Skip to main content

Full text of "Common disorders and diseases of childhood"

See other formats 


OXFORD  MEDICAL  PUBLICATIONS 


COMMON    DISORDERS 

AND 

DISEASES   OF  CHILDHOOD 

THIRD  EDITION 
THIRD   IMPRESSION 


PUBLISHED    BY    THE   JOINT    COMMITTEE    OF 

HENRY    FROWDE    AND    HODDER   AND    STOUGHTON 

17  WARWICK  SQUAKE,   NEWGATE  STEEET 

LONDON,    B.C.  4 


S 


OXFORD  MEDICAL  PUBLICATIONS 


.ft 


COMMON  DISORDERS  AND 
DISEASES  OF  CHILDHOOD 


BY 

GEORGE   FREDERIC   STILL 

M.A.,  M.D.  ^CANTAB.),  F.R.C.P.  (Loxn.) 

PROFESSOR   OF    DISEASES    OF   CHILDREN,    KING'S    COLLEGE,    LONDON 

PHYSICIAN  FOR   DISEASES  OF  CHILDREN,  KING'S   COLLEGE  HOSPITAL 

PHYSICIAN    TO    THE    HOSPITAL    FOR    SICK    CHILDREN,    GREAT    ORMOND    STREET 

HONORARY    ME3II5ER    OF   THE    AMERICAN    P^DIATRIC   SOCIETY 


THIRD  EDITION 
THIRD   IMPRESSION 


LONDON 

HENRY  FROWDE  HODDER  &  STOUGHTON 

OXFORD  UNIVERSITY  PRESS  WARWICK  SQUARE,  E.C, 

1920 


Impression  ^"1920 
First  edition,  1897 


TO 
MY   FRIEND    AND   FORMER   TEACHER 

SIR    JAMES    FREDERIC    GOODHART,    BART. 

M.D.,   HON.   LL.D.   (ABERD.),   F.B.C.P.    (LOND.) 

THIS   VOLUME 

IS    DEDICATED    IN    TOKEN    OF    HIGH    ESTEEM 
AND    AFFECTIONATE    REGARD 


Thoughts  that  have  tarried  in  my  mind  and  peopled  its  inner  chambers, 
Sober  children  of  reason,  or  the  desultory  train  of  fancy, 
Clear  running  wine  of  conviction  with  the  scum  and  lees  of  speculation, 
Corn  from  the  sheaves  of  science  with  stubble  from  mine  own  garner. 

Tun-Eii. 


PREFACE  TO  THE  THIRD  EDITION 

THE  preparation  of  the  Third  Edition  of  this  work  has 
been  under  difficulties  ;  one's  pen,  never  too  ready,  laboured 
'in vita  Minerva',  for  was  not  Mars  in  the  ascendant? 
Nevertheless,  I  have  striven  by  addition  and  correction  to 
increase  the  usefulness  of  the  book.  Dosage  has  required 
some  modification  in  conformity  with  official  alterations 
in  the  strength  of  various  preparations  in  the  new  (1914) 
edition  of  the  British  Pharmacopoeia.  A  chapter  has  been 
added  on  that  curious  and  little-understood  disorder  of 
children,  '  cooliac  disease  ',  and  one  on  tuberculous  glands 
in  the  neck,  and  by  numerous  additions  to  other  chapters 
I  have  endeavoured  to  keep  abreast  of  recent  advances 
in  medical  knowledge.  For  Medicine  there  is  no  abiding 
in  one  stay  ;  like  the  Athenians,  we  are  always  seeking 
after  some  new  thing  ;  but  we  seek  it,  not  because  it  is 
new,  but  in  the  hope  that  it  is  better  :  only  we  must  beware 
lest  the  glamour  of  novelty  put  a  spurious  value  upon 
methods,  especially  of  diagnosis  and  treatment,  which  can 
only  be  appraised  at  their  true  value  when  time  and 
experience  shall  have  shown  their  fallacies  and  limitations. 

G.  F.  S. 
July  1915. 


PREFACE  TO  THE  SECOND  EDITION 

THERE  is  perhaps  less  of  trepidation  in  a  second  appear- 
ance than  in  the  first  introductory  bow.  Judgement  has 
been  passed,  and  if  some  have  noted  only  faults,  others  have 
found,  with  Cervantes,  that  '  there  is  no  book  so  bad  but 
something  good  may  be  found  in  it'. 

But  indeed  it  would  be  churlish  not  to  acknowledge  the 
many  kindly  words  of  appreciation  as  well  as  of  criticism 
which  have  come  to  me  from  many  lands,  from  friends 
known  and  unknown.  These  have  lightened  in  no  small 
degree  the  burden  of  responsibility  which  one  must  needs 
feel,  who  sends  forth  a  book  intended  to  be  a  guide  and  help 
in  the  every-day  problems  of  disease. 

One  cannot  but  realize  that  some  of  the  faults  and 
omissions  of  the  earlier  edition  remain,  and  must  perforce 
remain,  owing  to  the  purpose  and  character  of  the  book. 
In  particular  I  must  crave  indulgence  for  its  apparent 
egoism — a  fault  it  is  true,  but  one  which  was  inseparable 
from  the  object  I  had  in  view,  which  was  less  to  present 
a  formal  and  impersonal  treatise  on  diseases  of  children 
than  to  extract  from  my  own  experience  such  facts  and 
conclusions  as  might  be  helpful  to  others. 

In  the  present  edition  I  have  followed  this  same  plan  in 
dealing  with  several  disorders,  amongst  which  may  be  men- 
tioned enlarged  tonsils  and  adenoid  hypertrophy,  epilepsy, 
asthma  and  hydrocephalus,  which  were  not  included  in  the 
previous  edition. 

The  rapid  march  of  scientific  investigation  has  necessitated, 


x  PREFACE  TO  THE  SECOND  EDITION 

even  since  this  book  was  first  published  barely  two  years  ago, 
considerable  modification  of  views  on  some  of  the  diseases 
of  children,  for  instance,  infantile  paralysis  and  congenital 
syphilis.  Other  alterations  and  additions  have  been  made 
wherever  such  changes  seemed  likely  to  be  of  value,  and  if 
the  revision  and  extension  which  the  work  has  undergone 
add  to  its  usefulness  I  shall  be  well  content. 

G.  r.  s. 

February  1912. 


PREFACE  TO  THE  FIRST  EDITION 

THE  original  plan  of  this  work  was  the  putting  together 
of  lectures  delivered  at  King's  College  Hospital  and  at 
the  Hospital  for  Sick  Children,  Great  Ormond  Street ;  and 
in  accordance  therewith  I  had  intended  to  call  the  volume 
'  Lectures  on  Diseases  of  Children '.  But  as  the  patchwork 
grew  it  became  evident  that,  if  it  was  to  be  in  any  sense 
a  connected  whole,  it  would  be  well  to  combine  with  the 
lectures  other  clinical  studies,  which  had  been  written  at 
various  times  for  other  purposes.  Some  of  these  studies, 
as  also  of  the  lectures,  have  appeared  already  in  medical 
journals  or  in  hospital  reports,  but  only  very  few  in  the  form 
in  which  they  now  appear,  for  larger  experience  has  called 
for  modifications  and  additions,  and  I  have  not  scrupled 
to  mutilate  and  transform  my  progeny  until  they  bear 
scarce  the  semblance  of  their  former  selves. 

For  the  most  part,  however,  these  chapters  appear  now 
for  the  first  time,  and  having  abandoned  my  original  scheme, 
I  was  at  a  loss  to  find  a  name  for  my  '  farrago  libelli '.  It  is 
no  systematic  treatise,  it  has  no  claim  to  vie  with  the  many 
textbooks  which  deal  with  the  whole  subject  of  disease  in 
childhood,  nor  indeed  is  it  written  on  the  lines  which  a 
systematic  work  demands ;  I  have  chosen  rather  to  be 
selective  and  discursive  as  it  suited  my  bent ;  I  have  dis- 
regarded altogether  that  sense  of  proportion  and  perspective 
which  is  of  the  very  essence  of  a  systematic  textbook. 

My  theme  is  mainly  the  everyday  and  the  commonplace, 
the  disorders  which  bulk  most  largely  in  the  out-patient 
and  in-patient  clin:cs  of  a  children's  hospital,  and  in  the 


xii  PREFACE  TO  THE  FIRST  EDITION 

routine  of  private  practice.  On  this  ground  I  have  adopted 
the  title  '  Common  Disorders  and  Diseases  of  Childhood  ', 
which  at  any  rate  conveys  the  main  purpose  of  the  book. 
But  I  have  not  debarred  myself  from  including  some  dis- 
orders which  cannot  by  any  stretch  of  the  imagination  be 
regarded  as  common ;  for  instance,  infantile  scurvy  and 
congenital  hypertrophy  of  the  pylorus — conditions  which, 
when  they  do  occur,  are  apt  to  be  mistaken  for  much  more 
common  disorders. 

Throughout  I  have  had  in  view  chiefly  the  practical  and 
clinical  aspects  of  disease,  particularly  diagnosis  and 
treatment ;  but  where  pathology  or  morbid  anatomy  had 
a  direct  bearing  upon  any  practical  point  I  have  not  hesi- 
tated to  consider  it  in  detail. 

Coming  fresh  to  the  perusal  of  my  work  at  its  finish,  I  am 
only  too  conscious  of  its  many  faults  and  failings.  For  one 
thing  I  notice  a  monotonous  repetition  of  such  phrases 
as  '  I  think  ',  and  '  in  my  experience '  ;  these,  on  considera- 
tion, I  have  left  unaltered,  for  they  may  serve  to  remind 
the  reader  that  the  views  expressed  are  for  the  most  part 
personal  opinions  based  on  personal  experience,  and  although, 
as  Oliver  Wendell  Holmes  remarks,  'a  man's  opinions  are 
generally  worth  more  than  his  arguments  ',  yet,  in  things 
scientific,  opinions  are  only  to  be  accepted  in  so  far  as  they 
are  found  to  tally  with  the  observations,  not  of  one  man, 
but  of  many. 

For  the  cases  and  statistics  which  I  have  recorded 
wherever  they  seemed  to  emphasize  or  illustrate  points  of 
practical  importance  I  need  make  no  excuse.  In  medicine, 
every  addition  to  the  sum  of  observed  facts,  though  it  be 
but  a  drop  in  the  ocean  of  clinical  experience,  has  a  value 
of  its  own ;  and  for  this  reason  I  have  endeavoured  as  far 
as  possible  to  compile  figures  and  observations  from  my 
own  case-books  rather  than  to  borrow  from  other  writers. 


PREFACE  TO  THE  FIRST  EDITION  xiii 

But  if  my  direct  debt  to  others  can  be  measured,  it  is 
impossible  to  estimate  what  I  owe  indirectly  to  the  writings 
of  far  better  observers  than  myself  ;  there  is  scarcely 
a  writer  on  diseases  of  childhood  in  Great  Britain,  America, 
or  elsewhere  from  whom  I  have  not  at  some  time  drawn 
valuable  aid  in  the  study  of  disease  in  children. 

Whatever  I  have  consciously  borrowed  I  have  tried  to 
acknowledge  in  the  text ;  but,  as  I  have  already  implied,  the 
source  from  which  I  have  chiefly  drawn  has  been  my  own 
clinical  records,  and  if  I  have  made  no  reference  to  this  or 
that  writer's  work  it  is  not  for  lack  of  appreciation,  but 
because  it  would  have  been  inconsistent  with  the  purpose 
of  this  book  to  make  it  a  resume  of  other  people's  observa- 
tions. 

To  the  Editors  of  the  Lancet,  British  Medical  Journal, 
Practitioner,  and  ClinicalJournal,  I  owe  thanks  for  permission 
to  make  use  of  articles  or  lectures  which  I  had  contributed 
to  their  pages,  and  which  I  have  now  used  in  their  original 
or  in  modified  form.  My  indebtedness  for  some  of  the 
illustrations  is  acknowledged  in  the  text :  others  are  inserted 
by  the  kind  permission  of  the  Lancet,  of  Dr.  L.  E.  Creasy 
and  of  Messrs.  Power  and  Murphy. 

In  conclusion,  I  must  thank  the  Publishers  and  Printers 
for  much  care  and  patience  in  the  production  of  this  book, 
and  also  Mr.  J.  K.  Murphy,  F.R.C.S.,  for  kindly  advice  on 
several  points.  To  my  sister,  Miss  A.  Still,  I  am  indebted 
for  invaluable  assistance  in  the  preparation  of  charts,  the 
compilation  of  the  index,  and  other  laborious  details  of 
publication. 

G.  F.  STILL. 

HA.RLEY  STREET,  W. 


CONTENTS 

CHAPTER  PAGE 

I.  MEDICAL   ASPECTS    OF   GROWTH   AND   DEVELOP- 
MENT IN  CHILDHOOD       .....         1 
II.  BREAST-FEEDING  AND  ITS  LIMITATIONS         .         .       17 

III.  THE  MODIFICATION  OF  Cow's  MILK  FOR  INFANT- 

FEEDING       .......       30 

IV.  CURD-INDIGESTION    ......       52 

V.  ON  THE  USE  AND  ABUSE  OF  CONDENSED  MILK 

AND  PATENT  FOODS       .         .         .         .         .62 

VI.  COMMON    FAULTS    AND    FALLACIES    IN    INFANT- 
FEEDING       .         .         .         .         .  .76 

VII.  RICKETS  ...  ....       84 

VIII.  INFANTILE  SCURVY    .         .         .         .         .         .108 

IX.  FLATULENCE  AND  COLIC  IN  INFANCY   .         .         .123 
X.  INFANTILE  MARASMUS        .         .         .         .         .132 

XI.  HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS         .     151 
XII.  ABDOMINAL   PAINS   IN   CHILDREN    BEYOND   THE 

AGE  OF  INFANCY  .         .         .         .         .         .168 

XIII.  INDIGESTION   IN    CHILDREN    PAST   THE    AGE    OF 

INFANCY       .......     176 

XIV.  THE    MEDICAL   ASPECT    OF   DENTAL   CARIES   IN 

CHILDHOOD  .         .         .         .         .         .193 

XV.  CONSTIPATION  IN  INFANCY  AND  CHILDHOOD  .     201 

XVI.  INFANTILE  DIARRHCEA         .....     215 

XVII.    ON  SO-CALLED  CCELIAC  DISEASE  .  .  .       236 

XVIII.  BILIOUS  ATTACKS,  so  CALLED,  IN  CHILDREN          .  247 
XIX.  FEVER  OF  OBSCURE  CAUSATION  ....  260 
XX.  INTESTINAL  WORMS  .         .         .         „         .         .286 
XXI.  JAUNDICE  IN  CHILDREN      ,  300 
XXII.  ENLARGED  TONSILS  AND  ADENOIDS     .         .         .  314 
XXIII.  LARYNGITIS    STRIDULOSA,    AND    OTHER    AFFEC- 
TIONS KNOWN  AS  '  CROUP  '     ,  326 


xvi  CONTENTS 

CHAPTER 

XXIV.  ASTHMA  IN  INFANCY  AND  CHILDHOOD     .         .  342 

XXV.  BRONCHITIS          ......  353 

XXVI.  BRONCHO-PNEUMONIA  .....  363 

XXVII.  PNEUMONIA 370 

XXVIII.  EMPYEMA    .                                      ...  383 

XXIX.  TUBERCULOSIS 396 

XXX.  ABDOMINAL  TUBERCULOSIS  IN  CHILDREN          .  423 

XXXI.  ON  TUBERCULOUS  GLANDS  IN  THE  NECK          .  441 

XXXII.  TUBERCULOUS  MENINGITIS     ....  453 

XXXIII.  RHEUMATISM 469 

XXXIV.  HEART  DISEASE  IN  CHILDREN  :   ENDOCARDITIS  486 
XXXV.  RHEUMATIC  PERICARDITIS  IN  CHILDREN           .  504 

XXXVI.  CHOREA 514 

XXXVII.  CONGENITAL  HEART  DISEASE          .          .          .  533 

XXXVIII.  NEPHRITIS  IN  CHILDREN        ....  549 

XXXIX.  SOME  URINARY  DISORDERS  IN  CHILDHOOD       .  562 

XL.  PYELITIS  IN  INFANCY  AND  CHILDHOOD    .         .  568 

XLI.  MENTALLY  DEFICIENT  CHILDREN    .         .         .  583 

XLII.  MONGOLIAN  IMBECILITY         .         .         .          .611 

XLIII.  NERVOUS  CHILDREN      .  622 

XLIV.  HABIT-SPASM 634 

XLV.  CONVULSIVE  DISORDERS  IN  INFANCY       .          .  648 

XLVI.  EPILEPSY  IN  INFANCY  AND  CHILDHOOD             .  668 

XL VII.  INFANTILE  PARALYSIS  .....  684 

XLVIII.  THE  CEREBRAL  PALSIES  OF  CHILDHOOD  .         .  701 

XLIX.  HYDROCEPHALUS  .         .         .         .         .712 

L.  ENURESIS  AND  FAECAL  INCONTINENCE     .         .  726 

LI.  DISORDERS  OF  SPEECH           ....  740 

LII.  SLEEPLESSNESS,  Loss  OF  APPETITE,  AND  SOME 

OTHER  SYMPTOMS      .....  755 

LIU.  HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY  764 

LIV.  ON  CERTAIN  MORBID  HABITS  IN  CHILDREN      ,  775 

LV.  CONGENITAL  SYPHILIS  .  792 

INDEX  821 


CHAPTER  I 

MEDICAL    ASPECTS    OP    GROWTH    AND    DEVELOP- 
MENT IN   CHILDHOOD 

INFANCY  and  childhood  differ  from  all  other  periods  of  life 
in  being  pre-eminently  the  time  of  rapid  development  both 
physical  and  mental.  It  is  this  peculiarity  which  gives  to  many 
of  the  diseases  of  childhood  special  characters  so  that  both  in 
their  clinical  course  and  in  their  morbid  anatomy  they  differ 
from  disease  in  later  life.  Delay  in  the  acquirement  of  functions 
and  perversions  of  development,  for  instance  of  the  bones  in 
rickets,  constitute  no  unimportant  part  of  the  morbid  mani- 
festations in  early  life.  For  the  recognition  of  departures  from 
the  normal,  it  is  necessary  to  know  what  constitutes  normal 
physical  and  mental  development :  the  medical  man,  especially, 
who  is  frequently  confronted  with  parents  anxious  to  know 
whether  their  child  is  up  to  the  normal  standard  in  this  respect 
or  that,  must  needs  have  some  knowledge  of  the  facts  and  figures 
of  development  in  infancy  and  childhood  ;  he  must  be  familiar 
with  the  normal  course  of  events,  as  well  as  with  the  variations 
which  occur  as  the  result  of  ill  health.  No  man  can  carry  in  his 
memory  all  the  weights  and  measures,  dates  and  numbers  which 
might  be  or  have  been  compiled  in  connexion  with  this  subject  of 
growth  and  development  ;  but  it  is  possible  with  very  little  effort 
to  carry  in  the  mind  a  sufficient  outline  of  statistics,  to  enable  us 
to  fill  in  the  particular  figure  for  any  intervening  age  with  suffi- 
cient accuracy  for  practical  purposes.  I  shall  not  attempt  to 
reproduce  here  any  exhaustive  tables,  but  only  to  give  such  facts 
and  figures  as  can  be  stored  in  the  memory  and  so  kept  readily 
available  for  use. 

Let  it  be  remembered  that  Nature  is  no  stickler  for  uniformity  : 
we  say  that  the  first  tooth  should  appear  at  six  months,  but  one 
infant  will  have  it  at  four  months,  another  will  not  have  it  till 
nine  months,  but  both  may  be  perfectly  healthy  ;  and  so  with 
the  weight,  how  much  unnecessary  anxiety  there  often  is  because 

STILL 


2  COMMON  DISORDERS  OF  CHILDHOOD 

an  infant  weighs  a  pound — nay,  even  a  few  ounces — less  than 
the  tabulated  weight  for  the  age  !  a  figure  which  has  been 
obtained  merely  by  average  from  widely  differing  weights. 
Similarly  in  mental  development,  there  is  a  certain  range  of 
variation  which  is  consistent  with  mental  health  ;  one  child  will 
say  several  words  at  twelve  months,  another  who  proves  sub- 
sequently to  be  equally  intelligent  will  say  nothing  until  he  is 
nearly  eighteen  months  old.  Let  it  be  recognized  that  our 
standards  of  development  represent  averages  only,  and  that 
there  is  a  variation  which  belongs  to  health  as  well  as  one  which 
belongs  to  ill  health. 

Weight.  There  is  no  more  delicate  index  of  the  health  of  an 
infant  than  the  progress  of  the  weight,  which  should  be  recorded 
weekly  until  the  end  of  the  first  year,  and  once  a  month  during 
the  second  year.  Such  a  record  is  often  of  great  value  when 
illness  occurs  and  particularly  if  there  is  any  digestive  disorder. 
A  history  of  the  different  modes  of  feeding  which  have  been 
tried  tells  us  very  little  when  we  have  no  other  information  beyond 
vague  statements  that  this  or  that  food  did  not  agree,  but  when 
there  is  in  addition  a  definite  record  of  the  weight  from  week  to 
week,  a  comparison  of  this  with  the  dates  of  changes  in  feeding 
often  gives  important  guidance. 

There  are  times  when  weighing  more  often  may  be  necessary  ; 
in  severe  cases  of  marasmus,  where  success  in  treatment  depends 
upon  frequent  adjustment  of  the  feeding  to  the  capacity  of  the 
infant,  it  may  be  advisable  to  weigh  twice  a  week  or  even  on 
alternate  days  :  if  a  whole  week  is  allowed  to  elapse  before  the 
effect  of  the  feeding  is  determined  by  the  infant's  weight 
several  ounces  may  be  lost  in  the  meantime  for  lack  of  some 
needful  change  in  feeding,  and  every  ounce  lost  may  seriously 
diminish  the  infant's  chance  of  recovery. 

But  in  health,  there  is  no  need  to  weigh  more  than  once  a  week, 
and  indeed  more  frequent  weighing  gives  rise  to  frequent  and 
groundless  alarm,  for  the  irregularities  which  are  normally  present 
in  the  weekly  rate  of  progress  are  still  more  in  evidence  when  the 
infant  is  weighed  at  shorter  interval?,  and  it  is  difficult  for 
parents  to  realize  that  Nature's  line  of  progress  in  an  infant's 
weight  is  not  the  regular  curve  which  is  misleadingly  drawn  on 
some  weight-charts  as  the  normal  line,  but  is  often  rather  a  zig- 
zag than  a  curve.  No  infant  gains  the  same  amount  every  week, 
sometimes  it  is  less,  sometimes  more,  and  not  very  rarely  in 
health  there  is  little  or  even  no  gain  one  week  and  perhaps 
a  larger  gain  than  usual  the  following  week. 


GROWTH  AND  DEVELOPMENT  3 

With  these  cautions,  the  following  data  make  a  useful  method 
of  carrying  in  one's  mind  the  average  weight  in  health  : 

Birth 71b. 

At  5  months       .         .         .  14  Ib. 

At  12  months     .         .         .         .     21  Ib. 

At  2  years          .         .         .         .     28  Ib. 

At  7  years  .         .         .         .     49  Ib. 

The  weight,  as  will  be  seen,  is  doubled  at  five  months,  trebled 
at  twelve  months,  quadrupled  at  two  years  ;  all  these  weights 
may  be  remembered  as  multiples  of  seven. 

A  child  should  gain  about  4  Ib.  a  year  between  the  end  of  the 
second  year  and  the  age  of  seven  years  ;  and  6  Ib.  a  year  from 
the  age  of  seven  years  to  the  age  of  thirteen  years. 

During  infancy  the  progress  of  the  weight  is  arrested  by  the 
most  trivial  disturbance  of  health,  a  little  bronchial  catarrh, 
even  a  simple  coryza,  is  cause  enough,  and  constipation,  especially 
chronic  constipation,  is  a  common  cause  of  failure  to  gain  weight. 
The  effect  of  dentition  also  is  very  striking  ;  often  the  weight 
ceases  to  rise  or  rises  very  little  so  long  as  a  coming  tooth  is 
worrying  the  child,  whereas  directly  the  tooth  is  cut  the  weight 
begins  to  rise  more  rapidly  again.  In  part,  no  doubt,  this  is  due 
to  the  loss  of  appetite  which  so  often  accompanies  difficult  denti- 
tion, but  I  think  not  entirely,  for  the  arrest  of  weight  occurs 
sometimes  where  the  infant  continues  to  take  food  well,  and  it 
seems  possible  that  it  may  be  due  in  part  to  some  influence  on 
the  nervous  control  of  metabolism.  Whatever  the  explanation 
may  be,  the  effect  of  such  slight  causes  on  the  weight  is  worth 
remembering,  for  the  feeding  is  often  changed  quite  unnecessarily 
and  unwisely,  where  the  fault  lies  not  in  the  food  but  in  some 
merely  transient  disturbance  such  as  I  have  mentioned. 

Length.  The  length  of  the  new-born  infant  is  1 9  inches ;  at  one 
year  it  is  27  inches  :  and  during  each  subsequent  year  up  to 
five  years  of  age  there  is  a  gain  of  3J  inches  ;  and  each  sub- 
sequent year  a  gain  of  2  inches  up  to  the  age  of  fifteen  years, 
when  growth  becomes  much  less  rapid. 

Size  of  head.  The  measurement  of  the  head  is  of  importance 
chiefly  in  connexion  with  mental  deficiency  and  where  the  possi- 
bility of  hydrocephalus  is  in  question. 

The  most  useful  measurement  is  the  circumference  ;  this  is 
often  taken  through  fixed  points  such  as  the  frontal  eminence 
and  the  occipital  protuberance,  but  such  points  are  difficult  to 
locate  exactly  so  as  to  be  sure  that  any  subsequent  measurement 
is  taken  through  precisely  the  same  points  ;  it  is  therefore  better 
to  take  the  largest  circumference  which  can  be  obtained. 

B  2 


4  COMMON  DISORDERS  OF  CHILDHOOD 

The  maximum  circumference  at  various  ages  is,  according  to 
my  own  observations  : 

Birth     .  .  .  .  .13  inches. 

3  months  .  .  .  .15  inches. 

5  months  .  .  .  .16  inches. 

9  months  .  .  .  .17  inches. 

12  months  .  .  .  .18  inches. 

3  years  .  .  .  .  .19  inches. 

7  years  .  .  .  .  .20  inches. 

13  years  .  -  .  .21  inches. 

In  the  mentally  defective  the  head  is  usually  below  the  average 
in  size.  In  a  series  of  one  hundred  children  of  feeble  intellect 
the  head  showed  a  circumference  decidedly  below  the  average  in 
60  per  cent.,  while  in  6  per  cent,  the  circumference  was  consider- 
ably above  the  average.  Apart  from  the  few  forms  of  mental 
defect  which  are  regularly  associated  with  abnormally  large  size 
of  the  head  (cretinism,  hydrocephalic  idiocy,  and  the  so-called 
hypertrophy  of  the  brain),  an  unusually  large  circumference  is 
met  with  in  rickets,  achondroplasia,  and  hydroccphalus. 

Fontanelles.  The  anterior  fontanelle  varies  greatly  in  size  at 
birth  ;  in  some  infants  it  measures  scarcely  half  an  inch  in 
either  direction,  in  others  it  measures  about  two  and  a  half 
inches  laterally  and  fully  three  inches  antero-posteriorly.  In 
some  infants,  again,  it  diminishes  steadily  in  size  from  the  time 
of  birth  ;  in  others,  and  probably  in  the  majority,  it  enlarges 
until  about  the  age  of  nine  months  and  then  gradually 
diminishes.  At  one  year  it  should  measure  not  more  than  one 
inch  in  either  direction.  It  should  close  about  the  age  of  eighteen 
months ;  but  in  this  also  there  is  considerable  variation,  I  have 
found  the  fontanelle  completely  closed  in  a  healthy  infant  at 
thirteen  months,  I  have  also  observed  it  to  be  open  at  two  and 
a  half  years  without  any  evidence  of  disease. 

The  commonest  cause  of  delay  in  closure  is  rickets,  in  which 
the  fontanelle  is  often  open  as  late  as  two  and  a  half  or  three 
years :  I  have  seen  it  open  as  late  as  four  and  a  half  years  in 
this  disease.  There  are  other  causes  :  the  fontanelle  may  be 
kept  open  by  the  tension  of  hydrocephalus  :  in  the  Mongol  type 
of  imbecility  there  is  often  considerable  delay  in  closure,  I  have 
known  the  fontanelle  to  be  open  in  these  children  as  late  as  six 
years  of  age.  There  are  also  infants  in  whom,  without  any 
evidence  of  disease,  the  ossification  of  the  skull  is  unusually 
slow,  so  that  not  only  does  the  anterior  fontanelle  remain  open 
unusually  late,  but  sometimes  the  parietal  bones  remain  un- 
united  at  their  upper  borders,  and  the  posterior  fontanelle, 


GROWTH  AND  DEVELOPMENT  5 

which  is  usually  closed  within  six  weeks  after  birth,  remains 
open  for  three  or  four  months,  and  sometimes  the  lateral 
fontanelles,  anterior  and  posterior,  which  should  be  closed  or 
almost  closed  at  birth,  are  open  for  several  weeks.  In  these 
cases  there  is  often  some  diffuse  yielding  on  pressure  near  the 
edges  of  the  parietal  and  occipital  bones,  but  such  a  condition 
is  not  to  be  confused  with  cranio tabes,  which,  as  its  name 
implies,  is  an  acquired  condition,  a  loss  of  already  formed  bone, 
whereas  the  diffuse  yielding  to  which  I  refer  is  due  only  to 
delay  in  the  formation  of  bone. 

Dentition 

The  cutting  of  the  milk-teeth  begins  with  the  appearance 
of  the  lower  central  incisors,  which  takes  place  usually  between 
the  ages  of  six  and  eight  months.  But  there  is  considerable 
variation  in  this :  some  healthy  infants  show  their  first 
tooth  at  four  or  five  months,  whilst  others,  apparently  equally 
healthy,  show  no  teeth  till  nine  or  ten  months,  occasionally 
even  until  twelve  or  thirteen  months  old.  Both  unusually  early 
and  unusually  late  dentition  seem  to  be  a  family  trait  in  some 
cases  ;  in  one  family  under  my  observation  one  boy  showed  the 
first  lower  incisor  at  fourteen  days,  and  his  second  at  twenty-one 
days  old  ;  his  brother  was  born  with  one  lower  incisor  :  in  another 
family  one  girl  had  two  lower  incisors  at  six  weeks  old,  her  sister 
had  her  first  tooth  at  four  months. 

Such  unusually  early  commencement  of  dentition  unfortu- 
nately does  not  mean  an  unusually  early  completion  of  dentition  ; 
there  is  often  a  long  interval  between  the  earliest  eruption  and 
the  next  tooth  ;  for  instance,  the  child  already  mentioned  who 
had  her  two  lower  incisors  at  six  weeks,  had  no  more  by  the  time 
she  was  seven  months  old.  The  presence  of  teeth  at  birth  is 
seldom  followed  by  the  cutting  of  other  teeth  before  the  usual 
time  ;  these  congenital  teeth  also  are  apt  to  be  small  and  ill- 
placed  in  the  gum  ;  this,  however,  is  not  always  so  ;  I  have 
known  them  to  be  as  good  as  those  acquired  at  the  usual  time. 

Whilst  the  effect  of  rickets  is  to  delay  dentition,  syphilis,  unless 
complicated  by  rickets,  as  it  often  is,  seems  not  to  interfere 
with  the  eruption  of  teeth,  indeed  it  has  been  thought  rather  to 
conduce  to  early  dentition ;  this,  however,  I  cannot  affirm  from 
my  own  observations. 

The  date  of  appearance  of  the  individual  milk-teeth  varies 
greatly.  At  twelve  months  eight  teeth  should  be  present,  and 
the  twenty  teeth  should  have  been  cut  by  the  end  of  the  second 


6  COMMON  DISORDERS  OF  CHILDHOOD 

year.  But  the  intervals  between  the  cutting  of  teeth  are  most 
irregular  :  teeth  may  be  cut  in  quick  succession  for  a  time  and 
then  a  long  pause  may  occur  ;  for  example,  Rose  H.  cut  two 
teeth  at  the  age  of  four  months,  and  at  twelve  months  she  had 
twelve  teeth,  but  during  the  next  eight  months,  without  any 
apparent  cause,  no  more  teeth  appeared.  In  other  cases  where 
dentition  appears  to  have  proceeded  very  slowly  for  several 
months  it  is  completed  with  unexpected  rapidity  by  the  appear- 
ance of  several  of  the  later  teeth  in  quick  succession. 

The  order  of  eruption  is  more  constant,  and  is  as  follows  : 

Lower  central  incisors. 

Upper  central  incisors. 

Upper  lateral  incisors. 

Lower  lateral  incisors. 

First  upper  and  lower  molars. 

Canines. 

Second  upper  and  lower  molars. 

Irregularity  in  the  order  of  dentition  is,  however,  not  very  rare 
in  healthy  infants.  In  some  forms  of  mental  deficiency  depen- 
dent on  developmental  faults  in  the  brain,  abnormalities  both 
in  the  time  and  in  the  order  of  dentition  are  particularly  frequent  : 
in  Mongolian  imbecility,  for  instance,  there  is  often  no  eruption 
of  teeth  until  some  time  in  the  second  year,  and  the  first  to  appear 
is  very  commonly  a  molar  :  a  Mongol  child,  Eva  C.,  at  the  age 
of  twenty-one  months,  had  only  two  teeth,  and  these  were  molars  ; 
at  the  age  of  two  years  and  eleven  months  six  molars  had  appeared 
and  had  been  followed  by  two  lower  central  incisors  ;  a  micro- 
cephalic  idiot  who  showed  her  first  tooth  at  seventeen  months 
had  only  ten  at  twenty-two  months,  which  had  appeared  in  this 
order  :  two  upper  central  incisors,  one  lower  lateral  incisor,  four 
molars,  one  upper  lateral  incisor,  two  lower  central  incisors. 

Disorders  associated  with  dentition.  Teething  as  an  ex- 
planation of  symptoms  is  too  often  a  cloak  for  ignorance,  but 
I  would  protest  against  the  tendency  nowadays  to  assume  that 
because  dentition  is  a  physiological  process  therefore  it  is 
incapable  of  causing  disturbance  of  health:  pregnancy  is  a 
physiological  process,  but  I  suppose  no  one  would  deny  that 
pregnancy  may  disturb  the  health  in  many  ways.  It  has  been 
said  that  teething  produces  nothing  but  teeth.  I  venture  to 
think  that  there  is  more  wit  than  truth  in  this  :  and,  at  the 
risk  of  being  considered  old-fashioned  and  unscientific,  I  shall 
mention  some  of  the  disorders  to  which  in  my  opinion  teething 
may  give  rise.  I  admit  the  difficulty  of  proof  ;  we  ail  know  that 


GROWTH  AND  DEVELOPMENT  7 

coincidences  are  apt  to  be  mistaken  for  cause  and  effect,  but 
I  am  not  inclined  to  disregard  the  accumulated  experience  of 
generations  of  intelligent  parents,  and  still  less  the  observations 
of  skilled  observers,  who  affirm  without  hesitation  that  dentition 
may  cause  certain  disturbances  of  health.  How  it  causes  these 
disturbances  may  be  doubtful  :  knowing  how  profoundly  nervous 
influence  can  modify  the  functions  of  most  organs  in  the  body, 
I  see  nothing  improbable  in  the  supposition  that  some  of  the 
disorders  produced  by  dentition  may  be  due  to  reflex  nervous 
disturbance ;  and  I  am  the  more  inclined  to  think  so  when  I  see, 
as  I  sometimes  do,  an  infant  who  has  become  '  nervous  ',  with 
occasional  twitching,  rolling  his  eyes  up,  and  giving  a  short  sharp 
cry,  and  clearly  being  on  the  verge  of  convulsions,  whilst  the 
gum  is  swollen  and  tense  over  a  coming  tooth,  whereas  no  sooner 
has  the  tooth  come  through  than  all  these  symptoms  rapidly 
subside.  If  such  excitability  of  the  nervous  system  can  be  pro- 
duced, as  I  think  it  undoubtedly  can,  by  dentition,  I  see  no  reason 
why  the  transient  bronchial  catarrh,  or  the  slight  looseness  of 
the  bowels  which  recurs  in  some  infants  with  the  eruption  of  the 
teeth,  may  not  be  due  to  nervous  influence. 

Certainly  there  is  nothing  more  improbable  in  this  view  than 
in  the  supposition  that  an  infant  who  has  been  sucking  a  '  dummy ' 
or  living  on  a  particular  food  for  weeks  or  months  without  dis- 
turbance of  health,  should  suddenly  develop  symptoms  of  dis- 
order from  these  sources,  coincidently  with  the  eruption  of 
a  tooth,  and  then,  after  losing  these  symptoms  directly  the 
tooth  is  cut,  should  develop  them  again  when  another  tooth  is 
cut,  and  all  this  without  dentition  playing  any  part  in  the  pro- 
duction of  the  symptoms.  I  am  well  aware  that  there  arc  infants 
who  cut  their  teeth  without  the  slightest  disturbance  of  health, 
but  when  I  am  told  that  dentition  cannot  disturb  the  health, 
and  that  even  local  worry  is  never  due  to  teething  but  to  a  septic 
condition  of  the  gum  from  dirty  '  comforters '  or  from  contamina- 
tion by  the  various  aids  to  teething  which  are  in  common  use, 
I 'confess  that  I  am  not  convinced. 

It  is  quite  possible  that  an  inflammation  of  the  gums  may  be 
induced  in  this  way  and  may  make  them  tender,  especially  when 
distended  by  a  coming  tooth  ;  but  as  a  matter  of  observation 
there  is  no  vestige  of  any  such  inflammation  to  be  seen  in  many 
cases  where  it  is  obvious  to  any. one  who  is  familiar  with  baby- 
language  that  there  is  considerable  discomfort  around  the  coming 
tooth.  It  seems  reasonable  to  suppose  that  the  discomfort  may 
be  due,  as  the  appearances  suggest,  to  tension  in  the  gum  ; 
certainly,  unless  the  appearances  wholly  belie  the  facts,  there  is 


8  COMMON  DISORDERS  OF  CHILDHOOD 

often  considerable  tension  before  the  tooth  is  cut,  and  when  one 
considers  that  tension  from  any  cause  is  one  of  the  most  potent 
producers  of  pain  one  may  well  suppose  that  even  slight  tension 
can  cause  discomfort.  I  suspect  that  long  before  the  gum  has 
a  distended  appearance  there  may  be  some  tension  in  the  deeper 
parts  :  I  would  not  even  reject  with  scorn  the  view  put  forward 
by  Mr.  Tomes  that  there  are  two  stages  at  which  a  coming  tooth 
may  cause  irritation  ;  the  first  when  it  is  forcing  its  way  through 
the  bony  ring  at  the  margin  of  the  alveolus,  the  other  when  it 
is  making  its  way  through  the  gum.  I  am  satisfied  from  my 
own  observations  that  dentition  sometimes  begins  to  cause 
definite  and  characteristic  symptoms,  particularly  the  slight 
nervous  excitability  which  I  have  mentioned,  several  weeks 
before  any  teeth  are  cut  and  before  there  is  any  visible  dis- 
tension of  the  gum. 

I  suppose  the  first  indication  of  the  approach  of  dentition  is 
usually  the  increase  of  saliva  :  the  infant  begins  to  drivel. 
Unfortunately  this  is  not  all  in  many  cases.  The  infant 
becomes  fretful,  sleeps  badly,  awaking  often  with  a  cry,  and 
as  a  result  of  disturbed  sleep  soon  comes  to  look  pale  and 
'  out  of  sorts  '.  Not  only  does  he  cram  his  fingers  into  his  mouth 
and  attempt  to  bite  any  object  within  reach,  but  often  he  plucks 
at  his  ears  or  at  the  hair  over  the  temple,  and  beats  his  head 
with  his  fists,  or  bangs  it  against  the  pillow  or  the  side  of  the  cot. 
Head-rolling  also,  the  monotonous  movement  of  the  head  from 
side  to  side  as  the  child  lies  in  its  cot,  is  probably  due  in  some 
cases  solely  to  the  irritation  of  teething  ;  I  say  '  in  some  cases  ' 
because  it  is  important  to  remember  that  both  head-rolling  and 
head-banging  may  be  due  to  the  much  more  serious  irritation 
of  middle-ear  catarrh. 

A  very  common  result  of  the  worry  of  dentition  is  loss  of 
appetite:  sometimes  for  the  few  days  immediately  preceding  the 
eruption  of  a  tooth,  sometimes  for  a  much  longer  period  of  many 
weeks  during  the  dentition  period,  the  infant  will  refuse  some 
feeds  entirely,  and  take  others  only  in  small  quantity,  and  though 
the  appetite  may  improve  when  a  troublesome  tooth  has  been 
cut,  it  soon  fails  again  with  the  worry  of  another  tooth.  This 
loss  of  appetite  during  dentition  would  be  of  no  importance 
were  it  not  for  the  anxiety  which  it  causes  to  parents  ;  it  may 
retard  the  gain  of  weight,  but  otherwise  has  no  ill  effect,  and  the 
medical  man  can  assure  the  parents  that  it  is  a  common  and 
harmless  result  of  teething. 

Failure  to  gain  weight,  or  diminution  in  the  rate  of  gain  is,  as 


GROWTH  AND  DEVELOPMENT  9 

I  have  already  stated,  another  very  common  result  of  dentition  : 
occasionally  even  there  may  be  a  loss  of  an  ounce  or  two  in  the 
week  whilst  a  tooth  is  worrying,  but  it  is  exceptional  for  any 
actual  loss  of  weight  to  occur  ;  as  a  rule  the  effect  is  only  a  reduc- 
tion in  the  rate  of  gain,  so  that  an  infant  who  has  been  gaining 
perhaps  6  to  8  ounces  per  week  gains  only  one  or  two  ounces 
during  a  week  when  the  gum  happens  to  be  tense  and  worried. 
In  this  way  the  progress  of  the  weight  is  apt  to  be  very 
irregular  in  some  infants  during  the  period  of  dentition, 
but  the  rapid  gain  of  weight  in  the  intervals  between  the 
cutting  of  teeth  is  generally  sufficient  to  compensate  for  the 
delay. 

Dentition  alone  seems  to  be  sufficient  cause  for  a  rise  of  tem- 
perature in  some  infants  ;  indeed  it  would  be  strange  if  this  were 
not  so.  A  slight  dyspepsia  or  a  little  constipation  will  certainly 
cause  a  considerable  degree  of  fever  for  a  few  hours  in  some  older 
children,  and  in  nervous  children  an  evening  rise  of  temperature 
to  about  100°  for  many  weeks  may  be  due  to  very  slight  causes, 
dietetic  or  otherwise  :  it  might  be  expected,  therefore,  that 
during  the  first  few  months  of  life,  when  nervous  instability  is 
even  greater  than  in  later  childhood,  the  peripheral  irritation 
which  is  obvious  in  the  hot  tense  gums  and  in  the  fretfulness  of 
the  infant  should  express  itself  sometimes  in  a  rise  of  tempera- 
ture. The  fever  is  sometimes  transient,  reaching  101°  or  102°, 
and  subsiding  after  a  few  hours  ;  sometimes,  and  I  think  more 
rarely,  there  is  an  evening  rise  to  about  1003  for  several  weeks 
during  the  progress  of  dentition. 

Two  disorders  which  are  often  attributed  to  the  influence  of 
teething  are  bronchitis  and  diarrhoea.  How  often  one  hears  the 
tale  that  a  baby  '  cuts  its  teeth  with  the  bronchitis.'  Now 
I  have  no  doubt  that  in  many  cases  the  association  is  merely 
fortuitous  ;  infancy  is  a  time  of  life  which  is  particularly  prone 
to  bronchitis,  as  it  is  also  to  diarrhoea,  and  both  must  therefore 
be  coincident  often  with  dentition.  But  I  think  there  is  more 
than  coincidence  in  some  cases  :  both  bronchitis  and  diarrhoea 
are  clearly  traceable  to  nervous  influences  in  certain  disorders 
of  later  childhood,  the  bronchial  catarrh  of  the  asthmatic  child, 
and  the  lienteric  diarrhoea  to  which  Trousseau  gave  the  name  of 
'  nervous  diarrhoea  '  are  admittedly  dependent  upon  nervous 
influences,  and  sometimes  upon  influences  very  remote  from  the 
organs  affected  ;  the  asthmatic  bronchitis,  for  instance,  may  be 
started  by  too  heavy  a  meal,  or  by  some  particular  smell.  It  is 
at  least  possible,  therefore,  that  the  worry  of  dentition  may,  by 


10  COMMON  DISORDERS  OF  CHILDHOOD 

its  effect  upon  the  nervous  system,  cause  a  transient  diarrhoea 
or  a  bronchial  catarrh.  It  seems  to  me  more  reasonable  to 
admit  some  such  hypothesis  as  this,  than  to  ignore  the  very 
general  experience  both  of  the  laity  and  of  more  competent 
observers  that  some  infants  suffer  with  a  recurrence  of  bronchial 
catarrh,  or  with  looseness  or  green  coloration  of  stools,  whenever 
the  gums  become  swollen,  tense,  and  irritated  by  a  particularly 
troublesome  tooth. 

I  hold  no  special  brief  for  the  nervous  origin  of  the  catarrh  in 
these  cases  :  it  may  be  as  some  have  suggested  that  the  explana- 
tion is  to  be  sought  in  some  disordered  state  of  the  mucous 
membrane  of  the  mouth,  with  alteration  of  saliva  interfering 
with  digestion,  and  that  the  respiratory  mucosa  undergoes 
a  catarrhal  change  by  extension  from  some  catarrhal  condition 
of  the  oral  mucosa,  but  against  such  an  explanation  is  the  fact 
that  the  mucous  membrane  of  the  mouth  in  general,  or  even  of 
the  gums  themselves,  only  exceptionally  shows  any  inflamma- 
tory change  with  dentition.  Catarrhal  stomatitis  is  occasionally 
seen  over  the  gums  as  a  greyish-white  discoloration,  as  if  the 
gum  had  been  rubbed  with  silver  nitrate,  but  this  is  uncommon 
in  my  experience  and  its  appearance  does  not  suggest  that  there 
is  any  sufficient  alteration  in  the  mucosa  or  secretions  to  account 
either  for  diarrhoea  or  bronchitis. 

I  have  repeatedly  seen  children  who  throughout  the  first 
dentition  had  occasional  attacks  of  vomiting  coming  on  without 
apparent  cause,  and  with  little  or  no  disturbance  of  the  bowels, 
and  passing  off  again  after  a  day  or  two.  Each  attack 
occurred  just  as  a  tooth  was  coming  through  the  gum,  and 
the  recurrence  of  this  association  has  been  so  striking  as  to 
leave  no  doubt  whatever  in  rny  mind  that  the  vomiting  was 
excited  by  the  worry  of  dentition. 

Dentition  certainly  exercises  a  very  marked  effect  in  increasing 
the  instability  of  the  nervous  system  :  some  infants  when  much 
worried  by  a  coming  tooth  show  a  tendency  to  convulsive  twitch- 
ing, sometimes  with  upward  rolling  of  the  eyes  or  occasional 
slight  strabismus,  and  although  they  may  never  lose  conscious- 
ness or  fall  into  a  general  convulsion,  they  are  evidently,  so  to 
speak,  on  the  brink  of  such  an  attack.  In  infants  already  pre- 
disposed by  neuropathic  heredity  or  by  rickets  to  ordinary 
infantile  convulsions  or  to  epilepsy,  the  period  of  dentition  is 
undoubtedly  a  time  of  peril.  I  shall  have  occasion  hereafter 
to  consider  the  distinction  between  infantile  convulsions  and 
epilepsy  ;  here  it  need  only  be  said  that  attacks  like  petit  mal 


GROWTH  AND  DEVELOPMENT  11 

are  sometimes  much  aggravated  by  dentition,  and  I  have  known 
them  to  cease  when  the  last  tooth  had  been  cut. 

A  common  effect  of  dentition,  and  a  very  troublesome  one, 
is  sleeplessness  ;  it  does  not  seem  to  be  caused  by  any  pain,  but 
rather  to  be  part  of  the  general  nervous  excitability  of  this 
period  in  some  infants. 

Various  skin  eruptions  are  commonly  attributed  by  parents 
to  teething,  and  if  lichen  urticatus  be  related  to  nervous  influences, 
as  urticaria  certainly  is,  it  seems  conceivable  that  dentition  may 
play  some  part  in  its  production,  as  is  often  supposed  ;  but  I  have 
never  been  able  to  satisfy  myself  that  either  lichen  urticatus  or 
eczema  bore  any  special  relation  other  than  coincidence  to 
teething.  Both  are  particularly  frequent  during  the  teething 
period  ;  lichen  urticatus  is  closely  related  to  digestive  disturb- 
ance, and  may  in  this  way  be  indirectly  connected  with  the 
eruption  of  teeth,  which,  as  I  have  already  mentioned,  is  apt  to 
be  associated  with  disorder  of  the  bowels,  but  both  these  skin 
eruptions  are  common  also  before  and  after  the  dentition  period, 
and  show  on  the  whole  so  little  tendency  to  recurrence  specially 
at  the  times  when  the  teeth  are  appearing,  that  there  does  not 
seem  to  be  sufficient  ground  for  asserting  that  they  are  due  to 
teething. 

A  rare  association  with  dentition  is  violent  screaming  without 
apparent  cause  :  this  is  quite  independent  of  any  digestive 
disorder  and  not  obviously  due  to  any  pain.  It  occurs  in  some 
cases  several  times  in  the  day  and  night,  and  this  continues  with 
remissions  for  many  weeks  during  the  most  troublesome  stages 
of  dentition.  This  screaming  has  seemed  to  me  comparable  to 
the  violent  paroxysms  of  screaming  without  apparent  cause  or 
upon  the  slightest  thwarting  which  occur  occasionally  in  children 
of  markedly  nervous  temperament.  The  paroxysms  in  both 
cases  are  so  violent  and  so  obviously  unnatural  that  medical 
advice  is  sought  ;  unfortunately  the  condition  is  sometimes 
very  intractable  and  is  particularly  distressing,  as  the  screams 
of  the  child  can  be  heard  at  a  considerable  distance,  and  might 
give  neighbours  the  idea  that  the  child  was  being  ill-treated. 

Photophobia  is  another  rare  result  of  the  irritation  of  den- 
tition. It  is  so  pronounced  that  the  child  will  cover  his  eyes 
with  his  hands  or  bury  his  face  in  the  pillow  or  against  his  mother's 
breast,  when  exposed  even  to  the  moderate  light  of  a  sunless 
day.  In  a  brighter  light,  he  will  screw  up  his  eyelids  tightly  like 
a  child  with  a  corneal  ulcer,  but  examination  shows  that  there 
is  nothing  abnormal  in  the  eyes  or  eyelids,  though  in  some  of 
these  cases  the  eyes  will  '  water  '  when  exposed  to  light.  In  one 


12  COMMON  DISORDERS  OF  CHILDHOOD 

child,  aged  fifteen  months,  the  photophobia  persisted  for  nine 
weeks  ;  in  another,  aged  ten  months,  it  began  six  days  before  the 
eruption  of  the  first  tooth,  and  lasted  at  least  four  months.  In 
some  cases  the  photophobia  is  so  extreme  that  the  child  cries  or 
even  screams  violently  as  if  in  pain  when  exposed  to  any  bright 
light,  or  even  to  ordinary  daylight. 

I  have  seen  cases  in  which,  during  the  eruption  of  a  tooth, 
meningitis  has  been  simulated  by  head  retraction,  which  passed 
off  soon  and  which  seemed  to  be  due  entirely  to  some  reflex  irrita- 
tion from  the  teeth.  Increased  tension  in  the  middle  ear 
sometimes  produces  head  retraction  in  infancy,  as  has  been 
proved  by  the  rapid  disappearance  of  head  retraction  after 
puncture  of  the  mcmbrana  tympani  ;  and  therefore  it  seems 
only  natural  that  the  irritation  of  a  tense  gum  might  have  a  similar 
effect.  Of  course  it  is  possible  that  in  such  cases  there  is  actually 
some  middle  ear  catarrh,  to  which  the  head  retraction  is  due 
rather  than  to  any  irritation  of  the  gums,  but  if  so  there  has  been 
nothing  else  to  suggest  ear-irritation  in  the  cases  to  which  I  refer. 

Parents  very  commonly  attribute  discharge  from  the  ear  to 
the  influence  of  dentition,  but  although  the  two  are  often  co- 
incident I  know  of  no  special  tendency  of  otorrhcea  to  recur  with 
recurring  stress  of  teething,  nor  of  any  reason  for  supposing  that 
there  is  any  causal  connexion  :  but  if  the  bronchial  catarrh 
which  occurs  with  dentition  spreads  by  extension  from  the  oral 
mucosa,  there  may  be  some  catarrhal  condition  of  the  pharynx 
and  naso-pharynx  also  which  would  account  for  the  otitis 
media. 

A  rare  disorder  which  is  closely  related  to  dentition  is  spasmus 
nutans  or  head-nodding  with  nystagmus.  This  disorder  is  so 
distinctly  coincident  with  dentition  in  its  onset  and  cessation, 
and  is  so  definitely  aggravated  by  the  eruption  of  a  fresh  tooth, 
that  I  am  disposed  to  share  Henoch's  view  that  there  is  a  causal 
relation. 

With  regard  to  all  these  dentition  disorders  it  is  clear  that  the 
causal  relation  of  dentition  to  the  disorder  is  an  assumption 
resting  upon  no  more  solid  basis  than  the  observation  of  many 
cases  in  which  the  occurrence  of  the  disorder  has  not  only 
coincided  with  the  period  of  dentition  but  has  shown  a  special 
tendency  to  coincide  repeatedly  with  times  of  special  irritation 
when  a  tooth  was  nearing  eruption.  This,  however,  seems  to  me 
a  reasonable  and  warrantable  assumption  in  many  instances, 
and  with  increasing  experience  I  am  inclined  rather  to  enlarge 
than  to  restrict  my  own  conception  of  the  role  of  dentition  in 
producing  disturbance  of  various  kinds  in  infancy.  At  the  same 


GROWTH  AND  DEVELOPMENT  13 

time  one  cannot  fail  to  recognize  the  danger  of  attributing  too 
readily  to  dentition  disorders  which  may  really  have  some 
entirely  different  origin  and  which  are  apt  to  be  lightly  esteemed 
when  they  are  considered  as  '  only  due  to  teething  '  :  many 
a  case  of  diarrhoea,  dependent  upon  faulty  feeding,  or  of  otitis 
media  due  to  some  remediable  condition  of  the  naso-pharynx,  is 
neglected  with  disastrous  result  because  it  happens  to  occur 
during  the  teething  period  and  is  regarded  as  a  harmless  pheno- 
menon incidental  to  the  process  of  dentition. 

The  second  dentition  occurs  at  a  much  less  perilous  age  than 
the  first  :  the  extreme  nervous  instability  of  infancy  has  passed 
away  and  there  is  not  the  special  liability  to  catarrh  of  mucous 
membranes  which  is  so  striking  a  feature  in  the  first  two  years  of 
life  ;  moreover,  most  of  the  second  teeth  are  not  obliged  to  force 
their  way  through  unbroken  gums  as  must  the  milk  teeth.  And 
here  I  would  point  out  to  those  who  assert  that  the  first  dentition 
is  a  natural  process  and  therefore  cannot  be  a  painful  process 
or  produce  any  irritation  sufficient  to  cause  symptoms,  that  the 
eruption  of  the  wisdom  teeth,  which  does  involve  the  cutting 
of  a  way  through  the  unbroken  gum,  and  which  occurs  at  an 
age  (eighteenth  to  twenty-fifth  year)  when  subjective  symptoms 
can  be  accurately  described  by  the  sufferer,  produces  not  merely 
local  discomfort  but  neuralgic  pain  and  also  high  temperature  in 
some  cases. 

The  order  of  the  second  dentition  is  subject  to  much  variation  : 
it  begins  usually  with  the  appearance  of  the  first  molars  or  the 
central  incisors  at  the  age  of  six  years,  the  sequence  being 
commonly  thus  : 

Permanent  teeth.  Date  of  eruption. 

First  molars  ('  Six-year-old  molars ')  .         .6  years 

Central  incisors      .......       7 

Lateral  incisors      .......       8 

First  bicuspid         .......       9 

Second  bicuspid     .         .         .         .         .         .         .10 

Canine .11 

Second  molars  ('  Twelve-year-old  molars  ')    .         .     12 
Wisdom-teeth. 

In  the  large  majority  of  children  the  second  dentition  is  an 
entirely  uneventful  process,  scarcely  attracting  the  notice  of 
the  children  or  its  parents  ;  but  there  are  children,  particularly 
those  of  unusually  nervous  temperament,  in  whom  it  does,  I  think, 
occasionally  produce  some  disturbance.  I  have  known  children 


14  COMMON  DISORDERS  OF  CHILDHOOD 

to  become  fretful  and  grind  their  teeth  at  night  when  the  second 
dentition  was  just  beginning  and,  after  the  tooth  which  was 
apparently  causing  worry  had  come  through,  these  symptoms 
passed  off.  Two  of  the  common  nervous  disorders  of  childhood, 
habit  spasm  and  acquired  enuresis — acquired,  I  mean,  as  distinct 
from  the  enuresis  which  is  a  persistence  of  the  infantile  condition 

have  their  onset  most  frequently  between  the  fifth  and  the 

eighth  year,  the  time  when  the  second  dentition  is  commencing  : 
it  seems  possible  that  their  occurrence  at  this  time  is  due  at  least 
in  part  to  increased  nervous  instability  produced  by  the  second 
dentition. 

Mental  Development 

The  mental  development  of  the  child  is  subject  to  even  greater 
variation  than  the  physical  growth.  Immediately  after  birth  the 
healthy  infant  shows  evidence  of  ordinary  tactile  and  tempera- 
ture sensation,  and  taste  is  certainly  present  within  the  first 
twelve  hours  :  an  infant,  aged  ten  hours,  made  a  grimace  of 
displeasure  and  then  refused  altogether  to  suck  when  I  placed 
a  camel-hair  brush  moistened  with  a  solution  of  quinine  between 
its  lips,  whereas,  immediately  after,  when  I  tried  it  similarly  with 
the  same  brush  moistened  with  a  solution  of  sugar,  the  infant 
sucked  vigorously  and  smacked  his  lips  with  evident  satisfaction. 

Sight  is  present  within  a  few  hours  after  birth,  at  any  rate 
a  bright  light  causes  blinking  just  before  the  infant  is  twenty- 
four  hours  old  ;  this  of  course  may  mean  nothing  more  than  the 
power  of  distinguishing  light  from  darkness  ;  it  is  very  difficult 
to  ascertain  at  what  age  objects  are  first  distinguished. 

At  four  weeks  a  healthy  infant  follows  objects  with  his  eyes,  but 
with  very  little  constancy,  and  even  at  four  months  I  have  found 
that  some  healthy  infants  will  take  no  notice  whatever  of  a  piece 
of  white  paper  about  three  inches  square  passed  in  front  of  their 
eyes  at  a  distance  of  about  three  inches.  This  is  noteworthy  in 
connexion  with  the  examination  of  infants  for  supposed  blind- 
ness or  mental  deficiency.  I  have  sometimes  seen  the  sight  tested 
by  threatening  the  eye  suddenly  with  the  finger-tip,  but  up  to 
the  age  of  six  months  many  perfectly  healthy  infants  take  no 
notice  whatever  of  this  movement,  and  the  sudden  closure  of  the 
eyes,  which  is  expected  to  result  from  it,  was  very  inconstant 
even  at  the  age  of  eight  months.  A  bright  metal  object  or  a 
moderately  bright  light  is  more  reliable  as  a  test  for  the  sight  ; 
often  the  feeding-bottle  is  still  better,  for  the  infant's  eagerness 
on  seeing  it  leaves  no  doubt  as  to  the  sight. 


GROWTH  AND  DEVELOPMENT  15 

Hearing  is  usually  stated  to  be  absent  during  the  first  two  or 
three  days,  but  I  doubt  if  this  is  so.  An  infant,  aged  ten  hours, 
showed  no  sign  whatever  of  hearing  the  loud  noise  of  beating 
a  tin  tray  ;  but  another,  aged  twenty  hours,  showed  some  facial 
contraction  suggesting  that  a  sudden  shrill  whistle  was  heard, 
and  more  clear  evidence  of  hearing  was  obtained  on  the  second 
day.  By  the  age  of  four  weeks  the  infant  appreciates  sound 
sufficiently  to  be  easily  disturbed  by  noise.  At  four  months  old 
there  should  be  no  difficulty  in  attracting  the  attention  by  noises. 

The  question  of  deafness  is  one  which  often  arises  in  cases  of 
delayed  development  of  speech.  Parents'  statements  as  to  their 
child's  hearing  are  apt  to  be  misleading  :  a  mother  will  speak  to 
her  child  who  is  sitting  on  her  lap,  to  try  whether  he  hears  : 
she  forgets  that  the  vibration  of  her  chest  and  even  her  breath 
when  she  speaks  are  readily  felt  by  the  child,  and  concludes  that 
the  attraction  of  the  child's  attention  is  evidence  of  hearing  :  or, 
again,  in  asking  the  child  some  simple  question,  such  as  '  Where 
is  Daddy  ?  ',  she  unconsciously  attracts  the  child's  attention  by 
some  movement  of  her  face  or  eyes,  or  even  of  her  hands.  It  is 
very  necessary  to  eliminate  such  influences  in  examining  a  young 
child  for  deafness,  the  sound  used  should  be  made  behind  the 
child  or  out  of  his  sight,  and  at  such  a  distance  that  the  in- 
fluence of  tactile  sensation  can  be  eliminated  :  it  is  well  also 
to  engage  the  child's  interest  with  some  toy  or  other  object  so 
that  the  child  is  not  likely  to  look  round  in  the  direction  of  the 
noise  by  mere  coincidence.  A  familiar  voice,  especially  the 
mother's,  calling  the  child  from  an  adjoining  room,  is  often 
a  satisfactory  test  for  a  child's  hearing. 

Mental  deficiency  may  simulate  deafness  ;  the  mentally  defec- 
tive child  is  often  curiously  stolid,  taking  no  notice  whatever 
of  calls  or  commands,  and  yet  perhaps  a  few  minutes  later 
showing  that  he  hears  readily  when  he  chooses  to  do  so. 

I  have  occasionally  met  with  a  curious  condition  in  which 
the  child's  behaviour  was  very  suggestive  of  complete  deafness, 
although  the  history  showed  that  the  child  was  neither  deaf  nor 
imbecile.  In  these  cases  the  child,  when  addressed  by  a  stranger, 
remained  absolutely  blank  so  far  as  any  sign  of  hearing  or  interest 
went,  so  that,  were  it  not  for  the  history  that  wken  he  was  with 
members  of  his  own  family  or  familiar  friends  he  both  heard  and 
talked,  one  might  easily  have  supposed  the  child  to  be  deaf  and 
dumb.  Such  children  usually  show  other  evidence  of  mental 
peculiarity,  either  in  backwardness  of  speech  development,  or  in 
unnatural  violence  of  temper,  or  in  some  other  trait  which  marks 
them  a§  '  odd  '  children. 


16  COMMON  DISORDERS  OF  CHILDHOOD 

There  are  cases  also  in  which  deafness  is  simulated  by  a  failure 
of  interpretation  of  speech,  although  it  is  heard  apparently 
perfectly :  these  are  the  cases  of  so-called  congenital  word- 
deafness  :  the  child  can  hear  and  can  be  taught  to  repeat  words, 
but  the  words  convey  no  meaning  to  him  ;  such  children  tested 
by  speaking  to  them  appear  absolutely  deaf,  moreover  speech 
is  absent  until  special  training  has  been  given,  so  that  the  child 
m:ght  easily  pass  for  a  deaf-mute,  were  it  not  clear  on  testing 
him  in  other  ways  that  even  slight  sounds  are  well  heard. 

The  age  at  which  a  child  sits,  stands,  and  walks  is  a  point  of 
some  importance  in  the  recognition  of  imbecility,  and  also  in 
relation  to  physical  disorders  such  as  rickets. 

The  normal  infant  during  the  first  three  months  of  life  when 
supported  in  the  sitting  position  is  unable  to  hold  his  head  up 
steadily,  it  tends  to  loll  in  one  direction  or  another.  At  the  age 
of  four  months  many  infants  can  support  the  head  firmly  in  the 
erect  position  ;  if  this  cannot  be  done  at  six  months,  some  morbid 
condition  is  present,  either  imbecility  or  physical  disease. 

During  the  first  few  months  an  infant  makes  no  attempt  to 
reach  with  his  hand  objects  shown  to  him  ;  at  three  to  four 
months  old  some  effort  is  made  to  reach  objects,  but  the  co- 
ordination is  very  defective  so  that  the  efforts  are  at  first  quite 
unsuccessful,  but  gradually  the  hand  becomes  steadier,  and  by 
the  age  of  four  months  a  healthy  infant  can  often  reach  accurately 
for  what  it  wants,  failure  to  do  this  at  six  months  of  age  should 
suggest  some  mental  defect. 

At  the  age  of  nine  months  most  healthy  infants  can  sit  up 
without  support  :  inability  to  sit  up  alone  at  the  age  of  twelve 
months  in  an  infant  otherwise  in  good  general  health  usually 
indicates  mental  deficiency.  At  ten  months  old  many  infants 
can  just  stand  with  slight  assistance,  at  twelve  months  walking  is 
possible  with  such  slight  support  as  having  one  hand  held  ;  if 
standing  is  delayed  after  fifteen  months  there  is  probably  some 
disease  physical  or  mental. 

The  development  of  speech  will  be  considefed  more  fully  in 
connexion  with  speech  disorders  (Chapter  LI)  ;  here  it  may 
be  said  that  about  the  age  of  six  months  the  infant  begins  to 
associate  names  with  persons  and  things,  so  that  the  child  will 
look  towards  the  object  named ;  at  ten  months  many  infants  use 
one  or  two  single  words  such  as  '  man  '  or  '  Dad  ',  and  at  fourteen 
months  several  single  words,  such  as  '  up  ',  '  go,'  '  puss,'  &c., 
should  be  used  ;  and  simple  sentences  such  as  '  go  ta-ta  ',  *  dear 
dolly,  at  eighteen  months. 


CHAPTER  II 
BREAST-FEEDING  AND  ITS  LIMITATIONS 

No  one,  I  suppose,  will  deny  that  breast-feeding  has  its  limita- 
tions and  even  its  failures,  and  it  is  with  these  rather  than  with 
its  wonted  uneventful  success  that  the  medical  man  is  concerned. 
But  lest  I  should  seem  to  pass  over  the  value  of  breast-feeding 
too  lightly,  I  will  insist  here  upon  its  enormous  importance  to 
the  welfare  of  an  infant.  Hand-fee'ding,  even  with  the  utmost 
care,  involves  risks  which  are  reduced  to  a  minimum  by  breast- 
feeding. The  Registrar- General's  reports  show  that  the  chief 
causes  of  death  in  the  first  six  months  of  life  are  diarrhoea  in  its 
various  forms  and  wasting  conditions  comprised  under  the 
heading  '  Debility,  Atrophy,  Inanition'.  Some  statistics  which 
I  collected  at  the  Hospital  for  Sick  Children,  Great  Ormond  Street, 
showed  that  96  per  cent,  of  the  deaths  from  infantile  diarrhoea 
occurred  in  infants  who  were  being  hand-fed  entirely  or  partially 
(92  per  cent,  entirely)  :  and  the  severe  degrees  of  marasmus  or 
wasting  in  infancy  which  end  fatally  are  seen  almost  exclusively 
in  hand-fed  children.  But  apart  from  risk  to  life  there  are  many 
disorders  which  beset  the  hand-fed  child  far  more  often  than  the 
baby  at  the  breast  :  the  sleepless  infant  who  screams  with  flatu- 
lence and  colic  is  nearly  always  the  hand-fed  infant ;  the  infant 
who  fails  to  gain  weight  and  drives  doctor  and  parents  to  their 
wits'  end  in  the  effort  to  find  some  food  that  will  suit,  is  the  hand- 
fed  infant ;  rickets  is  almost  entirely  a  disease  of  hand -fed  infants  : 
convulsions  are  also,  I  think,  much  commoner  in  these  infants 
than  in  those  who  are  suckled.  Taking  haphazard  from  my 
notes  thirty  cases  of  convulsions  in  infants  under  nine  months  of 
age,  I  find  that  twenty  were  entirely  hand-fed  at  the  time  of  the 
convulsion,  only  eight  were  entirely  breast-fed.  Some  figures 
reported  by  Dr.  Sykes  illustrate  well  how  much  an  infant's 
chance  of  life  is  diminished  by  hand-feeding  ;  in  the  Borough 
of  St.  Pancras,  London,  in  1905,  it  was  found  that  in  a  mortality 
of  127  per  1,000  during  infancy,  102-6  were  hand-fed  entirely  or 
partially  (92-4  per  cent,  entirely),  while  only  24-4  were  infants 
who  had  been  entirely  breast-fed. 

Let  us  beware  then  how  we  counsel  a  mother  not  to  suckle 
her  child  ;  it  is  a  heavy  responsibility  and  one  which  I  ven- 


18  COMMON  DISORDERS  OF  CHILDHOOD 

ture  to  think  is  often  taken  too  lightly.  There  are  reasons 
enough  which  may  make  it  advisable  to  stop  breast-feeding,  but 
these  must  be  weighed  carefully  before  such  a  step  is  taken. 

How  often  one  hears  the  statement,  '  I  never  could  suckle  my 
children  '  put  forward  as  a  reason  for  not  attempting  to  suckle 
a  subsequent  infant.  Undoubtedly  there  are  many  women  who 
cannot  suckle  any  of  their  children,  but  it  would  be  well  if  medical 
men  would  impress  upon  mothers  that  failure  in  a  previous  effort 
to  breast-feed  is  no  reason  whatever  for  assuming  that  there  will 
necessarily  be  failure  also  in  suckling  a  later  child  ;  a  mother 
whose  milk  has  failed  either  in  quantity  or  in  quality  in  the  feeding 
of  earlier  children,  may  yet  suckle,  and  suckle  successfully  for 
several  months,  a  subsequent  infant. 

And  here  I  would  emphasize  particularly  the  importance  of 
breast-feeding  during  the  first  few  weeks  of  life.  It  is  in  these 
early  days  when  an  infant  has  so  feeble  a  hold  on  life  that  any 
disorder  of  digestion,  such  as  is  apt  to  occur  with  hand-feeding, 
is  specially  dangerous,  and  it  is  at  this  time  that  the  digestion  is 
most  easily  disturbed.  Breast-feeding  at  this  time,  even  if  it 
can  be  continued  only  for  six  weeks  or  two  months,  seems  to  give 
the  infant  a,  start  in  life,  which  may  be  of  vital  importance  when 
the  difficulties  and  dangers  of  hand-feeding  have  to  be  faced. 

Examination  of  breast-milk.  Breast- milk  is  often  judged  to 
be  unsuitable  on  quite  insufficient  grounds.  Perchance  the  baby 
has  cried  and  seemed  uncomfortable  after  the  breast-feeds  ;  or 
he  does  not  seem  satisfied.  The  weight  is  rising,  but  perhaps 
not  very  regularly,  7  ounces  one  week  and  only  2  or  3  ounces 
the  next  week,  and  the  over-anxious  mother  has  appealed 
to  the  doctor.  Now  what  happens  ?  The  doctor  very  rightly 
says  that  he  would  like  to  see  the  milk  and  tells  the  mother  to 
draw  some  off  for  him  to  examine.  The  mother,  having  no 
special  directions  given  to  her,  naturally  draws  off  some  milk 
at  the  time  when  her  breast  is  most  full,  just  before  she  feeds 
her  infant  :  and  at  his  next  visit  the  doctor  sees  a  poor  watery- 
looking  specimen  of  milk,  which  he  unhesitatingly  condemns  as 
unfit  for  the  infant.  Now  this  is  no  imaginary  occurrence  ;  it 
has  happened  again  and  again  in  my  own  experience  ;  and  it 
involves  a  serious  mistake.  The  milk  which  is  drawn  first  from 
the  breast,  the  '  foremilk  '  as  it  is  sometimes  called,  is  normally 
much  thinner  and  poorer  than  the  later  milk  ;  there  is  a  gradual 
increase  in  the  richness  of  the  milk  from  the  beginning  of  a  feed 
until  the  end  ;  the  last  milk  is  much  richer  than  the  foremilk. 
The  fact,  therefore,  that  a  woman's  milk,  drawn  off  with  no  special 


BREAST-FEEDING  AND  ITS  LIMITATIONS          19 

precautions,  looks  thin  and  watery  proves  nothing  whatever  as 
to  the  suitability  or  unsuitability  of  her  milk.  The  only  way  in 
which  a  reliable  opinion  can  be  formed  as  to  the  quality  of  breast- 
milk  is  by  examination  either  of  a  mixed  sample  of  the  whole 
contents  of  the  breast,  or  by  examination  of  the  middle  third. 
The  former,  of  course,  would  be  the  more  accurate,  but  any  one 
who  has  attempted  to  pump  off  the  contents  of  a  breast  will  know 
'that  this  is  often  very  difficult  and  sometimes  impossible;  so 
that  in  practice  it  is  more  convenient  to  take  the  middle  third, 
which  perhaps  owing  to  the  stimulus  of  sucking,  where  the  infant 
has  first  been  allowed  to  suck  a  small  quantity,  is  much  more 
easy  to  obtain.  The  directions  to  be  given  are  these  :  the  mother 
is  first  to  time  several  feeds  and  so  ascertain  how  long  the  infant 
usually  takes  to  empty  the  breast  :  then  the  infant  is  to  be  put 
to  the  breast  for  exactly  one-third  of  this  time,  and  immediately 
afterwards  about  1  ounce  of  milk  is  to  be  withdrawn  (with 
breast-pump  if  possible,  otherwise  by  gently  squeezing)  for 
examination  ;  the  infant  can  then  take  the  milk  that  remains  in 
the  breast .  In  this  way  a  sample  is  obtained  which  shows  approxi- 
mately the  average  quality  of  the  milk.  But  even  so  it  is  seldom 
possible  by  mere  inspection  to  form  any  reliable  judgement  as  to 
the  suitability  of  breast-milk  for  an  infant  ;  occasionally,  but, 
I  think,  very  rarely,  the  middle  milk  will  be  found  to  be  so  thin 
that  its  unsuitability  may  be  reasonably  inferred ;  far  more  often 
it  is  only  by  analysis  that  an  opinion  of  any  value  can  be  formed. 

Composition  of  breast-milk.  This  brings  me  to  the  compo- 
sition of  breast-milk,  and  let  me  say  at  once  that  for  a  scientific 
understanding  of  the  everyday  difficulties  of  infant  feeding,  an 
accurate  knowledge  of  the  percentage  composition  of  the 
common  foods,  particularly  human  milk  and  cow's  milk,  is 
absolutely  essential  ;  no  mortal  man  can  carry  in  his  memory 
the  percentage  composition  of  every  food  that  is  used  for 
infants,  but  every  medical  man  ought  to  know  the  average 
proportions  of  the  various  constituents  of  human  milk  and 
cow's  milk  ;  for  upon  the  composition  of  these  two  milks 
turn  most  of  the  practical  problems  of  infant -feeding. 

Human  milk  has  an  average  specific  gravity  of  1030-1032 
and  is  composed  thus  : 

Proteid       .         .         .       2-0  per  cent,  j  Casein  0-6  per  cent. 

(  Lactalbumen  14  per  cent 
Fat     .         .         ...       3-5  per  cent. 
Lactose       .         .         .       7-0  per  cent. 
Salts  .         .         .  0-2  per  cent. 

Water         .         .         .     87-3  per  cent. 

c2 


20  COMMON  DISORDERS  OF  CHILDHOOD 

The  striking  feature  in  its  composition  is  the  low  proportion  of 
curd-forming  proteid,  casein,  as  compared  with  the  soluble  and 
much  more  easily  digested  proteid  lactalbumen,  which,  unlike 
the  casein,  is  not  precipitated  by  acids  or  by  rennet.  The  con- 
stituents which  vary  most  in  quantity  are  the  fat  and  the  proteid, 
especially  the  fat  ;  the  sugar  is  much  more  constant. 

The  following  observations  will  show  how  fallacious  examina- 
tion of  the  milk  may  be  when  a  chance  specimen  is  taken 
without  special  precaution  to  obtain  the  middle  third  :  in  one 
case  the  foremilk  showed  only  0-4  per  cent,  of  fat,  while  the 
middle-milk  showed  3-2  per  cent.  ;  in  one  specimen  of  foremilk 
there  was  1-4  per  cent,  of  fat,  in  one  of  after-milk  10  per  cent, 
of  fat. 

Another  fallacy  I  must  mention :  it  might  be  concluded  hastily 
that  the  specific  gravity  would  afford  some  guidance,  but  this  is 
not  so,  unless  either  the  proportion  of  fat  or  of  proteid  in  the 
milk  is  known.  If  the  sugar  and  salts  may  be  assumed,  as  they 
fairly  may,  to  be  constant  in  their  proportions,  then  the  variation 
of  specific  gravity  will  depend  on  the  proteids  and  the  fat.  The 
effect  of  a  high  percentage  of  fat  is  to  lower  the  specific  gravity  : 
the  effect  of  a  high  proportion  of  proteid  is  to  raise  the  specific 
gravity.  Therefore,  if  the  proportion  of  neither  is  known,  a  high 
specific  gravity  might  be  due  either  to  a  low  fat  percentage  or 
to  a  high  proteid  percentage  :  and  conversely  a  low  specific 
gravity  might  be  due  to  a  high  fat  percentage  or  to  a  low  proteid 
percentage.  But  if  the  percentage  of  one  is  known,  then  we 
can  form  a  reliable  opinion  as  to  whether  the  percentage  of  the 
other  is  above  or  below  the  normal .  It  is  usual  to  ascertain  the 
fat  percentage  as  this  is  more  easily  determined  than  that  of  the 
proteid. 

If  it  is  known  that  the  fat  percentage  is  unduly  low,  then  a  low 
specific  gravity  must  mean  that  the  proteids  also  are  low,  while 
if  the  fat  percentage  is  above  the  average  then  a  normal  specific 
gravity  must  mean  that  the  proteid  percentage  is  higher  than 
normal.  The  estimation  of  fat  with  a  high-speed  centrifuge  is 
a  very  simple  matter.  But  if  no  centrifuge  is  at  hand  it  can  be 
done  very  fairly  accurately  by  the  following  method.  A  cylin- 
drical five  cubic  centimetre  measure,  having  a  diameter  of  three- 
eighths  of  an  inch,  and  graduated  in  cubic  centimetres  and 
millimetres,  is  filled  with  the  breast-milk  exactly  up  to  the  five 
cubic  centimetre  mark,  it  is  then  corked  and  allowed  to  stand  for 
exactly  twenty-four  hours.  The  cream  rises  to  the  top  and  is 
read  off  in  cubic  millimetres.  Empirically  the  cream  readings 


BREAST-FEEDING  AND  ITS  LIMITATIONS          21 

are  found  to  correspond  with  fat-percentages   approximately 
thus  : 

Cream.  Fat. 

2  cubic  millimetres  =  2-8  per  cent. 

3  cubic  millimetres  =  3-5  per  cent. 

4  cubic  millimetres  —  4-4  per  cent. 

5  cubic  millimetres  =  5-6  per  cent. 

For  taking  the  specific  gravity  if  only  a  small  quantity  of  milk 
can  be  obtained,  so  that  even  a  small  urinometer  is  not  available, 
I  use  specially  made  glass  beads  which  any  scientific  glass-blower 
will  make  for  the  purpose,  each  bead  being  made  so  as  just  to 
float  in  fluids  of  a  specific  gravity  which  is  marked  on  the  bead. 

Nowadays  there  are  many  laboratories  where  a  complete 
analysis  of  breast-milk  can  be  obtained ;  and  when  this  is  practi- 
cable it  is  well  worth  while  to  have  such  an  analysis  done  ;  but 
it  is  to  be  remembered  that  it  is  useless  sending  a  sample  for 
analysis  unless  it  be  either  the  middle  portion  of  the  milk,  or 
the  entire  contents  of  a  full  breast.  In  this  way  information 
may  sometimes  be  obtained  which  may  be  of  great  practical 
value,  for  to  some  extent  it  is  possible  to  modify  the  composition 
of  breast-milk  ;  and  I  would  insist  upon  the  duty  of  attempting 
to  overcome  any  fault  that  is  detected  in  the  breast-milk  before 
concluding  that  it  is  necessary  to  wean  the  child.  Even  if  it 
is  necessary  to  wean  the  child,  the  information  gained  from  an 
analysis  of  the  breast- milk  may  still  be  of  value  in  showing  what 
particular  modification  or  dilution  of  cow's  milk  is  likely  to  suit 
the  infant. 

Having  said  thus  much  of  the  value  of  analysis  in  cases  of 
difficulty  in  digestion  of  breast-milk,  I  must  add  that  it  has  been 
my  own  experience  that  only  in  a  minority  of  cases  does  analysis, 
however  full  and  accurate,  give  any  practical  help.  I  have 
analysed  breast-milk  in  many  cases  where  an  infant  was  doing 
badly,  and  sometimes  where  the  infant  was  wasting  considerably 
in  spite  of  an  ample  supply  of  milk,  and  I  have  often  found  that, 
so  far  as  ordinary  analysis  could  show,  the  milk  was  perfectly 
good :  nevertheless,  the  substitution  of  hand-feeding  partly 
or  entirely  has  been  followed  by  immediate  improvement.  I 
have  no  explanation  to  offer  for  this  occurrence  ;  but  it  suggests 
that  there  are  subtler  constituents  in  milk  than  proteid,  fat,  and 
sugar.  For  instance,  it  is  known  that  there  are  several  ferments 
normally  present  in  milk,  and  who  shall  say  but  that  these  may 
vary  in  quality  or  quantity  and  affect  its  digestibility  ?  and  again, 
if  the  addition  of  one  to  two  grains  of  sodium  citrate  to  a  three- 
ounce  feed  can,  as  it  certainly  docs,  affect  the  digestibility  of  the 


22  COMMON  DISORDERS  OF  CHILDHOOD 

milk,  it  seems  possible  that  variations  in  the  salts  of  the  milk 
may  be  more  important  than  we  know.  However  this  may 
be,  it  is  noteworthy  that  an  exact  analysis  of  the  three  chief 
constituents  of  the  milk  may  not  throw  any  light  upon  the 
infant's  failure  to  thrive. 

Faults  in  breast-milk.  I  suppose  the  commonest  complaint 
is,  '  My  milk  does  not  satisfy  the  baby  '  ;  a  state  of  things  which 
may  depend  either  upon  deficiency  in  quantity  or  deficiency  in 
quality  of  the  milk.  In  the  former  case  the  infant  cries  angrily 
after  he  has  taken  the  breast  for  a  few  minutes,  and  then  perhaps 
goes  to  sleep  and  wakes  again  crying  for  the  breast  some  time 
before  it  is  due  :  in  the  latter  where  the  milk  is  thin  and  watery, 
there  may  be  an  abundant  flow  of  milk  and  the  infant  may  seem 
satisfied  and  fall  asleep  for  a  short  time  after  a  feed,  but  then 
begins  to  cry  with  flatulence  and  discomfort.  What  is  to  be 
done  ?  certainly  not  to  wean  the  child  off-hand.  If  the  milk  is 
deficient  in  quantity  it  may  be  possible  to  increase  it.  The 
effect  of  rest  in  promoting  the  flow  of  milk  is  often  very  striking, 
many  mothers  have  noticed  it  themselves.  A  day  or  two  spent 
chiefly  on  the  sofa  or  in  bed  may  restore  the  flow,  and  a  little 
care  in  avoiding  all  unnecessary  exertion  may  enable  a  mother 
to  continue  the  suckling.  Then  in  the  way  of  diet  something 
can  be  done  :  more  milk,  or  gruel,  or  perhaps  a  glass  of  stout  with 
the  mid-day  meal  may  promote  the  flow  of  milk.  But  here 
I  must  insert  a  caution  :  whilst  I  do  not  think  there  is  the  least 
doubt  that  a  small  amount  of  alcohol  in  this  form  sometimes  makes 
suckling  possible  where  it  would  otherwise  have  to  be  stopped, 
I  think  it  is  a  measure  never  to  be  advised  unless  other  aids  have 
failed.  Apart  from  the  possibility  of  inducing  in  the  mother 
the  alcohol  habit,  it  seems  that  even  a  small  amount  of  alcohol 
taken  by  some  women  produces  some  change  in  their  milk 
whereby  it  disagrees  with  the  infant.  A  more  useful  means  in 
some  cases  is  the  administration  of  malt  extract  to  the  mother 
three  times  a  day  after  her  meals;  this  may  work  only  in- 
directly by  improving  her  digestion,  but,  however  this  may 
be,  it  seems  to  improve  not  only  the  flow  of  the  milk  but  also 
its  quality  in  some  cases.  Recently  it  has  been  found  that 
powdered  Cotton  Seed  extract,  which  can  be  obtained  under  the 
trade  name  '  Lactagol  ',  is  often  very  effective  in  improving  both 
the  quantity  and  the  quality  of  the  breast  milk.  A  teaspoonful 
of  this  preparation  is  given  three  times  daily  mixed  with  milk  or 
cocoa. 

If  the  milk  is  thin  and  watery  but  abundant,  a  liberal  diet  of 
proteid  food,  chops,  steaks,  joints,  fish,  poultry,  eggs,  is  to  be 
advised  ;  it  is  a  curious  fact  that  a  diet  rich  in  proteid  seems  to 
increase  not  only  the  Droteid  in  the  milk  but  also  the  fat. 


BREAST-FEEDING  AND  ITS  LIMITATIONS         23 

But  supposing  that  with  all  our  efforts  we  fail  to  improve  the 
milk  in  quantity  or  quality,  there  may  still  be  no  justification 
for  weaning.  Some  women  can  continue  suckling  if  the  strain 
is  reduced  by  substituting  hand-feeding  two  or  three  times  daily, 
other  women  have  milk  enough  to  suckle  their  infant  at  night 
when  they  are  resting  in  bed  although  they  are  unable  to  provide 
enough  for  the  day  also  :  not  only  is  the  flow  of  milk  usually 
more  copious  at  night  but  its  quality  is  richer  owing,  no  doubt, 
to  the  rest,  so  that  even  if  the  failure  to  satisfy  be  due  to  deficiency 
in  quality,  it  may  still  be  possible  to  suckle  at  night. 

Here,  however,  a  difficulty  may  arise  which  may  make  it 
necessary  to  wean  the  child.  Breast-milk  which  is  scanty 
often  seems  to  act  as  an  irritant,  sometimes  making  the 
infant  sick,  often  making  him  cry  with  colic,  and  occasionally 
starting  a  greenness  and  looseness  of  the  stools.  Moreover,  it  is 
remarkable  how  an  infant  seems  to  detect  some  change  in  the 
milk  when  it  is  diminishing  in  quantity  ;  sometimes  before  the 
mother  or  the  doctor  is  aware  that  the  supply  is  failing,  the  infant 
will  take  a  dislike  to  the  breast-milk,  and  may  refuse  it  altogether. 

