to the sphincter, every other day, may also be of assist-
ance.
DISEASES OF GASTROENTERIC TRACT. 157
CASE 36. Malcolm B., the third child of healthy parents,
was born at full term after a normal labor. He was normal at
birth and weighed eight pounds. He was nursed for nine
months, but during the last two months had had one or two
feedings of modified milk daily in addition. He was then
weaned and given an unmodified top milk, which contained
about 7.50% of fat, 4.50% of sugar and 3.50% of proteids.
The bowels, which had previously moved regularly, immedi-
ately became constipated, enemata, suppositories or some
drug being always required to get a movement. The move-
ments were white, dry and crumbling and had a disagreeable
acid odor. There was no vomiting. He took nothing but
this top milk, except occasionally a little broth with rice,
until he was fourteen months old. He was then changed to
five feedings of seven ounces of a top milk and Mellin's Food
mixture, which contained about 5.70% of fat, 6% of sugar
and 3% of proteids, and after about three weeks was given a
little beef juice in addition. The constipation was rather less
marked on this diet but still very troublesome. He was seen
when fifteen months old.
Physical Examination. He was well developed and nour-
ished, but flabby and a little pale. The fontanelle was 2 cm.
in diameter. He had seven teeth. His tongue was clean.
There was no rosary. The heart and lungs were normal.
The abdomen was negative, its level a little below that of the
thorax. The liver was just palpable. The spleen was not
palpable. The extremities were normal. There was no spasm
or paralysis; the knee-jerks were equal and normal ; Kernig's
sign was absent. There was a slight general enlargement of
the peripheral lymph nodes. The weight was twenty-two
pounds and eight ounces.
Diagnosis. The chief trouble is, of course, Constipation.
Constipation is, however, really a symptom and not a disease.
It is not a satisfactory diagnosis unless modified by some
term denoting the cause of the constipation. In this instance
the cause of the constipation is very evident, namely, the
excessive amount of fat in the food. No more than four
per cent of fat should ever be given ; he was getting nearly
twice that. The white, dry and crumbling stools are most
I58 CASE HISTORIES IN PEDIATRICS.
characteristic, being composed of unutilized fat in the form
of soaps. The improvement after the change of food, one
result of the change being a reduction in the amount of fat, is
further evidence that an excess of fat was the cause of the
constipation. A part of the improvement may possibly,
however, be attributed to the malt sugar in the Mellin's Food
and the beef juice, both of which usually have a laxative
action. The flabbiness of the skeletal muscles indicates an
additional atonic element in the etiology, because, when the
skeletal muscles are feeble, the intestinal muscles are usually
in the same condition.
Prognosis. The prognosis is good for rapid recovery,
because the chief cause of the trouble, the excess of fat in the
food, can be removed at once.
Treatment. The treatment is, of course, primarily by
regulation of the diet to remove the cause of the trouble.
Whole milk, or whole milk with an ounce of oat water to
each feeding, will probably give a sufficiently low fat. He is
old enough to have something beside milk; in^fact, babies of
his age are almost certain to do badly in some way if they do
not have something to eat beside milk. A reasonable diet to
start him on is as follows:
Whole milk or whole milk with oat water.
Beef juice, one or two tablespoonf uls ; or
Mutton or chicken broth, two to four ounces, once daily.
Bread or zwiebach in broth or beef juice.
Barley jelly, oat jelly, farina or rice, one to three table-
spoonfuls twice daily.
Orange juice, one to three tablespoonf uls, once daily.
While regulation of the diet is removing the cause of the
trouble, it may be necessary to relieve the symptom, constipa-
tion, for a time by the use of enemata of suds or sweet oil,
suppositories of soap, glycerin or gluten, or milk of magnesia,
in doses of from one-half to one teaspoonful once or twice
daily.
It goes without saying that fresh air, a good routine and
everything which tends to improve the general condition will
aid in the relief of the constipation by improving the muscular
tone and removing the atonic element.
DISEASES OF THE GASTROENTERIC TRACT. 1 59
Massage of the abdomen for five or ten minutes morn-
ing and night will stimulate the intestinal peristalsis and
help to strengthen the abdominal muscles. The baby is
old enough to be trained to have a movement at a regular
hour and to use his muscles in defecation. From four to
six ounces of water daily between his meals will also be of
service.
!6o CASE HISTORIES IN PEDIATRICS.
CASE 37. Robert A., fifteen months old, was the first
child of healthy parents. He was breast-fed during the first
year and was not constipated during this time. He was then
given a mixture of Mellin's Food and milk and became very
much constipated. After that he was given Imperial Granum,
and other articles of diet were soon added. When seen he was
taking milk, oat jelly, bread, orange juice and Bovinine.
The bowels did not move except with the aid of gluten sup-
positories. The movements were large, brown or yellow in
color, coated with mucus, and usually had bright blood on the
outside. Defecation was very painful. During it the child
became cold and perspired and stiffened out. Otherwise he
was well. He sat up but did not creep or try to stand. He
apparently did not have too large an amount of food.
Physical Examination. He was good-sized but fat and
flabby. The muscles seemed poorly developed. His color
was good. The fontanelle was nearly closed. The tongue was
clean. He had twelve teeth. There was a slight rosary.
There was also a slight retraction of the chest at the insertion
of the diaphragm. The abdomen was not distended and was
perfectly lax. The liver was palpable 1 cm. below the costal
border in the nipple line. The spleen was not palpable. The
extremities were normal except for a slight enlargement of
the epiphyses at the wrists. There was no spasm or paralysis.
The knee-jerks were equal and normal. There was no
Kernig's sign. There was no enlargement of the peripheral
lymph nodes. The genitals were normal except that the
prepuce was rather tight. There was a crack at the edge of
the anus, both back and front, about one quarter of an inch
long and one eighth of an inch deep. This crack bled easily
when the anus was stretched. Rectal examination was
negative.
Diagnosis. The diagnosis of constipation is, of course,
evident. This diagnosis is, however, not sufficient. It is
necessary to determine the type and the cause of the constipa-
tion. The pain during defecation and the bright blood on the
outside of the movement are almost enough of themselves to
justify the diagnosis of fissure of the anus without physical
examination. This condition is, of course, proved by the
DISEASES OF GASTROENTERIC TRACT. l6l
physical examination. The fissure and the pain caused by it
are, therefore, the cause of the constipation, and the consti-
pation is of the spasmodic type. The large size of the move-
ments suggests some other etiological factor. This suggestion
is corroborated by the facts that the child does not creep or
try to stand, and the general flabbiness. That is, the muscular
development is poor. It is fair to assume that the intestinal
muscles are also weak and the intestinal peristalsis feeble.
The constipation is, therefore, partly of the atonic type.
The cause of the weakness of the muscles is shown by the
rosary, the retraction of the lower chest and the enlargement of
the epiphyses at the wrists, all of them manifestations of
rickets. The final diagnosis is, therefore, Constipation,
chiefly of the Spasmodic Type; Fissure of the Anus;
Mild Rickets. An interesting point is that the malt sugar
in the Mellin's Food, which usually acts as a laxative, had
the opposite effect in this instance.
Prognosis. The prognosis is perfectly good with time and
proper treatment. The fissure should heal in a few weeks
with very simple treatment. Stretching the sphincter is
almost never necessary. It will probably take somewhat
longer to relieve the constipation because, on account of the
pain in the past, the child will continue to be afraid to have a
movement even after the fissure is healed, and the atonic
element will remain after the spasmodic element is relieved.
The active stage of the rickets, shown chiefly by the weak
musculature, should yield quickly to treatment. The bony
signs will persist for many months but will eventually dis-
appear.
Treatment. The first object of the treatment is to heal the
fissure. To do this, it is first necessary to keep the movements
soft. Until this is accomplished by regulation of the diet, it
can best be done with an enema of an ounce of sweet oil
daily. If this is not effectual, he may be given one or two
teaspoonfuls of milk of magnesia in his milk daily. Local
cleanliness and the application of boracic acid ointment will
then quickly heal the fissure. It will almost certainly not be
necessary to stretch the sphincter.
A rational routine and diet for him will be as follows:
1 62 CASE HISTORIES IN PEDIATRICS.
6 a.m. Whole milk, 8 ounces.
9 A.M. Orange juice, 2 tablespoonfuls.
io A.M. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, 10
ounces.
2 P.M. Mutton or chicken broth, 3 ounces; or beef juice,
2 tablespoonfuls. Bread or zwiebach, I slice. One-half baked
apple or 2 tablespoonfuls of prune juice. Whole milk, 4
ounces, if desired.
6 p.m. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, 10
ounces.
Water should be forced.
Massage of the abdomen twice daily will stimulate the
peristalsis and improve the muscular tone. Much fresh air
and sunlight will help the rickets and general condition, and
hence the atonic element of the constipation. Tincture of
nux vomica, in drop doses, three times a day, before meals,
will also tend to improve the general condition and the intesti-
nal tone.
DISEASES OF GASTRO-ENTERIC TRACT. 1 63
CASE 38. Charles B., seven and one-half years old, was
not very carefully fed, but had not been especially indiscreet
just before the onset of this illness. He had had a number of
similar attacks in the past.
He complained of pain in his stomach in the late afternoon
of December 2, and vomited a considerable amount of un-
digested food and mucus mixed with bile. His temperature
that night was 1040 F. He nevertheless slept well. He
vomited several times during the next two days and the
vomitus always contained bile. The bowels did not move
either day, as all the drugs given were vomited. His tempera-
ture ranged between ioo° F. and 1020 F. He had no pain.
He did not seem very sick, but did not care to get out of bed.
He did not want anything to eat, but had taken a little milk
and broth. A dose of Epsom salts given on the morning of
the 5th was retained and resulted in several large, loose,
gray or light grayish-yellow movements, which had a very
foul odor, but did not contain undigested food or mucus.
Slight yellowishness of the conjunctivae was noticed that
afternoon. He was seen at 4 p.m., December 5.
Physical Examination. He was well-developed and nour-
ished and perfectly clear mentally. He was a little pale.
The conjunctivas had a slight yellow tinge. The tongue was
moist and moderately coated; the papillae were unusually
distinct. The mouth and throat were normal. There was no
rigidity of the neck. The heart and lungs were normal. The
level of the abdomen was below that of the thorax. There
was no muscular spasm or tenderness and no masses were
felt. The upper border of the liver flatness was at the upper
border of the sixth rib in the nipple line. The liver was
palpable just below the costal border in the nipple line. It
was not tender. The gall-bladder was not palpable and there
was no tenderness in this region. The spleen was not palpable.
The extremities were normal. There was no spasm or
paralysis; the knee-jerks were equal and normal; there was
no Kernig's sign. There was no enlargement of the peripheral
lymph nodes. The rectal temperature was 99. 2° F. ; the
pulse was 80.
The urine was clear and dark reddish yellow in color ; when
164
CASE HISTORIES IN PEDIATRICS.
shaken the froth was yellow. The reaction was acid; the
specific gravity, 1,024. It contained neither albumin, sugar
nor acetone. The sediment showed nothing abnormal.
Diagnosis. Inflammation of the gall-bladder and gallstones
are extremely rare at this age. . The absence of pain and of
enlargement and tenderness of the gall-bladder, together
with the low temperature, exclude them in this instance.
The vomiting of bile, the enlargement of the liver (which
should not be palpable at this age), the yellowness of the
conjunctivae, the clay-colored stools and the dark urine are
so characteristic of Acute Duodenal Indigestion that it
is hardly necessary to exclude other diseases. A number
of other conditions ought, perhaps, to be considered, how-
ever, for the sake of completeness. These are, acute gastric
indigestion, recurrent vomiting and appendicitis. None of
them show jaundice, clay-colored stools or bile in the urine.
There is none or very little fever in recurrent vomiting, and
there are local signs in the abdomen in appendicitis. Tuber-
cular meningitis should be thought of in this instance, as
always when a child vomits. It can, of course, be excluded
at once on the presence of the characteristic symptoms of
duodenal indigestion and the absence of all signs of meningeal
irritation.
Prognosis. There is, of course, no danger as to life. The
most acute stage is already over. It will probably be one or
two weeks, however, before bile reappears in the movements
and convalescence really begins. During this time, while not
seriously ill, he will be very miserable and irritable. If he is
neglected or improperly treated, there is considerable danger
that the condition will run over into chronic duodenal indi-
gestion. He is almost certain to have more attacks in the
future, unless great care is taken with his diet.
Treatment. The most acute stage being over, the treat-
ment is now principally regulation of the diet. Experience
has shown that these patients do best when they are fed almost
entirely on proteids, the starches being kept low, and the
fats and sugars entirely excluded. A reasonable diet for him
at present is whey, skimmed milk, junket from skimmed
milk, strained broths, beef juice, white of egg, and toast
DISEASES OF GASTRO-ENTERIC TRACT. 165
bread and zwiebach in small amounts. Lean meat and simple
cereals may be added to his diet as he improves ; next, orange
juice and green vegetables. It is always wise to wait longer
than seems necessary before increasing the diet.
There is no drug which will diminish the swelling in the
duodenum or at the orifice of the common bile duct. Time
and rest of the duodenum by care in the diet will alone accom-
plish this. The so-called " cholagogues " are contra-indicated
for two reasons: they do not increase the flow of bile and
there would be no object in increasing it, if they did. Phos-
phate of soda in doses of a teaspoonful, more or less, is the
best laxative. Tincture of nux vomica seems to be of some
utility in these cases and is worthy of a trial. Seven drops,
three times a day, before eating, is about the right dose for
this patient.
He must be kept in bed and kept warm until convalescence
is well established, because over-exertion and chilling are
very apt to bring on a relapse.
1 66 CASE HISTORIES IN PEDIATRICS.
CASE 39. Dorothy R. was the second child of healthy
parents. The first child died in convulsions, when three
months old. There had been no miscarriages. She was
born at full term, after a normal labor, was normal at birth
and was said to have weighed eleven pounds. She had never
had anything to eat except her mother's milk. She seemed
perfectly well until she was two weeks old, when she began
to be jaundiced. The jaundice increased for two weeks until
she was "brown all over," but she had been "getting
bleached" during the last week. The stools were dark-
green during the first few days of life, but were orange-
yellow from this time until the appearance of the jaundice,
when they became white. They continued to be white until
a physician gave her some powders, after which they were
blackish-green. The powders were stopped at the end of two
weeks, since when the stools had been -very light yellow in
color. The urine had been brown since the appearance of
the jaundice. She seemed somewhat drowsy during the first
two weeks after the beginning of the jaundice, but had been
brighter during the last week. She had, however, taken the
breast well. Her mother did not know whether she had had
any fever or not. She was admitted to the Children's Hos-
pital when five weeks old.
Physical Examination. She was well developed and fairly
nourished, and acted like a normal baby of her age. The
skin, mucous membranes and conjunctivae were deeply jaun-
diced. There were a few hemorrhagic spots in the roof of
the mouth and a small ecchymosis on one foot. The heart
and lungs were normal. The upper border of the liver flat-
ness in the nipple line was in the fourth space. The lower
border of the liver was palpable five cm. below the costal
border in the same line. The spleen was not palpable and
the abdomen was normal. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. There was no enlargement of the peripheral
lymph nodes. The rectal temperature was 98. 6° F. ; the
pulse, 128; the respiration, 30. She weighed eight pounds.
The urine was greenish-brown and feebly acid in reaction.
It contained no albumin or sugar, but a large amount of bile.
DISEASES OF GASTROENTERIC TRACT. 1 67
The stools were smooth and light yellow in color. There
was a slight excess of fat in the form of fatty acids and soap.
Bile was present by the corrosive sublimate test.
Diagnosis. Congenital obliteration of the bile ducts can
be excluded by the late appearance of the jaundice, the ab-
sence of enlargement of the spleen, the yellow color of the
stools and the presence of bile in them. 'Icterus neonatorum
can be ruled out on the late appearance of the jaundice, the
history of white stools, the presence of a large amount of bile
in the urine and the enlargement of the liver. The late
appearance of the jaundice, the white stools and the absence
of enlargement of the spleen are inconsistent with congenital
icterus. The good family history, the fact that she was born
at full term, the absence of enlargement of the spleen and of
other signs of syphilis and the white stools exclude congenital
syphilis. If she had had a septic infection with this amount
of jaundice she would have been much sicker, would not be
in such good general condition and would not have had white
stools. Acute duodenal indigestion is uncommon at this
age, but does occur. The acute onset of jaundice, white
stools and brown urine, without severe constitutional symp-
toms, in a previously well baby is most characteristic. The
slight enlargement of the liver, the absence of enlargement
of the spleen and the normal temperature are consistent with
it. The presence of bile in the stools shows that the obstruc-
tion is no longer complete. She is, therefore, undoubtedly
recovering from an attack of Acute Duodenal Indigestion.
Prognosis. The prognosis is good. A rapid and unevent-
ful recovery may be confidently expected.
Treatment. Her mother should continue to nurse her.
She should be given eight feedings in the twenty-four hours,
the intervals being two and one-half hours during the day
and four and one-half at night. It will be well to give her
one-half an ounce of water sweetened with saccharin before
or with each nursing. This will serve to dilute the milk
which, judging from the excess of fat in the stools, is some-
what rich in fat. There is no indication for the administra-
tion of drugs.
1 68 CASE HISTORIES IN PEDIATRICS.
CASE 40. Russell H., three years old, was born at full
term, was normal at birth and weighed ten and one-half
pounds. His parents were healthy and there had been no
known exposure to tuberculosis. He was breast-fed and when
six months old weighed thirty pounds. His mother began to
give him other food very early and for the past year his diet
had been very unsuitable for a child of his age. He was given
very little meat or vegetables, but many sweets and bananas.
His appetite had been poor for nearly six months, during
which time he had lost eight pounds. Recently it had been
necessary to force him to eat. He had not vomited, but was
inclined to constipation. The movements were at times
greenish; at others, clay-colored. They never contained
mucus. He had been very forward up to the past six months.
Since then he had grown steadily weaker, so much so that he
had fallen down several times on a short walk two days be-
fore. His mother said that he " seemed tired all the time,"
and that he did not " romp and play " as formerly. He was
irritable and picked his nose a great deal. His mother, sus-
pecting worms, had given him "True's Elixir " several times,
but had never obtained any worms. He had had no serious
illnesses, merely an occasional cold.
Physical Examination. He was fairly developed and nour-
ished. His color was fair. There was no jaundice. His
tongue was moist and moderately coated; the papillae were
unusually distinct. There was a tendency to keep his mouth
open and a small amount of adenoids was felt with the
finger. The tonsils were not enlarged. The heart and lungs
were normal. The liver and spleen were not palpable. The
abdomen was moderately enlarged, but lax. There were no
indications of fluid and no masses were felt. The extremities
were normal. There was no spasm or paralysis; the knee-
jerks were equal and normal. There was no enlargement of
the peripheral lymph nodes. He weighed thirty-seven pounds.
The urine was pale, acid in reaction and contained neither
albumin nor sugar.
Diagnosis. Loss of appetite, progressive failure in weight
and strength and irritability are symptoms common to so
many diseases that they are of no special importance in diag-
DISEASES OF GASTRO-ENTERIC TRACT. 169
nosis. The history of over-feeding with sweets and bananas
and of clay-colored stools, together with the enlargement of
the abdomen, when taken with these other symptoms, are,
however, most characteristic of Chronic Duodenal Indi-
gestion and amply sufficient to justify that diagnosis. The
moist coated tongue with prominent papillae is another point
in favor of this disease. The only other possibility worthy
of serious consideration is chronic diffuse tuberculosis. While
this might account for the general symptoms, chronic duo-
denal indigestion does so equally well. There are no local
manifestations of tuberculosis, and several of the character-
istic symptoms and signs of chronic duodenal indigestion are
present. Tuberculosis can, therefore, be ruled out.
The mother's diagnosis of "worms" would not be worth
mentioning if this diagnosis was not made so often, not only
by mothers and grandmothers, but also by doctors who
ought to know better, when children lose their appetite and
are irritable, especially if they pick their noses. None of
these symptoms are characteristic of the presence of worms.
Picking the nose is merely a manifestation of nervousness;
irritability and anorexia of a host of conditions. In fact, the
author's experience leads him to believe that when children
are thought to have worms they are almost invariably suf-
fering from some other trouble and that when worms are
found the children usually seem perfectly well. The absence
of worms in the stools after the administration of an anthel-
mintic rules them out in this instance.
Prognosis. There is no danger to life except from inter-
current disease, to which the child is predisposed by his
weakened condition. Recovery is likely to be slow at best
and to be interrupted by relapses. How rapidly he improves
depends largely on how carefully the mother follows direc-
tions. It will be two or three months, at any rate, before he
is well. He is very likely to have a recurrence of his trouble
unless he is very carefully fed and watched over for several
years.
Treatment. The treatment is mainly dietetic. Sweets
and fats must be entirely excluded from his diet for a time,
and starches given only in moderation. The following diet ia
a reasonable one for him:
170
CASE HISTORIES IN PEDIATRICS.
Skimmed milk.
Mutton broth.
Chicken broth.
Beef broth.
Beef juice.
White of egg.
Lamb chop.
Mutton chop.
Roast chicken.
Boiled chicken.
Roast lamb.
Roast mutton.
Beef steak.
Roast beef.
Scraped beef.
Boiled fish.
Stale bread.
Toast bread.
Whole wheat bread.
Milk toast.
Zwiebach.
Plain crackers.
Educators.
Barley jelly.
Oatmeal jelly.
Petti John.
Cream of wheat.
Wheat germ.
Farina.
Rice.
Baked potato.
Mashed potato.
Plain macaroni.
Peas.
String beans.
Spinach.
Asparagus.
Summer squash.
Lettuce.
Stewed celery.
Orange juice.
Junket.
Blanc mange.
Tapioca.
After he begins to improve, the amount of the starches may
be increased, then yolk of egg and a little butter added, and
finally whole milk substituted for skimmed milk. It is wise,
however, to be very cautious about increasing the diet.
Sugar, or foods containing sugar, must not be given for many
months; saccharin may be used in its place if necessary.
Hygienic treatment is also of importance. It is especially
necessary to avoid fatigue and chilling. He should take a
rest of one or two hours at noon, get up late and go to bed
early, and be warmly dressed, especially about the abdomen.
Tincture of nux vomica seems to help this condition.
The dose for this boy is three drops, three times a day, before
meals, given in a little water, not in syrups or mixtures.
He may not like it, but he can be made to take it. Phosphate
of soda and cascara sagrada are the best laxatives, if any
are needed.
DISEASES OF GASTRO-ENTERIC TRACT. 171
CASE 41. John F., the third child of healthy parents,
was born at full term after a normal labor, was normal at
birth and weighed eight pounds and twelve ounces. He was
put at once on a weak modified milk, as there was no breast
milk. The milk was gradually strengthened until, when he
was three and one-half weeks old, he was taking a mixture
containing about 5% of fat, 3.50% of sugar and 1% of pro-
teids. He thrived on this until he was five weeks old, when
his temperature suddenly rose to 103. 8° F. and his abdomen
became distended. He then had a large, watery, green, foul
movement and the temperature dropped to 100.80 F. He
was given a half a teaspoonful of castor oil and put on barley
water containing 1.50% of starch. He had several small
movements like the first from the castor oil. Twenty-four
hours later, as he seemed much better, his mother put him
back on the milk mixture. The temperature rose again in a
few hours to 103. 8° F., the abdomen became distended again
and he became stupid and twitchy. He was seen in con-
sultation that evening.
Physical Examination. He was fairly developed and nour-
ished and of fair color. The fontanelle was a little depressed.
There was no rigidity of the neck. The pupils were equal and
reacted to light. The mouth was dry; the tongue slightly
coated. The heart and lungs were normal. The abdomen
was much enlarged, tense and everywhere tympanitic. There
was no localized muscular spasm. The liver and spleen were
not palpable. The extremities were normal. There was
considerable spasm of both arms and legs with a tendency to
twitching; there was no paralysis; the knee-jerks were equal
and lively ; Kernig's sign was absent. There was no enlarge-
ment of the peripheral lymph nodes. There was no evidence
of inflammation about the navel. The rectal temperature
was 103. 50 F.
Diagnosis. There can be no doubt, of course, that the
location of the disturbance is in the intestine. The green,
foul movements, the high temperature and the evidences of
toxic absorption show that there is something more than a
disturbance of the equilibrium of digestion, that fermentative
processes are going on in the bowel and that the condition is
172 CASE HISTORIES IN PEDIATRICS.
bacterial in origin. The small number of movements and
the absence of mucus and blood show that the intestinal wall
is probably not involved. The diagnosis is, therefore, Acute
Intestinal Indigestion of the Fermentative Type.
The stupor, the spasm of the extremities and the tendency
to twitching would be considered by many to be evidences of
a complicating meningitis. Meningitis is, however, a very
unusual complication of the acute diarrheal diseases of in-
fancy, while symptoms of meningeal irritation are not at all
uncommon. Meningitis is, therefore, extremely improbable
in this instance. The depression of the fontanelle alone is,
moreover, almost sufficient to rule it out. The nervous symp-
toms are to be regarded, therefore, merely as evidences of
toxic absorption, or possibly as effects of the high temperature.
It is possible that the excessive amount of fat in the food
may have predisposed the baby to this attack by disturbing
the equilibrium of the digestion.
Prognosis. The condition is a grave one because of the
age of the patient, the distention of the abdomen, the high
temperature and the presence of nervous symptoms. The
facts that the temperature dropped and the general condition
improved rapidly after he was cleaned out and the milk
stopped make it probable that a repetition of the treatment
will have the same result. Put in figures, the chances are
probably about three to one in favor of recovery.
Treatment. The first thing to do is to empty the bowels.
Castor oil is the safest and most effectual drug for this pur-
pose. As the object of the oil is to clean out the bowels, the
dose must be large enough to do it. Two teaspoonfuls is none
too large, even for a baby of five weeks. In the meantime the
colon should be irrigated in order to relieve the distention and
empty the lower bowel. It will probably not be necessary
to repeat it unless the distention recurs, because the chief
seat of the trouble is in the small, not in the large, intestine.
All food must be stopped. Babies bear the withdrawal of
food without much difficulty, but cannot get on without
water. They must be given as much water in the twenty-
four hours as they normally get in their food. This baby
needs at least twenty ounces of water in the twenty-four
DISEASES OF GASTRO-ENTERIC TRACT. 1 73
hours. If he will not take it from the bottle, spoon or dropper,
it must be given with a stomach tube. In urgent cases it
may be given by the bowel by the drop method, or subcu-
taneously in the form of physiological salt solution. It will
probably not be necessary to have recourse to these measures
in this instance. The water not only prevents the loss of
fluid from the tissues, thus keeping up the equilibrium of
the circulation, but favors the elimination of toxic substances
through the kidneys.
The duration of the period of starvation depends on the
temperature, the character of the movements and the general
condition of the patient. It is impossible to state in advance
how long this period will be in any individual case. In all
probability, not more than twenty-four or forty-eight hours
in this instance.
It is wiser, on general principles, to begin feeding with some
other food than milk. This is usually some form of starch
or sugar. This baby is only five weeks old and ought not to
have its power of digesting starch pushed too hard. A 0.75%
solution of starch in the form of barley water, with 7% of
milk sugar, will be suitable to begin with.
When it is time to begin milk the best milk is human milk.
Nothing else compares with it in these conditions. Next to
it is modified cow's milk. In general, it is wiser to begin with
some combination very low in fat. The substitution of whey
for some of the feedings of barley water and sugar will be a
good way to begin in this instance. The addition of a small
amount of skimmed milk to the barley water and sugar mix-
ture is another way. Another is a whey mixture low in fat
and relatively high in proteids, such as fat 1%, sugar 6%,
whey proteids 0.75%, casein 0.25%, without lime water.
There are no drugs which can have any effect on the local
condition. No stimulants are needed at present. The castor
oil and irrrigation will, in all probability, relieve the disten-
tion. The temperature is not high enough or the nervous
manifestations marked enough to require special treatment.
The emptying of the bowels and the water diet will diminish
the toxemia, and the temperature and nervous symptoms,
which are caused by it, will then gradually disappear.
174 CASE HISTORIES IN PEDIATRICS.
CASE 42. Dana B., the second child of healthy parents,
was delivered at full term by low forceps and weighed eight
pounds and nine ounces. He was much asphyxiated as the
result of two turns of the cord about his neck, and did not
breathe well until he was two days old. He was nursed, with
one feeding of a mixture containing 4% of fat, 6% of sugar
and 0.50% of proteids, daily, for two weeks. During this
time he did not vomit, had some colic and was slightly con-
stipated. His weight dropped to seven pounds and two
ounces. He was then weaned and given a mixture of about
the same strength. He did not vomit, but had several green
and curdy movements daily. Two weeks later he was changed
to a mixture containing 3% of fat, 3.25% of sugar and 2.50%
of proteids, which he took for a week. He did not vomit, but
the movements were of the same character. The next week
he had a mixture containing 4% of fat, 1.10% of sugar,
0.80% of proteids and 1.10% of starch. The story was the
same as before. He was finally put on a Mellin's Food mix-
ture containing 3.70% of fat, 4% of sugar and 1.15% of
proteids, which he was taking when seen in consultation,
when two months old. He took ten feedings of three ounces,
giving about 150 calories and 3.2 grams of proteid per kilo.
He did not vomit, but was constipated. The movements,
which were yellow, contained small curds and much mucus.
He was taking olive oil for the constipation. He had lost
seven ounces in the last week on this mixture and weighed
seven pounds and two ounces, about one and one-half pounds
less than at birth. He had had no fever at any time.
Physical Examination. He was small and poorly nourished,
but of fair color. The fontanelle was a little depressed.
The bones of the skull did not overlap. He was bright and
intelligent. His mouth was healthy, his tongue clean. There
was no rosary. The heart and lungs were normal. The
abdomen was a little sunken, but otherwise normal. The
liver was just palpable, the spleen was not palpable. The ex-
tremities were normal. There was no spasm or paralysis;
the knee-jerks were not obtained; Kernig's sign was absent.
There was no enlargement of the peripheral lymph nodes.
A movement which was seen was small, loose, greenish-
DISEASES OF GASTRO-ENTERIC TRACT. 1 75
yellow in color, without odor, and composed mostly of mucus,
with a few small, soft, green and yellow curds.
Diagnosis. The trouble in this instance is undoubtedly
digestive. The absence of vomiting and the persistence of
undigested movements show that the trouble is intestinal and
not gastric. The absence of fever and of signs of fermenta-
tion in the movements rule out infectious diarrhea and in-
testinal indigestion of the fermentative type. The diagnosis
is, therefore, Chronic Intestinal Indigestion of the type
due to disturbance of equilibrium.
The cause is, of course, to be sought in the food. He was
undoubtedly underfed while on the breast. While on the
bottle he was somewhat overfed most of the time. The
fats were no higher than most babies can digest, but were
more than he was able to handle, as is shown by the small,
soft curds in the movements. It was a mistake to give olive
oil for the constipation, because it increased the amount of
fat to be handled when the baby was already unable to take
care of that in the food. It is very probable that it also in-
creased the tendency to constipation. The proteids were at
times too low to cover the proteid need, at other times much
too high. There were, however, at no time any definite
signs of proteid indigestion. The sugars were usually too
low, but were apparently well digested.
Prognosis. Although he has lost considerable weight, his
general condition is fairly good and the movements not very
bad. It ought not to be very difficult, therefore, to fit the
food to his digestive capacity. It will, however, probably
take a good many weeks to get him to digesting properly
and gaining regularly.
Treatment. The treatment consists, of course, in regula-
tion of the diet. The best food is human milk. It is not
a necessity in this instance, however, as he will almost cer-
tainly do well on suitable modifications of cow's milk. If he
does not, a wet nurse can be obtained later. The history
gives two fairly definite indications as to the regulation of the
diet. They are to give him less food and to cut down the fat.
The calories lost by cutting down the fat can be made up, if
necessary, by giving more sugar, which he is able to digest.
176 CASE HISTORIES IN PEDIATRICS.
Whey proteids are more easily digested than casein. It will
be well, therefore, to start him on a whey mixture. Lime
water is contra-indicated because it throws work from the
stomach on to the intestine, which is the part involved. The
following mixture is a suitable one :
Fat, 2.00%
Sugar, 7-°o%
Whey proteids, 0.75%
Casein, 0.25%
He should have ten feedings of two and a half ounces.
This gives about 120 calories and 2.3 grams of proteid per kilo.
The constipation will probably take care of itself after
regulation of the diet. If not, enemata or suppositories will
be better in this instance than drugs by mouth.
DISEASES OF GASTRO-ENTERIC TRACT. 1 77
CASE 43. Arthur S. was the only child of delicate and
neurotic parents. There had been one miscarriage before
and another since his birth. There had been no known
exposure to tuberculosis. He was delivered by forceps at
full term, was normal at birth and weighed eight pounds.
He had whooping-cough when he was two years old and
several attacks of tonsillitis during his third winter. He had
an attack of otitis media when three months old and another
shortly before he was seen. He had always been very nervous.
His resistance was poor and he "went to pieces" on the slight-
est provocation. He could not play with other children with-
out being completely upset, and was much disturbed if a
visitor came to the house. He was active and played hard
when allowed to do so. He was out of doors much of the
time and slept out at night. He slept, however, rather
poorly.
He had no disturbance of the digestion until the previous
August, when he had an attack of diarrhea and vomiting,
lasting two weeks. He had had repeated attacks of diarrhea,
lasting several days, every one to three weeks since then.
His appetite was poor during the attacks and he had con-
siderable gas and pain in the abdomen. There was, however,
no nausea, vomiting or fever. The stools were of good color,
but loose, foul and undigested. He lost weight rapidly during
the attacks and hardly got it back after one attack before
he had another. His mother thought that his attacks were
in some way connected with his food and that some of them
were caused by potato and green vegetables. She was not,
however, very certain of these points, and had not noticed
whether the attacks were connected with overfatigue or
excitement. His diet was a very good one. He was seen
early in January, when four years old.
Physical Examination. He was fairly developed and
nourished and of good color. He looked delicate, however,
and appeared nervous and excitable. His tongue was nearly
clean, his throat normal. The heart and lungs were normal.
The level of the abdomen was that of the thorax. Nothing
abnormal was detected in it. The liver and spleen were not
palpable. The extremities were normal. There was no
I78 CASE HISTORIES IN PEDIATRICS.
spasm or paralysis. The knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
He was about two inches taller than the average child of his
age, but weighed about two pounds less. His weight without
clothes was thirty-seven and one-quarter pounds.
Diagnosis. The diagnosis of Chronic Intestinal Indi-
gestion, with recurrent exacerbations, is very evident. This
diagnosis is, however, not sufficient. It is necessary, in
order to treat the condition satisfactorily, to find out which
of the food elements he can digest and which he can not.
His mother was told, therefore, to feed him as she had been
doing, to keep a careful record of exactly what he ate, and to
bring in his stools and urine for examination. He took 23.3
grams of fat, 106 grams of carbohydrates and 75 grams
of proteid, having a caloric value of 958, which is equal to
56 calories per kilo and amply covers the proteid need.
He had considerable gas and two stools during the twenty-
four hours. The stools were large and had the consistency
and appearance of pea soup. The reaction was highly
acid and the odor acid. They gave a marked macroscopic
reaction for starch with the iodine test. Microscopically
there were many starch granules and iodophilic organisms,
both cocci and bacilli. There was no undigested fat or
muscle fibre. The urine contained no albumin or sugar and
showed no reaction with Millon's reagent. It is evident,
therefore, that the disturbance in this instance is due to the
fermentation of the carbohydrates. The final diagnosis is,
therefore, chronic intestinal indigestion with intolerance of
carbohydrates.
Prognosis. He will undoubtedly eventually recover. It
will, however, take a number of months, and perhaps sev-
eral years, of the most careful treatment to bring this about.
Recovery will certainly be slow and interrupted by many
relapses.
Treatment. The treatment consists in adapting his diet
to his digestive capacity. He is unable to digest carbohy-
drates. They must, therefore, be diminished and the caloric
value of his food kept up by the substitution of fats and
proteids for them. It is impossible to know in advance how
DISEASES OF GASTRO-ENTERIC TRACT. 1 79
much carbohydrates he can take. He is unable to take 106
grams without marked disturbance of the digestion. It will
be well, therefore, to cut the amount of carbohydrates down
to 60 grams. If he is unable to utilize this amount, it will
have to be diminished. If he is able to utilize it, it may be
gradually increased. It is important to give him part of his
food in the form of milk. A quart of milk contains 43 grams
of carbohydrates. This allows only 17 grams in all the rest
of his food. It will be wiser, therefore, in the twenty-four
hours, to give him only one and one-half pints of milk which
contains 32 grams of carbohydrates and allows 28 grams for
the rest of his diet. It is important, in order to satisfy his
appetite, not to give these carbohydrates in too concentrated
a form, because, if they are, he will feel that he is not getting
enough to eat. Two slices of bread, for example, in the
whole day would more than cover his allowance, but would
not in any way satisfy him. If, however, he is given three
tablespoonfuls of cereal containing 16.5 grams, 1 tablespoon-
ful of macaroni containing 5 grams, and one-half of a slice
of bread containing 7.5 grams of carbohydrates, he will get a
much greater variety and a much greater bulk of food, and
still not get but 29 grams of carbohydrates. The caloric
value of one and one-half pints of milk, 3 tablespoonfuls of
cereal, one tablespoonful of macaroni and one-half of a slice
of bread is 644. The average child of his age requires about
1 125 calories. It will probably be possible to satisfy him for
the present with 1000 calories per day. An egg containing
72 calories, an ounce of meat containing 60 calories, and an
ounce of butter containing 225 calories, will just make up the
required amount. If preferred, cream can be substituted for
part of the milk and the butter diminished.
It will be well to cut out green vegetables and potatoes
from his diet in the beginning, because his mother thinks
that they may have been the cause of several of his attacks
in the past. It will probably be possible to give the vege-
tables, if not the potato, a little later. The following list
will be a suitable one for him at present. Saccharin may be
used in place of sugar, if necessary.
i8o
CASE HISTORIES IN PEDIATRICS.
Milk.
Cream.
Mutton broth.
Chicken broth.
Bouillon.
Soft boiled eggs.
Dropped eggs.
Scrambled eggs.
Lamb chop.
Mutton chop.
Beef steak.
Roast lamb.
Roast mutton.
Boiled mutton.
Roast beef.
Roast chicken.
Boiled chicken.
Broiled chicken.
Minced meat.
Boiled fish.
Broiled fish.
White bread.
French bread.
Plain crackers.
Plain educators.
Milk toast.
Cream of wheat.
Wheat germ.
Germea.
Ralston.
Farina.
Rice.
Plain macaroni.
Plain spaghetti.
Butter.
Cream cheese.
Junket.
Baked custard.
Plain blanc mange.
There is no indication for drugs. He must, however, be
carefully guarded against fatigue and excitement.
DISEASES OF GASTRO-ENTERIC TRACT. l8l
CASE 44. Eleanor S., five and one-half years old, was
the only child of healthy parents. There had been no deaths
or miscarriages and no known exposure to tuberculosis. She
was perfectly well until she was one and one-half years old,
since when she had had repeated attacks of indigestion. She
had, however, been better than usual during the year preced-
ing the present attack, which had begun two months before.
She had been having three or four undigested stools daily
and had occasionally vomited. Her diet had been cut down
without much effect on the symptoms. Her appetite was
poor, she had a little fever most of the time, had lost at least
five pounds in weight and much strength and color.
Physical Examination. She was small, thin and pale, but
unusually intelligent. Her tongue was clean and her throat
normal. The heart and lungs were normal. The abdomen
was much enlarged, the circumference of the chest at the
nipples being 47 cm., while the greatest circumference of
the abdomen was 52I cm., and that at the navel, 48 cm. It
was everywhere tympanitic. No masses were felt and there
were no evidences of fluid. The liver and spleen were not
palpable. The kidneys were normal. There was no spasm
or paralysis. The knee-jerks were equal and normal. The
peripheral lymph nodes were not palpable. The rectal tem-
perature was ioo° F. Her weight, with her clothes, was 27
pounds (the average is 39.6 pounds), and her height, without
her shoes, 36! inches (the average is 41.3 inches).
Diagnosis. The diagnosis of Chronic Intestinal Indi-
gestion is self-evident. This diagnosis is, however, not suffi-
cient. It is necessary, in order to treat the condition
satisfactorily, to find out which of the food elements she can
digest and which she cannot. Her mother was told, there-
fore, to feed her as she had been doing, to keep a careful
record of exactly what she ate and to bring in her stools
and urine for examination. She took 30 grams of fat, 100
grams of carbohydrates and 24 grams of proteid in the
twenty-four hours, having a caloric value of 787. She had
three stools which were soft, cream-colored, smooth, except
for the presence of vegetable chaff, foul in odor and alkaline
in reaction. Microscopically they contained a large amount
1 82 CASE HISTORIES IN PEDIATRICS.
of soap and fatty acid splinters, but no starch, muscle fibres
or mucus. The urine contained no albumin or sugar, but
showed a very marked positive reaction with Millon's re-
agent. The soap and fatty acid crystals in the stools show
that she is unable to take care of even 30 grams of fat in
the twenty-four hours, which is far less than the average fat
capacity at this age, while the foul odor of the stools and the
positive reaction with Millon's reagent show that there is
putrefaction of the proteids. The final diagnosis is, there-
fore, chronic intestinal indigestion with marked intolerance
of fat and diminished tolerance of proteids.
Prognosis. She will probably eventually recover. It will,
however, take a number of years of the most careful treat-
ment to bring this about. She will, moreover, almost cer-
tainly always be small.
Treatment. The treatment consists in adapting her diet
to her digestive capacity. The fats must be eliminated as
far as possible and the proteids reduced to approximately
the amount necessary to cover her proteid need. Milk
proteids are the best, because the products of the decomposi-
tion of the proteids of milk are somewhat less toxic than those
of the proteids of meat and eggs. The lactic acid forming
organisms have an inhibitory action on the proteolytic
bacteria. They should be given, therefore, to diminish the
decomposition of the proteids. They are best administered
in the form of buttermilk. A quart of buttermilk contains
35 grams of milk proteids, which is equal to about 3 grams
of proteid per kilo of her weight, an amount amply sufficient
to cover her proteid need. It contains about 5 grams of fat
and provides 360 calories. The average caloric need at her
age is 1200. She is so small, however, that she does not re-
quire as many calories as the average child of her age. Her
caloric need, reckoned at 70 calories per kilo, is only 800.
It will be well, however, on account of her small size and
emaciation, to give her, if possible, 1 000 calories daily. The
additional calories must be given in the form of carbohy-
drates. One ounce of crackers, two slices of bread, a potato
the size of an egg, four tablespoonfuls of cereal, four tea-
spoonfuls of sugar and the juice of an orange will, for example,
DISEASES OF GASTRO-ENTERIC TRACT.
183
provide 620 calories and bring the total number of calories
up to 980. (See Table of Food Values, page 449.) They
will add only 4 grams of fat and but little proteid. It is,
of course, not necessary to give the same carbohydrate
foods every day; in fact, she will tire of her diet much less
quickly, if they are varied from day to day. The following
carbohydrate foods are suitable for her:
White bread.
French bread.
Whole wheat bread.
Plain crackers.
Educators.
Oatmeal.
Cream of wheat.
Wheat germ.
Germea.
Ralston.
Farina.
Rice.
Hominy.
Cracked wheat.
Shredded wheat biscuit.
Baked potato.
Mashed potato.
Boiled potato.
Stewed potato.
Plain macaroni.
Plain spaghetti.
Tapioca.
Sago.
Orange juice.
Grapes.
Sugar.
It will probably be possible, a little later, when the proteid
putrefaction has been overcome by the lactic acid bacilli and
the excess of carbohydrates, to add broths, clear soups, white
of egg and lean meat to her diet. It will also be well, in order
to increase the variety of her food, to substitute skimmed
milk for a part of the buttermilk. Still later, strained green
vegetables and a little fruit may also be added. A reasonable
diet for her will then be as follows :
Buttermilk.
Skimmed milk.
Mutton broth.
Chicken broth.
Bouillon.
White of egg.
Lamb chop.
Mutton chop.
Beef steak.
Roast lamb.
Roast mutton.
Boiled mutton.
Roast beef.
Roast chicken.
Boiled chicken.
Broiled chicken.
White bread.
French bread.
Whole wheat bread.
Plain crackers.
Educators.
Milk toast.
Oatmeal.
Cream of wheat.
Wheat germ.
Germea.
Ralston.
Farina.
Rice.
Hominy.
Cracked wheat.
Shredded wheat bis-
cuit.
Baked potato.
Mashed potato.
Boiled potato.
Stewed potato.
Plain macaroni.
Plain spaghetti.
Strained string beans.
Strained spinach.
Strained peas.
Asparagus.
Stewed celery.
Baked apples.
Stewed prune pulp.
Grapes.
Orange juice.
Junket.
Corn starch pudding.
Tapioca.
Sago.
Plain blanc mange.
I84 CASE HISTORIES IN PEDIATRICS.
There is little to be hoped from drugs in this instance.
There is no indication for hydrochloric acid and pepsin,
because the gastric digestion is but little impaired. Pan-
creatin will be destroyed in the stomach and can, therefore,
do no good. It will be well, however, to give her five drops
of the tincture of nux vomica, in a teaspoonful or more of
water, three times a day, before meals, to stimulate her
appetite. All forms of oil are, of course, contraindicated.
DISEASES OF GASTROENTERIC TRACT. 1 85
CASE 45. Ernest B. was the third child of healthy
parents. He was born at full term, October 1 1 , after a normal
labor, was normal at birth and weighed eleven and one-
quarter pounds. His mother had an abundance of milk and
was better in health than she had ever been. He nursed well
and did not vomit, but cried a great deal and had many loose,
green stools, containing fine curds and a little mucus. The
milk was analyzed October 23 and found to contain 2.75% of
fat, 5.05% of sugar and 3.94% of proteids. The attending
physician got the mother out of bed when the baby was two
weeks old and out of doors when he was four weeks old with
the hope of reducing the proteids in the milk by exercise.
The baby, nevertheless, continued to cry almost constantly
and to have eight or ten movements, of the same character,
daily. He did not vomit, however, and gained steadily in
weight. When seen November 29, at the age of seven weeks,
he weighed thirteen pounds and ten ounces, having gained ten
ounces in the last week. He was getting seven feedings in the
twenty-four hours, the intervals between the nursings being
three hours during the day and four and one-half hours at
night. He had been weighed before and after nursing for
several days and found to get about twenty-eight ounces of
milk during the twenty-four hours. His mother felt un-
usually well in every way and was not worried or nervous.
She did not take care of the baby and was, therefore, not dis-
turbed by the crying. She was taking very little exercise,
however, and was not out of doors more than one or two
hours a day. Another analysis of the milk was made the day
that he was seen and it then contained 2.65% of fat, 5-95% of
sugar and 2.93% of proteids.
Physical Examination. He was well developed and nour-
ished and of good color. The posterior fontanelle was closed.
There was no rosary. The heart, lungs and abdomen were
normal. The lower border of the liver was palpable two cm.
below the costal border in the nipple line. The spleen was not
palpable. The extremities and external genitals were nor-
mal. There was no irritation of the buttocks. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
1 86 CASE HISTORIES IN PEDIATRICS.
The stools were small, very loose, green, slightly acid in
reaction and contained a few small, soft curds and a little
mucus, but were not frothy.
Diagnosis. He has, without question, a disturbance of
the intestinal digestion. This must be connected in some
way with the breast-milk. It cannot be due to an excess of
milk, because twenty-eight ounces of this milk will not give
him more than 90 calories per kilo. It must be due, there-
fore, to something in the composition of the milk. It cannot
be due to the fat, because the percentage of fat is somewhat
low and the stools show no evidences of fat indigestion beyond
a few small curds. It certainly is not caused by the sugar,
because the percentage of sugar in the milk is within the
normal limits, there is no irritation of the buttocks, the
acidity of the stools is slight and they are not frothy. It is
evident, by exclusion, therefore, that it must be due to the
proteids. This conclusion is corroborated by the high per-
centage of the proteids and by the symptoms, which are
those characteristic of an excess of proteids in breast-milk.
The diagnosis is, therefore, Intestinal Indigestion from
an Excess of Proteids in the Breast-Milk.
Prognosis. The percentage of proteids in the milk has
dropped from 3.94 to 2.93 since the mother has been out of
bed, although she has taken but little exercise and has been
out of doors but little. She is well and is not nervous or
worried. The excessive amount of proteids is undoubtedly
due, therefore, to lack of exercise. It is possible for her to
get it. If she does, the percentage of proteids will rapidly
fall to normal and the symptoms of indigestion cease.
Treatment. Exercise diminishes the amount of proteids
in the milk, if they are excessive. If the exercise is carried
to the point of fatigue, however, they increase again. The
treatment in this instance consists, therefore, entirely in
regulation of the mother's exercise. She must exercise out
of doors until she is comfortably tired, but not fatigued.
Walking is the best form of exercise for her at this time of
year. There is no reason why she should not eat a general
diet and lead an ordinary life in every way.
DISEASES OF GASTRO-ENTERIC TRACT. 1 87
CASE 46. Sally B., three and one-half months old, was
born at full term after a normal labor and weighed six and
one-fourth pounds. She was breast-fed for ten days, when
the milk gave out and she was put on modified milk. She
got on very well indeed until she was two months old, when
she weighed nine pounds. She then had a severe attack of
influenza and was very ill for about two weeks. During her
illness she lost some weight and was left much depressed
generally. She had finally begun to digest well again and had
a little more than regained her weight. She was taking eight
feedings of three ounces of a mixture, prepared at a laboratory,
supposed to contain 2.50% of fat, 5.50% of sugar, 0.50% of
whey proteids and 0.25% of casein, with lime water 10% of
the total quantity. It was winter and the mixture was
pasteurized at 1550 F.
Without any known cause she began to vomit and to have
much gas and discomfort. The vomitus smelled sour. She
also began to have watery, light-green movements of a sour
odor, which did not contain curds or mucus, and which
irritated the buttocks. She had no fever.
Physical Examination. She was fairly developed and nour-
ished. There was moderate pallor. The anterior fontanelle
was 3 cm. in diameter and slightly depressed. The tongue
was slightly reddened. There was no rosary. The heart and
lungs were normal. The abdomen was slightly distended, but
otherwise normal. The liver was palpable 2 cm. below the
costal border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no spasm or pa-
ralysis; the knee-jerks were equal and normal; there was no
Kernig's sign. The rectal temperature was 980 F. The
stools were as described above.
Diagnosis. The negative physical examination and normal
temperature rule out everything outside of the digestive
tract. The absence of fever, the time of year and the pasteuri-
zation of the food make a bacterial infection very improbable.
The cause of the trouble must, therefore, be sought in the
food. The combination of sour vomiting, flatulence and
watery, green, sour, irritating stools points strongly to
trouble in the digestion of the sugar. This hardly seems rea-
1 88 CASE HISTORIES IN PEDIATRICS.
sonable, however, in a baby that had for months been taking
from five per cent to seven per cent of milk sugar without
trouble. Analysis of the food by a competent chemist showed,
however, that it contained nearly ten per cent of sugar.
The fat and proteid contents were reasonably accurate.
The diagnosis, therefore, is Acute Gastric and Intestinal
Indigestion from an excessive amount of sugar.
Prognosis. The prognosis is good, as the cause of the
trouble can easily be remedied.
Treatment. The treatment is, of course, the correction of
the mistake in the preparation of the food. As this mixture
gives but 86 calories and 1.3 grams of proteid per kilo, it
will also be well to increase the percentage of the proteids a
little.
DISEASES OF GASTRO-ENTERIC TRACT. 1 89
CASE 47. Mary S., six months old, was the fourth child
of healthy parents. There had been no known exposure to
tuberculosis. She was born at full term after a normal labor,
was normal at birth and weighed five and one-half pounds.
She was started at first on a weak mixture, copied from
Dr. Holt's little book, " The Care and Feeding of Children,"
and did very well for a time. The gain in weight was, how-
ever, very slow, and she did not reach eight pounds until she
was five months old. She had lost half a pound since then.
Because of the slow gain in weight, the physician in charge
rapidly strengthened the formulae, but apparently never
inquired into the details of the preparation of the food. The
parents, being even more anxious than the physician to have
the baby gain in weight, used gravity cream from Jersey
milk instead of the 10% top milk specified in the book, and
finally bought thick, pasteurized cream from a dealer. Her
appetite became very poor. When she came to me, when
six months old, her mother was attempting to give her eight
feedings of four ounces at two and one-half hour intervals.
She seldom took more than twenty ounces in the twenty-four
hours, however, and this only after much urging, two and a
half hours often being needed to get in two and one-half
ounces. She seldom seemed hungry, but, if she did, was
always satisfied with an ounce. She never vomited unless
the food was forced too much. She occasionally had a little
colic but always had a good deal of rumbling in the abdomen
and passed much gas from the bowels. The bowels were
usually constipated. The movements were small, crumbly,
very light yellow, apparently well digested and without much
odor. She was taking the following mixture:
Pasteurized rich cream, 5^ ounces.
Whole milk (Jersey), 2\ ounces.
Lime water, i^ ounces.
Water, i8i ounces.
Milk sugar, 1 dessertspoonful.
Physical Examination. She was small and thin and moder-
ately pale. She was feeble but intelligent. The veins on the
scalp were prominent. The anterior fontanelle was 3 cm. in
diameter and level. The posterior fontanelle was still open.
190 CASE HISTORIES IN PEDIATRICS.
There was no cranio tabes. The throat was normal; the
tongue somewhat reddened. There were no teeth. There
was a marked rosary. The heart and lungs were normal.
The abdomen was large, but lax. There was no dullness and
no tumor was made out. The liver was palpable 3 cm.
below the costal border in the nipple line. The spleen was
not palpable. The extremities were normal. There was no
spasm or paralysis; the knee-jerks were equal and normal;
there was no Kernig's sign. There was no enlargement of the
peripheral lymph nodes. Her weight was seven and one-half
pounds.
Diagnosis. The physical examination justifies nothing more
than the diagnosis of malnutrition with a slight and unim-
portant amount of rickets. The cause of the malnutrition
must be sought in the history. The satiation after taking a
small amount of food, taken in connection with the lack of
marked symptoms of indigestion and the slow gain, suggest
at once too rich a food. The small size, crumbly character
and light-yellow color of the stools are very characteristic
and show that they contain fat in the form of soap. The
story of the substitution of gravity cream from Jersey cows
for 10% top milk from ordinary cows, and later of rich bottled
cream for the gravity cream, corroborates, of course, the
assumption that the food was too rich in fat. It shows also
how necessary it is for the physician to know exactly how the
food which he orders is prepared.
The mixture which the baby was taking, if made of 10%
cream and whole milk from Holstein or Ayreshire cows, as
it was supposed to be, would contain about 2.40% of fat,
3.25% of sugar and 0.90% of proteids, a weak food for the
age. If made of gravity cream from average milk it would
have contained about 3.40% of fat. The modified milk in
the bottle, however, looked like cream, and when examined
was found to contain 8.8% of fat.
The diagnosis is, therefore, Indigestion (chiefly intestinal),
malnutrition and rickets from an Excess of Fat in the
Food. The author wishes to call particular attention to the
fact that in this instance, as in almost all others of disturbed
nutrition or digestion from an excess of fat in the food, the
DISEASES OF GASTRO -ENTERIC TRACT. I9I
excess was a gross one, the amount being far beyond the
normal top limit of 4%.
Prognosis. The prognosis is good on a reasonable diet.
The gain in weight will probably be slow, and it will be a
long time before the baby will be able to take as high a per-
centage of fat as the average baby, as it is always difficult to
develop the ability to digest fat again when it has once been
seriously impaired.
Treatment. The treatment is entirely by regulation of the
diet. Human milk would be the best food and would almost
certainly agree, in spite of its comparatively high fat content.
Next to this is some modification of cow's milk. The milk
should come from Ayreshire or Holstein cows. The per-
centage of fat should be low because of the impaired power of
digestion of fat. The caloric value can be made up by higher
percentages of sugar and proteids. There is no indication
for the addition of an alkali. Three ounces is as much as she
ought to be expected to take at a feeding. Eight feedings,
at two and a half hour intervals, will be sufficient. The
following formula is a suitable one:
Fat, 2.50%
Sugar, 5-00%
Proteids, 1-25%
This gives 100 calories and 2.6 grams of proteid per kilo.
The baby should not be fed at other than the regular inter-
vals and, if she does not take the food willingly, the attempt
to make her take it should not be prolonged over half an
hour. If the constipation persists it may be treated by
enemata of suds or sweet oil, or by suppositories of soap,
glycerin or gluten, but not by sweet oil by the mouth.
I92" CASE HISTORIES IN PEDIATRICS.
CASE 48. John B., the fifth child of healthy parents, was
born at full term after a normal labor. He was normal at
birth and weighed eight and three-fourths pounds. He was
not nursed, but was started at once on a modified milk con-
taining 2.50% of fat, 5.50% of sugar, 0.80% of proteids, with
lime water 5% of the total quantity. He did not thrive on
this and was soon put on a mixture containing 3.40% of fat,
6.50% of sugar, 1.50% of proteids and 0.75% of starch. The
lime water was still 5% of the total quantity. He took this
well, but was not satisfied. He did not vomit, but was
constipated. The movements contained many large, tough
curds, but were of good color and did not contain mucus.
When four weeks old he was changed to a pancreatized mix-
ture containing 3% of fat, 3.50% of sugar and 2% of proteids.
When seen, at five months, he was still taking this mixture,
getting six or seven feedings of four ounces at three-hour
intervals. Seven feedings of four ounces of this mixture
gives 106 calories and 4.2 grams of proteid per kilo. He was
also taking two teaspoonfuls of olive oil daily. He did not
vomit, but had considerable gas. The bowels did not move
without laxatives. The movements were light green or yellow
in color and always contained large, hard curds, but no
mucus. He did not gain in weight.
Physical Examination. He was bright and happy. He
was small and thin and his color was fair. The fontanelle
was 3 cm. in diameter and level. The bones of the skull did
not overlap. The tongue was slightly reddened; the mouth
and throat were otherwise normal. There was no rosary.
The heart and lungs were normal. The level of the abdomen
was slightly below that of the thorax; nothing abnormal was
detected in it. The liver was palpable 1 cm. below the costal
border in the nipple line. The spleen was not palpable. The
extremities were normal. There was no spasm or paralysis;
the knee-jerks were equal and normal ; there was no Kernig's
sign. There was no enlargement of the peripheral lymph
nodes. His weight was eight pounds and thirteen ounces.
Diagnosis. The physical examination justifies nothing
more than a diagnosis of malnutrition. The slight reddening
of the tongue is probably merely the result of local irritation
DISEASES OF GASTRO-ENTERIC TRACT. 193
from the nipple, but may be a manifestation of gastric indi-
gestion. The large, hard curds in the movements show that
the casein is not properly digested. The amount of proteid
in the food, 4.2 grams of proteid per kilo, is, moreover,
excessive. There is nothing about the movements to show-
any disturbance of the digestion of either fat or sugar. The
absence of vomiting, combined with the constipation and the
flatulence, point to intestinal indigestion rather than to
gastric. The failure to gain and the constipation suggest
an insufficient supply of food. One hundred and six calories
per kilo ought, theoretically, to be enough, but probably is
not, as the caloric needs presumably depend somewhat on the
age as well as on the weight. That is, a well baby of five
months needs more calories per kilo than a fat baby of the
same weight of one month. The diagnosis of malnutrition
from an insufficient supply of food, and mild Intestinal
Indigestion from an Excess of Proteids in the Food is,
therefore, justified.
Prognosis. The cheerfulness and the absence of marked
signs of wasting show that the disturbance of nutrition is
not a severe one. The disturbance of digestion is only in that
of the proteids. These can be easily considerably lowered
and still cover the proteid needs, while the fat and sugar can
be increased to cover the caloric needs. The prognosis is,
therefore, good.
Treatment. The treatment is, of course, entirely by regu-
lation of the diet and not by the administration of drugs.
Human milk, as in all the chronic disturbances of digestion
or of malnutrition in infancy, is the best food. In this
instance, however, it does not seem a necessity.
The caloric value of the food can best be increased by rais-
ing the percentage of sugar to 7, as the sugar is at present
altogether too low. There is also no objection to giving five
ounces at a feeding. After this is done it will not be necessary
to increase the percentage of the fat, which is now a reason-
able one. The percentage of proteids should be lowered
somewhat, as the excessive amount is throwing unnecessary
work on the eliminative organs, and they are not needed to
keep up the caloric value of the food, which can be supplied
194 CASE HISTORIES IN PEDIATRICS.
by the fat and sugar, which are digested. A considerable
proportion of the proteids should be given in the form of
whey proteids, as the large curds show that it is the casein
which is not digested. An alkali is not indicated, as there is
no vomiting. The following formula meets these indications :
Fat,
3-00%
Sugar,
7.00%
Whey proteids,
o.75%
Casein,
0.25%
Seven feedings of five ounces of this mixture give 159
calories and 2.6 grams of proteid per kilo.
Another method of rendering the casein more digestible is
by the addition of starch to the food, which by its mechanical
action prevents the formation of large curds; 0.75% of starch
has as much effect as larger amounts. There is no objection
to giving this amount of starch because, while it is true that
the amylolytic function is only partially developed at this
age, it is practically always sufficiently developed to take
care of this or even somewhat larger amounts of starch
without difficulty. This action of starch is, however, rather
unreliable. Peptonization, or, as it should be called, pancreat-
ization, of the food, if properly done, also usually prevents
the formation of large curds. If not properly done, as was
probably the case in this instance, it is ineffective.
The reddened tongue requires no treatment. Change of
nipples and regulation of the diet will correct it.
The bowels may be moved, if necessary, by enemata of
suds or sweet oil, suppositories of soap, gluten or glycerin, or
by milk of magnesia, in doses of from one-half to one tea-
spoonful, once or twice daily.
DISEASES OF GASTRO-ENTERIC TRACT. 195
CASE 49. Catherine L., six and one-half years old, was
the first child of healthy parents. She was born about a month
premature and for the first year had a feeble digestion and
was very difficult to feed. During the first two years of her
life she had repeated attacks of vomiting, some of which
resembled the recurrent vomiting seen in older children.
After this, however, these attacks ceased, although her diet
always had to be very carefully regulated. There was always
a tendency to constipation and to duodenal indigestion.
She had never had any severe attacks of duodenal indigestion,
however, as they could always be aborted by care in the diet
and early treatment. During the last year her digestion had
been much stronger than ever before. Early in June she had
an attack of what was supposed to be duodenal indigestion.
Recovery from this was rapid, however, and she had been
perfectly well until August 21. That afternoon she went to a
children's party and was a good deal excited. The food at the
party was very simple and she did not over-eat. She began to
vomit during the night. The vomitus contained a great deal
of bile. The morning of the 22d her temperature was about
ioo° F. She continued to vomit bile during the day and
night of the 22d, and also a little in the morning of the 23d.
The vomitus continued to contain much bile. The tempera-
ture during the 22d and the morning of the 23d ranged
between ioo° F. and 1010 F. Examination of the abdomen
during the 22d showed nothing whatever abnormal. In the
early morning of the 23d there was a little tenderness in the
right iliac fossa, with a suggestion of spasm. There was and
had been no pain in the abdomen. The bowels had been
moved freely by enemata during the 22d. About noon of
the 23d she had a chill and the temperature rose to 1040 F.,
but soon began to drop again. At that time there was no
pain in the abdomen, but muscular spasm and tenderness in
the right iliac fossa were rather more marked. The blood
count at that time showed 26,200 leucocytes.
She was then given a dose of castor oil, which during the
afternoon produced a movement containing more or less
mucus. She was seen in consultation at 5 P.M. on the 23d.
Physical Examination. Her face looked a little pinched,
196 CASE HISTORIES IN PEDIATRICS.
but she was bright and happy. She was not vomiting and
had no pain whatever. The pupils were equal and reacted to
light and accommodation. There was no rigidity of the neck.
The ears were normal. The heart and lungs showed nothing
abnormal. The level of the abdomen was considerably below
that of the thorax. When very deep pressure was made in
the right iliac fossa she said that it hurt her a little, but gave
no evidence of pain unless questioned. In fact, she smiled
and talked while the abdomen was being examined. There
was also very slight muscular spasm in the right iliac fossa.
No tumor could be felt and there was no dullness. The ab-
domen was otherwise negative. The liver and spleen were
riot palpable or enlarged to percussion. The extremities
showed nothing abnormal. There was no Kernig's sign.
The knee-jerks were equal and lively. The temperature in
the mouth was 1010 F., and the pulse 120.
Diagnosis. The diagnosis in this case lies between tubercu-
lar meningitis, acute duodenal indigestion and appendicitis.
Tubercular meningitis should be thought of in this instance
as in every illness in a child beginning with vomiting. It can
be ruled out at once, however, on the absence of all signs of
meningeal irritation and the presence of signs of trouble in
the abdomen. The white count is also against tubercular
meningitis, but does not rule it out, as there may be a leuco-
cytosis in tubercular meningitis.
The points in favor of acute duodenal indigestion are the
previous history of attacks of duodenal indigestion and of
feeble digestion in the past, the typical onset of the attack with
vomiting of bile, the low temperature and the slightness of
the physical signs of appendicitis. The points in favor of
appendicitis are the persistence of the symptoms after proper
treatment for duodenal indigestion, the pinched face, the
chill, the leucocytosis and the physical signs, namely, localized
muscular spasm in the right lower abdomen and the slight
tenderness in this region on deep pressure. The persistence
of the symptoms in spite of treatment is merely suggestive
of appendicitis and not inconsistent with duodenal indigestion.
The chill is very suggestive of appendicitis, but chills do
sometimes occur in duodenal indigestion. A leucocytosis as
DISEASES OF GASTRO-ENTERIC TRACT. 197
high as 26,200 practically never occurs in duodenal indigestion
at this age, and in connection with the chill and the physical
signs is extremely important in the diagnosis. The localized
muscular spasm is almost pathognomonic of appendicitis
when taken in connection with the other symptoms and signs.
The deep tenderness is corroborative evidence of that fur-
nished by the muscular spasm. It might be thought that the
physical signs were too indefinite to be of much importance.
This is not so, however, as indefiniteness of the physical signs
is characteristic of appendicitis in childhood. Finally, the
previous attacks which were called duodenal indigestion
may equally well have been recurrent attacks of appendicitis.
The diagnosis of Appendicitis, therefore, seems positive.
The condition of the appendix is always problematical.
In this instance it is justifiable to conclude from the good
general condition, the high white count and the mildness of
the physical signs that perforation has certainly not occurred
and that in all probability there is but little extension of the
inflammation outside of the appendix. The appendix, how-
ever, may very possibly be ulcerated and ready to perforate.
Prognosis and Treatment. The prognosis is always more
uncertain in childhood than in later life because of the
greater difficulty in determining the exact condition of the
appendix before operation. There is no question but that an
immediate operation should be done in this instance. She
is in good condition to bear an operation and, since it is im-
possible to find out the exact condition of the appendix, it
is far wiser to operate at once than to run the risk of extension
of the inflammation or perforation. The prognosis with
immediate operation is very good because the appendix has
almost certainly not perforated and there is probably but
little inflammation about it.
I98 CASE HISTORIES IN PEDIATRICS.
CASE 50. Ethel H., four years old, was the extremely
nervous child of nervous parents. She had always been well
except for measles and chicken-pox. She vomited a little the
morning of August 6, but seemed well in every way the next
day. The following day, which was extremely hot, she went
to Revere Beach and ate a considerable amount of ice cream.
She slept fairly well that night, but on the morning of the
9th vomited once and began to complain of pain about the
navel. A physician, who was called, found the temperature
1020 F. The respiration was rapid, but the lungs were normal.
He gave two teaspoonfuls of castor oil and stopped all food.
She had three or four loose, foul movements, which contained
a little mucus, but no blood, as the result of the castor oil. The
abdominal pain continued and was very severe. The tempera-
ture the morning of the 10th was 103. 50 F. The bowels
moved three times during that day, the movements being of
the same character. The abdominal pain continued. The
evening temperature was 1010 F. The pulse ranged between
145 and 160, and the respiration between 40 and 80. There
was no cough and the lungs remained normal. She vomited
several times that night and, on account of the severe pain
in the abdomen, slept but little. The temperature by rectum
the morning of the nth was 99. 6° F., the pulse 140. She
took no food, but drank considerable water. She vomited
several times that morning. She had had a little brandy,
some bismuth and chalk mixture and two doses of Castoria.
She was very restless and complained constantly of pain in
the abdomen. The abdomen was distended and tender from
the first, the physician thought less so that morning. The
physician had felt that the pain was 'exaggerated because
of the nervous temperament of the child. She was seen in
consultation at noon, August n.
Physical Examination. She was well-developed and fairly
nourished. There was moderate pallor. She was very rest-
less, tossing from side to side and constantly crying out from
pain in the abdomen. She lay on her back with the legs
flexed on the abdomen; extending them caused pain. Her
face looked pinched. The tongue was dry, but not coated.
The heart and lungs were normal. The abdomen was only
DISEASES OF GASTRO-ENTERIC TRACT. 199
moderately enlarged, but very tense. No localized spasm
could be made out. She complained whenever the abdomen
was touched, but no more so on deep than on light pressure.
There was no localized tenderness. There were no signs of
fluid in the abdomen. The liver and spleen were not palpable.
Rectal examination showed nothing abnormal, but caused
much pain. The extremities were normal. There was no
spasm or paralysis. The knee-jerks and Kernig's sign could
not be obtained because of the child's resistance. The rectal
temperature was ioi°F.; the pulse, 156. A movement,
passed during the examination, consisted of a few small
masses of brownish mucus.
Diagnosis. Pneumonia is suggested by the sudden onset
and the comparatively greater rise in the rate of the respira-
tion over that of the pulse. The location of the pain in the
abdomen is not against pneumonia, because the pain in
pneumonia in childhood is often localized in the abdomen.
The abdomen is also often tense in the early stages of pneu-
monia in childhood. The drop in the temperature without a
corresponding diminution in the rate of the respiration, the
absence of cough, grunting respiration and movement of the
alae nasi, the absence of physical signs in the lungs and
the pinched face are together sufficient to exclude pneumonia.
The free movements of the bowels are sufficient to rule out
intestinal obstruction.
The diagnosis lies, therefore, between intestinal toxemia
and appendicitis. The history of eating ice cream on a hot
day is suggestive of intestinal toxemia, but is not inconsistent
with appendicitis. The continuance of the symptoms in
spite of catharsis and starvation is against toxemia, but does
not exclude it. The character of the stools is much against
toxemia. The vomiting is consistent with either condition
and hence is of no importance in the differential diagnosis.
Distention of the abdomen is, however, unusual in toxemia,
and tenderness and pain extremely rare. These two points
are sufficient in themselves to turn the scale in favor of
appendicitis.
The general abdominal distention accounts for the lack of
localized spasm and tenderness and suggests a beginning or
200 CASE HISTORIES IN PEDIATRICS.
developing general peritonitis. The drop in the temperature
with no improvement in the other symptoms is strong evi-
dence that perforation has occurred and peritonitis begun.
The diagnosis is, therefore, Appendicitis with probable
perforation and beginning peritonitis.
An examination of the blood was not made in this instance
and would not have helped, because a high white count is
consistent with either condition. Moreover, a low white
count is consistent with either depression after perforation
or intense toxemia.
Prognosis and Treatment. The prognosis in this instance
is practically hopeless. The only chance lies in immediate
operation.
DISEASES OF GASTRO-ENTERIC TRACT. 201
CASE 51. Nathaniel C, three years old, had always been
very well and strong. There had been no indiscretion in
diet. The milk supply was supposedly above reproach; his
surroundings were ideal. He complained of indefinite pains
in the legs and abdomen during the day of November 19, but
was up and dressed. His nurse gave him some castor oil in
the morning. When seen by his physician at 3 p.m. the physi-
cal examination was entirely negative; the temperature,
1 00. 50 F. He began to have loose movements during the
night, which were not carefully observed. The morning of
the 20th the movements were very foul and began to contain
slight streaks of blood. He did not seem really sick. The
rectal temperature was 990 F. He had six movements con-
taining blood and mucus during the day of the 20th. Part
of them were foul, the others were not. He was given bis-
muth during the day and his bowels were irrigated in the
evening. He had six more movements of the same character
during the night. He had eight similar movements during the
day, which were preceded and followed by pain. He had been
nauseated for the first time during the afternoon, but had not
vomited. He had had nothing but water during the day, but
had taken a mixture of bismuth and salol with ten drops of
paregoric every two hours. He was seen in consultation at
7 p.m., November 21.
Physical Examination. He was well developed and nour-
ished and of good color. He was perfectly intelligent. The
tongue was moist and but slightly coated. The heart and
lungs were normal. The abdomen was sunken and negative,
except that he complained of slight pain on deep pressure in
the left lower quadrant. Nothing else abnormal was made
out. The liver and spleen were not palpable. The extremi-
ties were normal. There was no spasm or paralysis ; the knee-
jerks were equal and normal; Kernig's sign and the neck
sign were absent. There was no enlargement of the peripheral
lymph nodes. Rectal examination showed nothing abnormal.
The rectal temperature was ioo°F.; the pulse, 100.
The movements were small and composed almost entirely
of green mucus and blood.
Diagnosis. The continued moderate temperature and the
202 CASE HISTORIES IN PEDIATRICS.
small movements of mucus and blood associated with pain
are so charactertisic of Infectious Diarrhea of the dysen-
teric type that no differential diagnosis from the other forms
of diarrhea is necessary. The only other possibility, intus-
susception, can be ruled out on the slow onset, the absence of
vomiting and the negative abdominal and rectal examinations.
Prognosis. Infectious diarrhea of this type is always a
serious disease. The patient is not out of danger until he is
well. It is impossible to say so early in the disease as this
what course it may take. The relatively low temperature, the
comparatively small number of movements, the absence of
vomiting, the nearly clean tongue and the good general con-
dition make the prognosis in this instance comparatively
good. The chances at present seem to be about three out of
five in favor of recovery.
Treatment. It is doubtful if he has been thoroughly cleaned
out. A tablespoonful of castor oil is, therefore, indicated.
It will probably be wiser to continue the starvation for twenty-
four hours longer. He must, however, have a sufficient supply
of water. This is, for a boy of his age, about a quart in twenty-
four hours. If he will not take it by mouth, it may be given
high in the bowel by the drop method. His condition at
present is hardly serious enough to warrant the use of salt
solution subcutaneously. It will probably be wise to begin
nourishment after twenty-four hours. Milk in any form is
contra-indicated. Starches, such as barley, arrowroot or
rice, in the form of waters or jellies, either with or without
milk sugar or malt sugar to increase their nutritive value, will
be best borne. If he will not take starches in this form there
is no objection to giving them in the form of crackers, zwie-
bach or toast. Weak mutton or chicken broth may be given,
not as foods (because they are practically without nutritive
value), but to induce him to take the starchy foods and as a
means of introducing water. Beef juice is contra-indicated
because it is so prone to decomposition by the intestinal
bacteria. Albumen water is likely to produce urticaria and
has but little nutritive value, the white of an egg containing
but twelve calories. A few ounces of albumin water, made as
it usually is with the white of one egg to eight ounces of water,
DISEASES OF GASTRO-ENTERIC TRACT. 203
has, therefore, practically no nutritive value. It is, like beef
juice, prone to decomposition by the intestinal bacteria. It
is, therefore, contra-indicated.
Irrigation of the bowels once or twice in the twenty-four
hours with physiological salt solution, or a i% solution of
boracic acid, is indicated to cleanse the colon. It has no
direct healing action. The irrigation should be given with a
soft rubber catheter, No. 25 French, passed as high as possible
into the bowel, with the patient lying on the back with the
hips elevated. The fluid is then allowed to run in from a bag
hung not more than two feet above the level of the patient.
It should be allowed to run in until the abdomen is slightly
distended, then allowed to run out, and so on, until the wash
water returns clean. The object of the irrigation is to cleanse
the colon. Enough liquid should be used to do this, no matter
whether it is much or little. Irrigation should never be done
more than twice in the twenty-four hours. If it depresses or
disturbs the patient much, it should be omitted, as under
these conditions it does more harm than good.
Bismuth, salol and other preparations of like nature have,
in the author's opinion, little or no effect on infectious
diarrhea. It disturbs the patient to take them and interferes
with the administration of food and water. It will be wiser,
therefore, not to give them in this instance. Paregoric and
other preparations of opium are, on general principles, contra-
indicated in all forms of diarrhea, because their action is to
diminish the number of movements by depressing peristalsis
and not by relieving the cause of the increased peristalsis.
The increased peristalsis is nature's effort to get rid of the
poisonous intestinal contents. Nature's effort should, there-
fore, not be interfered with. In infectious diarrhea of the
dysenteric type, however, when there is a very large number
of small movements accompanied by pain and tenesmus
which prevent the patient from getting proper rest, it is
allowable to give opium in some form to diminish the excessive
peristalsis and to quiet the patient. There is no danger, if
proper care is used, of doing harm by retaining the intestinal
contents too long. Paregoric, in doses of ten or fifteen drops,
may be given in this instance, therefore, if necessary.
204 CASE HISTORIES IN PEDIATRICS.
CASE 52. Pearl P., one year old, had always been well.
She was fed on raw, unmodified cow's milk. She had had some
slight disturbance of the bowels about the middle of July,
but had almost entirely recovered. She suddenly began to
vomit about noon, July 28. The vomitus consisted at first
of milk, but soon became watery; it did not contain bile.
Diarrhea came on in a few hours. The movements were at
first fecal in character, but soon became watery and colorless.
She vomited and had a movement every few minutes. Thirst
became marked, but everything taken was vomited. Castor
oil and calomel were also vomited. Her temperature that
night was 1040 F. The next morning she was much collapsed.
She was seen in consultation at 9 a.m., twenty-one hours after
the onset.
Physical Examination. She had evidently lost much weight.
Her skin was dry and her extremities cold and blue. The
fontanelle was much depressed. Her eyes were wide open and
staring, but she took very little notice. The pupils were
equal and reacted to light. Her tongue was dry. She held
her head rigidly backward. The heart and lungs were normal.
The abdomen was much sunken but not rigid. Neither liver
nor spleen were palpable. She tossed her arms about con-
stantly. Her legs were somewhat rigid ; the knee-jerks were
equal and exaggerated ; Kernig's sign could not be determined
because of the rigidity. The rectal temperature was 1040 F.,
the pulse 160, and the respiration 60. The vomitus and move-
ments looked like turbid water.
Diagnosis. The history and physical examination are so
typical of Cholera Infantum that there is no need of con-
sidering any other disease. The nervous symptoms are due
to a combination of toxemia and loss of fluid.
Prognosis. The prognosis is very grave. There is probably
not more than one chance in twenty of recovery. The
disease is, however, to a certain extent, self-limited. If she
lives through. the next thirty-six hours the chances of recovery
will be very much better.
Treatment. The main indications for treatment in this
condition are (1) to empty the stomach and bowels of their
toxic contents; (2) to supply fluid to the tissues which are
DISEASES OF GASTRO-ENTERIC TRACT. 205
being so seriously drained; (3) to restore the surface circula-
tion; (4) to reduce the temperature; (5) to keep the patient
alive until the disease has run its course.
Nature is already doing her best to empty the stomach and
bowels. Nothing can be done to help her. Cathartics will be
vomited and stomach washing and irrigation of the bowels
will only increase the collapse. There is no objection, how-
ever, to giving the baby cool water to drink, even if it is
vomited, as it will make her more comfortable and help to
wash out the stomach.
The only way in which fluid can be supplied to the tissues
is by the administration of physiological salt solution subcu-
taneously. She should be given from four to eight ounces at
a time, repeated every three or four hours if absorbed.
The surface circulation is best restored by the application
of heat externally in the form of heaters or hot packs. She
should be at once surrounded with heaters and, if this is not
successful, be put in a pack at ioo° F., or a little higher.
Restoration of the surface circulation will usually reduce the
internal temperature. If it does not, irrigation of the colon
with water at 900 F. will usually do so. Her temperature is
hardly high enough to require this at present.
It is useless to give stimulants or other drugs by the mouth,
as they will not be retained. All drugs must, therefore, be
given subcutaneously. The best stimulant is caffein. This
may be given subcutaneously in the form of caffeine-sodium
benzoate. The dose for this baby is one quarter of a grain
every three or four hours. Strychnia, in doses of 1-500 of a
grain, may also be given subcutaneously, if necessary. Alcohol
is contra-indicated. Adrenalin is indicated if the cardiac
failure increases. Unfortunately it has very little action when
given subcutaneously, and intravenous injection is very
difficult in a baby of this age. If the restlessness increases,
morphia, in doses of 1-100 of a grain, given subcutaneously,
will aid by quieting her and saving her strength.
Food of any description is contra-indicated until the vomit-
ing and diarrhea have stopped. The first food given should
be a 1% solution of starch in the form of barley water, with
5% of milk sugar added.
206 CASE HISTORIES IN PEDIATRICS.
CASE 53. Louise C, six years old, had complained for
about a week of itching and burning about the anus, after go-
ing to bed. Her mother examined her the night before she
was seen and found what she thought were pin-worms about
the anus. She had no other symptoms whatever, did not
pick her nose, was not nervous or irritable, had a good appe-
tite and digested her food well.
Physical Examination. She was well developed and nour-
ished and of good color. Her tongue was clean. The heart,
lungs, liver, spleen, abdomen and extremities were normal.
There was no irritation of the vulva or about the anus and
no enlargement of the inguinal lymph nodes. The things
which the mother thought were worms were examined and
found to be really pin-worms.
Diagnosis. The symptoms in this instance, itching and
burning about the anus after going to bed, are those most
characteristic of Pin-worms and should always suggest their
presence. The next most common symptom is irritation of
the vulva and vagina. The symptoms usually thought to
be pathognomonic of pin-worms — picking the nose, nervous-
ness, irritability and disturbance of the digestion — are usu-
ally conspicuous by their absence and, if present, are almost
invariably due to other causes. The diagnosis of pin-worms
should never be made, however, unless, as in this instance,
the worms are seen by the physician, because shreds of vege-
table or fruit fibre are often mistaken for them by mothers
and nurses.
Prognosis. It will require several weeks, and probably a
number of months, of continuous treatment to completely
eradicate the worms. If the treatment is kept up long enough
however, it can certainly be done.
Treatment. The life history of the parasite shows the lines
along which treatment must be directed. The eggs enter
through the mouth, and are hatched in the small intestine.
The worms reach their full development in the large intestine
and lay their eggs in the rectum. The children get the eggs
on their fingers, put their fingers in their mouths, and the
circle is completed. Every precaution must be taken, there-
fore, to insure strict cleanliness and to prevent reinfection.
DISEASES OF GASTRO-ENTERIC TRACT. 207
The next thing to do is to dislodge the worms from the upper
bowel, wash them down and, if possible, out. She should,
therefore, be given a tablespoonful of Epsom salts or some
other saline to clean out the bowels. Salines are better than
castor oil, because castor oil favors the absorption of san-
tonin. When the bowels are well emptied, she should be
kept on broth and toast for twenty-four hours and given
three doses of one-quarter of a grain each of calomel and
santonin during the day. This should be followed by another
dose of Epsom salts.
It is evident that drugs given by the mouth can do but little
good after the upper bowel has once been thoroughly cleared
of the worms, since those that remain are all in the large
bowel and rectum. They must be reached from below. She
should, therefore, be given an enema of three ounces of
sweet oil every night, followed in ten or fifteen minutes by
an enema of a pint of soapsuds. The worms are caught in
the oil and are washed out by the suds. These enemata
must be kept up until no worms are obtained, and then for
some weeks longer. If they are given up at once, the worms
will almost certainly appear again in a few weeks.
208 CASE HISTORIES IN PEDIATRICS.
CASE 54. Thomas S., five and one-half years old, was the
child of healthy parents. He had always been well and
vigorous, except for measles when two and whooping-cough
when four years old. His appetite had not been very good
for a year, but he had had no symptoms of indigestion and
his bowels had moved regularly. He had had no cough, had
slept well, had been to school regularly and had seemed
unusually vigorous. He had not picked his nose, been irri-
table or showed any other signs of nervousness. He had
passed worms, resembling angle worms, at times for a year,
but his mother had paid no attention to it, because he seemed
so well. She showed the last worm to some of her friends,
however, and they frightened her so much that she brought
him to the Infants' Hospital.
Physical Examination. He was well developed and nour-
ished and of good color. His skin was in good condition.
His tongue was clean and his nose and throat normal. The
heart, lungs and abdomen were normal. The liver and spleen
were not palpable. The extremities were normal. There
was no spasm or paralysis. The knee-jerks were equal and
normal. There was a slight general enlargement of the
peripheral lymph nodes.
The mother brought in a large round worm which he had
passed three days before.
Diagnosis. The worm having been brought in and ex-
hibited, there can be, of course, no doubt as to the diagnosis
of Round Worms. It is very noticeable, however, that there
is nothing whatever in the history to suggest the presence of
worms, except the fact that he has passed them. This is
the usual story, and the symptoms ordinarily attributed to
worms — picking the nose, pain in the abdomen, disturbance
of the digestion, malnutrition, nervousness, irritability,
sleeplessness and the like — are, as is ordinarily the case, all
lacking. He has, in fact, not only shown none of these
symptoms, but has been unusually well and strong.
Prognosis. The prognosis is good, as it is usually easy to
eradicate round worms by the administration of santonin.
The chances of reinfection are much less than they are with
pin-worms.
DISEASES OF GASTROENTERIC TRACT. 20Q.
Treatment. He should be given a tablespoonful of Epsom
salts, or some other saline, to clean out the bowels. Salines
are better than castor oil, because castor oil favors the
absorption of santonin. When the bowels are well emptied,
he should be kept on broth, with a little toast, for twenty-
four hours and given three doses of one-half of a grain each of
calomel and santonin at four hour intervals. This should be
followed by one or more doses of Epsom salts. This course
of treatment will, in all probability, result in the passage of
all the worms in the intestine. It will be well, however, to
examine the stools for ova in three or four weeks. If any are
found, the treatment must be repeated.
210 CASE HISTORIES IN PEDIATRICS.
CASE 55. Millard R. was admitted to the Children's
Hospital when four and one-half years old. When two and
one-half years old he passed a portion of a tape worm, con-
sisting of 175 segments. He had passed small portions every
few months since then, and a month before had passed a
piece, consisting of 150 segments. He had been perfectly
well, however, in every way. He had had no pain or dis-
comfort and no disturbance of the digestion. He had not had
a voracious appetite, had gained steadily in weight and had
shown none of the nervous symptoms usually attributed to
worms.
Physical Examination. He was well developed and nour-
ished and of good color. His tongue was slightly coated.
The heart, lungs and abdomen were normal. The liver and
spleen were not palpable. The extremities were normal.
There was no spasm or paralysis and the deep reflexes were
normal. The segments which he brought with him were
those of the taenia mediocanellata.
Diagnosis. He unquestionably has a Tape Worm.
Prognosis. The worm will probably be obtained at the
first trial, if sufficient care is taken in carrying out the details
of the treatment. If it is not, the treatment must be repeated
at intervals until the worm is finally obtained.
Treatment. It is very important to have the intestines
emptied of everything but the worm before the anthelmintic
is administered. The diet for the next two days should be
made up of foods which have but little residue, such as clear
soups, whey, white of egg and orange juice, and the amount
should be limited to that just sufficient to satisfy the pangs of
hunger. He may also have a little toast. He should be
given enough of some cathartic, preferably Epsom salts or
castor oil, to produce several large, loose movements of the
bowels each day. He should be given a cup of hot beef tea
or clear broth on waking the morning of the third day. This
should be followed in one-half an hour by the anthelmintic.
The best anthelmintic is Tanret's preparation of the tannate
of pelletierine. The dose for this age is one-third of a bottle,
which is equal to about one and one-half grains of the drug.
If this drug is not obtainable, ten minims of the oleoresin of
DISEASES OF GASTRO-ENTERIC TRACT. 211
aspidium may be given in its place. He should be given two
tablespoonfuls of Epsom salts one-half hour later and one
tablespoonful every subsequent hour until the worm is passed.
He will be less likely to vomit the anthelmintic and the salts
if he is kept up and walking about than if he lies still in bed.
When the worm begins to come he should sit on a vessel filled
with warm water, because the worm is less likely to break off
and is more certain to be passed intact if it finds itself in
comfortable surroundings. It should never be pulled, as it
is almost certain to break if any force is used. If part of the
worm remains in the bowel while the rest is out, it can often
be dislodged by a large enema of warm water.
Everything which is passed should be saved and carefully
examined in order to determine whether or not the head has
been passed, the treatment being of no avail unless this is
obtained. It is important to remember in this connection
that the head is dark colored and not much larger than the
head of a pin and that the upper part of the neck is very thin.
Unless this is borne in mind, the head is very likely to be
overlooked and thrown away.
SECTION IV.
DISEASES OF NUTRITION.
CASE 56. Cynthia M., the first child of healthy parents,
was born at full term after a normal labor, and weighed
ten and one-fourth pounds. The breast-milk gave out after
two weeks and she was put on a rather strong modification
of milk, on which, nevertheless, she did fairly well. She
began to vomit when two months old and the gain in weight
became very slow, but the movements remained normal.
When four months old she was put on a home modified milk
which contained about 2% of fat, 9.60% of sugar, 0.75% of
whey proteids and 0.40% of casein. She had seven feedings
of six ounces. She vomited less while taking this mixture,
but continued to regurgitate. She had one normal move-
ment daily, but her weight remained stationary. She had
some colic. The sugar in the mixture was reduced to 6%
and the vomiting and colic became less. When five months
old, as she did not gain, she was changed to a home modified
mixture which contained about 1.80% of fat, 1.10% of sugar,
0.90% of proteids and 0.50% of starch. She took seven feed-
ings of six ounces. She was not at all satisfied, vomited less
than before and had very little colic, but was somewhat
constipated. The movements were normal in character.
She held her weight the first week, but lost half a pound the
second week. She was then seen, when six months old. She
slept well, had plenty of fresh air and did not act sick.
Physical Examination. She was fairly developed and
nourished. Her color was good. She was a little flabby.
The fontanelle was level. The mouth was healthy and the
tongue clean. She had one tooth. There was a very slight
rosary. The heart and lungs were normal. The level of the
abdomen was that of the thorax, and nothing abnormal was
detected in it. The liver was palpable I cm. below the costal
213
214 CASE HISTORIES IN PEDIATRICS.
border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no spasm or paraly-
sis; the knee-jerks were equal and normal ; Kernig's sign was
absent. There was no enlargement of the peripheral lymph
nodes. She weighed thirteen pounds.
The movement was yellow and salve-like in consistency,
except in one place where it was a little granular and brittle.
The odor was slight. The reaction was alkaline (presumably
from the relatively large amount of proteid in relation to the
fat). Microscopically it showed no undigested fat, starch or
casein.
Diagnosis. The physical examination shows nothing ab-
normal except flabbiness and a slight rosary. The former is,
of course, merely a sign of malnutrition. The rosary means
rickets, but when it is slight and the only bony sign of the
disease, as in this instance, the rickets is of practically no
importance and need not be considered. The very slight
amount of the vomiting and the normal movements show that
there can be no disturbance of digestion sufficient to account
for the loss of weight. The evident hunger and the tendency
to constipation point strongly to an insufficient supply of
food as the cause. Whether this is so or not can, of course,
be determined practically by giving more food and awaiting
the result. Proceeding in this way, however, there is no guide
as to how much more food should be given. It is far better
to calculate the caloric value of the food and thus know the
truth at once, and, if the baby is under-fed, know how much
so, and also how much more food to give.
A baby of six months requires, on the average, about 100
calories per kilo daily in order to thrive and gain. This baby
weighs 5.9 kilos and, therefore, needs about 600 calories
daily. It is not a difficult matter to calculate the caloric
value of the food. Forty-two ounces equals 1,260 ccm.;
1.8% of fat equals 1.8 grams of fat in 100 ccm. of food, or 22.6
grams in 1,260 ccm. The caloric value of I gram of fat is
9.3 calories. The caloric value of the fat in the food is, there-
fore, 210 calories. The caloric value of proteid, sugar and
starch being the same, 4.1 calories per gram, they can be
calculated together. Figuring in the same way as for the fat,
DISEASES OF NUTRITION. 215
they together furnish 129 calories. The total value of the
food is, then, 339 calories or 57 calories per kilo, only a little
more than half the caloric needs.
A baby must not only get a certain number of calories
daily in its food, but it must also get at least 1.5 grams of
proteid per kilo in order to thrive. It will gradually fail and
die if the proteids are insufficient, even if the food contains a
sufficient number of calories. This baby's food contained
0.9% of proteid or 11.3 grams in the 42 ounces. This is equal
to 1.9 grams of proteid per kilo and amply covers the proteid
needs. This ample supply of proteids explains her good
general condition and the fact that she has not appeared
sick.
The diagnosis is, therefore, Malnutrition from an In-
sufficient Supply of Food. The knowledge that the caloric
value of the food is insufficient also enables us to rule out
infantile atrophy, a condition in which there is a progressive
loss of weight, while the caloric value of the food is normal
and there are no symptoms of indigestion.
Prognosis. The prognosis is, of course, perfectly good if
the caloric value of the food is increased. There seems to be
no reason why it cannot be in this instance as the stools show
that all the components of the food are digested.
Treatment. The best food for infants, whether sick or well,
is human milk. A wet nurse is, therefore, the best treatment
for this patient. A wet nurse is not necessary in this instance,
however, as the baby can undoubtedly be easily fed on some
modification of cow's milk.
Past experience shows that it will not be wise to give this
baby over six per cent of sugar. It is advisable to keep the fat
down when babies vomit. It will, therefore, be wise to keep
the percentage of fat as low as is consistent with meeting the
caloric needs. There is no objection to giving a reasonably
high percentage of proteids, as the baby has already shown
her ability to digest them. It will be wise to continue the
starch in the mixture, since the examination of the stools
shows that the baby can digest it and it adds to the caloric
value of the food. Six feedings of five and one-half ounces
each ought to be about right for her age and weight.
2l6 CASE HISTORIES IN PEDIATRICS.
The following formula meets these indications and covers
both the caloric and proteid needs:
Fat, 2.50%
Sugar, 6.00%
Proteids, 1-50%
Starch, 0.75%
Six feedings of 5J ounces give 565 calories, or 96 calories
per kilo, and 14.8 grams of proteid, or 2.5 grams of proteid per
kilo.
Approximately the same mixture can be prepared at home
as follows:
Gravity cream (16%), 5 ounces
Skimmed milk, 10 ounces
Barley water (1.50%
starch), 18 ounces
Milk sugar, 2 rounded and 1 level
tablespoonful
Two teaspoonfuls of barley flour to a pint of water makes a
1.50% starch solution. One rounded tablespoonful of milk
sugar is equal to about half an ounce.
No drugs are indicated.
DISEASES OF NUTRITION. 217
CASE 57. David W., was born at full term and was the
only child of healthy parents. There was no history of tuber-
culosis in the family and no known exposure to it. He weighed
nine pounds at birth, but fell to six pounds in the first three
weeks, and when seen in consultation at eleven months
weighed but ten pounds. He had always been fed on milk,
prepared in various ways. During the first month the mixture
had been sterilized. This apparently upset the baby and
caused considerable constipation. A little later he was given
one part of whole milk to three of water, but as the move-
ments contained curds, the strength was reduced to one part
of whole milk to six of water. As he still passed curds, he
was given a condensed milk mixture, containing one part of
condensed milk to twelve of water. As he did not gain and
continued to have curds in the stools, he was given a modified
milk mixture prepared at a laboratory. He was at first given
straight proteids of one per cent; later, part of the proteids
were given in the form of whey proteids. He did better on
this, but the movements still contained curds. This was
stopped after a few months and he was put on condensed
milk again. As he did not gain, he was put back on modified
milk. During the last month he had been taking six feedings
of 5! ounces of a mixture containing 2.75% of fat, 6.00% of
sugar and 0.25% of proteids, but was not gaining.
He had been constipated during all this time, except for
two short attacks of diarrhea a month or two before he was
seen. He had always taken his food well and had almost
never vomited. The movements had always been fairly well
digested, except that they at times contained a few curds.
He was a quiet baby and almost never fussed.
Physical Examination. He was small and poorly nourished.
Pallor was marked. The skin was somewhat dry. The
anterior fontanelle was 2 cm. in diameter, the level being
somewhat below that of the surrounding bones. He had two
lower incisors. There was no rosary. The heart and lungs
were normal. The level of the abdomen was below that of
the thorax; it was lax, easily palpable and showed nothing
abnormal. The liver was palpable 2 cm. below the costal
border in the nipple line; the spleen was not palpable. The
2l8 CASE HISTORIES IN PEDIATRICS.
extremities showed nothing abnormal. There was no spasm
or paralysis; the knee-jerks were equal and normal. There
was a slight general enlargement of the superficial lymph
nodes. The weight was ten and one-half pounds.
Diagnosis. The examination shows nothing except mal-
nutrition. It gives no clue as to its cause. This must be
sought in the history. In general, the causes of malnutrition
which give no physical signs beyond those of malnutrition
are congenital syphilis, chronic diffuse tuberculosis, infantile
atrophy, chronic indigestion and starvation.
Disturbance of nutrition is the main symptom in some
cases of congenital syphilis. The good family history, the
absence of any other signs of syphilis and the presence of
other causes for the malnutrition rule it out in this instance.