And  this  brings  me  to  another  common  complaint  from 
mothers  :  '  My  milk  does  not  agree  with  the  baby.'  Now  as 
I  have  already  mentioned  incidentally,  a  scanty  milk  is  apt  to 
disagree,  and  there  are,  as  I  shall  show,  other  causes  for  the  dis- 
agreement ;  but  before  assuming  that  there  is  any  fault  in  the 
milk,  it  is  very  necessary  to  make  sure  that  the  fault  is  not 
rather  in  the  feeding  ;  a  mother's  milk  may  be  perfectly  sound, 
but  if  the  baby  is  fed  haphazard — '  when  he  wants  it,'  or  '  when 
he  cries  ' — the  result  is  likely  to  be  unsatisfactory.  There  must 
be  regularity  in  the  feeding  and,  as  a  general  rule,  I  am  strongly 
in  favour  of  waking  an  infant  for  its  feeds  at  the  proper  time. 
If  this  is  done  from  the  beginning,  the  infant  usually  very  soon 
gets  into  the  habit  of  waking  just  as  the  feed  is  due,  and  goes  off 
to  sleep  again  quite  easily  after  it. 

An  infant  should  be  fed  every  two  hours  during  the  first 
two  months,  except  at  night,  when  the  intervals  may  be  three 
hours  :  during  the  next  month  it  should  be  fed  every  two  and 
a  half  hours  by  day,  and  three  hours  by  night,  and  from 
the  end  of  the  third  month  onwards  it  should  be  fed  every 
three  hours  by  day,  and  may  miss  one  feed  at  night,  until  the 
age  of  six  months,  when  it  may  miss  two  feeds  at  night. 

Where  the  mother's  milk  is  very  profuse,  trouble  arises  some- 
times from  the  very  ease  with  which  the  milk  is  sucked  ;  the 
infant  gulps  the  milk  down  in  haste  and  repents  at  leisure, 
screaming  with  flatulence  and  colic.  This  is  difficult  to  prevent. 
To  some  extent  the  mother  may  regulate  the  flow  by  compressing 


24  COMMON  DISORDERS  OF  CHILDHOOD 

the  nipple  between  her  fingers,  and  it  may  assist  if  the  baby  is 
taken  from  the  breast  at  short  intervals  during  the  feed  ;  or  the 
difficulty  may  be  overcome  by  using  a  nipple-shield  with  a  teat, 
which  will  not  allow  too  easy  a  flow.  I  have  often  thought  that 
digestive  disturbances  in  breast-fed  babies  resulted  from  excessive 
feeds.  Certainly,  if  a  mother  has  an  average  quantity  of  milk, 
one  breast  should  be  sufficient  for  an  infant,  and  trouble  is  likely 
to  result  from  allowing  the  baby  to  empty  both  breasts  at  a  feed  : 
but  even  with  the  milk  of  one  breast  only,  I  think  that  some 
infants  take  too  much  and  scream  in  consequence  with  wind  and 
discomfort.  Undoubtedly  an  infant  can  tolerate  and  digest  a 
larger  bulk  of  breast-milk  than  of  cow's  milk  or  of  any  artificial 
food,  but  if  one  may  judge  from  the  analogy  of  hand-feeding, 
I  think  it  is  quite  clear  that  too  large  a  bulk  of  food,  quite  apart 
from  its  quality,  is  a  cause  of  much  gastric  disturbance  in  infancy. 

Apart  from  these  causes,  however,  there  are  cases — and  by  no 
means  infrequent — in  which  the  milk  obviously  disagrees  ;  the 
stools  are  green,  sometimes  of  a  bright  grass-green  colour  through- 
out, sometimes  of  a  dark  olive-green  colour  ;  slimy,  perhaps, 
but  not  too  frequent  ;  the  infant  is  evidently  uncomfortable 
after  the  feeds  ;  the  weight  is  rising,  but  erratically.  In  other 
cases  there  is  frequency  of  the  stools,  which  are  green  and  waterjr; 
I  have  known  as  many  as  twelve  and  thirteen  stools  in  the 
twenty-four  hours ;  the  buttocks  become  red  and  excoriated,  the 
weight  ceases  to  rise  or  actually  falls,  the  infant  takes  the  feeds 
well,  but  seems  uncomfortable,  passes  wind  often  by  mouth  and 
bowel,  and  clearly  is  not  thriving.  What  is  the  meaning  of  all 
this  ?  Analysis  of  the  milk  explains  it  in  some  cases,  but  not  in 
all  ;  I  have  found  an  abnormally  high  proteid  percentage  alone 
as  the  apparent  explanation  of  green  stools  where  there  was  no 
diarrhoea.  For  instance,  a  female  infant  aged  three  weeks  was 
brought  to  me  for  screaming  and  some  vomiting  after  feed  ; 
analysis  of  the  breast-milk  (middle  third)  showed  fat  3-0  per 
cent.,  proteid  2-5  per  cent.,  sugar  6-0  per  cent.  Where,  as  more 
often  happens,  the  stools  are  not  only  green,  but  very  frequent 
and  loose,  so  that  there  is  actual  diarrhoea,  I  have  several  times 
found  that  the  fat  was  in  excess,  more  rarely  the  proteid  also. 
For  instance,  in  one  such  case  the  middle-milk  showed  fat  6-5 
per  cent.,  proteid  1-7  percent.,  sugar  7-0  per  cent. ;  in  another, 
fat  4-4  per  cent.,  proteid  1-8  per  cent.,  sugar  (approximately) 
6-5  per  cent. 

But  I  am  not  at  all  sure  that  in  every  case  where  in  spite  of 
properly  managed  breast-feeding  the  milk  continues  to  disagree, 


BREAST-FEEDING  AND  ITS  LIMITATIONS          25 

the  trouble  is  due  to  abnormal  character  of  the  milk ;  I  suspect 
that  in  some  of  these  cases  the  explanation  is  better  expressed 
as  a  foreign  mother  put  it,  when  she  held  out  her  wasted  baby  to 
me  and  said  :  '  De  baby  se  not  agree  wid  de  milk.'  In  one 
instance  I  had  three  wet-nurses  in  succession  for  an  infant  shortly 
after  birth ;  with  each  and  all  the  result  was  the  same,  frequent 
loose  green  watery  stools  ;  whereas  directly  a  simple  whey 
mixture  or  peptonized  cow's  milk  was  used,  in  the  intervals  while 
a  fresh  wet-nurse  was  being  obtained,  the  stools  at  once  improved, 
so  that  ultimately  the  attempt  to  feed  on  the  breast  was  aban- 
doned and  the  infant  did  perfectly  well  with  hand-feeding. 

There  is  no  doubt  that  some  infants  are  remarkably  intolerant 
of  fat,  as  others  are  of  carbo-hydrate,  and  it  may  be  that  for  such 
the  proportion  of  fat  or  sugar  normally  present  in  mothers'  milk 
is  too  high.  If,  however,  it  is  found  that  the  milk  is  abnormally 
rich,  this  fault  can  be  overcome  to  a  certain  degree.  As  proteid 
is  increased  by  shortening  the  intervals  between  feeding,  so  an 
undue  proportion  of  proteid  may  be  reduced  by  lengthening  the 
intervals  between  feeds,  if  feeding  has  been  too  frequent. 

The  effect  of  exercise  is  also  to  be  remembered,  both  the  pro- 
teid and  the  fat  may  be  reduced  by  increasing  the  amount  of 
exercise.  In  some  of  these  cases  I  think  that  too  much  is  being 
done  in  the  way  of  stuffing  the  mother  with  meat  and  milk.  In  one 
instance  where  a  suckling  woman  was  having  two  quarts  of  milk 
a  day  in  addition  to  liberal  feeding  with  beefsteaks  and  mutton- 
chops,  the  breast-milk  which  disagreed  with  the  infant  contained 
3  per  cent,  of  proteid  ;  a  reduction  of  the  diet  reduced  the  per- 
centage of  proteid  within  three  days  to  1-7  per  cent.  But  if  the 
milk  still  remains  excessively  rich,  there  are  three  ways  in  which 
the  difficulty  may  sometimes  be  surmounted  ;  the  infant  may 
be  allowed  to  suck  for  about  4-5  minutes  at  both  breasts,  so  that 
he  gets  only  the  weaker  foremilk,  instead  of  taking  the  whole 
contents  of  one  breast  at  each  feed.  If  this  methcd  is  used  the 
infant  must,  of  course,  be  strictly  timed,  otherwise  he  will  take 
too  much  ;  another  procedure  is  to  give  J-l  ounce  of  plain 
water  to  which  a  quarter  of  a  teaspoonful  of  milk  sugar  may  be 
added  immediately  before  each  breast-feed,  in  the  hope  that 
the  breast-milk  may  be  diluted  in  the  infant's  stomach  ;  the 
third  is  to  give  some  drug  which  may  aid  digestion.  Sodium 
citrate  may  be  given  thus  :  Sodii  Citratis  gr.  ij  Aq.  Anethi  ad  3j, 
immediately  before  the  infant  is  put  to  the  breast.  Sodium 
Bicarb,  gr.  ij,  Papain  gr.  j  with  2  drachms  of  water  just  before 
each  feed  certainly  helps  in  some  cases. 


20  COMMON  DISORDERS  OF  CHILDHOOD 

A  possibility  always  to  be  remembered  where  the  breast-milk 
appears  to  be  disagreeing  with  an  infant  is  that  the  mother  may 
be  taking  some  drug  which  is  either  excreted  in  the  milk  or 
affects  the  milk  indirectly ;  all  the  saline  aperients  are  excreted 
to  some,  extent  in  the  milk,  as  also  potassium  iodide,  mercury, 
sodium  salicylate,  arsenic,  and  antimony  (and  even  some  of  the 
vegetable  aperients  in  common  use,  senna,  and  castor  oil),  ar.d 
possibly  the  alkaloids  of  opium. 

It  would  be  interesting  to  know  whether  any  of  the  hypnotics 
in  common  use,  especially  the  newer  ones,  have  any  deleterious 
influence  on  the  milk,  for  they  are  used  not  uncommonly  for 
mothers  soon  after  delivery.  One  thing  is  quite  clear,  that  the 
less  drugs  a  nursing  woman  takes,  the  safer  for  the  infant. 

Wet-nursing 

I  cannot  leave  the  subject  of  breast-feeding  without  some 
reference  to  wet-nursing,  which  in  my  opinion  might  with  advan- 
tage be  used  much  more  often  than  it  is  in  this  country.  There 
is  nothing  more  striking  in  the  whole  range  of  therapeutics  than 
the  effect  of  wet-nursing  upon  an  infant  who  is  steadily  emaciating 
upon  this  and  that  modification  of  cow's  milk  or  other  artificial 
food  ;  often  from  the  day  the  breast-milk  is  begun  there  is  a  rapid 
gain  of  weight,  and  the  infant  becomes  contented  and  restful 
instead  of  wl lining  and  miserable.  Unfortunately,  wet-nursing 
is  beset  with  difficulties  ;  in  the  first  place,  it  is  often  very 
difficult  to  secure  a  wet-nurse  ;  in  the  second  place,  when  a 
woman  is  found  who  is  willing  to  suckle,  she  may  be  unsuitable 
for  various  reasons  ;  in  the  third  place,  from  one  cause  or  another, 
her  milk  may  not  suit  the  infant  ;  and  last,  but  not  least,  the 
infant  may  absolutely  refuse  to  take  the  breast. 

My  own  experience  leads  me  to  think  that  it  matters  little 
whether  the  wet-nurse's  infant  is  of  the  same  age  as  the  foster- 
child,  even  approximately  ;  certainly  it  does  not  matter  in  the 
least  what  may  be  the  complexion  of  the  wet-nurse,  or  her 
character,  so  far  as  the  milk  is  concerned  ;  although  the  latter 
consideration  may  be  a  weighty  one,  when  an  unmarried  woman 
is  to  be  introduced  into  a  household  as  wet-nurse. 

The  first  point  to  be  determined  is  the  health  of  the  wet-nurse, 
and  in  this  matter  the  utmost  care  is  needful.  In  one  instance 
under  my  own  observation,  a  wet-nurse  who  had  undergone 
medical  examination,  was  approved  as  healthy  and  suckled 
an  infant  for  some  months  before  it  became  evident  that  the 


BREAST-FEEDING  AND  ITS  LIMITATIONS          27 

woman  was  very  ill,  she  died  with  acute  miliary  tuberculosis 
after  a  few  weeks'  illness ;  it  transpired  that  she  had  had  haemo- 
ptysis before  she  was  engaged  as  wet-nurse,  and  diarrhoea  on  and 
off  most  of  the  time  she  was  suckling,  but  she  had  apparently 
deliberately  concealed  her  illness.  I  saw  the  infant  for  a  }rear 
or  more  after  the  suckling  was  discontinued,  but  fortunately  it 
did  not  show  any  sign  of  tuberculosis.  In  another  instance,  after 
much  trouble,  I  had  secured  as  I  thought  a  suitable  wet-nurse, 
when  it  was  found  that  her  head  was  swarming  with  pediculi. 
In  a  third  case  an  apparently  healthy  woman  whom  I  was  about 
to  engage  brought  her  infant  to  be  examined  ;  it  looked  so  clean 
and  healthy  in  the  face  that  I  was  almost  tempted  to  dispense 
with  a  complete  examination,  but  on  undressing  it  I  found  a  verj7 
characteristic  syphilitic  rash  over  the  buttocks  and  thighs.  This 
last  possibility,  syphilis  in  the  mother,  is  the  most  difficult  to 
exclude  by  ordinary  clinical  examination  ;  as  is  well  known,  it 
is  common  for  the  mother  to  show  no  signs  whatever  of  this 
disease,  although  her  infant  shows  indubitable  evidence  ;  it  may 
be  doubtful  whether  in  such  cases  a  woman  is  liable  to  transmit 
the  disease  to  a  foster-child,  but  certainly  it  is  not  justifiable  to 
run  the  risk  ;  moreover,  if  her  infant  be  syphilitic  the  mother 
may  at  any  time  develop  manifestations  of  syphilis,  for  instance 
condylomata,  from  which  infection  might  be  conveyed  to  a  foster- 
child  ;  for  these  reasons  it  is  important  to  exclude  as  far  as 
possible  syphilis  in  her  offspring  as  well  as  in  the  wet-nurse  her- 
self. Now  as  I  have  shown  elsewhere,  the  first  manifestations 
of  syphilis  in  an  infant  may  be  delayed  at  least  as  late  as  the 
third  month,  and  occasionally  they  are  delayed  much  longer ; 
clearly  every  week  of  freedom  from  evidence  of  syphilis  in  the 
infant  adds  to  the  security  against  syphilis  in  the  wet-nurse,  and, 
therefore,  if  the  milk  is  equally  suitable  in  quality  when  her  own 
infant  is  two  or  three  months  old,  it  is  better  to  engage  a  wet- 
nurse  whose  infant  has  reached  that  age,  than  to  engage  one 
whose  infant  is  only  two  or  three  weeks  old. 

In  view  of  the  evidence  which  has  accumulated  now  as  to  the 
value  of  the  Wassermann  test,  this  should  certainly  be  done  as 
part  of  the  examination  of  the  wet-nurse  if  there  is  the  slightest 
ground  for  supposing  that  syphilis  may  be  present.  There  are 
those  indeed  who  hold  that  it  should  be  done  in  every  case  before 
a  wet-nurse  is  engaged,  but  often  it  is  impracticable,  and  in  many 
cases,  for  instance  where  the  wet-nurse  is  a  married  woman  with 
several  healthy  children,  it  is  unnecessary. 

It  is  usually  taught  that  much  attention  should  be  paid  to  the 


28  COMMON  DISORDERS  OF  CHILDHOOD 

appearance  of  the  woman's  breasts,  their  size  and  fullness,  and 
to  her  own  healthy  appearance  ;  as  a  matter  of  experience  ] 
think  these  are  most  fallacious  guides  ;  it  is  of  much  more 
importance  to  know  how  her  milk  has  suited  her  own  infant. 
I  have  seen  fine  healthy-looking  girls  with  excellent  breasts  fail 
completely  as  wet-nurses,  whilst  a  sickly,  pale  girl,  with  flabby 
empty-looking  breasts,  has  nursed  an  infant  for  many  months 
with  excellent  result.  But  even  the  effect  of  her  milk  on  her 
own  child  is  not  an  absolutely  reliable  guide,  for  it  does  not 
always  follow  that  one  who  has  successfully  nursed  her  own 
infant  can  equally  successfully  nurse  another  infant  ;  nor  indeed 
does  it  follow  that  if  she  has  failed  with  one  infant  she  will  fail 
with  another.  It  has  been  shown  that  breast-milk  which  dis- 
agrees entirely  with  one  infant  may  suit  another  admirably,  and 
I  have  seen  the  converse,  a  milk  which  had  suited  one  infant  well 
for  several  weeks  producing  green  and  loose  stools  in  another 
infant.  In  fine,  it  comes  to  this,  a  wet-nurse  is  always  an 
experiment. 

I  am  much  inclined,  in  the  rare  cases  where  it  is  practicable,  to 
have  a  wet-nurse's  own  infant  with  her  ;  for  I  have  so  often  seen 
a  good  wet-nurse  become  homesick,  or  fretting  as  to  her  own 
infant  who  is  away  from  her,  with  the  result  that  her  milk  has 
either  begun  to  disagree  with  the  foster-child,  or  has  fallen  off  in 
quantity.  There  is  a  great  tendency  to  treat  these  wromen, 
especially  if  they  be  unmarried,  as  mere  machines  for  the  supply 
of  milk  ;  no  sooner  is  the  baby  satisfied  than  he  is  taken  away  from 
the  wret-nurse  and  she  is  hustled  out  of  the  room,  perchance  to 
mope  or  to  idle  away  her  time  in  some  distant  part  of  the  house, 
until  the  next  feed  is  due.  This  is  bad  from  every  point  of  view  ; 
a  wet-nurse,  even  though  she  be  unmarried — possibly  even  more 
on  that  account — needs  kindness  and  consideration.  It  may  be 
that  if  she  were  allowed  to  do  more  for  the  infant  than  merely 
feed  it,  the  satisfaction  of  her  maternal  instinct  would  go  far  to 
keep  her  milk  in  good  condition  ;  employment  of  some  kind 
must  be  found  for  a  wet-nurse  if  her  milk  is  to  continue  good, 
and  I  know  of  no  better  way  of  employing  her  than  in  looking 
after  the  needs  of  the  infant  beyond  its  meals.  Of  course,  strict 
supervision  is  necessary,  but  if  those  under  whom  the  wet-nurse 
is  placed,  the  domestic  nurse  and  the  trained  nurse,  are  tactful 
persons,  this  can  be  done  without  making  the  wet-nurse  feel,  as 
is  too  often  the  case,  that  she  is  a  prisoner  watched  night  and 
day  and  never  trusted  to  handle  the  infant  except  at  its  meals. 
If  there  is  accommodation  for  the  wet-nurse's  own  child,  it 


BREAST-FEEDING  AND  ITS  LIMITATIONS          29 

must,  of  course,  in  most  cases  be  fed  by  hand  entirely,  and 
supervision  will  be  necessary  to  prevent  surreptitious  suckling 
of  the  infant ;  but  it  will  sometimes  be  good  policy  to  allow 
breast-feeding  of  this  infant  once  or  twice  a  day,  for,  compared 
with  the  small  wants  of  the  wasted  feeble  foster-child,  not  only 
may  its  stronger  sucking  and  large  appetite  encourage  the  flow 
of  milk,  but  the  mental  satisfaction  of  the  wet-nurse  may  be  well 
purchased  at  the  price  of  depriving  the  foster-child  of  one  or 
two  breast-feeds  daily,  and  substituting  hand-feeds  therefor. 
In  any  case  there  must  be  no  suckling  of  the  wet-nurse's  offspring 
in  the  two-  or  three-hourly  intervals  between  the  breast-feeding 
of  the  foster-child,  for  this  would  entail  shortening  of  the 
intervals  between  suckling  and  so  probably  alter  the  composition 
of  the  milk  by  increasing  the  curd  :  any  suckling  of  the  wet- 
nurse's  child  must  take  place  at  the  time  when  a  feed  would  have 
been  due  for  the  foster-child. 

A  wet-nurse  usually  requires  supervision  outdoors  even  more 
thai  indoors  ;  some  trustworthy  person  should  accompany  her 
whenever  she  goes  out  ;  otherwise  if  her  child  or  her  home  be 
near  enough,  she  will  certainly  go  thither  and  perchance  bring 
back  infection  or  livestock,  or  she  may  obtain  drink  or  eatables 
which  will  disturb  the  character  of  her  milk.  Lastly,  it  is  very 
necessary  to  make  quite  sure  that  the  wet-nurse's  bowels  act 
regularly  ;  an  aversion  to  taking  aperients  leads  a  wet-nurse 
sometimes  to  conceal  the  fact  that  she  is  constipated,  and  for 
this  reason  it  may  be  necessary  even  to  arrange  for  inspection  of 
the  daily  evacuation. 

With  all  these  difficulties  it  is  hardly  to  be  wondered  at  that 
the  use  of  wet-nurses  is  generally  recognized  as  an  extreme 
resource  ;  no  one  can  be  more  cognizant  of  these  obstacles  than 
I  am,  but,  none  the  less,  I  have  seen  so  many  wasting  infants 
saved  from  what  appeared  to  be  certain  death  by  the  use  of 
a  wet-nurse,  that  I  feel  sure  it  is  a  resource  which  should 
always  be  recommended  if  necessary. 

Lastly,  it  is  worth  remembering  that  if  a  wet-nurse  cannot  be 
obtained  there  may  be  some  neighbouring  mother  who  cannot 
leave  her  house,  but  has  an  abundant  supply  of  milk  from  which 
she  would  be  willing  to  spare  some,  if  it  were  drawn  off  once  or 
twice  a  day  to  be  given  by  bottle  to  the  wasting  infant.  Even 
a  couple  of  feeds  of  breast-milk  daily  for  a  week  or  two  may  be  of 
vital  importance  to  such  an  infant.  Valuable  help  has  even  been 
obtained  by  making  a  collection  daily  of  small  quantities  of 
breast-milk  from  several  mothers,  and  so  obtaining  enough  for 
a  feeble  infant. 


CHAPTER  III 

THE   MODIFICATION  OF  COW'S   MILK  FOB 
INFANT-FEEDING 

I  SUPPOSE  that  most  of  us  when  we  first  entered  upon  the 
practice  of  our  profession  cherished  a  faith  that,  failing  the 
mother's  milk,  the  only  proper  food  for  an  infant  was  cow's  milk, 
and  that  it  was  the  simplest  thing  in  the  world  to  feed  an  infant 
successfully  if  only  this  golden  rule  were  remembered.  A  very 
little  experience,  alas  !  and  any  such  belief  in  the  simplicity  of 
infant-feeding  has  been  rudely  shaken  ;  often,  indeed,  if  cow's 
milk  is  ordered  at  all,  it  is  ordered  with  fear  and  trembling,  and 
on  the  first  sign  of  its  disagreeing,  recourse  is  had  to  some  patent 
food  or  condensed  milk. 

Far  be  it  from  me  to  pass  any  sweeping  condemnation  on  such 
methods  of  feeding  ;  it  is  the  abuse,  not  the  use  of  these  foods 
and  condensed  milks  which  is  so  disastrous  ;  used  with  an 
intelligent  appreciation  of  their  composition,  and  of  the  ages 
and  conditions  for  which  they  are  suitable,  they  undoubtedly 
have  their  value.  But  none  the  less  it  is  true  as  a  general 
statement  that  there  is  not  a  single  patent  food  or 
condensed  milk  in  the  market  which  can  adequately  replace 
fresh  cow's  milk  in  the  feeding  of  an  infant  who  is  deprived  of  the 
mother's  milk  ;  and,  moreover,  that  a  vast  amount  of  infantile 
suffering  and  misery,  and  no  small  sacrifice  of  infant  life,  are  due 
solely  to  the  indiscriminate  feeding  of  infants  with  these  artificial 
preparations. 

Even  when  the  unsatisfactory  result  of  such  resources  is 
evident  in  gastro-intestinal  trouble  of  one  kind  or  another,  or  in 
failure  to  gain  weight  as  the  infant  should,  any  proposal  to  give 
cow's  milk  is  commonly  met  with  the  objection,  '  It  is  no  use 
ordering  cow's  milk  ;  we  have  tried  that,  and  the  baby  can't 
take  it.'  In  such  cases  the  question  always  arises  in  my  mind, 
'  Has  sufficient  care  been  taken  in  the  modification  of  the  milk  ?  ' 
Too  often  one  finds  that  a  mixture  has  been  used  which  differs 
so  widely  from  human  milk  that  it  is  little  wonder  if  the  infant  fails 
to  thrive  upon  it.  Judging  from  my  own  experience,  I  am 
inclined  to  think  that  there  is  a  certain  number  of  infants  who 


COW'S  MILK  FOR  INFANT-FEEDING  31 

cannot  take  cow's  milk,  modify  it  as  you  will  ;  but  I  am  con- 
vinced that  this  number  is  extremely  small,  and  that  the  vast 
majority  of  infants  will  thrive  excellently  on  cow's  milk,  provided 
this  has  been  properly  modified. 

The  first  and  absolute  essential  for  the  intelligent  modification 
of  cow's  milk  for  infant-feeding  is  a  knowledge — I  mean  a  practical 
working  knowledge — of  the  exact  average  composition  of  human 
milk  and  cow's  milk.  Undoubtedly  mere  rule  of  thumb  will  serve 
for  the  feeding  of  many  a  vigorous  infant  ;  but  if  our  sole  idea  of 
modification  of  milk  is  to  dilute  it  once,  twice,  or  thrice,  and  throw 
in  '  a  little  sugar  '  and,  perchance,  '  some  cream,'  trusting  to 
luck  or  to  the  mother,  or,  worse  still,  to  the  monthly  or  domestic 
nurse,  to  adjust  the  proportions,  we  shall  certainly  have  many 
failures  in  our  efforts  to  feed  even  healthy  infants,  and  many 
more  in  the  case  of  weakly  infants  or  those  whose  digestion  has 
already  been  impaired  by  disease  or  unsuitable  diet.  It  is 
especially  these  more  difficult  cases — and  are  they  not  common 
enough  in  every  one's  practice  ? — in  which  accurate  and  intelli- 
gent modification  of  cow's  milk  is  all-important. 

Now,  as  in  this  chapter  I  shall  have  to  refer  again  and  again  to 
the  percentage  composition  of  milk  and  of  various  modifications 
of  milk,  let  me  say  at  the  outset  that  such  percentages  are  only 
a  convenient  method  of  calculating  approximately  the  composi- 
tion of  the  food  ;  and  for  clinical  purposes  a  strictly  exact  per- 
centage of  anyone  constituent  is  neither  necessary  nor  practicable. 
We  have  heard  a  great  deal  recently  about  'percentage-feeding  ', 
as  if  it  were  some  great  discovery.  There  is  nothing  new  in 
'  percentage-feeding' ;  like  Monsieur  Jourdain  with  his  '  prose  ', 
we  have  used  it  all  our  medical  lives,  whether  we  knew  it  or  not  ; 
the  only  innovation — and  a  very  important  one — is  that  the 
medical  man  should  know  approximately  what  percentage  he  is 
giving.  It  makes  no  difference  whatever,  whether  the  medical 
man  prescribes  equal  parts  of  milk  and  water,  or  prefers  to  order 
casein,  1-625  per  cent.  ;  lactalbumen,  0-375  per  cent.  ;  fat,  1-75 
per  cent.,  &c.  (assuming  the  average  composition  of  cow's  milk 
to  be  as  stated  below) ;  but  it  does  make  a  very  great  difference 
whether  he  realizes  that  the  difficulty  in  digesting  cow's  milk  lies 
in  the  large  proportion  of  casein  l  which  it  contains,  and  whether 
he  understands  how  to  get  over  this  difficulty  without  reducing 

1  The  terms  casein  and  caseinogen,  strictly  used,  refer  respectively  to  the 
formed  curd  and  the  potential  curd,  i.e.  the  curd-forming  proteid  before  it  is 
coagulated ;  for  brevity'  sake  the  term  casein  has  been  used  sometimes 
where  caseinogen  would" have  been  more  strictly  accurate. 


32  COMMON  DISORDERS  OF  CHILDHOOD 

the  other  important  constituents  of  milk  to  a  harmful  degree, 
or  falling  into  the  not  less  disastrous  mistake  of  making  the  food 
too  rich  in  cream  or  sugar. 

Below  is  shown  the  average  composition  of  human  milk  and 
cow's  milk.  For  convenience'  sake  I  shall  leave  the  salts  out  of 
consideration;  they  undoubtedly  have  their  importance,  but  we 
know  so  little  about  them,  and  they  probably  play  such  a  com- 
paratively insignificant  part  in  nutrition,  that  it  is  hardly  worth 
while  to  burden  our  memories  with  their  percentage.  The  pro- 
portion of  water  can  also  be  left  unmentioned  ;  it  forms,  of 
course,  the  residue  of  the  percentage. 

Human  milk.  Cow's  milk. 

Casein,  I  Casein, 

Proteid,  0-6  per  cent.  Proteid,  3-25  per  cent. 

2  per  cent.      Lactalbumen,  4  per  cent,  j  Lactalbumen, 

14  per  cent.  (        0-75  per  cent. 

Fat,  3-5  per  cent.  Fat,  3-5  per  cent. 

Sugar,  7  per  cent.  Sugar,  4  per  cent. 

Proteids.  The  one  great  obstacle  to  the  digestion  of  cow's 
milk  is  the  large  quantity  of  curd  which  is  formed  when  it 
enters  the  stomach,  and  this  is  due  to  the  heavy  percentage  of 
caseinogen  which  it  contains.  This  caseinogen  forms  a  curd 
when  mixed  either  with  acid  or  with  rennet,  whereas  the 
remaining  proteid,  lactalbumcn,  is  only  coagulated  by  heating 
above  160°  F. 

Lactalbumen  is  so  easy  of  digestion  that  so  far  as  this  portion 
of  the  proteid  is  concerned  no  dilution  of  cow's  milk  is  necessary ; 
the  only  object  of  dilution  is  the  reduction  of  the  casein  to  a 
proportion  which  the  infant  can  digest. 

If  human  milk  is  to  be  taken  as  the  measure  of  a  healthy  infant's 
power  of  digestion,  it  is  clear  that  in  order  to  reduce  the  propor- 
tion of  casein  in  cow's  milk  to  this  standard,  considerable  dilution 
is  necessary.  Fortunately  nature  has  provided  even  the  youngest 
infant  with  some  range  of  accommodation  in  its  powers  of  diges- 
tion, and  many  an  infant  will  digest  a  larger  proportion  of  casein 
in  cow's  milk  than  the  average  composition  of  mother's  milk 
might  suggest. 

But,  notwithstanding  this  power  of  accommodation,  I  think 
I  shall  be  correct  in  saying  that  a  large  majority  of  the  failures 
in  infant-feeding  with  cow's  milk  are  due  to  insufficient  dilution. 

For  an  infant  two  or  three  weeks  old  it  is  a  common  practice 
to  order  a  mixture  of  one  part  of  milk  with  two  parts  of  water — 
that  is,  1  in  3.  This,  of  course,  means  division  of  each  percentage 


COW'S  MILK  FOR  INF  ANT -FEEDING  33 

by  3  ;    and  a  comparison  with  human  milk  shows  how  widely 
such  a  mixture  differs  therefrom. 

Human  milk.  Cow's  milk  and  water,  1  in  3. 

(  Casein,  /  Casein, 

Proteid,  0-6  per  cent.  Proteid,  1-08  per  cent. 

2  per  cent.  ,  Lactalbumen,  1-3  per  cent.  1  Lactalbumen, 

(      1.4  per  cent  {      0-25  per  cent. 

Fat,  3-5  per  cent.  Fat,  1-16  per  cent. 

Sugar,  7  per  cent.  Sugar,  1-3  per  cent. 

The  casein  is  still  nearly  double  the  proportion  which  occurs 
in  human  milk.  (I  am  not  at  present  considering  the  other 
constituents  ;  my  object  now  is  only  to  show  how  far  the  ordinary 
dilution  fails  in  its  sole  purpose — namely,  the  reduction  of  the 
casein,  the  curd  proteid.) 

Even  if  three  parts  of  water  are  used  with  one  of  milk, 
there  is  still  a  slight  excess  of  casein,  as  can  be  seen  from  the 
following  comparison  (the  percentages  will,  of  course,  be 
divided  by  4)  : 

Human  milk.  Cow's  milk  and  water,  1  in  4. 

f  Casein,  (  Casein, 

Proteid,                 0-6  per  cent.  Proteid,                 0-81  per  cent. 

2  per  cent,  j  Lactaibumen,  1  per  cent,  j  Lactalbumen, 

1      1-4  per  cent.  I      0- 18  per  cent. 

Fat,  3-5  per  cent.  Fat,  0-87  per  cent. 

Sugar,  7  per  cent.  Sugar,  1  per  cent. 

It  is  evident  that  in  order  to  reduce  the  curd-forming  proteid 
to  the  same  proportion  as  is  present  in  the  mother's  milk,  four 
parts  of  diluent  must  be  added  to  one  part  of  milk  (1  in  5).  The 
percentages  will  thus  be  divided  by  5,  and  the  result  will  be  as 
shown  here  : 

Human  milk.  Cow's  milk  and  water,  1  in  5. 

I  Casein,  (  Casein, 

Proteid,                 0-6  per  cent.  Proteid,                    0-65  per  cent. 

2  per  cent.  1  Lactalbumen,  0-8  per  cent.  1  Lactalbumen, 

(      1-4  per  cent.  1      0-1 5  per  cent. 

Fat,  3-5  per  cent.  Fat,  0-7  per  cent. 

Sugar,  7  per  cent.  Sugar,  0-8  per  cent. 

But  how  often  is  milk  diluted  to  this  extent  ?  Hardly  ever, 
even  during  the  first  few  weeks  of  the  infant's  life  ;  and  yet  it  is 
considered  a  matter  of  surprise — or  at  any  rate  an  evidence  of 
some  peculiar  weakness  in  the  infant's  digestion — that  an  infant 
suffers  with  colic  or  vomiting  or  other  gastro -intestinal  trouble, 
and  fails  to  thrive  when — say  at  four  weeks -old — it  is  having 
milk  diluted  with  only  two  parts  of  water  or  barley-water.  Surely 

STILL  T\ 


34  COMMON  DISORDERS  OF  CHILDHOOD 

the  wonder  is  that  so  many  infants  manage  to  digest  their 
food  in  spite  of  the  excess  of  curd  which  the  usual  dilution 
entails. 

Now  I  do  not  for  a  moment  wish  to  advocate  any  extreme 
dilution  for  the  vigorous  infant  who  can  digest  the  larger  pro- 
portion of  curd — the  more  of  this  that  the  child  can  take  and 
digest  the  better — but  I  do  wish  to  insist  very  strongly  on  the 
necessity  for  more  accurate  modification  of  cow's  milk,  if  only  in 
respect  of  the  faulty  excess  of  curd,  before  rejecting  this  food  in 
favour  of  any  of  the  far  less  satisfactory  substitutes  with  which 
the  market  is  flooded. 

In  a  very  large  number  of  cases  where  milk-feeding  is  tried  and 
found  wanting,  the  failure  is  due  simply  to  insufficient  dilution. 
Even  at  the  age  of  four  or  five  months  some  infants  cannot  digest 
a  mixture  of  equal  parts  of  cow's  milk  and  water  (casein,  1-6 
per  cent.)  ;  and  when  it  is  remembered  that  the  proportion  of 
curd  in  mother's  milk  scarcely  increases  at  all  during  the  Jater 
months  of  lactation,  we  might  expect  that  even  at  such  an  age 
it  may  be  necessary  to  dilute  cow's  milk,  if  not  to  so  great  an 
extent  as  in  the  earlier  months,  at  any  rate  much  further  than  is 
usually  done. 

So  far  I  have  considered  only  the  curd-forming  proteid  in  cow's 
milk,  but  obviously  any  such  dilution  as  I  have  mentioned 
involves  serious  alteration  in  the  proportion  of  the  other  con- 
stituents also  ;  and  no  doubt  it  is  this  fact  which  accounts  for 
the  common  practice  of  insufficient  dilution. 

The  proportion  of  lactalbumen,  which  at  the  outset  is  little 
more  than  half  that  in  human  milk,  becomes  still  more  deficient 
if  fhe  ordinary  diluents,  such  as  water,  barley-water,  lime- 
water,  &c.,  are  used. 

On  this  point  I  shall  have  more  to  say  later  ;  here  I  will  only 
point  out  that  whilst  it  is  the  proportion  of  casein,  not  the  pro- 
portion of  total  proteids,  which  has  to  be  corrected  by  dilution,  it 
is,  nevertheless,  important  that  the  resulting  total  of  casein 
plus  lactalbumen  should  not  be  far  below  that  present  in  human 
milk.  The  right  course  in  determining  the  degree  of  dilution  in 
any  case  where  there  is  difficulty  of  curd-indigestion,  is  to  deter- 
mine it  solely  with  reference  to  the  proportion  of  curd-forming 
proteid  which  the  infant  can  digest,  and  then  in  one  way  or 
another  to  rectify  as  far  as  possible  the  deficiency  of  lactalbumen, 
fat,  and  sugar.  It  is  the  curd-forming  part  of  the  proteids — the 
casein  alone — not  the  lactalbumen,  which  has  to  be  considered 
in  deciding  what  degree  of  dilution  is  necessary. 


COW'S  MILK  FOR  INFANT-FEEDING  35 

Having  said  thus  much  as  to  the  theoretical  grounds  which 
determine  the  dilution  of  cow's  milk,  I  hope  I  shall  not  appear 
inconsistent  when  I  say  that  there  is  no  need  whatever  to  work 
out  mathematical  calculations  or  percentage  problems  in  every 
case  of  infant-feeding  that  comes  before  us.  Common  experience 
has  determined  what  dilution  is  sufficient  to  overcome  the  curd 
difficulty  for  a  healthy  infant  with  ordinarily  good  digestion,  and 
as  a  matter  of  routine  it  is  more  convenient  to  remember  these 
data  of  experience  in  simple  terms  of  dilution  than  in  any  formulae 
of  percentage  composition. 

Only  let  the  medical  man  carry  in  his  mind  the  exact  com- 
position of  milk  so -that  at  any  time,  when  it  may  be  necessary, 
he  can  calculate  readily  the  exact  composition  of  a  particular 
mixture.  The  ability  to  do  this  sometimes  means  all  the  differ- 
ence between  success  and  failure  in  infant-feeding,  especially  in 
those  difficult  cases  where  a  minute  variation  in  the  proportion 
of  this  or  that  constituent  of  the  feed  is  sufficient  to  disturb 
digestion. 

For  the  healthy  infant,  experience  shows  that,  as  a  general 
rule,  the  following  dilutions  are  successful  : 

Age.  Dilution. 

3  months  ....  Equal  parts  of  milk  and  diluent. 

6  months  ....  Twice  as  much  milk  as  diluent. 

9  months  ....  Three  times  as  much  milk  as  diluent. 

The  advance  from  one  dilution  to  another  is,  of  course,  to  be 
made  gradually,  the  more  gradually  the  better  ;  and  it  is  always 
to  be  remembered  that  heal  thy  infants  vary  in  their  requirements, 
so  that  a  mixture  which  may  be  strong  enough  to  nourish  one 
infant  perfectly,  may  be  insufficient  for  another  ;  some  infants 
will  do  well  on  equal  parts  of  milk  and  water  as  early  as  eight 
weeks  old,  nay  there  are  medical  men  who  advocate  for  infants 
undiluted  milk  from  a  few  weeks  old,  but,  none  the  less,  I  think 
that  the  proportions  mentioned  above  may  be  taken  as  good 
working  standards,  and  that  trouble  arises  far  more  often  from 
diluting  too  little  than  from  diluting  too  much. 

The  dilution  given  at  the  age  of  three  months  is  reached  by 
a  gradual  advance  from  birth  thus  : 

Age.  Milk.          Diluent. 

At  birth  ...  1  4 

One  week         ...  1  3 

One  month      ...  1  2 

Two  months  ...  1  1  \ 

Three  months  .  1  1 

D2 


30  COMMON  DISORDERS  OF  CHILDHOOD 

Ay  will  be  seen,  the  proportions  mentioned  above,  if  expressed 
in  terms  of  percentage  composition,  would  be  as  follows  : 

Age.  Proteid.         Approximate  Composition  of  Proteid. 

3  months  2-0  per  cent.  Casein  1-6 

Lactalbumen  0-4 
6  months  2*  6  per  cent.  Casein  2-1 

Lactalbumen  0-5 
9  months  3-0  per  cent.  Casein  2-4 

Lactalbumen  0-6 

It  seems  likely  that  the  proportion  of  proteid  in  these  mixtures 
is  more  than  is  absolutely  necessary  ;  in  human  milk  the  total 
proteid  is  often  below  2  per  cent,  at  any  period  of  lactation :  and 
experience  seems  to  show  that,  so  long  as  the  deficiency  of  fat 
and  sugar  in  diluted  cow's  milk  is  corrected,  a  proportion  of 
about  2  per  cent,  of  proteid  or  very  slightly  above,  is  sufficient. 
But  in  this  very  correction  lies  a  practical  difficulty  ;  the  sugar  is 
easily  enough  arranged,  but  the  fat  cannot  always  be  adjusted 
conveniently  ;  cream  is  not  always  easily  obtained,  and  if  it  is, 
may  be  of  doubtful  quality,  so  that  we  are  constrained  sometimes, 
especially  in  dealing  with  the  poor,  to  use  mixtures  in  which 
nothing  further  is  attempted  than  simple  dilution  and  addition 
of  sugar.  Under  these  circumstances  it  is  important  that  the 
dilution  should  be  as  little  as  is  consistent  with  digestion,  lest  the 
deficiency  of  fat  give  trouble  by  inducing  rickets  or  otherwise 
interfering  with  nutrition.  As  a  matter  of  experience,  I  think 
it  may  be  said  that  given  a  fairly  good  milk  supply,  dilution  in 
the  proportions  mentioned  above  gives  just  a  sufficiently  high 
proportion  of  fat  to  avoid  the  occurrence  of  rickets. 

There  are,  of  course,  other  factors  in  the  production  of  rickets 
besides  deficiency  of  fat  in  the  diet  ;  the  presence  of  starch, 
especially  of  much  starch,  may  prevent  the  assimilation  of  the 
fat  that  is  present  and  so  aggravate  the  evil  of  a  low  proportion 
of  fat  :  but  assuming  that  a  milk  mixture  is  given  which  contains 
no  starch,  the  above  proportions  can  safely  be  used  without 
addition  of  cream.  Any  further  dilution  makes  some  compen- 
satory addition  of  fat  necessary,  if  the  risk  of  rickets  is  to  be 
avoided. 

Cream  and  fat.  The  methods  of  correcting  deficiency  of  fat 
in  the  food  are  worthy  of  careful  study. 

However  little  cow's  milk  is  diluted,  there  is  necessarily  some 
deficiency  of  fat  in  the  mixture  ;  compare,  for  instance,  the 
following  mixtures  of  cow's  milk  and  water,  with  human 
milk  : 


COW'S  MILK  FOR  INFANT-FEEDING  37 

Human  milk.            Cow's  milk  and  water  Cow's  milk,  2  parts  / 

Equal  parts.  Water,  1  part . 

Proteid  2                           Proteid  2  Proteid  2-6  per  cent. 

Fat        3-5                        Fat         1-75  Fat        2-2  per  cent. 

Sugar     7-0                        Sugar    2-0  Sugar    2-6  per  cent. 

Our  aim  should  be  to  give  a  proportion  of  fat  corresponding  as 
closely  as  possible  to  that  present  in  human  milk,  say  3-3-5  per 
cent,  of  fat. 

If  we  had  a  standardized  cream,  it  would  be  perfectly  simple  to 
correct  the  percentage  of  fat  in  our  diluted  mixture  by  addition 
of  the  required  proportion  of  cream.  Such  a  cream  is  much 
needed  ;  at  the  present  time,  so  far  as  I  know,  there  is  only  one 
dairy  in  London  which  regularly  supplies  a  cream  warranted 
to  contain  a  constant  and  declared  percentage  of  fat.  But  in 
the  absence  of  such  cream  what  is  to  be  done  ?  There  are 
several  ways  of  getting  out  of  the  difficulty.  It  is  sometimes 
convenient  to  use  *  top-milk  ',  by  which  is  meant  the  upper 
portion  of  milk  which  has  been  allowed  to  stand  in  a  vessel 
until  the  cream  (i.e.  the  fat)  has  risen  to  the  top;  if  this 
upper  part  be  used  for  dilution  instead  of  the  lower,  it  has 
the  advantage  of  containing  the  additional  fat  which  has  risen 
from  the  lower  part,  whilst  the  proportion  of  proteids  is  scarcely 
altered,  so  that  the  result  of  subsequent  dilution  is  to  diminish 
the  proteid  without  causing  as  great  a  deficiency  of  fat  as  occurs 
when  ordinary  milk  is  diluted. 

With  average  London  milk  (i.e.  milk  which  contained  3-2  to 
3-5  per  cent,  of  fat)  which  had  been  allowed  to  stand  three  hours, 
I  obtained  the  following  results  : 

Quantity  of  top-milk  taken  from  one  quart  of  Proportion 

milk  after  three  hours.  of  fat. 

1  pint          .....       5-5  per  cent. 

15  ounces      .....       6-5  per  cent. 

10  ounces      .         .         .         .         .8-0  per  cent. 

5  ounces      .....     11-0  per  cent. 

But  such  a  method  is  unsatisfactory  ;  the  resulting  percentages 
of  fat  are  subject  to  considerable  variation,  and  as  this  variation 
occurs  in  a  comparatively  small  percentage,  it  makes  the  use  of 
such  cream  unreliable  where  accurate  modification  of  milk  is 
necessary.  The  richer  gravity  cream — that  is,  cream  made  by 
allowing  milk  to  stand  several  hours,  and  then  skimming  off 
the  cream  which  has  risen  without  taking  with  it  any  of  the  milk 
below  the  level  of  the  cream — is  open  not  only  to  the  objection 
of  variability  of  richness,  but  also  to  a  more  serious  one,  namely, 


38  COMMON  DISORDERS  OF  CHILDHOOD 

that  its  preparation  involves  prolonged  standing  of  the  milk, 
which  at  any  time,  but  especially  in  warm  weather,  is  accom- 
panied with  risk  of  chemical  change  from  bacterial  contamina- 
tion. I  have  known  cream  to  be  prepared  in  this  way  by  allowing 
ordinary  London  milk  to  stand  as  long  as  twelve  hours  after  it 
had  been  delivered  to  the  retail  purchaser,  and  as  such  milk  was 
probably  at  least  twelve  hours  stale  when  it  was  delivered,  and 
the  cream  from  it  would  be  used  for  infant-feeding  several  hours 
after  its  preparation  was  completed,  the  practical  risk  of  bacterial 
contamination  must  be  a  very  real  one,  however  much  it  may 
be  possible  in  theory  to  reduce  it  by  special  precautions. 

In  the  country,  where  milk  is  available  for  home  use  almost 
directly  it  is  drawn  from  the  cow,  this  objection  is  less  serious  ; 
but  even  so  it  cannot  be  desirable  that  milk  should  be  left  standing 
fifteen  to  seventeen  hours,  as  it  sometimes  is,  for  the  cream  to 
rise.  Where,  however,  only  such  cream  is  available,  it  may  be 
useful  to  know  that  a  quart  of  milk  allowed  to  stand  twelve  to 
fifteen  hours  at  the  ordinary  temperature  of  a  cool  dairy  will  yield 
a  cream  containing  17  to  25  per  cent,  of  fat  ;  and,  as  a  working 
hypothesis,  it  is  safe  to  assume  that  simple  gravity  cream  (not 
clotted  cream)  contains  24  per  cent,  of  fat  ;  some  samples  will 
contain  less,  very  few  will  contain  more. 

Far  better  than  any  such  methods  is  the  use  of  centrifugal 
cream,  such  as  is  supplied  by  any  of  the  large  dairy  companies 
in  London  and  is  commonly  sold  in  the  shops  of  London  and  other 
large  towns.  In  the  preparation  of  this  cream  there  is  no  stand- 
ing of  the  milk  for  many  hours  ;  the  cream  can  be  separated 
from  the  milk  in  a.  few  minutes  by  a  centrifugal  machine,  and  with 
such  a  machine  working  at  a  fairly  constant  rate  the  cream  made 
at  any  particular  dairy  shows  only  slight  variations  in  strength. 

Out  of  twenty-three  samples  bought  from  twelve  shops  in 
various  parts  of  London,  sixteen  showed  a  proportion  of  fat 
between  40  and  50  per  cent.  ;  only  three  contained  less  than  40 
per  cent.  (36,  36-8,  and  38-4  per  cent,  respectively)  ;  five  showed 
proportions  varying  from  50  to  54  per  cent.  ;  the  average  fat 
percentage  of  the  whole  twenty-three  samples  was  46-3. 

Now  the  addition  of  fat  which  is  required  in  any  mixture  for 
infant -feeding  is  practically  never  more  than  3  per  cent.,  and 
much  more  often  only  2  or  2-5  per  cent,  is  required.  In  order  to 
obtain  this  with  a  cream  containing  40  to  50  per  cent,  of  fat,  a 
dilution  of  1  in  16  at  least  is  necessary;  and  it  is  evident  that  an 
error  even  of  16  per  cent,  in  the  assumed  fat  percentage  of  the 
cream  would  involve  only  an  error  of  1  per  cent,  in  the  fat  of  the 


COW'S  MILK  FOR  INFANT-FEEDING  39 

mixture  ordered.  For  practical  purposes  48  per  cent,  may  be 
taken  as  the  average  proportion  of  fat  in  centrifugal  cream — this 
is,  I  think,  a  safer  average  than  46-3,  which  was  obtained  only 
when  the  few  exceptionally  low  percentages  were  included — and 
on  this  assumption  the  error  either  way  cannot  be  more  than  10 
per  cent,  at  the  utmost,  and  will  very  rarely  be  more  than  6  per 
cent,  in  either  direction  ;  so  that  if  we  ordered,  as  is  commonly 
necessary,  a  dilution  of  1  in  24 — that  is,  2  per  cent,  of  fat  (the 
cream  must  be  assumed  to  contain  48  per  cent,  of  fat), — the 
utmost  possible  error  is  less  than  0-5  per  cent,  in  either  direction, 
and  it  will  rarely  be  as  much  as  0-25  per  cent. 

It  is  therefore  a  perfectly  simple  matter  to  correct  the  fat 
deficiency  in  any  mixture.  For  example,  suppose  the  infant  is 
to  have  one  part  of  milk  with  three  of  water,  this  will  reduce  the 
fat  in  the  milk  from  3-5  to  0-8  per  cent,  approximately  ;  it  is 
necessary  to  add  sufficient  cream  to  raise  the  percentage  from 
0-8  to  3 — 3-5  per  cent.  The  addition  of  1  drachm  of  cream 
(assumed  to  contain  48  per  cent,  fat)  to  2J  ounces  of  the  mixture, 
i.e.  1  to  20,  will  be  the  addition  of  2-4  per  cent,  fat  approximately, 
raising  the  total  fat  percentage  of  the  mixture  to  3-2  per  cent. 

A  further  advantage  of  this  high-percentage  centrifugal  cream 
is  the  very  small  proportion  which  it  is  necessary  to  add  to  any 
milk  mixture  ;  this  makes  it  possible  to  neglect  all  the  other 
constituents  of  the  cream,  except  the  fat,  in  calculating  the 
resulting  percentages  in  the  mixture.  With  any  weaker  cream 
of  which  a  larger  quantity  must  be  added,  it  becomes  necessary 
to  consider  the  proteid  and  sugar  in  the  cream  as  well  as  in  the 
milk,  and  this  makes  the  matter  somewhat  complicated. 

I  have  sometimes  used  butter  dissolved  in  the  food,  and  have 
generally  found  that  infants  tolerated  it  well.  It  is  more  easily 
obtainable  by  the  poor  than  cream,  and  is  sometimes  available 
when  cod-liver  oil  is  not  at  hand  or  is  disliked.  By  the  addition 
of  a  piece  of  butter  about  three-quarters  of  an  inch  square  to 
a  four-ounce  feed  of  milk  and  water  the  fat  was  raised  from  1-5 
to  3-5  per  cent.  But  so  large  a  quantity  of  butter  may  disagree, 
and  for  an  infant  three  or  four  months  old,  I  have  usually  ordered 
a  piece  the  size  of  a  large  pea,  to  be  put  into  a  feed  of  three  or 
four  ounces  of  diluted  milk. 

I  do  not  think  this  method  is  to  be  recommended  where  other 
means  are  available  for  supplying  the  deficiency  ;  even  with 
vigorous  shaking  it  is  difficult  to  mix  the  butter  thoroughly  with 
the  rest  of  the  mixture  ;  the  taste  of  the  butter  is  very  obvious, 
and  may  be  distasteful ;  and  lastly,  butter  is  very  commonly 


40  COMMON  DISORDERS  OF  CHILDHOOD 

adulterated  with  other  substances,  especially  preservatives, 
which  may  prove  harmful  to  the  infant. 

Sugar.  I  come  now  to  the  correction  of  the  deficiency  of 
sugar,  which  is  easy  enough. 

But  here,  again,  I  must  point  out  that  Nature  is  not  the  hard 
taskmaster  which  some  writers  would  make  her,  and  it  is  not 
necessary  to  adhere  rigidly  to  any  exact  percentage.  Some  infants 
thrive  excellently  on  4  to  5  per  cent,  of  sugar,  while  others  will 
do  equally  well  on  8  to  10  per  cent.  But,  none  the  less,  I  think 
that  Nature  has  shown  us  the  most  generally  suitable  proportion 
in  the  milk  which  she  has  provided — namely,  the  mother's  milk, 
which  contains  6  to  7  per  cent,  of  sugar  ;  some  infants  are  troubled 
with  flatulence  or  colic  or  diarrhoea  directly  this  proportion  is 
exceeded  even  by  as  much  as  1  per  cent.  It  is  evident  that  in 
using  cow's  milk  for  infant-feeding,  even  if  it  were  used  undiluted, 
some  addition  of  sugar  would  be  desirable,  for  it  contains  only 
4  to  5  per  cent,  of  milk  sugar.  Dilution  involves  reduction  of 
this  proportion  ;  for  example,  if  milk  be  diluted  with  three 
parts  of  water,  the  percentage  of  sugar  will  be  only  1  per  cent. 

Elaborate  methods  have  been  devised  for  adding  the  exact 
quantity  of  sugar  necessary  to  yield  a  proportion  of  7  per  cent., 
and  with  this  object  some  writers  have  recommended  the  use  of 
a  solution  of  sugar  as  a  diluent  for  cow's  milk.  This  seems  to  me 
far  less  satisfactory  than  the  use  of  the  dry  sugar  itself  ;  the 
solution  is  much  less  convenient  for  storage,  arid  what  is  much 
more  important,  it  adds  an  unnecessary  risk  to  infant-feeding 
by  affording  an  excellent  medium  for  *the  growth  of  micro- 
organisms while  it  is  waiting  to  be  used.  The  argument  in 
favour  of  it  is  the  facility  it  offers  for  exactly  modifying  the 
percentage  of  sugar  when  a  standardized  solution  is  at  hand, 
and  this,  of  course,  is  easily  prepared. 

But  I  would  venture  to  object  that  in  the  first  place  no  such 
extreme  exactitude  is  necessary  ;  and  in  the  second,  a  quite 
sufficiently  exact  percentage  is  obtainable  by  simpler  methods. 

A  level  teaspoonful  (using  a  teaspoon  which  holds  2  drachms 
of  water,  i.e.  rather  a  large  domestic  teaspoon)  of  milk  sugar  in 
3  ounces  of  any  fluid  gives  a  5  per  cent,  solution  of  sugar.  There- 
fore if  this  quantity  be  added  to  a  three -ounce  feed  of  any  milk 
mixture,  5  per  cent,  of  sugar  has  been  added  ;  and  as  the  original 
proportion  of  sugar  in  the  mixture  is  readily  calculated  by  simple 
division,  according  to  the  number  of  times  the  milk  has  been 
diluted,  the  total  percentage,  after  addition  of  the  milk  sugar, 
is  known  without  any  difficulty.  Similarly  a  lump  of  ordinary 


COW'S  MILK  FOR  INFANT-FEEDING  41 

white  cane  sugar,  half  an  inch  square,  in  3  ounces  of  fluid,  gives 
a  5  per  cent,  solution. 

With  these  two  data  alone  it  is  easy  to  regulate  the  percentage 
of  sugar  accurately  enough  for  the  feeding  of  an  infant  with  the 
most  delicate  digestion.  The  quantity  of  sugar  which  must  be 
added  to  a  feed  of  any  amount,  or  of  any  proportions,  can  easily 
be  calculated,  and  also  easily  measured  with  sufficient  accuracy 
to  ensure  a  proportion  of  5  to  7  per  cent,  of  sugar.  As  a  matter 
of  fact,  with  any  of  the  ordinary  milk  mixtures  made  with  such 
diluents  as  water,  barley-water,  or  lime-water,  the  addition  of 
5  per  cent,  of  sugar  will  give  a  total  percentage  which  is  quite 
near  enough  to  Nature's  average  for  practical  purposes.  For 
instance,  if  the  milk  has  been  diluted  with  two  parts  of  water, 
the  sugar  will  have  been  reduced  to  1-3  per  cent.,  and  the  addition 
of  sugar  in  the  proportion  of  one  teaspoonful  of  milk  sugar,  or 
one  lump,  half  an  inch  square,  of  cane  sugar,  to  3  ounces  of  the 
milk  mixture,  will  raise  the  total  sugar  percentage  to  6-3  ;  while 
if  two  parts  of  milk  to  one  of  water  are  being  given,  the  mixture 
will  contain  2-6  per  cent,  of  sugar,  and  addition  of  sugar  in  the 
proportion  suggested  will  raise  the  percentage  to  7-6.  By  making 
the  added  teaspoonful  of  sugar  slightly  less  full,  or  reducing  the 
size  of  the  lump  of  the  sugar  added,  it  is  easy  to  keep  the  resulting 
percentage  within  the  7  per  cent,  limit,  if  desired. 

The  choice  between  milk  sugar  and  cane  sugar  is  not,  I  think, 
one  of  very  great  importance,  but  I  prefer  the  former  if  expense 
is  no  difficulty,  for  it  has  seemed  to  me  less  liable  to  cause  flatu- 
lence. The  result  of  modifying  milk  as  I  have  suggested  can  be 
seen  from  the  following  example,  in  which  a  3-ounce  mixture 
has  been  prepared,  containing  one  part  of  milk  with  three  parts 
of  water.  The  cream,  as  I  have  said,  may  be  considered  merely 
as  an  addition  of  fat  ;  its  fluid  bulk  and  also  its  proteid  and 
sugar  constituents  bear  so  minute  a  proportion  to  the  whole 
mixture  that  they  may  be  left  out  of  account  for  the  sake  of 
convenience. 

Mixture.  Resulting  percentages. 

Milk    ...       6  drachms.  Casein     .         .     0-81  per  cent. 

Water          .         .      18  drachms.  Lactalbumen  .     0-18  per  cent. 
Cream  (48  per  cent. 

fat)  .         .         -I?  drachms.  Fat     .     .         .3-87  per  cent. 

Milk  sugar  .         .     1  level  teaspoonful.  Sugar       .         .     6-00  per  cent. 

The  obvious  defect  in  such  a  mixture,  as  compared  with 
human  milk,  is  the  low  percentage  of  lactalbumen — a  defect 
which  is  present  to  some  extent  in  cow's  milk,  even  before 


42  COMMON  DISORDERS  OF  CHILDHOOD 

dilution,  but  which  is  increased  when  any  of  the  ordinary  diluents 
(water,  barley-water,  lime-water)  are  used  to  dilute  the  milk. 

Diluents.  What  diluent  is  best  in  the  modification  of  milk  ? 
In  theory  there  is  one,  and  only  one  ideal  diluent,  and  that  is 
whey.  Whey  is,  in  fact,  Nature's  diluent  for  milk,  and  milk 
may  be  regarded  as  whey  containing  in  suspension  curd-forming 
proteid  and  fat.  When  the  curd  is  strained  off  it  carries  with  it 
the  greater  part  of  the  fat,  and  there  is  left  a  clear  or  slightly 
turbid  fluid,  the  whey,  which  contains  all  the  original  constituents 
of  milk  except  the  casein  and  fat  (a  varying  proportion  of  the 
fat,  but  rarely  more  than  1  per  cent.,  according  to  my  own 
analyses,  can  be  retained  in  the  whey,  if  the  curd  is  thoroughly 
broken  up  before  straining)  ;  in  particular,  the  whey  contains 
practically  the  same  proportion  of  lactalbumen,  salts,  and  sugar, 
as  was  originally  present  in  the  milk. 

If,  therefore,  whey  be  used  as  a  diluent,  however  far  the  dilution 
be  carried,  in  order  to  reduce  the  proportion  of  curd-forming 
proteid,  there  will  be  no  dilution  whatever  of  the  lactalbumen. 

This  makes  an  apprec:able  difference  in  the  nutritive  value  of 
the  mixture.  In  the  example  given  above,  the  substitution  of 
whey  for  water  would  raise  the  proportion  of  lactalbumen  from 
0-18  per  cent,  to  0-75  per  cent.,  and  the  proportion  of  total 
proteids,  therefore,  from  about  1  per  cent,  to  1-5  per  cent.;  arid 
this  increase  in  the  proteids  is  obtained  without  increasing  the 
difficulty  of  digestion. 

The  use  of  whey  involves  some  care  in  its  preparation,  if  the 
whey  is  to  be  of  the  greatest  possible  value.  The  rennet  or 
curdling  ferment  which  is  used  to  prepare  the  whey  must  be 
destroyed  by  heat  before  the  whey  is  used  as  a  diluent,  otherwise 
the  ferment,  being  still  active,  will  curdle  the  milk  to  which  the 
whey  is  added  ;  but  if  a  temperature  above  160°  F.  is  used,  the 
lactalbumen  is  coagulated.  To  avoid  this,  a  temperature  of  150° 
to  155°  may  be  used,  which  destroys  the  ferment  but  does  not 
coagulate  the  lactalbumen. 

This  is,  I  think,  desirable,  but  not  absolutely  necessary  ;  the 
change  in  the  lactalbumen,  which  results  from  heating  even  to 
boiling-point,  seems  to  interfere  little,  if  at  all,  with  its  digesti- 
bility, and  probably  equally  little  with  its  nutritive  value.  Of 
course,  if  whey  is  used  as  a  diluent,  it  must  be  remembered  that 
the  percentage  of  sugar  in  the  milk  is  not  reduced  at  all,  and 
therefore  less  addition  is  necessary  to  raise  the  4  per  cent,  present 
to  the  required  6  to  7  per  cent.  The  fat  in  the  whey  must  also 
be  considered.  If  the  whey  has  been  made  without  breaking  up 


COW'S  MILK  FOR  INFANT-FEEDING  43 

the  curd  at  all,  the  amount  of  fat  present  (0-2  to  0-5  per  cent.) 
is  so  small  that  it  can  be  disregarded  ;  but  as  some  breaking 
up  of  the  curd  has  usually  taken  place  before  the  whey  is 
strained  off,  it  is  generally  more  accurate  and  certainly  safer 
for  practical  purposes  to  assume  that  the  whey  contains  1  per 
cent,  of  fat,  and  that  therefore  the  resulting  deficiency  of  fat, 
when  milk  is  diluted  with  whey,  is  1  per  cent,  less  than  it  would 
be  if  water  were  used  as  diluent. 

The  following  modification  may  be  compared  with  that  shown 
above : 

Mixture.  Resulting  percentages. 

Milk   ...       6  drachms.  Casein     .         .     0-81  per  cent. 

Whey          .         .     18  drachms.  Lactalbumen  .     0-75  per  cent. 

Cream     (48     per  Fat  .         .3-3  per  cent, 

cent,  fat)          .       1|  drachms.  Sugar      .         .6-50  per  cent. 
Milk   ...       I  level  teaspoon- 
ful. 

Here  the  proportion  of  curd-forming  proteid  has  been  reduced 
without  reducing  the  proportion  of  lactalbumen  ;  the  mixture 
approximates  more  nearly  to  human  milk  in  respect  of  its  lactal- 
bumen than  is  possible  with  any  other  diluent. 

But  the  preparation  of  whey  entails  a  certain  amount  of 
trouble  and  makes  infant-feeding  more  expensive  than  when 
plain  water  or  barley-water  is  used  as  diluent,  so  that  its  use, 
though  excellent  in  theory,  is  not  generally  practicable.  In 
many  cases,  however,  it  has  proved  useful,  and  I  have  found 
even  hospital  out-patients  willing  to  use  it  for  several  months. 

If  whey  cannot  be  obtained,  barley-water  has  no  doubt  some 
advantages  over  plain  water  in  rendering  the  curd  more  flocculent. 
This  has  been  disputed,  but  in  some  experimental  observations 
which  I  made  with  cow's  milk  and  acetic  acid  it  seemed  that 
dilution  with  barle}7- water  resulted  in  a  slightly  less  tough  curd 
than  when  plain  water  was  used  as  diluent:  and  it  is,  I  think, 
indisputable  that  some  infants  can  digest  cow's  milk  better  when 
it  is  diluted  with  barley-water  than  when  diluted  with  plain 
water.  It  may  be  granted  also  that  for  an  infant  who  can  digest 
starch,  barley-water  may  increase  to  a  very  small  degree  the 
intrinsic  value  of  the  mixture.  But  in  spite  of  these  possible 
advantages  I  have  no  great  liking  for  its  use  in  infant-feeding. 

Barley-water  consists  practically  of  nothing  more  than  water 
with  a  little  starch  :  prepared  by  any  of  the  ordinary  methods 
whether  from  pearl-barley  or  from  prepared  barley,  it  contains 
1  to  2  per  cent,  of  starch.  It  is  quite  certain  that  an  infant's 


44  COMMON  DISORDERS  OF  CHILDHOOD 

power  of  digesting  starch  is  very  slight  during  the  first  few  months 
of  life  ;  although  there  is  probably  some  amylolytic  power  both 
in  the  salivary  and  in  the  pancreatic  secretion  even  at  birth  ; 
indeed  in  an  extract  from  the  salivary  glands  of  a  stillborn 
infant  I  found  distinct  amylolytic  power.  But  clinical  experience 
shows  that  starch  digestion  remains  very  feeble  in  most  infants 
for  at  least  six  or  seven  months  after  birth  ;  and  even  0-5  to 
1  per  cent,  of  starch  seems  to  be  more  than  some  infants  can 
digest. 

I  have  several  times  seen  slight  degrees  of  rickets  where  barley- 
water  had  been  used  from  early  infancy,  and  there  is  no  doubt 
that  it  is  not  uncommonly  a  cause  of  flatulence  and  discomfort, 
and  sometimes  of  looseness  of  the  bowels  and  of  redness  about 
the  buttocks.  These  objections  apply,  of  course,  specially  to 
infants  under  the  age  at  which  starch  becomes  a  suitable  element 
in  the  food,  a  point  which  I  shall  consider  later  :  here  I  will  only 
say  that  in  my  opinion  starch  is  best  avoided  until  the  age  of 
nine  months. 

I  have  sometimes  used  rice-water  as  a  diluent,  prepared  by 
soaking  two  heaped  tablespoonfuls  of  rice,  previously  washed, 
for  three  hours  in  a  quart  of  warm  water,  and  then  allowing  the 
mixture  to  simmer  for  an  hour  before  straining.  For  infants  of 
nine  months  or  more  with  looseness  of  the  bowels,  this  is  certainly 
preferable  to  barley-water  as  being  less  laxative,  and  I  have 
seen  good  results  with  it  ;  but  nowadays  we  have  a  less  trouble- 
some resource  in  simple  dilution  with  water  and  the  addition 
of  sodium  citrate,  which  is  at  once  a  more  effective  method  of 
assisting  digestion  of  the  curd  and  at  the  same  time  of  diminish- 
ing looseness  of  the  bowels  ;  the  nutritive  value  of  any  of  the 
cereal  decoctions  which  have  been  used — barley-water,  rice-water 
or  oatmeal-water — is  so  small  as  to  be  hardly  worth  considering. 

My  own  bias  is  in  favour  of  plain  water  as  a  routine  diluent 
for  milk  in  infant-feeding  ;  in  the  large  majority  of  cases  the 
infant  does  perfectly  well  with  such  dilution,  if  the  proportions 
are  properly  arranged  ;  moreover,  it  has  the  great  advantage 
of  simplicity.  The  addition  herewith  of  lime-water  has  a  certain 
value  :  in  some  experiments  which  I  made  a  few  years  ago,  lime- 
water  seemed  to  have  some  definite  though  slight  effect  in 
diminishing  the  firmness  of  the  curd,  and  I  think  that  there  can 
be  no  doubt  from  clinical  experience  that  it  assists  digestion  to 
some  extent  ;  but  in  my  opinion  its  chief  value  is  in  counteracting 
any  tendency  to  looseness  of  the  bowels.  The  proportion  of 
lime-water  to  be  added  is  £  to  1  ounce  to  every  3  ounces  of  milk- 


COW'S  MILK  FOR  INFANT-FEEDING  45 

mixture,  or  if  the  more  concentrated  liquor  calcis  saccharatus 
be  used,  15  to  30  drops  to  every  3  ounces. 

For  a  healthy  infant  who  is  able  to  digest  the  milk  simply 
diluted  with  water  there  is  nothing  to  be  gained  by  the  addition 
of  lime-water.  It  has  been  customary  to  contrast  the  acidity  of 
cow's  milk  with  the  neutral  or  alkaline  reaction  of  human  milk 
and  to  advise  the  addition  of  some  alkali,  whether  lime-water  or 
bicarbonate  of  soda  (gr.  iv  added  to  each  feed  of  3  ounces)  to 
counteract  the  acidity  :  but  is  this  necessary  ?  The  success  of 
buttermilk,  or  milk  acidified  with  lactobacillin,  and  of  whey 
prepared  by  curdling  milk  with  acids,  such  as  sherry  or  tartaric 
acid,  clearly  proves  that  acidity  per  se  is  not  necessarily  harmful 
to  the  infant ;  and  clinical  experience  abundantly  proves  that 
healthy  infants  thrive  on  mixtures  of  fresh  cow's  milk  in  which 
no  attempt  has  been  made  to  neutralize  the  acidity. 

But  there  is  another  reason  which  I  often  hear  assigned  for 
the  addition  of  lime-water  to  milk  :  '  We  are  giving  lime-water 
to  prevent  rickets.'  Now  how  or  when  this  idea  arose,  that  lime- 
water  is  of  any  value  in  the  prevention  of  rickets,  I  do  not  know, 
but  that  it  is  an  entirely  mistaken  idea  is  shown  by  many  facts, 
one  of  which  is  that  cow's  milk,  even  if  it  were  diluted  with  two 
parts  of  water — a  degree  of  dilution  which,  if  continued  for  many 
months,  would  almost  certainly  result  in  rickets — would  still 
contain  a  very  much  larger  proportion  of  lime  salts  than  does 
human  milk.  Lime-water  is  neither  preventive  nor  curative  of 
rickets. 

Laboratory  modification.  Having  said  this  much  about  the 
home  modification  of  cow's  milk,  I  must  mention  also  the 
*  laboratory  modification  '  of  milk  and  '  percentage  feeding ', 
of  which  we  have  heard  so  much  within  the  past  few  years. 
How  far  is  any  such  exact  modification  practicable  ?  A  very 
interesting  paper  has  been  written  by  Dr.  Wentworth,  of 
Boston,  U.S.A.,  showing  that  of  twenty-six  milk  prescrip- 
tions made  up  at  a  milk  laboratory  in  that  city,  not  a  single 
one  corresponded  exactly  with  what  was  ordered  ;  there  was 
as  much  as  0-2  per  cent,  variation  in  the  proteids,  and  as 
much  as  1  per  cent,  error  in  the  fat  and  in  the  sugar.  I  have 
made  a  few  control  analyses  of  the  same  kind  myself,  and  have 
found  small  variations  (as  much  as  0-5  per  cent,  in  the  fat  and 
rather  less  in  the  proteids)  from  the  formula  ordered  ;  but  I  con- 
fess I  am  more  inclined  to  wonder  at  the  degree  of  accuracy 
which  was  attained  than  to  criticize  these  slight  deviations. 
At  the  same  time  these  observations  show  that  even  at  a  special 


46  COMMON  DISORDERS  OF  CHILDHOOD 

laboratory  the  percentages  obtained  are,  if  more  accurate  than 
those  obtained  with  home  modification,  still  only  approximate  ; 
and  to  expend  scrupulous  care  over  the  second  place  of  decimals 
— as  I  have  seen  done — in  writing  a  '  milk  prescription  '  is  either 
to  humbug  ourselves  or  our  patients. 

But  is  any  such  strict  accuracy  either  necessary  or  desirable  ? 
Surely  not,  if  Nature  is  to  be  our  guide.  Human  milk  varies  not 
only  with  the  health  of  the  mother  and  her  diet,  but  even  with 
the  time  of  day  and  with  the  portion  of  breast-milk  taken. 
I  have  found  a  difference  of  1  per  cent,  in  the  fat  in  two  samples 
of  a  woman's  milk  taken  at  11  a.m.  and  11  p.m.  respectively,  and 
I  have  repeatedly  found  the  morning  milk  of  women  to  be  richer 
in  fat  than  the  evening  milk.  In  the  milk  first  drawn  from  the 
breast  I  have  found  as  little  as  0-4  per  cent,  of  fat  when  the  middle- 
milk  at  the  same  feed  contained  3-2  per  cent,  of  fat,  so  that 
obviously  the  infant  will  get  a  food  varying  in  its  average  com- 
position according  to  the  completeness  with  which  it  empties 
the  breast.  A  rigidly  fixed  percentage  of  each  constituent  is  not 
only  unnecessary,  but  is  also  unnatural. 

Nevertheless  it  is  clear  that  there  is  a  certain  range  of  varia- 
tion in  the  proportion  of  each  constituent  which  is  permissible 
for  any  particular  infant,  and  this  range  has  no  very  wide  limits. 
The  value  of  a  knowledge  of  the  percentage  composition  of  milkj 
and  the  methods  by  which  the  percentage  of  each  constituent 
can  be  regulated  approximately,  lies  in  its  enabling  us  to  deter- 
mine with  some  degree  of  accuracy  what  these  limits  are,  and 
when  we  have  determined  them,  to  regulate  the  proportion  of 
each  constituent  so  that  it  falls  within  this  range.  Where  expense 
is  no  object,  it  is  a  very  great  convenience  to  have  milk  mixtures 
supplied  with  the  proportions  already  regulated  according  to 
the  medical  man's  instructions  ;  but  let  it  be  realized  that  this 
regulation  of  percentages  is  carried  out  in  exactly  the  same  way 
as  is  done  in  the  home  modification  of  milk,  and  that  any  medical 
man  who  possesses  a  working  knowledge  of  the  average  com- 
position of  milk  and  cream  (or,  still  better,  can  obtain  analyses 
of  the  particular  milk  and  cream  which  are  to  be  used),  can 
regulate  the  percentages  of  proteids,  fat,  and  sugar,  with  sufficient 
accuracy  for  any  practical  need  of  infant -feeding. 

But  here  I  wish  to  insist  upon  an  extremely  important  point 
in  the  preparation  of  an  infant's  food,  whatever  its  nature  may 
be,  namely  the  use  of  accurate  measures  of  quantities  :  the 
doctor  orders  one  part  of  milk  to  two  parts  of  water,  and  the 
nurse  thinks  she  can  calculate  the  amounts  by  rough  measure- 


COW'S  MILK  FOR  INFANT-FEEDING  47 

ment  in  a  jug,  or  a  domestic  tablespoon  is  used  which  may  give 
correct  proportions  but  probably  makes  the  total  amount  of 
the  feed  much  larger  than  was  intended.  No  constituent  is  more 
often  inaccurately  measured  than  the  cream,  and  accuracy  is 
specially  needful  in  the  measurement  of  this,  for  a  very  small 
excess  of  cream  is  likely  to  give  rise  to  trouble  :  the  nurse  has 
perhaps  a  measure  graduated  in  tablespoonfuls,  but  often  she  has 
none  showing  drachms,  so  a  domestic  teaspoon  is  used  with  the 
result  that  twice  the  quantity  of  cream  ordered  is  given. 

A  domestic  teaspoon  very  commonly  holds  2  drachms,  and 
sometimes  2£  or  3  drachms  :  and  it  is  a  serious  matter  if  2  drachms 
of  the  ordinary  centrifugal  cream,  containing  48  per  cent,  fat, 
are  given  instead  of  1  drachm  in  a  3-ounce  mixture,  for  the  result 
will  be  a  mixture  containing  altogether  about  5  per  cent,  of  fat, 
or  even  more,  and  it  is  no  wonder  if  the  infant  is  sick,  or  has  loose 
stools.  Cream  should  be  measured  in  a  minim  measure,  and  the 
other  constituents  of  the  food  in  an  accurately  graduated  glass 
measure. 

Boiling  of  milk.  Lastly  I  come  to  the  important  question, 
should  the  milk  be  boiled  ?  Now  on  this  point  I  wish  to  speak 
with  no  uncertain  voice,  and  the  more  so,  as  I  have  often  been 
responsible  in  former  years  for  the  usage  of  raw  milk,  that  is,  milk 
unheated  except  to  the  feeding  temperature  of  100°  F.  Not  only 
throughout  infancy,  but  throughout  the  whole  period  of  child- 
hood, the  use  of  raw  milk  is  attended  with  very  serious  danger, 
a  danger  which,  in  my  opinion,  altogether  outweighs  the  dis- 
advantages of  heating  the  milk  by  pasteurization,  boiling  or 
sterilization.  As  is  well  known,  the  tubercle  bacillus  is  present 
in  cow's  milk  not  very  rarely ;  and  even  if  cows  are  tested  with 
tuberculin  at  intervals,  it  is  still  not  certain  that  they  will  remain 
free  from  tuberculosis  in  the  intervals  ;  so  that  even  where  cows 
are  kept  by  private  individuals  specially  for  their  children  and 
examined  with  every  expert  care,  I  hold  that  nevertheless  the 
milk  should  not  be  given  raw. 

According  to  my  own  observations,  29  per  cent,  of  the  cases 
of  tuberculosis  in  childhood  are  due  to  alimentary  infection  ; 
and  I  have  been  even  more  impressed  with  the  clinical  sequence 
which  I  have  repeatedly  observed  :  a  child  of  good  family  history, 
who  has  always  had  boiled  or  pasteurized  or  sterilized  milk, 
usually  because  he  has  been  living  somewhere  where  hygienic 
conditions  were  unsatisfactory,  is  brought  to  London  or  to  some 
place  where  the  parents  suppose  that  milk  is  sufficiently  pure  to 
be  given  raw,  and  within  a  few  months  after  he  begins  the  use  of 


48  COMMON  DISORDERS  OF  CHILDHOOD 

ra\v  milk  he  develops  tuberculosis.  I  have  seen  pitiful  cases 
of  this  sort  where  it  seemed  as  if  life  were  thrown  away  by  the 
giving  of  raw  milk. 

There  are,  of  course,  other  risks  besides  tuberculosis ;  for 
instance  especially  in  the  summer  an  acute  infective  diarrhoea 
may  result  from  some  milk-borne  bacteria,  and  occasionally 
scarlet  fever,  typhoid  and  diphtheria,  may  be  conveyed  by  raw 
milk.  If  the  heating  of  milk  will  avoid  these  risks,  what  objection 
can  be  raised  to  so  simple  a  precaution  ? 

Amongst  the  laity  one  finds  two  objections  very  often  raised 
when  one  suggests  heating  the  milk  ;  the  first  is  that  any  con- 
siderable heating  of  the  milk  makes  it  less  nourishing ;  the  other 
is,  that  boiled  milk  is  a  cause  of  rickets.  It  cannot  be  denied 
that  marked  changes  occur  in  milk  as  the  result  of  heating  it  to 
the  boiling-point  or  even  nearly  to  the  boiling-point  :  certain 
ferments  usually  present  in  the  fresh  milk  are  killed  :  the  lactal- 
bumen  undergoes  some  change  by  which  it  probably  becomes 
slightly  less  digestible  :  the  casein  is  somehow  altered  so  that 
it  is  less  completely  curdled  by  rennet :  and  some  of  the  salts, 
particularly  the  calcium  salts,  are  said  to  become  less  soluble; 
but  has  all  this  any  practical  importance  ?  Experience  shows 
that  boiled  milk  is  digested  usually  just  as  easily  as  unboiled 
milk,  and  there  is,  so  far  as  I  know,  no  evidence  that  its  nutritive 
value  is  impaired  in  any  way  except  in  one  special  direction, 
namely  as  an  antiscorbutic. 

It  is  quite  certain  that  heating  milk,  especially  if  the  heating 
is  to  the  boiling-point  or  higher,  and  is  prolonged  for  many 
minutes,  renders  it  scorbutic  ;  but  if  one  may  judge  from  the 
rarity  of  scurvy  in  infants  fed  on  milk  which  has  merely  been 
heated  just  to  the  boiling-point  without  prolonging  the  boiling, 
it  is  only  scorbutic  to  a  very  slight  degree,  and  certainly  less  so 
than  is  sterilized  milk.  Pasteurized  milk,  that  is  milk  heated  to 
155°-160°  F.,  for  twenty  minutes,  is  even  less  open  to  this 
objection,  for  although  cases  are  on  record  in  which  it  has 
apparently  produced  scurvy,  they  are  excessively  rare.  So  far 
as  its  nutritive  value  is  concerned,  I  think  it  may  be  taken  as 
proved  by  experience  that  milk,  whether  pasteurized  or  heated 
to  just  below  the  boiling-point,  loses  so  little,  that  this  dis- 
advantage is  not  worth  considering  in  comparison  with  the  safety 
gained  thereby  from  tuberculous  infection. 

The  idea  that  rickets  is  produced  by  boiled  milk  has,  so  far  as 
I  know,  no  foundation  whatever  :  in  fact,  I  suspect  it  arose  from 
the  confusion  produced  by  the  unfortunate  term  *  scurvy  rickets  ', 


COW'S  MILK  FOR  INFANT-FEEDING  49 

which  was  in  use  before  it  was  recognized  that  infantile  scurvy 
is  not  a  form  of  rickets  and  has  no  essential  connexion  with 
rickets. 

A  far  more  practical  objection  to  the  use  of  boiled  milk  is  the 
dislike  which  many  children  show  to  its  taste  and  to  the  *  skin  * 
which  forms  on  the  top  of  it.  The  latter  is  easily  removed  with 
a  spoon,  but  if  the  milk  has  been  allowed  to  stand  many  minutes 
before  it  is  removed  some  of  the  cream  will  be  removed  with  it, 
and  the  milk  rendered  by  so  much  the  poorer.  The  taste  is 
a  difficulty  which  with  some  children  is  insuperable.  On  every 
ground,  I  think,  pasteurization  is  to  be  preferred  to  boiling  if  it 
is  practicable  :  it  necessitates  some  special  apparatus — various 
so-called  *  sterilizers  ',  such  as  Aymard's  or  Hawkesley's,  which 
can  be  obtained  through  any  instrument-maker  or  chemist,  will 
serve  the  purpose — and  it  requires  care.  If  on  grounds  of  expense 
and  trouble  pasteurization  is  impracticable,  I  think  the  next  best 
procedure — which  has  the  great  advantage  of  being  perfectly 
simple — is  to  heat  the  milk  until  bubbles  just  begin  to  rise,  but 
not  so  that  it  *  rises  to  the  boil '. 

Goat's  Milk.  When  boiled  or  pasteurized  milk  is  so  distasteful 
to  the  child  that  it  cannot  be  given,  the  difficulty  may  be  over- 
come by  substituting  goat's  milk,  which  does  not  require  boiling 
or  pasteurizing,  as  the  goat  is  almost  entirely  immune  from 
tuberculosis. 

There  is  a  popular  idea  that  goat's  milk  has  necessarily  an 
unpleasant  flavour  of  its  own,  but  obtained  from  cleanly  and 
properly-kept  goats,  the  milk  is  quite  indistinguishable  in  taste 
from  cow's  milk. 

It  must  be  remembered,  however,  that  goat's  milk  is  fully  as 
rich  as  cow's  milk,  and  therefore  in  any  particular  case  may  require 
dilution  upon  the  same  lines.  This  will  be  evident  from  its  com- 
position : 

_.  m  (  Casein  3-0  per  cent. 

Proteid  .          .  3-7  \  T 

(  Lactalbumen  0-7  per  cent. 

Fat  .  .  .  4  2  per  cent. 
Sugar  .  .  .  4-0  per  cent. 
Salts  .  .  .0-5  per  cent. 

So  far  as  digestibility  is  concerned,  goat's  milk  offers  no  advantage 
over  cow's  milk,  but  its  comparative  safety  as  regards  tuber- 
culosis is  a  very  real  gain,  and  in  the  country  the  small  cost  of 
keeping  a  goat  brings  it  within  the  reach  of  most.  In  towns, 
goat's  milk  is  less  readily  available,  but  in  London  at  any  rare  it- 
can  be  obtained  from  various  suburban  sources. 


50  COMMON  DISORDERS  OF  CHILDHOOD 

Humanized  Milk.  To  obviate  the  necessity  for  careful 
modification  of  milk  at  home,  many  of  the  large  dairy  companies 
sell  what  they  call  humanized  milk,  and  on  this  subject  I  must  say 
a  few  words,  for  I  frequently  find  that  one  of  these  preparations 
has  been  given  under  the  impression  that  the  milk  has  undergone 
some  mysterious  change  whereby  it  is  rendered  more  digestible 
than  an  ordinary  milk  mixture  prepared  at  home.  The  term 
'  Humanized  '  has  an  attractive,  not  to  say  alluring,  sound  which 
is  apt  to  be  misleading  :  humanized  milk  is  nothing  more  than  an 
ordinary  mixture  of  diluted  milk  with  cream  and  sugar,  and  differs 
in  no  way  from  a  similar  mixture  made  at  home,  except  that  the 
shop-sold  mixture  has  usually  been  sterilized  at  a  very  high  tem- 
perature. The  reason  of  its  success  in  some  cases  is  simply  that 
a  careful  accuracy  is  maintained  in  the  proportions  of  the  mixture 
— a  point  in  which  home  modification,  especially  when  left  to  an 
untrained  domestic  nurse,  too  often  fails. 

As  examples  of  such  preparations  from  well-known  London 
dairies,  the  following  analyses,  for  which  I  am  indebted  to  the 
Companies  named,  may  be  quoted  : 

Aylcsbury  Dairy  Company.  Humanized  Milk. 