The slight general enlargement of the superficial lymph nodes
does not point either to syphilis or tuberculosis. It is com-
mon to all disturbances of nutrition in infancy and is, conse-
quently, of no diagnostic value. Chronic diffuse tuberculosis,
meaning by this term the condition in which there are
numerous tubercular foci scattered throughout the body,
larger and older than the miliary tubercle, but not large enough
or so situated as to give physical signs, is not very infre-
quent in infancy. It cannot be recognized on physical exam-
ination, but only by the tuberculin test. It cannot be ruled
out in this instance, but is less probable than some other
conditions. The symptoms of indigestion are not suffi-
cient to account for the malnutrition.
Barring chronic diffuse tuberculosis, which can only be
positively excluded by a tuberculin test, the diagnosis lies,
therefore, between infantile atrophy and starvation. The
term, " infantile atrophy," should be limited to those cases
in which there is a progressive loss of weight in spite of a
sufficient intake of food, there being at the same time no
symptoms of disturbance of the digestion. In this class of
cases there is presumably some obscure disturbance of absorp-
tion or metabolism. Clinically they form a very definite
group. It is probable, however, that, with the increase of our
knowledge of chemical pathology, they will, in the future, be
classified in some other way.
DISEASES OF NUTRITION. 219
While he was taking the condensed milk and whole milk
mixtures he was unquestionably not getting enough calories,
but in the last mixture he got 105 calories per kilo, or just
about enough to cover his caloric needs. A baby cannot
thrive, however, even if the food contains a sufficient number
of calories, if it does not also contain proteids enough to
cover the proteid needs. The condensed milk and whole
milk mixtures contained, respectively, 0.66%, 0.87% and
0.50% of proteids, which were probably not quite enough to
meet the proteid needs. His last mixture gave but 0.5
grams of proteid per kilo, while he needed at least 1.5 grams
of proteid per kilo. The diagnosis of infantile atrophy is,
therefore, not justified because, while he is getting a sufficient
number of calories, he is not getting enough proteid, and the
condition is best called Malnutrition from an Insufficient
Amount of Proteid in the Food. If he does not begin to
gain weight when the proteid is increased enough to cover his
proteid needs, the diagnosis will have to be changed to
infantile atrophy, which has probably developed as the
result of the continued insufficient supply of proteids.
Prognosis. The prognosis must be held in abeyance until
the effect of an increase in the proteids is known. If he begins
to gain when they are increased, the prognosis is good ; if he
does not, it is very grave unless he is given human milk. If
he gets this he will probably recover, because babies with
atrophy can usually utilize the proteids of human milk even if
they cannot those of cow's milk.
Treatment. The treatment consists in the regulation of
the food. Human milk is altogether the best food for him.
It will almost certainly cure him whether the condition is
proteid starvation or atrophy. If he cannot get this, the next
best thing is some modification of cow's milk. He is digesting
the present mixture, which, however, does not contain enough
proteid. The natural thing to do, therefore, is to leave the
percentages of fat and sugar unchanged and to increase the
proteids to 0.75% in order to cover his proteid needs, keeping
the number and amount of the feedings the same. There is
no indication for medicinal treatment.
220 CASE HISTORIES IN PEDIATRICS.
CASE 58. Helen S. was the second child of healthy
parents. She was born January 1, at full term, after a normal
labor, was normal at birth and weighed six and one-quarter
pounds. She had never had anything but the breast and
had done well in every way up to May 21, when she weighed
thirteen pounds and four ounces. She had appeared per-
fectly well since then, but had not gained any in weight.
She had formerly nursed for twenty minutes, but recently
had nursed well for only four or five minutes, after which she
would not try any more, although her mother felt very
confident that the breasts were not emptied. She seemed
satisfied and did not appear hungry before the next feeding
time. She was nursed six times in the twenty-four hours.
She did not vomit. The bowels moved daily without assist-
ance, but the stools were small and hard. Her mother was
well. She was taking about three pints of milk, cocoa and
soup daily, as well as a little malt, and was gaining rapidly in
weight. She thought, however, that, in spite of the extra
liquid and malt, the amount of milk was somewhat less than
it was a month before. The baby was seen June 6, when a
little more than five months old.
Physical Examination. She was well developed and nour-
ished and of good color. The anterior fontanelle was three
cm. in diameter and level. The mouth and throat were
normal. She had two teeth. There was no rosary. The
heart, lungs and abdomen were normal. The lower border
of the liver was palpable two cm. below the costal border in the
nipple line. The spleen was not palpable. The extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and normal. There was no enlargement
of the peripheral lymph nodes. She weighed thirteen and
one-quarter pounds.
Diagnosis. The failure to gain in weight and the slight
constipation, in the absence of all symptoms of illness, point
strongly to an insufficient amount of food. So does also
the voluntary shortening of the time of nursing, it being a
very common thing for babies to stop nursing after they have
satisfied the pangs of hunger, if the supply of milk is insuffi-
cient and it is very hard work to get it. The fact that she
DISEASES OF NUTRITION. 221
does not appear hungry before the next feeding is not in-
consistent with this explanation, because it is not very un-
common for babies not to appear hungry, even when the supply
of milk is insufficient for them to gain on, if they are getting
enough to cover their actual needs and to keep their weight
stationary. The fact that her mother thinks there is still milk
in the breast after she has stopped nursing is of no impor-
tance, because it is impossible for a woman to know whether
there is milk in the breast or not, unless it is very full.
The trouble with the milk may be in the quantity, the
quality or both. The only way to find out how much milk
the baby is getting is to weigh it before and after every
nursing for several days. It is not necessary to undress the
baby to do this. The increase in weight will show, of course,
how much milk has been taken. If the baby will not keep
still, the mother can weigh herself before and after nursing.
Her loss represents, of course, the baby's gain. The absence
of all symptoms of indigestion and the failure to gain in
weight show that the failure to nurse well is not because the
milk is too rich as a whole, while the absence of symptoms of
indigestion proves that there is no excess of any individual
element. If there is any trouble with the quality of the milk,
it must be, therefore, that it is weak as a whole or in some one
of its constituents. The only way to find out whether it is
or not, is to analyze it.
The baby was weighed before and after nursing for several
days and found to be getting about three ounces at a feeding,
or an average of eighteen ounces a day. The analysis of the
milk showed that it contained 1.09% of fat, 6.50% of sugar
and 1.91% of proteids. That is, she was getting only about
one-half as much milk as she should and this milk was
markedly deficient in fat. Eighteen ounces of this milk
contained about 240 calories, which gave her only about 40
calories per kilo, or less than half enough to cover her
caloric needs. The diagnosis of Malnutrition from an
Insufficient Amount of Food, which was made on the
symptomatology, is, therefore, verified.
Prognosis. The mother is well; she is taking a sufficient
amount of extra liquids and has been nursing for five months.
222 CASE HISTORIES IN PEDIATRICS.
It is very improbable, therefore, that the amount of milk can
be increased again, although it is possible that the percent-
age of fat can be made higher. The baby is in good condi-
tion and her digestion is normal. She can be confidently
expected, therefore, to thrive and gain when enough modi-
fied cows' milk is added to her diet to cover her caloric needs.
Treatment. It is useless to attempt to increase the amount
of the breast-milk by giving more liquids, because more than
three pints of extra liquid in the twenty-four hours, instead
of increasing the amount of milk, almost invariably either
upsets the mother's digestion or makes her grow fat. It is
possible that a somewhat larger proportion of fat and meat
in the mother's food may increase the percentage of fat in
the milk, although the evidence in favor of this action is not
very convincing. It will be well, therefore, to have her take
more cream, butter, meat and eggs than she has been taking.
The liquids which are most useful in increasing the supply
of milk are gruels; next to them, milk and cocoa. Prepara-
tions of malt have no especial value, and are likely to dis-
turb the digestion of both mother and child. There are no
drugs which have any action in increasing the supply of
milk. The best way to increase or to keep up the supply of
milk is to empty the breasts thoroughly at regular intervals.
The baby should, therefore, be given both breasts at each
nursing, the intervals and number of nursings being kept as
they are at present. She should be weighed before and after
nursing from time to time in order to determine about how
much she is getting. She should then be given enough
modified cows' milk after the breast to bring the amount
at each feeding up to six ounces. The modified milk should
contain a high percentage of fat to make up for the deficiency
of fat in the breast-milk. A mixture containing 4% of fat,
7% of milk sugar and 1.75% of proteids will be a suitable
one. There is no indication for the addition of an alkali.
Eighteen ounces of this mixture, which, judging from the
amount of breast-milk she has been taking, is about the
amount which will be necessary to bring up the amount at
each feeding to 6 ounces, contains nearly 400 calories. This
will amply cover her caloric needs.
DISEASES OF NUTRITION. 223
CASE 59 Almira R. was admitted to the Children's
Hospital when thirteen months old. Her parents, who were
Italians, were well, as were two older children. There had
been no deaths or miscarriages. Her mother, who brought
her to the hospital, could speak but little English and on this
account but little could be learned about her. She was
nursed entirely for five months, after which she was given
food from the table in addition. She had recently been
taking condensed milk, eggs, rice, macaroni, and probably
many other things also, during the day and been given the
breast at frequent intervals all night. She had been sick
ever since she had begun to take other food in addition to
the breast-milk. She had vomited every two or three days
and had had several undigested stools daily. She had had
a little cough recently, but her mother did not know whether
she had been feverish or not.
Physical Examination. She was poorly developed and
nourished and moderately pale. She was feeble, but noticed
what was going on about her. The parietal and frontal emi-
nences were somewhat enlarged and the top of the head
flattened. There was no craniotabes. The anterior fonta-
nelle was four cm. in diameter and slightly depressed. The
tongue was covered with a moist, white coat. She had eight
teeth. The area of the cardiac dullness could not be deter-
mined, because of the deformity of the chest. The sounds
were normal and apparently in the normal position. There
were no murmurs. There was a very marked rosary and a
large depression on both sides of the chest, into which the
flexed arms fitted. The sternum was prominent. There was
marked flaring of the lower ribs. She was unable to sit
alone and there was a marked curve of weakness. Both
sides of the chest moved alike. There was moderate retrac-
tion of the lower ribs on inspiration. There was a small area
of dullness at the angle of the scapula on the right and an-
other small patch, at the level of the angle of the scapula, in
the left posterior axillary line. Respiration in these areas
was bronchovesicular. Fine and medium moist rales were
heard all over the chest, both back and front. The abdo-
men was protuberant, soft and tympanitic. There was no
224 CASE HISTORIES IN PEDIATRICS.
tenderness and no masses were felt. The upper border of the
liver flatness was at the upper border of the sixth rib in the
nipple line; the lower border was palpable four cm. below
the costal border in the same line. The spleen was not pal-
pable. There was moderate bowing of the lower legs and
marked enlargement of the epiphyses at the wrists and
ankles. There was no spasm or paralysis. The knee-jerks
were equal and normal. There was a moderate general en-
largement of the peripheral lymph nodes. The rectal tem-
perature was 990 F. ; the pulse, 120; the respiration, 35.
She weighed fourteen pounds.
The leucocytes numbered 22,400.
The sputum contained no tubercle bacilli.
Diagnosis. The enlargement of the parietal and frontal
eminences, the widely open fontanelle, the marked rosary,
the deformity of the chest, the enlargement of the epiphyses
at the wrists and ankles and the bowing of the legs justify
the diagnosis of a high grade of Rickets. The deformity of
the chest is undoubtedly also due in part to the Italian
method of swathing their babies. The disturbance of the
nutrition due to the improper feeding is without question
the chief cause of the rickets, although it is probable that
improper hygienic surroundings and lack of fresh air and
sunlight also played a part in its production. The rales and
the two areas of dullness and bronchovesicular respiration
show that there is an accumulation of liquid in the bronchi
and partial solidification of the lungs. The absence of
tubercle bacilli in the sputum shows that the trouble is not
tubercular. Do these signs show that there is a bronchitis
and bronchopneumonia or are they merely the manifesta-
tions of the retention of the bronchial secretions and atelec-
tasis of the lungs as the result of the deformity and defective
expansion of the chest? The physical signs are consistent
with either condition, as is the increase in the rate of the
respiration. The diagnosis must be made, therefore, in some
other way. The leucocytosis seems, at first thought, to count
strongly in favor of bronchitis and bronchopneumonia. It
becomes of less importance, however, when the frequency of
leucocytosis in disturbances of nutrition, associated with
DISEASES OF NUTRITION. 225
anemia and rickets, is remembered. The normal tempera-
ture and pulse rate, on the other hand, are inconsistent with
bronchitis and bronchopneumonia and are sufficient to rule
it out. The diagnosis of Atelectasis of the Lungs and
retained secretions from defective expansion of the chest is,
therefore, justified.
Prognosis. The disturbance of the digestion has lasted
so long, her general condition is so poor, the deformity of the
chest is so marked and it interferes so much with the expan-
sion of the lungs that the chances are very much against her
recovery. She probably will not live more than a few weeks.
If she recovers, the improvement will be very slow and she
will almost certainly be left with a misshapen chest.
Treatment. The treatment consists principally of regu-
lation of her surroundings and her diet. She must be given
the greatest possible amount of fresh air and sunlight. The
best food for her is human milk, even if she is thirteen months
old. Her mother's milk is insufficient in quantity and prob-
ably poor in quality. She ought, therefore, to have a wet
nurse. If this is not feasible, the best substitute is some
form of modified cows' milk. A mixture containing 3% of
fat, 6% of milk sugar, 1.50% of proteids and 0.75% of starch,
with lime water 20% of the milk and cream in the mixture,
will be a suitable one. Seven feedings of six ounces at three-
hour intervals should be sufficient for the present. Strych-
nia, in doses of ^^ of a grain, every four hours, will stimu-
late the respiration and improve her general condition.
226 CASE HISTORIES IN PEDIATRICS.
CASE 60. George T. was the only child of healthy par-
ents. He was born two months before he was expected. He
had never been nursed, but had been fed on whole cow's milk,
more or less diluted with water. He had never done well.
He vomited at times directly after feeding, but never between
feedings. His bowels were constipated ; the movements were
smooth. His head sweat a great deal. He was fussy and slept
poorly. He was brought to the hospital when eleven months
old. '
Physical Examination. He was small and thin, weighing
but nine pounds. Pallor was marked. He could hold up his
head, but was unable to sit alone. When supported he sat
with a marked general kyphosis. This disappeared when he
lay on his face. The frontal and parietal eminences were so
much enlarged that the top of the head showed a depression
between them both longitudinally and across. The anterior
fontanelle was 5 cm. in diameter and depressed. There was
no craniotabes. The pupils were equal and reacted to light.
There were no teeth. The mouth and throat were normal.
There was a marked rosary and there was a depression around
the lower part of the chest at the level of the insertion of the
diaphragm, with moderate flaring of the ribs below. The
heart and lungs were normal. The liver was palpable 3 cm.
below the costal border in the nipple line ; the spleen was not
palpable. The extremities showed nothing abnormal except
a moderate enlargement of the epiphyses at the wrists and
ankles. There was no spasm or paralysis; the knee-jerks
were equal and normal. There was a moderate general en-
largement of the peripheral lymph nodes. There was no
eruption.
The urine was pale, slightly acid, of a specific gravity of
1,010 and contained no albumin.
Blood.
Hemoglobin,
25%
Red corpuscles,
2,566,000
White corpuscles,
15,000
Small mononuclears,
62%
Large mononuclears,
3%
Polynuclear neutrophiles,
34%
Eosinophiles,
1%
Case 60.
George T., Rachitic head. John S., Hydrocephalic head.
Curve of weakness. Case 60.
DISEASES OF NUTRITION. 227
There was moderate variation in the size, but none in the
shape or staining reaction, of the red corpuscles. No nucle-
ated forms were seen.
Diagnosis. The diagnosis is, of course, Rickets and
Secondary Anemia. The enlargement of the frontal and
parietal eminences with the resultant "square" head, the
rosary and the enlargement of the epiphyses at the wrists and
ankles are pathognomonic of rickets. The weakness of the
back, the large anterior fontanelle, the absence of teeth and
the deformity of the chest are, in this instance, undoubtedly
also signs of rickets, but are not pathognomonic, as they may
be caused by other conditions.
The rachitic enlargement of the head, so well shown in this
baby, is not infrequently mistaken for hydrocephalus. There
should not, however, be any difficulty in distinguishing be-
tween them. The enlargement of the rachitic head is due to.
the overgrowth of bone on the outside ; that of the hydroceph-
alic head, to increased pressure on the inside. The rachitic
head is asymmetrical and flattened on top ; the hydrocephalic,
symmetrical and rounded. In the former the fontanelle is
level or sunken; in the latter, bulging. In rickets the eyes
appear normal ; in hydrocephalus, they are prominent. These
differences are well shown in the accompanying photographs.
The kyphosis seen in this instance is often mistaken for the
deformity of Pott's disease. The diagnosis between them is,
however, a simple one. The deformity in rickets is due to
muscular weakness, is a general rounded curve, involving the
whole spine, and disappears on extension. That in Pott's
disease is due to deformity of the bone, is a local angular
protuberance, involving only part of the spine, and does not
disappear on extension.
The blood picture is that of a secondary anemia of a moder-
ate grade. The percentage of hemoglobin is relatively lower
than the number of red corpuscles. This "chlorotic" type
of blood is characteristic of the secondary anemias of infancy.
The white count is so little above the normal that it can hardly
be called a leucocytosis, especially as the differential count of
the white cells is normal for this age. The anemia should not
be regarded as a symptom of the rickets, but merely as
228 CASE HISTORIES IN PEDIATRICS.
another manifestation of the same disturbance of nutrition
which caused the rickets. The fact that he was born pre-
maturely probably predisposed him to the development of
anemia, because premature infants have, as a rule, a smaller
reserve supply of iron in the liver than those born at full term.
Prognosis. The prognosis as to life is good. The activity
of the rachitic process will quickly cease under proper treat-
ment, but the bony deformities will still remain. The rosary
and enlargement of the epiphyses will disappear in a year or
two. The deformity of the chest will probably never entirely
disappear, and his head will probably always be a little large
and peculiarly shaped, but not enough so to attract any
attention.
Treatment. The treatment is hygienic and dietetic, not
medicinal. He should be given the maximum amount of
fresh air and sunlight and should be especially protected
against all sorts of contagion.
Breast milk is undoubtedly the best food for him, although
he is eleven months old. In all probability, however, he
will not take the breast. The milk can be obtained, never-
theless, with a pump and fed to him in a bottle. Even a
little human milk will help him to utilize modified cows' milk.
There are no special indications as to what proportion of
modified milk will best suit him, except that he has not done
well on the combination of low fat and sugar with high pro-
teids, which he has had in the past. A reasonable mixture
for him is:
Fat, 3.50%
Sugar, 7-00%
Proteids, 1-5°%
Starch, 0.75%
An alkali is not indicated in this instance as there has been
no disturbance of the gastric digestion. Six feedings of six
ounces are sufficient for his weight. If the constipation con-
tinues on this mixture, he may have from one-half to two
tablespoonfuls of orange juice daily. If this does not relieve
the constipation, he may have from one-half to two tea-
spoonfuls daily of the milk of magnesia.
DISEASES OF NUTRITION. 229
The saccharated carbonate of iron in three-grain doses, or
ferratin in two-grain doses, will help the anemia. The author
has not seen any better results when cod-liver oil and phos-
phorus have been given in addition to regulation of the diet
and hygienic surroundings than when they have not, and
consequently seldom prescribes them.
230 CASE HISTORIES IN PEDIATRICS.
CASE 61. Dorothy C. was the only child of healthy
parents. There had been one miscarriage subsequent to her
birth. There was no tuberculosis in the family and she had
had no known exposure to it. She was born at full term,
after a normal labor, and weighed seven and one-half pounds.
She was fed from the first on modified cows' milk and did
well, except for some eczema on the face between the fifth
and eighth months, until she was a year old, when she had
an attack of infectious diarrhea. She was then well until
she was two years old, since when she had had, three or four
times each year, an attack of diarrhea, accompanied by dis-
tention of the abdomen and much loss of weight, lasting from
three to five weeks. In these attacks she had from six to ten
shiny, loose, green, foul movements daily. Four months
before she was seen, she had a very severe attack of diarrhea
from which she had not rallied, although the diarrhea ceased
after the usual period. She was weak and had frequent,
slight, dull headaches. She had become markedly pale. Her
appetite was poor. She had no nausea or vomiting. Her
bowels moved once or twice daily, the movements usually
being more or less undigested, but sometimes constipated.
Knock-knees had been noticed for a year and one-half. Her
physician was sure, however, that she had shown no signs of
rickets before she was five years old. She was seen in con-
sultation, when seven and one-half years old.
Physical Examination. She was fairly developed and
poorly nourished. Pallor was marked. She was intelligent,
but listless. Her head was of normal size and shape. Her
tongue was slightly coated, her teeth good, her throat normal.
There was a venous hum in the neck. There was a moderate
rosary and some flaring of the lower chest. There was also
slight scoliosis. The lungs were normal. The heart was
normal, except for a slight systolic murmur at both base and
apex. When she stood, the whole abdomen was protuberant,
the enlargement being most marked in the lower half. When
she lay down, the level of the abdomen was that of the
thorax. The upper half was tympanitic, the lower half mod-
erately dull. There was dullness in the flanks, which changed
slightly with change of position. There was no fluid wave.
DISEASES OF NUTRITION. 23 1
There was no muscular spasm or tenderness, and no masses
were felt. The upper border of the liver flatness was at
the sixth rib in the nipple line. The lower border was felt
just below the costal border in the same line. The upper
border of the splenic dullness was at the eighth rib. The
spleen was palpable three and one-half cm. below the costal
margin. There was marked knock-knees and marked en-
largement of the epiphyses at the wrists and ankles. There
was no spasm or paralysis. The knee-jerks were equal and
normal. The rectal temperature was 100.20 F. ; the pulse,
120; the respiration, 25. She weighed, without her clothes,
thirty and one-half pounds (the average is forty- three pounds).
The urine was of normal color, clear, acid in reaction and
contained no albumin or sugar. The sediment contained a
few squamous cells and leucocytes.
Blood.
Hemoglobin
42% (Sahli)
Red corpuscles,
3,600,000
White corpuscles,
32,000
Mononuclears,
44%
Polynuclear neutrophiles,
52%
Eosinophiles,
2%
Mast cells,
2%
There was moderate variation in the size and shape of the
red corpuscles with a tendency to macrocytosis. There was
moderate achromia and marked polychromatophilia. Four
normoblasts and three megaloblasts were seen in counting
one hundred white cells.
A stool, which was examined the day after taking 22
grams of fat, 223 grams of carbohydrates and 26 grams
of proteid, was brown, foul and contained considerable
mucus. There was no gross pus, but a few leucocytes
were seen. No red corpuscles were seen with the micro-
scope. There was a moderate excess of neutral fat and a
considerable excess of fatty acids and soaps. There was no
starch.
A skin tuberculin test was negative.
The Roentgenographs of the wrists, ankles and knees
showed the typical changes of rickets.
232 CASE HISTORIES IN PEDIATRICS.
Diagnosis. She has, without question, Chronic Intes-
tinal Indigestion with acute exacerbations and with in-
tolerance of fat. The large, pendulous abdomen is, in all
probability, due to the enlargement of the intestines as the
result of the chronic intestinal indigestion. The dullness in
the flanks and the slight change in dullness with change of
position is, without question, due to the presence of liquid
feces in the lax intestines and not to free fluid in the peri-
toneal cavity.
The rosary, the flaring of the lower chest, the scoliosis, the
knock-knees and the enlargement of the epiphyses are posi-
tive signs of rickets. If the testimony of the parents as to
her good health during the first two years and that of her
physician that she showed no signs of rickets before she was
five years old can be believed, the rickets must have devel-
oped recently, that is, it is a case of Late Rickets. The
Roentgenographs show signs of active, not of healed, rickets
and, therefore, corroborate the diagnosis.
The macrocytosis, the presence of megaloblasts and the
slight excess of mononuclear cells suggest to a certain extent
pernicious anemia. The other characteristics of the blood
are, however, those of Secondary Anemia. The blood
picture, as a whole, is typical of the secondary anemia with
leucocytosis seen in infancy. It is probable that in connec-
tion with the rickets, usually a disease of infancy, there has
also been a reversion of the hemopoietic system with the
resulting formation of a younger type of blood. Enlargement
of the liver and spleen are not uncommon in the disturbances
of nutrition associated with rickets and anemia in infancy.
It is presumable that the enlargement in this instance is also
simply a manifestation of the same disturbance of nutrition
which is the cause of the rickets and the anemia.
The sequence of events has been apparently as follows:
chronic intestinal indigestion with acute exacerbations and
with intolerance of fat; disturbance of the nutrition as the
result of the chronic intestinal indigestion, with the develop-
ment of rickets, secondary anemia and enlargement of the
liver and spleen. It is possible that the intolerance of fat has
resulted in sufficient loss of calcium to result in the develop-
DISEASES OF NUTRITION. 233
ment of rickets. This is, however, somewhat doubtful. The
whole picture is a very common one in infancy, but extremely
rare in childhood.
Prognosis. She will almost certainly recover in time. It
will require, however, many months, and probably years, of
the greatest attention to her diet, hygienic surroundings and
care.
Treatment. The treatment consists primarily in regula-
tion of the diet to her digestive capacity. Fat must be
entirely cut out and the required number of calories made up
by an extra amount of carbohydrates and proteid. (See
Case 44.) The elimination of the fat from the food will pre-
sumably influence the rachitic process favorably. There is
no indication for the administration of calcium salts, because
there is certainly no deficiency in these salts in the food, the
disturbance of ossification being due to inability either to
absorb or to make use of them. The author has not seen any
better results when cod liver oil and phosphorus have been
given in rickets than when they have not, and seldom pre-
scribes them. Intolerance of fat would seem, moreover, to
contraindicate the use of cod liver oil in this instance. It will
be well to give her both arsenic and iron for the anemia. She
should be given one minim of Fowler's Solution, well diluted,
three times daily, after meals. The dose should be increased
one minim daily until toxic symptoms appear. It should
then be reduced to the last dose which did not cause toxic
symptoms and kept there. She should be given ten grains
of the saccharated carbonate of iron or ferratin, three times
daily, after meals. She should be given, of course, the maxi-
mum possible amount of fresh air and sunshine, should be
kept in bed for the present and guarded in every way against
fatigue and exposure.
234 CASE HISTORIES IN PEDIATRICS.
CASE 62. Pauline P. was born July 15 at full term after
an instrumental labor, was normal at birth and weighed
eight pounds. Her father learned, about July 1, that he had
pulmonary tuberculosis and went West about two weeks
after she was born. She was put at once on modified milk
and did very well. About October 1, when ten weeks old, she
went West and joined her father. He slept out of doors and
was very careful not to expose her to infection. After going
West she was fed on equal parts of whole milk and water,
prepared with Mellin's Food. This did not agree with her
very well. She returned to her home in the East, February I,
having been with her father about four months. She was
then put on a mixture of whole milk and water, prepared with
" Peptogenic Milk Powder." In the course of the preparation
of the food, the milk was brought to a boil. She had been
taking this food for three and one-half months when she was
seen. She had taken and digested it well and gained steadily
in weight.
She stopped creeping about April 20. April 26 she fell out
of a low chair to the floor, striking on her forehead. She did
not seem hurt, except for a bruise on the right side of the
forehead. Beginning with the next day she cried a great
deal during her bath, and May 1 it was noticed that motions
of the legs caused pain. The pain on motion of the legs
increased. She lay on her back and kept her legs drawn up.
When quiet in this position she had no pain. She was very
much afraid of being touched and began to cry when any one
approached her. The upper gums became inflamed about:
May 10. Her appetite had fallen off and she had lost some
weight and much color since the appearance of the pain,
although she had shown no signs of indigestion. Her tempera-
ture had not been taken, but she had not appeared feverish.
The urine had not stained the diapers. She was seen in con-
sultation May 17, when ten months old.
Physical Examination. She was fairly developed and nour-
ished and moderately pale. She was very much afraid of
being touched. The fontanelle was level. There was an
ecchymosis, about the size of a five-cent piece, on the right
side of the forehead. The two lower central incisors had
DISEASES OF NUTRITION. 235
erupted and the gum was normal about them. The upper
gum was distended by the four incisors. The gum was a
little purplish over them. The tongue was clean and the
throat normal. There was a slight rosary. The heart, lungs
and abdomen were normal. The liver was palpable 2 cm.
below the costal border in the nipple line ; the spleen was not
palpable. The spine was perfectly flexible. She preferred to
lie on her back with the legs flexed at the hips and knees.
Neither active nor passive motions were limited, but motions
at the hips and knees caused much pain. There was no
definite tenderness and no swelling about the bones or joints.
The arms were not tender and were used freely without dis-
comfort. The knee-jerks were equal and normal; Kernig's
sign was absent; sensation to touch and pain was normal.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was 98. 6° F.
Diagnosis. Tuberculosis of the spine or hip-joints had been
seriously considered by the physician in charge because of
the known exposure to tuberculosis. The normal mobility
of the spine and at the hips, together with the normal tempera-
ture, rule this out. The grandmother thought that the fall
might be the cause of the pain. The baby had, however,
stopped creeping before the fall and showed no evidence of
injury at the time. It is hard to conceive, moreover, of an
injury which would involve both legs and not show any
physical signs. Infantile paralysis and multiple neuritis
might be thought of on account of the pain. Infantile paraly-
sis can be at once excluded because of the absence of paralysis
and the presence of normal reflexes after three weeks. Multi-
ple neuritis can be ruled out because at this age it is almost
always a sequela of diphtheria and, consequently, is seldom
accompanied by pain. The reflexes are intact, moreover, and
there is no paralysis or disturbance of sensation. Osteomye-
litis and periosteitis seldom occur in more than one place at a
time and can be excluded on the good general condition and
the absence of fever and localized tenderness. The combina-
tion of pain without physical signs is characteristic of rheuma-
tism in early life. Rheumatism almost never occurs in
early infancy, however, and will not account for the swollen
236 CASE HISTORIES IN PEDIATRICS.
and purplish gum. The slow onset, the unwillingness to use
the legs, the pain on motion and the position in which the
legs are held are almost pathognomonic of Scurvy and justify
that diagnosis without any other evidence. The combination
of these signs with the swollen, purplish gum, another char-
acteristic sign of scurvy, cannot be accounted for in any other
way, and makes the diagnosis absolute. The ecchymosis
on the forehead may be a scorbutic manifestation but, on
the other hand, may be simply the result of the fall. The
prolonged use of boiled milk is corroborative evidence of
the diagnosis of scurvy, as it is undoubtedly one of the causes
of this disease.
Prognosis. The prognosis is absolutely good. She will be
perfectly well in a week if properly treated.
Treatment. The first step in the treatment is to remove
the probable cause of the disease, that is, boiling the milk.
There seems to be no reason for changing the composition of
the food as she was doing very well on it except for the scurvy.
The mixture contains 2% of fat, 6.50% of sugar and 1.75% of
proteids. It is always unwise to continue peptonization over
long periods because it tends to weaken the digestive power.
It will, therefore, be wise to replace the " Peptogenic Milk
Powder " (which is composed largely of milk sugar) by milk
sugar and to add starch, in the form of barley water, to hinder
the formation of large curds. The following combination is a
suitable one:
Whole milk, 24 ounces
Barley water (1.50% starch), 24 ounces
Milk sugar, 4 rounded tablespoonfuls
This mixture contains 2% of fat, 6.50% of sugar, 1.75% of
proteids and 0.75% of starch. The sugar should be mixed
with the hot barley water and the mixture cooled before the
milk is added. She should take six feedings, of from seven
to eight ounces.
She will undoubtedly recover in time on the " fresh " food,
but recovery will be slow. Fruit juices, however, have a
specific action in infantile scurvy, and should, therefore,
always be given. They will cure the process even if the cause
is not removed. Orange juice is the best, because it is the
Deformity of legs in Scurvy.
DISEASES OF NUTRITION. 237
most readily taken. Babies seldom object to it. It may be
given plain or diluted with water. There is no objection to
the addition of cane sugar if the orange is sour. It may be
given all at one dose or divided into two doses. It is best
given about an hour before a feeding, when the stomach is
empty. One ounce is the proper dose. Less than this may
be ineffectual, more is unnecessary. She should have, there-
fore, an ounce of orange juice daily. This dose should be
continued until all symptoms of the disease have disappeared.
It will be wise to keep it up for some time longer, but the dose
need not be as large.
238 CASE HISTORIES IN PEDIATRICS.
CASE 63. Laliah P. was the first child of healthy parents.
She was born at full term and weighed six and one-half
pounds. She had always been fed on pasteurized milk
prepared at a laboratory. She had done very well until she
was six months old, when she ceased to gain and lost her
appetite. When she was seven months old her mother noticed
that the urine at times stained the diapers red. This staining
was attributed by the physician in charge to uric acid. It
continued intermittently for a month, when the urine was
examined and found to contain fresh blood, but no casts.
Micturition was not increased in frequency and was not
painful. There were no other symptoms whatever except
failure to gain in weight. She was seen in consultation when
eight months old.
Physical Examination. She was well developed and nour-
ished, but somewhat pale and flabby. She was bright and
happy. The anterior fontanelle was 3 cm. in diameter and
level. The mouth and throat were normal. There were no
teeth. There was no rosary. The heart and lungs were nor-
mal. The level of the abdomen was somewhat above that
of the thorax; it was everywhere tympanitic and nothing
abnormal could be detected. Very careful examination failed
to find any enlargement of the kidneys. The liver was pal-
pable 2 cm. below the costal border in the nipple line; the
spleen was not palpable. The extremities were normal.
There was no spasm, paralysis or tenderness. Neither active
nor passive motions caused pain. The knee-jerks were equal
and normal; Kernig's sign was absent. There was a slight
general enlargement of the peripheral lymph nodes. She
weighed thirteen pounds.
The urine was pale with a slightly reddish tinge, feebly
acid, of a specific gravity of 1,006 and contained a trace of
albumin. The sediment showed a few red blood corpuscles
and an occasional leucocyte, but no other formed elements.
Diagnosis. The only causes of hematuria, not associated
with bleeding elsewhere, in infancy, which really deserve
consideration are irritation from crystals of uric acid, sarcoma
of the kidney and scurvy. Tuberculosis of the kidney is
almost unheard of at this age, and, when present, the urine
DISEASES OF NUTRITION. 239
more often contains pus than blood. Vesical calculi are also
very unusual at this age and rarely cause hematuria at any
age unless the patient is very active. Irritation from uric
acid crystals can be ruled out in this instance on the examina-
tion of the urine. The absence of frequent and painful
micturition also make it improbable. The hematuria is
perfectly consistent with either sarcoma of the kidney or
scurvy. Pain is rare in sarcoma at this age, and constitutional
symptoms are usually absent until the tumor has attained
considerable size. Hematuria appears before the tumor is
palpable in about forty per cent of the cases. Hematuria
is not infrequently the earliest symptom of scurvy, appearing
before pain and tenderness in the extremities or sponginess of
the gums. An absolute diagnosis between sarcoma and scurvy
in this instance is, therefore, impossible. The chances are
very much in favor of scurvy, however, because of the much
greater frequency of scurvy than of sarcoma of the kidney,
the long continuance of the pasteurization of the milk, which
predisposes to the development of scurvy, and the loss of
appetite and failure to gain in weight, which usually precede
and are almost invariably associated with scurvy. The
chances are, in fact, so much in favor of Scurvy that it is
justifiable to make a positive diagnosis of this disease and to
consider sarcoma as merely an extremely remote possibility.
Prognosis. The prognosis is perfectly good. The bleeding
will almost certainly cease within a week under proper
treatment.
Treatment. The treatment is simple. It consists in stop-
ping the pasteurization of the milk and in giving an ounce of
orange juice daily. If it is inadvisable in any instance to omit
pasteurization because of an unreliable supply of milk or hot
weather, orange juice alone will cure the trouble.
24O CASE HISTORIES IN PEDIATRICS.
CASE 64. Margaret M. was the ninth child of healthy
parents. All the others, except one that had died at birth,
were alive. There was no history of tuberculosis in the family
and no known exposure to tuberculosis.
She was born at full term and was breast-fed for three
weeks, since when she had been fed on condensed milk.
The movements had always been green and loose. She had,
however, taken her food well, had not vomited and had
gained fairly well in weight. She began to vomit about the
middle of July and a week later began to have from five to
seven movements daily. These were watery, green or yellow
in color, had a foul odor and contained a few small curds and
considerable mucus. Blood was noticed once. She was ad-
mitted to the Children's Hospital August 7, when three
months old. Her temperature was then 1040 F., but, as the
result of treatment, dropped to normal the next day, where
it remained, except for a rise of temperature lasting two
days a few days later.
Physical Examination at entrance. She was poorly de-
veloped and much emaciated. There was moderate pallor.
The mouth and tongue were red and dry. The anterior fon-
tanelle was 3^ cm. in diameter and depressed. The bones of
the skull overlapped a little. There was no rosary. The
heart and lungs showed nothing abnormal. The abdomen
was sunken, but otherwise negative. The liver was palpable
3 cm. below the costal border in the nipple line. The spleen
was not palpable. The extremities showed nothing abnormal.
The knee-jerks were not obtained. The cervical lymph nodes
were slightly enlarged. A few dysentery bacilli were found
in the stools.
Under careful treatment and feeding the vomiting and
number of movements diminished and their character steadily
improved, so that on August 17 she was having two pasty,
yellow movements daily. She took her food well and did not
vomit. At that time she was taking twelve feedings of two
ounces of a mixture containing 2% of fat, 5% of sugar, 0.25%
of whey proteids and 0.25% of casein. Her weight, however,
had fallen from five pounds and fourteen ounces to five
pounds and eight ounces. Her general condition was, if
DISEASES OF NUTRITION. 24I
anything, worse than a few days before. The amount of food
was increased to two and one-half ounces on the 18th, while
the fats were increased to 2.50% and the sugar to 6% on the
19th. She took her food well and did not vomit, but con-
tinued to have from two to four perfectly normal movements
daily. In spite of this, however, she continued to lose about
one ounce daily, so that on the 21st she weighed but five
pounds and four ounces.
Diagnosis. The physical examination shows nothing ab-
normal except the signs of malnutrition. It gives no clew as
to its cause. The striking thing in the history is the pro-
gressive loss of weight without any symptoms of indigestion
or fever. The trouble is undoubtedly a recent one and the
result of the mild attack of infectious diarrhea, since the baby
had previously done fairly well. The only two conditions
which need to be considered are starvation and infantile
atrophy. The food taken August 17 gave 115 calories and
1.4 grams of proteid per kilo, and that taken August 19, 160
calories and 1.6 grams of proteid per kilo, more than enough
to cover both the caloric and proteid needs. Starvation can,
therefore, be ruled out. The picture corresponds exactly
to the definition of Infantile Atrophy, a condition in which
there is a progressive loss of weight in spite of a sufficient
intake of food, there being at the same time no symptoms of
disturbance of the digestion.
Prognosis. The prognosis is practically hopeless unless
the baby can get human milk. The chances are not very good
if she can, because there is a strong probability that the dis-
turbance of metabolism has gone so far that she will not be
able to utilize even human milk.
Treatment. The only treatment which offers any reason-
able chance of recovery is human milk. She must have it
at any cost. There is no other food which is worthy of con-
sideration in this instance. There is nothing to be hoped
from medicinal treatment.
SECTION V.
SPECIFIC INFECTIOUS DISEASES.
CASE 65. Bessie F. was born November 21, 1894. She
was seen in consultation May 10, 1900. Both her parents
had died of pulmonary tuberculosis during the previous year.
She had lived with them up to the time of their death. One
brother, six years old, was well. There had been no other
children.
She had measles when two years old and was said to have
had influenza in February, 1900. She began to complain of
pain in the abdomen about the first of March, 1900. The
pain continued for several weeks and then ceased. Swelling
of the abdomen was noticed about the middle'of March and
had slowly but steadily increased. Her appetite was good.
She vomited after breakfast, however, two or three times a
week. Her diet was a reasonable one for her age. Her bowels
moved once in two or three days. The character of the move-
ments had not been noted. She had had a cough during the
day for about a month. She had lost both flesh and color.
Physical Examination. She was well-developed and fairly
nourished, but somewhat pale. She was bright and happy.
Her tongue was moist and moderately coated. The heart
was normal. There was slight dullness in both backs below
the eighth space, with normal but somewhat diminished
respiration and voice sounds. Fine, crackling, moist rales
were occasionally heard in the dull area. The upper border of
the liver flatness in the nipple line was in the fourth space.
The lower border of flatness was 3 cm. above the costal border.
The splenic dullness could not be determined. The edge of
the spleen was not felt. The abdomen was much enlarged
and the walls were tense. The distention was uniform. There
was no enlargement of the superficial abdominal veins.
There was dullness in the lower portion and in both flanks.
243
244 CASE HISTORIES IN PEDIATRICS.
While the child lay on her back the upper line of dullness was
concave. The rest of the abdomen was tympanitic. The
area of dullness changed with change of position. A fluid
wave was present. There was no edema of the extremities or
of the face. There was no enlargement of the superficial
lymph nodes. The rectal temperature was 990 F. ; the pulse,
120. The urine showed nothing abnormal; the blood was
not examined.
Diagnosis. The principal abnormality observed in the
physical examination is the presence of fluid in the abdominal
cavity. Both borders of the liver are higher than they should
be, while the total width of the liver flatness is normal, show-
ing that the liver is merely displaced upward by the pressure
of the fluid in the abdomen. The absence of the splenic
dullness is presumably due to its displacement upward and
backward. The rales show that the dullness and diminished
respiration and voice sounds in the lower backs are not due
to fluid in the pleural cavities. They are satisfactorily ex-
plained by the displacement of the liver upward and the
consequent compression and congestion of the lower portions
of the lungs. This condition also explains the cough.
The dullness in the flanks, the concavity of the upper border
of the dullness, when she lies on her back, and the change of
the area of dullness with change of position prove that the
fluid is free in the abdomen and not confined in an ovarian
or other cyst.
Free fluid in the abdominal cavity may be due to causes
either within or without the cavity. When due to causes
outside of the abdominal cavity, there is usually edema of
other parts of the body and, if the trouble is in the heart, the
signs of passive congestion in other organs. The absence of
edema and of the signs of passive congestion and the normal
condition of the heart and urine rule out all causes outside of
the abdomen in this instance.
The possible causes located within the abdomen are those
diseases and conditions which result in portal congestion and
diseases of the peritoneum. The two causes of portal con-
gestion are disease of the liver and compression of the portal
vein. The absence of enlargement of the spleen and of the
SPECIFIC INFECTIOUS DISEASES. 245
superficial abdominal veins makes portal congestion very
improbable. The normal size of the liver practically excludes
disease of this organ. The age of the child is also much against
any chronic disease of the liver. The absence of an alcoholic
or syphilitic history and of all signs of syphilis, the two most
common causes of chronic disease of the liver at this age,
makes disease of the liver still more improbable. Compression
of the portal vein is usually due to a new growth of some sort,
usually enlarged lymph nodes, they, in turn, usually being
tubercular. In the light of the prolonged exposure to tuber-
culosis, a tubercular infection of the abdominal lymph nodes
is not at all unreasonable in this instance and cannot be
excluded on the negative physical examination, because an
enlarged lymph node, too small to be palpable, can, if located
in the right place, exert much pressure on the portal vein.
As already explained, however, the absence of enlargement of
the spleen and of the superficial abdominal veins makes
portal congestion very improbable.
The diseases of the peritoneum to be considered are chronic
serous peritonitis, malignant disease of the peritoneum and
tubercular peritonitis. There is much doubt as to whether
there is such a disease as chronic serous peritonitis. If there
is, it almost never occurs before puberty. Malignant disease
of the peritoneum is extremely rare, almost always results in
palpable tumors and is accompanied by greater cachexia than
is present in this instance. Both of these conditions can be
excluded, therefore, if any other more reasonable explanation
can be found. Tubercular peritonitis of the ascitic form is
not at all uncommon at this age; the onset and progress of
the illness in this instance are most characteristic of this
disease; the prolonged exposure to tuberculosis makes a
tubercular infection very probable. The diagnosis of Tuber-
cular Peritonitis seems, therefore, amply justified.
An examination of the ascitic fluid will aid' materially in
confirming the diagnosis. The fluid from portal congestion
is a transudation; that from disease of the peritoneum, an
exudation. In the former the specific gravity of the fluid is
below 1,015 and it usually contains less than 2% of albumin,
while in the latter, the specific gravity is above 1,015 and it
246
CASE HISTORIES IN PEDIATRICS.
usually contains more than 4% of albumin. The cells in a
transudation are usually few and endothelial in character.
The fluid in tubercular peritonitis usually contains many
cells, and these are largely lymphocytes. Characteristic
tumor cells are not infrequently found in the fluid when there
is malignant disease of the peritoneum. Tubercle bacilli
may often be found in the fluid in tubercular peritonitis, and
animal inoculations are almost always positive. The diagno-
sis of tubercular peritonitis is, however, justified in this
instance without an examination of the fluid.
A skin tuberculin test would be of interest in this child, but
not of great aid in diagnosis. If positive, it merely shows that
the child has a tubercular focus somewhere, not that the
trouble in the abdomen is tubercular, although it is, of course,
important corroborative evidence. If negative, it does not
prove that the trouble in the abdomen is not tubercular,
because the test is often negative when the tuberculosis is
of the miliary type, as it is in this instance.
Prognosis. Favorable points in this instance are the
unusually good general condition, the absence of fever and
of evidences of tuberculosis elsewhere. Her chances of re-
covery are probably about even, provided she can have proper
treatment.
Treatment. The author does not believe in a routine
operative treatment in this disease, even in the ascitic form,
and does not think that, on the whole, the cases that are
operated on do any better than those that are not. He
believes in leaving the fluid alone unless it is causing too
much discomfort or doing harm by the compression of other
organs. He then believes in tapping rather than in opening
the abdomen, leaving the latter as the last resort when the
abdomen fills up rapidly after tapping. The treatment as
regards the ascites is, therefore, in this instance, expectant.
The further treatment is that of tuberculosis in general:
an out-of-door life, day and night; quiet and forced feeding.
There is no indication for drugs.
SPECIFIC INFECTIOUS DISEASES. 247
CASE 66. Mary D., seven years old, was the child of
healthy parents. Three other children were well and one had
died at birth. There was no tuberculosis in the family and no
known exposure to tuberculosis.
She was born at full term after a normal labor. She was
nursed for eight months and did very well. During her fourth
year she had had diphtheria, measles, whooping-cough and
chicken pox, and was not in very good health during the next
year. Since then she had been very well indeed.
She was taken suddenly sick July 30 with a pain in the
abdomen, but did not go to bed. The next day she vomited
everything she took except water, and the pain continued.
The pain and vomiting were worse on August 1 and she
stayed in bed most of that day. She vomited the morning of
August 2, but had no pain. She had no pain and did not vomit
on the 3d and 4th, but stayed in bed. The bowels had moved
regularly; the character of the movements was not known.
She entered the Children's Hospital August 5.
Physical Examination. She was well developed and nour-
ished. She lay comfortably in bed and did not look acutely
sick. The pupils were equal and reacted to light and accom-
modation. There was no rigidity of the neck. There was
moderate pallor of the skin and mucous membranes. The
tongue was moist and covered with a thin white coat. The
throat was normal. The heart and lungs showed nothing
abnormal. The liver flatness extended from the upper border
of the sixth rib to the costal margin; the edge was not felt.
The upper border of splenic dullness was in the eighth space;
the edge was not felt. The abdomen was full and the walls
were held rigidly. Examination was difficult, deep palpation
being impossible. There were no rose spots. An indefinite
mass was felt above the symphysis pubis, extending one half
way to the umbilicus. This mass was still present after the
bladder had been emptied by catheterization. There was
also an indefinite resistance just above the right iliac crest.
There was dullness in this region and over the mass in the
hypogastrium. There was no shifting dullness and no fluid
wave. There was slight general tenderness throughout the
abdomen. The extremities showed nothing abnormal. There
248
CASE HISTORIES IN PEDIATRICS.
was no spasm or paralysis. The knee-jerks were not obtained.
The plantar reflexes were normal. There was no edema.
There was slight enlargement of the cervical lymph nodes.
Rectal examination showed nothing abnormal. The tem-
perature was 1020 F.; the pulse, 94; the respiration, 25.
Urine (drawn by catheter): Normal color, acid, 1,018, no
albumin or sugar. The sediment contained a few leucocytes
and a few fine granular and hyaline casts.
Blood: Leucocytes, 13,700.
Diagnosis. The points which are of value in the differential
diagnosis in this instance are an acute abdominal affection
of five days' duration ; the good general condition ; a definite
tumor in the hypogastrium when the bladder is empty; an
indefinite resistance and dullness above the right iliac crest;
the negative rectal examination; and the slight degree of
the leucocytosis.
The only diseases which are really worthy of consideration
are appendicitis, some disease of the female pelvic organs
and tubercular peritonitis. The urine shows merely a mild
degenerative nephritis, which is of no importance either in
diagnosis or in prognosis. The fever is consistent with all of
these diseases and is, therefore, of no aid in the differential
diagnosis.
The history is much more suggestive of appendicitis than
of the other conditions. Against it are the good general
condition in spite of the tumor in the abdomen, the location
of the tumor, the presence of another indefinite mass, the
negative rectal examination .and the slight degree of the
leucocytosis.
The location of the tumor is consistent with some inflam-
matory process in the female pelvic organs. Against this
diagnosis are the extreme rarity of inflammatory processes
in these organs at this age, the location of the other indefinite
mass, the negative rectal examination (which at this age
amounts to a vaginal examination), and the slight degree of
the leucocytosis.
In favor of tubercular peritonitis is the presence of two
masses, presumably due to the same cause, which do not
correspond to the findings in any other condition and which
SPECIFIC INFECTIOUS DISEASES. 249
are consistent with the lesions found in tubercular peritonitis.
The fact that these masses cannot be felt on rectal examina-
tion is not inconsistent with the location of the tumors in
tubercular peritonitis, but is with that of the tumors of ap-
pendicitis and inflammatory processes in the pelvic organs.
The slight degree of the leucocytosis is also consistent with
tubercular peritonitis. The absence of a family history of or
exposure to tuberculosis and the acuteness of the onset may
be urged against the diagnosis of tubercular peritonitis. A
tubercular family history is, however, of little or no impor-
tance either for or against tuberculosis unless there has been
exposure. The absence of a history of exposure to tuberculo-
sis does not count in any way against tuberculosis, although,
of course, a history of exposure points strongly toward it.
The history of measles and whooping-cough in the past,
both of which are known to predispose to the development of
tuberculosis, is of some importance in this instance. An
onset as acute as in this instance is unusual, but not un-
common enough to count much against the diagnosis of
tubercular peritonitis. The good general condition is more
consistent with this disease than with the others under con-
sideration. The diagnosis of Tubercular Peritonitis is,
therefore, justified. It is undoubtedly of the Caseous or
fibrocaseous type.
Prognosis. The prognosis in this type of tubercular
peritonitis is not nearly as good as in the ascitic form. She
probably has about one chance in three of recovery.
Treatment. Operation cannot possibly do any good in this
instance. The masses are too extensive to be removed, and
opening the abdomen cannot of itself be of any benefit. The
further treatment is that of tuberculosis in general; an out-
of-door life day and night, quiet and forced feeding. There
is no indication for drugs.
250 CASE HISTORIES IN PEDIATRICS.
CASE 67. Olga R., seven years old, was the fourth child
of healthy parents. The other children were well and there
had been no miscarriages. There was no history of tuber-
culosis in either family and there had been no known exposure
to it. She was nursed for ten months and was very well
until she had the diphtheria, when four years old. She had
not been as vigorous since then, but had had no illnesses,
except a primary pleurisy with effusion a year before.
She began to cough a little, early in July. She did not
seem sick, however, until two weeks later, when she became
somewhat feverish and lost her appetite. The fever gradu-
ally increased and after four days she 'went to bed and re-
mained there. The fever had continued, but the cough
had diminished. She had perspired freely at night, but
had had no chills. Her appetite had been very poor.
She had vomited twice the night before. The bowels had
moved daily without help and the stools had appeared
normal. She had complained of pain in the abdomen for
several days. She was admitted to the Children's Hospital,
August 5.
Physical Examination. She was well developed but poorly
nourished. Her skin was somewhat pale, but the mucous
membranes were of good color. She was perfectly clear
mentally. The pupils were equal and reacted to light.
Her tongue was moist and covered with a thick, white coat.
The heart was normal. There was slight dullness with
slightly diminished but vesicular respiration on the left side
below the fifth rib in the mid-axillary line and the eighth in
the scapular line. There was no change in the vocal resonance
or tactile fremitus and no friction rub nor rales were heard.
The liver was not palpable. The upper border of the splenic
dullness was at the ninth rib, the edge was not palpable.
The level of the abdomen was slightly below that of the
thorax. It was everywhere tense and generally tender.
The muscular spasm and tenderness were, however, most
marked in the right lower quadrant. The abdomen was
tympanitic throughout and no masses could be felt. There
were no rose spots. There was no spasm or paralysis, but she
lay with her legs drawn up. The knee-jerks were equal and
SPECIFIC INFECTIOUS DISEASES. 25 1
normal. Kernig's sign was absent. There was no enlarge-
ment of the peripheral lymph nodes. The rectal examina-
tion showed nothing abnormal. The rectal temperature was
103. 8° F. ; the pulse, 148; the respiration, 40.
The urine was normal in color, turbid, acid in reaction,
of a specific gravity of 1026, and contained no albumin or
sugar. The sediment consisted of amorphous urates and a
few small, round cells.
The leucocytes numbered 11,700.
The Widal test was negative.
Diagnosis. The absence of rose spots and enlargement of
the spleen, together with the negative Widal reaction after
two weeks, the frequent pulse and the sunken, rigid abdo-
men rule out typhoid fever. Appendicitis is strongly sug-
gested by the greater intensity of the muscular spasm and
tenderness in the right lower quadrant. The duration of the
illness before the onset of pain in the abdomen and vomiting,
the regular action of the bowels, the absence of dullness and
tumor in the right iliac fossa and the negative rectal exami-
nation are very much against it. The most important point
against it, however, is the normal white count, an increase
in the number of white cells being a constant accompaniment
of appendicitis, unless the system is overwhelmed by the
toxemia. The good general condition shows that this is
not the case in this instance. Appendicitis can, therefore,
be excluded. The low white count in combination with the
good general condition also rules out all forms of septic
general peritonitis.
There is, nevertheless, evidently some extensive inflam-
matory process going on in the abdomen, almost certainly
in the peritoneum. The only acute general disease of the
peritoneum which is not accompanied by leucocytosis, pro-
vided that the patient is not overwhelmed by toxemia, as
this child is not, is tuberculosis. The diagnosis of Tuber-
cular Peritonitis is, therefore, a reasonable one, and seems
warranted by the facts. The history of the primary serous
pleurisy, which, in childhood as in later life, is almost inva-
riably tubercular, is another point in favor of this diagnosis.
The dullness and diminished respiration in the lower left
252 CASE HISTORIES IN PEDIATRICS.
back and axilla are probably due to thickening of the pleura
as the result of this illness.
Prognosis. She is not in any immediate danger. The
acuteness of the symptoms will probably last but a short
time, after which the course and prognosis will be that of
tubercular peritonitis in general. The fact that there has
also been a tubercular infection of the pleura in this instance
renders her chances of recovery rather less favorable than the
average.
Treatment. There is at present no indication for a laparo-
tomy. She must be kept quiet in bed, given a maximum
amount of fresh air and sunlight and fed carefully. Her diet
for the present should consist of milk, broth, cereals, milk
toast, baked custard and junket. The temperature is not
high enough to require special treatment. There is at
present no indication for the use of stimulants.
SPECIFIC INFECTIOUS DISEASES. 253
CASE 68. Frank S. was the only child of healthy parents.
He had always been breast-fed and had never had any dis-
turbance of the digestion. He lived during the first two
months of his life in a house with a young man who had
pulmonary tuberculosis and had since died of it. The young
man had, however, not been much with him. He was well
until he was a little over five months old, when he had what
was called bronchopneumonia. He did not recover well from
this illness and the cough continued. He had lost weight
and strength rapidly during the last month. He was ad-
mitted to the Infants' Hospital when eight months old.
Physical Examination. He was fairly developed and
nourished and somewhat pale. The anterior fontanelle was
two cm. in diameter and slightly depressed. The bones of the
skull overlapped a little. The mouth and throat were nor-
mal. He had no teeth. There was a moderate rosary. The
heart was normal. There was dullness in the left front above
the fourth rib and in the back above the spine of the scapula.
The sense of resistance was not markedly increased. The
respiration was nowhere normal in this area, being in some
places bronchial and in others bronchovesicular. The voice
sounds were increased. There was no change in the tactile
fremitus. There were numerous fine, medium and coarse,
high-pitched, moist rales in this area. There was an occa-
sional fine, moist rale in both lower backs. The right lung
was otherwise normal. The abdomen was sunken, but
showed nothing else abnormal. The lower border of the
liver was just palpable below the costal border in the nipple
line. The spleen was not palpable. The extremities and
genitals were normal, as were the deep reflexes. There was
a general slight enlargement of the peripheral lymph nodes.
The rectal temperature was 98. 6° F. ; the pulse, 120; the
respiration, 30. He weighed eleven and one-half pounds.
Diagnosis. The only abnormal physical signs outside of
those in the lungs are the rosary and the general evidences of
malnutrition. The rosary being the only sign of rickets, it is
fair to conclude that the rickets is an unimportant factor. It
is also reasonable to assume that, since he has always been
nursed and has never had any disturbance of digestion, the
254 CASE HISTORIES IN PEDIATRICS.
disturbance of the nutrition is due to the trouble in the lungs.
The fine, moist rales at the bases of the lungs behind are
undoubtedly due merely to defective expansion of the lungs.
The signs at the left apex are those of partial solidification.
This may be due to a chronic bronchopneumonia or to tuber-
culosis. The long duration of the symptoms, the localiza-
tion of the signs in one spot, the absence of evidences of
bronchitis and the normal temperature are much against
bronchopneumonia and in favor of tuberculosis. The history
of a definite exposure to tuberculosis during the first two
months of his life makes the diagnosis of Pulmonary Tuber-
culosis almost certain. An absolutely positive diagnosis
is impossible, however, on this data. It should be confirmed
by an examination of the sputum or a skin tuberculin test.
The failure to find tubercle bacilli in the sputum will not
exclude tuberculosis, because it is often very difficult to get
a satisfactory sample in infancy. A negative tuberculin test
will practically rule it out, while a positive test at this age is
almost certain proof that the suspected lesion is tubercular.
Prognosis. The prognosis of pulmonary tuberculosis at
this age is hopeless. He will probably live for three or four
months, unless the process becomes disseminated, when he
will die in a few weeks.
Treatment. There is no medicinal treatment. Human
milk, which he is now getting, is the best food for him. He
must be given all the fresh air and sunlight possible. Further
than this, nothing can be done.
SPECIFIC INFECTIOUS DISEASES. 255
CASE 69. Elizabeth N. was an only child. Her mother
was well, but her father had "bronchitis and pleurisy" and,
being unable to work, remained at home to take care of her
while her mother went out to work. She was nursed for
three months, after which she was fed on condensed milk.
She had never had any disturbance of the digestion, but dur-
ing the last few weeks her appetite had been very poor.
She began to cough when five months old. She was treated
in the wards of the Children's Hospital for ten days, when
six months old, for what was thought to be bronchopneu-
monia. When she was discharged the lungs were normal
except for slight dullness in the lower left back. Her tem-
perature had been normal for five days. She was readmitted
to the Children's Hospital when she was eight months old.
The cough had persisted, being worse during the last two
weeks. She had recently lost weight very rapidly.
Physical Examination. She was poorly developed and
nourished, pale and feeble. The anterior fontanelle was one
and one-half cm. in diameter and sunken. The bones of
the skull overlapped. The throat was slightly reddened and
the tongue slightly coated. She had two teeth. There was
a slight rosary. The right border of the cardiac dullness
was two cm. to the right of the median line; the left and
upper borders could not be determined because of the dull-
ness in the left chest. The action was regular and the sounds
normal. The left side of the chest moved less than the right.
There was marked dullness over the whole left side, except
between the spine of the scapula and its angle, where the
percussion note was flat. The sense of resistance was some-
what, but not markedly, increased. The respiration was
everywhere diminished, in places being bronchial, in others
bronchovesicular in character. There was a small area at
about the middle of the scapula where it was amphoric.
The voice sounds were loud and bronchial in the flat area;
diminished, but changed in character, elsewhere. The tactile
fremitus was somewhat increased, especially in the flat area.
A few medium and coarse moist rales were heard both in
front and behind. There were also many fine and medium
moist rales in the right back. The abdomen was a little
256 CASE HISTORIES IN PEDIATRICS.
full, but otherwise normal. The liver was just palpable in
the nipple line. The spleen was not palpable. The epiph-
yses at the wrists and ankles were slightly enlarged and
there was moderate clubbing of the fingers and toes. The
peripheral lymph nodes were slightly enlarged. The rectal
temperature was 990 F.; the pulse, 140; the respiration, 55.
The leucocyte count was 35,500.
Diagnosis. There can be no doubt from the examination
of the chest that there is more or less complete solidification
of the whole left lung and, judging from the amphoric res-
piration, a small cavity at about its middle. There is also a
bronchitis on the right side. There are no evidences of an
accumulation of fluid. It is safe to conclude from the long
duration of the symptoms, the emaciation without disturb-
ance of the digestion and the clubbing of the fingers and toes
that the condition is a chronic one. The only disease which
at this age can cause such extensive solidification with cavity
formation, limited to one lung, is tuberculosis. Further evi-
dence in favor of tuberculosis is the father's illness, which is
almost certainly tuberculosis. There is, therefore, every
reason why she should have tuberculosis. The large number
of white cells does not count against it, because at this stage
there is almost invariably a secondary infection with the
pus organisms. The enlargement of the peripheral lymph
nodes does not count either for or against tuberculosis, be-
cause enlargement of the peripheral lymph nodes occurs in
all disturbances of nutrition in infancy. The diagnosis of
Pulmonary Tuberculosis is, therefore, the only one possible.
The rosary and the enlargement of the epiphyses show that
she also has a mild grade of rickets.
Prognosis. The prognosis is absolutely hopeless. She
probably will not live more than a week.
Treatment. The treatment can be only symptomatic.
SPECIFIC INFECTIOUS DISEASES. 257
CASE 70. Elizabeth D. was 12 years old. Her father
died of pulmonary tuberculosis before she was born. Her
mother continued to live in the same house. Her only
brother died of diabetes mellitus when he was ten years old.
She had measles and mumps when four months old and had
trouble with her digestion for a time when she was ten years
old. She had always been tall and slight and rather easily
tired. She had had a dry cough for three months, which
was more troublesome during the day than at night. She
had had no pain in her chest and had raised almost nothing.
Her mother thought that she had been a little feverish in the
late afternoon and early evening. Her appetite was good
and she had no disturbance of the digestion. She had not
been weighed for some months, but her mother thought that
she had lost a little weight.
Physical Examination. She was tall and slight, but of
good color and did not look sick. She breathed quietly with
her mouth shut. The throat was normal, the tongue nearly
clean. The right chest moved somewhat less than the left
and the respiratory sound was diminished over the whole of
the right side. There was dullness with bronchovesicular res-
piration (more nearly bronchial than vesicular), prolonged
expiration, increased spoken and whispered voice, increased
fremitus and an occasional high-pitched moist rale at the
right apex in front above the third rib. The heart was
normal. The liver and spleen were not palpable. The
abdomen and extremities were normal. There was no en-
largement of the peripheral lymph nodes. The mouth
temperature was 99.40 F. She weighed, with her clothes,
eighty- three pounds (average is 78.7 pounds).
Diagnosis. The slow onset of the symptoms and the signs
of partial solidification at the right apex, together with the
slight fever and the history of exposure to tuberculosis in
infancy, present such a characteristic picture of the develop-
ment and early stage of Pulmonary Tuberculosis, as it
occurs in later childhood, that there can be no doubt as to
the diagnosis. The only other possibility is a local infection
of the lung by the influenza bacillus. This is not at all
probable but, in order to make the diagnosis positive, the
258 CASE HISTORIES IN PEDIATRICS.
sputum should be examined and the skin tuberculin test
tried. The finding of tubercle bacilli in the sputum will
make the diagnosis absolute; a positive tuberculin reaction
will be only corroborative evidence.
Prognosis. The area of lung involved is comparatively
small, she is in good general condition, her appetite and
digestion are good, she has the reparative power of growth
to help her. The chances are, therefore, if she has proper
treatment, much in favor of recovery.
Treatment. The treatment of pulmonary tuberculosis at
this age is essentially the same as in adult life. She must
leave school and devote all her energies to getting well.
She should live out of doors day and night and for the pres-
ent keep as nearly absolutely quiet as possible. She should
have three regular meals daily and milk and eggs between
them. There is no indication for drugs except possibly for
some simple sedative, like chloroform water, to control the
cough.
SPECIFIC INFECTIOUS DISEASES. 259
CASE 71. Margaret M. was admitted to the Infants'
Hospital when 18 months old. She had lived with her mother
up to the time of the latter's death from pulmonary tuber-
culosis, a year before. She had been boarded out since then
and the woman who brought her knew practically nothing as
to her history. During the first two weeks of her stay in the
hospital she took her food fairly well, did not vomit and had
regular, somewhat constipated, but well digested movements.
She lost three-quarters of a pound during this time. Her
temperature varied irregularly between ioo° F. and 103. 50 F.,
her pulse between 120 and 140, and her respiration between
45 and 50. The subcutaneous tuberculin test was not tried,
because of the elevated and irregular temperature. The skin
tuberculin test was unknown at that time.
Physical Examination. She was poorly developed and
nourished and moderately pale. The anterior fontanelle was
three cm. in diameter and depressed. She had five teeth.
The mouth and throat were healthy. She was able to sit up,
but the spine showed a marked curve of weakness. There
was a very slight rosary. The heart was normal, except for a
soft, systolic murmur at the base. There was a venous hum
in the neck. There was slight dullness with increased bron-
chovesicular respiration, slightly increased voice sounds and
an occasional high-pitched moist rale in the left front above
the third rib. The lungs were otherwise normal. There was
no dullness between the scapulae, but the bronchial voice was
heard as low as the fourth dorsal spine. The lower border of
the liver was palpable one cm. below the costal border in the
nipple line. The spleen was not palpable. The level of the
abdomen was that of the thorax. Nothing abnormal was
detected in it. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's sign was absent. There was a general slight en-
largement of the peripheral lymph nodes. She weighed ten
and one-half pounds.
The urine was pale, acid in reaction, of a specific gravity
of 1010 and contained neither albumin nor sugar.
26o case histories in pediatrics.
Blood.
Hemoglobin, 52%
Red corpuscles, 4,528,000
White corpuscles, 13,800
Small mononuclears, 12%
Large mononuclears, 7%
Polynuclear neutrophils, 80%
Eosinophiles, 1%
There was considerable variation in the size of the red cells
and slight irregularity in their shape and color. No nucleated
red cells were seen while counting 250 leucocytes.
Diagnosis. The changes in the blood are characteristic of
secondary anemia. The murmur at the base of the heart
and the venous hum in the neck are undoubtedly due to the
anemia. The absence of all evidences of indigestion during
her stay in the hospital, although she lost weight rapidly
during this time, shows that the malnutrition is not due to
any disease of the gastro-intestinal tract. Infantile atrophy
would have to be considered, if it were not for the fever and
signs in the lung. The rosary, which is the only positive
sign of rickets, is so slight that it is evident that the rickets
is merely another evidence of the disturbance of nutrition.
The signs at the left apex and the fever suggest broncho-
pneumonia. The disturbance of nutrition is, however, un-
doubtedly of long duration, there are no other foci in the
lungs, no evidences of bronchitis and almost no leucocytosis.
A tubercular infiltration will explain the physical signs at the
left apex equally well, and, when the prolonged exposure to
tuberculosis during the first six months of her life is taken
into consideration, seems much more probable. The dis-
turbance of nutrition is, however, greater than would be
expected from the limited extent of the process in the lungs
and suggests the presence of tuberculosis elsewhere. The
bronchial voice sound over the upper dorsal spines shows that
there is enlargement of the tracheo-bronchial lymph nodes.
Enlargement of these nodes is so seldom due to anything but
tuberculosis that it is safe to conclude that they are tuber-
cular in this instance. There is no positive evidence of
tuberculosis elsewhere, the peripheral lymph nodes being
SPECIFIC INFECTIOUS DISEASES. 26 1
enlarged so commonly in all disturbances of nutrition in
infancy that it is impossible to tell whether they are or are
not tubercular. The disturbance of nutrition is so marked,
however, and the tendency to dissemination is so great in
infancy, that it is safe to assume that there are other foci of
tuberculosis in the body and that the process, instead of being
simply a local one in the lungs, is a Chronic Diffuse Tuber-
culosis.
Prognosis. The prognosis is absolutely hopeless. She
probably will not live more than two or three weeks.
Treatment. Nothing whatever can be done for her except
to make her as comfortable as possible.
2^2 CASE HISTORIES IN PEDIATRICS.
CASE 72. George G., three years old, was the child of
healthy parents. One other child was well and one had died
of cerebrospinal mermgitis " caused by a fall." There had
been no miscarriages. There was no tuberculosis in the family
and no known exposurt to tuberculosis. He had always been
perfectly well.
It was noticed on September 4 that his appetite was poor
and that he seemed dull, sleepy and tired. He continued in
this condition, although up and about the house, until Sep-
tember 10, when he went to bed. He vomited in the night
and the next day seemed decidedly worse and began to com-
plain of pain in the abdomen. That night he became restless,
threw his head back on the pillow and " kicked out with his
feet." He also became very cross and irritable. The irri-
tability continued, but he remained conscious. He vomited
again on September 12. The bowels were constipated from
the beginning, moving only with enemata. The pain in the
abdomen continued. He made no complaint of headache.
Strabismus appeared on September 14 and persisted. That
night he began to cry out as if in pain. This symptom con-
tinued. He was admitted to the Children's Hospital
September 16.
Physical Examination. He was fairly well developed and
nourished, but looked sick. He was dull mentally but con-
scious. He could not speak plainly, but was able to make his
wants known. He was irritable and cried out occasionally
as if in pain. There was double convergent strabismus.
He was able to see. The pupils were dilated and equal, but
did not react to light. There was no discharge from the nose
or ears. The lips were red and cracked. The tongue was
dry and covered with a moderate brown coat. The tonsils
were slightly reddened and prominent. There was no herpes.
The heart and lungs showed nothing abnormal. The level of
the abdomen was below that of the thorax; there was no
definite muscular spasm; it was tympanitic and not tender;
no masses were made out. The upper border of the liver
flatness was at the upper border of the fifth rib ; the edge was
palpable 3 cm. below the costal border in the nipple line.
The spleen was not palpable. There were no rose spots or
SPECIFIC INFECTIOUS DISEASES. 263
petechia?. The head was not held backward, but there was
slight rigidity of the neck and complete flexion was resisted
and caused pain. There was no spasm or paralysis of the
extremities. The knee-jerks were normal and equal. Ker-
nig's and Babinski's signs were absent. There was no ankle
clonus. Sensation to pain was normal. There was no en-
largement of the peripheral lymph nodes. The rectal tem-
perature was 1020 F., the pulse no (normal is 100), the
respiration 30. The urine was high-colored, strongly acid,
of a specific gravity of 1,026, and contained neither albumin
nor sugar. The blood showed 23,000 leucocytes.
Diagnosis. The early history suggests nothing more than
a disturbance of digestion. The completed history points
strongly to meningitis, although typhoid with symptoms of
meningeal irritation is a possibility. The strabismus, the
dilated and reactionless pupils, the slight rigidity of the neck
and the pain on motion, the absence of enlargement of the
spleen and of rose spots and the leucocytosis are sufficient,
when taken together, to positively rule out typhoid. The
absence of retraction of the head and of marked rigidity of
the neck, of spasm or paralysis of the extremities and of
Kernig's and Babinski's signs, as well as of changes in the
knee-jerks, is somewhat unusual, but not enough so to count
materially against meningitis. The relatively low pulse is
consistent with either condition. The diagnosis of menin-
gitis is, therefore, certain.
The diagnosis of meningitis, however, is not sufficient. It
is necessary to go further and to determine the kind of menin-
gitis. When meningitis does not develop in the course of
some other acute disease it is practically invariably either
tubercular or cerebrospinal, and other types do not need
to be considered. The diagnosis in this instance, therefore,
lies between the tubercular and cerebrospinal forms. The
diagnosis between tubercular and cerebrospinal meningitis
in infancy and early childhood is often a very difficult one,
because most of the points which help in the diagnosis in later
childhood are so uncertain at this age that little dependence
can be placed upon them. In most cases, however, a very
probable diagnosis can be made.
264 CASE HISTORIES IN PEDIATRICS.
In this instance the absence of a tubercular family history
and of exposure to tuberculosis does not count at all against
tubercular meningitis or in favor of cerebrospinal meningitis.
The slow onset is in favor of the tubercular form, but does not,
by any means, rule out the cerebrospinal. The absence of
herpes and eruptions does not count against the cerebrospinal
form or in favor of the tubercular, because herpes and
eruptions are very unusual in cerebrospinal meningitis at
this age. Retraction of the head, marked rigidity of the
neck, spasm and paralysis of the extremities, Kernig's and
Babinski's signs, and changes in the pupils may be absent
in both, but are more often wanting in the tubercular
form. The leucocytosis is in favor of cerebrospinal menin-
gitis, but is not inconsistent with the tubercular form, in
which a leucocytosis sometimes occurs. The weight of the
evidence is, therefore, somewhat in favor of Tubercular
Meningitis, enough so, in fact, to justify this diagnosis.
There is, however, a reasonable possibility that the trouble
really is cerebrospinal meningitis. The only way in which an
absolute diagnosis can be made is by lumbar puncture.
Since lumbar puncture is a harmless procedure, and since
cerebrospinal meningitis can in most instances be cured by
the antimeningitis serum, a lumbar puncture should be done
at once in order that he may have the advantage of the serum
treatment if the disease is cerebrospinal meningitis instead
of tubercular meningitis, as it seems.
The normal cerebrospinal fluid is perfectly clear, like
distilled water, does not form a fibrin clot on standing, and
never contains more than 0.1% of albumin, or more than
twenty cells per cubic millimeter. The vast majority of these
cells are mononuclear. The fluid in tubercular meningitis is
usually slightly turbid, sometimes clear, rarely very turbid
or purulent, forms a fibrin clot on standing and contains more
than 0.1% of albumin and more than twenty cells per cubic
millimeter. The vast majority of these cells are mononuclear,
usually lymphocytes, the percentage varying from 80 to 98.
The proportion of polynuclear cells usually increases with the
progress of the disease. Tubercle bacilli can be found in the
fluid in about ninety per cent of the cases, if the examination
SPECIFIC INFECTIOUS DISEASES. 265
is careful enough. If the examination is hasty, they will
usually be missed. A fluid should never be passed as normal
because it appears clear when drawn. If a fibrin clot does not
form in twenty-four hours, tubercular meningitis can be
excluded. The fluid in cerebrospinal meningitis is usually
markedly turbid, often purulent, sometimes nearly clear,
forms a fibrin clot or a sediment of pus on standing, contains
more than 0.1% of albumin and several hundred cells per
cubic millimeter. The vast majority of these cells are poly-
nuclear, the percentage usually varying between 75 and 90.
The percentage of mononuclear cells gradually increases and
finally exceeds the polynuclear in cases which recover. The
meningococcus is almost invariably present in the acute
stage. Under normal conditions the cerebrospinal fluid
flows out slowly, drop by drop, while in both forms of menin-
gitis it usually, but not always, flows out more rapidly or
even spurts out.
The fluid obtained by lumbar puncture in this instance
was slightly cloudy, showed a definite fibrin clot in six hours,
and contained one hundred and twenty-five cells to the
cubic millimeter, 83% of which were lymphocytes. No
organisms were seen in the examination of one cover slip.
The diagnosis of tubercular meningitis is, therefore, verified
by the results of the lumbar puncture.
Prognosis. It is true that there are a few instances on
record of recovery from tubercular meningitis. These are,
however, so few in comparison with the vast number of fatal
cases that it is not justifiable to give anything but an abso-
lutely hopeless prognosis.
Treatment. There is no curative treatment for tubercular
meningitis. Repeated lumbar punctures will, however, often
relieve headache and other symptoms of increased cerebral
pressure, such as convulsions and twitching. It has no
effect on the progress of the disease, and is not indicated at
present in this instance. In spite of the hopeless prognosis,
he must be nursed and fed as if he were certain to get well.
If he will not swallow, he must be fed with a tube. Further
treatment must be symptomatic.
266 CASE HISTORIES IN PEDIATRICS.
CASE 73. Marion H., seven months old, was the second
child of healthy parents. There had been no deaths or
miscarriages and she had had no known exposure to tuber-
culosis. She was born at full term, after a normal labor, and
was normal at birth. She had always been nursed and had
had no illnesses, except an occasional "cold." She had been
restless and nervous when awake since April 14, but had
slept most of the time. She had nursed poorly, but had not
vomited. Her bowels were constipated. Several stools,
which were passed after she had taken castor oil, were green-
ish and contained curds and mucus, but no blood. She had
had some discharge from the nose and eyes since April 17.
She had had no convulsions, rigidity or twitching, and had
not coughed. Her mother thought that she had not been
feverish. She was admitted to the Infants' Hospital, April
19.
Physical Examination. She was well developed and
nourished, and of good color. Her head was of normal size
and shape. There was slight craniotabes. The posterior
fontanelle was not quite closed. The anterior fontanelle
was five cm. in diameter and bulged markedly. The ear
drums were normal. There was a purulent discharge from
the eyes. The pupils were equal and reacted to light, but
she did not notice. The nares were crusted. She had no
teeth. The mouth and throat were normal. There was no
rigidity or tenderness of the neck and no neck sign. There
was a marked rosary. The heart and lungs were normal.
The abdomen was sunken but not rigid; nothing abnormal
was detected in it. The liver was palpable two cm. below
the costal border in the nipple line. The spleen was not
palpable. The extremities were normal, except for slight
enlargement of the epiphyses at the wrists. She held her
arms a little rigidly. The knee-jerks were equal and lively.
Kernig's sign was absent, as was the contralateral reflex.
There was no enlargement of the peripheral lymph nodes and
no eruption. The rectal temperature was 1050 F. ; the pulse,
130; the respiration, 30.
The urine was of normal color, clear, acid in reaction and
contained neither albumin nor sugar.
SPECIFIC INFECTIOUS DISEASES. 267
Diagnosis. The history throws but little light upon the
diagnosis. Otitis media and pyelitis, which should always
be thought of in infancy when the symptoms are as indefinite
as in this instance, can be excluded on the normal condition
of the ears and urine. Pneumonia, which should be con-
sidered in spite of the absence of cough, can be ruled out
on the normal condition of the lungs and the fact that the
respiration is relatively slower than the pulse. The undi-
gested stools suggest to a certain extent disease of the digestive
tract. When it is remembered, however, that there are no
other symptoms of indigestion, that they appeared only after
a dose of castor oil and that undigested stools are the rule in
all serious illnesses in infancy, it is evident that the trouble
must be located elsewhere. The late appearance of the
discharge from the nose and eyes shows that these organs
were affected secondarily.
The craniotabes, the open posterior fontanelle, the large
size of the anterior fontanelle, the rosary and the enlargement
of the epiphyses at the wrists are all signs of rickets and have
no connection with the present illness. The one important
positive physical sign is the bulging of the anterior fontanelle.
This shows that there is an increase in the intracranial
pressure. The normal size and shape of the head and the
absence of separation of the bones of the cranium show that
this increase in pressure is not due to chronic internal hydro-
cephalus and that it is of recent development. For all
practical purposes, the only cause of an increase of intra-
cranial pressure sufficient to cause bulging of the anterior
fontanelle in infancy is meningitis. This sign is, of itself,
enough to warrant the diagnosis of meningitis, even if all
other signs of the disease are lacking. A positive diagnosis
of meningitis is, therefore, justified. The failure to notice
and the slight rigidity of the arms are corroborative evidence
of its correctness.
The meningitis in this instance did not develop in the course
of any other disease. It is, therefore, almost certainly either
tubercular or cerebrospinal. It is always difficult, and not
infrequently impossible, to make a diagnosis on the symp-
tomatology between these two forms in infancy. The slow
268 CASE HISTORIES IN PEDIATRICS.
onset and the absence of marked signs of cerebral irritation
are somewhat in favor, however, of the tubercular type. A
lumbar puncture must be done, nevertheless, to settle the
diagnosis, because of the possibility of cure by the use of the
antimeningitis serum, if it is caused by the meningococcus.
A lumbar puncture was done, and 20 cc. of very slightly
turbid fluid, under moderate pressure, allowed to run off.
This fluid formed a small fibrin clot and contained 80 cells
to the cubic mm., 90% of which were mononuclear. No
organisms were seen in the examination of one slide. (See
Case 72.) A positive diagnosis of Tubercular Meningitis
is thus warranted.
Prognosis. The prognosis is hopeless. (See Cases 72
and 74.) She probably will not live more than four or five
days.
Treatment. The treatment can be only symptomatic.
(See Cases 72 and 74.)
Opisthotonos in Meningitis.
SPECIFIC INFECTIOUS DISEASES. 269
CASE 74. Bessie M., eighteen months old, was the third
child of healthy parents. The two older children had died
in infancy, one of pneumonia, the other of infectious diarrhea.
There had been no miscarriages. She had not been exposed,
as far as known, to tuberculosis. She was born at full term,
after a normal labor, and was normal at birth. She had had
no illnesses, with the exception of an occasional "cold."
She was still on the breast, but took several feedings daily
of milk and barley water. There had been no indiscretion
in diet before the onset of her illness. She had an attack of
vomiting, followed by a convulsion, May 13. She had vom-
ited four or five times daily since then, but had had no more
convulsions. She was stupid after she came out of the con-
vulsion, however, and had so remained. There had been no
rigidity, twitching or retraction of the head at any time. She
had been given nothing but the breast since the onset of her
illness and had taken this very poorly since May 17. The
bowels had been somewhat constipated, but the stools were
well digested. She was admitted to the Infants' Hospital,
May 20.
Physical Examination. She had evidently lost much
weight. She was very pale, with a slight tinge of cyanosis
about the lips. She lay perfectly limp and almost never
moved. The anterior fontanelle was two cm. in diameter
and level. There was no rigidity or retraction of the neck
and no neck sign. The pupils were widely dilated and re-
acted but little to light. She did not notice. The ear drums
were normal, as were the mouth and throat. She had eleven
teeth. There was no rosary. The heart and lungs were
normal. The respiration was of the Biot type. The abdo-
men was much sunken, but not tense. Nothing abnormal
was detected in it. The liver and spleen were not palpable.
The extremities were normal. There was no spasm of the
extremities. She did not respond in any way to the prick
of a pin. There was, however, probably no paralysis, be-
cause she sometimes moved both her arms and legs. The
knee-jerks were absent, as was Kernig's sign and the contra-
lateral reflex. There was no enlargement of the peripheral
lymph nodes and no eruption. The vasomotor irritability
27O CASE HISTORIES IN PEDIATRICS.
of the skin was, however, much increased. The rectal tem-
perature was 1020 F.; the pulse, 170; the respiration, 50.
The urine was high in color, acid in reaction, of a specific
gravity of 1030 and contained neither albumin nor sugar.
The leucocytes numbered 10,000.
Diagnosis. The sudden onset with vomiting suggests
acute gastric indigestion. The absence of any indiscretion
in diet, the persistence of the vomiting in spite of an exclu-
sive diet of breast-milk, and the absence of all signs of intesti-
nal indigestion are, however, against this diagnosis. So also
is the stupidity, which is out of proportion to the severity of
the symptoms of gastric disturbance. The continued vom-
iting, the constipation and the stupidity are, moreover, con-
sistent with meningitis. Uremia, which in an older child
or an adult would also be suggested by these symptoms, is
very uncommon in infancy and can be excluded at once on
the normal condition of the urine. The widely dilated pupils,
the diminution in the reaction of the pupils to light, the
failure to notice, the Biot type of respiration and the in-
creased vasomotor irritability of the skin all point strongly
to meningitis. It is unusual, however, to have spasm, paral-
ysis, the knee-jerk, Kernig's sign, the neck sign, the contra-
lateral reflex and bulging of the fontanelle all absent in
meningitis. The absence of bulging of the fontanelle is espe-
cially strong evidence against it. The rapid pulse and res-
piration do not count against it, however, because, contrary
to the general belief, slowing of the pulse and respiration
occurs but seldom in meningitis in infancy. While bulging
of the fontanelle, if acute, is almost certain proof of men-
ingitis in infancy, the absence of bulging does not rule it
out, because the intracranial pressure is sometimes not in-
creased enough to bulge the fontanelle, especially if the
exudation is markedly purulent or gelatinous. In the so-
called flaccid type of tubercular meningitis, moreover,
flaccidity is the most prominent symptom and all signs of
cerebral irritation are, as in this instance, absent. In the
absence of all physical signs of any other disease, the diag-
nosis of meningitis seems justified. The sudden onset points
to the cerebrospinal type; the absence of leucocytosis, to
SPECIFIC INFECTIOUS DISEASES. 27 1
the tubercular form. Flaccidity and the absence of all evi-
dences of cortical irritation are less unusual in tubercular than
in cerebrospinal meningitis. A probable diagnosis of Tuber-
cular Meningitis of the flaccid type seems, therefore, a
reasonable one. A lumbar puncture should be done, how-
ever, to confirm the diagnosis (see Cases 72 and 73).
Lumbar puncture was done and ten cc. of a very slightly
turbid fluid, under low pressure, allowed to run out. This
fluid contained eighty cells to the cubic millimeter and formed
a fine fibrin clot. The cells were all lymphocytes. No organ-
isms were found on a hasty examination. The diagnosis of
tubercular meningitis is, therefore, correct.
Prognosis. The prognosis is hopeless (see Cases 72 and
73) . She probably will not live more than two or three days.
Treatment. The treatment can be only symptomatic (see
Cases 72 and 73).
272 CASE HISTORIES IN PEDIATRICS.
CASE 75. Girdham D., three years old, took rather a
long walk with his mother the afternoon of December 27,
which was a very cold and windy day. He had sausages for
supper, which was not an unusual occurrence, and went to
bed apparently perfectly well. He vomited several times
during the latter part of the night. A physician who saw him
the next morning found nothing abnormal on physical
examination. He cleaned him out with castor oil, gave him
bicarbonate of soda and limited his diet to broth and albumin
water. He did not vomit any more, had a comfortable day
and slept well the night of the 28th. He was a little stupid all
day on the 29th, but from time to time complained of head-
ache. In the afternoon the physician found that his neck was
a little stiff and that his pulse was irregular. The bowels had
not moved during the day. He was seen in consultation at
6 P.M.
Physical Examination. He was well developed and nour-
ished and of good color. He was somewhat stuporous but,
when roused, was rational, although irritable. Passive
movements of the neck were a little limited and caused some
pain. The neck sign was absent. The membranae tym-
panorum showed nothing abnormal. The pupils were equal
and reacted to light. There was no enlargement of the cervical
lymph nodes. The tongue was moderately coated, the throat
normal. The heart was normal, except that it was somewhat
irregular in force and rhythm. The lungs and abdomen
showed nothing abnormal. The liver and spleen were not
palpable. The extremities were normal. There was no spasm
or paralysis; the knee-jerks were equal and normal; Kernig's
and Babinski's signs were absent; there was no contra-
lateral reflex. The rectal temperature was 1010 F., the pulse
140.
Diagnosis. The only conditions to be considered in this
instance are intestinal toxemia and meningitis. The appear-
ance of the symptoms of disturbed digestion immediately
after the taking of improper food, following over-exertion and
exposure to cold, make toxemia the more probable. The only
things which really suggest meningitis are the persistence of
the symptoms after catharsis and limitation of the diet and
SPECIFIC INFECTIOUS DISEASES. 273
the slight rigidity of the neck. Disturbances of digestion and
toxemia not infrequently persist, however, after catharsis
and starvation, and symptoms of meningeal irritation are
not at all uncommon in intestinal toxemia. The slightly
stuporous condition, the irritability and the irregularity of
the pulse are consistent with either condition. The absence
of all physical signs of meningeal irritation, except the slight
rigidity of the neck, is strongly against meningitis, but does
not exclude it, because these symptoms are not infrequently
lacking for several days, or even longer, after the onset. The
chances seem very much in favor of intestinal toxemia, but
there is enough to suggest meningitis to justify a lumbar punc-
ture for diagnosis. This is a harmless procedure and, now
that cerebrospinal meningitis can usually be cured by the
antimeningitis serum, if it is administered Qarly, should be
done in every case in which there is a reasonable probability
of meningitis. The sudden onset and rather rapid develop-
ment of the stuporous condition suggest cerebrospinal
rather than tubercular meningitis, but they are not in-
consistent with the tubercular form at this age.
The fluid obtained by lumbar puncture was under high
pressure and very turbid. A large fibrin clot formed on
standing. The fluid contained 2,600 cells per cubic
millimeter. So many of the cells were broken down that a
differential count was impossible. There was, however, un-
doubtedly a large excess of polynuclear cells. Numerous
Gram-decolorizing diplococci were seen within the cells.
(See Case 72 for description of the normal cerebrospinal
fluid and of the fluid in meningitis.) The results of the exami-
nation of the fluid obtained by lumbar puncture justify, of
course, an absolute diagnosis of Cerebrospinal Meningitis.
Prognosis. The chances for recovery, if he is treated with
the antimeningitis serum, are better than even, because it
is less than forty-eight hours since the onset, the symptoms
are comparatively mild and the organisms are all within the
cells. This latter point shows that nature is making a fairly
successful struggle against the infection.
Treatment. Another lumbar puncture must be performed
as soon as the antimeningitis serum can be secured. All the
274
CASE HISTORIES IN PEDIATRICS.
fluid that will run out must be allowed to escape. An equal
amount of serum must then be introduced through the same
needle, provided that 30 ccm. or more has run out. If less
than that has been obtained, 30 ccm. must still be given, un-
less undue resistance is met in giving this amount. This, or
a larger dose, according to the amount of fluid which escapes,
must be repeated daily until no micro-organisms can be
found in smears made from the fluid. If the temperature
remains much elevated or the symptoms are not improving,
the serum treatment must be continued even if the organisms
have disappeared. Far better results are obtained from good-
sized doses, frequently repeated, in the beginning, than from
smaller doses or from the same or larger doses at longer inter-
vals. Rigidity of the neck alone is not an indication for the
continuance of the treatment, since rigidity often persists
well into convalescence. No other treatment, except regula-
tion of the bowels and of the diet, is indicated in this instance.
SPECIFIC INFECTIOUS DISEASES. 275
CASE 76. Timothy D., twelve years old, was the child of
healthy parents. An uncle had died of pulmonary tubercu-
losis a year before. He had not lived with him, but had seen
him repeatedly. He had always been well, except for an
illness " similar to the present " a year before.
He began to be dizzy about August 26, but had no other
symptoms except constipation. He was first seen by his
physician September 2. The physical examination and the
urine then showed nothing abnormal. His bowels were
thoroughly cleaned out, but the dizziness persisted. Septem-
ber 6 he began to complain of stiffness in the neck and held
his head turned to the right. Passive motions were, however,
but little limited and did not cause pain. The pupils were
equal and reacted to light. The knee-jerks were equal and
normal. Kernig's and Babinski's signs were absent. The
neck was stiffer September 8 and he began to complain of
pain in the neck. The pulse also became slow, running be-
tween 56 and 64. He began to vomit on the 9th and the rigid-
ity and pain in the neck became much worse. The highest
temperature up to the morning of the 9th was 990 F. ; that
morning it was ioo° F. The constipation had persisted. He
was seen in consultation at 4 p.m., September 9.
Physical Examination. He was well developed and nour-
ished and of good color. He was perfectly conscious, but
cried out occasionally from pain in the back of the neck.
There was no retraction of the neck, but he held his head
rigidly and turned to the right. All motions of the neck
caused much pain. The neck sign could not be tested be-
cause of the rigidity. There was no enlargement of the cervi-
cal lymph nodes. The tongue was moderately coated; the
throat normal. The pupils were equal and reacted both to
light and accommodation. There was no strabismus. The
membranae tympanorum showed nothing abnormal. The
heart and lungs were normal. The liver and spleen were not
palpable. The abdomen was sunken, but not rigid. There
was no spasm or paralysis of the extremities. The knee-jerks
were equal and not exaggerated. The cremasteric and ab-
dominal reflexes were present and not unusually lively.
There was a marked Kernig's sign on both sides. Babinski's
276
CASE HISTORIES IN PEDIATRICS.
sign was absent and there was no clonus. There was no dis-
turbance of sensation. There was no eruption. The taches
cerebrales were marked. The mouth temperature was ioo°
F., the pulse 60.
Diagnosis. There can be no doubt, of course, that he has
meningitis. The only question is whether it is tubercular or
cerebrospinal. The known exposure to tuberculosis and the
slow onset point strongly toward the tubercular form. There
is nothing in the physical examination which is not consistent
with either type. The absence of eruptions does not count
at all against cerebrospinal meningitis since eruptions are
far more often absent than present in this disease in child-
hood. It may be remarked in passing that the taches cere-
brales are of no importance in the diagnosis of meningitis, as
they are present in all sorts of conditions in childhood. It is
also worthy of mention that the abdomen, while often sunken
from the lack of food, is almost never rigid in meningitis. In
spite of the fact that the disease is almost certainly tubercular,
a lumbar puncture should be done to make the diagnosis
certain, because the fact that he has been exposed to tubercu-
losis does not prove that he has contracted it, and because
the onset of cerebrospinal meningitis is sometimes slow and, if
it is cerebrospinal meningitis, the serum treatment may save
him.
A lumbar puncture was done at once and 45 ccm. of very
turbid fluid under moderate pressure was allowed to run out.
The marked turbidity of the fluid points very strongly to
cerebrospinal meningitis (see Case 72 for description of the
cerebrospinal fluid in health and disease), and much over-
balances the points previously mentioned in favor of tubercu-
lar meningitis. It justifies a probable diagnosis of Cere-
brospinal Meningitis and makes it obligatory to treat him
on this basis without waiting for the results of the examination
of the fluid.
Treatment. He should be given 45 ccm. of antimeningitis
serum, which is equal to the amount of fluid withdrawn,
through the same needle without withdrawing it. It is un-
wise to wait for the examination of the fluid, because the
symptoms are marked and the earlier the serum is given the
SPECIFIC INFECTIOUS DISEASES.
277
more likely he is to recover. The serum can do no harm if
the disease proves to be tubercular and, if it is cerebro-
spinal, considerable time is saved by not waiting for the ex-
amination. If the examination of the cerebrospinal fluid
shows that the trouble really is cerebrospinal meningitis, this,
or a larger dose, according to the amount of fluid which escapes,
must be repeated daily until no micro-organisms can be found
in smears made from the fluid. If the temperature remains
much elevated or the symptoms are not improving, the
serum treatment must be continued even if the organisms
have disappeared. Rigidity of the neck alone is, however,
not an indication for the continuance of the treatment, since
rigidity not infrequently persists well into convalescence.
The withdrawal of the fluid will probably relieve the headache.
If it does not, an ice cap will probably help it.
The fluid which was withdrawn showed a small deposit of
pus and a fibrin clot. Ninety-nine per cent of the cells were
polynuclear and the diplococcus intracellularis was found
both within and without the cells, thus verifying the diag-
nosis of cerebrospinal meningitis.
Prognosis. The prognosis in this instance is somewhat
against recovery, because of the long duration of the illness
before the beginning of treatment. The slow onset and the
low temperature are, however, points in his favor.
278
CASE HISTORIES IN PEDIATRICS.
CASE 77. Simon R., seven years old, was taken suddenly
sick on the night of March 6 with pain in his head and moder-
ate fever. He vomited several times during the first twenty-
four hours, but not afterward. His bowels were opened freely
with calomel the next day and had moved daily since then.
The movements were loose, but otherwise normal. He had
had no cough or nose-bleed. The pain in the head continued
and the temperature gradually rose to 1050 F. He was seen
in consultation March 10.
Physical Examination. He was slight but muscular. His
color was good. There was no eruption. He complained of
pain all over his head, but of nothing else. He was perfectly
rational. The pupils were equal and reacted to both light
and accommodation. There was no strabismus or facial
paralysis. The ear-drums were normal. The throat showed
nothing abnormal. The tongue was dry and moderately
coated. There was no tenderness or rigidity of the neck.
The heart was normal. Percussion of the lungs showed noth-
ing abnormal. The respiratory murmur and voice sounds were
slightly diminished in the lower right back, but not changed
in character. The level of the abdomen was below that of the
thorax. The walls were lax and palpation was easy. There
was no muscular spasm and no tenderness. The liver was not
palpable. The upper border of the splenic dullness was on
the eighth rib. The spleen was not palpable. There was
no spasm or paralysis of the extremities. The knee-jerks
were lively and equal. Kernig's and Babinski's signs were
absent. Sensation to touch was normal. The cervical lymph
nodes were slightly enlarged. The temperature by mouth
was 1050 F., the pulse no, the respiration 28.
Diagnosis. Several diseases which it would have been
necessary to consider at first, because of the acute onset, can
now be ruled out on the duration of the illness and the
absence of their typical symptoms and physical signs after
four days. These are acute indigestion, malaria, scarlet fever,
tonsillitis and otitis media. The other diseases which are
suggested by the history are pneumonia, meningitis (more
probably cerebrospinal than tubercular) and influenza.
The acute onset with vomiting and the continued high
SPECIFIC INFECTIOUS DISEASES.
279
temperature are very characteristic of pneumonia; the head-
ache is not inconsistent with this diagnosis. Cough, while
often absent for one or two days, almost always develops,
however, by the fourth day. The physical signs in the lungs,
namely, localized diminution of the respiratory murmur and
voice sounds, are rather characteristic of pneumonia in an
early stage and are often all that can be found for several days.
Something more definite would, however, be expected by the
fourth day. The pulse is slower than would be expected with
a temperature of 1050 F. in pneumonia, and the rate of the
respiration is not increased out of proportion to that of the
pulse. This latter point is an extremely important one and,
when taken in connection with the indefiniteness of the symp-
toms and physical signs, is sufficient to rule out pneumonia.
The acute onset, the persistence of the headache and the
relatively slow pulse and respiration suggest meningitis. The
clear mind and the absence of all signs of meningeal irritation
make it, however, extremely improbable. It is certainly not
probable enough to justify a lumbar puncture for diagnosis.
The history and lack of physical signs are consistent with
influenza. The duration of the illness without the develop-
ment of any catarrhal symptoms, the relatively slight prostra-
tion and the comparatively slow pulse are, however, against
it. Influenza seems a more reasonable diagnosis than the
others, but is far from being satisfactory.
Is there any other disease which will explain the symptoms
and physical signs better? There is, and that disease is
typhoid fever. An acute onset is not unusual in typhoid
in children. Nose-bleed is relatively infrequent at this
age. A diffuse headache is characteristic of this disease.
The spleen is enlarged (the normal upper limit of dullness is
at the ninth rib). The relatively slow pulse (the normal rate
at seven years is 90), without any symptoms of increased
cerebral pressure or meningeal irritation, is almost pathogno-
monic. It is too early for rose spots, and abdominal symp-
toms are as often absent as present in typhoid at this age.
A probable diagnosis of Typhoid Fever seems, therefore,
justified.
There are several laboratory tests which may be tried
28o CASE HISTORIES IN PEDIATRICS.
which will aid more or less in the diagnosis. Typhoid fever
has no leucocy tosis ; neither has influenza. A white count
will be, therefore, of no assistance in differentiating between
these two diseases. A low white count will, in this instance,
practically rule out pneumonia and cerebrospinal meningitis.
Pneumonia, meningitis and typhoid all show the diazo-
reaction; influenza does not. This test might, therefore, be
of some assistance in differentiating between typhoid and
influenza. It is too early to expect a positive Widal reaction,
and it is hardly worth while to try it at present. A blood
culture will almost certainly settle the diagnosis at once, as
they are positive in about ninety per cent of all cases of
typhoid at this stage.
Prognosis. The prognosis of typhoid fever at this age is
very good. He is in good condition and his prognosis is at
least as good as the average. The duration of the fever will
probably not be over three weeks. There is very little chance
of hemorrhage, practically none of perforation.
Treatment. He must, of course, be kept in bed. The
author does not believe in a strict milk diet in this disease.
It does not provide enough calories, is very monotonous and
tends to cause constipation. He is very sure that patients
who are fed more liberally are in better condition at the
end of the disease and that they convalesce more rapidly.
Broths and beef tea have almost no nutritive value,
are likely to stir up peristalsis, and should consequently
be given but sparingly. A suitable diet for this boy is as
follows:
Milk, broth, beef tea, barley jelly, rice jelly, farina, milk
toast, blanc mange, baked custard, junket, ice cream.
His fever will probably not require much treatment. If
his temperature is constantly over 1040 F., or he is depressed,
or shows symptoms of disturbance of the nervous system as
the result of the fever, it will require treatment. Sponge
baths of alcohol and water, equal parts, at 900 F., every four
hours, will probably be sufficient to control it. An ice-cap
for the headache and suds enemata for constipation, if
present, are all that are necessary at present in addition to
regulation of the diet and baths.
SPECIFIC INFECTIOUS DISEASES. 28 1
CASE 78. Spencer S., eleven months old, was the only
child of healthy parents. There had been no deaths or mis-
carriages and he had had no known exposure to tuberculosis.
There was an epidemic of typhoid fever, caused by infected
milk, in the Jamaica Plain district of Boston at the time when
he was taken sick. He lived, however, in the West End. The
milk which he took was bought at a store in the neighborhood,
the proprietor of which said that none of his milk came from
the Jamaica Plain dealers. He had not been away from home
and there was no typhoid fever in the West End. His milk
was not heated, he took unboiled water and was given a taste
of almost everything on the table.
He vomited several times March 28, but not afterward.
His appetite became poor and he had two or three green stools,
containing much mucus, daily. Fever was first noticed
March 30. He was drowsy most of the time and coughed
occasionally. He was admitted to the Infants' Hospital,
April 8.
Physical Examination. He was well developed and nour-
ished and of good color. He was conscious, but drowsy.
The anterior fontanelle was one cm. in diameter and somewhat
depressed. There was no rigidity of the neck and no neck
sign. The pupils were equal and reacted to light. The
mouth and tongue were somewhat dry. The tongue was
clean. The throat was normal. He had five teeth. There
was a moderate rosary. The heart was normal. The lungs
were normal, except for a moderate number of fine, moist
rales in both backs. The level of the abdomen was that of
the thorax. There was no spasm or tenderness and nothing
abnormal was felt. The lower border of the liver was
palpable two cm. below the costal border in the nipple line.
The spleen was palpable two cm. below the costal border.
There were numerous light pink spots, about the size of a pin
head, scattered over the abdomen. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and rather feeble. Kernig's sign was absent.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was I03.8°F.; the pulse, 138; the
respiration, 36.
282 CASE HISTORIES IN PEDIATRICS.
The urine was high-colored, clear, acid in reaction and con-
tained no albumin or sugar.
The leucocytes numbered 11,000. No plasmodia malariae
were seen.
Diagnosis. The slight disturbance of the digestion, shown
by the abnormal stools, does not seem sufficient to cause such
marked constitutional symptoms or such a high temperature.
Neither does the bronchitis seem severe enough to account
for them. The absence of leucocytosis is, moreover, much
against both bronchitis and a primary disturbance of diges-
tion as the cause. The clean tongue is also against a primary
disturbance of the digestion. It is evident that they are
both secondary to some other disease. He is in good condi-
tion and of good color, the only manifestation of rickets is the
rosary, and the liver is of normal size. The enlargement of
the spleen is, therefore, undoubtedly a manifestation of the
acute illness. The normal pulse-respiration ratio shows that
he has not pneumonia. The points on which the diagnosis
must be made are, then, an acute disease with a high tem-
perature and with the pulse and respiration having the normal
relation to the temperature and to each other, enlargement
of the spleen, a macular rash on the abdomen and the absence
of leucocytosis. Of the acute diseases not accompanied by
leucocytosis, measles and mumps can be excluded by the
absence of their characteristic signs, and malaria by the
absence of plasmodia. Influenza can be ruled out on the en-
largement of the spleen and the duration of the symptoms.
Acute miliary tuberculosis is rendered improbable by the
enlargement of the spleen, the rash, the relatively good gen-
eral condition and the comparatively slight acceleration of
the pulse and respiration. The enlargement of the spleen
and the rash are more consistent with typhoid fever than
with any other condition. The drowsiness is also character-
istic of typhoid. The acute onset and the absence of nose-
bleed do not count against typhoid, because an acute onset
is the rule in typhoid in infancy and nosebleed is unusual.
The pulse rate is perhaps increased a little more, relatively to
the temperature, than would be expected in typhoid. In
infancy, however, the increase is, as a rule, relatively greater
SPECIFIC INFECTIOUS DISEASES. 283
than in older children and adults. The pulse rate does not
count, therefore, against typhoid. Bronchitis is very common
in typhoid fever in early life. Its presence in this instance
is corroborative evidence in favor of typhoid. The diagnosis
of Typhoid Fever is, therefore, a reasonably certain one.
A Widal test should be tried. This being the eleventh day
of the illness, it should be positive, if the trouble really is
typhoid. The presence of an epidemic of typhoid in the city
is of interest but, in the absence of any apparent exposure, of
but little aid in diagnosis.
Prognosis. Typhoid fever, while a comparatively mild
disease in childhood, is a more serious matter in infancy and
is often fatal. He is in good condition, however, has no
complications, has already been ill eleven days, which is at
least one-half the usual duration of typhoid in infancy and
early childhood, and may, therefore, be confidently expected
to recover. The temperature will probably fall to normal
by a rapid lysis, without marked remissions, in the course of
about ten days.
Treatment. He should be given seven feedings of six
ounces of a mixture containing 2.50% of fat, 7% of sugar,
I-5°% of proteids and 0.75% of starch. There is no indica-
tion for the addition of an alkali. He should also be given
sixteen ounces or more of water during the twenty-four hours.
He is not depressed by the fever and shows no symptoms of
disturbance of the nervous system. No treatment is neces-
sary, therefore, for the fever. There is no indication for the
administration of drugs.
284 CASE HISTORIES IN PEDIATRICS.
CASE 79. Mary L., six years old, was the third child of
healthy parents. The other children were alive and well.
Her mother had had, however, two miscarriages. There was
no history of tuberculosis in either family or of exposure to
it. She had had no illnesses, but had been thin and delicate
during the last two years.
She began to complain, late in the afternoon of September
1, of headache, fever and general malaise. These symptoms
persisted. Her appetite was poor and she vomited consid-
erable dark-brownish, frothy material several times during
the next two days. She was given Castoria the first night,
had four loose, yellowish-brown movements on September 2
and eight or nine watery, green movements on each of the
two succeeding days. She had the nosebleed September 5.
The next day she began to complain of general abdominal
pain and to hold her right thigh flexed. She was admitted
to the Children's Hospital, September 7. Her bowels had
moved freely that morning after an enema.
Physical Examination. She was poorly developed and
nourished and moderately pale. She was irritable, restless,
hyperesthetic and at times slightly delirious, so that but
little reliance could be placed on her statements as to pain.
Her face was a little anxious. The pupils were equal and
reacted to light. There was no rigidity of the neck or neck
sign. Her tongue was moist and covered with a heavy
white coat. The throat, heart and lungs were normal. The
liver and spleen were not palpable. The liver flatness ex-
tended to the costal border. The upper border of splenic
dullness was on the ninth rib. The abdomen was slightly
distended and everywhere tympanitic. There was moder-
ate general tenderness, somewhat more marked in the right
lower quadrant than elsewhere. An irregularly shaped, mod-
erately moveable mass, about three cm. wide and eight cm.
long and moderately tender, was felt in the neighborhood of
McBurney's point. There was definite muscular spasm in
this region. There were no evidences of fluid in the abdo-
men. The right thigh was held about three-quarters flexed
on the abdomen and extension caused pain. The knee-
jerks were equal and slightly increased. Kernig's sign was
absent on the left and could not be determined on the right
SPECIFIC INFECTIOUS DISEASES. 285
because of the pain. There was no enlargement of the
peripheral lymph nodes. Rectal examination showed bulg-
ing and resistance on the right. There was no eruption.
The rectal temperature was 105. 5°F.; the pulse, 128; the
respiration, 30.
The urine was high-colored, acid in reaction, of a specific
gravity of 1015, and contained a trace of albumin, but no
sugar. The sediment showed nothing but a few small round
and squamous cells.
The leucocytes numbered 13,400.
The Widal test was negative.
Diagnosis. The diagnosis in this instance lies between
tubercular peritonitis, appendicitis and enlargement of the
mesenteric lymph nodes, presumably as a complication of
typhoid fever. Abdominal pain, tumor, muscular spasm and
tenderness and resistance on the right on rectal examination
are symptoms common to all these diseases and are, there-
fore, of little importance in differential diagnosis. The
flexion of the thigh is a secondary symptom and unimpor-
tant. The onset is not characteristic of any of them and
can, therefore, be disregarded. The history of failing health
for two years is suggestive of a tubercular infection, l?ut,
although making tubercular peritonitis a little more prob-
able, is of comparatively little importance. The mobility of
the tumor is much against appendicitis, but perfectly con-
sistent with tubercular peritonitis and enlargement of the
mesenteric lymph nodes in typhoid. The increase in the
number of white cells, although somewhat unusual in tuber-
cular peritonitis, is not inconsistent with it, while it is not
great enough to count much against typhoid fever. It counts
materially against appendicitis, however, because the white
count in this disease is high unless the system is overwhelmed
by the toxemia, and in this instance the other symptoms
show that this is not the case. The temperature is higher
than would be expected in tubercular peritonitis or appen-
dicitis, but, while more characteristic of typhoid, is not in-
consistent with either condition. The increase in the rate
of the pulse is much less than would be expected in tuber-
cular peritonitis and appendicitis, when the height of the
temperature is taken into consideration. A relatively slow
286 CASE HISTORIES IN PEDIATRICS.
pulse is, however, characteristic of typhoid fever and is
strong evidence in favor of this disease. The nosebleed
points somewhat toward typhoid. The absence of enlarge-
ment of the spleen and of rose spots and the negative Widal
test do not count at all against it at this stage. It is possible,
therefore, to rule out appendicitis on the mobility of the
tumor, the relatively slight leucocytosis in connection with
the fairly good general condition and the relatively slow
pulse. It is more difficult to exclude tubercular peritonitis,
but the relatively slow pulse is much against it. There is
nothing inconsistent with enlargement of the mesenteric
glands in typhoid fever, except the leucocytosis. This is so
slight, however, that it is not sufficient to rule it out. There
are, moreover, a number of points in favor of typhoid fever.
The most important of them is the relatively slow pulse.
Less important are the nosebleed and the fact that the tem-
perature is higher and the nervous symptoms more severe
than would be expected from the local conditions in the
abdomen. An almost positive diagnosis of Typhoid Fever
with Enlargement of the Mesenteric Glands is, there-
fore, justified. A blood culture ought to be made to verify
the diagnosis, as at this time it will almost certainly be posi-
tive if the disease is typhoid fever. A skin tuberculin test
will not be of much assistance. A negative result may mean
either the absence of tuberculosis or an overwhelming infec-
tion with tuberculosis, while a positive result merely shows
that there is tuberculosis somewhere, not that the present
trouble is tuberculosis.
Prognosis. Her temperature is high and the nervous
symptoms are moderately severe. A high temperature and
marked nervous symptoms are, however, of less significance
in the child than in the adult. Her heart is strong, her lungs
are clear, the pulse is not unduly rapid, the mortality from
typhoid fever in early life is very low, the enlargement of the
mesenteric lymph nodes does not increase the gravity of the
illness. She may, therefore, be confidently expected to recover.
Treatment. The enlargement of the lymph nodes calls
for no especial treatment. The general management of
typhoid fever in childhood is described in Case 77.
SPECIFIC INFECTIOUS DISEASES.
287
CASE 80. Althea P., five and one-half months old, was
the only child of healthy parents and had always been per-
fectly well. There had been no miscarriages. Her father had
had a severe " cold " in his throat and nose about two weeks
before. She had had a " cold in the nose " for a week, but
had not appeared sick or feverish. She had taken the breast
well up to the last two days. The discharge had irritated
the upper lip a little. There had been no other symptoms.
Physical Examination. She was well developed and nour-
ished and of good color. The anterior fontanelle was 3 cm.
in diameter and level. She showed a slight tendency to keep
her mouth open. There was a small amount of thin, watery
discharge from the nose which irritated the upper lip. The
turbinates were a little swollen and reddened and had a few
crusts on them. No membrane was seen. The throat was
perfectly normal. There was no rosary. The heart and lungs
were normal. The level of the abdomen was that of the
thorax. It showed nothing abnormal. The liver was palpable
2 cm. below the costal border in the nipple line. The spleen
was not palpable. The extremities were normal. There was
no spasm or paralysis. The knee-jerks were equal and normal.
Kernig's and Babinski's signs were absent. There was no
enlargement of the peripheral lymph nodes The rectal
temperature was 99. 2° F.
Diagnosis. Syphilitic rhinitis can be at once excluded on
the good family history, the previous good health, the good
general condition, the history of exposure to her father's
" cold " and the absence of all other signs of syphilis. The
only thing to suggest diphtheritic rhinitis is the persistence
of a watery discharge which irritates the upper lip. The
absence of constitutional symptoms, fever and enlargement of
the cervical lymph nodes does not count at all against diph-
theritic rhinitis, because a persistent, irritating, nasal dis-
charge without other symptoms is most characteristic of this
disease in infancy. The chances are, of course, much in
favor of a simple rhinitis, but the watery, irritating character
of the discharge is suspicious enough to demand a bacterio-
logical examination. This was made and an almost pure
culture of the Klebs-Loeffier bacillus was found, justifying
2gg CASE HISTORIES IN PEDIATRICS.
the suspicion of Diphtheritic Rhinitis. The presumption is
that her father had had diphtheria and that she had caught
it from him.
Prognosis. The prognosis is perfectly good. Extension of
the process is very unusual, even if it is untreated. The
chief danger is of infection of those about her.
Treatment. The treatment is the administration of the
antitoxin of diphtheria. Fifteen hundred units, repeated in
two days, will probably be sufficient; more must be given if
the discharge persists. Local treatment is hardly necessary,
but some simple alkaline solution, dropped in the nose with a
medicine dropper, every few hours, will probably make her
more comfortable. She must be isolated until two consecutive
negative cultures have been obtained from both the nose and
throat.
SPECIFIC INFECTIOUS DISEASES. 289
CASE 81. Martin S., six years old, began to have a loud,
ringing cough with slight difficulty in breathing during the
night of May 23. The cough and difficult respiration con-
tinued without diminution during the 24th. That night the
difficulty in respiration increased considerably, so that he
slept but little. He was no better on the morning of the 25th
and was not able to talk aloud. During the day the difficulty
in breathing increased very rapidly, so that he had to sit up
to breathe. He became cyanotic and was unable to take
nourishment. His temperature during these days had ranged
from normal to 1010 F. Repeated examinations of the throat
had shown nothing abnormal. He was seen in consultation
at 7.30 p.m., May 25.
Physical Examination. He was a large, strong boy. He
was markedly cyanotic and was sitting up in bed with his
head stretched forward. The inspiration was noisy. The
cough was harsh and dry. He was unable to speak above a
whisper. The cervical lymph nodes were slightly enlarged.
The tonsils were moderately enlarged and somewhat reddened,
but there was no exudation upon them. There was no nasal
discharge. There was sinking in of the supraclavicular spaces,
of the lower intercostal spaces and of the epigastrium with
each inspiration. Percussion of the lungs was normal. The
respiratory murmur was very feeble, but not abnormal in char-
acter. Very many loud, medium and coarse, moist rales were
heard over both chests. The rales were alike in both chests
and both behind and in front. There was nothing abnormal
about the heart except the rapidity of its action. The
abdomen was normal. The liver and spleen were not palpable.
The extremities were not examined. The axillary tempera-
ture was 1010 F., the pulse 150, the respiration 24.
Diagnosis. The cyanosis and the retraction of the epi-
gastrium, intercostal and supraclavicular spaces are simply
manifestations of some obstruction to the entrance *of air
into the lungs and do not indicate where the obstruction is
located. The head is stretched forward in order to make
breathing easier by straightening the upper air passages.
The normal condition of the nose and throat rules out ob-
struction above the larynx. The signs in the lungs are not
.290 CASE HISTORIES IN PEDIATRICS.
sufficient to account for so much cyanosis and retraction.
The fact that the rales are alike in both chests, both back and
front, shows, moreover, that they are not made in the bronchi,
but transmitted from above. The relatively low rate of the
respiration also shows that the trouble in the lungs is not the
cause of the cyanosis and retraction. The obstruction must,
therefore, be situated in the larynx. The noisy inspiration,
the harsh dry cough and the whispering are all characteristic
of inflammation of the larynx and corroborative of the
diagnosis of laryngeal obstruction.
The next point to be determined is whether the trouble in
the larynx is catarrhal or diphtheritic. The progressive
increase in the difficulty in respiration is almost'pathognomonic
of laryngeal diphtheria and entirely different from the course
of catarrhal laryngitis, in which the obstruction is not con-
tinuous and progressive, but occurs in paroxysms, being
worse at night than during the day. The progressive in-
crease in the symptoms is of itself sufficient to justify the
diagnosis of Laryngeal Diphtheria. The slight degree of
the fever is consistent with either condition, but is more
characteristic of laryngeal diphtheria than of catarrhal
laryngitis, in which the temperature is usually higher. The
absence of marked inflammation of the throat and of enlarge-
ment of the cervical lymph nodes does not count at all against
laryngeal diphtheria because in primary laryngeal diphtheria
the throat is usually not involved and, as there is but little
absorption from the larynx, the lymph nodes are not enlarged.
It would be criminal, in this instance, to await bacteriological
verification of the diagnosis. A negative culture, if taken
from the throat, would not, in fact, invalidate the diagnosis
of laryngeal diphtheria, because the diphtheria bacilli are
often absent from the throat when the diphtheritic process
begins in the larynx.
Prognosis. The prognosis is practically hopeless without
intubation, and very grave with intubation unless antitoxin
is given freely. With intubation and antitoxin the chances
are in his favor, because he is in good general condition, there
is no involvement of the throat, practically no septic absorp-
tion and his heart is strong.
SPECIFIC INFECTIOUS DISEASES. 291
Treatment. Intubation should be done at once. He
should be given six thousand units of antitoxin as soon as he
has quieted down after the intubation. This dose should be
repeated in eight hours. It is impossible to state in advance
whether he will need more or not. If his temperature drops
to normal and the general condition remains good, it will
probably not be necessary to repeat it. If he coughs up the
tube and the obstruction does not return, further doses will
not be needed; otherwise, the antitoxin must be continued,
perhaps in larger doses. The tube should be removed on the
third or fourth day. If the obstruction recurs it must be
replaced. It is far wiser to have some one competent to
remove and replace the tube in the house as long as the tube
is in the larynx than to leave him alone, because emergencies,
such as blocking of the tube and coughing up the tube, are
liable to occur at any time and, if not met immediately, are
likely to prove fatal.
The food should be milk and soft solids, like junket, baked
custard, ice cream, soft cereals and soft toast. Some children
take liquids better; some, soft solids. It is impossible to tell
in advance which he will take better. Most children take
their food best sitting up. It is wiser, therefore, to try him
first in this position. If he has trouble in taking it in this way
he may be able to take it better lying on his back with his
head lower than his body. If he has much difficulty in taking
food, it is safer to feed him with a tube introduced through
the mouth than to persist with other methods. No other
treatment is indicated at present.
292 CASE HISTORIES IN PEDIATRICS.
CASE 82. Isabelle C, eight years old, had had measles
but not scarlet fever. She had been perfectly well during the
last six months. She slept well the night of November 16,
ate her usual breakfast, had a normal movement of the bowels
and went to school apparently in good health. Soon after
reaching school she began to have a rather severe headache,
but said nothing about it. When her father went after her at
noon, he found her very feverish and having a chill. She was
a little nauseated, complained of headache and was very
nervous and excited. She was seen at 3 p.m.
Physical Examination. She was well developed and nour-
ished and in good general condition. She was very nervous
and much excited. She complained of feeling cold and of
headache. The headache was general, not localized. She
was generally hyperesthetic. There was no rigidity or tender-
ness of the neck. The pupils were equal and reacted to light.
The throat was normal. The tongue was slightly coated.
The membranae tympanorum were normal. The heart and
lungs were normal. The liver and spleen were not palpable.
The level of the abdomen was that of the thorax; nothing
abnormal could be detected in it. There was no spasm or
paralysis. The knee-jerks were equal and normal; Kernig's
and Babinski's as well as the neck sign were absent. There
was no enlargement of the peripheral lymph nodes and no
eruption. The temperature, by mouth, was 102. 8° F., the
pulse 120, the respiration 35.
The urine was high in color, acid in reaction, of a specific
gravity of 1 ,024, and contained no albumin or sugar.
The leucocytes numbered 8,100. No plasmodia were seen.
Diagnosis. This onset is consistent with that of almost
any of the acute diseases. Certain of them are, however,
much more probable than the others. These are scarlet
fever, tonsillitis, influenza and pneumonia.
Malaria is unlikely in November, and in Boston. It is
excluded by the absence of plasmodia in the blood. The
acute onset with headache suggests, to a certain extent,
meningitis. The hyperesthesia is also rather suggestive.
The headache and hyperesthesia are, however, equally well
explained by the temperature. An onset as acute as this is
SPECIFIC INFECTIOUS DISEASES. 293
very unusual in tubercular meningitis at this age. The ab-
sence of all signs of meningeal irritation is also against
meningitis in any form. The low white count practically
rules out cerebrospinal meningitis. The absence of sore throat
at this time, only a few hours after the onset, does not, of
course, rule out scarlet fever and tonsillitis, but makes them
somewhat improbable. Neither a rash nor signs in the lungs
can be expected thus early. The relatively greater increase
in the rate of the respiration over that of the pulse suggests
pneumonia, but it is hardly marked enough to be of much
importance. There is nothing about the onset and symptoms
inconsistent with influenza, and the absence of physical signs
is entirely consistent with this disease. The leucocyte count
is of great assistance in this instance. The low count practi-
cally rules out scarlet fever, tonsillitis and pneumonia, all of
which have a marked leucocytosis, and is characteristic of
influenza, the only other condition to be seriously considered.
The diagnosis of Influenza seems, therefore, justified.
Prognosis. There is, naturally, no danger as to life. The
fever will probably not last many days and she will be able
to return to school in a week or ten days.
Treatment. The treatment is simple; a tablespoonful of
castor oil, laxol or syrup of senna, to empty the bowels; a
diet of milk, broth and simple starchy foods; an ice-cap for
the headache; phenacetin and salol, 2\ grains each, every
three hours, for the headache and general discomfort.
294 CASE HISTORIES IN PEDIATRICS.
CASE 83. Leonard O., nineteen months old, had always
been well. He was in Windham, Conn., on a visit from Sep-
tember 2*] to October 4. He was well while there but was
severely bitten by mosquitoes. Although the weather was
cool and he had eaten nothing unusual, he began to have
loose movements of the bowels October 17. He continued to
have four or five loose, greenish movements, without curds or
mucus, daily. His appetite was poor, but he did not vomit.
He was feverish and sick all day on the 17th, but, aside from
the loose movements, had no very definite symptoms. He
was fairly well on the 18th, but was worse again on the 19th.
When he woke in the morning of the 21st he was cold and
rather blue and his face looked pinched. Heaters were ap-
plied and brandy given, and after a few hours he became
warm again. He then seemed a good deal relaxed, sweat
quite freely and was depressed all day. He was seen October
22. He then appeared fairly well, but was quiet and looked
run down.
Physical Examination. He was well developed and nour-
ished, but rather flabby. Pallor was marked. He had twelve
teeth. The anterior fontanelle was not quite closed. The
tongue was clean and the throat normal. There was a slight
rosary. The heart, lungs and abdomen were normal. The
liver was palpable 3 cm., and the spleen 1 cm., below the costal
border. The extremities were normal. There was no spasm
or paralysis. The knee-jerks were equal and normal. There
was no enlargement of the peripheral lymph nodes. The
rectal temperature was normal. A movement which was
seen was watery, black (presumably from bismuth) and foul,
but contained no curds or mucus. The urine was pale,
slightly acid in reaction, of a specific gravity of 1,012 and
contained no albumin.
Diagnosis. The periodic increase in the severity of the
symptoms ought at once to suggest the possibility of malaria,
in spite of the persistance of the diarrhea. The peculiar
condition on waking on the 21st, taken in connection with
the subsequent sweating and depression, makes this diagnosis
very probable. In fact, this combination is very character-
istic of the malarial paroxysm in infancy, at which age the
SPECIFIC INFECTIOUS DISEASES. 295
chill is usually replaced by cyanosis and cold extremities.
The sweating in this instance was, however, more pronounced
than is usual. The marked pallor and the enlargement of
the spleen are further corroborative evidence. A slight
enlargement of the spleen, as in this instance, is, however, not
very uncommon in many acute infections in infancy. The
enlargement may, moreover, be a chronic one due to the same
disturbance of nutrition in the past which caused the rickets,
the results of which are shown in the open fontanelle, the
slightly delayed dentition and the rosary. Further evidences
in favor of malaria are the stay in a malarial district and the
fact that he was bitten by mosquitoes. The time between the
possible infection and the development of the symptoms
corresponds, moreover, to the average incubation period of
malaria. The diagnosis of Malaria is, therefore, justified.
This diagnosis should, however, never be made positively
without an examination of the blood. The blood was ex-
amined in this instance and a single infection with the tertian
organism found.
Prognosis. The prognosis is, of course, good. Malaria in
infancy usually yields very promptly to treatment,
i Treatment. The treatment is, of course, the administration
of quinine. The same rules apply to its use in infancy as in
later life. Babies will usually take the sulphate of quinine in
solution by mouth without difficulty and without vomiting.
If it is vomited it may be given in a suppository. It is rarely
necessary to give it subcutaneously. This boy should have
2 grains of the sulphate of quinine by mouth, or 2\ grains by
rectum, in the late evening of the 22d, 24th, 26th and 28th.
He ought not to have any paroxysms after the first two doses
and, theoretically, should be cured by the four doses. In
order to be doubly safe, however, it will be well to give him
1 grain of sulphate of quinine twice daily for two days, four
times, at intervals of a week. The saccharated carbonate of
iron, in doses of 3 grains, three times daily, after eating, will
help the anemia. The loose movements are a symptom of
the malaria and will cease with the cure of this condition.
296
CASE HISTORIES IN PEDIATRICS.
CASE 84. Ruth A., three and one-half years old, had
always been well, except for an attack of chicken-pox a year
previously. She became a little feverish and began to com-
plain of pain in the left wrist during the afternoon of March
9. Her temperature that night was 100.50 F. Nothing ab-
normal was detected about the arm. There was no history
of any injury. The next morning the temperature was
102. 50 F. and there was more pain and some tenderness, but
no heat or redness, in the wrist. From this time on the
temperature and the pulse-rate rose steadily and the pain
became very severe. Aspirin, in fairly large doses, had had
no effect on either the pain or the temperature. She had had
no chills and had not vomited. She was seen in consultation
late in the afternoon of March 11, forty-eight hours after
the onset.
Physical Examination. She was well developed and nour-
ished and of good color. She was actively delirious but, when
roused, answered rationally. There was no rigidity or tender-
ness of the neck and no neck sign. The pupils were equal and
reacted to light. The throat was normal, the tongue moder-
ately coated. The heart, lungs and abdomen were normal.
The liver and spleen were not palpable. The extremities
were normal, except for the left arm. There was no spasm or
paralysis. The knee-jerks were equal and normal. Kernig's
sign was absent. The lymph nodes in the left axilla were
slightly enlarged and tender; the other peripheral lymph
nodes were not palpable. There was considerable deep swell-
ing in the upper two thirds of the left forearm with moderate
tenderness on pressure, more marked over the radius than over
the ulna. There was no redness, but some heat. There was
also a little swelling about the elbow- joint and in the lower
portion of the upper arm. There was no tenderness over the
elbow-joint and no evidences of effusion into the joint.
Passive motions were slightly limited at the elbow, but not
at the wrist. The rectal temperature was 1040 F., the pulse
160.
Diagnosis. The diagnosis is not a difficult one. Scurvy
can be ruled out by the age of the child, the acuteness of the
onset, the high temperature and the localization of the process
SPECIFIC INFECTIOUS DISEASES. 297
in one extremity. Rheumatism is unusual at this age and, as
a rule, its symptoms are mild. If they are severe, they are
located in the joints, not in or about the shafts of the bones,
and several joints are involved at once. Inflammation of
the superficial tissues can be ruled out by the absence of
redness and the deepness of the swelling. The trouble must,
therefore, be located in or about the shafts of the bones, that
is, it is an osteomyelitis or a periosteitis. It is unimportant
for practical purposes whether it is a periosteitis, an osteo-
myelitis or both, for in any case an immediate operation is
necessary. The swelling shows that there is certainly a k
Periosteitis. In all probability there is an Osteomyelitis
also, although the absence of extreme localized tenderness is
somewhat against it.
Prognosis. The prognosis is very grave. The chances are
much against recovery even with an immediate operation.
Treatment. The treatment is immediate operation.
298 CASE HISTORIES IN PEDIATRICS.
CASE 85. Lillian H. was nine months old. Her parents
were well. Two children had died of "cholera infantum"
and there had been one miscarriage. She was born at full
term, after a normal labor, was normal at birth and weighed
six pounds. She was nursed for a month, after which she
was given modified milk for a month. This did not agree
with her and she was put on a mixture of two teaspoonfuls
of condensed milk in eight ounces of water, which was given
to her whenever she cried. Her digestion had been all right
since starting the condensed milk and she had gained weight
fairly well. Swelling and tenderness of the right arm was
noticed one week and swelling of the left leg three days before
her admission to the Infants' Hospital. The swelling of both
arm and leg had increased. They had apparently caused
considerable pain and had interfered with her sleep. She
had been feverish, but the temperature had not been taken.
Physical Examination. She was fairly developed and
nourished, and of fair color. The anterior fontanelle was
one cm. in diameter. The tongue was moderately coated.
There were two teeth. The gums were healthy about them.
There was an ulcerated area in the median line, at the junc-
tion of the hard and soft palates, about one-half an inch
long and one-quarter of an inch wide, with a small super-
ficial ulceration on each side of the soft palate. The throat,
heart and lungs were normal. The abdomen was large and
lax, but otherwise normal. The lower border of the liver
was palpable two cm. below the costal border in the nipple
line. The spleen was not palpable. The left arm was nor-
mal. There was marked swelling of the right hand and
forearm up to the elbow. The skin was tense and shiny
and, about the wrist, very red, while in the upper portion it
was brawny. This swelling was exquisitely tender. Motions
at the elbow were free and caused but little pain. There was
no motion at the wrist, but the fingers could be moved a
little. She lay with the thighs flexed on the abdomen and
the legs flexed on the thighs. The right leg, however, was
normal in every way. There was swelling, redness and heat
over the upper portion of the left leg. Motions at the knee
caused pain, but were not limited. Motions at the hip and
SPECIFIC INFECTIOUS DISEASES. 299
ankle were normal. The rectal temperature was I03°F.;
the pulse, 160; the respiration, 50.
The leucocyte count was 48,000.
Diagnosis. The fact that she has taken nothing but
condensed milk for seven months, the pain, tenderness and
swelling in the extremities and the position of the legs suggest
scurvy. The high temperature, the normal condition of the
gums, the asymmetrical distribution of the swellings, the
presence of redness and heat, and the leucocytosis are,
however, sufficient to rule out this disease. The onset is
more acute and the superficial evidences of inflammation
are more marked than is usual in tuberculosis, the swelling
involves the shafts of the bones rather than the joints and
two extremities are involved at the same time. Syphilis
is suggested by the ulcerations in the mouth. They are,
however, not manifestations of syphilis but simply the result
of abrasion of the mucous membrane and constitute the
condition known as Bednar's Aphtbje. There are no other
evidences of syphilis, the temperature is high and the inflam-
mation is acute. Tuberculosis and syphilis can, therefore,
be excluded. The leucocytosis, moreover, is much against
both of these conditions and shows that there is some acute
inflammatory condition. It is impossible to tell from the
examination whether the lesions involve the bones of the
forearm and leg and the wrist joint as well as the periosteum,
but, as in most cases of inflammation of the bones and joints
in infancy the original focus is in the bones and extends into
the joint and to the periosteum, the chances are that in this
instance there is a Periosteitis and an Osteomyelitis of
the Radius, with purulent inflammation of the wrist joint,
and a Periosteitis and Osteomyelitis of the Tibia.
Prognosis. The condition is a very serious one. She is
almost certain to die within a few days of general sepsis,
unless she is operated upon immediately. If she is, there
is a fair chance of her recovery.
Treatment. T^he treatment is immediate operation. If
periosteitis is found, the bone should be investigated and the
medullary canal opened, if necessary. If there is a purulent
inflammation of the joint, it should be freely opened.
300 CASE HISTORIES IN PEDIATRICS.
CASE 86. John D. was the second child. The first child
was born dead at eight months. There had been no other
pregnancies. His mother had had no symptoms of syphilis;
his father was not seen.
He was born at full term after a normal labor and was
normal at birth. Dryness of the palms and soles and cracking
of the lips was noticed when he was two weeks old. A week
later he began to have trouble in breathing through his nose
and kept his mouth open. The trouble in breathing steadily
increased, and when he was four and a half weeks old he
began to have great difficulty in nursing. He did not vomit.
The movements from the bowels were normal. He had had
no fever. He was seen in consultation when five weeks old.
Physical Examination. He was small but well-nourished.
There was slight cyanosis of the lips and extremities. The
anterior fontanelle was 3 cm. in diameter and slightly de-
pressed. The posterior fontanelle was not quite closed.
The pupils were equal and reacted to light. There was no
strabismus. There was a slight purulent discharge from the
left eye. He lay with his head held back. The neck was,
however, freely moveable. His mouth was open and no air
entered through the nose. His breathing was irregular,
difficult and rapid. There was a slight purulent discharge
from one nostril. The nasal mucous membrane was much
swollen, but no membrane was visible. A probe could be
passed through both nostrils, but with considerable difficulty;
its passage caused bleeding. Examination with forceps by a
nose and throat specialist showed no adenoid growth. There
was nothing abnormal in the pharynx or in the region of the
tongue. The lips were cracked. There was retraction of the
epigastrium with inspiration. The heart and lungs were
normal, except that at times no respiratory sound could be
heard. The cry was strong and of normal character, when he
had breath enough to cry. The abdomen was negative.
There was no enlargement of the liver or spleen. The genitals
were normal. There were no mucous patches about the anus.
The extremities were normal except for redness, thickening
and scaling of the palms and soles. There was no spasm or
paralysis of the face or of the extremities. The knee-jerks
SPECIFIC INFECTIOUS DISEASES. 301
were equal and normal. Kernig's sign was absent. There
was a fine desquamation over the whole body, but no erup-
tion or scars of any old eruption. The rectal temperature
was 1040 F. ; the pulse 160, but fairly strong. The baby
seemed a good deal exhausted.
Diagnosis. The purulent discharge from the eye is an
incidental and unimportant complication. The retraction of
the epigastrium with inspiration shows that there is an ob-
struction to the entrance of air somewhere in the respiratory
tract, but gives no hint as to the location of the obstruction.
The cyanosis has the same significance. The clear, strong
cry rules out any obstruction in the larynx. The high tem-
perature and rapid respiration suggest some pathological
condition in the lungs. The character of the respiration and
the absence of physical signs in the lungs rule this out, how-
ever, and the temperature can be explained equally well by
toxic absorption from the nose and exhaustion. The negative
examination of the throat rules out obstruction from adenoids,
retropharyngeal abscess or malformation. The obstruction
to the entrance of air must, therefore, be located in the nose.
The reason that the baby is so much troubled by this obstruc-
tion is that he has not yet learned to breathe through his
mouth, and that it prevents him from getting sufficient
nourishment. It is the nasal obstruction which is causing
the serious symptoms in this instance, and it is this condition
which must be relieved in order to save the baby's life. The
retraction of the head is not a sign of meningitis, but merely
the result of the baby's effort to get more air by straightening
the upper air passages.
The possible causes of the nasal obstruction in this instance
are simple rhinitis, diphtheritic rhinitis and syphilitic rhinitis.
Any one of them, even the simple rhinitis, can, at this age,
cause symptoms as serious as those present in this instance.
Both simple and diphtheritic rhinitis usually have more dis-
charge than there is in this instance, and the discharge in
nasal diphtheria is usually thin and irritating. The absence
of visible membrane does not rule out nasal diphtheria, be-
cause it is often absent or out of sight in this disease. While,
however, there is nothing about the symptoms or local con-
302
CASE HISTORIES IN PEDIATRICS.
ditions to exclude simple or diphtheritic rhinitis, there is
much in the history and physical examination which points
toward syphilitic rhinitis. The previous stillbirth, the ap-
pearance of dryness of the palms and soles and cracking of the
lips at two weeks and of nasal obstruction at three weeks, and
the redness, thickening and scaling of the palms and soles,
while individually not of much importance, together make
the diagnosis of Syphilitic Rhinitis practically certain. The
good health of the mother does not, of course, count in any
way against the diagnosis of syphilis, because syphilis is
often transmitted from father to child, although the mother
shows no signs of the disease.
Prognosis. The prognosis is very grave, because the cause
of the obstruction, the syphilis, cannot be removed at once
and it is doubtful whether the nasal obstruction can be re-
lieved by local treatment for so long a time as will be required
to get the syphilis under control. A point in his favor is that
he is nursed.
Treatment. The specific treatment of the syphilis must, of
course, be begun at once. The local treatment of the nasal
obstruction is, however, of more immediate importance and,
next to this, the administration of food. A 1-5,000 solution of
adrenalin chloride is more likely to relieve the nasal obstruc-
tion than anything else. This is best applied by dropping it
into the nose with a medicine dropper while the baby is lying
on its back, so that it can run downward over the nasal
mucosa. Five drops in each nostril every hour should be
sufficient. If it is not effective in this strength, it is hardly
worth while to try stronger solutions. If it does not give
relief, a 0.5% solution of cocaine may be tried. This must be
used cautiously, as babies are very easily poisoned by cocaine.
If these measures are unsuccessful, pieces of rubber tube (a
catheter is suitable), as large as can be passed into the nose
and long enough to reach the pharynx, may be inserted into
both nostrils.
If the nasal obstruction is relieved by these procedures the
baby will probably be able to take the breast. If he is not,
the milk must be withdrawn with a breast pump or squeezed
out by hand and given to him with a dropper or a Breck
SPECIFIC INFECTIOUS DISEASES. 3°3
feeder, or through a stomach-tube passed through the mouth.
He ought to get at least sixteen ounces in the twenty-four
hours; twenty ounces if possible.
A piece of mercury ointment, half the strength of the offici-
nal unguentum hydrargyrum, the size of a large pea, should
be rubbed in daily, the location of the application varying
from day to day. This should be continued, with occasional
short interruptions, for a year. It must be remembered in
this connection that the earliest symptom of mercurial
poisoning in infancy is diarrhea, not salivation. It should
then be used, as a matter of precaution, one month in every
three for three or four years and, even if there are no symp-
toms, again for a couple of years at the time of the second
dentition, and at puberty.
304 CASE HISTORIES IN PEDIATRICS.
CASE 87. John N. was the only child. His parents said
that they were and always had been well. There had been
one previous miscarriage. He was born at full term, after
a normal labor, and was normal at birth. He had never had
anything but breast-milk, but had been nursed very irregu-
larly. He often vomited immediately after nursing and had
from two to six yellowish-green movements, containing small
curds, daily. His mother said that he had moved his legs
and arms freely until he was two weeks old, since when he
had gradually stopped using them, so that now he almost
never moved them. He began to scream with pain whenever
his arms and legs were handled, when he was about four weeks
old. A nasal discharge appeared when he was three weeks
old and had persisted. He had apparently had no fever
and had, she thought, gained in weight. The urine had not
stained the diapers. He was seen at the Infants' Hospital
when two months old.
Physical Examination. He was fairly developed and
nourished, but a little pale. The head was of good shape.
The anterior fontanelle was one and one-half cm. in diam-
eter and level. There was no rigidity of the neck. The
pupils were equal and reacted to light. The mouth and lips
were healthy. There was an irritating, watery discharge,
mixed with blood, from the nostrils, which were somewhat
obstructed. A bacteriological examination of this discharge
showed no Klebs-Lceffler bacilli. There was no rosary. The
heart and lungs were normal. There was a small umbilical
hernia. The abdomen was otherwise normal. The lower
border of the liver was palpable three cm. below the costal
border in the nipple line. The spleen was palpable one and
one-half cm. below the costal border. There was no enlarge-
ment of the peripheral lymph nodes. The anus and genitals
were normal. He held his arms closely to his sides, flexed
to about a right angle at the elbow and with the hands
sharply flexed at the wrists and turned to the ulnar side.
The fingers and thumbs were flexed at the metacarpo-
phalangeal and extended at the phalangeal joints. He was
able to make all motions with his arms and hands, but they
caused pain. Passive motions were not limited, but caused
SPECIFIC INFECTIOUS DISEASES. 305
much pain. There was considerable swelling at the wrists
at the level of the epiphyseal line and for a short distance
above it. There was also a bony swelling in the upper third
of the left forearm. These swellings were tender, but not
red or hot. He held his thighs partially flexed on the abdo-
men with the legs flexed at the knees to about a right angle.
He could make all motions with his legs, but they were con-
siderably limited. Passive motions were also limited and
caused much pain. There was considerable swelling at the
ankles at the level of the epiphyseal line and for some dis-
tance above it, as well as of the lower portion of the right
femur. These swellings were very tender, but not red or
hot. The knee-jerks and Kernig's sign could not be deter-
mined, because of the spasm.
The rectal temperature was ioo°F. ; the pulse, 120; the
respiration, 30.
The urine was pale, clear, acid in reaction, and contained
no albumin.
Diagnosis. Peripheral neuritis can be excluded on the
age of the child, the absence of cause, the spasm of the ex-
tremities and the presence of the swellings. Spastic diplegia
can be ruled out on the tenderness and swelling. Scurvy,
which is strongly suggested by the tenderness and swelling
of the bones, is rendered very improbable by the age of the
child and the fact that it has never had anything but breast-
milk. The location of the swellings is, moreover, not quite
that of the swellings in scurvy, which are situated over the
diaphysis and do not extend over the epiphyseal line. The
age of the baby, the absence of a rosary and the presence of
pain and tenderness exclude rickets. The history of gradu-
ally increasing unwillingness to use the extremities, beginning
at two weeks in a baby previously normal, accompanied
by pain, tenderness and swelling in the extremities, is very
characteristic of the acute epiphysitis of congenital syphilis.
So is the location of the swellings. The position of the
extremities is that usually assumed in this condition. The
previous miscarriage, the bloody, irritating nasal discharge
and the enlargement of the spleen are corroborative evidence
in favor of this diagnosis. In fact, these things, when taken
306 CASE HISTORIES IN PEDIATRICS.
together, make the diagnosis of Syphilitic Epiphysitis,
or Parrot's syphilitic pseudoparalysis, unquestionable. The
thickening and irregularity at the epiphyseal lines at the
wrists and ankles, shown in the radiographs taken at this
time, confirmed this diagnosis, as did the positive Wasserman
test which was obtained from the blood a few days later.
Prognosis. The prognosis of this condition, when properly
treated, is very good. Even if separation of the epiphyses
has occurred, reunion always takes place and usually without
any deformity.
Treatment. A piece of mercury ointment, one-half the
strength of the officinal unguentum hydrargyrum, the size
of a large pea, should be rubbed in daily, the location of the
application varying from day to day. (See Case 86.) He
should be kept on the breast, but should be nursed regularly,
being given eight feedings in twenty-four hours, at two and
one-half hour intervals. Boracic acid ointment should be
applied to the upper lip and liquid albolene dropped in the
nose every few hours.
SPECIFIC INFECTIOUS DISEASES. T>°7
CASE 88. Kenneth B. was admitted to the Children's
Hospital when six years old. He was the only child. His
mother had had, however, two miscarriages, four and two
years before he was born. His father was not seen. His
mother denied any knowledge of venereal infection and had
never had any symptoms of it. There was no tuberculosis
in either family and there had been no known exposure
to it.
He was born at full term and was a large, healthy baby.
He was weaned when two months old and had considerable
disturbance of the digestion during the first two years. His
digestion and appetite had been good since that time. He
had had occasional "colds" during infancy, but no contin-
uous snuffles. He had never had a rash or complained of
sore throat or headache. He had measles when three, and
whooping-cough when five years old, soon after which he
was treated at the Massachusetts Charitable Eye and Ear
Infirmary for interstitial keratitis. He had seen very little
with his left eye since then. His teeth began to decay soon
after they appeared. He had lost some weight recently, but
was active and seemed happy and well. Six months before
he was seen a lump, the size of a silver dollar, was noticed
on the right shin. This lump had steadily increased in size.
A similar swelling appeared on the left leg two months later.
Neither had been painful, but the one on the right shin had
been somewhat tender for several weeks.
Physical Examination. He was fairly developed and nour-
ished, and somewhat pale. The ear drums were normal.
There were corneal opacities in both eyes, more marked on
the left. The tongue was clean, the throat normal. There
were no mucous patches or rhagades about the mouth. The
teeth were much decayed. The heart and lungs were normal.
The abdomen was sunken and lax. Nothing abnormal was
detected in it. The upper border of the liver flatness was at
the sixth rib in the nipple line. The lower border was palpable
one and one-half cm. below the costal border in the same
line. The spleen was not palpable. The genitals were nor-
mal. There was a firm thickening over both tibiae ante-
riorly, giving a sabre-like deformity. The swelling on the
308 CASE HISTORIES IN PEDIATRICS.
right was purplish at the summit, somewhat tender and fluc-
tuated. The extremities were otherwise normal. There was
no spasm or paralysis. The knee-jerks were equal and nor-
mal. There were no mucous patches about the anus. There
were many palpable lymph nodes, the size of peas, in the
neck, groins and axillae. The epitrochlear glands were the
size of split peas. There was no eruption and there were no
scars of old eruptions. The rectal temperature was 990 F. ;
the pulse, 100; the respiration, 20.
The urine was of normal color, acid in reaction, of a specific
gravity of 1024, and contained no albumin or sugar.
The leucocytes numbered 4200.
A skin tuberculin test was negative.
Diagnosis. The lesions which require explanation are the
swellings over the tibiae, one of which is evidently breaking
down. The normal temperature, the low white count and
the absence of pain show that there is no pyogenic infection
of the bones. The negative tuberculin test excludes tuber-
culosis as the cause. It would be most unusual to have
enlargement of both tibiae if the disease was sarcoma, the
growth of the tumor would have been much more rapid and
the general condition much more impaired. The only other
disease which can cause such swellings is syphilis. The
deformity of the legs is, moreover, the typical one of this
disease. It is not unusual for gummatous deposits to break
down. The general enlargement of the peripheral lymph
nodes, especially of the epitrochlears, is corroborative evi-
dence in favor of syphilis, as are the corneal scars resulting
from the interstitial keratitis. The fact that the liver is pal-
pable is of some, but not of much, importance, because the
liver is sometimes normally palpable at this age. The his-
tory of previous miscarriages is confirmatory evidence of
syphilis. So also are the decayed teeth, in that they show
an early disturbance of the nutrition. A positive diagnosis of
Syphilitic Osteoperiosteitis with breaking down of a
gummatous deposit in the right tibia is, therefore, justified.
Prognosis. The prognosis as to life is good. The lesion
of the right tibia will heal under antisyphilitic treatment.
Some deformity of the tibiae will undoubtedly remain.
Kenneth B. Case 88.
SPECIFIC INFECTIOUS DISEASES. 309
Treatment. The broken down area on the right tibia must
be opened and, if a sequestrum of bone is found, it must be
removed. He should be given iodide of potash in as large
doses as he can bear. He will probably be able to take one
or two drachms daily without injury. It will also be well
to start him on a course of inunctions with mercurial oint-
ment (Unguentum Hydragyri). Bichloride of mercury may
be substituted for this a little later.
310 CASE HISTORIES IN PEDIATRICS.
CASE 89. Allen W., sixteen years old, came home from
boarding-school for the spring vacation, April 11. He had
never had chicken-pox. He had been successfully vaccinated
when an infant and again when twelve years old. There had
been an epidemic of chicken-pox in the school and he had
been repeatedly exposed, the last time having been on March
28. There had also been a number of cases of small-pox in
the city near which the school was situated. He had been
feeling perfectly well and was sure that there had been no
eruption on his skin while he was at school. He noticed a
small blister on his chest when he dressed, April 12. That
afternoon he began to feel feverish and sick and went to bed.
His temperature was then 1020 F., and there were several
pimples on his chest. He was seen the next morning. He
had passed a restless night, because of itching, but was then
feeling somewhat better. He had some headache, but no
backache.
Physical Examination. He was well developed and nour-
ished and of good color. He was perfectly clear mentally
and did not appear seriously ill. His trunk was covered
with papules and vesicles. There were a few on the extremi-
ties and face and a number on the scalp. The papules did
not have a shotty feel, the vesicles were all unilocular and
there were no pustules. There was no eruption in the mouth
or throat. The tongue was moderately coated. The heart,
lungs, liver, spleen, abdomen and extremities were normal.
The temperature in the mouth was ioo°F. ; the pulse, 96;
the respiration, 24.
Diagnosis. The diagnosis lies between a rather severe
case of chicken-pox and a mild case of small-pox. The known
exposure to chicken-pox points much more directly to chicken-
pox than does the possible exposure to small-pox. The two
successful vaccinations in the past, the last one only four
years ago, makes small-pox extremely improbable. The
absence of prodromal symptoms and of an initial rash, the
appearance of the eruption first on the chest, the greater
abundance of the eruption on the trunk than elsewhere, the
absence of a shotty feeling in the papules, the unilocular
character of the vesicles and the absence of pustules are,
SPECIFIC INFECTIOUS DISEASES. 311
when taken together, sufficient to rule out small-pox. There
can be no doubt, therefore, that he has a severe case of
Chicken-pox.
Prognosis. There is no danger as to life. New crops of
papules will probably continue to appear for several days.
The temperature will continue slightly elevated for three or
four days, but the constitutional symptoms will probably
cease sooner than that. There will be no scars, if he does
not scratch. Acute nephritis has been known to develop
after chicken-pox. This happens so seldom, however, that
it hardly needs to be considered, even as a possibility.
Treatment. It will not be necessary to confine his hands,
because he is old enough to appreciate the harm which he
may do by scratching. He should be well smeared, however,
with some simple ointment, such as unguentum zinci oxidi
or unguentum aquae rosae, in order to allay the itching. If
this does not quiet it, a solution of bicarbonate of soda, a
mixture of equal parts of alcohol and water, or a one per cent
solution of carbolic acid may be tried. If none of these is
effectual, a saturated solution of camphor in ether may be
painted on and allowed to dry. He should be kept in bed
until his temperature is normal and the constitutional symp-
toms have ceased. He should be given a rather light diet
and made to drink considerable water. An occasional dose
of five or ten grains of a mixture of equal parts of phenacetine
and salol will probably make him more comfortable. No
further treatment, unless it be a laxative, is required.
He should be kept in quarantine until all the scabs have
come off. It will not be necessary to disinfect his room.
312 CASE HISTORIES IN PEDIATRICS.
CASE 90. James T., ten years old, had had none of the
eruptive diseases. There was an epidemic of measles in
Boston at the time, and one of the boys at his school had come
down with it February 13. He began to be feverish during
the afternoon of February 25, and, as he expressed it, "felt
bum." His mouth temperature that night was 1030 F. It
dropped to ioo° F. the next morning and remained under
ioi.5°F. until the afternoon of March 1, when it rose to
102.10 F. He continued to feel miserable, but was up and
about the room until the afternoon of March 1. A loose
cough, which developed the first night, had persisted. His
conjunctivae became a little inflamed February 28. His
appetite was poor, but there had been no disturbance of
the digestion or other symptoms. He was seen late in the
afternoon of March 1.
Physical Examination. He was fairly developed and
nourished and of fair color. He was perfectly clear mentally.
The conjunctivae were somewhat injected and there was
slight photophobia. The ear-drums were normal. There
was a moderate nasal discharge. The whole throat was
slightly reddened and there was an excessive amount of naso-
pharyngeal secretion. The tongue was moist and moder-
ately coated. There were numerous pearly-white spots, the
size of the shaft of a pin, surrounded by reddened areas, the
size of the head of a pin or a little larger, on the inside of both
cheeks. The heart, lungs and abdomen were normal. The
liver and spleen were not palpable. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and normal. There was no enlargement of the
peripheral lymph nodes and no eruption. The tempera-
ture, taken in the mouth, was 102. i° F.; the pulse, 120; the
respiration, 35.
The leucocytes numbered 18,000.
Diagnosis. The sudden onset of an acute disease, associ-
ated with catarrhal symptoms, in a child known to have been
exposed to measles twelve days before (this being the usual
incubation period of measles) , is very strong presumptive evi-
dence in favor of measles. The persistence and increase of
the catarrhal symptoms, although the temperature is lower
SPECIFIC INFECTIOUS DISEASES. 313
than in the beginning, is characteristic of the prodromal
stage of measles and strengthens the evidence in favor of
this disease. The slight leucocytosis and the absence of
symptoms pointing to any other condition are consistent
with this diagnosis. The spots in the mouth are unques-
tionably Koplik's spots. These spots are pathognomonic of
Measles and make the diagnosis certain. This being the
fifth day of the disease and the temperature having begun to
go up again, it can be confidently expected that the eruption
will appear during the night or to-morrow.
Prognosis, He is in good general condition, his tempera-
ture is not very high, he is not seriously intoxicated and his
lungs are clear. He can be expected, therefore, with proper
care, to recover quickly without complications or sequelae.
Children of his age are less likely than infants and young
children to develop severe bronchitis or bronchopneumonia.
Treatment. He should be kept in bed until his tempera-
ture is normal, the eruption faded and the signs of bronchitis,
if he has it, gone. It is not only not necessary but actually
harmful to shut children with measles up in a hot, close,
dark room, as was formerly done. The temperature of the
room should be kept at about 6o° F. and the windows should
be kept open enough to give an abundance of fresh air. The
room need not be darkened, unless the light hurts his eyes.
His diet should be made up chiefly of milk and starchy foods.
Water should be given freely. He should be given cleansing
baths regularly, there being no more danger in bathing
patients with measles than those with other diseases. His
eyes should be washed frequently with a 4% solution of
boracic acid. He may be given five grain doses of a mixture
of equal parts of phenacetine and salol, every three or four
hours, if he is uncomfortable. If he develops bronchitis, it
should be treated like any other bronchitis (see Cases 104 and
105). He should be kept in isolation until the desquamation
and all catarrhal symptoms have ceased. It will not be neces-
sary to disinfect the room after his recovery, a thorough
airing being amply sufficient to prevent contagion.
314 CASE HISTORIES IN PEDIATRICS.
CASE 91. Nathaniel T., seven years old, lived in the
country in an isolated house. He did not go to school and
had not been away from home for several weeks. He was
seen in consultation, March 26.
A boy, eleven years old, came to visit him, March 9, from
a school in which there was an epidemic of German measles.
This boy had not had any of the eruptive diseases. Having
felt perfectly well previously, he vomited March 11, and soon
after an eruption appeared on the neck and chest. The
fauces were red and the temperature in the mouth 1010 F.
The eruption gradually extended all over the body and ex-
tremities and lasted three days. The efflorescence was uni-
form, but the tongue was not characteristic of scarlet fever.
There was no enlargement of the cervical lymph nodes. The
diagnosis of scarlet fever was made and he was isolated. He
did not desquamate at all, however, and felt perfectly well
and had no temperature after the second day.
The tutor, a young man who had had both scarlet fever
and measles, went to bed feeling perfectly well, March 25.
He was feverish during the night and on going to bathe in
the morning noticed a profuse rash on his chest. He was
seen at noon. His temperature, taken in the mouth, was
990 F. There was no Koplik's sign. There was a rash over
the chest, back and arms, resembling closely that of measles,
but none on the face or legs. His eyelids were not puffy and
there was no nasal discharge.
A chambermaid, who had been taking care of the room of
the first patient, felt feverish the morning of March 26, and
noticed a rash. She had had no prodromal symptoms. She
also was seen at noon. Her temperature, taken in the mouth,
was ioo° F. Her conjunctivae were a little injected and her
eyelids a little puffy. She was, however, very much alarmed
and had been crying for several hours. There was no rash in
the throat and no Koplik's sign in the mouth. The papillae
of the tongue were not enlarged. There was a rash on the
face, chest and arms which resembled measles, but was rather
brighter in color and was here and there confluent. There
was no enlargement of the cervical lymph nodes.
Nathaniel T. had been perfectly well until March 24, when
SPECIFIC INFECTIOUS DISEASES. 315
he was a little feverish. The temperature was normal the
morning of March 25, but there was a fine rash here and there
on the body. This disappeared during the day, but his
temperature went up to 1010 F. that night. The rash ap-
peared again the morning of March 26 and the temperature,
taken in the mouth, was ioo° F. He was seen at noon.
Physical Examination. He was well developed and nour-
ished and of good color. He seemed to feel perfectly well.
There was no eruption in the throat and no Koplik's sign in
the mouth. The tongue was slightly coated, but the papillae
were not enlarged. He had no cough or nasal discharge and
the conjunctivae were not inflamed. There was no enlarge-
ment of the cervical lymph nodes. The heart, lungs, liver,
spleen, abdomen and extremities were normal, as were the
deep reflexes. There were a few light-pinkish papules, about
the size of the head of a pin or a little larger, scattered over
the body and arms. There was no eruption on the face or
legs. His mouth temperature was 99. 6° F.
Diagnosis. It is evident that the last three patients have
the same disease. It is also evident, from the fact that the
onset in all occurred within a period of forty-eight hours,
that they must have contracted it from the same source. It
seems reasonable to suppose that the visitor was this source
and that he also has the same disease. The period of incu-
bation in the last three patients was approximately fourteen
days. This, of itself, is sufficient to make scarlet fever very
improbable, the period of incubation in this disease being
almost never over eight days. The tutor has already had
scarlet fever, and second attacks of this disease are very
uncommon. The onset in all of them was comparatively
mild, none of them have a sore throat, redness of the fauces,
enlargement of the papillae of the tongue or of the cervical
lymph nodes, while the eruption does not resemble that
of scarlet fever. Scarlet fever can, therefore, be positively
excluded. The diagnosis lies, then, between measles and
German measles. The period of incubation is consistent with
either disease. Nathaniel is the only one of the three that
had any prodromal symptoms, and they were very slight.
The chambermaid is the only one that has any catarrhal
316 CASE HISTORIES IN PEDIATRICS.
symptoms, and they are probably the result of crying. None
of them have any eruption in the throat, and Koplik's sign is
absent in all. Measles can, therefore, also be excluded. The
only point against German measles is the absence of enlarge-
ment of the cervical lymph nodes. This is of very little
importance in the diagnosis from measles, however, as it is
often absent in German measles and often present in measles.
It is very evident, therefore, that Nathaniel has German
Measles. It is also plain that the visitor had the scarlatini-
form type of the disease, with an unusually acute onset, and
that he brought the disease with him from school.
Prognosis. There is, of course, no danger to life. He will
probably not feel any sicker than he does to-day. The rash
will almost certainly be gone within three days and there will
be no desquamation.
Treatment. It will be wise to keep him in bed and on
a rather light diet until his temperature has reached normal
and the rash has faded. No other treatment is necessary.
He should be kept away from other children for three weeks,
unless their parents are willing that they should have the
disease.
SPECIFIC INFECTIOUS DISEASES. 317
CASE 92. Mary M., seven years old, had always been
well, except for frequent attacks of acute gastric indigestion
as the result of indiscretions in diet. She had never had any
eruption in these attacks. She had been a little out of sorts
and had complained of a sore throat for two days, but had
been to school in spite of it. She had not vomited and had
eaten nothing unusual. She was seen early in the morning
of the third day.
Physical Examination. She was well developed and nour-
ished, and did not look or act especially sick. Her cheeks
were somewhat flushed. Her tongue was covered with a
slight, white coat, except at the tip and edges, which were
clean. The papillae were somewhat enlarged and showed
distinctly through the coating. The tonsils were moderately
enlarged, but there was no exudation on them. The whole
throat was bright red and it could be seen that on the soft
palate this redness was due to a large number of very fine,
bright red spots. The heart, lungs, abdomen and extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and normal. There was no enlargement of
the peripheral lymph nodes. There was a bright red rash
over the front of the neck and the whole trunk. It extended
on to the upper arms and downward over the anterior surface
of the thighs. It was most marked in the folds of the axillae
and groins. It was found on close inspection to be made
up of minute red spots, corresponding to the papillae of the
skin, with normal skin between them. It did not itch. The
temperature, taken in the mouth, was 1020 F. ; the pulse,
112; the respiration, 24.
Diagnosis. The only diseases which need to be considered
in this instance are erythema from indigestion or food poison-
ing, German measles and scarlet fever. Erythema can be
ruled out on the absence of all signs of indigestion and of any
indiscretion in diet, the eruption in the throat and the en-
largement of the papillae of the tongue. The peculiar dis-
tribution of the rash and the greater intensity of the eruption
in the folds of the axillae and groins are also against it. Ger-
man measles can be excluded on the eruption in the throat
and the enlargement of the papillae of the tongue, although
318 CASE HISTORIES IN PEDIATRICS.
the mildness of the onset and the constitutional symptoms
suggest it. The diagnosis of Scarlet Fever by exclusion is,
therefore, justified. The eruption in the throat, the enlarge-
ment of the papillae of the tongue, the distribution of the rash,
its peculiar characteristics and the greater intensity of the
eruption in the folds of the skin make up a symptom-complex,
moreover, which is characteristic of scarlet fever and which
is presented by no other disease.
Prognosis. She has a very mild type of the disease. The
tonsils are but little enlarged, there is no exudation in the
throat and the cervical lymph nodes are not enlarged,
although this is the third day of the disease. The chances
of any severe infection of the throat and cervical lymph
nodes are, therefore, small. Acute nephritis very seldom
develops, if patients are properly fed and protected. She
will be. Inflammation of the heart and joints sometimes
occurs. There is no way of avoiding these complications.
Fortunately, however, they are comparatively infrequent.
She can be expected, therefore, to recover quickly without
complications.
Treatment. She must be put to bed and kept there until
desquamation has ceased. The temperature of the room
should be kept between 6o° F. and 640 F. Her diet should
be so regulated as to provide a sufficient number of calories
and at the same time throw as little work as possible on the
kidneys, that is, on exactly the same lines as in acute ne-
phritis (see Case 137) in order to prevent its development.
She should drink a large amount of water in order to dilute
as much as possible the products of metabolism which are
eliminated by the kidneys. She should take at least a quart
of water daily in addition to the liquid which she gets in her
food. Her throat should be sprayed frequently with some
mild alkaline wash, like the liquor antisepticus alkalinus.
She should be given a cleansing bath daily, after which she
should be anointed freely with vaseline or lanoline. She will
require no other treatment, unless it* be for the relief of
symptoms like constipation or sleeplessness.
She must be isolated with her attendant until desquama-
tion and all catarrhal symptoms and discharges, if any de-
SPECIFIC INFECTIOUS DISEASES. 319
velop, have ceased. If desquamation does not appear at
the usual time, she must be isolated for three weeks. If it
does not appear before this, it is safe to assume that it will
not later. Nothing that has not been previously disinfected
should go out of her room. All scraps of food and other
small articles, such as pieces of gauze or muslin used in place
of handkerchiefs, that can be disposed of in the room should
be destroyed there. When she has ceased desquamating she
should be given a disinfecting bath in her room, step out of
the door into a clean blanket and dress elsewhere in her
clean clothes.
320 CASE HISTORIES IN PEDIATRICS.
CASE 93. Gertrude W., twelve years old, was the only
child of healthy parents. There was, however, a marked tend-
ency to nephritis and an excess of uric acid in the urine in
both families. She had always been well, except for measles,
complicated by nephritis, when she was six years old. She
had the family tendency to an excess of uric acid in the urine,
however, and had to take large amounts of water in order to
keep well.
She had a chill and vomited early in the morning of No-
vember 23. The vomiting continued all day. The temper-
ature rose quickly to 1 04° F. and had ranged between 1040 F.
and 1050 F. since that time. The throat became sore during
the day. An urticarial eruption appeared during the morning
of November 24 and had come and gone since then. The
typical rash of scarlet fever developed in addition during the
morning of November 25. The vomiting began again and had
persisted. The bowels were thoroughly moved by calomel
during the day. She passed urine freely up to 10 a.m.,
November 25. Nine ounces were obtained by a catheter
at 3 a.m., November 26. This urine was black, of a specific
gravity of 1025, and contained a large trace of albumin.
The sediment, which was very heavy, contained a little
normal blood, very many dark-brown, cast-like bodies and
much granular detritus. Her pulse ran about 120 and was
of good character up to the afternoon of November 25.
Since then it had varied between 130 and 150 and had been
feeble. She was seen in consultation at 9 a.m., November 26.
Physical Examination. She was an unusually large, well
developed girl. She was very drowsy, but was conscious
when roused. The tongue was very red and dry; the papillae
were much enlarged. The whole throat was a brilliant red.
The tonsils were considerably enlarged, but there was no exu-
dation on them. The cervical lymph nodes were not enlarged.
The cardiac impulse was somewhat feeble and diffuse. The
upper border of the cardiac dullness was at the upper border
of the third rib, the right border three and one-half cm. to
the right, and the left eight and one-half cm. to the left of
the median line. The action was slightly irregular and the
first sound a little weak. There were no murmurs. The
SPECIFIC INFECTIOUS DISEASES. 32 1
lungs and abdomen were normal. The liver and spleen were
not palpable. There was no dullness over the pubes and the
bladder could not be felt. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. There was a typical scarlet fever rash on the
face, neck and chest, with a characteristic white line about
the mouth. There were also many large and small blotchy,
erythematous areas, in many places somewhat elevated above
the surface, scattered over the trunk and extremities. The
hands and feet were slightly cyanotic. The axillary tem-
perature was 1050 F.; the pulse, 140; the respiration, 35.
Diagnosis. She undoubtedly has a very malignant type
of Scarlet Fever. Myocarditis and acute nephritis have
already developed.
Prognosis. The infection is such a virulent one, as is
shown by the early development of myocarditis and ne-
phritis, that her chances of recovery are very slight. The
family tendency to nephritis and uric aciduria, already mani-
fested in her in the past, makes the outlook still more unfa-
vorable. She will probably not live more than forty-eight
hours.
Treatment. She should, of course, be isolated and the
usual precautions necessary in the treatment of scarlet fever
taken (see Case 92). It is very hard to know just how to
treat her. It will be unwise to attempt to reduce the tem-
perature by the use of cold externally, because of the danger
of increasing the congestion of the kidneys. An ice cap will,
however, probably do no harm in this way and may perhaps
reduce the temperature a little. She should have an abun-
dance of fresh, cool air to breathe to stimulate the vaso-motor
system, but must at the same time be well protected. Warm
baths should be tried with the hope of relieving the kidneys
by inducing sweating. The danger of increasing the tem-
perature in this way must, however, be borne in mind. Hot
air baths are contraindicated on this account. Her bowels
must be freely opened, also with the object of relieving the
kidneys. Epsom salts, in doses of one-half an ounce, will
do this most satisfactorily, if they are not vomited. If they
are, compound jalap powder in doses of thirty grains, or
322 CASE HISTORIES IN PEDIATRICS.
trituration of elaterin in doses of one-half of a grain, may be
tried. Water is, on general principles, contraindicated by
the acute congestion of the kidneys (see Case 137). She has
a tendency to uric aciduria when well, however, and in health
requires large quantities of water. It will be well, therefore,
to allow her a pint of water in the twenty-four hours. Food
should be stopped entirely for the next twenty-four or forty-
eight hours. Little can be expected from cardiac tonics or
stimulants, because the weakness of the heart is due to myo-
carditis. The cardiac tonics are, moreover, contraindicated
by the acute congestion of the kidneys. It will be wise,
however, to give her one-sixtieth of a grain of strychnia every
three hours, and caffeine-sodium benzoate, in doses of one
grain, from time to time, if necessary.
SPECIFIC INFECTIOUS DISEASES. 323
CASE 94. Charles T., eleven years old, had never had
the mumps, but had been exposed to them at school three
weeks before. He went to bed feeling perfectly well, but
was waked up several times in the night by pain in his face.
He found in the morning that his face was swollen and some-
what painful and that it hurt him to open his mouth and
chew. He did not feel sick in other ways. He was seen at
ten in the morning.
Physical Examination. He was a large, strong boy in very
good condition. His cheeks were a little flushed. There
was a diffuse swelling on the left side of the face extending
upward in front of the ear, forward to the beginning of the
zygomatic arch, downward to a little below the angle of
the jaw, backward to the sternocleidomastoid muscle and
upward behind the ear. This swelling was moderately ten-
der, but was not red and did not fluctuate. There was a
similar swelling over the ramus of the lower jaw on the right.
The mouth was somewhat dry and the tongue slightly coated.
There was reddening and swelling about the mouths of
Stenson's ducts. The throat was normal. The heart, lungs,
abdomen, external genitals and extremities were normal.
The liver and spleen were not palpable. The temperature
in the mouth was 99.40 F.
Diagnosis. The only diseases which need to be considered
are cervical adenitis and mumps. The presumption is that
he has mumps, because the swelling appeared exactly three
weeks after the known exposure to mumps, that is, at the
end of the usual period of incubation. The sudden appear-
ance of the swelling without any previous inflammation of
the throat or mouth is characteristic of mumps. Cervical
adenitis develops more slowly and is always preceded by
some inflammatory condition in the mouth or throat. The
position of the tumor is that of the parotid gland. The
swelling in cervical adenitis does not extend on to the face
or around the ear, but is all behind the jaw. The dryness of
the mouth and the reddening and swelling about the open-
ings of Stenson's ducts are also characteristic of mumps
and do not occur in cervical adenitis. The disease is,
therefore, certainly Mumps.
324 CASE HISTORIES IN PEDIATRICS.
Prognosis. There is no danger as to life. The swelling
on the right side will increase for a time, but that on both
sides will probably be gone in a week. The constitutional
symptoms will not last more than three or four days. The
submaxillary glands may also be involved, but the chances
are that they will not. It is possible that orchitis may de-
velop in the course of ten days or two weeks, but very improb-
able, as this complication is very unusual in children under
twelve years of age. Acute nephritis, endocarditis, permanent
deafness and suppuration of the parotid gland have been
known to develop as sequelae of mumps, but they occur so
seldom that they hardly need to be taken into consideration.
Treatment. He should stay in bed until the swellings have
subsided, and, on account of the danger of the development
of orchitis, should be very careful about exposure for at least
three weeks. Heat applied externally by means of a poultice,
an electric heating pad or a hot-water bag, will probably make
him more comfortable, His mouth should be rinsed several
times daily with some simple alkaline wash, like the liquor
antisepticus alkalinus. He may have five grains of a mixture
of equal parts of phenacetine and salol, every three hours,
if his head aches or he is generally uncomfortable. He may
have anything within reason to eat that he is able to take
without discomfort. He should keep away during the next
four weeks from people who have not had the mumps. It
will not be necessary to disinfect his room.
SPECIFIC INFECTIOUS DISEASES. 325
CASE 95. Elmer B., seven years old, had always been
well, except for occasional "colds" and an attack of chicken-
pox when he was five years old. There was an epidemic of
whooping-cough in the town where he lived and there had
been a number of cases in the school which he attended. He
began to have a "cold in his head" ten days before he was
seen. The nasal discharge had diminished, but a cough,
which developed after two or three days, had persisted.
Spraying the nose and throat had had no effect on it. It had
been frequent, short and dry at first, but during the last few
days he had coughed much less often. The cough had
become more paroxysmal in character, however, and was
harder. He had "strangled" quite badly in one attack the
morning of the day he was seen, and had vomited from cough-
ing once the day before. His general health had not been
affected in any way and his appetite and digestion were good.
He had not whooped. He had been taken out of school
when the coryza began, but had been allowed to play and
sleep in the same room with his younger sister. The object
of the mother in calling a physician was to find out whether
or not he had whooping-cough, in order that he might go back
to school if he had not, and that she might take proper
measures to protect the younger child, if he had.
Physical Examination. He was well developed and nour-
ished, and of good color. He acted perfectly well. There
was a slight nasal discharge and the pharynx and fauces were
slightly reddened. The mouth and throat were otherwise
normal. The heart, lungs, abdomen and extremities were
normal. The intensity of the respiratory sound was the same
on both sides. The bronchial voice sound was not heard
below the seventh cervical spine. The liver and spleen were
not palpable. The deep reflexes were normal and the pe-
ripheral lymph nodes were not enlarged. He coughed once
during the examination. The cough was somewhat paroxys-
mal in character, but there was no whoop. His temperature,
taken in the mouth, was 98. 40 F.
Diagnosis. The presence of an epidemic of whooping-cough
in the town and the fact that there have been a number of
cases in his school are strong presumptive evidence in favor
326 CASE HISTORIES IN PEDIATRICS.
of whooping-cough. The persistence of the cough, in spite of
the subsidence of the coryza, the slightness of the signs of
local inflammation in the throat and the absence of all evi-
dences of bronchitis also points strongly to whooping-cough.
So does the good general condition and the absence of all
other symptoms. More important than anything else, how-
ever, is the change in character of the cough from frequent,
short and dry to paroxysmal at longer intervals. The vomit-
ing with the cough is corroborative evidence. The absence
of a whoop at the end of ten days does not count much
against whooping-cough, because the whoop in many in-
stances does not appear for several weeks and sometimes
even not at all. The slightness of the signs of local irritation
in the nose and throat and the paroxysmal character of the
cough seem sufficient to exclude local irritation as the cause.
A paroxysmal cough, in some instances associated with a
sound much like a whoop, sometimes develops after influenza.
The onset, together with the absence of fever and constitu-
tional symptoms, is, however, sufficient to rule out this
condition as the cause. Enlargement of the tracheo-bron-
chial lymph nodes also sometimes causes a paroxysmal cough.
The absence of the bronchial voice sound below the seventh
cervical spine and of all evidences of compression from
enlarged glands excludes this condition. The diagnosis of
Whooping-cough seems justified, therefore, although he has
not whooped. It will be well also to examine the blood. The
finding of a leucocytosis with a relative lymphocytosis will be
strong confirmatory evidence that he has whooping-cough.
Prognosis. Judging from the mildness of the symptoms
and the absence of complications at the end of ten days, he
will have a mild and short attack. He is, moreover, in good
general condition and well able to bear the loss of rest and
food, if it turns out to be a severe one. His circumstances
are such that he will receive the best of care and be guarded
against exposure. In all probability, therefore, he will have
no complications and will pass through the disease without
being much pulled down by it.
Treatment. It is very important for him to have an
abundance of fresh air. There is no reason why he should
SPECIFIC INFECTIOUS DISEASES. 327
not be out of doors on pleasant days, even if it is January.
If the weather is bad, he should play in the house in a room
with the windows open. If this is not feasible, he should
change from room to room, each room, as he vacates it, being
thoroughly aired before he returns to it. The windows should
also be well open at night. It will not be necessary to change
his diet, if he does not vomit. If he vomits, he must be given
another meal to make up for the one he has lost. If the
vomiting is very frequent, it will be well to feed him every
three or four hours with comparatively small amounts of those
foods which leave the stomach quickly, such as milk, raw
eggs and starches. It will also be well, if the vomiting is
severe, to try the abdominal belt recommended by Kilmer.
Local applications to the nose and throat are useless. So
also are applications to the chest. Inhalations of steam, plain
or medicated with creosote or similar drugs, may help him
some, but must not be used to the exclusion of fresh air.
There are no drugs which limit the course of whooping-cough,
although there is a considerable number which diminish
the frequency and severity of the paroxysms to a certain
extent. To do good, however, they must be pushed up to
their physiological limit. It seems hardly advisable to use
them in this instance, therefore, unless the symptoms become
much more severe than appears probable. If it becomes
necessary to use any of them, antipyrin, bromoform or the
bromides are the ones most likely to help him. If his sleep
is much disturbed, there will be no objection to giving him
bromide, sulphonal or trional at night.
The bacillus described by Bordet and Gengou is, without
much doubt, the cause of whooping-cough. The treatment
of this disease with vaccines, prepared from this organism, has
thus far been so unsatisfactory, however, that it is hardly
worthy of a trial.
It will be useless to attempt to separate him from his sister
now, because, as whooping-cough is contagious from the
appearance of the catarrhal symptoms, she certainly has
already contracted the disease. He should, however, be kept
away from other children who have not had it, until he has
ceased to whoop and to have definite paroxysms.
SECTION VI.
DISEASES OF THE NOSE, THROAT, EARS AND
LARYNX.
CASE 96. Virginia G., seven months old, had always had
a rather feeble digestion, but had recently been doing very
well on a wet nurse. She had had a " cold in the head "
about six weeks before. Soon after recovery from this cold,
which lasted about a week, she began to have paroxysms of
cough at night and during her naps. The cough disturbed her
sleep considerably, but not enough to affect her general con-
dition. She did not cough much when awake, had no nasal
discharge or fever, did not snore at night or keep her mouth
open, and nursed well.
Physical Examination. She was small but fairly nourished
and of fair color. The anterior fontanelle was 3 cm. in di-
ameter and level. There was no snuffles and she kept her
mouth shut. There were no teeth and the gums were not
inflamed. The fauces were normal. The membranse tym-
panorum were normal. There was a slight rosary. The
heart, lungs and abdomen were normal. The liver was
palpable 2 cm. below the costal border in the nipple line.
The spleen was not palpable. The extremities were normal.
There was no spasm or paralysis; the knee-jerks were equal
and normal. The cervical lymph nodes were slightly enlarged.
Diagnosis. The physical examination shows nothing in
the nose, fauces or chest to account for the cough. There are
no evidences of otitis media, difficult dentition or disturbance
of digestion, all of which are sometimes said to be causes of
reflex cough. A " nervous " cough probably does not occur
at this age. Nevertheless, she coughs, and there must be
some cause for it. This cause will probably be found in the
nasopharynx, the only region not investigated in the physical
examination, in spite of the absence of all of the symptoms of
adenoids common in older children. An examination of the
329
330 CASE HISTORIES IN PEDIATRICS.
nasopharynx then showed a small amount of soft Adenoids,
not sufficient to interfere in any way with respiration. Ade-
noids of this sort, however, if inflamed, will often secrete just
enough fluid to keep up a constant tickling of the throat and
cough when the baby is asleep. They are one of the most
common causes of persistent cough in infancy.
Prognosis. Removal of the adenoids will stop the cough at
once.
Treatment. It is hardly worth while to waste time on
palliative measures, such as applications to the nasopharynx
through the nose or mouth, when operation will remove the
cause at once and hence cure the cough. The operation is a
simple one and not at all dangerous. There is, moreover, a
certain amount of risk in leaving the adenoids in situ, because
they are often the starting point of attacks of rhinitis and
otitis media and, if they increase in size, will cause obstruction
to nasal respiration. It is true that they may grow again but,
if they do, they can be removed again. In the meantime, the
baby is relieved of its symptoms and freed from the dangers
to which adenoids expose it.
NOSE, THROAT, EARS AND LARYNX. 33 1
. CASE 97. John W., twenty-five months old, had always
had a rather feeble digestion and been backward in develop-
ment. He had taken less and less solid food during the last
three months, and for the last month had refused everything
but liquids. Swallowing seemed to trouble him. He did not
vomit, had no flatulence or hiccough, and had one small,
normal movement daily. He had lost considerable weight,
strength and color during the past month. He had no cough
or nasal discharge, kept his mouth shut and did not snore at
night. There had been no fever.
Physical Examination. He was fair-sized, but flabby and
pale. The anterior fontanelle was not quite closed. There was
no nasal discharge. The membranae tympanorum were nor-
mal. He kept his mouth shut. He had twenty teeth. His
tongue was clean. The tonsils were somewhat enlarged, but
not inflamed. There was a slight rosary. The heart and lungs
were normal. The liver was palpable 2 cm. below the costal
border in the nipple line. The spleen was not palpable. The
abdomen was rather large and lax, but otherwise normal.
The extremities were normal. There was no spasm or paraly-
sis; the knee-jerks were equal, but rather feeble; there was
no Kernig's sign. There was no enlargement of the peripheral
lymph nodes.
Diagnosis. The rosary shows that he has, or has had, a
certain amount of rickets. The open fontanelle and large
abdomen are probably also manifestations of the same dis-
ease. The flabbiness and pallor are presumably due to an
insufficient supply of food. The unwillingness to eat can
hardly be due to loss of appetite from indigestion because
there are no other symptoms of indigestion. The enlargement
of the tonsils seems hardly great enough to interfere mechani-
cally with the swallowing of solid food. There must be,
therefore, some other cause. This will probably be found in
the nasopharynx, as Adenoids in some way often make
swallowing difficult. Examination of the nasopharynx with
the finger showed a large mass of firm adenoids situated
posteriorly, so that they did not interfere with respiration.
In the absence of any other explanation it is almost certain
that the adenoids, or the adenoids and the enlarged tonsils
332 CASE HISTORIES IN PEDIATRICS.
together, make the swallowing of solid food so uncomfortable
that he is unwilling to take it. In consequence, he is taking
an insufficient amount of nourishment and this, in turn, is
the cause of the progressive failure.
Prognosis. The removal of the tonsils and adenoids will
soon be followed by willingness to take solid food. When he
begins to take a proper amount of nourishment he will soon
regain his weight, strength and color.
Treatment. The treatment is the immediate removal of
the tonsils and adenoids.
NOSE, THROAT, EARS AND LARYNX. 333
CASE 98. Mary S., four years old, had had a slight
nasal discharge and seemed a little feverish all day. She went
to bed feeling fairly well, however, after eating her usual
supper. Soon after going to sleep she began to cough from
time to time, the cough being dry, hard and metallic. About
nine o'clock her parents heard her breathing noisily and ap-
parently struggling in her sleep. When they got to her they
found her sitting up in bed moderately cyanosed and breath-
ing with much difficulty. Inspiration was noisy and difficult,
expiration quiet. She occasionally gave a short, dry, metallic
cough. She tried to cry out, but could not raise her voice
above a whisper. At times she clutched at her throat. She
was seen at 9.30 p.m.
Physical Examination. She was then breathing quietly
and her color was good. Her voice was hoarse and her cough
metallic. There was a slight nasal discharge and the throat
was a little reddened. The heart, lungs and abdomen were
normal. The liver and spleen were not palpable. The
extremities showed nothing abnormal. There was no spasm
or paralysis. The knee-jerks were equal and lively. Kernig's
sign was absent. There was no enlargement of the peripheral
lymph nodes. The rectal temperature was 1010 F.
Diagnosis. The only diseases to be considered are laryn-
geal diphtheria and catarrhal laryngitis with " spasmodic
croup." The sudden onset and the short duration of the
difficulty in respiration positively rule out laryngeal diph-
theria, in which the onset is slow and the difficulty in respira-
tion steadily increases without intermissions. The history
of the nasal discharge during the day and the occurrence of
the attack in the early evening are also very characteristic of
11 spasmodic croup." The diagnosis is, therefore, Catarrhal
Laryngitis with " spasmodic croup."
Prognosis. There is, of course, no danger as to life. She
may or may not have another attack during the night. She
is likely to have paroxysms the next two or three nights
unless they are prevented by treatment. Having had " spas-
modic croup " once, she is likely to have it for the next few
years whenever she " catches cold."
Treatment. This attack is a mild one and does not require
334 CASE HISTORIES IN PEDIATRICS.
very active treatment. She should have twenty drops of the
wine of ipecac and ten drops of paregoric at once, and ten
drops of the wine of ipecac and five drops of paregoric every
hour for two or three doses, the object being to relax, but not
to nauseate her. A " croup kettle " or a dish of boiling water
in the room will moisten the air and will aid in preventing the
recurrence of the paroxysms. The temperature of the room
should be kept at about 640 F. She should be kept in the
house or, if feverish, in bed for the next three or four days, and
should be given ten drops of the wine of ipecac every hour,
beginning at 3 p.m., until bedtime, each afternoon. If the
paroxysms recur, the treatment recommended for to-night
should be repeated.
NOSE, THROAT, EARS AND LARYNX 335
CASE 99. George T., thirteen months old, began to refuse
his food February 24. He was feverish and lost weight
rapidly. He took his food very poorly, but did not vomit and
his dejections were normal. He had a frequent, painful
cough. There was no nasal discharge. He was sent to the
Infants' Hospital February 28 with the diagnosis of bronchitis.
Physical Examination. He was fairly developed and nour-
ished. He was pale, but not cyanotic. The general appear-
ance was that of sepsis. The anterior fontanelle was 3 cm.
in diameter and level. There was slight puffiness about the
eyes. There was a considerable general, soft, non-fluctuant
swelling in the right neck, extending forward from about the
angle of the jaw to just beyond the median line and downward
over the clavicle. The alae nasi moved with respiration.
There was no nasal discharge. He held his head slightly
extended and kept his mouth open. His throat was full of
thick mucopurulent material which rendered inspection
difficult. The right tonsil was moderately enlarged and some-
what reddened. The respiration was somewhat difficult, but
not noisy. His cry was clear. There was no retraction of the
suprasternal, supraclavicular or intercostal spaces. Per-
cussion of the lungs showed nothing abnormal. Respiration
was normal in character but diminished in intensity. Numer-
ous medium and coarse moist rales were heard throughout
both chests, both back and front. They were exactly alike
on both sides. The same sounds were heard under the upper
part of the sternum and in the middle of the back. The
abdomen showed nothing abnormal. The liver was just
palpable in the nipple line. The spleen was not palpable.
The extremities showed nothing abnormal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There was no Kernig's sign. The rectal temperature was
104.50 F., the pulse 150, the respiration 35.
The urine was high in color, acid in reaction, of a specific
gravity of 1,020, and contained no albumin or sugar.
The leucocyte count was 30,000.
Diagnosis. The quiet respiration and the clear cry show
that there is no trouble in the larynx. The facts that the
rales are alike on both sides, both back and front, and that
336 CASE HISTORIES IN PEDIATRICS.
the same sounds are heard under the manubrium and in the
middle of the back show that they are made high up and
transmitted downward through the bronchi, and not made
in the chest. This, of course, rules out bronchitis. The high
temperature, the marked leucocytosis and the general appear-
ance of sepsis point very strongly to a focus of pus somewhere.
The soft, non-fluctuant character of the swelling in the neck
is not consistent with an external abscess. The swelling of
the tonsils is not as much as would be expected if there was a
peritonsillar abscess. The unwillingness to take food, the
puffiness of the eyes, the swelling of the neck, the position of
the head and the prominence of the tonsil all suggest an
inflammatory process in the nasopharynx. The collection of
pus is, therefore, probably in the nasopharynx; that is, there
is almost certainly a Retropharyngeal Abscess. It is
noted in the physical examination that, on account of the
large amount of mucopurulent material in the throat, inspec-
tion was difficult, and, therefore, presumably unsatisfactory.
In such cases inspection alone is not sufficient and will often
fail to reveal serious conditions. The throat should always
be palpated when inspection is not perfectly satisfactory.
Palpation, in this instance, showed that the right side of the
pharynx was filled by a tense, elastic swelling which extended
downward to the level of the larynx and pushed the tonsil
forward, thus confirming the diagnosis of retropharyngeal
abscess.
Prognosis. The prognosis is grave even if the abscess is
opened at once, as it should be, because the baby is in poor
condition and generally septic and may not be able to rally
even when the source of infection is removed.
Treatment. The treatment is to open the abscess at once.
It is not safe to leave it alone, because if it does not rupture of
itself it interferes with deglutition and respiration and there
is constant absorption from the abscess, and if it does open
itself there is danger of suffocation from the sudden dis-
charge of pus or of a secondary inhalation bronchopneu-
monia. It is far better to open it through the mouth than
from the outside. The best way to open it is with a knife,
guarded except at the point, passed along the finger as a
NOSE, THROAT, EARS AND LARYNX. 337
guide. A gag must not be used, because, if the mouth is
opened too widely, sudden death may result from the pressure
of the abscess on the pneumogastric nerve. The mouth can
be held sufficiently wide open with the finger or a tongue
depressor. The incision is best performed with the patient in
the upright position. If he is tipped forward the instant the
incision is made, there is no danger of pus entering the air
passages. The incision must be opened up widely with the
finger in order to insure the thorough emptying of the ab-
scess cavity. The abscess should be squeezed once or twice
daily with the finger to keep up the drainage and to prevent
the opening from closing. It will be well to wash out the
mouth several times daily with some mild alkaline solution.
If he does not take his food well he must be fed with a tube,
introduced through the mouth. No stimulation is necessary
at present.
338 CASE HISTORIES IN PEDIATRICS.
CASE ioo. Jennie C. was the first child of healthy parents.
She was born after a normal labor, was nursed for six months
and did well. When six months old she was said to have had
pneumonia and some brain trouble with it; at any rate, she
had convulsions. During and since this illness she had been
fed on Horlick's Malted Milk, prepared with water. She had
lost weight, had vomited occasionally and had had a dozen or
more small, green, watery movements daily. Her nose was
always stopped up. She kept her mouth open and had con-
siderable cough. For two weeks she had had many attacks
daily in which she made a crowing sound, held her breath and
got black in the face. During the last week several of these
attacks had terminated in convulsions. She was seen when
seven months old.
Physical Examination. She was fairly developed and nour-
ished. The anterior fontanelle was 5 cm. in diameter, but
level. There was no craniotabes. The head was of good
shape. The eyes were rather prominent. She was bright and
intelligent. The pupils were equal and reacted to light.
The nares were partially occluded and the mouth was kept
open. The throat showed nothing abnormal on either in-
spection or palpation. An attempt to introduce the finger
into the nasopharynx was unsuccessful. The tongue was
dry and considerably coated. There were no teeth. There
was a marked rosary. She held up her head, but was unable
to sit alone. The heart and lungs were normal. The abdomen
was rather large and lax. The lower border of the liver was
palpable 3 cm. below the costal border in the nipple line.
The spleen was not palpable. There was slight enlargement
of the epiphyses at the wrists. There was no spasm or paraly-
sis of the extremities. The knee-jerks were equal and lively.
There was no Kernig's sign. During the examination she
started to cry, then drew in her breath with a crowing noise,
stopped breathing and became moderately cyanosed. After
perhaps a minute she began to breathe again and her color
quickly became good. The mother said that this attack was
a very mild one and not nearly as severe as many.
Diagnosis. The condition here is a complicated one. She
undoubtedly has a chronic intestinal indigestion as the result
NOSE, THROAT, EARS AND LARYNX. 339
of improper feeding. She also has a moderate amount of
rickets. This is proved by the marked rosary and the en-
largement of the epiphyses at the wrists. Other abnormalities
which are presumably signs of rickets are the large fontanelle,
the delayed dentition and the lax abdomen. She has, in
addition, a chronic rhinitis and presumably adenoids, al-
though this is not proven, since the attempt to examine the
nasopharynx was unsuccessful.
The most important conditions, however, at any rate in the
opinion of the parents, are the attacks of asphyxia and the
convulsions. These attacks are so characteristic of the con-
dition known as Laryngismus Stridulus that a differential
diagnosis is hardly necessary. The diseases which might
possibly be confused with it are congenital laryngeal stridor,
catarrhal laryngitis and laryngeal diphtheria. Congenital
stridor is present at birth, or develops soon after, is constant
instead of being paroxysmal and is not accompanied by
cyanosis. The attacks of difficult respiration in catarrhal
laryngitis occur less frequently and usually only at night, are
of longer duration and the breath is never held in them.
The difficulty with respiration in laryngeal diphtheria is
constant and progressive and the breath is not held.
Laryngismus stridulus is not properly a disease, but merely
a manifestation of the spasmophilic diathesis. In this dis-
ease there is a marked increase in the nervous excitability,
which shows itself in various ways, the most characteristic
manifestations being laryngismus stridulus, tetany and
convulsions. The convulsions in this instance are undoubt-
edly merely another manifestation of this diathesis. It is
almost certainly due to some disturbance in the metabolism
of calcium. It is uncertain whether this disturbance is or is
not due to parathyroid insufficiency. There is in all proba-
bility a deficiency of calcium salts in the blood in the spas-
mophilic diathesis. It is very possible that her food during
the past month contained an insufficient amount of calcium,
or contained it in a form not easily utilized. The rickets is to
be regarded, therefore, merely as another manifestation of
the disturbance of nutrition from the unsuitable food and
not as the cause of the paroxysmal attacks. The rhinitis and
340 CASE HISTORIES IN PEDIATRICS.
adenoids can have no direct etiological connection with the
attacks, but may possibly act as exciting causes through
reflex irritation.
Prognosis. The immediate prognosis of the attacks is,
on the whole, good, but must be guarded, because babies do
sometimes die in these attacks. The prognosis in general de-
pends very largely on whether or not she can get the best
treatment. If she can, recovery will be rapid ; if she cannot,
the chances are rather against her.
Treatment. The immediate treatment of an attack is to
slap her on the back or to dash cold water on her face or chest.
Artificial respiration is sometimes necessary. Most attacks
will, however, cease quickly if nothing is done. Bromide of
soda, in doses of from three to five grains, in an aqueous solu-
tion, three or four times daily, will tend to diminish the
frequency of the paroxysms.
The treatment of the spasmophilic diathesis, and at the
same time of the intestinal indigestion and rickets, consists
in regulation of the diet. Human milk always quickly re-
lieves this condition. A purely carbohydrate diet relieves it,
but much less promptly and is, moreover, not suitable for a
baby of this age. A return to cow's milk in any form, at any
rate until a considerable time has elapsed, almost invariably
causes a return of the symptoms. The only rational food for
this baby is, therefore, human milk. If she cannot get it she
must be given a starch and sugar solution for as long a time
as is possible, due regard being paid to her general condition,
and then quickly worked on to some^modification of cow's
milk.
It is possible that the administration of some of the calcium
salts, like the lactate, may do good. The indications are so
doubtful and the results to be expected so slight compared
with those obtained from human milk that they are, however,
hardly worthy of consideration. Parathyroid extract, in
doses of one twentieth of a grain, three times daily, would
seem a more rational treatment, but has not as yet been used
enough to prove whether or not it is of benefit.