No.  1.  No.  2.                  No.  3. 

Proteid  .          .          .     1-10  2  2L                     294 

Fat         .          .          .     3  88  3-79                     3-82 

Sugar     .          .          .538  542                     d  93 

WdforcFs  Dairy  Company.  Humanized  Milk. 

'  Modified.'  '  Facsimile.'  '  Enriched.' 

Proteid.          .          .093  1-35  2-00 

Fat         .          .          .     3-10  360  4-00 

Sugar     .          .          .     6  40  6-60  6  50 

Friern  Manor  Dairy  Company.     Humanized  Milk. 

No.  1.             No.  2.            No.  3.  Special. 

Proteid  .          c          .      15                 1-8                 2-0  0-6 

Fat          ...35                 35                 35  35 

Sugar     ...      7-0                 7-0                 70  70 

The  Express  Dairy  Company,  under  the  name  of  '  Infants'  Milk  ', 
supplies  milk  modifications  of  three  different  strengths,  in  bottle, 
containing  sufficient  for  each  feed  according  to  the  age  of  the 
child.  The  composition  of  the  three  preparations  is  :  A,  proteid 
1-00  per  cent.,  fat  3-00  per  cent.,  sugar  6-00  per  cent.  ;  B,  proteid 
1-5  per  cent.,  fat  3-75  per  cent.,  sugar  6-75  per  cent.  ;  and  C,  pro- 
teid 2-00  per  cent.,  fat  4-00  per  cent.,  sugar  6-50  per  cent. 

Humanized  milk  is  sometimes  valuable  where  the  home  con- 
ditions make  accurate  milk  modification  impracticable,  only  let 


COW'S  MILK  FOR  INFANT  FEEDING  51 

it  be  remembered  that  there  is  no  special  digestibility  of  the  curd 
in  these  preparations  ;  they  are  neither  more  nor  less  digestible 
than  any  home-made  milk  mixture  containing  the  same  propor- 
tion of  curd.  It  is  therefore  a  mistake  to  order  humanized  milk 
where  a  home-made  mixture,  containing  the  same  or  a  smaller 
amount  of  casein,  or  where  a  peptonized  milk,  has  already  failed. 
The  complete  sterilization  of  most  of  these  commercial  human- 
ized milks  is  an  important  point  to  be  considered  in  their  use  ; 
for  a  short  time,  say  three  or  four  weeks,  this  may  constitute  no 
objection  ;  it  will,  indeed,  be  an  advantage  where  they  are  used 
upon  a  journey,  but  for  ordinary  purposes  it  is  certainly  a  grave 
fault,  for  experience  shows  that  infantile  scurvy  is  far  more 
likely  to  result  from  a  fully  sterilized  milk  than  from  one  that  has 
only  been  pasteurized  or  heated  just  to  the  boiling  point. 


CHAPTER  IV 
CURD-INDIGESTION 

I  SUPPOSE  there  is  no  commoner  difficulty  in  infant-feeding 
than  curd-indigestion.  To  some  extent  this  is  a  preventable 
disorder,  in  the  sense  that  if  cow's  milk  is  properly  diluted  from 
the  beginning,  curd-indigestion  does  not  arise  at  all  in  the  large 
majority  of  infants.  It  is  induced  in  many  cases  by  insufficient 
dilution  of  the  milk  during  the  first  few  weeks  of  life  ;  the  infant 
who  is  given  equal  parts  of  milk  and  water  at  a  month  old 
is  likely  enough  to  fall  into  a  troublesome  condition  of  curd- 
indigestion;  once  upset  the  digestion  of  an  infant  by  injudicious 
feeding  and  the  power  of  digesting  curd  is  often  so  impaired  that 
it  seems  to  be  wellnigh  lost  altogether  for  a  time  and  it  may  be 
weeks  or  even  months  before  cow's  milk  can  be  given  at  the 
proper  strength  for  the  age.  I  have  considered  the  subject  of 
dilution  already;  here  I  will  only  repeat  the  opinion  I  have 
already  expressed,  that  insufficient  dilution  of  milk  is  a  much 
commoner  source  of  trouble  than  is  too  great  dilution. 

But  curd-indigestion  is  certainly  not  always  due  to  faulty 
dilution  ;  there  are  infants  who  from  the  very  beginning  show 
an  extraordinary  intolerance  of  the  curd  of  cow's  milk,  so  that 
even  when  dilution  is  carried  to  quite  an  extreme  degree  they  are 
still  unable  to  digest  the  curd.  For  these,  as  well  as  for  the  cases 
in  which  this  trouble  arises  from  improper  feeding,  we  must  have 
some  method  of  securing  assimilation  of  a  sufficient  proportion  of 
proteid.  As  I  have  shown  in  the  previous  chapter,  there  are 
reasons  why  dilution  should  not  be  carried  to  an  extreme  degree  : 
indeed,  where  circumstances  make  the  addition  of  cream  a  diffi- 
culty, it  is  most  important  that  dilution  should  be  as  little  as  is 
consistent  with  satisfactory  digestion.  In  some  way  or  other 
therefore  we  must  assist  the  digestion  of  curd  in  these  cases  where 
moderate  dilution  is  not  sufficient. 

Sodium  citrate.  Where  the  difficulty  is  slight,  I  think  that  by 
far  the  best  means  is  the  addition  of  sodium  citrate  to  the  feed. 
How  this  acts  is  uncertain ;  it  has  been  stated  that  whereas  under 
ordinary  circumstances  curd  consists  of  tough  calcium  paracasein, 


CURD-INDIGESTION  53 

when  sodium  citrate  is  given  the  calcium  combines  with  the  citrate, 
and  a  much  less  tough  sodium  paracasein  is  formed.  But  this  is 
mere  theory  ;  the  clinical  fact  is  certain,  that  many  infants  who 
have  previously  had  difficulty  with  curd,  can  digest  cow's  milk  well 
when  sodium  citrate  is  added.  The  amount  to  be  given  is  gr.  ij- 
gr.  iv  in  each  feed,  according  to  the  amount  of  milk  contained 
in  the  mixture  :  for  milk  up  to  1  ounce  2  grains  should  be 
used  ;  for  any  larger  amount  of  milk,  3-4  grains  are  required. 
Sodium  citrate  is  easily  soluble  in  water,  and  is  most  conveniently 
prescribed  with  the  required  dose  dissolved  in  a  drachm  of  water, 
1  drachm  to  be  added  to  each  feed. 

This  has  the  great  advantage  over  barley-water  that  it  is  not 
liable  to  cause  flatulence,  nor  has  it  any  tendency  to  cause 
rickets,  while  it  is  superior  to  peptonizing  inasmuch  as  it  does 
not  render  the  food  scorbutic  ;  but  it  must  be  remembered  that 
it  does  not  assist  digestion  to  the  same  degree  as  peptonization 
does,  and  therefore  fails  entirely  in  the  severe  cases  of  curd- 
indigestion  in  which  peptonized  milk  may  succeed. 

Sodium  citrate  has,  moreover,  one  very  marked  effect  which, 
whilst  usually  a  drawback,  is  sometimes  an  advantage  ;  namely, 
that  it  is  constipating.  Almost  invariably  one  finds  that  after 
sodium  citrate  has  been  used  for  a  few  days  there  is  complaint 
that  the  bowels  are  costive,  and  if  the  addition  of  cream  to  the 
milk  is  not  sufficient  to  prevent  this,  it  is  often  necessary  to  give 
some  drug  regularly  two  or  three  times  a  day  such  as  manna, 
grey  powder,  or  senna,  to  counteract  the  effect.  From  my  own 
observations  I  do  not  think  that  anything  is  to  be  gained  by 
giving  sodium  citrate  in  larger  doses  than  those  I  have  mentioned. 
Indeed,  I  think  that  harm  may  possibly  be  done  by  very  large 
doses  ;  in  the  case  of  a  wasted  infant  to  whom  10  grains  of  sodium 
citrate  had  been  given  in  each  feed,  general  oedema  appeared 
within  a  few  hours  after  these  doses  were  begun  and  the  doctor, 
suspecting  it  might  be  due  to  the  sodium  citrate,  stopped  this 
drug,  whereupon  the  oedema  subsided  ;  he  again  added  the 
sodium  citrate,  and  again  the  oedema  appeared. 

Peptonization.  If  there  is  still  curd-indigestion  in  spite  of 
careful  dilution  of  the  milk  and  the  addition  of  sodium  citrate, 
I  think  the  wisest  plan  generally  is  to  proceed  at  once  to 
peptonization  of  the  milk.  For  this  purpose  Fairchild's  Pepto- 
genic  Milk  Powder  is  useful  ;  one  cap-full  (the  screw-cap  of  the 
bottle  in  which  it  is  sold  is  to  be  used  as  a  measure)  is  sufficient 
to  peptonize  a  pint  of  milk  mixture,  whatever  the  strength  of 
the  mixture  may  be,  and  no  sugar  is  to  be  added,  for  there  is 


64  COMMON  DISORDERS  OF  CHILDHOOD 

sufficient  in  the  powder.  Dr.  B.  Myers  kindly  estimated  the 
sugar  in  this  powder  for  me,  and  found  that  the  addition  of 
one  cap -full  to  a  pint  of  diluted  milk  raised  the  proportion 
of  sugar  by  3-4  per  cent.  The  milk  and  water  and  cream, 
if  any  is  to  be  used,  are  mixed  cold,  and  the  powder  then 
added,  and  the  whole  warmed  very  slowly  either  over  a  flame 
which  is  small  and  capable  of  regulation  so  that  the  fluid 
comes  to  boiling-point  in  not  less  than  ten  minutes,  or  else 
by  standing  the  mixture  in  a  vessel  of  hot  water  as  hot 
as  the  hand  can  bear  for  twenty  to  forty  minutes,  and  then 
pouring  into  a  saucepan  and  heating  just  to  the  boiling-point. 
This  latter  method  is  best  for  the  severe  cases  in  which  full 
peptonization  is  required.  The  proportion  of  water  and  milk  must 
be  adjusted  to  the  capacity  of  the  infant  ;  in  the  case  of  a  feeble 
wasted  infant,  6  ounces  of  milk  to  14  ounces  of  water  will  do  for 
a  beginning,  and  a  slow  advance  can  be  made  by  increasing  the 
milk  by  J  ounce  and  diminishing  the  water  by  J  ounce  once  every 
week  or  ten  days.  It  is  often  wise  to  withhold  cream  altogether 
at  first,  and  if  it  is  to  be  added  at  all  it  must  in  these  cases  be 
added  in  much  smaller  proportion  than  the  directions  sold  with 
the  Peptogenic  Powder  advise.  It  will  often  be  found  that 
2  drachms  to  the  pint  is  as  much  as  an  infant  will  tolerate  and 
at  the  most  6  drachms  of  the  ordinary  town-sold  centrifugal  or 
'  separated  '  cream  will  be  sufficient. 

In  ordering  peptonized  milk  for  an  infant  it  should  always  be 
impressed  upon  the  parents  that  it  is  only  to  be  used  for  a  limited 
time,  the  shorter  the  better,  and  that  if  it  is  necessary  to  continue 
its  use  for  many  weeks  some  antiscorbutic,  either  raw  meat  juice 
or  fruit  juice,  must  be  given  in  adequate  quantities,  as  the  risk 
of  scurvy  from  peptonized  milk  is  a  very  real  one  ;  this,  however, 
hardly  applies  to  the  first  four  months  of  life,  in  which  scurvy  is 
almost  if  not  quite  unknown  ;  it  is  after  the  end  of  the  fourth 
month  and  especially  in  those  cases  in  which  patent  foods  have 
been  used  for  many  weeks  before  peptonized  milk  is  begun,  as  is 
oftan  the  case,  that  scurvy  is  likely  to  occur. 

Except  for  the  possibility  of  scurvy  I  know  of  no  objection  to 
the  use  of  peptonized  milk  ;  it  has  been  feared  that  to  pre-digest 
the  food  artificially  would  prevent  proper  development  of  the 
digestive  function  of  the  infant  ;  this  objection  I  think  has  no 
foundation  whatever  ;  in  fact,  as  a  matter  of  experience,  infants 
who  are  fed  thus  even  for  several  months  ultimately  digest  as 
well  as  any  other  infant,  and  generally  much  sooner  acquire 
lormal  digestion  than  those  who  are  allowed  to  struggle  along 


CURD-INDIGESTION  65 

beset  with  frequent  digestive  disturbance  from  the  attempt  to 
live  on  food  which  is  ill  adapted  to  their  feeble  digestive  capacity. 

A  more  weighty  objection,  if  it  be  proved,  is  the  possibility  of 
impairing  growth  by  the  use  of  peptonized  milk.  Certainly  some 
of  the  infants  who  are  fed  for  a  long  time  on  peptonized  milk  are 
for  some  years  fragile-looking  and  under  the  proper  weight,  but 
it  must  be  remembered  that  the  reason  for  using  peptonized  food 
was  great  and  continued  feebleness  of  digestion,  and  the  proba- 
bility is  that  any  infant  with  similar  digestive  difficulty  whether 
fed  on  peptonized  milk  or  otherwise  would  bo  below  the  average 
in  growth  and  development ;  in  short,  it  is  not  clear  that  the 
poor  development  is  a  result  of  the  peptonized  milk,  and  I  can 
assert  from  a  very  considerable  experience  of  its  use  that  in  the 
large  majority  of  cases  where  pre-digested  milk  is  used  for  several 
months  the  child  is  subsequently  fully  up  to  the  average  in  growth 
and  weight. 

The  return  to  unpeptonized  milk  must  be  made  very  gradually  : 
using  the  Peptogenic  Milk  Powder,  I  am  in  the  habit  of  ordering 
a  gradual  replacement  of  the  contents  of  the  measure  by  milk 
sugar  ;  one  fourth  part  at  first,  then  a  half,  and  then  three- 
quarters  is  to  be  milk  sugar,  and  so  on  till  the  whole  measure 
contains  only  milk  sugar ;  these  changes  are  made  at  intervals 
of  a  week  or  ten  days,  while  the  time  and  manner  of  peptonization 
is  otherwise  unchanged  :  in  this  way  it  is  usually  easy  by  degrees 
to  dispense  with  peptonizing  altogether.  Another  mode  is 
gradually  to  diminish  the  time  of  peptonization.  Whatever 
method  is  used  I  think  that  where  there  has  been  much  difficulty 
of  curd-digestion  it  is  wise  to  continue  the  peptonization  until 
the  proportions  of  milk  and  water  used  are  up  to  the  proper 
strength  for  the  age,  or  at  any  rate,  not  far  short  of  it. 

But  in  spite  of  full  peptonization  it  will  occasionally  be  found 
that  an  infant  cannot  digest  the  curd  of  cow's  milk.  In  theory 
the  next  step  should  be  the  removal  of  the  curd  altogether  as  is 
done  in  the  preparation  of  whey. 

Whey.  Whey  is  usually  made  by  the  addition  of  a  teaspoonful 
of  some  preparation  of  rennet  such  as  Benger's  or  Lazenby's 
Rennet,  or  Fairchild's  Pepsencia  to  a  pint  of  milk  warmed  to 
100°  F.  After  addition  of  the  rennet,  and  stirring  it  thoroughly 
into  the  milk,  the  milk  is  allowed  to  stand  until  a  solid  mass  of 
curd  has  formed,  and  the  whey  has  so  far  separated  that  it  can 
be  strained  off  as  a  slightly  turbid  fluid.  Whey  made  in  this 
manner  consists  of  lactalbumen  0-75  per  cent.,  fat  0-2  per  cent., 
sugar  4  per  cent.,  from  which  analysis  it  is  clear  that  not  only 


56  COMMON  DISORDERS  OF  CHILDHOOD 

lias  the  casein  or  curd  disappeared,  but  entangled  in  its  meshes  the 
fat  globules  also  have  been  almost  entirely  removed,  so  that 
whey  is  but  poor  food  if  used  alone.  To  some  extent  the  whey 
can  be  made  less  deficient  in  fat  by  breaking  up  the  curd  very 
thoroughly  with  a  fork  before  straining  ;  in  this  manner  I  have 
had  prepared  from  ordinary  London  milk  (3-2  per  cent,  fat) 
a  whey  containing  0-8  per  cent,  fat,  and  with  richer  milk  it 
is  possible  to  obtain  a  whey  containing  about  1-5  per  cent, 
of  fat. 

Now  in  theory  such  a  food  as  this  should  suit  admirably  in 
cases  where  there  is  difficulty  of  curd-digestion,  and  sometimes 
it  does.  When  this  is  so,  by  the  addition  of  cream  in  suitable 
amount  (1  measured  drachm  of  the  ordinary  48  per  cent. 
'  separated  '  cream  to  every  3  ounces  of  whey)  and  of  sugar 
(half  a  level  teaspoonful  of  milk  sugar  to  the  3  ounces)  we 
may  make  a  food  which  may  be  continued  for  many  weeks  with 
excellent  result.  The  low  proportion  of  proteid  may  be  rectified 
by  adding  raw  beef  juice,1  1  drachm  to  every  3  ounces. 

Where  expense  is  a  serious  consideration,  as  in  the  case  of 
hospital  out-patients,  I  have  sometimes  used  with  excellent 
results  a  whey  prepared  with  tartaric  acid  after  a  method 
devised  by  Dr.  Bernard  Myers  and  myself.  My  own  observations 
on  this  tartarated  whey  were  as  follows  :  tartaric  acid  gr.  viij 
dissolved  in  half  a  drachm  of  water  was  added  to  half  a  pint  of 
milk  whicli  had  been  heated  till  it  just  began  to  bubble.  After 
stirring  the  tartaric  solution  enough  just  to  mix  it  well  with  the 
boiling  milk,  the  mixture  was  kept  simmering  for  five  minutes  ; 
it  curdled  and  was  then  strained  through  butter  muslin.  This 
gave  a  whey,  somewhat  turbid,  with  no  appreciable  acid  taste, 
but  faintly  acid  to  litmus  ;  its  specific  gravity  was  1030  ;  it 
contained  fat  1-2  per  cent.,  total  proteid  0-58  per  cent.  On 
experimental  addition  of  about  15  drops  of  pure  acetic  acid 
(which  would  coagulate  casein  if  any  were  present),  no  further 
curd  was  formed  ;  but  on  warming  the  whey  to  100°  F.,  and 
adding  15  drops  of  rennet  to  1  ounce  of  whey,  a  light  flakey 
curd  rppcared  and  floated  on  the  top,  but  only  forming  a  thin 
layer  which  disappeared  on  shaking  the  whey.  I  found  that  milk 
could  be  added  to  this  tartarated  whey  without  any  curd  being 
formed  in  spite  of  its  slight  acidity.  Whey  prepared  thus  costs 
g\  penny  per  half  pint  (above  the  cost  of  the  milk)  whereas  if  any 

1  Quarter  of  a  pound  of  raw  beef  is  minced  finely  and  placed  in  a  cup  with 
just  enough  water  to  cover  it,  let  it  stand  two  hours  covered  in  a  cool  place, 
then  squeeze  through  muslin. 


CURD-INDIGESTION  57 

form  of  rennet  is  used,  the  cost  is  J-f  penny  per  half  pint.  It 
has  also  the  advantage  that  it  is  distinctly  richer  in  fat  than  is 
rennet-made  whey,  owing  to  the  fact  that  the  curd  does  not  form 
en  masse  but  only  in  small  clots,  and  so  does  not  entangle  so  many 
of  the  fat  globules,  and  evidently  there  is  also  some  proteid  left  in 
the  whey  which  is  coagulable  by  rennet,  and  which  would  there- 
fore be  absent  from  rennet-made  whey. 

I  have  used  the  tartarated  whey,  as  I  said,  with  excellent 
results,  I  have  also  seen  it  fail  several  times  :  but  where  any  food 
may  fail,  and  where  the  more  expensive  methods  of  feeding  are 
not  available,  this  cheap  method  of  preparing  whey  is  certainly 
worthy  of  trial.  Sugar  in  the  proportion  of  one  lump  of  white 
sugar  half  an  inch  square,  or  one  level  teaspoonful  of  milk  sugar 
to  every  6  ounces  of  this  tartarated  whey,  will  bri'ng  the  propor- 
tion of  sugar  to  6-7  per  cent.,  a  suitable  proportion  in  most  cases. 
It  will  seldom  be  necessary  to  increase  the  proportion  of  fat  by 
adding  cream,  for  the  cases  in  which  such  whey  is  necessary  are 
just  those  in  which  it  is  usually  advisable  to  give  also  a  low  pro- 
portion of  fat,  and  for  the  two  or  three  weeks  during  which  it  may 
be  found  necessary  to  use  this  whey,  the  fat  present  in  it  will  often 
be  sufficient. 

Yet  another  form  of  whey  and  one  which  is  extremely  useful  under 
certain  conditions  is  white  wine  whey  or  sherry  whey.  Where 
curd-indigestion  has  already  reduced  an  infant  to  a  state  of  emacia- 
tion and  exhaustion,  especially  where  there  is  much  vomiting,  and 
where  indigestion  is  associated  with  much  screaming  soon  after 
feeds,  I  have  often  found  that  improvement  at  once  followed  the 
use  of  sherry  whey.  From  some  experiments  which  we  made  upon 
this  food,  Dr.  B.  Myers  and  I  concluded  that  the  best  method  of 
preparing  sherry  whey  is  as  follows  :  10  ounces  of  milk  are  heated 
until  just  boiling,  then  2J  ounces  (accurately  measured)  of  cooking 
sherry  are  added  and  heat  is  applied  until  the  mixture  begins 
actually  to '  boil  up  ',  when  it  is  removed  from  the  fire  and  allowed 
to  stand  three  minutes  ;  the  curd  is  then  strained  off  through 
a  two-fold  layer  of  butter  muslin.  It  is  best  to  use  a  '  cooking 
sherry  '  (costing  about  a  shilling  per  bottle)  not  a  '  drinking 
sherry  '  (costing  about  2s.  Id.  per  bottle  or  more),  for  the  cheaper 
cooking  sherry  is  more  acid  and  therefore  a  less  quantity  is 
required  to  curdle  the  milk  ;  we  found  that  3-4  ounces  of  '  drink- 
ing sherry  '  were  required  where  2J  ounces  of  the  cheaper  sherry 
was  sufficient.  This  is  a  point  of  practical  importance,  for,  how- 
ever prepared,  sherry  whey  contains  a  considerable  proportion  of 
alcohol,  and  it  is  desirable  to  keep  this  proportion  low,  otherwise 


58  COMMON  DISORDERS  OF  CHILDHOOD 

the  quantity  of  the  food  which  can  be  given  at  each  feed  is 
necessarily  very  limited. 

c  Drinking  sherry  '  we  found  to  contain  16-46  per  cent,  of  alcohol 
by  weight,  whereas  '  cooking  sherry  '  contained  14  per  cent,  of 
alcohol  by  weight  ;  clearly,  as  more  of  the  drinking  sherry  would 
be  required,  and  it  contains  more  alcohol,  the  whey  prepared 
with  it  would  contain  much  more  alcohol  than  that  prepared 
with  the  cooking  sherry.  Taking  brandy  as  a  convenient  stan- 
dard of  comparison  in  considering  the  alcoholic  value  of  sherry 
whey,  we  found  that  prepared  according  to  the  directions  given 
above,  this  whey  contained  2-3  per  cent,  of  alcohol  by  weight 
and,  as  average  brandy  contains  42-5  per  cent,  of  alcohol, 
1  ounce  of  sherry  whey  is  equivalent  in  respect  of  alcohol  to 
25-8  minims  of  brandy. 

The  effect  of  sherry  whey,  however,  like  that  of  the  various 
alcoholic  liquors,  does  not  depend  merely  upon  the  amount  of 
alcohol  present ;  there  are  other  constituents  which  take  a  part 
in  determining  the  effect  of  each  particular  wine  or  spirit,  and 
there  can,  I  think,  be  no  doubt  that  the  essential  oils  or  volatile 
ethers  present  in  sherry,  contribute  to  the  carminative  effect 
which  is  one  of  the  virtues  of  this  food.  On  account  of  the  alcohol 
which  it  contains,  sherry  whey  is  quite  unsuitable  for  prolonged 
use.  I  have  sometimes  used  it  as  the  only  food  for  several 
days,  but  it  is  best  used  to  replace  some  other  food  only  at  the 
alternate  feeds  or  two  or  three  times  a  day.  Its  use  should  be 
discontinued  as  soon  as  the  digestive  trouble  has  subsided.  The 
cases  for  which  sherry  whey  is  most  suited  are  those  in  which,  on 
account  of  intolerance  of  larger  feeds,  a  very  small  amount  has 
to  be  given  at  each  feed  ;  at  any  period  of  infancy  I  think  2-2J 
ounces  of  sherry  whey  should  be  considered  the  largest  amount 
allowable,  although  I  have  in  exceptional  cases  given  larger 
quantities  for  two  or  three  days  with  decided  benefit,  for 
instance,  3  ounces  every  three  hours  to  an  infant  of  six  months, 
and  even  4  ounces  every  three  hours  to  an  infant  of  twelve 
months.  Sherry  whey  is,  in  fact,  to  be  regarded  only  as  an 
emergency  food  which  may  be  of  the  greatest  value  in  carrying 
an  infant  round  a  dangerous  corner,  but  is  to  be  discarded 
directly  the  emergency  is  past. 

In  practice,  however,  it  is  surprising  how  often  whey  of  any 
kind  fails  in  cases  where  there  is  curd-indigestion,  or  perhaps 
one  should  rather  say  where  there  is  intolerance  of  milk,  for  it 
really  seems  in  some  cases  as  if  the  infant's  difficulty  were  not 
merely  with  the  curd  but  with  cow's  milk,  however  modified. 


CURD-INDIGESTION  59 

These  are  the  cases  in  which  every  now  and  then  some  patent 
food  or  condensed  milk  succeeds  after  all  other  feeding  has 
failed,  and  gains  thereby  a  reputation  for  general  suitability 
which  is  wholly  unwarranted,  inasmuch  as  the  prolonged  use  of 
the  very  food  which  seemed,  when  used  only  for  a  few  weeks,  to 
save  the  infant's  life,  is  likely  to  produce  disastrous  results  such 
as  rickets  and  scurvy.  Before,  however,  considering  these  foods 
I  must  mention  another  and  more  valuable  means  of  overcoming 
the  difficulty  of  curd-digestion,  namely,  the  use  of  asses'  milk. 

Asses'  milk.  The  composition  of  this  is  shown  by  the  accom- 
panying analysis : 

,    (  Casein       .         .       1-0  per  cent. 
Proteid          .  1.8  per  cent,  j  Lactalbumen     .       O.g  per  cent. 

Fat       ......  1-0  per  cent. 

Lactose          .....          .  5-5  per  cent. 

Salts 0-4  per  cent. 

Water 91-3  per  cent. 

Asses'  milk  should  not  be  heated  to  the  boiling-point  ;  it  is 
only  to  be  warmed  to  the  ordinary  feeding  temperature  (100°  F.) 
and  is  given  undiluted,  unless  it  be  necessary  to  add  some  lime- 
water  or  sodium  citrate  to  counteract  the  slightly  laxative  effect 
which  is  a  peculiarity  of  asses'  milk.  If  either  of  these  must  be 
added,  as  small  a  bulk  of  water  as  possible  should  be  used  with 
them,  otherwise  the  extremely  weak  asses'  milk  will  be  made 
still  weaker  ;  for  this  reason  the  liquor  calcis  saccharatus  is 
preferable  to  lime-water  for  this  purpose  (20-30  drops  may  be 
used  to  every  3  ounces),  or  sodium  citrate,  gr.  iij  may  be  used 
dissolved  in  half  a  drachm  of  water  ;  this  is  more  convenient  for 
measurement  than  the  plain  powder,  but  tabloids  are  prepared 
by  Messrs.  Burroughs  &  Wellcome  which  might  be  used  for  this 
purpose. 

Asses'  milk  is  very  weak  both  in  proteid  and  in  fat,  and  it  is 
partly  on  this  account  that  it  is  so  easy  of  digestion,  but  not 
only  so,  for  the  curd  formed  is  finer  and  more  like  the  curd  of 
human  milk  than  would  be  that  of  cow's  milk  diluted  down  to 
the  same  strength.  Upon  asses'  milk  the  stools  often  rapidly 
lose  their  undigested  appearance,  the  infant  ceases  to  whine  and 
cry,  and  there  may  be  a  rise  in  weight  for  two  or  three  weeks, 
but,  as  might  be  supposed,  so  weak  a  food  is  not  sufficient  to 
secure  much  continued  progress  in  weight,  and  my  own  experience 
has  been  that  it  is  almost  always  necessary  after  a  short  time 
to  abandon  the  asses'  milk  on  this  account  ;  nevertheless,  as  a 


60  COMMON  DISORDERS  OF  CHILDHOOD 

temporary  measure,  I  have  again  and  again  found  it  of  great 
value. 

There  is,  however,  another  reason  why  asses'  milk  can  seldom 
be  continued  long  ;  in  London  it  costs  six  shillings  per  quart,  and 
in  most  parts  of  the  country  it  is  obtained  from  London,  so  that 
then  there  is  the  added  cost  of  conveyance,  making  the  cost 
prohibitive  except  for  the  wealthy. 

Wet-nurse.  But  there  is  a  better  resource  than  asses'  milk, 
in  these  cases  where  fresh  cow's  milk  cannot  be  digested,  namely, 
a  wet-nurse  ;  I  have  already  referred  to  the  wonderful  improve- 
ment which  usually  follows  the  use  of  a  wet-nurse  ;  here  I  will 
only  say  that  I  believe  there  are  some  infants  whose  feebleness 
of  digestion  is  such  that  no  preparation  of  cow's  milk,  and  no 
patent  food  will  save  them,  the  one  and  only  resource  which 
will  succeed  is  a  wet-nurse. 

In  such  cases  the  change  which  often  follows  at  once  upon  the 
use  of  a  wet-nurse  is  truly  remarkable  ;  the  infant  who  has  been 
wasting  for  weeks  and  crying  continually  in  fretful  misery  will 
often  gain  weight  rapidly,  sometimes  at  an  almost  incredible  pace  ; 
I  believe  I  am  right  in  saying  that  I  have  known  nearly  a  pound 
gained  in  three  days  when  a  marasmic  infant  began  being  suckled 
by  a  wet-nurse,  and  hardly  less  gratifying  is  the  placid  content- 
ment which  takes  the  place  of  the  former  fretfulness. 

Dried  milk.  But  if  asses'  milk  and  a  wet-nurse  are  imprac- 
ticable luxuries  as  they  must  needs  be  for  the  majority,  what 
is  to  be  done  if  peptonized  milk  has  failed  ?  The  recent  in- 
troduction of  desiccated  milk  has,  I  think,  furnished  us  with  one 
useful  resource  in  such  cases  ;  there  have  long  been  upon  the 
market  preparations  of  desiccated  milk  combined  with  malted 
cereals  ;  such  are  the  Allenbury  Foods,  and  Horlick's  Malted 
Milk,  but  these  have  the  great  disadvantage  that  they  contain 
an  excessive  proportion  of  carbo-hydrate  (not  starch,  but 
soluble  carbo-hydrates,  the  products  of  malting),  and  this 
excess,  though  it  serves  to  increase  the  fattening  property 
of  these  foods,  is  liable  to  set  up  digestive  trouble  at  the  time, 
and  probably  eventually  to  favour  the  occurrence  of  rickets. 

The  plain  desiccated  milk  is  free  from  this  objection  while  it 
shows  the  same  fine  division  of  curd  when  an  acid  is  added  to 
the  solution  of  the  milk  powder,  and  for  this  reason  is  sometimes 
digested  well  where  even  peptonized  milk  has  failed.  It  can  be 
obtained  in  various  strengths  ;  for  instance,  the  'Cow  and  Gate' 
Brand  is  prepared  in  three  strengths,  one  consisting  of  full  milk, 
dried  into  a  powder,  another  consisting  of  milk  from  which  half 


CURD-INDIGESTION  61 

its  original  fat  has  been  removed,  called  *  Half-cream  Milk',  and 
another  called  '  Dried  Separated  Milk  ',  made  from  skim  milk, 
and  said  to  contain  about  1  per  cent,  of  fat.  Another  firm  pre- 
pares a  dried  milk  to  which  cream  and  milk  sugar  have  been 
added  before  desiccation  so  that  a  sufficient  amount  of  water  can 
be  added  to  reduce  the  proportion  of  proteid  as  low  as  2-5  per 
cent,  without  reducing  the  fat  below  3  per  cent.,  and  at  the  same 
time  there  is  no  excess  of  sugar.  This  preparation,  sold  under  the 
name  of  Glaxo,  has  the  following  composition  : 


Proteid        .         .     2 1-7  per  cent. 
Fat      .         .         .     25-4  per  cent. 


Mineral  salts        .       5-2  per  cent. 
Water          .         .       4-8  per  cent. 


Milk  Sugar  .         .42-9  per  cent. 

After  dilution  according  to  their  directions,  it  contains  ono 
tenth  of  these  proportions,  so  that  there  is  fat  2-5  per  cent.,  pro- 
teid 2-1  per  cent.,  milk  sugar  4-29  per  cent.  Upon  one  or  other 
of  these  preparations  of  desiccated  milk  an  infant  will  often 
thrive  excellently  for  a  time,  but  I  think  it  is  very  advisable 
that  parents  as  well  as  medical  men  should  know  that  any  drying 
of  milk  must  render  it  liable  to  cause  scurvy  if  used  too  long,  and 
therefore  these  desiccated  milks,  though  safe  enough  for  an  infant 
under  four  months  of  age  when  scurvy  rarely  if  ever  occurs, 
should  not  be  used  for  older  infants  for  more  than  a  few  weeks 
unless  some  antiscorbutic  such  as  raw  meat  juice  or  orange  juice 
is  added  to  the  diet. 


CHAPTER  V 

ON   THE  USE  AND  ABUSE  OP   CONDENSED  MILK 
AND  PATENT  FOODS 

ONE  outcome  of  the  common  difficulty  in  curd  digestion  is  the 
widespread  and  too  often  indiscriminate  use  of  condensed  milk 
and  patent  foods.  How  often  one  hears  that  an  infant '  couldn't 
take  fresh  cow's  milk  ',  so  recourse  was  had  forthwith  to  some 
patent  food  !  Now  I  venture  to  say  that  in  the  large  majority  of 
such  cases,  the  infant  could  have  taken  fresh  cow's  milk  per- 
fectly well,  had  it  been  properly  adapted  from  the  beginning  to 
the  child's  digestive  po\vers :  often  it  has  been  given  insufficiently 
diluted  or  in  too  large  bulk  or  no  attempt  has  been  made  to  over- 
come the  difficulty  by  such  methods  as  I  have  described  in  the 
preceding  chapter,  and  perhaps  the  most  useful  of  all  measures  in 
such  cases,  partial  peptonization,  has  not  been  tried  at  all. 

'  But,'  says  one,  '  surely  peptonized  milk  is  scorbutic,  and 
therefore  just  as  objectionable  as  any  patent  food.'  To  this  1 
would  reply  that  peptonized  milk  is  undoubtedly  scorbutic ,  though 
when  only  peptonized  for  a  short  time,  say  ten  or  twelve  minutes, 
it  seems  to  have  very  little  tendency  to  produce  scurvy,  certainly 
much  less  than  any  of  the  patent  foods  most  commonly  used  ; 
but  even  when  more  fully  peptonized,  such  milk  has  still  the  very 
great  advantage  over  patent  foods,  that  the  composition  of  the 
mixture  can  be  adjusted  by  gradual  increase  or  decrease  of  this 
or  that  constituent  to  the  requirements  of  the  particular  infant, 
deficiency  of  fat  and  excess  of  sugar  and  presence  of  starch  can 
be  avoided,  and  the  transition  from  the  peptonized  milk  to  un- 
peptonized  fresh  milk  can  be  graduated  so  finely  that  it  is  rarely 
difficult  by  this  means  to  coax  a  feeble  digestion  into  tolerating 
a  plain  mixture  of  fresh  milk.  It  cannot  be  questioned  that  the 
digestive  disturbance  and  failure  of  nutrition  which  results  from 
curd  indigestion  are  sometimes  overcome  by  substituting  for 
fresh  cow's  milk  condensed  milk  or  some  patent  food  in  which 
milk  is  present  in  a  desiccated  form  and  therefore  gives  a  fine 
loose  curd  which  is  much  easier  of  digestion  than  the  large  tough 
clot  of  fresh  cow's  milk  ;  but  if  at  the  same  time  we  are  compelled 
by  the  composition  of  the  food,  to  give  a  proportion  of  sugar 


CONDENSED  MILK  AND  PATENT  FOODS          63 

which  is  much  higher  than  an  infant  should  have,  or  a  proportion 
of  fat  which  is  far  too  low,  we  shall  sometimes  merely  substitute 
one  form  of  indigestion  for  another,  and  in  place  of  curd  indi- 
gestion we  shall  produce  in  the  infant  the  flatulence,  colic,  dis- 
turbed sleep  and  looseness  of  the  bowels  which  are  the  evidences 
of  carbo-hydrate  indigestion  ;  or  if  the  infant  is  not  so  readily 
upset  by  excess  of  sugar  or  starch,  we  may  find  after  some  months 
that  although  the  infant  has  appeared  to  thrive,  the  low  propor- 
tion of  fat  in  the  food  has  led  to  some  degree  of  rickets,  so  slight 
it  may  be  that  only  a  trained  observer  would  detect  it,  but  some- 
times so  evident  that  none  can  overlook  it. 

But  the  mischief  does  not  end  here,  for  the  lay  public  seeing 
that  Dr.  So-and-so  ordered  Somebody's  Patent  Food  with  good 
result,  conclude  that  what  suits  one  infant  must  suit  another, 
and  that  even  if  that  particular  food  does  not  suit,  Somebody 
Else's  Infant  Food  may  equally  well  be  tried,  and  knowing 
nothing  about  the  particular  properties  of  particular  foods,  and 
the  conditions  under  which  a  particular  patent  food  or  condensed 
milk  may  sometimes  be  advantageous,  they  use  these  various 
4  foods  '  with  disastrous  result,  inflicting  upon  infants  a  vast 
amount  of  needless  misery  and  suffering,  sometimes  even  with 
fatal  ending. 

Amongst  the  out-patients  of  a  children's  hospital,  one  of  the 
commonest  sights  is  the  miserable  screaming  emaciated  infant 
who  has  been  fed  upon  some  patent  food  or  condensed  milk,  and 
although  amongst  the  well-to-do  the  infants  are  rarely  allowed  to 
fall  into  such  a  condition,  because  a  doctor  is  usually  consulted 
before  the  mischief  has  gone  so  far,  yet  I  can  say,  from  my  own 
observation,  that  the  minor  disturbances  from  this  cause  are 
common  enough  in  all  classes,  and  I  have  sometimes  seen  in  the 
infants  of  the  well-to-do  advanced  marasmus,  and  many  times 
very  severe  scurvy  from  the  use  of  patent  foods. 

One  is  tempted,  indeed,  to  condemn  all  such  preparations  un- 
conditionally and  without  exception  ;  but  such  condemnation 
would  be  too  sweeping  ;  there  are  conditions  and  circumstances 
which  may  not  only  justify  the  use  of  condensed  milk  or  a  patent 
food  but  may  even  make  it  advisable  if — and  it  is  a  very  important 
if — these  preparations  be  used  with  an  intelligent  appreciation 
of  their  composition  and  properties,  and  therefore  of  the  particular 
age  and  conditions  for  which  each  is  suited. 

The  exact  composition  of  each  of  these  preparations,  whose 
name  is  legion,  it  is  impossible  to  retain  in  the  memory  ;  but  it 
is  certainly  possible  for  any  medical  man  to  know  the  chief 


64  COMMON  DISORDERS  OF  CHILDHOOD 

features  of  all  the  preparations  which  are  in  common  use.  These 
various  foods  fall  into  two  groups :  (I)  those  intended  as  substitutes 
for  fresh  cow's  milk,  and  (II)  those  intended  as  additions  to  cow's 
milk.  These  are  usually  further  classified  in  some  such  way  as 
this  : 

I.  Foods  intended  as  substitutes  for  fresh  cow's  milk. 

(1)  Condensed  milk:   desiccated  milk  (Glaxo). 

(2)  Dried  milk  with  cereal, — starch  completely  converted  : 

Allenbury,  Nos.  1  and  2  ;   Horlick's  Malted  Milk. 

(3)  Dried  milk  with  cereal, — starch  partially  converted  : 

Carnrick's  Soluble  Food  ;  Milo  Food. 

II.  Foods  intended  as  additions  to  fresh  cow's  milk. 

(4)  Cereal, — starch  completely  converted  :   Mellin;  Hovis 

Baby  Food,  No.  1  ;  Moseley's  Food. 

(5)  Cereal, — starch  partially  converted  :   Allenbury  Food 

No.  3  ;  Benger's  Food  ;  Savory  &  Moore's  Food  ; 
Theinhardt's  Soluble  Food. 

(6)  Cereal, — starch  mostly  unconverted  :  Ridge's   Food  ; 

Neave's  Food  ;  Frame  Food  ;  Robb's  Biscuits  ; 
Chapman's  Wheat  Flour. 

Upon  the  relative  value  of  these  preparations,  their  individual 
faults  and  virtues,  some  light  may  be  thrown  by  certain  general 
considerations.  In  the  first  place,  I  would  emphasize  the  fact 
that  the  presence  or  absence  of  starch  in  a  food  is  by  no  means 
the  only  point  which  determines  its  suitability  for  infant-feeding : 
a  food  may  not  contain  a  particle  of  starch  and  yet  may  be 
extremely  faulty  as  an  infant  food. 

It  is  clear,  however,  that  a  large  proportion  of  patent  foods 
do  contain  starch  :  in  the  above  classification  it  will  be  seen  that 
only  those  foods  mentioned  under  groups  (1),  (2),  and  (4)  are  free 
from  starch,  and  the  question  arises  whether  any  starch  is  per- 
missible to  an  infant,  and  if  so,  at  what  age.  My  own  experience 
leads  me  to  think  that  even  such  a  small  amount  of  starch  (1  to  2 
per  cent.)  as  is  present  in  barley-water  is  often  harmful,  and  that 
all  foods  containing  any  starch  whatever  should  be  avoided  until 
the  infant  is  eight  or  nine  months  old,  and  even  then  starch- 
containing  foods  should  only  gradually  be  introduced,  so  that  by 
the  end  of  the  tenth  month  an  infant  may  be  having  two  meals 
of  starch-containing  food  in  the  day.  Such  preparations  as 
Benger's  Food,  and  Savory  &  Moore's  Food,  both  of  which 
contain  a  small  proportion  of  starch  after  preparation  in  accord- 
ance with  the  makers'  directions,  are  therefore  unsuitable  for 
the  feeding  of  an  infant  during  the  first  eight  or  nine  months  of 


CONDENSED  MILK  AND  PATENT  FOODS          65 

life,  although  after  this  age  there  is  no  objection  on  this  score  to 
their  use  once  or  twice  a  day  ;  indeed,  most  of  them  may  be 
useful  in  this  way  as  a  step  in  the  introduction  of  starch-feeding. 

But  this,  as  I  have  said,  is  only  one  of  the  several  points  which 
have  to  be  considered  in  deciding  whether  a  food  is  suitable  for 
infant-feeding :  the  question  whether  the  carbo-hydrate  present 
is  soluble  or  insoluble,  that  is  to  say,  whether  it  is  all  in  the  form 
of  sugar  or  the  products  of  malting,  or  is  partly  in  the  form  of 
the  insoluble  starch,  is  of  great  importance ;  but  whether  soluble 
or  insoluble  there  is  yet  another  point  to  be  considered,  and  one 
which  is  too  often  overlooked  with  reference  to  the  carbo-hydrate 
contents  of  an  infant's  food,  namely,  the  quantity.  Many  of  the 
proprietary  foods  as  given  to  the  infant,  contain  a  proportion 
of  carbo-hydrate  which  is  greatly  in  excess  of  that  present  in 
human  milk.  In  human  milk  carbo-hydrate  is  of  course  present 
only  as  the  soluble  sugar,  and  very  rarely  exceeds  7  per  cent, 
under  any  conditions  ;  usually  it  is  between  6  and  7  per  cent., 
while  the  proportion  of  fat  is  about  3-5  per  cent. :  so  that  the 
proportion  of  fat  to  carbo-hydrate  is  approximately  1  to  2. 

It  seems  hardly  credible  in  the  face  of  Nature's  standard  that 
the  profession  should  be  informed,  as  it  is  by  one  manufacturer's 
advertisement,  that  the  '  normal  standard  for  infants'  foods 
prepared  from  milk  and  dextrinized  cereals  ',  is,  fat,  5  per  cent., 
carbo-hydrate,  71-5  per  cent. !  If  such  a  food  is  to  be  used  with 
addition  of  water  only,  it  is  clear  that  by  no  possible  adjustment 
can  it  be  made  a  suitable  food  for  any  period  of  infancy  :  if  it  is 
to  be  used  as  an  addition  to  milk  it  is  equally  clear  that,  in  order 
to  prevent  excess  of  carbo-hydrate,  so  very  small  a  proportion  of 
the  food  would  have  to  be  added,  that  the  fat  in  the  food  becomes 
a  negligible  quantity,  and  the  food  can  only  be  considered  as  an 
addition  of  a  small  quantity  of  carbo-hydrate  to  the  milk  mixture, 
the  fat  in  which  is  just  as  much  or  as  little  as  there  would  be  in 
the  plain  milk-and-water  mixture  without  the  addition  of  this 
*  food  '.  But,  according  to  the  makers'  directions,  the  foods  are 
usually  to  be  given  in  considerably  larger  proportion  than  would 
bring  the  proportion  of  sugar  even  approximately  to  that  present 
in  human  milk,  and  this  constitutes  a  grave  defect  in  nearly  all 
these  patent  foods. 

In  the  Allenbury  Foods,  No.  1  and  No.  2,  for  instance,  the 
proportion  of  carbo-hydrate,  when  the  food  is  diluted  according 
to  the  maker's  directions,  is  10  to  11  per  cent.,  that  is  half  as 
much  again  as  the  percentage  present  in  human  milk  ;  while 
Horlick's  Malted  Milk  contains  nearly  12  per  cent,  when  four 

STILL  F 


68  COMMON  DISORDERS  OF  CHILDHOOD 

teaspoonfuls  of  the  food  are  diluted  with  eight  tablespoor.fuls  of 
water  as  directed.    Mellin's  Food,  again,  which  is  intended  to  be 
used  as  an  addition  to  fresh  milk,  is  altogether  free  from  starch, 
and  on  this  ground  commendable  as  an  infant's  food,  but  when 
one  comes  to  investigate  the  proportion  of  carbo-hydrate  which 
it  would  necessitate  in  the  milk  mixture,  if  given  in  accordance 
with  the  maker's  directions,  it  can  be  understood  why  it  some- 
times gives  the  infant  flatulence  and  looseness  of  the  bowels. 
Mellin's  Food         .         .         .7  heaped  teaspoonfuls. 
Fresh  milk     .         .         .         .15  tablespoonfuls  (7|  ounces) 
Cold  water     ....     5  tablespoonfuls  (2£  ounces) 

These  are  the  directions  for  preparing  two  meals  for  an  infant 
of  six  months  and  over.  Using  an  ordinary  teaspoon,  of  2  d  rachms 
fluid  capacity,  I  found  that  a  heaped  teaspoonful  of  Mellin's  Food 
weighed  85  grains ;  of  this  70  per  cent,  is  carbo-hydrate.  Calcu- 
lation on  this  basis  shows  that  the  mixture,  as  directed,  would 
contain  about  12  percent,  of  carbo-hydrate.  If  Mellin  is  to  be 
used — and  there  is  no  doubt  that  it  sometimes  assists  the  diges- 
tion of  milk,  and  moreover  acts  as  a  gentle  laxative — it  should 
be  used  only  in  such  proportions  as  to  avoid  excess  of  carbo- 
hydrate. It  is  convenient  to  know  that,  with  a  teaspoon  of  two- 
clrachm  fluid  capacity,  a  heaped  teaspoonful  of  Mellin's  Food  in 
3  ounces  of  any  milk  mixture,  means  the  addition  of  about 
5  per  cent,  of  carbo-hydrate  to  that  already  present  in  the  diluted 
milk,  so  that  at  no  period  of  infancy  should  this  food  be  added 
in  a  higher  proportion,  and  no  sugar  should  be  allowed  with  it. 

Undoubtedly  there  are  infants  who  will  tolerate  and  even 
thrive  upon ,  a  food  containing  more  than  the  breast-milk  standard , 
7  per  cent.,  of  carbo-hydrate  ;  but  it  is  equally  certain  that  there 
are  many  infants  who  suffer  from  flatulence,  discomfort,  and 
looseness  of  bowels  whenever  this  proportion  is  exceeded,  even 
to  a  very  slight  degree. 

But  here  I  wish  to  emphasize  a  general  principle  of  the  greatest 
importance  in  infant-feeding,  namely,  that  the  suitability  of 
a  particular  food  for  prolonged  use  is  not  proved  by  the  mere  fact 
that  it  is  taken  well,  and  produces  no  immediate  ill  effects.  The 
evil  results  of  unsuitable  food  may  not  appear  until  the  food 
has  been  continued  several  weeks  or  months  ;  indeed,  in  the  case 
of  rickets  or  scurvy  the  food  which  has  produced  the  disease  has 
often  appeared  to  suit  excellently,  so  far  as  freedom  from  obvious 
digestive  disturbance  is  concerned.  It  seems  likely  that  excess 
of  carbo-hydrate,  when  continued  for  several  months,  has  some 
such  slowly  produced  effect,  favouring  the  ultimate  onset  of 


CONDENSED  MILK  AND  PATENT  FOODS          67 

rickets,  probably  by  interfering  in  some  way  with  the  assimila- 
tion of  fat. 

And  this  brings  me  to  another  very  serious  fault  which  is  com- 
mon to  many  of  these  trade  preparations  as  given  to  the  infant, 
namely,  deficiency  of  fat.  My  own  observations  support  the  views 
put  forward  by  the  late  Dr.  Cheadle,  that  the  chief  dietetic  factor 
in  the  production  of  rickets  is  deficiency  of  fat-assimilation. 
a  deficiency  usually  dependent  upon  deficiency  of  fat  in  the  food, 
but  occasionally — so  it  appears — due  to  defective  assimilation 
of  the  fat  which  is  present  in  the  food.  The  whole  process  of 
fat-assimilation,  and  the  part  played  in  metabolism  by  fat  taken 
as  such  in  the  food,  is  still  very  imperfectly  known,  but  there  is 
experimental  evidence  to  show  that  the  assimilation  of  one 
food-constituent  is  influenced  by  the  proportion  of  other  food 
constituents  present  in  the  diet,  and  there  are  clinical  facts  which 
suggest  strongly  that  excess  of  carbo-hydrate,  whether  soluble 
or  insoluble,  interferes  with  the  assimilation  of  fat.  Whilst 
therefore  deficiency  of  fat  is  in  itself  a  serious  fault,  the  deficiency 
probably  becomes  even  more  harmful  when  associated  with 
excess  of  carbo-hydrate,  and  it  seems  likely  that  a  proportion  of 
fat,  which  is  just  sufficient  to  prevent  disorder  of  nutrition,  so 
long  as  no  excess  of  carbo-hydrate  is  present,  may  become  insuffi- 
cient, when  its  assimilation  is  hindered  by  an  associated  excess 
of  carbo-hydrate. 

But  what  constitutes  deficiency  of  fat  ?  Obviously  no  hard- 
and-fast  rule  can  be  laid  down,  but  if  the  occurrence  of  rickets 
may  be  taken  as  an  indication,  in  most  cases,  of  deficiency  of 
fat  in  the  diet — an  assumption  which  has  yet  to  be  proved,  but 
which  affords,  I  think,  the  most  useful  working  hypothesis — 
then  it  would  appear  that,  at  three  months  old,  1-75  per  cent, 
of  fat,  at  six  months  old  2-25  per  cent.,  and  at  nine  months  old 
2-5  per  cent,  of  fat,  is  the  minimum  which  will  protect  from  rickets, 
and  that  even  these  proportions  are  not  sufficient  for  the  purpose 
if  there  is  associated  therewith  an  excess  of  sugar  or  starch. 

These  proportions  I  give  as  the  result  of  clinical  observation 
upon  the  occurrence  of  rickets  in  infants  fed  upon  plain  milk-and- 
water  mixtures  of  various  dilutions  at  different  ages  :  if  an  infant 
is  fed  with  equal  parts  of  milk  and  water  at  three  months  old, 
gradually  increased  to  two  parts  of  milk  to  one  of  water  at  six 
months,  and  three  parts  of  milk  to  one  of  water  at  nine  months, 
there  is  very  little  risk  of  rickets,  whereas  feeding  with  weaker 
mixtures  often  does  result  in  rickets.  I  have  assumed  on  grounds 
which  I  shall  explain  in  a  later  chapter,  that  the  proportion  of 

F2 


68  COMMON  DISORDERS  OF  CHILDHOOD 

fat  in  the  food  is  the  cause  which  determines  the  occurrence  or 
non-occurrence  of  rickets,  and  in  this  way  have  arrived  at  these 
figures  as  a  useful  working  standard. 

These  proportions,  it  must  be  understood,  are  not  those  to  be 
recommended,  they  are  simply  the  minimum  which  can  be  used 
without  harmful  results.  The  proportion  of  cow's  milk  fat  upon 
which  a  healthy  baby  will  usually  do  best,  is  about  2-5  per  cent, 
during  the  first  few  weeks  of  life,  gradually  increased  up  to  about 
3  per  cent,  at  three  months  old  :  I  say  advisedly  '  cow's  milk  fat  ' 
because  very  many  infants  cannot  take  as  large  a  proportion  of 
this  as  they  can  of  the  fat  which  is  present  in  human  milk.  It  is 
never  necessary,  and  seldom  wise,  to  exceed  3-5  per  cent,  of  fat, 
more  often,  I  think,  a  proportion  of  3  per  cent,  will  be  found 
sufficient  throughout  the  whole  period  of  bottle-feeding. 

But  how  far  do  the  patent  foods  fulfil  these  conditions  ? 
A  glance  at  the  published  analyses  of  the  various  foods  which  are 
advertised  as  substitutes  for  fresh  cow's  milk,  and  which  are 
intended  to  be  used  simply  diluted  with  water,  will  show  that 
not  one  of  them  is  either  in  accordance  with  the  standard  of 
human  milk,  or  fulfils  the  requirements  which  are  necessary  if 
the  risk  of  rickets  is  to  be  avoided. 

Fat.         Carbo-hydrate. 

Condensed  Milk  ( Nestle' s) .         .     13-1  54-2 

Allenbury  No.  1          .         ,         .     16-7  66-6 

Allenbury  No.  2          ...     14-9  68-7 

Horlick's  Malted  Milk        .         .       8-4  63-5 

Milo  Food          ....       4-4  77-7 

Carnrick's  Soluble  Food    .         .       2-5  76-2 

It  is  evident  that  no  dilution  can  so  adjust  these  proportions 
as  to  make  the  percentage  both  of  fat  and  carbo-hydrate  cor- 
respond with  the  standard  of  human  milk :  as  a  matter  of  fact  in 
nearly  all  cases  as  the  food  is  used  the  fat  is  deficient,  often  ex- 
tremely deficient,  and  the  carbo-hydrate  is  considerably  in  excess. 
Such  foods  are  therefore  unsuitable  for  prolonged  use  in  infant- 
feeding,  but  they  may  nevertheless  serve  a  useful  purpose  in  the 
cases  of  severe  milk-indigestion,  where  it  is  necessary  to  feed 
for  a  short  time  with  some  food  which  yields  little  or  no  curd, 
and  which  contains  a  low  proportion  of  fat. 

There  are  cases  where,  owing  to  extreme  intolerance  of  fresh 
milk,  especially  during  the  first  few  weeks  of  life,  a  weak  solution 
of  carbo-hydrate,  even  if  there  is  associated  therewith  a  small 
proportion  of  starch,  seems  to  be  assimilated  better  than  any- 
thing else  :  and  in  such  cases  one  of  these  foods  diluted  rather 
beyond  the  maker's  directions  so  as  to  bring  the  soluble  carbo- 


CONDENSED  MILK  AND  PATENT  FOODS          69 

hydrates  in  it  down  to  a  more  suitable  proportion,  will  sometimes 
tide  the  infant  over  a  period  of  danger  :  but  it  is  to  be  remem- 
bered that  such  feeding  amounts  to  little  more  than  a  diet  of 
sugar  and  water. 

There  is  yet  another  point  which  must  be  remembered  in  com- 
paring these  manufactured  products  with  human  milk  or  fresh 
cow's  milk,  namely,  that  a  statement  of  percentage  composition, 
although  it  affords  some  guidance,  gives  but  an  incomplete  and 
sometimes  misleading  description  of  a  food.  For  instance,  two 
foods  may  contain  a  precisely  similar  percentage  of  fat  and  yet 
differ  in  their  fat-value.  Compare  a  dried  milk  food  with  a  dilu- 
tion of  fresh  cow's  milk  containing  the  same  percentage  of  fat  : 
in  the  latter,  the  emulsion  of  fat  is  extremely  fine  and  the  fat 
is  easily  assimilable  ;  in  the  former,  the  emulsion  is  so  imperfect 
that,  even  before  the  infant  has  time  to  finish  his  feed,  the  fat 
has  risen  in  yellow  droplets  floating  on  the  surface,  a  fault  which, 
in  some  cases,  seems  to  interfere  considerably  with  the  assimila- 
tion of  the  fat,  part  of  which  indeed  is  apt  to  remain  coating  the 
sides  of  the  bottle.  On  the  other  hand,  compare  a  dried  milk  food 
with  a  dilution  of  fresh  cow's  milk  in  which  the  percentage  of 
proteid  is  the  same  ;  the  proteid  in  the  former  produces  so  little 
curd  that  an  infant  may  assimilate  it  easily  when  he  is  unable 
to  digest  the  curd  of  the  fresh  cow's  milk. 

A  statement  of  percentage  composition,  moreover,  tells  us 
nothing  of  the  subtle  changes,  whatever  they  may  be,  by  which 
the  nutritive  value  of  a  food  is  so  impaired  in  the  process  of 
manufacture  that  if  its  use  be  continued  for  some  months  the 
food  is  liable  to  set  up  all  those  serious  symptoms  which  consti- 
tute scurvy  and  which  sometimes  end  in  death.  It  might  be 
thought  that  this  risk  would  be  limited  to  those  patent  foods 
which  are  used  only  with  plain  water  with  no  addition  of  fresh 
milk  :  but  so  far  from  this  being  the  case,  my  own  statistics 
show  that  a  large  proportion  of  cases  of  infantile  scurvy  arise 
where  a  patent  food  is  being  added  to  fresh  milk,  and  I  believe 
that  in  this  respect  those  foods  which  contain  an  active  digestive 
ferment,  such  as  Savory  &  Moore's  and  Benger's  Foods  are 
more  risky  than  others  in  which  there  is  no  such  ferment. 
Even  the  addition  of  completely  malted  cereal,  such  as  Mellin's 
Food,  to  milk  seems  to  involve  some  risk  of  scurvy,  and  I  have 
repeatedly  seen  infantile  scurvy,  when  the  chief  or  only  article 
of  diet  was  one  of  the  starchy  foods,  such  as  Ridge's,  Neave's,  or 
Frame  Food,  made  with  fresh  milk,  which,  however,  in  most  if  not 
in  all  cases,  was  boiled. 


70  COMMON  DISORDERS  OF  CHILDHOOD 

Condensed  milk  is  liable  to  cause  infantile  scurvy,  whether 
used  alone  or  in  combination  with  some  patent  food.  I  have 
notes  of  at  least  fifteen  cases  in  which  condensed  milk  with  or 
without  some  patent  food  had  produced  this  disease,  and  one 
of  these  cases  proved  fatal. 

There  is  every  reason  to  suppose  that  the  dried  milks  which 
have  recently  been  introduced,  will  prove  to  be  at  least  as 
dangerous  in  this  respect  as  condensed  milk. 

Now  I  am  well  aware  that  infantile  scurvy  is  not  a  common 
disease,  but  it  is  such  a  cruelly  painful  affection  when  it  does 
occur  that  we  may  well  hesitate  to  give  what  might  seem  to  be 
an  indiscriminate  sanction  to  the  use  of  foods  which  are  respon- 
sible not  only  for  grievous  suffering  but  actually  for  death  in 
some  cases.  Any  physician  attached  to  a  children's  hospital 
necessarily  sees  a  specially  large  proportion  of  the  less  common 
diseases  of  childhood  but,  making  allowance  for  this,  I  think 
that  my  own  experience  shows  that  infantile  scurvy,  though 
uncommon,  is  unfortunately  no  great  rarity.  I  have  notes  of 
sixty -four  cases  which  have  been  under  my  own  personal  observa- 
tion :  five  of  which  died  after  much  suffering.  Out  of  these 
sixty-four  cases  no  less  than  fifty-eight  were  being  fed  upon 
patent  foods  or  condensed  milk  (see  Chap.  VIII). 

Condensed  Milk 

I  turn  now  to  the  consideration  of  condensed  milk  :  one  hears 
sometimes  that  an  infant  could  not  take  fresh  cow's  milk,  so  it 
was  put  on  condensed  milk,  and  straightway  its  digestive  troubles 
mended,  and  if  only  the  condensed  milk  had  been  stopped,  after 
two  or  three  weeks,  no  harm  would  have  been  done  ;  but  it  has 
been  continued  for  several  months,  and  now  the  child  has  rickets. 
What  has  happened  ?  The  infant  was  probably  tried  at  first 
with  a  mixture  of  fresh  milk  and  water,  1  to  2,  perhaps,  even, 
equal  parts  ;  and  he  was  sick  or  had  colic,  so  resort  was  had  to 
condensed  milk ;  a  teaspoonf ul  in  4  ounces,  or  even  in  6  or  8  ounces 
of  water.  The  following  figures  will  show  how  such  mixtures 
compare  with  the  milk  previously  tried  : 

Condensed  Milk.  Fresh  Milk. 

One  teaspoonful  to  4  ozs.    One  teaspoonful  to  6  ozs.    With  two-thirds  water. 
Proteid      .         .     0-9  per  cent.  0-6  per  cent.  1-3  per  cent. 

Fat  .         .         .     1-0  per  cent.  0-75  per  cent.  1-2  per  cent. 

Sugar        .         .     4-5  per  cent.  3-2  per  cent.  1-3  per  cent. 

(+  added  sugar). 

It  is  evident  that  the  condensed  milk  in  these  mixtures,  which 
are  in  common  use,  is  diluted,  especially  as  to  the  proteid,  which 


CONDENSED  MILK  AND  PATENT  FOODS    71 

has  nearly  always  been  the  cause  of  the  difficulty  with  fresh 
milk,  to  a  degree  which  was  never  tried  when  the  cow's  milk  was 
given  fresh.  I  have  seen  cases  in  which  condensed  milk  has 
been  given  in  the  strength  of  a  teaspoonful  to  8  ounces  of  water 
(proteid,  0-45  per  cent.,  fat,  0-5  per  cent.)  because  '  fresh  milk 
would  not  agree  '  :  the  fresh  milk  had  never  been  diluted  with 
more  than  an  equal  quantity  of  Water,  whereas  the  dilution  of 
the  condensed  milk  was  equivalent,  so  far  as  proteid  was  con- 
cerned, to  one  part  of  fresh  milk  with  seven  parts  of  water  ! 
It  would  probably  be  correct  to  say  that  in  a  large  proportion  of 
the  cases,  in  which  an  infant  is  supposed  to  be  unable  to  digest 
fresh  cow's  milk  whereas  it  can  digest  condensed  milk,  the 
difference  depends  far  less  upon  any  special  digestibility  of  the 
curd  of  condensed  milk  than  upon  the  simple  fact  that  it  is 
diluted  to  a  degree  which  was  never  tried  with  the  fresh  milk. 

In  calculating  the  strength  of  a  condensed  milk  mixture,  it 
must  of  course  be  remembered  that  a  domestic  teaspoonful  is 
not  a  drachm,  and  that,  if  the  spoon  be  dipped  in  the  can,  there 
is  further  allowance  to  be  made  for  the  viscid  milk  which  clings 
to  the  undersurface  of  the  spoon.  For  purposes  of  calculation, 
I  have  ascertained  by  experiment  that  if  an  average  teaspoon 
(capacity  when  brimful  about  2  drachms)  be  used,  by  dipping 
it  in  the  can  and  taking  up  as  much  as  can  be  withdrawn  without 
special  care,  the  condensed  milk  may  be  reckoned  as  approxi- 
mately 3iij ;  with  a  larger  teaspoon  (capacity  3iij)  the  condensed 
milk  should  be  reckoned  as  fully  3iv ;  whereas,  if  the  milk  is  poured 
from  the  can  into  the  teaspoon,  so  that  none  adheres  below,  the 
amount  held  by  the  average  teaspoon  should  be  considered  3ij. 
The  undiluted  condensed  milk  contains  approximately  : 

Proteid         .         .         .         .11  per  cent. 

Fat 1 1  per  cent. 

Sugar  .         .         .         .55  per  cent. 

(In  the  'Milkmaid'  Brand  there  is  9  per  cent,  of  fat,  in  Nestle' s  'Nest'  Brand 
13-1  per  cent.,  according  to  my  own  analyses.) 

so  that,  for  instance,  with  an  average  teaspoonful  to  3  ounces 
of  water,  the  mixture  is  3  drachms  to  24  drachms,  =  1  to  8  or 
1  in  9,  that  is,  proteid  1-2  per  cent.,  fat  1-1-5  per  cent.,  sugar 
6  per  cent.  As  a  ready  way  of  calculating  approximately  the 
strength  of  a  condensed  milk  mixture,  this  is,  I  think,  sufficiently 
accurate  to  be  of  practical  value. 

It  is  evident  that  this  dilution,  one  teaspoonful  of  the  con- 
densed milk  to  3  ounces  of  water,  reduces  the  proportion  of  sugar 
approximately  to  that  present  in  human  milk,  and  that  any  less 


72  COMMON  DISORDERS  OF  CHILDHOOD 

dilution  would  make  the  sugar  excessive.  On  the  other  hand 
any  further  dilution  would  make  the  deficiency  of  fat  even  more 
marked  ;  so  that  if  condensed  milk  is  to  be  used  at  all  this  is 
the  proper  degree  of  dilution  of  the  ordinary  sweetened  variety. 

Such  a  mixture  sometimes  proves  useful  as  a  temporary  food 
for  two  or  three  weeks,  where  there  is  much  difficulty  in  digesting 
fresh  milk  ;  the  resulting  curd  from  condensed  milk  is  somewhat 
less  firm  than  that  from  fresh  cow's  milk,  and  intolerance  of  fat 
is  very  common  in  infants  with  disordered  digestion,  so  that  the 
low  proportion  of  fat  may  be  no  objection  to  this  food  for  a  short 
period.  The  prolonged  use  of  the  ordinary  sweetened  condensed 
milk  is  a  common  cause  of  severe  rickets ;  sometimes,  no  doubt, 
owing  to  excessive  dilution  of  the  milk  with  correspondingly 
great  deficiency  of  fat  ;  but,  as  I  have  shown,  however  it  may 
be  diluted,  it  is  impossible  to  avoid  one  or  other  of  the  two  faults 
which  play  an  important  part  in  the  production  of  rickets, 
deficiency  of  fat  and  excess  of  carbohydrate. 

Very  possibly  it  might  be  used  for  longer  periods  without  harm 
if  cream  in  proper  proportion  were  added  to  the  mixture,  but 
the  very  circumstances  which  most  commonly  lead  to  the  use 
of  condensed  milk,  poverty  and  inability  to  prepare  milk  mix- 
tures which  require  careful  measurement  of  the  several  con- 
stituents, are  just  those  which  usually  make  the  use  of  cream 
impracticable.  If  the  ordinary  fresh  '  separated  ',  that  is 
centrifugal  cream,  which  is  sold  in  the  shops  of  London  and 
other  large  cities  in  the  country,  is  to  be  used  for  this  purpose, 
a  carefully  measured  drachm  of  this  48  per  cent,  cream  to  every 
3  ounces  of  the  mixture  of  condensed  milk  and  water  will  raise 
the  proportion  of  fat  from  1-1-5  up  to  3-3-5  per  cent. 

Much  less  open  to  objection  are  the  various  brands  of  unsweet- 
ened condensed  milk.  In  these  the  milk  after  sterilization  has 
been  evaporated  in  vacuo  down  to  about  a  third  of  its  volume  ; 
no  cane  sugar  has  been  added  and  in  some  cases  the  proportion 
of  fat  in  the  milk  has  been  slightly  increased  by  the  addition  of 
cream  before  condensation. 

The  '  Ideal  '  Brand  is  stated  by  the  makers  to  contain  : 
Proteid      ....       8- 3  per  cent 
Fat  ....     12-4  per  cent. 

Milk  Sugar         .         .         .     16-0  per  cent. 

The  addition  of  three  parts  of  water  to  one  part  of  the  unsweet- 
ened condensed  milk  will  give  a  mixture  containing  : 

Proteid      ....     2-08  per  cent. 

Fat  .         .         .         .3-1    percent. 

Milk  Sugar         .         .         .4-0    percent. 


CONDENSED  MILK  AND  PATENT  FOODS 


73 


If  to  Bounces  of  such  a  mixture  half  an  average-sized  teaspoon- 
f  ul  of  milk  sugar  be  added  the  proportion  of  sugar  will  be  raised 
to  6-7  per  cent.,  and  so  far  as  percentage  composition  goes 
the  resulting  food  would  do  very  well  for  an  infant  of  three  to 
six  months  of  age.  For  a  younger  infant  dilution  with  four  or 
five  parts  of  water  would  be  required,  making  the  proportions 
as  follows  : 


Unsweetened  Condensed  Milk. 
%  ounce  with  water  2£  ounces, 

i.  e.  1  to  5. 

Proteid  .  .1-4  per  cent. 
Fat  .  .  .2-0  per  cent. 
Milk  Sugar  .  .2-6  per  cent. 


Unsweetened  Condensed  Milk. 
%  ounce  to  2  ounces  water, 

i.  e.  1  to  4. 

Proteid  .  .1-6  per  cent. 
Fat  .  .  .2-4  per  cent. 
Milk  Sugar  .  .  3-0  per  cent. 


The  weaker  mixture  with  the  addition  of  a  teaspoonful  of  milk 
sugar  to  every  3  ounces  is  suitable  for  an  infant  in  the  first 
month  or  six  weeks,  the  other  with  the  addition  of  half  a  tea- 
spoonful  of  milk  sugar  to  every  3  ounces  is  suitable  for  an  infant 
between  the  ages  of  six  weeks  and  three  months. 

A  similar  preparation  is  that  made  by  the  Aylesbury  Dairy 
Company  under  the  name  of  '  Humanoid  ',  the  composition  of 
which  is  stated  to  be : 

Proteid  ....  4-2  per  cent. 
Fat  ....  10-2  per  cent. 
Milk  Sugar  .  .  .  17-8  per  cent. 

In  this  the  proportion  of  proteid  has  been  made  lower,  so  that 
without  any  great  deficiency  of  fat  it  is  possible  to  give  a  low 
proportion  of  curd  and  so  to  overcome  the  digestive  difficulty 
of  some  infants.  Diluted  with  water,  the  resulting  mixture 
will  be  : 


Humanoid  1  part,  Water  2  parts. 
Proteid  .  .  1-4  per  cent. 
Fat  .  .  .  3-4  per  cent. 
Milk  Sugar  .  .5-9  per  cent. 


Humanoid  1  part,  Water  3  parts. 
Proteid  .  .  1-0  per  cent. 
Fat  .  .  .  2-5  per  cent. 
Milk  Sugar  .  .4-4  per  cent. 


It  is  evident  that  such  a  preparation,  if  it  can  be  used  with  the 
less  dilution,  one  part  of  the  '  Humanoid  '  to  two  of  water,  is 
not  even  open  to  the  objection  that  there  is  any  deficiency  of 
fat  or  excess  of  sugar,  the  proportions  in  fact  of  proteid,  fat, 
and  sugar  are  theoretically  excellent.  In  this  respect  it  is 
superior  to  the  ordinary  brands  of  unsweetened  condensed  milk ; 
its  cost  however  is  greater,  and  it  is  therefore  hardly  within 
the  reach  of  the  poorer  classes,  who  indeed  comparatively  rarely 
use  any  preparation  of  unsweetened  condensed  milk  owing  to 


74  COMMON  DISORDERS  OF  CHILDHOOD 

its  being  slightly  more  costly  than  the  sweetened  brands.  The 
difference  in  cost  depends  not  only  on  the  actual  price  per  tin, 
but  on  the  fact  that,  '  owing  to  the  greater  dilution  required,'  less 
of  the  sweetened  condensed  milk  is  used,  and  when  each  tin  is 
opened  the  milk  in  it  will  remain  fit  for  use  much  longer,  owing 
to  the  preservative  effect  of  the  cane  sugar,  than  will  the  unsweet- 
ened milk,  which  must  be  used  within  thirty-six  hours. 

The  curd  of  condensed  milk,  whether  sweetened  or  unsweet- 
ened, appears  to  be  just  as  large  as  that  of  fresh  cow's  milk 
when  an  acid  is  added,  but  it  is  certainly  digested  more  easily  by 
an  infant  ;  and  I  have  seen  nutrition  improved  by  the  use  of 
this  unsweetened  condensed  milk,  where  other  much  weaker 
modifications  of  fresh  milk  had  failed.  But  none  the  less  I  am 
averse  to  its  continued  use,  for  there  is  clear  evidence  that 
condensed  milk,  whether  from  the  boiling  or  sterilization  which 
forms  part  of  the  process  of  manufacture  or  whether  from  the 
condensation  in  vacuo,  is  capable  of  producing  infantile  scurvy. 

One  reason  assigned  for  the  use  of  condensed  milk  and  patent 
foods  is  their  freedom  from  bacterial  contamination,  and  there- 
fore supposed  virtue  in  the  prevention  of  summer  diarrhoea. 
Now  I  venture  to  doubt  whether  this  argument  is  really  sound  : 
with  regard  to  the  ordinary  sweetened  condensed  milk  my  own 
observations  seemed  to  show  that  exactly  the  opposite  was  the 
case,  for  whilst  it  was  found  that  12  per  cent,  of  infants  attending 
hospital  for  ailments  of  all  sorts,  were  being  fed  on  condensed 
milk,  it  was  shown  that  25-8  per  cent,  of  infants  dying  of 
diarrhoea  had  been  fed  on  condensed  milk.  It  does  not  seem 
reasonable  to  suppose  that  this  association  is  the  result  of  any 
special  infection  from  condensed  milk  ;  it  is  far  more  likely 
that  an  unhealthy  condition  of  intestine  induced  by  excess  of 
sugar  in  the  food,  or  by  the  fat  starvation  which  the  use  of 
condensed  milk  so  often  involves,  makes  a  favourable  soil  for 
the  multiplication  of  bacteria  reaching  the  intestine  from  other 
sources.  In  the  same  way,  I  believe  that  other  patent  foods, 
partly  by  the  excess  of  carbohydrate  which  they  contain,  and 
partly  by  their  deficiency  in  fat,  actually  pre-dispose  to  those 
infective  conditions  which  are  known  as  '  Summer  Diarrhoea  '. 

It  may  be  doubted  whether,  apart  from  breast-feeding,  there 
is  any  safer  food  in  this  respect  than  ordinary  fresh  milk,  properly 
modified  and  pasteurized  or  scalded  ;  I  suspect  that  in  the 
prophylaxis  of  infantile  diarrhoea  we  are  apt  to  lay  too  much 
stress  upon  the  possible  introduction  of  the  bacteria  of  diarrhoea 
by  fresh  milk  and  too  little  stress  upon  the  danger  of  diminishing 


CONDENSED  MILK  AND  PATENT  FOODS          75 

the  resisting  power  of  the  intestine  by  feeding  with  unsuitable 
food  which  by  its  excess  of  carbohydrate  supplies  the  material 
for  fermentation,  and  by  its  deficiency  of  fat  may  favour  the 
general  tendency  to  catarrhal  conditions  of  mucous  membrane 
which  we  know  to  be  one  feature  of  rickets. 

Lastly,  I  would  point  out  that  upon  the  medical  profession 
there  rests  no  small  responsibility  in  the  use  and  abuse  of  con- 
densed milk  and  patent  foods  for  infants.  Useful  as  most  of 
these  may  occasionally  be,  the  lay  public,  even  if  not  misled  by 
advertisements,  has  not  the  requisite  knowledge  to  discriminate 
between  the  different  conditions  under  which  different  foods 
may  safely  be  used  in  infant-feeding.  The  doctor's  orders, 
unless  most  carefully  guarded  and  hedged  about  with  cautions 
for  each  particular  case,  are  apt  to  be  taken  as  a  general  sanction 
for  the  particular  food  ordered.  We  may  well,  therefore,  be 
careful  in  our  advice,  lest  we  should  seem  to  countenance  the 
indiscriminate  use  of  these  trade-preparations,  and  thereby  add 
to  the  deplorable  suffering  which  such  ignorant  use  brings  upon 
infants.  Of  this  I  feel  sure,  that  the  more  the  medical  man 
knows  of  the  many  simple  methods  of  adapting  fresh  milk  to 
the  needs  of  the  infant,  the  less  use  he  will  find  for  condensed 
milk  or  patent  foods. 


CHAPTER  VI 

COMMON  FAULTS  AND  FALLACIES  IN 
INFANT-FEEDING 

THE  first  fault  to  which  I  would  draw  attention  is  neither 
in  the  food  nor  in  the  manner  of  feeding,  but  in  the  personnel 
which  directs  the  feeding  :  why  is  it  that  one  hears  so  often 
from  the  present-day  monthly  nurse,  such  expressions  as  this : 
'  I  always  feed  my  babies  with  such  and  such  a  mixture,'  or 
1  witli  such  and  such  amounts  at  each  feed  '  ?  or  again,  why 
do  we  hear  the  modern  domestic  nurse,  especially  in  the  upper 
classes,  talking  of  the  feeding  of  an  infant  as  if  she  forsooth 
with  less  than  a  smattering  of  knowledge  of  the  very  rudiments 
of  infant-feeding  were  a  competent  person  to  direct  the  feeding 
of  a  baby  ?  I  am  afraid  that  in  many  such  instances  the  fault 
lies  with  the  medical  man  :  he  has  attended  the  confinement, 
he  has  taken  admirable  care  of  the  mother  ;  but  has  left  the 
details  of  feeding  the  infant  to  the  monthly  nurse,  or  perhaps  if 
artificial  feeding  is  inevitable  he  has  said,  '  Oh,  try  him  with 
some  milk  and  water  '  ;  leaving  the  nurse  to  decide  on  the 
proportions,  and  to  add  sugar  and  possibly  eream  on  her  own 
responsibiHty.  Naturally  enough  when  the  food  disagrees,  the 
nurse,  seeing  that  the  doctor  apparently  attaches  so  little  impor- 
tance to  details,  begins  to  modify  the  feeding  on  her  own  account, 
and  what  is  the  result  ?  First  and  most  important,  that  the 
infant  suffers  ;  secondly,  that  after  the  nurse  has  already  done 
mischief  by  her  'experienced  '  inexperience,  off  go  the  parents 
to  a  '  specialist  ',  probably  without  even  mentioning  it  to  their 
family  doctor  ;  and  it  is  not  much  to  be  wondered  at,  if  they 
say,  '  Doctor  So-and-so  is  very  good  for  ladies,  but  he  takes  no 
interest  in  babies.'  If  the  medical  man  who  attends  the  con- 
finement would  give  detailed  directions  as  to  the  feeding  of  the 
infant,  and  see  to  it  that  as  long  as  he  was  attending  no  nurse, 
whether  trained  or  untrained,  presumed  to  alter  the  feeding 
except  in  accordance  with  his  directions,  he  would  do  good 
service  to  the  infant  and  at  the  same  time  would  prevent  such 
very  natural  criticism  as  that  to  which  I  have  referred. 

And   here   let    me   emphasize   the  importance   of   detail   in 


FAULTS  AND  FALLACIES  IN  INFANT-FEEDING    77 

direction  ;  to  tell  a  mother  to  give  her  child  equal  parts  of  milk 
and  water  may  be  admirable  advice  as  far  as  it  goes  ;  but  if  the 
mother  or  the  nurse  is  to  guess  what  quantity  is  to  be  given, 
and  how  often,  and  whether  sugar  is  to  be  added  and  if  so  how 
much,  the  result  of  the  doctor's  advice  or  rather  of  the  defective- 
ness  of  his  advice  may  be,  and  often  is,  disastrous. 

Next  I  wish  to  mention  a  fallacy  which  I  venture  to  think 
misleads  not  only  the  laity  but  also  many  medical  men  in  infant- 
feeding  :  namely  that  because  an  infant  is  gaining  weight  and 
has  neither  sickness  nor  diarrhoea  on  a  particular  food,  therefore 
this  food  is  a  good  one.  The  proof  of  the  pudding  is  not  only 
in  the  eating,  it  is  also  in  the  after-results,  and  in  the  case  of 
infant-feeding  this  result  may  not  be  apparent  for  months. 
I  may  mention  as  a  well-marked  instance  of  this,  the  fact  recently 
pointed  out  by  Dr.  Holt  that  an  infant  fed  with  a  mixture  of 
milk  and  water  and  cream,  containing  too  high  a  proportion  of 
fat,  say  5-7  per  cent.,  may  appear  to  thrive  upon  it  almost 
extravagantly,  and  may  be  for  a  time  fat  and  jolly,  but  sooner 
or  later,  perhaps  not  till  the  child  is  more  than  six  months  old, 
the  evil  effects  of  the  excess  of  fat  in  the  food  begin  to  appear, 
and  marasmus,  rickets  or  some  troublesome  digestive  disorder 
is  the  outcome  of  what  seemed  to  suit  so  excellently  :  take 
again  as  a  much  less-marked  instance  the  common  mixtures  of 
milk  and  barley-water;  everything  goes  smoothly  enough  appar- 
ently, but  how  often  one  finds  when  the  infant  has  reached  nine 
or  ten  months  old,  that  there  is  very  slight  but  definite  rickets, 
the  proportion  of  fat  has  been  lower  than  it  should  be,  and 
starch  has  been  given  in  the  form  of  barley-water  long  before 
a  child  should  have  any.  I  mention  these  particular  instances 
because  they  are  faults  which  are  more  easily  overlooked  and 
are  more  often  ignored  than  such  generally  recognized  faults  as 
occur  in  the  condensed  milk,  which  may  be  excellently  digested 
and  may  increase  the  infant's  weight  steadily  but  ultimately 
produces  a  more  or  less  marked  degree  of  rickets,  or  the  patent 
food — Allen  &  Hanbury's,  Benger's,  or  Savory  &  Moore's,  or 
what  you  will — which  agrees  so  well  but  ultimately  may  produce 
scurvy. 

And  this  brings  me  to  the  mention  of  one  particular  fault 
which  like  those  to  which  I  have  already  referred  may  not 
produce  any  apparent  ill  effect  until  it  has  been  continued  for 
many  weeks  or  even  months, — I  mean  feeding  with  too  large 
a  bulk  of  fluid.  This  is  I  believe  quite  one  of  the  commonest 
faults  in  infant-feeding  in  all  classes. 


78  COMMON  DISORDERS  OF  CHILDHOOD 

I  see  many  infants  with  some  such  history  as  this  :  at  the  age 
of  six  weeks  the  infant  was  having  3  ounces  at  a  feed,  at  two 
months  3|  or  4  ounces,  and  by  the  time  he  is  three  months  old 
he  is  having  6  or  even  7  ounces. 

For  a  time  the  infant  appears  to  be  doing  perfectly  well :  he  is 
gaining  weight  not  only  steadily  but  rapidly  and  perhaps  the 
most  punctilious  of  theorists  could  not  find  a  flaw  in  the  pro- 
portions of  the  milk-mixture  ;  there  may  perhaps  be  some  slight 
posseting,  but  what  of  that  ?  and  so  it  goes  on  until  the  infant  is 
some  three  or  four  months  old  :  and  then  the  trouble  begins, 
the  child  ceases  to  gain  weight,  then  begins  to  lose  definitely,  he 
begins  to  vomit,  not  severely  but  enough  to  make  the  marasmus 
worse  ;  and  soon  the  infant  is  a  wasted  child  with  no  organic 
disease  to  be  found  but  with  a  stomach  so  intolerant  that  it 
rejects  this  food  and  that  ;  and  the  wasting  continues  until  at 
last  in  despair  the  doctor  does  what  ought  to  have  been  done 
months  before,  cuts  down  the  size  of  the  feed  :  but  unfortunately 
the  stomach  long  abused  is  not  to  be  appeased  by  this  tardy 
diminution  of  the  feed  to  the  proper  amount  for  the  age,  it  is 
often  necessary  to  give  much  smaller  and  weaker  feeds  than 
would  be  suitable  for  a  healthy  infant  of  the  same  age,  and 
even  then  there  are  often  weeks  and  weeks  of  trouble  before  the 
child  begins  to  assimilate  food. 

If  one  inquires  why  such  large  feeds  were  given,  one  is  told 
that  the  infant  seemed  hungry  ;  and  that  as  the  stools  were 
well  digested  and  the  weight  was  progressing  so  rapidly,  the 
feeds  were  increased  in  size. 

It  is  obvious  that  Nature's  method  is  to  allow  an  infant  to 
suck  until  he  is  satisfied,  but  the  hand-fed  infant  is  not  fed  on 
Nature's  food,  and  experience  shows  that  with  substitute  feeding, 
however  carefully  we  may  strive  to  imitate  human  milk,  it  is 
necessary  to  restrict  the  quantity  of  each  feed  within  certain 
limits.  But  says  the  mother,  '  the  infant  is  not  satisfied,  surely 
we  must  give  a  larger  feed  ? '  Yes,  but  only  within  those  limits ; 
if  the  proper  bulk  of  feed  for  the  age  has  been  reached  and  the 
infant  is  still  not  satisfied,  increase  the  strength  of  the  feed,  not 
its  size.  By  increasing  the  proportion  of  milk  or  cream  it  is 
often  possible  to  satisfy  the  appetite  of  the  infant  without 
increasing  the  amount  of  the  feed  at  all,  and  by  so  avoiding 
excessive  bulk  of  feed,  one  may  avoid  troublesome  digestive 
disturbance. 