NOSE, THROAT, EARS AND LARYNX. 34 1
CASE 1 01. Florence F., who was nearly three years old,
was the first child of healthy parents. She was born at full
term, after a normal labor, was normal at birth and weighed
ten pounds. She was nursed for thirteen months and then
given at once whatever her parents ate. She had been
perfectly well in spite of this, except for a convulsion, without
known cause, when she was eighteen months old. She had
had her adenoids removed when she was two years old.
She came in from her play about noon, February 14,
vomited her breakfast and immediately had a severe con-
vulsion. Her diet was then somewhat restricted, but was
still too hearty for a child of her age. She had had five
convulsions since then, one of which was preceded by vomit-
ing. The bowels moved involuntarily in one of them and
she slept for a long time after another. The convulsions had
not occurred at any definite time in relation to the taking of
food/ and no connection between the convulsions and any
special article of diet could be made out. Her appetite had
continued good, her bowels had moved regularly and the
stools had looked well digested. She had complained from
the first, however, of pain in the abdomen and also of pain
in the back of the head. She also often put her hands to
her head. She had slept poorly at night and had been very
fussy during the day. She was very feverish for several
days after the first convulsion and again between March 22
and March 25. She had probably had some fever all the
time, although her temperature had not been taken. She
had run about as usual until the morning of the day she was
seen, when she refused to either walk or stand. She was seen
March 28.
Physical Examination. She was fairly developed and
nourished, and of fair color. She was perfectly clear men-
tally, but fussy and hard to examine. There was no rigidity
of the neck or neck sign. She both saw and heard. There
was no spasm or paralysis of any of the muscles supplied by
the cranial nerves. There was no coryza and the throat was
normal. The tongue was slightly coated. The heart and
lungs were normal. The abdomen was sunken and lax;
nothing abnormal was detected in it. The liver and spleen
342 CASE HISTORIES IN PEDIATRICS.
were not palpable. She would not stand or walk, but used
her legs normally when lying down. There was no spasm or
paralysis of the extremities. The knee-jerks were equal and
normal. Kernig's and Babinski's signs were absent. There
was no enlargement of the peripheral lymph nodes. The
rectal temperature was ioo.4°F.; the pulse, 112; the res-
piration, 24.
The urine was of normal color, clear, acid in reaction, of
a specific gravity of 1012 and contained neither albumin nor
sugar.
The leucocyte count was 20,000.
Diagnosis. The improper diet, the association of some of
the convulsions with vomiting and the pain in the abdomen
and head point to some disturbance of the digestion as the
cause of the convulsions. The fever is not inconsistent with
this supposition. Against this explanation are the good
appetite, the absence of vomiting except at the time of the
convulsions, the normal and regular stools, and, to a less
extent, the leucocytosis. The long continuance of the symp-
toms without the development of any physical signs of cere-
bral or meningeal irritation practically excludes all forms of
meningitis and encephalitis. A cerebral tumor would not be
accompanied by fever and pain in the abdomen, would not
be likely to cause a leucocytosis and ought by this time to
have produced some focal symptoms. Idiopathic epilepsy is
not accompanied by fever, leucocytosis or pain in the head
and abdomen. None of these explanations is, therefore,
satisfactory. The leucocytosis and fever show that there
must be a focus of inflammation somewhere. The physical
examination has thus far failed to reveal its location and the
normal condition of the urine rules out disease of the urinary
tract. Inflammation of the middle ear is probably the most
common cause of obscure fever at this age, is often accom-
panied by marked reflex symptoms and very frequently
produces no symptoms to draw attention to the ear. It is
usually preceded or accompanied by some symptoms of
inflammation of the nose or throat, none of which are present
in this instance. When this possibility is thought of, how-
ever, the pain in the head, the putting of the hands to the
NOSE, THROAT, EARS AND LARYNX. 343
head, the disturbed sleep and the irritability are found to be
characteristic of it and to point toward it. The ears ought,
therefore, to be examined. This was done and both drums
were found to be red and bulging and the landmarks indis-
tinguishable. Otitis Media is, therefore, undoubtedly the
cause of the peculiar symptoms. The convulsions are reflex
in origin ; the pain in the abdomen is a referred pain, or, more
probably, not in the abdomen at all, but merely a manifesta-
tion of the child's inability to locate pain.
Prognosis. The pain, restlessness and irritability will
almost certainly cease as soon as the ears are opened. The
temperature will soon drop to normal and there will be no
recurrence of the convulsions.
Treatment. The treatment is immediate paracentesis of
both drums, followed by syringing of the ears with warm
water, three or four times daily.
344 CASE HISTORIES IN PEDIATRICS.
CASE 102. John R., six months old, began to have a
slight " cold in the head " February 15, but had no other
symptoms. Three days later he was taken suddenly sick with
fever, cough and difficulty in breathing. He lost his appetite,
but showed no other symptoms of gastro-enteric disturbance.
Swallowing seemed to cause discomfort. He apparently had
no pain and did not put his hand to his ear. He was taken to
a physician, February 21, who found the rectal temperature
1 04.2 ° F., the pulse 160 and the respiration 52. He sent the
baby to the Infants' Hospital with the diagnosis of pneumonia.
He was not seen and examined until the next day.
Physical Examination. He was a large, fat baby. His
color was good. He took considerable interest in his sur-
roundings. The alse nasi did not move and the respiration
was not grunting or painful, even when he cried. The
anterior fontanelle was 3 cm. in diameter and level. There
was no tenderness on pressure over the mastoids. There was
no rigidity of the neck. The pupils were equal and reacted to
light. There was a slight nasal discharge. The tongue was
moderately coated. The throat was slightly reddened, but
otherwise normal. The heart and lungs were normal. The
liver was palpablej2 cm. below"the costal border in the nipple
line. The spleen was not palpable. The extremities were
normal. There was no- spasm or paralysis. The knee-jerks
were equal and lively. There was no Kernig's sign. There
was no enlargement of the peripheral lymph nodes. The
rectal temperature was ioo° F., the pulse 115, the respiration
38.
The urine was pale, clear, acid in reaction, of a specific
gravity of 1,012 and contained no albumin.
Diagnosis. The acute onset with fever, cough and diffi-
culty in breathing and the relatively greater increase in the
rate of the respiration over that of the pulse point strongly to
pneumonia. His general appearance, the absence of motion
of the alae nasi and of grunting and painful respiration, the
drop in the temperature and the normal condition of the
lungs, while they do not exclude pneumonia, make it very
improbable. Some other cause for the symptoms must be
sought. The only place which has not been investigated is
NOSE, THROAT, EARS AND LARYNX. 345
the ear. The absence of pain, putting the hand to the ear and
tenderness on pressure over the mastoids, does not count at
all against otitis media. Pain is often absent in this disease.
Babies seldom put their hands to their ears when they have
otitis media and often do under other conditions. Tenderness
over the mastoids is extremely rare in middle-ear disease at
this age. Examination of the ears showed marked redness
and some bulging of the right, and slight reddening of the
left membrana tympani, showing that the trouble was
Otitis Media.
Prognosis. The prognosis is good both as to life and the
maintenance of normal hearing if the proper treatment is
carried out. If the ear is opened early and proper drainage
secured, extension to the mastoid, sinuses or meninges very
seldom occurs at this age. If the drum is opened before it
ruptures, it usually heals without a scar and leaves the hear-
ing unimpaired.
Treatment. The right drum should be opened at once.
The left should not be touched at present. Both ears should
be syringed three or four times daily with warm water.
346 CASE HISTORIES IN PEDIATRICS.
CASE 103. Joseph B., twenty-two months old, was seen
in consultation July 22. He lived in a malarial district. He
had always been delicate and pale. He had had a cough and
a slightly elevated temperature since an attack of bronchitis
in the early spring. He had seemed worse and the tempera-
ture had been higher and more irregular during the last two
weeks. He had had a chill the night before, which was fol-
lowed by a temperature of 1050 F. and sweating. His appe-
tite had been poor, but there had been no symptoms of indi-
gestion, and the movements had been normal. Nothing
abnormal had been found on physical examination except
pallor and a slight enlargement of the spleen. The urine had
shown nothing abnormal. An almost positive diagnosis of
malaria had been made on the basis of the chill, fever and
sweating, the enlargement of the spleen, the pallor and the
apparent absence of any other cause for the symptoms.
Physical Examination. He was small and only fairly
nourished. Pallor was marked. The anterior fontanelle was
closed. He had twelve teeth. There was a slight nasal dis-
charge and there was a little mucopurulent secretion in the
nasopharynx. His tongue was moderately coated. There
was a slight rosary. The heart and lungs were normal. The
abdomen was rather large but lax. The liver was palpable
2 cm. below the costal border in the nipple line. The spleen
was palpable 3 cm. below the costal border. The extremities
showed nothing abnormal. There was no spasm or paralysis.
The knee-jerks were equal and normal. Kernig's sign was
absent. There was a slight general enlargement of the
peripheral lymph nodes.
The urine. was pale, clear, slightly acid in reaction, of a
specific gravity of 1,015 and contained no albumin or sugar.
The sediment showed no formed elements.
Blood.
Hemoglobin,
42%
Red corpuscles,
4,560,000
White corpuscles,
30,000
Small mononuclears,
45-5%
Large mononuclears,
6.0%
Polynuclear neutrophiles,
47-5%
Eosinophiles,
1.0%
NOSE, THROAT, EARS AND LARYNX. 347
There was much variation in the size and shape of the red
corpuscles, but no nucleated forms were seen. No plasmodia
malariae were seen.
Diagnosis. The leucocytosis and the absence of plasmodia
at once exclude malaria. The rosary means a slight but
unimportant amount of rickets. The blood has the character-
istics of secondary anemia in infancy. The enlargement of
the spleen is probably due to the same cause as the anemia.
The continued irregular temperature and the chill suggest
tuberculosis or confined pus. Tuberculosis at this age is
rarely accompanied by chills, and it is unusual to have a high,
irregular temperature without some physical signs of tubercu-
losis. Tuberculosis is, however, the most probable diagnosis
unless some other cause for the symptoms can be found. The
most common locality for confined pus in infancy, when it
is not discovered on a routine examination, and when the urine
is normal, is the middle ear. The nasal discharge and the
mucopurulent secretion in the nasopharynx suggest, in this
instance, the possibility of an infection of the middle ear.
An examination of the ears showed bulging and reddening of
both membranae tympanorum. Paracentesis showed pus in
both middle ears. The diagnosis is, therefore, Otitis Media.
Prognosis. The prognosis is good. The temperature will
gradually work down to normal and the general condition
improve. There is but little chance of extension to the mas-
toid cells or to the sinuses. .Hearing will probably not be
impaired.
Treatment. Now that the ears have been opened, the
treatment is syringing with warm water, three or four times
daily, until the discharge has ceased and the incisions have
healed.
SECTION VII.
DISEASES OF THE BRONCHI, LUNGS AND PLEURA.
CASE 104. John J., three years old, started in with a
" cold in his head " and cough, January 10. The nasal dis-
charge diminished and the cough became drier on the 12th.
He did not seem at all sick until the 13th. The cough was
then much more severe and apparently painful. His appe-
tite was poor and he appeared feverish.
Physical Examination. He was well developed and nour-
ished. His cheeks were flushed. There was a slight nasal
discharge. The ear drums were normal. The whole throat
was moderately reddened, but there was no enlargement of
the tonsils and no exudation. His tongue was slightly coated.
The lungs showed nothing abnormal except a few sibilant and
sonorous rales scattered throughout both chests, both back
and front. The heart was normal. The abdomen was normal.
The liver and spleen were not palpable. The extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and normal. There was no enlargement of
the peripheral lymph nodes. The rectal temperature was
100.80 F., the pulse 132, the respiration 34.
Diagnosis. The diagnosis is, of course, Bronchitis.
Prognosis. The prognosis at present is perfectly good.
The only danger is of a consecutive bronchopneumonia.
This ought not to develop if he has proper care and treatment.
Treatment. The treatment of bronchitis depends on the
stage of the bronchitis and the condition of the bronchial
mucous membrane. The bronchitis in this instance is in the
early stage. The bronchial mucous membrane is congested,
dry, swollen and reddened, and consequently there is but
little secretion. The object of the treatment at this stage is
to relax the mucous membrane and in this way increase the
secretion. The drugs which will do this are the so-called
349
35° CASE HISTORIES IN PEDIATRICS.
" sedative " expectorants. These are tartar emetic, apo
morphin and ipecac. The only one of these which is safe
to give to children is ipecac. This may be given as the wine
or syrup. It should be given in water, not mixed with syrups,
which are inert and disturb the digestion. The object of the
ipecac is to cause relaxation of the mucous membrane, not
nausea or vomiting. From five to ten drops every two hours
is about the right dose for this boy. The alkalies have some-
what the same action and may be used instead of ipecac.
A moist atmosphere also tends to moisten and relax the
bronchial mucous membrane. It will be well, therefore, to
have a vessel of boiling water ora" croup-kettle " near him.
The object of the sedative expectorants is to relax the
bronchial mucous membrane and in this way to hasten the
cure of the disease. Their dosage and the length of time that
they are given must be regulated by the condition in the
bronchi, as revealed by physical examination. They are not
given for the symptom, cough, and in using them, therefore,
the amount of coughing must not be considered. The symp-
tom, cough, is best controlled by some preparation of opium.
The safest form of opium for a child is paregoric. This boy
may have from five to fifteen drops every two or three hours
for the cough if it is troublesome. This also should be given
in water, not in syrup. The ipecac and paregoric must not be
combined in the same prescription, because they are given for
entirely different purposes, and it is necessary to be able to
give either one without giving the other. He needs the
ipecac constantly; he may need the paregoric only occasion-
ally.
It will be well to give him a tablespoonful of castor oil, or
one or two teaspoonfuls of syrup of senna at once. The diet
should be liquids and soft solids. It will be much wiser for
him to stay in bed. He should have plenty of fresh air, but
will probably be more comfortable if the temperature does
not go below 6o° F.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 35 1
CASE 105. Henry L., twenty-six months old, had always
Deen well, except for an occasional slight attack of indigestion.
He was taken sick, January 16, with fever and cough. His
temperature had varied between ioo° F. and 1040 F. ever
since and the cough had continued. The cough, which was
at first dry, had, however, become loose. The physician who
had had charge of him said that he had bronchitis and gave
him ipecac and inhalations of compound tincture of benzoin.
He had taken his food poorly, but had not vomited and had
had normal stools. He was seen at 9 A.M., January 22.
Physical Examination. He was well developed and nour-
ished, but a little pale. He was sitting up in bed, playing
with his toys, but coughed frequently. The cough was loose.
He had no coryza and his voice was clear. The pharynx was
slightly reddened. The ear drums were normal. The heart
was normal. There were a moderate number of medium and
coarse moist rales on both sides behind and a few in front.
The lungs were otherwise normal. The abdomen was nega-
tive and the liver and spleen were not palpable. The ex-
tremities were normal. The knee-jerks were equal and
normal. There was no enlargement of the peripheral lymph
nodes. The rectal temperature was ioo° F. ; the pulse, 124;
the respiration, 40.
Diagnosis. He has an uncomplicated Bronchitis.
Prognosis. The prognosis is good, barring the possibility
of a consecutive bronchopneumonia. This ought not to
develop, if he has proper care and treatment.
Treatment. The treatment of bronchitis depends on the
stage of the bronchitis and the condition of the bronchial
mucous membrane. The bronchitis in this instance has
passed the early stage. The bronchial mucous membrane
is still somewhat swollen and reddened, but is no longer dry.
It is relaxed and is secreting moderately freely. It is time,
therefore, to stop the ipecac, which is a sedative expectorant,
and give one of the so-called "stimulant" expectorants to aid
the mucous membrane to clear itself of the products of
inflammation within it and to restore its tone. The best of
them is the chloride of ammonium. One-half of a grain every
two hours will be enough for him. The taste is best dis-
352 CASE HISTORIES IN PEDIATRICS.
guised by the fluid extract of licorice. The following pre-
scription is a suitable one :
Chloride of ammonium gr. xii
Fluid extract of licorice 3 ii
Water ad 3 iv
Sig. One teaspoonful every 3 hours.
The chloride of ammonium is given for its action on the bron-
chial mucous membrane, not directly for the symptom, cough,
and should, therefore, be given continuously. If his cough is
very troublesome, he may be given five or ten drops of pare-
goric, in water, every two or three hours to control it. The
paregoric should not be given any oftener than is necessary,
however, because, if it is given too freely, it will prevent him
from clearing his tubes thoroughly and will thus do harm.
It will be well to continue the vaporization of the compound
tincture of benzoin, although it is usually less effective in this
than in the early stage.
He should have plenty of fresh air, but will probably be
more comfortable if the room does not go below 6o° F. He
should stay in bed. His diet should consist of milk, junket,
cereals, milk toast, bread, broth and custard.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 353
CASE 106. Mary J., nine months old, had always been a
well, strong baby. She began to have a little running from
the nose March i. March 3 she began to cough a good deal
and to have a little fever. March 4 she had more fever,
coughed a great deal and had considerable rattling in the
chest. She took but little food, but digested that little well.
She grew rapidly worse and was seen in consultation the
night of March 5.
Physical Examination. She was well developed and nour-
ished, but markedly cyanotic. The alae nasi moved with
respiration. She was unable to lie down and was very rest-
less. The examination was superficial because of her critical
condition. The throat showed nothing abnormal. The
cardiac area was not determined ; the action was regular, the
sounds feeble. There was sinking in of the supraclavicular
and lower intercostal spaces, as well as of the epigastrium,
with each inspiration. There was vesicular resonance all
over the lungs. The respiratory sound was feeble, but normal
in character. The vocal resonance was not determined.
Both chests were full of fine and medium moist rales, the fine
predominating. The rales were easily palpable. The ex-
tremities were cold and the whole body covered with perspira-
tion. The temperature was not taken. The pulse was faster
than could be counted. The respiration was 80.
Diagnosis. The diagnosis is, without question, Bronchitis.
The finer and medium-sized tubes are involved to a much
greater degree than the larger.
Prognosis. The condition is a very critical one and, while
not hopeless, the chances are very much against recovery.
She will probably not live twenty-four hours. If she does,
her chances are somewhat better.
Treatment. Her condition is critical and the treatment
must be immediate and energetic. The first indication is to
clear out the bronchial tubes. Alternate dippings in water
from 1050 F. to no° F. and from 650 F. to 750 F., as is done
in resuscitating new-born infants, will probably make her cry,
breathe deeply and cough, and in this way get rid of the
excessive secretion. If this method is not successful, the wine
or syrup of ipecac, in teaspoonful doses, will make her vomit
354 CASE HISTORIES IN PEDIATRICS.
and in this way clear out the bronchial tubes. She must then
be given plenty of fresh air and, if necessary, oxygen. The
oxygen is given for the symptom, cyanosis, and must be given
continuously as long as the cyanosis lasts, not intermittently
as it usually is. The dippings and ipecac may be repeated as
necessary. It must not be forgotten, however, that ipecac
used in this way is depressing and, consequently, a dangerous
remedy. If the dippings and ipecac do not relieve her, atropin,
in doses of 1-500 grain, may be given subcutaneously with the
object of diminishing the secretion.
She also needs immediate stimulation. Strychnia is a
respiratory as well as a cardiac stimulant and is, therefore,
doubly indicated. It should be given subcutaneously, in
doses of 1-300 grain, every two or three hours, as necessary.
Caffeine-sodium benzoate, or salicylate, in doses of from
one eighth to one fourth of a grain, given subcutaneously,
will also aid in keeping up the heart.
She should be fed every two hours, and will probably not
take more than an ounce at a time, if she does that. She will
probably not be able to take the bottle. The best way to
give the food is with a Breck feeder. If she will not take it
in this way, a dropper or spoon may be tried. Human milk
is the best food for her; next to this, a weak modified milk,
for example, one containing 2% of fat, 6% of sugar, 0.75% of
whey proteids and 0.25% of casein.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 355
CASE 107. Clifton R., two years old, had always been
well. Four days before he was seen, while eating dried figs
in a room with his brother who was playing with some nails,
he suddenly began to cough and choke. His mother picked
him up by the heels and slapped his back and he vomited his
last meal together with a quantity of figs. He continued to
cough almost constantly and at times had attacks of choking.
He coughed up what was thought to be a piece of fig early the
next morning during one of these attacks. There was, how-
ever, no improvement in the symptoms after it. The tem-
perature went up to 1020 F. on the third day and at his
entrance to the Children's Hospital the next day was 1030 F.
He had eaten very little for two days, but had had no diffi-
culty in swallowing and had shown no symptoms of indiges-
tion.
Physical Examination. He was well developed and nour-
ished, but a little pale. He was clear mentally. There was
no nasal discharge and he kept his mouth shut. The throat
showed nothing abnormal to either inspection or palpation.
The ear-drums were normal. He was short of breath, but
was able to lie down. His voice was clear. There was no
dullness under the manubrium and the thymus was not
palpable above it. There was no increased dullness in the
middle back and the bronchial voice sound was not heard
below the seventh cervical spine. The heart was normal,
except that the second pulmonic sound was slightly accentu-
ated. The chest was symmetrical, but the left side moved
less in respiration than the right. The respiratory sound
was much diminished over the whole left chest, but normal in
character. The voice sounds and fremitus were slightly dimin-
ished on the left side and an occasional dry rale was heard on
that side, both in front and behind. There was no change in
the percussion note. The lower border of the liver was palpa-
ble two cm. below the costal border in the nipple line. The
spleen was not palpable. The abdomen, genitals and extrem-
ities were normal, as were the deep reflexes. The rectal tem-
perature was 1030 F. ; the pulse, 136; the respiration, 40.
The urine was pale, acid in reaction and contained no
albumin or sugar. The sediment showed a few leucocytes,
small round and squamous cells.
356 CASE HISTORIES IN PEDIATRICS.
A Roentgenograph showed no foreign body in either the
trachea or bronchi.
Diagnosis. The physical examination shows nothing in
the nose, nasopharynx, throat or larynx to account for the
symptoms, and there are no signs of enlargement of the thy-
mus or bronchial lymph nodes which might cause pressure on
the trachea or bronchi from without. The physical signs are
inconsistent with solidification of the lung or an accumula-
tion of fluid. The rales do not show a sufficient amount of
bronchitis to account for the severity of the symptoms. The
sudden onset of the coughing and choking points very strongly
to the inhalation of some foreign body, in this instance either
a piece of fig or a nail. The normal condition of the throat
and the clear cry prove that it cannot be located above the
trachea. The fact that less air enters the left chest than the
right and that the respiratory sound is diminished equally
over the whole left side show that the Foreign Body must
have passed through the trachea and lodged in the Left
Primary Bronchus. The absence of a shadow in the
Roentgenograph shows that it cannot be a nail. It must,
therefore, be a piece of fig, which would not give a shadow.
The rise in temperature indicates that there has been an
infection of the bronchus; the rales, a secondary bronchitis
or an accummulation of the bronchial secretions from in-
ability to clear the tubes properly.
Prognosis. The prognosis is very grave unless the piece
of fig can be removed very soon. It may soften and be
coughed up before much damage has been done to the bron-
chus. The fever shows, however, that considerable harm has
already been done. The chances are, therefore, that before
it is expelled an abscess or gangrene of the lung will have
developed which will eventually cause death.
Treatment. Bronchoscopy should be done at once by a
thoroughly competent man, and, if the piece of fig can be seen
and grasped, it must be removed. If it cannot be removed,
there is little to do at present except to look after the gen-,
eral condition. If evidences of abscess or gangrene of the
lung develop, an attempt should be made to reach it from the
outside. Even if the operation is successful, he will, however,
probably not recover.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 357
CASE 108. Benjamin A. was seen in August, 1909, when
seven years old. His father was rheumatic ; his mother and
four other children were well. He had had measles and
whooping-cough when two years old and chicken-pox at six
years. He had had an operation for the removal of adenoids
in 1906 and another in 1908. One tonsil was also supposed
to have been removed at the latter operation. In April, 1907,
when at his home in Mt. Vernon, Ohio, he had a very severe
attack of asthma, lasting several weeks. He had another
severe attack in July, 1907, while visiting at Port Huron. He
then went to the island of Mackinac, where he was immedi-
ately relieved. He spent the summer there and had only one
slight attack. During the winter of 1907-08, which was
spent in Mt. Vernon, he had many slight attacks, which
continued during the spring of 1908, when he was in Jackson-
ville, 111. He passed the summer in the Rocky Mountains at
an altitude of 6000 feet and was perfectly well. He slept out
of doors at home during the winter of 1908-09 and had only
a few mild attacks. About a week before he was seen, while
at Bass Rocks, Mass., he had the most severe attack since the
first one. He had been fairly well between the attacks, but
always kept his mouth open and snored at night. He was
rather indiscreetly fed and was subject to mild attacks of
indigestion. His mother thought that some of the attacks
of asthma were brought on by indigestion and that she had
been able to abort some of them by giving calomel at the
beginning. She had not been able to trace any connection
between the attacks and any special article of food.
Physical Examination. He was well developed and nour-
ished and of good color. He kept his mouth open and had a
typical adenoid face. A considerable amount of soft ade-
noids was felt with the finger. The tonsils were much en-
larged and did not look as if they had ever been touched.
The tongue was nearly clean; the teeth were good. The
area of cardiac dullness was normal, while the area of flatness
was much diminished. The heart sounds were normal. The
respiration was somewhat wheezy and expiration was pro-
longed. The chest was everywhere hyperresonant. The
respiratory sound was normal in character, but the expiration
358 CASE HISTORIES IN PEDIATRICS.
was prolonged. There was no change in the vocal resonance
or fremitus. A moderate number of sibilant rales was heard
on both sides, both behind and in front. The upper border
of the liver flatness was at the upper border of the eighth rib
in the nipple line; the lower border was not palpable. The
spleen was not palpable. The abdomen showed nothing
abnormal. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
Diagnosis. The wheezy respiration, prolonged expiration
and sibilant rales confirm the diagnosis of Asthma, which was
made by his former physicians. The hyperresonance of the
chest, the diminution of the area of cardiac flatness and the
displacement of the lung-liver boundary downward show that
there is a moderate degree of Emphysema of the Lungs. He
also has Adenoids and Chronic Hypertrophy of the
Tonsils.
Prognosis. The prognosis in this, as in all cases of asthma,
is indefinite. There is no way of finding out whether he will
continue to have attacks all his life or whether they will sooner
or later cease. The chances of recovery are, however, better
than they would be if he was an adult. The outlook is more
favorable than usual in this instance, moreover, because there
is an abnormal condition in the throat which may be at the
bottom of the trouble. If this is so, the removal of the tonsils
and adenoids will probably stop the attacks. If the asthmatic
attacks cease, the emphysema will diminish and what remains
will be corrected through the changes incident to the growth
of the lungs.
Treatment. The adenoids and tonsils should be removed
at once. He should then be taken to a high and dry climate,
where experience has shown that he does best. It will be
wiser for him to remain away from home for a year but, if
this is not feasible, he should sleep out of doors as he did last
winter. There are no definite indications as to diet, as he has
little or no disturbance of the digestion and no connection
between the attacks and any special articles of food has been
made out. He should be given a reasonable, simple diet for
his age. It will be well, in addition, to cut eggs out of his
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 359
diet, as in many instances they seem to predispose to, or
bring on,Jthe attacks. If the attacks persist after the removal
of the tonsils, it will be well to try the effect of iodide of
potassium, given over considerable periods of time, in doses
of from three grains to five grains, three times daily, after
meals. It is best administered in essence of pepsin. The
syrup of hydriodic acid may be used if desired. The objec-
tion to it, however, is that, as a teaspoonful represents only
a little more than one grain of the iodide of potassium, the
quantity of syrup which has to be given in order to give
enough of the iodide is liable to disturb the digestion.
He will probably be most comfortable during an attack in
a room at from 66° F. to 68° F., with the air somewhat moist.
Nitrate of potassium paper or some of the various asthma
powders should be burned in the room. These powders are
all more or less similar in their composition, being, as a rule,
made up of various combinations of nitrate of potassium,
belladonna, hyoscyamus and stramonium leaves and opium,
yet one combination is most effectual in one case and another
in another. It will be well, therefore, to try different com-
binations until one is found which relieves him. It will also
be advisable to try the subcutaneous injection of from three
to five minims of the i-iooo solution of adrenalin chloride,
which in some instances is very efficacious. If these measures
do not relieve him, it may be necessary to give him a few
whiffs of chloroform or a subcutaneous injection of morphia.
It will be wise to give him one thirty-second of a grain first;
if this does not relieve him, the dose may be increased to one-
sixteenth or even to one-eighth of a grain.
360 CASE HISTORIES IN PEDIATRICS.
CASE 109. Winthrop W.'s mother had had asthma when
a child. His sister, about two years older than he, had
eczema when a baby, and began to have attacks of asthma,
which were not stopped by the removal of the tonsils jnd
adenoids, when she was three and one-half years old.
He was well as a baby, except for repeated "colds," which
were less frequent after the removal of his adenoids, when he
was fourteen months old. He had a very severe attack of
laryngeal diphtheria, requiring intubation, when he was
eighteen months old, after which he had repeated attacks of
catarrhal laryngitis and many "colds." His tonsils and a
small amount of adenoids were removed when he was four
years old. The "colds" and attacks of laryngitis were,
however, as frequent and as severe as before. He was seen
in one of these attacks when four and one-half years old. He
had had a little coryza, accompanied by a tight cough and a
little hoarseness, the day before, but had slept well. He
began to choke up rather quickly at 9 a.m. and was seen at
II A.M.
Physical Examination. He was well developed and nour-
ished. His color was good. He was able to lie down, but
breathed much more easily when sitting up. There was a
little nasal discharge and the throat was generally reddened.
His voice was clear. The heart was normal. The pulmonary
resonance was normal and the respiration vesicular. Expira-
tion was, however, much prolonged. There was no change
in the vocal resonance or fremitus. A few sibilant rales were
heard over both lungs, both in front and behind. There was
no retraction of the intercostal spaces or epigastrium with
inspiration. The abdomen was normal. The upper border
of the liver flatness was in the fifth space in the nipple line;
the lower border was not palpable. The spleen was not
palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was 99.4°F.; the pulse, no; the
respiration, 18.
Diagnosis. The sudden onset of difficult respiration sug-
gests some affection of the larynx, either catarrhal or diph-
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 36 1
theritic. The clear voice, the absence of retraction of the
intercostal spaces and epigastrium and the prolonged expira-
tion exclude it. The sibilant rales show that there is a slight
Bronchitis. The bronchitis does not, however, explain the
prolonged expiration, and the difficulty in breathing is out
of proportion to the signs of bronchitis. The only condition
with which this combination of physical signs, sibilant rales,
prolonged expiration and difficult respiration, is consistent
is Asthma.
Prognosis. The prognosis in this, as in all cases of asthma,
is indefinite. He may continue to have attacks all his life
or they may sooner or later cease. The chances of recovery
are, however, much better than they would be if he was older.
The facts that the attacks have persisted in spite of the
removal of his tonsils and adenoids and that his sister also
has asthma make his chances somewhat less favorable than
the average.
Treatment. The temperature of the room should be kept
between 66° F. and 68° F. A dish of water on which com-
pound tincture of benzoin has been poured should be kept
boiling constantly, and ten drops of the wine of ipecac and
ten drops of sweet spirit of nitre given every hour. If this
treatment does not relieve him, nitrate of potassium paper
or one of the various asthma powders may be burned in the
room (see Case 108) or from two to three minims of the
i-iooo solution of adrenalin chloride given subcutaneously.
If these methods are ineffectual, he maybe given one twenty-
fourth of a grain of heroin by mouth, or, if necessary, a few
whiffs of chloroform or a subcutaneous injection of one
forty-eighth of a grain of morphia. This dose may be
increased to one thirty-second or even to one-sixteenth of a
grain, if necessary.
After the attack is over, it will be well to give him two or
three grains of the iodide of potassium, three times daily, for
a considerable time (see Case 108). He should be given a
simple, reasonable diet for his age. It will also be well to
cut out eggs. It is also important to keep his bowels well
open. If the attacks continue to recur, a change of climate
should, if possible, be tried. In this instance, as in most
362 CASE HISTORIES IN PEDIATRICS.
others, there are no definite indications as to what climate
will help him, except that, as he is living in Boston, it will be
well to try first some high, dry, inland locality. The selec-
tion of a climate must be, however, largely a matter of
experiment.
DISEASES OF THE BRONCHI, LUNGS AND PLEUILE. 363
CASE 1 10. Lizzie O., four years old, began to cough early
in April. She began to whoop in about a week. She was but
little depressed by the whooping-cough and got on very well
until about the first of May. The cough then became worse,
she lost her appetite and failed in flesh and strength. She
began to be feverish and on May 6 went to bed. From that
time she grew rapidly worse. She had frequent paroxysms of
whooping and much cough without whooping. She raised a
good deal of mucopurulent sputum. She was unable to lie
down with comfort the night of May 8 and was more or less
blue. She took almost no nourishment and was very restless.
She was seen in consultation May 9.
Physical Examination. She was fairly developed and nour-
ished but had evidently lost considerable weight. She was
bolstered up by pillows in a reclining position as she was
unable to lie flat. There was marked cyanosis of the face and
extremities. The alae nasi moved with respiration. She ap-
peared very sick. Examination of the throat showed nothing
abnormal. There was no retraction of the supraclavicular or
intercostal spaces, but a little of the epigastrium. The
cardiac impulse was diffuse; the apex in the fifth space just
outside the nipple line. The upper border of relative dullness
was at the lower border of the second rib; the right border
nearly at the right parasternal line. The first sound was
short and rather feeble, and at the mitral area was followed by
a soft blowing murmur. The second pulmonic sound was no
louder than the second aortic. There was dullness on per-
cussion in the lower left back below the angle of the scapula,
and extending outward from the spinous processes to the
scapular line. In this area the respiration was bronchial in
character, but diminished in intensity. The vocal resonance
and fremitus were increased. There were numerous high-
pitched, fine and medium moist r<iles. In the right axilla,
at about the level of the sixth rib, there was an area of dullness
about the size of a silver dollar. Respiration was here broncho-
vesicular and accompanied by many fine, moist, high-pitched
rales. Elsewhere respiration was normal in character, but
diminished in quantity. There were many medium and
coarse moist rales throughout both chests. The abdomen
364 CASE HISTORIES IN PEDIATRICS.
showed nothing abnormal. The liver and spleen were not
palpable. The extremities were normal. The knee-jerks
were equal and normal. There was no edema and no enlarge-
ment of the peripheral lymph nodes. The rectal temperature
was 1040 F., the pulse 200, and the respiration 88.
Diagnosis. The signs of bronchitis and the presence of
two separate areas of solidification in the lungs prove that
she has a Bronchopneumonia. There is nothing about the
physical signs to show whether this is or is not tubercular.
While it is true that whooping cough, more than any other
disease except measles, predisposes to the development of
tuberculosis, the infection far more often takes the form of
a bronchial adenitis than of a bronchopneumonia. Non-
tubercular bronchopneumonia is very common in whooping
cough; tubercular, very rare. The chances are, therefore,
very much in favor of its being non-tubercular. The finding
of tubercle bacilli in the sputum would, of course, prove
it to be tubercular; their absence would not exclude tubercu-
losis. The process is so acute that the skin tuberculin test
would probably be negative even if it is tubercular. The
white blood count would not help because, even if the broncho-
pneumonia is primarily tubercular, there is almost certainly a
secondary infection which will cause a leucocytosis. It is of
no importance anyway, in her present condition, to make a
diagnosis between the two forms, because it will make no
difference in the treatment.
The diffuse cardiac impulse, the enlargement of the heart
upward and to the right, the short, feeble first sound, and the
diminution of the second pulmonic sound (the second pul-
monic sound is normally louder than the second aortic at
this age) show marked weakness and dilatation. The systolic
murmur at the apex is almost certainly due to a relative in-
sufficiency of the mitral valve, as there is no reason to suspect
an endocarditis, and the dilatation of the heart is amply suffi-
cient to account for an insufficiency. It is impossible to deter-
mine whether the dilatation of the heart is due to the strain
of coughing, to a myocarditis in connection with the broncho-
pneumonia, or to both. The chances are that it is largely
due to the strain of coughing, which falls on the right side of
DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 365
the heart, since only the right side of the heart is enlarged,
while the enlargement is usually more uniform in myocarditis.
It is very probable, however, that there may be a small
myocarditic element.
Prognosis. She is in a very serious condition. She has
hardly reached the height of her whooping-cough, she has
bronchopneumonia and her heart is dilated. She has a chance
of recovery, but only a small one.
Treatment. The first thing to do is to favor oxygenation
of the blood by giving her a liberal supply of fresh air. At
this time of year she may be put out of doors or by the open
window. If fresh air does not relieve the cyanosis, she must
be given oxygen. The indication for oxygen is cyanosis. She
should, therefore, be given oxygen continuously as long as she
is cyanotic, not intermittently, as is usually done.
The next indication is to stimulate the heart. Her con-
dition demands a quick stimulant at once. Sulphate of
strychnia in doses of I -120 grain, or caffeine-sodium benzoate
or salicylate, in doses of one half a grain, repeated every two
hours to every four hours, as necessary, are the best drugs.
Aromatic spirits of ammonia, in fifteen-drop doses, may tide
over an emergency. She also needs a cardiac tonic to
strengthen and build up the heart wall. Digitalis is the best
of the cardiac tonics. Five drops of the tincture every four
hours will be none too much for her at present. If the digitalis
takes hold, the strychnia and caffein may be diminished or
omitted. She should be fed every two hours with small
amounts of milk and soft solids, such as custard, junket,
smooth cereals, blanc mange and ice cream.
The results of the treatment of whooping-cough are at
best most unsatisfactory. To do good, the drugs must be
given up to their physiological limit. In such doses they will
certainly do harm in this instance. If the lungs are not too
much filled up, there is no objection to giving morphia, in
doses of from one thirty-second to one twenty-fourth of a
grain, to control excessive cough, nervousness, sleeplessness
and discomfort.
366 CASE HISTORIES IN PEDIATRICS.
CASE III. William R., twenty-three months old, was
the third child of healthy parents. The other children were
well. There had been no deaths or miscarriages. He had
had no known exposure to tuberculosis. He was not nursed,
but had been artificially fed from the first by his mother
without professional advice. He had a severe attack of
diarrhea, lasting a month, when six months old. Since then
he had been pale and delicate and had had frequent attacks
of indigestion.
He broke out with measles, March 18. The attack was a
light one and he seemed all right, March 23. Two days
later, however, he began to cough and seemed feverish. He
was seen by his physician March 27. His rectal temperature
was then 1020 F., his pulse 150 and his respiration 50. There
were many moist rales in both sides of the chest, but no signs
of solidification. The temperature was higher the next day,
but he gradually improved up to the morning of April i, the
temperature having dropped to 102° F., the pulse to 130 and
the respiration to 40, while the cough had diminished.
Since then his temperature had ranged between 1030 F. and
1040 F. and his respiration had become more rapid, while
expiration was accompanied by a moan. He had taken his
food reasonably well, had not vomited and had had normal
movements from the bowels, but had, nevertheless, failed
considerably in general condition. He had been quiet, except
when coughing, and had slept the greater part of the time.
His mother had refused to open the windows or to force him
to eat. He was seen in consultation at 11 a.m., April 2. He
was found in a small room with double windows, the windows
and doors being shut tight and the shades pulled down.
Physical Examination. He was small and poorly nourished.
He was markedly pale, but not at all cyanotic. He was
feeble, but conscious. He had sixteen teeth. There was no
nasal discharge and the throat was normal. The tongue was
moderately dry and considerably coated. The cardiac im-
pulse was neither visible nor palpable. The left border of the
cardiac dullness was six cm. to the left of the median line,
the upper border at the lower border of the second rib, and
the right border two cm. to the right of the median line. The
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 367
first sound was of fair strength. The second sound at the
pulmonic area was moderately accentuated. There were no
murmurs. A few medium and coarse, moist rales were heard
over the left lung, both in front and behind. There was
moderate dullness with diminished respiration over the right
lower lobe. The respiration was normal in character, except
in a small spot in the axilla, where it was broncho-vesicular.
The voice sounds and tactile fremitus were not changed.
Very many fine, moist rales were heard over the whole right
lower lobe, and a moderate number of fine and medium, moist
rales over the upper and middle lobes. The abdomen was
normal. The lower border of the liver was just palpable in
the nipple line. The spleen was not palpable. The extremi-
ties were normal. There was no spasm or paralysis. The
knee-jerks were equal, but diminished. There was no en-
largement of the peripheral lymph nodes. His rectal tem-
perature was 1040 F. ; his pulse, 160; his respiration, 72.
Diagnosis. The rales show that there is a general Bron-
chitis. The dullness, diminished respiration and fine, moist
rales over the right lower lobe show that there is an exudation
into the alveoli and beginning solidification. The broncho-
vesicular respiration in the axilla shows that the process has
in this spot gone on to complete, or nearly complete, solidifi-
cation, that is, that there is also a Bronchopneumonia.
The accentuation of the second pulmonic sound is due to the
increased pressure in the pulmonary circulation resulting
from the obstruction to the flow of blood through the lungs.
The process in the lungs may be either tubercular or non-
tubercular. The physical signs are equally consistent with
either condition. The absence of any known exposure to
tuberculosis does not count especially against a tubercular
bronchopneumonia, because every baby is exposed to tuber-
cular infection many times before it is two years old. Measles
is, moreover, more likely than any other disease, except
whooping-cough, to light up a latent tubercular focus. Simple
bronchopneumonia is, however, very common, while tuber-
cular bronchopneumonia is relatively rare. The chances are,
therefore, that he has a non-tubercular bronchopneumonia.
The sputum can probably be obtained without much difficulty
368 CASE HISTORIES IN PEDIATRICS.
by introducing a cotton swab into the pharynx and making
him cough. The finding of tubercle bacilli in the sputum will
make the diagnosis of tuberculosis positive. Tuberculosis
cannot be excluded, however, if they are not found. A skin
tuberculin test may also be tried. If it is negative, tuber-
culosis can be practically excluded ; if it is positive, a probable
diagnosis of tubercular bronchopneumonia is justified.
Prognosis. He is seriously ill. The facts that he has
always been delicate and has never had a good digestion are
against him. On the other hand, however, there are no
evidences of cardiac weakness, there are no signs of solidifica-
tion except in the right lower lobe, his digestion is now good,
he is willing to take food and he is clear mentally. He has,
moreover, not had any fresh air or proper nursing. It is
reasonable to expect that he will do better when these are
provided, as they must be. The chances are, therefore,
considerably in his favor.
Treatment. The first and most important thing in the
treatment is'to move him into a room without double win-
dows, push up the shades, open the windows and give him
a large amount of fresh air and sunlight. The next thing to
do is to get a capable nurse to keep the windows open and
the shades up, and to make him take his food. He should
be fed every three hours with milk and starchy foods. He
may also have orange juice, if he likes it. His temperature
is not very high, is not causing any disturbance of the nervous
system, and, therefore, requires no treatment. There are no
evidences of cardiac weakness. Stimulants are consequently
not needed. The fresh air will almost certainly relieve his
cough. There are no drugs which will help the broncho-
pneumonic process in the lung. The bronchitis is not very
severe and he is clearing his tubes well. There is, therefore,
no urgent need of expectorants, which are, moreover, more
likely to disturb his digestion than to alleviate the patho-
logical condition in the bronchi. It will be wiser, therefore,
not to give them to him.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 369
CASE 112. Andrew D., seven months old, was the third
child of healthy parents. The other children were well and
there had been no miscarriages. There was no tuberculosis in
either family and there had been no known exposure to it. He
was born at full term, after a normal labor, was normal at birth
and weighed seven and one-quarter pounds. He had always
been well, except for a very mild attack of whooping cough,
from which he had recovered, a month before. He was
nursed for several months and did very well. Since then he
had been given a mixture of three parts of whole milk and
one part of water, to which Mellin's Food had been added.
He had thrived on that as well as he had on the breast-milk.
He had a convulsion, followed by fever, the morning of
April 11. His temperature had been about 1030 F. since
then and he had had four more convulsions, the last one
during the evening of the eleventh. He was given castor oil
immediately after the first convulsion and had had several
loose, green, curdy stools as the result. He had not vomited,
coughed, or shown any evidences of pain. He was seen in
consultation at 5 p.m., April 12.
Physical Examination. He was fairly developed and
nourished, and of fair color. He was clear mentally. The
anterior fontanelle was three cm. in diameter and level.
There was no rigidity of the neck or neck-sign. The pupils
were equal and reacted to light. The ear drums were normal.
There was no nasal discharge, but the pharynx was slightly
reddened. The cardiac impulse was indistinctly palpable six
cm. to the left of the median line. The left border of the car-
diac dullness corresponded to the impulse. The right border
was two cm. to the right of the median line; the upper
border was in the third space. The action was regular and
the sounds normal. The second pulmonic sound was slightly
accentuated. The respiration was rapid and grunting and
the alae nasi moved. The left chest did not move quite as
much as the right and the respiratory sound was not quite
as loud in the left back as elsewhere. Nothing else abnormal
was detected in the lungs. The level of the abdomen was
that of the thorax. It was everywhere tympanitic and there
was no tenderness or spasm. The lower border of the liver
370 CASE HISTORIES IN PEDIATRICS.
was palpable one cm. below the costal border in the nipple
line. The spleen was not palpable. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and normal. Kernig's sign was absent. There
was no enlargement of the peripheral lymph nodes and no
eruption. The rectal temperature was I03°F.; the pulse,
140; the respiration, 72.
Diagnosis. The sudden onset, the continued high fever
and the relative increase in the rate of the respiration over
that of the pulse (1 to 2 instead of the normal 1 to 4) are
sufficient, in the absence of all physical signs of other diseases,
to justify an almost positive diagnosis of Pneumonia. The
diminution of the motility and of the respiratory sound on the
left side, which are not infrequently the earliest physical
signs of pneumonia, are sufficient to make this diagnosis
certain. The grunting respiration and the motion of the
alae nasi are corroborative evidence. The absence of cough
does not count materially against pneumonia, because cough
is often absent in the early days of pneumonia in infancy.
Meningitis, which is suggested to a certain extent by the
continuance of the convulsions, can be excluded on the level
fontanelle and the absence of all physical signs of cerebral
irritation. The loose, green stools are undoubtedly due to
the castor oil, together with some disturbance of the digestion
from the fever.
Prognosis. He is not at present dangerously ill. This
is only the second day of the disease, however, and he would
naturally not show much constitutional depression at this
time. It is too early, therefore, to give any definite prognosis.
Pneumonia is, however, a very serious disease in infancy, very
different from what it is in childhood. The prognosis should,
therefore, be guarded. All that can be said is that he is doing
well now and that it is impossible to say whether he will
recover or not.
Treatment. See Cases 113 and 114. His temperature is
not unduly high and he has shown no evidences of disturbance
of the nervous system for nearly twenty-four hours. The
fever, may, therefore, be disregarded. There is no dis-
turbance of the heart or circulation. Stimulation is, there-
DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 37 1
fore, contraindicated. He has been doing well on his present
food. It will not be well to change it now that he is sick,
although it is not an ideal one. It will be advisable, however,
to dilute it one-half with water. He should be given eight
feedings of four ounces, at intervals of three hours. He should
also be given water freely.
372 CASE HISTORIES IN PEDIATRICS.
CASE 113. Michael D., seven years old, went to school on
the morning of January 24 perfectly well, as far as was known,
except that his bowels had not moved for nearly a week.
While playing at recess one of his playmates struck him in
the abdomen with his fist. Shortly afterward he became
faint and nauseated and was sent home by his teacher. He
vomited soon after reaching home and continued to do so for
twenty-four hours. He was given two grains of calomel in
divided doses during the afternoon and night of the 25th,
and a teaspoonful of Epsom salts the next morning, but his
bowels had not moved. He continued to complain of nausea,
headache and pain in the abdomen. The abdominal pain was
general, not localized. He had coughed a little since the morn-
ing of the 26th. He had felt very hot, but his temperature had
not been taken. He had not been delirious. He was seen
about 4 p.m., January 26.
Physical Examination. He was fairly developed and nour-
ished. He was perfectly clear mentally. The cheeks were
flushed. His face was not pinched. The alae nasi moved with
respiration. The tongue was moist and moderately coated.
The throat was slightly reddened, but was otherwise normal.
The cardiac impulse was in the fifth space, just inside the nip-
ple line. The right border of dullness was 1 cm. to the right of
the right sternal border, the upper border at the middle of the
third rib. The sounds were normal. The second pulmonic
sound was somewhat the louder. There was slight dullness
in the right back below the angle of the scapula with slightly
diminished respiration of normal character. The vocal reso-
nance and fremitus were normal. There were no rales. The
upper border of the liver flatness was at the upper border of
the sixth rib, the lower border was not palpable. The spleen
was not palpable. The level of the abdomen was considerably
above that of the thorax; it was everywhere tympanitic.
There was no muscular spasm, but the whole abdomen was
somewhat tender, the tenderness being most marked in the
right iliac fossa. There was, however, no tumor or dullness
in this region. There were no evidences of free fluid in the
abdomen. The extremities were normal. There was no
spasm or paralysis; the knee-jerks were equal and diminished;
DISEASES OF THE BRONCHI, LUNGS AND PLEUR/E. 373
there was no Kernig's sign. There was no enlargement of
the peripheral lymph nodes. Rectal examination showed
nothing abnormal beyond a mass of hard feces in the rectum.
The rectal temperature was 1040 F., the pulse 140, the respira-
tion 60.
The urine was high in color, extremely acid in reaction,
and of a specific gravity of 1,030. It contained no albumin or
sugar, but a large excess of urates. The sediment showed
nothing abnormal.
The leucocyte count was 36,000.
Diagnosis. The history of the acute onset of vomiting
and pain in the abdomen immediately after a blow in that
region makes some acute inflammatory condition in the ab-
domen seem the most obvious diagnosis. The persistent
constipation, the continuance of the pain and the abdominal
distention and tenderness all corroborate this diagnosis.
The greater tenderness in the right iliac fossa points to an
involvement of the appendix. Further consideration, how-
ever, makes this diagnosis seem less probable. The absence of
the pinched face, of free fluid in the abdomen and of muscular
spasm makes general peritonitis very improbable. The
absence of localized spasm, tumor and dullness in the right
iliac fossa and the negative results of the rectal examination
practically rule out appendicitis. The blow of another small
boy could hardly rupture any organ, there was no collapse
and there are no signs of peritonitis, as would be expected if
any organ had been ruptured fifty-three hours before. The
condition of the urine also counts against any injury to the
kidney. The history of constipation before the injury and
the mass of hard feces in the rectum suggest that constipa-
tion may be the cause of the abdominal symptoms, and that
they, and perhaps the blow as well, may be purely coincidences
and that the real trouble is located somewhere else.
The cough suggests some trouble in the lungs. It is a well-
known fact that the pain in pneumonia is often referred by
children to the abdomen and that distention of the abdomen
is very common in pneumonia at this age. Localized diminu-
tion of the respiratory sound is often the earliest sign of pneu-
monia. When associated with dullness, as in this instance, it
374 CASE HISTORIES IN PEDIATRICS.
is most suspicious. The relative increase in the rate of the
respiration over that of the pulse (2^ to I instead of the normal
4 to 1 ) in an acute disease with a high temperature is almost
pathognomonic of pneumonia. The motion of the alae nasi,
while it points toward trouble in the respiratory tract, does
not necessarily mean that that trouble is pneumonia. Mo-
tion of the alae nasi is, moreover, not uncommon when there
are inflammatory processes in the abdomen. It is, therefore,
not of much diagnostic importance in this instance. The
flushing of the cheeks is merely a sign of fever and is not espe-
cially suggestive of pneumonia, as is often supposed. The
diminution of the knee-jerk is of but little importance, but
nevertheless is another point in favor of pneumonia. The
high leucocyte count is characteristic of pneumonia, but is
not inconsistent with an inflammatory process in the abdomen
and hence is of practically no importance in the differential
diagnosis. The points in favor of pneumonia are so much
more numerous and fit together so much better than do those
in favor of an inflammatory process in the abdomen that a
positive diagnosis of Pneumonia is justified. The abdominal
symptoms are presumably in part due to the constipation
and in part secondary to the pneumonia. The blow was
purely a coincidence.
Prognosis. The prognosis of pneumonia in children is,
on the whole, very good. He is a strong boy and at present
is not any sicker than he would be expected to be. His
chances ought to be at least as good as the average. He can
be confidently expected to recover. A certain number of
children with pneumonia are unfortunate enough to develop
empyema. He may or may not be one of these. It is
impossible to tell.
Treatment. The most important part of the treatment is
to give him a large supply of fresh air. All the windows in
his room should be wide open. He can be protected from the
wind, if necessary, by a screen. This being January, he must
be warmly covered and will probably need a cap and heaters,
perhaps mittens. If he is treated in this way his fever will,
in all probability, not require any treatment. Applications
to the chest, whether poultices, cotton jackets or mud, can
DISEASES OF THE BRONCHI, LUNGS AND PLEUILE. 375
have no effect on the pneumonic process, tend to overheat
the patient and, if heavy, interfere with the respiration by
their weight. There are no drugs which have any effect on
the pneumonic process. His heart is strong. Medicinal
treatment is, therefore, contra-indicated.
The vaccine treatment of pneumonia is, in the author's
opinion, irrational and, consequently, unjustifiable. Cough
is not likely to be troublesome if he gets plenty of fresh air.
If it is, and there is no edema of the lungs or bronchitis,
heroin, in doses of from one twenty-fourth to one twelfth of a
grain, will probably make him more comfortable and not do
any harm. He should be fed once in three hours with milk
and soft solids, such as simple cereals, custard, blanc mange,
ice cream and milk toast. Care should be exercised in giving
him milk because of the constipation.
The constipation will probably be relieved by low enemata
of suds. If they are not sufficient, high enemata of suds, oil
or glycerin may be tried. If these are unsuccessful, a table-
spoonful of castor oil or two teaspoonfuls of syrup of senna
will probably be effectual.
376 CASE HISTORIES IN PEDIATRICS.
CASE 114. Matthew L., twenty-six months old, had al-
ways been unusually strong and vigorous, but very nervous
and excitable. He had had a little " cold in the head " for
two or three days, but had not seemed at all sick. The appe-
tite was rather poor, February 19, and consequently he was
not given as much to eat as usual. His bowels moved nor-
mally just before he went to bed. He was very restless and
feverish all night and toward morning vomited several large
curds of milk. He had a severe convulsion about 8.30 a.m. on
the 20th. The colon was washed out and a considerable amount
of well-digested, yellow feces obtained. He was given two
tablespoonfuls of castor oil, which resulted in three large,
loose, yellow movements which contained a little undigested
food. He had no more convulsions, but twitched a little
from time to time. He coughed occasionally, and moving,
coughing and crying seemed to hurt him. The rectal tem-
perature had ranged between 1040 F., and 104.50 F. He was
seen in consultation at 9 A.M., February 21.
Physical Examination. He was well developed and nour-
ished. Pallor was marked and there was a slight tinge of
cyanosis about the lips. He was perfectly conscious, but
restless and irritable. There was a slight tendency to rigidity
and he twitched occasionally. There was no stiffness or
tenderness in the neck. The pupils were equal and reacted to
light. The alae nasi moved with respiration. The ear drums
were normal. The tongue was moderately coated. The
throat was normal. The heart and lungs were normal. The
liver and spleen were not palpable. The extremities were
normal. There was no definite spasm of the extremities and
no paralysis. The knee-jerks were equal and slightly dimin-
ished. Kernig's sign was absent. There was no enlargement
of the peripheral lymph nodes, and no eruption. The rectal
temperature was 104.60 F., the pulse 140, the respiration 70.
The leucocytes numbered 24,000.
Diagnosis. The persistence of the high temperature in
spite of the thorough emptying of the bowels, the practically
normal character of the movements and the cessation of the
vomiting rule out all affections of the gastro-intestinal tract.
The absence of sore throat and eruptions rules out tonsillitis
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 377
and scarlet fever, while the absence of catarrhal symptoms
and the leucocytosis exclude influenza. The initial convul-
sion and the persistence of twitching, together with the slight
tendency to rigidity, suggest, to a certain extent, some form
of meningitis, more probably the cerebrospinal. The normal
mental condition and the absence of all physical signs of
meningeal irritation, unless the twitching and tendency to
rigidity be such, practically exclude meningitis. An initial
convulsion, moreover, is not uncommon at the onset of any
acute disease in childhood, and a high temperature often
causes twitching and a tendency to rigidity in nervous chil-
dren. These points do not count much, therefore, in favor
of meningitis. The continued high temperature, the slight
cough, the pain on motion, cough and crying, and, more than
all, the much greater increase in the rate of the respiration
than in that of the pulse (2 to 1 instead of the normal 4 to 1),
make the diagnosis of Pneumonia practically certain in
spite of the absence of physical signs in the lungs. The move-
ment of the alse nasi, the slight tinge of cyanosis about the
lips and the diminution of the knee-jerks, although not of
much importance, are corroborative of this diagnosis, while
the leucocytosis is consistent with it.
Prognosis. The prognosis of pneumonia in childhood is
very good. In infancy, however, it is a far more serious dis-
ease. This boy has always been strong and well, is in good
general condition and probably will not have much lung
involved. The symptoms of nervous irritability do not make
the outlook any less favorable. The chances are, therefore,
very much in favor of his recovery.
Treatment. See Case 11 3- The windows must be kept
wide open, day and night. The cool, fresh air will probably
lower the temperature somewhat, and thus diminish the
nervous symptoms. If they persist, the temperature must
be reduced by bathing. The coal-tar products should never
be used in pneumonia, either to reduce the temperature or
to relieve nervous symptoms. The temperature needs to be
reduced, not because it is 104.60 F., but because in this
instance this degree of temperature causes nervous symptoms.
If it did not, it would not be necessary to treat it. Sponge
378 CASE HISTORIES IN PEDIATRICS.
baths of alcohol and water, equal parts, at 900 F., will prob-
ably be sufficient to control it. If they do not, fan baths will
almost certainly be effectual. Fan baths are given in this
way: The patient is stripped and wrapped in cheesecloth.
This is then wet with water at ioo° F. and the patient fanned.
The temperature is reduced by the evaporation of the water.
The cheesecloth is wet from time to time as the water evapo-
rates. Children seldom object to this form of bath. If this is
ineffectual, he may be given a cold pack at from 6o° F. to
700 F. Children seldom bear tub baths well, and it is, as a
rule, wiser not to use them. If necessary, he may be given
sodium or potassium bromide, in doses of from three to five
grains, from time to time. There is no indication for stimula-
tion at present.
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 379
CASE 115. David K., eight years old, had had the measles
when a baby. Since then he had always been well. August
20 he began to complain of a little pain in his lower left chest,
which was worse when he ran or played. August 22 he began
to have a little cough, which was dry and not accompanied
by pain. After the beginning of the cough the pain in the
chest ceased, his appetite became poor and he acted weak
and tired. His mother said that he wanted to sit alone by
himself instead of playing with the other children. She
thought that he had been feverish and said that he had sweat
profusely at night. He was first seen August 30.
Physical Examination. He was well developed and nour-
ished, but somewhat pale. There was no dyspnea, except on
exertion. The tongue was moist with a moderate white coat
in the center. The throat was normal. The cardiac impulse
was visible in the fourth space in the left parasternal line.
The right border of the relative cardiac dullness was about
two thirds of the distance from the right border of the sternum
to the right nipple. The upper border of the relative cardiac
dullness was at the lower border of the second rib. The heart
sounds were normal in character, but louder to the right of
the sternum than to the left. The second pulmonic sound
was considerably louder than the second aortic. The left
chest moved somewhat less in respiration than the right.
The intercostal spaces were the same on both sides. There
was dullness in the left back from the spine to the angle of
the scapula, below which there was flatness. The whole left
axilla was flat. There was dullness in the left front from the
upper border of the third rib to the upper border of the fourth
rib, below which there was flatness. There was dullness in
Traube's space. The respiration was loud and bronchial
below the upper level of dullness, both in back and in front.
The voice sounds were increased; the vocal fremitus dimin-
ished. No rales were heard. Above the level of dullness the
respiration and voice sounds were normal in character and a
few fine moist rales were heard. There was a marked sense of
resistance over the dull and flat areas. There was exaggerated
vesicular resonance over the whole right chest. The respira-
tion was loud and distinctly puerile. The voice sounds and
38O CASE HISTORIES IN PEDIATRICS.
fremitus were normal. No extraneous sounds were heard.
The upper border of the liver flatness in the nipple line was at
the upper border of the seventh rib. The lower border of the
liver was palpable 2 cm. below the costal border. The spleen
was not palpable. The dullness was not determined because
of the dullness in the left chest. The abdomen showed noth-
ing abnormal. The extremities were normal. There was no
spasm or paralysis and the knee-jerks were equal and normal.
There was no enlargement of the peripheral lymph nodes.
The mouth temperature was 101.20 F., the pulse 130 and the
respiration 48.
Diagnosis. The trouble is, of course, located in the left
chest. The only question is whether there is solidification of
the lung or an effusion into the pleural cavity. If the trouble
is in the lung, it is, judging from the history, more probably
tubercular than pneumonic. The diminution in the motion
of the left chest and the mere presence of dullness or flatness
are of no importance in differential diagnosis. The points
in favor of solidification of the lung are the normal level of
the intercostal spaces, the loud bronchial respiration and the
increased voice sounds. The intercostal spaces are, however,
often level in childhood, even when there is considerable
fluid in the pleura, because the elastic chest gives as a whole,
while in the adult the rigid chest wall does not give and the
intercostal spaces yield. Theoretically, the respiration and
voice sounds ought not to be transmitted through fluid;
practically, they often are in childhood. The explanation is
presumably to be found in the elasticity of the thoracic wall
at this age. The bronchial character of the respiration in
pleural effusion is due to the compression of the lung. The
points in favor of consolidation of the lung are, therefore, not
as important as they at first appear.
The points in favor of a pleural effusion are the distribution
of the dullness and flatness, which follows gravity rather than
the lobes of the lung, the displacement of the heart to the
right, the dullness in Traube's space (which means depres-
sion of the diaphragm), the diminished fremitus, the absence
of rales and the marked sense of resistance. The distribution
of the dullness and flatness is not of quite as much importance
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 38 1
in this instance as it usually is, because the trouble, being
tubercular, would not be as likely to be lobar in its distribu-
tion as would a pneumonia. It may be argued that, if the
diaphragm is depressed, the spleen ought to be palpable.
The location of the spleen is such, however, that depression
of the diaphragm does not displace it. The displacement of
the heart and diaphragm is positive proof of the presence of a
pleural effusion. The marked sense of resistance is almost
positive proof of effusion, as this is practically never felt to
the same extent over a solid lung. The diminished fremitus
and the absence of rales are of much less importance, as they
can be explained in other ways.
The accentuation of the second pulmonic sound is, of course,
due to the increased pressure in the pulmonary circulation.
The physical signs in the right chest are characteristic of
compensatory emphysema. The upper border of the liver
flatness is as much below the normal level as the lower border
is below the costal margin, showing that the liver is not
enlarged, but merely displaced downward.
The next point to be decided is whether the effusion is
serous or purulent. The effusion in this instance is, judging
from the history, primary, that is, it is not secondary to some
other acute disease. Primary pleurisy at this age is almost
always serous; secondary, almost always purulent. The
sweating is merely a sign of weakness and does not count at
all in favor of a purulent effusion. The temperature is con-
sistent with either condition. There is nothing about the
physical signs which is of any value in differential diagnosis.
A leucocyte count would probably be of considerable assist-
ance in diagnosis because there is almost never a leucocytosis
with a primary serous effusion, and almost always a marked
leucocytosis when the fluid is purulent. The absence of
leucocytosis in primary serous effusions is presumably due to
the fact that they are almost invariably tubercular. The only
positive method of diagnosis is exploratory puncture. It is
reasonably safe to make a diagnosis of Serous Pleurisy in
this instance, however, on the history.
A skin tuberculin test will aid much in determining whether
or not the effusion is or is not tubercular. A more certain
382 CASE HISTORIES IN PEDIATRICS.
method, however, is by the examination of the fluid obtained
by exploration or aspiration. There are, as a rule, a large
excess of lymphocytes in the tubercular cases, and of poly-
nuclear cells in the acute infectious variety. If the fluid is
digested before the examination (inoscopy), tubercle bacilli
can be found in a large proportion of the tubercular cases;
in fact, more positive results are obtained in this way than
by animal inoculations.
An. exploratory puncture was done and a serous fluid, which
contained an excess of lymphocytes and a few tubercle bacilli,
was obtained.
Prognosis. There is no danger to life from the effusion if
it is not allowed to accumulate enough to cause symptoms of
pressure. It is not an especially serious form of tuberculosis.
The prognosis is, therefore, that of tuberculosis in general.
Treatment. The effusion is not causing any symptoms from
pressure on other organs. It is, therefore, wiser not to with-
draw it at present. Applications to the chest wall are useless.
It is unreasonable to expect that diuretics and cathartics will
draw the fluid from the pleural cavity, in which the pleura is
inflamed and not in a condition to absorb fluid, rather than
from the tissues. They cannot be of use, anyway, unless
liquids are excluded from the diet. It is very unwise to cut
liquids out of a child's diet, and, moreover, free catharsis is
very weakening. They cannot, therefore, do much, if any,
good, and are almost certain to do harm by interfering with
the ingestion of food and weakening the patient. They
ought not to be used in this instance. If the fluid increases
enough to cause symptoms of pressure, or if it does not begin
to diminish after ten days or two weeks, it should be with-
drawn. If the chest refills, the aspiration may have to be
repeated several times.
He must be kept quiet in bed and well fed. The further
treatment is that of tuberculosis in general.
DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 383
CASE 116. Sophy L. was seen in consultation when four
and one-half years old. She had always been delicate. Seven
and one-half weeks previously she was taken suddenly ill
with a pneumonia involving the whole left lower lobe. She
was under the care of Dr. G. for a week. The crisis did not
occur during this time. Dr. G. was then discharged and
another doctor called in. The crisis is said to have occurred
on the eighth or ninth day. A week later Dr. G. was again
given charge of the case. He found the temperature running
between 1030 F. and 1040 F. It dropped a little after a few
days and since then had ranged between 1010 F. and 1020 F.
She had had no chills, but had sweat freely, especially about
the head. She was not short of breath and did not complain
of pain. She coughed occasionally. Her appetite was good,
but she was somewhat constipated. She had lost weight
steadily. She had been up and about the house for ten days.
An examination of the sputum for tubercle bacilli had been
negative.
Physical Examination. She was slight, thin and somewhat
pale. There was no cyanosis. She cried loudly without
distress. The cardiac impulse was palpable just to the left
of the sternum. The impulse was also palpable to the right
of the sternum and was stronger there than on the left. The
cardiac dullness extended from 2 cm. inside the right nipple
to I cm. to the left of the left border of the sternum. The
heart sounds were louder to the right than to the left of the
sternum. The sounds were not abnormal. The left side of
the thorax appeared larger than the right, and moved much
less than the right in respiration. The left intercostal spaces
were nearly obliterated. There was flatness in the left chest
above the third rib in front, the fifth in the axilla and the mid-
scapula behind. In this area respiration was bronchial, and
the voice sounds and fremitus slightly increased. Below the
flat area down to the fifth space in front, the sixth space in
the axilla and in the whole back there was flat tympany.
Below this there was loud tympany. In these areas respira-
tion was diminished, but almost vesicular in character. The
voice sounds were diminished, but not changed in character.
The vocal fremitus was absent. There was tympany in
384 CASE HISTORIES IN PEDIATRICS.
Traube's space. There was a very marked sense of resistance
over the whole left chest, more marked in the lower portion
than in the upper. The right chest was somewhat hyper-
resonant, except that there was a triangular area of dullness
in the back, the apex being at the level of the spine of the
scapula, the side along the back bone and the base along the
tenth rib, extending outward about two inches. The respira-
tion was of normal character, but louder than normal over
the whole right side. The upper border of the liver flatness
was at the upper border of the sixth rib; the lower border
was palpable 4 cm. below the costal border in the nipple line.
The spleen was not palpable. The abdomen was rather full,
but not tense or tender. The extremities showed nothing
abnormal. There was no general enlargement of the super-
ficial lymph nodes. The rectal temperature was 1000 F., the
pulse 120, the respiration 35.
Diagnosis. The history is so characteristic of an empyema
secondary to pneumonia that it hardly seems necessary to
consider anything else, unless the physical examination proves
this supposition to be wrong. Other remote possibilities are
an unresolved pneumonia, an acute tubercular pneumonia
which has changed to a chronic condition, and a secondary
tubercular infection consecutive to a pneumococcus pneu-
monia.
The physical signs are, however, confusing. The marked
displacement of the heart to the right, the enlargement of
the left chest, the obliteration of the left intercostal spaces,
and the triangular area of dullness in the right back (Grocco's
sign) prove that there is something in the left pleural cavity.
The tympany in the lower portion suggests that this may be
air. The marked sense of resistance proves that it is fluid.
It would be almost unheard of, moreover, to have fluid or
solid lung in the upper part of the chest and air alone in the
lower. The tympanitic sound is undoubtedly transmitted
from the abdomen, and the vesicular respiration and normal
voice sounds from the right side. The bronchial respiration
and increased voice sounds and fremitus in the upper portion
suggest strongly that the upper half of the chest is filled by
solid lung. The marked sense of resistance and the marked
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 385
displacement of the heart, together with the well-known fact
that in children the respiration and voice sounds, and some-
times even the fremitus, may be transmitted through fluid if
the tension is high enough, show conclusively that the upper
as well as the lower portion of the chest is filled with fluid.
The bronchial character of the respiration is due to the com-
pression of the lung, which is presumably squeezed into a
small mass at the root. The tympany in Traube's space is
probably also transmitted from the abdomen and does not
mean that the diaphragm is in its normal position.
The signs in the right chest are characteristic of a compen-
satory emphysema. The upper border of the liver flatness is
slightly lower than normal, but not as much so as the lower
border. This shows that the liver is enlarged. The enlarge-
ment is probably due to fatty change, resulting from mal-
nutrition and toxic absorption, although it may possibly be
amyloid.
There is undoubtedly fluid in the left pleural cavity. This
fluid accumulated after pneumonia, and the patient is a child.
The chances are, therefore, at least nineteen out of twenty
that it is purulent rather than serous. The absence of chills
does not count against, nor the presence of sweating for, a
purulent effusion, because chills are rather unusual with an
empyema at this age, and sweating is common in all conditions
of weakness. The diagnosis of Purulent Pleurisy is, there-
fore, justified without an exploratory puncture.
Prognosis. If the chest is not opened she will almost cer-
tainly fail steadily and finally die. There is, however, a small
chance that the pus may eventually find a way out for itself
or become encapsulated and absorbed. In either case, she
is certain to be left with a very greatly deformed chest. If
the chest is opened at once she will almost certainly recover,
because her general condition is surprisingly good under the
circumstances and the evidences of septic absorption com-
paratively slight. It is six weeks since the appearance of the
effusion, it is very large, the lung is much compressed and
probably more or less bound down by adhesions. The
chances are, therefore, that it will not fully expand and that
she will be left with some deformity.
386 CASE HISTORIES IN PEDIATRICS.
Treatment. The only rational treatment in this instance
is the opening and draining of the pleural cavity. It is true
that in rare instances recovery ensues in pneumococcus
empyema after tapping. This happens so seldom, however,
that it cannot be regarded as a justifiable procedure. The
almost invariable result is that the pus reaccumulates and
that the chest has to be finally opened. In the meantime the
general condition has been further impaired as the result of
the continued septic absorption, and the lung has been further
compressed and its complete expansion rendered more diffi-
cult. The long duration and the large amount of the effusion
in this instance make the chances of cure from aspiration
even less than the average. She should, therefore, be operated
on at once. The author believes that resection of a rib gives
much better results than simple incision. A resection should
certainly be done in this instance because, on account of the
duration of the process, there are probably large clots and
masses of caseous material which could not be satisfactorily
cleaned out through an incision.
DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 387
CASE 117. Joseph C. was the only child of healthy
parents. There was no tuberculosis in either family and
there hadjbeen no known exposure to it. He was born a
month before he was expected. He was fed from the first
on simple dilutions of milk with water. His digestion was
good, but he was always anemic. He had pneumonia about
the middle of December, but was considered well early in
January. His temperature rose again January 22 and the
respiration became rapid and difficult. His physician found
dullness with bronchial respiration and voice sounds over
the whole left chest. Although the heart was in normal
position, he suspected the presence of fluid and tapped him
twice in the lower back and once in the lower axilla, but
obtained nothing. From this time on he ran an irregular
temperature, which varied between normal and 1050 F.
The respiration continued rapid and he had a troublesome
cough. He took his food fairly well and had no disturbance
of the digestion but, nevertheless, lost weight steadily. He
was seen in consultation March 8, when thirteen and one-
half months old.
Physical Examination. He was long, thin, feeble and very
pale. The anterior fontanelle was one cm. in diameter.
The bones of the skull overlapped a little. He had eleven
teeth. The ears and throat were normal. There was a
moderate rosary. The cardiac impulse was felt distinctly in
the second, third and fourth interspaces. The left and
upper borders of dullness could not be determined because
of the dullness in the left chest. The right border was two
cm. to the right of the median line. The action was regular
and the sounds strong. There was a systolic murmur at
the base of the heart and a venous hum in the neck. The
second sound at the pulmonic area was slightly accentuated.
The left side of the chest moved less than the right. There
was no bulging of the intercostal spaces. There was flat-
ness with a very marked sense of resistance in the left front
and axilla above the fifth rib and in the back above the spine
of the scapula. The respiration and voice sounds were loud
and bronchial in the flat area while the tactile fremitus was
diminished. There was slight tympany over the rest of the
388 CASE HISTORIES IN PEDIATRICS.
left side, the respiration and voice sounds being diminished
and bronchial in character. There was tympany in Traube's
space. Grocco's sign was absent. The right chest was
hyperresonant and the respiration exaggerated, but vesicular.
The abdomen was large, lax and tympanitic. The lower
border of the liver was palpable one cm. below the costal
border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no spasm or paral-
ysis. The knee-jerks were equal and normal. Kernig's sign
was absent. The genitals were normal. There was no en-
largement of the peripheral lymph nodes. The rectal temp-
erature was 99.40 F. ; the pulse, 120; the respiration, 35.
The leucocyte count was 24,000.
Diagnosis. The trouble in this instance is unquestion-
ably located in the upper portion of the left chest. The only
conditions which need to be considered are solidification of
the lung, presumably due to an unresolved pneumonia, and
an accumulation of fluid, almost certainly pus. The ab-
normalities in the physical signs in the lower portion of the
chest are of no importance in differentiating between them,
the tympany being transmitted from the abdomen, the
diminished respiration being due to the diminution in the
expansion on that side, while the bronchial respiration may
be transmitted from either a solid or a compressed lung.
Grocco's sign would, of course, be absent with an accumula-
tion of fluid in the upper chest. The systolic murmur at
the base of the heart and the venous hum in the neck are
both signs of the evident anemia. The accentuation of the
second pulmonic sound is due to the increased pressure in
the pulmonary circulation. The flatness is consistent with
either condition. Loud bronchial respiration and voice sounds
are heard so commonly over accumulations of fluid in infancy
that they do not count much in favor of solidification of the
lung. The absence of bulging of the intercostal spaces is
somewhat against an accumulation of fluid, but is not of
much importance, because bulging of the intercostal spaces
is unusual in infancy, the chest yielding as a whole first.
The location of the flat area, which corresponds fairly closely
to the upper lobe, and the normal position of the heart are
DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 389
strong evidence in favor of solidification of the lung. The
long duration of the illness, the marked irregularity of the
temperature, the diminution of the tactile fremitus, the leu-
cocytosis and, more than all else, the very marked sense of
resistance, count, on the other hand, in favor of an accumu-
lation of pus. If there is an empyema it is, of course, en-
capsulated in the upper portion of the chest, the lung below
being bound to the parietal pleura. The pressure of the
fluid would be exerted chiefly on the upper lobe which
would be much compressed before the lower portion would
be affected. The location of the flat area would, therefore,
naturally correspond fairly closely to that of the upper lobe.
The absence of displacement of the heart does not count as
much against an empyema as at first appears, because with an
encapsulated empyema at the apex it would almost certainly
be caught in the adhesions below and held in position. The
evidence seems, therefore, much in favor of an encapsulated
empyema at the apex, certainly enough so to demand an
exploratory puncture.
A needle was introduced high in the axilla, just behind the
anterior axillary line, and pus withdrawn, thus justifying the
diagnosis of Encapsulated Empyema.
Prognosis. The baby has always been anemic and is in
very poor general condition. The chances are, therefore,
very much against his recovery, even if he is operated upon
immediately. The facts that the heart is not displaced and
that the fluid is retained in the upper portion of the chest
show that the lung must be bound down by very firm adhe-
sions. The chances are, therefore, that the lung will not
fully expand and that, if he recovers, he will be left with
some deformity of the chest.
Treatment. The treatment is the immediate resection of
a rib as low down as is consistent with reaching the cavity.
Drainage will be better in this way than if a rib is removed
higher up. (See Case 116.)
390 CASE HISTORIES IN PEDIATRICS.
CASE 118. Jeremiah M. was five years old. His parents
and two other children were living and well. There had been
no deaths or miscarriages. There was no tuberculosis in the
family and there had been no known exposure to it. He had
been perfectly well until he had the measles, five weeks before
his admission to the Children's Hospital. This was followed
in two weeks by pneumonia. There had been no drop in the
temperature since then. The cough had continued, but the
pain in the side, which was very troublesome at first, had
ceased. He was able to take but little nourishment, had
frequent attacks of dyspnea and slept very poorly.
Physical Examination. He had lost much weight and color.
He was clear mentally, but apathetic. He was able to lie
down. The alae nasi moved with respiration. The mem-
branse tympanorum were normal. The throat was normal,
the tongue but little coated. The left chest moved much less
than the right. The cardiac impulse was indistinctly pal-
pable in the fourth space, just outside the left nipple line.
The right border of the cardiac dullness was three cm. to the
right of the median line; the upper and left borders could
not be determined because of the dullness in the left chest.
The action was regular. The heart sounds were louder to
the left than to the right of the sternum and were of fair
strength. The second sound at the pulmonic area was
slightly accentuated. There were no murmurs. The right
chest was slightly hyperresonant and the respiratory sound
was louder than normal. There was flatness with a marked
feeling of resistance in the left axilla above the sixth rib,
below which there was tympany continuous with that in
Traube's space. There was moderate dullness over the
middle third of the left scapula. The rest of the left chest was
slightly dull. The respiration was much diminished in the
flat area and bronchial in character. It was somewhat
diminished over the rest of the left chest, but nearly normal
in character. The voice sounds were diminished and bron-
chial in the flat area; of normal intensity, but slightly
bronchial, elsewhere. The tactile fremitus could not be deter-
mined, because he would neither speak loudly nor cry. There
were a few fine, high-pitched moist rales in the left front and
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 391
an occasional medium moist rale throughout the back. The
abdomen was sunken and tympanitic. The upper border of
the liver flatness in the nipple line was at the upper border
of the sixth rib; the lower border was not palpable. The
spleen was not palpable. The extremities were normal and
there was no spasm, paralysis or disturbance of the deep
reflexes. There was no enlargement of the peripheral lymph
nodes. The rectal temperature was 1020 F.; the pulse, 132;
the respiration, 40.
The urine was cloudy, acid in reaction, of a specific gravity
of 1028, and contained no albumin or sugar. The sediment
consisted of amorphous urates.
The leucocyte count was 23,400.
Diagnosis. Reasonable explanations for the persistence
of the fever and other symptoms are an extension of the
pneumonia, the development of a purulent pleurisy, some
incidental complication, or that the trouble was not pneu-
monia, as supposed, but tuberculosis. The absence of any
physical signs of disease outside of the lungs and the normal
condition of the ears and urine rule out all incidental compli-
cations. His good condition before the onset of the illness,
the absence of any signs of tuberculosis elsewhere, the rarity
of acute tubercular pneumonia at this age and the fact that
the signs in the lungs are more consistent with another con-
dition rule out tuberculosis. The diagnosis lies, then, between
solidification of the lung, due to an extension of the pneu-
monic process, and a purulent pleurisy. Fever, rapid pulse
and respiration, motion of the alae nasi, cough, diminished
mobility on the left side and leucocytosis are common to both
diseases and hence of no aid in distinguishing between them.
The flatness in the axilla is consistent with either condition,
as is the bronchial character of the respiration. The marked
diminution in the intensity of the respiratory and voice
sounds is more characteristic of an accumulation of fluid, but
can occur in solidification of the lung if a bronchus is ob-
structed. The bronchial character of the respiration and
voice sounds may be due to pneumonic solidification of the
lung or to compression of the lung by fluid. These signs
are, therefore, of but little assistance. The marked sense of
392 CASE HISTORIES IN PEDIATRICS.
resistance, however, counts strongly in favor of an accumula-
tion of fluid, more strongly than any other point counts in
favor of pneumonia, so strongly, in fact, as to justify a prob-
able diagnosis of this condition. The normal position of the
heart and the tympany in Traube's space prove that there
cannot be any large accumulation of fluid in the pleural
cavity. Small quantities of fluid are usually situated, more-
over, in the lower back rather than in the axilla. If there is
fluid present, it must, therefore, be encapsulated. The sense
of resistance and the diminution in the respiration are more
marked than would be expected from an encapsulated empy-
ema of no greater size than that indicated by the area of
flatness in the axilla. The location of this area is that in
which the signs of interlobar empyema are usually most
marked. An accumulation of fluid between the lobes, reach-
ing the surface in the axilla, will account for the marked sense
of resistance and the diminution in the respiration. The
greater dullness under the middle third of the scapula is
corroborative evidence in favor of this supposition. A
diagnosis of Interlobar Empyema is, therefore, a reasonable
one. The slight dullness over the rest of the left chest is
probably due to thickening of the pleura; the diminished
respiration, to thickening of the pleura and the defective
expansion on that side; the slightly bronchial character of
the respiration, to partial compression of a portion of the lung;
the rales, to defective expansion and slight congestion. The
tympany in the lower axilla is undoubtedly transmitted from
the abdomen.
Whenever the physical signs point as strongly to a purulent
pleurisy as they do in this instance, an exploratory puncture
should be done at once. A needle was, therefore, introduced
into the fifth left space in the mid-axillary line and pus
obtained, thus confirming the diagnosis.
Prognosis. If the chest is not opened he will almost cer-
tainly fail steadily and finally die. There is a small chance
that the pus may break through into a bronchus or be
absorbed. In either case he will be left with a badly damaged
lung and probably with a deformed chest. If the chest is
opened at once he will almost certainly get well, because his
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 393
general condition is fair and the evidences of septic absorp-
tion comparatively slight. There being but little compres-
sion of the lung, and the pus being between the lobes where,
if adhesions form, they will do no harm, he can be expected
to recover with a practically normal chest.
Treatment. The only rational treatment in this instance
is the opening and draining of the pleural cavity. It is true
that in rare instances recovery ensues in pneumococcus em-
pyema after tapping. This happens so seldom, however,
that it cannot be regarded as a justifiable procedure. The
almost invariable result is that the pus reaccumulates and
that the chest has to be finally opened. In the meantime,
the general condition has been further impaired as the result
of the continued septic absorption, and the lung has been
further compressed and its complete expansion rendered more
difficult. He ought, therefore, to be operated on at once.
Resection of a rib allows much freer drainage than does
simple incision and is, therefore, the preferable procedure.
394 CASE HISTORIES IN PEDIATRICS.
CASE 119. Charles C, three years old, entered the Chil-
dren's Hospital, February 5, because of a hemorrhage from
his stomach. He was well developed and nourished, but
very pale. There was a venous hum in the neck and a sys-
tolic murmur at the pulmonic area. The left border of the
cardiac dullness was six cm. to the left and the right border
two and one-half cm. to the right of the median line, while
the upper border was at the middle of the third rib. The
lungs were normal. The upper border of the liver flatness
was in the fifth space in the nipple line ; the lower border was
palpable three cm. below the costal border in the same line.
The spleen was palpable four cm. below the costal border.
The abdomen was normal and there was no edema.
Examination, February 10, showed a little puffiness of the
eyelids. There was dullness on the right side below the angle
of the scapula behind and the sixth rib in the axilla, extend-
ing forward as far as the anterior axillary line. The respir-
atory and voice sounds were diminished in this area, but
not changed in character. The tactile fremitus was slightly
diminished and the sense of resistance increased. The left
border of the cardiac dullness was as before, and the lower
border of the liver was in the same position. There was
shifting dullness and a slight fluid wave in the abdomen.
The diagnosis of effusion in the right pleural cavity was
made, a needle introduced in the eighth space in the poste-
rior axillary line and about two ounces of bloody serum with-
drawn. He began to breathe badly during the afternoon and
slept but little that night, although supported by pillows.
The physical examination, February II, was as follows:
Physical Examination. His breathing was difficult and
labored and he was unable to lie down. There was, how-
ever, no cyanosis. The right side of the chest moved but
little in respiration, but it did not appear larger than the
left and there was no bulging of the intercostal spaces. There
was tympany over the whole right front and over the back
below the angle of the scapula and outside of the inner border
of the scapula, where there was dullness. The respiration
was somewhat diminished over the whole side, amphoric in
character in the tympanitic area, bronchovesicular in the dull
Charles C. Case 119.
DISEASES OF THE BRONCHI, LUNGS AND PLEURvE. 395
area. The voice sounds were everywhere diminished, but
bronchial in character. The tactile fremitus was absent. The
sense of resistance was diminished. The coin sound was
present, but there was no succussion sound. The right
border of the cardiac dullness was at the left border of the
sternum ; the left border, eight cm. to the left of the median
line. The upper border of the liver flatness, in the nipple
line, was just above the costal border. The liver was pal-
pable three cm. below the costal border in the nipple line.
The rectal temperature was I02.8°F.; the pulse, 160; the
respiration, 60.
Diagnosis. There can be no doubt as to the diagnosis of
Pneumothorax with collapse of the lung. The tympanitic
percussion note, the amphoric respiration, the diminution in
the voice sounds, the absence of fremitus, the diminished
sense of resistance and the coin sound are all characteristic
of this condition. The facts that the right side moves in
respiration, that there is no enlargement of that side and no
bulging"]of the intercostal spaces, that the respiratory sound
is not much diminished and that there is not much displace-
ment of the heart and liver show that the opening from the
lung into the pleural cavity is still patent, that is, that it is
an open pneumothorax. The absence of the succussion sound
shows that there is little, if any, fluid in the pleural cavity.
It is probable that the lung was pricked with the needle
during the aspiration the day before and that the pneumo-
thorax is the result. The diagnosis of pneumothorax is con-
firmed by the accompanying Roentgenograph.
Prognosis. The pneumothorax being due to a mechanical
injury to the lung and not to disease, the prognosis is good.
The opening will almost certainly close in the course of one
or two days and the air be absorbed inside of two weeks.
! Treatment. There is no treatment for the pneumothorax.
It is useless to withdraw the air while the opening into the
lung is still patent; it will be unnecessary after it is closed.
Treatment, as far as it is directed to the pneumothorax,
must, therefore, be symptomatic and for comfort. That of
the original disease may have to be modified, but need not be
interrupted.
396 CASE HISTORIES IN PEDIATRICS.
CASE 120. Frank H. was an only child. His mother
was alive and well, his father had been dead some years.
The cause of his death was not known. There was no tuber-
culosis in either family and there had been no known expo-
sure to it. He was born at full term, after a normal labor,
was nursed by his mother and was perfectly well until he
was seven and one-half years old, when a tumor was discov-
ered in the scrotum. The right testicle, with a tumorous
mass, was removed a few months later at the Boston City
Hospital by Dr. F. B. Lund. Dr. F. B. Mallory reported that
the mass was a malignant mixed tumor. He remained well
for two years, when he had pneumonia of the left lower lobe,
which cleared up entirely. This was followed, a few months
later, by whooping-cough. His appetite had been poor and
he had failed steadily in weight and strength since the
pneumonia. A week before he entered the Children's Hos-
pital, when ten years old, he began to have pain in the left
chest, which was increased by a deep breath. The pain was
followed, in a few days, by shortness of breath. He had but
little cough, however, and raised nothing. He had had no
hemoptysis, night sweats, dysphagia, abdominal pain or
swelling of the ankles, and had been up and about the house.
Physical Examination. He was well developed, but poorly
nourished and moderately pale. His tongue was somewhat
coated, his throat normal. The cardiac impulse was pal-
pable in the fifth left space, seven cm. to the left of the median
line. The upper and left borders of the cardiac dullness
could not be determined because of the flatness in the left
chest; the right border was three cm. to the right of the
median line. The action was regular and the sounds normal.
The left side did not move with respiration and the inter-
costal spaces were somewhat less distinct than on the right.
The circumference of the two sides at the level of the nipples
was, however, the same. There was flatness over the whole
left side of the chest and in Traube's space. The sense of
resistance was much increased. The respiratory and voice
sounds were diminished and bronchial in character. The
tactile fremitus was absent. No rales were heard. The right
side was hyperresonant and the respiratory sound was exag-
DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 397
gerated. The upper border of the liver flatness was at the
upper border of the fifth rib in the nipple line and of the sixth
rib in the mid-axillary line. The lower border was pal-
pable three and one-half cm. above the anterior superior
spine, seven cm. below the costal border in the nipple line
and twelve and one-half cm. below the tip of the ensiform.
It ran under the left costal border just inside the left ante-
rior axillary line. The surface was smooth, except in the
epigastrium, where there was a protrusion about three cm.
in height and seven cm. by three cm. in diameter. The
spleen was not palpable. There were no signs of fluid in
the abdomen and no other masses were felt. The super-
ficial veins of the abdomen and of the left side of the chest
were dilated. The left testicle was normal. There was a
scar on the right side of the scrotum, which was empty.
The extremities were normal. There was no spasm or paraly-
sis. The knee-jerks were equal and normal. Kernig's sign
was absent. There was no enlargement of the peripheral
lymph nodes. The mouth temperature was ioo° F. ; the
pulse, 120; the respiration, 40.
The urine was clear, acid in reaction, of a specific gravity
of 1032 and contained no albumin or sugar.
Diagnosis. When it is taken into consideration that the
enlargement of the liver followed the removal of a malig-
nant tumor of the testicle, that it is nodular and not accom-
panied by jaundice, ascites or enlargement of the spleen,
there can be no question as to the diagnosis of Sarcoma of
the Liver. The condition in the left chest is more obscure.
The immobility of the left side, the partial flattening of the
intercostal spaces, the flatness over the whole side and in
Traube's space, the diminished respiration and voice sounds,
the absence of fremitus and the increased sense of resistance
seem, at first thought, to prove conclusively that there is a
large accumulation of fluid in the left pleural cavity. The
heart is, however, not displaced more than one-half of a
cm., but this may be, of course, because it is bound down by
adhesions. Judging from the position of the lower border
of the liver, the dullness in Traube's space may be equally
well due to the enlarged liver. Grocco's sign is absent.
398 CASE HISTORIES IN PEDIATRICS.
These are strong points against a pleural effusion. Is it
possible to explain the other signs in any other way? It
certainly is. A massive tumor involving the whole lung
will give flatness and a marked sense of resistance over the
whole side. If the bronchi are partially obliterated, the
respiratory and voice sounds will be diminished and bron-
chial in character and the fremitus absent. The heart will
not be displaced and Grocco's sign will be absent, as in this
instance. The enlargement of the superficial veins of the
left side of the chest also points strongly to a new growth in
the lung. The diagnosis of a massive Sarcoma of the Lung
is, therefore, certain.
Prognosis. The prognosis is absolutely hopeless. He
will probably not live more than a few weeks, certainly not
more than a few months.
Treatment. Nothing can be done, except to make him as
comfortable as possible.
SECTION VIII.
DISEASES OF THE HEART AND PERICARDIUM.
CASE 121. Dillaway F., the second child of healthy par-
ents, was delivered by version at full term, was apparently
normal at birth and weighed seven and one-half pounds. He
was very badly fed during his first year and suffered from
indigestion during his second year. A murmur was discovered
in his heart during a routine examination when he was ten
months old. When he was two years old he had influenza,
followed by pneumonia. Since then he had been well, except
for symptoms of adenoids and occasional nosebleeds, which
were probably due to them, until the last few months, during
which he had had a recurrence of his indigestion. He was
seen when four years old. He had never been short of breath
or cyanotic.
Physical Examination. He was fairly developed and nour-
ished and looked well. His color was good, but when he
cried there was, perhaps, a slight tinge of cyanosis in the
cheeks. His throat was normal, his tongue moderately coated.
There was no deformity of the chest. The cardiac impulse
was visible and palpable in the fifth space in the nipple line,
6| cm. to the left of the median line (normal is in fourth space,
6 cm. to left of median line). The left border of the relative
cardiac dullness corresponded to the impulse. The upper
border of the relative dullness was at the upper border of the
second rib (normal is in the second space), and the right bor-
der 3 cm. to the right of the median line (normal is 2f cm.).
There was no dullness under the manubrium. The action
was regular; the rate, 90 (normal). A very distinct thrill was
felt in the second left interspace. It was also palpable, but
much less distinctly, over the rest of the precordia. The
first sound was everywhere distinct, but was followed over
the whole precordia by a loud, rough murmur, loudest in the
second left interspace. This murmur was also audible in the
399
400 CASE HISTORIES IN PEDIATRICS.
neck and over the whole chest, back and front. The second
pulmonic sound was much louder than the second aortic, so
much louder that it was undoubtedly accentuated. The
lungs and abdomen were normal. The liver and spleen were
not palpable. The extremities were normal. There was no
clubbing of the fingers or toes. There was no spasm or pa-
ralysis. The knee-jerks were equal and normal. There was
no enlargement of the peripheral lymph nodes.
Diagnosis. This boy undoubtedly has a cardiac lesion.
The first thing to be decided is whether it is congenital or
acquired; next, to determine, if possible, what the lesion is.
The points in favor of a congenital lesion in this instance are
the fact that the murmur was discovered when he was only
ten months old, before he had had any disease likely to be
accompanied by endocarditis; the slight enlargement of the
heart in comparison with the intensity of the murmur; and
the location of the greatest intensity of the murmur and of the
thrill and their distribution, which do not correspond to those
of any of the acquired lesions. The points against a congenital
lesion are the absence of bulging of the precordia and of all
the usual signs of interference with the oxygenation of the
blood. There is, however, no reason for bulging of the pre-
cordia when the heart is no more enlarged than in this
instance, and it is perfectly possible to have congenital lesions
which from their nature, or from the presence of compensa-
tory lesions, do not interfere with the oxygenation of the
blood. A positive diagnosis of Congenital Heart Disease
is, therefore, justified.
It is impossible during life to make a certain diagnosis of
the exact lesion in congenital heart disease, although a prob-
able diagnosis is often possible. In this instance the location
of the maximum intensity of the murmur and of the thrill in
the second left interspace and the transmission of the murmur
into the neck point strongly to a narrowing of the pulmonic
orifice. The absence of all signs of deficient oxygenation of
the blood shows that there must be some compensatory lesion.
The accentuation of the second pulmonic sound suggests that
this lesion is an open ductus arteriosus.
Prognosis. He has reached the age of four years and has
DISEASES OF THE HEART AND PERICARDIUM. 401
passed through a pneumonia without the appearance of any
symptoms referable to the heart, has perfect compensation
with but little cardiac enlargement, and has developed nor-
mally. It seems reasonable to suppose, therefore, that his
cardiac lesion will not interfere with his growth and develop-
ment and that he will reach adult life and perhaps attain old
age. The prognosis in this instance is as good, if not better,
than it would be if he had an acquired lesion.
Treatment. He requires no treatment at present, except
that it will be advisable for him to avoid continued, excessive
exertion. If failure of compensation develops, the treatment
will be that of failure of compensation in general.
402 CASE HISTORIES IN PEDIATRICS.
CASE 122. Francis H. was the third child of healthy-
parents. The other children were alive and well and there
had been no miscarriages. He was born at full term, after
a normal labor, and weighed nine pounds. He was somewhat
cyanotic at birth and it was hard to establish respiration.
The trained nurse who had charge of him at first did not
notice that he was cyanotic. When his mother took charge
of him, when he was a month old, she noticed, however, that
he became a little blue on crying. She thought that the
cyanosis on crying had not increased since then and that his
color was good at other times. She had also noticed that he
breathed quickly when he was asleep and that he had a
tendency to keep his mouth open. He had a "funny little
cough" in the beginning, which improved somewhat after
the first week. She said that recently he had coughed "like
an old man." He had been fed on modified cows' milk since
he was a week old, but had had no disturbance of the diges-
tion. He had had no illnesses. He was seen in consultation
when three months old.
Physical Examination. He was fairly developed and
nourished. When quiet, he was pale, except that the hands
and feet were a little bluish. When he cried, he was every-
where deeply cyanotic. The anterior fontanelle was level.
The pupils were equal and reacted to light. The mouth and
throat were normal, and the tongue was clean. The chest
was of good shape. The cardiac impulse was not visible, but
was indistinctly palpable in the fourth space, six cm. to the
left of the median line. There was no thrill. The left
border of the cardiac dullness corresponded to the impulse.
The upper border was under the second rib ; the right border,
two cm. to the right of the median line. The action was
perfectly regular and the sounds were strong. The second
pulmonic sound was normal. The first sound in the third and
fourth left spaces was at times followed by a short, blowing
murmur, which was not transmitted. No murmurs were
heard elsewhere. The lungs were normal. The lower border
of the liver was palpable three cm. below the costal border in
the nipple line. The spleen was not palpable. The abdo-
men was normal. There was no clubbing of the extremities.
DISEASES OF THE HEART AND PERICARDIUM. 403
There was no spasm or paralysis. The knee-jerks were equal
and normal. There was no enlargement of the peripheral
lymph nodes. He weighed ten pounds.
Diagnosis. The cyanosis and the cardiac murmur being
the only abnormal physical signs, it is evident that the trouble
is located in the heart. The cyanosis proves that the condi-
tion is not functional, but organic. The facts that he is but
three months old, that he has been cyanotic since he was a
month old and probably since birth, that he has had no
illnesses to cause endocarditis, that the heart is not enlarged,
that the second pulmonic sound is not accentuated, although
the murmur is in the mitral area, and that there is no enlarge-
ment of the liver and spleen or edema of the lungs or extremi-
ties, in spite of the cyanosis, are sufficient to show that the
lesion in the heart is not acquired. It must, therefore, be
congenital. The combination of cyanosis and a cardiac mur-
mur without enlargement of the heart, weakening of the heart
sounds and evidences of passive congestion in other organs is,
moreover, characteristic of Congenital Heart Disease.
It is never possible to make a positive diagnosis as to the
exact location of the lesion in congenital heart disease. The
location of the murmur and the absence of enlargement of
the heart and of changes in the second sounds point strongly
in this instance, however, to a defect in the ventricular
septum. The slight intensity of the murmur is consistent
with either a very small or a large opening. The deepness
of the cyanosis on exertion makes it almost certain that it is
a large one.
Prognosis. It is impossible to more than guess how long
he will live. Judging from the intensity of the cyanosis when
he cries, the rapidity of the respiration and the frequent cough,
it is probable that he will not live more than a year. He may
die suddenly at any time and can hardly be expected to
survive any acute disease of the lungs. He may, however,
live for a number of years.
Treatment. There is nothing to do for him at present,
except to take good care of him. If evidences of failure of
compensation develop, the treatment will be that of failure
of compensation in general.
404 CASE HISTORIES IN PEDIATRICS.
CASE 123. Elic S. was born one month before he was
expected, after a normal labor, and weighed three pounds.
There had been one previous miscarriage. Two younger
children were well. Jaundice appeared a few days after
birth, but disappeared in a week. He was breast-fed for nine
months and did well. He had had no disturbances of diges-
tion since then. He had scarlet fever at two years and
whooping-cough at three years. His mother noticed, when
he was four months old, that his lips, cheeks and nails were
bluish and that at times the whole body was blue. The
cyanosis increased rapidly, so that after a short time there
was always some general cyanosis present. The intensity
of the cyanosis varied, however, from time to time. The
cyanosis was increased by exertion, exposure to cold and
excitement. He had always been weak muscularly and had
never been able to walk far without getting out of breath.
He was able to sleep with one pillow and had never had any
convulsions, edema or pain. His appetite and digestion were
good. He was bright and happy; in fact, seemed perfectly
normal, except for the cyanosis and dyspnea on exertion.
He was seen when five years old.
Physical Examination. He was fairly developed and
nourished, but somewhat flabby muscularly. He was per-
fectly normal mentally, but restless and excitable. He was
able to lie down flat without discomfort. There was marked
general cyanosis, which was greater in the extremities and
lips than elsewhere. The conjunctivae were slightly discolored
from the cyanosis. There was no bulging of the precordia.
The cardiac impulse was palpable in the fourth space in the
nipple line, six and one-half cm. to the left of the median line.
The left border of the cardiac dullness corresponded to the
impulse. The upper border of dullness was at the upper
border of the third rib. The right border was four cm. to the
right of the median line. The action was regular. The first
sound was somewhat short. The second pulmonic sound
was louder than the second aortic, but no louder than would
be expected at this age. No abnormal sounds were heard.
There was no thrill and no dullness under the manubrium.
The lungs showed nothing abnormal. The thymus was not
Normal hand.
Clubbing of the fingers in congenital heart disease.
DISEASES OF THE HEART AND PERICARDIUM. 405
palpable in the suprasternal space. There was no increased
dullness over the upper dorsal spinous processes and no
change in the respiration or voice sounds in this area. The
abdomen was normal. The upper border of the liver flatness
was at the lower border of the fifth rib in the nipple line. The
liver and spleen were not palpable. The extremities were nor-
mal, except for marked clubbing both of the fingers and of the
toes. There was no edema. There was no spasm or paralysis.
The knee-jerks were equal and normal. Kernig's sign was
absent. There was no enlargement of the peripheral lymph
nodes.
The urine was clear in color, acid in reaction, of a specific
gravity of 1015, and contained no albumin, sugar or acetone.
The sediment contained merely a few small round and squa-
mous cells.
Blood.
Hemoglobin, 140% (Sahli)
Red corpuscles, 1 1 ,376,000
White corpuscles, 12,000
Small mononuclears, 27%
Large mononuclears, 5%
Polynuclear neutrophiles, 68%
There was no achromia, polychromatophilia or poikilocytosis,
and no nucleated red cells were seen.
Diagnosis. The chief abnormalities in this instance are
the cyanosis, the clubbing of the extremities and the poly-
cythemia. The normal condition of the lungs and the
intensity of the polycythemia exclude disease of the lungs
as the cause of the symptoms, while the absence of all signs of
enlargement of the tracheo-bronchial lymph nodes and thy-
mus and of pressure on other organs by them shows that they
cannot be the cause. The onset of the cyanosis when the
boy was still on the breast and the absence of all signs of
indigestion is much against an enterogenous cyanosis, which
is, moreover, not accompanied by clubbing of the extremities
and polycythemia. Methemoglobinemia from drugs can
also be excluded for the same reasons. Chronic polycy-
themia with cyanosis and enlargement of the spleen (ery-
thremia or erythrocytosis megalosplenica) can be ruled out
406 CASE HISTORIES IN PEDIATRICS.
on the age of the child, the absence of the peculiar bluish-red
color, the absence of enlargement of the spleen and the
absence of a polynuclear leucocytosis and of nucleated red
cells. The cause of the symptoms must be, therefore, some
Congenital Cardiac Malformation. The enlargement of
the heart to the right is corroborative evidence in favor of this
diagnosis. The absence of a murmur does not count much
against it, because it is a well-known fact that there may be
no murmur in congenital heart disease, even when other signs
are marked. The malformations with which the symptoms
are reasonably consistent in this instance are absence of the
ventricular septum, transposition or irregular origin of the
great vessels and pulmonary atresia with some compensatory
malformation. There ought not, however, to be a second
pulmonic sound if there is pulmonary atresia, and it should
be accentuated if there is a transposition of the vessels. It
is idle to speculate as to the exact lesion, however, as it is
obviously impossible to determine positively what it is.
Fortunately a knowledge of this point is not of importance in
relation to the treatment.
Prognosis. He is five years old, has survived scarlet fever
and pertussis, has developed fairly well and has no disturb-
ance of the digestion. It seems reasonable to suppose,
therefore, that he will live for a number of years. Any
disease of the lungs will, however, probably prove rapidly
fatal. If he lives, he will not be able to do any active work
and will always have to lead a sedentary life.
Treatment. The treatment at present consists in the
avoidance of all exertion sufficient to cause shortness of
breath. If evidences of failure of compensation, such as
edema of the lungs, enlargement of the liver, ascites or
anasarca develop, the treatment will be that of failure of
compensation in general.
DISEASES OF THE HEART AND PERICARDIUM. 407
CASE 124. William C.'s father had died of tuberculosis
just before he was born. He had had no known exposure to
tuberculosis. He had been unusually rugged until he was
eight years old, when he had otitis media followed by inflam-
mation of the mastoid and operation. A considerable amount
of adenoids was removed at the same time. He was kept out
of school for a year, but did not regain his strength. He was
easily tired and not nearly as vigorous as before. An enlarge-
ment of several of the cervical lymph nodes, which had de-
veloped at the time of the mastoid operation, persisted until
his tonsils were removed, when he was ten and one-half years
old, since when they had become much smaller. He had
chicken-pox when eleven and one-half years old and was
considerably pulled down by it. Since then he had been
generally below par and very easily tired. His appetite had
been poor, but he had shown no signs of indigestion. His
bowels had moved regularly, and the movements had been
normal. He had had no cough. He complained a little of
shortness of breath on exertion, but never of palpitation.
Once, after unusual exertion, and at another time after
getting tired, he had run a temperature between 990 F. and
ioo° F. for several days. At other times his temperature had
been normal. He had been kept very quiet during the last
few months and not allowed to take any active exercise. He
went to bed early and usually slept about eleven hours, but
had no rest during the day. He had grown tall very rapidly
during the last six months. He was of a very nervous type
and was much worried about himself. He had no bad habits.
He was seen when eleven and three-fourths years old.
Physical Examination. He was tall and rather slight, but
of fair color. His throat and mouth were healthy and his
tongue nearly clean. There was no venous hum in the neck.
The cardiac impulse was palpable in the fourth left space,
7! cm. to the left of the median line. The left border of the
relative cardiac dullness was 7% cm. to the left, and the right
border 3 cm. to the right of the median line; the upper border
was at the upper border of the third rib. That is, taking his
height into consideration, the measurements to the left were
a little small, while the others were normal. The cardiac
408 CASE HISTORIES IN PEDIATRICS.
action was somewhat irregular in rhythm; the rate, 88.
The cardiac action was steadied by exertion. The first sound
was everywhere of fair strength. It was at times followed,
both at the pulmonic and mitral areas, by short murmurs
which were not transmitted. The second pulmonic sound was
not accentuated. The lungs and abdomen were normal.
The liver and spleen were not palpable. The extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and lively. Kernig's sign was absent.
Numerous lymph nodes, varying in size from that of a pea to
that of a large bean, were palpable in the neck. There was
no enlargement of the axillary and inguinal and no evidence
of enlargement of the bronchial lymph nodes. His weight
was eighty-nine and one-fourth pounds (average, seventy-
six and one-half pounds). His height was fifty-nine and
three-fourths inches (average, fifty-five).
The urine was clear, highly acid in reaction, of a specific
gravity of 1,038 and contained no albumin or sugar.
Blood.
Hemoglobin, 90%
Red corpuscles, 4,500,000
White corpuscles, 7,200
Smears of the blood showed nothing abnormal in either the
red or the white corpuscles.
Diagnosis. The enlargement of the cervical lymph nodes
is in all probability not tubercular, because it came on in the
course of an acute disease, has never shown any tendency to
suppurate and has diminished in size since the tonsils were
removed. The fact that his father died of tuberculosis is of
no importance, because he was not exposed to tuberculosis
from him. There are no evidences of tuberculosis elsewhere.
It is reasonably safe to conclude, therefore, that his poor
condition is not due to tuberculosis.
The point of chief interest is the condition of the heart.
It is certainly not an acute one. Is the trouble organic or
functional? Anemic murmurs do not have to be considered
because of the condition of his blood and the absence of a
venous hum in the neck. The absence of enlargement of the
DISEASES OF THE HEART AND PERICARDIUM. 409
heart, taken in combination with the strong first sound and
the absence of accentuation of the second pulmonic sound,
show that there is no dilatation or hypertrophy of the heart,
which would certainly be present if there was any chronic
leakage at the mitral orifice. The presence of a murmur at
the pulmonic orifice and the absence of transmission of the
murmurs is also against an organic lesion. The steadying of
the heart on exertion, the rapid growth, the nervous tempera-
ment, the history of the previous illnesses and the fact that
he is about the age of puberty, all point to a functional condi-
tion. It is safe to conclude, therefore, that the Cardiac
condition is Functional, not organic.
Prognosis. The prognosis is perfectly good with time. It
will probably be several years before he will be strong and
vigorous. The irregularity of the heart and the murmurs will
probably disappear much sooner.
Treatment. The treatment must be by regulation of his
daily life, not by drugs. In the first place, he must be assured
that there is nothing serious the matter with him, that his
weakness is merely the result of his illness and his rapid growth
and that he will surely be all right again. He must not go to
school more than half a day. If he does not go at all, he will
have too much time to think about himself. He must be
amused in quiet ways. He must partly undress and lie down
for an hour at noon and rest, even if he does not sleep. He
must be in bed at eight. It will be a good thing for him to
sleep out of doors. He can walk, drive, ride in an automobile,
play golf and work a little about the house, but must not
play baseball or football, ride a bicycle or skate. He may
have any reasonable food. He should have three good meals
and a lunch in the morning. Care must be taken that his
bowels move regularly. Tincture of nux vomica, in eight-
drop doses, three times daily, before meals, will probably
improve his appetite and his general condition.
410 CASE HISTORIES IN PEDIATRICS.
CASE 125. Samuel C, four and one-half years old, had
been perfectly well since an attack of acute nephritis two
years before. About two weeks before he was seen he began
to complain of pain and stiffness in the ankles, wrists and
elbows. He apparently did not feel sick and was not feverish.
He had been allowed to be out of doors as usual, although it
was winter. He had had no treatment. The day he was seen
he had not seemed quite as well, although nothing very definite
had appeared. He was seen in the evening.
Physical Examination. He was well developed and nour-
ished and of good color. He did not seem sick. He com-
plained of slight pain when his ankles, wrists and elbows were
moved. The right wrist was tender on pressure; the other
joints were not. There was no redness, heat or swelling about
any of them. The cardiac impulse was visible and palpable
in the fifth space, 8 cm. to the left of the median line (the
normal is in the fourth space, 6 to 6§ cm. to the left of the
median line). The upper border of the relative cardiac
dullness was at the lower border of the second rib (normal
is in second space), the right border 2 \ cm. to the right of the
median line (normal), and the left border 8 cm. to the left of
the median line (normal is 6 to 6| cm.). The cardiac action
was somewhat irregular; the rate was 104 (normal is 90 to
100). The first sound at the apex was strong, but continued
into a short, blowing murmur, transmitted into the axilla.
The second sound at the apex was reduplicated. The second
sound at the pulmonic area was accentuated. The lungs and
abdomen were normal. The liver and spleen were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. There was no enlargement of the peripheral
lymph nodes. There was no venous hum in the neck. The
mouth temperature was 1020 F.
Diagnosis. The history and the conditions found in the
joints are typical of Rheumatism in childhood, at which age
marked joint and constitutional symptoms are very un-
common. The disease is, therefore, very often overlooked,
as it was in this instance. Unfortunately the heart is involved
even more frequently in this mild type of rheumatism in
childhood than it is in the severe type in adult life.
DISEASES OF THE HEART AND PERICARDIUM. 4II
There is undoubtedly something abnormal about the heart.
The possibilities are acute endocarditis, myocarditis and an
anemic murmur. The latter can be at once excluded on the
good color, the absence of a venous hum in the neck and the
enlargement of the heart. The absence of a murmur at the
pulmonic area is also against it. Myocarditis can be ruled out
on the character of the impulse, the strength of the first sound
and the accentuation of the second sound in the pulmonic
area. The absence of enlargement to the right and of much
increase in the rate of the pulse is also against it. The diag-
nosis is, therefore, by elimination, Acute Endocarditis of
the mitral valve. The combination of a systolic murmur at
the apex with a strong impulse, strong first sound, but little
increase in the rate of the heart, enlargement limited to the
left side and an accentuation of the second pulmonic sound, is,
moreover, characteristic of an early endocarditis of the mitral
valve.
Prognosis. There is no immediate danger to life from the
endocarditis, the chief immediate danger being the simul-
taneous involvement of the myocardium and pericardium.
When all parts of the heart are involved, the prognosis is
always a grave one. There is, however, very little chance of
complete recovery. The disease is almost certain to result
in permanent deformity of the mitral orifice. There is, more-
over, great danger of recurrence of the rheumatism in the
future with further damage to the endocardium. It must be
remembered in this connection that the murmurs due to
acute endocarditis frequently disappear, to be followed later
by those due to cicatricial changes in the orifices. The dis-
appearance of the murmur does not, therefore, justify a
favorable prognosis. This can only be given when the mur-
mur has not reappeared after an interval of one or two years.
Treatment. The author is one of those who believe that
the salicylates do good in rheumatism. It seems reasonable
that, if they help rheumatism, they will have a favorable
influence upon the endocarditis, which is a manifestation of
rheumatism. It is hard to understand, at any rate, how they
can do any harm in rheumatism, as some writers claim they
do. The most satisfactory preparation of salicylic acid for
412 CASE HISTORIES IN PEDIATRICS.
children is aspirin. This boy should have five grains every
three hours until the joint symptoms and fever are relieved,
unless he gets toxic symptoms. If he does, the dose should be
reduced. It should be continued in the same dose, three
times a day, for several days or a week longer.
The most important thing in the treatment of acute endo-
carditis in childhood is rest. Everything else is subordinate.
He must be kept in bed not only during the acute stage, but
for months longer. Three months is the minimum. A week
in bed at this time may mean a year of life later. In the
beginning he must be kept flat or as nearly flat as is possible.
Judgment must be used in this connection, however, because
he may fret and fuss so much at being kept flat that he will
bring more strain on his heart than if he is allowed to sit up.
His life must be most carefully regulated for a year or two
after he gets up, and the amount of exertion limited. He will
feel perfectly well and will wish to do what other children do.
He must, however, be restrained. His whole life must be
planned so as to save the heart.
His compensation is perfectly good. There is, therefore,
no call for either cardiac stimulants or tonics. If he is restless
or uncomfortable, he may be given the bromide of sodium or
potassium in five- or ten-grain doses, or morphia in doses of
from one thirty-second to one sixteenth of a grain.
There are no special indications as to his diet. He must be
given a milk and starchy diet at first. Later, there is no
objection to meat and eggs. Special attention must be paid
to his nutrition, as the condition of the heart muscle depends
to a considerable extent on the general nutrition.
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Chart of Case 126.
DISEASES OF THE HEART AND PERICARDIUM. 413
CASE 126. Carl J., eleven years old, had three brothers
living and well. His parents and a sister had died of acute
diseases. He had measles and whooping-cough when nine
years old and had been circumcised two months before the
onset of his illness. The heart was examined at that time,
but nothing abnormal was detected. He was taken sud-
denly sick July 26 with vomiting, fever and headache. The
vomiting and headache ceased after twenty-four hours, but
the fever continued. He did not complain of sore throat,
but the physician who saw him on July 28 found the throat
reddened, the tonsils large and the fauces and pharynx cov-
ered with purulent material. The heart was not enlarged
at that time, but a loud systolic murmur was heard all over
the precordia and in the axilla. The rest of the physical
examination was negative. The throat cleared up rapidly
and no new physical signs developed. The fever continued,
however, as is shown by the accompanying chart. He had
a chill on August 6 and on August 8 two chills, with two
marked exacerbations of temperature. He took his food
fairly well and had no disturbance of the digestion, but
lost weight and strength very rapidly. He was troubled by
headache, mostly occipital, after August I, and complained
constantly of pain in the legs. This was not helped by
aspirin, and Roentgenographs showed no disease of the
bones or joints. The urine, which was examined July 29,
was clear, acid in reaction and contained no albumin or
sugar. The sediment showed a few leucocytes and large
round cells, but no casts. A skin tuberculin test on July 21
was negative. Widal tests on July 31 and August 9 were
negative. Blood cultures on July 31 and August 6 were also
negative. The leucocyte count, July 29, was 5600, with
60% of polynuclear cells. It was 12,400, with 85% of polynu-
clears, on August 6, and on August 9, 12,000 with 80% of
polynuclears. No plasmodia malarise were found at three
examinations. He was seen in consultation, August 9.
Physical Examination. He had evidently lost much flesh.
He was perfectly clear mentally. There was no rigidity of
the neck or neck sign. The pupils were equal and reacted to
light. The tongue was considerably coated. The throat
414 CASE HISTORIES IN PEDIATRICS.
was normal. The cardiac impulse was in the fifth space,
seven and one-half cm. from the median line. The left
border of dullness was one-half cm. farther out, the right
border three and one-half cm. to the right of the median
line, the upper border at the upper border of the third rib.
The action was regular. The first sound at the mitral area
and apex was replaced by a loud, blowing murmur, trans-
mitted into the axilla. The first sound was audible at the
base of the heart, as was the murmur. The second sound at
the pulmonic area was accentuated. There was no venous
hum in the neck. The lungs were normal and there was no
evidence of enlargement of the tracheo-bronchial lymph nodes.
The liver was not palpable. The upper border of the splenic
dullness was at the ninth rib. The spleen was not palpable.
The abdomen was level, soft and tympanitic. There were
no rose spots. The extremities were normal. There was
no spasm or paralysis. The knee-jerks were equal and nor-
mal. There was no Kernig's sign. He was generally hyper-
esthetic, especially in the legs. The inguinal and axillary
lymph nodes were palpable and seemed tender. The rectal
temperature was 105. 2° F. ; the pulse, 124; the respiration, 30.
Diagnosis. The diseases to be considered in this instance
are typhoid fever, malaria, acute miliary tuberculosis, rheu-
matism with endocarditis and malignant endocarditis. The
temperature and pulse rate, while not characteristic of
typhoid fever, are not inconsistent with it. The increase in
the number of white cells is so slight that it does not count
against it. Typhoid fever can be positively excluded, how-
ever, on the negative blood culture on the sixth day, the
negative Widal test on the fifteenth day of the disease, the
absence of rose spots and enlargement of the spleen at two
weeks, and the relative increase of the polynuclear leuco-
cytes. The onset was quicker, moreover, than is usual in
typhoid at this age. Malaria is suggested by the irregu-
larity of the temperature, the chills and the absence of a
marked leucocytosis. It can be ruled out on the absence
of enlargement of the spleen, the failure to find plasmodia on
three occasions and the relative increase of the polynuclear
leucocytes. The irregular temperature and the rapid loss
of weight and strength are suggestive of the typhoidal type
DISEASES OF THE HEART AND PERICARDIUM. 415
of acute miliary tuberculosis, as is the absence of marked
leucocytosis. The negative tuberculin test does not count
against it, because it is very often negative in this type of
tuberculosis. There are, however, no physical signs of any
primary focus and the pulse is slower than is usual in this
disease. It would be hard to exclude it, however, if the
signs in the heart did not point so strongly to trouble there.
The presence of these signs is, moreover, strong negative evi-
dence against typhoid fever and malaria. Rheumatism with
endocarditis is suggested by the pains in the extremities and
the signs of a cardiac lesion. The pains are general and indefi-
nite, however, there are no evidences of involvement of the
joints and aspirin has not relieved them. The general con-
dition is much worse than would be expected if this was the
trouble, when it is taken into consideration that the heart
is but little enlarged. It seems as if there must be some-
thing more serious than this the matter with him. The
high, irregular temperature, the chills and the rapid loss of
weight and strength show that there is a septic infection of
some sort. The absence of all evidences of infection, except
in the heart, proves that this must be the seat of the infec-
tion. The diagnosis of malignant endocarditis seems, there-
fore, a reasonable one. The relative increase in the number
of polynuclear leucocytes is also in favor of this diagnosis.
The reason that the leucocytosis is not larger, as it would
be expected to be, is probably because the system is over-
whelmed by the infection. It is harder to explain the nega-
tive blood cultures. All that can be said is that, while blood
cultures are usually positive in malignant endocarditis, they
are not always so. The negative blood cultures do not seem
sufficient, therefore, to in any way counterbalance the evi-
dence in favor of Malignant Endocarditis, which is the
only diagnosis consistent with the symptoms and which is
undoubtedly the correct one. The infection presumably came
from the throat.
Prognosis. The prognosis is absolutely hopeless. He will
probably not live more than a week or ten days, but may
linger on for several weeks.
Treatment. There is no curative treatment. All that can
be done is to make him as comfortable as possible.
416 CASE HISTORIES IN PEDIATRICS.
CASE 127. Philip N. was admitted to the Children's
Hospital, October 10, when seven and one-half years old.
His parents and five other children were alive and well.
Five had died of various diseases. There had been no mis-
carriages. He had had no known exposure to tuberculosis.
He had always been well, except for measles and whooping-
cough in infancy, until he had rheumatism a year before.
This was complicated by acute endocarditis and chorea. He
was in bed for eleven weeks, after which he made a slow but
good recovery. He had played about with the other boys
all summer and had had no shortness of breath or palpitation.
He was taken suddenly sick October 3 with headache, fever
and dyspnea. Pain, redness and swelling appeared in the
right knee the next day and since then the other knee, the
right ankle and both wrists had been affected. He had also
had some pain in the precordia, which at times ran up into
the left shoulder. He had taken his food well, had not
vomited and had had regular movements of the bowels.
Physical Examination. He was well developed and nour-
ished and moderately pale. There was a tinge of cyanosis
in the cheeks, about the mouth and in the hands and feet.
His expression was anxious and he was unable to lie down
with comfort. The tongue was covered with a moist, white
coat. The throat was normal. The cardiac impulse was
heaving. It was seen and felt most distinctly in the fifth
space, ten and one-half cm. to the left of the median line.
The left border of the cardiac dullness was eleven cm. to the
left of the median line (normal is seven cm.) and the right
border four and one-half cm. to the right of the median line
(normal is two and one-half cm.). The cardio-hepatic angle
was acute. The upper border of the cardiac dullness was in
the second space (normal is under third rib). The action
was regular, the rate 140. The first sound at the apex was
somewhat feeble and was followed by a loud, blowing mur-
mur, which was transmitted into the axilla and back. Both
sounds were feeble in the aortic area. The second sound in
this area was followed by a short, harsh murmur, which was
heard much more distinctly in the third left space and which
could be followed down to the apex, where it became inaudible.
DISEASES OF THE HEART AND PERICARDIUM. 417
The second sound in the pulmonic area was louder than that
in the aortic area. There was a Corrigan pulse, a capillary
pulse and a pistol-shot sound in the groin. The lungs were
normal, except for a few fine, moist rales at the bases behind.
The upper border of the liver flatness in the nipple line was
at the upper border of the fifth rib; the lower border was
palpable three cm. below the costal border in the same line.
The spleen was just palpable. The abdomen was slightly
distended, but otherwise normal. The extremities showed
nothing abnormal, except slight clubbing of the fingers and
toes. There was no tenderness or edema. The knee-jerks
were equal and lively. There was no enlargement of the
peripheral lymph nodes. The rectal temperature was 99.20
F.; the pulse, 140; the respiration, 44.
The urine was of normal color, acid in reaction, of a specific
gravity of 1023, and contained no albumin, sugar or bile.
The white corpuscles numbered 15,600.
Diagnosis. He undoubtedly has Chronic Valvular
Disease of the Heart. If the marked enlargement of the
heart was due to an acute disease of the heart, whether
endocarditis, myocarditis or a combination of the two, occur-
ring in association with the Rheumatism during the last
week, the impulse would not be heaving, the murmurs would
not be so loud and the signs of failure of compensation would
be very marked. The systolic murmur at the apex is indica-
tive of mitral insufficiency. The characteristics of the dia-
stolic murmur are those of the murmur of aortic insufficiency.
This diagnosis is confirmed by the Corrigan pulse, the capil-
lary pulse and the pistol-shot sound in the groins. The
increase in the rate of the pulse and respiration are out of
proportion to the increase in the temperature and greater
than would be expected in chronic valvular disease as well
compensated as it seems to be in this instance. This excessive
increase in the rate of the pulse and respiration, together with
the slight tinge of cyanosis, the anxious expression, the
tendency to orthopcea and the precordial pain, show that
there is some acute cardiac lesion in addition to the chronic
valvular disease. The absence of a friction rub and of the
signs of effusion into the pericardium shows that the peri-
418 • CASE HISTORIES IN PEDIATRICS.
cardium is not involved. It is probable that, as is usual in
such cases, both the endocardium and myocardium are
affected. The relatively strong first sound shows, however,
that the myocardium is not severely involved. A probable
diagnosis of Acute Endocarditis seems, therefore, justifi-
able. The fine rales in the back and the enlargement of the
liver and spleen are undoubtedly the result of the disease
of the heart.
Prognosis. The rheumatism will yield quickly to treat-
ment and the acute endocarditis will, in all probability, quiet
down. He will be left, however, with a heart more damaged
than it was before. This damage is so great that, although
it is probable that compensation will soon be reestablished,
it is only a question of time when it will break down again.
It may be reestablished several times, but it will sooner or
later give out once for all. He will almost certainly die of
cardiac failure within a few years.
Treatment. The treatment of rheumatism and acute
endocarditis, as well as inferentially of chronic valvular
disease, is discussed elsewhere (see Case 125). He should be
given five grains of aspirin every three hours for the present.
He should be kept as quiet as possible in bed and bolstered
up enough so that he can breathe freely. His diet should
consist of milk prepared in various ways, starches, ice cream
and custard. He should be given five or six small feedings
during the twenty-four hours. Water should not be pushed,
as large amounts increase the strain on the circulation. If
he is restless and uncomfortable, he should be given bromide
of soda in 15 grain doses. If this does not quiet him, it will
be wise to give him morphia in doses of from jfc to iV °f a
grain. While digitalis is not indicated in acute endocarditis
and myocarditis, it is useful when there is failure of compen-
sation in the course of chronic valvular disease, as in this
instance. He should be given five minims of the tincture of
digitalis every six hours ; more if necessary.
DISEASES OF THE HEART AND PERICARDIUM. 419
CASE^ 128. Ernest M., nine years old, was admitted to the
Children's Hospital January 5, on the sixth day of a pneu-
monia of the left lower lobe. He was in good condition and the
physical examination showed nothing else abnormal. The
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cardiac impulse was visible and palpable in the fifth space,
7 cm. to the left of the median line and just inside the nipple
line. The upper border of the relative cardiac dullness was
at the upper border of the third rib; the left border corre-
420 CASE HISTORIES IN PEDIATRICS.
sponded to the impulse and the right border was 2\ cm. to the
right of the median line (all normal). The action was regular.
The first sound was of fair quality. The second sounds were
alike. There were no murmurs.
The crisis, as will be seen by the chart, occupied two days.
The temperature reached normal the afternoon of January 7.
The pulse remained good during the crisis. The temperature
remained down and the lung began to clear at once, but the
pulse became infrequent and irregular the night of the 8th.
The examination the next morning, January 9, was as follows:
Physical Examination. He was perfectly comfortable and
of good color. The cardiac impulse was wavy and visible in
several spaces. It was most distinctly palpable in the fifth
space, 8£ cm. to the left of the median line. The upper
border of the relative cardiac dullness was in the second space,
the left border was just outside the point of maximum im-
pulse and the right was 4 cm. to the right of the median line.
The action was irregular in both force and rhythm; the rate
was 68 (normal is 80 to 90). All the beats were transmitted
to the wrist. The first sound was everywhere short and some-
what feeble. The second sounds were alike. There were no
murmurs. There was still a little dullness and a few moist
rales over the left lower lobe. The physical examination
showed nothing else abnormal.
Diagnosis. The physical signs are those of weakness and
dilatation of the heart. The weakness and dilatation cannot
be the results of an endocarditis, because the heart was
normal four days before and no leakage which did not show
then could possibly have caused so much dilatation and weak-
ness in four days. There is no cause outside of the heart to
account for its sudden failure. The cause of the dilatation and
weakness must, therefore, be in the heart wall. That is, there
is a Myocarditis. The diminution of the second sound at
the pulmonic area at entrance (the second pulmonic sound is
normally louder than the second aortic at this age) showed
that the right ventricle was unable to meet the increased
resistance in the pulmonary circulation and gave warning of
what happened later.
Prognosis. The prognosis is a grave one. A marked
DISEASES OF THE HEART AND PERICARDIUM. 42 1
diminution in the pulse-rate in myocarditis is as serious, if
not more so, than a marked increase in the rate. He may die
at any time; he may slowly improve and finally recover
entirely. It is impossible to forecast what will happen. The
outlook depends to a considerable extent on the treatment.
Treatment. The most important part of his treatment is
quiet. He must be kept perfectly flat and not allowed to sit
up for any reason whatever. He must be kept flat, or nearly
flat, until the cardiac action and rate are normal and all signs
of dilatation and weakness have disappeared. He may then
begin to gradually get up and about. Alcohol is useless in
myocarditis, except as a food. In large doses it undoubtedly
does harm. Strychnia may possibly help some. Digitalis
cannot act on a degenerated muscle. Nitroglycerin is danger-
ous because it predisposes to vasomotor paralysis. There is,
therefore, no drug treatment indicated at present. He may
have liquids in moderate amounts, soft solids and eggs. It
will be wiser to give him small meals five or six times in the
twenty-four hours than large ones at longer intervals.
422 CASE HISTORIES IN PEDIATRICS.
CASE 129. Mary M., seven years old, had had measles,
whooping-cough and rheumatism in the past. She com-
plained of "pain in her stomach" January 3, and two days
later began to have pain in the knees and could not use her
legs. The pain left her knees January 7 and she began to
complain of precordial pain and shortness of breath. Twitch-
ing of the face and extremities began January 9. She had,
nevertheless, taken food fairly well and had had no disturb-
ance of the digestion. She was admitted to the Children's
Hospital, January 13, and was seen soon after.
Physical Examination. She was fairly developed and
nourished, but very pale. There was moderate cyanosis of
the lips and cheeks. She was bolstered up on pillows, was
gasping for breath and took almost no notice of what was
going on about her. The cardiac impulse was just palpable
in the fifth left space, a little outside the nipple line. The
left border of the cardiac dullness was in the midaxillary line,
the upper border at the upper 'border of the second rib and
at the middle of the manubrium, whence the right border ran
diagonally downward and outward, reaching the upper border
of the liver flatness at the sixth rib, just inside the right nipple
line. The cardiac action was regular, but the sounds were
very feeble. The second pulmonic was louder than the
second aortic sound. No murmurs were heard and there
was no friction rub. There was marked dullness, with
bronchial respiration, in the left back below the level of the
middle of the scapula between the median and scapular lines.
There were many fine, moist rales throughout both backs.
The lower border of the liver was palpable at about the level
of the navel in the nipple line. The liver was tender. The
spleen was not palpable. There was no edema of the face
or extremities. There were occasional involuntary twitch-
ings of the face and extremities. No further examination
was made, because of her critical condition. The mouth
temperature was ioi.2°F.; the pulse, 132; the respiration,
40.
Diagnosis. The position of the impulse, well inside the
left border of the cardiac dullness, the obtuse cardio-hepatic
angle and the relatively slight increase in the rate of the heart,
DISEASES OF THE HEART AND PERICARDIUM. 423
together with the feebleness of the heart sounds while the
second pulmonic is louder than the second aortic sound, are
so different from the physical signs found in dilatation of the
heart with failure of compensation, the only condition with
which it could be confused, that an absolute diagnosis of
Pericarditis with Effusion is justified. The area of
dullness and bronchial respiration in the left back is pre-
sumably the result of compression of the lung and is corrobo-
rative evidence in favor of a pericardial effusion. The fine
rales in the backs are indicative of edema of the lungs from
interference with the pulmonary circulation. The enlarge-
ment and tenderness of the liver are undoubtedly due to
trouble in the heart, but suggest that there is some other
lesion in addition to the pericarditis. The history of rheu-
matism in the past and the loud second pulmonic sound
suggest that there is also some valvular lesion. It is im-
possible to determine at present, however, whether this is
the case or not. She has, of course, Rheumatism and
Chorea as well as pericarditis. The pericarditis having
developed in the course of rheumatism and chorea, the effu-
sion is almost certainly serous in character.
Prognosis. She will die within a few hours, if the fluid is
not removed at once from the pericardium. It is impossible
to say whether it will reaccumulate after its removal, but the
chances are that it will not. No more definite prognosis can
be given until the condition of the myocardium and endo-
cardium is determined after the withdrawal of the fluid. If
she recovers, she will probably be left with an adherent peri-
cardium, which may or may not cause trouble in the future.
Treatment. The pericardium must be emptied at once.
The fifth right interspace is, as a rule, the best place to tap it.
The trocar should be introduced in this instance about two
cm. inside of the right nipple line, which will be far enough
out to avoid the internal mammary artery. As much fluid
as possible should be withdrawn. It is probable that eight
or ten ounces will be obtained. A light icebag should then
be suspended over the precordia in such a way that it will not
cause pressure. It will probably make her more comfortable
and may, perhaps, hinder the reaccumulation of the fluid. It
424 CASE HISTORIES IN PEDIATRICS.
will be well also to give her three drops of the tincture of
digitalis every four hours for the present. If disease of the
endocardium is discovered after the withdrawal of the fluid,
it may be necessary to give her larger doses. The treatment
of pericarditis is given in more detail in Case 130.
DISEASES OF THE HEART AND PERICARDIUM. 425
CASE 130. Levi P., fifteen years old, had had repeated
attacks of rheumatic fever since he was four years old. He
began to be short of breath on exertion when he was fourteen,
but this was never severe enough to cause any inconvenience.
He occasionally suffered from palpitation. He had another
attack of rheumatic fever the latter part of May. Since then
dyspnea and palpitation had been very troublesome and any
exertion completely exhausted him. His appetite was good
and his bowels moved regularly. He had no signs of indiges-
tion. He had a slight cough, but no expectoration. The
dyspnea and palpitation finally became so troublesome that
he gave up and went to bed June 16. He was able to lie
down, but was more comfortable sitting up. Rest in bed
made him more comfortable until June 20, when he began to
complain of pain and oppression in the chest. He became
rapidly worse, so that on the 22d he was unable to lie down
with comfort, was restless and had begun to vomit. The
temperature, which had been running between normal and
1010 F., gradually went up to 1020 F., and the rate of the
pulse and respiration rose from 100 and 25 to 140 and 40,
respectively. He was seen in consultation June 22.
Physical Examination. He was well developed^and nour-
ished. He was restless and unable to lie down. His expres-
sion was anxious. He was everywhere slightly cyanotic.
The cardiac impulse was not visible; it was palpable in the
fourth space, midway between the sternum and the nipple
(normal is fifth space, 1 cm. inside the nipple). The upper
border of the relative cardiac dullness was at the upper border
of the second rib (normal is middle of third rib); the left
border 13 cm. (normal is 8 or 9 cm.) to the left of the median
line; the right border 6 cm. (normal is 3 to 4 cm.) to the right
of the median line in the fourth space, and 7 cm. to the right
of the median line in the fifth space. The action was regular;
the rate, 140. The heart sounds were markedly feeble. The
first sound at the apex was preceded by a faint, rumbling sound
and directly followed by a soft, blowing sound which was
transmitted toward the axilla. The second pulmonic sound
was somewhat louder than the second aortic. There was a
soft, double, rubbing sound close to the ear and increased by
426 CASE HISTORIES IN PEDIATRICS.
pressure of the stethoscope, synchronous with the heart beat,
under the manubrium and in the second spaces. The pulse
was fairly strong. There was an area of dullness, with bron-
chovesicular respiration and slightly increased voice sounds,
at the base of the left lung, extending outward about 7 cm.
from the median line and upward about 5 cm. There were
numerous very fine, moist rales in both lower backs. The
lungs were otherwise normal. The upper border of the liver
flatness was at the upper border of the sixth rib in the nipple
line ; the lower border was not palpable. The spleen was not
palpable. The abdomen was normal. The extremities showed
nothing abnormal. There was no spasm or paralysis and no
edema.
The urine was high, acid in reaction, of a specific gravity of
1,024 and contained neither albumin nor sugar. The sedi-
ment showed nothing abnormal.
Diagnosis. The trouble is, of course, entirely cardiac.
The condition in the heart is, however, a fairly complicated
one. The location of the impulse well inside the left border
of the cardiac dullness, the combination of feeble heart sounds
with a regular action, a reasonably strong pulse, and an accen-
tuated second pulmonic sound, and the extension of the
right border of dullness farther to the right in the fifth than
in the fourth space (thus making the cardio-hepatic angle
obtuse) prove that there is a Pericardial Effusion. The
peculiar characteristics of the double rubbing sound under
the manubrium and in the second spaces show that there is
also a Dry Pericarditis at the base. This is corroborative
evidence of pericardial effusion. The presence of cyanosis
and distress without edema and enlargement of the liver and
spleen also counts in favor of a pericardial effusion and against
a dilatation of the heart. The effusion developed immedi-
ately after an attack of rheumatism, and is, therefore, almost
certainly serous. The absence of marked irregularity in the
temperature and of chills and sweating is also in favor of a
serous fluid.
The double murmur at the apex shows that there is a lesion
at the Mitral orifice, certainly Insufficiency, probably
Stenosis, perhaps only roughening of the orifice. The
DISEASES OF THE HEART AND PERICARDIUM. 427
effusion into the pericardium makes it impossible to determine
the size of the heart. The accentuation of the second pul-
monic sound shows, however, that there must be hypertrophy
of the heart and that, if there are both dilatation and hyper-
trophy, the hypertrophy is in the ascendance. The history of
repeated attacks of rheumatism and of dyspnea and palpita-
tion before the present illness shows that the lesion is a chronic
one. The accentuation of the second pulmonic sound is
corroborative evidence. The strength of the pulse, the good
second sound and the regularity of the heart show that the
myocardium is but little, if at all, affected.
The area of dullness and bronchovesicular respiration in
the lower left back is due to compression of the lung by the
pericardial effusion. The rales^how a small amount of edema
of the lungs.
Prognosis. The prognosis in this instance, as always in
pericarditis with effusion, especially if associated with chronic
valvular lesions, is a very grave one. The most favorable
point here is the absence of myocardial involvement. There
is a reasonable chance, perhaps one in four, that he will sur-
vive the present acute condition. He will be left, however,
not only with a chronic valvular lesion, but also with an ad-
herent pericardium. He is also very liable to have more
attacks of rheumatism and further involvement of the heart.
If he survives the present attack, the chances are, therefore,
that he will live but a few years.
Treatment. The first thing to be decided is whether it is
advisable to tap the pericardium. The heart is standing up
to the increased work very well, as is shown by the regularity
of its action, the good pulse and the accentuation of the second
pulmonic sound ; there is almost no edema of the lungs and
no signs of passive congestion elsewhere. If he can be kept
under close observation, it will be wise to delay aspiration in
the hope that the effusion will diminish rather than increase.
If the heart weakens or signs of passive congestion appear, the
pericardium must be tapped at once. Blisters and the appli-
cation of other counterirritants to the precordia can do no
good, will make him uncomfortable and increase the chances
of septic infection. A light ice-bag, suspended over the pre-
428 CASE HISTORIES IN PEDIATRICS.
cordia so as not to cause pressure, may make him more com-
fortable and in some instances seems to favor the absorption
of the fluid. Tincture of digitalis, in doses of five drops every
four hours, will help the heart to meet the increased work
thrown on it by the pressure of the fluid in the pericardium.
This dose may be doubled or trebled, if necessary. He may
sit up or lie down, according to which is the more comfortable.
Fresh air will make his breathing easier. Oxygen may be
given, if necessary. There is no objection to morphine, in
doses of from one sixteenth to one eighth of a grain, if he is
very uncomfortable.
He must be fed often with small amounts of liquids and soft
solids, since swallowing is often very painful and chewing
tiresome.
DISEASES OF THE HEART AND PERICARDIUM. 429
CASE 131. Clarence G., eleven years old, was the child of
healthy parents. There was nothing in the family history to
suggest syphilis. There was no tuberculosis in the family and
he had had no known exposure to it. He was born at full
term after a normal labor and was normal at birth. He was
breast-fed and was very well as a baby. He had measles and
whooping-cough when five, diphtheria when six, scarlet fever
when seven, and chicken-pox when nine years old. He had a
short indefinite illness, associated with pains in the extremi-
ties, in January, 1907, which was called " grippe." His ab-
domen began to swell about the first of April, 1907. Some
months later he began to be short of breath and to have a
little swelling of the legs. The swelling of the abdomen and
the dyspnea did not change much, but the swelling of the
extremities often disappeared entirely for a time. His appe-
tite and digestion continued good. Recently he had been
unable to lie down with comfort, had had some cough and
more swelling of the legs. He had had no fever. He was seen
September 9, 1908.
Physical Examination. He was well developed and nour-
ished and of good color, but unable to lie down without much
discomfort. There was no edema of the face or chest, and no
enlargement of the superficial veins of the chest. There was
no tracheal tug and no diastolic collapse of the veins in the
neck. The tongue was clean, the throat normal. There was
no dullness under the manubrium. The cardiac impulse was
not visible and was only feebly palpable in the region of the
nipple. There was no systolic retraction either here or in the
back. The upper border of the relative cardiac dullness was
at the upper border of the third rib; the left, just outside the
left nipple (normal is 1 cm. inside); the right, 5 cm. to
the right of the median line (normal is 3 cm. to the right of
the median line). The cardio-hepatic angle was acute. The
action was regular. The first sound was a little short and
sounded a little distant. The second pulmonic sound was not
accentuated. There were no murmurs. There was dullness,
changing to flatness toward the base, on the left side below
the spine of the scapula behind, the fifth rib in the axilla and
the third rib in front. The respiration and voice sounds in
430 CASE HISTORIES IN PEDIATRICS.
this area were somewhat diminished in intensity, but not
changed in character. The vocal fremitus was somewhat
diminished. A few rales were heard. There was dullness over
the whole right back with a few fine, moist rales at the base.
The abdomen was much and symmetrically enlarged. There
was no enlargement of the superficial veins. There was
flatness in the flanks and hypogastrium, the upper border of
the flatness being concave when he lay on his back. The
area of flatness changed with change of position and there
was a definite fluid wave. No masses were felt. The upper
border of the liver flatness was at the upper border of the
fifth rib in the nipple line (normal is at the upper border of
the sixth rib); the lower border of the liver was palpable
II cm. below the costal border in the nipple line (not nor-
mally palpable). The spleen was not palpable. There was
some edema of the external genitals and legs. The pulse was
stronger in the left than in the right wrist, and was of the
paradoxical type. There was no enlargement of the peripheral
lymph nodes.
The urine was normal in color, acid in reaction and of a
specific gravity of 1,025. It showed a very slight trace of
albumin, but did not contain sugar. The sediment showed an
occasional hyaline and fine granular cast, a few free leucocytes
and many squamous cells.
Blood.
Hemoglobin,
80%
Red corpuscles,
5,600,000
White corpuscles,
6,700
Mononuclears,
22%
Polynuclear neutrophiles,
76%
Eosinophiles,
1%
Myelocytes,
1%
There was no variation in the size or shape of the red cells
and no stippling.
A skin tuberculin test was negative.
Diagnosis. The most reasonable explanation of this boy's
condition is as follows: The illness which was called " grippe "
was in all probability rheumatism. He developed a low-grade
pericarditis and mediastinitis which resulted in the oblitera-
DISEASES OF THE HEART AND PERICARDIUM. 431,
tion of the pericardial cavity and the formation of adhesions
between the pericardium and the mediastinal tissues. The
negative tuberculin test shows that this process was not
tubercular, as it sometimes is. The points in favor of this
assumption are the feeble cardiac impulse and the enlarge-
ment of the area of dullness in connection with normal heart
sounds, the paradoxical pulse and the difference in the strength
of the pulse in the two wrists. Many other signs, sometimes
present in this condition, are, it is true, lacking, but these
seem sufficient to justify the diagnosis.
The inflammatory process extended to the pleurae and
resulted in the formation of pleural adhesions and thickening,
which account for the signs in the backs. The pleural adhe-
sions interfere with expansion of the lungs, as does the pressure
of the distended abdomen and of the enlarged liver, and cause
a congestion at the bases, which accounts for the rales.
The chronic adhesive pericarditis produced a cirrhosis of
the liver. This type of cirrhosis is a peculiar one and due only
in part to passive congestion. It is not accompanied by the
signs of congestion in other organs. The first symptom of
this condition which is usually noticed is, as in this instance,
enlargement of the abdomen as the result of ascites. The
edema of the external genitals and legs is due to the pressure
of the fluid in the abdomen on the inferior vena cava, not to
passive congestion. The changes in the urine are presumably
largely due to passive congestion of the kidneys from the
pressure of the ascitic fluid on the renal veins and cava.
The final diagnosis is, therefore, Chronic Adhesive Peri-
carditis, with sequelae.
Prognosis. There is, of course, no cure for the lesions in
the pericardium, mediastinum, pleurae and liver. He will
probably live, however, for a number of years.
Treatment. Tapping the abdomen from time to time will
make him much more comfortable. Other treatment must
be symptomatic.
SECTION IX.
DISEASES OF THE LIVER.
CASE 132. Richard B. was weaned suddenly July I, when
about nine months old, because his mother was found to be
pregnant. He was very large at birth and had gained weight
very rapidly. He was not as active, either physically or
mentally, as most babies of his age. He was given a very
improper diet and after a few days began to vomit and have
loose, undigested movements. A careful physical examina-
tion, made by a physician who saw him July 11, showed the
edge of the liver 2 cm. below the costal border in the nipple
line. He was then cleaned out thoroughly and given only
water. He was kept on water some days, nutrient enemata
being given in addition. These were, however, not well re-
tained. After about ten days he was given cereal waters,
which he did not like and of which he took very little. He
continued to have from three to four loose, yellow movements
daily and, in consequence, he was given no milk until August
1 , when he was put on a mixture of one part of skimmed milk
and three parts of arrowroot water. He took about twenty-
four ounces of this mixture in twenty-four hours. His move-
ments had become a little firmer since the milk was begun.
He had been cleaned out thoroughly several times during the
last three weeks and had had his bowels irrigated once or twice
daily. He had been taking bismuth steadily, as well as three
drops of whiskey every three hours. His temperature had
varied from normal to ioo° F. He lay quietly most of the
time and seldom cried, although he occasionally whined.
The physician had noticed a hard swelling in the abdomen
about ten days before. It had steadily increased in size. He
was seen in consultation August 4.
Physical Examination. He was still a good-sized baby,
although he had evidently lost much weight. He was very
433
434 CASE HISTORIES IN PEDIATRICS.
pale and paid very little attention to anything that was done
to him. The anterior fontanelle was 3 cm. in diameter and
somewhat depressed. The bones of the skull did not overlap.
There was no rigidity of the neck. There was a venous hum
in the neck. The pupils were equal and reacted to light.
The tongue was slightly coated; the mouth and throat were
normal. He had six teeth. The heart and lungs were normal.
The upper border of the liver flatness in the nipple line was
at the upper border of the fifth rib. The edge of the liver
could be felt running across the abdomen just above the
right anterior superior spine to the left costal border in the
nipple line. The liver was hard, the surface smooth, the edge
slightly rounded. It was slightly tender. The spleen was
not palpable. The abdomen was otherwise normal. The
extremities were normal except for slight edema of the feet.
There was no spasm or paralysis. The knee-jerks were equal
and feeble. Kernig's sign was absent. There was a fine pur-
puric eruption on the abdomen and on the feet. There was
no enlargement of the peripheral lymph nodes. The rectal
temperature was 980 F.
The urine was pale, acid in reaction, and of a specific
gravity of 1,010. It contained neither albumin nor sugar.
Diagnosis. The most striking thing in the physical examina-
tion is the enlargement of the liver, which has developed in
less than three weeks. This enlargement has come on too
rapidly to be due to any form of cirrhosis ; it cannot be due to
passive congestion, because the heart and lungs are normal;
there is no cause for amyloid change; the enlargement is too
uniform for malignant disease. The only reasonable ex-
planation for the enlargement is fatty change. The cause of
this fatty change is not difficult to find. He has had practi-
cally no nourishment for more than three weeks, and must
also have had a certain amount of toxic absorption from the
intestines during this time. Disturbance of nutrition is one
of the most common causes of fatty change in the liver, and
intestinal toxemia in infancy almost always causes fatty
degeneration of the liver. The pathological condition in the
liver is undoubtedly a mixture of fatty infiltration and de-
generation, the infiltration being the more important. The
DISEASES OF THE LIVER. 435
hard, smooth surface ~and the slightly rounded edge are also
characteristic of the fatty liver. The diagnosis of " Fatty
Liver " is, therefore, justified.
The pallor and the venous hum in the neck are signs of
anemia, which is undoubtedly also due to the disturbance of
the nutrition from the lack of food. The purpuric eruption is,
likewise, merely a sign of disturbed nutrition.
Prognosis. The prognosis is a serious one. It is impossible
to determine at once whether or not the disturbance of
nutrition has progressed so far that recovery is impossible
when proper food is given. Time alone can settle this point.
Treatment. The only food which is likely to be utilized in
this instance is human milk. This should be obtained at
any cost. If he will not nurse or take it well from the bottle,
it must be given through a tube passed through the mouth.
If human milk cannot be obtained, a modified milk, low in
fat and high in sugar and proteids, will be the best substitute.
A mixture containing 1.00% of fat, 7.00% of sugar and 2.00%
of proteids is a suitable one. There are no drugs that will
help him. It is important, of course, to handle him as little
as possible, to keep him warm and to give him a large supply
of sunlight and fresh air.
436 CASE HISTORIES IN PEDIATRICS.
CASE 133. William H.'s father and mother were living and
well, as were three other children, one older and two younger
than the patient. There had been no deaths in the family,
but his mother had miscarried after her first child was born.
He had had no known exposure to tuberculosis. He was born
at full term and had always been well except for an attack of
bronchopneumonia when he was a month old, and measles
and mumps when he was three years old. His digestion
had always been good. No history of alcoholism could be
obtained.
He had been running down since the early spring, but was
still able to be up and about most of the time. He was often
drowsy and frequently complained of headache. He had been
more or less jaundiced since May. The skin was nearly clear
at times, but the eyes were always yellow. His appetite was
good and he did not vomit or complain of pain in the abdomen.
The bowels moved daily; the movements were rather light in
color, but never gray or white. The urine was often dark
colored and had recently stained his clothing yellow. He was
seen September 26, when six years old.
Physical Examination. He was well-developed and fairly
nourished. The skin, conjunctivae and mucous membranes
were distinctly yellow. His tongue was clean; his teeth in
fair condition. The throat was normal. The cardiac impulse
was palpable in the fourth space in the nipple line, 6 cm. to
the left of the median line. The upper border of the relative
cardiac dullness was at the upper border of the third rib, the
right border 2§ cm. to the right of the median line. The
action was regular. The first sound was of fair strength, but
was followed at the apex and pulmonic area by very faint
murmurs, which were not transmitted. The second pulmonic
sound was not accentuated. There was a venous hum in the
neck. The lungs were normal. The upper border of the liver
flatness was in the fifth space ; the lower border was palpable
4 cm. below the costal border in the nipple line. The edge was
somewhat rounded, the surface smooth. The gall bladder
was not palpable, no masses could be made out, and the liver
was not tender. The spleen was not palpable and was not
enlarged to percussion. The abdomen was moderately dis-
DISEASES OF THE LIVER. 437
tended and the superficial veins in the upper portion enlarged.
There was slight dullness in the flanks, but it did not change
with change of position, and there was no fluid wave. The
extremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and normal. There was no edema
of the extremities. There was no enlargement of the periph-
eral lymph nodes. There was no eruption and no scars of old
eruptions. There were no mucous patches or rhagades. The
rectal temperature was normal.
The urine was dark in color, acid in reaction, of a specific
gravity of 1,030, and contained the slightest possible trace
of albumin and much bile, but no sugar. The sediment
showed many small round cells, a few red blood corpuscles,
leucocytes and squamous cells, and an occasional hyaline and
fine granular cast.
The stools were loose, brownish and foul, and were shown by
chemical examination to contain bile pigment.
The leucocyte count was 9,900.
A skin tuberculin test was negative.
Diagnosis. Syphilis of the liver can be ruled out on the good
family history and the absence of all other signs of syphilis.
Less important points against syphilis of the liver are the
presence of jaundice and the absence of enlargement of the
spleen. Tuberculosis of the liver can be excluded on the nega-
tive tuberculin test. The facts that there are two murmurs,
that they are not transmitted, that the second pulmonic
sound is not increased, that the heart is not enlarged and that
there is a venous hum in the neck show that the murmurs in
the heart are anemic. The heart being otherwise normal,
cirrhosis of the liver secondary to chronic adhesive peri-
carditis can be eliminated. The presence of bile in the stools
rules out duodenal indigestion and obstruction of the large
bile ducts. Abscess of the liver can be excluded on the
absence of fever and the low white count. The marked jaun-
dice and the beginning ascites are also against it. The smooth
surface of the liver and the presence of jaundice without
obstruction of the large ducts makes a new growth extremely
improbable. The diagnosis is, therefore, by exclusion,
Cirrhosis of the Liver. The absence of enlargement of the
438 CASE HISTORIES IN PEDIATRICS.
spleen, which is one of the earliest signs of hypertrophic
cirrhosis, and without which this diagnosis is not justified,
makes cirrhosis of the atrophic variety, in the pre-atrophic
stage, the most probable diagnosis. There is nothing in the
history to account for the development of the cirrhosis, since
chronic alcoholism and disease of the gastro-enteric tract can
be excluded.
Prognosis. There is no chance for recovery. He will
probably not live many months.
Treatment. The treatment can be only symptomatic.
DISEASES OF THE LIVER. 439
CASE 134. Richard D. was seen in consultation when six
years old. His mother had had a cancer of the breast removed
eight years before. She was well for six years, when she had
a recurrence in the liver and glands, and died a year later.
He had always been well before the present illness.
He had not been up to mark since an attack of chicken-pox
several weeks before he was seen. There had, however, been
no definite symptoms. Enlargement of the abdomen and of
the superficial lymph nodes was first noticed a week before.
The abdomen had increased in size very rapidly during the
week. His appetite had fallen off, but there had been no
nausea, vomiting or pain in the abdomen. The bowels had
moved regularly; the movements were of good color and
looked perfectly digested. He had lost weight, strength and
color very rapidly during the week. The temperature had
been moderately elevated during the early part of the week,
but had been normal for three days.
Physical Examination. He was well developed and nour-
ished, but had evidently lost considerable weight and color.
There was no jaundice. The tongue was nearly clean; the
throat normal. The heart and lungs were normal. The
abdomen was much enlarged and there was distinct bulging
in the epigastrium. The superficial abdominal veins were
moderately enlarged. The upper border of the liver flatness
in front was at the lower border of the fifth rib; behind, in
the eighth space on the right and the ninth space on the left
side. The lower border of the liver reached to the right
anterior superior spine, ran across the abdomen midway
between the pubes and the navel and thence nearly to the
left anterior superior spine. The left border was concealed
by the greatly enlarged spleen, which filled up the left flank
and overlapped the liver. The surface of the liver was
markedly irregular. Several masses, the size of hens' eggs,
were easily felt, and there was one, the size of an orange, in
the epigastrium. The liver was slightly tender. There were
no evidences of fluid in the abdomen. The kidneys were not
palpable. There was no edema of the extremities, which were
normal. There was no spasm or paralysis. The knee-jerks
were equal and normal. Kernig's sign was absent. There
440 CASE HISTORIES IN PEDIATRICS.
were numerous lymph nodes, varying in size from that of a
bean to that of a walnut, in the neck, a few small ones in the
axillae, and several, the size of marbles, in the groins.
The urine was normal in color, acid in reaction, of a specific
gravity of 1,015 and contained neither albumin, sugar nor
bile. The sediment showed nothing abnormal.
Stained specimens of the blood showed slight achromia, but
no irregularity in the size or shape of the red corpuscles and
no nucleated forms. There were no plasmodia and no leu-
cocytosis. There were fifty-four polymorphonuclear neu-
trophiles to forty-six mononuclear cells.
Diagnosis. The diagnosis lies between malignant disease
of the liver and acute lymphatic leukemia in an aleukemic
stage. The points which suggest leukemia most strongly are
the enlargement of the spleen and of the peripheral lymph
nodes. It is true that in very rare instances there are times
in the course of acute leukemia in which the number of white
cells is not increased. In such instances, however, the pro-
portion of mononuclear cells remains much higher than in
this instance, in which the number of mononuclear cells is not
much above the normal limit. Primary malignant disease of
the liver is extremely rare, there being but thirty-nine cases
on record. The trouble in the liver in this instance is, there-
fore, almost certainly secondary. The usual location of the
primary lesion is in the suprarenal capsule. The enlargement
of the spleen and lymph nodes is, therefore, like that of the
liver, probably due to metastatic malignant involvement
rather than to leukemia. The diagnosis of secondary Malig-
nant Disease of the Liver is, therefore, justified. Sarcoma
of the suprarenal capsule is much more common than carci-
noma. The chances are, therefore, that the disease of the
liver in this instance is sarcoma. The fact that his mother
had a carcinoma is in all probability merely a coincidence.
Prognosis. The prognosis is, humanly speaking, abso-
lutely hopeless. He will probably not live but a few weeks.
Treatment. It will be well to try the mixed toxins of the
streptococcus of erysipelas and the bacillus prodigiosus,
recommended by Coley. Little or nothing can be hoped from
them, however, in this instance.
SECTION X.
DISEASES OF THE KIDNEYS AND BLADDER.
CASE 135. Walter B., fourteen years old, had had measles,
whooping cough, chicken-pox, influenza and tonsillitis, but
not scarlet fever, diphtheria or rheumatism. His urine had
been examined from time to time in the past, but had never
contained albumin. He had an acute attack of appendicitis
the latter part of December, 1909, which required operation
and drainage. He had been below par for some time before
this operation and had not been well since then, although he
had had no very definite symptoms. He was easily tired, did
not feel able to go to school and did not care to play. His
appetite and digestion were good. He had no cough or fever.
His chief complaint was of pain in the left iliac fossa, which
was not dependent on either food or exertion. Micturition
was at times a little painful, but was not increased in fre-
quency. He thought that he did not pass any more urine than
normal, and did not have to get up at night. He had always
been thin and had lost some weight since the operation. He
was seen at 2 p.m., May 27, 1910.
Physical Examination. He was thin and rather flabby,
but not pale. He looked pulled down and was very nervous.
His tongue was clean. His heart was normal except that at
times the rhythm was a little irregular. The lungs were
normal. The liver and spleen were not palpable. The ab-
domen was sunken and showed nothing whatever abnormal
except the scar of the operation. The kidneys were not
palpable. The genitals were normal. The extremities were
normal. There was no spasm or paralysis; the knee-jerks
were equal and normal. There was no edema and no
enlargement of the peripheral lymph nodes.
The freshly passed urine was normal in color, clear, alka-
line in reaction, of a specific gravity of 1,025, and showed a
trace of albumin with nitric acid. The centrifugalized sedi-
441
442 CASE HISTORIES IN PEDIATRICS.
ment showed a few small, round cells and no bacteria. The
gravity sediment showed neither cells, casts nor blood.
Diagnosis. It is evident, in the first place, that the pain
in the abdomen has no connection with the albumin in the
urine. It is almost certainly due to adhesions formed at the
time of the appendicitis. A bacterial infection of the urinary
tract can be excluded on the absence of bacteria and pus
corpuscles in the urine. The other possibilities are chronic
nephritis and orthostatic albuminuria. His age and the fact
that he does not get up at night to pass water are much against
chronic interstitial nephritis. He has not had scarlet fever
or diphtheria, the usual precursors of chronic parenchymatous
nephritis at this age, and has never at any time had any
symptoms of acute nephritis. The absence of all organic
elements in the sediment, moreover, while possible in chronic
interstitial nephritis, is very unusual; it practically excludes
chronic parenchymatous nephritis. The high specific gravity
is against chronic interstitial nephritis; the small amount of
urine against chronic parenchymatous nephritis. The normal
condition of the urine at various examinations in the past is
also very much against the existence of any form of chronic
nephritis. His age and slight build are in favor of orthostatic
albuminuria. So also is the impaired muscular tone resulting
from his enfeebled condition after the operation, which pre-
disposes him to lordosis, the probable cause of orthostatic
albuminuria. Although the diagnosis of orthostatic albumi-
nuria seems reasonably certain, it will be wise to examine the
urine further in order to settle the diagnosis. The albumin in
orthostatic albuminuria is present only in the urine excreted
when the patient is in the upright position. It is usually
constantly present in interstitial nephritis or, if not, there is
no regularity about its appearance. More urine is passed
during the day than during the night in orthostatic albumi-
nuria, while the reverse is the case in chronic interstitial
nephritis. The total amount of the urine is unchanged in
orthostatic albuminuria, while it is increased in interstitial
nephritis.
The twenty-four-hour amount of urine was thirty-one
ounces. Twelve ounces were passed during the night and
DISEASES OF THE KIDNEYS AND BLADDER. 443
nineteen ounces during the day. The urine passed on getting
up in the morning was pale, clear, acid in reaction, of a specific
gravity of 1,030, and showed no albumin by either the heat
or nitric acid tests. That passed during the morning was pale,
clear, acid in reaction, of a specific gravity of 1 ,032 and showed
a trace of albumin by the nitric acid test. That passed dur-
ing the afternoon was pale, clear, acid in reaction, of a specific
gravity of 1,030, and showed a slight trace of albumin by
the nitric acid test. No cells or casts were found in the
gravity sediment of any of the specimens. The diagnosis of
Orthostatic Albuminuria is thus confirmed.
Prognosis. The prognosis of this condition is good. It
probably never leads to chronic nephritis. The duration is
indefinite. It will probably persist in this instance until he
gets back into good physical condition and grows heavier and
more muscular.
Treatment. There is no specific treatment. The treat-
ment consists in regulation of his life with the object of getting
him into good general condition as soon as possible. It is
not necessary to diminish the proteids in his diet. It will,
however, be advisable for him to lie down for a time daily.
444 CASE HISTORIES IN PEDIATRICS.
CASE 136. Harry D., eleven years old, had had frequent
attacks of recurrent vomiting since he was a baby. He had
had an attack of infantile paralysis, involving both legs and
one arm, two months before. Nausea and vomiting began
November 2 1 and continued in spite of several doses of calo-
mel, which resulted in a number of large, well-digested move-
ments. He had taken and retained very little nourishment,
and had, in consequence, lost considerable weight and strength.
He had had no fever. The urine passed during the day of the
26th was clear but small in amount. That night he had con-
siderable pain in the abdomen, especially on the left side.
It was not very severe and not paroxysmal. It did not run
down into the penis, and micturition was not frequent or
painful. The urine passed during the night was not dimin-
ished in amount but was distinctly bloody. He was rather
lame the morning of the 27th, but had no pain. The urine
continued to be bloody. His bowels moved well, but he
continued to vomit. His mouth temperature rose to 1010 F.
He was seen in consultation at noon, November 27.
Physical Examination. He was fairly developed and nour-
ished and a little pale. His tongue was dry and covered with a
thin, brown coat. The cardiac area was normal, the sounds
fairly strong, the action regular, the rate 120. The lungs were
normal. The liver and spleen were not palpable or enlarged
to percussion. The abdomen was much sunken. There was
slight tenderness on deep pressure in the left flank, but no
muscular spasm, dullness or tumor. The kidneys were not
palpable and there was no tenderness over the ureters. The
genitals were normal. The extremities were not examined.
The urine was red, strongly acid in reaction, of a specific
gravity of 1,020 and contained a trace of albumin, consider-
able acetone and a little diacetic acid, but no sugar. The
sediment was very abundant and was almost entirely com-
posed of acid sodium urate crystals. It also contained a
moderate number of normal red blood corpuscles and an
occasional leucocyte, but no other cells or casts.
Diagnosis. He undoubtedly has one of his ordinary attacks
of recurrent vomiting. The disturbance of metabolism at the
bottom of the attack, the insufficient supply of food, or both
DISEASES OF THE KIDNEYS AND BLADDER. 445
together, explain the presence of acetone and diacetic acid
in the urine. The pain in the abdomen and the hematuria
require further explanation. The condition is an acute one,
and the examination of the kidneys shows nothing abnormal.
It is unnecessary, therefore, to consider such conditions as
sarcoma or tuberculosis of the kidney. Acute nephritis is
seldom accompanied by pain. It can be excluded on the
absence of cells and casts. The most probable explanation
would, at first thought, seem to be a renal calculus. The
pain was, however, not localized or paroxysmal and did not
run down into the penis. Micturition was not painful or
increased in frequency. These facts do not, of course, rule
out a renal calculus, but make it less probable than at first
appeared. A large number of sharp crystals in the urine
might easily irritate the kidney sufficiently to cause the sort
of pain present in this instance and hematuria. It is hard to
conceive of anything sharper than the crystals of acid sodium
urate which were so numerous in this boy's urine. Irritation
of the kidneys and urinary tract from crystals of acid sodium
urate is, therefore, the most reasonable explanation of the
Hematuria. The disturbance of metabolism at the root of
the recurrent vomiting, together with that due to an insuffi-
cient supply of food, and the concentration of the urine resulting
from an insufficient supply of water, account satisfactorily for
the formation of the acid sodium urate crystals.
Prognosis. The prognosis is good. The attack of recur-
rent vomiting will yield quickly to treatment. The hematuria
will cease with relief of the attack of vomiting, and probably
sooner if more water can be introduced into the system.
Treatment. See Case 27 for the treatment of recurrent
vomiting. The indications for the treatment of the hematuria
are to increase the amount of the urine and diminish its
acidity. These can best be met by high injections of from
eight to twelve ounces of a solution of one teaspoonful of
bicarbonate of soda 'in eight ounces of water every four
hours. The same solution may be given by mouth, in tea-
spoonful or tablespoonful doses, every fifteen or twenty min-
utes. Fortunately, this method of treatment is also the one
most useful in recurrent vomiting.
446 CASE HISTORIES IN PEDIATRICS.
CASE 137. Frances S., two and one-half years old, was the
child of healthy parents. Three other children were living
and well; none had died, but there had been two miscarriages.
There was no history of tuberculosis in the family and there
had been no known exposure to it.
She had always been well and strong. She had a cough for
a few days about the 10th of August. Her parents noticed
at this time that her eyelids were a little swollen in the morn-
ing. Not much was thought of it, however, as the swelling
was gone by noon. It became more marked about a week
later and had persisted. Swelling of the legs and abdomen
also appeared in a few days and had steadily increased. It
was noticed at this time that she was not passing as much
urine as usual. She was put on an exclusively milk diet, which
she took well. Her bowels had been kept well open by
cathartics. She was admitted to the Children's Hospital,
September 7.
Physical Examination. She was markedly pale, but did
not appear very sick. There was marked general anasarca.
Her eyelids were so much swollen that it was difficult to see
her eyeballs. The pupils were equal and reacted to light.
Her tongue was considerably coated. Her teeth were in bad
condition and there was a slight pyorrhea alveolaris. The
tonsils were ragged and injected. There was a venous hum
in the neck. The cardiac impulse was neither visible nor
palpable, probably because of the anasarca. The upper
border of the relative cardiac dullness was in the second space,
the right border 2\ cm. to the right, and the left border 5 cm.
to the left of the median line. The first sound was of good
strength and was followed at the mitral area by a soft murmur,
which was not transmitted. The second pulmonic sound was
not accentuated. There was slight dullness, with diminished
vesicular respiration and numerous fine, moist rales, below
the sixth rib and extending outward to the mid-axillary line
on both sides. The upper border of the liver flatness was in
the fifth space in the nipple line ; the edge was not palpable.
The spleen was not palpable. The abdomen was much and
symmetrically distended. The superficial veins were not
enlarged. The percussion note was flat over the whole ab-
DISEASES OF THE KIDNEYS AND BLADDER.
447
domen except in the epigastrium, where it was tympanitic.
The upper border of the fiat area was concave. The area of
flatness changed with change of position, and there was a
fluid wave. There was no spasm or paralysis of the extremi-
ties. The knee-jerks were equal and normal. There was no
enlargement of the peripheral lymph nodes. There was no
eruption or desquamation. The rectal temperature was
ioo° F., the pulse no, the respiration 30.
Four ounces of urine were passed in the first twenty-four
hours of her stay in the hospital. It was brownish in color,
turbid, acid, of a specific gravity of 1,030 and contained
twenty grams of albumin per liter, but no sugar or acetone.
The sediment showed large numbers of hyaline, fine and
coarse granular casts, and a few blood casts, as well as large
numbers of red and white blood cells.
Diagnosis. She undoubtedly has Acute Nephritis. The
normal size of the heart and the absence of accentuation of
the second aortic sound prove that there is no chronic trouble
back of it. The etiology is obscure. The ragged, injected
tonsils or the diseased teeth and gums may have been the
portal of entry for the infection. The venous hum in the neck
and the murmur in the heart are anemic in origin and
unimportant.
Prognosis. The prognosis is grave. She is passing but little
urine and has general anasarca, ascites and edema of the
lungs. A more definite prognosis can be given in a few days
after it has been seen how well she responds to treatment.
If she responds quickly, she will probably recover entirely in
time. If she does not respond, she will probably not live
many days.
Treatment. Her kidneys are congested and engorged with
blood, the glomeruli and tubules are blocked and the epithe-
lium degenerated. They are able to excrete but little and are
practically impervious to water. If they were not, she would
not be edematous. Water must, therefore, be stopped en-
tirely for the present. It ought not to be given again until the
kidneys have begun to excrete fairly freely and the edema and
ascites are diminishing.
Her kidneys should be spared the work of excretion as
448 CASE HISTORIES IN PEDIATRICS.
much as possible. The products of the metabolism of certain
foods are excreted with difficulty, and those of others easily.
Those substances which are excreted with the most difficulty
are urea, creatinin and phosphoric acid. Urea is derived
from proteids: meat, eggs and milk. It would seem wise,
then, to cut out all proteids from her diet. Nothing is gained,
however, by reducing them below a certain point, because,
even in starvation, a certain amount of urea is formed as the
result of. the destruction of the body tissues. If enough pro-
teid is given to cover this nitrogenous waste, the body tissues
are saved and the kidneys are not worked any harder than
when no proteid is given. The amount of proteid required to
balance the necessary nitrogenous metabolism of the body is
known as the minimum proteid need, and is, in a child of this
age, about twenty grams. Creatinin is derived from creatin.
This is contained in meat and especially in meat extracts and
meat broths. Meat extracts and broths contain little else and
have but little nutritive value. They should, therefore, be
entirely excluded from her diet. Milk contains but little
creatinin. Phosphoric acid is present in large amounts in
meats, yolk of egg, milk and many vegetables. The addition
of calcium carbonate to the food, however, prevents its
passage through the kidneys and causes it to be excreted by
the intestines. The products of the metabolism of fat, sugars
and starches are excreted by the kidneys without much
difficulty.
It is not only necessary, however, to cover her proteid need,
but also to cover her caloric needs. These are a little under
1 ,000 calories. She can get along very well for a time, how-
ever, on 800 or 900 calories.
The problem is, then, to lay out a diet for her which will
contain 800 or 900 calories and about 20 grams of proteid.
The best form in which to give the proteid is milk. Six hun-
dred cubic centimeters of milk will give 21 grams of proteid,
but only about 400 calories. If milk enough is given to fur-
nish 900 calories it will contain 47 grams of proteid, which is
more than double the minimum proteid need. The disad-
vantages of an exclusively milk diet are thus evident. If
200 ccm. of gravity cream (16% fat) is substituted for 200
DISEASES OF THE KIDNEYS AND BLADDER.
449
ccm. of milk, the mixture will provide 600 calories. The
remainder of the caloric need can be met by giving sugar and
starch. For example, as is shown in the following table of
food values, two tablespoonfuls of cereal will give 50 cal-
ories, two teaspoonfuls of sugar 50 calories, one slice of bread
75 calories, and a piece of butter one inch square and one-
half inch thick, about 65 calories, making a total of 840 cal-
ories, which covers fairly satisfactorily her caloric needs, and
does not add much to the proteids.
Table of Food Values.
Whole milk, 1 quart,
Skim milk, I quart,
Gravity cream, 1 pint,
Buttermilk, I quart,
Whey, 1 quart,
Beef juice, 1 ounce,
Crackers, 1 ounce,1
Bread, 1 slice,3
Zwiebach, 1 slice,4
Shredded wheat biscuit,
Oatmeal and other cereals (cooked), 1 tablespoonful,
Rice (cooked), I tablespoonful,
Potato, size of large egg,
Macaroni (cooked), I tablespoonful,
( Whole,
Egg ] Yolk,
( White,
Fish \ (co°ked), I ounce,2
Butter, ij inches cube = 1 ounce,
Olive oil, I tablespoonful,
Sugar I Cane, 1 rounded teaspoonful,
\ Milk, I rounded tablespoonful,
Green peas (cooked), 1 tablespoonful,
Carrots )
Squash > (cooked), I tablespoonful,
Turnip )
Orange, medium sized,
Apple, medium sized,
1 Crackers vary so much in size that they must be weighed to determine how many it takes to
weigh an ounce.
2 The lean of a lamb chop weighs about an ounce; so does a piece of meat about 1} inches cube.
3 Bread, one slice = four inches square and three-eighths inch thick = i ounce.
* Zwiebach, one slice = large slice.
Clear soups and broths made without rice or barley have practically no nutritive value.
The nutritive value of the " fodder " vegetables, such as spinach, string beans, asparagus, lettuce,
tomatoes and cucumbers, is so slight that it may be disregarded.
The addition of 30 grains of prepared chalk to the milk and
cream mixture will probably render the phosphoric acid prac-
tically inert. The chief objection to the milk in this instance
ilories.
Grams.
F. C.
p.
670
38
43
34
4OO
860
360
260
IO
77
5
5
43
22
43
43
35
14
35
9
IO
2
120
3
20
3
75
0.5
15
3
120
3
20
3
105
0.5
22
3
25
5-5
1
45
10
1
100
20
2
30
0.5
5
1
72
60
5
5
7
4
12
3
60
225
3
24
7
125
25
60
14
6
15
40
7
3
30
6
1
50
13
70
17
450 CASE HISTORIES IN PEDIATRICS.
is the water which it contains, a little more than a pint. In
her present condition even this amount of water may do harm.
It will be wise, therefore, to disregard her proteid needs for
twenty-four or forty-eight hours and give her nothing but
carbohydrates and fat. In fact, it will do her no harm if she
takes no nourishment at all for twenty-four or forty-eight
hours.
There are no drugs which can directly aid her kidneys to do
their work. Digitalis and drugs of its class have no direct
action on the kidneys, but increase the flow of urine by
strengthening the action of the heart and thus sending more
blood through the kidneys. Her kidneys are already engorged
with blood. It is, therefore, not only irrational to increase
the flow of blood to her kidneys, but also very likely to in-
crease the trouble. Caffein, theobromin and their prepara-
tions have a direct stimulant action on the renal epithelium.
Her renal epithelium is in no condition to respond to stimula-
tion and, moreover, stimulation may do harm by increasing
the inflammation. The action of alkalies is probably the
same as that of other diffusible bodies which are excreted by
the kidneys and which during their excretion increase the
flow of urine. As the object of the treatment is to spare the
kidneys, it hardly seems rational to give alkalies at this time
to increase the work which they have to do. All drug treat-
ment is, therefore, contra-indicated.
It is possible, however, to spare the kidneys by making the
bowels do part of their work. She must, therefore, be made
to have three or four large, watery movements of the bowels
daily. Compound jalap powder, in doses of fifteen grains, or
compound licorice powder, in doses of from one to two tea-
spoonfuls, will probably do this best in this instance, as she
will probably not object to them as she would to concentrated
solutions of Epsom salts, the ideal cathartic in this condition.
The free catharsis will also help to diminish the edema.
It is important to get rid of the edema. The best way to
accomplish this is by free diaphoresis. This spares the kid-
neys by getting the water out of the system, but does not save
them in other ways, because it is certain that but little urea
is eliminated in this way, and there is no proof that toxic i
DISEASES OF THE KIDNEYS AND BLADDER.
451
substances are excreted by the skin. Pilocarpin is the only
diaphoretic drug powerful enough to be of any practical
utility. It is, however, a very dangerous drug on account of
its liability to cause edema of the lungs, and should never be
used except in an emergency. Her condition is not serious
enough to justify its use. The application of heat externally
is far safer and usually more effectual. It is very difficult to
keep a child in a hot-air bath long enough to get good results,
as they soon become restless and kick the coverings loose.
They object much less to hot packs. She should be wrapped
in a blanket and put in a tub of water between 1050 F. and
1100 F. and kept there from ten to fifteen minutes. She
should then be taken out, wrapped in a hot, dry blanket and
kept surrounded by heaters for from one-half to two hours.
This should be repeated daily as long as there is much edema.
452 CASE HISTORIES IN PEDIATRICS.
CASE 138. Nora C, aged thirteen months, lived in a town
in which malaria was common. She was breast-fed for five
months. She was then weaned gradually and put ona" hit-
or-miss " mixture of top milk with Mellin's Food, on which
she did very well. Early in August, about three weeks before
she was seen, she began to be feverish and was given calomel.
The next day she was better, but two days later she had a
chill. She had had no chills since then, but had sweat pro-
fusely at times and had lost much weight. Her temperature
had not been normal but once in the last two weeks, and had
been very irregular. The food had been changed to a weak
top milk and barley water mixture. She had not vomited,
but had been constipated. The movements, however, were
normal in character. The Widal reaction, tested three days
before, was negative. The diagnosis of malaria having been
made, on the basis of the irregular temperature, the chill, the
sweating and the negative Widal test, she had been given
quinine in considerable doses during the last six days without,
however, any improvement in the symptoms.
Physical Examination. She was well developed and nour-
ished, but a little pale and flabby. The anterior fontanelle
was 3 cm. in diameter and level. She was irritable, but not
stupid. Her mouth and throat showed nothing abnormal.
She had eight teeth. There was no rosary. The heart, lungs
and abdomen showed nothing abnormal. The liver was
palpable 2 cm. below the costal border in the nipple line.
The spleen was not palpable. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. There was no enlargement of the peripheral
lymph nodes.
The blood showed 80% of hemoglobin, and 37,600 white
corpuscles.
Diagnosis. The negative Widal test and the leucocytosis
rule out typhoid fever. The absence of enlargement of the
spleen and the leucocytosis, as well as the failure of the quinine
to influence the symptoms, exclude malaria. The fever, chills,
sweating and leucocytosis point to a purulent process some-
where. There is nothing about the symptomatology to sug-
gest the location of this process. In such instances the middle
DISEASES OF THE KIDNEYS AND BLADDER. 453
ear and the urine must always be investigated, since in infancy
both otitis media and pyelitis often cause marked general,
without any local, symptoms. If the trouble is not found in
one, it is almost certain to be found in the other. If both are
normal, the trouble is most often tubercular.
The ears were examined and found normal.
The fresh urine was cloudy, pale, neutral in reaction and
contained a very slight trace of albumin. The sediment ob-
tained by centrifugalization showed very many pus cells,
free and in clumps, a few small round, squamous, oval and
caudate cells, and many motile bacteria. These bacteria
were later shown to be colon bacilli.
The diagnosis is, therefore, Pyelitis, or, better, infection
of the urinary tract by the bacillus coli.
Prognosis. There is practically no danger as to life. She
will probably recover in a few weeks, but there is a reasonable
probability that the condition will persist, with intermissions,
for many months. In some instances the urine continues to
contain bacteria, and at times pus, for years, although there
is no constitutional disturbance. There is very little danger
that the process will extend to the kidney tissue or that it
will involve anything more than the superficial layers of the
pelvis and bladder.
Treatment. Local treatment of the bladder is of compara-
tively little value because the infection is not localized in
the bladder but involves the whole urinary tract. It is better,
therefore, not tause it in this instance. Hexamethylenamin,
the best drug of its class, liberates formaldehyde readily in the
urine and has a strong antiseptic action. Unfortunately the
colon bacillus is comparatively insusceptible to its action.
Hexamethylenamin is usually less effective than the alkalies,
which, in spite of the fact that the colon bacillus grows more
luxuriantly in alkaline than in acid media, are often very
useful. It will be well, therefore, to give her ten grains of the
citrate of potash, well diluted, three times a day. If this dose
is not sufficient to make the urine highly alkaline, larger doses
must be given. If the urine does not clear up under this treat-
ment, hexamethylenamin, in doses of from one-half grain to
one grain, three times a day, should be tried. If the trouble
454
CASE HISTORIES IN PEDIATRICS.
still persists, it will be well to try the effect of suddenly chang-
ing the reaction of the urine every three of four days, which
sometimes clears up the urine very quickly. It can be made
alkaline with the citrate of potash and acid with benzoic acid,
in doses of from one to three grains, three times a day.
If the trouble still continues, the vaccine treatment may be
tried, but too much must not be hoped from it. In some in-
stances it works very well ; in others it has no effect whatever.
An autogenous vaccine must be used. It will be well to begin
with 25,000,000 every three or four days, increasing the dose
rather rapidly to 100,000,000. The treatment can be carried
on satisfactorily without determinations of the opsonic index.
DISEASES OF THE KIDNEYS AND BLADDER. 455
CASE 139. Mary W., aged seven months, was taken sud-
denly sick with high fever the night of July 7. No cause for
the fever could be made out. The temperature ran between
1030 F. and 1050 F. up to the time she was seen in consulta-
tion, July 14. The physical examination had always been
negative. She had had a slight cough in the beginning. She
had taken her food poorly, but had vomited but once. The
bowels had moved regularly and the movements had been
normal. She had always been conscious, but during the last
two days had seemed tender all over and had held her head
backward. During the last two or three days micturition had
been painful but not increased in frequency, and the urine
had left greenish-yellow spots on the diapers.
Physical Examination. She was well developed and nour-
ished, but had evidently lost some weight and color. She was
conscious, but irritable. The anterior fontanelle was 3 cm.
in diameter and depressed. There was no rigidity or tender-
ness of the neck and no neck sign. The pupils were equal and
reacted to light. The ear-drums were normal. The tongue
was dry, the throat and gums normal. There were four teeth.
The heart, lungs and abdomen were normal. The liver was
just palpable in the nipple line. The spleen and kidneys were
not palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's sign was absent and there was no contralateral
reflex. There was no enlargement of the peripheral lymph
nodes. The rectal temperature was 103.60 F., the pulse 160,
the respiration 40.
A stool which was seen was loose, smooth, yellow and
contained no curds or mucus. There were several small
spots, looking like pus, on the diaper.
Diagnosis. The most probable diseases in this instance are
pneumonia, cerebrospinal meningitis and pyelitis. The
sudden onset, the continued high fever and the slight cough
suggest pneumonia, but the absence of physical signs after a
week and the fact that the rate of the respiration is not in-
creased out of proportion to that of the pulse make it ex-
tremely improbable. Meningitis is suggested by the history
of general tenderness and of the tendency to hold the head
456 CASE HISTORIES IN PEDIATRICS.
backward. It can be ruled out at once, however, on the de-
pressed fontanelle and the absence of all signs of meningeal
irritation or increased cerebral pressure. A lumbar puncture
was done, however, at the request of the attending physician.
The fluid ran out slowly, drop by drop, was perfectly clear,
did not form a fibrin clot and contained no cells or bacteria
(for description of the cerebrospinal fluid in health and
disease see Case 72), thus proving that the trouble was not
meningitis.
The continued high fever without physical signs and with
normal ears suggests at once the possibility of pyelitis. The
painful micturition and the greenish-yellow spots on the
diapers make this diagnosis almost certain. The urine was,
therefore, obtained with a catheter. It was pale, turbid, acid
in reaction and contained many pus cells and motile bacteria,
which were later proved to be colon bacilli. The results of
this examination confirm, of course, the diagnosis of
Pyelitis.
Prognosis. See Case 138.
Treatment. See Case 138.
DISEASES OF THE KIDNEYS AND BLADDER. 457
CASE 140. Catherine R. was the fourth child of healthy
parents. There had been no deaths or miscarriages. She had
not, as far as known, been exposed to tuberculosis.
She was born at full term after a normal labor and was
normal at birth. She was breast-fed, but was given in addi-
tion bread, potatoes and, in fact, a taste of almost everything
on the table. Her digestion was good in spite of her faulty
diet, and she gained steadily in weight up to an attack of
bronchitis, when she was nine months old. She did not seem
as well after the bronchitis and ceased to gain, although her
appetite and digestion continued good. Enlargement of the
abdomen was noticed when she was nine and a half months
old, and had increased rapidly since then. The abdomen had
not been tender and the urine had never been red. She was
seen in consultation when ten months old.
Physical Examination. She was fairly developed and nour-
ished. Her skin was pale, but her lips were red. The anterior
fontanelle was 2 cm. in diameter and level. She had four
teeth. Her tongue was clean and her throat normal. There
was no rosary. Her heart and lungs were normal. The liver
was palpable 3 cm. below the costal border in the nipple line.
The spleen was not palpable. The left half of the abdomen
was nearly filled by a hard, smooth, rounded mass. It had
no definite borders, was flat on percussion and not at all
tender. It filled the flank and evidently originated deep in
the abdomen. It was not movable and its position was not
influenced by the respiration. The abdomen showed nothing
else abnormal. The extremities were normal and there was
no edema. There was no spasm or paralysis; the knee-jerks
were equal and normal; Kernig's sign was absent. There
was no enlargement of the peripheral lymph nodes. The
mass could be felt on rectal examination.
Stained smears of the blood showed no changes in the red
corpuscles and no leucocytosis. A large majority of the
white corpuscles were lymphocytes, although there was a
slight excess of eosinophiles.
Diagnosis. The location of the mass deep down in the
flank and its rounded character, without definite borders,
prove that it is not a tumor of the spleen. The tumors in
458 CASE HISTORIES IN PEDIATRICS.
caseous or fibrocaseous tubercular peritonitis are not as large,
are irregular in outline and usually multiple. Enlargement
of the retroperitoneal lymph nodes might cause a tumor in
this region, but it would not be as large and would be irregular
in outline. The only organ whose enlargement would cause
a tumor in this location is the left kidney. This tumor must,
therefore, be the left kidney. The possible causes of enlarge-
ment of the kidney are hydronephrosis, pyonephrosis and
sarcoma. Hydronephrosis is extremely rare at this age, she
has had no attacks of pain and there is no fluctuation. Pyo-
nephrosis is also extremely uncommon at this age, there is
nothing in her history to suggest an infection of the urinary
tract, she has no fever or leucocytosis, her general condition
is good and there is no fluctuation. Sarcoma of the kidney is
more common at this age than at any other, it develops
insidiously without much disturbance of the nutrition, and
the tumor in this instance corresponds in its physical char-
acteristics to those of sarcoma of the kidney. The eosino-
philia is also suggestive of a new growth. The absence of
hematuria does not count against sarcoma, because it occurs
in but a small proportion of the cases. The diagnosis of
Sarcoma of the Kidney is, therefore, justified.
Prognosis. The prognosis without operation is absolutely
hopeless. She will probably not live more than three or four
months. It is not much better with operation. The opera-
tion is a serious one and often fatal. Recurrence takes place
in the neighboring tissues in the large majority of those that
survive the operation. A few recover.
Treatment. The only treatment is the immediate removal
of the tumor.
DISEASES OF THE KIDNEYS AND BLADDER. 459
CASE 141. Frank N. was the only child of healthy
parents. He had had much trouble with his digestion be-
tween his fourth and ninth years and had always been subject
to bronchitis. He had measles at two years and broke his
arm when five years old. When ten and one-half years old
he had pneumonia, followed by empyema. The sinus did
not close for six months. He was very much pulled down by
this illness and did not regain his strength until six months
later. Puffmess of the eyelids had been noticed from time
to time ever since the closing of the sinus, but no attention
was paid to it until six months later, when swelling of the feet
also appeared. At this time he was often unable to put on
his shoes in the morning and hardly able to open his eyes
during the early part of the day. His physician, who was
then called, found that he was passing about one quart of
urine daily, which was acid in reaction, of a specific gravity of
1016 and contained one-eighth per cent of albumin. The
sediment was not examined. He cut meat and eggs out of
the boy's diet and advised the ingestion of large amounts of
water. Under this treatment the edema diminished, but the
urine continued to contain albumin. During this time he had
no headache, dizziness, nausea or vomiting and appeared well
except for the edema of the eyelids. The swelling of the feet
had returned about a month before he was seen, when twelve
years old, but had disappeared again during the last week,
which he had spent in bed on account of an attack of acute
bronchitis.
Physical Examination. He was fairly developed and
nourished and very pale. His face was generally puffy and
the eyelids were so much swollen that it was difficult for him
to open them wide enough to see. The tongue was moist and
considerably coated. The throat was normal. The cardiac
impulse was in the fifth space, nine cm. to the left of the
median line. The left border of dullness corresponded with
the impulse. The right border was three cm. to the right of
the median line and the upper border at the third rib. The
action was regular, the sounds were strong and there were no
murmurs. The second sounds at the pulmonic and aortic
areas were of the same intensity. There was a venous hum
46O CASE HISTORIES IN PEDIATRICS.
in the neck. The tension in the radial arteries was not per-
ceptibly increased. The scar of the old operation for empy-
ema was in the lower right axilla. The lungs were normal,
except that there were many sibilant and sonorous rales on
both sides, both in front and behind. The upper border of
the liver flatness was at the upper border of the sixth rib in
the nipple line; the lower border was not palpable. The
spleen was not palpable. There was slight dullness in the
flanks, which did not change with change of position. There
was no fluid wave. The abdomen was otherwise normal.
There was no edema of the extremities or of the external
genitals. There was no enlargement of the peripheral lymph
nodes.
The twenty-four hours amount of urine was thirty-four
ounces. It was of normal color, acid in reaction, of a specific
gravity of 1016 and contained at least two per cent of albumin.
The centrifugalized sediment contained very many casts,
hyaline, fine granular, coarse granular, epithelial, fatty and
waxy. It also contained a moderate number of leucocytes
and small round cells, a few normal and abnormal red blood
corpuscles, an occasional compound granule cell and much
free fat.
Diagnosis. The Bronchitis is merely an incidental com-
plication. The examination of the urine shows that he has
nephritis. The duration of the edema, the enlargement of
the heart and the increase in the intensity of the second sound
at the aortic area show that it is chronic. The appearance of
the symptoms coincident with the long-continued discharge
of pus from the chest suggests that amyloid disease of the
kidneys is the cause of the trouble. The absence of enlarge-
ment of the liver and spleen and the large amount of albumin
and fat in the urine show, however, that this is not the case.
The age of the child, the edema, the absence of an increase
in the amount of urine, the large amount of albumin and the
character of the sediment rule out chronic interstitial ne-
phritis. The diagnosis is, therefore, by exclusion, Chronic
Parenchymatous Nephritis. The history, the absence of
an increase in the amount of urine, the large amount of
albumin and the presence of waxy casts and fat in the sedi-
DISEASES OF THE KIDNEYS AND BLADDER. 461
ment are, moreover, characteristic of this condition. The
red blood corpuscles in the sediment show that there is also
an acute exacerbation of the process.
Prognosis. The prognosis is hopeless. He will almost
certainly not live more than a year, probably not but a few
months.
Treatment. The principles of the treatment of acute
nephritis are described in Case 137. This being a hopeless
condition, it will not be necessary to limit his diet as closely
as in the acute form. There is no objection to giving him a
part of his proteids in the form of meat and eggs, although it
will be wise to exclude broths. There is not sufficient edema
to call for the application of heat externally, but it will be
well to keep his bowels freely open. It is not advisable, in
spite of the edema, to cut down his liquids enough to make
him uncomfortable. They should be limited, however, to
this extent. He ought to stay in bed until over the bronchi-
tis. There is no reason why he should not then be up and
about, but he should avoid exposure and fatigue. That is,
his life and treatment should be regulated so as to make him
live as long as possible, but his routine should not be so
rigorous as to make his last days miserable. The treatment
of this type of bronchitis is described in Case 104.
462 CASE HISTORIES IN PEDIATRICS.
CASE 142. Richard P., five and one-half years old, was
the first child of healthy, normal parents. He had always
been well. He had never ceased to wet the bed, although he
had not wet his trousers since he was old enough to wear
them. He usually wet the bed soon after going to sleep and
again in the early morning. He slept very heavily. Re-
moval of his adenoids and circumcision had not diminished
the frequency of the wetting. He had had no other treatment,
except that the ingestion of liquids had been somewhat limited
during the latter part of the day. His appetite and digestion
were good and his bowels moved regularly. No pin- worms
had ever been seen. He was not especially nervous.
Physical Examination. He was well developed and nour-
ished and of good color. He seemed of normal intelligence
and did not appear at all neurotic. His tongue was clean,
his teeth good and his throat normal. The heart, lungs and
abdomen were normal. The liver and spleen were not pal-
pable. There was no irritation of the penis and no irritation
about the anus. The extremities were normal. There was no
spasm or paralysis. The knee-jerks, cremasteric and ab-
dominal reflexes were normal. There was no enlargement
of the peripheral lymph nodes.
The urine was of normal color, clear, highly acid in reaction,
of a specific gravity of 1030, and contained neither albumin
nor sugar.
Diagnosis. The diagnosis is, of course, Nocturnal Enu-
resis. It is, moreover, undoubtedly, not organic in origin,
but of the so-called "functional " or "essential " type. There
are no evidences of inflammation or irritation of the rectum,
penis, urethra or bladder. The only possible reflex cause is,
then, the highly acid and concentrated urine. It is probable,
however, that this is merely a temporary condition and not
the real cause of the trouble. Neither he nor his parents are
neurotic, his general condition is good and he is not anemic.
Increased irritability of the spinal centres cannot, therefore,
be the cause. It must be, then, interference with the normal
cerebral control of the spinal centres. This interference
cannot be due to adenoids, as they have been removed. It is,
in all probability, the result of a combination of somewhat
DISEASES OF THE KIDNEYS AND BLADDER. 463
tardy development of the cerebral centres and the depressing
influence of very deep sleep on their action.
Prognosis. He is certain to get over it, because as time
goes on the cerebral centres will develop and be able to control
the spinal centres, even during deep sleep. It is impossible
to know how long it will be before this happens, probably,
however, not under a year. Careful treatment will pre-
sumably relieve the condition to a certain extent and perhaps
hasten recovery.