Of  course  the  amount  of  the  feed  has  to  be  increased  gradually 
as  the  infant  grows  older,  and  some  big  infants  will  require  more 


FAULTS  AND  FALLACIES  IN  INFANT-FEEDING    79 

than  a  smaller  infant  of  the  same  age  ;  but  on  the  whole  it  is 
possible  to  lay  down  simple  rules  as  to  the  amounts  of  the 
feeds.  During  the  first  week  the  feeds  should  be  1J  ounces, 
at  the  second  week  2  ounces  ;  at  the  end  of  the  sixth  week 
2J  ounces  ;  at  three  months  3  ounces  ;  and  from  this  time  up 
to  the  end  of  the  eighth  month  the  food  should  be  at  the  rate 
of  1  ounce  for  every  month  of  age  :  i.e.  4  ounces  at  four  months, 
5  ounces  at  five  months,  and  so  on.  For  an  exceptionally  large 
infant  an  additional  ounce  may  be  allowed,  i.e.  3+1  ounces  at 
three  months,  4  +  1  ounces  at  four  months,  5+1  ounces  at 
five  months,  and  so  on.  In  giving  these  directions  as  to  the 
amounts  I  am  assuming  that  the  proper  intervals  of  feeding  are 
observed,  namely,  two-hourly  up  to  the  age  of  two  months,  and 
three-hourly  from  the  age  of  three  months  up  to  the  end  of  the 
ninth  month.  But  here  I  would  add  a  caution :  '  Nature  does 
nothing  by  leaps,'  and  he  will  be  most  successful  in  infant-feeding 
who  makes  every  change  whether  of  amount  or  interval  gradually. 

Connected  with  this  fault  of  excessive  bulk  is  a  fallacy  which 
I  have  sometimes  heard  seriously  propounded,  that  it  makes  no 
difference  whether  one  gives  a  food  containing  a  lower  or  higher 
proportion  of  proteid  or  fat,  provided  the  infant  takes  more, 
the  result  is  the  same  ;  for  instance,  if  an  infant  has  4  ounces 
of  a  mixture  containing  1-5  per  cent,  of  fat,  this  is  just  as  good 
as  2  ounces  containing  3  per  cent.  To  this  I  would  reply  that 
undoubtedly  to  a  certain  extent  such  compensation  is  possible, 
but  only  to  a  very  limited  extent ;  directly  the  bulk  of  the  food 
is  increased  beyond  what  experience  shows  to  be  the  proper 
amount  for  the  age,  there  is  a  risk  of  slowly  producing  the 
chronic  feebleness  of  digestion  which  I  have  already  mentioned 
as  arising  from  excessive  bulk  of  feeds. 

The  next  point  to  which  I  turn  is  the  so-called  *  nursery 
milk  '.  Parents  often  tell  me  that  they  are  having  nursery 
milk  for  their  infants,  and  they  say  it  with  an  air  of  satisfac- 
tion, as  if  'nursery  milk'  were  the  ultima  Thule  of  perfection. 
Now  I  would  warn  doctors  and  parents  to  beware  of  'nursery 
milk'.  The  milkman  apparently  imagines  that  a  milk  which 
from  his  point  of  view  is  an  exceptionally  good  one,  namely, 
an  exceptionally  rich  one,  is  therefore  particularly  suited  to 
the  infant,  who,  as  he  knows,  requires  '  good  milk  ',  so  he 
either  puts  aside  to  be  sold  at  a  special  price  the  milk  of 
a  cow  which  has  recently  calved,  and  which  therefore  is 
specially  rich,  or  having  some  Jersey  cows  he  reserves  their  milk 
to  be  sold  for  nursery  use  while  that  of  the  ordinary  Shorthorn 


80  COMMON  DISORDERS  OF  CHILDHOOD 

is  supplied  to  the  ordinary  customer ;  in  some  cases  he  sells  as 
'  nursery  milk  '  strippings,  that  is  to  say,  the  milk  obtained  from 
a  cow  byre-milking  a  few  minutes  after  the  ordinary  milking  has 
been  completed.  However  it  is  obtained,  some  of  these  so-called 
nursery  milks  contain  so  high  a  percentage  of  fat  that  they  are 
practically  a  weak  cream.  Some  time  ago  I  had  an  infant 
brought  to  me  because  he  was  doing  badly  and  the  food  did  not 
agree.  I  found  he  was  on  nursery  milk,  and  I  ascertained  by 
analysis  that  this  milk  contained  12  per  cent,  of  fat  :  in  another 
similar  case,  the  nursery  milk  contained  about  6  per  cent,  of  fat. 
The  most  suitable  milk  for  infant-feeding  is  the  milk  of  a  mixed 
herd  of  Shorthorn  cattle,  such  as  is  supplied  for  ordinary  uses  ; 
nursery  milk  is  best  avoided  altogether,  unless  an  analysis  can  be 
obtained  and  the  particular  dairyman's  interpretation  of  '  nur- 
sery milk  '  is  known.  Obviously,  when  the  doctor  is  having 
such  rich  milk  diluted  as  if  it  were  ordinary  milk,  it  is  likely 
enough  that  trouble  will  ensue. 

But  nursery  milk  does  not  always  mean  a  specially  rich  milk  ; 
sometimes,  indeed,  it  is  difficult  to  guess  on  what  grounds  it  is 
supposed  to  be  particularly  suitable  for  the  nursery  ;  the  only 
appreciable  difference  in  some  instances  being  that  it  is  particu- 
larly poor  milk  for  which  a  particularly  high  price  is  charged  ;  for 
example,  in  '  nursery  milk '  for  which  an  extra  charge  was  made 
to  a  poor  woman  who  could  ill  afford  it,  the  proportion  of  fat  was 
2-1  per  cent.  One  dairyman  who  supplied  'nursery  milk'  for 
which  he  charged  a  specially  high  price  admitted  that  the  only 
special  feature  in  it  was  that  it  had  been  pasteurized,  whereas 
the  milk  sold  at  the  ordinary  price  was  fresh  milk.  In  the  case 
of  one  infant  wrho  was  under  my  care,  and  was  being  fed  on 
special '  nursery  milk  '  the  ingenuous  dairyman  explained  to  the 
mother  that  the  difference  in  the  nursery  milk  and  the  ordinary 
milk  was  that  he  put  colouring  matter  in  ordinary  milk  whereas 
1  nursery  milk  '  was  not  coloured.  Some  recent  observations  on 
'  nursery  milk  ',  obtained  from  some  of  the  best-known  dairy 
companies  in  London,  have  shown  that  so  far  from  being 
specially  pure  and  clean,  it  was  dirtier  and  more  contaminated 
than  the  ordinary  milk.  In  some  instances  it  contained  from 
two  to  five  times  as  many  bacteria  as  the  ordinary  milk,  obtained 
at  the  same  time  from  the  same  dairy  company. 

I  have  repeatedly  known  difficulty  to  arise  where  the  milk  of 
Jersey  cows  was  being  used,  without  due  allowance  for  its  extra 
richness.  A  comparison  between  this  milk  and  that  of  the 
ordinary  Shorthorn,  which  is  the  cow  in  common  use  for  dairy 


FAULTS  AND  FALLACIES  IN  INFANT-FEEDING   81 

purposes  in  England,  will  show  how  considerably  this  may  affect 
the  composition  of  the  food 


Ordinary  Shorthorn's  milk. 
Proteid  .         .     4-0  per  cent. 

Fat       .         .         .3-5  per  cent. 
Sugar    .         .         .     4-0  per  cent. 


Jersey  cow's  milk. 
Proteid          .   -     .     4-5  per  cent. 
Fat        .         .         .     5-2  per  cent. 
Sugar    .         .         .     4-0  per  cent. 


Now  if  this  Jersey  milk  be  treated  as  if  it  were  of  the  same 
composition  as  the  ordinary  Shorthorn  milk,  and  a  drachm  of 
ordinary  cream  (48  per  cent.)  is  added  to  a  three-ounce  feed  of  equal 
parts  of  milk  and  water,  the  resulting  fat  percentage,  instead  of 
being  approximately  3-75  per  cent.,  will  be  4-6  per  cent.,  a  pro- 
portion which  is  more  than  many  infants  can  tolerate.  If  cream 
is  not  available  and  the  only  modification  of  milk  which  is  prac- 
ticable is  simple  dilution  and  addition  of  sugar,  undoubtedly  there 
is  some  advantage  in  using  a  milk  in  which  the  fat  is  relatively 
more  abundant  than  the  proteid,  as  in  that  from  Jersey  cows,  for 
the  dilution  required  will  result  in  less  deficiency  of  fat  than  it 
would  with  other  milk  ;  but  if  cream  can  be  added  there  is  no 
ad  vantage  in  using  a  specially  rich  milk ;  the  only  point  of  practical 
importance,  so  far  as  the  composition  of  the  milk  is  concerned, 
is  that  we  should  know  the  strength  of  the  milk,  and  this  we  can 
know  just  as  well  with  ordinary  Shorthorn  milk  as  with  a  Jersey 
cow's  milk  :  if  we  must  add  cream,  it  is  just  as  easy  to  rectify 
a  small  deficiency  as  a  large  deficiency  of  fat  in  the  diluted  milk. 
The  last  point  of  which  I  wish  to  speak  is  the  vagueness  with 
which  cream  is  often  ordered.  I  ask,  '  What  is  being  given  ?  '  and 
I  am  told,  *  Milk  and  water  with  some  cream,  a  couple  of  teaspoon- 
fuls  of  cream  in  a  three-ounce  feed.' 

'  But  what  strength  cream  is  being  used  ? '  *  It  is  very  good  cream 
from  a  very  reliable  dairy,'  I  am  told,  and  when  I  point  out 
that  this  is  not  sufficient,  we  must  have  some  idea  of  its  strength, 
people  are  sometimes  quite  vexed  that  I  should  insist  upon  such 
minutiae  ;  as  who  should  say,  we  bought  this  arsenic  mixture 
from  a  good  chemist,  he  supplies  excellent  drugs,  why  worry 
about  the  quantity  of  Liq.  Arsenicalis  in  each  drachm  ?  Such 
an  attitude  with  reference  to  a  potent  drug  would  be  absurd  ; 
but  cream,  be  it  remembered,  if  given  in  excess  is  a  potent  irritant, 
and  may  set  up  diarrhoea  or  vomiting,  or  if  given  in  slighter 
excess  for  a  long  period  may  produce  more  chronic  disturbance 
of  digestion  as  I  have  already  mentioned.  It  is  very  necessary, 
therefore,  that  the  strength  of  the  cream  should  be  taken  into 
account  if  cream  is  to  be  used  at  all.  I  have  considered  the 
composition  of  cream  according  to  the  method  of  its  preparation 

SPILL  G 


82  COMMON  DISORDERS  OF  CHILDHOOD 

in  a  previous  chapter,  here  I  will  only  reiterate  the  practical 
conclusions  to  which  my  own  observations  have  led  me  :  first,  that 
gravity  cream,  or  skimmed  cream,  may  safely  be  regarded  as 
containing  on  the  average  24  per  cent,  of  fat,  and  varies  so  much 
in  its  strength  that  it  is  very  unsatisfactory  for  infant-feeding; 
secondly,  that  '  separated  '  cream,  that  is,  cream  made  by  a 
centrifugal  machine  or  '  Separator  '  (as  almost  all  the  cream  sold 
in  London  and  other  large  towns  is)  should  be  reckoned  as  con- 
taining 48  per  cent,  of  fat. 

On  several  occasions  when  the  need  for  ordering  cream  accord- 
ing to  its  strength  has  been  realized,  and  I  have  asked  what 
cream  is  being  used,  I  have  been  told,  '  The  usual  20  per  cent, 
cream.'  Now,  if  there  is  one  thing  which  does  not  exist  in  this 
country  as  a  regular  article  of  commerce  it  is  a  20  per  cent,  cream, 
but  there  is  a  widespread  notion  that  this  is  the  usual  strength  of 
cream,  and  this  notion  has  arisen,  I  fancy,  entirely  from  the 
writing  of  American  authors,  who  are  able  to  buy  a  20  per  cent, 
cream.  In  London,  certainly,  unless  a  standardized  cream  of 
that  strength  is  made  to  special  order,  it  may  be  taken  for  granted 
that  the  cream  is  not  a  20  per  cent,  cream,  and  if  cream  is  bought 
as  fresh  cream  from  any  milk-shop,  the  strength  may  safely  be 
assumed  as  approximately  48  per  cent. 

In  ordering  cream  I  would  advise  every  medical  man  to  think 
in  percentages,  and  always  to  keep  the  fat  percentage  of  the 
feeds  rather  below  the  standard  of  human  milk,  in  which  the  fat 
is  3-5  per  cent.  It  is  easy  to  exceed  the  proportion  which 
an  infant  will  tolerate  ;  I  think  it  will  be  found  that  3  per 
cent,  is  quite  as  much  as  many  an  infant  can  bear,  and  some 
will  do  better  with  slightly  less.  When  this  limit  is 
exceeded  some  infants  will  suffer  with  vomiting  or  looseness  of 
bowels. 

'  But,'  says  one, '  the  mother's  milk  contains  3-5  to  4  per  cent,  of 
fat,  surely  the  child  ought  to  be  able  to  stand  more  fat.'  Yes  ; 
perhaps  he  should,  on  theoretical  grounds,  if  only  fat  3-5  to  4  per 
cent,  always  meant  the  same  thing  ;  but  here  comes  in  one  of 
the  fallacies  not  only  of  the  so-called  '  percentage-feeding  ',  but 
also  of  those  specious  advertisements  which  prove  conclusively 
that  the  percentage  composition  of  some  patent  food  corresponds 
exactly  with  that  of  mother's  milk.  It  is  not  merely  the  per- 
centage or  proportion  of  fat  that  has  to  be  considered  ;  the  fat 
in  two  different  foods  may  be  identical  in  percentage,  but  may 
differ  widely  in  its  digestibility  and  nutritive  value,  the  difference 
being  due  sometimes  to  subtle  physical  differences,  sometimes 


FAULTS  AND  FALLACIES  IN  INFANT-FEEDING      83 

to  equally  subtle  chemical  differences.  And  these  remarks 
apply  even  to  the  ordinary  milk  or  cream  and  water  mixtures  : 
the  fat  globules  of  cow's  milk,  even  before  it  is  altered  by  heating 
and  watering,  differ  in  size  from  those  of  human  milk,  the  cow's 
milk  fat  has  also  a  higher  melting  point  than  the  fat  of  mother's 
milk ;  moreover,  in  diluting  cow's  milk  with  water,  we  disturb 
the  emulsion  of  the  fat  to  such  a  degree  that  its  digestibility 
may  well  be  affected.  But  however  this  may  be,  it  is  to  be 
remembered  that  in  the  making  of  cream  the  fat  of  milk  is 
thrown  out  of  its  emulsion  almost  altogether  ;  and  although  we 
may  mix  it  with  water  or  milk  subsequently  it  is  very  unlikely  that 
we  can  restore  the  fat  to  a  state  of  emulsion  anything  like  so 
perfect  as  exists  in  natural  milk  ;  and  this  is,  I  think,  one  reason 
why  infants  will  only  tolerate  a  very  moderate  proportion  of  fat 
given  in  the  form  of  cream. 

But  there  may  be  other  reasons  :  a  very  large  proportion  of 
commercial  cream  contains  boric  acid  used  as  a  preservative,  and 
this  has  been  thought  to  disagree  in  some  cases ;  moreover,  com- 
mercial cream  sold  as  fresh  cream,  is  often  so  stale  that  the  ordinary 
preservatives  may  not  suffice  to  prevent  the  growth  of  harmful 
bacteria  in  it;  in  a  recent  case  in  which  a  dairyman  was  being 
prosecuted  for  adding  starch  to  thicken  cream,  a  witness 
admitted  that  it  was  very  usual  in  the  trade  to  keep  cream  four 
days  in  stock. 

Lastly,  it  must  be  pointed  out  that  cream  may  be  just  as  dan- 
gerous as  milk  in  conveying  tuberculous  infection.  One  often 
finds  that  a  child  is  having  all  milk  carefully  boiled  whilst  cream 
is  being  given  freely  without  any  precautions. 

To  some  extent  this  risk  depends  upon  the  method  of  prepara- 
tion. It  has  been  shown  by  experiment  that  cream  prepared  by 
a  separator  contains  a  small  number  of  bacteria  of  any  sort, 
compared  with  milk,  but  if  the  milk  from  which  it  was  made 
was  tuberculous,  some  tubercle  bacilli  remain  in  the  cream. 
Cream  made  by  gravity,  i.  e.  as  top  milk,  will  show  a  much  larger 
number  of  bacteria.  It  is  only  when  cream  has  been  subjected 
to  a  high  temperature,  either  by  pasteurizing  or  boiling,  as  can 
easily  be  done  in  any  milk  mixture  to  which  it  is  added,  or  when 
it  has  been  prepared  by  the  old-fashioned  method  of  scalding  in 
pans,  which  has  been  customary  in  Devon  and  Cornwall,  that  it 
may  be  considered  free  from  this  risk. 


G2 


CHAPTER  VII 
RICKETS 

RICKETS  is  one  of  the  commonest  disorders  of  early  life  amongst 
the  poorer  population  of  large  cities,  nor  is  it  very  rare  in  its 
slighter  manifestations  amongst  the  well-to-do,  and  yet  there 
are  few  diseases  which  are  more  easily  preventable.  Undoubtedly 
there  are  problems  in  its  causation  which  we  cannot  solve  at 
present,  but  enough  is  known  to  enable  us  to  reduce  its  occurrence 
almost  if  not  quite  to  a  vanishing-point,  if  only  this  knowledge 
could  be  diffused  and  carried  into  effect  amongst  the  poorer 
classes. 

My  own  statistics  showed  that  of  children  in  London  under 
the  age  of  three  years  who  were  brought  to  hospital  for  various 
diseases,  44-6  per  cent,  showed  rickets,  while  Dr.  John  Thomson 
in  Edinburgh,  amongst  children  of  the  same  age,  found  that 
1  rather  more  than  50  per  cent.  '  were  affected  by  this  disease. 
In  Manchester,  Dr.  Ritchie  found  that  30-3  per  cent,  of  '  sick 
children'  (he  does  not  state* their  ages)  had  rickets:  figures 
taken  in  several  large  cities  in  America  and  in  various  parts  of 
Europe,  show  that  the  proportion  of  rickety  children  amongst 
hospital  out-patients  is,  generally  speaking,  from  30  to  80  per  cent. 

It  is  commonly  supposed  that  rickets  is  less  frequent  in  rural 
districts  than  in  large  towns  ;  this  seems  probable,  but  I  know 
of  no  statistics  that  prove  it  ;  it  is  quite  certain  that  rickets  is 
by  no  means  uncommon  in  the  country,  and  I  would  lay  stress 
upon  this  fact,  for  some  have  pointed  to  such  causes  as  over- 
crowding and  lack  of  sunlight  and  defective  sanitation  as  causes 
of  rickets,  whereas  clinical  evidence  seems  to  show  that  rickets 
has  no  necessary  connexion  with  environment. 

An  infant  whose  feeding  is  suitable  does  not  get  rickets,  though 
he  live  in  the  worst  of  .London  slums,  and  rickets  is  treated  daily 
amongst  the  out-patients  of  a  children's  hospital  with  no  change 
whatever  in  the  child's  environment,  and  yet  correction  of  the 
diet  and  the  addition  of  cod-liver  oil  produces  rapid  improvement. 

For  practical  purposes  I  think  it  cannot  be  too  emphatically 
laid  down  that  rickets  is  a  food  disorder  ;  it  means  faulty  feeding 
or  faulty  assimilation  ;  and  wherever  poverty  or  ignorance  leads 
to  the  use  of  improper  food  for  infants,  there  rickets  will  be  pre- 


RICKETS  85 

valent.  In  crowded  cities  and  factory  towns  where  the  struggle 
for  existence  is  great,  and  where  poverty  abounds,  and  the 
mother  as  well  as  the  father  must  go  out  to  work,  the  infant  is 
likely  to  be  weaned  too  early,  and  to  be  fed  on  improper  food, 
and  on  cheap  substitutes  for  fresh  milk  such  as  condensed  milk ; 
it  is  in  this  way  that  rickets  becomes  a  disease  of  the  cities  rather 
than  of  the  country.  Even  amongst  the  well-to-do,  the  stress 
of  town  life  exercises  an  injurious  influence  on  infant-feeding, 
for  it  makes  women  less  capable  of  suckling  their  infants  and  so 
necessitates  hand-feeding  with  its  attendant  risks,  one  of  which 
is  rickets. 

Dietetic  causes.  Is  it  possible  to  determine  the  particular 
fault  in  diet  which  underlies  the  occurrence  of  rickets  ?  A  com- 
parison of  the  various  diets  upon  which  rickets  arises  gives, 
I  think,  some  guidance ;  they  may  be  grouped  as  follows,  in 
the  order  of  their  frequency  in  the  causation  of  this  disease  : 

(1)  Starch-containing  foods,  e.g.  potato,  biscuits,  bread  and 
butter,  sopped  bread,  cornflour,  with  more  or  less  milk. 

(2)  Condensed  milk,  usually  excessively  diluted. 

(3)  Patent   foods,  whether   containing    starch    or   not,    and 
whether  made  with  or  without  fresh  milk. 

(4)  Cow's  milk  excessively  diluted  without  addition  of  cream. 

(5)  Breast-milk  with  addition  of  starch-containing  foods. 

(6)  Breast-milk  alone  ;  when  the  milk  is  thin. 

Upon  every  one  of  these  diets  rickets  is  known  to  occur  ;  and 
clearly  if  there  is  one  particular  fault  which  induces  rickets,  it 
must  be  common  to  all  these  methods  of  feeding. 

Starch-containing  food  has  often  been  blamed,  but  it  cannot  be 
the  essential  factor,  for  in  groups  (2),  (4),  and  (6)  there  is 
no  starch,  and  some  of  the  worst  degrees  of  rickets  occur  on 
excessively  diluted  condensed  milk. 

Deficiency  of  proteid  has  been  suggested,  but  the  child  who 
becomes  rickety,  as  many  infants  do,  because  cow's  milk  is  being 
given  diluted  with  an  equal  quantity  of  water  when  the  child  is 
eight  or  nine  months  old,  is  having  an  amount  of  proteid  fully  up 
to  the  normal  if  the  proportion  in  human  milk  may  be  taken  as 
a  standard. 

Excess  of  sugar  is  certainly  not  common  to  all  the  diets  ;  indeed 
in  the  very  one  in  which  it  is  usually  supposed  to  give  trouble, 
namely,  where  condensed  milk  is  used,  the  occurrence  of  rickets 
almost  always  goes  with  excessive  dilution  of  the  condensed  milk 
so  that  the  sugar  is  actually  below  the  normal  proportion,  some- 
times only  3  to  4  per  cent,  instead  of  the  normal  7  per  cent. 


86  COMMON  DISORDERS  OF  CHILDHOOD 

Deficiency  of  lime  salts  cannot  account  for  rickets  where  cow's 
milk  is  used  as  the  only  food,  diluted  say  half  and  half  at  eight 
months,  for  the  proportion  of  lime  salts  in  cow's  milk  is,  according 
to  some  observers,  about  three  times,  according  to  others  about 
six  times,  as  large  as  in  human  milk. 

The  occurrence  of  rickets  upon  diets  (2),  (4),  and  (6),  suggests 
that  the  fault  is  one  of  defect  ;  it  is  a  negative  rather  than  a 
positive  fault,  and  as  neither  deficiency  of  proteid  nor  of  lime 
salts,  nor  of  sugar  seems  to  be  in  question,  we  are  almost  driven 
to  the  conclusion  that  deficiency  of  fat  is  the  fault  in  point. 

Deficiency  of  fat  is  certainly  common  to  diets  (2),  (4),  and  (6)  ; 
it  is  usual  in  diets  (1)  and  (3),  but  what  about  diet  (5),  in  which 
breast-milk;  often  of  good  quality,  is  given  with  addition  of  starch 
foods  ?  this  appears  at  first  sight  opposed  to  the  fat  deficiency, 
but  here  I  would  point  out  that  wherever  assimilation  is  hindered 
by  unsuitable  feeding,  a  child  may  be  starved  of  this  or  that  food 
constituent  just  as  effectually  as  if  it  were  withheld  altogether  ; 
the  fact  that  a  diet  contains  a  sufficiency  of  fat  will  not  prevent  fat- 
starvation  if  at  the  same  time  the  child's  power  of  assimilation  is 
diminished  by  unsuitability  of  the  food  in  other  respects. 

If  a  child  is  given  starch  at  an  age  at  which  starch  cannot  be 
properly  digested,  or  is  given  starch  at  any  age  in  excess,  the 
power  of  assimilation  for  food  in  general,  including  fat,  may  be 
diminished,  and  in  this  way  rickets  may  arise  from  fat-starvation 
on  any  of  the  diets  in  which  starch  is  given  in  addition  to  milk, 
even  though  the  milk  given  may  contain  a  sufficiency  of  fat. 

As  a  matter  of  fact  where  potato,  &c.,  or  a  patent  food  is  being 
given  in  addition  to  milk,  one  usually  finds  amongst  the  poorer 
classes  that  the  milk  is  also  being  diluted  too  much  for  the  age  ; 
and  where  a  patent  food  is  used  without  milk,  it  is  almost  always 
deficient  in  fat,  though  some  of  the  least  objectionable  of  the 
patent  foods  contain  just  enougli  fat  to  prevent  rickets  if  the 
child's  digestion  is  good  enough  to  ensure  assimilation  of  the  fat 
that  is  present. 

The  fault  which  disturbs  digestion,  and  so  prevents  assimilation 
of  fat  need  not  necessarily  be  starch,  or  excess  of  starch  ;  it  may 
be  excess  of  soluble  carbo-hydrates,  sugar,  dextrin,  &c.,  which 
are  particularly  liable  to  upset  the  digestion  in  some  infants. 
Where  the  proportion  of  fat  should  be  just  sufficient  to  protect 
from  rickets,  the  addition  of  an  excess  of  soluble  carbo-hydrate, 
such  as  is  present  in  many  of  the  starch-free  patent  foods,  may 
be  sufficient  in  this  way  to  cause  fat-starvation,  and  so  to  induce 
rickets. 


RICKETS  87 

In  rare  cases  the  fault  which  disturbs  digestion  and  causes  fat- 
starvation  is  excess  of  fat  itself  ;  if  cream  is  added  to  a  milk 
mixture  so  that  it  contains  6  or  7  per  cent,  of  fat,  an  infant 
may  gain  weight  well  for  a  time,  but  soon  the  digestion  may 
suffer,  and  rickets  may  occur  for  exactly  the  same  reason 
as  in  cases  where  starch  is  given,  namely,  because  the 
resulting  disorder  of  digestion  prevents  assimilation  of  the  fat 
in  the  food. 

Fat-starvation  as  the  cause  of  rickets  accords  well  with  the 
clinical  facts  so  far  as  the  diet  preceding  the  onset  of  rickets  is 
concerned  ;  but  there  is  other  evidence  which  gives  strong  con- 
firmation to  this  view.  Mr.  Bland-Sutton's  observations  upon 
animals  in  the  Zoological  Gardens  showed  that  young  monkeys, 
bears,  and  lions  suffered  severely  with  rickets  when  fed  upon 
diets  in  which  fat  was  deficient,  but  directly  milk,  cod-liver  oil, 
and  pounded  bone  were  added  to  the  diet,  they  recovered  from 
their  rickets.  It  might  be  objected  that  the  recovery  was  due 
to  the  lime  salts  of  the  pounded  bone,  but  when  this  treatment 
of  the  animals  is  compared  with  the  routine  treatment  of  rickets 
in  children  by  the  administration  of  cod -liver  oil,  it  seems  almost 
certain  that  the  effective  element  in  these  therapeutics  was  the 
fat  of  the  milk  and  cod-liver  oil. 

There  can  hardly  be  stronger  evidence  of  the  correctness  of  the 
fat-starvation  theory  than  the  treatment  which  prevails  at  most 
English  hospitals,  of  administering  cod -liver  oil  for  rickets  : 
moreover,  experience  at  the  Children's  Hospital,  Great  Ormond 
Street,  has  shown  that  any  oil  is  equally  effective  provided  it  can 
be  taken  without  disturbing  digestion.  It  is  noteworthy  also 
that  where  phosphorus  is  used  for  the  treatment  of  rickets  it  is 
usually  given  in  oil. 

I  am  well  aware  that  occasionally  cases  occur  in  which  it  is 
difficult  to  explain  the  occurrence  of  rickets  upon  the  theory  of 
fat-starvation,  or  indeed  upon  any  theory,  but  after  inquiring 
carefully  into  the  methods  of  feeding  in  a  very  large  number  of 
cases  of  rickets,  I  am  satisfied  that  no  other  theory  is  so  generally 
applicable. 

No  doubt  there  may  be  other  contributing  factors ;  for  instance, 
the  syphilitic  infant  is,  I  think,  specially  prone  to  develop  rickets, 
and  it  may  be  that  any  condition  which  diminishes  the  vigour 
of  assimilation — whether  it  be  ill  health  from  lack  of  fresh  air, 
or  a  feeble  constitution  because  the  infant  was  born  of  a  very 
young  or  weakly  mother — may  favour  the  onset  of  rickets,  but 
as  a  working  hypothesis  I  think  it  may  safely  be  held  that  rickets 


88  COMMON  DISORDERS  OF  CHILDHOOD 

means  deficiency  of  fat-assimilation,  whether  the  defect  be  in 
the  food  or  in  the  assimilation. 

If  this  were  more  generally  realized,  some  of  the  common 
mistakes  in  infant-feeding  might  be  avoided.  There  is  one 
which  I  must  mention  here,  for  I  have  met  with  it  frequently  : 
I  find  that  an  infant  is  having  lime-water  in  his  milk,  and  that 
this  is  being  given  to  prevent  or  to  cure  the  rickets.  There  is 
no  evidence  that  lime-\vater  has  any  effect  whatever  either  in 
preventing  or  in  curing  rickets  ;  indeed,  I  think  that  both  on 
clinical  and  on  experimental  grounds  it  maybe  confidently  stated 
that  it  has  no  value  for  either  purpose. 

Age-incidence.  There  is  one  other  important  practical  point 
which  I  wish  to  emphasize  in  connexion  with  the  etiology  of 
rickets,  namely,  its  age-incidence :  I  quote  the  following  figures 
from  the  article  on  Rickets  in  Osier's  Modern  Medicine.  They 
were  taken  from  consecutive  patients  under  the  age  of  three 
years  in  my  out-patient  clinic  : 

Birth  to         Months         Months        Years       Years 
3  months.          3-6.  6-12.  1-2.  2-3. 

Rickets  ....     10  10  24  38  18 

No  Rickets      .     .     31  24  22  27  20 

These  statistics  do  not  show  the  age  at  which  the  disease 
began,  for  this  it  is  impossible  to  determine  in  a  disease  of  such 
insidious  onset,  but  they  show  that  the  proportion  of  children  who 
have  rickets  is  larger  in  the  second  year  of  life  than  at  any  time 
in  the  first  year,  a  fact  which  suggests,  what  I  believe  to  be  true, 
that  the  onset  of  rickets  is  often  not  until  the  end  of  the  first 
year,  if  not  in  the  second  year.  The  bearing  of  this  upon  the 
feeding  in  infancy  (infancy  I  use  here,  as  elsewhere,  to  mean  the 
first  two  years  of  life)  is  important  ;  the  fact  that  the  infant  has 
been  having  nothing  but  breast-milk  for  nine  or  ten  months,  may 
not  safeguard  him  from  rickets  if  the  feeding  after  this  age  is 
faulty  either  in  excess  of  starch,  or  in  deficiency  of  fat.  Mothers 
are  apt  to  think  that  when  an  infant  has  been  weaned  at  nine 
months,  he  can  have  starchy  food,  bread  and  butter,  sops,  &c., 
at  every  meal,  and  that  it  matters  little  how  much  milk  is  taken  ; 
whereas,  for  the  prevention  of  rickets  it  is  most  important  that 
up  to  the  end  of  the  second  year,  milk  should  form  a  large  part 
of  the  diet,  and  that  the  fat  should  be  increased  by  giving  the 
yolk  of  an  egg  daily  ;  of  course,  at  this  age,  much  more  starch 
can  be  taken  than  in  the  first  year,  for  it  can  be  digested,  and 
therefore,  in  moderation,  does  not  interfere  with  assimilation 
of  fats. 


RICKETS  89 

Symptoms 

The  characteristic  symptoms  of  rickets  are  familiar  enough: 
the  fretfulness  at  onset,  with  disturbed  sleep,  in  which  the 
child  likes  to  throw  the  bedclothes  off  and  lie  uncovered, 
sweating  about  the  head  during  sleep,  the  lateness  of  dentition, 
the  '  beading  '  of  the  ribs,  the  epiphysial  thickening  at  the  ends 
of  the  long  bones,  especially  the  radius,  the  large  protuberant 
abdomen,  the  reluctance  or  inability  to  stand  which  makes  the 
child  late  in  learning  to  walk,  or  if  he  has  already  learnt  makes 
him  'go  off  his  legs  ',  the  late  closure  of  the  fontanelle,  the  softness 
of  bones  and  ligaments  which  makes  the  bones  bend  and  the 
joints  yield,  with  resulting  '  bandy -legs',  knock-knee,  or  other 
deformity,  the  large  size  of  the  head  with  its  square  shape,  the 
stooping  curve  of  the  spine,  which  is  only  one  manifestation  of 
the  general  muscular  weakness,  and  with  all  these  the  tendency 
to  convulsive  disorders  and  to  catarrh  of  the  respiratory  and 
alimentary  tract. 

Amongst  these  symptoms  no  doubt  those  which  affect  the 
bones  are  the  most  prominent,  but  let  it  be  realized  that  rickets 
is  not  merely  a  disease  of  the  bony  structures.  One  of  the  greatest 
obstacles  to  the  right  understanding  of  rickets  is  the  conception 
of  this  disease  as  merely  an  affection  of  bone  and  cartilage. 
Rickets  is  a  general  disturbance  of  metabolism,  and  its  effects 
are  not  limited  to  any  one  tissue  of  the  organism. 

Such  apparently  disconnected  phenomena  as  a  tendency  to 
catarrh  of  mucous  membranes,  muscular  weakness,  and  increased 
nervous  instability  must  be  recognized  no  less  than  the  charac- 
teristic bone  change,  as  manifestations  of  rickets.  This  recogni- 
tion becomes  a  matter  of  considerable  practical  importance  in 
some  cases,  for  it  happens  not  very  rarely  that  one  or  other  of 
these  manifestations  altogether  overshadows  the  bone  changes, 
and  if  we  fail  to  recognize  rickets  as  the  cause  of  the  trouble  in 
these  cases,  we  fail  to  recognize  an  important  indication  for  treat- 
ment. I  recall  cases  in  which  a  child  of  eighteen  months  or  two 
years  has  been  brought  to  me  with  limbs  so  feeble  and  weak  that 
even  to  a  medical  man  the  possibility  of  infantile  paralysis  had 
suggested  itself,  but  the  key  to  the  condition  was  to  be  found  in 
other  indications  of  rickets,  such  as  delayed  dentition  and  delayed 
closure  of  fontanelle  and  slight  beading  of  the  ribs,  symptoms 
which  were  so  slight  that  the  possibility  of  so  much  muscular 
weakness  being  due  to  rickets,  where  the  osseous  changes  were  so 
slight,  had  hardly  been  considered. 


90  COMMON  DISORDERS  OF  CHILDHOOD 

In  some  cases,  similarly,  severe  nervous  symptoms  such  as  con- 
vulsions, and  laryngismus  stridulus,  are  the  result  of  rickets 
where  bony  manifestations  are  so  slight  as  only  to  be  detected 
by  careful  examination. 

It  would  seem  indeed  that  not  only  may  rickets  affect  several 
tissues  but  the  stress  of  rickets  may  fall  upon  particular  tissues 
in  particular  cases ;  just  as  tuberculosis  in  one  case  attacks 
especially  serous  membranes,  in  another  bones  or  joints,  and 
in  a  third  lymphatic  glands,  while  other  tissues  escape,  or  are  only 
slightly  infected.  Tissue  proclivity  is  a  vague  and  shadowy 
subject  at  present  ;  but  there  is  good  reason  for  believing  that 
not  only  individuals  but  also  families  may  manifest  a  proclivity 
of  certain  tissues  to  disease,  so  that  not  only  in  one  child,  but  in 
several  children  of  a  family  the  stress  of  a  disease  falls  on  a  certain 
tissue.  A  child  was  brought  to  my  out-patient  clinic  with  tuber- 
culous meningitis,  making  the  fourth  child  in  that  family  who 
died  of  that  particular  form  of  tuberculosis  ;  Dr.  J.  Thomson 
has  published  instances  in  which  congenital  syphilis  in  the  same 
way  showed  a  selective  incidence  on  certain  tissues  in  certain 
families,  and  the  late  Dr.  Finlayson  of  Glasgow  drew  attention 
to  the  occurrence  of  hypertrophic  cirrhosis  in  several  members  of 
the  same  family.  I  have  seen  instances  which  suggested  strongly 
that  the  same  holds  good  of  rickets,  and  that  tissue  proclivity 
both  in  the  individual  and  in  the  family  may  determine  that 
in  one  case  the  muscular,  in  another  case  the  osseous,  and  in 
a  third  perhaps  the  nervous  symptoms  may  predominate. 

Passing  now  from  theory  to  fact,  I  shall  consider  some  of  the 
symptoms  of  rickets  :  an  infant  with  this  disease  is  often  fretful ; 
but  is  rickets  ever  painful  ?  The  question  is  one  of  practical 
importance  in  reference  to  the  detection  of  infantile  scurvy  which 
usually  occurs  in  an  infant  who  already  has  rickets  ;  the  pain 
and  tenderness  of  scurvy  is  too  often  attributed  to  rickets  ;  as 
far  as  my  owrn  observation  goes,  rickets  never  produces  any 
acute  pain  or  tenderness  such  as  is  seen  in  scurvy  ;  I  fancy  that 
it  does  rarely  produce  some  very  slight  degree  of  tenderness,  so 
that  the  child  cries  if  the  limbs  are  handled  roughly  ;  but  cer- 
tainly the  presence  of  any  considerable  degree  of  tenderness 
should  suggest,  not  rickets,  but  scurvy. 

Delay  of  dentition  is  a  very  frequent  symptom,  and  one  of 
considerable  value  in  diagnosis  ;  it  was  noted  in  76  per  cent,  of 
my  cases.  The  first  tooth  may  not  make  its  appearance  until  the 
age  of  eighteen  months,  but  it  is  exceptional  to  be  as  late  as  this. 
The  normal  variability  in  the  date  of  dentition  is  to  be  remem- 


RICKETS 


91 


bered  (see  Chapter  I)  ;  the  laity  nowadays  have  often  a  smattering 
of  knowledge  of  the  indications  of  rickets,  and  if  there  be  no 
teeth  at  the  age  of  nine  or  ten  months,  an  anxious  mother  is  very 
ready  to  conclude  that  her  child  has  rickets  ;  whereas  late  denti- 
tion alone  is  quite  insufficient  evidence. 

Whether  rickets  plays  any  part  in  the  production  of  dental 
decay  is  disputed  ;  it  is  pointed  out  that  the  calcification  of  the 
temporary  teeth  is  so  far  advanced  at  birth  that  it  is  unlikely 
rickets  could  exert  any  influence  upon  their  formation ;  but  the 
permanent  teeth  whose  calcification  takes  place  almost  entirely 
during  the  first  year  might  suffer ;  it  would  be  interesting  to  know 


FIG.  1.  Costochondral  displacement  in  severe  rickets.  Section  through  costo- 
chondral  junction,  showing  formation  of  'internal  bead'  (the  lower  edge  in 
the  figure  is  the  internal  surface)  by  dislocation  of  the  bony  rib  so  that  it 
joins  the  costal  cartilage  almost  at  a  right  angle  instead  of  end  to  end.  The 
specimen  shows  also  rachitic  thickening  and  irregularity  of  epiphysial  line. 
From  patient  in  Fig.  5. 

what  proportion  of  the  very  large  number  of  children  with  caries 
of  the  permanent  teeth  have  suffered  with  rickets  in  the  first  year 
of  life. 

Even  if  the  formation  of  the  milk  teeth  cannot  be  influenced  by 
rickets  it  is  still  possible  that  the  unhealthy  condition  of  the 
saliva  from  the  improper  and  indigestible  food  which  causes 
rickets  may  favour  the  onset  of  caries.  Some  such  explanation 
seems  to  me  necessary  to  explain  the  early  decay  of  the  teeth 
which  is  common  in  rickets. 

Beading  of  the  ribs,  the  rickety  rosary,  is  one  of  the  most  con- 
stant symptoms  of  rickets,  though,  as  I  shall  point  out,  a  just 
palpable  bossing  at  the  juncture  of  rib  and  cartilage  is  not  neces- 


92 


COMMON  DISORDERS  OF  CHILDHOOD 


sarily  rachitic.  The  beading  is  best  marked  in  the  fifth,  sixth, 
and  seventh  ribs,  and  at  post  mortem  examination  is  seen  to  be 
more  marked  on  the  inner  than  on  the  outer  surface. 

There  is  also  a  spurious  beading  on  the  internal  surface  which 
is  entirely  different  in  its  formation,  as  can  be  seen  on  cross  sec- 
tions. It  is  produced  by  a  partial  or  complete  dislocation  back- 
wards of  the  bony  rib,  so  that  instead  of  joining  the  cartilage  end 
to  end,  it  meets  it  at  an  angle  (see  Fig.  1).  In  these  cases  there 
is  often  no  beading  to  be  felt  externally,  although  there  is  a 
very  large  '  spurious  bead  '  internally  and  although  the  rachitio 
change  is  present  in  extreme  degree. 


FIG.  2.     Tailor  position  in  rickets:  forearms  bent  by  partially 
supporting  weight  of  trunk. 

The  so-called  '  posterior  beads  '  are  only  found  in  severe  cases, 
and  are  really  projections  due  to  green-stick  fractures  which  take 
place  near  the  posterior  angles  of  the  ribs. 

The  thickening  of  the  epiphysial  junctions,  which  is  most 
noticeable  usually  at  the  lower  end  of  the  radius  and  the  tibia  is 
due,  like  the  beading  of  the  ribs,  to  excessiy^_ajidjrregular_pro- 
]^er&tioj^cd.Gaj:i^^QCG^&n^^_eg^r^  ossification  with  increased 
vascularity  producing  a  lengthening  and  widening  of  the  epiphy- 


RICKETS  93 

sial  line,  which  is  felt  clinically  as  the  epiphysial  enlargement 
near  the  ends  of  the  bones.  This  is  not  limited  to  the  long  bones ; 
occasionally  it  is  well  marked  on  the  scapula  at  the  epiphysial 
line  just  above  the  lower  angle. 

It  is  remarkable  that  a  change  so  pronounced  at  the  site  where 
the  growth  in  length  of  the  bone  mainly  occurs,  should  affect 
the  stature  so  little  as  it  does  ;  but  stunted  growth  is  certainly 
to  be  reckoned  among  the  results  of  rickets.  Actual  dwarfing, 
which  fortunately  is  of  rare  occurrence,  is  usually  associated 
with  bending  or  distortion  of  the  bones  ;  but  I  have  often  seen 
ill-grown  children  whose  stunted  growth  I  believed  to  be  attri- 
butable to  rickets,  although  no  bending  of  the  bones  was  present  ; 
and  I  have  little  doubt  that  a  slight  degree  of  rickets,  which 
in  other  respects  may  have  little  effect  upon  the  child's  future, 
may,  by  the  stunting  of  growth  which  it  causes,  be  a  lifelong 
handicap. 

The  gross  deformities  of  rickets  are  in  large  measure  preventable 
if  the  disease  is  recognized  early  and  proper  precautions  are 
taken ;  the  two  chief  changes  are  bending  of  bones  and  green-stick 
fractures.  There  are  two  factors  in  their  production  :  (1)  the 
softness  of  the  bones,  which  is  due  partly  to  the  relative  poorness 
of  the  newly  formed  bone  in  lime  salts,  and  partly  to  the  rarefaction 
of  the  older  bone  ;  (2)  mechanical  influences,  particularly  pres- 
sure and  traction,  the  former  in  supporting  the  weight  of  the 
body,  the  latter  from  the  action  of  muscles  or  the  dragging  of  an 
unsupported  limb. 

Bending  of  the  bones  of  the  upper  limb,  especially  of  the 
forearms,  occurs  chiefly  when  the  child  uses  its  arms  to  support 
its  weight  in  crawling  or  in  sitting  tailorwise.  This  posture, 
shown  in  Fig.  2,  is  often  assumed  by  children  with  severe  rickets, 
and  the  forearms  are  used  to  assist  the  weak  spinal  muscles  in 
supporting  the  trunk  in  the  erect  position. 

The  common  deformity  of  the  clavicle,  which  is  a  sharp  pro- 
jection upwards  and  forwards  at  the  junction  of  the  inner  and 
middle  third,  is  in  part  due  to  muscular  traction,  but  in  part  to 
the  weight  of  the  arm  dragging  downwards  the  outer  part  ; 
similarly  the  forward  curving  of  the  femur  is  due  largely  to  the 
weight  of  the  leg  dragging  upon  the  lower  end  of  the  femur  as  the 
child  sits  on  its  mother's  arm  or  lap.  The  common  curve  of  the 
tibia  outwards  and  forwards  in  the  lower  third,  and  the  general 
outward  curve  of  the  femur,  and  the  occasional  deformity  in  the 
neck  of  the  femur,  coxa  vara,  are  all  the  results  of  the  super- 
imposed weight  of  the  trunk  acting  upon  the  softened  bones  of 
the  lower  limbs. 


94  COMMON  DISORDERS  OF  CHILDHOOD 

Nor  is  it  only  the  bones  which  yield  to  mechanical  influences 
in  rickets ;  the  ligaments  are  unduly  soft  and  lax,  as  can  be  seen 
in  some  rickety  children  in  the  extraordinary  contortions  of 
which  their  joints  are  capable  ;  some  rickety  children  can  easily 
put  their  toes  behind  their  ears,  and  the  knee-joint  can  be  felt  to 
be  altogether  abnormally  lax.  In  part  the  yielding  of  ligaments 
is,  no  doubt,  due  to  the  feebleness  and  laxity  of  the  muscles 
which  afford  but  little  support  for  the  joints,  but  it  is  probably 
due  also  to  some  change  at  present  unknown  in  the  ligaments 


FIG.  3.     Kyphosis  due  to  weakness  of  back -muscles  in  rickets, 
themselves.      Consequently  any  stress  upon  joints  is  likely  to 
result  in  deformity  in  addition  to  that  resulting  from  bent  or 
fractured  bones. 

The  prevention  of  these  deformities  consists  in  relieving  the 
bones  as  far  as  is  practicable  of  weight  or  traction  by  keeping 
the  child  as  much  as  possible  off  his  legs,  if  necessary  by  the  use 
of  splints,  and  securing  recumbency  as  much  as  possible  :  this 
is  one  of  the  many  conditions  in  which  the  excellent  habit  of 
a  midday  sleep  gives  invaluable  help  ;  a  '  pram  '  in  which  the 
child  can  lie  down  at  other  times  will  assist  in  securing  fresh  air 
as  well  as  recumbency.  If  only  parents  would  realize  the 


RICKETS  95 

importance  of  keeping  the  child  who  has  rickets  off  his  legs 
until  the  softness  of  the  bones  has  been  rectified  by  proper 
dieting  and  the  administration  of  cod-liver  oil,  we  should  not 
see  the  deplorable  deformities  which  are  so  often  inflicted  upon 
the  rickety  child  by  parental  carelessness  or  ignorance. 

The  general  rounding  of  the  spine  which  constitutes  the  rickety 
kj^hosis  (Fig.  3)  and  which  is  due  to  muscular  weakness,  in 
which  the  muscles  of  the  spine  partake,  is  sometimes  a  striking 
symptom :  the  child  seems  to  'sink  down  in  a  heap ',  when  he  is 
put  in  the  sitting  position.  It  is  curious  that  this  symptom,  which 
is  by  no  means  a  constant  one,  should  have  attracted  the  atten- 
tion of  Glisson  and  his  contemporaries  so  much  that  they  devised 
the  name  '  rachitis  '  (pa^is)  as  an  alternative  for  the  popular 
name  '  rickets  '. 

The  head  of  the  rachitic  child  is  often  characteristic,  not  only 
in  the  late  closure  of  the  anterior  fontanelle,  but  in  shape  and 
size.  Large,  square,  and  flat  on  the  top,  is  an  accurate  descrip- 
tion of  the  head  in  many  cases  ;  in  addition,  the  rickety  skull 
can  often  be  felt  to  be  so  deeply  grooved  by  the  vessels  of  the 
scalp,  that  their  course  can  be  traced  by  one's  finger-nail.  If 
it  be  asked  why  the  head  is  large  in  rickets,  the  answer  is  not 
clear  :  some  observers,  amongst  whom  is  Stoeltzner,  have 
described  a  dilatation  of  the  ventricles  in  rickets,  but  I  have  never 
found  such  a  condition  myself  :  the  calvarium  is  undoubtedly 
thickened  in  some  cases,  especially  in  the  position  of  the  frontal 
and  parietal  eminences,  so  that  a  rachitic  bossing  is  produced, 
and  I  am  much  inclined  to  think  that  thickening  may  occur 
nearer  to  the  fontanelle,  producing  a  condition  like  Parrot's 
nodes  without  congenital  syphilis,  but  I  am  not  aware  that  there 
is  ever  sufficient  thickening  to  account  for  the  large  size  of  the 
skull  in  some  cases  of  rickets ;  moreover,  if  the  large  size  of  the  head 
were  due  to  an  exuberance  of  bone  formation  one  would  expect 
the  fontanelle  to  be  closed  rather  earlier  than  is  normal  in  these 
cases,  whereas  the  reverse  is  true  :  e.g.  Arthur  C.,  aged  2J 
years,  came  to  me  with  a  marked  degree  of  rickets,  the 
tibiae  were  bowed,  the  radial  epiphyses  considerably  enlarged, 
and  the  head,  which  was  of  the  characteristic  square  shape  of 
rickets,  measured  20J  inches  (the  normal  average  circumference 
at  this  age  is  about  18|  inches),  the  fontanelle,  which  should  be 
closed  at  about  eighteen  months,  measured  1J  inches  in  both 
directions. 

The  large  size  of  the  head  is  not  so  far  as  my  own  observations 
go  associated  with  any  special  mental  characteristics  ;  the  child 


96  COMMON  DISORDERS  OF  CHILDHOOD 

with  severe  rickets,  like  any  other  invalid  child  who  is  perforce 
much  in  the  company  of  adults  and  unable  to  join  fully  in  other 
children's  games,  is  apt  to  become  quaint  and  precocious  in  his 
ways  of  thought  and  speech,  but  I  am  as  little  able  to  confirm 
the  *  great  acuteness  of  mind  '  which  Underwood  1  described 
as  '  observed  in  this  and  some  other  chronical  complaints  ', 
as  Sir  W.  Jenner's  assertion 2  that  children  with  extreme 
rickets  are  almost  always  deficient  in  intellectual  capacity  and 
power. 


FIG.  4.  Craniotabes.     Skull  showing  characteristic  shape  and  distribution 
of  patches  of  true  craniotabes. 

I  turn  now  to  a  vexed  question,  the  relation  of  craniotabes  to 
rickets  ;  craniotabes  consists  of  a  thinning  of  the  bones  of  the 
skull  :  usually  of  the  posterior  part  of  the  parietals  and  the 
upper  part  of  the  occipital,  rarely  of  the  upper  part  of  the 
temporal.  It  occurs  usually  in  round  or  oval  patches,  J-l  inch 
in  diameter,  situated  near  but  not  actually  reaching  the  suture. 
Sometimes  there  is  a  more  diffuse  thinning  of  the  bone  adjoining 
the  sutures,  but  the  nature  of  the  thinning  must  then  be  regarded 
as  doubtful,  in  very  young  infants  certainly  it  may  indicate 
nothing  more  than  a  physiological  variation  in  the  rate  of 
ossification. 

1  Treatise  on  Diseases  of  Children.     Lond.,  1784. 
8  Lectures  on  Rickets,  vol.  iii,  p.  416. 


RICKETS  97 

The  round  or  oval  patches  are  most  characteristic,  with  the 
peculiar  crackling  sensation  which  they  give  when  they  yield 
like  parchment  under  the  pressure  of  one's  finger. 

My  own  clinical  investigations,  so  far  from  inclining  me  to 
accept  the  view  that  true  craniotabes  is  always  of  syphilitic 
origin,  have  led  me  to  regard  this  connexion  as  quite  exceptional. 
Of  twenty-five  consecutive  cases  of  craniotabes  only  two  were 
noted  to  be  syphilitic  and  one  possibly  syphilitic ;  there  was 
definite  rickets  in  twenty  of  the  remaining  cases,  in  two  rickets 
was  doubtful  ;  but  in  two  out  of  the  three  syphilitic  cases  there 
was  rickets  also,  and  in  the  third  case  it  was  not  noted  whether 
rickets  was  present.  So  that  in  at  least  twenty-two  out  of  the 
twenty-five  cases  rickets  was  present. 

But  even  when  craniotabes  appears  to  be  associated  with 
syphilis  without  rickets,  there  may  be  a  fallacy  :  I  have  used 
the  term  '  true  craniotabes  '  above,  because  there  is  such  a  thing 
as  delay  of  bone  formation,  in  contrast  to  absorption  of  already 
formed  bone  ;  the  latter  alone  in  my  opinion  should  be  described 
as  craniotabes.  I  have  already  mentioned  (Chapter  I,  p.  5) 
that  there  are  infants  whose  skulls  remain  thin,  and  whose 
sutures  and  fontanelle  remain  open  longer  than  usual  without 
any  evidence  of  disease  of  any  kind ;  in  these  children  the  edges 
of  the  parietal  and  occipital  bones  may  show  at  two  or  three 
months  of  age  a  diffuse  thinness,  and  may  yield  on  pressure  just 
like  the  softened  bone  in  craniotabes. 

In  some  infants  syphilis  seems  to  retard  bone  formation  in 
this  way,  and  a  soft-yielding  bone  at  the  age  of  seven  or  eight 
months  may  really  be  simply  a  persistence  of  the  unossified 
condition  which  is  found  in  very  young  infants. 

In  one  of  the  syphilitic  infants  I  have  mentioned,  I  watched 
the  child  from  the  age  of  eight  weeks  until  it  was  seven  months 
old  ;  during  the  whole  of  this  time  there  was  diffuse  thinness 
of  the  bones  adjoining  the  parieto-occipital  sutures,  and  I  suspect 
that,  although  I  have  included  this  case  amongst  my  series  of 
craniotabes,  it  should  rather  be  classified  as  delayed  ossification 
due  to  syphilis. 

But  delay  of  ossification  is  certainly  quite  an  exceptional 
result  from  syphilis  ;  indeed  the  reverse  is  usual  :  I  have  fre- 
quently observed  the  skull  of  a  syphilitic  infant  to  be  noticeably 
firmer  than  that  of  a  healthy  infant  of  the  same  age ;  a  fact  which 
makes  it  improbable  that  syphilis  should  be  the  usual  cause  of 
craniotabes. 

There  is  another  reason  that  makes  me  chary  of  attributing 


98  COMMON  DISORDERS  OF  CHILDHOOD 

craniotabes  to  syphilis :  namely  the  effect  of  antirachitic  treat- 
ment. One  of  the  most  striking  illustrations  of  the  value  of 
fat  in  rickets  is  the  remarkable  rapidity  with  which  craniotabes 
disappears  in  rickety  children  under  the  administration  of  cod- 
liver  oil.  I  have  noticed  this  in  several  cases;  in  some  it  has 
been  much  diminished  and  in  others  it  has  completely  disappeared 
in  seven  to  ten  days  ;  in  these  cases  no  mercury  was  given. 

Another  argument,  and,  I  think,  a  very  strong  one  in  favour 
of  the  rachitic  nature  of  craniotabes  is  its  close  association  with 
laryngismus  stridulus.  Out  of  twenty-two  cases  of  craniotabes 
in  which  the  point  was  noted  seventeen  had  well-marked  laryn- 
gismus stridulus.  This  spasmodic  affection  of  the  larynx  is 
generally  acknowledged  to  be  one  of  the  convulsive  manifesta- 
tions of  rickets  ;  out  of  sixty-seven  cases  of  laryngismus  stridulus 
sixty-three  were  certainly  rickety,  three  probably  had  rickets, 
only  one  was  thought  to  show  none  of  the  bone  affections  of 
rickets  ;  no  one  has  ever  suggested  as  far  as  I  know  that 
laryngismus  stridulus  has  any  connexion  with  syphilis. 

Lastly  I  would  point  out  that  it  has  long  been  recognized  that 
syphilis  aggravates  rickets ;  some  of  the  most  extreme  degrees 
of  the  characteristic  changes  of  rickets  are  seen  where  the  disease 
is  associated  with  syphilis,  and  it  is  likely  enough  therefore  that 
if  craniotabes  is  a  manifestation  of  severe  rickets,  it  should  occur 
where  these  two  diseases  are  associated. 

A  striking  feature  of  rickets  is  the  protuberant  abdomen,  the 
'  pot-belly  ',  which  is  in  part  an  indication  of  the  cause,  and  in 
part  a  result  of  the  disease.  Disordered  digestion,  usually  from 
excessive  sugar  or  starch  in  the  food,  causes  fermentation, 
flatulence,  and  catarrh  in  the  intestine  so  that  assimilation  is 
hindered  and  rickets  results;  rickets  in  its  turn  predisposes  to 
catarrh  of  mucous  membrane  so  that  flatulent  distension  easily 
occurs.  But  there  are  other  factors  producing  the  large  abdomen 
of  rickets  :  the  pelvis  is  unduly  small,  the  e version  of  the  lower 
ribs  displaces  the  liver  and  spleen  downwards,  and  the  lax 
muscles  of  the  abdominal  wall  afford  insufficient  support  to 
the  bulging  contents.  The  recti  muscles  are  often  separated  in 
the  midline  as  much  as  half  an  inch  or  more  by  the  chronic 
distension,  but  this  'diastasis  of  the  recti ',  as  it  has  been  called, 
is  not  peculiar  to  rickets,  it  is  seen  with  any  chronic  enlargement 
of  the  abdomen. 

Chronic  intestinal  catarrh,  to  whatever  cause  it  is  due,  is  not 
necessarily  associated  with  diarrhoea ;  it  may  show  itself  in 
chronic  constipation  ;  and  so  it  comes  about  that  the  rickety 


RICKETS  99 

child  is  often  troubled  with  constipation,  which  no  doubt  is  also 
favoured  by  the  general  lack  of  muscular  '  tone  '  in  the  muscles 
of  the  abdominal  wall  as  well  as  in  those  of  the  intestine.  There 
is  also  a  special  liability  to  acute  intestinal  catarrh  with  diarrhoea : 
a  tendency  which  exposes  the  rickety  child  to  special  danger 
in  the  summer  months. 

More  dangerous  still  is  the  special  tendency  of  rachitic  children 
to  catarrh  of  the  respiratory  tract.  My  own  experience  has 
abundantly  taught  me  never  to  regard  as  trivial  even  the 
slightest  bronchial  catarrh  in  a  child  with  rickets  ;  the  danger 
is  greatest  where  there  is  much  rachitic  distortion  of  the  chest- 
wall  ;  a  child,  such  as  that  shown  in  Fig.  5,  with  a  chest  pinched 
in  laterally,  so  that  there  is  a  depression  at  the  anterior  part  of 
the  axilla,  and  a  transverse  furrow  (Harrison's  sulcus)  just  above 
the  everted  costal  margin,  is  a  bad  subject  for  bronchitis  ;  there 
is  already  but  poor  expansion  of  the  alveoli  and  if  the  catarrh 
spreads  down  to  the  alveoli,  as  it  is  very  apt  to  do  in  rickety 
children,  the  resulting  broncho-pneumonia  is  apt  to  prove  fatal. 

Another  manifestation  of  rickets  which  may  be  altogether  out 
of  proportion  to  the  bone  changes,  and  which  therefore  is  some- 
times not  recognized  as  rachitic,  is  anaemia.  This  is  of  all 
degrees  and  is  sometimes  very  profound  :  the  child's  face  is 
I  think  generally  whiter  than  in  the  anaemia  of  congenital 
syphilis,  where  it  is  usually  of  a  markedly  yellowish  tinge.  The 
spleen  is  little  if  at  all  enlarged,  and  herein  the  simple  secondary 
anaemia  of  rickets  differs  from  the  so-called  '  splenic  anaemia  of 
infants  '  where  the  spleen  is  greatly  enlarged,  reaching  often 
below  the  level  of  the  umbilicus.  There  is  nothing  character- 
istic about  the  blood  changes  in  the  rickety  anaemia  :  the  haemo- 
globin is  diminished  in  proportion  to  the  diminution  of  red 
corpuscles  ;  a  differential  count  of  the  white  corpuscles  shows  no 
disproportion  of  polymorphonuclears  or  of  lymphocytes. 

The  recognition  of  the  cause  of  the  anaemia  is  of  great  practical 
importance,  for  the  dietetic  treatment  is  hardly  less  important 
tharj  drugs ;  and  cod-liver  oil  is  more  likely  to  do  good  than  iron. 
I  shall  have  more  to  say  of  splenic  anaemia  under  the  head  of 
syphilis.  It  is  quite  certain  that  splenic  anaemia  is  associated 
with  rickets  in  a  large  proportion  of  the  cases,  but  in  many  there 
is  also  some  evidence  of  syphilis  :  the  remarkable  frequency  of 
Parrot's  nodes  with  splenic  anaemia  is  also  noteworthy  as  suggest- 
ing a  syphilitic  origin.  But  at  present  the  status  of  splenic 
anaemia  remains  undetermined,  it  can  only  be  said  that  both 
syphilis  and  rickets  appear  to  play  some  part  in  its  causation. 

H2 


100  COMMON  DISORDERS  OF  CHILDHOOD 

Diagnosis.  One  might  imagine  that  a  disease  with  so  many 
characteristic  symptoms  must  always  be  easy  of  recognition  :  as 
a  matter  of  fact  it  is  often  extremely  difficult  to  be  sure  when 
rickets  is  present  :  this  is  sufficiently  obvious  from  the  discrep- 
ancies between  various  observers  as  to  the  frequency  of  rickets  : 
in  my  own  clinic  one  observer  found  that  95  per  cent,  of  the 
children  in  the  second  year  of  life  had  rickets,  whereas  my  own 


FIG  5.      Characteristic  deformity  of  chest  in  severe  rickets. 

figures  showed  58  per  cent.  :  some  continental  writers  have 
asserted  that  70  to  80  per  cent,  of  new-born  children  have 
rickets!  whereas  Fede  and  Cacace  of  Naples  found  that  only 
0-4  per  cent,  had  rickets  at  birth,  and  for  my  own  part  I  am 
very  doubtful  whether  rickets  ever  occurs  at  birth. 

Any  one  who  has  attempted  to  collect  statistics  as  to  the 
frequency  of  rickets  will  very  soon  realize  the  difficulty  of 
deciding  what  constitutes  rickets:  in  its  extreme  degrees  any 


RICKETS  101 

one  can  recognize  it,  in  its  slightest  degrees  the  most  experienced 
observers  may  be  doubtful  of  it. 

Sweating  about  the  head  is  a  symptom  to  which  very  little 
diagnostic  significance  can  be  attached  :  as  supposed  evidence 
of  rickets  in  infants  and  of  tuberculosis  in  older  children  it  often 
causes  quite  a  needless  amount  of  alarm  :  children  who  are  out 
of  sorts  from  any  cause  are  particularly  prone  to  sweat  about 
the  head  during  sleep  ;  certainly  apart  from  other  much  more 
distinctive  evidence  head-sweating  must  not  be  taken  as  evidence 
of  rickets,  or  of  tubercle. 

Beading  of  the  ribs  is  another  symptom  to  which  I  think  it 
is  possible  to  attach  too  much  significance  :  the  junction  of  the 
bony  rib  and  the  costal  cartilage  is  often  distinctly  palpable  as 
a  small  boss-like  elevation  within  a  few  weeks  after  birth,  and  if 
this  alone  were  sufficient  evidence  of  rickets  it  would  be  true 
that  almost  all  children  are  rickety,  but  recent  observations  on 
the  histology  of  this  slight  beading  of  the  ribs  have  shown  that 
it  may  exist  with  no  rachitic  change  whatever.  I  need  not 
describe  here  the  characteristic  microscopic  appearances  at  the 
epiphysial  line  in  rickets  :  suffice  it  to  say  that  these  are  entirely 
lacking  in  some  of  the  supposed  '  headings  '  found  during  earliest 
infancy.  Undoubtedly,  taken  in  conjunction  with  other 
symptoms,  even  a  very  slight  beading  is  of  importance,  but  by 
itself  it  does  not  necessarily  indicate  rickets. 

The  size  of  the  fontanelle  is  so  variable  in  healthy  infants 
during  the  first  six  months  of  life  that  I  do  not  think  any  signifi- 
cance as  evidence  of  rickets  can  safely  be  attached  to  the  size  of 
the  fontanelle  at  this  stage  :  it  is  only  after  the  age  of  six  months 
and  especially  in  the  second  and  third  year  that  its  size  comes 
to  have  an  importance  in  this  respect  :  if  the  fontanelle  measures 
much  more  than  1  inch  in  each  direction  at  one  year,  or  is 
open  after  the  age  of  two  years  this  is  suggestive  of  rickets. 

Late  eruption  of  the  teeth  is  certainly  important  ;  taken  in 
conjunction  with  other  characteristic  signs  it  is  valuable  evidence 
of  rickets. 

In  connexion  with  the  diagnosis  of  rickets  I  would  again 
emphasize  the  special  incidence  of  the  disease  upon  particular 
tissues  in  particular  cases  :  one  case  may  be  brought  to  the 
medical  man  for  convulsions,  while  the  osseous  changes  of 
rickets  are  present  only  in  the  slightest  degree,  another  case  is 
brought  for  the  large  abdomen,  another  for  its  bronchitis,  and 
another  for  its  profound  anaemia,  another  for  pronounced  mus- 
cular weakness,  and  in  all  these  the  bone  manifestations  may  be 


102  COMMON  DISORDERS  OF  CHILDHOOD 

limited  to  slight  beading  of  the  ribs,  lateness  in  dentition  and 
delay  in  closure  of  the  fontanelle  but  none  the  less  the  symptoms 
for  which  the  child  is  brought  are  rachitic. 

Treatment 

The  prevention  of  rickets  lies  in  *  the  proper  feeding  of  the 
infant.  The  surest  safeguard  against  rickets  is  breast-milk,  and 
if  a  mother  is  unable  to  perform  her  bounden  duty  in  this  respect 
to  her  child  and  a  wet-nurse  is  impracticable,  the  next  best 
preventive  of  rickets  is  fresh  cow's  milk.  Now  there  are  certain 
fallacies  with  regard  to  the  use  of  fresh  cow's  milk  which  I  wish 
to  mention  in  this  connexion  :  when  I  advise  that  all  milk  for 
infants  should  be  either  pasteurized  or  boiled  I  am  often  met 
with  the  objection  '  but  surely  boiled  milk  causes  rickets  !  '. 
I  know  of  no  evidence  that  pasteurizing  or  boiling  milk  has  any 
connexion  whatever  with  the  production  of  rickets  :  I  suspect 
that  this  mistake  has  arisen  from  the  long-standing  confusion 
introduced  by  the  unfortunate  and  misleading  term  '  scurvy 
rickets  '  ;  there  is  no  doubt  that  the  boiling  of  milk  tends  to 
diminish  or  destroy  its  antiscorbutic  power,  but  rickets  and 
scurvy  are  entirely  independent  diseases  and  clinical  experience 
shows,  I  think,  that  the  heating  of  milk,  at  any  rate  within  the 
limit  of  pasteurization  or  of  just  reaching  the  boiling-point,  does 
not  render  it  liable  to  produce  rickets. 

Again,  I  find  an  infant  with  pronounced  rickets  and  I  ask 
how  it  has  been  fed  ;  I  am  told  that  it  has  always  had  fresh 
milk,  but  when  I  inquire  into  the  proportions  of  milk  and  water 
I  find  that  at  the  age  of  six  months  the  infant  is  having  equal 
parts,  in  other  words,  the  child  is  only  having  1-75  per  cent. 
at  most  of  fat.  Let  it  be  remembered  that  if  fresh  milk  is  too 
much  diluted,  it  may  cause  rickets  just  as  much  as  any  other 
food  which  involves  fat-starvation.  It  is  not  sufficient  to  instruct 
a  mother  to  give  cow's  milk  to  her  child,  the  proportions  of  milk  and 
water,  and  the  amount  of  cream,  if  any  is  available,  to  be  added, 
must  all  be  carefully  adjusted  according  to  the  age  of  the  infant. 

Again,  I  am  told  that  an  infant  is  having  fresh  milk  and 
nevertheless  has  developed  rickets  :  but  on  inquiry  it  turns  out 
that  the  infant  is  having  in  the  milk  some  starch-containing 
food,  patent  or  otherwise  ;  or  perhaps  once  or  twice  a  day  is 
having  bread-sop  or  mashed  potato  when  the  child  is  seven  or 
eight  months  old.  As  I  have  already  pointed  out,  anything, 
be  it  food  or  disease,  which  interferes  with  the  child's  power  of 
assimilation  may  cause  fat-starvation  and  rickets  :  and  even 


RICKETS  103 

though  a  milk  mixture  contain  enough  fat  to  prevent  rickets 
if  it  were  given  without  the  addition  of  starch  or  of  too 
much  sugar,  either  of  these  additions  may  so  interfere  with 
assimilation  that  the  child  becomes  rickety.  It  is  not  enough  to 
instruct  a  mother  to  give  fresh  milk,  we  must  warn  her  that 
the  addition  of  starch-containing  foods  or  of  foods  containing 
excess  of  carbo-hydrate,  whether  sugar  or  the  products  of  malting, 
may  prevent  the  good  results  of  the  fresh  milk. 

Here  I  shall  venture  to  reiterate  what  I  have  said  elsewhere  as 
to  the  doubtful  expediency  of  using  barley-water  as  a  diluent 
for  milk  in  infant-feeding.  I  have  often  noticed  slight  degrees 
of  rickets  where  this  has  been  done,  and  I  suspect  that  even  the 
small  proportion  of  starch  (1  to  2  per  cent.)  present  in  barley- 
water  may  be  responsible  for  the  rickets  in  some  of  these  cases  : 
especially  where  the  barley-water  has  been  used  habitually  for 
an  infant  less  than  six  months  of  age,  and  where  the  milk  has 
at  the  same  time  been  diluted  so  much  that  the  slightest  inter- 
ference with  assimilation  would  make  its  proportion  of  fat 
insufficient. 

Now  I  turn  to  another  error  which  has  somehow  gained 
currency,  the  belief  that  in  adding  lime-water  to  milk  we  are 
providing  a  valuable  prophylactic  against  rickets.  As  far  as 
I  know  there  is  not  the  least  evidence  that  lime-water  has  any 
value  whatever  either  for  the  cure  or  for  the  prevention  of  rickets. 
Cow's  milk  contains  so  much  larger  a  proportion  of  lime  salts 
than  human  milk  that  even  if  it  were  diluted  excessively  it 
would  still  be  richer  in  these  salts  than  is  breast-milk.  Moreover 
experience  shows  that  rickets  arises  in  spite  of  free  use  of 
lime-water  in  infant-feeding. 

The  proper  food  during  the  first  eight  or  nine  months  for  an 
infant  who  for  some  inevitable  reason  is  deprived  of  breast- 
milk,  is  fresh  cow's  milk  :  and  the  most  important  item  in 
the  prevention  of  rickets  is  to  secure  a  sufficient  proportion  of 
fat ;  as  a  matter  of  clinical  observation  I  think  it  may  be  said 
that  for  an  infant  over  three  months  of  age  a  proportion  of  fat 
below  2  per  cent,  involves  some  risk  of  rickets,  and  that  at  any 
time  during  the  first  year  safety  from  rickets  is  better  assured 
by  a  proportion  of  fat  reaching  about  3  per  cent.  The  addition 
of  starch  in  any  form  to  the  diet  of  an  infant  under  eight  months 
of  age,  is  liable  to  interfere  with  assimilation  and  in  this  way 
involves  danger  of  rickets,  especially  if  the  milk  mixture  is 
already  poor  in  fat.  Similarly,  excess  of  sugar  or  of  the  products 
of  malting  favours  the  onset  of  rickets  and,  as  I  have  shown  in 


104  COMMON  DISORDERS  OF  CHILDHOOD 

a  previous  chapter,  the  much-advertised  malted  foods  which 
are  prepared  by  the  addition  of  water  without  milk  are  faulty 
both  in  their  excess  of  the  soluble  carbo-hydrates  and  in  their  low 
proportion  of  fat,  and  for  this  reason  are  liable  to  produce  rickets. 

The  next  point  of  importance  upon  which  I  would  insist  very 
strongly  is  this  :  the  risk  of  rickets  is  not  limited  to  the  first 
nine  months  of  life.  It  seems  quite  clear  in  some  cases  that 
rickets  has  begun  later,  sometimes  in  the  second  year,  and  in 
most  of  these  cases  one  finds  that  the  mother,  instead  of  intro- 
ducing starch-feeding  gradually  at  eight  or  nine  months  of  age 
by  giving  one  starch-containing  feed  a  day  for  a  month  and 
then  two  feeds  daily,  has  given  starch  at  every  feed  or  almost 
every  feed  from  this  age  onwards,  with  the  result  that  not  only 
has  the  child  satisfied  its  appetite  with  bread  and  butter  or 
farinaceous  food  to  the  neglect  of  milk,  but  the  digestion  which 
only  gradually  acquires  the  power  of  dealing  satisfactorily  with 
starch  has  been  disordered,  so  that  even  what  milk  is  taken  is 
but  poorly  assimilated. 

From  nine  months  old  up  to  the  end  of  the  tenth  month  an 
infant  should  not  have  more  than  one  meal  a  day  of  starch- 
containing  food  :  I  like  Robb's  Biscuits,  or  '  Malted  Rusks  ' 
for  a  start,  but  at  this  time  there  is  no  objection  to  any  of  the 
partially  malted  cereal  foods  or  to  the  unconverted  cereal  foods, 
only  let  it  be  quite  clear  that  such  '  foods  '  are  to  be  given  only 
once  a  day. 

At  the  age  of  eleven  months  two  starch-containing  meals  can 
be  given  in  the  day,  one  of  which  I  think  may  advantageously 
be  a  milk-pudding  either  of  pearl  sago  or  ground  rice.  The 
rest  of  the  feeds  are  to  be  milk,  not  less  than  1J  pints  of 
milk  should  be  taken  daily.  In  addition  the  yolk  of  an  egg 
v^ery  lightly  boiled  should  be  given  daily  from  the  age  of  nine 
months.  Next  to  milk  I  know  of  no  food  which  is  of  more 
value  in  the  prevention  of  rickets  and  in  the  cure  of  it,  than 
yolk  of  egg  :  it  contains  about  20  per  cent,  of  fat,  which  is  of  a 
particularly  easily  assimilable  kind. 

After  the  age  of  twelve  months  a  dessertspoonful  of  gravy  of 
fried  bacon  with  a  little  crumbled  bread  soaked  in  it  makes  a 
valuable  food.  Throughout  the  second  year  it  is  most  important 
that  a  child  should  have  abundance  of  milk,  and  that  the 
diet  should  not  be  too  largely  starch-containing.  Chicken  or 
veal  broth,  fish,  boiled  brains,  red  gravy,  custard,  blancmange, 
all  these  are  useful  as  variations  which  avoid  the  starchy  element. 
The  child  who  at  fourteen  or  fifteen  months  lives  mainly  on  bread 


RICKETS  105 

and  butter  and  potatoes  is  hardly  less  likely  to  develop  rickets 
than  the  infant  who  at  six  months  is  fed  upon  some  starchy 
patent  food. 

When  rickets  is  already  present  the  first  point  which  requires 
attention  is  the  diet ;  it  must  be  corrected  in  accordance  with 
the  child's  age  upon  the  lines  which  I  have  just  laid  down. 

The  drug  treatment  which  in  this  country  is  generally  admitted 
to  be  of  most  value  is  the  administration  of  cod-liver  oil  :  and 
here  I  shall  draw  attention  to  what  I  believe  to  be  an  error  in  its 
administration  in  some  cases.  I  find  an  infant  of  eighteen 
months  or  two  years  having  a  domestic  teaspoonful  of  plain 
cod-liver  oil  as  a  dose,  with  the  result  that  the  child's  digestion 
is  upset,  a  large  part  of  the  oil  is  passed  in  the  stool,  and  probably 
more  harm  is  done  than  good.  Cod-liver  oil  is  best  given  in 
doses  of  20  to  40  minims  in  an  emulsion  or  mixed  with  malt  : 
I  am  rather  in  favour  of  the  latter  method,  especially  where  the 
infant  is  old  enough  to  be  having  some  farinaceous  food  in  his 
diet,  for  the  diastasic  effect  of  the  malt  helps  to  prevent  starch- 
indigestion. 

There  seems  to  be  no  specific  virtue  in  cod-liver  oil,  any  other 
oil  will  do  equally  well  provided  that  it  can  be  taken  without 
disturbing  digestion  or  causing  nausea  by  its  taste.  At  one 
time  we  used  at  the  Children's  Hospital,  Great  Ormond  Street, 
olive  oil,  and  pilchard  oil  and  cotton-seed  oil,  made  into  as 
palatable  emulsions  as  possible,  and  these  seemed  to  be  as  useful 
as  cod-liver  oil  except  that  they  were  more  apt  to  cause  nausea 
or  digestive  disturbance. 

In  some  parts  of  Europe  phosphorus  is  the  drug  most  used 
for  rickets  (-3^0  grain  may  be  given  three  times  a  day)  but  as  it 
is  usually  given  in  oil  one  cannot  but  suspect  that  the  vehicle 
may  be  of  more  importance  than  the  drug.  It  is  difficult  to 
believe  that  deficiency  in  the  intake  of  phosphorus  can  be  the 
cause  of  rickets,  for  according  to  Bunge,  cow's  milk  contains 
nearly  six  times  as  much  phosphorus  as  human  milk,  so  that 
even  with  the  excessive  dilutions  of  cow's  milk  which  produce 
rickets,  there  would  be  no  deficiency  of  phosphorus.  It  is, 
however,  possible  to  reconcile  the  apparent  discrepancies  in 
treatment :  for  according  to  some  recent  observations  by  Freund, 
the  urine  of  children  taking  an  increased  amount  of  fat  in  the 
food,  shows  an  increased  amount  of  phosphates  ;  which  pre- 
sumably indicates  that  the  absorption  of  phosphates  from  the 
food  is  in  some  way  facilitated  by  the  larger  intake  of  fat  ; 
according  to  Ritter  phosphates  are  present  in  abnormally  high 


106  COMMON  DISORDERS  OF  CHILDHOOD 

proportion  in  the  faeces  of  children  with  rickets :  in  other  words, 
phosphates  are  deficiently  absorbed  from  the  food  :  this  deficient 
absorption  of  phosphates  would  be  explicable  by  the  theory  of 
fat-starvation  if  Freund's  observation  be  correct. 

Whilst  therefore  an  explanation  is  given  of  the  value  of  fat 
in  the  dietetic  and  in  the  drug  treatment  of  rickets,  it  is  quite 
conceivable  that  when  the  possibility  of  absorbing  phosphates  is 
increased  by  increasing  the  proportion  of  fat  in  the  diet,  as  it 
probably  is  in  most  cases  where  phosphorus  is  relied  upon,  the 
increased  intake  of  phosphorus  may  be  of  value. 

Possibly  a  similar  explanation  may  apply  to  the  use  of  the 
various  preparations  of  iron-  or  calcium-phosphate  and  of  hypo- 
phosphites  which  some  have  thought  useful  in  rickets  ;  I  confess 
that  so  far  as  my  own  experience  of  them  has  gone — and  it 
has  chiefly  consisted  in  observing  the  effects  of  this  treatment 
in  the  hands  of  others — they  have  seemed  to  be  of  little  value  : 
they  may  assist  treatment  by  improving  the  appetite,  but 
apparently  have  no  specific  virtue  in  rickets. 

I  have  discussed  the  treatment  of  rickets  so  far,  as  if  it  con- 
sisted solely  in  dieting  and  drugs  :  but  I  would  not  have  it 
supposed  that  no  importance  is  to  be  attached  to  general  hygiene 
in  the  prevention  and  cure  of  this  disease.  It  seems  to  me 
certain  that  rickets  cannot  be  produced  by  lack  of  sunlight  or 
of  fresh  air  or  by  any  climatic  conditions,  it  is  a  diet  disorder  and 
is  curable  by  dieting,  but  this  does  not  make  it  any  the  less 
probable  that  such  factors  may  play  some  part  by  interfering 
witli  the  child's  general  health  and  vigour  and  so  influencing 
its  assimilation  and  nutrition  and  predisposing  to  rickets.  The 
rickety  child  is  undoubtedly  the  better  for  plenty  of  sunlight 
and  open  air,  and  I  would  send  him,  if  possible,  to  a  bracing 
seaside  place,  such  as  Herne  Bay,  Broadstairs,  or  Folkestone. 
I  like  also  cold  douches — the  infant  should  sit  in  a  tepid 
bath  while  some  colder  water  is  poured  over  his  shoulders  and 
back  :  and  after  the  bath  gentle  massage  of  the  limbs  helps 
to  restore  firmness  and  '  tone  '  to  the  flabby  muscles. 

I  have  already  referred  to  the  importance  of  keeping  the 
child's  weight  off  his  limbs  as  much  as  possible  during  the  acute 
stage  of  rickets  ;  for  this  purpose  splints  are  to  be  used  if  necessary 
to  prevent  the  child  from  standing  and  in  severe  cases  even 
from  sitting.  Where  deformity  has  already  occurred,  it  is 
remarkable  how  much  it  may  be  diminished  if  effectual  means 
are  taken  to  keep  the  child  from  carrying  the  weight  of  his 
trunk  upon  the  limbs  for  several  months  :  during  this  time  the 


RICKETS  107 

nutrition  of  the  muscles  should  be  maintained  by  massage  twice 
or  even  thrice  daily. 

The  nervous  affections  of  rickets  I  shall  consider  under  the 
heading  Convulsive  Disorders  ;  suffice  it  here  to  say.  that  the 
nervous  excitability  of  rickets  subsides  very  rapidly  under  the 
administration  of  cod-liver  oil,  but  where  there  are  already 
indications  of  a  convulsive  tendency  whether  in  the  form  of  an 
ordinary  convulsion,  or  of  laryngeal  spasm,  or  of  '  facial  irrita- 
bility '  or  tetany,  it  is  safest  to  give  bromide  in  combination 
with  the  cod-liver  oil  :  a  formula  I  often  use  for  this  purpose 
is  as  follows  :  Potassii  Bromid.  gr.  ij,  Liquor  Calcis  Ct)xv, 
Glycerin  O)v,  Spirit.  Menth.  Pip.  tt)lj,  Ol.  Morrhuae  ad  3j,  ter 
die.  Under  the  influence  of  bromide  the  convulsive  tendency 
disappears  even  more  rapidly  than  with  the  oil  alone,  and  as 
there  is  always  some  danger  to  life  attaching  to  these  convulsive 
manifestations  it  is  only  right  to  adopt  the  speediest  method  of 
escape  from  the  danger. 


CHAPTER  VIII 
INFANTILE    SCURVY 

INFANTILE  scurvy  is  often  spoken  of  as  if  it  were  a  disease  of 
recent  discovery  and  of  modern  development.  Its  recognition 
all  over  the  scientific  world  is  justly  associated  with  the  names 
of  two  distinguished  physicians  both  connected  with  the  Great 
Ormond  Street  Children's  Hospital,  the  late  Dr.  Cheadle  and 
Sir  Thomas  Barlow,  to  whose  investigations  is  due  almost  all 
that  is  known  of  the  pathology  of  the  disease.  But  to  sup- 
pose that  infantile  scurvy  was  unknown,  or  even  that  its 
true  nature  as  a  scorbutic  condition  complicating  rickets  was 
unrecognized  until  the  nineteenth  century  is  an  error,  and  one 
that  has  crept  into  many  textbooks. 

As  long  ago  as  the  middle  of  the  seventeenth  century,  Glisson, 
in  his  Treatise  on  the  Rickets,  had  not  only  described  the  character- 
istic symptoms  of  infantile  scurvy,  but,  with  more  accuracy 
than  some  of  his  successors,  had  recognized  that  it  was  scurvy 
complicated  with  the  rickets  and  not  an  acute  form  of  rickets. 
In  the  English  translation,  published  in  1651  (p.  249),  he  says  : 
'  The  Scurvy  complicated  with  this  affect  (rickets)  hath  these 
signs  :  (1)  They  that  labour  under  this  affect  do  impatiently 
endure  Purgations  ;  but  they  who  are  only  affected  with  the 
Rachites  do  easily  tolerate  the  same.  (2)  They  are  much 
offended  with  violent  exercises,  neither  can  they  at  all  endure 
them.  But  although  in  this  affect  (rickets)  alone  there  be  a  kind 
of  slothfulness  and  aversation  from  exercise,  yet  exercise  doth 
not  so  manifestly,  at  least  not  altogether  so  manifestly,  hurt 
them  as  when  the  Scurvy  is  conjoyned  with  the  rachites. 
(3)  Upon  any  concitated  and  vehement  motion  they  draw  not 
breath  without  much  difficulty,  they  are  vexed  with  divers 
pains  running  through  their  Joynts,  and  these  they  give  warn- 
ing of  by  their  crying.  ...  (4)  Tumors  do  very  commonly 
appear  in  the  Gums.  (5)  The  urin  upon  the  absence  of  the 
accustomed  Feaver  is  much  more  intens  and  encreased.' 

Glisson  (ibid.,  p.  227)  actually  emphasizes  what  is  not  yet 
sufficiently  recognized,  that  there  is  no  essential  connexion 


INFANTILE  SCURVY  109 

between  infantile  scurvy  and  rickets  ;  he  says,  *  the  Scurvy  is 
sometimes  conjoyned  with  this  affect,'  and  after  mentioning 
as  causes  heredity,  infection,  and  the  possibility  that  it  may  be 
1  produced  from  the  indiscreet  and  erroneous  regiment  of  the 
infant ',  though  he  attributed  it  chiefly  to  climatic  influences, 
he  adds,  4  for  it  (scurvy)  scarce  holdeth  any  greater  commerce 
with  this  Diseas  (rickets)  than  with  other  diseases  of  longer 
continuance.' 

Such  terms  as  '  scurvy  rickets  ',  '  acute  rickets,'  and  '  hsemor- 
rhagic  rickets ' — names  which  would  imply  that  scurvy  is 
a  variety  of  rickets — have  been  responsible  for  much  confusion. 
Obscure  though  the  exact  aetiology  of  infantile  scurvy  may  be, 
it  is  clear  from  clinical  facts  that  this  affection  arises  from  causes 
entirely  distinct  from  those  which  produce  rickets  ;  severity  of 
rickets  raises  no  special  probability  of  scurvy  ;  indeed  the  worst 
cases  of  scurvy  are  often  associated  with  very  slight  rickets,  and 
in  some  cases  with  none.  Both  diseases  are  due  to  faults  of 
diet,  and  it  is  likely  enough  that  a  diet  which  is  faulty  in  one 
respect  may  be  faulty  in  another  ;  the  particular  fault  which 
produces  rickets  may  be,  and  no  doubt  often  is,  present  when 
the  diet  shows  also  the  particular  fault  which  produces  scurvy. 
But  the  fault  is  not  one  and  the  same  ;  witness  the  many  infants 
who  suffer  with  severe  rickets  after  being  fed  from  an  early  age 
with  potato,  which  would  seem  when  given  at  that  age  to  favour 
if  not  actually  to  cause  the  occurrence  of  rickets,  whereas  there 
is  probably  no  more  powerful  agent  than  potato  in  the  prevention 
or  cure  of  infantile  scurvy. 