Treatment. He cannot help wetting the bed when he is
asleep. Not being responsible for the condition, he ought
not, therefore, to be punished for it. Appeals to his pride or
rewards may be of some assistance, but probably will not.
He should be given water freely, to diminish the concentration
of the urine, and citrate of potash in doses large enough to
make the reaction neutral or slightly alkaline. Fifteen grains,
three or four times daily, will probably be sufficient to do this.
The water must all be given, however, before 4 p.m., because,
if given later than this, it will increase the tendency to wet the
bed by filling up the bladder. He should, for the same reason,
have as dry a supper as possible. He should pass water just
before going to bed and should be waked up early in the
evening to pass it again. He should also be made to pass it
when his parents go to bed and as soon as he begins to wake
up in the morning. He should sleep on a hard bed. His
coverings must be carefully regulated. If he is too warm, he
will sleep more soundly and be more likely to wet, while, if
he is cold, he will secrete more urine, which will also cause
him to wet the bed. It will be well to raise the foot of the
bed about six inches, as this tends to take the pressure of the
urine off of the sensitive neck of the bladder. Belladonna is
indicated in this instance, because of its action in diminishing
reflex excitability. He should be given five drops of the tinc-
ture of belladonna after supper. The dose should be increased
one drop each night until toxic symptoms appear. It should
then be diminished two drops, and kept at this point for some
months. He is in good condition and shows no signs of
nervous irritability. Tonics and nerve stimulants, such as
strychnia, are, therefore, not indicated.
SECTION XI.
DISEASES OF THE BLOOD.
CASE 143. Mary J. was seen when twenty-three months
old. Her mother had died soon after her birth of a cancer
which she had had during the pregnancy. She had always
been fed exclusively on modified milk. She had had no ill-
nesses except several slight digestive upsets when about a
year old. She took her food well and did not vomit, although
at times she seemed nauseated. Her bowels moved regularly
and the movements were normal. She was listless and quiet
and her temperature was usually a little subnormal.
Physical Examination. She was well developed and nour-
ished, but moderately pale. The anterior fontanelle was closed
and her head was of good shape. She had twelve teeth. Her
tongue was clean and her mouth and throat normal. There
was a venous hum in the neck. The heart was normal
except for a systolic murmur at the pulmonic area, which was
not transmitted. The lungs were normal. There was a
slight rosary. The level of the abdomen was that of the
thorax. The liver was palpable 1 cm. below the costal border
in the nipple line. The spleen was not palpable. The ex-
tremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and normal. There was no
enlargement of the peripheral lymph nodes.
The urine was pale, clear, faintly acid in reaction, of a
specific gravity of 1,012, and contained neither albumin nor
sugar. The sediment showed nothing abnormal.
Blood.
Hemoglobin, 50% (normal = 70%)
Red corpuscles, 5,122,000 (normal = 5,500,000 to 6,000,000)
White corpuscles, 11,300 (normal = 10,000 to 12,000)
Mononuclears, 31 %>
Polynuclear neutrophiles, 65% I (normal)
Eosinophils, l/o
Mast cells, 3%,
465
466 CASE HISTORIES IN PEDIATRICS.
The red corpuscles showed some variation in size and shape
and some achromia, but no nucleated forms.
Diagnosis. The venous hum in the neck and the systolic
murmur at the pulmonic area are, of course, merely signs of
the very evident anemia. The percentage of hemoglobin is
about seventy per cent of the normal, while the number of
red corpuscles is about ninety per cent of the normal. The
morphological changes in the red corpuscles are so slight that
they are of but little importance. The blood picture is, there-
fore, that of chlorosis. The diagnosis of chlorosis is for many
reasons, however, not justified in this instance, in spite of the
characteristic blood picture.
In the first place, the percentage of hemoglobin is always
relatively low in infancy. This is presumably due to the
fact that the infant normally receives an insufficient supply
of iron in its food and that the reserve of iron present in the
liver at birth is not large enough to keep the percentage of
hemoglobin at the adult standard. The reserve of iron is,
moreover, often insufficient, and in any event is compara-
tively easily exhausted. It is seldom sufficient to outlast the
first year. This relative disproportion between the hemo-
globin and the number of red corpuscles, when compared
with the adult standard, is almost always exaggerated in the
blood diseases of infancy.
This infant was, on account of her mother's illness during
the pregnancy, probably born with an insufficient reserve of
iron. She has never had any food but milk, which does not
contain enough iron to meet the needs of the normal infant's
system. Her reserve, being insufficient, was undoubtedly
exhausted long before the end of the first year, so that for a
year or more she has been unable to make up for the lack of
iron in her food and has been falling more and more behind.
That is, the causes which make the hemoglobin low under
normal conditions in infancy are much exaggerated in her
case. The diagnosis of chlorosis is, therefore, not justified
in this instance. The real condition is a Secondary Anemia,
due to the long-continued exclusive milk diet.
Further evidence against the diagnosis of chlorosis in these
cases is that they occur indifferently in boys and girls, and
DISEASES OF THE BLOOD. 467
that they have no pathologic connection with the nervous or
genital systems.
Prognosis. The addition of other foods to her diet and the
administration of iron will improve the condition of the
blood very rapidly.
Treatment. Beef juice and egg should be at once added to
her diet because of the iron which they contain. Starchy foods
should also be added. She is old enough to digest them and
needs a more varied diet in order to thrive. The best forms
of iron for her are the saccharated carbonate and ferratin.
The former may be given in five-grain and the latter in three-
grain doses, three times daily, after food.
468 CASE HISTORIES IN PEDIATRICS.
CASE 144. Alma H., seven months old, was the second
child of healthy parents. There was no tuberculosis in the
family and there had been no known exposure to tuber-
culosis. She was born at full term after a normal labor,
was normal at birth and weighed ten pounds. She had had
nothing but the breast and had always done well. The
outside of the house had been painted just before the onset of
her illness. Her mother also menstruated for the first time
just at the time of the onset. Her parents affirmed that she
was perfectly well and had a good color on April 2. Marked
pallor was noted the next day. She had had no hemorrhages
or other symptoms of illness. The pallor became yellowish
on April 6 and the mucous membranes pale on April 7.
There had been no increase in the pallor up to April 1 1 , when
she was seen. The conjunctivae had not been yellow, the
movements had been dark green in color and the urine had
not contained bile. She had had no hemorrhages and had
not been tender. She had taken her food well and had not
vomited. She had had no fever, but at times had seemed
chilly and had had cold and blue extremities, but no sweat-
ing. She had become very quiet, but was not fussy.
Physical Examination. She was decidedly apathetic. She
was well developed and nourished, but very pale. The skin
had a decided yellowish tinge, but the conjunctivae were clear.
The anterior fontanelle was 2 cm. in diameter and level.
There was no rigidity of the neck and the head was of good
shape. The tongue was clean; the mouth, gums and throat
normal. There were no teeth. There was a slight venous
hum in the neck. There was no rosary. The heart was nor-
mal except for a slight systolic murmur at the pulmonic
area, which was not transmitted. The lungs and abdomen
were normal. The liver was palpable 3 cm. below the costal
border in the nipple line. The spleen was not palpable.
There was no tenderness or swelling of the extremities except
a little puffiness of the feet. There was also a little puffiness
about the eyes. There was no spasm or paralysis. The knee-
jerks were equal and normal. There was no enlargement of
the peripheral lymph nodes. There were no hemorrhages
into the skin and no eruption or scars of old eruptions.
diseases of the blood. 469
Blood.
Hemoglobin, 20% (normal = 70%)
Red corpuscles, 1,492,000 (normal = 5,500,000 to 6,000,000)
White corpuscles, 11,000 (normal = 10,000 to 14,000)
Small mononuclears, 68% (normal = 40% to 50%)
Large mononuclears, 7% (normal = 10%)
Polynuclear neutrophiles, 21% (normal = 35% to 45%)
Eosinophiles, 4% (normal = 1% to 5%)
The red corpuscles showed marked variation in size, the
tendency being toward large forms. There was slight
poikilocytosis and moderate polychromatophilia, but no
stippling. Three normoblasts were seen in counting one
hundred white cells. Some of the white cells were very
large, looking like large cells from the bone marrow, and were
throwing off blood plates. There was a large increase in the
number of blood plates. No malarial organisms were seen.
Diagnosis. It is very hard to believe that, in the absence
of hemorrhages, the anemia developed as rapidly as the par-
ents affirm. The blood picture is that of a more chronic con-
dition, and it seems probable, therefore, that the parents did
not notice the condition until it was fully developed. It is
also difficult to believe that the painting of the house or the
mother's menstruation had anything to do with its develop-
ment. The absence of stippling of the red cells is much against
lead poisoning. Menstruation sometimes causes disturbances
of digestion, but not anemia. It is more probable that the
breast milk, while suitable in other ways, was deficient in
iron, and that after the reserve supply in the liver was
exhausted the anemia developed gradually. Scurvy can be
ruled out as a cause on the absence of tenderness and swelling
of the extremities and of hemorrhages. Malaria can be
excluded on the absence of plasmodia in the blood.
The morphological changes in the red corpuscles, the
predominance of the large over the small forms of red cells,
the presence of nucleated cells and the large percentage of
mononuclear leucocytes would in the adult point strongly
toward pernicious anemia. The tendency common to all the
anemias of infancy to revert to a younger type of blood and
the normal preponderance of mononuclear leucocytes and of
470 CASE HISTORIES IN PEDIATRICS.
greater variation in their size make these points of practically
no importance in the diagnosis of pernicious anemia in in-
fancy. In all probability, moreover, pernicious anemia does
not occur at this age. The large number of blood plates
present in this instance would exclude it, even in an adult.
Acute lymphatic leukemia in an aleukemic stage is sug-
gested to a certain extent by the changes in the red cells and
the comparatively large proportion of mononuclear leuco-
cytes. The absence of enlargement of the spleen and lymph
nodes and the age are much against it. The slight signifi-
cance of the changes in the red cells and of the excess
of mononuclear leucocytes has already been explained.
The large number of blood plates practically excludes
leukemia.
There is nothing about the blood picture which is in any
way inconsistent with a secondary anemia in infancy. A
diagnosis of Secondary Anemia is, therefore, justified, a
possible cause being a deficiency of iron in the mother's milk.
Prognosis. The condition of the blood will undoubtedly
improve rapidly if iron is given.
Treatment. The baby has done so well in every other way
on its mother's milk that it is unwise to wean it, since any
deficiency of iron in the milk can be very easily •remedied by
the administration of iron. This may be given by mouth in
the form of the saccharated carbonate or of ferratin. When
the anemia is as marked as it is in this instance it is better,
however, to give it subcutaneously, because the improvement
begins so much sooner and is so much more rapid than when
it is given in the ordinary way. The best form of iron for
subcutaneous use is the aqueous solution of the citrate.
This can be put up in pearls and sterilized, and when pre-
pared in this way remains sterile indefinitely. It is not irri-
tating. If given subcutaneously, the injection rarely causes
much pain, but, if given intramuscularly, it is often very
painful and sometimes causes slight symptoms of shock. It
must be given with a glass syringe with asbestos packing and
a platinum needle. The syringe and needle must, of course,
be sterilized. The dose for this infant is three quarters of a
grain, every other day.
DISEASES OF THE BLOOD. 47 X
CASE 145. Jennie R., the daughter of healthy parents,
was one of twins. The other had always been well. Another
child was well, while a fourth had died in infancy of "sum-
mer complaint." She was nursed for five weeks, after which
she was given modified milk, prepared at a laboratory, for
three weeks. She had been fed since this time on a modified
milk, prepared at home. The mixture, which was a weak
one, had not been changed, however, for seven months.
During this time she had had no disturbance of digestion,
but had gained very slowly. She had a slight attack of diar-
rhea when nine months old, which yielded quickly to treat-
ment and was followed by constipation. Since then she had
taken a stronger modification of milk and had had no dis-
turbance of digestion. She was seen when ten months old
because she was not thriving.
Physical Examination. She was fairly developed and nour-
ished. There was moderate pallor of the skin and mucous
membranes. The anterior fontanelle was three cm. in
diameter and level. The head was flattened on top and be-
hind, but there was no craniotabes. There were two teeth.
She sat alone feebly, but with the spine straight. There was
a marked rosary. There was slight retraction of the chest at
the insertion of the diaphragm. The heart and lungs were
normal. The abdomen was distended but otherwise normal,
except for a slight umbilical hernia. The upper border of the
liver flatness was at the upper border of the fifth rib ; the lower
border of the liver was palpable three cm. below the costal
border in the nipple line. The spleen was felt running out
from beneath the costal border in the left anterior axillary
line to the right of the umbilicus, then downward and back-
ward to the left anterior superior spine and backward into
the loin. The surface was smooth, the consistency firm.
The notch was felt distinctly in the left nipple line, midway
between the costal border and the navel. The extremities
were normal except for a moderate enlargement of the epiph-
yses at the wrists. There was a slight general enlargement
of the peripheral lymph nodes. She weighed ten pounds and
two ounces.
472 CASE HISTORIES IN PEDIATRICS.
The urine was pale, acid, of a specific gravity of 1015 and
contained no albumin or sugar.
Blood.
Hemoglobin, 40% (normal = 70%)
Red corpuscles, 4,000,000 (normal = 5,500,000 to 6,000,000)
White corpuscles, 18,750 (normal = 10,000 to 12,000)
Small mononuclears, 344% (normal = 40% to 50%)
Large mononuclears, 12.6% (normal = 10%)
Polynuclear neutrophils, 51% (normal = 35% to 45%)
Eosinophiles, .2% (normal = 1% to 5%)
Myelocytes, 1.8%
The red corpuscles showed marked variation in size, shape
and staining reaction. There was no tendency to large forms,
but a slight tendency to oval forms. Sixteen normoblasts
and nine megaloblasts were seen in counting five hundred
white corpuscles.
Diagnosis. The flattening of the head, the rosary, the
retraction of the chest at the insertion of the diaphragm and
the enlargement of the epiphyses at the wrists are signs of
rickets, as is probably the delay in the eruption of the teeth.
The general enlargement of the peripheral lymph nodes is
merely a manifestation of a disturbance of the nutrition.
The pallor and the changes in the blood show that she has an
anemia. The presence of myelocytes, megaloblasts and such
marked morphological changes in the red corpuscles would
suggest, in an adult, pernicious anemia. In an infant, how-
ever, they are merely evidences of the tendency of the blood
to revert to a younger type. The greater relative diminution
in the percentage of hemoglobin than in the number of red
corpuscles, 57% against about 70%, is characteristic of
secondary anemia in infancy. (See Case 143.) The leucocy-
tosis may or may not be directly connected with the anemia.
It is not at all uncommon in secondary anemia in infancy,
however, and is of no especial significance. The blood changes
are, therefore, entirely consistent with those of secondary
anemia.
There is, in addition, a marked enlargement of the spleen.
What is the connection, if any, between the rickets, the
DISEASES OF THE BLOOD. 473
anemia and the enlargement of the spleen? Is any one of
them the cause of the others, or are they all manifestations of
some common cause? It is certain that the anemia and the
splenic tumor could not have caused the rickets. Could the
rickets have caused the anemia and splenic tumor? While
it is conceivable that they might have, the chances are very
much against it, because the study of large series of cases
shows that there is no connection whatever between the sever-
ity of the rickets and that of the anemia and the size of the
spleen, many babies showing marked rickets and no anemia,
others mild rickets and severe anemia, and so on. In the
same way, marked enlargement of the spleen is often found
in connection with mild rickets and no enlargement of the
spleen in some of the most marked cases. The study of other
series of cases shows that there is no connection between the
size of the spleen and the changes in the blood, very marked
changes being present in the blood when the spleen is not
enlarged, very slight when the spleen is much enlarged, and
so on. It seems reasonable to conclude, therefore, that the
rickets, the anemia and the enlargement of the spleen are all
manifestations of some common cause. This cause is not
hard to find. It is undoubtedly the disturbance of nutrition
due to the prolonged use of too weak a food.
The combination of marked changes in the blood and
splenic tumor, as is present in this instance, has often been set
aside as a special disease and described under various names,
the most common of which is anemia infantum pseudoleuke-
mica. The combination is always, however, as in this in-
stance, accidental, and does not constitute a specific disease.
The characteristics of the anemia are, as already shown,
those of secondary anemia in infancy, and the enlargement
of the spleen is merely a manifestation of the same disturb-
ance of nutrition which is responsible for the anemia. It is
better to speak of it, therefore, as Secondary Anemia with
Splenic Tumor.
Prognosis. The prognosis is perfectly good. When the
underlying disturbance of nutrition is corrected the spleen
will diminish rapidly in size and the anemia will quickly
improve. The spleen will probably not be palpable after
474 CASE HISTORIES IN PEDIATRICS.
two or three months and the blood will be normal at least as
soon.
Treatment. The treatment is regulation of the diet to
correct the disturbance of nutrition. The administration of
iron will also hasten the return of the blood to normal. The
following mixture is a suitable one for her:
Fat, , 4%
Sugar, 7%
Proteids, 2.50%
Starch, 0.75%
There is no indication for the addition of an alkali. Six
feedings of five ounces will much more than supply the
caloric needs indicated by her weight, but will probably be
no more than are required when her age and surface area
are taken into consideration.
One or two tablespoonfuls of beef juice, once daily, given
at the same time as one of her feedings, will aid in supplying
the needed iron. It will be wiser, however, to give iron in
addition. It may be given as the saccharated carbonate or
in the form of ferratin. The dose of the former is three
grains; that of the latter, two grains, three times daily.
DISEASES OF THE BLOOD. 475
CASE 146. George S., eight years old, was the child of
healthy parents. Three brothers were well. One child had
died of tubercular meningitis and another was born dead at
full term. There had been no miscarriages. There was no
history of hemorrhages in either family, except that the
daughter of a maternal aunt, when eight years old, had bled
steadily for twelve hours after the extraction of a tooth.
She had had, however, no other hemorrhages before or since.
His mother had had what was called chlorosis at the time of
puberty. He had never been outside of eastern Massachu-
setts.
He was born at full term, after a normal labor, and weighed
five and one-half pounds. He was nursed for five months and
did well. He had whooping-cough when six months old,
pneumonia at one year and measles at one and one-half years.
He had been well since then, but had always been a little pale.
Five months before he was seen he complained of headache
without obvious cause, and the next morning had a severe
nosebleed which was finally stopped, after two hours, by
plugging the anterior nares. He had been somewhat paler
since the nosebleed but was considered well. He always had
more or less "black and blue" spots on him, however, some
of which were apparently not due to injuries. A week before
he was seen he became listless and much paler. There had
been a little bleeding from the gums during the last two days.
His appetite was good. He had no symptoms of indigestion,
his bowels moved regularly and the stools did not contain
blood. He had no dizziness, headache or dyspnea. He was
admitted to the Children's Hospital, August 16.
Physical Examination. He was poorly developed and
nourished and somewhat listless. There was marked pallor
of the skin and mucous membranes. His teeth were poor,
but the gums were healthy and there was no bleeding from
them. The area of cardiac dullness was normal and the
action regular. The first sound was somewhat feeble and
there was a systolic murmur over the whole precordia. There
was a venous hum in the neck. The lungs and abdomen were
normal. The upper border of the liver flatness was at the
sixth rib in the nipple line; the lower border was just palpable
476 CASE HISTORIES IN PEDIATRICS.
below the costal border in the same line. The spleen was not
palpable. The extremities were normal. There was no
enlargement of the peripheral lymph nodes. There were a
few ecchymoses on the legs and thighs. The temperature
was normal.
The urine was clear, acid in reaction, of a specific gravity of
1 01 5 and contained neither albumin nor sugar. The sedi-
ment showed nothing abnormal.
The stools showed that there was no disturbance of the
digestion of any of the food elements. They contained some
mucus but no blood or pus. All foods containing blood were
stopped for forty-eight hours. The stools were then ex-
amined by the guiac test and no blood found.
A skin tuberculin test was negative.
Blood.
Hemoglobin 18% (Sahli)
Red corpuscles 672,000
White corpuscles, 8,000
Small mononuclears, 37%
Large mononuclear and transition forms, 10%
Polynuclear neutrophils, 49%
Eosinophils, 4%
There was some achromia and slight poikilocytosis and
stippling of the red cells. Many of the red cells were as large
as the leucocytes. No nucleated red cells were seen and no
abnormal forms of white cells. Many of the white cells were
broken down. The coagulation time was two and one-half
minutes.
He was kept under observation at the hospital and at the
Convalescent Home until Nov. 1. During this time he had
no hemorrhages and gained in weight. He said that he felt
well and while at the Convalescent Home was able to play
with the other children. Repeated examinations of the
stools failed to find either parasites or their ova and no Plas-
modia were found in the blood. He was unable to take
arsenic, even in minute doses, without showing toxic symp-
toms. He apparently did as well, or better, without iron
than with it, whether it was given by mouth or under the
skin. He was still pale and waxy. The murmur in the
DISEASES OF THE BLOOD. 477
heart and the venous hum were still present. The liver and
spleen were not palpable. There was no enlargement of the
peripheral lymph nodes.
Blood.
Hemoglobin, 20% (Sahli)
Red corpuscles, 790,000
White corpuscles, - 3,800
Small mononuclears, 41%
Large mononuclears and transition forms, 2%
Polynuclear neutrophils, 57%
There was slight polychromatophilia and considerable macro-
cytosis, but very little poikilocytosis. There was no stip-
pling of the red cells and no nucleated cells were seen. There
were no abnormal forms of white cells. The blood platelets
numbered 320,000. The coagulation time was two and one-
half minutes. The clot was normal.
Diagnosis. The history of the bleeding in his cousin and
of the severe nosebleed and "black and blue spots" in the
past, together with the recent oozing from the gums, suggest
hemophilia. When it is remembered that the cousin is a
girl, that she had had no other hemorrhages and that he has
had but one severe hemorrhage, this history is, however,
much less suggestive. The normal coagulation time of the
blood and the normal character of the clot, are, moreover,
sufficient to exclude hemophilia. The characteristics of the
blood are not those of leukemia. An aleukemic stage would
hardly last so long and there is no excess of lymphocytes.
There is, moreover, no enlargement of the spleen or lymph
nodes. The fact that he has never been outside of eastern
Massachusetts, together with the absence of parasites and
their ova in the stools at repeated examinations, rule out
anemia from the hookworm or other intestinal parasites.
The absence of blood in the stools by the guiac test shows
that there is no concealed intestinal hemorrhage. There is
nothing in his history or physical examination to account for
the anemia. It did not improve, moreover, when he was in
the country and having good food. The anemia is more
marked than is usual in secondary anemia without obvious
cause, the color index is slightly above normal, there is a
478 CASE HISTORIES IN PEDIATRICS.
considerable macrocytosis and there is no leucocytosis. It
is almost certain, therefore, that, in spite of the normal
number of blood platelets and the absence of a relative lym-
phocytosis, the anemia is of the primary rather than of the
secondary type. There are usually, however, marked mor-
phologic changes in the red corpuscles and many normoblasts
and megaloblasts in pernicious anemia, which is not the case
in this instance. The absence of morphologic changes in the
red cells and of nucleated cells is characteristic of the blood
picture in the aplastic type of this disease, so that it cannot
be excluded on this account. In this type, however, there is
usually little or no macrocytosis and a marked diminution in
the polynuclear neutrophiles. It is evident, therefore, that
the blood picture does not exactly correspond to that of any
of the types of anemia. Taking everything into considera-
tion, however, a probable diagnosis of Pernicious Anemia
of the Aplastic Type seems justified.
Prognosis. If the diagnosis is correct, the prognosis is
hopeless. He will probably not live many months.
Treatment. There is very little to be done for him medic-
inally. He cannot take arsenic and does better without
iron than with it. The most that can be done, therefore, is
to take the best possible care of him, to feed him as well as
possible, to keep him quiet and to give him the maximum
amount of fresh air and sunlight.
DISEASES OF THE BLOOD. 479
CASE 147. Lester J. had always been well, but a little
delicate. A slight enlargement of the cervical lymph nodes
was noticed about the first of June. It had not increased
materially up to July 10, when he came down with scarlet
fever. The scarlet fever was of a very mild type and he was
out of quarantine August 13. The swelling in the neck
increased very rapidly after the onset of the scarlet fever.
The temperature rose again August 20 and ran between
1030 F. and 1040 F. Enlargement of the spleen was noticed
for the first time August 23, but may have been present be-
fore, as it had not been looked for until that time. The size
of the liver was not investigated. The mouth and throat
became sore August 26, and several spots of membrane ap-
peared in the mouth. A culture showed no diphtheria bacilli.
He had had no disturbance of digestion, looseness of the
bowels or hemorrhages, and had not lost weight, strength or
color. He had not seemed seriously sick until a few days
before he was seen in consultation, August 27, when six
years old.
Physical Examination. He was small, slight and flabby,
but not very pale. There was an ulcerated area, the size of a
dime, covered with false membrane, on the left side of the
mouth. The whole throat was slightly reddened. The tonsils
were moderately enlarged. The tongue was somewhat dry
and slightly coated. There was no nasal discharge. There
was a large mass of discrete, non-tender lymph nodes in the
left side of the neck, which filled up the whole neck, extend-
ing forward even with the chin and downward to the clavicle.
There were numerous small lymph nodes in the right side of
the neck. There was no dullness under the manubrium or
in the middle of the back, and the bronchial voice sounds did
not extend below the seventh cervical spine, showing that there
was no considerable enlargement of the bronchial lymph
nodes. There was no venous hum in the neck. The heart,
lungs and abdomen were normal. The upper border of the
liver flatness was at the upper border of the fifth rib (normal
is in the fifth space). The lower border was palpable, running
from just above the right anterior superior spine, through a
point two thirds the distance from the ensiform to the navel,
480 CASE HISTORIES IN PEDIATRICS.
to the left costal border in the nipple line. The surface of the
liver was hard and smooth, the edge rounded. The spleen
was palpable, running out from the costal border between the
left nipple and anterior axillary lines, downward and for-
ward almost to the median line, backward to the left anterior
superior spine and upward into the flank. The surface was
smooth, the consistency hard, the edge rounded, the notch
distinct. The extremities were normal. There was no spasm
or paralysis. The knee-jerks were equal and normal. There
were numerous lymph nodes, the size of marbles, in the axillae
and groins, and one, the size of a walnut, on the occiput.
The epitrochlear lymph nodes were not palpable. The
mouth temperature was 1040 F.
The urine was high in color, extremely acid in reaction, and
of a specific gravity of 1,032. It was loaded with urates, but
contained no albumin or sugar. The sediment showed a few
small round cells, but no casts.
Blood.
Hemoglobin, 70%
Red corpuscles, 3,520,000
White corpuscles, 128,000
Mononuclears (almost entirely lymphocytes), 99-2%
Polynuclear neutrophils, .6%
Myelocytes, .2%
There was a very little variation in the size of the red
corpuscles, but none in their shape or color. No nucleated
cells were seen while counting five hundred white corpuscles.
Diagnosis. Without the examination of the blood the
diagnosis would lie between lymphatic leukemia and Hodg-
kin's disease. The enlargement of the liver and the ulceration
of the mouth would, however, make lymphatic leukemia the
more probable. The examination of the blood proves con-
clusively that the trouble is Lymphatic Leukemia. The
enlargement of the lymph nodes preceded the attack of
scarlet fever by six weeks. It is almost certain, therefore,
that this was merely a coincidence and that it played no part
in the etiology of the leukemia.
Prognosis. The prognosis is absolutely hopeless. He will
probably not live more than one or two weeks.
DISEASES OF THE BLOOD. 48 1
Treatment. There is nothing to be expected from treat-
ment. Arsenic and iron should be tried, however, with the
hope that they may alleviate the condition and perhaps pro-
long life. The arsenic is best given in the form of Fowler's
solution. It will be well to begin with three drops, three
times a day, increasing the dose one drop daily until the
physiological limit is reached. Other treatment must be
symptomatic.
482 CASE HISTORIES IN PEDIATRICS.
CASE 148. Mary C, three years old, was the only child of
healthy parents. There had been no deaths or miscarriages.
She was born at full term after a normal labor, was normal
at birth and weighed eight pounds. She was nursed for
seven months and did very well. Since then she had taken
milk well, but it had been very hard to induce her to take
other food. She had, nevertheless, been very well.
Seven weeks before she was seen in consultation she began
to seem a little out of sorts and to lose color. The chief
symptom had been anorexia and the greatest difficulty had
been experienced in getting her to take anything, even milk.
She had vomited occasionally, probably as the result of the
forcing of food rather than of indigestion. There had been
a tendency to constipation, which had been easily relieved
by castoria. The movements had been well digested. Her
only complaint was of being tired. She did not want to play
with other children, but preferred to keep quiet or lie down.
She had not lost weight but had steadily lost color. Purpuric
spots had appeared on the legs a week previously. She had
slept poorly and perspired freely. She had had no fever.
Physical Examination. She was well developed and nour-
ished, but very pale. Her flesh was firm. There was no
edema. The tongue was clean, the mouth and throat normal.
There was a venous hum in the neck. The heart was normal,
except for a slight systolic murmur at the pulmonic area,
which was not transmitted. The lungs were normal. The
liver and spleen were not palpable. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and normal. There was no enlargement of the
peripheral lymph nodes. There were a dozen or more pur-
puric spots, varying in size from that of a split pea to that of
a dime, scattered over the arms and legs, there being more
on the legs than on the arms.
Blood.
Hemoglobin,
25%
Red corpuscles,
2,560,000
White corpuscles,
15,400
Lymphocytes,
99%
Polynuclear neutrophiles,
1%
DISEASES OF THE BLOOD. 483
There was a little variation in the size and shape of the
red corpuscles, but most of them were of normal size. There
was moderate achromia, but no polychromatophilia. There
was no stippling. One normoblast was seen for each one
hundred leucocytes. No plasmodia or blood plates were
seen.
Diagnosis. The diagnosis lies between a rather severe
anemia, secondary to an insufficient or improperly balanced
diet over a long period, with lymphocytosis, and lymphatic
leukemia in an aleukemic stage. The symptomatology is
consistent with either diagnosis. The diminution in the
hemoglobin and in the number of the red corpuscles, as well
as the morphological changes in them, are consistent with
either condition. A percentage of lymphocytes as high as
ninety-nine per cent is practically unheard of outside of
lymphatic leukemia and is of far more importance in differ-
ential diagnosis than the comparatively slight increase in the
total number of the white cells, because the number of white
cells is often for a time but little increased in lymphatic leu-
kemia. The absence of blood plates is of itself, moreover,
sufficient to turn the scale in favor of leukemia, in which the
blood plates are markedly diminished, while in secondary
anemia they are normal or increased in number. The lymph
nodes and spleen are usually, but not always, enlarged in
lymphatic leukemia. The absence of such enlargement in
this instance does not, therefore, rule it out. The diagnosis
is, therefore, Lymphatic Leukemia.
Prognosis. The prognosis is absolutely bad. She will
probably not live more than one or two months.
Treatment. She must, if possible, be made to take a more
varied diet. If she will not take sufficient food, it must be
given through a stomach tube, passed through the mouth.
There is little to be expected from medicinal treatment.
Arsenic and iron should be tried, however, with the hope that
they may alleviate the condition and perhaps prolong life.
The arsenic is best given in the form of Fowler's solution. It
will be well to begin with two drops, three times daily,
increasing the dose one drop daily until the physiological
limit is reached. Other treatment must be symptomatic.
484 CASE HISTORIES IN PEDIATRICS.
CASE 149. Carl G. was the only child of healthy parents
and was born at full term. His mother had had one mis-
carriage at six months, probably as the result of albuminuria.
He lived on a farm in the country and had always drunk the
unsterilized milk from a herd of cows which had for many
years been infected with tuberculosis. He had had measles
and chicken-pox as a baby and an abscess in the neck at two
years, which was opened and healed well.
He began to be out of sorts about the first of January,
when six and one-half years old. There were no very definite
symptoms, however, so that a physician was not called until
about the middle of March. He found that the boy was
running an irregular temperature, which at times went as
high as 103. 50 F., and that he had an enlarged liver and a
very large spleen. The urine showed nothing abnormal.
The leucocytes numbered 6,000. Typhoid fever was suspected,
but a Widal test was negative. He then improved for a
time in every way and probably had little or no fever, although
his temperature was not taken. He was up and about, played
out of doors and seemed much like himself, except that he
was easily tired.
The fever returned about the middle of August. The tem-
perature was very irregular, most of the time being normal
or subnormal, but reaching 1030 F. or 103. 50 F. for a time
almost every day. Malaria was suspected, although there
were no chills or sweating. Several examinations of the fresh
blood failed, however, to show any plasmodia, and there was
no change in the temperature when quinine was given.
There had been no change in the size of the liver and spleen.
The urine showed nothing abnormal. The red corpuscles
numbered 3,700,000 and the white corpuscles, 6,000. He
had lost some color. His appetite and digestion had been
good throughout and he had not lost weight. He had had
no cough, but several nosebleeds, one of them very severe.
He was seen in consultation, August 29, when a little more
than seven years old.
Physical Examination. He was fairly developed and
nourished, but moderately pale. He did not look especially
sick. His tongue was clean and moist, his teeth poor. The
DISEASES OF THE BLOOD. 485
nose and throat were normal. There was no venous hum in
the neck. The heart and lungs were normal. The abdomen
was considerably enlarged, but there were no evidences of
fluid and no masses were felt. The superficial abdominal
veins were not enlarged. The upper border of the liver
flatness was at the upper border of the fifth rib in the nipple
line (normal is in fifth space) and at the upper border of
the ninth rib in the scapular line (normal is at the tenth
rib). The lower border of the liver was palpable, running
out from the right flank, 4 cm. below the costal border in
the right anterior axillary line, through a point two thirds
the distance from the tip of the ensiform to the navel, and
under the costal border in the left nipple line. The liver was
not tender, its surface was smooth, its edge sharp. The
spleen was palpable, running out from beneath the costal
border in the left nipple line, downward and inward nearly
to the navel, downward and outward to below the level of
the left anterior superior spine, then backward into the
flank, which it filled. It was firm, smooth and not tender.
The edge was somewhat rounded, the notch distinct. The
extremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and normal. There was no
enlargement of the peripheral lymph nodes and no evidence
of enlargement of the tracheo-bronchial lymph nodes. There
was no edema. There was no eruption and no scars of old
eruptions.
The urine was normal in color, acid in reaction, of a specific
gravity of 1,020, and contained neither albumin nor sugar.
The sediment showed nothing abnormal.
Blood.
Hemoglobin, 9°%
Red corpuscles, 3,520,000
White corpuscles, 5>7°°
Mononuclears (the majority small), 60.0%
Polynuclear neutrophiles, 38.7%
Myelocytes, 1.3%
The red corpuscles showed no changes in size, shape or
coloring, and no nucleated cells or plasmodia were seen.
Diagnosis. The diagnosis lies between lymphatic leu-
486 CASE HISTORIES IN PEDIATRICS.
kemia in an aleukemic stage, Hodgkin's disease and that very
indefinite class of cases known as splenic anemia or anemia
with splenic tumor. Tuberculosis, which is suggested by
the prolonged use of milk from a tuberculous herd, can be
excluded by the absence of signs of tuberculosis elsewhere,
the slight impairment of the general condition after six
months, the fact that the liver and spleen are apparently
alone involved and that the enlargement of these organs is
regular. A tuberculin test would not be of much assistance.
If negative, it would, of course, exclude tuberculosis, but, if
positive, it would not prove that the enlargement of the liver
and spleen and the fever are tubercular in origin. Syphilis
can be ruled out on the good family history, the previous
good health, the fever and the absence of all other signs of
syphilis in the past or present. Cirrhosis of the liver is
rendered very improbable by the absence of cause, ascites,
jaundice and enlargement of the superficial abdominal veins,
the fever and the relatively great enlargement of the spleen.
Lymphatic leukemia in an aleukemic stage can be practi-
cally eliminated on the duration of the illness, the low white
count on several occasions (the aleukemic stage usually being
a short one), the absence of morphological changes in the
red cells and the marked enlargement of the liver and spleen
without enlargement of the lymph nodes.
The fever, the condition of the blood, the enlargement of
the liver and spleen and the relatively slight impairment of
the nutrition are all consistent with Hodgkin's disease. It
is almost unheard of, however, to have so much enlargement
of the liver and spleen without enlargement of either the
superficial or deep lymph nodes. Hodgkin's disease can,
therefore, be excluded.
The most probable diagnosis is, therefore, splenic anemia,
or better, Anemia with Splenic Tumor. This is, however,
not a very satisfactory diagnosis because it does not describe
a definite pathological entity, but is merely a term applied
to a group of cases in which there is enlargement of the spleen
and anemia, but of which the pathology and etiology are
very varied. It is at present, however, impossible to classify
them any more accurately.
DISEASES OF THE BLOOD. 487
Prognosis. The prognosis is very uncertain. He may
gradually improve and grow up with a large liver and spleen,
which do not cause any symptoms or inconvenience, or they
may both finally return to their normal size. He may, on
the other hand, fail rapidly and die in a few months or live
on for some years and then die. The chances are that he
will not live more than a year.
Treatment. The treatment must, in the main, be hygienic
and symptomatic. It will be well to try arsenic thoroughly.
It is best given in the form of Fowler's solution. It will be
well to begin with three drops, three times a day, increasing
the dose one drop daily until the physiological limit is reached.
It should then be continued, in doses somewhat below the
physiological limit, for several months. If he does not im-
prove, or continues to fail, splenectomy ought to be consid-
ered, because, while it is a serious operation and if successful
does not always relieve the symptoms, it sometimes results
in a cure.
488 CASE HISTORIES IN PEDIATRICS.
CASE 150. William S. was the only child of healthy
parents. There had been no deaths or miscarriages. There
was no history of tuberculosis in either family and there had
been no known exposure to it. He was born at full term, was
normal at birth, was nursed for nine months and had always
been perfectly well. A small gland was noticed in the left
side of the neck in the latter part of January. Another
gland was noticed on the right side about two weeks later.
He also lost a little weight and color and his digestion was
not quite as good as usual. The glands increased in size,
so that by the first of March they were as large as pigeons'
eggs. A skin tuberculin test at that time was negative. He
was then given malt extract and his diet regulated. His
general condition improved rapidly, but there was no diminu-
tion in the size of the glands. He passed into the hands of
another physician about the middle of April. This physician
prescribed the syrup of the iodide of iron, which he had taken
continuously since that time. The glands began to enlarge
again, however, and had continued to increase steadily in
size. Enlarged glands were discovered in the groins and
axillae about the middle of July. His mother did not know
whether they had grown larger since then or not. His tem-
perature had never been taken, but his mother thought that
he had been a little feverish at night. His appetite and
digestion were good and he had not lost weight or color. His
neck had seemed a little tender during the past week, but
was not painful. He was seen in consultation, September 13,
when three years old.
Physical Examination. He was well developed and nour-
ished and of fair color. The whole of both sides of the neck
was filled up with a hard, non-tender mass, which extended
well backward and so far forward that the chin was hardly
distinguishable. The swelling ran up behind the ears, but
not in front of them. Discrete glands could be made out
in some places, but in others the surface was smooth. There
was no heat or redness. A chain of glands, varying in size
from that of a marble to that of a robin's egg, could be felt
running down behind the clavicles. The pupils were equal
and reacted to light. The tongue was clean, the teeth good
DISEASES OF THE BLOOD. 489
and the throat normal. He kept his mouth shut and there
was no nasal discharge. There were several glands, the size
of large beans, in each axilla and the epitrochlear glands were
as large as peas. There was no dullness under the sternum,
the respiratory sound was the same on both sides and the
bronchial voice did not extend downward below the cervical
spines. The heart and lungs were normal. No enlarged
glands were found in the abdomen. The upper border of
the liver flatness was at the upper border of the fifth rib
in the nipple line. The lower border was palpable six cm.
below the costal border in the same line. Its surface was
smooth. The spleen was just palpable. There were nu-
merous glands, varying in size from that of a pea to that of a
robin's egg, in both groins. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. There were no mucous patches or rhagades.
There was no eruption and there were no scars of former
eruptions.
Blood.
Hemoglobin, 75%
Red corpuscles, 4,500,000
White corpuscles, 24,800
Mononuclears, 19%
Polynuclear neutrophils, 81%
The red corpuscles were normal in every way and no ab-
normal forms of the white cells were seen.
Diagnosis. The bilateral enlargement of the glands in the
neck and the general distribution of the glandular enlarge-
ment, as well as the enlargement of the liver and spleen, are
strong evidence against tuberculosis as the cause of the
adenitis, while the absence of a history of tuberculosis does
not count in any way against it. It is excluded by the
negative tuberculin test. There is nothing in the history to
suggest syphilis and there are no physical signs of syphilis
either at present or in the past. Enlargement of the lymph
nodes to this extent from syphilis is, moreover, very unusual,
especially without other marked signs of the disease. Syphi-
lis can, therefore, be excluded. Leukemia can be excluded
on the results of the examination of the blood. It is more
490 CASE HISTORIES IN PEDIATRICS.
difficult to rule out lymphosarcoma. The chief points against
it are the good general condition after nine months, the
absence of involvement of the adjacent structures, the
absence of enlargement of the tracheo-bronchial lymph nodes
after so many months and, more than all, the fact that the
whole picture is so absolutely characteristic of Pseudo-
leukemia or Hodgkin's Disease. The appearance of the
enlargement in the cervical glands first, the general distribu-
tion of the adenitis, the enlargement of the liver and spleen,
the mild anemia and the slight polynuclear leucocytosis are
all so typical of the early stage of this disease that there can
be no doubt that this is the true diagnosis.
Prognosis. While some cases of this disease are said to
have recovered, they are so few in number and the diagnosis
in them is open to so much doubt that the prognosis is
practically hopeless. He will, however, probably live for a
number of years to die finally from cachexia or from the
results of the pressure of the enlarged tracheo-bronchial and
mediastinal glands on the adjacent organs. Remissions in
the symptoms and temporary diminutions in the size of the
glands may be expected.
Treatment. Arsenic is the most useful drug in this disease.
He should be given two drops of Fowler's Solution, well
diluted with water, three times daily, after eating. The dose
should be increased one drop daily until the limit of tolerance
is reached. It should then be stopped for a few days, after
which the dose should be two drops less than the one which
caused the toxic symptoms. The drug should be given in
this dose, with occasional intermissions, for many months.
There is, of course, some danger of causing a peripheral
neuritis. This happens comparatively seldom, however, and
the good which the arsenic does justifies the risk. Treatment
with the Roentgen ray has diminished the size of the glands
in many instances and ought to be given a thorough trial.
Local treatment is useless. The removal of the glands should
not be undertaken unless they are causing serious symptoms
from pressure on other organs.
DISEASES OF THE BLOOD. 49 1
CASE 151. Charles C. was the first child of healthy
parents. One younger child was well; there had been no
deaths or miscarriages. He was born at full term, after a
normal labor, was twenty-four inches long and weighed ten
and one-half pounds. He was nursed entirely for five
months, after which he was given diluted cows' milk in addi-
tion. He cried almost constantly until he was fifteen months
old, but did not vomit and had normal stools. He was
always pale, however, and enlargement of the abdomen and
spleen were noticed at that time. He had a very severe
attack of whooping-cough when he was twenty months
old, followed in a few months by chicken-pox and scarlet
fever.
Early in February, 1909, when nearly three years old, he
vomited a large amount of blood and had a number of tarry
stools. He was treated in the Children's Hospital for nine
weeks. His blood at entrance showed 55% of hemoglobin,
2,112,000 red corpuscles and 25,700 white corpuscles, of
which 17% were lymphocytes and 83% polynuclear neutro-
philes. There was no achromia and but little polychro-
matophilia. The red corpuscles varied somewhat in size,
but not in shape. The blood platelets were normal. Three
days later the hemoglobin had dropped to 30% and the red
corpuscles to 1,474,000, but the morphology of the red cells
was unchanged. The blood, when he was discharged from
the hospital two months later, showed 70% of hemoglobin,
3,224,000 red corpuscles and 6900 white cells. The differen-
tial count showed :
Small mononuclears, 28.5%
Large mononuclears, 1-5%
Polynuclear neutrophiles, 66.5%
Eosinophiles, 3-5%
The red cells showed slight achromia and slight variation in
size. There were no nucleated cells and the blood platelets
were normal.
The liver was palpable three cm. and the spleen four cm.
below the costal border when he entered the hospital. When
he was discharged the liver reached but one cm. below the
492 CASE HISTORIES IN PEDIATRICS.
costal border, while the size of the spleen was unchanged.
The abdomen was rather large, but otherwise normal. The
urine showed nothing abnormal and a skin tuberculin test
was negative.
He was perfectly well from that time on, except that he
was pale and had a large abdomen. He ate everything and
had no symptoms of indigestion. In February, 191 1, he had
another attack, without known cause, in which he vomited
a considerable amount of blood and had tarry stools. He
was treated at that time in the Massachusetts General
Hospital. His blood then showed 40% of hemoglobin and
1,500,000 red corpuscles, but when he left the hospital
it contained 65% of hemoglobin and 3,500,000 red cor-
puscles. Nothing was found in the throat to account for
the bleeding.
He was seen March 11, 191 1, just after his discharge from
the hospital. He was then five years old. He was very pale
and weak. There was a venous hum in the neck and a
systolic murmur over the whole precordia. The heart was
otherwise normal. The lungs were normal. The liver was
not palpable, but the spleen extended seven cm. below the
costal border. He improved rapidly in every way after this
and was well, except for an attack of diarrhea in July, 191 1.
He was admitted to the Children's Hospital for observation,
August 3, 191 1, when five and one-half years old.
Physical Examination. He was fairly developed and
nourished and of fair color. His tongue was clean, his teeth
in fair condition and his throat normal. There was a slight
venous hum in the neck. The heart and lungs were normal.
The upper border of the liver flatness was at the upper border
of the sixth rib in the nipple line; the lower border was not
palpable. The spleen was palpable eight cm. below the
costal border. It was hard and smooth. The edge was
rounded, but the notch was not felt. The abdomen was large
and lax, but otherwise normal. The genitals were normal.
There was no enlargement of the peripheral lymph nodes.
The skin was normal and there were no scars of old eruptions,
no mucous patches and no rhagades. The rectal tempera-
ture was normal.
DISEASES OF THE BLOOD. 493
The urine was normal in color, acid in reaction, of a specific
gravity of 1 01 8 and contained neither albumin nor sugar.
Blood.
Hemoglobin, 90% (Sahli)
Red corpuscles, 6,896,000
White corpuscles, 6,600
Mononuclears, 21%
Polynuclear neutrophiles, 79%
The red corpuscles were normal in every way and there were
no plasmodia.
A skin tuberculin test was negative.
Diagnosis. The important points in this case are the
recurrent hemorrhages, the temporary enlargement of the
liver and the enlargement of the spleen. The blood has
never shown anything more than the evidences of a second-
ary anemia from hemorrhage and is now normal. Ulcer
of the stomach can be ruled out on the rarity of this condition
in early childhood, the absence of other symptoms of ulcer
and the enlargement of the spleen. Hereditary syphilis,
which is suggested by the enlargement of the spleen, can be
excluded on the good family history, the absence of all other
evidences of syphilis in the past or at present, the absence of
enlargement of the liver and the fact that hemorrhages of
this severity very seldom occur in syphilis except in the
severest cases and in connection with other very marked
symptoms of the disease. The enlargement of the spleen
cannot be due to malaria, because there are no plasmodia in
the blood and because hemorrhages do not occur in this
disease. It is harder to exclude cirrhosis of the liver. The
age at the onset of the symptoms, the absence of a cause, the
normal size of the liver, which is almost invariably enlarged
in cirrhosis in childhood, and the absence of ascites and
jaundice seem sufficient, however, to rule it out. The
hemorrhages show that the enlargement of the spleen is not
merely the result of some disturbance of nutrition in the past.
Pseudoleukemia can be excluded on the absence of enlarge-
ment of either the superficial or deep lymph nodes after two
and one-half years. The case undoubtedly belongs, there-
494 CASE HISTORIES IN PEDIATRICS.
fore, in the very indefinite class of diseases known as primitive
splenomegaly, splenic anemia or Banti's disease. It does
not correspond exactly, however, to any of the recognized
types, simple splenomegaly, Banti's disease, the family or
infantile form of Gilbert and Fournier or the chronic endo-
thelioma of the spleen of Gaucher. The distinctions between
these types are so indefinite clinically and there are so many
cases that do not correspond to any of them that it hardly
seems worth while to compare this case with each one of them
in detail. The diminution in the size of the liver coincidently
with an increase in the size of the spleen and the severe
hemorrhages make it resemble, however, the picture of
Banti's Disease more than that of the others. There is,
however, no pigmentation of the skin and at present no
anemia.
Prognosis. If he does not die suddenly from hemorrhage,
he will probably live for many years to eventually die with
the symptoms of cirrhosis of the liver. There is, of course,
no way to determine whether he will have more hemorrhages
or not. The chances are, however, that he will. If he does,
any one of them may prove fatal.
Treatment. There is nothing to be hoped from medicinal
treatment, as there is no drug that can affect in any way the
size of the spleen or diminish the chances of hemorrhage.
It is possible that treatment with the Roentgen ray may
diminish the size of the spleen. This method should, there-
fore, be tried. If it does not do so materially, the spleen
should be removed, because if it is not removed he is liable
to a hemorrhage, which may prove fatal, at any time. The
spleen is not adherent, the boy is in good condition and
should, therefore, stand the operation well. The chances of
death from the operation are, therefore, less than the chances
of death from hemorrhage if the spleen is not removed.
SECTION XII.
DISEASES OF THE NERVOUS SYSTEM.
CASE 152. Ronald P., six years old, was the only child of
very nervous parents. His father was alcoholic, but there was
no history of syphilis. His home surroundings were very
exciting and he was under little control. He had an ungov-
ernable temper and was in the habit of biting, fighting and
swearing when opposed. He had had the croup every winter,
but no other affections of the respiratory tract. His diet
was a fair one for the country, and his appetite and digestion
were good. He had had no other illnesses.
Three months before he was seen in consultation he began
to throw his arms up over his head in a peculiar manner, the
motions always being the same. A diagnosis of chorea was
made by his physician and he was given Fowler's solution.
Soon after taking this he began to clear his throat constantly,
while there was no diminution in the movements of his arms.
More than nine drops of Fowler's solution a day caused
edema of the eyelids, congestion of the conjunctivae and a
nasal discharge. He had taken it fairly regularly in small
doses, however, up to the time he was seen. He had begun
to shrug his shoulders about six weeks before. The peculiar
motions of the arms, the clearing of the throat and the
shrugging of the shoulders all persisted. The movements
and the clearing of the throat ceased during sleep. He did
not seem sick in other ways.
Physical Examination. He was fairly developed and
nourished and of good color. He was very excitable and was
constantly clearing his throat and shrugging his shoulders
during the examination. He could keep still when he tried.
The pupils were equal and reacted to light and accommoda-
tion. There was no coryza and he kept his mouth shut.
Examination with the finger showed no adenoids. The throat
was normal. The tongue was clean and was protruded
495
496 CASE HISTORIES IN PEDIATRICS.
without tremor. The heart, lungs and abdomen were normal.
The liver and spleen were not palpable. The extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and slightly diminished. Kernig's and
Babinski's signs were absent. There was no ankle clonus.
The cremasteric reflexes were normal, the abdominal lively.
The genitals were normal. There was no enlargement of
the peripheral lymph nodes. There was no eruption and no
irritation of the skin.
Diagnosis. The diagnosis lies betweeen chorea and habit
spasms. The clearing of the throat is not at all like chorea,
the motions are limited in number and always the same, he
can control them to a considerable extent, and there is no
tremor of the tongue. Chorea can, therefore, be excluded
and a positive- diagnosis of Habit Spasms made. These are
especially likely to develop in children of neurotic parentage
and living in exciting surroundings, as in this instance.
There is usually some local cause for the development of
the individual spasms, such as an uncomfortable hat, a
badly fitting collar or a poorly adjusted suspender. No
definite cause for the motions of the arms and the shrugging
of the shoulders was made out in this boy. The irritation
of the nose and throat caused by the arsenic was presumably
the primary cause of the clearing of the throat; its continu-
ance is due to the underlying neurotic condition.
Prognosis. These habit spasms never lead to chorea.
They are likely to persist for long periods, however, or to
be replaced by others, because, even if the local cause can
be found and removed and the individual spasm relieved, it
is very difficult to get at the underlying trouble, that is, the
inherited neurotic temperament. The prognosis is worse
than usual in this instance, because the home surroundings
are so bad and because he has not been controlled in the past.
Treatment. The treatment of habit spasms can be divided
into three parts: that directed to the removal of the local
cause of the individual spasm, if it is still present; that of
the individual spasm ; and that directed to the improvement
of the underlying neurotic condition. Nothing was found
in this instance to account for the peculiar motions of the
DISEASES OF THE NERVOUS SYSTEM. 497
arms or the shrugging of the shoulders. The local cause,
whatever it was, must, therefore, have been accidentally
remedied. The best treatment for the shrugging of the
shoulders and the motions of the arms is to have him make
these motions before a mirror for several minutes, several
times daily. What is at present an involuntary act will
come by practice under the control of the will again and hence
be performed only voluntarily. The arsenic, which was, by
the irritation which it caused, presumably the original cause
of the clearing of the throat, has already been stopped. It
is possible, however, that some local irritation still persists.
This can be treated by some mild alkaline or oily spray like
the liquor antisepticus alkalinus of the Pharmacopeia, or
the following mixture:
Menthol, I gr.
Camphor, i gr.
Liquid albolene, i oz.
The treatment of the underlying neurotic condition is a
very difficult matter. It includes, in the first place, regula-
tion of his home surroundings in general. It is probable that
little can be done in this direction. His diet, exercise, amuse-
ments and rest must all be carefully laid out. He must have
much fresh air and ought not to go to school at present.
Drugs will probably not be of much assistance, although
the tincture of nux vomica in five-drop doses, three times
daily, before meals, and eisenzucker or ferratin in five-
grain doses, three times daily, after meals, may be of some
assistance.
498 CASE HISTORIES IN PEDIATRICS.
CASE 153. Miriam T., three years old, was the first child
of nervous and not very vigorous parents. She had always
been somewhat delicate and very excitable. She had for
some weeks been having one or more attacks, almost every
evening, in which she cried out as if in terror. She was
usually awake by the time her mother or her nurse reached
her and was almost always able to tell what it was that she
feared. These were usually things which she had seen or
heard about during the day. It was learned, on questioning,
that both her mother and her nurse had been in the habit of
reading and telling stories to her, which were much too old
for her. She had recently been unwilling to go to sleep in
her room alone. Her diet was a good one and she had only
cereal and bread with milk for supper. She had no symptoms
of indigestion. She was a very active child and wanted to
be on her feet all the time. She had a rest of an hour at noon,
but did not go to sleep. She was, therefore, as a rule, very
tired and irritable by night.
Physical Examination. She was fairly developed and
nourished and of good color. She was mentally precocious
and highly excitable, but docile and easy to examine. There
was no nasal discharge or obstruction. Her tongue was clean.
There was no enlargement of the tonsils and no adenoids
could be felt with the finger. The heart, lungs and abdomen
were normal. The liver and spleen were not palpable. The
extremities were normal. There was no spasm or paralysis.
The knee-jerks were equal and unusually lively. There was
no enlargement of the peripheral lymph nodes.
Diagnosis. There can be no doubt, of course, as to the
diagnosis of Pavor Nocturnus. The normal condition of
the nose and throat shows that the attacks cannot be due to
imperfect oxidization as the result of obstruction to the
respiration. The absence of all symptoms and signs of
indigestion, together with the fact that she has a light supper,
rule out indigestion as the cause. Moreover, when night
terrors are due to disturbances of the digestion, the children
are very seldom able to tell of what they are afraid ; in fact,
they often do not know, when awakened, that they have cried
out or been afraid. When night terrors are due to an un-
DISEASES OF THE NERVOUS SYSTEM. 499
stable and overs timulated nervous system, however, the
children almost always know of what they are afraid, not
only during the attack, but also after they are awake. The
attacks in this instance are of this type. It is easy to see why
her nervous system is unstable and overstimulated. She is
the neurotic child of neurotic parents, plays too hard and has
too little rest, and is excited and worried by stories which
require an excessive amount of mental effort on her part or
which she can only partly understand.
Prognosis. The attacks will gradually diminish in fre-
quency and finally cease, if her life is so regulated that she
does not get overtired, either physically or nervously, and
hears only such stories as are suitable for her age.
Treatment. The treatment consists in regulating her life
so that she does not get overtired, in guarding her from
excitement and in stopping all stories which are liable to
disturb or frighten her. She must not be allowed to run
about as much as she pleases, but must be wheeled in her
carriage or taken out to drive a part of the time. She must
have a long rest at noon and get to bed by half-past five in
the afternoon. She must be left to amuse herself as much as
possible and must not be played with any more than is
absolutely necessary. She ought not to see anyone outside
of her immediate family. If any stories are told to her, they
must be simple and have nothing in them which is unpleasant
or exciting. It will be well to give her ten grains of the
bromide of soda at bedtime for a few nights in order to break
the habit of waking up in the early evening, into which she
has fallen.
500 CASE HISTORIES IN PEDIATRICS.
CASE 154. Porter M., four years old, was the fourth child
of healthy parents. He was born at full term after a normal
delivery and was normal at birth. His father had had several
convulsions when a child. One of his brothers, ten years old,
was in an asylum for epileptics for convulsions which began
after a fall out of bed at two years.
He had always been perfectly well up to six months before,
when, in common with his sister, he had an acute attack of
fever and vomiting, apparently due to drinking milk from a
sick cow. Both had convulsions at the onset of the illness.
His sister had no more. He was in bed four days and had
several convulsions during that time. His next convulsion
was two weeks after he was up and about. Since then he
had had a great many convulsions, lasting from one to five
minutes. His mother thought that he did not lose con-
sciousness in them. He never frothed at the mouth, bit
his tongue or passed urine or feces. He also had many very
short attacks in .which he apparently lost consciousness
momentarily, dropped things, stared for an instant and so
on, but never fell down. Various diets had been tried with-
out effect. He was for some time on a strictly vegetable
diet, at another had nothing but malted milk for a month,
and at another only milk, bread and cookies. His appetite
was good and he had no signs of indigestion except that
he was ver> constipated. The movements at times con-
tained mucus, but were otherwise normal. He had been
circumcised and had adenoids removed without any effect
on the convulsions. His mental condition was perfectly
normal.
About six weeks before he was seen in consultation the
convulsions became much more frequent and severe and
bromide was begun. Since small doses had no effect on the
convulsions, the dosage was increased until he was taking
enormous amounts with the addition of chloral. Since
taking the bromide he had become so stupid that he could
not hold up his head or hold things in his hands, kept his
mouth open and drooled constantly. His appetite had
fallen off and he had lost considerable weight. The severe
attacks were relieved by the bromide, but he continued to
DISEASES OF THE NERVOUS SYSTEM. 501
have the mild ones. The bromide had been diminished during
the last week and he had begun to be more like himself.
Physical Examination. He was fairly developed and
nourished and moderately pale. He took very little notice
of his surroundings, although at times he brightened up
momentarily and appeared perfectly normal mentally. He
held up his head with some difficulty and could hardly sit
alone. He could walk with help, but very feebly and un-
steadily. He kept his mouth open and drooled constantly.
There was no spasm or paralysis of any of the muscles con-
trolled by the cranial nerves. The fundi of the eyes showed
nothing abnormal. The ear-drums were normal. The tonsils
were large, but not inflamed. The tongue was considerably
coated. The heart, lungs and abdomen were normal. The
lower border of the liver was just palpable in the nipple
line. The spleen was not palpable. The extremities were
normal. There was no spasm or paralysis. All his motions
were, however, unsteady and feeble. The knee-jerks were
equal and normal, as were the abdominal and cremasteric
reflexes. Kernig's and Babinski's signs were absent. The
sensation to touch and pain was slightly dulled. He was
circumcised. There was no enlargement of the peripheral
lymph nodes.
The urine showed nothing abnormal.
Diagnosis. The bromide intoxication obscures the diag-
nosis to a certain extent. There is but little doubt, however,
that the stupidity and muscular weakness are due to the bro-
mide and not symptoms of any cerebral disease. The omis-
sion of the bromide will quickly settle this point. The absence
of spasm, paralysis, changes in the reflexes and of Kernig's
and Babinski's signs, and the normal condition of the
fundi, prove that there is no gross cerebral lesion. The
diagnosis lies, therefore, between "idiopathic" epilepsy and
reflex convulsions, presumably from disturbance in the
digestive tract, since all other causes of reflex convulsions
are excluded by the physical examination. The family
history is of but little aid, as the tendency to convulsions
from slight causes, shown in the father and sister, balances
the epilepsy in the brother. The onset of the convulsions
502 CASE HISTORIES IN PEDIATRICS.
with the onset of an acute disease is somewhat against
epilepsy, but does not by any means exclude it, because the
first convulsions may have caused some cerebral lesion which
resulted in epilepsy, or the acute disease may have lighted
up a latent epilepsy. The nature of the attacks, which,
according to the parents, are not accompanied by an initial
cry or loss of consciousness, is somewhat against epilepsy,
but does not exclude it, because a cry is often lacking in
epilepsy and because the parents may be wrong as to the
retention of consciousness. In fact, they probably are, be-
cause if he loses consciousness in the slight attacks he almost
certainly does in the more severe ones. On the other hand,
the symptoms of disturbance in the digestive tract are hardly
severe enough to make it probable that there is sufficient
intestinal irritation or toxic absorption from the intestines
to cause so many and so severe convulsions. Regulation of
the diet and of the bowels has had, moreover, no effect on
the number or severity of the convulsions. The chances
are, therefore, that the condition really is Epilepsy. The
only way to settle the diagnosis positively, however, is by
careful regulation of the diet, bowels and general routine
for a considerable time. If the convulsions persist, the
diagnosis of epilepsy will be confirmed; if they cease, it will
have to be changed to reflex convulsions.
Prognosis. The prognosis depends on the final diagnosis.
If this is epilepsy, there is a possibility of recovery, but the
chances are very much against it. The convulsions will,
however, probably become much less frequent but more
severe.
Treatment. The bromide should be stopped for the
present in order to determine positively as to his mental and
physical condition. He should be put on a diet of milk and
starches to diminish intestinal putrefaction and his bowels
kept freely open, preferably with some mild saline, like
phosphate of soda. There is no objection to adding fruit
and green vegetables to the diet for their laxative action.
He must, of course, be carefully watched to prevent him from
injuring himself during the attacks.
DISEASES OF THE NERVOUS SYSTEM. 503
CASE 155. Francis M., eight years old, was the second
child of healthy parents. The other child died of diarrhea
in infancy. There had been no miscarriages. There was
no history of epilepsy in either family. He was borni'at full
term, after a normal labor, and was normal at birth. He
was breast-fed for eighteen months and was well, except for
mumps at three and one-half years, until he was four years
old. At this time he had a series of convulsions lasting twelve
hours, followed by a period of unconsciousness lasting thirty-
six hours, as the result of an indiscretion in diet following a
long walk and playing in the sun all day in August. He was
treated in the Children's Hospital at that time and no cause
for the convulsions and unconsciousness was found outside of
the indiscretion in diet and exposure to heat. He was dis-
charged well at the end of a week. ] []
He began to have convulsions soon after this and had
continued to have them. He usually had one or two con-
vulsions a week, but sometimes went two or three weeks
without any. They ordinarily came in the early morning,
during sleep, and lasted four or five minutes, after which he
slept until it was time to get up. He was backward at school,
probably because he did not go to school until he was seven
years old. His teacher said that he learned fairly easily, but
that at times he seemed uninterested. At home he was mis-
chievous and hard to manage.
Four weeks before he was seen, twitching of the right arm
and leg, with some weakness and awkwardness of that side,
developed and he began to drag his right foot a little when he
walked. His speech became a little indistinct. He was
restless at night and tossed about the bed, but did not twitch
when he was asleep. His appetite continued good and his
bowels regular.
Physical Examination. He was well developed and nour-
ished and of good color. He seemed perfectly normal
mentally, but his speech was a little indistinct. The pupils
were equal and reacted to light and accommodation. The
fundi were normal. His tongue was protruded in the median
line and was decidedly tremulous. The throat was normal.
There were frequent, involuntary twitching movements of
504 CASE HISTORIES IN PEDIATRICS.
both sides of the face. There was no rigidity of the neck or
neck sign. The heart, lungs, abdomen and genitals were
normal. The liver and spleen were not palpable. The
extremities were normal. There were frequent involuntary
movements of the right arm and leg, and occasionally of the
left arm and leg. The involuntary movements all ceased
when he was asleep. He walked somewhat awkwardly and
had rather poor control of his right leg. He was unable to
make fine movements with his right arm. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's and Babinski's signs were absent. There was no
wasting of the muscles and no disturbance of sensation to
touch or pain. There was no enlargement of the peripheral
lymph nodes. The mouth temperature was 98. 6° F. ; the
pulse, 90; the respiration, 16.
He was seen in a convulsion. The convulsion was general
and clonic and was not preceded by a cry. It lasted about a
minute, after which he slept for an hour. The face was
cyanotic. There was no frothing at the mouth, but he would
have bitten his tongue if the jaw had not been held.
Diagnosis. The character of the convulsions, their fre-
quent repetition without obvious cause, the fact that they
occur more often at night than during the day, together with
the fact that up to the last month there have been no other
symptoms of disturbance of the nervous system, justify a
positive diagnosis of Idiopathic Epilepsy. The next point
to be decided is whether the new symptoms which have
appeared within the last month are manifestations of the
same cerebral lesion which causes the epilepsy or of some
entirely distinct condition. The facts that the involuntary
motions are more marked on the right side than on the left,
that the right arm and leg are not used as well as the left and
that there is a disturbance of the speech, suggest that there
is a lesion of the cortex in the left motor area. The involun-
tary motions are, however, not limited to the right side, they
are equally active on both sides of the face, the tongue is
protruded in the median line, the disturbance in speech is not
aphasic in character but merely a manifestation of awkward-
ness in the use of the tongue, the fundi are normal, there is
DISEASES OF THE NERVOUS SYSTEM. 505
no spasm of the extremities and the deep reflexes are normal.
These points are sufficient to rule out a localized cortical
lesion and point very strongly to chorea. The tremulousness
of the tongue is very strong evidence in favor of this diag-
nosis, while the fact that the motions stop during sleep justi-
fies, in connection with other evidence, a positive diagnosis
of Chorea.
Prognosis. The chorea is of a relatively mild type and
recovery may be expected in a few weeks. The only danger
from the chorea is of a complicating cardiac lesion. The
chances of recovery from the epilepsy are very small, although
better than they would be if he was an adult. The con-
vulsions will, however, probably become less frequent but
more severe.
Treatment. The most valuable thing in the treatment of
chorea is quiet, both physical and mental. He should be
put to bed and kept there until the symptoms are much
improved, and then allowed to get up gradually. He ought
to be left by himself as much as possible. Whoever is with
him must be quiet and he must be amused in quiet ways.
Visitors should not be allowed. He should, of course, be
given all the fresh air and sunlight possible. The next most
important point in the treatment is the regulation of the
diet. He must be fed liberally with food suitable for his age,
due consideration being paid to the fact that he is in bed.
There are no special indications as to the kind of diet in
chorea. It will be well, however, to keep the meat and eggs
low in this instance, because of the epilepsy. It will be wise,
on account of the undoubted relationship between chorea and
rheumatism, to give him five grains of aspirin, three times
daily, after meals, for a time, in order to diminish the chances
of the development of endocarditis. His appetite, digestion
and color are good and there is, therefore, no indication for
the administration of a tonic. Arsenic, in the writer's
opinion, has no specific action in chorea, whatever good it
may do being due to its action as a tonic. It is not indicated,
therefore, in this instance. A warm bath at bedtime will un-
doubtedly quiet him and may be given oftener, if necessary.
If he becomes more restless, he may be wrapped in a cold,
506 CASE HISTORIES IN PEDIATRICS.
wet sheet, with a blanket outside, and left in it for an hour
daily.
It will be well to give him twenty grains of bromide of soda
at bedtime for the epileptic convulsions. It is not necessary
to give it during the day, because his convulsions are almost
entirely nocturnal. The bromide will have more effect if
salt is largely eliminated from his diet. It will probably be
necessary for him to take bromide for a long time, perhaps
in considerably larger doses. In giving it, it must not be
forgotten, however, that in childhood, bromide has a very
depressing action both on the mind and body and that, unless
used with discretion, it may do far more harm than good.
DISEASES OF THE NERVOUS SYSTEM. 507
CASE 156. Mary B., two years old, was the second child
of extremely neurotic parents. She had always been far
ahead of her age in her mental development. She was not
nursed but was fed during the first year on modified milk,
prepared at home, and then on a very careful diet. She had
always been very constipated and had had various laxatives,
enemata and suppositories almost constantly since birth.
Her digestion, except for occasional acute upsets, had been
otherwise fairly good. She had had no other illnesses except
two attacks of bronchitis and a mild attack of pyelitis. She
sat up alone at eleven months and walked at twenty months.
She cut her first tooth at ten months, but had eight when a
year old.
She began to have convulsions when a year old. She
almost always had one or two, and often as many as half a
dozen, daily. The longest interval between convulsions
during the year had been ten days. They almost always
came on when she was angry, frightened or in pain. A fit
of crying almost always ended in a convulsion. She would
often have one if she was refused anything which she wanted.
A fall or a bump was usually followed by one. She often had
one during defecation, if the movement was hard. She was
seen in one, which came on as the result of a rectal examina-
tion. She cried, held her breath and became a little blue.
She then gave a short cry, stiffened out, raised her clenched
hands before her face and then slowly dropped them. She
was not cyanotic, breathed regularly during the attack,
made no other movements, lost consciousness and passed
both urine and feces. The attack did not last more than half
a minute. She was dull and pale for several minutes after
it. Her mother said that this was an unusually severe one
and that many of them were merely slight " fainting spells."
The attacks occurred more frequently when the bowels were
not moving freely, when she was cutting teeth, when she
was not kept free from excitement, and when she was below
par physically. She had never had any definite attacks of
laryngismus stridulus, and Trousseau's symptom and the
facial phenomenon had been absent at repeated examinations.
Physical Examination. She was small but fairly nourished.
508 CASE HISTORIES IN PEDIATRICS.
Her flesh was firm and her color good. Her mental develop-
ment was nearer that of a child of three than of two years.
The anterior fontanelle was not quite closed. There was no
craniotabes. She had sixteen teeth. Her mouth and throat
were normal and her tongue clean. There was no spasm or
paralysis of any of the muscles controlled by the cranial
nerves. There was a slight rosary. The heart, lungs and
abdomen were normal. The liver was just palpable in the
nipple line. The spleen was not palpable. The extremities
were normal. There was no spasm or paralysis. The knee-
jerks were equal and normal. Kernig's and Babinski's signs
were absent, as were Trousseau's sign and the facial phe-
nomenon. There was no enlargement of the peripheral
lymph nodes.
The urine was pale in color, acid in reaction and of a specific
gravity of 1,015. It containd neither albumin nor sugar.
The sediment showed nothing abnormal.
Diagnosis. The absence of Trousseau's symptom, the
facial phenomenon and attacks of laryngismus stridulus
shows that the convulsions are not manifestations of the
spasmophilic diathesis (see Cases 100 and 164). The absence
of spasm and paralysis, the normal condition of the reflexes,
the absence of Kernig's and Babinski's signs and the normal
mental development rule out any gross cerebral lesion. The
diagnosis lies, therefore, between " idiopathic epilepsy " and
reflex convulsions from slight causes in a child with an unu-
sually irritable nervous organization. The character of the
convulsions and their long continuance are in favor of epilepsy.
The strongest point against it is the fact that the convulsions
never occur without some definite cause. This fact, while
it does not rule out epilepsy, is important enough to more
than counterbalance the character and continuance of the
convulsions and to make epilepsy very improbable. The
chances are, therefore, against epilepsy and in favor of
Reflex Convulsions. Time alone, however, can settle the
diagnosis positively. If they persist after she grows older and
can be better controlled, the diagnosis will have to be changed
to epilepsy.
Prognosis. The convulsions will probably gradually
DISEASES OF THE NERVOUS SYSTEM. 509
diminish in frequency and finally cease as she grows older
and can be reasoned with and taught self-control.
Treatment. The treatment consists in regulation of her
diet and bowels, and in training her in self-control. This
will, however, be very difficult because crossing her is very
likely to bring on a convulsion. She must be made to obey
and to lead a normal life even if the number of convulsions is
temporarily increased, as in this way only can she be con-
trolled. Quiet surroundings and freedom from excitement are
especially important in this connection. There is no direct
indication for medicinal treatment. Everything which will
tend to improve her physical condition is, of course, of im-
portance. The most minute details of her life must be looked
into and regulated.
510 CASE HISTORIES IN PEDIATRICS.
CASE 157. Frances B., five years old, was the only child
of neurotic parents, belonging to neurotic families. There
had been no other pregnancies. She had always been per-
fectly well except for occasional "colds" and an attack of
pneumonia a few months before. She had, however, always
been very excitable and unusually bright for her age. It was
noticed when she was only a few months old that she often
rubbed her legs together and appeared to enjoy it. A little
later it was noticed that she would stop after a short time and
perspire freely. The real significance of this was not appre-
ciated, however, until she was about three years old. She
had done it only when undressed and in bed up to a
year before, since when she had also done it when up and
dressed. She rubbed her legs together without any very
wide motions and had perfectly definite orgasms with re-
laxation and perspiration. She had been reasoned with
and mildly punished, but was apparently unable to con-
trol herself when left alone. There had been no increased
frequency of micturition and no pain on micturition. No
pin-worms had been seen on repeated examinations. Her
hygienic surroundings, diet and care were ideal. She had
been especially protected against overexcitement and over-
fatigue.
Physical Examination. She was well developed and nour-
ished and of good color. In fact, she was the picture of
health. She was very forward mentally, but did not appear
unduly nervous or excitable. No adenoids were felt with the
finger. Her tongue was clean, her teeth good and her throat
normal. The heart, lungs and abdomen were normal. The
liver and spleen were not palpable. The extremities were
normal. There was no spasm, paralysis or disturbance of
sensation. The knee-jerks were equal and normal and there
was no Kernig's sign. There was no enlargement of the
peripheral lymph nodes. The internal surfaces of the labiae
were slightly reddened. The prepuce was adherent to the
clitoris, but there was no evidence of local irritation. There
was no vaginal discharge.
The urine was pale, slightly acid in reaction, of a specific
gravity of 1015 and contained no albumin or sugar.
DISEASES OF THE NERVOUS SYSTEM. 511
Diagnosis. This habit, which is usually spoken of as
masturbation, is better described by the term, Pseudo-
masturbation, because, although it is sometimes associated,
as in this instance, with a definite orgasm, it does not and
cannot have at this age the same significance as in later
childhood and adult life. At this time it is simply a habit,
like picking the nose, indulged in because it is pleasant and
without any definite purpose or sexual idea. Further evi-
dence that this habit is not true masturbation is her good
general condition and her normal intelligence, which show
that neither her mental nor her physical development have
been in any way affected by it. It is a habit that must be
stopped, however, because, if it is not, it will, as she grows
older, lead to true masturbation.
Prognosis. It will be unusually difficult to break up the
habit in this instance, because it has persisted since early
infancy and is increasing. She is, moreover, old enough to
have a strong will of her own, but not old enough to have
much moral sense or to be very successfully reasoned with.
Her neurotic tendencies will make her harder to control, but,
on the other hand, her mental forwardness will make it easier
to reason with her.
Treatment. In the first place all sources of local irritation
must be removed. The urine is normal and there are no pin-
worms in this instance. The slight irritation of the inner
surfaces of the labiae is probably an effect rather than a cause.
It should, however, be treated with some simple salve, like
boracic acid ointment. It will be wise to strip back the
foreskin, under ether if necessary, and remove any smegma
that may be present. Amputation of the clitoris, as is some-
times recommended, is absolutely unjustifiable. Her drawers
and night clothes should be lined with linen, wherever they
come in contact with the inner surface of the thighs and
genitals. Nothing will be gained by punishment. It will be
much more likely to make her tricky and deceitful than to
stop the habit. She must be told not to do it, but told in
the same way that she would be told to stop picking her nose
or biting her nails. If it is spoken of as if it were some
terrible thing or too much made of it, the result will be to
512 • CASE HISTORIES IN PEDIATRICS.
attract her attention to it and make her do it more. Great
tact must be used in talking with her not to suggest the habit
to her.
She must be watched constantly during the day, but in
such a way that she does not realize that she is under sur-
veillance. Someone must stay in the room with her, if she
has a rest at noon. She must not be left alone at night until
after she has gone to sleep. Someone must sleep in the room
with her to prevent her from doing it when she wakes in the
morning. If this plan is not feasible or sufficient, an appara-
tus consisting of an iron bar firmly attached to a band about
each thigh, which will prevent her from rubbing her thighs
together, may be applied.
DISEASES OF THE NERVOUS SYSTEM. 513
CASE 158. Eva C. was the second child of healthy parents.
Two other children were well. There had been no deaths
or miscarriages. She was born at full term and was thought
to have been normal at birth. A physician who saw her when
she was eleven weeks old, because of a convulsion, told her
parents, however, that her head was small. She had had
repeated slight convulsions since that time, except when she
was taking bromide. She was nursed for a year. Since then
she had had only liquids, because she refused to chew or
swallow anything solid. She had never had any disturbance
of the digestion. She was very backward in every way. She
sat up first at one year and cut her first tooth at the same time.
She had never held things in her hands. Her parents thought
that she noticed light, but nothing else. They were sure that
she did not hear. She rolled her head from side to side con-
stantly, except when she was asleep. She seldom cried.
She was seen when seventeen months old.
Physical Examination. She was well developed and
nourished, and of good color. The shape of her head was
very peculiar, in that there was almost no occiput. The face
and forehead were normal. The anterior fontanelle was
closed. The occipito-frontal circumference of the head was
37.5 cm. ; that of the chest at the level of the nipples, 46 cm.
The average circumference of both at this age is about 46 cm. ;
that of the head being slightly- the larger. The antero-
posterior diameter of the head was 12 cm. ; the lateral, 10 cm.
The pupils were equal and reacted to light. She did not,
however, notice anything, even light. The fundi showed
nothing abnormal. She did not pay any attention to sounds.
The mouth, throat and tongue were normal. She had three
teeth. The thyroid was indistinctly palpable. She held her
head up well, but sat up very unsteadily. There was no
rosary. The heart, lungs and abdomen were normal. The
lower border of the liver was palpable three cm. below the
costal border in the nipple line. The spleen was not palpable.
The extremities showed nothing abnormal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
Kernig's sign was absent. She would not hold anything in
her hands, even when it was placed in them. Sensation to
514 CASE HISTORIES IN PEDIATRICS.
touch and pain was normal. The skin was soft and there was
no eruption or scars of old eruptions. Her hair was fine and
thick. There was no enlargement of the peripheral lymph
nodes.
Diagnosis. She is unquestionably a low-grade idiot.
There are no signs of cretinism. The history is not that of
amaurotic idiocy and the fundi are normal. The face is
not of the Mongolian type. The head is not hydrocephalic,
but is much smaller than normal. The diagnosis of Micro-
cephalic Idiocy is, therefore, without doubt, the correct one.
Prognosis. Very little improvement can be expected.
She will always be a very low-grade idiot. The chances are,
however, that she will not live to grow up, but will die of some
intercurrent disease within the next one or two years.
Treatment. There is nothing to do for her except to feed
her and keep her warm and clean. Craniectomy is a useless
procedure, because the small size of the head is not due to a
premature closing of the fontanelles and sutures, but to the
small size of the brain. The mental defect is not caused by
pressure of the bones on the brain, but is due to a congenital
cerebral malformation. The fontanelles and sutures close
early and the head is small because, on account of the small
size of the brain, the intracranial pressure is not sufficient to
keep the bones apart. She may be given five grains of the
bromide of sodium from three to six times daily, if the con-
vulsions persist and are severe.
DISEASES OF THE NERVOUS SYSTEM. 515
CASE 159. Joseph C. was the first child of healthy Jewish
parents. There had been no miscarriages. He was born at
full term after a normal labor and was normal at birth,
although very small. He was breast-fed entirely until he
was eight and one-half months old, after which he was ration-
ally fed. His digestion had always been good. He " acted
just like any other baby " until he was three or four months
old, smiled, took things in his hands, was interested in his
surroundings and kicked out with his legs. He had not
learned to hold up his head, however. He then ceased to
develop mentally and soon began to deteriorate, so that
when he was eight months old his parents were sure that he
was " not bright." He became dull and stupid, did not notice,
would not hold things in his hands and seldom moved.
Rigidity of the extremities developed when he was fourteen
months old, and twitching of the face when he was seventeen
months old. He began to have convulsions a few days before
he was seen, when eighteen months old. He had taken his
food well up to a few days before, when he began to have
difficulty in swallowing.
Physical Examination. He was fairly developed and nour-
ished, but markedly pale. His head was of good shape and of
normal size. The anterior fontanelle was 3 cm. in diameter
and slightly depressed. There was no craniotabes. He was
unable to hold up his head, which rolled limply from side to
side. He heard but could not see. The pupils were equal
and reacted to light. His expression was vacant. He kept
his mouth open and drooled constantly. He had six teeth.
The throat was normal and there were no adenoids. He could
not sit up. The back showed a marked curve of weakness.
There was a moderate rosary. The heart, lungs and abdomen
were normal. The liver was palpable 1 cm. below the costal
border in the nipple line. The spleen was not palpable. He
lay on his back and seldom moved, except to turn his head.
He held his hands flexed at the wrists, with the fingers
partially flexed. There was, however, very little resistance
to passive extension of the fingers and hands. The arms
dropped flaccidly when lifted up. He usually held his legs
and feet extended. There was at times marked opposition to
5l6 CASE HISTORIES IN PEDIATRICS.
passive motions; at others, the legs were perfectly flaccid.
The knee-jerks were usually absent; when present, they
were very feeble. The cremasteric and abdominal reflexes
were present. There was no ankle clonus. Kernig's and
Babinski's signs were absent. Sensation to both touch and
pain was present. There was a slight general enlargement
of the peripheral lymph nodes. There was no eruption and
there were no scars of old eruptions. There were no mucous
patches about the mouth or anus and no rhagades about the
mouth. The rectal temperature was 990 F. ; the pulse, no; the
respiration, 30. He weighed seventeen and one-half pounds.
The urine was high in color, acid in reaction and of a specific
gravity of 1,024. It contained neither albumin nor sugar.
The sediment showed an excess of urates, but no cells or casts.
Diagnosis. This boy is undoubtedly an idiot. His race,
the normal condition at birth, the normal development for
some months followed by progressive physical and mental
deterioration, taken together with the general flaccidity and
the blindness, form a combination so characteristic of Amau-
rotic Idiocy that a positive diagnosis of this condition is
justified without further examination. There is no other
condition which shows just this combination of history and
physical signs. The diagnosis should, however, be verified
by an examination of the fundi which in this disease present
a picture which is absolutely pathognomonic. This is a dark,
reddish-brown, circular spot occupying the site of the macula
lutea and surrounded by a whitish zone about twice the
diameter of the optic disk. The eyes of this boy were exam-
ined and the characteristic picture found, thus verifying the
diagnosis.
Prognosis. The prognosis is absolutely hopeless. If he is
not fed with a tube, he will quickly starve to death. If he is
fed with a tube, he may live for many months. Sooner or
later, however, he will die of bronchopneumonia or some other
intercurrent disease.
This disease is preeminently a familial one. The chances
are, therefore, that if his parents have more children, some
or all of them will be afflicted with the disease. They may,
however, all escape.
DISEASES OF THE NERVOUS SYSTEM. 517
Treatment. There is no treatment for this disease. Nothing
can be done to relieve it or to shorten its course. It is not
justifiable to let him die of starvation. He must be fed
with a stomach tube, therefore, and taken care of until he
dies.
518 CASE HISTORIES IN PEDIATRICS.
CASE 1 60. Helen T.'s parents were feeble but not alco-
holic or especially nervous. One other child was well. There
had been no deaths or miscarriages.
She was born at full term after a normal labor, and seemed
normal at birth. She had always been fed on condensed
milk and recently had had crackers in addition. She had
never been ill, except for a mild attack of diarrhea a month
before. She had always been backward, but her parents had
not thought much of it until she was sixteen months old.
She had never learned to sit up alone and could say but one
or two words. She was usually quiet and good-natured, but
moaned occasionally. She was seen when two years old.
Physical Examination. She was fairly developed and
nourished, but pale and flabby. Her expression was dull and
stupid. She stared about without taking much notice, but
could see and hear. She usually lay quietly, with the excep-
tion of coarse movements of her arms and fingers. She
apparently amused herself by making a peculiar sucking
noise and frequently made grimaces by putting out her
tongue and rolling up her eyes. Her cry was hoarse but she
said nothing. Her head was of good shape. The fontanelles
were closed. The circumference of the head was 45 cm.
(normal is 48 cm.); that of the chest, 43 cm. (normal is
51 cm.). Her hair was soft and fine. The palpebral openings
were narrow and the eyes appeared deep-set. The outer
canthi were slightly higher than the inner. The epicanthic
folds were not marked. The pupils were equal and reacted
to light. The nose was short and flat and wider than usual
between the eyes. She had twelve teeth. Her tongue was
somewhat enlarged, but moist and smooth. She kept it
protruded beyond the lips most of the time. A moderate
amount of adenoids was felt with the finger. The throat was
otherwise normal. The neck was of normal length and there
were no supraclavicular pads. The thyroid was of normal
size. She was able to hold up her head, but not to sit alone.
There was a marked curve of weakness. There was a slight
rosary. The heart and lungs were normal. The abdomen
was slightly enlarged, but otherwise normal. The liver and
spleen were not palpable. The extremities were of normal
DISEASES OF THE NERVOUS SYSTEM. 5 19
length, the distance from the anterior superior spine to the
sole being forty-six per cent of the total length. The epiphyses
at the ankles were slightly enlarged. The hands were of good
shape, except that the little fingers curved in rather more
than usual. She had no idea of standing up or what her legs
were for. There was no spasm or paralysis. The knee-jerks
were equal and normal. Kernig's sign was absent. There
was no enlargement of the peripheral lymph nodes. The skin
was normal.
The urine was cloudy, straw-colored, acid in reaction, and
contained neither albumin nor sugar. The sediment consisted
of amorphous phosphates.
Blood.
Hemoglobin,
Red corpuscles,
White corpuscles,
70%
5,192,000
12,400
Diagnosis. This child is, of course, an idiot. The history
and the fact that she sees rule out amaurotic idiocy. The
normal size and shape of the head exclude hydrocephalic and
microcephalic idiocy. The absence of spasm, paralysis and
exaggerated reflexes shows that there is no gross cerebral
lesion, either congenital or as the result of hemorrhage at
birth. The enlargement and protrusion of the tongue and the
expression of the face suggest cretinism to a certain extent.
This can be excluded, however, on the fineness of the hair,
the normal condition of the skin, the absence of supraclavicu-
lar pads, the normal length of the neck and of the extremities
and the normal shape of the hands and feet. There are many
points about the physical examination which are in favor of
the Mongolian type of idiocy. These are the hoarse cry,
the narrow palpebral openings, the obliqueness of the eyes,
the distance between the eyes, the short and flat nose, the
enlargement of the tongue and the incurvation of the little
fingers. The incurvation of the little fingers is so common
however, even in normal persons, that it is of little importance.
It is true that the back of the head is of good shape, that the
epicanthic folds are not marked, that the angle of the eye
is but very little increased and that the tongue is not dry and
520 CASE HISTORIES IN PEDIATRICS.
fissured. Marked changes in the tongue almost never develop
as early as two years, however, and the head is not always
flattened anteroposteriorly in Mongolian idiocy. The angle
of the eyes and the development of the epicanthic folds are
merely questions of degree. The diagnosis of Mongolian
Idiocy is, therefore, justified.
Prognosis. Mongolian idiots are extremely susceptible to
infection and resist disease very badly. She will probably,
therefore, not live many years. There is no prospect that she
will become a useful member of society or able to support
herself. She will probably be able to walk and can probably
be taught to feed herself and be cleanly in her habits. Little
more than this can be expected.
Treatment. She should be placed in some institution for
the feeble-minded, because children are better taught and
better cared for in such institutions than at home and be-
cause, when in an institution, they do not serve as bad
examples to other children.
Joseph C. Case 159.
Helen T. Case 160.
DISEASES OF THE NERVOUS SYSTEM. 52 1
CASE 161. John D. was the eighth child of healthy
parents. There had been no deaths or miscarriages. He was
born at full term after a very difficult labor in which his head
was much bruised and the left clavicle broken. His head was
much misshapen at birth, but when he was a month old seemed
perfectly normal. His mother noticed when he was two
months old that his head was becoming larger. She thought
that it had increased in size very rapidly during the last week.
When he was two and one-half months old she noticed that
the eyes "dropped down" and that he did not close the lids
when he was asleep. She said that he moved his extremities
normally, but that he was quieter than her other babies had
been. He rarely cried and took but little notice. In fact,
she was not sure that he could see. He was entirely breast-
fed, had had no disturbance of digestion and had gained
steadily in weight. He was seen in consultation when three
months old.
Physical Examination. He was well developed and nour-
ished and of good color. The head was much and symmetri-
cally enlarged. The anterior fontanelle was six cm. in diam-
eter and bulging, while the posterior fontanelle was two cm.
in diameter. The saggital, coronal, frontal and lambdoid
sutures were open. The occipito-frontal circumference of the
head was forty-six cm. (average is 39.5 cm.). The superficial
veins of the scalp were much enlarged. The forehead was
very prominent and the face appeared small. He could not
close his eyelids and a quarter of an inch of conjunctiva was
visible above the iris when the eyes were open. The pupils
were equal and reacted to light. He both saw and heard.
There was no spasm or paralysis of any of the muscles sup-
plied by the cranial nerves. There was no nasal discharge
and he kept his mouth shut. The heart, lungs, abdomen and
genitals were normal. There was no rosary. The circum-
ference of the chest at the nipples was thirty-nine cm. (aver-
age is 38 cm.). The lower border of the liver was palpable
two cm. below the costal border in the nipple line. The
spleen was not palpable. The extremities were normal.
There was no spasm or paralysis. The knee-jerks were equal
and normal. Kernig's sign was absent. There was no
522 CASE HISTORIES IN PEDIATRICS.
enlargement of the peripheral lymph nodes. There was no
eruption and there were no scars of any old eruption. There
were no mucous patches or rhagades about the mouth or
anus.
Diagnosis. There can be no doubt, of course, that the
trouble is Congenital Chronic Internal Hydrocephalus.
Rachitic enlargement of the head, the only condition with
which it could be confused, can be excluded on the age of the
baby, the symmetry of the head, the bulging of the fontanelle,
the open sutures, the enlargement of the veins of the scalp,
the pushing down of the eyes and the absence of all other
signs of rickets. The absence of spasm, paralysis, exaggera-
tion of the deep reflexes and Kernig's sign is presumably due
to the relatively slow accumulation of the fluid, the brain
having had time to accommodate itself to the gradual in-
crease in the pressure. Syphilis can be excluded as the cause
of the hydrocephalus in this instance on the good family
history and the absence of all signs of syphilis. The etiology
is, therefore, as in most such cases, entirely obscure.
Prognosis. The prognosis is practically hopeless. The
head will almost certainly increase steadily in size and death
ensue in a few months. It is barely possible, however, that
the process will, after a time, cease. If it does, he will in all
probability be more or less deficient mentally and probably
be partially paralyzed. There is a small chance, however,
that he may be normal both mentally and physically, except
for a large head. There is no possibility of a diminution in
the size of the head, even if the process ceases and he survives.
Treatment. It being possible to exclude syphilis as the
etiological factor in this case, nothing whatever can be
accomplished by medicinal treatment. The removal of the
fluid by lumbar puncture or by tapping the lateral ventricles
is a useless procedure, because it does not remove the cause
of the trouble and the fluid consequently quickly reaccumu-
lates. The injection of astringent solutions into the lateral
ventricles is open to the same objection. Draining the
cerebrospinal fluid into the peritoneal cavity through a
trephine opening in a lumbar vertebra is a simple operation
and temporarily effective. Unfortunately, the opening is
DISEASES OF THE NERVOUS SYSTEM. 523
always soon closed by adhesions or the overgrowth of granu-
lation tissue, even when a silver tube is used. Various
operations, the object of which is to drain the fluid from the
lateral ventricles into the subarachnoid space, one of the
cerebral sinuses or a vein in the neck, are possible. They are
all open to the same objection and that is, that unless the
connection is made through some normal channel, like a
transplanted vein or artery, Nature quickly heals the wound
and stops the drainage. If a transplanted vessel is used to
make the connection there is, however, a reasonable chance
of permanent cure. All these operations are, of course,
extremely dangerous. This baby can see and hear, and has
no spasm or paralysis. If the process can be stopped now
and further increase of intracranial pressure prevented, he
will almost certainly develop normally both physically and
mentally. He is in good general condition and a good
operative risk. He is practically certain to die if he is not
operated upon or, if he does not, to be a paralytic imbecile.
It seems justifiable, therefore, to advise an operation for
permanent drainage through a transplanted vessel, provided
a surgeon competent to perform the operation is available,
although the chances are that he will die during or as the
result of the operation.
524 CASE HISTORIES IN PEDIATRICS.
CASE 162. Joseph K. was the second child of healthy
parents. The other child was well and there had been no
miscarriages. He was born at full term, after a normal labor,
and was normal at birth. He was breast-fed, gained rapidly
in weight and developed normally until he was nine months
old, when he had an attack of cerebrospinal meningitis.
The parents thought that he had been blind and deaf since
this illness, and had noticed that his head had increased
rapidly in size during the past month. He took the breast
well and had no disturbance of digestion. He was brought
to the Infants' Hospital, when he was eleven months old,
because of the blindness, deafness and enlargement of the
head.
Physical Examination. He was well developed and nour-
ished and of fair color. His head was somewhat enlarged,
the occipito-frontal circumference being forty-eight cm.
(average is 45 cm.). The enlargement was symmetrical.
The anterior fontanelle was four and one-half cm. in diam-
eter and bulging. The posterior fontanelle and sutures were
closed. He was able to hold up his head, but rather feebly.
He could not sit alone. The conjunctivae were not visible
above the irides. The pupils were equal and reacted to
light. He could not see and probably could not hear. The
fundi were normal. There was no spasm or paralysis of any
of the muscles supplied by the cranial nerves. He had six
teeth. There was no rigidity of the neck and no neck sign.
There was a very slight rosary. The circumference of the
chest at the nipples was forty-four cm. (average is 45 cm.).
The heart, lungs, abdomen and genitals were normal. The
lower border of the liver was palpable two cm. below the costal
border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no paralysis of the
extremities, but there was a little spasm in the legs. There
was a tendency to keep the legs crossed. The knee-jerks
were equal, but much exaggerated. There was at times a
marked ankle clonus on the right. Kernig's sign was marked
on the right, slight on the left. There was no enlargement
of the superficial lymph nodes. The rectal temperature was
98. 6° F, ; the pulse, 120; the respiration, 30.
DISEASES OF THE NERVOUS SYSTEM. 525
Lumbar puncture was done and forty cc. of perfectly clear
fluid under somewhat increased pressure allowed to run off.
The level of the fontanelle was then that of the surrounding
bones. This fluid contained about tV% of albumin and did
not deposit a fibrin clot.
Diagnosis. The enlargement of the head and the bulging
of the anterior fontanelle show that there is an increase in the
intracranial pressure. This is proved by the fact that when
lumbar puncture was done the cerebrospinal fluid ran off
under increased pressure. The absence of changes in the
optic nerves, the normal position of the eyes and the closed
sutures show that this pressure is not extreme. The fact
that the sutures are closed is of comparatively little impor-
tance, however, because they are often fairly firmly united at
nine months. When it is taken into consideration that this
increased cerebral pressure followed an attack of cerebro-
spinal meningitis, there can be no doubt that it is due to an
Acquired Internal Hydrocephalus as the result of this
disease. The hydrocephalus in this instance cannot be due
to obstruction of any of the foramina, because the fluid ran
off freely on lumbar puncture. It must be due, therefore,
either to some obstruction to the veins of Galen or to some
pathological change in the choroid plexus. The absence of
a fibrin clot and of an increased percentage of albumin in the
cerebrospinal fluid shows that there is no inflammation at
present. The increase in the cerebral pressure does not seem
sufficient to account for the blindness and probable deafness.
These are almost certainly due to degenerative changes in
the nerves resulting from the cerebrospinal meningitis. The
spasm of the legs, the tendency to keep the legs crossed,
the exaggeration of the knee-jerks, the ankle clonus and the
Kernig's sign may be due to cerebral irritation from the in-
creased intracranial pressure, but are more probably due to
meningeal or cortical changes caused by the meningitis.
Prognosis. The blindness and deafness are, of course,
irremediable. The spasm of the extremities, being in all
probability due to lesions of the cortex or meninges, will
persist. These lesions are very likely, moreover, to be the
cause of convulsions in the future. There is a reasonable
526 CASE HISTORIES IN PEDIATRICS.
chance that the hydrocephalus may not increase or may,
perhaps, even diminish, as the result of the absorption or
contraction of the inflammatory tissue which is causing the
obstruction to the circulation.