The  clinical  picture  of  the  fully-developed  disease  is  striking 
enough  ;  an  infant  who  has  been  fed  upon  one  of  the  patent 
foods,  with  or  without  milk,  or  on  milk  which  has  been  condensed, 
sterilized,  or  otherwise  altered,  has  been  ailing  for  some  weeks, 
has  taken  food  badly  and  probably  lost  weight.  Moreover  the 
mother  says  it  cries  whenever  it  is  touched,  and,  as  she  puts  it, 
'  has  lost  the  use  of  its  limbs.'  The  infant  is  pale,  it  lies  quiet 
perhaps  until  it  is  approached,  when  it  cries  out  in  obvious 
dread  of  being  touched  ;  the  legs  lie  motionless  usually  with  the 
thighs  slightly  abducted  and  everted  and  the  knees  slightly 
flexed  ;  the  arms  are  less  often  affected.  There  may  be  some 
swelling  of  part  of  one  or  other  of  the  limbs,  obliterating  the 
natural  curves.  Any  handling  of  the  affected  limbs  causes 
a  piteous  cry,  evidently  of  acute  pain.  If  teeth  are  present  the 
gums  around  them  are  swollen  and  purple,  occasionally  projecting 
like  a  mass  of  granulations  almost  completely  hiding  the  teeth, 


110 


COMMON  DISORDERS  OF  CHILDHOOD 


and  bleeding  readily  when  touched.  The  urine  is  perhaps 
smoky,  if  not  red  with  blood. 

Such  in  outline  is  the  characteristic  picture  of  infantile  scurvy, 
which  I  shall  now  consider  in  more  detail,  chiefly  with  reference 
to  diagnosis  and  treatment. 

Age-incidence.  The  age  at  which  infantile  scurvy  begins  is 
a  point  of  considerable  importance  in  diagnosis.  As  the  accom- 
panying chart  of  sixty-four  cases  under  my  own  observation 
shows,  its  onset  is  almost  limited  to  the  later  half  of  the  first 
year  of  life,  and  in  nearly  80  per  cent,  of  the  cases  the  disease 
begins  between  the  ages  of  six  months  and  ten  months. 

MONTH  OF  ONSET 


FIG.  6.     Age-incidence  of  infantile  scurvy  (sixty-four  cases). 

So  marked  is  this  special  age-incidence,  that  given  an  infant 
of  six  to  twelve  months  and  a  history  of  tenderness  in  the  limbs, 
the  diagnosis  of  scurvy  should  at  once  suggest  itself  as  a  possi- 
bility. In  several  of  the  cases  in  this  series  the  disease  had  been 
diagnosed  as  '  rheumatism  ' — a  mistake  which  ought  never  to 
occur,  for  rheumatism  is  practically  an  unknown  disease  under 
the  age  of  eighteen  months,  and  indeed  is  exceedingly  rare  under 
the  age  of  three  years.  This  chart  shows  also  that  in  no  case 
did  scurvy  begin  before  the  age  of  five  months — a  point  which 
distinguishes  this  disease  from  many  cases  of  syphilitic  epiphysitis 
which  begins  most  often  under  the  age  of  three  months. 

Mode  of  onset.      So  much   stress   has   been  laid  upon   the 


INFANTILE  SCURVY  111 

affection  of  the  gums  and  upon  the  tender  swellings  in  the 
limbs  in  infantile  scurvy  that  there  is  danger  of  forgetting 
that  in  many  cases  there  are  other  more  insidious  symptoms 
which  may  appear  some  weeks  before  these  obvious  mani- 
festations. An  infant  who  has  thriven  hitherto  upon  some 
patent  food  begins  to  ail,  the  weight  ceases  to  rise  or 
actually  falls,  the  feeds  are  taken  badly,  and  the  child 
is  fretful  and  miserable  ;  there  is  no  swelling  of  limbs,  perhaps 
no  definite  tenderness  anywhere,  and  the  gums  are  perfectly 
normal ;  but  that  these  early  symptoms  indicate  scurvy  may 
be  shown  not  only  by  the  rapid  improvement  within  two  or 
three  days  on  antiscorbutic  treatment,  but  also  in  some  cases 
by  the  presence  of  blood  in  the  urine  even  in  this  early  stage. 

I  doubt  whether  the  onset  of  scurvy  is  ever  really  sudden, 
but  undoubtedly  the  more  pronounced  symptoms  may  appear 
quite  suddenly,  and  are  then  apt  to  be  mistaken  for  the  results 
of  traumatism  ;  for  example,  an  infant,  aged  eight  months,  was 
brought  to  me  because  he  was  '  not  getting  on  '  ;  there  had  been 
some  tenderness  in  the  legs  for  at  least  four  weeks,  but  the 
nature  of  this  had  not  been  recognized  ;  one  morning  the  child 
had  his  usual  bath  and  then  went  to  sleep  for  a  short  time : 
he  awoke  with  the  left  eye  partly  closed  by  great  swelling  of  the 
lids,  which  were  discoloured  and  soon  looked  as  if  bruised  ; 
it  was  concluded  that  during  the  bathing  the  child  must  have 
struck  his  eye  against  the  side  of  the  bath.  The  history,  how- 
ever, of  feeding  with  Allenbury  and  Benger's  foods,  the  tender- 
ness of  the  legs,  and  the  presence,  as  examination  showed,  of 
blood  in  the  urine,  all  pointed  to  scorbutic  haemorrhage,  and  the 
rapid  disappearance  of  the  swelling  and  haemorrhage  from  the 
lids  under  antiscorbutic  diet  confirmed  the  diagnosis. 

It  would,  I  think,  be  rash  to  assert  that  the  supposition  of 
traumatism  is  wrong  in  all  such  cases.  The  haemorrhagic 
tendency  of  scurvy  may  well  favour  the  occurrence  of  haemor- 
rhage from  slight  traumatism,  which  would  have  no  such  effect 
in  a  healthy  infant,  and  this  view  is  supported  by  the  situation 
of  superficial  haemorrhages  ;  for  example,  in  one  case  the  only 
subcutaneous  haemorrhage  was  over  the  bony  prominence  of  the 
sacrum,  a  part  obviously  exposed  to  pressure  and  jarring ;  in 
another  which  was  sent  to  me  as  a  case  of  infantile  paralysis  the 
efforts  of  the  doctor  to  obtain  a  knee-jerk  had  resulted  in  a  sub- 
cutaneous haemorrhage  over  the  patella. 

Limb  affection.  Perhaps  the  most  striking  feature  of  infantile 
scurvy  is  the  tenderness  of  the  limbs  and  loss  of  movement.  These 


112  COMMON  DISORDERS  OF  CHILDHOOD 

symptoms  occur  much  more  often  in  the  lower  limbs  than  in  the 
upper.  In  the  sixty-four  cases  tenderness  or  swelling  was  present 
as  follows :  in  forty-seven  in  the  legs  only,  in  ten  in  legs  and  arms, 
in  one  in  the  arm  only.  In  six  out  of  the  sixty-four  cases  there 
was  no  tenderness  in  any  of  the  limbs  :  the  diagnosis  in  these 
cases  rested  on  the  association  of  a  scorbutic  diet  with 
hsematuria,  confirmed  in  two,  where  teeth  were  present,  by 
affection  of  the  gums,  and  in  all  by  the  rapid  cessation  of 
hsematuria  on  antiscorbutic  diet. 

With  the  tenderness  there  is  sometimes  associated  some  visible 
or  palpable  swelling  of  the  affected  limb,  but  in  many  cases  this 
is  so  slight  that  it  is  easily  overlooked  ;  and  as  it  is  the  result 
chiefly  of  subperiosteal  haemorrhage  it  may  be  detected  only  by 
careful — and,  I  would  add,  most  gentle — palpation  of  the  bone 
as  a  vague,  deep  thickening.  The  situation  of  this  thickening  is 
of  some  importance  ;  it  is  not  limited  to  the  epiphysial  region 
like  an  epiphysitis,  but  extends  some  distance  along  the  shaft  of 
the  bone — a  point  which  should  distinguish  it  also  from  any  joint 
affection.  In  my  own  cases  the  swelling  has  been  most  often 
about  the  lower  third  of  the  tibia  or  the  femur  (Fig.  7),  but  any 
part,  or  the  whole,  of  the  shaft  may  be  surrounded  by  sub- 
periosteal haemorrhage,  and  occasionally,  though  much  more 
rarely,  similar  deep  haemorrhage  may  occur  over  the  flat  bones 
of  the  skull,  producing  large  bluish  swellings  on  the  head  which 
may  simulate  sarcoma,  or  over  the  scapula,  as  in  a  specimen  in 
the  museum  of  the  Children's  Hospital,  Great  Ormond  Street. 

The  loss  of  movement  in  the  affected  limbs  is  so  marked  that 
the  disease  had  been  mistaken  more  than  once  in  my  series  for 
infantile  paralysis — a  mistake  which  hardly  ought  to  occur,  for 
the  acute  tenderness,  the  severe  pain  on  passive  movement,  the 
swelling  and  local  thickening,  and  the  associated  conditions  of 
the  gums  and  urine  are  all  features  quite  foreign  to  infantile 
paralysis.  The  loss  of  movement  is  no  doubt  due  partly  to  fear 
of  the  acute  pain  which  movement  causes  ;  but  it  may  also  be 
due  partly  to  mechanical  disability,  for  not  only  is  the  periosteum 
stripped  off  the  bone  by  the  underlying  haemorrhage, but,  as  I  have 
seen  in  some  autopsies  on  infantile  scurvy,  the  muscles  also  in 
severe  cases  are  infiltrated  with  serum  and  extravasated  blood. 
Occasionally  there  is  further  disablement  from  separation  of 
epiphyses  by  extensive  haemorrhage  at  the  epiphysial  line  ;  in 
one  case  which  I  examined  epiphyses  had  been  separated  in  all 
four  limbs.  This  danger  of  separation  of  epiphyses,  which  is  due 
to  effusion  of  blood  at  the  epiphysial  junction,  is  a  point  to  be 


INFANTILE  SCURVY 


113 


remembered  in  the  handling  of  these  infants  with  scurvy.  Cases 
have  been  recorded  also  in  which  fracture  occurred  in  the  shaft 
of  the  bone. 

(Edema.  The  occasional  occurrence  of  oedema  over  the 
thickened  part  of  the  limbs  in  scurvy  is  worthy  of  notice.  In 
the  diagnosis  between  scurvy  and  suppurative  periostitis  it 
might  have  been  thought  that  oedema  pointed  to  the  presence 
of  pus.  This  is  certainly  not  so  ;  I  have  seen  well-marked 
pitting  of  the  skin  on  gentle  pressure  in  cases  of  infantile  scurvy. 


FIG.  7.    Skiagram  of  legs  in  infantile  scurvy.     Showing  haemorrhage 
surrounding  lower  two-thirds  of  femora. 

Gums.  The  characteristic  appearance  of  the  gums  has  already 
been  mentioned,  but  it  is  to  be  remembered  that  any  great  swelling 
or  discoloration  of  the  gums  is  by  no  means  a  constant  feature  ; 
often  it  requires  careful  observation  to  detect  the  little  affection 
that  exists.  There  may  be  only  a  thin  purple  line  or  minute  patch 
of  red  discoloration  at  the  free  edge  of  the  gum  ;  and  I  have 
specially  noted  that  in  some  cases  it  was  only  on  the  posterior 
edge  of  the  gum  behind  the  tooth,  and  therefore  very  easily  over- 
looked. 

It  is  generally  stated  that  where  there  are  no  teeth  there  is  no 


114  COMMON  DISORDERS  OF  CHILDHOOD 

gum  affection  ;  this  is  not  strictly  accurate,  for  where  the  teeth 
are  close  up  to  the  surface  of  the  gum,  but  not  actually  through, 
I  have  seen  haemorrhage  in  the  gum  over  them.  When  teeth  are 
present  the  gums  are  not  necessarily  affected  ;  in  seven  out  of 
thirty-nine  cases  in  which  teeth  were  present  in  my  series  the 
gums  showed  nothing  abnormal. 

Very  rarely  the  gums  are  markedly  affected  when  there  is  no 
other  obvious  symptom  of  scurvy.  In  one  of  my  cases  there  was 
no  tenderness  whatever  in  the  limbs,  although  the  gums  showed 
very  marked  swelling  and  purple  discoloration.  In  another 
some  tenderness  had  been  noticed  in  the  legs,  but  had  passed  off 
when  I  saw  the  child,  whose  gums  were  swollen  and  purple.  In 
both  these  cases  the  existence  of  scurvy,  suggested  by  the  diet 
and  the  gums,  was  proved  by  the  finding  of  blood  in  the  urine. 

Palatal  haemorrhage.  I  wish  to  call  attention  here  par- 
ticularly to  a  manifestation  of  scurvy  which  has  not,  I  think, 
attracted  much  notice,  namely  haemorrhage  in  the  mucous 
membrane  of  the  hard  palate.  The  discoloration  occupies 
the  middle  part  of  the  vault  of  the  hard  palate  ;  it  has  not 
in  my  cases  extended  forward  to  the  alveolar  portion,  nor 
backward  to  the  soft  palate.  The  colour  varies  from  a  bright 
blood  red  to  a  deep  almost  black  purple.  As  in  the  gums, 
the  affected  area  may  become  secondarily  inflamed  and  the 
mucous  membrane  over  it  roughened.  Such  were  the  appearances 
in  four  of  my  cases,  but  as  I  had  not  looked  for  this  manifestation 
in  the  earlier  cases  I  cannot  tell  in  what  proportion  it  is  to  be 
found.  This  palatal  haemorrhage  is  certainly  noteworthy,  as  it 
may  assist  diagnosis  when  it  occurs — as  in  three  out  of  my  four 
cases — in  infants  who,  owing  to  absence  of  teeth,  show  no  gum 
affection. 

Orbital  haemorrhage.  '  Black  eye  '  in  an  infant  six  to 
twelve  months  old,  without  obvious  traumatism,  should  sug- 
gest the  possibility  of  scurvy  ;  but  it  is  not  a  very  frequent 
symptom.  It  was  present  in  six  out  of  the  sixty-four  cases,  and 
in  five  of  these  was  sufficient  to  cause  protopsis  of  the  eye. 
Curiously  enough,  in  all  six  it  was  the  left  eye  that  was  affected. 
The  discoloration  appears  usually  chiefly  or  only  in  the 
upper  lid. 

Urinary  symptoms.  The  diagnostic  importance  of  the  urine 
in  infantile  scurvy  is  not  sufficiently  appreciated.  Urinary 
changes  are  actually  more  constant  than  the  gum  affection, 
and  an  examination  of  the  urine  will  usually  clinch  the 
diagnosis  if  there  be  any  doubt.  During  the  last  few  years 


INFANTILE  SCURVY  115 

I  have  examined  the  urine  of  all  cases  under  my  notice 
as  far  as  possible,  and  out  of  38  cases  only  4  showed  nothing 
abnormal.  In  12  there  was  blood  only,  in  9  blood  and  casts, 
in  2  blood  and  pus,  in  2  pus  only,  and  in  9  albumen  only  ;  so  that 
the  proportion  of  cases  showing  some  urinary  change  was  89 
per  cent.,  and  the  proportion  showing  haematuria  was  60  per  cent. 

But  it  must  not  be  supposed  that  blood  is  to  be  detected  by 
the  naked-eye  appearance  of  the  urine  in  this  proportion  of 
cases.  In  many  the  amount  of  blood  was  so  small  that  it  was 
seen  only  by  careful  microscopic  examination  ;  and  when  pus 
was  present,  although  sufficient  to  attract  attention  at  once 
under  the  microscope,  it  was  not  sufficient  in  any  of  my  cases  to 
be  detected  by  the  naked  eye,  although  in  one  there  was  enough 
to  make  the  urine  slightly  turbid. 

It  is  generally  stated  that  haematuria  may  be  the  only  symptom 
of  infantile  scurvy  ;  and  if  the  haemorrhagic  manifestations  are 
to  be  taken  as  the  only  evidence  of  scurvy,  this  is  certainly  so. 
In  three  of  the  cases  mentioned  above  there  was  no  affection  of 
the  limbs  or  gums — in  fact,  no  characteristic  symptom  except 
haematuria  ;  but  in  all  three  there  had  been  wasting  recently, 
and  one  was  fretful  and  miserable,  and  another  would  not  take 
his  food  ;  there  were,  in  fact — as  I  suspect  there  usually  are  in 
these  cases  where  haematuria  is  stated  to  be  the  only  symptom 
of  scurvy — those  vague  symptoms  of  disturbed  nutrition  which 
I  have  described  as  marking  the  onset  of  scurvy.  The  presence 
of  casts  in  the  urine  in  association  with  the  blood  may  indicate 
a  nephritis  in  some  cases.  As  I  have  pointed  out 1  the  casts  are 
sometimes  numerous,  and  easily  found  without  centrifuging, 
and  the  albuminuria  occasionally  persists  for  many  weeks  or 
months.  The  occurrence  of  pyuria  with  acid  or  neutral  urine, 
and  without  any  special  evidence  of  irritability  of  the  bladder, 
would  seem  to  point  to  a  pyelitis,  and  this  was  the  clinical 
condition  in  three  of  my  cases.  The  recognition  of  this  pyuria 
is  of  some  practical  importance,  for,  like  the  nephritis,  it  is 
apt  to  persist  after  all  the  acute  symptoms  of  scurvy  have 
passed  away.  In  one  case  where  the  tenderness  and  loss 
of  movement  in  the  legs  had  begun  to  improve  within  forty- 
eight  hours,  and  were  as  usual  cured  in  a  few  days  by  anti- 
scorbutic diet,  the  pyuria  persisted  nearly  five  weeks,  and 
during  this  time  the  child  remained  pale,  and  failed  to  gain 
weight  until  the  pyelitis  began  to  subside.  Not  only  may  the 
pyelitis  retard  the  infant's  recovery,  but  it  seems  likely  that  this 
1  Lancet,  Aug.  13,  1904. 
12 


116  COMMON  DISORDERS  OF  CHILDHOOD 

condition,  which  when  it  occurs  as  a  primary  affection  in  infants 
causes  severe  pyrexia,  may  account  in  some  cases  for  the  high 
temperature  which  sometimes  accompanies  infantile  scurvy.  In 
a  case  in  which  the  urine  showed  pus  without  blood  the  tem- 
perature was  104-4°  ;  and  in  one  of  the  cases  in  which  the  pus 
was  associated  with  blood,  a  slighter  degree  of  pyrexia  persisted 
for  nine  days  after  antiscorbutic  treatment  began,  although  the 
gum  symptoms  and  tenderness  of  limbs  had  rapidly  subsided  ; 
the  pyuria  in  this  case  lasted  twelve  days. 

Temperature.  Pyrexia  in  infantile  scurvy,  although  rather 
the  exception  than  the  rule,  is  by  no  means  a  rarity  ;  the 
temperature  may  be  raised  to  101°  to  102°  F.  when  the  infant 
comes  under  treatment,  but  it  subsides  generally  within 
a  few  days  as  the  acute  symptoms  of  scurvy  disappear. 
In  some  cases,  however,  the  temperature  rises  to  103°  to 
105°  F.,  and,  as  I  have  pointed  out,  this  may  depend  upon 
the  presence  of  pyelitis.  The  occurrence  of  fever  in  infantile 
scurvy  is  worth  remembering,  for  this  symptom,  like  the 
oedema  to  which  I  have  referred,  has  been  regarded  as  point- 
ing to  suppurative  periostitis — a  very  serious  mistake  if  it  leads 
to  incision,  a  measure  which  would  only  increase  the  risks  of 
infantile  scurvy.  If  the  possibility  of  scurvy  is  borne  in  mind, 
and  the  history  of  feeding  and  the  gums  and  the  urine  are  investi- 
gated, this  error  is  not  likely  to  arise. 

Other  haemorrhages.  Haemorrhage  into  the  skin  is  quite  the 
exception  in  infantile  scurvy  ;  it  was  present  in  six  out  of  the 
sixty-four  cases,  excluding  those  in  which  orbital  haemorrhage 
showed  as  '  black  eye'  ;  in  two  cases  it  showed  as  a  linear 
bruise  running  downwards  and  outwards  for  nearly  an  inch  from 
just  below  the  inner  canthus  ;  in  one  the  situation  was  the  scar 
of  vaccination. 

Mucous  membranes.  I  have  already  mentioned  haemorrhage 
in  the  mucosa  of  the  hard  palate.  The  visceral  mucous  mem- 
branes may  be  similarly  affected  ;  in  a  specimen  figured  in  the 
museum  of  the  Children's  Hospital,  Great  Ormond  Street, 
haemorrhage  had  occurred  into  the  mucous  membrane  of  the 
bladder.  Bleeding  from  mucous  membranes  is  not  very  common  ; 
in  three  of  my  cases  slight  epistaxis  had  occurred,  and  in  one  of 
these  there  was  bleeding  also  from  one  ear.  Less  rare  is  the 
passage  of  streaks  of  blood  with  the  stools  (noted  in  eight  cases). 

Visceral  haemorrhage.     Post  mortem  examination  showed  in 
one  of  my  cases  that  extensive  haemorrhage  may  occur  in  con 
nexion  with  viscera,  though  such    an   occurrence   is    probably 


INFANTILE  SCURVY  117 

rare.  A  boy,  aged  thirteen  months,  who  had  been  fed  on 
Savory  &  Moore's  food  mixed  with  condensed  milk  since 
the  age  of  four  months,  had  much  swelling  and  tenderness 
in  the  left  thigh  and  leg,  and  purple  swelling  of  the  gums. 
He  was  admitted  under  my  care  at  King's  College  Hospital, 
and  at  once  put  upon  antiscorbutic  diet,  but  developed 
diarrhoea  and  died  within  a  few  days.  Autopsy  showed,  in 
addition  to  the  subperiosteal  haemorrhage  in  the  leg,  that 
there  were  strands  of  old  adhesions  over  the  right  lung,  and 
in  the  meshes  thus  formed  there  was  a  layer  of  fresh  blood-clot 
about  one-eighth  of  an  inch  thick  over  a  large  portion  of  the 
lung.  Another  case  in  which  visceral  haemorrhage  raised  an 
important  practical  point  was  one  seen  in  consultation  with 
Dr.  H.  J.  Spon,  The  child,  aged  eight  months,  had  been  fed  on 
the  Allenbury  foods  and  had  tender  swelling  about  the  lower 
third  of  the  right  femur,  and  some  scorbutic  affection  of  the  gums  ; 
the  infant  was  extremely  ill,  and  was  passing  blood  and  mucus 
frequently  from  the  bowel  ;  it  had  vomited  twice  on  the  day 
when  I  saw  it.  The  abdomen  was  flaccid  and  hollow,  but  in  the 
direction  of  the  transverse  colon  it  showed  an  elongated  sausage- 
like  tumour  which  on  palpation  was  firm,  and  seemed  to  vary 
in  hardness  at  intervals  during  palpation.  Had  there  been  no 
scurvy  I  think  no  one  would  have  doubted  that  there  was  an 
intussusception.  The  child  continued  to  vomit,  but  the  bowels 
were  open,  and  after  consultation  with  my  surgical  colleague, 
Mr.  P.  J.  Steward,  and  an  unsuccessful  attempt  to  reduce  the 
tumour  by  injecting  fluid  into  the  bowel,  it  was  decided  to  post- 
pone operation,  as  the  possibility  of  the  tumour  being  hsemor- 
rhagic  was  in  our  minds  ;  moreover,  the  child's  general  condition 
seemed  almost  desperate.  Under  antiscorbutic  treatment  the 
child  improved,  and  I  heard  subsequently  from  Dr.  Spon  that 
the  abdominal  tumour  became  less,  and  gradually  disappeared 
after  several  weeks.  I  suppose  there  can  be  no  doubt  that  in 
this  case  there  was  a  mass  of  blood-clot  surrounding  the  bowel, 
perhaps  in  the  wall  of  the  bowel. 

Joints.  As  already  mentioned,  infantile  scurvy  is  sometimes 
mistaken  for  some  joint  affection  ;  careful  examination,  however, 
shows  that  the  tenderness  and  swelling  is  not  connected  with  the 
joints,  but  with  the  shaft  of  the  bone.  Whilst,  however,  I  know  of 
no  clinical  evidence  that  arthritis  ever  forms  part  of  infantile 
scurvy,  haemorrhage  into  joints  certainly  may  occur;  in  one  of  my 
cases  there  was  found  at  autopsy  a  fresh  blood-clot  about  the  size 
of  a  shilling,  lying  free  in  the  intercondylar  part  of  the  knee-joint, 


118 


COMMON  DISORDERS  OF  CHILDHOOD 


In  a  drawing  preserved  at  the  Children's  Hospital,  Great  Ormond 
Street,  a  haemorrhage  is  shown  under  the  synovial  membrane  of 
the  acetabulum  in  a  case  of  infantile  scurvy. 

Prognosis 

There  are  few  diseases  in  which  the  effect  of  treatment  is  so 
striking  as  in  infantile  scurvy ;   under  efficient  antiscorbutic  diet 


FIG.  8.  Sub  periosteal  ossification  in  infantile  scurvy.  Section  of  femur 
showing  at  upper  end  a  layer  of  bone  enclosing  the  decolorized  blood-clot 
between  the  periosteum  and  the  shaft  of  the  femur. 

the  tenderness  and  pain  on  movement  is  usually  appreciably 
less  in  forty-eight  hours,  and  I  would  lay  it  down  as  a  rule  that 
if  proper  antiscorbutic  dieting  has  produced  no  definite  improve- 
ment within  four  days  the  diagnosis  of  scurvy  should  be  questioned. 
But  although  such  rapid  diminution  of  the  tenderness  and  pain 
may  be  expected,  other  symptoms  persist  longer  ;  the  sub- 
periosteal  haemorrhage,  if  large,  may  cause  some  deep  thickening 


INFANTILE   SCURVY  119 

to  remain  for  two  or  three  weeks.  Occasionally  the  thickening 
remains  for  many  weeks  or  months,  in  spite  of  the  complete 
disappearance  of  all  other  symptoms  of  scurvy.  This  is  explained 
by  a  specimen  in  the  museum  of  the  Children's  Hospital,  Great 
Ormond  Street,  which  shows  a  layer  of  bone  deposited  by  the 
separated  periosteum  and  forming  a  bony  sheath  enclosing  the 
subperiosteal  haemorrhage  (Fig.  8).  I  am  indebted  to  Dr.  Lees  for 
kind  permission  to  mention  this  case,  which  was  under  his  care. 
But  apart  from  the  mere  persistence  of  symptoms,  there  are 
other  more  serious  risks  in  infantile  scurvy.  I  have  several  times 
heard  medical  men  make  light  of  the  danger  of  scurvy  from 
patent  foods  on  the  ground  that  not  only  is  scurvy  an  uncommon 
result,  but  that  when  it  occurs  it  is  speedily  cured  by  simple 
changes  in  the  diet.  No  doubt  the  risks  of  scurvy  would  be 
minimized  if  the  disease  were  detected  at  its  earliest  onset ;  as 
a  matter  of  fact,  it  is  hardly  ever  recognized  until  the  infant 
has  already  passed  through  weeks  of  needless  and  intense  suffer- 
ing. This,  surely,  is  serious  enough  ;  but  there  is  also  a  very 
real  risk  to  life  ;  in  five  out  of  the  sixty-four  cases  the  "disease 
proved  fatal  by  diarrhoea  and  exhaustion,  and  even  when  death 
does  not  result  there  is  sometimes  prolonged  disturbance  of 
nutrition,  so  that  the  infant  fails  to  gain  weight  and  remains  ill- 
nourished  and  frail  for  weeks  or  months  after  all  other  symptoms 
of  scurvy  have  disappeared.  The  renal  symptoms  may  influence 
the  prognosis — in  one  of  my  cases  of  nephritis  with  scurvy  the 
child  showed  a  trace  of  albumen  in  the  urine,  and  was  frail  in 
appearance  two  years  after  the  occurrence  of  scurvy — and  pyelitis 
may  persist  for  several  weeks  and  nutrition  may  suffer  therewith. 
The  mere  presence,  however,  of  blood  in  the  urine  does  not  seem 
to  be  of  serious  import ;  it  usually  ceases  in  a  week  or  ten  days 
under  antiscorbutic  treatment. 

Prevention  and  Treatment 

Scurvy  is  an  entirely  preventable  disease,  and  it  is  important, 
therefore,  to  know  the  foods  upon  which  it  is  liable  to  arise.  In 
the  subjoined  table  are  stated  the  kinds  of  food  in  use  for  several 
weeks  or  months  before  the  appearance  of  scurvy  in  this  series 
of  cases  : 

Patent  foods  containing  dried  milk,  prepared  according  to  direc- 
tions with  water  only 18  cases 

Patent  foods  prepared  with  fresh  milk 22  cases 

„        „  ,,  „  condensed  milk 11  cases 

M         f.  „  „   sterilized  milk 1  case 

„        „  „  ,,  fresh  (unboiled)  milk  ....       1  case 


120  COMMON  DISORDERS  OF  CHILDHOOD 

Condensed  milk  diluted  with    plain  water,  barley-water,  or  lime- 
water          ...........       5  cases 

Sterilized  milk .3  cases 

Peptonized  milk        ..........       1  case 

Boiled  milk 2  cases 

In  the  above  table,  where  '  fresh  milk  '  was  used  in  mixing  the 
food,  it  was  usually,  if  not  always,  heated  to  boiling  during  the 
process. 

It  is  clear  that  the  mere  fact  that  cow's  milk  is  mixed  with 
a  patent  food  is  not  sufficient  to  prevent  scurvy.  Nor  can  it  be 
shown  that  the  occurrence  of  scurvy  when  fresh  milk  is  thus 
used  is  due  to  the  degree  of  dilution  rather  than  to  the  patent 
food,  for  in  some  of  my  cases  the  milk  had  been  used  for  many 
weeks  in  the  proportion  of  not  less  than  two  parts  of  milk  to  one 
part  of  water,  and  in  others  with  equal  parts  of  milk  and  water. 
The  extreme  rarity  of  scurvy  from  plain  boiled  milk  when  used 
even  more  diluted  than  this  seems  to  prove  also  that  the  scurvy 
in  these  cases  is  not  due  to  the  boiling  of  the  milk  but  to  the  addi- 
tion of  the  patent  food.  In  one  of  my  cases  in  which  scurvy 
resulted  from  the  use  of  diluted  milk  withMellin's  Food  the  milk 
had  been  heated  only  to  about  167°  F.  for  some  months,  and  had 
been  used  fresh  without  even  pasteurization  for  three  weeks  before 
the  onset  of  scurvy  (the  milk  was  examined  chemically  and  bac- 
teriologically,  and  certainly  had  not  been  sterilized,  and  there 
seemed  no  ground  for  disbelieving  the  statement  that  it  had  not 
been  heated,  except  to  the  usual  temperature  of  the  feeds).  The 
antiscorbutic  power  of  fresh  unboiled  milk  is  evidently  slight, 
and  is  diminished  or  destroyed  by  heating,  but  from  the  rarity 
of  scurvy  on  boiled  milk  compared  with  the  fact  that  boiled  milk 
is  probably  the  commonest  of  all  infant  foods,  it  would  seem  that 
milk  has  but  little  tendency  to  produce  scurvy  if  merely  heated 
to  the  boiling-point  for  a  few  seconds,  as  is  commonly  done. 

In  order  to  prevent  the  occurrence  of  scurvy  in  an  infant  fed 
upon  some  scurvy-producing  food,  it  is  advised  to  add  some  anti- 
scorbutic food  to  the  diet,  and  for  this  purpose  raw  meat  juice, 
orange,  or  grape  juice  are  commonly  used.  It  might  seem  hardly 
necessary  to  point  out  that  the  meat  juice  must  be  from  fresh 
meat,  and  probably  from  uncooked  meat  ;  but  I  have  found  in 
at  least  three  instances  that  some  patent  meat  juice,  or  one  of 
the  concentrated  meat  preparations  which  are  so  widely  adver- 
tised, was  being  given  with  the  idea  that  it  would  prevent  or  cure 
scurvy.  As  far  as  I  have  seen,  such  preparations  are  entirely 
worthless  as  antiscorbutics.  The  red  gravy  from  cooked  meat 


INFANTILE  SCURVY  121 

was  shown  to  be  ineffectual  in  one  of  my  cases  where  the  child 
was  having  one  tablespoonful  of  this  red  gravy  daily  as  an 
addition  to  its  diet  of  Allenbury  Food  No.  2,  with  one  feed  of 
baked  flour  with  water  and  a  little  cream.  In  another  case 
occasional  feeds  of  beef-tea  had  not  prevented  the  onset  of  scurvy. 
Even  raw  meat  juice,  unless  given  sufficiently  freely  and  regularly, 
may  not  prevent  scurvy.  In  one  of  the  most  severe  cases  raw 
meat  juice  had  been  given  for  five  months  before  the  disease 
began  ;  and  in  the  only  case  in  my  series  which  arose  on  pep- 
tonized  milk  the  infant  was  having  a  teaspoonful  of  raw  meat 
juice  three  times  a  day  on  every  alternate  day,  then,  owing  to 
some  looseness  of  bowels,  it  was  omitted  fourteen  days,  by  the 
end  of  which  time  the  infant  showed  well-marked  scurvy. 

Fruit  juice,  though  probably  a  more  powerful  antiscorbutic 
than  raw  meat  juice,  is  not  an  unconditional  safeguard.  In  the 
case  already  mentioned  where  red  gravy  of  cooked  meat  was 
being  given  with  the  Allenbury  Food,  the  juice  of  two  black  grapes 
had  also  been  given  daily  for  four  and  a  half  months  before  the 
scurvy  began ;  in  another  case  where  scurvy  had  been  recognized 
the  juice  of  four  grapes  had  been  given  daily  for  fourteen  days  with 
no  apparent  improvement  (on  potato  there  was  definite  improve- 
ment in  two  days). 

No  doubt  this  failure  of  fruit  juice  depends  upon  insufficiency 
of  dose  ;  but  it  may  be  that  this  insufficiency  is  relative,  not 
absolute — that  it  requires  a  larger  amount  of  fruit  juice  to  prevent 
the  scorbutic  tendency  of  some  foods  than  of  others.  The  superior 
potency  of  potato  as  an  antiscorbutic  seems  to  me  quite  certain, 
but  as  I  have  almost  always  given  also  raw  meat  juice  or  orange 
juice  my  own  results  do  not  illustrate  this  point,  and  some  of  my 
cases  have  shown  very  rapid  improvement  on  orange  juice  alone. 
While,  however,  potato  seems  specially  valuable  in  the  treatment 
of  scurvy,  it  is  less  suitable  for  prophylaxis,  for  although  it  is 
usually  tolerated  well  for  a  few  weeks  during  treatment  it  is  more 
apt  to  cause  digestive  disturbance  than  is  fruit  juice,  and  is  there- 
fore less  suitable  for  prolonged  use  as  a  regular  addition  to 
the  diet. 

The  potato  is  prepared  by  boiling  or  steaming  in  the  ordinary 
way  with  care  to  obtain  a  floury  potato  ;  the  outer  floury  portion 
is  then  scraped  off  and  beaten  up  thoroughly  with  enough  milk 
to  make  a  smooth  cream,  sufficiently  thick  to  pour  out  of  a  jug 
rather  heavily — potato  2  heaped  teaspoonfuls  (with  average 
2  drachm  teaspoon)  to  1  ounce  of  milk  ;  1J  to  2  teaspoonfuls  of 
this  potato  cream  are  given  three  or  four  times  daily  ;  after  two 


122  COMMON  DISORDERS  OF  CHILDHOOD 

or  three  weeks  the  dose  of  this  should  be  gradually  reduced,  and 
omitted  altogether  within  four  weeks  from  the  commencement 
of  treatment.  The  mode  of  giving  the  potato  cream  is  of  some 
importance  ;  most  infants  take  it  best  mixed  up  with  the  ordinary 
feed,  but  if  this  is  done  it  should  be  mixed  with  a  portion  only  of 
the  feed  to  ensure  the  whole  of  the  potato  cream  being  taken, 
otherwise,  if  part  of  the  food  is  left,  the  child  does  not  get  the 
full  dose  of  potato.  Occasionally  it  is  taken  more  readily  given 
separately  ;  in  either  case  it  is  often  disliked  at  first,  but  I  have 
rarely  had  any  serious  difficulty  in  getting  it  taken.  In  addition 
2  teaspoonfuls  of  raw  meat  juice  may  be  given  three  or  four  times 
in  the  twenty-four  hours,  and  sometimes  J  teaspoonful  of  orange 
juice  two  or  three  times  a  day,  but  any  looseness  of  the  bowels 
should  make  us  cautious  in  adding  this  to  the  potato  cream,  for 
diarrhoea  in  infantile  scurvy  is  a  serious  complication,  as  Glisson 
seems  to  ha.ve  observed.  At  the  same  time,  the  child  is  placed 
on  a  diet  of  milk  which  has  been  heated  just  short  of  boiling-point 
and  diluted  with  water  ;  the  scurvy-producing  *  food  '  is  of 
course  stopped. 

The  necessity  for  moving  and  handling  the  infant  as  little  as 
possible  is  obvious  ;  the  pain  caused  by  pulling  on  socks,  shoes, 
and  tight  sleeves,  and  by  bathing  is  so  evident  and  so  piteous  to 
behold  that  it  is  only  humane  to  have  the  infant  wrapped  in  loose 
clothing  and  let  him  lie  undisturbed  as  much  as  possible  ;  the 
duration  of  the  tenderness  and  pain  is  only  a  few  days  after 
proper  treatment  is  begun,  so  that  all  ordinary  dressing  and 
bathing  and  outing  may  well  be  in  abeyance  until  all  tenderness 
and  pain  have  gone, 


CHAPTER  IX 
FLATULENCE  AND  COLIC  IN  INFANCY 

How  often  we  hear  that  a  baby  is  c  always  crying  ',  or  has  *  the 
screaming  convulsions  ',  a  complaint  which  at  that  age  usually 
means  colic  from  some  cause  or  other.  Colic  in  an  infant  is 
never  to  be  regarded  as  a  trivial  symptom  ;  it  is  easy  enough  for 
us  to  assure  the  parents  that  it  is  of  no  serious  significance,  and 
that  it  means  simply  flatulence,  or  a  little  curd  in  the  stool,  but 
those  who  have  to  be  continually  with  the  infant  know  best  how 
extremely  distressing  is  the  uncontrollable  and  violent  screaming 
which  may  last  for  an  hour  or  more  in  spite  of  every  effort  to 
soothe  the  child.  Moreover,  colic  in  an  infant  is  of  consequence 
quite  apart  from  the  distress  which  it  causes  to  the  parents,  for 
it  will  be  found,  as  a  rule,  that  the  infant  who  screams  much  with 
colic  is  not  gaining  weight  as  he  should  do;  moreover,  in  those 
who  are  predisposed  by  neurotic  inheritance  to  convulsions, 
the  abdominal  discomfort  which  is  evidenced  by  colic  is  very  apt 
to  give  rise  to  a  convulsive  attack,  and  in  very  young  and  feeble 
infants  colic  may  produce  serious  collapse.  The  attack  of 
screaming  is  followed  by  grey  pallor  of  the  face  with  a  pinched 
appearance  of  the  nose,  the  extremities  become  blue  and  cold, 
the  pulse  becomes  very  feeble,  and  the  infant-  sinks  back 
exhausted. 

There  are  three  common  causes  of  colic  in  infants — flatulence, 
constipation,  and  undigested  food  in  the  intestine  ;  and  even 
though  it  may.  be  obvious  from  the  history  that  one  or  other  of 
these  is  present,  it  is  well  to  examine  the  abdomen  in  every  case, 
for  valuable  information  is  often  to  be  obtained  in  this  way. 
If  the  colic  be  due  to  flatulence,  the  treatment  required  will  vary 
according  to  the  position  of  the  flatulence,  it  may  be  gastric,  it 
may  be  intestinal  ;  and  a  glance  at  the  abdomen  may  show  at 
once  where  the  trouble  is,  the  distended  stomach  may  stand  up  in 
bold  relief,  or  the  colon  or  small  intestine  may  be  seen  and  felt  to 
be  distended  with  gas.  Obviously  it  is  useless  to  give  enemata  if 
the  flatulence  is  of  gastric  origin  ;  and  equally  useless  to  give 
gastric  carminatives  or  to  wash  out  the  stomach  if  the  colic  is 
due  to  gas  in  the  intestine.  For  instance,  I  saw  in  consultation 


124  COMMON  DISORDERS  OF  CHILDHOOD 

a  feeble  infant  aged  eighteen  days,  who  had  apparently  abdo- 
minal distress  leading  to  convulsions  and  leaving  the  child  blue 
and  collapsed.  One  might  have  ordered  some  bromide  as  an 
ftnema  off-hand,  but  this  would  have  been  bad  treatment,  for 
inspection  of  the  abdomen  showed  that  the  stomach  was  quite 
ballooned  and  tense  with  gas,  whereas  the  intestine  showed  little 
or  no  distension  ;  gastric  lavage,  with  bicarbonate  of  soda 
solution  (gr.  iv  to  the  ounce)  was  advised,  and  the  infant  made 
a  good  recovery. 

It  is  remarkable  how  much  distress  and  disturbance  is  produced 
in  infants  by  flatulence.  Gastric  flatulence  often  leads  to  vomiting 
after  every  feed  ;  the  infant  belches  up  the  gas  and  food  together, 
and  in  this  way  nutrition  may  suffer.  It  is  the  usual  cause  of 
hiccough  in  infants,  and  hiccough,  although  usually  of  little 
importance,  may  become  serious  if  it  occurs  often  and  lasts  long 
in  feeble  infants,  for  it  exhausts  them  considerably.  When  the 
gastric  distension  has  been  considerable,  I  have  seen  it  so  hamper 
the  respiration  that  the  infant  grunted  with  the  difficulty  of 
breathing  and  lay  with  the  head  retracted  like  a  case  of  meningitis, 
evidently  to  give  the  muscles  of  respiration  as  free  play  as 
possible. 

As  in  older  children,  gastric  flatulence  is  also  one  of  the  causes 
of  sleeplessness,  and  I  think  not  an  uncommon  one  in  infants. 

Again,  on  palpation  of  the  abdomen,  scybala  may  be  distinctly 
felt  in  the  colon,  indicating  the  need  for  immediate  use  of  an 
enema.  In  such  cases  an  injection  of  warm  olive  oil,  say  half  an 
ounce,  followed  by  3  or  4  ounces  of  warm  soapy  water,  will  often 
give  immediate  relief. 

But  palpation  of  the  abdomen  may  reveal  something  more 
serious  than  flatulence.  The  possible  presence  of  intussusception 
is  never  to  be  forgotten  in  the  case  of  an  infant  who  has  suddenly 
started  screaming  without  obvious  cause,  and  it  is  no  easy 
matter  to  exclude  the  possibility  at  once  in  some  cases.  More 
than  once  I  have  been  called  to  an  infant  who  had  been  screaming 
violently  for  an  hour  or  more,  and  had  evident  pain  in  the 
abdomen,  which  with  the  presence  of  mucus  and  some  vomiting, 
and  even  a  trace  of  blood  in  the  stool  suggested  that  there  might 
be  an  intussusception,  and  it  was  only  after  the  most  careful 
watching  and  examination  that  one  could  make  a  diagnosis. 

I  was  called  to  see  a  female  infant  aged  four  months  :  she  was  being 
fed  on  Savory  &  Moore's  Food  :  two  days  previously  at  10  p.m.  she  had 
suddenly  begun  to  scream,  and  continued  screaming  for  two  hours.  A 
hot  bath  had  been  given  and  an  enema  administered :  the  child  was  then 


FLATULENCE  AND  COLIC  IN  INFANCY    125 

sick,  and  at  8  a,m.  the  next  morning,  after  vomiting  green  material,  she 
passed  some  blood  and  mucus  with  only  a  trace  of  faeces.  Vomiting  con- 
tinued throughout  the  day  and  at  5  p.m.  she  again  passed  mucus  stained 
with  red  blood,  with  little  or  no  faecal  matter.  During  the  next  night  she 
was  restless,  waking  frequently  and  crying  out  with  pain  in  the  abdomen. 
I  saw  her  about  midday  of  the  second  day,  i.  e.  about  thirty-eight  hours  after 
the  onset  of  the  attack,  the  bowels  had  been  open  twice  that  day,  the  first 
stool  consisted  only  of  mucus  with  a  trace  of  blood,  the  second  of  similar 
blood-stained  mucus,  and  a  trace  of  green  faeces.  There  had  been  only  slight 
vomiting  in  the  previous  eighteen  hours.  The  infant  was  small  and  pale, 
but  did  not  look  extremely  ill ;  she  lay  for  a  few  moments  quiet  and  then 
began  to  scream  in  evident  pain.  Palpation  of  the  abdomen  was  impossible, 
the  infant  held  it  rigid  and  screamed  continuously  as  long  as  any  attempt 
was  made  to  feel  the  abdomen  and  at  most  other  times.  One  was  loathe  to 
give  an  anaesthetic,  for  the  cessation  of  vomiting,  and  the  appearance  of  faecal 
material  in  the  last  stool,  and  the  duration  of  the  attack  in  so  young  an  infant 
without  more  evidence  of  extreme  collapse,  all  seemed  to  tell  against  a  diagnosis 
of  intussusception,  so  I  waited  an  hour  or  more  to  see  if  the  infant  would  fall 
asleep,  which  she  did  eventually,  when  I  was  able  to  palpate  the  abdomen 
and  failed  to  find  any  tumour.  An  enema  of  warm  olive  oil  with  4  ounces 
of  soap  and  water  brought  away  a  large  quantity  of  mucus,  no  faecal  material  : 
white  wine  whey  was  ordered  for  feeding,  to  alternate  with  very  weak  pepton- 
ized  milk :  the  symptoms  steadily  diminished  and  the  child  made  a  good 
recovery. 

I  suspect  that  occasionally,  perhaps  more  often  than  we 
imagine,  there  really  is  an  intussusception  which  undergoes 
spontaneous  reduction.  When  one  sees  the  slight  intussuscep- 
tions which  are  so  frequently  found  at  autopsies  on  children, 
sometimes  several  in  various  parts  of  the  small  intestine,  one 
can  well  suppose  that  occasionally  a  similar  condition  might  occur 
during  life  ;  it  is  true  that  these  intussusceptions  of  the  dying 
are  only  in  the  small  intestine  and  nearly  always  in  the  reverse 
direction  to  those  met  with  clinically,  but  sometimes  they  are 
in  the  same  direction  :  and  it  is  noteworthy  that  like  the  ordinary 
clinical  intussusception,  they  are  much  commoner  in  infants  than 
in  older  children.  It  seems  likely  enough  that  in  the  small 
intestine  with  its  smooth  and  even  wall,  an  intussusception  may 
occur  more  easily  and  reduce  itself  more  easily  than  when  it  is 
of  the  ordinary  ileo-caecal  or  ileo-colic  variety.  The  sacculated 
and  thicker  wall  of  the  large  intestine  may  tend  to  prevent 
the  occurrence  and  spontaneous  reduction  of  an  intussusception, 
but  even  here  there  is  no  doubt  that  spontaneous  reduction  does 
occur  sometimes. 

In  a  child  aged  2^  under  my  care  at  King's  College 
Hospital,  the  typical  symptoms  of  intussusception,  including  an 
obvious  sausage-shaped  tumour,  had  occurred  three  times  at 
intervals  of  eight  months,  and  ten  days.  On  the  first  two 


126  COMMON  DISORDERS  OF  CHILDHOOD 

occasions  the  severe  symptoms  of  vomiting,  colic,  constipation, 
and  passage  of  blood  and  mucus,  all  passed  off  and  the  tumour 
disappeared  without  surgical  interference,  although  on  the 
second  occasion  the  child  was  so  extremely  bad  that  the  surgeon 
decided  against  operation  only  because  the  intussusception  had 
been  present  two  days,  and  there  seemed  no  hope  that  the  child 
would  stand  the  severe  shock  of  a  bowel  resection.  On  the  third 
occasion  acute  peritonitis  occurred  with  the  intussusception,  and 
the  child  died  ;  a  large  intussusception  was  found  with  its  layers 
only  slightly  adherent,  so  that  it  had  probably  only  occurred 
quite  recently.  The  case  was  evidently  one  of  relapsing  intussus- 
ception. 

My  colleague,  Mr.  Kellock,  tells  me  of  an  infant  upon  whom  he 
operated  at  Great  Ormond  Street  Hospital  for  the  same  affection. 
The  usual  symptoms  had  been  present,  including  the  tumour,  but 
on  opening  the  abdomen,  the  lower  part  of  the  ileum  was  found 
to  be  much  congested,  as  if  it  had  recently  been  constricted  by 
an  intussusception,  which  had  already  disappeared. 

I  do  not  quote  these  cases  as  any  argument  in  favour  of  post- 
poning operation  where  there  is  clear  evidence  of  intussusception, 
as  a  general  rule  delay  in  such  cases  is  most  dangerous,  but  I 
mention  them  because  they  support,  I  think,  the  view  that  slighter 
intussusceptions  perhaps  of  the  ileic  variety  may  occasionally 
be  the  explanation  of  severe  screaming  in  an  infant  who  is  vomit- 
ing and  passing  blood  and  mucus  with  little  or  no  fsecal  matter, 
and  yet  gradually  recovers. 

Any  screaming  in  an  infant  which  suggests  abdominal  pain  calls 
for  examination  of  the  stools.  A  stool  with  lumps  of  white  curd 
in  it  or  a  green  stool  with  much  mucus,  may  point  to  indigestion 
as  the  cause  of  colic  ;  there  is  a  particularly  close  relation  between 
abdominal  pain  and  the  presence  of  much  mucus  in  the  stools  ; 
I  think  the  pain  in  such  cases  is  probably  due  to  the  mechanical 
difficulty  of  driving  the  tenacious  viscid  mucus  along  the  intestine, 
which  consequently  makes  violent  efforts  at  peristalsis,  and  so 
produces  the  abdominal  pain. 

Occasionally  the  stools  may  reveal  some  gross  fault  of  diet  : 
I  was  puzzled  by  an  infant  of  twelve  months  with  symptoms  of 
intestinal  disturbance  without  apparently  sufficient  cause,  but 
a  few  hours  later  examination  of  the  stools  cleared  up  the  mystery 
by  demonstrating  the  pips  of  red  currants  which  the  nursery 
maid  had  been  giving  surreptitiously,  in  addition  to  further 
evidence  of  nursery  carelessness  in  the  shape  of  a  collar  stud, 
two  solid  knobs  out  of  the  baby's  rattle,  and  a  long  hair  ! 


FLATULENCE  AND  COLIC  IN  INFANCY     127 

Again  the  presence  of  gaseous  fermentation  with  resulting 
flatulence  and  colic  in  the  intestine,  may  sometimes  be  evident 
in  the  frothy  character  of  the  stools.  The  hardness  and  dryness 
of  the  stools  which,  as  I  have  sometimes  been  told,  *  rattle  like 
marbles  in  the  chamber,'  may  also  account  sufficiently  for  colic. 

Investigation  of  the  diet  will  be  necessary  in  every  case  ; 
abdominal  pain  in  infants  is  usually  the  result  of  some  fault  in 
the  method  of  feeding,  or  in  the  food  itself  ;  too  large  feeds  are 
often  being  given,  with  the  result  that  the  persistently  over- 
distended  stomach  falls  into  a  state  of  chronic  catarrh,  if  indeed 
this  be  the  correct  interpretation  of  the  flatulence  which  so  often 
marks  the  dyspepsia  of  these  cases.  Too  frequent  feeding  is 
another  common  cause  for  colic :  and  this  applies  to  breast- 
feeding quite  as  much  as  to  hand-feeding.  Indeed,  apart  from 
the  overtaxing  of  digestion  and  resulting  flatulence  and  dyspepsia 
which  result  from  too  frequent  feeding,  whether  with  substitute 
feeding  or  with  breast-milk,  there  is  in  the  case  of  the  latter 
a  special  reason  why  this  fault  should  produce  colic  :  any  exces- 
sive shortening  of  the  intervals  between  milking  whether  in  the 
cow  or  in  the  woman  is  found  to  increase  the  proportion  of  curd 
in  the  milk. 

Too  much  carbo-hydrate  is  a  fruitful  source  of  flatulence  and 
colic.  There  is  not  sufficient  attention  paid  to  the  proportion  of 
sugar  in  infant-feeding  :  '  put  some  sugar  in  the  feeds,'  is  not 
sufficient  direction  to  a  mother  or  nurse,  who  very  naturally  puts 
in  as  much  as  she  thinks  will  sweeten  the  food  sufficiently  to 
gratify  the  infant's  taste  ;  as  if  it  mattered  not  the  least  whether 
the  food  contained  5  per  cent,  or  10  per  cent,  of  sugar.  For- 
tunately, on  the  whole,  the  tendency  is  to  add  less  sugar  than 
Nature  allows :  human  milk  contains  7  per  cent,  of  sugar.  Cow's 
milk  contains  4  per  cent,  before  it  is  diluted  ;  a  very  ordinary 
addition  to  a  mixture  of  cow's  milk  and  water  is  a  teaspoonful 
of  sugar,  a  level  teaspoonful  of  which,  in  3  ounces  of  fluid,  means 
the  addition  of  5  per  cent,  of  sugar  to  the  fluid,  so  that  with  any 
dilution  of  cow's  milk,  there  is  not  likely  to  be  much  excess  of 
sugar,  if  only  one  teaspoonful  is  added  ;  but  if  a  heaped  tea- 
spoonful  or  more  is  added,  the  allowable  maximum  of  7  per  cent, 
will  be  exceeded. 

Far  more  often  the  excess  of  carbo-hydrate  is  being  given  in  the 
form  of  the  products  of  malting.  Many  of  the  best  known 
patent  foods,  which  contain  no  starch  whatever,  are  open  to 
objection  on  this  account :  the  Allenbury  Foods,  Nos.  1  and  2,  for 
instance,  contain  when  diluted  according  to  the  maker's  directions 


128  COMMON  DISORDERS  OF  CHILDHOOD 

10 to  1 1  per  cent,  of  carbo-hydrate ;  Horlick's  Malted  Milk,  as  given, 
often  contains  about  12  per  cent.  ;  Mellin's  Food,  which  is 
intended  to  be  an  addition  to  milk,  consists  almost  entirely  of 
soluble  carbo-hydrates  (about  70  per  cent.)  and  therefore,  although 
starch-free,  too  much  of  it  may  cause  flatulence  and  colic ;  used 
in  accordance  with  the  maker's  directions,  seven  heaped  teaspoon- 
f  uls  to  7J  ounces  of  milk,  and  2J  ounces  of  water,  for  an  infant  of 
six  months  and  over,  the  total  proportion  of  carbo-hydrate  in 
the  mixture,  if  the  heaped  spoon  contains,  as  I  found  it  to  do, 
85  grains,  would  be  12-5  per  cent. 

If  a  carbo-hydrate  food  be  used,  whether  it  consists  of  soluble 
carbo-hydrate  like  Mellin's,  or  of  insoluble  carbo-hydrate  or 
starch,  as  in  so  many  patent  foods,  allowance  ought  to  be  made 
for  this  in  calculating  the  amount  of  sugar,  if  any,  to  be  added. 
In  the  case  of  Mellin's  food,  it  is  safer  to  add  no  sugar,  for  even 
with  one  level  teaspoonful  of  Mellin's  in  a  three-ounce  feed  the  per- 
centage of  carbo-hydrate  will  be  so  nearly  correct  that  any  further 
addition  is  almost  certain  to  mean  excess. 

Experience  shows  that  there  are  some  infants  who  will  not  only 
tolerate  but  thrive  upon  a  food  containing  sugar  or  other  carbo- 
hydrate in  a  proportion  somewhat  above  that  present  in  human 
milk  :  but,  none  the  less,  to  give  an  infant  a  food  which  contains 
more  than  7  per  cent,  of  carbo-hydrate  is  always  to  run  a  risk 
of  slimy  loose  stools  with  flatulence  and  colic ;  certainly  one  of 
the  common  causes  of  pain  in  the  abdomen  in  infants  is  the 
use  of  starch-containing  foods,  which  set  up  fermentation  and 
so  produce  either  flatulence  or  a  mucous  catarrh  in  the  intestines. 
I  have  already  considered  these  foods  in  Chapter  V,  here  I  will 
only  say  that  in  some  infants  the  merest  trace  of  starch  in  the 
food  seems  sufficient  to  cause  abdominal  discomfort,  and  for  this 
reason  even  barley-water  must  be  looked  upon  with  suspicion 
when  the  cause  of  colic  is  in  question. 

Too  much  fat  in  the  food  is  no  doubt  a  much  less  common  cause 
of  abdominal  pain  in  infancy  than  excess  of  carbo-hydrate,  but 
I  have  seen  cases  which  strongly  suggested  that  the  pain  was  due 
to  excessive  addition  of  cream,  and  where  breast -milk  has  caused 
screaming,  the  proportion  of  fat  in  it  has  sometimes  been  found 
unusually  high.  However  this  may  be,  there  is  no  doubt  that 
cream,  even  when  carefully  proportioned,  is  very  apt  to  cause 
digestive  disturbance,  and  when  colic  in  infants  is  due  to  indi- 
gestion it  is  often  wise  to  diminish  cream  or  omit  it  altogether 
for  a  time. 

Insufficient    dilution    of   milk  is  a  common  fault  in   infant- 


FLATULENCE  AND  COLIC  IN  INFANCY    129 

* 

feeding,  and  the  undigested  curd  which  results  therefrom  is  one 
of  the  causes  of  abdominal  pain  and  screaming.  Even  with 
breast-feeding,  the  proportion  of  curd  may  be  higher  than  the 
infant  can  digest ;  I  have  found,  when  breast-milk  was  disagree- 
ing, the  proteid  of  human  milk  as  high  as  3  per  cent,  instead  of 
the  usual  bare  2  per  cent.,  and  it  can  be  understood  therefore 
why  the  administration  of  some  plain  water  just  before  suckling 
sometimes  relieves  colic  due  to  this  cause. 

Gross  faults  in  the  diet  may  require  correction  ;  the  infant  who 
at  six  months  old  is  having  odd  scraps  of  '  unconsidered  trifles  ' 
at  its  parents'  meals,  is  likely  to  have  abdominal  pain.  I  some- 
times find  that  bananas  are  being  given  to  quite  young  infants, 
no  doubt  in  consequence  of  the  popular  fallacy  that  bananas 
are  easily  digestible  :  whatever  theory  may  suggest,  experience 
shows  that  bananas  are  very  badly  digested  by  infants  and  young 
children,  and  it  is  no  matter  for  surprise  if  an  infant  cries  with 
abdominal  pains  when  such  food  is  allowed.  As  we  all  know 
there  are  infants  who  will  take  and  apparently  suffer  no  ill  effects 
from  food  which  causes  serious  digestive  disturbance  in  most 
infants,  but  this  is  no  argument  for  sanctioning  such  food  for 
routine  use. 

Lastly,  I  must  point  out  that  although  colic  in  infants  is 
a  gastro-intestinal  disorder  in  the  very  large  majority  of  cases, 
it  is  possible  that  occasionally  it  may  be  of  quite  different  causa- 
tion. In  examining  the  bodies  of  infants  I  have  occasionally 
found  small  concretions  in  the  pelvis  of  the  kidney,  the  size  of 
millet  seed  or  slightly  larger,  and  any  one  who  frequently  examines 
the  diapers  of  infants  must  be  familiar  with  the  deposits  of  uric 
acid  which  are  sometimes  to  be  found  on  them. 


Treatment 

In  considering  the  causes  of  abdominal  pain  in  infants  I  have 
indicated  the  lines  upon  which  treatment  must  proceed  ;  in 
the  majority  of  cases  some  fault  in  feeding  will  require  cor- 
rection, but  here  I  must  emphasize  a  point  of  some  practical 
importance  ;  a  baby's  digestion,  once  upset  by  feeding  un- 
suitable for  its  age,  is  often  not  to  be  won  back  to  better  ways 
by  simply  substituting  such  feeding  as  would  be  correct  for 
a  healthy  infant  at  the  same  age  :  it  is  usually  necessary  to  give 
food  which  is  considerably  weaker  in  strength  and  less  in  quantity 
than  would  naturally  be  given  to  an  infant  of  that  age  ;  and  if 
milk  is  being  used  the  screaming  will  generally  be  stopped  most 


130  COMMON  DISORDERS  OF  CHILDHOOD 

quickly  by  giving  a  very  dilute  peptonized  milk  without  added 
cream  for  a  few  days.  I  have  often  found  that  the  mere  discon- 
tinuance of  barley-water  causes  rapid  diminution  of  the  flatu- 
lence and  colic  :  and  in  the  slighter  cases  the  addition  of  sodium 
citrate  (3  grains  in  a  drachm  of  water)  to  each  feed  is  sometimes 
sufficient. 

I  must  not  repeat  here  what  I  have  said  elsewhere  on  the 
methods  of  overcoming  curd-indigestion,  and  on  the  proper 
adaptation  of  milk  to  the  needs  of  an  infant  (vide  Chapters  III 
and  IV)  but  it  must  be  remembered  that  the  proper  application 
of  the  general  principles  of  infant-feeding  constitutes  the  most 
important  part  in  the  prevention  and  treatment  of  colic  in 
infants. 

There  can  be  no  doubt  of  the  value  of  the  ordinary  carmina- 
tives for  abdominal  pain  due  to  gastric  flatulence.  I  am  fond 
of  the  Tinct.  Carminativa,  of  which  one  or  two  minims  can  be 
given  in  an  alkaline  mixture;  for  instance,  Sodium  Bicarb,  gr.  ij, 
Tinct.  Carminativa  (B.  P.  C.)  Cl)j,  Glycerin  O)v,  Aq.  ad  3j,  three 
or  four  times  a  day,  ten  minutes  before  a  feed :  or  one  minim  of 
sal  volatile,  or  a  minim  of  Spirit.  Ammon.  Fretidus,  or  five  minims 
of  Tinct.  Cardamomi  Co.  with  one  minim,  of  Spirit.  Chloroformi 
may  be  used  instead  of  the  Tinct.  Carminativa.  The  carbonate 
of  magnesium  may  do  more  good  than  the  bicarbonate  of  soda 
in  these  cases,  2  grains  of  either  making  a  suitable  dose  for  an 
infant  up  to  a  year  old  :  or  the  sulpho-carbolate  of  soda,  one 
grain  for  an  infant  under  one  year,  may  be  used  in  the  hope  that 
it  may  exercise  some  antiseptic  effect  in  preventing  fermentation. 
Creosote  also  in  doses  of  one-eighth  of  a  minim  is  sometimes  very 
effective  for  this  purpose.  Bismuth  is,  I  think,  distinctly  valu- 
able if  gastric  flatulence  is  very  constant  ;  three  or  four  grains 
of  the  carbonate  with  two  grains  of  bicarbonate  of  soda  suspended 
by  a  couple  of  grains  of  compound  tragacanth  powder  in  a  drachm 
of  dill-water  makes  a  suitable  prescription,  but  bismuth  is  only 
to  be  used  for  a  few  days  to  relieve  the  abdominal  pain  when  very 
frequent  ;  its  continued  administration  is  only  likely  to  aggravate 
the  constipation  which  so  often  accompanies  and  increases  the 
distress. 

Papain  gr.  j  administered  before  every  alternate  feed  is  some- 
times useful,  and  I  have  known  Taka-diastase  in  small  doses  to 
give  decided  relief. 

Nux  vomica  is  a  rational  therapeutic  in  cases  where  the 
stomach  seems  to  become  so  distended  with  gas  that  it  has 
difficulty  in  expelling  it,  and  as  a  matter  of  experience  I  think 


FLATULENCE  AND  COLIC  IN  INFANCY  131 

it  is  distinctly  useful  in  doses  of  quarter  of  a  minim  for  an  infant 
up  to  six  months,  and  half  a  minim  from  six  months  to  one  year. 

There  is  a  small  point  which  may  be  worth  mentioning  in 
connexion  with  prescribing  for  these  cases  of  flatulent  colic  in 
infancy  ;  it  applies  also,  only  perhaps  in  less  degree,  to  children 
past  the  age  of  infancy,  namely  the  choice  of  a  sweetening  agent. 
It  is,  I  think,  well  to  avoid  syrups  as  much  as  possible  ;  the 
amount  of  sugar  contained  in  the  syrup,  though  small,  may  be 
quite  enough  to  favour  flatulence  in  an  infant  who  already  has 
flatulence  and  colic  from  inability  to  digest  the  carbo-hydrate 
in  the  food  ;  glycerine  is  not  open  to  this  objection,  and  chloro- 
form-water or  the  spirit  of  chloroform  (tt)i-ij ),  used  with  or  without 
glycerine,  has  the  advantage  that  it  not  only  sweetens  but 
also  exerts  some  anti-fermentative  action  in  the  stomach. 

But  now,  what  is  to  be  done  when  the  attack  of  colic  is  on,  and 
the  baby  screaming  with  pain  and  drawing  his  legs  up  in  evident 
abdominal  distress  ?  By  frequently  changing  the  infant's 
position,  letting  him  be  for  a  minute  or  two  on  his  stomach,  over 
the  nurse's  shoulder,  then  on  his  back  upon  her  lap,  then  in  the 
sitting  position,  and  so  on,  the  eructation  of  wind  maybe  assisted, 
or  the  application  of  hot  flannels  or  a  piece  of  spongiopiline, 
wrung  out  of  hot  water,  to  the  abdomen  may  give  temporary 
relief.  For  gastric  flatulence  a  drop  of  sal  volatile,  or  5  to  10 
drops  of  brandy,  according  to  the  age,  in  a  teaspoonful  of  warm 
water,  or,  better,  dill-water,  may  ease  the  distress.  I  have  often 
found  salad  oil  useful  in  these  cases,  about  20  drops  with  half 
a  teaspoonful  of  warm  water  and  1  drop  of  sal  volatile.  If 
a  feed  is  to  be  given,  sherry  whey  is  worth  trying  ;  it  suits  some 
of  these  cases  excellently,  having  a  very  definite  carminative 
effect.  Whether  there  is  constipation  or  not,  a  warm  enema 
of  plain  water  or  of  warm  olive  oil,  followed  by  4  to  6  ounces 
of  water,  has  often  a  remarkable  effect  in  rapidly  soothing 
the  infant.  Lastly,  and  I  put  it  last  because  I  think  it  is  best 
avoided  if  possible,  opium  in  some  form  may  be  not  only  per- 
missible but  advisable,  when  the  infant  has  been  screaming  for 
a  long  time,  perhaps  an  hour  or  more,  for  the  resulting  exhaustion 
may  be  serious  in  a  feeble  infant.  Dover's  Powder,  in  doses  of 
J  grain  at  three  months,  J  grain  at  six  months,  J  grain  at  one 
year,  is  perhaps  the  most  convenient  and  effectual  form. 


CHAPTER  X 
INFANTILE   MARASMUS 

MARASMUS,  or  wasting,  is  a  symptom  rather  than  a  disease, 
and  like  most  symptoms  it  may  result  from  many  different 
causes. 

I  begin  with  this  platitude  because  I  think  there  is  a  tendency 
to  jump  to  the  conclusion  that  whenever  an  infant  is  wasting 
there  must  be  something  wrong  in  the  food,  and  that  all  that  is 
required  is  to  change  the  food  and  keep  on  changing  it  until  the 
weight  begins  to  rise.  Undoubtedly  digestive  trouble  from 
unsuitable  feeding  is  by  far  the  commonest  cause  of  wasting  in 
infancy,  but  even  so  it  does  not  follow  that  the  food  requires 
changing  ;  it  may  be  that  the  fault  is  not  in  the  food,  but  in  the 
manner  of  feeding,  particularly  in  the  frequency  or  the  size  of 
feeds  ;  moreover,  there  are  other  cases  by  no  means  infrequent 
in  which  the  wasting  is  not  due  to  any  fault  in  the  food  or  in  the 
manner  of  feeding,  but  to  some  cause  in  the  infant  such  as 
chronic  constipation  or  congenital  syphilis. 

The  causes  of  wasting  in  infancy — and  under  the  term  wasting 
I  shall  include  failure  to  gain  weight  as  well  as  actual  loss  of 
weight — fall  into  one  or  other  of  these  two  categories,  faults  in 
the  food  or  feeding,  and  faults  in  the  infant. 

The  commonest  of  all  causes  is  unsuitable  food,  but  I  would 
emphasize  the  fact  that  in  the  large  majority  of  cases  marasmus 
is  due  not  to  any  gross  impropriety  in  the  food,  but  to  some 
slight  excess  or  deficiency  in  one  or  other  of  the  constituents  of 
an  ordinary  milk  mixture. 

Occasionally  it  is  true  the  fault  is  gross  :  for  instance,  a  female 
infant,  aged  ten  months,  was  brought  to  me  at  hospital  for 
wasting  :  at  the  age  of  about  eight  months  she  had  been  fed  on 
fish,  greens,  and  potatoes  ;  then,  owing  to  symptoms  of  indi- 
gestion, she  was  fed  for  a  whole  month  on  nothing  but  barley- 
water,  a  pint  and  a  half  with  half  an  ounce  of  brandy  daily  : 
what  wonder  that  she  was  emaciated  !  Fortunately  such  gross 
mal-feeding  is  quite  uncommon. 

Far  more  often  the  fault  is  insufficient  dilution  of  cow's  milk 
in  the  early  months  of  life.  The  infant  who  is  given  equal  parts 


INFANTILE  MARASMUS  133 

of  milk  and  water  at  a  month  old  is  likely  to  waste  :  and  a  mix- 
ture of  two  parts  of  milk  to  one  of  water  at  three  months  may 
have  the  same  result.  I  am  well  aware  that  there  are  infants 
who  will  tolerate  and  thrive  on  undiluted  cow's  milk  almost  from 
birth,  and  I  have  used  this  method  of  feeding  with  good  results, 
but  in  my  experience  its  success  is  the  exception,  not  the  rule  ; 
and  I  have  no  hesitation  in  saying  that  marasmus  is  more  often 
due  to  insufficient  than  to  excessive  dilution  of  milk.  As  a  general 
rule  the  proper  dilution  is  equal  parts  of  milk  and  water  at  three 
months,  two  parts  of  milk  to  one  part  of  water  at  six  months,  and 
three  parts  of  milk  to  one  of  water  at  nine  months  ;  the  transition 
from  one  strength  to  another  is  to  be  made  of  course  gradually. 

Another  common  fault  which  is  responsible  for  wasting  is  an 
excessive  proportion  of  cream.  An  infant  may  tolerate  an 
average  proportion  of  4  per  cent,  of  fat  in  human  milk,  but 
the  cream  from  cow's  milk  is  less  easily  borne ;  there  are  many 
infants  who  cannot  digest  a  mixture  containing  more  than  3  per 
cent,  of  this  fat.  Often  I  find  that  a  wasted  infant  has  been 
given  two  teaspoonfuls  of  cream  in  a  feed  of  3  ounces,  consisting 
of  equal  parts  of  milk  and  water  :  no  attempt  has  been  made 
to  ascertain  the  strength  of  the  cream,  and  this  proves  to  be  the 
ordinary  48  per  cent,  cream,  the  percentage  of  fat  in  the  mixture 
therefore  is  5  to  6  per  cent.  ;  and  after  gaining  weight  rapidly 
perhaps  on  this  mixture  for  a  time,  the  infant  has  begun  to 
waste. 

Herein  lies  the  importance  of  a  practical  working  knowledge 
of  the  composition  of  milk  and  of  the  ordinary  foods  in  common 
use  for  infant-feeding.  Percentage  analysis  may  be  and  often 
is  a  very  incomplete  guide  to  the  choice  of  food,  but  it  gives  at 
any  rate  one  means  by  which  we  may  compare  any  food  with 
the  ideal  standard,  human  milk,  and  with  the  standards  of 
artificial  feeding  which  experience  has  shown  to  be  most  generally 
successful.  Nature  is  lenient  in  her  requirements,  exacting  no 
slavish  adherence  to  decimal  points  of  percentage  as  some  would 
have  us  believe,  yet  there  are  fairly  well-defined  limits  of  varia- 
tion which  must  be  observed  if  an  infant  is  to  thrive.  To  give 
an  infant  a  food  which  contains  less  than  2  per  cent,  of  fat 
after  the  first  threa  months  of  life  is  to  incur  the  risk  of  rickets, 
on  the  other  hand  to  give  a  food  containing  over  5  per  cent,  of  fat 
is  to  expose  the  infant  to  risk  of  gradual  failure  of  assimilation,  if 
not  to  acute  digestive  disorder.  So,  too,  with  the  sugar  ;  any 
excess  of  sugar  is  likely,  sooner  or  later,  to  bring  flatulence  and 
discomfort,  with  loose  or  slimy  stools  and  wasting.  It  is  remark- 


134  COMMON  DISORDERS  OF  CHILDHOOD 

able  how  little  sugar  seems  to  be  necessary,  but  nutrition  is  likely 
to  be  poor  where  the  sugar  percentage  falls  much  below  5  per  cent., 
while,  on  the  other  hand,  sugar  above  8  or  9  per  cent,  is  very  apt 
to  cause  digestive  disturbance,  especially  flatulence  and  colic.  In 
the  proportion  of  sugar  is  to  be  included  any  other  carbo-hydrate, 
whether  soluble,  as  in  the  products  of  malting,  or  insoluble,  as 
starch .  But  starch,  in  my  opinion,  should  not  enter  at  all  into  the 
diet  of  an  infant  under  nine  months  of  age  ;  it  is  quite  certain 
that  the  small  proportion  of  starch  in  an  ordinary  mixture  of 
milk  diluted  with  barley-water,  that  is  to  say,  0-5  to  1  per  cent, 
of  starch  at  most,  is  commonly  taken  without  ill  effects,  but  as 
I  have  already  pointed  out,  even  this  small  proportion  sometimes 
causes  disturbance,  and  certainly  in  large  proportion,  as  it  is 
present  in  the  majority  of  starch-containing  patent  foods,  starch 
is  a  potent  factor  in  exciting  a  chronic  dyspepsia  which  may 
result  in  considerable  wasting.  These  are  the  cases  that  every 
medical  man  is  familiar  with,  the  infants  whose  big  tumid 
abdomen,  contrasting  strangely  with  the  thinly  covered  chest 
and  wasted  limbs,  suggests  the  possibility  of  some  tuberculous 
disease  of  mesenteric  glands  or  peritoneum. 

In  hospital  practice  feeding  with  condensed  milk  is  often 
responsible  for  marasmus  ;  in  these  cases  the  fault  is  usually  in 
the  excessive  dilution.  An  extreme  example  of  this  was  the 
feeding  of  an  infant  aged  three  months,  who  was  brought  to  me 
for  wasting  :  condensed  milk  was  being  given  in  the  proportion 
of  4  teaspoonfuls  to  2  pints  of  water,  which  would  yield  a  mixture 
containing  at  most,  proteid,  0-5  per  cent.;  fat,  0-7  per  cent.; 
sugar,  2-75  per  cent.  :  practically  nothing  more  than  a  weak 
solution  of  sugar  in  water.  Even  when  diluted  most  carefully 
(an  average  teaspoonful  to  3  ounces  of  water),  so  that  the  pro- 
portions become . 

Proteid        .         .         .         .1-2  per  cent. 

Fat     .         .         .         .         .1-5  per  cent. 

Sugar  ....     6^0  per  cent. 

it  is  clearly  not  suitable  for  infant-feeding  beyond  the  first  few 
weeks  of  life.  If  excess  of  sugar  is  to  be  avoided  in  the  ordinary 
sweetened  condensed  milk  it  must  be  diluted  so  that  the  pro- 
portion of  proteid  and  fat  becomes  quite  insufficient. 

Fresh  cow's  milk  is  sometimes  given  too  much  diluted  :  I  see 
infants  who,  at  the  age  of  six  months  and  sometimes  older,  are 
having  equal  parts  of  milk  and  water,  or,  as  more  often  happens, 
equal  parts  of  milk  and  barley-water ;  for  most  parents  cherish 
a  mistaken  idea  that  in  giving  barley-water  they  are  supplying 


INFANTILE  MARASMUS  135 

a  valuable  food  which  makes  the  proportion  of  milk  quite  a 
secondary  matter,  and  the  result  is  an  ill-nourished  infant  with 
rickets.  If  an  infant  cannot  tolerate  the  curd  of  a  milk 
mixture  stronger  than  this  at  six  months,  either  cream  must 
be  added  to  the  mixture,  or  the  use  of  a  stronger  mixture  must 
be  made  possible  by  adding  sodium  citrate  or  by  peptonizing  the 
milk. 

The  manner  of  feeding  is  sometimes  more  responsible  than 
the  food  for  wasting  in  infancy.  Even  with  breast-feeding 
irregularity  in  the  intervals  of  suckling  may  be  sufficient  to 
disturb  digestion  and  produce  marasmus,  so,  too,  does  feeding 
*  whenever  he  cries  ',  which  generally  means  that  the  infant  is 
taking  milk  almost  every  hour  or  even  oftener.  It  is  always 
a  wonder  to  me  how  mothers — who  know  well  enough  that  if  they 
themselves  took  meals  haphazard,  sometimes  at  short  intervals 
sometimes  at  long  intervals,  they  would  suffer  very  quickly  with 
indigestion — expect  their  babies,  whose  digestion  is  so  much 
more  easily  upset,  to  digest  and  thrive  when  they  are  fed  in 
this  irregular  manner. 

Even  with  regularity  the  intervals  may  be  wrong  ;  too  infre 
quent  feeding  is  very  rare,  occasionally  I  see  infants  who  are 
being  fed  only  three  times  a  day  when  they  should  be  having 
food  every  three  hours  ;  but  this  is  quite  unusual,  more  often 
one  sees  marasmic  infants  who  are  being  fed  with  the  full  amount 
for  the  age,  at  intervals  of  two  hours  or  less,  when  the  interval 
ought  to  be  three  hours  :  to  feed  an  infant  of  three  months  with 
3  or  4  ounces  every  two  hours  is  to  overtax  digestion,  and 
induce  marasmus.  Even  when  it  is  necessary,  as  it  often  is,  in 
various  diseases  to.  reduce  the  size  of  feeds  considerably  below 
the  normal  amount  for  the  age,  and  when  on  this  account  the 
feeds  must  be  given  more  frequently  than  to  a  healthy  infant, 
I  think  that  it  is  always  desirable  to  lengthen  the  intervals  of 
feeding  as  soon  as  it  is  possible. 

Another  cause  of  marasmus  which  I  have  mentioned  else- 
where but  shall  mention  again  here,  for  it  is  not,  I  think, 
generally  realized,  is  the  use  of  feeds  too  large  for  the  age. 
An  infant  is  given  2  ounces  when  he  is  a  fortnight  old,  at 
a  month  or  six  weeks  old  he  is  getting  3  ounces,  and  by  the 
time  he  is  three  months  old  his  feeds  are  perhaps  6  ounces. 
Now  what  happens  ?  At  first  the  weight  rises  rapidly  ;  at 
three  or  four  months  old  the  infant  is  a  theme  of  admiration, 
his  weight  is  considerably  above  the  average  and  everything 
seems  couleur  de  rose;  then  comes  a  pause,  the  weight  is  not 


136  COMMON  DISORDERS  OF  CHILDHOOD 

rising  ;  then  it  begins  to  fall  ;  there  is  perhaps  no  marked 
evidence  of  digestive  disturbance,  the  stools  are  normal  or  almost 
normal,  there  is  no  vomiting,  but  clearly  the  infant  is  not  thriving, 
and  by  degrees  he  falls  into  a  state  of  marasmus,  from  which  it  is 
extremely  difficult  to  extricate  him  ;  indeed,  I  regard  these  cases 
of  marasmus  from  too  large  feeds  as  some  of  the  most  difficult 
to  treat. 

Of  course  there  must  be  some  elasticity  in  the  size  of 
feeds,  for  a  large  infant  will  require  more  than  a  small  infant 
of  the  same  age,  but  it  is  seldom  wise  to  exceed  the  amounts 
which  I  have  already  mentioned  (p.  79)  as  suitable  at  each 
month. 

And  here  I  will  insist  again  upon  a  point  which  I  think  is  some- 
times forgotten,  that  an  infant  may  gain  weight  steadily  and 
even  unusually  rapidly  for  a  time  upon  feeding  which  is  never- 
theless disastrous  in  its  subsequent  results  :  witness  the  rapid 
gain  in  weight  which  infants  often  make  upon  foods  containing 
starch  or  an  unduly  high  proportion  of  sugar  ;  the  result  of 
which,  after  months  of  apparent  thriving,  is  rickets,  or  failure 
of  digestion  with  consequent  marasmus. 

Excess  of  cream  may  have  a  similar  effect  :  at  first  it  causes 
a  large  gain  in  weight  and  the  infant  seems  to  be  thriving  admir- 
ably, but  after  a  few  weeks  or  months,  with  or  without  obvious 
signs  of  digestive  disturbance,  the  power  of  assimilation  is 
exhausted  and  the  weight  begins  to  fall. 

The  question  whether  a  particular  food  or  mode  of  feeding 
is  suitable  for  prolonged  use,  must  be  determined  not  merely 
by  the  immediate  results  but  by  its  subsequent  effect  as 
proved  by  the  evidence  of  experience  in  a  large  number  of 
cases. 

/  The  cause  of  marasmus,  as  I  have  already  said,  may  lie  rather 
in  the  infant  than  in  the  feeding,  and  if  the  term  marasmus  could 
ever  be  properly  used  to  signify  a  disease  rather  than  a  symptom 
it  would,  I  think,  be  in  certain  cases,  which  seem  to  form  a  group 
by  themselves,  as  lacking  any  sufficient  explanation  for  their 
wasting.  These  are  infants  who  either  from  birth  or  from  a  few 
weeks  after  birth  begin  to  lose  weight  in  spite  it  may  be  even  of 
breast-feeding,  and  steadily  go  downhill  or  pass  through  many 
vicissitudes  in  the  way  of  feeding,  before  they  slowly  emerge 
from  a  parlous  state  of  feebleness  and  marasmus  into  a  healthy 
state  of  nutrition.  Such  a  condition  sometimes  occurs  in  suc- 
cessive children  in  the  same  family  a.bout  the  same  age  :  each 
infant,  after  it  reaches  the  age  of,  perhaps,  two  or  three  month,*, 


INFANTILE  MARASMUS  137 

begins  to  waste  without  any  other  evidence  of  digestive  dis- 
turbance, and  without  any  apparent  fault  in  the  feeding. 
/  For  these  cases,  as  I  say,  we  have  no  satisfactory  explanation. 
I  have  sometimes  been  tempted  to  apply  to  them  the  theory  of 
Sir  William  Gower's  '  abiotrophy ',  which  supposes  some  tissues 
to  be  endowed  in  certain  individuals  with  less  than  the  ordinary 
share  of  durability  ;  it  would  seem,  in  fact,  as  if  certain  infants 
have  their  function  of  assimilation  endowed  with  so  little  staying 
power  that  after  a  few  weeks'  use  it  falls  gradually  into  abeyance, 
and  the  result  is  intractable  marasmus.  Some  of  these  infants 
are  feeble  from  the  time  of  birth,  and  it  is  evident  that  the  power 
of  assimilation,  like  the  other  functions,  suffers  from  the  general 
feebleness  and  lack  of  vitality. 

A  clinical  fact  which,  perhaps,  throws  light  upon  some  of  these 
cases  is  the  remarkable  difficulty  which  certain  infants  show  in 
digesting  particular  constituents  of  food  :  this  idiosyncrasy  may 
apply  to  fat,  to  sugar,  or  to  proteid,  and  is  seen  in  connexion  with 
breast-feeding  as  well  as  in  artificial  feeding.  One  infant  will 
thrive  perfectly  on  the  ordinary  proportion  of  proteid  and  sugar, 
but  directly  the  fat  in  the  food  exceeds  a  very  low  proportion 
(perhaps  1-5  or  2  per  cent.)  there  is  digestive  trouble  ;  another 
infant  will  thrive  on  the  ordinary  proportion  of  proteid,  but  seems 
unable  to  digest  the  ordinary  proportion  of  sugar.  It  seems 
reasonable  to  suppose  that  in  some  cases  the  idiosyncrasy  may 
apply  to  more  than  one  of  these  constituents,  so  that  nutrition 
is  difficult,  perhaps  even  impossible.  However  this  may  be,  it  is 
I  think  clear  that  there  is  a  group  of  cases  in  which  the  marasmus 
is  due  to  a  primary  failure  of  the  processes  of  assimilation, 
whether  for  particular  food-stuffs  or  for  food  in  general. 

A  very  common  group  of  cases  is  that  in  which  marasmus 
follows  upon  a  more  or  less  acute  gastro-intestinal  disturbance, 
in  which  there  has  been  diarrhoea  with  or  without  vomiting. 
Every  autumn  many  such  cases  are  seen  after  the  prevalence  of 
summer  diarrhoea.  The  stools  are  no  longer  watery  or  particu- 
larly frequent,  but  they  are  green  and  slimy,  and  contain  white 
pellets  of  undigested  fat  or  curd,  or  are  simply  unduly  pale  or 
almost  white  throughout.  The  infant  has  gradually  become 
emaciated  and  miserable,  and  food  after  food  has  been  tried 
without  arresting  the  gradual  decrease  in  weight.  Some  of  these 
cases  resist  all  treatment,  and  it  is  at  least  a  plausible  suggestion 
that  in  them  there  is  some  profound  alteration  in  the  lining 
membrane  of  the  intestine  which  interferes  with  absorption. 
Various  observers  have  described  such  changes  :  a  small  cell 
infiltration  of  the  deeper  parts  of  the  mucous  membrane  is  said 
to  give  rise  to  fibrous  replacement  of  the  glandular  parts  of  the 


138          COMMON  DISORDERS  OF  CHILDHOOD 

mucosa,  so  that  a  cirrhosis  of  the  absorptive  tissues  results,  and 
if  such  a  change  were  extensive,  nutrition  would  be  impossible  ; 
as  a  rule,  however,  it  is  said  to  occur  only  over  small  areas  of 
intestines,  so  that  there  is  enough  absorptive  surface  remaining  to 
support  nutrition.  But  even  if  such  a  change  does  really  occur 
in  some  cases — and  some  observers  have  disputed  its  occurrence 
in  the  belief  that  the  appearances  described  might  have  been 
due  to  post  mortem  change — it  is  not  necessary  to  suppose  that 
it  occurs  in  all  ;  a  simple  disturbance  of  function,  an  intestinal 
dyspepsia,  may  be  the  explanation  of  the  marasmus  in  these 
cases. 