Treatment. There is no medicinal treatment which can
hasten the resolution of the newly formed tissue, which is
the cause of the hydrocephalus. It is possible, however, that
the withdrawal of the fluid by lumbar puncture may, by
diminishing the intracranial pressure, favor resolution. It
seems rational, therefore, to do this and to repeat the opera-
tion as often as is necessary to keep down the pressure. If
there is no improvement after repeated punctures it will then
be time to consider the advisability of some operation to
establish permanent drainage (see Case 161). It seems
hardly worth while to attempt this, however, when it is
taken into consideration that the baby is blind and deaf and
has a spastic paraplegia.
Hydrocephalus.
Deformity of head and chest in Rickets.
DISEASES OF THE NERVOUS SYSTEM. 527
CASE 163. Marion S. was the first child of young and
unusually vigorous parents. There had been no previous
miscarriages. She was delivered at full term by low forceps
and weighed six and one-half pounds. She was very feeble
at first, but rallied after twenty-four hours. The breast-milk
gave out after three days and she was given a strong modified
milk. She did not vomit, but the bowels were constipated
and she did not gain in weight. She began to vomit, however,
when four weeks old. The vomiting was at first more like
regurgitation and always occurred in the first hour after
feeding. A wet-nurse was procured two days later. She
would not take the breast and consequently was given two
ounces of breast-milk with one teaspoonful of water every
two and one-half hours. The vomiting continued, neverthe-
less, soon became explosive in character, and was at times
apparently accompanied by pain. The constipation became
more marked, movements being obtained only by enemata.
These were very small, brownish-green in color and sticky in
consistency. She had had only whey and water during the
last twenty-four hours. The water had been retained; the
whey, however, had been vomited immediately or, if not,
retained for two or three feedings and then vomited. She
had lost weight and strength very rapidly during the last
week. The physician who had had charge of the baby up to
twenty-four hours before she was seen in consultation, when
six weeks old, had said that she was normal at birth, and had
either not noticed or had not said anything about the con-
dition of the fontanelle. The mother, however, thought that
the fontanelle had always been a little full. Divergent
strabismus was noticed the day before she was seen.
Physical Examination. She was small and thin, but of
fair color. She was evidently uncomfortable and cried out
frequently. Her condition was so serious that careful meas-
urements of the head and chest were not made. The head
was, however, large when compared with the chest. The
enlargement was symmetrical. The forehead was somewhat
prominent. The anterior fontanelle was about four cm. in
diameter and bulging. The posterior and lateral fontanelles
were open, the posterior fontanelle being two cm. in diam-
528 CASE HISTORIES IN PEDIATRICS.
eter. The sagittal, coronal, frontal and lambdoid sutures
were open. The conjunctivae were not visible above the
irides and the eyelids closed normally. There was no stra-
bismus. The pupils were equal and reacted to light. There
was no nasal discharge. There was no rigidity of the neck or
neck sign. The heart and lungs were normal. The level of
the abdomen was that of the thorax. There was no visible
peristalsis over the stomach, and no tumor in the region of
the pylorus was felt. The liver was palpable two cm. below
the costal border in the nipple line. The spleen was not
palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal, but exagger-
ated. There was a slight Kernig's sign on both sides. There
was no enlargement of the peripheral lymph nodes. There
was no eruption and there were no scars of old eruptions.
There were no mucous patches about the mouth or anus.
The rectal temperature was 980 F. ; the pulse, 140; the respi-
ration, 25. She weighed five pounds.
Diagnosis. The vomiting, constipation and loss of weight
seem at first to point directly to some disease of the stomach.
The explosive character of the vomiting, the fact that the
vomiting has increased in spite of the change to human milk
and the meconium-like stools suggest that it is stenosis of
the pylorus. The divergent strabismus and the fullness of
the fontanelle point, however, to some trouble in the head.
When this possibility is taken into consideration, it is evident
that the continued vomiting and its explosive character may
be equally well explained by an increase in the intracranial
pressure. The symmetrical increase in the size of the head,
the prominence of the forehead, the open fontanelles and
sutures and the bulging of the anterior fontanelle are all
evidences of an increase in the intracranial pressure. The
only chronic condition which can cause such a marked
increase in pressure at this age is Congenital Internal
Hydrocephalus. The exaggeration of the knee-jerks and
the positive Kernig's sign are further evidences of cerebral
disease. The evidence in favor of the brain as the location
of the trouble is so strong that it hardly seems necessary to
mention that the absence of visible gastric peristalsis and of
DISEASES OF THE NERVOUS SYSTEM. 529
a palpable tumor at the pylorus counts very strongly against
stenosis of the pylorus. Syphilis can be excluded as the
cause of the hydrocephalus in this instance on the good family
history, the fact that the baby was born at full term and the
absence of all signs of syphilis. The etiology is, therefore,
as in most such cases, entirely obscure.
Prognosis. The prognosis is practically hopeless. The
increase in the intracranial pressure will almost certainly
continue and the head steadily increase in size. She will
probably not live more than a few days, or at most a few
weeks. It is barely possible, however, that the pressure will
after a time cease. If it does, she will, in all probability, be
more or less deficient mentally and partially paralyzed.
Treatment. It being possible to exclude syphilis as the
etiological factor in this instance, nothing whatever can be
accomplished by medicinal treatment. The various opera-
tive procedures which may be employed in the treatment of
chronic internal hydrocephalus are described in Case 161.
It is obvious that the baby's general condition is at present
too poor to warrant any serious operation. Lumbar puncture
ought to be done, however, to diminish the intracranial
pressure. It is not likely to do any permanent good, but will
almost certainly diminish the discomfort and perhaps stop
the vomiting. It may be repeated as often as is necessary
to keep down the intracranial pressure. She should be given
half an ounce of whey every hour. If this is retained, human
milk, with 25% of lime water, half an ounce to one ounce
every two hours, should be tried.
530 CASE HISTORIES IN PEDIATRICS.
CASE 164. Jacob A. was the child of healthy parents-
One other child was well, two had died of " summer com-
plaint " and three of diphtheria. There had been no mis-
carriages.
He was fed from birth on a mixture of three parts of whole
milk and one of water. When five months old he was given
tea and crackers, and probably other things also, in addition.
He had always done well, had not vomited and had had nor-
mal movements. He began to cry almost constantly October
20. Swelling of the arms and legs appeared at the same time.
He was seen October 22, when ten months old.
Physical Examination. He was well developed and nour-
ished, but rather pale. He was perfectly conscious. The
parietal and frontal eminences were moderately enlarged, and
the head was somewhat flattened on top. The anterior fon-
tanelle was 4 cm . in diameter and level. The pupils were
equal and reacted to light. There was no craniotabes. He
had two teeth. The gums, mouth and throat were normal.
The tongue was clean. The ear-drums were normal. There
was a moderate rosary. The heart and lungs were normal.
The level of the abdomen was somewhat below that of the
thorax, but nothing abnormal was detected in it. The liver
was palpable 2 cm. below the costal border in the nipple line.
The spleen was not palpable. The epiphyses at the wrists
were slightly enlarged. There was a rather tense swelling of
the feet and legs half-way to the knees, and of the hands and
lower halves of the forearms. This swelling was not hot,
tender or red. It did not pit on pressure. He held his arms
partly flexed at the elbows and at the wrists. The hands were
turned a little to the ulnar side. The fingers and thumbs were
flexed sharply at the metacarpo-phalangeal joints and ex-
tended at the phalangeal joints, the thumb being inside the
fingers. The legs were held partially flexed at the knees and
partially extended at the ankles, with flexion of the toes at
the metatarso-phalangeal and extension at the phalangeal
joints. Any attempt to overcome the spasm in the arms and
legs caused much pain. The knee-jerks could not be tested
because of the spasm. Kernig's sign was absent. The facial
phenomenon was absent. Trousseau's symptom could not
DISEASES OF THE NERVOUS SYSTEM. 53 1
be tested because of the spasm. There was a slight general
enlargement of the peripheral lymph nodes. The rectal
temperature was ioi° F., the pulse no, the respiration 40.
A few minutes after the examination he became entirely
relaxed. The spasm returned again, however, in a short
time.
The urine was pale, clear, acid in reaction, of a specific
gravity of 1,010, and contained neither albumin nor sugar.
Diagnosis. Tetanus can be ruled out on the absence of
trismus and the characteristic position of the extremities.
Meningitis can be excluded on the normal mental state, the
level fontanelle, the absence of involvement of the cranial
nerves and of rigidity of the neck and the characteristic
position of the extremities. The age of the baby, the good
general condition, the intermittence of the paroxysms, the
pain in association with them and the swelling of the extremi-
ties are all characteristic of tetany. The position of the
extremities during the spasm is pathognomonic of Tetany
and makes the diagnosis positive. The swelling of the extrem-
ities is undoubtedly nervous in origin and belongs in the class
of the angioneurotic edemas. The enlargement of the frontal
and parietal eminences, the flattening of the top of the head,
the rosary and the enlargement of the epiphyses at the wrists
are signs of rickets, as is probably the delayed dentition.
Tetany is not properly a disease but merely a manifestation
of the spasmophilic diathesis. In this condition there is a
marked increase in the nervous excitability, which shows
itself in various ways, the most characteristic manifestations
being laryngismus stridulus, tetany and convulsions. The
spasmophilic diathesis is almost certainly due to some dis-
turbance in the metabolism of calcium. It is uncertain
whether this disturbance is or is not due to parathyroid
insufficiency. There is in all probability a deficiency of cal-
cium salts in the blood in the spasmophilic diathesis. His
diet, which has been largely made up of cow's milk has never
been deficient in calcium. The calcium in cow's milk is, how-
ever, not nearly as well utilized as that in human milk, so
that he may well not have absorbed a sufficient amount.
The rickets is, therefore, merely another manifestation of
532 CASE HISTORIES IN PEDIATRICS.
disturbance of nutrition and not the cause of the paroxysmal
contractions.
Prognosis. The prognosis depends very largely on whether
or not he can get the best treatment. If he can, the paroxysms
will quickly cease. If he cannot, they will probably continue
and other manifestations of the spasmophilic diathesis are
very likely to develop. There is no danger of death in a
paroxysm of tetany, but he may die in an attack of laryngis-
mus stridulus or during a convulsion.
Treatment. No treatment is necessary for the paroxysms
unless they are more severe than at present. A bath at I io° F.
is the best treatment. If the attacks become more severe, they
can be controlled to a certain extent by bromide of sodium or
potassium, in doses of from three to five grains, in an aqueous
solution, given three or four times daily. The attacks will be
less likely to develop if he is kept quiet and not disturbed.
The treatment of the spasmophilic diathesis consists in
regulation of the diet. Human milk always quickly relieves
this condition. A purely carbohydrate diet relieves it, but
much less promptly and is, moreover, unsuitable for a baby
of this age. A return to cow's milk in any form, at any rate
until a considerable time has elapsed, almost invariably
causes a return of the symptoms. The only rational food for
this baby is, therefore, human milk. If he cannot get it, he
must be given a starch and sugar solution for as long a time as
is possible, due regard being paid to his general condition, and
then gradually worked on to some modification of cow's milk.
It is possible that the administration of some of the cal-
cium salts, like the lactate, might do good, but the indications
are so doubtful and the results to be expected so slight com-
pared to those obtained with human milk that they are hardly
worthy of consideration. Parathyroid extract, in doses of
one-quarter of a grain, three times a day, would seem a more
rational treatment, but has not been used enough to prove
whether or not it is of any value.
DISEASES OF THE NERVOUS SYSTEM. ' 533
CASE 1 65. Baby T. was born at full term after a normal
first pregnancy. The membranes ruptured January II and
much liquor amnii drained away. Labor began the afternoon
of January 12. The pains were hard, but very little progress
was made. He was finally delivered by high forceps, after a
manual dilatation, at 3 a.m., January 13. The operation was
an easy one and did not take over an hour. The head was
considerably compressed at birth but the fontanelles did not
bulge. He weighed six and one-half pounds and seemed all
right in every way. He cried normally and passed both urine
and feces. He was not put to the breast but took water well.
He suddenly stopped breathing and became deeply cya-
notic at 8 p.m., January 13, seventeen hours after birth. He
was brought around by artificial respiration, but had another
similar attack about 9 p.m., which also required artificial
respiration. He had breathed quietly and normally since
then, but had not moved much and had not opened his eyes.
A little twitching of the face was noticed during the morning
of the 14th, and during the afternoon he moved his left arm
constantly, but had no rigidity or convulsions. He took a
little sugar and water during the day and passed both urine
and feces. He became more stupid during the evening and
could not be made to swallow. The pulse gradually fell
during the day from 160 to 120. The rectal temperature
varied between 990 F. and 99. 50 F. He was seen in consulta-
tion at 10.30 p.m., January 14.
Physical Examination. He was well developed and nour-
ished, and of good color. He could not be roused or made to
move. His neck was flaccid. The head was of good shape
and of normal size. The anterior fontanelle was 3 cm. and
the posterior fontanelle 2 cm. in diameter. Both bulged a
little. The sagittal and coronal sutures were i| cm. wide and
a little full; the other sutures were closed. The axes of the
eyes were parallel. The pupils were a little smaller than a
pinhead and did not react to light. A little dried blood was
seen high up in the nostrils. The mouth and throat were
normal. There was no facial paralysis and no marks of the
forceps. The heart, lungs and abdomen were normal. The
cord was healthy. The liver was palpable 1 cm. below the
534 CASE HISTORIES IN PEDIATRICS.
costal border in the nipple line. The spleen was not palpable.
The arms were held slightly flexed at the elbows and the
hands were clenched. The spasm was, however, very easily
overcome. There was no spasm of the legs. The knee-jerks
were not obtained. There was no Kernig's sign. The rectal
temperature was 99. 50 F., the pulse 140, the respiration 24.
Diagnosis. The diagnosis lies between some cerebral
lesion, intestinal toxemia and sepsis. The facts that he has
had no food, that his bowels have moved freely and that his
temperature is practically normal are sufficient, in connection
with the positive signs of cerebral trouble, to exclude intes-
tinal toxemia. The normal condition of the cord, the normal
temperature and the absence of any local manifestations of
sepsis rule out sepsis.
The age, lack of exposure and normal temperature exclude
meningitis. The bulging of the fontanelles and sutures
shows positively that there is an increase in the cerebral
pressure. This was not present at birth. An internal hydro-
cephalus could hardly have developed in seventeen hours.
Serous meningitis does not develop without a cause and is
usually accompanied by fever. The only reasonable ex-
planation for the increased cerebral pressure is, therefore, a
hemorrhage. The gradual development of the symptoms of
increased cerebral pressure is perfectly consistent with a slow
capillary oozing, which is the usual form of hemorrhage occur-
ring at or soon after birth. The presence of blood high up in
the nostrils is almost pathognomonic of cerebral hemorhage,
the blood coming through the cribriform plate. The diag-
nosis of Cerebral Hemorrhage is, therefore, justified. The
diagnosis is so certain that it hardly seems necessary to do a
lumbar puncture to confirm it. The spinal fluid does not
always contain blood, moreover, when there is a cerebral
hemorrhage, and the presence of blood does not always indi-
cate cerebral hemorrhage, because it may be due to the wound-
ing of some vessel during the puncture. The fact that the
involuntary motions were confined to the left arm suggests
that the hemorrhage is greater on the right than on the left
side of the brain. This point is not of much importance,
however, because, owing to the imperfect development of
DISEASES OF THE NERVOUS SYSTEM. 535
the cortical centers and the general nervous excitability at
this age, no very definite conclusions can be drawn from what
would be important localizing symptoms in an older child or
an adult.
Prognosis. He is almost certain to die if he is not operated
upon. If he does not die, he will surely be paralyzed and
probably feeble-minded. He will probably die during or soon
after the operation. If he does not, he may still be paralyzed,
but the paralysis will be less extensive than it will be if he is
not operated upon. There is a reasonable chance, however,
that the operation will relieve the symptoms and that he will
develop normally.
Treatment. He should be operated on immediately.
Delay will mean still further hemorrhage and more pressure
on and damage to the brain.
536 CASE HISTORIES IN PEDIATRICS.
CASE 166. Elsie L., two and one-fourth years old, was
the first child of healthy parents. There had been no mis-
carriages. She was born after a very difficult instrumental
vertex delivery at the end of a long labor and was almost dead
at birth. She was not nursed, as she was too weak to take
the breast. She did not thrive during infancy, but since then
her general condition had been good. She had had no con-
vulsions. She sat up alone at nine months and cut her first
tooth at a year. She began to stand at sixteen months, but
did not begin to walk at all until she was twenty-six months
old. Her gait was then noticed to be very peculiar. She was
brought because she did not walk well. She used her hands
well, talked early and was bright mentally. She controlled
the sphincters of the bladder and anus.
Physical Examination. She was well developed and nour-
ished and of good color. Her tongue was clean and her mouth
and throat normal. There was no rosary. The heart, lungs
and abdomen were normal. The liver and spleen were not
palpable. She talked well for a child of her age and seemed
bright. There was no spasm or paralysis of any of the muscles
supplied by the cranial nerves. There was no deformity of
the spine, and it was normally flexible. There was no paraly-
sis or spasm of the arms, and the reflexes of the arms were
normal. She stood with her knees close together, her body
flexed on the thighs, the knees partially flexed and the heels
a little off the ground. When she walked the knees rubbed
together and one leg crossed in front of the other. When
lying down the legs could be straightened on the thighs and
the feet brought to a right angle, but with some little diffi-
culty. Separation of the legs was resisted and was impossible
to more than a moderate extent. There was decided resist-
ance to hyperextension of the thighs. The knee-jerks were
equal, but much exaggerated. There was no ankle clonus.
The sensation was normal. The legs were warm, of good
color and not wasted. Kernig's sign was absent. Babinski's
phenomenon was present on both sides. There was no en-
largement of the peripheral lymph nodes.
Diagnosis. This little girl has a paraplegia with spasm.
The spasm, exaggeration of the reflexes and normal sensation
DISEASES OF THE NERVOUS SYSTEM. 537
rule out any lesion of the peripheral nerves. The spasm,
exaggeration of the reflexes and absence of wasting rule out a
lesion of the anterior horns, such as occurs in anterior polio-
myelitis. Transverse myelitis, except from disease of the
spine, almost never occurs at this age. There is no deformity
of the spine in this instance and it is normally flexible. Trans-
verse myelitis from other causes can be excluded on its rarity
at this age and the absence of loss of control of the sphincters
and of disturbance of sensation. The lesion must, therefore,
be in the brain. It is hard to conceive of a lesion anywhere
in the brain which would cause a spastic paraplegia without
other symptoms, except in the cortex. A lesion of the cortex
in the region of the upper portion of the post-central convolu-
tion on both sides of the longitudinal fissure would cause just
such a combination. Such a lesion in an infant is [usually a
congenital defect or the result of a subdural [hemorrhage at
birth. The long, hard labor, which is the usual cause of such
hemorrhages at birth, and her feeble condition after birth,
make it almost certain that in this instance the lesion is due
to a hemorrhage at birth. The diagnosis of Cerebral
Paralysis resulting from a subdural hemorrhage at birth is,
therefore, justified.
Prognosis. There will be no extension of the paralysis and
her mental development will be normal. There will be no
spontaneous improvement in the condition of the legs. Much
improvement in her walking can be expected, however,
from suitable operations and apparatus.
Treatment. Electricity and massage are useless in this
condition because there is no disturbance of the nutrition of
the muscles. It is probable that passive motions, if thor-
oughly carried out, will prevent further contractures, but it is
very doubtful if they will diminish those now present. Proper
operative procedures, perhaps followed by the application of
apparatus, ought to improve the position of her legs and make
walking much easier. Resection of the posterior nerve roots,
recently recommended for the relief of this condition, has not
as yet been tried out thoroughly enough to justify its use,
except as a last resort. She should be placed in the hands of
an orthopedic surgeon for treatment.
I
538 CASE HISTORIES IN PEDIATRICS.
CASE 167. John J., nine months old, was the third child
of healthy parents. There had been no deaths or miscar-
riages. There was no tuberculosis in either family and there
had been no known exposure to it. He had been well,
although bottle-fed, up to May 7, when he became feverish
and began to cough. There was much mucus in his throat.
A physician who saw him at the time said that he had broncho-
pneumonia. The cough and fever diminished after a few
days. He had several convulsions May 15, which were
followed by marked rigidity and almost constant twitching.
He became drowsy and refused to take his food. He did
not vomit and was not constipated. He was admitted to
the Infants' Hospital, May 16.
Physical Examination. He was well developed and nour-
ished and of good color. He was unconscious, but made
frequent involuntary motions. The anterior fontanelle was
three cm. in diameter and level. There was no rigidity of
the neck. The neck sign could not be determined, because
of the constant motion of the legs. The pupils were equal
and somewhat dilated. They reacted feebly to light. The
throat was slightly reddened, but otherwise normal. The
ear-drums were normal. The heart was normal. The lungs
were normal, except for an occasional moist rale in both
lower backs. The abdomen showed nothing abnormal.
The lower border of the liver was palpable one cm. below the
costal border in the nipple line. The spleen was not palpable.
There was slight spasm of the extremities, but no paralysis.
The knee-jerks could not be determined, because of the con-
tinuous motion. Kernig's sign was absent. There was no
enlargement of the peripheral lymph nodes. The rectal tem-
perature was 102.60 F. ; the pulse, 140; the respiration, 50.
The urine was clear, acid in reaction and contained no
albumin.
The leucocytes numbered 8,400.
Diagnosis. The signs in the lungs are not sufficient to
account for his condition. The unconsciousness, the dilated
and feebly reacting pupils and the spasm of the extremities,
together with the absence of signs of disease elsewhere, show
that, in spite of the fact that there is no bulging of the anterior
DISEASES OF THE NERVOUS SYSTEM. 539
fontanelle, the disease is in all probability located in the head.
The absence of rigidity of the neck and of Kernig's sign count
less against it than does the absence of bulging of the anterior
fontanelle. If the disease is located in the head, it is pre-
sumably some form of meningitis. The absence of leucocy-
tosis counts strongly against all forms of meningitis, except
the tubercular and the influenzal. The onset of the symptoms
in the course of a catarrhal process in the throat and of
bronchitis suggests that the trouble may be influenzal. This
is a relatively rare condition, however, while tubercular
meningitis is very common. The chances are, therefore, in
favor of tubercular meningitis. The diagnosis can be made,
however, only by lumbar puncture.
Lumbar puncture was done and three cc. of very turbid
fluid, under low pressure, were obtained. This fluid con-
tained a large number of cells, 98% of which were polynuclear
and 2% mononuclear. It also contained very many slender,
Gram-negative bacilli, which stained deeply at the poles.
The vast majority of these bacilli were outside of the cells.
The characteristics of this fluid are the same as those of the
cerebrospinal fluid in influenza meningitis, and the charac-
teristics of the bacilli correspond in every way to those of
the influenza bacillus. There can be no doubt, therefore,
as to the diagnosis of Influenza Meningitis.
Prognosis. The prognosis is practically hopeless. The
course is almost invariably short in this form of meningitis.
He will probably not live more than four or five days.
Treatment. The treatment can be only symptomatic.
54-0 CASE HISTORIES IN PEDIATRICS.
CASE 168. Mary J., five months old, was the only child
of healthy parents. She was breast-fed and had always been
well. She was taken suddenly sick, April 6, with convul-
sions, high fever, cough and labored breathing. She did not
vomit. The bowels moved twice daily and the stools were
normal. The cough, fever and labored breathing continued.
She was admitted to the Infants' Hospital, April 9.
Physical Examination. She was well developed and
nourished, but moderately pale. She was stupid, but nursed
fairly well. The respiration was grunting and accompanied
by motion of the alee nasi. The anterior fontanelle was three
cm. in diameter and level. There was no rigidity of the neck
or neck sign. The pupils were equal and reacted to light.
The ear-drums were normal. Nothing abnormal was de-
tected in the chest. The abdomen showed nothing abnormal.
The lower border of the liver was palpable two cm. below the
costal border in the nipple line. The spleen was not palpable.
There was no paralysis, but slight twitching and rigidity of
the extremities. The knee-jerks were equal and exaggerated.
Kernig's sign was absent. There was no enlargement of
the peripheral lymph nodes. The rectal temperature was
1040 F. ; the pulse, 180; the respiration, 40.
The urine was pale, slightly acid in reaction and contained
a slight trace of albumin. The centrifugalized sediment
showed only a few small and large round cells.
The leucocytes numbered 48,000.
Diagnosis. The sudden onset, the continued high tem-
perature, the cough, the grunting respiration, the motion of
the alae nasi and the leucocytosis are very characteristic of
lobar pneumonia. The convulsions at the onset, the stupor
and the slight twitching and rigidity of the extremities are
not inconsistent with it. The absence of physical signs of
pneumonia does not exclude it, because it is not uncommon
to find no physical signs for several days after the onset in
pneumonia at this age. The fact that the rate of the res-
piration is not increased as much as that of the pulse suggests,
however, that, in spite of the signs pointing to pneumonia,
this may really not be the trouble, because the rate of the
respiration is almost invariably increased out of proportion
DISEASES OF THE NERVOUS SYSTEM. 54 1
to that of the pulse in this disease. The knee-jerks are,
moreover; usually normal or diminished in pneumonia, not
exaggerated, as in this instance. The convulsions at the
onset, the stupor, the twitching and rigidity of the extremities
and the exaggeration of the knee-jerks are all suggestive of
some cerebral disease, either meningitis or encephalitis.
They are suggestive enough to justify, or rather to demand,
a lumbar puncture, because if there is a meningitis it is,
judging from the acuteness of the onset and the leucocytosis,
probably not tubercular but meningococcal.
Lumbar puncture was done and five cc. of very turbid
fluid, under low pressure, were obtained. This fluid de-
posited a fibrin clot, but remained cloudy. A smear showed
95% °f polynuclear and 5% of mononuclear cells. Very
many Gram-staining diplococci were found, both within and
without the cells. They were surrounded by a capsule, were
pointed at the ends and showed a tendency to form chains.
No cultures were made.
There is, therefore, a Meningitis. It is, however, not
due to the meningococcus, as was suspected, but to the
Pneumococcus. The turbid fluid and the large excess of
polynuclear cells are characteristic of this form of meningitis.
Pneumococcus meningitis is very seldom a primary condition,
but usually merely one of the manifestations of a general
pneumococcus infection. It is very probable, therefore, that
pneumonia may also develop in a few days.
Prognosis. The prognosis is practically hopeless, as pneu-
mococcus meningitis is almost invariably fatal. The course
is usually short. She will almost certainly not live more
than a week, probably less.
Treatment. The treatment can be only symptomatic.
542 CASE HISTORIES IN PEDIATRICS.
CASE 169. Frank F., eleven months old, was the only
child of healthy parents. He was nursed and had always
been perfectly well. He was taken suddenly ill with pneu-
monia of the right lower lobe, January 10. The tempera-
ture ran between 103. 50 F. and 104.50 F., his pulse between
140 and 160, and his respiration about 60. He was quiet,
but clear mentally, was able to nurse and had no disturbance
of the digestion. He became very restless, January 16, and
retraction of the neck and rigidity of the extremities devel-
oped. He also had clonic spasms of the extremities from
time to time. There was no change in the temperature,
pulse and respiration. He was seen at the Infants' Hospital,
January 17.
Physical Examination. He was well developed and nour-
ished. The cheeks were flushed and there was a tinge of
cyanosis about the mouth. The respiration was grunting
and the alae nasi moved with it. The neck was rigid and there
was moderate opisthotonos. The neck sign could not be
determined because of the rigidity of the neck. The anterior
fontanelle was three cm. in diameter and bulged markedly.
The membranae tympanorum were normal. There was
bilateral internal strabismus. The right pupil was much
dilated and neither reacted to light. He did not notice.
There was no rosary. The heart was normal, except that
the second sound at the pulmonic area was accentuated.
There was flatness, loud bronchial respiration, increased vocal
resonance and tactile fremitus, with an occasional high-
pitched, moist rale, over the right lower lobe. The rest of
the lungs was normal. The abdomen was normal. The
liver was« palpable two cm. below the costal border in the
nipple line. The spleen was not palpable. There was
constant twitching of the extremities, which were rigid. The
knee-jerks were equal and much exaggerated. Kernig's sign
could not be determined, because of the rigidity. The
superficial lymph nodes were not palpable and there was
no evidence of enlargement of the bronchial lymph nodes.
The rectal temperature was 104.60 F. ; the pulse, 180; the
respiration, 64.
The urine was high in color, acid in reaction, of a specific
gravity of 1,020 and contained no albumin.
DISEASES OF THE NERVOUS SYSTEM. 543
The leucocytes numbered 36,000.
Lumbar puncture was done and sixty cc. of clear fluid,
under very high pressure, were allowed to run off. This fluid
contained but six cells to the cubic millimeter and did not
deposit a fibrin clot on standing. No organisms were found
in the fluid and cultures from it were sterile.
Diagnosis. The sudden onset of the symptoms of in-
creased intracranial pressure and meningeal irritation in the
course of a Pneumonia points strongly to a pneumococcus
meningitis. The normal cerebrospinal fluid shows, however,
chat this is not the case. It also excludes a complicating
tubercular meningitis. The bulging fontanelle and the in-
creased pressure under which the cerebrospinal fluid escaped
when the lumbar puncture was done show, nevertheless, that
there is an accumulation of fluid within the cranium. The
absence of an excess of cells and of a fibrin clot in the cere-
brospinal fluid proves that this accumulation of fluid is not
due to an inflammatory process in the meninges. The most
reasonable explanation is that it is due to increased secre-
tion as the result of the irritation caused by the toxic prod-
ucts of the pneumococcus in the blood. The condition is,
therefore, the so-called Serous Meningitis.
Prognosis. The outlook is very dark, because, although
the intracranial pressure can be kept down by repeated
lumbar punctures, it shows a degree of toxaemia which of
itself is almost certain to prove fatal. The point most in his
favor is that, this being the seventh day of the pneumonia,
the crisis may be expected at any time.
Treatment. Nothing can be done to diminish the secretion
of cerebrospinal fluid. It can, however, be removed by
lumbar puncture as fast as it is formed. Lumbar puncture
should be done, therefore, as soon as there is much bulging
of the fontanelle and the fluid drawn off until the fontanelle
is depressed, even if the operation has to be repeated every
few hours. The further treatment is that of pneumonia in
general. (See Cases 113 and 114.)
544 CASE HISTORIES IN PEDIATRICS.
CASE 170. Robert K., two and three-fourths years old,
was the child of healthy parents. One brother was alive and
well, another had died at birth. There had been no mis-
carriages. There was no tuberculosis in the family and there
had been no known exposure to tuberculosis. He was born
at full term after a normal labor and was normal at birth. He
was nursed for eleven months. He had always been well,
except for measles a year before and frequent colds with
bronchitis.
He fell down stairs, striking his head, early in the morning
of August 3. He was apparently not hurt and appeared well
all day. He began to vomit during the morning of August 4
and continued to vomit, at intervals of about an hour, until
3 a.m., August 5. He did not vomit again. There had been
no known indiscretion in diet and the bowels were open. He
was delirious in the early morning. He was admitted to the
Children's Hospital at 2 p.m., August 5.
Physical Examination. He was well developed and nour-
ished and of good color. He was restless and irrational but,
when roused, noticed a little. There was no rigidity of the
neck and no neck sign. The pupils were equal and reacted to
light. The tongue was fairly clean. The throat, heart,
lungs and abdomen were normal. The liver and spleen were
not palpable. There was no spasm or paralysis. The knee-
jerks were equal and normal. Kernig's and Babinski's signs
were absent. There was no ankle clonus. The rectal tem-
perature was 99. 8° F., the pulse 120, the respiration 36.
The urine was light yellow in color, clear, acid in reaction
and contained no albumin, sugar or acetone. The sediment
contained a few epithelial cells and crystals of uric acid.
The fluid obtained by lumbar puncture was under con-
siderable pressure. It ran clear at first, but the last of it was
somewhat bloodstained. No fibrin clot formed in twenty-
four hours. It contained 360 cells to the cubic millimeter,
a part of which were undoubtedly due to the admixture of
blood. The differential count of these cells, which showed
90% of mononuclear to 10% of poly nuclear, shows that
only a few of them came from the blood, because, if many
,of them had come from the blood, the number of polynuclear
DISEASES OF THE NERVOUS SYSTEM.
545
cells would have at least equaled that of the mononuclear.
No tubercle bacilli or other organisms were seen on a routine
examination, and cultures were sterile.
He passed a very restless night and at times was quite
noisy, requiring morphia to keep him quiet. He was quiet
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and drowsy the morning of August 6. There was no rigidity
of the neck or neck sign. The pupils were equal and reacted
to light. The knee-jerks were equal and lively, the abdomi-
nal and cremasteric reflexes normal. There was no Kernig's
sign and no ankle clonus.
He was quiet August 7. There was slight rigidity of the
neck. The pupils were equal and reacted to light. The
546 CASE HISTORIES IN PEDIATRICS.
knee-jerks were present and equal, but sluggish. There was
a suggestion of Kernig's sign on the left but none on the right.
Babinski's phenomenon was absent.
He recognized and spoke to his parents and remembered
the names of friends and relatives August 8. He noticed
more and was afraid of the light used to test the reaction of
the pupils. They were equal and reacted to light. There
was no rigidity of the neck, and no neck sign. There was
no spasm or paralysis. The knee-jerks were equal and
normal. The abdominal and cremasteric reflexes were not
obtained. Kernig's and Babinski's signs were absent.
Sensation to touch and pain was normal.
The white blood count was 10,100.
Another lumbar puncture was done. The fluid was clear
and contained 480 cells to the cubic millimeter, 97% of
which were small mononuclear. Many of the cells were
degenerated. No organisms were seen in a routine exami-
nation, and cultures were sterile.
He was seen at 10 a.m., August 8.
Diagnosis. The positive findings in the cerebrospinal
fluid show that the trouble is located in the central nervous
system (see Case 38 for description of the normal cerebro-
spinal fluid and of the fluid in meningitis). They exclude
all forms of meningitis except the tubercular, but are also
consistent with acute poliomyelo-encephalitis, in the acute
stage of which the cerebrospinal fluid contains a considerable
excess of cells, largely small mononuclear. The diagnosis
lies, therefore, between tubercular meningitis and acute
poliomyelo-encephalitis. If it is poliomyelo-encephalitis,
the stress of the disease has fallen in this instance, of course,
on the cerebrum, and it can be spoken of as an encephalitis.
The absence of a family history of, or of exposure to,
tuberculosis does not rule out tubercular meningitis; the
history of an attack of measles in the past is a small point
in its favor. The acuteness of the onset is somewhat in
favor of encephalitis, but is not inconsistent with tubercular
meningitis. The fall was probably purely a coincidence,
but, in any case, is of no assistance in differential diagnosis
as it might predispose to the development of either condi-
DISEASES OF THE NERVOUS SYSTEM. 547
tion. There is nothing about the symptomatology which
is inconsistent with either condition, although the absence
of the neck sign and the slightness of the changes in the
reflexes and of the rigidity of the neck are somewhat against
tubercular meningitis. The improvement in the symptoms
and the drop in the temperature, while they suggest the
beginning of convalescence from encephalitis, do not by
any means exclude tubercular meningitis, because remissions
are characteristic of this disease. The absence of leuco-
cytosis is common to both diseases. The absence of a
fibrin clot in the cerebrospinal fluid counts against tuber-
cular meningitis; the absence of tubercle bacilli does not,
because they are not found in more than ten per cent of the
cases, if the examination is merely a routine one. A positive
diagnosis is, therefore, impossible. The weight of the
evidence, is, however, somewhat in favor of Encephalitis,
sufficiently so to justify it as a provisional diagnosis. Time
alone can decide whether or not it is correct.
Prognosis. If the diagnosis of encephalitis is correct,
the prognosis is very good. He will almost certainly recover
entirely and be left without sequelae, either mental or
physical.
Treatment. The treatment can only be symptomatic.
Nothing can be done m any way to modify the course of
the encephalitis.
548 CASE HISTORIES IN PEDIATRICS.
CASE 171. Fred C, seven and one-half years old, had
always been well except for measles and whooping-cough
some years before. He had been spending the summer in a
locality within twenty miles of which there had been several
cases of infantile paralysis during the past few weeks.
He complained of headache the afternoon of September 7.
He vomited and was somewhat feverish the next morning,
but went in bathing that noon as usual. He complained
in the evening that his throat felt a little full. He was given
a laxative that night and had a good movement the morning
of the 9th. He was brought home that day by train, a
journey of about one hundred and twenty-five miles. He
took a little milk and ate several crackers on the way. He
walked out of the station to his automobile without diffi-
culty. He undressed himself and ate a little supper, although
he complained that it was hard for him to swallow. He was
seen by his physician in the early evening. The physical
examination, including the throat, showing nothing abnormal.
His mouth temperature was 1030 F., his pulse 115, and rather
feeble. He collapsed about midnight and was seen again
soon after by his physician. He was then slightly cyanotic.
His pulse was very feeble and his respiration rapid. He was
unable to swallow anything, not even his saliva. He was
given an enema of hot milk and brandy and soon rallied.
His color continued bad and his respiration rapid, however,
and he was unable to swallow. He was seen in consultation
at 7.30 a.m., September 10.
Physical Examination. He was well developed and
nourished and perfectly clear mentally. His face and
extremities were a little dusky. There was no rigidity of
the neck. He could move his head, but could not turn
himself in bed. The pupils were equal and reacted to light.
There was no paralysis of the eye muscles and no facial
paralysis. His respiration was rapid but not noisy. He
was coughing constantly but feebly, and was all the time
trying, but usually unsuccessfully, to spit up bloody, frothy
mucus. He could stick out his tongue. There was no
paralysis of the soft palate. The throat was normal to inspec-
tion and palpation. He could speak a word or two at a time
DISEASES OF THE NERVOUS SYSTEM. 549
distinctly. Respiration was entirely diaphragmatic. There
was no movement of the chest wall, and the accessory mus-
cles of respiration were not acting. There was no retraction
of the suprasternal, supraclavicular or intercostal spaces.
The respiratory sound was feeble, alike on both sides and
normal in character. No rales were heard in front; the
backs were not examined. The cardiac area was normal,
the action a little irregular, the rate 124, the first sound
of fair strength, and there were no murmurs. The abdomen
was normal. The liver and spleen were not palpable. He
could move his arms, but the movements were feeble. The
abdominal and cremasteric reflexes were present. The legs
were not examined.
Diagnosis. The normal condition of the throat, the clear
voice, the quiet respiration and the absence of retraction
rule out all forms of obstruction of the air passages. There
is no disease of the lungs which causes bilateral immobility of
the chest. Edema of the lungs from cardiac failure is sug-
gested by the bloody, frothy expectoration, but is excluded
by the normal size and fair strength of the heart and the
absence of rales. The only possible explanation of the symp-
toms is paralysis of the muscles of respiration. This explana-
tion is justified by the physical examination. There is also
a paresis of the muscles of the arms and trunk. The diffi-
culty in deglutition and the irregularity of the pulse make
it probable that the pneumogastric nerve is also involved.
The only disease of the nervous system which will explain
the sudden appearance of this combination of symptoms is
acute poliomyelo-encephalitis, commonly known as Infan-
tile Paralysis.
Prognosis. The prognosis is absolutely hopeless. He will
probably live but a few hours.
Treatment. There is no treatment which can do more
than perhaps delay the fatal outcome a few hours. Oxygen
must be given freely. Strychnia and caffein-sodium ben-
zoate or salicylate may be given subcutaneously. The
administration of morphia subcutaneously is justifiable,
if he is very uncomfortable.
55° CASE HISTORIES IN PEDIATRICS.
CASE 172. John P., three years old, was the child of
healthy parents and had always been well and strong. He
had had a slight disturbance of the digestion August 20,
which had yielded promptly to catharsis and regulation of
the diet. He was restless and a little feverish during the
evening of August 28, was given a large dose of castor oil by
his mother and had several large, well-digested movements
from it. It was discovered the next morning that he could
not use his legs properly. He could move them in all direc-
tions, but the movements were feeble. The rectal tempera-
ture that morning was 1010 F. There was no increase in the
weakness of the legs during the day and he slept all that
night. The loss of power was much more marked, however,
the morning of the 30th. He complained of pain in his
feet for the first time that morning. There was no disturb-
ance of defecation or micturition. He had had no other
symptoms. He was seen in consultation August 30 at
10.30 A.M.
Physical Examination. He was well developed and
nourished and of good color. He was perfectly clear men-
tally. There was no paralysis of any of the muscles controlled
by the cranial nerves. The tongue was slightly coated;
the throat was normal. The heart, lungs and abdomen
were normal. The liver and spleen were not palpable.
He used his arms freely. He held up his head well. He
could sit alone, but rather feebly, the feebleness being due
to the insufficiency of his legs. There was no deformity of
the spine, which was normally flexible. The only motion
which he could make with his legs was to flex the left toes a
little. When the thighs were flexed on the body he could
hold the left one there for an instant; the right dropped
outward at once. The bones and joints were normal.
Passive motions were not limited or painful. The abdominal
and cremasteric reflexes were normal. The knee-jerks were
absent on both sides. Kernig's and Babinski's signs were
absent. Sensation to touch and pain was normal. There
was no enlargement of the peripheral lymph nodes. The
rectal temperature was 990 F.
Diagnosis. The history and physical examination exclude
DISEASES OF THE NERVOUS SYSTEM. 55 J
at once, of course, injuries and diseases of the bones and
joints. Rheumatism is not accompanied by flaccid paralysis.
The paralysis must be due, therefore, to some disease of the
nervous system. The absence of all symptoms of meningeal
irritation, the clear mind, the paraplegic distribution of the
paralysis and the absence of the knee-jerks exclude disease
of the brain. The sudden onset and the absence of disturb-
ances of sensation rule out disease of the peripheral nerves.
The lesion must, therefore, be located in the spinal cord.
The combination of loss of power and reflexes without dis-
turbance of sensation occurs only in lesions of the anterior
horns. Such lesions develop acutely in childhood only in the
disease known as Infantile Paralysis. This is, therefore,
the diagnosis.
Prognosis. The chance of the extension of the process
upward and of involvement of the respiratory muscles is so
slight that a positively favorable prognosis as to life is allow-
able. There will, in fact, in all probability be no further
extension of the paralysis. The paralysis is certain to im-
prove a great deal. It is impossible to state now how great
the improvement will be. He may recover entirely, but will
in all probability be left with considerable disability in the
right leg and a little in the left. There will be little improve-
ment after the first six months.
Treatment. Nothing whatever can be done to modify the
pathological process in the nervous system. There are no
drugs which can possibly do any good, since the harm is
already done. It is unreasonable to expect external applica-
tions to have any effect on the spinal cord, which is located
inside the vertebral column and has an entirely different blood
supply from the superficial tissues. The only thing that they
can do is to disturb the patient. While nothing can be done
to shorten the course of the disease or to limit its progress,
there is no doubt that the use or the attempted use of the
extremities involved tends, during the acute stage, to delay
the process of repair in the nervous system and possibly,
very early, to favor the extension of the process. He should,
therefore, be kept as quiet as possible for six weeks, when the
acute stage is presumably over. If he has much pain, he
552 CASE HISTORIES IN PEDIATRICS.
should be kept quiet for three weeks after the cessation of
the pain. Massage and electricity have the same action as
the use of the extremities and should not, therefore, be begun
for six weeks. It is very important during this period, how-
ever, to prevent the development of contractures, which make
the subsequent treatment much more difficult. The weight
of the bedclothes must be kept off of his legs by a cradle.
A light wire splint will prevent extension of the feet and
flexion of the knees. Strychnia is a stimulant to the motor
nerves and is, therefore, contra-indicated during the acute
stage. Hexamethylenamine cannot be expected to do any
good now, since the harm is already done. It is possible, how-
ever, that it may destroy or inhibit the growth of the micro-
organisms which cause the disease and prevent them from
escaping from the body and causing the disease in others.
It will be well, therefore, to give him three grains of hexa-
methylenamine three times daily. It goes without saying,
of course, that he must have good food and plenty of it, a
liberal amount of fresh air and sunlight and good care in
general.
After the expiration of the acute stage he can begin to try
to use his legs, must have vigorous and active treatment by
electricity and massage and will be helped by strychnia.
Treatment is most effectual during the first six months.
Little improvement can be expected after this time, except
from muscle training. It is extremely important, therefore,
to give him every attention during this time and not to put
off treatment until some future period.
DISEASES OF THE NERVOUS SYSTEM. 553
CASE 173. Nathaniel F., nine years old, had not been
away from home for some months and had seen no children
except a few with whom he went to a private school near by.
There had been but four cases of infantile paralysis in the
whole state during the year and the last one of these was
several months before. He had always been well, except
for whooping-cough at four and measles at six years, although
he had not been very vigorous until the past year. He was
vaccinated November 27. A number of other children who
were vaccinated at the same time, by the same physician,
with the same virus, were well. He did not seem quite like
himself December 3 and 4, and lay around the house instead
of going to school. His symptoms were attributed to the
vaccination, although the wound was perfectly healthy and
there was no undue inflammation about it. He seemed all
right December 5 and 6, and the morning of December 7.
He complained of headache on his return from school that
noon, vomited and went to bed. He had a restless night and
at times complained of severe headache. He was given
calomel by his mother and his bowels moved freely in the
morning. His legs seemed a little weak when he went to the
bathroom the next morning. He was first seen by his
physician at 10.30 a.m., December 8. His mouth tempera-
ture was then 104.20 F., he was a little tremulous and at times
irrational. The physical examination was negative. He
grew rapidly worse during the day and became more and more
irrational. When seen by his physician at 8.30 P.M. he com-
plained of pain when his neck was moved, but took but little
notice of anything else. The pupils were equal and reacted
to light. The knee-jerks were equal, but diminished. The
cremasteric and plantar reflexes were normal, but the ab-
dominal were absent. He moved his arms well, but was able
to move the legs only a little. The axillary temperature was
103. 50 F.; the pulse, 138; the respiration, 50. He continued
to grow worse during the night and was seen again by his
physician and a consultant at 2 a.m., December 9. He was
then unconscious. The pupils were equal and reacted to
light. He swallowed rather poorly. He was able to move
his arms a little, but had no control over his legs, which were
554 CASE HISTORIES IN PEDIATRICS.
flaccid. The abdominal and cremasteric reflexes were absent,
as were the knee-jerks. The left plantar reflex was normal,
the right was much diminished. The bowels had moved
involuntarily during the night and retention of the urine had
developed. The urine was drawn by a catheter and found
normal. Lumbar puncture showed no increase in the cere-
brospinal pressure. The fluid was clear and no fibrin clot
formed. No microscopic examination was made. The leu-
cocyte count was 12,000. His temperature was kept down
during the day by sponging. The pulse was regular and
averaged about 130. The respiration continued rapid and
became more and more diaphragmatic in type. He was
unable to take nourishment and did not retain enemata of
physiological salt solution. He was seen in consultation at
midnight, December 9.
Physical Examination. He was an exceptionally well
developed and nourished boy. The cheeks were flushed.
He was absolutely unconscious, except that when the eyelids
were raised he looked around a very little as if he had a certain
realization of what was going on about him. The pupils
were equal and reacted to light. There was no strabismus.
There was no rigidity of the neck or neck sign, and no spasm
or paralysis of the facial muscles. The mouth and throat
were evidently full of mucus, although they were not ex-
amined. There was some drooling, but not as much as there
would have been if he had not been able to swallow the
greater part of his saliva. There was almost no motion of
the right side of the chest and very little of the left, the
breathing being mostly diaphragmatic. The heart and lungs
were normal. The abdomen was level and negative. The
liver and spleen were not palpable. There was complete
flaccid paralysis of both the arms and legs. The abdominal
and cremasteric reflexes were absent, as were the knee-jerks
and the plantar reflexes. Kernig's sign was absent. It was
impossible to determine whether or not he felt pain. The
rectal temperature was 102.40 F. ; the pulse, 128; the res-
piration, 40.
Diagnosis. The flaccidity of the paralysis and the absence
of the superficial and deep reflexes show that the lesion is not
DISEASES OF THE NERVOUS SYSTEM. 555
located in the brain. The sudden onset, the high tempera-
ture and the absence of pain and disturbances of sensation in
the beginning are inconsistent with a peripheral paralysis.
The lesion must, therefore, be located in the spinal cord.
The combination of flaccidity and absent reflexes occurs only
when the anterior horns are involved. The progressive
character of the paralysis shows that the lesion is an ascending
one. The only disease in which this combination of symp-
toms occurs is the Ascending Type of Infantile Paralysis
(Poliomyelo-encephalitis). The fact that it is December is
not sufficient to exclude it, although infantile paralysis is rare
in the cold months. It is noteworthy, however, that the
weather had been unusually warm for the time of year for
nearly two weeks. This suggests the possibility that some
insect, usually destroyed by the cold, has acted as an inter-
mediate host.
Prognosis. The prognosis is practically hopeless. If the
process stops where it is he will survive, but will be left more
or less paralyzed. If it extends, as it almost certainly will,
he will die of respiratory paralysis in the course of the next
forty-eight hours.
Treatment. There is no specific treatment for this disease.
It is probably too late for hexamethylenamin to do any good,
as the harm has already been done. It will be well, however,
to give it to him in doses of 15 grains, every four hours. It
will, of course, have to be given by enema or through a tube,
as he is unable to swallow. He should be given oxygen, if the
difficulty with the respiration increases, and cardiac stimu-
lants when they are needed. It will also be well to give him
salt solution by rectum. It is hardly worth while to attempt
to give him nourishment, however, until it becomes evident
whether he is to survive or not, because he will not suffer
from the lack of food during the next forty-eight hours.
556 CASE HISTORIES IN PEDIATRICS.
CASE 174. Ambrose M., nine years old, had a sore throat
the last week in March. He was not sick enough to be in bed
and no physician was called. He returned to school after a
week. His voice became somewhat unnatural about April
25, and several days later liquids began to come through his
nose when he drank. He found, May 1, that he could not
see the blackboard very well, and a few days later began to
have some difficulty in walking steadily. These symptoms
were all present when he was seen, May 6.
Physical Examination. He was well developed and nour-
ished, but rather pale. His tongue was clean and was pro-
truded in the median line. The gums were healthy. His
throat was normal, except that the soft palate moved but
little when he spoke. His voice was somewhat hoarse.
There was moderate internal strabismus on the right. The
pupils were equal and reacted to both light and accommoda-
tion. The heart, lungs and abdomen were normal. The
liver and spleen were not palpable. He moved his arms freely
and his grip was strong. He moved his legs freely but with
little muscular power. He walked a little unsteadily. His
legs felt flabby and were rather cool. The knee-jerks were
absent on both sides. The abdominal and cremasteric re-
flexes were somewhat diminished. Kernig's and Babinski's
signs were absent. Sensation to touch was somewhat blunted,
but that to pain and temperature was normal. There was
no tenderness anywhere. There was no enlargement of the
peripheral lymph nodes.
The urine was normal in color, acid in reaction and of a
specific gravity of 1,018. It contained neither albumin nor
sugar.
Diagnosis. The paresis of the legs in combination with the
loss of the knee-jerks suggests to a certain extent infantile
paralysis. A slow onset and a paraplegic distribution of the
paralysis are, however, uncommon in infantile paralysis.
The disturbance of sensation shows that the lesion is in the
peripheral nerves, not in the anterior horns. The paresis of
the soft palate and of the right external rectus is, moreover,
not consistent with infantile paralysis, because, even with our
present conception of the pathology of this disease, it would
DISEASES OF THE NERVOUS SYSTEM. 557
be hard to conceive of a poliomyelo-encephalitis resulting in
paresis of the legs, one muscle of one eye and the soft palate
and nothing else. The only possible explanation of this com-
bination in a child of nine is a peripheral paralysis.
This combination is almost pathognomonic of diphtheritic
paralysis. The absence of pain and tenderness is also very
characteristic. The history of a sore throat a few weeks
before the onset of the paralysis makes the diagnosis of
Diphtheritic Paralysis positive. The only other form
of peripheral paralysis at all likely to occur in childhood,
that due to lead poisoning, can be excluded, not only be-
cause of the typical picture of diphtheritic paralysis which
this boy presents, but also on the distribution of the paralysis
and the absence of pain and tenderness and of a lead line
on the gums.
Prognosis. The prognosis is good. He will probably
recover from the paresis of the eye and throat in six or eight
weeks. The legs will probably not be well for from four to
six months. The reflexes will not return until some time
later.
Treatment. He must not use his eyes for near work.
It will be easier for him to take solid or semi-solid than
liquid food. He must be kept reasonably quiet. Exercise,
except in moderation, retards rather than hastens recovery.
Care must be taken to prevent, by the use of passive motions
or apparatus, the development of contractures. Massage
and electricity must be begun at once. Faradism is prefer-
able, if the muscles react to it; if they do not, galvanism
must be used. It must be remembered in this connection
that the object of both massage and electricity is merely to
keep the muscles in good condition until the nerves resume
their function, and that they have no direct curative action
on the nerves. He should be given strychnia in doses of
from one-sixtieth to one- thirtieth of a grain, three times
daily, after eating.
558 CASE HISTORIES IN PEDIATRICS.
CASE 175. Alfred B., two years old, was the fourth child
of healthy parents. There had been no deaths or miscar-
riages. There was no tuberculosis in either family and there
had been no known exposure to it. He was born at full term,
after a normal labor, and was normal at birth. He was
nursed during the first year; since then he had been on a
general diet. He had never been sick.
He was drowsy and somewhat feverish October 2, but had
no other symptoms whatever, no headache, coryza, cough,
vomiting or disturbance of the bowels. He seemed perfectly
well the next day. His parents were sure that there was
nothing the matter with him the morning of October 4.
That afternoon, while running after his father in the yard, he
tripped and fell down. When he got up it was noticed at
once that his right arm was paralyzed. He did not cry at the
time and did not seem hurt in any other way. He had been
perfectly well since this time and had partially regained the
use of his arm. He was seen October 23.
Physical Examination. He was well developed and nour-
ished and of good color. He was normal mentally. There
was no rigidity of the neck or neck sign. The mouth and
throat were normal. He had twelve teeth. There was no
spasm or paralysis of any of the muscles supplied by the
cranial nerves. There was no rosary. The heart and lungs
were normal. The abdomen showed nothing abnormal.
The lower border of the liver was just palpable in the nipple
line. The spleen was not palpable. There was no spasm or
paralysis of the left arm or legs. The knee-jerks were equal
and normal. Kernig's sign was absent. The cremasteric
reflexes were lively. The abdominal reflexes were not ob-
tained. The right arm hung limp by the side. He was
unable to raise it at the shoulder or to flex it at the elbow.
Inward rotation of the humerus was normal, but he was
unable to rotate it backward. Extension of the forearm on
the arm was normal. He pronated the forearm normally, but
could not supinate it as well as on the other side. All move-
ments of the wrist and fingers were normal. There was visi-
ble wasting of both the supra- and infra-spinatae and a little
of the upper arm. The scapular muscles felt flabby, as did
the deltoid and biceps. The sensation to touch was a little
DISEASES OF THE NERVOUS SYSTEM. 559
blunted over the area supplied by the right circumflex nerve.
There was very little reaction to pain and no tenderness any-
where. The deep reflexes could not be obtained in either
upper extremity. A Roentgenograph showed no evidence of
injury about the right shoulder joint or of disease of the bones.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was normal.
The urine was normal in color, clear, acid in reaction, and
contained no albumin or sugar.
Diagnosis. The persistence of the symptoms, the absence
of pain and tenderness and the normal condition of the
shoulder-joint and bones, as shown by the Roentgenograph,
exclude injury to the shoulder-joint or disease of the bones
as causes of the loss of power. The flaccidity of the paralysis
rules out any cerebral lesion. The lesion must be located,
therefore, in the lower motor neuron. The limitation of the
paralysis to a portion of the muscles of one extremity excludes
multiple neuritis. The sudden onset is inconsistent with a
localized peripheral neuritis. The distribution is not like
that of any of the usual types of this condition, and localized
peripheral neuritis is extremely unusual at this age. The
lesion must be situated, then, in the anterior horn of the
spinal cord or in the nerve trunks. If it is situated in the
anterior horn, the probable cause is acute poliomyelo-ence-
phalitis (infantile paralysis). The history of malaise and
fever two days before the onset of the paralysis strongly
suggests this etiology. The sudden onset of the paralysis
immediately after a fall is inconsistent with it. Is this story
of the sudden onset of the paralysis true, or was the paralysis
present before and not noticed until after the fall? If it was
present before the fall the history is most characteristic of
infantile paralysis; if it was not, the history is strongly
against infantile paralysis and in favor of some injury to the
nerve trunks. If this is the case, the malaise and fever two
days before must have been due to some other cause and were
purely a coincidence. It is impossible to know which is the
truth. The father, who is a reasonably intelligent man, is
positive, however, that the paralysis was not present until
after the fall. Is there anything about the distribution of
the paralysis which will aid in locating the lesion? The
560 CASE HISTORIES IN PEDIATRICS.
muscles involved are the supraspinatus and the infraspinatus,
the deltoid, the flexors of the forearm, that is, the biceps and
brachialis anticus, and, to a certain extent, the supinator
longus. This distribution of the paralysis is exactly that
which occurs in Erb's paralysis and obstetric paralysis, both
of which are due to an injury to the brachial plexus. The
ganglion cells of the nerves which supply these muscles are all
located in the fourth, fifth and sixth cervical segments. The
limitation of the lesion to these three segments is not incon-
sistent with infantile paralysis. It would be most unusual,
however, to have the lesion limited to the ganglion cells
controlling just the muscles affected when the lesion is located
in the brachial plexus, while the ganglion cells controlling
other muscles are entirely unaffected. It seems much more
reasonable that the lesion is located in the brachial plexus.
Another point in favor of this location is the blunting of the
sensation in the area supplied by the circumflex nerve (the
motor nerve of the deltoid), which shows that the sensory as
well as the motor fibres of this nerve are involved. This is
more consistent with a lesion outside than within the spinal
cord. The diagnosis of Erb's Paralysis, as the result of an
injury to the brachial plexus at the time of the fall, seems,
therefore, the most reasonable one.
Prognosis. The prognosis must at present be somewhat
indefinite. There will undoubtedly be a great deal of im-
provement in the paralysis. It is possible that there will be
complete recovery, but, in all probability, some permanent
disability will be left. How great this disability will be cannot
be told for a year or two, after which time little improvement
can be expected.
Treatment. The arm must be placed in a sling to take the
weight of the arm off of the shoulder muscles. He should be
encouraged to use it, and passive motions should be made to
prevent the development of contractures. Massage and
electricity should be begun at once, the object of them both
being to keep up the tone of the muscles until the nerves
regain their power. Faradism should be used if the muscles
react; if they do not, galvanism. There will be but. little
advantage in keeping up treatment after a year.
DISEASES OF THE NERVOUS SYSTEM. 561
CASE 176. Joseph R., four years old, was the child of
healthy parents. Five other children were well and there
had been no deaths or miscarriages. There had been no known
exposure to tuberculosis.
He was born at full term after a normal labor, was normal
at birth and weighed ten pounds. He was nursed for ten
months and did very well. He had otitis media, followed by
mastoid inflammation and operation, when he was one and
one-half years old, but made a perfect recovery. He had
measles when three and one-half years old and mumps a
few months later, but had otherwise been well and strong.
He was said to have had pneumonia, lasting eight or nine
days, in the early part of December, but was not very sick,
and had no marked cerebral symptoms. Soon after getting
up from the " pneumonia " he began to stagger a little, " as
if drunk." The staggering increased rather rapidly in severity
for a time and then remained unchanged. He also began to
complain of occipital headache at about the same time. The
headache was, however, never very severe, was not continu-
ous and did not prevent him from sleeping. He began to
vomit about Christmas and had continued to do so. The
vomiting had no apparent relation to food. There were no
other signs of indigestion, his appetite was good and his
bowels moved regularly. He sometimes vomited with great
force. He was bright and happy when his head did not ache,
and played as much as his unsteady gait would permit.
He had no trouble with sight or hearing and his memory was
good. He was seen January 28.
Physical Examination. He was fairly developed and nour-
ished and of good color. His skin was rather dry. He was
perfectly clear mentally. There was no tenderness on per-
cussion of the skull. Macewen's sign was absent. There was
no rigidity of the neck. He both saw and heard. The ear-
drums were normal. The pupils were equal and reacted to
light. The right eye showed an optic neuritis of the choked-
disk type with a fair amount of swelling; the left eye showed
similar but less marked changes. There was no spasm or
paralysis of any of the muscles controlled by the cranial
nerves. He held his head up straight and sat up straight.
562 CASE HISTORIES IN PEDIATRICS.
His tongue was clean and the mouth and throat normal. The
heart, lungs and abdomen were normal. The liver and spleen
were not palpable. He used his hands normally. He walked
a little unsteadily and, on turning, staggered and almost fell.
There was no tendency to fall to one side more than to the
other. There was no spasm of the legs, and when lying down
he could make all motions without difficulty. The knee-jerks
were equal and normal. Kernig's and Babinski's signs were
absent. The cremasteric and abdominal reflexes were normal.
Sensation to touch and pain was normal by rough tests. The
genitals were normal. There was no eruption and there were
no scars of old eruptions. There was no enlargement of the
peripheral lymph nodes. The mouth temperature was
98. 6° F., the pulse 96, the respiration 24.
The urine showed nothing abnormal.
The white corpuscles numbered 8,000.
A tuberculin skin test was negative.
Diagnosis. The persistent vomiting without other symp-
toms of indigestion, the projectile character of the vomiting,
the occipital headache without disturbance of digestion,
disease of the kidney or eyestrain, and the staggering gait
without disease of the ears form a combination of symptoms
that can be explained only by some trouble in the brain.
The optic neuritis proves that there is a cerebral lesion. The
condition is, of course, a chronic one. The first possibility
which suggests itself is an abscess of the brain resulting from
the otitis media two and one-half years before. Cerebral
abscess is very rare at this age and a latent period of two and
one-half years without any symptoms is most unusual. These
facts, together with the normal condition of the ears and the
absence of fever and leucocytosis, make an abscess extremely
improbable. Another possibility is that the illness which was
called pneumonia was, in spite of the lack of nervous symp-
toms, an encephalitis and that the present symptoms are
the result of it. It would be hardly possible, however, for an
encephalitis to be mistaken for a pneumonia, although a
pneumonia might easily be mistaken for an encephalitis.
The lesions caused by an encephalitis would not be likely to
cause an optic neuritis and would almost certainly produce
DISEASES OF THE NERVOUS SYSTEM. 563
some spasm, paralysis, change in the reflexes or mental dis-
turbance. The most reasonable explanation for his symptoms
is a rather rapidly growing cerebral tumor. The optic
neuritis, projectile vomiting and staggering all point to it.
The absence of Mace wen's sign does not count much against
the presence of a tumor, because it is often hard to elicit and
is often absent when the tumor is deep seated. The location
of the pain in the occiput and the reeling gait make it probable
that the Tumor is in the Cerebellum. The absence of spasm,
paralysis and changes in the reflexes is negative evidence in
favor of this location. Nearly forty per cent of cerebral
tumors in childhood are, moreover, in the cerebellum.
It is impossible to more than guess at the nature of the
tumor. The negative tuberculin test practically rules out a
solitary tubercle, although about fifty per cent of the cerebral
tumors in childhood are tubercular. Gumma is extremely
rare at this age, the family history is good, there is nothing
in his past history to suggest syphilis, and the physical exami-
nation shows no sign of syphilis in the past or at present. A
gumma can, therefore, be excluded. The chances lie between
a glioma and a sarcoma, the former being somewhat the more
probable as gliomata are more common than sarcomata at
this age.
Prognosis. The prognosis is hopeless. He will probably
not live more than three or four months, perhaps not as long.
Treatment. The treatment can be only symptomatic and
for. comfort. He must not be allowed to suffer pain when
morphia will relieve him. It will be well, perhaps, to give him
iodide of potash up to the physiological limit on the possi-
bility that the tumor may be a gumma. It will probably do
no good, but can do no harm. The chances of the successful
removal of the tumor by an operation are practically nil.
It will be only fair, however, to state the facts to the parents
and allow them to decide as to whether or not they wish an
operation. A lumbar puncture should not be done because
it is very likely to cause sudden death when there is a cerebral
tumor, especially if it is located in the cerebellum.
564 CASE HISTORIES IN PEDIATRICS.
CASE 177. Elizabeth C, three years old, was the only
child of extremely neurotic but healthy parents. There had
been no miscarriages. She had always been well.
Her mother left her with an attendant one afternoon.
She was pulled up from the floor by the arms a number of
times and had also swung on a gate with her arms extended.
She had had no fall. She complained a little of pain in her
left arm before she went to bed, but nothing was thought of
it. No one could tell whether she used her arm or not during
the late afternoon before she went to bed. She slept well
all night, seemed perfectly well in the morning and ate a
good breakfast, but did not use her left arm at all. She
apparently had no pain in it. She was seen at 2 p.m.
Physical Examination. She was well developed and nour-
ished and of good color. She was very bright and much
interested in her surroundings. There was no rigidity of
the neck and no paralysis of any of the muscles controlled
by the cranial nerves. She had twenty teeth. Her tongue
was clean; her gums, mouth and throat were normal. There
was a slight rosary. The heart and lungs were normal.
The abdomen was rather large and lax, but otherwise normal.
The liver and spleen were not palpable. Her left arm hung
limply by her side with the palm turned backward and the
fingers partially flexed. She would not reach out for or take
hold of anything. There was no tenderness about the joints
or bones or along the nerve trunks. There were no evidences
of fracture or dislocation. There was no swelling or redness.
Passive motions were not limited or painful. There was
apparently no disturbance of the sensations to touch or
pain. The reflexes of the arms were normal. She used her
right arm and legs freely. The knee-jerks were equal and
normal. Kernig's and Babinski's signs were absent. She
was slightly knock-kneed, but there was no enlargement of
the epiphyses at the wrists and ankles. There was no enlarge-
ment of the peripheral lymph nodes. There were no mucous
patches and no eruption or signs of old eruptions. The
rectal temperature was 98. 6° F.
Diagnosis. Scurvy, while a possibility, is very improbable
in a child of three on a general diet. It can be excluded on
DISEASES OF THE NERVOUS SYSTEM. 565
the localization of the symptoms in one extremity, the
absence of pain on passive motion and the absence of swelling
and tenderness. Syphilitic periosteitis can be ruled out on
the good family and past history, the absence of signs of
syphilis in the past or present, the absence of local tenderness
and swelling, and the localization in one extremity. Acute
periosteitis or osteomyelitis can be excluded on the good
general condition and the absence of fever, pain and tender-
ness. The history of fleeting pain is like that of rheumatism
at this age. Children do not stop using their extremities
when they have rheumatism, however, and the pain is usually
more general. The onset and development of the paralysis,
although unusual, are not inconsistent with infantile paraly-
sis, but the absence of fever and the retention of the reflexes
practically exclude it. The position of the arm suggests
that there may have been some pressure on the brachial
plexus. It is hard to see how this could have happened in her
case, and the absence of disturbances of sensation makes it
very improbable. There is no dislocation or evidence of
injury to the arm at present. It is very possible, however,
that there may have been a partial dislocation of the shoulder
as the result of the pulling up by the arms or of the swinging,
with immediate spontaneous reduction. The subconscious
memory of the pain caused by motion of the arm at that
time may account for the failure to use it now. This seems,
at any rate, the most plausible explanation. In an older
child or adult it would be called an Hysterical Paralysis.
Prognosis. The prognosis is perfectly good. If she can
be sufficiently interested in some game or toy to forget
herself entirely, she will use the arm at once.
Treatment. The treatment consists in getting her mind
entirely off of herself so that she will unconsciously use the
arm again.
566 CASE HISTORIES IN PEDIATRICS.
CASE 178. Susan T., two and one-half years old, was
brought to the Infants' Hospital from the Children's Aid
Society, which had had her two weeks. Her forehead was
large when she came to them and had not increased in size.
Her mother had not noticed the enlargement but, when it was
called to her attention, remembered that she had fallen out of
bed some weeks before. She had had cerebrospinal menin-
gitis six months previously, but had been well since then.
While with the Children's Aid Society she had seemed per-
fectly well, except that at times she acted as if her head was
painful.
Physical Examination. She was well developed and nour-
ished and of fair color. She seemed normal mentally. The
forehead projected forward, as is shown in the accompanying
photograph. The swelling was symmetrical and hard, but
not red or tender. The veins on its surface were enlarged.
Pressure on it caused no discomfort, spasm of extremities or
change in the pulse or respiration. There was no fluctuation.
The fontanelles and sutures were closed. Percussion of the
skull showed slight dullness in the left frontal region. The
conjunctivae were not visible above the irides. There was no
disturbance of vision and no spasm or paralysis of any of the
muscles supplied by the cranial nerves. She moved her head
freely, but rather guardedly. The heart, lungs and abdomen
were normal. There was no rosary. The lower border of
the liver was palpable two cm. below the costal border in the
nipple line. The spleen and kidneys were not palpable.
The extremities were normal. There was no spasm or
paralysis. The knee-jerks were equal and normal. Kernig's
and Babinski's signs were absent, as was the neck sign. She
ran about and played without difficulty. The rectal tem-
perature was 98. 6° F. ; the pulse, 100; the respiration, 20.
The leucocytes numbered 8,400.
Diagnosis. The bulging of the forehead cannot be due to
rickets, the enlargement in this disease being asymmetrical.
There are, moreover, no other signs of rickets. The history
of an attack of cerebrospinal meningitis some months before
suggests hydrocephalus as the cause of the swelling. It
would hardly be possible, however, for hydrocephalus to
Susan T. Case 178.
DISEASES OF THE NERVOUS SYSTEM. 567
bulge out the forehead without causing separation of the
sutures and general enlargement of the head. The fact that
the conjunctivae are not visible above the irides shows, more-
over, that there is no pressure downward on the orbital
plates. There are no other signs of increased cerebral
pressure, there being no spasm, paralysis or exaggeration of
the deep reflexes. Pressure on the tumor causes no symptoms
of cerebral irritation. Hydrocephalus can, therefore, be
excluded. The history of a fall suggests some injury to the
bones, with the formation of an abscess. The absence of
redness, tenderness and fluctuation, the low white count and
the normal temperature prove that this is not the case. The
only other possibility is a new growth involving the frontal
bones. The characteristics of the tumor are consistent with
this diagnosis, as is the absence of all signs of increased
cerebral pressure or irritation. New growths at this age are
almost invariably sarcomatous. The diagnosis of Sarcoma
of the Skull is, therefore, undoubtedly correct. Sar-
comata of the skull at this age are almost never primary but
secondary to sarcoma elsewhere, most often of the suprarenal
capsule, but sometimes of the brain. There is no tumor in
the kidney region in this instance, however, and there are no
symptoms of increased cerebral pressure or of focal irritation,
as would be expected if there were a tumor of the brain.
These might be absent, nevertheless, if the tumor was small
and situated in the frontal lobe. The dullness on percussion
over the left frontal region is suggestive of the presence of
such a tumor. It is, however, impossible to determine
whether the tumor of the skull is primary or secondary to
some focus elsewhere.
Prognosis. The prognosis is practically hopeless. If the
tumor of the skull is primary and can be removed, it is almost
certain to recur, while if it is secondary, the original focus
remains.
Treatment. The only treatment which offers the least
hope is the immediate removal of the tumor.
568 CASE HISTORIES IN PEDIATRICS.
CASE 179. James S. was the first child of healthy parents.
There was no history of mental defect, insanity, paralysis or
muscular dystrophy in either family. He was born at full
term, after an easy labor, appeared normal at birth and
weighed nine and three-quarters pounds. He was nursed
entirely for five months, given milk and barley water in
addition for five months and a rational diet during the last
five months. He had never had any symptoms of indigestion
and had had no illnesses, except a slight attack of bronchitis
when a year old. He had always weighed more than the
average baby of his age and had cut his teeth early, the first
two having erupted when he was only five months old. He
had developed normally mentally, but had always been back-
ward about doing things. He did not hold up his head well
until he was eight months old and then held it up very feebly.
He still had some difficulty in controlling it long at a time.
He could not sit up alone any length of time, but quickly fell
over. His arms were weak at first, but he had used them
well for a long time. He almost never attempted to use his
legs and was unable to roll over. He was brought on account
of his backwardness, when fifteen months old.
Physical Examination. He was a good-sized baby and of
good color. The head was of good shape and of normal size.
The anterior fontanelle was almost closed. He laughed,
played and was undoubtedly perfectly normal mentally. He
both saw and heard. The pupils were equal and reacted to
light. All motions of the face were normal. There were
eight teeth. The mouth and throat were normal. There
was no disturbance of deglutition and his cry was loud and
clear. He was able to hold up his head, but after a short
time it fell limply to one side or the other. There was no
rosary. The heart and lungs were normal and the respira-
tory excursion was normal. He was unable to sit alone and
when supported his back showed a marked curve of weakness.
The spine was normal. The abdomen showed nothing ab-
normal. The lower border of the liver was just palpable in
the nipple line. The spleen was not palpable. There was
no enlargement of the epiphyses at the wrists and ankles.
He lay with the right thigh rotated outward. When the legs
DISEASES OF THE NERVOUS SYSTEM. 569
were straightened there was a moderate amount of knock-
knees with separation of the legs. The heads of the femora
were in normal position and passive motions at the hips were
normal. He used his arms freely and they were reasonably
strong, although the muscles felt somewhat flabby. He used
his legs but little, but was able to make all motions with them,
either wholly or in part, although feebly. The muscles were
flabby, especially in the thighs. There was no apparent
enlargement of any of the muscles of either the arms or legs.
The knee-jerks, cremasteric and abdominal reflexes were
absent, as was Kernig's sign. Sensation to touch and pain
-was normal. No urine could be expressed from the bladder
and the anal sphincter was tight. There was no enlargement
of the peripheral lymph nodes.
Diagnosis. Weakness from malnutrition can be ruled out
by the size of the baby, the good color and the absence of any
disturbance of digestion or serious illness in the past. Mus-
cular weakness from rickets can be excluded on the absence of
all bony changes of this disease. Idiocy can be eliminated as
the cause of the disturbance of motility because of the normal
mental development. The absence of any acute illness in
the past and the fact that the baby has never been normal
rules out poliomyelo-encephalitis as the cause. The paresis
resulting from this disease is, moreover, seldom so widespread
as in this instance. It is almost never symmetrical and never
involves all the muscles of an extremity to the same degree.
There is no history of paralysis in either family, the weakness
was noticed soon after birth, it involves all the muscles of the
extremities to the same extent, there is no hypertrophy of any
groups of muscles and the weakness is steadily diminishing.
The muscular dystrophies, can, therefore, be excluded. The
only disease left to be considered is amyotonia congenita.
The history and physical examination of this patient corre-
spond exactly to those of this condition. Amyotonia Con-
genita is, therefore, the diagnosis.
Prognosis. This condition has been recognized for so short
a time that little is known as to the ultimate prognosis. The
fact that but one case has been described in the adult makes
it probable, however, that the children either die or recover
570 CASE HISTORIES IN PEDIATRICS.
completely. There is no involvement of the muscles of
organic life in this instance, there has been a progressive
improvement in the symptoms and the baby is normal in
other respects. The outlook is, therefore, very favorable.
He will probably be able to walk by the time he is three years
old. It seems reasonable to expect that he will eventually
attain full muscular power or that, if he does not, the weak-
ness will not be sufficient to handicap him in any way.
Treatment. There is no drug treatment which is of any
use in this condition. He ought not to be forced to attempt
to do things which he is unable to do. He should, however,
be encouraged to do the things which he is able and given the
best opportunity to exercise his muscles. This can be done
by letting him play for a time once or twice daily in a warm
room with his clothes off. Daily massage and the application
of faradic electricity every other day will also aid in develop-
ing the muscles.
SECTION XIII.
UNCLASSIFIED DISEASES.
CASE 1 80. 1 Sadie H. was the first child of healthy parents.
There had been no miscarriages. Her parents were Russians
and not related. There was no history of idiocy or nervous
diseases in either family.
She was born at full term after a normal labor, and seemed
normal at birth. She was nursed for ten months, after which
she was given a general diet. Her appetite and digestion
had always been good. Constipation began when she was
two months old and had persisted. A dry and scaly condi-
tion of the face, scalp and extremities developed when she
was three months old and had resisted all forms of treatment.
She had rather more hair than most children at birth, but
this soon dropped out and no more appeared until she was
nearly two years old. Her mother noticed when she was six
months old that her tongue seemed too large for her mouth
and that she drooled more than most babies. When she was
eight months old her mother noticed that she was not as
bright as other children of her age. Her mental development
had, as time went on, dropped progressively farther behind
that of other children of her own age. She was seen when
three and one-fourth years old, and could then say only
a few words. Her parents thought, however, that she
understood much of what was said to her. She had not
learned to control her sphincters. She cut her first tooth
when she was two years old and began to sit up a little
when she was two and one-fourth years old. She had not
learned to creep or stand. Her large tongue made swallowing
difficult and she drooled constantly.
Physical Examination. She took considerable interest in
her surroundings, but made no attempt to play with the
toys offered to her, although she held them in her hands for
a time. She knew her parents and said " Papa " and
571
572 CASE HISTORIES IN PEDIATRICS.
" Mamma " and a few other simple words. She was small
but fairly nourished. Her skin had a peculiar yellowish
pallor. She had considerable rather coarse hair. The face
and the top of the head were covered with a dry, scaly erup-
tion. The anterior fontanelle was closed. The head was of
good shape, except that it was somewhat flattened on top.
The bridge of the nose was flattened and the nostrils wide.
The lower lids were rather full. She kept her mouth open and
drooled constantly. The thickened and broadened tongue
protruded just beyond the lips. She had six incisor teeth
which, although only just through the gums, were much
blackened. The throat was normal. Her voice was hoarse
and deep. The rings of the trachea were distinctly pal-
pable. The neck was not especially short, and there were no
supraclavicular pads. She held up her head well but sat up
rather feebly, with a marked general kyphosis. This was
replaced by a slight lordosis in the lumbar region when she
was held upright. There was a moderate rosary and a little
flaring of the lower ribs. The heart and lungs were normal.
The level of the abdomen was much above that of the thorax,
but nothing else abnormal was detected in it. The lower
border of the liver was palpable just below the costal border
in the nipple line. The spleen was not palpable. The lower
legs and feet appeared puffy but did not pit on pressure.
The soles of the feet were flat, like those of an infant. The
forearms and hands were also puffy, especially in the palms.
The hands and feet were cold and the skin of the legs, feet,
arms and hands dry, and in places scaly. There was no
enlargement of the epiphyses, but the long bones of the
extremities seemed larger in circumference than normal.
The distance from the anterior superior spine to the sole of
the foot was forty-four per cent of the body length, while
it should be about fifty per cent. There was no spasm or
paralysis. The knee-jerks were equal and diminished.
Kernig's sign was absent. The external genitals were normal.
There was a slight general enlargement of the peripheral
lymph nodes. The rectal temperature was 980 F. She
weighed twenty-two and one-half pounds (average is thirty-
four and one-half pounds).
Sporadic Cretinism.
UNCLASSIFIED DISEASES. 573
Diagnosis. The history and physical examination of this
child are so characteristic of Sporadic Cretinism that there
is no opportunity for a differential diagnosis. The com-
bination of retarded mental and physical development,
yellowish pallor, coarse hair, dry and scaly skin, thickening
of the skin of the extremities, broad nose, large tongue,
hoarse and deep voice, apparent absence of the thyroid
gland, short legs, thickening of the long bones of the extremi-
ties and subnormal temperature is pathognomonic of the
disease. The flattening of the head, the rosary and the
flaring of the lower ribs are undoubtedly signs of a compli-
cating rickets. The delayed dentition, the kyphosis and the
enlargement of the abdomen may be due to either, but more
probably to the cretinism.
Prognosis. She will undoubtedly improve very materially,
both mentally and physically, but too much must not be
expected from the thyroid treatment when it is not begun
until the patient is over three years old. The physical
improvement will probably be much greater and more rapid
than the mental. She will almost certainly, however, not
attain normal stature, although her proportions will probably
be approximately normal and she will be reasonably active.
She will probably never develop sufficiently mentally to be
a free agent or to support herself, although she will probably
be able to do manual labor.
Treatment. The treatment is with some preparation of
the thyroid gland. The best preparation is the dessicated
extract. The initial dose for this child is one half a grain,
three times a day. It must be increased, one quarter of a
grain at a time, until toxic symptoms appear. These are
nervousness, fever and diarrhea. The dose must then be
put back to the largest one which did not cause toxic symp-
toms and kept there for many months. Later, it may be
safe to give smaller doses. It is needless to say that she
must continue to take thyroid extract as long as she lives.
Her father's financial condition is poor. It will be wise,
therefore, to place her in some institution for the care of
the feeble-minded.
574 CASE HISTORIES IN PEDIATRICS.
CASE 181. Rosamond S., the second child of healthy
but neurotic parents, was born at full term, after a normal
labor, was normal at birth and weighed seven pounds. She
was nursed for eight months, after which she was given
modified milk. This had been gradually strengthened, so
that at the time she was seen she was taking whole milk and
oatmeal jelly. She had never had any disturbance of diges-
tion or illnesses of any sort.
When she was six months old her mother noticed that her
respiration was unusually rapid and that at times it was a
little difficult. She was not sure, however, that these symp-
toms had not been present previously. Her physician found
nothing abnormal on physical examination at this time, but
thought that the difficulty with respiration was chiefly expira-
tory. The symptoms gradually increased in spite of the
administration of the syrup of hydriodic acid for two months.
The respiration continued rapid and was often a little wheezy,
the wheeziness occurring both with inspiration and expira-
tion. She was at times a little blue, but never markedly so.
She never appeared uncomfortable, however, and apparently
was not inconvenienced in any way. Slight suprasternal
retraction had been noticed during the last month and dull-
ness had been found under the manubrium. She was seen
in consultation when one year old.
Physical Examination. She was well developed and nour-
ished, and of good color. She was bright and happy and
seemed perfectly comfortable. The anterior fontanelle was
one and one-half cm. in diameter and level. She had three
teeth. She kept her mouth shut and there was no nasal
discharge. The throat was normal to inspection and palpa-
tion. Her cry and voice were clear. The respiration was
rapid but regular. There was slight suprasternal retraction
with inspiration. The relation between inspiration and
expiration was normal. When she was quiet the respiration
was inaudible; when she was active or excited it became a
little wheezy. The wheezing was usually more marked in
expiration than in inspiration. Extension of the head in-
creased the wheeziness. An indefinite resistance was felt in
the suprasternal notch, this resistance being more marked
UNCLASSIFIED DISEASES. 575
during expiration than during inspiration. There was moder-
ate dullness under the upper portion of the manubrium,
which did not extend down to the cardiac dullness or beyond
the edges of the manubrium. The heart and lungs were
normal. The intensity of the respiratory sound was the same
on both sides. There was no dullness in the interscapular
region and the respiratory and voice sounds were normal in
character over the upper dorsal spines. There was no
rosary. The abdomen showed nothing abnormal. The liver
was just palpable in the nipple line. The spleen was not
palpable. The extremities showed nothing abnormal. There
was no spasm or paralysis. The knee-jerks were equal and
normal. Kernig's sign was absent. There was no enlarge-
ment of the peripheral lymph nodes.
Diagnosis. The absence of nasal discharge and the closed
mouth rule out adenoids and nasopharyngitis as the cause of
the difficulty in respiration. The normal condition of the
throat, both to inspection and palpation, rules out enlarge-
ment of the tonsils and retropharyngeal abscess, while the
clear voice and cry exclude disease of the larynx. The normal
condition of the lungs rules out trouble below the trachea and
primary bronchi. The absence of dullness in the inter-
scapular region, the normal character of the respiratory and
voice sounds over the upper dorsal spines, the equal intensity
of the respiratory sound on the two sides and the increase in
the dyspnea on extension of the head exclude enlargement of
the tracheo-bronchial lymph nodes. The resistance in the
suprasternal notch is strong evidence in favor of enlargement
of the thymus. The increase in this resistance during expira-
tion, in which phase of respiration the thymus is more easily
palpable, makes this evidence stronger. The location of the
dullness under the upper portion of the manubrium is char-
acteristic of enlargement of the thymus. So also is the
increase in the intensity of the symptoms on extension of the
head, which narrows the upper opening of the thorax and
hence increases the pressure exerted by an enlarged thymus
on the neighboring structures. The diagnosis of an En-
largement of the Thymus is, therefore, justified. A
Roentgen ray photograph should be taken, however, to verify
576 CASE HISTORIES IN PEDIATRICS.
the diagnosis. The normal relation between inspiration and
expiration is also of some importance in differentiating
obstruction to respiration from enlargement of the thymus
from that due to other causes. The greater intensity of the
wheezing in expiration than in inspiration is rather unusual,
but does not seem sufficient to invalidate the diagnosis.
The enlargement of the thymus is almost certainly the
result of simple hypertrophy. The good general condition,
the slight amount of the enlargement after six months and
the absence of enlargement of the lymph nodes rule out a
malignant growth. There are no other signs of syphilis or
tuberculosis and the general condition is better than would
be expected if the enlargement was tubercular. The good
general condition and the absence of fever exclude an abscess.
All these affections of the thymus as well as cysts are, more-
over, extremely rare, while simple hypertrophy is relatively
common.
Prognosis. The facts that the thymus is still compara-
tively but little enlarged and that the symptoms of compres-
sion have increased so little during the six months since their
onset make it improbable that it will become large enough to
cause any severe symptoms of compression before the normal
atrophic changes, which begin at about two years, set in to
cause retrogression in size. The slight degree of the enlarge-
ment also makes it probable that the gland will diminish
rapidly in size under treatment. It is possible, however, that
the thymus may suddenly increase in size as the result of
acute congestion and cause sudden death from compression.
Enlargement of the thymus being in many instances a mani-
festation of the condition known as "status lymphaticus,"
it is also possible that she may die suddenly at any time.
Both of these possibilities are, however, extremely improbable.
Treatment. There is no drug treatment which will di-
minish the size of the thymus. The symptoms in this
instance are not severe enough at present to warrant thy-
mectomy, which is a dangerous operation and which, if
successful, is liable to be followed by interference with the
normal development of the nervous and osseous systems.
Treatment with the Roentgen ray is, however, safe and will,
UNCLASSIFIED DISEASES. 577
in all probability, hasten materially the involution of the
enlargement. It should, therefore, be begun at once. As
the symptoms are in no way urgent it will be wise, however,
not to push the treatment, but to give short exposures at
intervals of several days or even weeks.
578 CASE HISTORIES IN PEDIATRICS.
CASE 182. Sarah A., the second child of healthy parents,
was born at full term, January 6, after a normal labor. She
was cyanotic at birth and great difficulty was experienced in
getting her to breathe. She had never breathed properly,
but had not been cyanotic and had been able to nurse without
difficulty up to the last ten days. Since then the respiration
had been more difficult and she had had repeated attacks,
lasting one-half hour or more, in which she breathed with
great difficulty and became markedly cyanotic. The respira-
tion was easier, both during and between the attacks, when
she was held up than when she was lying down. She had had
no other symptoms, had shown no evidences of indigestion
and had gained steadily in weight as long as she was able to
nurse easily. She was admitted to the Infants' Hospital,
March 10, when nine weeks old.
Physical Examination. She was fairly developed and
nourished. Her color was good, except for a slight tinge of
cyanosis about the mouth. The anterior fontanelle was
three cm. in diameter and level. There was no nasal dis-
charge and she kept her mouth shut. The throat showed
nothing abnormal on either inspection or palpation. Her
cry was clear and fairly loud. There was slight retraction in
the suprasternal space and of the epigastrium with inspira-
tion. This was more marked when she was lying down flat
than when she was reclining or bolstered up. Expiration was
slightly prolonged, but the respiration was quiet. Extension
of the head increased the difficulty in respiration. There was
slight dullness under the manubrium, which was continuous
with the cardiac dullness. Nothing abnormal was detected
in the suprasternal space. The heart was normal. The
respiratory murmur was somewhat feeble, but alike on both
sides. The lungs showed nothing else abnormal. There was
no dullness in the interscapular space and the cry was normal
in character over the upper dorsal spines. The abdomen
showed nothing abnormal. The lower border of the liver
was palpable one cm. below the costal border in the nipple
line. The spleen was not palpable. The extremities were
normal. There was no spasm or paralysis. The knee-
jerks were equal and normal. There was no enlargement of
UNCLASSIFIED DISEASES. 579
the peripheral lymph nodes. The rectal temperature was
99° F.
During the attacks she became markedly cyanotic and
breathed with great difficulty, even when sitting up. There
was marked retraction of the suprasternal and supraclavicu-
lar spaces as well as of the lower chest and epigastrium with
inspiration. There was a whistling noise with both inspira-
tion and expiration, more marked with expiration. Expira-
tion was prolonged. The symptoms were much increased
by extension of the head.
Diagnosis. The absence of all physical signs of cardiac
disease, the development of the attacks of cyanosis without
evident cause and the signs of interference with the respira-
tion rule out congenital heart disease as the cause of the
symptoms. These must be due to some obstruction to the
respiration, either within or without the respiratory tract.
The absence of nasal discharge, the closed mouth and the
paroxysmal exaggeration of the symptoms rule out adenoids
and nasopharyngitis. Enlargement of the tonsils and retro-
pharyngeal abscess are excluded by the physical examination.
The clear cry shows that there is no trouble in the larynx.
The greater intensity of the whistling noise in expiration, the
prolongation of the expiration, the duration of the attacks
and the persistence of the symptoms between the attacks
rule out laryngismus stridulus. The normal condition of
the lungs rules out trouble below the trachea and primary
bronchi. The age of the baby, the absence of dullness in the
interscapular region, the normal sound of the cry over the
upper dorsal spines, the equal intensity of the respiratory
sound on the two sides and the increase of symptoms on
extension of the head and on lying down exclude enlargement
of the tracheo-bronchial lymph nodes. Moreover, the symp-
toms due to enlargement of these nodes rarely vary so
markedly in severity as in this instance. The obstruction to
the respiration must, therefore, be located in the trachea.
The absence of catarrhal symptoms shows that the obstruc-
tion must be due to pressure from the outside. The only
organ in this region whose enlargement is likely to cause
pressure on the trachea at this age is the thymus. The
580 CASE HISTORIES IN PEDIATRICS.
dullness under the manubrium is characteristic of enlarge-
ment of the thymus. So also is the increase in the intensity
of the symptoms on extension of the head and the variation in
the severity of the symptoms without evident cause. Pro-
longation of the expiration and greater difficulty in expiration
than in inspiration are somewhat unusual when the obstruc-
tion is due to Enlargement of the Thymus, but are not of
sufficient importance to have much weight against the points
in favor of this diagnosis. It should be verified, however, by
a Roentgen ray photograph. Other causes of enlargement of
the thymus at this age are so uncommon that it is safe to
conclude that the enlargement in this instance is due to simple
hypertrophy. The variations in the severity of the symptoms
are in all probability the result of variations in the congestion
of the organ.
Prognosis. The outlook in this instance is most unfavor-
able, because of the early development of the symptoms, the
progressive increase in their severity and the occurrence of
the suffocative attacks. She is likely to die suddenly in an
attack or to gradually fail and die from malnutrition. Her
only hope lies in the relief of the pressure by the removal or
the reduction of the size of the thymus.
Treatment. There is no drug treatment which will
diminish the size of the thymus. Two lines of treatment are
possible: operative, to relieve the pressure by the partial or
complete extirpation of the gland, or by anchoring it in a new
position ; exposure to the Roentgen ray, to relieve pressure by
causing its involution. The operative treatment is attended
by considerable danger, but, if successful, the relief will be
immediate. Treatment by the Roentgen ray is safe, but at
best several days must elapse before any improvement can
be expected and then the relief will be gradual. It is difficult
to determine which method to adopt. Either course exposes
the baby to grave dangers. It will probably be wiser, how-
ever, to try first fairly long daily exposures to the Roentgen
ray, and, if improvement does not begin in three or four days,
to operate.
UNCLASSIFIED DISEASES. 58 1
CASE 183. Jacob Z. was the sixth child of healthy parents.
The other children were well. There had been no mis-
carriages. He was born at full term, after a normal labor,
had been breast-fed and had been well except for occasional
slight disturbances of digestion and "colds in t'he head."
He developed a slight "cold in the head" and croupy
cough February 15. A culture taken February 18 showed
no Klebs-Lceffler bacilli, and the physical examination at
that time showed nothing abnormal except a nasal discharge
and moderate reddening of the throat. There was a dis-
charge from the right ear, February 24, and on the twenty-
eighth both ears were discharging freely. He had a convulsion
on the twenty-eighth and another on the twenty-ninth. He
took his food poorly after this, but did not vomit and had
normal movements. The rectal temperature during the last
week had ranged between 1010 F. and 1030 F. ; his pulse,
between 120 and 140; and his respiration, between 40 and 65.
He was admitted to the Infants' Hospital, March 1, when ten
months old.
Physical Examination. He was large and fat, but moder-
ately pale. The anterior fontanelle was three cm. in diam-
eter and level. There was slight rigidity of the neck, but no
neck sign. He noticed, but did not take interest enough to
reach out for things. The pupils were equal and reacted to
light. There was a profuse purulent discharge from both
ears. There was no swelling or tenderness over the mastoids.
There was a profuse purulent nasal discharge, but the mouth
was kept shut. The throat was generally reddened. The
pharynx was slightly edematous on palpation. Digital
examination of the larynx showed no swelling. The cry was
clear. There was no dullness over the manubrium. The
thymus could not be felt in the suprasternal space. There
was no rosary. The heart and lungs showed nothing abnor-
mal. The level of the abdomen was that of the thorax.
Nothing abnormal was detected in it. The lower border of
the liver was palpable four cm. below the costal border in the
nipple line. The spleen was palpable three cm. below the
costal border. The extremities showed nothing abnormal.
There was no spasm or paralysis. The knee-jerks were equal
582 CASE HISTORIES IN PEDIATRICS.
and normal. Kernig's sign was absent. The cremasteric
reflexes were feeble, the abdominal were not obtained. There
was no enlargement of the peripheral lymph nodes. The
respiration was regular, but very peculiar. Inspiration was
sighing, while expiration was forcible and often accompanied
by blowing out of the lips. There was no retraction any-
where. He was slightly cyanotic unless kept by the open
window. The rectal temperature was 1030 F. ; the pulse,
124; the respiration, 50.
The urine was normal in color, highly acid in reaction and
contained a large trace of albumin, but no sugar, acetone or
diacetic acid. The sediment showed a considerable number
of hyaline and coarse granular casts and casts with cells
adherent, but no blood or blood elements. There was,
however, no marked diminution in the amount of urine.
The fluid obtained by lumbar puncture was under low
pressure and perfectly clear. No fibrin clot was present after
twenty-four hours. The fluid contained two cells per cubic
millimetre.
Diagnosis. The inflammation of the nasopharynx and
middle ears is sufficient to account for the fever. It does not,
however, explain the rapidity of the respiration or its peculiar
type. If there was obstruction enough to the respiration in
the nose and nasopharynx to increase the rate to this extent,
the mouth would be kept open, the inspiration would not be
sighing and the expiration would not be forcible. The
absence of swelling at the entrance of the larynx and the clear
cry rule out trouble in the larynx. The character of the
respiration and the absence of retraction show, moreover,
that the increase in the rate of the respiration cannot be due
to obstruction either in the larynx or below it. The normal
condition of the lungs rules out disease of these organs as the
cause. This must be sought, therefore, outside of the respira-
tory tract. The absence of all signs of meningeal irritation
and the normal cerebrospinal fluid prove that it is not menin-
gitis. It is conceivable that the rapid respiration may be due
to reflex irritation from the ears. They are discharging freely,
however, and otitis media rarely causes reflex symptoms after
the discharge is well established. Reflex irritation would,
UNCLASSIFIED DISEASES. 583
moreover, not explain the cyanosis. The normal condition
of the heart and the relatively slight increase in the rate of
the pulse show that the rapid breathing is not due to cardiac
failure. The changes in the urine are characteristic of acute
degeneration of the kidneys and are not consistent with any
of the conditions which cause uremia. This can, therefore,
be excluded as the cause of the rapid respiration, as can also
acid intoxication, since there are no acetone bodies in the
urine. Sepsis is sometimes a cause of rapid respiration, but
only when it is severe. The changes in the urine are un-
doubtedly due to toxic absorption. The enlargement of the
liver and spleen may be interpreted in the same way. The
normal condition of the heart, however, makes this interpre-
tation very improbable. There are, moreover, no marked
general symptoms of sepsis, as would be expected if sepsis were
the cause of the rapid breathing. The only condition which
satisfactorily explains the peculiar, rapid respiration is status
lymphaticus. Disturbances in respiration associated with
cyanosis, not due to obstruction, are characteristic manifesta-
tions of this disease. The occurrence of convulsions without
definite cause is strong corroborative evidence of this expla-
nation in this instance. The enlargement of the liver and
spleen is consistent with this diagnosis. The absence of
signs of enlargement of the thymus does not militate against
it, because the symptoms in this condition are not due to
the presence of an enlarged thymus but to some form of auto-
intoxication. The diagnosis of Status Lymphaticus as the
cause of the rapid and peculiar respiration is. therefore, a
reasonable one.
Prognosis. The prognosis is practically hopeless. He will
almost certainly die during the next forty-eight hours.
Treatment. There is no specific treatment for the status
lymphaticus. He should be placed by an open window.
He will probably breathe more easily if bolstered up than
when lying down. There is no call for cardiac stimulants at
present. They will, moreover, probably prove to be of little
value. He should be nursed, if he will take the breast. If
he will not, the breast-milk should be taken with a pump and
fed to him in a bottle. If sufficient milk cannot be obtained
584 CASE HISTORIES IN PEDIATRICS.
in this way, he should be given modified milk in addition. A
mixture containing 2% of fat, 6% of milk sugar, 1.50% of
proteids and 0.75% of starch, without lime water, is a suitable
one. He should be offered four ounces, eight times daily, at
three hour intervals, but will probably not take it all.
The ears should be syringed with warm water three or four
times daily. It will probably be wiser not to disturb him
by any active treatment of the nose.
UNCLASSIFIED DISEASES. 585
CASE 184. Rosamond M., eight and one-half years old,
was the only child of healthy parents. There had been no
deaths or miscarriages. She had had no known exposure to
tuberculosis. She had always had a feeble digestion and had
had to be fed very carefully. She had had chicken-pox and
whooping-cough when seven years old and had had her
adenoids removed when she was six years old. She had,
however, continued to have frequent "colds in her head."
Her school and other duties prevented her from getting out of
doors more than one, or at most two, hours a day. She had
but little fresh air at night.
She had an acute, but not very severe, attack of tonsillitis
January 10, which was followed by enlargement of the cervical
lymph nodes. They caused her no discomfort. Her appetite
had been poor since then, but her digestion was not dis-
turbed. She had no cough and, her mother thought, no fever.
She was seen January 30.
Physical Examination. She was fairly developed and
nourished and of good color. There was no nasal discharge.
She kept her mouth open most of the time, but could breathe
freely with it shut. No adenoids were felt with the finger.
Her tonsils were not enlarged and appeared healthy. Her
throat was, however, very small and her palate highly arched.
Her teeth were good and her tongue was clean. The heart,
lungs and abdomen were normal. The liver and spleen were
not palpable. The extremities were normal. There was no
spasm or paralysis. The knee-jerks were equal and normal.
There were numerous discrete, non-tender, freely moveable
lymph nodes, varying in size from that of a pea to that of an
almond, in both sides of the neck. The inguinal and axillary
lymph nodes were not palpable. The bronchial voice was not
heard below the seventh cervical spine, the air entered both
sides of the chest alike and there were no evidences of in-
creased pressure within the mediastinum. The mouth tem-
perature was 98. 40 F.
The leucocytes numbered 8,400.
Diagnosis. She has, of course, Cervical Adenitis. The
absence of enlargement of the inguinal and axillary lymph
nodes and of all signs of that of the tracheo-bronchial lymph
586 CASE HISTORIES IN PEDIATRICS.
nodes shows that it is a local process. There seems to be no
reason to doubt the mother's statements that the enlargement
was not present before the recent attack of tonsillitis and that
it developed immediately after it. The process is, therefore,
evidently an acute one. The most important point to be
decided is whether it is simple or tubercular, leukemia being
excluded by the low white count and pseudoleukemia being so
improbable on account of its rarity that it need not be con-
sidered at this time. There is nothing about the physical ex-
amination which is of any aid in the diagnosis. When the
cervical lymph nodes enlarge in the course of, or immediately
after, some acute inflammatory condition in the nose or
throat, they are almost never tubercular. When, on the other
hand, they develop slowly, without obvious cause, they almost
always are tubercular. The chances are, therefore, that the
enlargement in this instance is non-tubercular. The absence
of fever is slightly against tuberculosis, that of a leucocytosis
in favor of it. Neither point is of much importance, how-
ever, as simple adenitis often shows no leucocytosis after the
most acute stage has passed and either condition may or may
not be accompanied by fever. A single observation of the
temperature, moreover, shows but little. The absence of a
history of exposure to tuberculosis does not count at all
against tuberculosis, because everyone is unknowingly ex-
posed to tuberculosis so frequently. A positive diagnosis on
the symptomatology and physical examination is, therefore,
impossible. On the doctrine of chances, however, the en-
largement is in all probability not tubercular. A skin
tuberculin test should be tried. A negative reaction will
practically prove that it is not tubercular. A positive reaction
will prove nothing as to its character, because the reaction
may just as well be due to some tubercular focus elsewhere
as to the neck. If the tuberculin test is positive, a certain
diagnosis can only be made after prolonged observation or
by the examination of an excised node.
The open mouth and the highly arched palate are the
results of the adenoids in the past.
Prognosis. If the enlargement is not tubercular, as it
almost certainly is not, it will probably entirely or almost
UNCLASSIFIED DISEASES. 587
entirely disappear within a few weeks, although a few small
nodes may persist. There is almost no chance of suppuration.
Treatment. There are no external applications which will
in any way hasten the resolution of these nodes. With the
possible exception of iodine, there is no drug which, when
given internally, will have any direct action upon them.
The treatment consists in so regulating her life as to put her
in the best possible general condition. It will be wise to
send her to school but one session, so that she can spend more
hours out of doors. She must have more air at night. There
are no special indications as to her diet, which must be adapted
to her rather feeble digestive powers. It will be well to give
her eight drops of the tincture of nux vomica, in a table-
spoonful of water, three times daily, before meals, to improve
her appetite and as a general tonic. It will also be well, on
account of the possible action of iodine in hastening resolu-
tion, to give her twenty drops of the syrup of the iodide of
iron, in water, three times daily, after meals.
If the enlargement of the lymph nodes does not disappear
in a few months the tonsils should be enucleated, in order to
remove the original and possibly the continued source of
infection and to diminish the chances of secondary infection
with tuberculosis.
588 CASE HISTORIES IN PEDIATRICS.
CASE 185. Joseph O'C. was the second child of healthy
parents. Two other children were well. There had been no
deaths or miscarriages. There was no history of tuberculosis
in either family and there had been no known exposure to it.
He was born at full term, after a normal labor, and was normal
at birth. His mother was unable to nurse him and great
trouble was experienced in finding anything to agree with
him during his first year. His digestion had been perfect since
then. He had an attack of laryngeal diphtheria, requiring
intubation, when he was twenty- two months old. This was
followed, a month later, by bronchopneumonia, since when
he had had repeated "colds" and several attacks of bronchitis.
His rectal temperature had never been normal since the
bronchopneumonia. It usually ranged between ioo° F. and
1010 F., but was sometimes higher. He had been kept in bed
most of the time during this period, because of the fever, not
being up more than an hour a day. He had been out of doors
during the summer, but had not been out at all during the
winter. He had been carefully fed. His appetite and diges-
tion were good and his bowels moved daily. He did not
cough, except when he had a "cold." He had been taking
a great variety of drugs. He was seen February 4, when
three years old.
Physical Examination. He was well developed and nour-
ished, but a little flabby. His color was good. His tongue
was clean and his teeth were in good condition. His throat
was normal. No adenoids were felt with the finger. The ear-
drums were normal. The voice was clear. There was no
dullness under the manubrium. The heart, lungs and abdo-
men were normal. The liver and spleen were not palpable.
The extremities were normal. There was no spasm or
paralysis. The knee-jerks were equal and normal. There
were a few lymph nodes, about the size of peas, in both sides
of the neck, but none were felt in the axillae or groins. The
bronchial voice sound was audible over the upper five dorsal
spines. There was no increased dullness or change in the res-
piration in the interscapular space and the respiratory sounds
were of the same intensity on both sides of the chest. The rectal
temperature was ioo°F.; the pulse, no; the respiration, 24.
UNCLASSIFIED DISEASES. 589
The urine was of normal color, clear, acid in reaction, of a
specific gravity of 1015 and contained neither albumin nor
sugar.
The leucocytes numbered 8,000.
Diagnosis. The physical examination shows that the con-
tinued fever is not due to toxic absorption from the mouth,
throat, nose or ears. The clean tongue, the good appetite,
the absence of all symptoms of indigestion and the regular
movements from the bowels show that it is not due to dis-
turbance in the digestive tract. The normal urine excludes
infection of the urinary tract and the absence of a leuco-
cytosis shows that there is no hidden inflammatory process
going on. The most probable explanation of the continued
fever is, therefore, that there is a tubercular focus somewhere
in the body. The fact that the fever followed an attack of
bronchopneumonia points strongly to the chest as the seat
of this focus. The lungs are normal. The bronchial voice
sound over the five upper dorsal spines shows, however, that
there is enlargement of the tracheobronchial lymph nodes.
It is evident from the absence of dullness and bronchial
respiration in the interscapular space and the equal intensity
of the respiratory sound on the two sides, together with the
absence of dullness under the manubrium and of all symptoms
of pressure, that this enlargement is not very marlced. It
seems fair to conclude, therefore, that, in the absence of all
signs of tuberculosis elsewhere, the cause of the fever is a
tubercular Bronchial Adenitis. A Roentgenograph should
be taken and a skin tuberculin test tried in order to confirm
the diagnosis.
Prognosis. The primary focus of tuberculosis at this age
is almost always in the tracheobronchial lymph nodes. The
tubercular process may extend from them directly to the
lungs or the tubercle bacilli may be carried through the blood
or lymph vessels, if they become infected, to any part of the
body. In the vast majority of instances, however, the disease
remains localized in the lymph nodes and recovery eventually
takes place. It is impossible to know what will happen in
this instance. He is in good general condition, there are no
evidences of tuberculosis elsewhere, the enlargement of the
590 CASE HISTORIES IN PEDIATRICS.
tracheobronchial lymph nodes is slight and there is but little
elevation of the temperature. The process is, therefore, not
a very active one. The chances are, therefore, that there
will be no extension and that he will eventually recover.
Treatment. He must be kept out of doors as much as
possible, preferably both day and night. If this is not
feasible, the windows must be kept wide open when he is in
the house. Too much attention has been attached to the
elevation of temperature, which has been but very little
above the normal limit for a three year old child. He should
not be kept so closely in bed, but should be allowed to get up
gradually and to take more exercise. This will improve his
general condition and strengthen his resistance. His digestion
being good, there is no reason for limiting his diet. All medi-
cines should be stopped.
UNCLASSIFIED DISEASES. 59 1
CASE 1 86. George R., two and one-half years old, was
the child of healthy parents. There were four other children
living and well, none had died and there had been no mis-
carriages. He had always been nervous but had had no
illnesses. He had had nothing to eat the night before the
onset of the present illness that had not been eaten by the
rest of the family, but had been playing out in the snow that
day and had got rather wet.
He had a number of attacks of rather severe abdominal
pain, lasting from fifteen minutes to an hour, during the night
of January II. He had no other symptoms and appeared all
right the next day. Both ankles became painful and swollen
January 13, and purpuric spots appeared on the ankles and
lower legs the next day. That day he had a very severe
attack of abdominal pain, followed by vomiting and diarrhea
which lasted for about twelve hours. Neither the vomitus
nor the stools contained blood. He was seen January 15
by his physician, who found nothing abnormal on physical
examination, except that both ankles were a little swollen
and tender and had purpuric spots about them. The tempera-
ture was then 990 F. and the pulse 140. He continued to have
attacks of severe abdominal pain, lasting from one hour to
two hours, but had no other symptoms of indigestion and the
bowels moved normally. Both abdominal and rectal exami-
nations were normal on January 1 8. The urine showed nothing
abnormal. The temperature had varied between normal and
990 F., the pulse between 120 and 150.
He did well from that time to January 24, when his scrotum
and penis suddenly became much swollen, the scrotum being
nearly three times its usual size and very painful. The
swelling was pinkish in color and did not pit on pressure. It
lasted but a few hours. Purpuric spots appeared on the but-
tocks at the same time. A similar swelling, the size of the
palm of the hand, appeared over the sacrum the next day and
disappeared again in a few hours. More purpuric spots also
appeared on the buttocks. The attacks of abdominal pain re-
curred on the 27th. Between them he apparently felt perfectly
well. He had no fever. He had been kept on a light diet
from the beginning, but this included eggs and broth. He
592 CASE HISTORIES IN PEDIATRICS.
was given citrate of potash at first and later three grains of
the lactate of calcium daily. His bowels had been kept well
open. He was seen in consultation January 28.
Physical Examination. He was well developed and nour-
ished and of good color. His tongue was slightly coated, his
teeth in good condition. His gums and throat were normal.
His heart and lungs were normal. The abdomen was a
little sunken and showed nothing abnormal. There were no
masses, no tenderness and no muscular spasm. The liver
and spleen were not palpable. The penis and scrotum were
normal. The extremities were normal. There was no spasm
or paralysis. The knee-jerks were equal and normal. There
was no Kernig's sign. There was no enlargement of the
peripheral lymph nodes. There were a few fading purpuric
spots about the ankles and buttocks. A rectal examination
showed nothing abnormal.
The urine was normal in color, clear, acid in reaction and
of a specific gravity of 1,016. It contained neither albumin
nor sugar. The centrifugalized sediment showed an excess of
urates and an occasional small round cell, but no casts.
Diagnosis. The attacks of abdominal pain with the at-
tendant vomiting and diarrhea, the swelling and the purpuric
eruption about the ankles, and the swelling and purpuric
eruption about the genitals and buttocks are undoubtedly
merely different manifestations of some abnormal systemic
condition. The swellings which appeared in the genitals and
over the sacrum have all the characteristics of angioneurotic
edema. The eruption on the buttocks deserves the name of
purpura simplex. The swelling and eruption about the ankles
is typical of purpura rheumatica. The attacks of abdominal
pain would be very hard to explain if they occurred alone,
but associated, as they are, with other manifestations of
purpura, they are quite characteristic of the condition known
as abdominal purpura or Henoch's disease. Giving these
various symptoms names does not, however, bring us much
nearer the diagnosis of the underlying condition. It does
emphasize the fact, however, that it is not justifiable to
describe the different forms of Purpura as if they were dif-
ferent diseases, and shows that they are merely different
UNCLASSIFIED DISEASES. 593
manifestations of the same condition. The association of
the condition known as angioneurotic edema, which is pre-
sumably due to a disturbance of the nervous control of the
walls of the blood vessels, with the purpuric condition makes
it probable that the purpura is due to some toxic action on
the vessel walls rather than to a bacterial infection. This
assumption is supported by the absence of fever. The
presence of the angioneurotic edema in association with the
purpura also makes it probable that the purpuric condition
is not due to any disturbance of the coagulability of the blood.
There is nothing in the history or physical examination to
suggest the origin of the toxic substance. The normal con-
dition of the gums and the good health of the other members
of the family rule out lead poisoning. The good health of the
rest of the family and the absence of symptoms of indigestion
make intestinal toxemia very improbable. The etiology
must, therefore, remain unsettled. It is possible that the
eggs and broth may have had something to do with the con-
tinuance of the condition, as they not infrequently cause
angioneurotic edema. The attacks of abdominal pain may
be due to an angioneurotic edema of the intestinal wall or to
a hemorrhage into the wall. The short duration of the attacks
and their frequent repetition, as well as the absence of blood
in the stools, makes an edematous condition much more
probable than a hemorrhagic.
Prognosis. There is no danger as to life unless, as some-
times happens, the local swelling in the intestinal wall
causes an intussusception. The prognosis as to duration is,
however, very indefinite as the condition not infrequently
persists, with longer or shorter intermissions, for many weeks
or even months.
Treatment. The etiology being so obscure, the treatment
can only be along general lines. He must be protected from
chilling and overexertion. His diet should be limited to milk
and starches, as they are less likely to form toxic substances
in the intestines than are the fats and proteids. He must be
given plenty of water and his bowels kept well open, preferably
with salines. Although the calcium salts have no special
influence on the coagulability of the blood, they have seemed
594 CASE HISTORIES IN PEDIATRICS.
clinically to be of some use in the treatment of angioneurotic
edema and similar conditions. It will be well, therefore, to
continue the lactate of calcium, but in larger doses, giving ten
grains daily. Animal sera hardly seem indicated at present
in this instance, because, if our reasoning is correct, the
difficulty is not impaired coagulability of the blood. If the
purpuric eruptions continue to recur, or if there are hemor-
rhages elsewhere, it will be wise, nevertheless, to give them a
trial. (See Case 17.)
Heat externally and paregoric, in doses of fifteen or more
drops, may be employed for the attacks of pain.
UNCLASSIFIED DISEASES. 595
CASE 187. William M. was the second child of healthy
parents. The older child was living and well and there had
been no deaths or miscarriages. He was born at full term,
after a normal labor, was normal at birth and weighed five
and one-half pounds. He was nursed for three months and
then given equal parts of cows' milk and water. He did well
on this until he was six months old. Since then he had
vomited several times daily and had had from six to eight
stools daily, some of which were green and some yellow. The
stools had contained curds up to the last five weeks, during
which he had taken nothing but barley water, prepared with
a little salt. He had, nevertheless, gained two pounds during
the last two weeks. He was admitted to the Children's
Hospital when eight months old.
Physical Examination. He was well developed and nour-
ished. The skin and mucous membranes were of fair color.
The anterior fontanelle was two cm. in diameter and level.
The mouth and throat were normal. There were no teeth.
Both the upper and lower eyelids were somewhat puffy.
There was no rosary. The cardiac area and sounds were
normal. There were no murmurs and there was no venous
hum in the neck. The lungs were normal. The upper
border of the liver flatness was at the upper border of the fifth
rib in the nipple line ; the lower border was palpable three cm.
below the costal border in the same line. The spleen was not
palpable. The abdomen showed nothing abnormal. The
feet were considerably and the legs moderately swollen.
They were not red, hot or tender, but pitted on pressure.
There was no enlargement of the peripheral lymph nodes.
The rectal temperature was 98. 6° F. He weighed fourteen
and three-quarters pounds.
Blood.
Hemoglobin,
55%
Red corpuscles,
4,764,000
White corpuscles,
13,000
Small mononuclears,
39%
Large mononuclears,
6%
Polynuclear neutrophiles, 55%
596 CASE HISTORIES IN PEDIATRICS.
There was moderate achromia, but no irregularity in the
size or shape of the red corpuscles and no polychromatophilia.
The urine was clear, of normal color, acid in reaction, of a
specific gravity of 1,012 and contained no albumin or sugar.
The sediment, obtained by centrifugalization, contained a few
leucocytes and small round cells.
Diagnosis. He undoubtedly has a chronic disturbance of
both the gastric and intestinal digestion. The most striking
abnormality, however, and the one which requires explana-
tion, is the edema of the face and lower extremities. It is
fair to assume, also, that there is an accumulation of fluid in
the tissues throughout the body, for it would manifestly be
impossible for him to have gained two pounds in two weeks
on barley water alone, except in this way. The normal
condition of the heart and urine shows that the edema cannot
be due to disease of the heart or kidneys. The blood shows
a slight anemia, not sufficient, however, to account for
the edema. It must be due in some way, therefore, to the
digestive disturbance or to the food. It may be that the
accumulation of liquid in the tissues is due to an excess of
salt, and possibly of starch, in the food, which interferes with
the normal processes of osmosis. It is conceivable that the
walls of the blood vessels may have been directly injured as
the result of the insufficient supply of food and of the absorp-
tion of toxic products from the intestines, and that they are
consequently unduly permeable. There is no proof, however,
that this ever happens. It may be, on the other hand, that
the increased permeability of the blood vessels is due to a
disturbance of the sympathetic vaso-motor control, either
from the disturbance of nutrition or from toxic or chemic
irritation of the terminal filaments of the nerves in the intes-
tines or vessels. This possibility is also insusceptible of
proof. It is wise, therefore, with our present lack of know-
ledge, to continue to speak of this condition as Idiopathic
or essential Edema, appreciating the fact, nevertheless, that
it is really always a secondary manifestation of some other
condition.
Prognosis. His general condition is reasonably good, his
heart and kidneys are normal and there is but little anemia,
UNCLASSIFIED DISEASES. 597
in spite of the disturbance of digestion for two months and
semi-starvation for five weeks. When these points are taken
into consideration, it is evident that the edema, although often
of serious import, is in this instance a relatively unimportant
symptom and that it does not render the prognosis unfavor-
able. He will undoubtedly recover promptly when he is given
proper food. His weight will diminish rapidly until the
excess of liquid in the tissues is eliminated, after which he
should begin to gain again.
Treatment. The treatment consists of regulation of the
diet. The best food for him is, as in all disturbances of
digestion in infancy, human milk. It is, however, not a
necessity in this instance. He will undoubtedly recover
without it. It will be wise to cut out the starch and salt in
order to favor the elimination of the liquid in the tissues. It
will also be well to keep the sugar a little low for the same
reason. It will be advisable, on general principles, to give
him a food relatively low in fat and relatively high in proteid.
A whey mixture is contraindicated on account of the salts
which it contains. A mixture which will fulfill these indica-
tions is one containing 2% of fat, 5% of milk sugar and 2%
of proteids, without lime water. Eight feedings of five ounces
will be sufficient to cover his caloric needs, if the extra weight
due to the edema is subtracted. He should not be given any
extra water. There is no indication for medicinal treatment.
598 CASE HISTORIES IN PEDIATRICS.
CASE 188. Douglas S., nine years old, was the fifth child
of healthy parents. The other children were living and well,
none had died and there had been no miscarriages. There
was no tuberculosis in either family and there had been no
known exposure to it. He had always been well, except for
measles when he was three years old. He was taken suddenly
ill with infectious diarrhea, August 18, and had a very severe
attack for his age. Improvement began about the tenth of
September and was very rapid, the temperature coming down
to normal and the movements to one in twenty-four hours,
without mucus or blood. There was a recurrence of the fever
and of the blood in the stools for a few days about the first
of October. He improved again rapidly, however, and was
sitting up in bed October 8 and 9. Since the beginning of his
illness the diet had been almost entirely composed of carbo-
hydrates. Two days later a little edema was noticed about
the eyes and in the feet. This had increased, so that when he
was seen, October 15, there was marked edema of the face and
considerable edema of the feet, legs, posterior surface of the
thighs and back. The temperature had been between ioo° F.
and 101.50 F., the pulse between no and 120 and the respira-
tion between 25 and 30 since the appearance of the edema.
He had taken his food well, but had had two or three loose
movements from the bowels daily, which did not contain
either mucus or blood.
Physical Examination. He felt perfectly comfortable and
his color was fair. The tongue was clean. There was no
venous hum in the neck. The cardiac area was normal, the
sounds were clear and strong, the action regular and there
were no murmurs. There was moderate dullness, with slightly
diminished respiration and voice sounds, in both backs below
the angles of the scapulae. The lungs were otherwise normal.
The liver and spleen were not palpable. The level of the
abdomen was that of the thorax. There was shifting dullness
in the flanks and a slight fluid wave. The extremities were
normal except for the edema. There was no spasm, paraly-
sis or disturbance of the reflexes. There was no enlargement
of the peripheral lymph nodes.
The urine was passed in sufficient amounts. It was pale,
UNCLASSIFIED DISEASES. 599
acid in reaction and of a specific gravity of 1,015. There was
the slightest possible trace of albumin by the heat test, but
none with nitric acid. It contained no sugar, acetone or
diacetic acid. There was no sediment, even on centrifugal-
ization.
The blood contained 90% of hemoglobin and 3,636,000 red
corpuscles.
Diagnosis. The normal condition of the heart rules out
disease or weakness of this organ as the cause of the dropsy.
The anemia is so slight that it cannot be due to that. Al-
though the urine contains the slightest possible trace of
albumin by the heat test, it is passed in sufficient amounts
and shows nothing else abnormal. The trace of albumin is
in all probability due merely to a very slight degeneration of
the kidneys from toxic absorption. It is well known that
such slight degenerative changes do not interfere to any
appreciable extent with the function of the kidneys. It is
certain, at any rate, that there is no affection of the kidneys
sufficient to cause a general dropsy. The dropsy must be
due, therefore, in some way to the infectious diarrhea or to
the food; that is, it belongs in the class of the so-called
Idiopathic Dropsies, which are really always secondary and
whose origin is extremely difficult to explain (see Case 187).
Prognosis. His general condition is reasonably good, his
heart is normal, there is but little anemia and the disturbance
of his kidneys is trifling. There is no longer blood and mucus
in the movements, which shows that in spite of the slight
elevation of the temperature the inflammatory condition in
the intestines is improving. It is reasonable to expect,
therefore, that with improvement in the local condition in the
intestines and the consequent improvement in the general
condition the causes of the dropsy, whatever they may be,
will become inactive and the excess of liquid will be quickly
eliminated.
Treatment. Table salt should be cut out of his diet and
the intake of liquids limited. Twenty-four ounces of milk
in twenty-four hours will be sufficient for him. He should
have no extra water. The remainder of his diet should be
made up of dry, starchy foods, such as toast, zweibach and
600 CASE HISTORIES IN PEDIATRICS.
cracker. This diet not only diminishes the intake of liquid,
but is also the one most suitable for his intestinal condition.
There being no inflammation of the kidneys, it is safe to force
them to eliminate more liquid by giving him five grains of
theobromine-sodium salicylate, three times daily. If this
does not increase the flow of urine, there will be no objection
to giving him five minims of the tincture of digitalis, three
times daily, increasing it to ten minims, three times daily, if
necessary. (See Case 137.)
UNCLASSIFIED DISEASES. 601
CASE 189. Lincoln F., fifteen months old, was the second
child of healthy parents. There had been no deaths or
miscarriages. He was born at full term after a normal
labor, was normal at birth and weighed ten pounds. He was
nursed for seven months and then given modified cow's
milk prepared at home, on which he did very well. Oatmeal
water was added to his milk when he was eleven months old,
but had to be stopped because it caused hives. He was then
put on whole milk and mutton broth. Barley water had
recently been added to the milk. He had lost his appetite
during the last month, but had had no nausea or vomiting.
He had been having from four to five small, green, foul
movements, containing small curds and mucus, daily. He
had been fussy and had had some colic. He had lost nearly
two pounds in weight.
Five days before he was seen all milk had been stopped
and he had been put on beef juice, broth, white of egg and
cereal jellies. He took his new food well and seemed better
for three days, but had been very fussy the last two days,
and had had five movements daily. These were loose, very
dark in color and had a very foul odor. Swelling of the
face appeared the day before, and that morning his hands and
feet were also swollen. He was seen at 2 p.m.
Physical Examination. He was well developed and nour-
ished, but rather flabby. His color was fair. The anterior
fontanelle was nearly closed. His face was somewhat puffy,
especially about the eyes. It was not reddened, but evidently
itched. He had three teeth. The gums, mouth and throat
were normal, the tongue moderately coated. There was no
venous hum in the neck. There was a slight rosary. The
heart, lungs and abdomen were normal. The liver was
palpable 2 cm. below the costal border in the nipple line.
The spleen was not palpable. The extremities were normal,
except that the hands and feet were somewhat swollen.
The swelling was not hot or red and did not pit on pressure.
There was no spasm or paralysis. The knee-jerks were not
obtained. Kernig's sign was absent. There was a slight
general enlargement of the peripheral lymph nodes. The
rectal temperature was normal.
602 CASE HISTORIES IN PEDIATRICS.
The urine was high in color, turbid, very acid in reaction,
of a specific gravity of 1,024, and contained no albumin or
sugar. The sediment consisted of crystals of urate of
ammonium.
Blood.
Hemoglobin, 65%
Red corpuscles, 5,240,000
White corpuscles, 12,000
Diagnosis. He undoubtedly has a chronic intestinal
indigestion and a slight amount of rickets. The condition
which requires explanation is the swelling of the face, hands
and feet. The analysis of the urine shows that it cannot
be due to disease of the kidney, the heart is normal and,
while the blood shows a very slight degree of anemia, it is
not sufficient to cause edema, and there is no venous hum in
the neck. The swelling does not pit on pressure, moreover,
and itches, showing that it is not an ordinary edema. It
must, therefore, belong in the class of the Angioneurotic
Edemas. These are in all probability due to some dis-
turbance of the vasomotor control of the blood vessels.
In this instance the edema is almost certainly connected in
some way with the intestinal disturbance. It may be due
either to irritation of the terminal sympathetic fibers in the
walls of the intestines or to the absorption of toxic or chemical
irritants from the intestines which act directly on the vas-
cular terminal filaments of the sympathetic. It is, of course,
impossible to say which. Its appearance at this time is
probably connected with the change of food five days before,
since no other element has been introduced. It cannot be
due to the broth or jellies, because he has had broth and
barley before without the appearance of edema. It must be
due, therefore, to either the beef juice or the white of egg.
The excessively foul odor of the stools suggests decomposi-
tion of the beef juice and the production of toxic substances,
while white of egg is known to be the food which most often
causes angioneurotic edema.
Prognosis. There is no danger connected with the an-
gioneurotic edema. It is merely a side issue and does not
alter the prognosis of the original intestinal indigestion.
UNCLASSIFIED DISEASES. 603
Treatment. The first thing to do is to stop both the beef
juice and white of egg, either or both of which may be the
cause of the swelling. The next thing to do is to give him
two teaspoonfuls of castor oil to empty the intestines of the
toxic products of the decomposition of the beef juice and
egg, which they probably contain. It will be well to stop
his food for twenty-four hours, giving him in its place at
least one quart of water. Alkalies seem to hasten the disap-
pearance of angioneurotic edema. He should, therefore,
be given about a dram of the citrate or acetate of potash or
of bicarbonate of soda, in water, during the twenty-four
hours. Equal parts of skimmed milk and barley water will
be a suitable mixture with which to begin, after the day of
water diet.
604 CASE HISTORIES IN PEDIATRICS.
CASE 190. Robert C, four years old, was the child of
healthy parents. He had always been well, except for
occasional "colds" and slight disturbances of the digestion.
He was taken suddenly sick, during the evening of March 26,
with fever, general malaise, headache and pains in the hands
and wrists. It was noticed the next morning that his face
was turned to the right and that there were large reddish,
elevated areas on the backs of the hands and wrists. Similar,
but smaller, spots appeared on the thighs and legs during the
day. The fever and pain continued, but no new symptoms
developed. His appetite was poor and the bowels consti-
pated. He was seen at the Boston Dispensary in the morning
of March 28.
Physical Examination. He was well developed and nour-
ished, but a little pale. The throat was normal, the tongue
thickly coated but moist. The head was pulled down a little
toward the left shoulder and the face turned to the right. All
the motions of the neck were limited, but did not cause pain.
The left sternocleidomastoid muscle was tense, but not tender.
The heart, lungs and abdomen were normal. The liver and
spleen were not palpable. There was no spasm or paralysis.
The knee-jerks were equal and normal. On the dorsal
surface of the hands and wrists were several dark-red areas,
varying in size from that of a dime to that of a fifty-cent
piece. These were not tender or painful, but were raised
one-quarter of an inch or more above the surface and were
surrounded by a zone of thickening. There were many
smaller spots of the same character about the knees, both
behind and in front. They also extended upward on to the
thighs and downward on to the legs. There was no enlarge-
ment of the peripheral lymph nodes. The mouth tempera-
ture was 1010 F. ; the pulse, 100; the respiration, 24.
Diagnosis. The skin lesions are so characteristic of
Erythema Multiforme that it is not necessary to consider
any other conditions. The Torticollis, coming on as it did
at the same time as the erythema, is undoubtedly also
Rheumatic in origin.
Prognosis. The prognosis as to life is, of course, good.
The only danger is of the development of some cardiac com-
UNCLASSIFIED DISEASES. 605
plication. The torticollis will yield promptly to treatment
with salicylic acid. The erythema may be more obstinate.
It is possible, but not probable, that new crops may develop
in spite of treatment.
Treatment. He should be given five grains of aspirin every
four hours until his temperature is normal and the pains have
ceased, unless toxic symptoms develop. The dose should
then be reduced to five grains, three times daily, in either
case, and continued for several days longer. The neck does
not require any local treatment. A simple dusting powder,
such as one drachm of powdered zinc oxide to one ounce of
starch, or stearate of zinc powder, will be all that is necessary
for the skin. The bowels should be opened with some simple
laxative, like licorice powder or syrup of senna, and his diet
limited to milk, broths and starchy foods. He should be
made to drink water freely and kept in bed until thoroughly
convalescent.
606 CASE HISTORIES IN PEDIATRICS.
CASE 191. Anita F., six years old, had a mild attack of
diphtheria, beginning February 10. Her temperature was
never over ioo° F., and the constitutional symptoms were
slight. She was given 500 units of antitoxin February 11,
3,000 February 14 and 3,000 February 16. Her throat was
clear February 21, and a negative culture was obtained
February 24. A profuse urticaria, accompanied by a slight
rise of temperature, appeared February 26. She had a severe
headache and very bad pains in the legs that night, so that
she slept but little. The headache ceased on the twenty-
seventh, but the pains in the legs continued with undiminished
severity. They were less troublesome on the twenty-eighth,
but motions of the legs caused much pain. The urticaria
reappeared that afternoon. Her temperature had ranged be-
tween 101.50 F. and 102. 50 F., while her pulse had been about
120. She was seen in consultation at 6 p.m., February 28.
Physical Examination. She was well developed and
nourished. Her cheeks were flushed. Her tongue was
moderately coated. Her throat was normal, except for slight
redness of the fauces. The heart, lungs and abdomen were
normal. The liver and spleen were not palpable. She lay
with the thighs flexed on the body and the legs on the thighs.
She was afraid to have her legs touched, but they could be
slowly straightened without causing much pain. Motion at
the ankles was free. There was slight swelling and tender-
ness, but no redness, about the left knee, but none elsewhere.
The knee-jerks could not be obtained because of the resist-
ance. There was no enlargement of the peripheral lymph
nodes. There were numerous erythematous areas, varying
in size from that of a split pea to that of a silver dollar,
scattered over the body and extremities. A factitious urti-
caria was easily produced. The rectal temperature was
103. 30 F. ; the pulse, 120; the respiration, 30.
The urine was high in color, strongly acid in reaction and
of a specific gravity of 1,028. It contained a large amount of
urates, but no albumin or sugar.
Diagnosis. The diagnosis of Antitoxin Poisoning, or
serum sickness, is plain in this instance. The latter term,
although not in common use in this country, is preferable to
UNCLASSIFIED DISEASES. 607
antitoxin poisoning, because the symptoms are not caused by
the antitoxin but by the horse serum in which it is contained.
Rheumatism, the only other disease which need be considered,
can be excluded on the rash, the factitious urticaria and the
history of the administration of antitoxin. Severe headache
is, moreover, very unusual in rheumatism in childhood. The
absence of swelling, redness and marked tenderness in the
joints does not count against rheumatism, because these
symptoms are comparatively uncommon in rheumatism at
this age.
Prognosis. There is no danger as to life or serious in-
flammation of the joints. The pain and fever will probably
persist for a number of days, or perhaps a week, longer. She
will probably have a tendency to urticarial eruptions for
several months.
Treatment. There is no specific treatment for antitoxin
poisoning. The salts of calcium, which were at one time
thought to have such an action, are probably inert. The
treatment must, therefore, be purely symptomatic. The diet
should consist of milk and starchy foods. Eggs must be
avoided because of their tendency to produce urticaria.
Water should be forced. The application of heat externally
and wrapping the legs in cotton will probably help the pains.
If they do not, she may be given two and one-half grains each
of phenacetin and salol every three or four hours. A mixture
of equal parts of alcohol and water or a lotion made up of ten
grams of powdered zinc oxide in one hundred cc. of a one-
half of one per cent solution of carbolic acid may be used for
the itching. If these applications do not relieve it, a saturated
solution of camphor in ether may be painted on and allowed
to dry.
608 CASE HISTORIES IN PEDIATRICS.
CASE 192. Evelyn S. was the only child of healthy
parents. There had been no deaths or miscarriages. She
was born at full term and was normal at birth. She had been
very well taken care of and had never been sick. She was
nursed for six months, after which she was given a mixture
of whole milk and strained oatmeal until she was fourteen
months old. Beef juice, broth, rice, eggs, toast, crackers,
potato and baked apple had since then been gradually added
to her diet. She had never taken more than two slices of
bread and one potato daily, and had never been given sugar
or sweets. She had been somewhat constipated for two
months. Her mother thought that she had drunk rather
more water and perhaps passed a little more urine during this
time, but would have thought nothing of it if it had not been
for the recent symptoms. Two weeks before she was seen
in consultation, when twenty months old, she suddenly began
to pass a great deal of urine and to be very thirsty. Her
mother thought that she drank at least a quart of water daily.
She was unable to tell how much urine she passed, but stated
that she urinated every few minutes both day and night.
The constipation had been more marked and she had lost
weight and strength very rapidly. Her appetite and diges-
tion had continued good and her diet had not been changed.
She complained constantly of being tired and slept a con-
siderable part of the time.
Physical Examination. She was much emaciated and
moderately pale. The skin of the face was dry, but it was
not dry elsewhere. The tongue was somewhat dry, but
not coated. She had twelve teeth. There was no rosary.
The heart and lungs were normal. The abdomen was
sunken, but otherwise normal. The liver and spleen were
not palpable. The extremities were normal. There was
no spasm or paralysis. The knee-jerks were equal and
normal. The cervical and inguinal lymph nodes were just
palpable.
The urine was pale, acid in reaction, of a specific gravity
of 1,040, and contained the slightest possible trace of albumin.
It contained a large amount of sugar, all of which was in the
form of glucose. Both acetone and diacetic acid were present
UNCLASSIFIED DISEASES. 609
in considerable amounts. The sediment showed nothing
abnormal.
Diagnosis. The symptoms are characteristic enough of
Diabetes Mellitus to justify this diagnosis, in spite of her
tender age, without an examination of the urine. The find-
ings in the urine confirm the diagnosis and also show that there
is an acid intoxication. Alimentary glycosuria can be ex-
cluded on the lack of an excess of carbohydrates in the food,
the general symptoms of diabetes, the large amount of sugar
in the urine and the evidences of acid intoxication.
Prognosis. The prognosis is hopeless. She will probably
not live more than a week, certainly not over a month.
Treatment. The general principles of the treatment of
diabetes are described in Case 193. It is very difficult to
apply them and to regulate the diet in an infant of twenty
months, whose food normally consists largely of milk, which
contains a large amount of sugar, and starches. It is very
hard to select a diet from the limited number of articles of
food which are suitable for a baby of this age which will
furnish a sufficient number of calories and not contain a large
amount of carbohydrates. It is impossible to get along with-
out both milk and starches. The amount of carbohydrates
in the starchy foods cannot be diminished in any way. They
must, therefore, be entirely excluded from the diet in the
beginning. It is possible to use milk by taking advantage of
the fact that cream contains a large amount of fat and a
relatively small amount of sugar. If cream is diluted until
the percentage of fat is no higher than the average infant
is able to digest, the percentage of sugar is very low and the
caloric value still reasonably high. A quart of whole milk,
for example, contains 670 calories and 43 grams of sugar,
while a quart of a dilution of one part of 32% cream with four
parts of water contains about 600 calories and only 6.5
grams of sugar. A healthy child of her age usually takes
nearly 1,200 calories in twenty-four hours. She can un-
doubtedly get along with 1,000 calories, or even less, for the
present. One quart of a one to four dilution of 32% cream
will give her 600 calories and 6.5 grams of sugar. The
percentage of fat in this mixture, 6.4%, is rather high, but
6lO CASE HISTORIES IN PEDIATRICS.
probably not high enough to disturb her digestion. This
must serve as the basis of her diet. She is old enough to
digest eggs and beef juice. Two soft boiled eggs and two
ounces of beef juice daily will add, respectively, 144 calories
and 20 calories, making a total of 764 calories, without in-
creasing the amount of carbohydrates. Broth is also allow-
able, but has practically no nutritive value. If she is not
reasonably satisfied with this amount of food, or continues
to lose weight rapidly, it will be necessary to give her more,
best in the form of diluted 32% cream, another pint of which
will bring the caloric value of her food above 1,000. There
is no other way in which the caloric value of her food can
be increased as much with so little increase in the amount
of carbohydrates, unless food which is certain to upset her
digestion is given.
The acetone and diacetic acid in the urine show that she has
an acid intoxication. This should be combatted with bicar-
bonate of soda. She can probably take as much as two
drachms a day, perhaps even more. It can be best given in
the milk.
UNCLASSIFIED DISEASES. 6ll
CASE 193. Charles W., eleven years old, was the child of
healthy parents. One brother was living and well. There
had been no deaths or miscarriages. His maternal grandfather
had had diabetes, but had died of tuberculosis.
He was born at full term, was normal at birth and weighed
six pounds. He had whooping-cough when one year old,
mumps and chicken-pox when small, and measles at four years,
but had otherwise been well. He had always eaten much
candy and had craved sweet foods. He had passed much
more urine during the last month than formerly, and had
drunk large quantities of water. He had to get up several
times at night to urinate and to allay his thirst. His appetite
was large. He had had no itching of the skin and no eruption.
He was admitted to the Children's Hospital, August 3.
Physical Examination. He was small and sparely
nourished. He was moderately pale, but did not look or act
sick. His skin was not dry or irritated, and there was no
eruption. His tongue was slightly coated, the mouth and
throat normal. The heart, lungs and abdomen were normal.
The liver and spleen were not palpable. The extremities were
normal. There was no spasm or paralysis. The knee-jerks
were equal and lively. There was no disturbance of sensation.
There was no enlargement of the peripheral lymph nodes.
He weighed fifty-two pounds.
He was allowed to eat as much as he wanted of the regular
hospital diet, but was not allowed to put sugar on his food.
He passed 560 ccm. of urine (the normal average is 1,200
ccm.) August 4, of a specific gravity of 1,041, which con-
tained 5.9% or 33.6 grams of sugar. It contained no albumin
or acetone, and the sediment showed nothing abnormal.
An accurate account of what he ate was then kept. He
took 85 grams of carbohydrates August 6 and passed 855 ccm.
of urine of a specific gravity of 1,018, which contained 1.8%
or 15.3 grams of sugar, but no acetone.
Diagnosis. There can be no doubt, of course, as to the
diagnosis of Diabetes Mellitus. A simple glycosuria can
be excluded on the persistence of the symptoms and the
presence of sugar in the urine when there is only a moderate
amount of carbohydrates in the food.
6l2 CASE HISTORIES IN PEDIATRICS.
Prognosis. There is practically no chance that he will
recover, although, judging from the fact that he was able to
make use of 70 grams of carbohydrates in twenty-four hours,
the disease is not of a very severe type. His expectation
of life is probably to be reckoned in months rather than in
years, but he may, with careful treatment, live for a number
of years. He is, however, very likely to suddenly develop
acid intoxication at any time and die after a few days.
Treatment. Drugs are of no use in the treatment of dia-
betes. The treatment consists in regulation of the diet. The
principles are simple. The diet must contain calories enough
to supply the caloric needs. The carbohydrates must be
cut down until the urine is free from sugar, but no lower
than is necessary to accomplish this, because of the danger
of -the development of acid intoxication. If the acetone
bodies appear in the urine when the carbohydrates are cut
down, they must be increased again until the acetone bodies
disappear. If the amount of the acetone bodies is small, it
is safe for a time, however, not to increase the carbohydrates,
but to neutralize the acetone bodies by giving bicarbonate
of soda. The water should not be limited.
A boy of his size needs approximately 1,300 calories daily.
It is a simple matter to lay out a diet for him which will
contain the proper number of calories and to regulate the
amount of carbohydrates which it contains by the use of the
table of food values given in Case 73.
His diet August 13 was as follows:
Cereal, l| oz. =
Rice, 1 1 oz. =
Bread, 1 oz. =
Meat, 6| oz. =
Eggs, 4 =
Butter, 3 oz. =
Tomato, 9 oz. =
Calories.
Carbohydrates.
37.5
8.2 grams.
67.5
15 grams.
75
15 grams.
390
. .
288.
. .
675
1,533
38.2 grams,
He passed 530 ccm. of urine of a specific gravity of 1,010,
which contained neither sugar nor acetone.
UNCLASSIFIED DISEASES. 613
The urine contained acetone the next day, however, al-
though the amount of carbohydrates in the food was the same.
The amount of carbohydrates was, therefore, gradually in-
creased, so that on August 17 he was taking 76 grams. He
passed on that day 470 ccm. of urine of a specific gravity of
1,026, which contained 2.3% or 10.8 grams of sugar, but no
acetone.
It was evident, therefore, that his tolerance for carbo-
hydrates lay somewhere between 38 grams and 76 grams.
A little more experimenting showed that he could take about
55 grams of carbohydrates without the appearance of sugar
in the urine, and that this amount prevented the formation
of the acetone bodies. The diet and the examination of the
urine on August 29 were as follows:
Calories.
Carbohydrates.
Cereal, 1^ oz. =
37-5
8.2 grams.
Rice, i§ oz. =
67.5
15 grams.
Bread, 2 oz. =
150
30 grams.
Meat, 5^ oz. =
330
Eggs, 4 =
288
Butter, i\ oz. =
337.5
Broth, 6 oz. =
...
Cucumber, 4 oz.
= ...
1,210.5
53.2 grams.
He passed 650 ccm. of urine of a specific gravity of 1,016,
which contained neither sugar nor acetone.
On this diet he held his weight and had no symptoms.
This diet should, therefore, be continued. It is unnecessary
to consider the use of any of the so-called " diabetic foods"
when he can take as much carbohydrate as at present.
614 CASE HISTORIES IN PEDIATRICS.
CASE 194. Byron H., thirteen and one-half years old,
was the third child of healthy parents. His father denied
syphilis and there had been no deaths or miscarriages. There
was no history of any similar trouble in either family. He
had always been well, except for whooping-cough as a baby
and influenza when five years old. He had never had any
injuries or symptoms of any disease of the nervous system.
He was bright mentally, but rather excitable. He was very
active, but did not get tired easily. About a month before
he was seen, he began to pass water frequently during the
day and had to get up at night to pass it. The increased
frequency of micturition was not preceded by any unusual
excitement, nervous shock or injury. The frequency of
micturition gradually increased for two weeks, since when it
had been about the same. Thirst began to be troublesome
after the first week. He was passing between one and one-
half and two gallons of urine in the twenty-four hours when
he was seen, and was constantly drinking water. His appe-
tite was normal, there was no disturbance of the digestion and
he was not constipated. He had lost a little weight in the
beginning, but had gained half a pound in the last week. He
felt a little weary and had a slight headache during the first
two weeks, but since then had been perfectly well.
Physical Examination. He was tall and rather slight. His
flesh was firm and his muscles were hard. His color was good,
but his skin was somewhat dry. He was of a decidedly
nervous temperament, but perfectly normal mentally. His
pupils were equal and reacted to both light and accommoda-
tion. All motions of the eyes were normal and there was no
limitation of the field of vision. His hearing was normal.
There was no spasm or paralysis of any of the muscles supplied
by the cranial nerves. The tongue was clean and moist and
the teeth were normal. The throat was normal. The area
of cardiac dullness was normal, and the second sound at the
aortic area was not accentuated. The radial arteries were
not thickened and the tension of the pulse was not increased.
The lungs and abdomen were normal. The liver and spleen
were not palpable. The extremities were normal. There was
no spasm or paralysis. The knee-jerks were equal and lively.
UNCLASSIFIED DISEASES. 615
Kernig's and Babinski's signs were absent. The sensation
to touch, pain and temperature was roughly normal. There
was no eruption on the skin and there were no scars of any
old eruption. There were no mucous patches in the mouth
or about the anus and no rhagades. There was no enlarge-
ment of the peripheral lymph nodes. He weighed eighty and
one-half pounds.
He secreted six ounces of urine in the course of one-half
hour while being examined, which was pale, slightly acid in
reaction, of a specific gravity of 1,002, and contained no
albumin or sugar.
Diagnosis. The fact that the increase in the frequency
of micturition preceded the thirst rules out polydipsia as the
cause of the polyuria. The absence of remissions or inter-
missions in the symptoms, of limitation of the field of vision
and of disturbances of sensation excludes hysteria as the
cause. The age of the child and the acute onset of the
symptoms, together with the absence of albumin in the urine,
enlargement of the heart, accentuation of the second aortic
sound, thickening of the arteries and increase in the pulse
tension, show that the polyuria is not a sign of chronic inter-
stitial nephritis. There can be no doubt, therefore, that the
trouble is Diabetes Insipidus. The absence of all signs of
increased intracranial pressure and of involvement of the
cranial nerves, as well as of an injury to the abdomen and of
tumors in it, shows that it is of the primary or idiopathic
type. Cerebral syphilis being the cause of a considerable
proportion of the cases of diabetes insipidus, even when they
are apparently primary, a Wassermann test should be done,
in spite of the absence of a syphilitic history, of all signs of
syphilis and of evidences of cerebral disease, to determine
whether it is the etiological factor in this instance.
Prognosis. The chances of recovery are very small, unless
the condition is due to cerebral syphilis, in which case they
are reasonably good. He will, however, probably live for
many years and perhaps attain old age.
Treatment. If the Wassermann test is positive, he should
be treated for syphilis. If it is not, it is difficult to decide
what drug, if any, to give him. The number of drugs which
6l6 CASE HISTORIES IN PEDIATRICS.
have been used and recommended in this disease shows of
how little value they all are. Strychnia is perhaps more
likely than the others to help him. He should be given one-
sixtieth of a grain of the sulphate of strychnia three times
daily, the dose being increased until it causes toxic symptoms.
It should then be reduced a little below this point and given
continuously for several months. If strychnia does not help
him, ergot or valerian may be tried. It will be well to attempt
to gradually reduce his intake of liquids. The reduction
should be carried to the point where the amount of the urine
ceases to diminish pro rata. Further reduction will be
harmful, in that fluid will be drawn from the tissues to keep
up the amount of urine.
UNCLASSIFIED DISEASES. 617
CASE 195. Mary B. was the first child of healthy parents.
There was no history of abnormal friability of the bones in
either family. There had been no previous miscarriages.
She was born at full term, after a normal labor lasting nine
hours. The presentation was foot and leg. When the leg
was pulled down, the mother being under ether, a snap was
heard. She was delivered manually, but very little force was
used. She was somewhat cyanotic and was held up by the legs
to drain. When she was examined it was found that both legs
were broken. She was seen in consultation five hours later.
Physical Examination. She was well developed and nour-
ished, of good color and seemed vigorous. The shape of the
head was normal. The bones of the skull were hard and the
fontanelles and sutures no wider than usual. The face was
normal and there was no depression of the bridge of the nose.
The shape of the chest was normal and there was no rosary.
The heart, lungs and abdomen were normal. The liver was
palpable two cm. below the costal border in the nipple line.
The spleen was not palpable. The legs appeared shortened
in their relation to the trunk, but the arms were of normal
length and shape. There was no enlargement of the epiphy-
ses of either the arms or legs. The right femur showed
evidences of a healed fracture at about its middle. Union
had occurred with an angular deformity outward and for-
ward. There was but little callus and the fracture must have
taken place at least three or four weeks before birth. There
was a loose fracture with slight crepitus at the junction of the
lower and middle thirds of the left femur. There was also
a slight anterior bowing independent of the fracture. There
was a fracture of the right tibia a short distance above the
lower epiphysis, and two fractures of the left tibia, both at
some distance from the epiphyses. The fibulae were intact.
There was apparently some forward and outward bowing of
the tibiae, which was not due to the fractures. The fractures
were not markedly painful. There was no enlargement of
the peripheral lymph nodes. The skin was soft, the hair fine
and nothing abnormal was detected about the thymus and
thyroid glands.
Diagnosis. Cretinism and chondrodystrophia fcetalis are
suggested by the shortening of the legs. There are, however,
6l8 CASE HISTORIES IN PEDIATRICS.
no other evidences of cretinism and there is no increase in the
friability of the bones in this disease. Chondrodystrophia
can be excluded on the shape of the head, the normal length
of the arms and the slightness of the shortening of the legs.
Osteomalacia is a disease of later life. Fetal rickets, provided
there is such a condition, can be ruled out on the normal con-
dition of the skull and the absence of a rosary and of enlarge-
ment of the epiphyses. Rachitic bones, moreover, are soft
and bend but do not break or, if they do, the fractures are
of the green-stick variety rather than complete as in this
instance. The only condition with which the lesions in this
baby are consistent is Osteogenesis Imperfecta, also known
as idiopathic osteopsathyrosis and fragilitas ossium. This is
undoubtedly the diagnosis.
Prognosis. The prognosis as to life is grave, in spite of the
good general condition, because the majority of the babies
who are born with this disease die in early infancy. If she
survives, she will undoubtedly continue to have repeated
fractures from the most insignificant causes. The fragility
of the bones gradually diminishes, however, and is much less
marked after puberty than before it. The individual frac-
tures heal quickly, and, if they are carefully treated, without
deformity.
Treatment. She must be kept on a pillow and handled as
little as possible. The clothes must be so arranged that they
can be put on and taken off without disturbing the arms.
She should not be put in a tub, but must be bathed on the
pillow. She ought not to be put to the breast, but should be
given breast-milk from a bottle. The fractures should, of
course, be reduced and splinted in the usual way. There is
no evidence to show that this disease is due to a deficiency of
calcium. There is, therefore, no indication for its adminis-
tration. Good results have been claimed from the use of
phosphorus in this condition. It ought, therefore, to be given
a trial. It is very likely to disturb the digestion, however,
and on this account must be given very cautiously. It will
be wise, therefore, to wait for some weeks before beginning it.
The most reliable preparation is the phosphorated oil. The
initial dose should be one-quarter of a minim, three times daily.
UNCLASSIFIED DISEASES. 619
CASE 196. Lena M. was the only child of healthy
parents. There had been no miscarriages and the parents
stated that they never had any venereal disease. She was
born at full term, after a normal labor, and was normal at
birth. She was fed on condensed milk during the first year
and did well. She had had no disturbance of the digestion
since then. In November, 1904, when a little more than
three years old, she began to complain of pains in the axillae,
for which no cause could be found. She had no pains else-
where. She lost her appetite, became very thin and finally
got so weak that she could not walk. She also had feverish
spells every few days. This condition lasted until June,
1905, when the pains and fever suddenly ceased and her
appetite returned. She gained as rapidly as she had lost in
the beginning and was soon perfectly well. She remained
well until February, 1906, when she had the measles. This
was followed by the suppuration of a gland in the neck, which,
however, soon healed. About the middle of March the pains
in the axillae returned and in a few days pains developed all
over the body. She lost her appetite and again began to fail
rapidly in flesh and strength. Swelling of the joints of the
fingers appeared in two weeks. The wrists and knees next
became swollen and finally the elbows and feet. The swelling
of the joints varied from time to time, but never disappeared.
Spontaneous pain ceased after a time, but pain on motion
and handling persisted. She had seemed feverish at times,
but, as a rule, there had apparently been no fever. There had
been no disturbance of the digestion and her bowels had
moved normally. Her appetite had improved during the
last two weeks and she had regained a little weight. She
was admitted to the Children's Hospital in August, 1906,
when five years old.
Physical Examination. She was poorly developed and
emaciated. Her skin was brownish. There was no aural or
nasal discharge. The tongue was clean, the teeth in fair
condition, the throat normal. She held her head rigidly in the
median line and all motions of the head were much limited.
She opened her mouth voluntarily only about one cm., but
it could be forced open about twice as far. A Roentgeno-
620 CASE HISTORIES IN PEDIATRICS.
graph of the cervical spine and the maxillary articulations
showed nothing abnormal. The whole back was rigid and all
motions were limited. The area of the cardiac dullness was
normal, as was the action of the heart and the sounds, except
for a soft, systolic murmur in the pulmonic area. The second
pulmonic sound was not accentuated and there was a venous
hum in the neck. The lungs and abdomen were normal.
The liver was palpable one cm. below the costal border in the
nipple line. The spleen was just palpable. There were
fusiform swellings, which were slightly reddened and tender
to pressure, about the elbows, knees, carpal, metacarpocarpal
and metatarsotarsal joints, all the phalangeal joints of the
hands, except the second joints of the two middle fingers and
the distal joints of the thumbs, and the maxillary. The
movements of all these joints were limited and painful.
Roentgenographs of the hands showed enlargement of the
distal portions of the two proximal phalanges, except of those
not clinically affected, which was due to a proliferation of the
periosteum, and slight blurring of the epiphyseal centres of
the affected portions. The legs were held flexed at a right
angle on the thighs. There was no limitation of motion at
the hip and shoulder joints. There was much wasting of the
muscles of both the arms and the legs. The knee-jerks were
present, but diminished. There was no disturbance of the
sensation to touch and pain. There was a general enlargement
of the peripheral lymph nodes, including the epitrochlear and
occipital, which varied in size from peas to almonds. There
were no rhagades or mucous patches and no eruption or
scars of former eruptions. The rectal temperature was 990 F. ;
the pulse, 120.
The urine was normal in color, acid in reaction, of a specific
gravity of 1,023 and contained no albumin, sugar or acetone.
Blood.
Hemoglobin, 50%
Red corpuscles, 3,700,000
White corpuscles, 13,000
Mononuclears, 20%
Polynuclear neutrophiles, 79%
Mast cells, 1%
Lena M. Case 196.
UNCLASSIFIED DISEASES. 621
Diagnosis. The appearance of the swellings in the joints
after measles and an abscess of the neck, the number of the
joints involved, the fusiform character of the swellings, the
enlargement of the spleen and peripheral lymph nodes,
the anemia, the discoloration of the skin and the relative
increase in the rate of the pulse in comparison with that of the
temperature are all so characteristic of that form of infectious
arthritis known as Still's Disease that there is no oppor-
tunity for a differential diagnosis from other forms of arthritis.
The absence of changes in the bones and cartilages of the
affected joints, as shown by the Roentgenographs, confirms
this diagnosis. The systolic murmur at the pulmonic area
and the venous hum in the neck are merely signs of the
anemia, while the slight enlargement of the liver is probably
due to fatty change resulting from the disturbance of the
nutrition.
Prognosis. There is no danger as to life. The process is
likely to continue for many months or even for a number of
years, however, perhaps skipping from joint to joint. She
will then recover her health and the swellings will in a great
measure disappear, but she will probably be left with more or
less deformities as the result of adhesions and thickening
about the joints.
Treatment. The salicylates and iodides are useless in this
disease. In this instance there are no symptoms which point
to the digestive tract as the source of the toxemia. There
are, therefore, no definite indications as to what she should
or should not eat. She ought, therefore, to be given a liberal,
easily digestible diet. Meats and foods prepared from them
are not contraindicated. It is very possible that there is a
mild bacterial infection at the bottom of the trouble. Un-
fortunately, experience has shown that blood cultures are
almost invariably negative and the liquid aspirated from the
joints sterile in this disease. It being, therefore, impossible
to determine the organism, and as only an autogenous vac-
cine can be expected to do good, it hardly seems rational
to give stock vaccines of many organisms on the chances
that one of them may be the right one. She should be
given iron for the anemia. The saccharated carbonate is a
622 CASE HISTORIES IN PEDIATRICS.
good preparation. Five grains, three times daily, should be
sufficient for her. She should be put on a frame with
traction on the legs and the affected joints baked daily.
The further treatment should be directed by an orthopedic
surgeon.
UNCLASSIFIED DISEASES. 623
CASE 197. Paul K., nine months old, was the second
child of healthy parents. There had been no deaths or mis-
carriages and no known exposure to tuberculosis. He was
born at full term, after a normal labor, and was normal at
birth. He was not nursed and some difficulty was experienced
in feeding him up to the time he was three months old, since
when he had thrived in every way. He began to be sick
about August I. He was fussy and evidently in pain. He
vomited a little at first, but this stopped when his food was
weakened. He had had no disturbance of the bowels. His
mother noticed August 16 that he "favored" his left leg a
little. He was first seen by his physician, August 19. He
found a temperature of ioo° F., but nothing abnormal on
physical examination. The temperature had ranged be-
tween 990 F. and 1010 F. since then. He was very fussy and
it was evident that he was in pain. The physician was, how-
ever, unable to locate its seat. He slept much better than
usual the night of August 22, and the next morning his mother
found that his left thigh was much swollen. Both she and
the physician were sure that it was not swollen the day before.
In spite of the swelling, he seemed more comfortable than for
several days. He was seen in consultation at 4 P.M., August 23.
Physical Examination. He was pale and feeble and had
evidently lost much weight. He was evidently in consider-
able pain. The anterior fontanelle was four cm. in diameter
and depressed. The pupils were equal and reacted to light.
There was no rigidity of the neck or neck sign. The ear-
drums were normal. He had two teeth. The mouth, gums
and throat were normal. There was no rosary. The heart,
lungs and abdomen were normal. The spine was flexible.
The lower border of the liver was palpable two cm. below
the costal border in the nipple line. The spleen was not
palpable. The arms and right leg were normal. He lay
with the left thigh flexed on the body and rotated outward
and the leg flexed on the thigh. The left thigh was much
and somewhat irregularly swollen. The swelling was most
marked in the upper portion and did not extend on to the
abdomen or leg. It was not in the superficial tissues and did
not pit on pressure. It was moderately tender, but not red
or hot. The whole left lower extremity was mottled, but the
624 CASE HISTORIES IN PEDIATRICS.
pulse was palpable in the foot. All motions at the left hip
were much limited and painful, those at the knee were free.
The right knee-jerk was normal and Kernig's sign was ab-
sent on that side. They could not be determined on the
left, because of the rigidity. There was no enlargement of
the peripheral lymph nodes. The rectal temperature was
100.40 F. ; the pulse, 160; the respiration, 32.
The urine was of normal color, clear, acid in reaction and
contained no albumin.
Diagnosis. Rheumatism can be excluded on the age of the
baby and the location of the swelling. Scurvy can be ex-
cluded on the localization of the swelling over one bone, the
sudden appearance of the swelling, the absence of tenderness
elsewhere and the normal condition of the gums. The long
continuance of pain and fever without any local manifesta-
tions, except a little unwillingness to use the left leg, and the
sudden appearance of the swelling with the simultaneous
diminution in the pain, is almost pathognomonic of the
rupture of a collection of pus which has been slowly accumu-
lating. The location of the swelling shows that the abscess
was located somewhere in the neighborhood of the hip joint.
It was in all probability in the joint itself and, judging from
the size of the swelling, also in the pelvis. When the capsular
ligament ruptured, the pus escaped into the neighboring
tissues. The diagnosis of Acute Arthritis of Infants is,
therefore, justified. The acute arthritides at this age are very
seldom tubercular. They are in most instances due to an
infection of the bone, usually in the neighborhood of the
epiphyseal line, with one of the pyogenic organisms, the
joints being involved secondarily. This is probably the case
in this instance.
Prognosis. The condition is a very serious one. He is
in reasonably good shape, however, and there are no evidences
of general sepsis or of the involvement of other bones or
joints. There is a reasonable chance of his recovery, there-
fore, provided he is operated on at once. If he survives, he
will almost certainly have a useful joint.
Treatment. The abscess cavity must be opened, cleaned
out and drained.
UNCLASSIFIED DISEASES. 625
CASE 198. Penelope C., eleven months old, had had much
trouble with her digestion until she was six months old, when
a wet-nurse was procured for her. She had done uninter-
ruptedly well since then and was still on the breast. She had
cut three teeth without any marked discomfort or disturbance
of any sort. She began to be fussy and to put her hands in
her mouth, September 3. She fussed, cried out and kept put-
ting her hands in her mouth all through the night of Septem-
ber 6. Her temperature at midnight was 1030 F. She was a
little more quiet the next day, but refused to nurse. She did
not vomit, however, and had two normal stools during the
day. She was seen at 4 p.m., September 7.
Physical Examination. She was well developed and nour-
ished and of good color, but was very fussy and irritable.
She kept crying out as if in pain and was constantly putting
her hand in her mouth. The anterior fontanelle was two
cm. in diameter and level. There was no rigidity of the neck
or neck sign. The pupils were equal and reacted to light.
The ear-drums were normal. There was no nasal discharge
or obstruction. She had three teeth. The gum was much
swollen and reddened over the left upper middle incisor,
which was apparently on the verge of erupting. The tongue
was clean and the throat normal. There was no rosary.
The heart, lungs and abdomen were normal. The lower
border of the liver was palpable two cm. below the costal
border in the nipple line. The spleen was not palpable.
The extremities were normal. There was no spasm or
paralysis. The knee-jerks were equal and normal. Kernig's
sign was absent. There was no enlargement of the periph-
eral lymph nodes. There was no eruption. The rectal tem-
perature was 1010 F.; the pulse, 112; the respiration, 28.
The urine was clear and contained no albumin or sugar.
The leucocytes numbered 10,000.
Diagnosis. Otitis media, which is strongly suggested by
the symptoms, can be excluded on the absence of all signs
of nasopharyngeal irritation, the normal white count and the
normal condition of the ear-drums. Pyelitis, which often
causes fever and symptoms of discomfort without physical
signs at this age, is ruled out by the low white count and the
626 CASE HISTORIES IN PEDIATRICS.
normal condition of the urine. Tubercular meningitis, which
must always be considered when a baby is ill and there are
no definite symptoms except fever and irritability, seems very
improbable in the light of the physical examination. It
cannot be excluded, however, unless some more reasonable
explanation of the symptoms can be found. There are no
symptoms pointing to disease of the gastrointestinal tract.
The low white count shows that there is no hidden inflamma-
tory process going on and the physical examination shows
nothing abnormal except the swelling and redness of the gum.
In the absence of all symptoms and physical signs of other
conditions it seems fair to conclude, therefore, that this is
the seat of the trouble and to make a diagnosis of Difficult
Dentition. The fussiness and the constant putting of the
hands to the mouth point strongly, moreover, to discomfort
there. The fever may easily be caused by reflex irritation
from the swollen gum.
Prognosis. The symptoms will probably cease at once
when the gum is lanced and the pressure relieved.
Treatment. The gum should be lanced at once.
UNCLASSIFIED DISEASES. 627
CASE 199. Harold C, five years old, had always been
well except for whooping-cough at two years, scarlet fever and
chicken-pox at three years and measles two months before.
He was admitted to the Children's Hospital, July 20, three
days after the onset of an infectious diarrhea. The physical
examination and the urine were normal at that time. He
had only a moderately severe attack of the disease, but lost
much weight and strength. The character of the stools began
to improve August 3, as did his general condition. The
temperature reached normal a week later and there was no
longer blood in the stools. Everything seemed to be going
well, except that from time to time he had a little fever.
The movements had diminished to two a day and he was
beginning to sit up in bed. It had from the first been very
difficult to keep his mouth clean, but there had been no
ulcerations. His mouth continued to be dirty and the odor
from it was very foul. A sloughing area, the size of a dime,
was noticed on the inside of the left cheek about noon,
September 2. It had not increased in size when he was seen
the next morning, but the cheek had become much swollen
during the night and a profuse, very foul-smelling discharge
from the mouth had appeared. He apparently had no pain.
Physical Examination. He was thin and pale. He was
perfectly clear mentally, but somewhat apathetic. The left
cheek was much swollen, but not red or hot and only slightly
tender. There was a profuse, very foul-smelling discharge
from the mouth. The whole of the inside of the mouth was
reddened, but there were no ulcerations, except in the left
cheek, where there was a sloughing area, the size of a dime.
Several of the teeth on this side were much decayed. The
throat was normal. The heart, lungs and abdomen were
normal. The liver and spleen were not palpable. The
extremities were normal, as were the superficial and deep
reflexes. The lymph nodes on both sides of the neck were
enlarged, more so on the left. The rectal temperature was
ioo° F.; the pulse, 130; the respiration, 30.
Diagnosis. The location of the sloughing area, the marked
swelling of the cheek without heat or redness, the foul odor
of the discharge, the relatively low temperature and the onset
628 CASE HISTORIES IN PEDIATRICS.
of the trouble during the convalescence from an acute disease
are so characteristic of Noma that it is unnecessary to con-
sider any other condition.
Prognosis. The prognosis is very grave. He may recover,
but in all probability the process will extend and he will die
of exhaustion and bronchopneumonia in the course of three
or four days.
Treatment. The sloughing area should be thoroughly
burned out at once with the actual cautery. The mouth
should be cleansed several times daily with a solution of
peroxide of hydrogen in order to diminish the chances of the
development of a secondary bronchopneumonia. This solu-
tion is also especially useful because the Bacillus fusiformis,
the probable cause of noma, is anaerobic. He should be given
as much fresh air as possible, preferably out of doors, and fed
freely with milk, gruel, cereal jellies, junket and milk toast.
He must be fed with a tube, passed through the nose, if he
will not take sufficient nourishment otherwise. Stimulation
is not needed at present, but probably will have to be started
by to-morrow.
UNCLASSIFIED DISEASES. 629
CASE 200. Joseph W. was the child of healthy parents.
Three other children were well and one had died of diarrhea
in infancy. There had been no miscarriages. He had had
no known exposure to tuberculosis. He was born at full
term, after a normal labor, and, except for whooping-cough at
three years, had been well until he was five and one-half years
old. He then began to complain of pain in the abdomen, and
it was noticed soon after that his abdomen was larger than
in the past. The abdomen had slowly increased in size since
then and he had had pain in it from time to time. His
appetite was not very good, but he did not vomit and his
bowels moved regularly. He did not gain in either height or
weight, did very poorly at school and did not care to play
with other children. His mother thought that he was usually
a little feverish at night. He was admitted to the Children's
Hospital when seven years old.
Physical Examination. He was fairly well developed and
nourished and of good color. The heart and lungs were
normal. The upper border of the liver flatness was at the
upper border of the sixth rib in the nipple line; the lower
border was not palpable. The spleen was not palpable. The
abdomen was considerably enlarged and there was a rounded
prominence in the epigastrium. Palpation revealed a mass
about the size and shape of a large egg-plant, with the small
end down, in the upper abdomen. It extended about three
cm. below the navel and further to the right than to the left
of the median line, but did not reach the costal border. Its
anterior surface was close to the abdominal wall. It was flat
on percussion and not tender. It was freely moveable later-
ally and downward but did not move with respiration. Its
surface was smooth and it felt hard, but somewhat elastic.
The rest of the abdomen and the flanks were tympanitic. The
kidneys were not palpable and nothing abnormal was de-
tected in the flanks. The genitals were normal, as were the
extremities. A few lymph nodes, the size of beans, were
palpable in the neck and groins. There was no evidence of
enlargement of the bronchial lymph nodes. Rectal examina-
tion showed nothing abnormal. The rectal temperature was
99° F.
63O CASE HISTORIES IN PEDIATRICS.
The urine was clear, acid in reaction, of a specific gravity of
1,018 and contained neither albumin nor sugar. The sediment
showed nothing but a few small round and squamous cells.
Blood.
Hemoglobin,
90%
Red corpuscles,
5,368,000
White corpuscles,
9,900
Mononuclears,
45%
Polynuclear neutrophiles,
54%
Eosinophiles,
1%
The red corpuscles showed nothing abnormal.
A skin tuberculin test was very strongly positive.
Diagnosis. The strip of tympanitic resonance between the
tumor and the costal border and the fact that it does not
move with respiration show that it cannot be connected with
the liver. Tumors of the spleen are not of this shape, are
not moveable downward and come out from under the costal
border. Tumors of the kidney come up into the abdomen
from the flanks, which, in this instance, are empty. It cannot,
therefore, be a tumor of either the spleen or kidneys. These
are, moreover, solid tumors, while this tumor has the shape
and feel of a cyst. It cannot be a cyst of the pancreas,
because it is superficial and freely moveable. The only other
cysts which occur in this region are those of the mesentery.
The mobility is consistent with this condition. The tumor
is, therefore, almost certainly a Cyst of the Mesentery.
These cysts are, as a rule, due to obstruction of the lymph
vessels, but are sometimes collections of pus resulting from
the breaking down of tubercular mesenteric lymph nodes.
The low white count and the normal temperature are con-
sistent with either condition. The strongly positive tuber-
culin test, in the absence of signs of tuberculosis elsewhere,
unless the slightly enlarged lymph nodes in the neck and
groins are such, suggests, but does not prove, that it is the
latter. There is no way of settling this point except by
operation.
Prognosis. He is in good general condition and the physi-
cal examination shows nothing abnormal outside of the abdo-
UNCLASSIFIED DISEASES. 63I
men. He should, therefore, stand an operation well. It ought
not to be, moreover, a very difficult matter to remove the
cyst. If it is not tubercular, its removal will cure him. If
it is tubercular, it is very probable that there are some other
tubercular lymph nodes elsewhere in the body which will
not, of course, be removed. The prognosis of tubercular ade-
nitis at this age is, however, very good with proper care and
treatment.
Treatment. The treatment is immediate operation.
INDEX
The heavy face numerals refer to the pages on which the disease named is the diagnosis of a
case; the other figures to the pages on which the disease or condition is mentioned.
Abdomen, examination of 35.
tumor of, 248, 285.
Abscess, 74.
epigastric, III.
of brain, 562.
of lung, 356.
of skull, 567.
peritonsillar, 336.
retropharyngeal, 21, 301, 336, 575,
„ 579-
Acid intoxication, 130, 583, 609, 610,
612.
Adenitis, bronchial, 589.
cervical, 585.
(See lymph nodes.)
Adenoids, 18, 25, 301, 330, 331, 339,
358, 462, 575, 579, 586.
examination for, 22.
Amyotonia congenita, 569.
Anemia, 50, 435, 437, 466, 469, 472,
477. 490, 596, 599, 602, 621.
chlorotic type, 466.
infantum pseudoleukemica, 473.
pernicious, 469, 470, 478.
secondary, 227, 232, 260, 347, 466,
470, 472, 477, 478, 483, 493.
secondary, with splenic tumor, 473.
splenic, 486, 494.
Aneurism, 119.
Angioneurotic edema, 50, 531, 592, 593,
602.
Antitoxin poisoning, 606.
Antrum, maxillary, 22.
mastoid, 23.
Anus, fissure of, 40, 161.
Appendicitis, III, 164, 196, 197, 199,
200, 248, 251, 285, 286, 373, 442.
Appendix, position of, 39.
Arthritis, acute, of infants, 624.
infectious, 621.
septic, 45.
Ascites, 37, 244, 431, 437, 447.
causes of, 244.
characteristics of fluid in, 245.
physical signs of, 244.
Asthma, 358, 361.
Atelectasis of lung, 83, 224, 225.
Babinski's phenomenon, 46.
Bacteriuria, 442, 453.
Band's disease, 494.
Baths, fan, 378.
pack, 378.
sponge, 377.
Bednar's Aphthae, 18, 299.
Bile ducts, congenital obliteration of,
71, 90, 91.
obstruction of, 437.
Bladder, capacity of, 42.
position of, 42.
Blood, characteristics of, 52, 63, 54.
Blood pressure, 29.
Bow-legs, 43.
Brain, abscess of, 562.
tumor of, 563, 567.
Branchial cyst, 67.
Breasts, engorgement of, 25, 89.
Breck feeder, 65.
Bronchitis, 224, 225, 256, 260, 282, 283,
290, 326, 336, 349, 351, 353, 356,
361, 364, 367, 460, 539.
Bronchopneumonia, 224, 225, 254, 260,
349, 351, 364, 367, 589.
Bronchus, foreign body in, 356.
Brudzinski's neck sign, 47.
Calculi, renal, 445.
vesical, 239.
Calories, use in infant feeding, 139, 176,
188, 191, 194, 202, 214, 216, 219,
222, 241, 474, 597, 609.
use in older children, 142, 179, 182,
233, 280, 318, 448, 449.
[ method of calculation in infant feed-
ing, 214.
table of caloric values, 449.
Caput succedaneum, 74.
Cephalhematoma, 74.
Cerebellar tumor, 563.
Cerebral hemorrhage, 106, 534, 537.
Cerebral paralysis, 46, 77, 122, 125,
305, 508, 519. 526, 535. 637, 559.
Cerebral tumor, 563, 567.
Cerebrospinal fluid, normal, 264, 265.
in meningitis, 264, 265.
Chest, anatomy of, 24.
growth of, 14.
position in examination of, 26.
Chicken breast, 26.
Chicken-pox, 311.
Chlorosis, 466.
Cholecystitis, 164.
633
634
INDEX
Cholera infantum, 116, 204.
Chondrodystrophia foetalis, 618, 619.
Chorea, 416, 423, 495, 496, 505.
Chvostek's symptom, 48.
Cirrhosis of liver, 431, 434, 437, 486,
493> 494-
Ccecum, position of, 39.
Colic, lead, 37.
Colitis, 37.
Colon, position of, 39.
Colostrum, 25.
Congenital atelectasis of lungs, 83.
cerebral defect, 537.
dilatation of the colon, 144.
dislocation of hip, 44.
heart disease, 82.
icterus, 90, 91.
laryngeal stridor, 85, 339.
malformation of bile ducts, 71, 90,
91, 167.
malformation of esophagus, 88.
malformation of intestine, 69.
muscular hypertonia, 106.
Constipation, 137, 143, 150, 155, 156,
157, 161, 175, 191, 192, 214, 220,
270, 373, 374. 528, 571, 608.
Convulsions, 339, 342, 343, 376, 377,
501, 502, 504, 507, 508, 515, 531,
_ 532, 540, 541. 58i, 583-
Craniotabes, 16.
Creeping, 43.
Cretinism, 17, 19, 23, 514, 519, 573,
617, 618.
Croup, spasmodic, 333.
Curve of weakness, 24, 227.
Cyanosis, enterogenous, 405.
Cyst, branchial, 67.
mesenteric, 630.
ovarian, 244.
Cystic hygroma of neck, 67.
Dentition, 20.
delayed, 531.
difficult, 328, 626.
Diabetes insipidus, 615.
Diabetes mellitus, 609, 611.
Diaphragm, position of, 26.
Diarrhea, 294.
classification of, 115, 116.
cholera infantum, 116, 204.
dysenteric type, 116, 202, 240.
fermentative, 116, 172, 175.
infectious, 116, 147, 175, 202, 241,
599-
nervous, 115.
Diastasis of recti muscles, 37.
Diphtheria, 235, 288, 290, 442.
laryngeal, 290, 333, 356.
nasal, 288, 301.
paralysis in, 557.
intubation in, 291.
Dropsy, idiopathic (see idiopathic
edema).
Ear, examination of, 22.
Edema, 50, 93, 450, 602.
angioneurotic, 50, 531, 592, 593, 602.
idiopathic, 596, 599.
of lungs, 83, 423, 427, 549.
Emphysema of lungs, 358, 381, 385.
Empyema (see pleurisy, purulent).
Encephalitis, 342, 541, 546, 547, 562.
Endocarditis, 324, 364.
acute, 411, 414, 415, 416, 417, 418,
420.
malignant, 414, 415.
Enuresis, nocturnal, 462.
Epilepsy, 342, 501, 502, 504, 508.
Epiphysitis, acute, 305.
syphilitic, 306.
Epstein's pearls, 18.
Erysipelas, 113.
Erythema, 317.
Erythema multiforme, 604.
Erythremia, 405.
Erythrocytosis megalosplenica, 405.
Esophagus, 21.
congenital malformation of, 88.
spasm of, 120.
stricture of, 120.
Extremities, deformities of, 43.
examination of, 43, 44, 45.
growth of, 13.
position of, 45.
size of, 45.
spasm of, 45.
Eyes, 23.
reaction to accommodation, 23.
reaction to light, 23.
Face, growth of, 17.
Facial phenomenon, 48.
Faculties, development of, 49.
Fat (see infant feeding).
Fede's disease, 19.
Feeding (see infant feeding).
Fissure of anus, 40, 161.
Fontanelles, 15.
Fragilitas ossium, 618.
Friction sounds, pleural, 35.
Gall bladder, examination of, 40.
inflammation of, 164.
Gallstones, 164.
Genitals, examination of external, 42.
German measles, 314, 315, 316, 317.
Glands (seejymph nodes).
Glioma, 563.
Glycosuria, alimentary, 609, 611.
Grasping, 43.
Grocco's sign, 32.
Growth, in height and weight, 11, 12.
of chest, 14.
of face, 17.
of head, 14.
relative of extremities and trunk, 13.
Habit spasms, 496.
Hair, 16.
Harrison's groove, 26.
Head, growth of, 14.
INDEX
635
Head, shape of, 14.
Hearing, 23.
Heart, area of, 28.
examination of, 27.
impulse of, 27.
sounds of, 29.
Heart disease, 583.
acute endocarditis, 411, 414, 415,
416, 417, 418, 420.
aortic insufficiency, 417.
chronic valvular disease, 400, 403,
408, 417, 423.
congenital, 82, 400, 403, 406, 579.
dilatation, 364, 409, 420, 423.
functional, 403, 408, 409, 411, 437,
447-
malignant endocarditis, 414, 415.
mitral insufficiency, 417, 426.
mitral stenosis, 426.
myocarditis, 411, 417, 418, 420, 427.
Hematoma of the sternocleidomastoid
muscle, 80.
Hematuria, 238, 239, 445, 458.
Hemophilia, 99, 100, 102, 103, 477.
Hemorrhage, cerebral, 106, 534, 537.
Hemorrhagic disease of the new-born,
38, 43. 99, 103.
Hemorrhoids, 40.
Henoch's disease, 592.
Hernia, epigastric, 37.
inguinal, 42, 72.
umbilical, 38.
Hip, congenital dislocation of, 44.
Hirschsprung's disease, 144.
Hodgkin's disease, 480, 486, 490, 493.
Hydrocele, of cord, 42.
encysted, of cord, 73.
Hydrocephalus, 14, 15, 16, 227, 526,
529, 534. 566, 567.
chronic internal, 267, 522, 525, 528.
Hydronephrosis, 458.
Hypertonia, congenital muscular, 106,
122.
Hypospadias, 43.
Hysteria, 37, 565, 615.
Icterus (see jaundice).
congenital, 90, 91.
neonatorum, 91, 167.
Idiocy, 569.
amaurotic, 514, 516, 519.
hydrocephalic, 514, 519.
microcephalic, 514, 519.
Mongolian, 17, 19, 514, 519, 520.
Incontinence of feces, 156.
Indigestion, 218, 263, 278, 282, 317,
328, 33L 342, 370, 376, 498, 589.
593, 626.
acute duodenal, 90, 91, 164, 167,
196.
acute gastric, 127, 133, 134, 150, 164,
188, 270.
acute intestinal, 188, 270.
chronic duodenal, 36, 71, 169, 437.
Indigestion, chronic gastric, 122, 125,
137, 141, 595.
chronic intestinal, 1 16, 137, 141, 175,
178, 181, 186, 232, 338, 595, 602.
intestinal, disturbance of equilib-
rium, 115, 171, 175, 188, 190,
193.
intestinal, fermentative type, 116,
172, 175.
Infant feeding, breast, 123, 138, 167,
173. 175. 186, 191, 193, 215, 219,
221, 222, 225, 241, 340, 354, 435,
470, 529, 583, 597, 618.
boiling, disadvantages of, 236.
calculation of calories, 214.
cow's milk, idiosyncrasy to, 138.
pasteurization, disadvantages of, 239.
results of excess of fat, 139, 157, 172,
175, 190, 215.
results of excess of proteids, 186, 193.
results of excess of salts, 596.
results of excess of starch, 138, 596.
results of excess of sugar, 138, 188.
results of insufficient food, 215.
results of insufficient proteids, 219.
use of albumin water, 202, 603.
use of alkalies, 123, 139, 173, 176,
191, 194, 222, 229, 283, 474, 529,
597. 603.
use of calories, 139, 176, 188, 191,
194, 202, 214, 216, 219, 222, 241,
474, 597, 609.
use of low fat, 123, 139, 173, 175, 191,
215, 435. 597-
use of pancreatizatton, 139, 194, 236.
use of proteids, 188, 215, 219, 435,
597-
use of salt, 597.
use of starch, 173, 194, 202, 205, 215,
216, 236, 340, 467, 597, 603.
use of sugar, 173, 175, 191, 193, 202,
205, 236, 340, 435, 597.
use of whey, 123, 135, 173, 529, 597.
use of whey proteids, 123, 139, 173,
176, 194-
Infantile atrophy, 215, 218, 241, 260.
Influenza, 133, 257, 278, 279, 280, 282,
292, 293, 326, 377, 430, 539.
Intestinal obstruction, 130, 199.
Intestinal toxemia, 199, 204, 272, 317,
434, 502, 534, 593, 602.
Intestine, congenital malformation of,
69.
Intoxication, acid, 130, 583, 609, 610,
612.
intestinal, 199, 204, 272, 317, 434,
502, 534, 593, 602.
Intussusception, 147, 150, 154, 202,
593- , , a
Irrigation of bowels, method, 203.
Jaundice, 70, 86, 90, 108, 164, 167, 397,
436, 437-
Kernig's sign, 47.
636
INDEX
Kidney, amyloid disease of, 460.
floating, 42.
sarcoma of, 37, 238, 239, 445, 458.
stone in, 445.
tuberculosis of, 238, 445.
tumors of, 42, 630.
Kidneys, examination of, 41.
passive congestion of, 431.
position of, 41.
Knee-jerks, examination of, 46.
Knock-knees, 43.
Koplik's spots, 19, 313, 314, 315, 316.
Lachrymal glands, 23.
Laryngismus stridulus, 85, 339, 508,
53i. 532, 579.
Laryngitis, catarrhal, 290, 333, 339,
360, 582.
diphtheritic, 290, 333, 339, 360.
Laughing, 49.
Lavage method, 134.
Lead, colic, 37.
poisoning, 593.
Leucocytosis, digestive, 53.
Leukemia, 477, 489, 586.
acute lymphatic, 440, 470, 480, 483,
486.
Lips. 17.
Liver, abscess of, 437.
amyloid, 385, 434.
cirrhosis of, 43 1 , 434, 437, 486, 493, 494.
examination of, 40.
fatty, 385, 434, 435, 621.
malignant disease of, 434, 437, 440.
position of, 40.
sarcoma of, 397, 440.
syphilis of, 437.
Lungs, abscess of, 356.
edema of, 83, 423, 427, 549.
examination of, 30.
gangrene of, 356.
percussion of, 30.
position of lobes, 31.
resonance of, 30.
sarcoma of, 398.
sense of resistance, 32.
Lymph nodes, abdominal, 245, 285,
286, 458, 630.
axillary, 585.
bronchial, 30, 85, 364, 589.
cervical, 79, 323, 408, 489, 585, 586.
epitrochlear, 48.
general enlargement of, 48, 440, 472,
621.
inguinal, 72, 585.
local enlargement of, 48.
occipital, 48.
tracheo-bronchial, 48, 119, 260, 326,
356, 490, 575, 579, 585, 589.
Macewen's symptom, 16.
Malaria, 278, 282, 292, 295, 347, 414,
452, 469. 493-
Malformation, congenital, of intestine,
69.
Malformation, congenital obliteration
of bile ducts, 71, 90, 91.
congenital, of esophagus, 88.
of nose, 301.
Malnutrition, 116, 137, 190, 192, 214,
218, 241, 253, 260, 434, 472, 473,
569, 580, 621.
from excess of carbohydrates, 116,
188.
from excess of fat, 116, 190.
from excess of proteids, 116, 193.
from insufficient food, 215, 221.
from insufficient proteids, 219.
Mastitis, 89.
Masturbation, 511.
Measles, 249, 282, 313, 314, 315, 316,
364. 367. 390, 546.
Meckel's diverticulum. 38.
prolapse of, 94, 97.
Mediastinitis, 430.
Meningitis, 37, 106, 130, 172, 263, 267,
276, 279, 292, 301, 342, 370, 377,
455. 456, 53i. 534. 539. 54L 546,
547. 551. 582.
cerebrospinal, 130, 133, 263, 264,
267, 270, 271, 273, 276, 278, 280,
293. 377. 455. 525. 54i. 566.
cerebrospinal fluid in, 264, 265.
influenza, 539.
pneumococcus, 541.
serous, 534, 543.
tubercular, 130, 164, 196, 263, 264,
267, 268, 270, 271, 273, 276, 278,
?93. 539. 541. 543. 546, 626.
Meningocele, 67, 74.
spinal, 67.
Mesentery, cyst of, 630.
Methemoglobinemia, 405.
Microcephalus, 614.
Mouth, examination of, 17.
Mucous polyp, 38.
Mumps, 282, 323.
Muscular dystrophy, 569.
Myelitis, transverse, 537.
Myocarditis, 321, 364.
Nasopharyngitis, 575, 579, 582, 625.
Nasopharynx, anatomy of, 22.
examination of, 22.
Navel, 37.
granuloma of, 38, 94, 96.
mucous polyp of, 38.
Neck, anatomy of, 23.
in cretinism, 23.
cystic hygroma of, 67.
Neck sign, 47.
Nekton's line, 44.
Nephritis, acute, 321, 324, 445, 447.
chronic, 442.
chronic interstitial, 442, 460, 615.
chronic parenchymatous, 442, 460.
degenerative, 248, 583, 599.
Neuritis, multiple, 235, 305, 537, 551,
555. 556, 557, 559.
INDEX
637
New-born, cerebral hemorrhage in, 534,
537-
hemorrhagic disease of, 38, 43, 99, 103.
septic infection of, 90, 91, 103, 106,
109, 111, 167, 534.
Noma, 628.
Nose, 17.
Noticing, 49.
Obstetric paralysis, 77.
Omphalitis, 109.
Orchitis, 324.
Orthostatic albuminuria, 442, 443.
Osteogenesis imperfecta, 618.
Osteomalacia, 618.
Osteomyelitis, 235, 297, 299, 308, 565.
Osteoperiosteitis, syphilitic, 308.
Osteopsathyrosis, idiopathic, 618.
Otitis media, 133, 267, 278, 328, 342,
343, 345, 347, 453. 562, 582, 625.
Ovarian cyst, 244.
Paralysis, examination for, 46.
cerebral, 46, 77, 122, 125, 305, 508,
519. 526, 535, 637, 555, 559.
diphtheritic, 557.
Erb's, 560.
facial, 77.
hysterical, 565.
infantile, 77, 235, 444. 537. 546, 549,
651, 555, 556, 557, 559, 560, 565,
569.
obstetric, 77, 560.
peripheral, 235, 305, 537, 551, 555,
556, 557, 559.
Parasites, intestinal, 477.
Pasteurization (see infant feeding).
Pavor nocturnus, 498.
Pelvis, characteristics of, 36.
inflammation in, 248.
Pericarditis, 430.
chronic adhesive, 431, 437.
dry, 426.
with effusion, 423, 426.
Periosteitis, 45, 235, 297, 299, 565.
syphilitic, 308, 565.
Peritonitis, 69, in, 200.
chronic serous, 245.
malignant, 245.
septic general, 251, 373.
tubercular, 37, 245, 248, 249, 251,
285, 286.
Perspiration, 50.
Phimosis, 43.
Pigeon breast, 26.
Pleural thickening, 252, 431.
Pleurisy, purulent, 381, 384, 385, 388,
389, 391, 392.
serous, 251, 356, 380, 381, 385, 394,
397. 398.
Pneumonia, 17, 33, 82, 133, 199, 267,
278, 279, 280, 282, 292, 293, 344,
369, 373, 374, 377, 380, 381, 384.
385. 390, 391. 392, 401. 419. 455.
540, 541, 543, 562.
Pneumonia, acute tubercular, 384, 391.
physical signs in, 34.
unresolved, 388.
Pneumothorax, 395.
Poisoning, antitoxin, 606.
bromide, 501.
lead, 593.
Poliomyelitis, 546, 549, 551, 555, 556,
. 557, 559. 56o, 565, 569.
Poliomyelo-encephalitis (see poliomy-
elitis).
Polycythemia, 405.
Polyuria, 615.
Pott's disease, 227, 235.
Prematurity, 63, 91.
Proteids (see infant feeding).
Pseudoleukemia, 480, 486, 490, 493,
586.
Pseudomasturbation, 511.
Pulse, rate of, 29.
rhythm of, 29.
Purpura, 435, 592.
abdominal, 592.
Henoch's, 592.
rheumatica, 592.
simplex, 592.
Pyelitis. 267, 442, 453, 455, 456, 589,
625.
Pylorus, position of, 38.
spasm of, 38, 122.
stenosis of, 38, 122, 125, 528.
Pyonephrosis, 458.
Rales, 34.
Rectum, anatomy of, 39.
prolapse of, 40.
Reflexes, abdominal, 46.
contralateral, 47.
cremasteric, 46.
plantar, 46.
Respiration, bronchial, 33.
character of, 32.
puerile, 32, 33.
rate of, 32.
ryhthm of, 32.
Retropharyngeal abscess, 21, 301, 336,
575. 579-
Rhagades, 17.
Rheumatism, 235, 297, 410, 41 r, 414,
415, 416, 417, 418, 423, 425. 426,
427, 430, 55L 565, 604, 607, 624.
Rhinitis, diphtheritic, 17, 287, 288, 301.
simple, 17, 287, 301, 326, 339.
syphilitic, 287, 301, 302, 305.
Rickets, 15, 16, 19, 20, 25, 43. 44, 161,
190, 214, 224, 227, 232, 253,256,
260, 267, 282, 295, 305, 331, 339.
347, 472, 473, 522, 531. 566, 569.
573. 602.
fetal, 618.
Riga's disease, 19.
Rosary, 25.
Saliva, 18.
Sarcoma of brain, 563, 567.
638
INDEX
Sarcoma, of kidney, 37, 238, 239, 445,
458.
of liver, 397, 440.
of lung, 398.
of skull, 667.
of suprarenal capsule, 440, 567.
of tibia, 308.
Scalp, veins of, 16.
Scarlet fever, 133, 278, 292, 293, 314,
315, 317, 318, 321, 377, 442, 480.
Sclerema, 50.
neonatorum, 93.
Scurvy, 45, 236, 238, 239, 296, 299,
305, 469, 564, 624.
Sensation, 48.
Septic infection, 415, 583, 589.
of new-born, 90, 91, 103, 106, 109,
111, 167, 534.
Serum sickness, 606.
Sinuses, frontal, 22.
Skin, examination of, 50.
color of, 50.
Small-pox, 310.
Smell, 17.
Smiling, 49.
Spasmophilic diathesis, 47, 339, 508,
531, 532.
Spina bifida, 24.
occulta, 24.
Spleen, chronic endothelioma of, 494.
examination of, 41.
position of, 41.
tumor of, 630.
Splenomegaly, primitive, 494.
Standing,. 43.
Starch (see infant feeding).
Starvation, 218, 241.
Status lymphaticus, 576, 583.
Stethoscope, 27.
Still's disease, 621.
Stomach, position of, 38.
capacity of, 39.
Stools, bacteriologic examination of, 61.
blood in, 60.
color of, 57.
curds in, 59.
in infancy, 54.
membrane in, 60.
microscopic examination of, 60.
mucus in, 59.
odor of, 57.
of breast-fed infants, 54.
of infants fed on artificial foods, 55,
56.
pus in, 60.
reaction of, 56.
starvation, 56.
Stridor, congenital laryngeal, 85, 339.
Sucking pads, 18.
Sugar (see infant feeding).
Suprarenal capsule, sarcoma of, 440,
567.
Sutures, 15.
Sweat glands 50.
Syphilis, 17, 18, 20, 43, 44, 48, 63, 71,
79, 82, 90, 91, 94, 99, 103, 106, 119,
167, 218, 245, 287, 299, 301, 302,
305, 306, 308, 437, 486, 489, 493,
^ 522, 529, 563. 565, 576, 615.
Taches cerebrales, 48, 276.
Tactile fremitus, 34.
Talking, 49.
Taste, 19.
Tears, 23.
Teeth, eruption of, 19.
"Hutchinson," 20.
Testicle, undescended, 42, 43, 72.
Tetanus, 106, 531.
Tetany, 45, 47, 339, 531, 532.
Throat, digital examination of, 21.
examination of, 20.
Thumb-sucking, 20.
Thymus, 27, 28, 30, 82, 579, 583.
cyst of, 576.
enlargement of, 85, 356, 575, 576,
580.
examination of, 35.
Thyroid gland, 79.
Tongue, 19.
Tonsilitis, 133, 278, 292, 293, 376, 586.
Tonsils, chronic hypertrophy of, 358.
enlarged, 331, 575, 579.
Torticollis, 80, 604.
Trousseau's symptom, 47.
Tuberculin test, 218, 246, 254, 258, 286,
308, 364, 368, 381, 415, 437, 486,
489. 563, 586, 589, 630.
Tuberculosis, 18, 48, 254, 256, 263, 285,
286, 299, 308, 347, 408, 414, 453,
486, 489, 546, 563, 576, 586, 587,
589. 630.
acute miliary, 282, 414.
chronic diffuse, 169, 218, 261.
family history of, 249.
history of exposure to, 249.
of brain, 563.
of hip, 235.
of kidney, 239, 445.
of lungs, 254, 256, 257, 364, 367, 380,
381, 384, 391.
of lymph nodes, 245, 256, 260, 586,
589, 630, 631.
of meninges, 264, 268, 271.
of peritoneum, 37, 245, 248, 249, 251,
285, 286, 458.
of spine, 227, 235.
Tumor, of abdomen, 248, 285, 630.
of cerebellum, 563.
of cerebrum, 563, 567.
of kidney, 630.
of spleen, 457, 630.
of testicle, 397.
of thymus, 576.
Typhoid fever, 251, 263, 279, 280, 282,
283, 285, 286, 414, 452.
Ulcer of stomach, 493.
INDEX
639
Urachus, patency of, 38, 94, 96.
Uremia, 270, 583.
Uric acid, 238, 239, 321.
Urine, amount of, 61.
characteristics of, 50.
in infancy, 51.
in the new-born, 50.
Urticaria, factitious, 607.
Vagina, hemorrhage from, 43.
Vasomotor disturbances, 48.
Voice sounds, 34,
Vomiting, nervous, 127, 130.
recurrent, 127, 130, 164, 444, 445.
Walking, 43.
Whey (see infant feeding).
Whey proteids (see infant feeding).
Whooping-cough, 249, 325, 326, 364,
365. 367.
Worms, 169.
pin-worms, 206, 462, 511.
round worms, 208.
tape worms, 210.
Date
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WS200
M885c
1913
Morse, John Lovett
Case histories in pediatrics
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WS200
M885c
1913
Morse, John Lovett
Case histories in pediatrics.
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