A  cause  of  marasmus  which  is  much  more  easily  overlooked 
than  might  be  supposed  is  congenital  syphilis,  for  there  may  be 
no  other  manifestation  of  the  disease  at  the  time,  and  it  may  be 
only  by  a  careful  inquiry  into  family  history,  or  by  the  state- 
ments of  the  parents,  that  the  syphilitic  origin  of  the  marasmus 
can  be  ascertained.  Usually  the  marasmus  in  these  cases  dates 
from  birth  ;  the  infant  was  a  '  fine  baby  born  ',  but  has  steadily 
wasted  since.  In  most  cases  other  symptoms  of  syphilis  show 
themselves  sooner  or  later,  but  certainly  it  is  not  right  to  wait 
for  these  before  administering  mercury,  even  if  there  be  only 
ground  for  suspecting  syphilis.  Unfortunately  even  free  adminis- 
tration of  mercury  seems  to  have  no  good  effect  in  some  un- 
doubted cases  of  syphilitic  marasmus  ;  there  are,  however, 
cases  in  which  nutrition  improves  rapidly  when  this  drug  is 
given  ;  so  that  the  diagnosis  is  a  matter  of  great  importance. 
The  occurrence  of  severe  marasmus  as  a  result  of  congenital 
syphilis  is  strong  reason  for  remembering  Colles's  law  that  the 
mother  of  an  infant  with  inherited  syphilis,  even  though  she 
has  shown  no  signs  of  the  disease  herself,  does  not  contract  the 
disease  from  her  infant.  There  is,  therefore,  no  justification  for 
stopping  the  mother  from  suckling  her  infant  because  he  has 
congenital  syphilis  ;  on  the  contrary,  it  is  highly  important  that 
the  infant  should  not  be  weaned,  for  if  to  the  syphilitic  marasmus 
there  is  added  the  marasmus  which  arises  so  often  from  digestive 
difficulties  with  hand-feeding,  the  child's  chance  of  survival  will 
be  by  so  much  the  less. 

Where  the  possibility  of  syphilis  is  in  question,  a  Wassermann 
test  may  give  help,  but,  as  a  rule,  it  is  unnecessary,  for,  so  far  as 
treatment  is  concerned,  the  simplest  and  most  satisfactory  course 
is  to  give  mercury  and  see  whether  any  good  results. 

The  marasmus  which  results  from  congenital  syphilis  is  always 
of  grave  prognosis  :  Dr.  Coutts  says,  in  his  Hunterian  lectures, 
'  Syphilitic  infants  with  atrophy  generally  die,  whether  such 
atrophy  dates  from  birth  or  many  months  later,  and  whether 


INFANTILE  MARASMUS  139 

treated  with  mercury  or  not  : '  but  '  generally  '  is  not  always  ; 
I  have  notes  of  several  syphilitic  infants  who,  in  spite  of  great 
wasting,  recovered  on  mercurial  treatment,  and  although  my 
own  experience  agrees  with  that  of  Dr.  Coutts,  as  to  the  intract- 
able character  of  the  marasmus  in  many  of  these  cases,  I  am 
satisfied  that  the  infant  can  sometimes  be  saved  by  mercurial 
treatment.  Why  an  infant  with  congenital  syphilis  should  waste 
is  not  clearly  understood  ;  it  seems  probable  that  in  some  cases 
there  may  be  gross  changes  in  the  intestinal  mucosa  :  Dr.  Coutts 
mentions  changes  in  the  mucosa,  like  those  mentioned  above  as 
resulting  from  gastro-enteritis  ;  changes  have  also  been  described 
in  the  vessels  of  the  mucosa,  apparently  a  syphilitic  endarteritis, 
which  might  well  lead  to  degenerative  changes  in  the  mucous 
membrane  ;  moreover,  the  production  of  cirrhosis  in  the  liver 
and  pancreas  by  congenital  syphilis  suggests  that,  short  of  such 
a  gross  lesion,  syphilis  might  affect  these  organs  sufficiently  to 
alter  their  secretion  in  quantity  or  quality,  and  so  affect  digestion. 
The  pathology  of  the  syphilitic  marasmus  must  remain  sub 
judice  :  the  importance  of  recognizing  its  occurrence  is  beyond 
question. 

There  is  one  cause  of  marasmus  upon  which  I  wish  to  lay  special 
stress,  for  it  is  so  often  ignored,  namely,  chronic  constipation. 
The  result  of  this  is  more  often  failure  to  gain  weight,  or  diminu- 
tion of  the  rate  of  progress,  than  actual  loss  in  weight,  but  some- 
times there  is  actual  wasting  from  this  cause.  Where  marasmus 
is  due  to  other  causes,  chronic  constipation  may  be  a  contributing 
factor,  and  all  efforts  to  improve  nutrition  may  fail  until  the 
constipation  is  remedied.  It  may  be  quite  useless — nay  worse 
than  useless — to  try  food  after  food  in  the  hope  of  hitting  upon 
one  which  will  '  suit  the  child ',  when  the  one  thing  needful  is 
regular  administration  of  some  laxative  drug  :  and  in  the  minor 
trouble  of  unsatisfactory  progress  in  weight  it  is  often  the  greatest 
mistake  to  change  the  food  which  may  be  suiting  the  child 
perfectly  when  chronic  constipation  is  really  the  cause  of  the 
slow  rate  of  progress.  The  infant  whose  bowels  are  open  once 
a  day  regularly  may  still  be  constipated,  if  the  stool  is  small  and 
dry,  and  this  may  be  sufficient  to  prevent  the  weight  from 
increasing  ;  but  when,  as  often  happens,  the  bowels  open  only 
once  in  two  or  three  days  there  is  still  more  likely  to  be  some 
disturbance  of  nutrition.  And  here  I  will  insist  upon  a  practical 
point  which  I  have  mentioned  elsewhere,  that  in  these  chronic 
cases  of  constipation  to  open  the  bowels  by  a  glycerine  or  soap 
suppository,  or  by  an  enema,  seems  to  be  less  satisfactory  in  its 


140  COMMON  DISORDERS  OF  CHILDHOOD 

results  than  to  open  them  by  some  drug  administered  by  the 
mouth.  Most  of  the  drugs  in  common  use  for  this  purpose  do 
more  than  merely  stimulate  peristalsis  of  the  colon,  as  an  enema 
or  suppository  does ;  many  of  them  act  by  promoting  the  flow 
of  secretions  into  the  small  intestine,  and  thus  may  serve  a 
valuable  purpose  as  an  emunctory,  with  a  much  wider  influence 
than  is  exerted  by  mere  mechanical  stimulation  of  the  rectum. 
I  doubt  not  that  some  of  the  successes  which  follow  the  use  of 
grey  powder  in  non-syphilitic  cases  of  marasmus  are  due  in  part 
at  least  to  the  laxative  effect  of  the  drug;  and  I  know  of  no  drug 
which  is  more  generally  useful  in  combating  chronic  constipa- 
tion in  infants.  If  the  ordinary  powder  of  hydr.  cum  cret.  gr.  J, 
sod.  bicarb,  gr.  j,  pulv.  cretse.  aromat.  gr.  j,  ter  die,  is  not  suffi- 
cient, a  combination  of  hydr.  cum  cret.  gr.  J-j,  pulv.  rhei.  co. 
gr.  ij-iij,  given  regularly  three  times  a  day,  seldom  fails  to  keep 
the  bowels  regular,  and  this  can  be  continued  for  several  weeks, 
or  even  months  if  necessary  ;  but  whatever  is  used  it  must  be 
given  every  day  regularly  in  sufficient  dose  to  keep  the  bowels 
just  working  well.  The  good  effect  is  lost  if  aperients  are  only 
given  occasionally  when  the  bowels  have  already  become  consti- 
pated for  twenty-four  hours  or  more. 

Another  condition  which  profoundly  affects  the  nutrition  of 
an  infant  apart  from  the  feeding  is  congenital  heart  disease. 
The  '  blue  child  J,  with  its  grey  livid  skin,  blue-black  lips,  and 
cyanosed  tongue,  congested  conjunctival  vessels,  and  blue 
fingers  and  toes,  excites  no  surprise  when  it  fails  to  thrive  and 
remains  a  feeble  puny  infant.  Every  medical  man  recognizes 
it  at  once  as  a  case  of  congenital  heart  disease,  and  rightly  attri- 
butes its  poor  nourishment  to  this  cause,  but  the  cases  to  which 
I  wish  to  direct  attention  are  the  much  less  rare  ones  in  which 
congenital  heart  disease  is  not  associated  with  any  cyanosis 
whatever,  and  in  which  the  abnormal  heart  condition  is  usually 
discovered  only  more  or  less  accidentally  in  the  course  of  routine 
examination  of  the  chest.  I  have  seen  many  such  cases  in  which 
the  infant  had  been  under  treatment  for  wasting  :  there  was 
nothing  to  call  attention  to  the  heart,  and  it  had  been  assumed 
that  the  food  was  at  fault.  First  one  food  was  tried  and  then 
another,  but  still  the  infant  failed  to  thrive  :  examination  of 
the  heart  showed  signs  of  congenital  heart  disease.  Such  cases 
were  the  following  : 

Emily  H.,  aged  seven  weeks,  was  brought  for  wasting;  she  had  been  fed 
on  the  breast  for  four  weeks,  but  as  she  was  evidently  not  gaining  weight 
the  mother  was  advised  by  a  nurse  to  wean  the  child  :  this  was  done  and  • 


INFANTILE  MARASMUS  141 

the  infant  was  given  a  mixture  of  milk  and  barley-water,  but  still  failing  to 
make  progress  she  was  seen  by  a  medical  man,  who  finding  the  infant  much 
wasted  did  not  examine  the  chest,  but  concluded  that  it  was  '  an  ordinary 
marasmus '  due  to  digestive  trouble,  and  treated  it  as  such.  Subsequent 
examination  shewed  that  although  there  was  not  the  least  cyanosis,  and  nothing 
in  the  child's  aspect  to  suggest  cardiac  disease,  there  was  nevertheless  '  a  loud 
systolic  blowing  bruit  heard  all  over  mid- portion  of  heart,  loudest  in  third 
space  and  over  fourth  rib,  about  one  finger's  breadth  from  sternum  '. 

Ellen  T.,  aged  fourteen  months,  was  a  fine  child  at  birth  but  had  wasted 
much  since  one  month  old.  She  had  been  under  medical  care  and  various 
methods  of  feeding  had  been  tried,  without  success ;  she  had  become  much 
emaciated,  weighing  6  Ib.  5  ozs.  at  fourteen  months.  Examination  of  the 
chest  shewed  a  '  roaring  systolic  bruit  all  over  praecordium '  ;  its  maximum 
was  just  to  the  left  of  the  lower  end  of  the  sternum.  There  was  no  cyanosis, 
and  no  clubbing  of  fingers  :  on  inquiry  it  was  stated  that  at  times  the  child 
had  been  short  of  breath. 

I  could  quote  several  similar  cases,  but  these  may  suffice  to 
show  how  easy  it  is  to  overlook  the  underlying  cause  of  marasmus, 
where  congenital  heart  disease  produces  little  or  no  symptom 
beyond  the  wasting.  Why  the  abnormal  condition  of  the  heart 
in  these  cases  should  affect  nutrition  in  this  way  is  not  very 
obvious,  but  there  is,  at  any  rate,  a  strict  analogy  in  the  wasting 
which  is  so  often  a  striking  feature  in  the  acquired  heart  disease 
of  older  children  ;  the  child  with  chronic  rheumatic  endocarditis, 
whether  there  be  any  failure  of  compensation  or  not,  often 
wastes  considerably;  indeed,  it  is  no  uncommon  thing  for  a  child 
at  the  school  age  to  be  brought  to  hospital  solely  for  wasting, 
when  auscultation  shows  well-marked  endocarditis,  the  existence 
of  which  had  never  been  suspected  as  the  child  had  had  no 
symptom  of  rheumatism  beyond  occasional  'growing  pains '. 

Unfortunately  the  recognition  of  congenital  heart  disease  in  an 
infant  does  not  give  us  much  help  in  the  treatment  of  the  resulting 
marasmus,  but  it  does,  I  think,  assist  us  to  some  extent.  In  the 
first  place,  it  is  no  small  thing  to  know  the  cause  of  any  symptom 
which  we  are  called  upon  to  treat ;  such  knowledge  gives  confi- 
dence to  the  doctor,  and  the  knowledge  that  the  doctor  knows 
what  he  is  dealing  with  gives  confidence  to  the  parents  ;  it  is 
far  more  satisfactory  to  be  able  to  say  to  the  parents,  '  the 
wasting  in  your  infant  is  not  due  merely  to  indigestion  or  to  lack 
of  a  suitable  food  but  depends  upon  the  deformity  of  the  heart ,' 
than  to  try  food  after  food  with  unexplained  failure  whilst  the 
parents  are  disappointed  and  dissatisfied  at  what  they  suppose 
to  be  the  doctor's  lack  of  skill  in  '  hitting  off  '  the  particular  food 
required.  In  the  second  place,  recognition  of  congenital  heart 
disease  as  a  cause  of  marasmus  will  prevent  the  hasty  assumption 


142  COMMON  DISORDERS  OF  CHILDHOOD 

that  because  the  infant  is  not  thriving  the  food  must  at  once  be 
changed ;  in  the  first  case  mentioned  above  the  weaning  which  was 
done  upon  the  unskilled  advice  of  a  nurse  was  probably  the 
worst  possible  step  which  could  have  been  taken.  Undoubtedly 
something  may  be  done  for  these  cases  by  very  careful  dieting, 
particularly  in  the  direction  of  such  easily  assimilable  food  as 
asses'  milk,  or  peptonized  milk,  or  whey  with  raw  meat  juice,  or 
a  temporary  use  of  desiccated  milk,  if  human  milk  is  not  avail- 
able ;  but  the  results  are  likely  to  be  much  less  satisfactory  than 
in  the  infant  whose  marasmus  is  due  only  to  digestive  disorder.  . 

Another  cause  for  chronic  wasting  in  infancy,  and  indeed  also 
in  later  childhood,  which  is  apt  to  be  entirely  overlooked,  is 
chronic  pyelitis.  I  have  seen  cases  in  which  no  suspicion  had 
been  entertained  that  there  was  anything  beyond  impaired 
digestion,  when  examination  of  the  urine  revealed  pus-cells  and 
bacillus  coli,  and  suitable  treatment  of  the  urinary  affection  was 
followed  by  rapid  improvement  in  nutrition. 

1  Have  not  mentioned  tuberculosis  hitherto  amongst  the  causes 
of  infantile  marasmus,  because  it  should  occupy  a  place  in  the 
background  rather  than  in  the  foreground  of  the  clinical  picture 
of  infantile  marasmus.  It  is  one  of  the  rarest  of  causes  of  chronic 
wasting  in  infants  under  three  months  of  age,  and  under  six 
months  of  age  is  still  so  uncommon  that  it  should  never  be 
diagnosed  lightly.  One  hears  again  and  again  in  hospital  prac- 
tice of  '  consumptive  bowels  '  as  a  cause  of  infantile  marasmus, 
but  almost  always  the  condition  to  which  it  is  applied  is  one  of 
faulty  feeding,  and  is  not  related  in  any  way  to  tuberculosis  ; 
the  sooner  this  term  '  consumptive  bowels  '  is  dropped  the  better, 
for  it  too  often  confers  upon  the  results  of  improper  and  some- 
times careless  feeding  the  dignity  of  a  dispensation  of  Providence, 
and  the  mother  is  led  to  regard  as  unalterable  and  unavoidable 
the  sufferings  of  an  infant  which  might  easily  have  been  prevented, 
and  can  still  be  remedied  by  proper  feeding. 

Again,  one  sees  cases  in  which  'tuberculous  peritonitis'  has  been 
diagnosed  on  the  grounds  of  wasting  with  a  distended  abdomen  ; 
when  the  condition  is  entirely  due  to  bad  feeding,  generally  with 
starch-containing  food  at  too  early  an  age.  All  degrees  of  dis- 
tension of  the  abdomen  may  result  from  this  cause,  but  the 
characteristic  doughy  feeling  and  the  firmer  masses  of  caseous 
infiltration,  particularly  the  transverse  band  just  above  the 
umbilicus,  which  are  found  by  palpation  in  matted  tuberculous 
peritonitis,  and  the  shifting  dullness  of  fluid  in  the  peritoneal 
cavity  characteristic  of  the  ascitic  form  of  tuberculous  peritonitis, 


INFANTILE  MARASMUS  143 

are  entirely  lacking  in  the  cases  to  which  I  refer,  and  in  their 
absence  we  should  be  very  chary  of  diagnosing  'tuberculous  peri- 
tonitis ',  unless  indeed  there  be  strong  evidence  of  tubercle  in  the 
lungs  or  elsewhere.  In  this  connexion  it  may  be  mentioned  that 
when  tubercle  does  affect  infants  under  six  months  of  age,  it  very 
rarely  presents  the  clinical  aspect  of  tuberculous  peritonitis ;  it 
far  more  often  appears  as  an  acute  pulmonary  tuberculosis,  or  a 
tuberculous  meningitis  or  a  tuberculous  disease  of  the  ear  or  of 
the  bones.  Amongst  100  consecutive  cases  of  tuberculous  peri- 
tonitis proved  by  autopsy  at  the  Children's  Hospital,  I  found 
not  a  single  case  under  the  age  of  six  months,  and  only  eight 
under  the  age  of  one  year. 

Whilst,  however,  tuberculosis  is  only  a  very  rare  cause  of 
chronic  wasting  in  an  infant  under  six  months,  it  must  certainly 
not  be  taken  for  granted  in  any  particular  case  of  marasmus  that 
tubercle  can  be  excluded  merely  on  account  of  age  :  there  are 
cases  in  our  post  mortem  records  at  the  Children's  Hospital  where 
extensive  tuberculosis  was  present  in  infants  as  young  as  eight 
weeks,  and  this  emphasizes  the  need  for  very  careful  examination 
of  the  chest  as  well  as  the  abdomen  in  every  case  of  infantile 
marasmus.  And  indeed  the  examination  needs  to  be  careful, 
for  it  is  remarkable  how  much  gross  disease  may  be  present  in  an 
infant's  chest  without  producing  signs  sufficient  to  suggest  any 
serious  affection  of  the  lungs :  I  well  remember  a  case  of  infantile 
marasmus  which  I  treated  without  a  suspicion  that  it  was  other 
than  due  to  simple  digestive  failure  ;  the  infant  died,  and  autopsy 
revealed  extensive  tuberculous  caseation  in  the  lungs. 

Complications.  To  whatever  causes  marasmus  is  due  there 
are  certain  symptoms  and  complications  which  are  incidental 
to  it,  and  which  are  of  practical  importance  as  they  may 
call  for  special  treatment.  A  feeble  wasted  infant  falls  an 
easy  prey  to  local  infections,  whether  it  be  in  the  mouth 
where  thrush  (oidium  albicans)  quickly  gains  a  hold  and  may 
set  up  sufficient  inflammation  to  make  an  infant  unwilling 
to  suck,  and  so  may  interfere  seriously  with  the  already 
difficult  nutrition ;  or  in  the  ear,  where  an  acute  otitis  media, 
leading  to  perforation  of  the  drum  and  discharge  of  pus  ex- 
ternally, is  a  not  uncommon  complication  of  marasmus  ;  or 
in  the  skin,  where  angry-looking  *  boils  '  or  small  superficial 
abscesses,  the  result  of  a  local  staphylococcal  infection,  are  apt  to 
occur  when  wasting  is  much  prolonged  and  severe.  Probably  these 
are  to  some  extent  preventable  by  good  nursing ;  if  the  mouth  be 
wiped  put  three  or  four  times  daily  with  some  glycerine  of  borax, 


144  COMMON  DISORDERS  OF  CHILDHOOD 

and  the  teats  used  on  the  feeding-bottle  are  kept  in  a  weak 
solution  of  borax,  thrush  might  be  prevented,  and  it  seems  likely 
that  frequent  cleansing  of  the  mouth  may  also  reduce  the  liability 
to  infection  of  the  middle  ear  from  the  naso-pharynx.  The  skin 
infection  occurs  especially  on  parts  where,  in  addition  to  sweat  or 
to  the  contamination  of  incessant  urine,  there  is  local  pressure, 
so  that  infective  material  is  rubbed  into  the  skin  ;  in  this  way 
superficial  abscesses  are  specially  apt  to  occur  on  the  back  of  the 
head,  and  about  the  buttocks  and  thighs  ;  these  are  to  be  pre- 
vented by  scrupulous  cleanliness,  by  frequent  changes  of  bed- 
linen  and  diapers,  and  free  use  of  the  ordinary  antiseptic  dusting 
powder  (boric  acid  1  part,  zinc  oxide  2  parts,  starch  powder 
2  parts).  Where,  in  spite  of  all  precautions,  the  abscesses  con- 
tinue to  recur,  as  they  sometimes  do,  for  several  weeks,  an 
autogenous  vaccine  is  sometimes  very  effectual. 

The  temperature  in  an  emaciated  infant  often  remains  sub- 
normal for  days  together,  and  this  I  always  regard  as  an  un- 
satisfactory sign  ;  it  means  considerable  exhaustion,  and  should 
quicken  our  anxiety  to  improve  nutrition,  for  a  very  slight 
additional  disturbance,  such  as  a  'little  looseness  of  the  bowels  ', 
may  then  endanger  the  infant's  life.  I  think  it  is  sometimes  an 
indication  of  the  need  for  stimulants  in  small  doses  three  or  four 
times  a  day,  either  brandy  in  doses  of  5  or  10  minims  for  an  infant 
under  nine  months  old,  or  tincture  of  nux  vomica  for  one  minim. 

Another  symptom  of  grave  significance  is  the  appearance  of 
oedema  ;  this  is  by  no  means  uncommon  in  prolonged  marasmus  ; 
it  usually  becomes  definite  first  in  the  feet  and  on  the  back  of  the 
hands,  but  I  have  often  noticed  as  its  earliest  manifestation  a 
watery  translucent  appearance  of  the  skin  of  the  face,  which 
may  soon  develop  into  definite  puffiness  of  the  eyelids  just  as 
occurs  in  the  dropsy  of  renal  disease  ;  with  this  oedema  of  infantile 
marasmus  the  urine  shows  no  albumen  whatever.  There  are 
certain  practical  points  which  are  worthy  of  attention  in  con- 
nexion with  the  oedema.  A  sudden  rise  in  weight  in  a  marasmic 
infant  may  be  due  to  the  occurrence  of  this  dropsy,  and  so,  instead 
of  meaning  improvement,  may  be  of  evil  significance  ;  dropsy 
is  not  necessarily  of  fatal  omen  ;  I  have  seen  infants  with 
very  marked  oedema  ultimately  make  a  good  recovery.  Its 
pathology  is  very  uncertain,  but  on  the  view  that  one  factor  in  its 
causation  is  retention  of  chlorides  in  the  system,  it  is  unwise  to 
use  ordinary  saline  solution  for  irrigation  of  the  bowel  where 
oedema  is  present. 

I  am  chary  also  of  using  '  citrated  milk  ',  i.e.  milk  to  which 


INFANTILE  MARASMUS  145 

sodium  citrate  has  been  added  to  facilitate  curd  digestion,  in 
any  case  of  severe  marasmus,  especially  if  the  skin  of  the  face 
already  shows  the  translucent  appearance  mentioned  above,  for 
I  have  known  its  use  followed  by  the  rapid  onset  of  oedema . 

In  one  instance  a  marasmic  infant,  aged  about  four  months, 
the  child  of  a  medical  man,  was  given  an  unduly  large  quantity 
of  sodium  citrate,  10  grains  in  each  feed,  with  the  result  that 
after  a  day  or  two  the  limbs  became  cedematous  ;  the  citrate  was 
stopped,  and  the  oedema  disappeared  ;  the  citrate  was  then  tried 
again,  and  again  the  infant  became  cedematous  and  lost  its  oedema 
when  the  citrate  was  stopped.  In  another  instance,  the  father, 
a  medical  man,  informed  me  that  after  giving  sodium  citrate  in 
the  usual  dose,  the  infant's  face  became  puffy,  whereupon  he 
stopped  the  sodium  citrate  and  the  puffiness  subsided.  Such 
an  occurrence  must,  I  think,  be  very  exceptional,  for  I  have  used 
sodium  citrate  very  extensively,  and  have  only  come  across  these 
two  instances  ;  but  it  must  be  added  that  I  have  used  citrated 
milk  chiefly  for  infants  with  only  slight  difficulty  of  curd  diges- 
tion,— it  has  not  seemed  to  me  to  be  suitable  for  the  severer 
cases  of  digestive  difficulty  with  much  marasmus. 

Purpura,  like  oedema,  is  a  symptom  of  very  grave  significance 
in  an  infant  with  marasmus  ;  these  two  symptoms  are  sometimes 
found  together.  It  has  always  seemed  to  me  probable  that  both 
purpura  and  oedema  are  dependent  upon  degenerative  change 
in  the  vessel  walls,  which  in  its  turn  may  result  partly  from  the 
impoverished  character  of  the  blood  and  partly  from  feebleness 
of  circulation  ;  the  latter  seems  evident  in  many  such  cases  from 
the  blue  and  cold  condition  of  the  extremities  which  is  associated 
with  the  oedema  and  purpura.  The  purpura  occurs  most  often 
on  the  trunk  and  usually  in  the  form  of  small  petechial  spots 
which  might  easily  be  mistaken  for  flea-bites,  from  which  they 
differ  in  lacking  the  central  dark  point  of  puncture  which  is 
characteristic  of  the  flea-bites  ;  but  sometimes  it  occurs  as  large 
bruise-like  patches  which  might,  as  I  have  known,  raise  the 
question  of  ill-treatment  or  carelessness  in  nursing,  when  the 
condition  was  purely  due  to  the  marasmus,  and  no  blame  what- 
ever attached  to  the  attendants. 

Prognosis.  The  outlook  in  any  case  of  infantile  marasmus 
depends  to  a  large  extent  upon  its  cause.  I  have  already  men- 
tioned the  intractable  nature  of  some  cases  of  syphilitic  marasmus ; 
the  cases  with  congenital  heart  disease  are  necessarily  serious,  inas- 
much as  the  cause  cannot  be  removed,  but  if  the  earliest  months 
of  infancy  can  be  passed  in  safety,  these  cases  may  live  on  for 


146  COMMON  DISORDERS  OF  CHILDHOOD 

years,  frail  at  first,  but  gaining  strength  and  nutrition  as  they 
grow  older.  I  always  regard  as  highly  unsatisfactory  the  infant 
who  is  losing  weight  with  no  apparent  cause  ;  these  are  infants 
whose  feeding  is  in  every  way  perfectly  correct,  the  stools  are  of 
normal  appearance,  and  there  is  no  evidence  of  gross  disease  of 
any  sort ;  such  cases  will  often  fail  to  respond  to  any  treatment 
for  many  weeks,  or  even  months,  and  sometimes,  baffling  every 
attempt  to  improve  nutrition,  will  slowly  emaciate  and  die  ; 
whereas  the  infant  whose  feeding  has  been  obviously  unsuitable, 
and  whose  stools  show  clear  evidence  of  disturbed  digestion, 
even  though  he  be  extremely  emaciated,  will  generally  improve 
when  treated  with  some  weak  and  easily  assimilable  food. 

There  are  certain  risks  to  which  a  marasmic  infant  is  specially 
liable  ;  as  might  be  expected  in  cases  where  there  is  much  diffi- 
culty in  digestion,  there  is  a  special  proneness  to  diarrhoea,  and 
especially  during  the  summer  months  a  marasmic  infant  is  always 
in  danger  of  an  attack  of  diarrhoea,  which  may  speedily  terminate 
in  fatal  collapse  :  another  danger  is  bronchitis  or  broncho-pneu- 
monia ;  it  is  very  noticeable  how  slight  may  be  the  physical  signs 
of  pulmonary  disease,  and  how  little  may  be  the  effect  upon  the 
temperature  in  a  much-wasted  infant.  For  instance,  Henry  C., 
aged  five  months,  was  under  treatment  for  marasmus  ;  during 
the  fortnight  before  death  the  temperature  was  only  once  above 
100°,  and  during  the  six  days  before  death  it  was  subnormal  : 
there  had  been  no  sign  in  the  lungs  at  any  time  except  occasional 
crepitation,  and  yet  post  mortem  examination  showed  in  addition 
to  the  usual  patches  of  pulmonary  collapse  definite  patches  of 
broncho-pneumonia  in  both  lower  lobes. 

There  is  another  possibility  of  which  it  is  well  to  be  forewarned, 
namely,  sudden  death.  I  do  not  mean  by  this  instantaneous 
death,  but  rather  a  sudden  collapse  which  ends  fatally,  perhaps 
in  half  an  hour  or  in  a  few  minutes.  In  some  cases  this  sudden 
termination  comes  with  a  convulsion,  but  in  others  the  infant's 
condition  has  appeared  to  be  no  worse  than  usual,  and  the  end 
comes  so  quietly  and  unexpectedly  that  the  infant  may  be  found 
dead  in  his  cot  where  he  was  left  but  a  few  minutes  before  in  no 
apparent  immediate  danger  of  death .  This  has  happened  several 
times  in  my  experience,  usually  in  cases  of  long  standing  and 
considerable  marasmus,  where  it  was  evident  that  the  infant  was 
very  feeble,  although  there  was  no  special  reason  for  expecting 
a  fatal  termination  at  that  particular  time. 


INFANTILE  MARASMUS  147 

Treatment 

The  treatment  of  infantile  marasmus  embraces  the  whole 
subject  of  infant-feeding  in  addition  to  the  treatment  of  the 
various  non-dietetic  causes  which  I  have  mentioned  above. 
I  cannot  repeat  here  all  that  I  have  already  said  as  to  infant- 
feeding,  but  I  will  emphasize  some  broad  principles  of  practical 
importance.  When  marasmus  is  dependent  upon  digestive 
difficulty,  a  weak  food  is  commonly  the  right  food  ;  it  is  often 
wise  to  start  afresh  with  veal  broth  only  or  chicken  broth,  to 
which  milk  sugar  may  be  added  in  the  proportion  of  a  teaspoonful 
in  every  3  ounces  ;  after  a  day  or  two  milk  freely  diluted  and 
peptonized  may  be  substituted  for  the  broth  at  alternate  feeds. 
A  more  readily  assimilable  food  where  even  the  weak  peptonized 
cow's  milk  cannot  be  assimilated  is  ass's  milk,  and  it  is  often 
very  remarkable  how  well  a  feeble  marasmic  infant  will  thrive  for 
a  time  on  ass's  milk  (given  undiluted,  for  its  extreme  weakness 
wherein  lies  a  large  part  of  its  virtue  calls  for  no  further  dilution). 
Where  ass's  milk  is  impracticable  on  account  of  expense,  one 
of  the  various  brands  of  plain  desiccated  milk  is  sometimes 
successful,  and  in  any  case  may  be  useful  as  a  temporary  food 
when  it  is  decided  to  try  something  a  little  stronger  than  ass's 
milk  or  much  diluted  cow's  milk.  If  fresh  milk  in  various  dilu- 
tions has  already  failed,  a  much  diluted  peptonized  milk  is  often 
the  quickest  method  of  overcoming  the  difficulty. 

Fats  are  very  commonly  ill-tolerated  by  marasmic  infants  ; 
the  addition  of  cream,  therefore,  is  very  often  best  avoided  alto- 
gether, and  if  any  is  used  it  should  be  given  in  very  small  quan- 
tities :  for  the  same  reason  cod-liver  oil  is  often  quite  unsuitable 
for  the  marasmic  infant  ;  it  retards  digestion  and  aggravates  the 
trouble. 

Lastly,  in  connexion  with  diet  I  would  insist  upon  the  need 
for  slowness  and  deliberateness  in  increasing  the  strength  of 
the  food.  I  know  only  too  well  how  difficult  it  is  to  resist  the 
temptation  to  make  the  milk  a  little  stronger  as  the  infant  seems 
to  be  assimilating  better  and  the  weight  is  rising  so  slowly  ;  but 
again  and  again  I  have  had  to  repent  of  yielding  to  this  tempta- 
tion ;  the  parents  have  urged  it,  the  nurse  has  urged  it,  and  in 
the  hope  of  hastening  the  slow  but  definite  progress,  we  have 
increased  the  strength  or  the  amount  of  the  milk  mixture,  or 
added  some  cream,  or  given  some  additional  food,  and  what  was 
the  result  ?  Instead  of  a  greater  gain,  the  next  weighing  has 
shown  a  loss,  and  perchance  before  we  could  show  any  further 

L2 


148          COMMON  DISORDERS  OF  CHILDHOOD 

progress,  it  has  been  necessary  to  go  back  to  some  mixture  even 
weaker  than  the  original.  So  long  as  an  infant  whose  weight  has 
previously  been  stationary  or  falling  is  showing  even  a  small 
progress  in  weight  on  some  particular  feeding,  it  is  usually  poor 
economy  to  make  any  change  ;  when  the  weight  no  longer  rises, 
if  the  stools  show  that  the  food  is  being  digested,  it  may  be  wise 
to  increase  the  quantity  or  the  strength  of  the  food  ;  or  it  may 
be  necessary  to  make  some  other  change  ;  but  so  long  as  the 
weight  is  rising  and  the  infant  seems  to  be  improving,  I  am 
convinced  that  the  soundest  principle  is  to  '  leave  \vell  alone  '. 

I  turn  now  to  another  item  in  the  treatment  of  these  cases, 
and  one  which  I  believe  to  be  of  no  small  importance,  namely, 
warmth.  In  these  days  of  open-air  treatment,  excellent  under 
proper  conditions,  but  carried,  as  it  often  seems  to  me,  to  a 
dangerous  absurdity,  people  are  apt  to  forget  how  vitally  essential 
warmth  is  to  feeble  infants.  No  one  appreciates  more  than  I  do 
the  value  of  fresh  air  for  infants  ;  there  can,  I  think,  be  no  doubt 
that  in  some  cases  of  marasmus  the  infant's  digestion  and  nutrition 
improve  if  he  can  be  taken  out  daily  in  a  suitable  climate  ;  but 
to  take  a  feeble  marasmic  infant  out  on  a  cold  raw  day,  so  that 
the  child  comes  in  with  its  hands  and  feet  cold  and  blue,  or  to 
keep  him  lying  in  a  room  with  the  window  wide  open,  and  the  room 
warmed  with  difficulty  to  60°  F.,  is  seriously  to  diminish  the 
infant's  chance  of  recovery.  If  any  one  doubts  that  warmth  is 
of  more  importance  to  a  puny  wasted  infant  than  open  air  let 
him  gain  some  experience  of  the  effects  of  the  incubator.  I  sup- 
pose next  to  breast-feeding  there  is  nothing  that  contributes 
more  to  save  the  life  of  an  infant  born  very  feeble  or  premature, 
than  the  incubator,  and  for  marasmic  infants  also  it  has  been 
found  of  the  greatest  value.  The  supply  of  fresh  air  in  an  incu- 
bator is  reduced  to  a  minimum,  while  the  temperature  is  kept  at 
80°  to  90°  F.  No  one  doubts  that  the  value  of  the  incubator  lies 
in  its  warmth,  which  saves  the  energy  and  so  maintains  the 
vitality  of  the  infant. 

Infants  stand  cold  badly,  and  much  worse  when  they  are 
already  enfeebled  by  illness  ;  I  have  never  forgotten  the  reproof 
which  an  aged  practitioner  administered  to  me  in  the  days  when 
1  was  newly  qualified,  and  on  a  cold  day  had  a  sick  infant  stripped 
while  I  examined  it  all  over  ;  he  told  me  in  effect  that  more  harm 
would  result  from  the  exposure  of  the  infant  than  good  from  my 
examination  :  and  though  I  would  advise  no  one  to  omit  careful 
examination  of  any  patient  he  is  called  upon  to  treat,  I  recognize 
that  there  are  conditions  in  which  all  needful  examination  can  be 


INFANTILE  MARASMUS  140 

made  and  ought  to  be  made  with  a  minimum  of  exposure,  and 
that  one  of  these  is  infantile  marasmus .  There  is  a  great  tendency 
at  all  ages  to  coldness  of  extremities  where  there  is  digestive  dis- 
order, but  in  the  infant  especially  this  is  a  very  striking  feature, 
and  the  marasmic  infant,  unless  the  utmost  care  is  taken,  has 
often  both  hands  and  feet  livid  with  cold,  showing  that  the 
circulation  is  feeble,  and  indicating  a  condition  of  depressed 
vitality  which  aggravates  the  difficulty  of  assimilation.  In  the 
case  of  severe  infantile  marasmus,  I  would  have  the  tem- 
perature of  the  room  kept  at  65°  F.,  and  there  should  be  hot 
water-bottles  in  its  cot  (with  proper  precaution,  of  course,  to 
prevent  the  hot  water-bottle  touching  and  scalding  the  infant), 
and  particular  care  should  be  taken  that  the  arms  and  legs  are 
covered  with  some  warm  clothing  down  to  the  wrists  and  ankles, 
indoors  as  well  as  outdoors,  for  it  is  much  easier  to  keep  the  hands 
and  feet  warm  if  there  is  some  covering  in  the  form  of  a  woollen 
sleeve  and  gaiter  for  the  limbs.  In  warm  summer  weather  by 
all  means  let  the  marasmic  infant  go  out  daily,  but  in  winter 
there  are  times  when,  in  my  opinion,  it  is  wiser  to  keep  the  infant 
indoors,  and  to  secure  fresh  air  by  change  of  rooms,  one  room 
being  thoroughly  ventilated  by  widely  opening  the  window  and 
then  re-warmed,  while  another  warm  room  is  in  use.  If  the 
extremities  still  remain  cold,  they  should  be  rubbed  with  gentle 
massage  twice  a  day. 

I  have  already  referred  to  the  important  part  played  by  consti- 
pation in  preventing  gain  of  weight  ;  and  have  described  how 
this  may  be  remedied  :  here  I  will  only  reiterate  what  I  have 
already  said,  that  an  essential  part  of  the  treatment  of  infan- 
tile marasmus  may  be,  and  often  is,  the  treatment  of  chronic 
constipation. 

Lastly,  a  word  with  regard  to  drugs,  which  may  directly  affect 
nutrition.  Cod-liver  oil  in  my  experience  is  very  rarely  useful  in 
the  treatment  of  infantile  marasmus ;  more  useful  is  malt  extract, 
which  may  be  used  as  a  sweetening  agent  instead  of  cane 
sugar  or  milk  sugar,  and  seems  sometimes  to  exert  a  distinctly 
beneficial  effect  in  promoting  nutrition ;  but  malt  is  not  to  be 
given  where  there  is  looseness  of  the  bowels  or  much  flatulence, 
and  in  any  case  is  to  be  used  in  small  quantity,  a  very  small 
half-tea-spoonful  to  a  three-ounce  feed  three  or  four  times  a  day. 

Some  very  interesting  observations  on  the  use  of  thyroid  in 
infantile  marasmus  have  been  recorded  by  Dr.  J.  W.  Simpson  * 
of  Edinburgh,  who  found  that  in  some  cases  where  there  was 

1  Scot.  Med.  and  Surg.  Journ.,  Dec.,  1906,  p.  504. 


150  COMMON  DISORDERS  OF  CHILDHOOD 

failure  to  thrive  in  spite  of  careful  feeding,  the  administration 
to  infants  of  three  and  four  months  old  of  J  to  J  grain  of  thyroid 
extract  given  three  times  daily  (Burroughs  &  Wellcome's  tabloids 
were  used),  without  any  alteration  of  the  diet,  was  followed  by 
a  more  or  less  steady  rise  in  weight.  In  some  cases  in  which  I 
have  tried  this  method  of  treatment  there  has  been  a  gain  of 
weight  where  hitherto  little  or  no  progress  had  been  made  ;  but 
bearing  in  mind  the  occasional  ill  effects  of  thyroid,  I  have  con- 
tented myself  with  using  the  doses  mentioned  only  once  or  twice 
a  day,. so  that  the  good  results  which  I  have  obtained  may  not 
fairly  represent  the  full  extent  of  its  usefulness. 

The  old-fashioned  practice,  but  I  think  a  good  one  apart  from 
its  'messiness',  is  to  rub  the  infant  with  oil,  preferably  neat's- 
foot  oil,  which  is  less  odoriferous  than  cod-liver  oil.  I  am  very 
doubtful  how  much,  if  any,  of  the  oil  can  be  absorbed  this  way  ; 
but  it  is  certain  that  oiling  the  skin  serves  to  maintain  the  warmth 
of  the  infant,  and  if  it  does  nothing  else,  it  is  good  on  this  account, 


CHAPTER  XI 
HYPERTROPHY  OP  THE   PYLORUS  IN  INFANTS 

THE  importance  of  early  diagnosis  and  of  a  clear  understanding 
of  the  lines  of  treatment  in  the  so-called  '  congenital  hypertrophy ' 
or  *  hypertrophic  stenosis  '  of  the  pylorus  in  infants  has  become 
increasingly  evident  within  the  past  few  years,  for  it  has  been 
shown  that  what  was  formerly  regarded  as  an  incurable  and 
inevitably  fatal  condition  is,  sometimes  at  least,  amenable  to 
treatment.  Judging  from  my  own  experience  I  should  say 
that  many,  perhaps  even  a  majority  of  these  cases,  recover 
completely  if  only  they  are  recognized  sufficiently  early  and 
subjected  to  suitable  treatment.  I  propose  to  deal  chiefly  with 
these  two  points,  diagnosis  and  treatment,  and  my  remarks  will 
be  based  upon  forty-two  cases  which  have  been  under  my  own 
personal  observation  either  in  hospital  practice  or  in  private 
consultation. 

The  salient  features  of  the  disorder  are  briefly  these  :  an 
infant  under  the  age  of  four  months  has  been  vomiting  his  food. 
The  vomiting  began  at  the  age  of  three  or  four  weeks  and  for 
the  first  week  or  so  was  thought  to  be  no  more  than  a  little 
indigestion  might  account  for.  But  it  persisted  and  soon  began 
to  attract  notice  more  by  its  persistency  than  by  its  frequency, 
for  it  occurred  perhaps  only  two  or  three  times  in  the  twenty-four 
hours.  Then  the  food  was  thought  to  be  at  fault  and  change 
after  change  was  made  in  the  feeding,  each  time  perhaps  with 
temporary  diminution  of  the  vomiting.  But  still  the  vomiting 
persisted  and  at  times  was  noticed  to  be  so  sudden,  copious, 
and  forcible  that  the  vomit  was  shot  out  a  foot  or  more  from 
the  mouth  and  perhaps  through  the  nostrils  as  well. 
.  Since  the  vomiting  began  the  bowels  have  been  costive,  perhaps 
only  opened  with  enemata.  And  now  the  infant  is  wasting  to 
a  marked  degree  and  perhaps  it  is  this  wasting  rather  than  any 
alarm  at  the  vomiting  which  leads  the  parents  to  seek  medical 
advice.  Such  is  the  history  which  leads  one  to  examine  specially 
for  the  two  characteristic  signs — visible  and  very  marked  peris- 
talsis of  the  stomach  and  a  palpable  thickening  of  the  pylorus — 
upon  which  the  diagnosis  rests. 


152          COMMON  DISORDERS  OF  CHILDHOOD 

Diagnosis.  Having  said  thus  much  by  way  of  general  descrip- 
tion I  shall  proceed  to  consider  in  detail  the  various  points  which 
bear  upon  diagnosis.  But  first  let  me  emphasize  the  fact  that  no 
symptoms  or  combination  of  symptoms,  however  suggestive  they 
may  be,  are  sufficient  for  the  diagnosis  of  congenital  hypertrophy 
of  the  pylorus  in  the  absence  of  the  two  characteristic  signs  which 
I  have  already  mentioned.  No  doubt  such  a  history  as  I  have 
outlined  would  be  strong  ground  for  suspecting  the  existence 
of  this  disease  and  the  suspicion  might  or  might  not  prove 
correct,  but  where  treatment,  especially  operative  treatment,  is  so 
vitally  serious  a  matter,  we  have  no  right  to  be  satisfied  with 
anything  short  of  certainty  and  this  depends  upon  the  presence 
of  well-marked  visible  peristalsis  of  the  stomach  associated  with 
palpable  thickening  of  the  pylorus. 

Sex.  No  great  stress  is  to  be  laid  on  sex  in  the  diagnosis  of 
this  disease,  but  none  the  less  the  remarkable  predominance 
of  males  is  to  be  remembered.  Out  of  forty-two  cases  in  which 
the  point  was  noted  thirty-five  were  males.  Not  only  is  this 
disorder  very  much  commoner  in  boys  than  in  girls,  but  when 
it  does  occur  in  girls  it  is,  I  think,  usually  of  milder  degree. 

Place  in  family.  Hardly  less  remarkable  than  the  sex  incidence 
is  the  tendency  for  this  disorder  to  affect  first  children  in  a  family 
rather  than  later  ones.  Out  of  thirty-eight  cases  in  which  I  noted 
the  position  in  family  no  less  than  eighteen  were  firstborn. 

Family  incidence.  The  question  is  often  asked,  when  one  case 
has  occurred  in  a  family,  especially  in  the  first  born,  whether  the 
subsequent  children  are  likely  to  suffer  from  the  same  condition. 
Formerly  I  had  always  replied  in  the  negative,  but  in  recent  years, 
amongst  a  large  number  of  cases  subsequent  to  the  forty- two 
mentioned  above,  I  have  seen  three  instances  of  two  children  in 
a  family  showing  congenital  hypertrophy  of  the  pylorus.  In 
two  of  these  the  children  affected  were  the  first  and  second  of  the 
family  ;  in  one  they  were  the  third  and  fourth.  The  rarity  of 
this  family  incidence  is  evident,  from  the  fact  that  only  these 
three  instances  were  observed  in  ninety-one  families  in  which 
the  condition  occurred. 

Age.  The  age  incidence  is  of  importance.  On  this  point  some 
misapprehension  has  arisen  out  of  the  nomenclature  of  the 
disease.  More  than  once  when  I  have  seen  these  cases  in  con- 
sultation and  have  spoken  of  the  condition  as  '  congenital  hyper- 
trophy of  the  pylorus  '  I  have  been  met  with  the  objection, 
'  But  this  is  impossible,  for  the  baby  was  perfectly  well  until  it 
was  four  or  five  weeks  old.  How  can  the  condition  therefore  be 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS      153 

congenital  ?  '  Let  rne  say  at  once  that  whatever  may  be  the 
correct  view  as  to  the  pathogeny  of  the  disease,  whether  it  be 
a  congenital  hyperplasia  of  the  muscular  tissue  of  the  pylorus 
or  a  congenital  lack  of  co-ordination  with  resulting  spasm  and 
thence  hypertrophy  as  Dr.  John  Thomson  has  suggested,  or 
whether  the  hypertrophy  be  entirely  of  post-natal  development, 
the  symptoms  are  very  rarely  congenital. 

Of  thirty-eight  cases  only  one  began  to  vomit  within  twenty- 
four  hours  after  birth,  and  six  others  within  the  first  week. 

The  term  'congenital  ',  therefore,  is  misleading,  and  although 
I  retain  it  as  perhaps  representing  a  correct  theory  there  is  no 
proof  that  all  cases  are  congenital  in  origin.  That  the  obstruction 
is  primarily  due  to  spasm  of  the  pylorus  I  regard  as  certain, 
and  to  me  it  seems  most  probable  that  the  hypertrophy  also  is 
the  result  of  spasm  ;  how  long  this  hypertrophy  may  take  to 
develop  we  cannot  tell ;  but  so  far  as  the  spasm  is  concerned 
I  see  no  reason  why  it  may  not,  like  the  disturbance  of  co-ordina- 
tion which  is  evident  in  the  hiccough  which  babies  so  easily  get, 
or  in  the  stuttering  which  is  almost  physiological  in  the  young 
child  who  is  learning  to  talk,  be  due  in  some  cases  to  irregularity  of 
function  beginning  after  birth ;  may  not  the  nervous  mechanism 
of  the  stomach  be  as  easily  disturbed  as  the  nervous  mechanism 
of  speech,  particularly  in  the  early  days  before  function  has 
become  stereotyped  by  usage  ?  Perhaps,  indeed,  the  analogy 
may  be  closer  than  this  and  the  tonic  spasms  of  the  muscles  of 
speech  find  a  counterpart  in  a  stuttering  stomach.  But,  however 
this  may  be,  the  point  I  would  emphasize  is  this,  that  the 
symptoms  very  rarely  date  from  birth ;  of  my  own  cases,  twenty- 
eight  certainly  and  one  other  probably,  dated  symptoms  (vomit- 
ing) from  before  the  end  of  the  fourth  week  ;  in  the  remaining 
cases  vomiting  began  between  the  fourth  and  the  end  of  the 
seventh  week.  It  is  not  always  possible  to  be  certain  of  the 
date  of  onset,  for  slight  regurgitation  which  the  parents  have 
regarded  as  normal  and  which  may  of  course  be  so  in  early 
infancy  has  sometimes  been  present  before  the  definitely  abnormal 
vomiting  began.  I  have  never  seen  a  case  in  which  vomiting 
began  later  than  the  seventh  week,  but  onset  at  least  as  late  as 
the  ninth  week  has  been  recorded. 

Obviously  these  facts  have  an  important  bearing  on  diagnosis. 
For  example,  in  the  case  of  an  infant  aged  nine  months  who  had 
been  vomiting  persistently  for  three  weeks  a  diagnosis  of  con- 
genital hypertrophy  of  the  pylorus  was  suggested,  but  in  such 
a  case  the  age  alone,  apart  from  various  other  indications,  was 


154  COMMON  DISORDERS  OF  CHILDHOOD 

almost  if  not  quite  sufficient  to  exclude  this  condition.  I  am 
aware  that  the  name  *  congenital  hypertrophy  of  the  pylorus  ' 
has  been  applied  to  a  condition  supposed  by  some  to  be  identical 
in  the  adult,  and  if  the  disease  is  primarily  spasmodic  it  is 
conceivable  that  it  might  begin  at  any  period  of  life,  but  so 
far  as  children  are  concerned  the  onset  of  the  disease  is  in- 
variably before  the  age  of  three  months,  and  unless  vigorous 
measures  are  adopted  death  usually  results  before  the  end  of  the 
fourth  month. 

Vomiting.  I  would  insist,  first,  with  regard  to  vomiting  that 
however  persistent  and  chronic  it  may  be,  it  is  never  per  se 
proof  that  an  infant  has  congenital  hypertrophy  of  the  pylorus. 
No  doubt  it  is  the  symptom  which  in  most  of  the  cases  has 
first  suggested  the  presence  of  this  condition,  but  it  is  only 
when  it  is  associated  with  the  characteristic  signs,  the  visible 
peristalsis  of  the  stomach  and  the  palpable  thickening  of  the 
pylorus,  that  it  becomes  diagnostic. 

Apart  from  its  persistency  the  vomiting  of  congenital  hyper- 
trophy of  the  pylorus  has  certain  features  which  are  suggestive 
of  the  disease.  1.  Its  forcible  character.  A  mother  informed 
me  recently  that  her  child  with  this  condition  '  pumped  up  ' 
his  food  suddenly  with  such  force  that  it  shot  more  than  two 
feet  from  the  mouth.  Her  account  may  have  been  exaggerated 
but  it  may  serve  to  illustrate  my  point.  She  also  mentioned 
another  frequent  result  of  this  forcible  expulsion  that  the  vomit 
comes  through  the  nostrils  also.  2.  Its  occurrence  in  an  infant 
who  has  been  carefully  fed ;  particularly  when,  as  happened  in  at 
least  sixteen  out  of  my  forty-two  cases,  the  infant  was  being 
fed  by  the  breast  only.  3.  Its  persistence  in  spite  of  such 
alterations  of  feeding  and  such  general  treatment  as  will  usually 
control  the  vomiting  of  dyspeptic  conditions.  4.  Its  large 
amount  showing  that  the  vomit  represents  more  than  one  feed, 
perhaps  the  accumulation  of  several  feeds  in  the  dilated  stomach. 
When  vomiting  in  an  infant  under  four  months  has  these  features 
there  is  very  strong  ground  for  suspecting  the  presence  of  con- 
genital hypertrophy  of  the  pylorus,  but  each  of  the  four,  including 
the  forcing  of  vomit  through  the  nose,  has  occurred  within  my 
own  experience  also  in  cases  in  which  there  was  no  reason  to 
suppose  the  presence  of  pyloric  obstruction. 

I  have  referred  incidentally  to  the  fact  that  the  vomiting  is 
sometimes  distinctly  influenced  by  diet.  In  most  cases  the 
improvement  is  only  short-lived,  perhaps  for  a  day  or  two, 
but  I  have  known  this  to  cause  error  in  diagnosis  ;  the  temporary 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS   155 

improvement  with  each  change  of  diet  was  taken  to  indicate 
that  the  vomiting  must,  be  dependent  simply  on  some  fault  in 
the  feeding.  The  observation  was  correct,  the  inference  was 
wrong. 

Naturally  much  stress  has  been  laid  upon  vomiting  as  a  pro- 
minent symptom  of  the  disease,  but  it  must  be  remembered 
that  the  vomiting  is  not  necessarily  frequent  ;  it  may  be  only 
once  or  twice  in  the  twenty-four  hours.  There  may  even  be 
an  interval  of  twenty-four  hours  in  which  there  is  no  vomiting. 
No  doubt  this  depends  to  some  extent  upon  the  degree  of  dilata- 
tion of  the  stomach  which  has  occurred,  but  I  suspect  that  it 
means  more  and  points  to  variation  in  the  degree  of  obstruction 
a  variation  which  seems  most  naturally  explained  by  varying 
degrees  of  spasm  of  the  pylorus  at  different  times. 

As  the  result,  no  doubt,  of  the  infrequency  of  vomiting  in 
some  cases  this  symptom  has  sometimes  attracted  much  less 
attention  than  the  wasting  which  accompanies  it,  and  in  two 
of  my  cases  at  least  the  vomiting  was  thought  scarcely  worth 
mentioning,  the  condition  being  regarded  as  simply  obstinate 
infantile  marasmus.  In  one  of  these  both  the  medical  attendant 
and  the  nurse  stated  that  the  vomiting  was  c  nothing  particular  ', 
but  on  cross- questioning  one  found  that  the  vomiting,  although 
it  occurred  sometimes  only  once  in  the  day,  was  often  more  in 
amount  than  one  or  even  two  feeds  and  that  it  was  shot  out  with 
unusual  force  through  the  mouth  and  nose. 

Constipation.  The  association  of  chronic  constipation  with 
this  persistent  vomiting  is  of  some  importance  in  diagnosis,  for 
where  chronic  vomiting  in  an  infant  at  this  age  is  dependent 
upon  faulty  diet  it  much  more  often  keeps  company  with  loose 
or  at  least  unhealthy  slimy  stools  and  frequent  action  of  the 
bowels.  But  there  are  exceptions  in  both  ways.  I  have  seen 
congenital  hypertrophy  of  the  pylorus  with  loose  and  frequent 
stools  and  I  have  notes  of  chronic  vomiting  with  constipation 
in  infants  who  showed  ho  evidence  of  congenital  hypertrophy 
of  the  pylorus.  Nevertheless,  I  think  it  is  a  useful  rule  to  examine 
carefully  for  congenital  hypertrophy  of  the  pylorus  in  all  cases 
where  chronic  constipation  is  associated  with  persistent  vomiting 
in  an  infant  under  the  age  of  four  months. 

Wasting.  This,  as  already  mentioned,  may  be  the  symptom 
which  has  attracted  most  attention  and  I  only  mention  it  again 
to  emphasize  the  possibility  of  mistaking  the  case  for  one  of 
marasmus  from  faulty  feeding.  I  suppose  there  can  be  no  doubt 
that  until  recently  these  cases  of  pyloric  obstruction  have  mostly 


156  COMMON  DISORDERS  OF  CHILDHOOD 

passed  for  the  common  marasmus  of  infancy  or  have  been 
attributed  to  unsuitable  feeding ;  and  the  mistake  is  easy  enough 
to  make,  for  the  history  may  differ  but  little  if  at  all  from  that 
of  many  a  commonplace  case  of  infantile  wasting. 

The  two  characteristic  signs.  My  own  experience  leads  me  to 
think  that  the  condition  is  overlooked  largely  because  the 
method  of  examination  for  the  two  characteristic  signs  is  not 
generally  understood.  In  several  of  my  cases  the  presence  of 
this  disease  had  been  suspected,  but  as  the  characteristic  signs 
were  supposed  to  be  absent  no  diagnosis  had  been  made,  whereas 
when  the  case  was  examined  under  the  requisite  conditions 
the  signs  were  shown  to  be  extremely  marked.  In  the  first 
place  it  must  be  recognized  that  these  two  signs  are  only  present 
at  intervals,  so  that  cursory  inspection  and  palpation  of  the 
abdomen  may  and  almost  always  do  result  in  overlooking  the 
condition  altogether. 

Patient  examination  occupying  perhaps  ten  or  fifteen  minutes 
may  be  necessary  before  the  signs  can  be  elicited,  and  occasionally, 
though  I  think  rarely  if  proper  precautions  are  taken,  examination 
on  a  second  occasion  may  be  required.  The  reason  of  this  is 
simple  :  both  signs  depend  upon  active  contraction  of  the 
muscular  wall  of  the  stomach,  and  just  as  happens  with  the 
uterus  during  labour,  at  one  time  it  is  easily  stimulated  to 
activity  and  at  another  it  remains  inactive  in  spite  of  all  efforts 
to  excite  contraction.  The  second  point  to  be  considered  is  the 
time  at  which  the  examination  is  to  be  made.  I  have  almost 
always  found  that  the  abdomen  has  been  examined  without 
any  reference  to  the  time  at  which  the  infant  was  last  fed,  and 
the  result  has  been  failure  to  detect  the  characteristic  signs. 
The  abdomen  should  be  examined  immediately  after  the  infant 
has  been  fed.  It  is  at  this  time,  and  apparently  in  some  cases 
hardly  at  all  except  at  this  time,  that  the  abnormal  peristalsis 
of  the  stomach  is  to  be  seen,  and  it  is  during  peristalsis  that  the 
thickened  pylorus  is  to  be  felt.  I  think  it  is  well  also  to  watch 
the  abdomen  during  the  taking  of  the  feed  ;  sometimes  after 
part  of  the  feed  has  been  taken  vigorous  peristalsis  of  the  stomach 
commences.  I  would  add  as  a  third  counsel,  and  one  particularly 
applicable  to  these  cases,  that  warm  hands  are  no  unimportant 
factor  in  the  palpation  of  an  infant's  abdomen. 

Visible  peristalsis  of  the  stomach.  Sometimes  spontaneously, 
sometimes  only  after  repeated  stroking  or  gentle  kneading  of 
the  epigastrium,  a  rounded  lump  varying  in  size  from  half  a  large 
walnut  to  half  a  Tangerine  orange  rises  at  the  left  costal  margin 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS      157 

and  passes  very  slowly  across  the  epigastrium  slightly  down- 
wards towards  the  right  hypochondrium.  Before  this  lump  has 
yet  reached  the  mid-line  a  second  similar  lump  is  already  rising 
at  the  left  costal  margin,  and  sometimes  before  these  two  have 
yet  disappeared  in  the  right  hypochondrium  a  third  is  already 
appearing  on  the  left  side,  so  that  at  one  time  three  bulging 
eminences  are  seen  like  a  chain  of  hills  extending  across  the 
epigastrium.  They  move  so  slowly  that  at  times  they  may 
even  be  seen  to  pause  altogether,  but  each  in  turn  fades  away 
in  the  right  hypochondrium,  and  a  succession  of  these  bulgings 
may  continue  to  appear  for  one  or  two  minutes.  This  peristaltic 
wave  is  so  gross  that  it  could  easily  be  seen  at  a  distance  of  two 
or  three  yards,  and  in  two  of  my  cases  the  mother  or  nurse  had 
already  noticed  it.  Upon  this  grossness  I  lay  some  stress  for  it 
is  of  importance  in  the  diagnosis. 

Two  questions  obviously  arise  with  regard  to  the  diagnostic 
significance  of  the  sign  :  (1)  Can  any  other  movement  be  mis- 
taken for  this  peristalsis  of  the  stomach  ?  (2)  Does  visible 
peristalsis  of  the  stomach  occur  in  infants  apart  from  this 
disease  ? 

There  are  two  movements  which  I  have  known  to  cause 
doubt  in  diagnosis.  One  is  the  voluntary  irregular  contraction 
of  the  muscles  of  the  abdominal  wall  which  in  an  infant '  squirm- 
ing '  about  as  an  infant  often  will,  especially  when  the  abdomen 
is  exposed  for  observation,  may  cause  local  bulgings  in  the 
hypochondrium  or  epigastrium,  but  these  although  they  may 
deceive  the  unwary  ought  not  to  cause  any  real  difficulty,  for  the 
bulging  produced  thus  does  not  travel  transversely  across  the 
epigastrium,  nor  does  it  appear  and  disappear  with  the  slow, 
even  regularity  of  the  gastric  peristalsis  ;  moreover,  it  is  definitely 
coincident  with  voluntary  muscular  effort.  The  other  movement 
is  much  more  difficult  to  distinguish  ;  it  is  peristalsis  of  the 
transverse  colon  in  certain  cases  where,  owing  to  an  unusual 
arrangement  of  parts,  peristalsis  is  from  left  to  right  in  a  portion 
of  the  colon.  In  an  infant  who  was  taken  to  King's  College 
Hospital  with  vomiting  at  the  age  of  five  weeks  I  found  definite 
but  very  slight  peristalsis  passing  from  left  to  right  in  the  epigas- 
trium ;  the  pylorus  could  not  be  felt  and  the  peristalsis  was  so 
slight  that  I  doubted  its  significance.  The  infant  looked  ill  and 
was  admitted  and  died  with  broncho-pneumonia  and  pleurisy. 
It  was  found  that  the  transverse  colon  passed  across  from  the 
hepatic  flexure  towards  the  left  hypochondrium  and  then  turned 
back  upon  itself  into  the  right  hypochondrium  before  passing 


158  COMMON  DISORDERS  OF  CHILDHOOD 

finally  across  the  epigastrium  to  the  splenic  flexure  ;  it  formed, 
therefore,  an  S-shaped  loop  in  one  part  of  which,  of  course, 
the  peristalsis  would  travel  from  left  to  right.  In  this  case  the 
feeble  character  of  the  peristalsis  had  suggested  during  life  that 
it  was  not  due  to  hypertrophy  of  the  pylorus.  With  regard  to 
the  second  question  I  think  it  may  be  said  that  visible  gastric 
peristalsis  of  such  marked  degree  as  that  to  which  I  have  referred 
is  during  the  first  few  months  of  life  almost,  perhaps  quite, 
peculiar  to  hypertrophy  of  the  pylorus.  So  far  as  my  own 
experience  goes  I  have  never  known  it  to  occur  apart  from  this 
condition. 

But  I  have  purposely  emphasized  the  degree  of  peristalsis,  for 
I  have  seen  in  infants  with  chronic  vomiting  and  constipation, 
where  there  was  no  other  evidence  of  pyloric  hypertrophy  and 
where  simple  treatment  by  careful  feeding  and  aperients  caused 
rapid  cessation  of  the  vomiting,  a  very  feeble  peristaltic  wave 
passing  over  the  stomach  just  after  feeding.  I  suspect  that  this 
might  be  found  more  often  if  specially  sought.  The  peristalsis 
in  these  cases  was  so  slight  that  it  could  only  just  be  detected 
by  inspection  of  the  abdomen  obliquely  in  a  good  light  ;  the 
pylorus  could  not  be  felt.  Of  course  it  may  be  argued  that  sucli 
cases  were  very  slight  degrees  of  pyloric  hypertrophy  and  this 
I  cannot  disprove.  The  peristalsis  to  which  I  have  referred 
as  a  characteristic  sign  of  hypertrophy  of  the  pylorus  and  which 
was  seen  in  all  my  cases  except  the  first  (which  occurred  some 
years  ago  before  the  methods  of  examination  were  known  to  me) 
is  something  altogether  more  striking  than  this,  and  if  it  happens 
to  occur  whilst  the  abdomen  is  uncovered  is  as  obvious  to  the 
layman  as  to  the  medical  man. 

Palpable  thickening  of  the  pylorus.  On  deep  palpation,  usually 
just  outside  the  right  nipple  line  and  about  a  third  of  the  distance 
from  the  umbilical  level  to  the  costal  margin,  a  hard  lump, 
barrel-shaped  and  seeming  perhaps  about  three-quarters  of  an 
inch  long  by  half  an  inch  wide,  is  to  be  felt  at  intervals.  This 
tumour,  the  hypertrophied  pylorus,  behaves  exactly  like  an 
intussusception  in  its  variations  of  palpability.  We  are  all 
familiar  with  the  intussusception  tumour  which  at  one  moment 
may  not  be  felt  at  all  and  the  next  moment  is  so  hard  that  it  is 
obvious  to  anyone.  So  it  is  with  the  pyloric  tumour  ;  it  is 
during  peristalsis  that  it  is  to  be  felt  ;  at  other  times  the  muscle 
is  so  soft  that  no  amount  of  tactus  eruditus  will  detect  it.  For 
this  reason  palpation  should  be  made  during  the  visible  peris- 
talsis of  the  stomach,  and  at  these  times  I  suspect  that  with 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS     159 

experience  the  pylorus  could  be  felt  in  every  case,  although  perhaps 
more  than  one  examination  may  be  necessary. 

In  forty-one  out  of  forty-two  cases  I  have  noted  the  hard 
pylorus  as  palpable  :  in  almost  all  these  cases  the  palpability 
was  confirmed  by  others  and  in  most  of  the  hospital  cases  by 
several  people. 

Occasionally,  even  when  there  is  no  visible  peristalsis  in  pro- 
gress at  the  time,  the  pylorus  can  be  felt  evidently  undergoing 
contractions,  being  palpable  and  hard  one  moment  and  com- 
pletely lost  the  next.  Such  contraction  may  be  excited  by 
gentle  kneading  with  the  tips  of  the  fingers  pressed  deeply  into 
the  abdomen  in  the  situation  of  the  pylorus. 

It  may  be  doubted  whether  any  assistance  is  to  be  gained 
from  an  anaesthetic  in  this  examination,  indeed  it  seems  probable 
that  it  might  actually  prevent  detection  of  the  pyloric  thickening 
by  hindering  indirectly  the  occurrence  of  peristalsis  ;  certainly 
any  anaesthetic  is  quite  unnecessary;  tact,  patience  and  warm 
hands  are  much  more  likely  to  be  successful.  No  doubt  the 
diagnosis  of  pyloric  hypertrophy  can  be  made  with  all  but 
certainty  from  the  visible  well-marked  peristalsis  of  the  stomach 
alone,  but  it  is  my  opinion  that  in  every  case  the  evidence  should 
be  clinched  by  feeling  the  thickened  pylorus. 

Treatment 

I  shall  preface  my  remarks  by  some  general  considerations 
on  the  treatment  of  this  disease. 

Within  the  past  few  years  successful  results  have  been  obtained 
by  operative  relief  of  the  pyloric  obstruction — a  method  of  relief 
which  seemed  at  first  to  promise  but  little  hope  at  so  frail  an  age. 
But  now  it  would  seem  that  there  is  a  danger  lest  the  very 
brilliance  of  this  success  should  lead  us  into  adopting  as  routine 
a  mode  of  treatment  which,  however  greatly  methods  may 
improve,  can  never  be  otherwise  than  dangerous  in  an  infant 
a  few  weeks  old.  If  the  disease  were  incurable  by  other  and 
far  less  dangerous  measures  we  might  well  accept  the  chance 
which  surgery  offers ;  but,  as  I  shall  show,  it  is  now  quite  certain 
that  there  are  cases  in  which  no  operation  whatever  is  necessary, 
and  there  are  other  cases  in  which  the  child's  chance  of  surviving 
operation  may  be  greatly  increased  by  the  use  of  simpler  measures 
for  a  time  until  the  infant  is  older  and  stronger  and  therefore 
in  a  better  position  for  operative  treatment.  If,  as  I  hold,  the 
hypertrophy  be  merely  a  secondary  phenomenon",  the  result  of 
spasm,  then  we  have  a  rational  basis  for  adopting  such  treatment 


160  COMMON  DISORDERS  OF  CHILDHOOD 

as  may  tend  to  allay  the  spasm,  and  if  this  can  be  done  one 
may  suppose  that  just  as  the  hypertrophied  muscles  of  the 
athlete  degenerate  when  he  ceases  his  exercises  so  the  hyper- 
trophied pylorus  loses  its  hypertrophy  and,  partly  from  the 
diminution  in  the  thickness  of  its  wall,  but  much  more  from  the 
cessation  of  spasm,  the  obstruction  ceases  to  exist. 

This  seems  to  me  the  most  natural  explanation  of  the  complete 
recovery  which  occurs  in  some  well-marked  typical  cases  under 
such  simple  treatment  as  repeated  stomach-washing  and  some- 
times even  with  simple  care  in  feeding.  How  these  measures 
allay  the  spasm  I  know  not,  but  that  they  do  is  I  think  actually 
demonstrable  in  the  gradual  disappearance  not  only  of  the 
vomiting  but  also  of  the  two  characteristic  signs  which  I  have 
mentioned. 

Passing  now  from  theory  to  more  practical  considerations 
I  would  point  out  that  by  whatever  method  this  disease  is 
treated,  whether  by  medical  or  by  operative  measures,  the  medical 
man  must  be  prepared  to  give  much  time  and  much  care  to  the 
case,  not  for  a  few  days  but  for  many  weeks  if  the  infant's  life 
i,s  to  be  saved.  It  might  be  imagined  that  operation,  inasmuch 
as  it  relieves  all  symptoms  of  pyloric  obstruction  forthwith,  would 
solve  all  difficulties  at  once,  a  ad  that  after  the  few  days  imme- 
diately succeeding  the  operation  but  little  care  would  be  required. 
As  a  matter  of  fact  it  is  often  far  otherwise  and  the  infant's 
life  hangs  in  the  balance  for  several  weeks  after  operation. 

One  factor  in  success  I  will  mention  here,  for  it  is  equally 
important  whatever  method  of  treatment  is  adopted — namely, 
an  accurate  weighing-machine.  Variations  in  weight,  so  helpful 
a  gauge  in  most  infantile  diseases,  are  of  the  utmost  importance 
in  this  condition,  where  the  requisite  changes  in  the  feeding  may 
be  many  and  may  be  of  vital  necessity  and  often  have  to  be 
determined  by  the  loss  or  gain  of  an  ounce  or  twro. 

Treatr  it  by  dieting  only.  As  already  mentioned  many  cases 
are  improved  temporarily  by  change  of  diet,  but  it  is  probably 
very  rarely  that  a  cure  can  be  effected  by  such  treatment  alone. 
Dr.  H.  Willoughby  Gardner,1  of  Shrewsbury,  has  published  the 
case  of  a  male  infant  whose  vomiting  began  at  the  age  of 
8J  weeks  and  who  showed  a  peristaltic  wave  '  almost  the  size  of 
a  small  Tangerine  orange  '  and  had  also  a  palpable  thicken- 
ing of  the  pylorus.  The  infant  was  fed  with  whey  alone  for 
a  time,  then  malt  was  added,  then  barley-water  and  maltine  were 

1  Lancet,  1903,  i,  p.  100. 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS    161 

given  occasionally,  and  gradually  raw  meat  juice  and  white  of 
egg  were  given  also.  For  a  long  time  all  residue-leaving  food 
was  avoided  and  the  amounts  at  each  feed  were  only  slowly 
increased  from  a  teaspoonful  every  twenty  minutes  to  two, 
three  and  four  teaspoonfuls  at  longer  intervals.  The  vomiting 
gradually  subsided,  all  symptoms  disappeared,  and  the  child  at 
the  age  of  10J  months  weighed  20  pounds. 

Drs.  J.  R.  and  W.  J.  Harper,1  of  Barnstaple,  by  whose  kindness 
the  accompanying  photograph  (Fig.  9)  is  reproduced  here,  have 
published  a  case  with  very  typical  symptoms  and  signs  of  con- 
genital hypertrophy  of  the  pylorus  :  the  vomiting  began  when 
the  infant,  a  male,  was  3 J  weeks  old ;  there  was  constipation  and 
gastric  peristalsis  sufficiently  obvious  to  be  photographed  and 
the  pyloric  tumour  could  be  felt. 

He  was  fed  with  teaspoonful  doses  of  hot  water  by  the  mouth 


FIG.  9.  Congenital  hypertrophy  of  the  pylorus.  Case  under  Drs.  W.  J. 
and  J.  R.  Harper;  showing  characteristic  wave  of  gastric  peristalsis:  complete 
recovery  without  operation. 

and  rectal  injection  of  nearly  half  a  pint  of  normal  saline  solution 
twice  a  day  at  first,  then  teaspoonful  doses  of  peptonized  milk 
by  mouth  with  Valentine's  meat  juice  and  white  of  egg  were 
gradually  introduced.  Enemata  either  saline  or  nuteient  were 
continued  for  over  a  month,  and  gradually  larger  quantities  of 
peptonized  milk  and  later  of  Benger'sfood  were  taken  by  mouth, 
and  the  child  made  a  complete  recovery. 

The  photograph  of  this  case  is  the  more  interesting  as  it  proves 
conclusively  that  well-marked  gastric  peristalsis  does  not  indicate 
necessity  for  operation ;  the  fact  also  that  the  pyloric  tumour 
was  felt  in  this  case  makes  it  certain  as  far  as  is  possible  that  this 
was  a  typical  case  of  hypertrophy  of  the  pylorus.  The  clinical 
course  shows  that  simple  dieting  may  be  sufficient  to  cure 
these  cases. 

1   Ibid.,  Aug.  19,  1905. 

STILL  M 


162          COMMON  DISORDERS  OF  CHILDHOOD 

I  have  had  one  case  in  which  the  effect  of  even  simpler  dietetic 
measures  was  equally  striking.  A  female  infant,  aged  six  weeks, 
was  brought  for  persistent  vomiting  which  had  begun  at  the 
age  of  three  weeks  ;  the  vomit  was  said  to  be  '  shot  right  out ', 
coming  through  the  nostrils  as  well  as  the  mouth.  The  infant 
had  been  carefully  fed  with  milk  and  barley-water.  A  well- 
marked  wave  of  gastric  peristalsis  was  seen,  but  on  the  two 
occasions  on  which  I  saw  the  child  at  this  stage  I  was  unable 
to  feel  the  pylorus.  The  food  was  changed  to  peptonized 
milk  and  some  bismuth  was  given.  Four  days  later  gastric 
peristalsis  was  still  very  obvious  and  vomiting  continued  ; 
gradually,  however,  the  vomiting  became  less,  and  after  about 
four  weeks  it  ceased.  The  gastric  peristalsis  also  gradually 
disappeared,  and  when  I  saw  the  infant  again  at  the  age 
of  7J  months  she  weighed  15 J  pounds  and  was  perfectly 
healthy.  In  this  case  the  failure  to  detect  palpable  hardening 
of  the  pylorus  may  be  considered  to  make  the  diagnosis  less 
than  absolutely  certain,  but  it  does  not  alter  the  importance  of 
the  clinical  fact  that  an  infant  with  chronic,  very  forcible  vomit- 
ing and  with  well-marked  visible  peristalsis  of  the  stomach 
recovered  gradually  with  simple  alteration  of  food, 

Treatment  by  nasal  feeding.  My  colleague,  Dr.  F.  E.  Batten, 
has  published  a  case  which  I  also  had  the  opportunity  of  watch- 
ing, in  which  an  infant,  aged  eleven  weeks,  with  typical  symp- 
toms and  with  the  two  characteristic  signs  pronounced,  recovered 
completely  with  nasal  feeding.  All  feeds  (consisting  of  2  ounces 
of  milk  and  1  ounce  of  barley-water)  were  given  by  the  nasal 
tube  for  twenty-seven  days,  except  on  one  day  when  bottle- 
feeding  was  unsuccessfully  tried.  I  have  not  used  this  method 
myself  ;  it  has  the  disadvantage  that  it  is  liable  to  cause  trouble- 
some excoriation  of  the  nostrils. 

Treatment  by  stomach-washing.  This  is  the  method  which, 
apart  from  operation,  promises,  I  think,  to  be  of  most  value,  and 
it  is  my  own  opinion  that  when  careful  feeding  with  some  thin 
fluid,  such  as  whey  and  raw  meat  juice,  fails  after  a  trial  of  a  few 
days  to  arrest  the  loss  of  weight,  which  is  the  chief  indication  of 
the  gravity  of  the  vomiting,  stomach-washing  should  be  given 
a  trial  in  every  case,  the  duration  of  its  trial  to  be  determined  by 
its  effect  upon  the  weight.  It  is  certain  that  some  cases  which, 
so  far  as  can  be  judged  clinically,  are  in  every  way  typical  in- 
stances of  pyloric  hypertrophy  and  which  show  just  as  marked 
signs,  as  cases  in  which  operation  is  deemed  necessary,  namely 
a  peristaltic  wave  travelling  in  bulging  prominences  across  the 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS    163 

pigastrium  and  a  hard  palpable  pylorus,  recover  completely 
so  far  as  my  present  experience  goes  show  no  tendency  to 
urrence  after  treatment  with  stomach-washing  alone. 

The  stomach  is  washed  out  twice  daily  for  several  weeks 
just  before  a  feed  and  then  once  daily  for  some  weeks  longer 
with  a  solution  of  sodium  bicarbonate  (2  grains  to  1  ounce) 
through  a  Jacques's  soft  rubber  catheter,  No.  12  or  14.  The 
frequency  of  the  washings  and  the  duration  of  treatment  depend 
upon  the  improvement  in  the  vomiting  and  especially  upon  the 
weight,  which  should  be  taken  every  alternate  day.  How  soon 
should  improvement  be  expected  ?  Not  necessarily  at  once. 
In  three  of  my  cases  which  subsequently  gained  weight  steadily 
under  this  treatment  the  weight  had  remained  almost  stationary, 
or  even  fallen  2  or  3  ounces  at  one  weighing  and  regained  its 
former  level  at  the  next,  for  two  or  three  weeks,  in  one  case 
for  five  weeks,  before  continuous  gain  began.  So  long  as  the 
infant  is  not  definitely  losing  ground  there  is  no  need  to  rush 
to  operation.  Of  course,  with  wasted  infants  at  this  early  age 
every  ounce  is  of  importance  and  the  utmost  care  and  judgement 
must  be  exercised  in  deciding  for  or  against  the  continuance  of 
medical  treatment  ;  certainly  so  long  as  there  is  any  gain  in 
weight  operation  may  and  in  my  opinion  should  be  deferred. 
The  food  during  this  treatment  has  generally  consisted  of  whey 
with  raw  meat  juice  or  a  very  weak  peptonized  milk  mixture 
perhaps  with  a  very  small  quantity  of  cream. 

Such  cases  were  the  following  : 

A  male  infant,  aged  8£  weeks,  seen  with  Dr.  A.  Reeves,  of  Streatham  Hill. 
In  addition  to  chronic  forcible  vomiting  the  infant  showed  very  marked  visible 
peristalsis  of  the  stomach  and  at  times  the  pylorus  could  be  felt.  He  had  lost 
2  pounds  |  ounce  in  weight  since  birth.  The  stomach  was  washed  out  first 
twice  and  then  once  daily  for  nineteen  weeks.  All  vomiting  gradually  ceased, 
the  weight  after  2£  weeks  began  to  rise  steadily,  the  two  characteristic  signs 
disappeared,  and  when  he  was  seen  at  fourteen  months  old  he  had  been  quite 
well  for  more  than  six  months  and  weighed  23 1  pounds. 

A  male  infant,  aged  eight  weeks,  seen  with  Dr.  C.  F.  Wakefield,  of  Horley. 
The  child  had  been  vomiting  very  forcibly  since  6£  weeks  old,  and  the  vomiting 
consisted  sometimes  of  more  than  the  last  feed  ;  he  showed  the  wave  of  gastric 
peristalsis  well  marked  and  the  pylorus  could  be  felt  distinctly.  The  stomach 
was  washed  out  at  first  twice  and  then  once  daily,  then  two  or  three  times  per 
week,  for  sixteen  weeks.  During  this  time  all  symptoms  and  signs  had  gradu- 
ally disappeared  ai^d  the  patient  seen  again  at  the  age  of  six  years  was  a  bonny 
healthy  child. 

Albert  D.,  aged  three  weeks,  came  under  my  care  in  King's  College  Hospital 
at  the  age  of  three  weeks  with  the  characteristic  symptoms  and  signs  of  con- 
genital hypertrophy  of  .the  pylorus  :  they  had  begun  on  the  fifth  day  after 
birth ;  Dr.  G.  P.  Young,  of  Hinckley,  then  my  house-physician,  washed  the 

M2 


164  COMMON  DISORDERS  OF  CHILDHOOD 

stomach  out  twice  daily  for  ten  weeks  and  subsequently  it  was  washed  out  once 
daily  ;  the  lavage  was  continued  altogether  for  six  months.  For  the  first  five 
weeks  the  weight  was  almost  stationary  and  some  vomiting  continued  ;  the 
weight  then  began  to  rise  and  the  child,  whose  weight  on  admission  was  5  pounds 
14  ounces  and  who  was  so  feeble  and  puny  that  laparotomy  would  have  been 
a  desperate  measure,  gained  weight  slowly  and  at  the  end  of  six  months  weighed 
12  pounds  8  ounces  and  left  the  hospital  in  a  thriving  condition. 

Walter  ('.,  aged  thirteen  weeks,  was  sent  to  me  with  the  usual  symptoms  of 
congenital  hypertrophy  of  the  pylorus.  They  had  appeared  at  the  age  of  four 
weeks  whilst  he  was  being  fed  on  breast-milk  only.  The  gastric  peristalsis  was 
so  marked  that  the  mother  herself  had  noticed  it,  and  the  thickened  pylorus 
which  was  palpable  at  that  time  could  still  be  felt  several  weeks  later.  The 
child  weighed  8  pounds  3  ounces  at  thirteen  weeks,  and  as  the  mother  was  able 
to  .suckle  it  I  advised  Dr.  Tremlett  Wills,  under  whose  care  the  infant  was,  to 
wash  out  the  stomach  daily  but  not  to  have  the  infant  weaned  until  the  proper 
time.  The  stomach-washing  was  continued  until  the  child  was  11]  months  old. 
1  heard  two  years  later  that  he  was  '  now  a  fine  sturdy  little  boy  '. 

In  another  case  an  emaciated  infant  with  the  usual  signs  and 
symptoms  of  pylorio  hypertrophy,  aged  seven  weeks,  and  already 
'  almost  too  feeble  to  cry  ',  was  treated  by  stomach- washing 
for  six  weeks  ;  at  first  she  gained  weight  slowly,  if  at  all,  and 
after  about  a  month  was  only  half  an  ounce  heavier  than  when 
washing  began  ;  then  she  began  to  gain  weight  steadily  and  in 
thirteen  days  had  gained  13J  ounces.  The  child  being  now 
stronger  it  was  decided  to  operate.  From  the  day  of  the  opera- 
tion, although  the  vomiting  was  stopped  thereby,  continuous 
marasmus  occurred,  and  the  child  died  in  convulsions  twenty- 
five  days  after  the  operation.  It  is  easy  to  be  wise  after  the 
event,  but  here  the  steady  gain  in  weight  which  had  commenced 
before  the  operation  makes  it  probable  in  the  light  of  the 
rases  already  mentioned  that  had  the  stomach- washing  alone 
been  continued  the  child  would  have  recovered. 

In  one  case  after  washing  out  the  stomach  for  fourteen  weeks 
there  hud  been  a  gain  of  22  ounces,  but  progress  was  so  slow 
that  operation  was  done  and  the  child  recovered.  In  two  other 
cases  where  stomach-washing  was  done  for  a  few  days  only 
there  had  already  been  slight  gain  in  weight,  but  it  was  decided 
to  operate. 

Whether  the  weight  rises  at  once  or  not  there  is  usually 
a  marked  diminution  of  the  vomiting  after  the  stomach  has 
been  cashed  out  for  a  few  days  ;  but  this  must  not  be  taken 
as  an  indication  for  stopping  the  stomach-washing  until  the 
infant  has  been  making  steady  and  considerable  progress  in 
weight  for  several  weeks. 

Having  said  this  much  of    the  success  of  stomach- washing 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS      165 

in  this  condition  I  must  mention  its  failures  and  possible  risks  ; 
in  four  cases  where  stomach-washing  was  tried  for  a  few  days 
only  there  was  no  improvement  ;  in  one  case  death  occurred 
with  some  pyrexia  about  forty-eight  hours  after  stomach- washing 
was  begun  and,  although  the  necropsy  showed  no  evidence  of 
vomited  material  in  the  respiratory  passages,  death  may  have 
been  due  to  matter  drawn  into  the  lungs  in  vomiting  during  the 
stomach- washing  ;  if  so  it  must  be  an  exceedingly  rare  accident, 
for  I  have  had  infants'  stomachs  washed  out  many  hundreds  of 
times  without  such  an  occurrence. 

In  another  case  a  dry  rotten  tube  was  inadvertently  used 
and  the  end  broke  off  in  the  stomach  necessitating  immediate 
resort  to  the  operative  treatment  which  we  had  intended  to 
defer  ;  the  pylorus  was  stretched,  but  an  accidental  rupture 
of  its  wall  was  overlooked  (the  operation  was  done  in  great 
haste  owing  to  extreme  feebleness  of  the  infant),  and  death 
occurred  about  twenty-seven  hours  later.  Such  exceedingly 
rare  accidents  must,  however,  weigh  but  little,  and  I  think  it 
remains  true  that  stomach-washing  is  a  procedure  which  should 
certainly  be  tried  in  the  pyloric  hypertrophy  of  infants  before 
resorting  to  operation  ;  in  some  cases  it  is  sufficient  alone  to 
secure  complete  recovery,  in  others  by  increasing  the  nutrition 
and  the  strength  of  the  infant  and  by  enabling  us  to  postpone 
operation  till  the  infant  is  a  few  weeks  older  it  increases  the 
chances  of  success  from  operation  ;  where,  however,  the  weight 
is  steadily  diminishing  for  several  days  in  spite  of  stomach- 
washing  the  question  of  immediate  operation  must  be  considered. 

Lastly,  I  would  insist  upon  an  important  point — namely, 
that  the  degree  of  gastric  peristalsis  (I  mean  the  size  of  the 
bulging  wave  which  is  seen)  and  the  palpability  of  the  hard 
pylorus  are  no  criteria  of  the  possibility  or  even  probability  of 
recovery  or  improvement  by  stomach-washing  or  of  the  likeli- 
hood of  necessity  for  operation  ;  the  most  pronounced  signs  and 
symptoms  may  occur  in  cases  which  respond  well  to  stomach  - 
washing  alone. 

Operative  Treatment.  The  actual  operation  to  be  done,  if  any 
be  necessary,  is  a  question  which  falls  outside  my  province  ; 
forcible  dilatation  of  the  pylorus,  pyloroplasty,  and  gastro- 
enterostomy  have  each  their  advocates.  Fourteen  cases  out  of 
forty-two  included  in  my  series  (one  of  which  was  only  seen 
by  me  once  in  consultation  and  was  subsequently  operated  upon 
successfully  by  Mr.  H.  J.  Stiles,  of  Edinburgh),  were  treated  by 
forcible  dilatation  of  the  pylorus — all  except  two  by  my  colleague, 


1G6  COMMON  DISORDERS  OF  CHILDHOOD 

Mr.  F.  Burgh ard — and  eight  of  these  fourteen  recovered.  One 
of  these  died  several  months  later  from  broncho-pneumonia. 

Operation  has  risks  apart  from  those  connected  with  shock 
and  with  the  operation  itself.  There  is  a  tendency  to  looseness 
of  the  bowels  after  it  and  also  a. difficulty  of  nutrition  which  in 
some  of  my  cases  seemed  to  make  death  from  marasmus  almost 
inevitable  for  some  weeks  after  the  operation  although  they 
ultimately  recovered  ;  an  important  point  this  which  increases 
the  need  for  careful  consideration  before  embarking  on  operative 
measures  and  which  increases  also  the  importance  of  previous 
stomach-washing  if  thereby  even  a  few  ounces  of  weight  can 
be  gained. 

Results  of  Treatment.  It  is  difficult  to  compare  the  results  of 
medical  treatment  witli  those  of  operation  :  for  in  several 
cases  which  proved  fatal  where  no  operation  was  done  the 
infant  was  already  so  bad  when  the  diagnosis  was  first  made 
that  he  died  within  three  or  four  days  and  was  not  likely  to 
have  been  saved  by  any  treatment.  In  one  case  where  no 
operation  was  clone  death  was  due  to  a  purely  accidental  cause, 
the  infant  appeared  to  be  doing  fairly  well  but  three  weeks 
after  the  onset  of  the  symptoms  of  congenital  hypertrophy  of 
the  pylorus  lie  suddenly  became  very  ill  and  was  found  at 
autopsy  to  have  died  of  acute  intussusception. 

Of  the  forty-two  cases  in  my  series  three  were  seen  in  the 
days  before  any  special  treatment  was  known  for  this  disorder, 
and  in  three  the  ultimate  course  of  the  case  could  not  be  ascer- 
tained. Of  the  remaining  thirty-six  cases  nineteen  recovered 
(including  the  case  mentioned  above  which  died  subsequently  of 
broncho-pneumonia). 

Of  the  nineteen  which  recovered  eight  w^ere  treated  by  opera- 
tion (in  three  of  these  the  infant  had  been  gaining  weight  with 
stomach-washing  before  the  operation  was  done)  eleven  were 
treated  medically  (nine  by  stomach-washing,  two  by  dietetic 
measures  only). 

Of  the  seventeen  cases  which  died  six  were  treated  by  opera- 
tion, eleven  by  lavage  or  dieting,  including  four  in  which  death 
occurred  within  a  few  days  after  I  first  saw  the  infant  who  was 
already  in  such  an  extreme  condition  that  any  treatment  was 
hopeless  and  also  the  case  in  which  death  was  due  to  acute 
intussusception. 

I  have  given  these  statistics  in  detail  not  as  supporting  any 
routine  practice  of  this  or  that  method  of  treatment  ;  but  to 
show  that  a  considerable  proportion  of  these  cases  can  be  cured 


HYPERTROPHY  OF  THE  PYLORUS  IN  INFANTS     167 

without  operation.  Each  case  must  be  carefully  considered  on  its 
own  merits  :  there  is  no  doubt  of  the  curability  of  this  disorder 
in  some  cases  by  stomach-washing  or  even  by  dietetic  measures 
alone  :  but  I  think  there  is  equally  no  doubt  that  in  some  the 
only  resource  which  will  save  life  is  operation. 


CHAPTER  XII 

ABDOMINAL  PAINS  IN   CHILDREN   BEYOND  THE 
AGE  OF  INFANCY 

I  KNOW  no  symptom  which  may  be  more  obscure  in  its  causa- 
tion than  colicky  abdominal  pain  in  childhood.  In  this  chapter 
I  shall  consider  the  various  conditions  to  which  it  may  be  due. 

The  commonest  cause  is,  as  in  infancy,  some  form  of  indigestion, 
most  frequently,  I  think,  the  disorder  to  which  Dr.  Eustace 
Smith  has  given  the  name  of  mucous  disease.  I  shall  refer  to 
this  more  fully  in  the  chapter  on  indigestion,  here  I  will  only 
recapitulate  its  chief  symptoms  :  the  child  is  usually  '  going 
thin  ',  his  lower  eyelids  are  puffy,  or  he  is  '  dark  under  the  eyes  ', 
he  sleeps  badly,  is  restless,  grinds  his  teeth,  or  talks  in  his  sleep, 
or  has  definite  night-terrors  ;  in  the  daytime  he  is  unnaturally 
nervous,  his  stools,  although  perhaps  costive,  show  an  excess  of 
mucus,  which  is  not  necessarily  present  in  every  stool,  but  will 
generally  be  noticeable  in  some  of  the  stools  if  these  are  observed 
for  several  days ;  and  lastly,  he  complains  of  frequent  slight  pains 
in  the  abdomen.  The  pain  is  usually  quite  transient,  lasting 
less  than  a  minute  ;  it  is  generally  not  severe  enough  to  make  the 
child  cry  out  ;  it  is  associated  sometimes  with  a  sudden  pallor 
of  the  face,  the  child  'turns  white' ;  this, however,  would  seem  to 
be  a  reflex  vasomotor  effect  which  does  not  depend  upon  the 
severity  of  the  pain,  for,  as  I  have  pointed  out  elsewhere,  it  is 
not  an  uncommon  symptom  of  indigestion  in  children  without 
any  pain  whatever. 

A  common  source  of  abdominal  pain  is  undigested  vegetable 
matter  in  the  intestines,  the  stools  are  large  and  of  '  porridgy  ' 
consistence,  and  in  them  are  to  be  seen  large  pieces  of  scarcely 
altered  fruit  or  vegetable,  such  as  banana,  potato,  or  cabbage. 
Difficulty  in  digesting  fruit  and  vegetables  is  so  common  in 
children  that  I  am  always  inclined  to  suspect  this  cause  where 
colicky  pains  of  obscure  causation  are  present.  It  is  to  be 
remembered  also  that  children  are  very  apt  to  bolt  their  food 
without  mastication,  and  vegetable  substance, if  not  thoroughly 
broken  up  in  the  mouth,  undergoes  but  little  change  during  its 
passa<^  through  the  body,  and  is  likely  to  act  as  an  irritant  : 
sometimes  examination  of  the  stools  from  these  children  with 
abdominal  pains  at  once  furnishes  a  clue  to  the  proper  line  of 


ABDOMINAL  PAINS  169 

treatment  ;  I  have  seen  large  masses  of  shreddy  pulp  of  banana, 
blocks  of  unbroken  potato,  and  pieces  of  cabbage-leaf  nearly  an 
inch  square  in  the  stools  ;  little  wonder  that  the  child  suffered 
with  colic ! 

In  some  cases  the  failure  to  masticate  food  which  underlies  the 
abdominal  pain  is  no  mere  faulty  habit,  but  is  due  entirely  to  the 
condition  of  the  teeth,  which  are  either  extremely  defective,  or 
are  so  tender  that  the  child  is  afraid  to  chew  its  food  ;  I  have 
several  times  seen  speedy  relief  of  colic  by  extraction  or  stopping 
of  carious  teeth. 

In  considering  indigestion  I  have  referred  to  the  case  of  a 
girl  aged  3|  years,  whose  recurring  abdominal  pains  were  so 
intractable,  that  the  presence  of  some  organic  disease  was  sus- 
pected, and  exploratory  laparotomy  was  proposed :  the  adminis- 
tration of  a  pancreatic  extract  proved  effectual  in  stopping  the 
pains  after  a  variety  of  other  remedies  had  failed.  In  this  case 
there  was  nothing  to  suggest  'mucous  disease  ',  but  I  suppose 
the  cessation  of  pain  when  pancreatic  extract  was  given,  showed 
that  the  colic  was  due  to  digestive  disorder.  Certainly  chronic 
indigestion  of  any  variety  is  very  apt  to  cause  recurring  colicky 
pain  in  children,  and  I  think  much  more  often  in  children  in  the 
earlier  part  of  childhood,  that  is,  before  the  age  of  six  years,  than 
between  the  ages  of  six  years  and  puberty. 

Next  to  digestive  disorder,  perhaps  the  commonest  cause  of 
occasional  slight  pains  in  the  abdomen  is  the  presence  of  thread- 
worms. It  can  hardly  be  supposed  that  the  mechanical  irritation 
caused  by  such  small  parasites  is  sufficient  to  excite  the  irregular 
or  unduly  vigorous  peristalsis  of  the  bowel,  which  no  doubt  under- 
lies colicky  pains,  but  post  mortem  examination  shows  that  the 
presence  of  many  threadworms  in  the  intestine  is  generally  asso- 
ciated with  an  excessive  quantity  of  mucus,  and  it  seems  likely 
that  it  is  this  rather  than  the  presence  of  worms,  which  is  the 
actual  exciting  cause  of  the  colic  in  these  cases,  for  excess  of  mucus 
in  the  intestine  from  any  cause  seems  to  be  very  liable  to  set  up 
colic  in  children. 

In  the  earliest  years  of  childhood,  perhaps  up  to  the  age  of  four 
or  five  years,  simple  constipation  is  sufficient  cause  for  frequent 
complaint  of  pains  in  the  abdomen,  but  in  later  childhood  con- 
stipation is  less  and  less  apt  to  cause  pain.  I  mention  this  differ- 
ence because  it  illustrates,  I  think,  a  physiological  point  which 
may  be  of  some  practical  importance.  It  would  seem  that  the 
sensitiveness  of  the  bowel  to  stimuli  decreases  as  the  child  grows 
older.  In  the  first  few  weeks  of  life,  constipation  is  an  exceedingly 


170  COMMON  DISORDERS  OF  CHILDHOOD 

common  cause  of  colic  and  screaming,  it  is  less  so  in  the  infant 
of  nine  months  or  a  year,  and  the  tendency  to  colic  from  this 
cause  seems  to  diminish  steadily  as  the  child  grows  older.  In 
other  words,  the  bowel  shares  in  the  general  nervous  instability 
of  childhood,  which,  as  we  know,  tends  to  diminish  spontaneously. 
Whether  this  nervous  irritability  produces  only  an  exaggeration 
of  normal  peristalsis,  or  whether  the  contractions  produced  are 
also  irregular  and  ineffective,  we  cannot  tell,  but  it  is  worthy  of 
note  that  during  the  earliest  years  of  childhood,  the  period  when 
colic  is  most  apt  to  occur,  many  of  the  functions  of  the  body  have 
not  yet  acquired  the  fixity  of  later  age,  the  heart,  for  example, 
easily  becomes  irregular,  the  excretion  of  urine  may  be  suspended 
for  many  hours,  muscular  co-ordination  is  easily  disturbed, 
stuttering  is  almost  physiological  in  the  very  young  child,  the 
rhythm  of  the  diaphragm  is  easily  disturbed  with  resulting 
hiccough,  and  so  on  :  it  seems  therefore  likely  enough  that  the 
colic  to  which  infants  and  young  children  are  so  specially  liable 
may  mean  irregularity  as  well  as  excess  of  peristalsis. 

But  if  the  bowel  shares  in  the  nervous  instability  which  is 
peculiar  to  early  life,  it  seems  more  than  probable  that  it  shares 
also  in  the  individual  peculiarities  of  children  in  this  respect : 
so  that  there  may  be  a  '  nervous  bowel  ',  if  I  may  use  such  a  term, 
a  bowel  which  goes  off  into  colic  upon  the  slightest  provocation 
by  stimuli  which  would  have  no  such  effect  in  a  less  nervous  child. 

There  can  be  no  doubt  that  such  a  condition  obtains  in  the  case 
of  so-called  lienteric  diarrhoea,  the  '  diarrhee  nerveuse  '  of 
Trousseau,  in  which  the  taking  of  food  is  almost  immediately 
followed  by  colicky  pain  in  the  abdomen  and  an  urgent  desire  to 
defalcate,  although  the  stools  may  not  be  loose  and  the  child  may 
be  quite  free  from  any  such  symptom  between  meals  ;  this  con- 
dition which  in  my  experience  is  much  more  common  in  boys  than 
in  girls  (thirteen  out  of  sixteen  cases  were  boys)  is  closely  asso- 
ciated with  nervous  excitability  ;  almost  always  the  child  is  said 
to  be  '  very  nervous ',  and  other  nervous  symptoms,  such  as  night- 
terrors,  sleep-talking,  and  enuresis,  are  present  ;  it  occurs  also 
specially  in  the  child  of  rheumatic  inheritance,  which  is  perhaps 
another  indication  of  its  nervous  connexion,  for  the  rheumatic 
child  and  the  child  of  rheumatic  parentage  show  a  very  marked 
tendency  to  t  he  nervous  temperament.  In  these  cases  of  nervous 
diarrho'a  the  colicky  pain  which  is  started  by  food  is  followed, 
as  a  rule,  by  evacuation  of  the  bowels  ;  but  this  is  not  always  so, 
sometimes  atone  meal  the  child  complains  only  of  the  abdominal 
pain,  while  at  another  there  is  also  urgency  of  defsecation.  Pos- 


ABDOMINAL  PAINS  171 

sibly  in  the  one  case  the  part  of  the  bowel  thrown  into  spasmodic 
contractions  is  higher  up  than  in  the  other  case,  so  that  def  secation 
does  not  result  ;  but,  however  this  may  be,  this  occurrence  of 
colic  without  evacuation  of  the  bowels  in  cases  of  so-called  '  ner- 
vous diarrhoea  '  supports  the  idea  that  in  some  children  the  main 
factor  in  the  tendency  to  colicky  pain  is  what  I  have  called 
a  nervous  bowel. 

There  is  another  disorder  in  which  one  is  tempted  to  suspect 
that  pains  in  the  abdomen  may  possibly  be  of  nervous  origin, 
namely,  cyclic  albuminuria.  This  is  probably  less  rare  than  is 
generally  supposed,  it  is  easily  overlooked,  for  there  is  little  to 
suggest  the  necessity  for  examining  the  urine,  and  even  when  the 
urine  is  examined,  the  nature  of  the  albuminuria  may  be  mis- 
taken unless  a  morning  as  well  as  a  midday  specimen  is  examined. 
The  vague  symptoms  for  which  children  with  this  disorder  are 
brought  to  the  medical  man  are  certainly  often  of  a  nervous 
character,  headaches,  night-terrors,  '  always  so  tired/  flushing 
of  the  face,  these  are  some  of  the  symptoms  which  I  have  noted 
particularly  in  these  cases,  and  with  these  are  associated  often 
colicky  pains  in  the  abdomen.  Dr.  L.  Guthrie  goes  so  far  as  to 
include  cyclic  albuminuria  amongst  the  functional  nervous  dis- 
orders of  childhood,  and  says  in  his  admirable  work  on  these  dis- 
orders, that  cyclic  albuminuria  is  evidence  of  nervous  instability 
affecting  chiefly  the  vasomotor  system.  I  doubt  whether  enough 
is  known  of  the  pathology  of  this  curious  disorder  to  justify  any 
dogmatic  statement  on  this  point ;  and  so  far  as  the  abdominal 
pains  associated  with  it  are  concerned,  it  must  be  remembered 
that  the  children  with  cyclic  albumiriuria  often  show  distinct 
evidence  of  digestive  difficulty  and,  as  Dr.  Guthrie  points  out, 
they  are  often  the  subjects  of  '  mucous  disease '  in  which  colicky 
pain  is  a  common  symptom. 

The  urine  should  be  examined  in  every  case  of  obscure  abdo- 
minal pain,  children  like  adults  are  subject  to  renal  calculus  and 
colic  therewith,  but  in  my  own  experience  this  has  been  rare  ; 
Leslie  S.,  aged  eleven  years,  was  under  my  care  for  several  months 
with  attacks  of  vomiting  which  were  thought  to  be  characteristic 
attacks  of  so-called  '  cyclic  vomiting  '  ;  the  mother  mentioned 
that  the  boy  had  some  pain  in  the  abdomen  during  the  attacks, 
but  laid  so  little  stress  on  the  pain  that  its  significance  was 
entirely  overlooked  ;  until  the  boy  was  suddenly  seized  one  day 
with  severe  pain  and  difficulty  in  passing  urine,  and  after  about 
twenty-four  hours  of  severe  pain  in  the  hypogastric  region,  passed 
a  rough  calculus  the  size  of  a  cherry-stone.  Inquiry  then  elicited 


172  COMMON  DISORDERS  OF  CHILDHOOD 

the  fact  that  with  each  attack  of  vomiting,  there  had  been  pains 
in  the  right  lumbar  region. 

There  is  another  cause  for  colicky  pain  in  connexion  with  the 
kidney  which  is  worth  remembering,  though  it  may  be  rare, 
namely,  movable  kidney.  I  once  saw  two  children  in  one  day, 
with  abdominal  pain  due  to  this  cause  ;  both  were  boys,  one 
aged  three  and  a  quarter  years,  the  other  aged  ten  years.  In 
the  former  there  were  attacks  of  colic  which  were  sometimes  severe 
enough  to  double  him  up,  but  more  often  apparently  slight,  and 
these  were  specially  apt  to  occur  when  he  wras  walking.  Palpa- 
tion of  the  abdomen  showed  that  the  left  kidney  was  freely 
movable  ;  the  urine  was  normal.  In  the  other  case  attention 
had  been  drawn  to  the  movable  kidney  by  pain  on  the  right 
side  of  the  abdomen  simulating  appendicitis.  Dr.  Jules  Comby 
has  drawn  attention  to  this  possibility  of  confusing  the  pain  due 
to  movable  kidney  with  that  due  to  appendicitis  in  young  chil- 
dren. I  have  found  a  freely  movable  kidney  on  the  right  side  in 
an  infant  under  twelve  months  old,  and  there  can  be  little  doubt 
that  the  condition,  though  seldom  detected  in  infancy,  is  some- 
times congenital,  so  that  even  in  infancy  it  is  a  possible  cause  for 
abdominal  pain. 

Biliary  colic  is  practically  unknown  in  childhood  ;  I  have  else- 
where referred  to  the  very  rare  occurrence  of  minute  biliary 
oalculi  in  early  infancy,  but  after  that  period  I  have  never  in  my 
own  experience  known  biliary  calculi  to  occur  under  the  age  of 
puberty,  and  I  was  only  able  to  find  eight  cases  on  record  in 
children  between  two  and  fourteen  years  of  age  ;  in  two  of  these 
it  was  stated  that  there  was  biliary  colic. 

Frequent  complaint  of  pain  in  the  abdomen  in  a  child  usually 
suggests,  amongst  other  possibilities,  the  presence  of  tabes  mesen- 
terica,  easeation  of  the  mesenteric  glands;  and  in  many  cases 
it  is  no  easy  matter  to  exclude  this,  but  if  the  glands  are  already 
firmer  as  well  as  larger  than  normal,  careful  palpation  may  detect 
them  without  difficulty.  The  parts  at  which  they  are  usually  to 
be  felt  most  easily  are,  I  think,  on  each  side  of  the  midline,  just 
below  or  just  above  the  level  of  the  umbilicus,  where  they  may  be 
felt  by  palpating  deeply  so  as  to  press  the  fingers  towards  the  sides 
of  the  bodies  of  the  vertebrae  ;  and  also  in  the  right  iliac  fossa. 

Frequent  recurrence  of  pain  with  enlarged  glands  in  the 
abdomen  generally  indicates  some  adhesions  between  the  glands 
and  surrounding  parts.  There  is  a  great  liability  to  the  formation 
of  bands  of  adhesion  between  caseous  glands  and  adjoining  coils 
of  intestine  or  the  parietal  peritoneum,  and  the  pain  may  be  due 


ABDOMINAL  PAINS  173 

to  dragging  of  these  adhesions,  but  it  may  be  due  to  a  more 
serious  cause,  the  catching  of  a  loop  of  intestine  under  one  of 
these  bands  ;  this  accident  I  have  seen  more  than  once  ending 
in  acute  strangulation.  No  doubt  the  colicky  pain  which  some- 
times accompanies  tuberculous  peritonitis  is  due  chiefly  to  drag- 
ging on  adhesions,  and  a  similar  pain  due  to  adhesions  sometimes 
follows  recovery  from  appendicitis,  whether  the  appendix  has 
been  removed  by  operation  or  not. 

Lastly,  it  is  always  to  be  remembered  that  the  earliest  evidence 
of  appendicitis  may  be  vague  pains  in  the  abdomen,  which  may 
not  be  sufficiently  severe  to  excite  any  alarm  in  the  minds  of 
parents  or  even  of  medical  men  until  the  supposed  'stomach- 
ache ',  which  with  a  little  vomiting,  was  thought  to  indicate 
'  bilious  attacks',  declares  its  nature  by  a  sudden  outburst  of  acute 
symptoms  of  appendicitis.  I  have  seen  such  recurring  attacks  of 
slight  pain  mistaken  for  indigestion  or  bilious  attacks  even  when 
the  child  was  under  frequent  medical  observation,  and  I  know 
of  no  way  to  avoid  this  mistake  but  by  repeated  careful  examina- 
tion of  the  abdomen  which  should  never  be  omitted  when  a  child 
complains  of  colicky  pains. 

Treatment 

I  have  grouped  together  in  this  chapter  the  conditions 
which  are  to  be  thought  of  when  a  child  is  brought  to  the 
medical  man  for  the  very  common  complaint  of  *  pains  in  the 
abdomen  ',  for  even  if  it  is  not  always  possible  to  arrive  at  a 
certain  diagnosis  of  the  exact  cause  of  the  pains,  we  can,  at  any 
rate,  by  bearing  in  mind  the  various  possibilities  exclude  some 
of  them  in  the  particular  case,  and  so  avoid  some  serious  errors  in 
treatment.  Obviously  the  treatment  will  vary  according  to  the 
probable  cause,  and  if  no  evidence  of  organic  disease  is  to  be 
found,  and  there  is  no  constipation  to  treat,  the  proper  course 
will  usually  be  to  diet  along  the  lines  laid  down  in  the  chapter 
on  indigestion,  especially  avoiding  those  foods  which  leave 
a  coarse  indigestible  residue,  such  as  brown  bread,  coarse  oat- 
meal, fruit  of  all  sorts  fresh  and  dried,  and  such  vegetables  as 
onions,  celery,  carrot,  turnips,  tomatoes,  and  of  course  all 
pickles.  Potatoes  also  are  best  avoided  in  these  cases.  Some- 
times even  more  important  for  these  children  than  dieting  is 
dentistry  ;  I  have  repeatedly  seen  recurring  colicky  pain  in 
children  rapidly  relieved  by  the  removal  or  stopping  of  carious 
teeth.  If  the  teeth  are  so  few  or  so  bad  that  proper  mastication 


174  COMMON  DISORDERS  OF  CHILDHOOD 

is  impossible,  the  only  thing  to  be  done  is  to  feed  the  child  on 
sopped  bread,  milk  broths,  lightly-boiled  eggs,  boiled  brains, 
pounded  fish,  custard,  blanc-mange,  and  sloppy  food  in  general, 
or  at  any  rate  such  food  as  can  be  sufficiently  broken  up  without 
the  aid  of  the  teeth. 

In  all  such  cases  it  will  be  wise  to  keep  the  bowels  acting  freely, 
but  to  use  for  the  purpose  laxatives  which  are  not  likely  to  gripe 
and  which  are  not  likely  to  retard  digestion.  Paraffin  is  particu- 
larly useful  in  such  cases,  and  most  children  take  it  well.  A 
formula  especially  useful  where  it  is  desirable  to  combine  an 
antifermentative  with  a  laxative  is  the  following,  which  is  in  use 
at  the  Children's  Hospital,  Great  Ormond  Street  : 


Pulv.  Tragacanth.          .          .      gr. 
01.  Amygdal.  Essent.    .          . 
Aq.  Chloroform,  ad       .          . 


11.  Paraflin  Liq.    .  a)  xl 

Sod.  Benzoat.  .  .  .  gr.  2-j 
Calc.  Hypophosph.  .  .  gr.  -f 
Pulv.  Acaciae  .  .  .  gr.  xx 

tcr  die,  ante  cib. 

This  is  suitable  for  a  child  of  five  years  ;  half  this  dose  may  be 
given  to  a  child  of  two  years.  Senna  in  small  doses  two  or  three 
times  a  day  is  good,  either  a  decoction  of  the  senna  pods,  four 
pods  soaked  in  a  wine-glassful  of  hot  water  for  three  or  four  hours, 
half  of  this  to  be  taken  twice  a  day,  or  half  a  drachm  of  syrup 
of  senna  in  a  teaspoonful  of  dill-water,  to  be  taken  two  or  three 
times  a  day  regularly  ;  or  one  of  the  preparations  of  malt  with 
cascara  may  do  good  by  combining  the  diastasic  effect  of  malt 
with  the  laxative  action  of  cascara  ;  this,  however,  must  be  used 
in  small  doses,  say  *-l  drachm  two  or  three  times  a  day,  rather 
than  in  one  big  dose,  which  is  apt  to  gripe. 

I  have  mentioned  above  the  striking  effect  of  pancreatin  in  an 
otherwise  intractable  case  of  abdominal  pains  in  a  young  child  ; 
the  glycerine  of  pepsine  a)  xx  ter  die,  or  Fairchild's  diazyme  in 
doses  of  -J-l  drachm  may  prove  useful,  and  I  have  found  the 
preparations  of  malt  with  pepsine  and  pancreatin  very  beneficial. 
The  pains  which  occur  with  cyclic  albuminuria  can  only  be 
combated  by  reducing  the  irritating  residue  of  food  in  the  intestine 
to  a  minimum  by  care  in  diet  as  suggested  above  ;  it  is  certain 
that  when  the  bowel  shows  that  excessive  nervous  irritability 
which  I  have  described  as  characterizing  the  so-called  lienteric 
or  nervous  diarrhoea,  some  foods  excite  the  pain  and  evacuation 
more  readily  than  others  ;  I  have  noted  particularly  that  hot 
drinks  of  any  kind  and  dried  fruit,  such  as  currants,  were  par- 
ticularly active  in  starting  the  colicky  pains.  So  that  although 
the  irritability  of  the  bowel  may  be  regarded  as  a  nervous  disorder, 


ABDOMINAL  PAINS  175 

it  is  to  be  treated  partly  by  dietetic  measures,  particularly  by 
excluding  all  foods  which  are  likely  to  leave  an  irritating  residue 
in  the  bowel.  The  nervous  excitability  of  the  bowel  in  such  cases 
is  rapidly  relieved  by  Dover's  powder,  which  not  only  stops  the 
frequency  of  evacuation  of  the  bowels,  but  also  causes  speedy 
cessation  of  the  pains  ;  it  should  be  given  in  doses  of  1 J-2  grains 
three  times  a  day  to  a  child  of  five  years  old,  and  2-3  grains  ter 
die  to  a  child  of  ten  years.  Arsenic  has  also  a  markedly  beneficial 
effect  in  these  cases,  and  is  worthy  of  trial  also  for  the  colicky  pains 
of  cyclic  albuminuria. 


CHAPTER  XIII 

INDIGESTION  IN  CHILDREN  PAST  THE  AGE 
OF  INFANCY 

AMONGST  the  common  disorders  of  childhood  perhaps  none  is 
commoner  than  indigestion,  but  it  appears  under  so  many  guises 
that  it  is  little  wonder  if  it  is  often  unrecognized  ;  certain  it  is 
that  the  varied  symptoms  to  which  it  gives  rise  are  often  attri- 
buted to  any  cause  but  the  right  one,  and  a  child  is  dosed  with  this 
and  that  medicine  when  the  one  thing  needful  is  a  revision  of  diet. 

I  shall  not  discuss  here  the  chemistry  or  the  physiology  of 
indigestion,  I  shall  consider  the  disorder  purely  from  the  clinical 
point  of  view  and  as  it  affects  children. 

The  child,  unlike  the  adult,  is  still  in  the  stage  of  active  con- 
struction ;  he  is  or  should  be  steadily  building,  and  therefore 
requires  an  income  sufficient  not  merely  for  the  upkeep  of  a 
structure  already  completed,  but  also  for  the  carrying  on  of  further 
building  ;  and  this  building  must  needs  be  continued  even  if  the 
income  is  insufficient  for  both  purposes  ;  so  that  in  this  case  the 
upkeep  of  the  already  completed  structure  will  suffer.  So  it  is 
that  many  disorders  which  in  the  adult  interfere  only  to  a  slight 
degree  with  the  general  nutrition  produce  a  much  more  noticeable 
degree  of  wasting  in  the  child ;  and  one  such  disorder  is  indigestion. 
How  often  one  hears  that  a  child  is  *  going  so  thin' :  the  appetite 
is  poor,  there  is  perhaps  occasional  pain  in  the  abdomen  ;  the 
child  is  languid  and  complains  of  feeling  tired  after  very  little 
exertion  ;  his  hands  and  feet  are  '  always  cold  ',  he  is  so  dark 
under  the  eyes,  or  perhaps  is  said  to  be  *  puffy  under  the  eyes  ', 
and  it  is  noticed  that  sometimes  his  face  turns  very  white  sud- 
denly as  if  lie  were  going  to  faint.  Such  a  history  as  this  usually 
means  that  the  digestion  is  at  fault  ;  but  the  symptom  that 
troubles  the  mother  most  is  the  wasting  which,  though  usually 
slight  in  degree,  is  sufficiently  obvious  to  a  mother's  eye. 

I  lay  stress  upon  this  wasting,  because  not  only  does  it  arouse 
the  parent's  anxiety,  but  even  to  the  medical  man  it  may  suggest 
possibilities  of  latent  tubercular  mischief,  and  in  those  cases  to 
which  Dr.  Eustace  Smith  gave  the  name  of  mucous  disease, 
where  there  is  with  chronic  indigestion  passage  of  excess  oi: 


INDIGESTION  177 

mucus  with  the  stools  (not  necessarily  with  all),  the  wasting  is 
sometimes  very  marked,  the  skin  becomes  dry  and  harsh,  and 
there  may  even  be  a  short  dry  cough  which  may  add  to  the  sus- 
picion of  tuberculosis,  although  the  effect  of  careful  dieting 
subsequently  shows  that  the  whole  trouble  is  indigestion. 

Next  to  the  wasting  I  suppose  there  is  no  symptom  which 
distresses  a  mother  so  much  as  the  loss  of  appetite,  which  is  a  very 
common  feature  of  indigestion  in  children.  I  would  direct  atten- 
tion especially  to  this  point  because  anorexia  in  young  children 
is  often  a  most  puzzling  and  baffling  symptom  ;  a  child  three  or 
four  years  old  will  sit  down  to  its  meal  and  absolutely  refuse  to 
eat  or  will  eat  so  little  all  day  that  the  parents  become  alarmed, 
and  often  if  an  attempt  is  made  to  coax  the  child  by  feeding  it 
with  a  spoon  the  child  will  actually  retch  as  if  the  very  idea  of 
food  nauseated  him.  Such  a  history  as  this  is  very  typical  of 
indigestion  in  a  young  child  :  Rose  B.,  aged  4~,  was  brought 
for  '  pains  in  the  stomach  '.  These  pains  were  referred  to  the 
epigastric  area,  and  were  only  occasional ;  the  mother  mentioned 
also  that  the  child  '  goes  white  '  suddenly  sometimes,  but  not 
apparently  in  relation  to  the  pains,  her  appetite  was  said  to  be 
very  bad,  after  taking  *  just  a  mouthful  she  says  she  has  had 
enough  '.  Many  times  I  have  been  told  that  a  child  complained 
of  '  feeling  full '  after  eating  only  a  few  mouthfuls,  a  symptom 
very  characteristic  of  indigestion. 

Pain  in  the  abdomen,  sometimes  in  the  epigastrium,  sometimes 
at  the  umbilicus  or  over  the  lower  part  of  the  abdomen,  is  also 
a  common  complaint  ;  the  pain  is  usually  quite  short  and  slight, 
but  sufficient  to  make  the  child  complain,  and  occasionally  it  is 
sharp  enough  to  make  the  child  cry  out  ;  it  is  not  necessarily 
just  after  meals.  As  in  the  case  mentioned  above,  this  is  often 
the  reason  for  bringing  the  child  to  the  doctor,  and  it  is  sometimes 
very  difficult  to  be  sure  of  the  exact  cause  of  the  pain.  The 
association  of  'going  thin  '  with  'pains  in  the  abdomen'  naturally 
suggests  the  possibility  of  some  tubercular  disease,  caseous 
mesenteric  glands,  or  early  tuberculous  peritonitis,  and  not  very 
rarely  sucji  a  possibility  seems  the  more  likely,  as  we  are  told 
that  the  child's  stomach  '  is  so  large  '  owing,  as  is  found  on 
examination,  to  the  chronic  flatulent  distension  of  indigestion. 
One  little  girl  aged  3 \  was  sent  to  me  for  pains  in  the  lower  part 
of  the  abdomen,  which  she  had  had  for  about  six  months  ;  she 
was  said  to  turn  white  with  the  pain,  though  she  did  not  cry  out ; 
she  had  become  more  nervous  lately,  and  did  not  sleep  well. 
She  had  lost  one  pound  in  weight  in  two  months.  The  bowels 

STILL  N 


178  COMMON  DISORDERS  OF  CHILDHOOD 

were  regular,  santonin  had  been  given,  but  no  worms  could  be 
found.  The  tongue  was  only  slightly  furred.  Nothing  abnormal 
was  to  be  felt  in  the  abdomen,  but  this  was  said  to  be  distended 
at  times.  Whilst  in  my  consulting-room,  the  child  had  an 
attack  of  the  pain,  in  which  she  bent  forwards  and  pressed  her 
hand  over  her  abdomen  in  evident  pain,  but  after  a  few  seconds 
she  was  quite  bright  again.  No  tuberculous  glands  could  be  felt, 
and  I  was  of  the  same  opinion  as  her  medical  attendant,  that  the 
pains  were  due  to  digestive  difficulty  ;  in  spite  of  dieting,  how- 
ever, and  various  drugs,  the  pains  were  so  persistent  that  the 
child  was  sent  to  a  surgeon  who  proposed  an  exploratory  laparo- 
tomy  ;  it  was  decided,  however,  to  give  a  further  trial  to  medical 
measures  before  resorting  to  any  surgical  procedure,  and  upon 
administration  of  a  pancreatic  extract,  the  pains  entirely  dis- 
cTppeared,  and  the  child  made  a  good  recovery. 

In  this  particular  case  the  stools  contained  no  mucus,  but  such 
colicky  pains  are  especially  common  where  the  child  frequently 
passes  mucus  in  the  stools.  Both  in  infancy  and  in  early  child- 
hood it  is  very  noticeable  how  often  the  passage  of  mucus  from 
the  bowel  lias  been  preceded  by  colicky  pain  in  the  abdomen,  and 
this  whether  the  mucus  be  due  to  indigestion  or  to  the  presence 
of  worms  ;  and  indeed  there  seems  to  be  a  sufficient  explanation 
to  any  one  who  has  made  many  autopsies  on  children,  in  the 
tenacious  viscid  layer  of  mucus,  which  so  often  coats  a  great 
part  of  the  intestine,  where  for  instance  there  are  threadworms  ; 
the  difficulty  of  driving  such  viscid  material  along  the  intestine 
must  be  great,  and  it  is  no  wonder  if  in  the  effort  to  do  so  the 
bo \vcl  undergoes  a  more  forcible  and  perhaps  irregular  peristalsis 
than  usual,  giving  rise  to  the  sensation  of  colic. 

The  case  to  which  I  have  just  referred  illustrates  another  of  the 
common  symptoms  of  indigestion  in  children,  an  increase  of 
nervous  instability.  Naturally  this  will  be  most  marked  in  the 
child  who  is  of  specially  nervous  temperament,  but  even  in  those 
who  have  hitherto  shown  no  such  tendency  the  nervous  symp- 
toms of  indigestion  are.  sometimes  very  marked.  Sometimes 
thcso  take  tho  form  only  of  frctfulncss  and  tearfulness,  '  the 
child  cries  almost  if  you  look  at  her  '  :  Audrey  B.,  aged  three 
years,  was  brought  to  me  with  the  history  that  for  nearly  six 
months  her  appetite  had  been  bad  and  she  had  suffered  with 
pains  in  the  abdomen;  a  fortnight  ago  she  had  vomited  one  day; 
frequently  she  would  suddenly  turn  a  greyish- white  colour; 
she  was  sometimes  restless,  and  cried  out  in  her  sleep  ;  her 
bowels  were  open  regularly  once  a  day,  but  there  was  mucus  in 


INDIGESTION  179 

the  stools  at  times  ;  there  were  no  worms  ;  lately  her  breath 
had  smelt  unpleasant ;  she  had  some  nocturnal  enuresis  ;  the 
symptom  upon  which  the  mother  laid  special  stress  was  the 
extreme  fretfulness  of  the  child,  and  this  had  become  worse  as 
the  symptoms  of  digestive  disturbance  increased.  Often  sleep 
is  disturbed,  the  child  either  lies  awake  long  after  going  to  bed, 
or  wakes  several  times  in  the  night  and  has  difficulty  in  going  to 
sleep  again, — a  symptom  which  to  my  mind  is  always  suggestive 
of  flatulence  in  stomach  or  bowel.  This  relation  of  insomnia  to 
indigestion  is  worth  remembering  ;  sleeplessness  is  often  an 
exceedingly  troublesome  symptom  both  in  infancy  and  in  child- 
hood and  its  causation  may  be  as  obscure  as  its  treatment  is 
difficult ;  but  if  the  possibility  that  indigestion  may  underlie  it 
is  borne  in  mind,  a  revision  of  the  dietary  may  be  successful 
where  other  measures  have  failed. 

A  common  symptom  of  indigestion  is  the  occurrence  of  night- 
terrors.  The  child  generally  about  an  hour  or  two  after  he  has 
fallen  asleep  starts  up  in  a  half-waking  condition  with  the  eyes 
open  but  recognizing  no  one,  and  screams  in  terror,  and  perhaps 
speaks  of  some  imaginary  object  or  person  at  which  he  is  frightened ; 
with  difficulty  the  child  is  thoroughly  awakened,  and  perhaps 
being  soothed  by  those  about  him  he  goes  off  to  sleep  again,  and 
next  day  has  no  recollection  of  the  night-terror.  These  attacks 
are  particularly  common  with  that  form  of  indigestion  in  which 
the  stools  contain  much  mucus,  the  *  mucous  disease '  already 
mentioned,  but  they  are  also  a  frequent  result  of  the  presence 
of  threadworms  in  the  intestine,  whether  from  the  direct  irrita- 
tion of  the  worms,  or  from  the  mucous  catarrh  which  is  associated 
with  their  presence.  Night-terrors  in  children  are,  I  think,  in 
the  very  large  majority  of  cases  of  intestinal  origin,  and  the 
irritation  of  undigested  food  is  an  important  factor  in  their  pro- 
duction. The  following  case  illustrates  the  association  of  dis- 
turbed sleep  with  indigestion.  Louis  G.,  3|-J,  was  brought  to 
me  because  his  appetite  was  very  poor  and  he  suffered  with 
sleeplessness.  On  going  to  bed  he  quickly  fell  asleep,  but  would 
wake  about  10  p.m.  and  lie  awake  till  4  a.m.  ;  on  several  occasions 
he  had  started  up  screaming  in  fright,  with  the  usual  symptoms 
of  night-terror  ;  on  other  nights  he  would  sob  for  hours  in  his 
sleep.  He  was  pale  and  puffy  under  the  eyes,  his  abdomen  was 
very  large,  and  he  had  occasional  colicky  pains  ;  his  motions 
contained  some  mucus  but  no  worms. 

The  complaint  that  a  child  '  changes  colour  ',  that  is,  goes  very 
pale  frequently  without  obvious  cause,  is  exceedingly  common, 

N2 


180  COMMON  DISORDERS  OF  CHILDHOOD 

and  points  I  think  almost  invariably  to  gastro-intcstinal  disorder, 
whether  it  be  indigestion  as  it  usually  is,  or  the  mucous  catarrh 
which  is  associated  with  the  presence  of  threadworms.  The 
pallor  comes  on  quite  suddenly  and  passes  off  after  some  minutes. 
At  one  time  I  supposed  that  it  was  never  accompanied  by  loss  of 
consciousness,  but  I  have  found  that  rarely  the  child  does  actually 
lose  consciousness,  and  may  even  sink  down  as  in  a  faint.  The 
term  '  vasomotor  epilepsy  '  has  been  applied  to  this  symptom, 
but  it  seems  to  me  in  every  way  a  most  undesirable  name,  for  it 
suggests  a  relationship  to  ordinary  epilepsy  for  the  existence  of 
which  we  have  no  warrant  whatever  ;  indeed,  the  clinical  fact 
that  there  seems  to  be  no  tendency  for  such  attacks  to  be  replaced 
by  any  other  epileptic  manifestations,  is  strongly  opposed  to 
any  such  relationship  ;  it  is  not  even  proved  that  the  pallor  is 
due  to  any  primary  vascular  disturbance  ;  it  is  quite  conceivable, 
indeed  it  is  probable,  that  the  pallor  is  due  to  cardiac  inhibition. 
It  is  evident  that  the  heart's  action  may  be  considerably  affected 
by  indigestion,  for  the  coldness  and  the  blueness  of  the  hands 
and  feet,  which  is  a  very  common  symptom  of  indigestion  at  all 
ages  from  infancy  upwards,  is  most  reasonably  attributed  to 
feebleness  of  cardiac  action. 

'  My  child  is  always  so  tired,  he  never  used  to  be  so,  but  now 
he  complains  of  feeling  tired  after  he  has  walked  ever  so  little  ' ; 
this  is  a  tale  that  one  hears  again  and  again,  and  the  subject  of 
it  is  generally  a  child  with  just  such  symptoms  as  I  have  already 
described — a  pale  or  sallow  child,  probably  'getting  thin'  lately, 
with  a  poor  appetite,  and  occasional  slight  pain  in  the  abdomen, 
with  cold  hands  and  feet,  and  perhaps  a  furred  tongue  and  costive 
bowels ;  in  fact,  the  symptoms  which  go  with  the  tiredness  are 
those  of  chronic  indigestion. 

The  appearance  of  the  child  is  often  in  itself  sufficient  to  sug- 
gest some  feebleness  of  digestion:  the  complexion  lacks  the  clear 
rod  tinge  of  health,  it  is  of  a  pale  white  or  sallow  opaque  colour, 
not  necessarily  with  pallor  of  mucous  membranes;  there  may 
indeed  be  no  actual  anaemia  ;  but  much  more  characteristic  is  the 
appearance  about  the  eyes,  which  is  well  described  by  the  mother 
as  '  dark  under  the  eyes  ',  or  '  dark  rings  around  the  eyes  '.  In 
other  cases  there  is  a  translucent  bluish  puffiness  of  the  eyelids, 
most  often  I  think  in  the  lower  eyelid.  The  dependence  of  these 
appearances  about  the  eyes  upon  indigestion  is  extremely  frequent ; 
both  of  them,  however,  are  also  associated  with  the  presence  of 
threadworms  in  the  intestine.  It  is  curious  how  many  symptoms 
are  common  to  indigestion  in  children  and  to  the  presence  of  these 


INDIGESTION  181 

worms  in  the  bowel.  I  have  often  thought  that  the  explanation 
may  lie  in  the  fact  that  both  conditions  produce  a  mucous  catarrh 
in  the  bowel,  and  that  it  is  this  common  factor  rather  than  the 
particular  form  of  irritation  of  the  intestinal  tract  which  deter- 
mines the  symptoms.  Puffiness  under  the  eyes  is,  of  course, 
not  peculiar  to  these  conditions  :  I  have  often  noticed  it  in 
children  with  cyclic  albuminuria,  but  the  doubt  has  arisen  in  my 
mind  whether  in  these  cases  also  there  may  not  be  some  digestive 
difficulty,  a  possibility  which  is  also  suggested  by  another,  not 
very  rare,  association  with  cyclic  albuminuria,  colicky  pains  in 
the  abdomen.  The  puffiness  which  accompanies  wrhooping- 
cough  and  nephritis  is  usually  more  marked,  and  less  limited  to 
the  eyelids  than  is  that  of  indigestion  ;  but  occasionally  with 
indigestion  only,  and  perhaps  particularly  where  the  child  is 
passing  excess  of  mucus  in  the  stools,  the  puffiness  of  the  eyes  is 
so  marked  as  to  suggest  one  or  other  of  these  diseases. 

Enlargement  of  the  abdomen  is  by  no  means  always  present 
with  indigestion,  but  it  is  very  frequent  ;  I  frequently  see 
children  concerning  whom  the  mother's  chief  anxiety  is  that 
'  the  stomach  is  so  large  ' ;  and  well  it  may  be,  for  the  child  is 
usually  being  fed  on  a  diet  in  which  bread-and-butter  and  por- 
ridge and  potatoes  and  fruit  play  far  too  large  a  part.  As  in  the 
infant  in  the  first  two  years  of  life,  the  abdominal  enlargement 
which  results  from  chronic  flatulent  distension  in  these  older 
children  sometimes  leads  diagnosis  astray,  and  abdominal  tuber- 
culosis is  suspected  where  only  digestion  is  at  fault.  The  distinc- 
tion lies  chiefly  in  the  evidence  from  palpation,  the  characteristic 
doughy  or  infiltrated  feeling  of  tuberculous  peritonitis  is  lacking, 
no  abnormal  masses  can  be  felt,  and  inquiry  almost  always 
elicits  a  history  of  other  symptoms  such  as  I  have  described 
pointing  to  indigestion. 

The  child  with  chronic  indigestion  sometimes  complains  of 
nausea,  and  there  may  be  vomiting,  perhaps  once  or  twice  at 
intervals  of  a  week  or  two  :  sometimes  the  vomiting  seems  to 
coincide  with  a  definite  exacerbation  of  digestive  disorder,  the 
breath  becomes  offensive,  the  tongue  furred,  and  the  complexion 
sallow,  and  therewith  the  child  vomits  two  or  three  times  within 
a  day  or  two,  and  perhaps  the  temperature  rises  to  100°  or  101°  ; 
probably  the  mother  calls  this  a  '  bilious  attack  ',  but  the  history 
and  the  result  of  dieting  shows  that  although  the  acute  attack 
lasts  only  a  couple  of  days  or  so,  it  is  part  of  a  much  more  chronic 
disturbance  of  digestion. 

The  stools  in  such  an  exacerbation  are  very  apt  to  be  pale  in 


182  COMMON  DISORDERS  OF  CHILDHOOD 

colour,  or  even  white  ;  and  here  I  would  point  out  how  common 
is  paleness  or  actual  whiteness  of  stools  in  the  dyspepsias  both  of 
infancy  and  of  early  childhood.  No  doubt  this  absence  of  pig- 
ment from  the  stools  means  some  deficiency  in  the  function  of 
the  liver.  The  late  Dr.  Cheadle  l  pointed  out  that  in  the  cases 
of  wasting  with  white  stools,  to  which  he  gave  the  name  of 
acholia,  bile  pigment  and  bile  acids  may  be  completely  absent 
from  the  fa3oes ;  but  it  would  be  a  pity  if  this  absence  of  bile 
from  the  stools  were  regarded  as  always  constituting  a  disease 
sui  generis,  it  is  rather  a  symptom,  and  a  very  common  one,  of 
indigestion,  especially  in  infancy  and  early  childhood.  It  seems 
certain  that  both  the  liver  and  the  pancreas  sometimes  fail  to 
contribute  their  share  to  the  digestive  secretions  in  the  bowel, 
and  it  may  be  that,  as  Dr.  Cheadle  suggested,  the  irritation  of 
dentition  exercises  some  reflex  inhibitory  influence  upon  these 
organs;  but  I  think  that  more  often  the  inhibiting  influence 
is  from  irritating  material  in  the  bowel,  and  that  the  pale  or  fatty 
stools  are  the  indication  of  deficiency  in  hepatic  or  pancreatic 
function,  and  are  usually  a  secondary  phenomenon ;  certainly 
they  often  do  not  make  their  appearance  until  there  has  been 
for  days  or  even  weeks  obvious  evidence  of  indigestion. 

The  offensive  odour  of  the  breath  which  I  have  mentioned 
incidentally  is  another  complaint  for  which  children  with  indi- 
gestion are  brought  to  the  doctor ;  of  course  there  are  other  reasons 
which  may  account  for  this  trouble,  foul  and  carious  teeth, 
decomposing  secretion  in  the  crypts  of  chronically  enlarged 
tonsils,  not  to  mention  the  much  more  pungent  offensiveness  of 
oziena,  or  of  bronchiectasis,  but  the  heavy  unpleasant  odour  of 
the  breath  in  indigestion  is  usually  less  persistent  than  in  these 
conditions,  and  certainly  has  none  of  the  metallic  nauseating 
smell  of  ozrciia  or  bronchiectasis  ;  it  is  usually  diminished  or 
abolished  for  a  time  by  a  dose  of  calomel,  but  to  prevent  its 
recurrence  careful  modification  of  diet  may  be  necessary. 

There  is  another  curious  symptom  of  which  children  sometimes 
complain,  and  I  have  several  times  had  them  brought  to  me  on 
account  of  it,  namely, '  shortness  of  breath  after  meals' :  the  child 
has  a  sensation  of  being  unable  to  get  air  enough,  in  fact  suffers 
with  a  kind  of  air  hunger,  so  that  he  takes  a  deep  inspiration  at 
intervals,  and  may  even,  as  in  one  case  under  my  observation, 
want  the  windows  opened,  so  that  he  may  get  more  air.  As 
an  isolated  symptom  this  might  puzzle  any  one  who  is  not 
familiar  with  it  ;  but  it  is  so  characteristic  of  indigestion  that 
1  Lancet,  May  30,  1903. 


INDIGESTION  183 

once  known  it  should  always  suggest  this  cause.  Children  also, 
like  adults  with  dyspepsia,  sometimes  complain  of  palpitation 
or  rather  of  distress  and  discomfort,  which  are  found  to  be  asso- 
ciated with  violent  beating  of  the  heart.  Lionel  C.,  aged  3|  years, 
was  brought  to  me  for  such  attacks  :  ten  days  previously  just 
after  his  dinner  he  had  seemed  ailing,  and  it  was  found  that  the 
heart  was  palpitating  violently,  and  continued  to  do  so  for  a  few 
minutes,  then  the  attack  ceased  ;  there  was  no  recurrence  until 
five  days  ago,  when  about  two  hours  after  dinner  a  similar  attack 
occurred  again  ;  a  bismuth  and  soda  mixture  prevented  a  recur- 
rence of  attacks. 

In  the  early  years  of  childhood,  up  to  five  or  six  years  of  age, 
as  in  the  first  two  years  of  life,  one  indication  of  digestive  disorder 
is  lichen  urticatus  ;  it  is,  however,  far  less  common  in  these 
older  children  than  in  infants.  Peggy  D.,  aged  8J  years,  was 
brought  to  me  because  she  had  become  so  nervous  lately  ;  she 
was  afraid  to  go  upstairs  in  broad  daylight  alone,  and  at  night 
she  was  terrified  if  left  by  herself  ;  lately  also  she  was  '  always 
tired  ',  and  it  was  noticed  that  she  turned  pale  suddenly  at 
times  ;  her  appetite  was  very  variable,  her  bowels  costive,  and 
she  complained  at  times  of  pain  about  the  navel.  Spots  (of  lichen 
urticatus)  some  of  which  were  present  when  I  saw  her,  came 
out  occasionally.  This  was  in  every  way  a  characteristic  history 
of '  the  child  with  chronic  indigestion,  but  the  lichen  urticatus 
is,  in  my  experience,  not  a  very  common  feature  at  this  age. 

A  much  more  rare  result  of  chronic  indigestion  is  a  curious 
dryness  of  the  hair,  which  looks  '  dead  ',  loses  its  natural  gloss, 
and  easily  comes  out,  so  that  the  hair  becomes  sparse  ;  this  is 
probably  not  peculiar  to  chronic  indigestion,  but  I  have  notes 
of  cases  in  which  the  child's  ill  health  was  apparently  the  result 
only  of  chronic  indigestion,  e.g.  Grace  R.,  aged  four  years,  was 
brought  for  occasional  attacks  of  vomiting  and  offensiveness  of 
stools  ;  she  turned  pale  often  suddenly  ;  her  breath  often  smelt 
unpleasant :  her  hair  lately  had  become  very  dry  and  dull- 
looking,  and  came  out  easily.  There  was  no  physical  sign  ;  the 
child  was  fairly  nourished,  and  apart  from  her  indigestion,  the 
child  seemed  healthy. 

Treatment 

I  turn  now  to  the  treatment  of  indigestion  in  childhood,  and 
first  I  would  emphasize  the  fact  that  faulty  digestion  does  not 
necessarily  mean  faulty  diet.  In  every  case  it  is  right  and 
necessary  to  investigate  the  diet  carefully,  but  there  are  other 


184  COMMON  DISORDERS  OF  CHILDHOOD 

points  to  be  considered.  Again  and  again  I  have  seen  children 
suffering  with  severe  symptoms  of  indigestion  whose  diet  was 
excellent  but  whose  teeth  were  atrocious,  and  a  few  visits  to  the 
dentist  have  cured  the  dyspeptic  symptoms  which  would  have,  and 
sometimes  had  already,  been  treated  in  vain  with  dieting  or  drug. 
In  some  of  these  cases  the  trouble  arises  from  actual  deficiency 
of  teeth,  the  child  has  lost  some  of  the  upper  or  lower  molars  on 
one  or  both  sides,  so  that  the  remaining  molar  is  little  or  no  use, 
having  no  corresponding  tooth  in  the  lower  or  upper  jaw,  as  the 
case  may  be,  to  bite  upon  ;  in  others  not  only  is  the  bite  of  some 
of  the  teeth  prevented  by  the  broken-away  carious  condition  of 
the  corresponding  tooth,  but  the  tenderness  of  the  teeth  and  fear 
of  pain  prevents  the  child  from  masticating  its  food,  which  is 
therefore  bolted  without  proper  chewing. 

Even  without  decayed  teeth,  children  are  only  too  apt  to  bolt 
their  food  without  proper  mastication  ;  with  many  this  is  simply 
faulty  habit,  and  to  some  extent  means  faulty  training,  and  may 
be  remedied  by  admonition,  but  it  is  often  a  habit  very  difficult 
to  break,  and  it  may  be  necessary  for  a  time  to  keep  the  child 
upon  '  sloppy  '  foods,  to  overcome  the  digestive  disturbance  ; 
certainly,  if  there  is  any  tendency  to  bolt  food,  it  should  all  be 
reduced  as  far  as  possible  to  a  thoroughly  broken  up  condition 
before  it  is  given  ;  fish,  meat,  or  poultry  should  be  shredded,  or 
pounded,  or  very  finely  minced,  and  potato  should  be  mashed  so 
thoroughly  as  to  be  reduced  to  a  powdery  or  flakey  consistence, 
and  similarly  other  foods  should  be  given  as  finely  divided  as 
possible. 

But  food-bolting  is  not  always  the  result  of  mere  faulty 
habit  or  of  decayed  teeth,  it  is  the  result  in  some  cases  of 
faulty  domestic  or  school  arrangements  ;  in  our  top-speed 
twentieth  century  life  even  a  child  suffers  from  the  all-pervading 
rush,  and  ten  minutes  have  to  serve  to  dispatch  a  meal  in  time  to 
catch  the  train  or  electric  car  to  school,  and  it  is  little  wonder  if 
the  hastily  swallowed  meal  is  ill  digested  :  often  a  different 
arrangement  of  the  meal-time  could  be  made  so  as  to  leave  the 
children  ample  time  for  a  leisurely  meal  before  it  is  time  for  school. 
Nor  is  it  only  the  exigencies  of  school  which  are  responsible  for 
too  hasty  meals  ;  a  child  even  in  its  earliest  years  often  takes 
more  interest  in  games  than  in  meals,  and  if  he  be  interrupted  in 
the  midst  of  some  interesting  game  to  come  to  a  meal,  will  hurry 
over  it,  if  allowed  to  do  so,  in  order  to  return  as  soon  as  possible 
to  his  play.  This  should  not  bo  permitted  either  at  school  or  at 
home  :  by  insisting  upon  the  child's  remaining  at  table  until  his 


INDIGESTION  185 

less-hurrying  companions  have  finished  their  meal,  or  until  a 
proper  time  has  been  spent  at  table,  this  inducement  to  food- 
bolting  might  be  avoided.  Mothers  and  nurses  are  sometimes 
responsible  for  this  habit  by  actually  hurrying  a  child,  and  telling 
him  to  *  be  quick  and  finish  his  meal '.  Of  course  there  are 
many  children  who  if  not  corrected  will  dilly-dally  over  food, 
paying  so  little  attention  to  it,  that  quite  an  inordinate  time  may 
be  spent ;  but  this  is  no  justification  for  making  a  child 
swallow  its  meals  hurriedly.  In  the  case  of  little  children  about 
three  or  four  years  of  age,  who  '  play  with  their  food  ',  as  the 
mother  says,  I  have  seen  a  mother  or  nurse  hasten  the  completion 
of  the  meal  by  feeding  the  child  with  a  spoon  at  such  a  pace  that 
the  child  had  scarce  time  to  take  breath  between  the  spoonfuls, 
and  in  one  case  the  mother  herself  noticed  that  the  child,  owing 
to  this  hasty  feeding,  suffered  with  indigestion  and  vomited  after 
these  lightning  meals. 

One  other  point  in  domestic  arrangement  ;  the  -time  of 
the  midday  sleep  in  relation  to  food  is  not,  I  think,  altogether 
unimportant.  It  goes  without  saying  that  this  excellent 
institution  should  be  kept  up  as  long  as  it  is  practicable. 
I  like  it  continued,  if  possible,  until  the  child  is  fully  seven 
years  old,  but  I  do  not  think  that  it  is  wise  that  a  child 
should  be  put  to  sleep  immediately  after  his  dinner,  nor  that  he 
should  take  his  dinner  immediately  after  awakening  ;  either 
practice  is  apt,  so  it  has  seemed  to  me,  to  favour  indigestion  : 
the  best  time  for  the  sleep  is  before  dinner,  but  so  that  the  child 
is  up  again  and  running  about  for  half  an  hour  before  the  mid- 
day meal.  Such  details  may  seem  trivial,  but  nothing  that  plays 
a  part  in  the  production  of  ill  health  should  be  beneath  the  notice 
of  a  physician  ;  the  whole  train  of  symptoms  which  are  associated 
with  indigestion  may  arise  from  causes  such  as  these. 

The  diet  has  now  to  be  considered,  and  I  shall  preface  my 
remarks  on  this  subject  by  two  pieces  of  practical  advice,  which 
are  of  wide  application  in  dietetics  :  the  first  is  this,  in  recom- 
mending this  or  that  article  of  food,  never  forget  that  what  is 
one  person's  meat  is  another  person's  poison  :  the  second  has 
been  oft  quoted,  but  will  bear  repetition ;  it  is  this,  never 
advise  what  a  patient  should  eat  until  you  know  what  he 
does  eat.  We  cannot  always  know  from  personal  observation 
the  idiosyncrasies  of  a  particular  child  whom  we  are  called  upon 
to  diet,  but  it  is  well  to  recognize  that  some  children  have  such 
idiosyncrasies  ;  the  more  I  see  of  children  the  less  I  am  inclined 
to  pooh-pooh  the  mother's  tale  that  the  child  v  cannot  take  this 


186  COMMON  DISORDERS  OF  CHILDHOOD 

or  that  food  '.  It  may  be  perfectly  true  as  a  generalism  that 
a  particular  food  is  an  excellent  one,  and  an  easily  digestible  one, 
but  it  may,  nevertheless,  be  anything  but  a  suitable  food  for  a 
particular  child  ;  eggs,  for  instance,  are  most  valuable  in  the 
feeding  of  children,  and  are  often  the  best  food  to  replace  some 
of  the  starchy  foods  which  so  commonly  cause  indigestion,  but 
there  are  healthy  children  who,  in  spite  of  a  liking  for  eggs,  are 
made  sick  by  the  smallest  quantity  of  egg,  even  when  it  is  given 
without  their  knowledge  in  their  food.  As  an  unusual  instance 
of  intolerance  of  a  particular  food,  I  may  quote  the  case  of  a 
boy  about  fourteen  years  of  age  who  was  said  to  be  unable  to 
take  porridge  because  it  was  alleged  the  face  swelled  after  he  had 
eaten  this  food.  Whilst  he  was  under  my  observation  a  plate  of 
porridge  was  given  one  day  for  breakfast ;  before  the  meal  was 
finished  the  left  half  of  the  face  was  beginning  to  swell,  and  by 
the  time  I  saw  the  boy  about  twenty  minutes  later  the  swelling 
was  so  considerable  that  the  left  eye  was  almost  completely 
closed  by  oedema  of  the  lids  ;  after  a  few  hours  the  swelling- 
disappeared.  These  cases  of  so-called  angeioneurotic  oadema 
are,  of  course,  very  exceptional,  but  they  serve  to  emphasize  the 
i  mportance  of  the  personal  equation  in  matters  of  diet. 

The  ascertaining  what  a  child  does  eat,  requires  some  care  ; 
a  mother  is  very  apt  to  give  the  doctor  an  admirable  outline  of 
an  ideal  diet,  which  represents  the  truth,  but  not  the  whole  truth  ; 
she  mentions  an  egg  or  some  bacon  fat  with  bread  and  butter  for 
breakfast,  a  midday  meal  of  chicken  or  joint  followed  by  milk 
pudding,  and  tea  consisting  of  bread  and  butter  with  sponge 
cako  and  milk,  but  she  omits  to  mention  that  the  child  has  a  raw 
apple  before  breakfast,  that  the  bread  eaten  is  whole-meal  bread, 
that  the  child  has  a  special  liking  for  potatoes  and  makes  the  mid- 
day meal  chiefly  of  potato,  and  that  sweets  and  biscuits  are  eaten 
at  odd  times  between  meals,  and  that  he  sometimes  stays  up 
at  night  to  dinner  with  his  parents,  and  then  has  just  a  taste 
of  whatever  is  going,  including  perhaps  some  pastry  and  a  few 
nuts  at  dessert.  The  diet  must  be  ascertained  in  detail  ;  it  is 
commonly  the  details  which  are  at  fault  rather  than  the  general 
plan. 

Now,  as  to  food  for  children  past  the  age  of  infancy,  I  think 
it  may  be  laid  down  as  a  useful  general  rule  that  the  dyspepsia 
of  childhood  is  most  commonly  a  carbo-hydrate  dyspepsia  :  cer- 
tainly in  the  large  majority  of  cases  treatment  upon  this  hypo- 
thesis gives  the  best  result.  There  are  children  who  prefer  bread 
and  butter  to  almost  any  other  food,  and  by  cramming  them- 


INDIGESTION  187 

selves  with  what  Shakespeare  aptly  describes  as  *  distressful 
bread',  they  set  up  a  condition  of  chronic  flatulent  distension  of 
the  abdomen,  so  that  the  child  is  brought  to  the  doctor  because 
'the  stomach  is  so  big',  and  'the  child  is  getting  thin'.  For 
the  child  with  indigestion  it  is  generally  advisable  to  cut  down 
the  amount  of  bread  to  a  minimum  :  unfortunately  it  is  difficult 
to  find  anything  to  replace  bread  satisfactorily,  but  by  adding 
something  of  a  different  nature  to  the  meals,  for  instance,  giving 
some  bacon  or  fish  for  breakfast,  and  an  egg  for  tea,  we  can 
satisfy  the  child's  appetite  with  less  bread,  and  I  think  that  even 
plain  light  biscuits,  such  as  'cream  crackers'  or  Marie  biscuits,  or, 
still  better,  one  of  the  various  babies'  biscuits,  such  as  Robb's 
Biscuits,  or  Hill's  Malted  Rusks,  which  may  be  eaten  dry  with  some 
butter,  are  less  harmful  for  these  children  than  bread.  I  think 
also  that  bread  soaked  in  milk  is  less  indigestible  than  dry  bread, 
and  a  teacupful  of  this  sopped  bread  may  form  part  of  breakfast 
or  tea.  Plain  Madeira  cake,  of  course  only  to  the  extent  of  a  small 
slice,  may  also  form  part  of  the  tea,  and  is,  I  think,  generally 
more  suitable  in  these  cases  than  sponge  cake,  which  is  apt  to 
be  tough  and  dry.  I  often  find  that  a  child  with  chronic  indi- 
gestion is  having  brown  bread,  which  the  mother  supposes  to  be 
more  nourishing  than  white  bread.  I  am  convinced,  from  my 
own  observation,  that  brown  bread  is  often  responsible  for 
digestive  trouble  in  children.  It  is  very  noticeable  how  easily 
the  mucous  membrane  of  the  intestinal  tract  is  irritated  in 
children  so  that  excess  of  mucus  is  passed  in  the  stools,  or  the  child 
has  colicky  pains  and  wastes,  when  foods  are  habitually  given 
which  leave  much  coarse  residue  in  the  bowel ;  such  a  food  is 
brown  bread,  and  the  coarser  the  brown  bread  the  worse  the 
result.  Whole-meal  bread,  for  instance,  is  particularly  bad  for 
such  cases,  indeed  I  doubt  if  it  is  ever  wise  to  give  a  coarse  brown 
bread  to  children.  Let  any  one  who  doubts  the  irritating  capa- 
bilities of  such  bread  give  it  for  a  couple  of  days  to  a  child  of  four 
or  five  years  old,  and  then  observe  the  stools,  which  are  seen 
even  with  the  naked  eye  to  be  studded  with  coarse  husk-like 
particles  of  entirely  undigested  grain.  There  is  one  more  point 
to  which  I  would  draw  attention  in  connexion  with  bread, 
namely,  the  erroneous  idea  that  bread  becomes  more  digestible 
when  it  is  toasted  :  so  far  from  this  being  the  case,  I  venture  to 
assert  that  as  a  rule  toast  is  far  more  likely  to  cause  indigestion 
than  untoasted  bread,  especially  when,  as  usually  happens,  only 
the  outer  surfaces  of  the  bread  are  toasted,  leaving  the  middle 
portion  tougher  or  less  easily  broken  up  by  the  teeth  and  mixed 


188  COMMON  DISORDERS  OF  CHILDHOOD 

with  the  saliva  than  is  plain  untoasted  bread.  Hot  buttered 
toast  is  even  more  objectionable  in  this  respect. 

Amongst  breakfast  dishes  there  is  one  which  is  a  fruitful 
source  of  trouble  in  children,  namely,  oatmeal  porridge.  Let 
me  not  be  misunderstood  ;  every  one  knows  that  porridge  suits 
many  children  excellently,  but  none  the  less  it  is  true  that  many 
children  with  symptoms  of  indigestion  will  begin  to  improve 
directly  the  breakfast  porridge  is  discontinued.  One  symptom 
in  particular  I  have  repeatedly  noticed  to  clear  up  when  the 
porridge  was  stopped,  namely,  lack  of  appetite  for  the  rest  of 
the  meals.  Oatmeal  porridge,  when  made  with  a  coarse  or 
medium  oatmeal,  gives  much  the  same  appearance  in  the  faeces 
as  does  brown  bread ;  the  undigested  fragments  of  oatmeal  can  be 
seen  scattered  throughout  the  stool,  and  may  well  keep  up  that 
chronic  mucous  catarrh  of  the  intestine  which  is  so  common 
a  feature  with  dyspepsia  in  childhood. 

In  connexion  with  the  child's  dinner,  potatoes  are  one  of  the 
most  troublesome  foods  :  most  children  are  very  fond  of  potato, 
and  many  children  suffer  much  from  it.  For  the  child  who  is 
passing  much  mucus  with  the  stools,  potato  and  fruit  are  par- 
t  icularly  harmful.  It  is  generally  wisest  in  such  cases  to  prohibit 
potato  altogether  for  a  few  months,  and  then  to  have  it  all 
thoroughly  mashed  with  a  proper  potato-squeezer,  not  with 
a  fork,  which  allows  unbroken  pieces  to  pass  between  the  prongs. 
In  theory  potato  should  be  an  easily  digestible  form  of  starch, 
but  where  a  child  masticates  badly  I  have  seen  pieces  almost  as 
large  as  a  filbert  passed  unaltered  in  the  stool,  and  even  when  the 
child  does  not  apparently  bolt  it  unmasticated  it  still  seems  to 
cause  irritation  in  some  children. 

Of  other  vegetables  I  like  best  for  children  with  weak  diges- 
tion green  vegetables  without  stalk,  such  as  spinach,  the  head 
of  asparagus,  the  leaf  of 'greens ',  thoroughly  mashed  Brussels 
sprouts,  and  the  head  of  cauliflower  and  seakale,  also  well  mashed ; 
vegetable  marrow,  too,  generally  agrees  well  ;  but  artichokes, 
carrots,  turnips,  and  onions,  are  to  be  avoided. 

In  the  way  of  meats,  roast  beef  (not  salt  beef)  or  mutton  are 
generally  suitable  ;  there  are  some  children  who  seem  to  digest 
mutton  better  than  beef  ;  either  should  be  given  underdone  if 
the  child  will  take  it  so  :  breast  of  chicken  or  turkey,  boiled  sole, 
plaice,  turbot  or  hake,  any  of  these  are  good  :  sweetbreads  and 
tripe,  the  latter  boiled  in  milk  and  served  with  bread  sauce  with- 
out onion,  are  easy  of  digestion  :  brains  also  boiled  in  milk  and 
mashed  up  with  bread  sauce  make  an  excellent  food,  but  one 


INDIGESTION  189 

which  only  a  few  children  will  take.  For  breakfast,  the  gravy  of 
fried  bacon,  and  for  children  past  the  age  of  three  years  a  little 
well-minced  fat  of  the  bacon  is  a  valuable  food  ;  most  children 
like  it,  especially  with  bread  crumbled  and  soaked  or  fried  in  the 
gravy.  Eggs,  as  I  have  already  suggested,  may  be  given  for  tea 
if  not  for  breakfast.  I  often  order  eggs  both  for  breakfast  and 
tea  for  children  who  take  them  well.  As  a  useful  addition  to 
tea,  also,  sardines  can  be  given  occasionally,  most  children  like 
them  and  take  them  without  any  digestive  difficulty. 

One  of  the  chief  offenders  in  the  dyspepsia  of  childhood,  is 
fruit.  As  a  rule  this  is  being  given  with  the  idea  of  preventing 
constipation,  and  the  result  is  anything  but  satisfactory.  In 
the  first  place  the  bowels  gradually  become  accustomed  to  the 
irritating  indigestible  residue  of  the  fruit  upon  which  its  laxative 
effect  depends,  so  that  more  and  more  fruit  is  required  to  fulfil 
the  purpose  :  in  the  second  place  this  same  indigestible  residue 
sets  up  a  chronic  mucous  catarrh  of  the  intestine  which  may 
interfere  considerably  with  nutrition.  To  give  a  child  a  raw 
apple  half  an  hour  before  breakfast  and  a  banana  after  breakfast 
is  quite  sufficient  in  many  cases  to  keep  up  a  troublesome  chronic 
indigestion.  I  mention  these  t\vo  fruits  in  particular  as  being 
specially  productive  of  digestive  trouble  :  there  is  a  popular 
misconception  as  to  the  banana  ;  it  is  supposed  to  be  easily 
digestible  :  the  fibres  which  run  lengthwise  down  the  centre  of 
the  banana  are  so  indigestible  that  they  are  often  passed  almost 
unaltered  in  the  stools.  I  have  more  than  once  had  children 
brought  to  me  by  their  parents  on  account  of  the  appearance  of 
extraordinary  worms  in  the  stool,  the  '  Worms  ',  as  it  turned  out 
on  examination  of  the  faeces,  were  nothing  but  undigested  banana 
fibres.  At  any  time  of  day  a  raw  apple  is  likely  to  aggravate 
indigestion  in  a  child,  but  one  can  hardly  imagine  a  worse  time 
to  give  it,  or  any  other  fruit,  than  an  hour  or  half  an  hour  before 
breakfast,  thereby  taxing  the  digestive  powers  heavily  just  before 
they  should  be  applied  unimpaired  to  the  task  of  breakfast. 

If  fruits  are  to  be  given  at  all  they  should  either  form  part  of 
one  of  the  three  main  meals  of  the  day,  or  should  be  given  at  a 
time  which  is  not  less  than  two  hours  distant  from  the  preceding 
and  coming  meal,  for  instance,  at  11  a.m.,  when  breakfast  is  at 
8  a.m.  and  dinner  at  1.30  p.m.  But  purely  as  a  matter  of  experi- 
ence I  would  strongly  urge  those  who  have  to  deal  with  children's 
indigestion  to  forbid  all  raw  fruit,  except  possibly  the  juice  of 
grapes  and  of  orange,  though  even  these  will  have  to  be  stopped 
in  some  cases.  Any  food  that  contains  much  indigestible  pip 


190  COMMON  DISORDERS  OF  CHILDHOOD 

or  fibre  is  bad,  and  for  this  reason  pears  and  figs,  whether  cooked 
or  uncooked,  are  harmful  ;  and  the  dried  fruits,  currants,  sul- 
tanas, and  raisins  are  bad.  Of  cooked  fruits  the  juice  of  any 
stewed  fruit  without  the  substance  of  the  fruit  can  be  given; 
in  this  way  prune  juice  may  be  allowed,  but  the  prune  itself 
is  to  be  forbidden  on  account  of  its  skin.  A  soft-baked  apple 
seldom  does  any  harm. 

On  similar  lines  the  choice  of  jams  is  limited  ;  it  is  generally 
u  ise  to  forbid  all  the  ordinary  jams  which  contain  the  substance 
of  the  fruit  (including  its  pips  or  skins)  and  to  replace  these  by 
the  clear  fruit  jellies  which  can  now  be  obtained  almost  any- 
where. For  children  who  like  very  sweet  things  honey  or  black 
treacle  or  golden  syrup  is  allowable,  and  Frame  Food  Jelly  is 
good,  having  the  advantage  that  it  has  some  diastasic  value. 

So  far  I  have  dealt  only  with  eatables,  but  I  would  not  have  it 
thought  that  indigestion  comes  only  from  what  a  child  eats,  it  may 
come  from  what  the  child  drinks.  A  common  fault  is  excess  of 
milk  in  a  child's  diet  ;  I  see  many  children  of  seven  or  eight  years 
old  who,  in  addition  to  a  substantial  dietary,  are  made  to  drink 
a  quart  of  milk  a  day,  in  which  perhaps  milk  sops  and  milk 
puddings  arc  not  included,  and  then  the  parents  wonder  that  the 
tongue  is  furred,  and  the  breath  heavy-smelling,  and  the  child 
seems  languid  and  evidently  has  indigestion.  By  all  means  let 
a  child  have  as  much  milk  as  it  can  easily  digest,  but  remember 
that  it  is  quite  possible  to  overdo  this  important  item  in  the  diet. 
It  is  often  advisable  to  dilute  milk  slightly  for  children  with 
indigestion,  and  in  some  cases  the  child  will  be  better  if  the 
amount  of  milk  is  greatly  reduced.  Tea  and  coffee,  of  course, 
should  not  be  allowed  at  all  to  the  child  with  indigestion,  and 
to  any  child  should  be  given  only  extremely  weak  :  cocoa  is 
usually  taken  well. 

The  timo  when  drink  is  taken  has  also  some  importance  ;  to 
drink  at  the-  beginning  of  a  meal,  or  to  wash  mouthful  after 
mouthful  down  with  frequent  drinks  is  to  favour  flatulence 
and  indigestion  ;  the  child  who  suffers  from  indigestion  should 
bo  taught  to  post-pone  drinking  until  the  end  of  the  meal,  and, 
if  he  be  a  thirsty  child,  it  may  be  well  to  let  him  have  a  drink 
of  water  one  hour  before  his  meals. 

Before  leaving  the  subject  of  diet  there  is  one  other  point  I  must 
mention,  for  it  is  one  which  I  believe  is  often  overlooked  in  the 
regimen  of  children  beyond  the  age  of  infancy,  namely,  the  inter- 
vals between  food.  I  have  thought  that  in  many  cases  indigestion 
was  clue  in  no  small  degree  to  the  giving  of  food  too  frequently. 


INDIGESTION  191 

Surely  if  an  infant  suffers,  as  it  very  frequently  does,  by  feeding 
at  intervals  of  two  hours,  say,  at  the  age  of  six  months,  it  is  only 
reasonable  to  suppose  that  other  children  too  are  likely  to  suffer 
from  a  similar  cause.  This  will  apply  particularly  to  feeding 
before  breakfast :  if  a  child  wakes  at  6  a.m.  and  does  not  have 
breakfast  until  8.30  a.m.  or  9  a.m.  it  is  wise  to  give  a  biscuit  or 
a  little  diluted  warm  milk  :  but  if  the  child  does  not  wake  till 
7  a.m.,  and  has  his  breakfast  at  8  a.m.  or  8.30  a.m.,  the  child  is 
better  without  any  food  before  the  breakfast.  Similarly  in  the 
middle  of  the  morning,  if  a  child  has  breakfast  at  8  a.m.  and  does 
not  dine  till  1.30  p.m.,  it  is  advisable  to  allow  some  light  refresh- 
ment such  as  milk  and  plain  cake  or  biscuit  at  11  a.m.,  but  if 
breakfast  is  at  8.30  a.m.  and  dinner  at  1  p.m.  a  child  will  often 
be  better  without  any  mid-morning  food,  the  appetite  comes 
uncloyed  to  dinner,  which  is  from  the  physiological  standpoint 
an  important  meal. 

In  this  connexion  must  be  mentioned  a  fault  of  regimen,  which 
is  responsible  for  continued  ill  health  in  some  children,  namely 
late  dinner.  Not  infrequently  I  see  boys  or  girls  at  the  school 
age,  sometimes  even  not  more  than  twelve  years  old,  who  are 
having  dinner  at  7  p.m.  or  8  p.m.  with  their  parents,  with  the 
result  that  they  are  pasty-faced,  unwholesome-looking  children, 
suffering  with  lassitude  or  headaches  in  the  morning,  and  showing 
in  various  ways  the  symptoms  of  indigestion.  Even  at  fifteen 
or  sixteen  years  many  children  are  much  better  without  any  meal 
after  5  or  5.30  p.m.,  except  a  light  supper  consisting  of  such  things 
as  biscuits,  Madeira  cake,  cocoa,  Benger's  Food,  or  milk. 

Lastly,  I  must  say  a  few  words  about  the  drug  treatment  of 
indigestion  in  children.  '  Going  so  thin  ',  as  I  have  already  said, 
is  one  of  the  commonest  complaints  from  the  mother  in  these 
cases :  there  is  a  tendency,  I  think,  with  the  medical  profession 
as  well  as  with  the  laity  to  fly  to  cod-liver  oil,  as  the  sovereign 
remedy  for  '  going  thin '  ;  but  not  wisely,  for  we  can  do  better  : 
indeed,  in  some  cases  cod-liver  oil  not  only  does  no  good,  it  seems 
actually  to  increase  the  trouble  by  retarding  digestion.  Far 
more  useful  in  most  of  these  cases  is  a  good  preparation  of  malt ; 
by  '  good '  I  mean  one  of  those  made  by  reliable  firms,  so  as  to 
contain  a  large  proportion  of  active  diastase.  The  value  of  these 
malt  preparations  resides  more  in  their  diastasic  value  than  in 
their  worth  as  containing  sugar.  The  chief  difficulty  for  the 
child's  digestion  as  a  rule  is  the  starch-containing  food,  and  it  is 
upon  this  that  malt  exercises  its  digestive  power  as  a  diastasic. 
I  attach  considerable  value  also  to  those  preparations  of  malt 


192          COMMON  DISORDERS  OF  CHILDHOOD 

which  arc  combined  with  pepsin  or  a  pancreatic  extract ;  there 
are  several  such  in  the  market. 

In  ordering  malt  for  a  child  it  is  easy  to  give  too  much,  with 
the  result  that  the  large  quantity  of  malt  sugar  in  it  sets  up  some 
gastric  disturbance  ;  this  I  have  seen  happen  many  times,  and 
for  this  reason  I  prefer  the  liquid  preparations,  which  allow  of 
accurate  measurement  in  a  medicine  glass  which  is  impossible 
with  the  thick  viscid  preparations  ;  1  to  2  drachms  three  times 
a  day  is  a  proper  dose  for  a  child  up  to  ten  or  twelve  years  of  age. 

But  even  malt,  though  it  gratifies  a  mother's  heart  as  being 
of  a  *  feeding  nature  ',  is  not  always  advisable  :  often  a  mixture 
of  rhubarb  and  soda,  with  some  mix  voinica  to  aid  the  gastric 
peristalsis,  will  do  more  good  than  anything  ;  and  if  there  is  not 
much  flatulence  and  the  appetite  is  poor,  I  have  often  found  a 
mixture  of  Acid  Phosph.Dil.,  Cl)x,  Tine.  Nucis  VomicaeCl)iij, Glycerin 
Cl)xv,  Aq.  Anethi  ad  7;ij,  three  times  a  day,  very  useful.  A  very 
important  point  in  the  treatment  of  indigestion  is  to  keep  the 
bowels  working  regularly  :  it  is  remarkable  how  very  frequently 
chronic  constipation  is  associated  with  chronic  indigestion  when 
one  might  have  expected  that  the  bowels  would  rather  have  been 
loose  owing  to  the  undigested  food.  I  have  considered  the 
treatment  of  constipation  elsewhere,  here  I  will  only  add  that 
in  those  cases  it  is  not  sufficient  to  open  the  bowels  by  mechanical 
stimulation  of  the  rectum  by  suppositories  or  enemata  ;  the 
greatest  benefit  will  be  obtained  only  by  giving  some  drug 
regularly  every  day  by  the  mouth  until  the  bowel  is  educated 
to  a  better  habit;  and,  above  all.  the  attempt  to  overcome  the 
constipation  in  these  cases  by  fruit  and  other  irritating  food  must 
not  be  allowed. 


CHAPTER   XIV 

THE   MEDICAL  ASPECT   OF  DENTAL   CARIES  IN 
CHILDHOOD 

CARIES  of  the  teeth  in  children  is  a  subject  which  must  interest 
every  medical  man  who  has  to  deal  with  diseases  of  childhood, 
for  dental  caries  is  an  important  cause  of  ill  health  in  children, 
and,  I  venture  to  think,  a  cause  which  is  too  often  overlooked. 
Moreover,  there  is  a  converse  fact  which  is  not  less  important, 
that  ill  health  in  the  child  is  responsible  for  many  cases  of  dental 
decay. 

Childhood  is  the  period  at  which  growth  and  development, 
physical  and  mental,  are  at  their  greatest  activity,  and  when, 
therefore,  it  is  most  essential  that  the  tissues  should  be  properly 
nourished.  If  it  be  true,  as  it  certainly  is,  that  dpntal  caries  inter- 
feres with  the  proper  assimilation  of  food,  then  its  occurrence  in 
childhood  is  likely  to  be  specially  mischievous. 

As  to  the  frequency  of  dental  caries  in  this  country  amongst 
children  at  the  school  age,  there  is  very  general  agreement ;  the 
statistics  of  most  observers  show  that  80  to  90  per  cent,  of  school 
children  have  some  decayed  teeth.  I  have  made  a  small  series 
of  obervations  on  this  point  myself  with  the  kind  assistance  of 
Dr.  C.  S.  Singer  and  Dr.  R.  Todd,  amongst  children  under  twelve 
years  of  age  brought  to  hospital  for  treatment  of  other  conditions. 

In  all  354  children  were  examined ;  out  of  226  between  the 
ages  of  five  and  twelve  years,  187 — that  is  82-7  per  cent. — showed 
carious  teeth,  while  out  of  128  between  two  and  five  years  of  age, 
50 — that  is  39-8  per  cent. — showed  caries.  Of  the  226  children 
between  the  ages  of  five  and  twelve  years,  55  had  not  less  than 
six  teeth  carious  or  missing,  many  had  seven  or  eight  decayed 
teeth,  some  ten  to  fifteen  ;  and  amongst  the  children  less  than 
five  years  old  four  or  five  carious  teeth  were  not  uncommon, 
and  some  had  nine  or  ten. 

It  is  clear  that  dental  decay  is  extremely  prevalent  amongst 
children,  and  the  question  arises,  How  far  does  dental  caries  at 
this  age  cause  any  mischief  beyond  local  pain  and  discomfort  ? 
It  were  much  to  be  desired  that  parents  as  well  as  medical  men 
should  realize  how  much  interference  with  the  health  of  a  child 

STTT.L  r» 


194  COMMON  DISORDERS  OF  CHILDHOOD 

may,  and  too  often  does,  result  from  dental  caries,  and  this 
although  there  may  never  have  been  the  slightest  toothache. 
The  commonest  evil  from  decayed  teeth  in  children  is  disorder 
of  digestion,  and  digestive  disorder  in  childhood  means  far  more 
interference  with  nutrition  than  it  does  in  adult  life,  for  in  child- 
hood nourishment  is  required  not  only  for  the  maintenance  of 
structure  already  built,  but  also  for  the  building  of  new  struc- 
ture, and  failure  of  digestion  means  failure  of  nourishment. 
Hence  it  comes  about  that  wasting  is  one  of  the  commonest 
symptoms  of  digestive  disorders  in  childhood,  and  this  disorder 
may  be,  and  often  is,  dependent  upon  caries  of  the  teeth  pre- 
venting thorough  mastication.  Common  enough  is  such  a  case 
as  this  : 

M.  A.,  aged  6  years,  has  been  '  getting  thin  '  for  several  months  :  she  has 
lost  her  appetite,  and  'her  stomach  is  getting  large',  a  history  suggestive 
enough  of  abdominal  tuberculosis  ;  but  examination  shows  no  sign  of  tubercle 
anywhere  ;  there  is  only  one  tooth,  a  very  carious  molar,  remaining  more  or 
less  whole  in  the  upper  jaw,  where  all  the  rest  of  the  teeth  are  only  decayed 
stumps  ;  in  the  lower  jaw  there  are  also  several  decayed  teeth.  The  child 
has,  in  fact,  no  wherewithal  to  carry  out  that  mastication  which  is  so  im- 
portant for  the  digestion  of  solid  food. 

It  is  unnecessary  to  multiply  instances  of  this  kind — they  are 
only  too  common  ;  I  will  only  repeat  what  I  wish  specially  to 
emphasize,  that  interference  with  nutrition  is  one  of  the  com- 
monest results  of  caries  of  the  teeth  in  children,  and  one  perhaps 
which  is  most  likely  to  mislead  both  parents  and  medical  men ; 
the  child  who  is  wasting  may  be  dosed  in  vain  with  this  drug  and 
that  when  the  one  thing  needful  is  treatment  of  decayed  teeth. 

It  has  been  said  that  the  child  is  an  inveterate  food  bolter  :  very 
often  he  is,  but  not  always  from  sheer  perversity  ;  the  reason 
may  be  caries  and  tenderness  of  teeth,  and  the  result  of  swallow- 
ing food  unchewed  may  be  not  only  impairment  of  nutrition  but 
also  colicky  pain  in  the  abdomen.  A  boy  of  eleven  years  was 
brought  to  me  for  pains  in  the  abdomen  ;  his  appetite  was  said 
to  be  very  bad  ;  there  was  nothing  abnormal  to  be  found  in  the 
abdomen,  but  examination  of  the  mouth  showed  that  thirteen 
of  his  teeth  were  carious.  The  dental  condition  was  improved  as 
far  as  possible  by  a  dental  surgeon  and  some  alkaline  mixture 
was  given,  afterwliich  the  pain  in  theabdomen  rapidly  diminished. 

Failure  of  appetite  I  have  already  mentioned  incidentally  as 
one  result  of  the  disturbance  of  digestion  due  to  carious  teeth  ; 
it  is  a  common  symptom  of  dyspepsia  in  childhood  and  one  which 
causes  no  little  anxiety  to  parents,  and  I  think  often  puzzles  the 
medical  man  by  its  obstinacy.  There  are  many  causes  for  failure 


DENTAL  CARIES  195 

of  appetite  in  childhood,  but  certainly  amongst  them  must  be 
reckoned  caries  of  the  teeth.  In  connexion  with  disordered 
digestion  from  dental  decay  I  must  mention  also  the  anaemia 
which  some  children  show  when  they  have  extensive  caries  of 
teeth.  Is  this  also  the  result  of  impaired  nutrition  from  disturbed 
digestion  ?  or  does  it  mean  some  chronic  poisoning  ?  Excellent 
work  has  been  done  on  the  bacteriology  of  dental  caries  by 
Mr.  Goadby  and  others,  but  I  think  more  investigation  is  wanted 
of  the  chemistry  of  the  mouth  in  dental  caries.  Dr.  William 
Hunter  has  drawn  attention  to  the  effects  of  oral  sepsis  on  the 
blood  ;  certainly  the  foully  offensive  smeU  of  the  breath  in 
children  with  extensive  decay  of  teeth  makes  it  difficult  to 
believe  that  they  can  escape  septic  absorption  altogether,  and 
it  may  be  that  the  anaemia  to  which  I  have  referred  is  one  result 
of  such  absorption.  I  have  spoken  of  the  digestive  disorder 
which  is  associated  with  dental  caries  as  if  it  were  due  only  to 
mechanical  disability  of  mastication,  but  it  seems  at  least  possible 
that  there  may  be  other  factors.  Any  one  who  has  tested  the 
secretions  about  carious  teeth  knows  that  they  are  often  dis- 
tinctly acid.  It  may  be  that  products  of  acid  fermentation 
mixing  with  the  food  retard  digestion,  or  it  may  be  that  other 
products  of  oral  decomposition  which  are  constantly  being 
swallowed  by  these  children  set  up  some  gastro -intestinal  dis- 
turbance. However  this  may  be,  there  is  no  doubt  that  decayed 
teeth  afford  a  nidus  for  bacteria  which  may  interfere  with  the 
child's  health  either  by  their  local  effect — for  instance,  by  pro- 
ducing some  form  of  stomatitis  or  gingivitis,  and  the  latter  is 
very  common  amongst  children  with  decayed  teeth — or  by  their 
passage  into  neighbouring  lymph  glands,  or  even  by  producing 
some  general  blood  infection. 

This  brings  me  to  a  very  important  question — the  relation  of 
caries  of  the  teeth  to  tuberculous  infection  of  the  lymphatic 
glands  in  the  neck.  Tubercle  bacilli  have  been  demonstrated  in 
carious  teeth  ;  carious  teeth  are  often  associated  with  enlarged, 
sometimes  with  undoubtedly  tuberculous,  glands  in  the  neck ; 
it  has  been  assumed,  therefore,  that  decayed  teeth  are  a  source 
of  tuberculous  infection  of  glands  in  the  neck.  Now,  this  is 
a  proposition  of  extreme  practical  importance ;  and  whilst 
I  would  not  for  a  moment  deny  the  existence  of  such  a  relation, 
I  think  there  is  a  great  need  for  careful  investigation  to  ascertain 
how  often  such  infection  occurs.  Smale  and  Colyer,  in  their  work 
on  Diseases  of  the  Teeth,  quote  Odenthal's  observation  that  of 
987  children  examined,  70-7  per  cent.  (697)  showed  glandular 

o2 


196  COMMON  DISORDERS  OF  CHILDHOOD 

enlargement,  and  more  than  half  of  these  had  carious  teeth, 
whereas  of  nearly  29  per  cent.  (267)  who  had  no  glandular  enlarge- 
ment only  five  showed  carious  teeth. 

Caries  of  the  teeth  is,  as  I  have  shown,  extremely  common  in 
children,  and  enlarged  glands  in  the  neck  are  also  extremely 
common,  but  it  must  be  remembered  that  pharyngeal  conditions, 
adenoid  hypertrophy,  and  tonsillar  enlargement,  are  probably 
responsible  for  much  of  the  glandular  enlargement,  and  it  is  no 
easy  matter  to  distinguish  in  all  cases  between  these  various 
sources  of  irritation.  We  want  more  information  as  to  the  pro- 
portion of  cases  in  which  glandular  enlargement  is  directly  due 
to  the  teeth,  and  also  as  to  how  often  the  glandular  infection 
from  decayed  teeth  is  of  tuberculous  nature.  Even  if  it  could  be 
proved  that  tubercle  bacilli  never  make  their  way  directly  from 
a  carious  tooth  to  a  lymphatic  gland,  it  would  still,  I  think,  be 
almost  certain  that  decayed  teeth  in  children  are  indirectly 
responsible  in  no  small  number  of  cases  for  tuberculous  infec- 
tion of  glands.  Whatever  causes  swelling  of  glands  in  a  child, 
whether  it  be  the  catarrh  of  whooping-cough  or  measles  causing 
the  mediastinal  glands  to  swell,  or  a  catarrh  in  the  naso-pharynx 
causing  the  cervical  glands  to  swell — whatever  the  cause  may  be, 
it  converts  those  glands  into  a  locus  minoris  resislentice,  and, 
especially  in  the  child  of  tuberculous  family,  is  a  powerful  pre- 
disposing cause  of  tuberculous  infection  of  those  particular 
glands.  For  this  reason  I  hold  that  decayed  teeth  are  a  real 
danger  to  the  child  whose  family  history  or  whose  own  past 
history  shows  a  tuberculous  tendency. 

There  is  another  direction  in  which  caries  of  the  teeth  seems 
to  be  responsible  occasionally  for  more  or  less  serious  trouble  in 
childhood,  namely,  as  a  cause  of  certain  nervous  disorders. 
I  refer  particularly  to  habit-spasm  and  epilepsy.  With  regard 
to  the  former,  there  is  no  doubt  that  some  slight  local  irritation, 
for  instance,  blepharitis,  a  sore  nostril,  or  eyestrain,  is  often  the 
start  ing-point  of  habit-spasm  in  a  child  ;  it  might,  therefore,  be 
expected  that  dental  worry,  whether  it  be  the  eruption  of  the 
second  teeth  or  the  discomfort  of  a  decayed  tooth,  might  also 
start  a  habit-spasm.  I  cannot  consider  here  how  this  conies 
about,  whether  by  increase  of  general  nervous  excitability,  or 
by  initiating  muscular  contractions  which,  at  first  voluntary  and 
purposive,  soon  become  habitual  and  involuntary,  but  I  will 
only  say  that  I  have  known  very  rapid  improvement  to  occur 
in  facial  habit-spasm  after  the  dentist  had  dealt  with  carious 
teeth,  and  that  the  onset  of  habit-spasm  occurs  much  more 


DENTAL  CARIES  197 

often  during  the  second  dentition  than  at  any  other  time  in 
childhood. 

As  to  the  relation  of  dental  worry  to  epilepsy,  I  cannot  do 
better  than  refer  to  Ramskill's  case  (quoted  by  Smale  and  Colyer)  : 
A  boy  of  thirteen  was  having  fits  at  intervals  of  one  to  three 
weeks.  Just  before  each  attack  he  put  his  hand  up  to  his  face 
and  complained  of  face-ache.  Extraction  of  a  carious  molar 
was  followed  by  complete  cessation  of  the  fits  up  to  the  time  of 
the  report,  which  was  four  months  after  removal  of  the  tooth. 
Sir  William  Gowers  also  mentions  two  cases,  in  which  epilepsy 
in  childhood  seemed  to  be  related  to  toothache.  Mr.  J.  G.  Turner 
has  also  mentioned  the  case  of  a  child  in  whom  epileptic  attacks 
were  greatly  reduced  in  frequency  by  extraction  of  dirty  and 
decayed  teeth. 

There  is  one  more  nervous  disorder  to  which  I  must  refer,  for 
it  is  one  in  which  the  part  played  by  dental  caries  is  too  often 
forgotten — namely,  headache.  My  own  experience  leads  me  to 
think  that  dental  caries  is  by  no  means  an  uncommon  cause  of 
headache  in  children.  Whenever  a  child  is  brought  to  me  com- 
plaining of  very  frequent  or  daily  headache,  especially  if  the 
headache  is  very  erratic  in  its  onset  and  disappearance,  coming 
and  going  quickly,  perhaps  more  than  once  a  day,  I  suspect  the 
possibility  of  its  being  due  to  teeth,  and  sometimes  the  complete 
success  of  dental  treatment  has  justified  my  suspicion.  The 
headache  in  these  cases  is  not  necessarily  localized  like  a  neuralgia : 
it  may  be  general,  or  referred  to  the  whole  frontal  or  vertical  or 
occipital  region,  so  that  so  far  as  the  child's  complaint  goes  there 
may  be  nothing  to  suggest  the  need  for  examination  of  the  teeth  ; 
moreover,  if  there  has  been  toothache  at  all,  there  may  be  none 
at  the  time  when  the  headaches  occur,  so  that  toothache  may 
not  be  mentioned. 

With  regard  to  the  causes  of  dental  caries  in  childhood,  there 
are  several  important  practical  questions  to  be  considered  :  Is  it 
due  to  neglect  of  the  toothbrush  ?  How  far  is  it  dependent  upon 
diet  ?  How  far  upon  the  general  health  of  the  child  ? 

For  my  own  part,  I  believe  that  all  three  causes  p  ay  their  part, 
and  that  in  one  case  one  factor,  in  another  another,  plays  the 
chief  part.  Of  the  importance  of  daily  cleansing  of  the  teeth 
I  have  not  the  least  doubt,  but  I  am  sometimes  impressed  with 
the  utter  failure  of  most  scrupulous^cleanliness  to  prevent  dental 
caries  in  children.  I  see  children  who  from  their  earliest  years 
have  had  their  teeth  cleansed  twice  daily,  and  yet  have  several 
decayed  teeth  ;  on  the  other  hand,  I  see  children  at  hospital. 


198  COMMON  DISORDERS  OF  CHILDHOOD 

who  have  never  used  a  toothbrush  in  their  lives,  with  a  perfect 
set  of  teeth.  I  do  not  know  what  proportion  of  boys  in  our 
upper-class  public  schools  clean  their  teeth  daily,  but  presumably 
a  far  larger  proportion  than  amongst  the  poorer  children,  of 
whom,  according  to  some  inquiries  which  I  have  made,  con- 
siderably more  than  50  per  cent,  of  those  at  the  school  age  have 
never  cleaned  their  teeth.  From  this  point  of  view  it  is  note- 
worthy that  in  one  of  our  great  public  schools,  according  to 
Sinale  and  Colyer,  87  per  cent,  of  the  boys,  with  an  average  age 
of  13^  years,  had  carious  teeth — a  proportion  fully  as  great  as 
among  the  children  of  the  poor.  There  is  also  a  curious  fact 
which  decomposing  food  debris  hardly  seems  to  account  for — 
namely,  the  difference  in  the  distribution  of  caries  at  different 
ages.  In  children  from  two  to  five  years  old,  in  my  own  series 
of  cases,  the  incisors  were  affected  in  three-fourths  of  the  cases  ; 
in  children  from  five  to  twelve  years  old  the  incisors  were  affected 
in  less  than  one-fourth  of  the  cases. 

I  mention  these  facts  only  to  emphasize  the  point  I  wish  to 
make — that  lack  of  cleanliness  is  not  the  only  factor  in  dental 
decay,  and,  indeed,  there  is,  I  think,  proof  of  this,  if  any  were 
needed,  in  the  black  enamel-lacking  condition  of  the  primary 
teeth  in  some  children  before  they  have  emerged  completely  from 
the  gum.  This  happens  sometimes  in  rickety  children,  and,  no 
doubt,  means  very  imperfect  formation  of  enamel,  so  that  the 
dentine  is  very  rapidly  exposed  to  bacterial  invasion  ;  this  may 
result  from  malnutrition  in  very  early  infancy,  for  it  seems 
probable  that  the  enamel  of  the  temporary  teeth  does  not  reach 
its  full  development  until  some  time  after  birth.  But  I  strongly 
suspect  that  there  are  also  congenital  differences  in  potentiality 
of  tooth  development,  just  as  there  are  in  potentiality  of  growth 
in  stature — so  that  it  is  natural  to  one  child  to  have  thick  enamel 
and  to  another  to  have  thin,  just  as  one  child  has  fine  hair  and 
another  coarse  ;  and  if  this  be  so  it  is  at  least  conceivable  that 
there  may  be  an  inherited  tendency  to  form  thin  or  imperfect 
enamel,  so  that  in  certain  families  there  may  be  a  special  liability 
to  early  caries,  as  has  been  thought  by  some  dental  authorities. 

The  occurrence  of  dental  caries  specially  with  rickets  suggests 
that  the  nutrition  of  a  child  during  the  first  year  of  life  may  have 
a  potent  influence  in  determining  the  occurrence  of  dental  decay 
in  the  permanent  teeth.  When  one  sees  how  profoundly  the 
growth  and  development  of  a  child  may  be  influenced  by  im- 
proper feeding  and  by  the  gastro-intestinal  disorders  which  result 
from  it,  one  can  hardly  doubt  that  the  development  of  the  teeth, 


DENTAL  CARIES  199 

and  so  their  power  of  resistance  to  caries,  must  also  be  influenced 
thereby. 

It  is  obvious  that  in  the  rickety  child  caries  sometimes  occurs 
too  early  to  be  due  to  any  local  effect  of  the  food  ;  but  when 
caries  occurs  later,  whether  in  rickety  or  non-rickety  children, 
the  possibility  of  direct  or  indirect  effect  of  diet  has  to  be  con- 
sidered. This  important  practical  point  calls  for  more  considera- 
tion than  I  can  give  it  here  ;  but  I  would  suggest  that  the  influence 
of  diet  is  chiefly  indirect,  that  whatever  causes  digestive  dis- 
turbance favours  the  onset  of  dental  caries.  Look  at  the  furred 
tongue,  notice  the  heavy  odour  of  the  teeth,  see  the  aphthae 
which  sometimes  occur  in  the  mouth  of  the  child  with  disturbed 
digestion — surely  all  these  are  indications  of  a  state  of  mouth 
which  must  favour  the  growth  of  bacteria  and  the  occurrence 
of  acid  fermentation  which  may  erode  the  enamel. 

There  is  no  doubt  that  the  acid  fermentation  of  sugar  has 
a  destructive  effect  upon  enamel,  but  I  very  much  doubt  whether 
sugar  taken  in  the  form  of  sweets  has  so  directly  a  harmful  effect 
as  is  commonly  supposed,  for  the  sugar  is  very  quickly  washed 
away  by  the  saliva.  I  found  that  fourteen  minutes  after  two 
large  chocolate-with-sugar  sweets  had  been  dissolved  in  the 
mouth  the  saliva  did  not  show  a  trace  of  sugar  with  Pavy's 
solution.  Starchy  food,  on  the  contrary — such  as  biscuits,  bread, 
and  potato — remains  in  every  crevice,  and  may  cause  acid  fermen- 
tation in  prolonged  contact  with  the  teeth.  Excess  of  sugar  and 
starch  and  the  taking  of  either  between  proper  meal  times  are 
common  sources  of  indigestion  in  children,  and  may  thus  indirectly 
favour  the  onset  of  caries. 

Prevention  and  Treatment.  Lastly,  the  all-important 
question  of  prevention  and  treatment  has  to  be  considered  ; 
and  here  the  physician  must  needs  go  delicately,  lest  he  be 
hewn  in  pieces  by  the  dental  expert.  We  have  heard 
much  recently  of  dental  inspection  in  schools  and  the  need 
for  dental  supervision  of  school  children  ;  but  I  would  em- 
phasize the  fact  that  the  mischief  is  present  in  a  large  pro- 
portion of  children  before  the  school  age.  My  own  observations 
showed  that  39-8  per  cent,  of  children  between  two  and  five 
years  of  age  had  decayed  teeth,  and  it  is  not  at  all  uncommon  to 
find  dental  caries  in  children  between  two  and  three  years  old. 
Evidently  the  prevention  of  dental  caries  must  date  from  earliest 
infancy.  The  most  important  step  in  this  direction  is  proper 
feeding  in  infancy.  Moreover,  if,  as  seems  almost  certain,  any 
disturbance  of  nutrition  occurring  during  the  first  two  or  three 


200  COMMON  DISORDERS  OF  CHILDHOOD 

years  of  life  may,  according  to  the  time  at  which  it  occurs,  in, 
fluence  the  development  of  the  primary  or  the  permanent  teeth 
and  render  them  specially  liable  to  decay,  then  the  importance 
of  proper  feeding  and  prevention  of  digestive  disorders  at  this 
age  becomes  still  more  apparent. 

I  would  have  every  mother  see  that  her  child's  teeth  are 
cleaned  morning  and  evening,  especially  the  latter,  from  the  time 
of  their  eruption,  doing  it  first  with  a  soft  rag  and  some  borax 
solution,  and  later  teaching  the  child  to  use  the  toothbrush  for 
himself. 

With  regard  to  treatment  let  me  say  this  much  :  I  am  fre- 
quently seeing  children  with  extensive  caries  of  teeth,  whose 
health  is  suffering  partly  from  indigestion,  partly  no  doubt  from 
chronic  poisoning  from  the  foulness  of  their  teeth.  I  send  them 
to  a  dentist,  and  I  am  told  that  he  advises  leaving  the  teeth  alone 
as  they  are  first  teeth.  Now,  I  am  well  aware  that  there  are 
reasons  which  make  it  desirable  not  to  remove  primary  teeth  if 
it  can  be  avoided  ;  but  I  have  wondered  sometimes  whether 
the  dentist  realized  how  much  the  child's  health  and  nutrition 
were  suffering  at  this  important  period  of  life  owing  to  the 
presence  of  these  teeth.  I  must  leave  it  to  the  dental  expert  to 
decide  whether  it  is  possible  to  save  the  tooth  by  stopping  it, 
or  whether  he  can  only  get  rid  of  the  caries  by  extraction,  but 
I  am  convinced  that  one  or  other  procedure  ought  to  be  adopted 
far  more  often  than  it  is  in  connexion  with  the  temporary  teeth. 
Moreover,  I  think  that  if  parents  would  take  their  children  regu- 
larly two  or  three  times  a  year  to  a  dentist  for  inspection  the 
primary  teeth  could  often  be  saved  by  timely  stopping  before 
the  extent  of  the  caries  makes  this  procedure  impracticable.  There 
is  an  unfortunate  idea  current  amongst  the  laity  that  there  is  no 
need  to  take  much  notice  of  decay  of  the  first  teeth,  whereas  in 
reality  decayed  teeth  at  that  period  are  perhaps  even  more  harm- 
ful than  at  a  later  age,  for  nutrition  is  more  easily  disturbed,  and 
its  disturbance  means  more  interference  with  general  develop- 
ment, glandular  enlargement  is  much  more  likely  to  result,  and 
probably  decay  in  a  temporary  tooth  not  only  destroys  the  present 
tooth,  but  favours  the  occurrence  of  caries  in  the  coming  perma- 
nent tooth. 


CHAPTER   XV 
CONSTIPATION  IN  INFANCY  AND   CHILDHOOD 

IN  infants,  during  the  breast-  or  bottle-feeding  period,  consti- 
pation is  a  very  common  trouble  ;  indeed  it  is  so  frequent  that 
one  is  almost  driven  to  suppose  some  special  cause  peculiar  to 
the  age.  It  might  be  suggested  that  the  reason  lies  in  the  pecu- 
liarity of  the  diet  at  this  time,  a  fluid  food  leaving  but  little  solid 
residue  to  stimulate  the  intestine  to  active  peristalsis  ;  but  this 
can  hardly  be  the  whole  explanation,  for  were  it  so  one  would 
expect  that  an  infant  fed  upon  cow's  milk,  with  its  large  tough 
curd,  would  be  less  liable  to  constipation  than  the  infant  fed 
upon  human  milk  with  its  fine  flaky  curd  :  as  a  matter  of  fact 
exactly  the  reverse  is  the  case,  constipation  is  common  enough 
in  breast-fed  infants,  but  it  is  not  nearly  so  frequent  as  in  those 
fed  on  cow's  milk. 

The  feeble  musculature  of  the  bowel  has  been  held  responsible 
for  the  frequency  of  this  trouble  in  infancy,  a  view  which  is 
supported  by  the  fact  that  feeble  and  premature  infants  are  even 
more  prone  than  other  infants  to  constipation.  One  can  hardly 
doubt  that  this  lack  of  muscular  strength  in  the  bowel  must 
be  one  factor,  but  it  cannot  be  the  only  factor,  for  the  feeblest 
infant  will  sometimes  prove  the  most  regular  in  its  bowel  actions, 
whilst  a  big,  strong  baby,  fed  similarly,  may  suffer  much  with 
constipation. 

The  possibility  that  an  anatomical  peculiarity  may  account 
for  this  tendency  was  suggested  by  some  observations  upon  the 
relative  length  of  the  large  intestine  and  the  body  at  different 
ages  ;  these  measurements  were  made  without  any  reference  to 
the  subject  of  constipation,  but  they  may  have  an  interesting 
bearing  upon  the  special  frequency  of  this  disorder  in  infancy. 
The  function  of  the  large  intestine  is  chiefly  the  absorption  of 
the  fluid  part  of  the  food:  Nature  has  providedvfor  infants 
a  food  capable  of  rapid  assimilation,  and  to-  secure  abundant 
absorption  special  provision  is  also  made  of  a  relatively  long 
colon.  Without  quoting  here  the  tables  of  figures  worked  out 
from  my  series  of  observations  I  may  say  that  although  the 


202  COMMON  DISORDERS  OF  CHILDHOOD 

measurements  varied  much  in  individual  children  at  the  same 
age,  they  show  on  the  whole  very  clearly  that  while  in  foetal  life 
the  large  intestine  is  very  short  relatively  to  the  length  of  the 
body — at  3J  months,  for  instance,  with  a  body  length  of  6  inches, 
the  large  intestine  measured  2-5  inches — this  shortness  gradually 
becomes  less  marked  until  at  full  term  the  large  intestine  is 
about  the  same  length  as  the  body. 

After  birth  the  large  intestine  rapidly  becomes  longer  relatively 
to  the  body,  and  up  to  the  end  of  the  second  year  is  usually 
several  inches,  often  as  much  as  4  or  5  inches,  longer  than  the 
body.  Towards  the  end  of  the  second  year  this  difference  be- 
comes less  marked,  and  by  the  time  the  child  is  three  or  four 
years  old  the  relation  is  reversed,  the  large  intestine  is  5  or  6  inches 
shorter  than  the  body,  and  in  later  years  this  relative  shortness 
is  even  more  marked;  for  instance,  at  nine  years  I  found  the  body 
length  45  inches,  the  large  intestine  only  35  inches  ;  at  11 J  years, 
with  a  body  length  of  56  inches,  the  large  intestine  measured 
43  inches.  From  these  observations  it  might  be  expected  that 
there  would  be  some  difference  in  the  anatomical  arrangement 
of  the  large  intestine  at  these  different  ages,  and  that  if  there 
were,  owing  to  its  relatively  excessive  length,  some  folding  and 
kinking  of  this  part  of  the  bowel  in  infancy,  these  folds  and 
kinks  would  be  more  or  less  straightened  out  in  later  childhood 
by  the  enlargement,  especially  in  length,  of  the  abdominal  cavity. 
It  was  pointed  out  by  Jacobi  that  this  is  so  :  the  colon  of  an 
infant  is  very  commonly  tortuous  and  folded  on  itself,  especially 
in  the  sigmoid  region,  where  it  often  forms  a  large  *  omega  '  loop 
passing  over  to  tho  right  side  of  the  abdomen,  or  even  up  into  the 
left  hypochondrium  before  finally  turning  down  to  the  rectum  : 
whereas  in  later  childhood  this  tendency,  though  persisting  in 
some  children,  is  less  common. 

There  can  be  little  doubt  that  the  sharp  turns  upon  itself 
which  the  colon  of  an  infant  often  makes  in  the  sigmoid  region 
must  offer  considerable  obstruction  to  the  course  of  the  faeces  ; 
the  presence  of  formed  fseces  must  still  further  accentuate  the 
kinking,  and  if  with  these  obstacles  there  is  also  excessive  feeble- 
ness of  musculature  it  is  easy  to  understand  why  an  infant 
should  be  especially  prone  to  chronic  constipation.  These 
observations  seem  to  explain  also  the  clinical  fact  that  the  con- 
stipation of  infancy  tends  to  right  itself  as  the  child  gets  older  ; 
the  folds  and  kinks  are  diminished  as  the  colon  is  straightened 
out  by  the  rapid  growth  in  length  of  the  abdomen,  and  thus 
it  may  be  truly  said  that  the  child  '  grows  out  of  '  the  constipa- 


CONSTIPATION  203 

tion.  It  may  be  that  a  contributing  factor  in  some  cases  of 
infantile  constipation  is  deficiency  of  bile  secretion  :  I  have 
elsewhere  pointed  out  that  the  bile  in  early  infancy  is  apt  to  be 
specially  viscid,  and  as  we  all  know  the  stools  in  infancy  and  in 
early  childhood  are  extremely  apt  to  become  pale  or  even  white 
at  times  with  very  slight  disturbance  of  digestion. 

I  have  dwelt  on  these  inherent  causes  of  constipation  in  infancy 
somewhat  fully  because,  even  though  they  afford  but  little 
guidance  in  treatment,  they  at  any  rate  afford  a  reasonable 
hypothesis  to  explain  the  difficulty  which  is  often  found  in  over- 
coming constipation  at  this  age  :  and  they  give  us  good  ground 
for  assuring  the  parents  that  there  is  every  probability  that  the 
trouble  will  disappear  as  the  child  grows  older. 

Both  in  infancy  and  in  early  childhood,  and  even  to  some 
extent  in  older  children,  there  is  a  negative  factor  which  may 
play  an  important  part  in  the  production  of  chronic  constipation  ; 
I  mean  the  absence  of  voluntary  effort  to  cultivate  regularity  ; 
the  child,  conscious  only  of  a  weak  desire  to  defsecate  and  of 
a  much  stronger  desire  to  go  and  play  with  its  toys,  neglects  the 
former  in  favour  of  the  toys,  and  what  is  wilful  neglect  at  the 
time  very  soon  becomes  real  inability.  A  good  nurse  can  do 
much  by  regularly  '  holding  out '  an  infant  at  certain  times,  or 
by  insisting  upon  an  older  child's  c  sitting  down  '  directly  after 
breakfast,  to  encourage  regular  action  of  the  bowels,  whilst 
a  nurse  careless  in  this  respect  may  be  responsible  in  large 
measure  for  chronic  constipation  in  the  child. 

In  some  children  a  sluggish  habit  of  mind  and  body  seems  to 
go  together;  certainly  there  are  phlegmatic  children  with  poor 
circulation  who  are  habitually  constipated,  and  I  am  the  more 
inclined  to  think  that  the  constipation  is  the  result  and  not  the 
cause  of  the  general  sluggishness  in  these  cases,  because  chronic 
constipation  is  so  often  a  marked  feature  with  actual  mental 
deficiency,  particularly  with  the  stolid  dullness  of  untreated 
cretinism. 

It  is  customary  in  textbooks  to  mention  fissure  of  the  anus  as 
a  cause  of  constipation  in  infancy ;  no  doubt  it  is  so  occasionally, 
but  in  my  own  experience  it  has  been  very  rare.  I  can  only 
recall  one  or  two  such  cases  amongst  the  many  thousands  of 
infants  I  must  have  treated  for  constipation,  and  I  should 
suppose  that  when  fissure  does  occur,  although  it  undoubtedly 
aggravates  the  constipation  owing  to  the  child's  fear  of  pain  on 
defsecation,  yet  the  fissure  is  not  originally  the  cause  but  the 
result  of  the  constipation  ;  and  any  treatment,  therefore,  must 


204          COMMON  DISORDERS  OF  CHILDHOOD 

be  adapted  not  merely  to  the  cure  of  the  fissure,  but  also  to  the 
cure  of  the  constipation  independently  of  the  fissure. 

Amongst  local  causes  a  very  important  one,  though  for- 
tunately a  very  rare  one,  is  anal  stenosis.  I  have  twice  seen 
children  past  the  age  of  infancy  with  severe  constipation  which 
had  been  treated  with  unsatisfactory  result  with  all  sorts  of 
remedies,  until  it  was  discovered  by  rectal  examination  that 
the  anus  was  so  small  that  it  was  difficult  to  get  even  one's  little 
linger  into  the  rectum  :  the  anus  was  enlarged  by  incision  with 
great  relief  in  both  cases.  I  have  seen  also  one  child  in  whom 
troublesome  constipation  was  at  length  explained  by  a  stenosis 
of  the  rectum  :  the  child  had  undergone  operation  for  imperf orate 
anus  in  infancy,  and  after  the  correction  of  this  deformity  the 
bowels  had  acted,  but  always  with  difficulty  :  rectal  examina- 
tion showed  a  constriction  about  an  inch  above  the  anus.  I  men- 
tion these  rarities  because  it  is  well  to  be  aware  of  their  occurrence, 
inasmuch  as  no  treatment  but  operative  interference  is  likely  to 
be  of  any  permanent  use. 


Results  of  Constipation 

Foremost  amongst  the  evil  results  of  habitual  constipation  in 
infancy  I  shall  put  marasmus,  meaning  by  this  rather  failure  to 
gain  weight,  or  very  slow  progress  in  nutrition,  than  active 
wasting.  I  lay  stress  upon  this  effect  because  I  know  from 
experience  how  little  importance  is  often  attached  to  constipa- 
tion when  a  baby  is  not  gaining  weight  :  all  sorts  and  varieties 
of  feeding  are  tried,  but  the  constipation  is  regarded  as  quite 
a  secondary  consideration  and  comes  in  for  very  scanty  treat- 
ment. In  many  such  cases  the  constipation  is  the  one  thing 
that  needs  attention,  and  if  regular  and  thorough  action  of  the 
bowels  is  ensured  by  daily  administration  of  some  suitable 
aperient,  the  weight  will  begin  to  rise  without  any  alteration 
whatever  in  the  feeding  ;  and  even  where  marasmus  is  dependent 
in  part  upon  difficulty  of  digestion,  the  correction  of  constipation 
is  often  as  important  as  suitable  feeding. 

There  is  another  result  of  constipation  in  infancy  which  I  think 
is  not  very  generally  recognized  as  such,  namely  chronic  vomit- 
ing. 1  do  not  refer  to  severe  vomiting,  such  as  occurs  with 
congenital  hypertrophy  of  the  pylorus,  but  to  the  cases  in  which 
an  infant  brings  up  perhaps  half  an  ounce  or  an  ounce,  and  does 
this  after  so  many  of  the  feeds  each  day  that  the  mother  becomes 
alarmed  ;  it  is  clearly  more  than  the  usual  slight  'posseting  '  of 


CONSTIPATION  205 

a  drachm  or  two,  and  the  weight  is  not  increasing  as  it  should  do. 
Here,  again,  the  treatment  that  is  required  is  often  no  change  in 
the  food  or  in  the  size  of  the  feeds,  but  simply  regular  administra- 
tion of  grey  powder,  or  some  such  aperient,  twice  or  three  times 
daily  to  keep  the  bowels  working  well. 

I  suppose  that  one  of  the  commonest  results  of  chronic  consti- 
pation in  infancy  is  screaming  :  the  infant  who  is  said  to  be 
'  always  screaming  '  is  very  commonly  suffering  from  habitual 
constipation  :  the  bowel,  unable  to  pass  its  contents  along, 
makes  vigorous  but  ineffectual  efforts,  and  the  result  is  colicky 
pain,  which  is  aggravated  often  by  the  presence  of  flatulence, 
a  very  frequent  accompaniment  of  constipation. 

A  more  serious  outcome  of  constipation  in  some  infants  is 
a  convulsion  ;  no  doubt  there  is  a  predisposition  in  such  cases 
to  convulsions,  but  it  is  the  intestinal  worry  of  constipation 
which  acts  as  the  exciting  cause  ;  and  I  would  point  out  that 
this  may  happen  where  the  infant  has  shown  no  evidence  qf 
colic  or  pain  from  the  loaded  bowel. 

The  straining  of  a  constipated  infant  is  liable  not  only  to  cause 
passage  of  streaks  of  blood  with  the  stools,  but  also  to  bring 
down  the  bowel  itself  in  the  form  of  a  prolapse,  or  to  produce 
some  variety  of  hernia.  Even  in  infancy  constipation  sometimes 
produces  piles  as  in  later  life.  I  have  seen  them  in  three  cases 
under  the  age  of  one  year  :  one  case,  a  girl  aged  seven  months, 
after  not  having  the  bowels  open  for  three  days,  showed  an 
external  pile  the  size  of  a  small  pea  ;  the  two  others  were  boys, 
one  of  whom,  at  the  age  of  8J  months,  had  three  large  external 
piles,  and  the  other,  at  the  age  of  about  nine  months,  had  also 
external  piles,  being  habitually  very  constipated.  I  saw  one 
boy,  at  the  age  of  3|  years,  in  whom  it  was  stated  that  piles  had 
been  detected  when  he  was  taken  to  a  hospital  at  the  age  of  one 
month. 

In  older  children,  as  in  infants,  habitual  constipation  interferes 
in  some  way  with  general  nutrition,  and  although  this  effect  is 
naturally  less  striking  at  an  age  when  the  gain  in  weight  should 
normally  be  slow  compared  with  that  in  infancy,  still  it  is  often 
quite  perceptible  to  the  medical  man,  as  well  as  to  the  mother. 
Moreover,  the  general  health  is  impaired  in  other  ways  ;  the 
child  is  sallow  or  of  pasty  complexion  ;  above  all,  he  is  languid 
and  easily  tires  on  exertion.  I  always  regard  this  complaint 
that  a  child  'gets  tired  so  quickly'  as  highly  characteristic  of 
two  common  disorders  in  childhood,  indigestion  and  constipation. 
The  child  who  is  constipated  is  apt  to  suffer  from  headaches  : 


206  COMMON  DISORDERS  OF  CHILDHOOD 

the  appetite  is  often  very  poor,  the  tongue  is  furred,  sometimes 
the  breath  is  offensive,  and  the  child  is  '  not  getting  on  '. 

On  the  other  hand,  it  is  surprising  how  little  acute  disturbance 
results  in  some  cases  from  prolonged  complete  constipation; 
a  fact  which  makes  it  the  more  necessary  to  exercise  constant 
supervision  of  children  in  this  respect,  for  they  will  pay  little 
attention  to  this  matter  themselves.  I  have  notes  of  an  infant, 
aged  nine  weeks,  who  was  brought  to  me  when  its  bowels  had 
not  been  opened  for  eight  days  :  of  another,  aged  1^,  whose 
bowels  had  not  been  open  for  fourteen  days,  and  another,  aged 
2J  years,  whose  bowels  had  not  been  open  for  five  weeks.  In 
this  last  case  I  had  to  break  up  the  hard  pieces  in  the  rectum 
with  a  metal  instrument  before  I  could  get  the  bowels  to  work. 
A  boy,  aged  5J  years,  was  brought  to  me  with  a  history  that  he 
had  always  been  very  costive  ;  his  bowels  were  usually  open 
only  once  a  week,  and  he  had  been  as  long  as  nearly  three 
weeks  without  an  evacuation  :  his  abdomen  was  distended  and 
a  large  mass  of  faeces  could  be  felt  in  the  colon.  This  was  not 
a  case  of  idiopathic  dilatation  of  the  colon,  but  simply  neglected 
constipation,  which  was  easily  set  right  eventually  by  the  regular 
administration  of  a  simple  mixture  of  senna  and  aloes. 

Treatment 

Some  at  least  of  the  constipation  in  childhood  might  be  pre- 
vented by  the  encouragement  of  regular  habit.  I  have  already 
referred  to  the  nurse's  duty  in  regard  to  infants  and  young 
children  :  I  wish  to  lay  stress  upon  the  mischief  often  done  to 
older  children  by  lack  of  care  in  this  matter.  The  boy  who  goes 
off  to  school  daily  is  allowed  to  take  his  breakfast  at  an  hour 
which  leaves  him  barely  time  to  snatch  a  hasty  meal,  much  less 
to  attend  to  the  evacuation  of  his  bowrels,  before  he  starts  for 
school,  when  by  insisting  upon  his  having  his  meal  half  an  hour 
earlier,  good  digestion  and  the  daily  evacuation  might  both  be 
ensured.  A  grave  fault  at  some  boarding-schools  is  insufficient 
provision  of  water-closets,  so  that  in  the  short  time  allowed 
between  breakfast  and  morning  school  it  is  practically  impossible 
for  all  the  boys  to  get  their  bowels  open.  School  masters  and 
mistresses  would  do  well  to  pay  more  attention  to  this  matter  : 
there  should  be  both  ample  accommodation  and  ample  time 
allowed,  both  are  altogether  insufficient  in  some  schools.  The 
practice  of  forbidding  children  to  leave  the  room  during  school 
hours  is  one  which  cannot  be  too  strongly  condemned  :  I  should 
hardly  have  thought  that  a  school  teacher  could  be  found 


CONSTIPATION  207 

ignorant  or  cruel  enough  to  do  such  a  thing,  but  I  have  repeatedly 
come  across  instances  in  which  a  child  had  been  unable  to  satisfy 
Nature's  needs,  or  had  passed  urine  or  faeces  in  school  because 
permission  to  leave  the  room  had  been  refused  :  children  at  the 
school  age  often  enough  suffer  from  false  modesty  in  this  respect, 
but  when  a  child  does  ask  to  leave  the  room  no  teacher  ought  to 
withhold  permission. 

Now  as  to  the  treatment  of  constipation,  I  must  first  consider 
the  dietetic  measures  which  may  be  of  value  :  but  let  me  say 
at  the  outset  that  in  my  opinion  the  treatment  of  constipation 
in  infancy 'and  in  childhood  by  diet  is  apt  to  be  most  unsatis- 
factory :  the  digestion  at  this  age  is  very  easily  upset,  and  the 
foods  which  exercise  a  laxative  action  upon  the  bowels  are  just 
those  which  are  apt  to  disturb  digestion  :  the  dietetic  treatment 
takes  us  in  fact  between  the  Scylla  of  constipation  on  the  one 
hand  and  .the  Charybdis  of  indigestion  on  the  other. 

In  the  case  of  the  breast-fed  infant  such  measures  are  seldom 
practicable  :  it  is  true  that  occasionally  the  trouble  is  due  to 
poorness  of  the  breast -milk,  and  we  may  try  by  increasing  the 
proteid  in  the  mother's  diet,  by  giving  her  more  eggs,  fish, 
poultry,  or  meat,  or  by  insisting  on  the  mother's  resting  much 
in  bed  or  on  the  sofa,  or  by  administering  to  her  some  preparation 
of  malt,  to  increase  the  richness  of  her  milk  :  but  as  a  rule  if 
any  dietetic  measures  are  to  be  tried  it  must  be  by  direct  addition 
to  the  breast-feeding. 

Some  have  recommended  that  one  or  two  feeds  of  a  cream 
mixture  should  be  given  daily  :  but  this  is  not  altogether  a  satis- 
factory method,  for  it  will  probably  be  necessary  for  this  purpose 
to  use  an  excessive  proportion  of  cream,  and  the  result  may  be 
digestive  disturbance.  The  administration  of  one  or  two  tea- 
spoonfuls  of  a  solution  of  sugar,  or  of  some  starchy  food  such  as 
oatmeal  mixed  with  milk,  may  purchase  an  action  of  the  bowels 
at  the  cost  of  flatulent  dyspepsia  which  may  be  worse  than  the 
constipation.  One  of  the  foods  which  contain  no  starch  but 
a  large  proportion  of  completely  malted  cereal  may  be  given 
once  or  twice  a  day  :  such  are  the  Allenbury  Foods  No.  1  and 
No.  2  and  Horlick's  Malted  Milk,  or  Mellin's  Food  mixed  with 
diluted  milk  according  to  the  maker's  directions  ;  any  of  these 
will  sometimes  be  sufficient  to  keep  the  bowels  regular,  and  used 
thus  only  once  or  twice  a  day  to  replace  breast-feeds  I  know 
of  no  objection  to  them  if  the  infant  is  able  to  tolerate  the  excess 
of  soluble  carbo-hydrate  which  they  contain  and  upon  which  their 
laxative  effect  depends. 


208  COMMON  DISORDERS  OF  CHILDHOOD 

For  the  hand-fed  infant  also  these  completely  malted  foods 
may  be  a  useful  addition  to  one  or  two  feeds  in  the  day,  if  this  is 
sufficient  for  the  purpose,  but  if  more  of  the  feeds  must  be  given 
to  ensure  regularity  of  action  it  becomes  a  question  whether 
it  is  not  better  to  give  drugs  than  to  risk  the  likelihood  of  flatulent 
dyspepsia,  which  occurs  very  readily  in  some  children  with  this 
class  of  food.  The  substitution  of  brown  Demerara  sugar  for 
milk  sugar  is  sometimes  successful,  and  I  have  used  treacle  in  the 
same  way  :  but  to  my  mind  any  of  these  methods  are  objection- 
able if  they  involve  giving  more  soluble  carbo-hydrate  than  an 
infant  should  take.  The  limit  which  should  not  be  exceeded  is 
7  per  cent. ;  if  brown  sugar  or  treacle,  in  the  proportion  of  a  small 
teaspoonful  to  a  three-ounce  feed  is  sufficient,  there  is  little  or  no 
objection  to  their  use,  but  if  more  must  be  used  such  a  method 
is,  I  think,  to  be  avoided  :  I  hesitate  to  say  that  there  is  abso- 
lutely no  objection  to  the  use  of  these  forms  of  sugar  when  given 
even  in  proper  proportion,  because  I  suspect  that  cane  sugar  is 
a  little  more  liable  to  set  up  flatulence  than  an  equal  quantity 
of  milk  sugar. 

I  sometimes  find  that  an  infant  is  having  a  food  containing 
far  too  much  cream  under  the  impression  that  the  constipation 
is  due  to  deficiency  of  fat  in  the  food,  and  that  therefore  the  fat 
should  be  increased  until  a  laxative  effect  is  obtained.  Here, 
again,  I  would  caution  against  using  a  proportion  of  fat  which 
exceeds  what  one  may  call  Nature's  limit,  the  3  to  4  per  cent, 
which  is  present  in  human  milk.  1  am  fully  in  agreement  with 
Dr.  Holt  as  to  the  harmful  effects  of  excessively  high  percentages, 
such  as  6  per  cent,  and  7  per  cent.,  which  are  often  being  given 
for  this  particular  purpose.  Dr.  Holt  points  out  that  not  only 
may  serious  disturbance  of  nutrition  result,  but  the  very  purpose 
of  the  added  fat  may  be  defeated,  for  excess  of  fat  will  some- 
times c.iuse  constipation.  If  by  raising  the  fat  percentage,  by 
addition  of  cream,  to  3  or  4  per  cent.,  we  can  procure  regular 
action  of  the  bowels,  I  know  of  no  better  way  :  but,  as  I  have 
already  pointed  out,  in  order  to  do  this  we  must  know  approxi- 
mately the  strength  of  the  cream  used,  and  even  when  we  have 
calculated  out  the  proportion  of  fat  to  a  nicety,  we  shall  still 
find  that  there  are  many  infants  who  are  extraordinarily  in- 
tolerant of  croam  and  in  whom  the  effect  of  even  a  very  modest 
addition  of  cream  is  to  produce  vomiting  or  diarrhoea.  It  is 
very  rarely  wise  to  exceed  one  measured  drachm  of  average 
London  cream  in  a  three-ounce  feed,  however  much  the  milk 
may  be  diluted  :  this  will  mean  the  addition  of  2  per  cent,  of 


CONSTIPATION  209 

fat  to  the  mixture  ;  the  use  of  1J  drachms  of  cream  (48  per  cent.) 
in  a  three-ounce  mixture  of  equal  parts  of  milk  and  water  would 
raise  the  proportion  of  fat  to  4-25  per  cent. 

In  children  past  the  age  of  infancy  dieting  for  constipation  is 
one  of  the  commonest  causes  of  indigestion.  The  average 
mother  has  a  profound  conviction  that  it  is  bad  to  give  drugs 
for  chronic  constipation  :  it  sounds  like  Nature's  ideal  to  give 
plenty  of  fruit,  and  surely  brown  bread  and  porridge  must  be 
so  nourishing  !  So  she  plies  her  child  with  fruit  and  more  fruit, 
and  whole-meal  bread  and  porridge,  and  at  first  the  constipation 
is  less  troublesome,  but  soon  it  is  as  obstinate  as  ever,  and  now 
the  mother  is  distressed  to  find  that  her  child  is  getting  thin, 
he  is  pale  and  puffy  under  the  eyes,  has  pains  in  the  abdomen,  is 
so  tired  and  has  no  appetite.  Now  what  does  all  this  mean  ? 
The  food  has  set  up  a  condition  of  chronic  indigestion,  which 
very  likely  has  taken  the  form  of  that  mucous  catarrh  of  the 
bowel  which  has  been  so  admirably  described  by  Dr.  Eustace 
Smith  in  his  treatise  on  the  Wasting  Diseases  of  Children.  This 
disorder  is  accompanied  usually  by  constipation  rather  than  by 
looseness,  and  the  one  essential  in  its  treatment  is  the  exclusion 
of  such  articles  as  fruit,  brown  bread,  and  porridge  from  the 
diet.  '  But,'  says  the  mother,  '  surely  drugs  must  irritate  the 
coats  of  the  bowel,  if  given  again  and  again.'  I  venture  to 
say  that  few  laxative  drugs  in  the  dosts  required  for  the 
treatment  of  chronic  constipation  are  so  irritating  to  the 
gastro-intestinal  mucous  membrane  as  the  foods  which  I  have 
just  mentioned  :  they  owe  their  effect  indeed  almost  entirely 
to  the  mechanical  irritation  caused  by  the  undigested  woody 
fibres,  husks,  and  grains,  which  are  often  passed  almost  unaltered 
in  the  stools  on  such  a  diet.  The  stools  of  some  children  who 
are  being  fed  on  brown  bread  or  porridge  are  a  mass  of  undigested 
material,  recognizable  even  by  the  most  unskilled  as  the  coarse 
particles  of  the  brown  bread  or  porridge  ;  one  can  only  wonder 
that  ill  results  from  such  food  are  not  more  common.  To  give 
a  child  an  apple  before  breakfast,  a  bowl  of  porridge  at  break- 
fast, banana  in  the  middle  of  the  morning,  and  brown  bread  at 
most  of  the  meals,  is  to  court  trouble  :  it  would  be  absurd  to 
say  that  any  one  of  these  articles  of  food  was  intrinsically  bad, 
we  all  know  they  are  excellent  as  occasional  foods  for  some 
children  :  but  none  the  less  I  am  sure  from  experience  that 
there  are  very  many  children  who  stand  raw  fruit  very  badly, 
and  that  to  ply  a  child  daily  with  such  foods  as  I  have  mentioned 
in  order  to  overcome  constipation  is  often  merely  to  add  the 


210  COMMON  DISORDERS  OF  CHILDHOOD 

troubles  of  indigestion  to  those  of  constipation.  The  proper  time 
to  give  raw  fruit,  if  it  is  to  be  given  at  all,  is  as  part  of  one  of 
the  meals,  for  instance,  at  the  end  of  breakfast  or  dinner,  and  if 
the  juice  of  an  orange,  or  some  grapes,  or  an  occasional  banana, 
given  thus  is  sufficient  to  keep  the  bowels  acting  regularly  no 
harm  may  be  done  by  such  treatment.  One  of  the  least  harmful 
of  fruit  aperients  is,  I  think,  the  juice  of  stewed  prunes,  which 
may  be  given  at  tea-time  or  at  supper. 

Coming  now  to  the  use  of  drugs  for  habitual  constipation  in 
infancy  and  childhood,  I  shall  first  lay  down  one  general  principle 
upon  the  recognition  or  non-recognition  of  which  rests  the 
success  or  failure  of  our  treatment  ;  it  is  this  :  the  object  of 
treatment  is  not  merely  to  open  the  bowels  when  constipated, 
but  to  prevent  constipation.  The  great  mistake  which  is  con- 
stantly made  in  the  treatment  of  this  disorder  is  to  prescribe 
some  drug  to  be  taken  '  when  required  '  :  let  me  lay  it  down  as 
a  rule  that  to  order  a  drug  to  be  given  '  when  the  child  is  con- 
stipated '  is  a  sure  way  to  fail  in  the  cure  of  habitual  constipation. 
Whatever  drug  is  used  should  be  given  regularly,  once,  twice, 
or  three  times  a  day,  in  such  a  dose  as  will  keep  the  bowels  open 
without  purging  :  and  its  administration  should  be  continued 
for  weeks  or  months  until  the  habit  of  regularity  in  the  action 
of  the  bowels  has  become  a  fixed  one  :  the  time  for  omission 
of  the  drug  is  to  be  found  by  attempting  to  drop  one  of  the 
daily  doses  or  to  reduce  the  size  of  the  doses  after  several  weeks 
of  treatment,  and  if  this  is  found  not  to  alter  the  regularity  of  the 
bowels,  the  other  doses  can  be  gradually  diminished  or  omitted. 
As  a  matter  of  fact  it  generally  becomes  evident  after  two  or  three 
months  that  the  bowels  are  working  so  easily  and  well,  that  there 
is  little  risk  in  reducing  and  gradually  omitting  the  medicine. 

The  choice  of  drugs  will  differ  according  to  the  age  of  the 
child.  For  infants  there  is  one  drug  which  is  sanctioned  and 
sanctified  by  tradition  from  time  immemorial,  castor  oil  :  and 
1  know  no  drug  which  is  responsible  for  more  chronic  constipation 
in  infancy  than  castor  oil.  Let  it  be  remembered  that  this 
drug  has  not  only  an  aperient  action  but  a  markedly  constipating 
effect,  which  follows  as  an  after  effect  when  a  large  aperient  dose 
is  given,  but  which  is  seen  more  evidently  when  a  small  dose, 
say  4  or  5  minims,  is  given  regularly  three  times  a  day,  when 
it  has  no  aperient  action  whatever,  but  makes  the  infant  very 
costive.  If  castor  oil  is  given,  as  it  often  is,  as  an  occasional 
aperient  to  an  infant  with  habitual  constipation,  the  effect  each 
time  is  to  open  the  bowels,  and  then  to  make  the  child  costive 


CONSTIPATION  2J1 

again,  and  so  the  bowel  is  encouraged  in  its  habit  of  constipation. 
There  is  no  better  nor  safer  aperient  than  castor  oil  where  it  is 
desired  merely  to  evacuate  the  bowels  once,  especially  if  subse- 
quent constipation  will  be  rather  an  advantage  than  otherwise, 
as  for  instance  in  the  case  of  an  infant  who  has  diarrhoea  from 
the  presence  of  irritating  food  in  the  bowel ;  but  where  there  is 
habitual  constipation  there  could  hardly  be  worse  treatment 
than  an  occasional  dose  of  castor  oil.  For  the  mildest  cases 
I  like  manna ;  a  piece  roughly  the  size  of  a  hazel-nut  may  be  put 
in  three  or  four  of  the  feeds  daily  ;  but  this  is  no  use  for  the 
more  severe  cases.  For  these  I  think  that  probably  the  most 
reliable  drug  is  grey  powder  :  I  am  in  the  habit  of  ordering 
Hyd.  c.  Cret.  gr.  J,  Sod.  Bicarb,  gr.  j,  Pulv.  Cretse  Aromat. 
gr.  j  ter  die,  and  if  this  is  not  sufficiently  strong  I  replace  it  by 
Pulv.  Rhei  Co.  gr.  ij-iij,  Hyd.  c.  Cret.  gr.  |-|  ter  die  (the  stronger 
doses  for  infants  over  three  months  if  required).  I  have  been 
asked  sometimes  whether  the  use  of  such  powders  for  several 
months  would  not  be  likely  to  injure  the  teeth  ;  I  have  paid 
special  attention  to  this  point  and  have  satisfied  myself  that  so 
far  from  injuring  the  teeth  the  mercurial  seemed,  if  it  had  any 
influence  upon  them,  to  act  as  a  preservative,  for  the  teeth  of 
children  treated  with  this  drug  were  often  exceptionally  good. 
Rarely  the  stronger  of  these  two  powrders  is  not  sufficient  ;  under 
these  circumstances  I  have  generally  given  a  simple  senna 
mixture  twice  or  three  times  a  day  in  addition  :  viz.  Syrup. 
Sennae  0)  x-xx,  Aq.  Anethi  ad  3  j,  telling  the  mother  to  increase  the 
dose  of  this  to  1J  or  2  drachms  if  necessary.  This  mixture  is 
sometimes  quite  sufficient  alone. 

My  colleague,  Dr.  Hutchison,  introduced  a  formula  which  I 
have  often  found  useful :  Tinct.Nuc.Vom.  ft)  j,  Tinct.  Hyoscyami 
ft)  v,  Tinct.  Aloes  O)  iv,  Syrup.  Sennse  O)  xv,  Aq.  Anethi  ad  6  j, 
which  may  be  given  three  times  a  day  to  an  infant  of  nine  months. 
Chronic  constipation  in  an  infant,  as  in  an  older  child,  is  some- 
times amenable  to  liquid  paraffin,  which  may  be  given  in  doses 
of  15-30  minims,  twice  or  three  times  daily  (see  p.  213),  and  I 
think  this  is  less  likely  to  upset  digestion  than  the  administration 
of  olive  oil,  which  is  sometimes  given  in  doses  of  half  a  teaspoonful 
or  more. 

For  infants  over  six  months  of  age  if  the  stools  are  pale  as 
well  as  costive  podophyllin  is  sometimes  useful ;  I  have  generally 
given  it  thus  :  Tinct.  Podophylh  Ct)j,  Tinct.  Nucis  Vomicae  Ct)j, 
Glycerini  O)  x,  Aq.  Anethi  ad  3  j  ter  die.  I  have  thought,  however, 
that  in  some  cases  it  griped  and  therefore  was  less  satisfactory 
than  those  I  have  already  mentioned. 

p2 


212          COMMON  DISORDERS  OF  CHILDHOOD 

Where  the  stools  are  dry  and  hard,  especially  if  there  is  much 
flatulent  colic  with  the  constipation,  the  saline  aperients  are 
good,  such  as  sodium  phosphate,  of  which  10  or  15  grains  may 
be  given  in  two  or  three  of  the  feeds  daily.  Dinneford's  Fluid 
Magnesia  or  Phillip's  Cream  of  Magnesia  are  both  excellent  in 
such  cases.  I  have  used  also  the  synthetic  purgative  purgen,  or 
phenol-phthalein,  both  for  infants  and  for  older  children. 
Oppenheimer's  preparation  of  this,  sold  under  the  name  of 
Laxoin,  is  in  convenient  form,  but  on  the  whole  it  has  not  seemed 
to  me  to  be  so  reliable  a  drug  as  the  older  aperients  already 
mentioned  ;  in  cases,  however,  where  a  fluid  stool  is  desirable, 
it  may  be  useful. 

For  older  children  I  think  that  the  preparations  of  cascara 
with  malt  make  an  excellent  drug  for  habitual  constipation  ; 
and  I  prefer  those  made  in  liquid  form  as  capable  of  accurate 
measurement,  which  is  very  desirable,  so  that  the  mother  may 
ascertain  exactly  what  dose  is  necessary.  One  of  these  pre- 
parations, given  in  a  dose  sufficiently  small  to  allow  of  its  being 
given  three  times  daily  immediately  after  meals,  has  the  great 
advantage  that  it  not  only  acts  as  an  aperient,  but  also  by  its 
diastasic  value  assists  the  digestion  of  starch  which  is  often 
at  fault  in  these  children.  The  plain  preparations  of  cascara 
without  malt  have  seemed  to  me  more  apt  to  gripe,  and  also 
less  reliable  in  their  action. 

A  mixture  like  that  mentioned  above  for  infants,  containing 
mix  vomica  and  senna  and  aloes,  but  with  larger  doses  of 
these  drugs  according  to  the  age,  often  acts  very  satisfactorily. 

The  preparations  sold  as  Syrup  of  Figs,  which  consist  chiefly  of 
senna,  form  a  useful  laxative  for  chronic  constipation,  and  can 
be  given  in  doses  of  1-2  drachms  every  night  if  necessary 
for  many  weeks  or  months  without  the  slightest  harm.  For 
children  who  object  to  the  taste  of  medicine  of  any  kind  as  some 
will,  simply  because  it  is  medicine,  an  infusion  of  senna  pods 
makes  a  useful  aperient,  as  it  is  practically  tasteless,  and  if 
necessary  ean  be  concealed  in  milk  or  any  liquid  food.  Three  to 
six  pods  should  be  soaked  in  a  wine-glassful  of  cold  water  for 
several  hours,  and  the  resulting  infusion  should  be  given  at  night. 
A  pleasant  and  effectual  method  of  administering  senna  is  to  give 
it  in  the  form  of  a  fruit  paste  made  as  follows  :  Take  1  Ib.  of 
French  plums,  1  Ib.  of  Demerara  sugar,  l-i  oz.  of  pounded  senna, 
and  *  oz.  of  ground  ginger.  Stew  the  plums  in  a  little  water 
until  very  tender,  while  hot  remove  the  stones,  then  add  the  rest, 
mix  and  beat  to  a  paste.  One  teaspoonful  of  this  paste  may  be 


CONSTIPATION  213 

given  to  a  child  of  four  years  every  night.  Recently  Agar-agar 
has  come  into  use  for  these  cases  of  habitual  constipation  ;  a  par- 
ticular preparation  of  this  is  sold  under  the  name  of  Regulin. 
This  is  given  in  doses  of  one  to  four  tea  spoonfuls  mixed  with 
cream  or  any  moist  food,  such  as  jam  or  mashed  vegetables. 

Paraffin  is  very  successful  in  some  cases.  It  is  given  in  doses 
of  twenty  to  forty  minims  in  an  emulsion,  a  useful  formula  for 
which  is  given  on  p.  174.  When  larger  doses  are  required,  it  is 
more  convenient  to  give  the  plain  liquid  paraffin,  of  which  1-4 
drachms  may  be  given  two  or  three  times  daily  before  meals. 
For  those  who  dislike  the  plain  paraffin  there  are  now  prepara- 
tions sold  in  which  it  is  mixed  with  malt,  or  supplied  in  a  jelly- 
like  form,  pleasantly  flavoured  and  coloured.  But,  with  all  this 
assistance,  paraffin  does  not  always  agree  ;  there  are  children 
who  are  made  sick,  and  others  whose  digestion  is  impaired  by  it, 
and  it  is  not  very  uncommon  for  children  to  pass  the  liquid 
paraffin  speedily  through  the  bowels  without  obtaining  any 
proper  evacuation  of  faeces;  as  the  mother  puts  it,  the  paraffin 
simply  runs  through  the  child. 

For  children  with  *  mucous  disease  ',  I  think  the  decoction 
of  aloes  recommended  by  the  late  Dr.  Eustace  Smith  is  particu- 
larly useful:  Potassii  Citrat.  gr.  iv,  Spirit.  Chloroformi  tt)  1|, 
Glycerin.  O)  xv,  Decoct.  Aloes  Co.  ad  3  ij  ter  die. 

In  mild  cases  of  constipation  sulphur  is  sometimes  very 
useful  :  it  may  be  given  either  as  the  sulphur  lozenges  of  the 
British  Pharmacopoeia,  of  which  two  may  be  taken  every  night 
by  a  child  aged  five  or  six  years,  or  as  the  confection  of  sulphur, 
which  may  be  combined  with  the  confection  of  senna,  half 
a  teaspoonful  of  each. 

A  very  useful  powder  to  be  given  every  night  is  Powdered 
Rhubarb  5  gr.,  Potassium  Sulphate  5  gr. 

I  have  seen  excellent  results  even  in  severe  cases  of  chronic 
constipation  from  Apenta  Water  given  every  morning,  -J-l  wine- 
glassful,  before  breakfast. 

Whichever  of  these  various  drugs  are  used  it  is  to  be  impressed 
upon  the  parents  that  regularity  of  the  bowels  must  be  procured 
and  maintained,  if  not  by  one  drug  then  by  another,  and  that 
the. aim  of  treatment  is  to  establish  a  regular  habit,  and  that 
although  it  may  require  several  weeks  or  months  of  patient 
perseverance  in  treatment  to  do  this,  it  can  generally  be  done  ; 
after  a  time  drugs  can  be  reduced  in  frequency  and  then  in  dose, 
and  so  by  degrees  discontinued. 
There  is  yet  the  use  of  enemata  and  suppositories  to  be  con- 


214  COMMON  DISORDERS  OF  CHILDHOOD 

sidcrod.  On  several  grounds  I  think  that  these  are  less  satis- 
factory for  chronic  constipation  than  treatment  by  mouth  : 
the  action  of  the  bowel  is  made  to  depend  on  local  mechanical 
stimulation  in  excess  of  the  normal  stimulus,  and  when  this  has 
to  be  repeated  frequently  for  long  periods,  the  bowel  is  certainly 
not  encouraged  to  respond  to  the  less  powerful  normal  stimulus, 
but  rather  habituated  to  the  tolerance  of  accumulated  faeces,  and 
children  I  think  even  more  easily  than  adults  come  to  rely  upon 
finch  artificial  assistance.  Another,  and  I  feel  sure  a  very  real 
objection,  is  the  dilatation  of  the  rectum  and  perhaps  of  the 
sigmoid  which  may  result  from  continual  use  of  enemata.  In 
a  little  boy  I  examined  who  had  been  treated  habitually  by 
enemata,  I  found  the  rectum  ballooned  and  evidently  to  some 
degree  atonic  :  such  a  condition  must  favour  the  accumulation 
of  faoces,  especially  if  the  sensitiveness  to  the  normal  stimulus 
is  dulled  by  the  continued  use  of  enemata  ;  and  lastly  I  suspect, 
though  I  cannot  prove,  that  the  emunctory  function  of  the  whole 
bowel  is  less  thoroughly  performed  when  action  is  induced 
simply  by  rectal  stimulation  than  when  it  is  caused  by  drugs 
which  promote  the  secretory  activity  of  intestinal  glands  or 
promote  the  flow  of  bile,  or  stimulate  the  whole  of  the  neuro- 
muscular  apparatus  of  the  intestine. 

If  enemata  are  to  be  used  at  all — and  in  some  cases  they  are 
inevitable,  for  in  no  other  way  can  the  bowel  be  made  to  work, 
while  in  others  they  may  be  necessary  occasionally  when  the 
daily  action  from  aperients  fails — the  smallest  sufficient  bulk  of 
fluid  should  be  used  in  order  to  avoid  dilatation  of  the  rectum 
and  sigmoid  ;  for  this  reason  olive  oil  is  much  to  be  preferred 
to  plain  soap  and  water  ;  for  whereas  6  or  8  ounces  or  more  of 
the  latter  may  be  required,  generally  half  an  ounce  of  olive  oil 
witli  2  or  3  ounces  of  warm  soap  and  water  is  quite  sufficient  ; 
a  much  smaller  quantity  of  glycerine  is  effective,  but  this  is, 
I  think,  to  be  avoided  for  it  is  a  much  more  powerful  stimulus, 
and  is  therefore  more  likely  to  establish  tolerance  of  lesser  stimuli ; 
for  the  same  reason  glycerine  suppositories  are  objectionable, 
but  the  use  of  a  small  piece  of  soap  cut  into  the  shape  of  a  small 
suppository  half  an  inch  long  is,  I  think,  less  open  to  objection. 

I  have  said  nothing  about  massage;  occasionally  I  have  found 
it  of  value  for  those  older  children,  especially  in  combination 
with  a  morning  dose  of  Apenta  Water  or  some  such  draught, 


CHAPTER  XVI 


INFANTILE   DIARRHOEA 

ONE  of  the  commonest  and  most  troublesome  of  the  disorders 
of  infancy  is  diarrhoea,  and  there  is  no  disease  which  is  respon- 
sible for  so  large  a  number  of  deaths  as  are  due  to  diarrhoea  at 
this  age.  The  following  statistics  compiled  from  the  Registrar- 
General's  reports  give  some  idea  of  its  fatality : 


DEATHS  FROM  ALL  CAUSES 
IN  LONDON. 

DEATHS  FROM  DIARRHCEA 
IN  LONDON. 

Total  under 
1  year  old. 

Under 
3  months. 

3  months  to 
6  months. 

Total  under 
1  year. 

Under 
3  months. 

3  months  to 
6  months. 

1891 
1892 
1893 
1894 
1895 

20,776 
20,441 
21,814 

18,812 
22,252 

9,662 
9,614 
10,282 
9,033 
10,091 

4,286 
4,162 
4,752 
3,680 
4,755 

2,272 
2,340 
3,265 
1,866 
3,803 

608 
745 
953 
518 
1,024 

742 
845 
1,144 
620 
1,282 

1901 
1902 
1903 
1904 
1905 

19,678 
18,307 
17,223 

19,012 
16,603 

9,565 
8,927 
8,594 
9,050 
8,253 

4,113 
3,545 
3,463 
3,948 
3,224 

4,029 
2,542 

2,818 
4,408 
3,347 

1,071 
590 
729 
1,076 

869 

1,383 
859 
981 
1,474 
1,092 

From  these  figures  it  can  be  seen  that  on  the  average  2,000- 
4,000  infants  under  one  year  of  age  die  annually  in  London 
alone  from  diarrhoea,  and  that  in  spite  of  improved  sanitation 
the  proportion  of  deaths  due  to  diarrhoea  in  the  first  year  of  life 
has  rather  increased  than  diminished  during  the  past  ten  years. 
Another  interesting  fact  also  appears  that  a  much  smaller  pro- 
portion of  the  deaths  from  diarrhoea  during  the  first  year  occur 
within  the  first  three  months  than  in  the  subsequent  months 
of  the  first  year,  a  fact  which  no  doubt  has  its  explanation, 
not  in  any  special  resistance  to  diarrhoea  at  this  period,  for,  as 
every  clinician  knows,  diarrhoea  is  more  dangerous  to  an  infant 
under  three  months  than  to  an  older  infant,  but  in  the  fact  that 
breast-feeding  is  much  commoner  during  these  first  three  months 
than  in  later  months.  One  might  even  venture  to  draw  from 
these  figures  the  conclusion  that  improved  sanitation  is  a  far 
less  powerful  means  for  reducing  the  death  rate  due  to  infantile 


216          COMMON  DISORDERS  OF  CHILDHOOD 

diarrhoea  than  is  the  inculcation  and  encouragement  of  breast- 
feeding. 

At  the  Hospital  for  Sick  Children,  Great  Ormond  Street, 
statistics  showed  that  96  per  cent,  of  the  infants  up  to  the  age 
of  nine  months  who  died  of  diarrhoea  were  being  hand-fed 
(4  per  cent,  partially,  92  per  cent,  entirely);  only  4  per  cent, 
were  entirely  breast-fed  at  the  time  of  onset  of  diarrhoea.  From 
the  same  source  it  was  found  that  90  per  cent,  of  the  deaths 
from  diarrhoea  in  children  occurred  during  the  first  year  of 
life  ;  it  is  evident,  therefore,  that  to  suckle  an  infant  for  nine 
or  ten  months  is  to  save  it  from  a  very  serious  risk. 

Here  I  would  emphasize  an  important  point,  namely,  the 
special  liability  to  severe  diarrhoea  in  infants  fed  upon  con- 
densed milk.  It  has  been  argued  that  one  of  the  merits  of  con- 
densed milk  is  sterility,  and  that  therefore  it  is  specially  useful 
in  avoiding  the  risk  of  diarrhoea  in  infancy.  Experience  proves 
that  this  is  not  so;  on  the  contrary,  feeding  with  condensed 
milk  seems  to  render  an  infant  particularly  liable  to  severe 
diarrhoea.  Details  of  the  feeding  of  100  infants  in  consecutive 
series,  without  regard  to  the  ailment  for  wrhich  they  were  brought 
to  hospital,  showed  that  12  per  cent,  had  been  fed  on  condensed 
milk,  whereas  similar  details  in  a  series  of  112  cases  of  fatal 
diarrhoea  in  infants  showed  that  at  least  25' 8  per  cent,  of  these 
cases  had  been  fed  on  condensed  milk. 

Among  the  factors  which  play  a  part  in  the  causation  of 
diarrhoea  none  is  more  prominent  than  a  high  mean  temperature 
of  the  atmosphere.  Each  year  in  London  the  diarrhoeal  mortality 
begins  to  rise  early  in  July,  reaches  its  maximum  in  August  or 
September,  and  subsides  to  what  may  be  called  its  normal  level 
about  the  middle  of  October;  moreover,  in  a  general  way  it  may 
be  said  that  the  hotter  the  summer  the  greater  is  the  diarrhceal 
mortality.  The  chart  shown  here  (Fig.  10)  illustrates  these  points 
How  this  high  atmospheric  temperature  acts  is  entirely  un- 
known. It  can  hardly  be  by  direct  effect,  for  if  so  the 
breast-fed  should  suffer  equally  with  the  hand-fed ;  it  seems 
more  likely  that  it  favours  the  growth  of  bacteria,  which  are 
easily  carried  by  food,  especially  by  milk,  and  perhaps  grow 
with  special  ease,  as  so  many  micro-organisms  do,  in  milk. 
Whence  the  organism  comes  or  how  it  reaches  the  milk  is  also 
mere  matter  of  conjecture;  possibly  in  some  cases,  as  Dr.  Nash 
of  Norwich  has  suggested,  it  may  be  conveyed  by  the  common 
house-fly.  Dr.  Ballard's  observation  that  the  temperature 
curve  shown  by  the  four-foot  earth  thermometer  corresponds 


INFANTILE  DIARRHCEA 


217 


more  closely  than  that  of  the  atmospheric  temperature  with  the 
curve  of  prevalence  of  infantile  diarrhoea,  favours  the  idea  of 
some  soil-inhabiting  micro-organism,  but  none  of  the  various 
bacteria  which  have  been  suspected  as  possible  causes  of  infantile 
diarrhoea  have-been  shown  to  be  specially  connected  with  the  soil. 


May.  June.       July. 


Aug.       Sept. 


Oct. 


Nov. 


FIG.  10.  Chart  showing  seasonal  incidence  of  infantile  diarrhoea.  The 
continuous  line  shows  the  mortality  from  diarrhoea  in  children  under  two 
years  of  age ;  the  dotted  line  shows  the  mean  atmospheric  temperature. 

Hitherto  it  cannot  be  said  that  any  micro-organism  of  the 
many  which  have  been  described  in  recent  years  as  causal  agents 
in  infantile  diarrhoea  has  been  proved  to  bear  a  specific  relation 
to  the  disease  ;  it  seems  possible  that  infantile  diarrhoea,  even 
in  its  most  epidemic  form,  may  be  due  to  many  different  micro- 
organisms. In  some  cases  the  bacillus  enteritidis  sporogenes 


218          COMMON  DISORDERS  OF  CHILDHOOD 

described  by  Dr.  Klein  may  be  the  cause,  in  others  the  diarrhoea 
may  be  due  to  streptococci,  but  according  to  the  recent  observa- 
tions of  Dr.  Flexner  and  others  at  the  Rockefeller  Institute  in 
New  York,  the  Bacillus  of  Dysentery  (Shiga's  Bacillus  or  allied 
forms)  would  seem  to  be  present  in  so  large  a  proportion  of 
the  cases  of  '  summer  diarrhoea  '  as  strongly  to  suggest  a  causal 
relation.  This  last  micro-organism  hr.,s  been  found  occasionally 
in  small  numbers  in  the  stools  of  healthy  infants  :  it  may  be  that 
bacteria  which  normally  inhabit  the  intestinal  tract  may  under 
certain  conditions  multiply  excessively  and  assume  pathogenic 
properties. 

But  whilst  in  the  majority  of  cases  infantile  diarrhoea,  especially 
as  it  occurs  in  the  summer  months,  is  due  to  some  micro-organism, 
and  is  in  this  sense  'infective',  there  is  no  reason  to  suppose 
that  it  is  always  so.  Indigestible  food,  certain  drugs,  perhaps 
exposure  of  the  abdomen  to  chill,  as  is  so  apt  to  happen  in  the 
infant  whose  nether  parts  are  too  often  left  uncovered,  and 
probably  the  irritation  of  dentition,  may  all  be  causes  of  diar- 
rhoea. Arising  from  these  conditions  the  diarrhoea  is  usually 
a  mild  and  transient  affair,  but  whatever  the  cause  may  be,  if  it 
persists  so  that  the  catarrhal  condition  of  the  intestine  is  repeat- 
edly induced,  the  repetition  of  '  insults  to  the  intestinal  mucosa  ', 
as  Dr.  Flexner  expressively  calls  them,  renders  the  intestine 
specially  liable  to  bacterial  invasion  ;  in  this  way  what  began 
as  a  simple  gastro-intestinal  catarrh  from  indigestible  food  may 
pass  into  a  severe  infective  gastro-enteritis  or  ileocolitis. 

Diarrhoea  in  infants  as  in  older  persons  may  be  secondary 
to  many  diseases,  to  most  of  the  specific  fevers,  to  pneumonia 
and  to  empyema,or  it  may  be  a  symptom  of  tuberculous  ulcera- 
tion  of  the  bowel  ;  but  here  I  am  not  concerned  with  these 
secondary  diarrhoeas,  and  would  only  point  out  that  sometimes 
most  unexpectedly  what  has  been  regarded  as  an  ordinary 
gastro-enteritis  proves  at  autopsy  to  be  due  to  tuberculous 
disease  of  the  intestine. 

Infantile  diarrhoea  falls  perhaps  most  naturally  into  three 
groups  :  (1)  Gastro-intestinal  catarrh,  (2)  Gastro-enteritis  and 
Ileocolitis,  (3)  Cholera  Infantum. 

The  morbid  anatomist  may  go  further,  and  classify  in  accord- 
ance with  the  lesions  found;  he  may  distinguish  a  follicular 
enteritis  from  a  gastro-enteritis  with  no  enlargement  of  follicles  ; 
lie  may  differentiate  a  simple  ileocolitis  from  an  ulcerative  or 
a  membranous  colitis ;  but  for  the  clinician  to  draw  such  dis- 
tinctions is  usually  to  assume  more  than  he  knows. 


INFANTILE  DIARRHOEA  219 

Even  the  classification  adopted  here  assumes  distinctions 
which  are  not  always  possible  ;  who  shall  say  where  gastro- 
intestinal catarrh,  or,  as  some  would  call  it,  intestinal  dyspepsia, 
passes  into  gastro-enteritis  ?  And  certainly  it  is  often  quite 
impossible  on  any  clinical  grounds  to  determine  whether  a  case 
is  one  of  gastro-enteritis  or  of  ileocolitis.  The  recent  researches 
on  the  dysentery  bacillus  raise  hopes  that  at  some  time  a  clinical 
classification  in  accordance  with  bacteriological  differences  may 
be  practicable,  but  the  time  is  not  yet.  Even  the  distinction 
of  infective  from  non-infective  diarrhoea  is  not  altogether  reliable 
in  the  present  state  of  our  knowledge.  Until  we  know  which 
micro-organisms  cause  diarrhoea,  we  can  only  surmise  that 
most  of  the  severer  cases  of  diarrhoea  in  infancy  are  due  to  some 
infection ;  it  is  quite  conceivable  that  toxic  substances  in  the 
food — for  instance,  products  of  bacterial  action  on  milk  before 
it  has  been  swallowed  by  the  infant — may  set  up  acute  catarrhal 
change  in  the  intestine  without  assistance  from  bacteria  in  the 
bowel.  Recognizing  these  limitations,  we  may  adopt  the  group- 
ing suggested  as  being  of  some  practical  value  in  indicating 
lines  of  treatment. 

Gastro-intestinal  catarrh,  the  simple  diarrhoea,  or  intestinal 
dyspepsia  of  some  writers,  is  the  mildest  form  of  diarrhoea. 
It  begins  often  with  some  evidence  of  colic,  the  infant  cries 
fretfully  and  draws  up  his  legs  as  if  in  pain,  there  is  often  some 
vomiting  at  this  stage,  and  within  a  few  hours  there  is  diarrhoea. 
The  bowels  are  open  perhaps  six  or  seven  times  a  day,  the  stools 
are  loose,  at  first  yellow  and  then  greenish  and  slimy,  and  often 
studded  with  pieces  of  white  curd.  The  parts  about  the  anus 
are  apt  to  become  reddened  and  excoriated.  The  infant  remains 
fretful  and  sleeps  badly ;  the  temperature  is  often  raised  to 
101°-102°,  sometimes  much  higher,  for  a  few  hours,  but  soon 
falls  to  normal.  If  the  attack  lasts  more  than  a  few  hours  the 
limbs  become  flabby,  and  the  weight  is  found  to  have  fallen. 

Such  attacks  are  often  self-terminated  when  the  irritating 
substance,  which  is  commonly  some  undigested  food,  has  been 
evacuated  by  the  diarrhoea ;  in  others  a  dose  of  castor  oil  ejects 
the  offending  material  and  then  the  diarrhoea  ceases. 

If  the  cause  is  allowed  to  remain,  for  instance,  by  the  con- 
tinuance of  unsuitable  feeding,  the  catarrh  becomes  chronic  and 
gradually  the  infant  falls  into  a  condition  of  marasmus  ;  occa- 
sionally an  attack,  which  is  apparently  of  this  mild  type  and  due 
to  some  unsuitable  food,  passes  into  one  of  the  severer  forms, 
and  becomes  gastro-enteritis  or  ileocolitis  ;  this  danger  is  specially 


220  COMMON  DISORDERS  OF  CHILDHOOD 

to  be  remembered  in  the  summer  when  no  looseness  of  the  bowels 
in  an  infant,  however  slight  it  may  appear,  is  to  be  regarded  lightly. 

G astro- enteritis  and  lleocolitis  ('  Inflammatory  Diarrhoea ' : 
'Infective  Diarrhoea').  There  can  be  no  doubt  that  in  some 
cases  the  stomach  and  upper  part  of  the  intestine  are  much  more 
affected  than  the  lower  part,  whereas  in  others  the  stress  of  the 
inflammatory  process  falls  on  the  lower  end  of  the  ileum  and 
colon  ;  moreover,  it  is  possible  in  some  cases  to  recognize  clinically 
that  the  colon  is  the  Beat  of  some  acute  inflammation.  In 
accordance  with  these  facts  we  may  speak  of  a  gastro-enteritis 
in  the  one  case  and  an  ileocolitis  in  the  other  ;  only  let  it  be 
recognized  that  in  many  cases  clinically  no  such  distinction 
is  possible,  and  pathologically  it  is  probable  that  an  ileocolitis 
very  rarely  occurs  apart  from  some  enteritis  or  gastro-enteritis. 
Ileocolitis,  then,  may  be  taken  to  indicate  those  cases  in  which 
from  certain  characters  of  the  stool  and  the  local  distension  or 
tenderness  of  the  colon  it  is  probable  that  this  is  the  part  which 
is  chiefly  affected. 

In  most  cases  of  acute  gastro-enteritis  the  onset  is  more  or 
less  sudden :  the  infant  begins  to  vomit,  passes  a  few  loose, 
perhaps  green  and  slimy  stools,  and  then  the  stools  become 
watery,  often  of  a  dark  brownish  colour  and  very  offensive, 
and  the  bowels  are  open  perhaps  ten  or  twelve  times  a  day. 
Vomiting  varies  much  in  severity  in  these  cases:  sometimes  the 
child  vomits  only  two  or  three  times  a  day,  although  the  diar- 
rhea continues  very  frequent ;  in  other  cases  the  vomiting 
continues  for  several  days,  severe  and  frequent.  The  appearance 
of  the  infant  is  affected  much  more  speedily  by  severe  vomiting 
than  by  diarrhoea  :  the  eyes  become  sunken,  the  face  has  a 
pinched  appearance,  and  the  fontanelle  is  depressed  much  sooner 
in  these  cases  with  severe  vomiting  than  in  those  in  which  the 
fluid  taken  reaches  the  intestine,  for  although  diarrhoea  may 
hurry  the  intestinal  contents  along  very  rapidly  there  is  oppor- 
tunity for  some  absorption  to  take  place.  In  any  case,  after 
even  a  few  hours  of  diarrhoea  the  limbs  lose  their  firmness,  the 
fontanelle  becomes  depressed  and  the  infant  begins  to  look  ill. 
The  tongue  at  first  is  somewhat  furred,  but  after  a  few  days  is 
often  particularly  clean  and  almost  unnaturally  red.  The 
abdomen  is  often  somewhat  tumid  with  coils  of  small  intestine 
visibly  distended,  but  it  is  supple  and  free  from  tenderness. 
The  temperature,  even  if  it  is  raised  for  the  first  few  days,  soon 
becomes  normal,  and  if  the  diarrhoea  is  prolonged  a  subnormal 
temperature  is  common. 


INFANTILE  DIARRHOEA  221 

In  most  cases  the  vomiting  ceases  after  a  few  days,  but  the 
diarrhoea  continues  and  after  fluctuating  for  a  week  or  two  may 
slowly  subside  ;  too  often,  however,  it  becomes  worse  rather 
than  better,  and  as  a  fatal  ending  approaches  the  vomiting 
reappears  and  the  temperature  rises  rapidly  to  104°  or  higher. 

In  other  cases  the  diarrhoea  continues  several  weeks  but  with 
less  severity  than  at  first  :  the  bowels  are  open  perhaps  five  or 
six  times  a  day,  and  any  attempt  to  advance  in  feeding  beyond 
some  very  dilute  and  weak  food  causes  an  alarming  increase  of 
the  diarrhoea  ;  and  so  between  diarrhoea  and  starvation  the  infant 
goes  slowly  down  hill,  becoming  more  and  more  wasted  and  feeble 
until  exhaustion  with  some  exacerbation  of  diarrhoea,  and  perhaps 
a  sudden  hyperpyrexia,  ends  the  scene. 

Ileocolitis  differs  from  gastro-enteritis  in  several  points  :  the 
temperature  is  usually  higher  and  the  pyrexia,  which  is  irregular 
and  of  intermittent  or  remittent  type,  lasts  longer ;  the  abdomen 
is  full  and  distension  of  the  colon  is  sometimes  obvious,  and  there 
may  be  tenderness  of  the  abdomen,  especially  along  the  region 
of  the  colon  ;  tenesmus  and  prolapse  are  apt  to  occur  ;  but  the 
most  constant  feature  is  the  character  of  the  stools,  which  in 
addition  to  loose  brown  or  yellow  faecal  matter,  contain  much 
mucus  often  mixed  with  streaks  of  blood. 

Cholera  Infantum  is  much  rarer  than  either  of  the  preceding, 
but  it  may  be  doubted  whether  it  differs  in  kind.  The  symptoms 
differ  in  their  extreme  acuteness  and  intensity  ;  the  infant  in 
twelve  hours  may  pass  from  perfect  health  to  a  dying  condition. 
The  face  becomes  grey,  with  pinched  nostrils,  the  eyes  sunken 
with  a  dull  vacant  appearance,  the  fontanelle  deeply  depressed, 
the  tongue  is  dry  and  brown,  the  extremities  are  cold  and  blue 
albeit  the  temperature  may  be  105°  or  106°  in  the  rectum,  the 
skin  is  dry  and  loose  over  the  sunken  abdomen  and  the  infant 
lies  in  quiet  apathy,  or  flings  its  arms  restlessly  from  side  to  side 
as  it  licks  its  dry  lips  in  the  misery  of  thirst ;  with  these  symp- 
toms there  is  sometimes  associated  complete  absence  of  sleep  ; 
a  symptom  of  most  sinister  significance — indeed,  I  think,  almost 
always  presaging  death. 

Vomiting  in  these  cases  is  almost  always  extremely  severe  ; 
even  teaspoonful  doses  of  water  are  vomited  ;  the  stools  at  first 
yellow  and  loose  quickly  become  completely  liquid  with  a  charac- 
teristic colourless  '  rice-water  '  appearance,  the  resemblance  of 
which  to  that  seen  in  Asiatic  cholera  (with  which,  of  course,  the 
infantile  disease  has  no  connexion)  has  suggested  the  name  of 
cholera  infantum. 


222  COMMON  DISORDERS  OF  CHILDHOOD 

The  temperature  is  usually  subnormal,  but  in  some  cases,  as 
already  mentioned,  it  is  much  raised  ;  the  respiration  is  rapid 
and  shallow,  sometimes  almost  panting  ;  the  pulse  becomes 
extremely  rapid  and  barely  to  be  felt  at  the  wrist,  and  with 
increasing  exhaustion  the  child  dies  within  a  day  or  two  after 
the  onset  of  the  diarrhoea.  But  cholera  infantum  is  not  always 
fatal,  the  case  which  looks  most  desperate  will  sometimes  recover, 
the  stools  begin  to  show  some  trace  of  colour,  they  become  less 
watery,  and  slowly  the  diarrhoea  ceases. 

Such  are  the  symptoms  in  the  three  groups  of  infantile  diar- 
rhoea :  their  differences  are  chiefly  differences  of  severity ;  indeed, 
beyond  the  points  which  I  have  mentioned  as  indicating  affection 
of  the  colon,  I  doubt  whether  there  is  any  valid  point  of  dis- 
tinction other  than  that  of  severity. 

The  so-called  cholera  infantum  has  nothing  whatever  to 
distinguish  it  from  a  very  severe  case  of  gastro-enteritis  but  the 
colourless  appearance  of  the  stools,  and  at  present  we  have  no 
proof  that  this  indicates  more  than  an  extreme  degree  of  severity 
of  the  irritating  process  in  the  bowel,  and,  as  I  have  already 
pointed  out,  it  is  impossible  to  draw  any  sharp  line  of  distinction 
between  gastro-intestinal  catarrh  and  gastro-enteritis.  I  em- 
phasize this  point  because  I  think  there  is  a  tendency  nowadays 
to  force  infantile  diarrhoea  into  various  groupings  with  no 
sufficient  clinical  grounds,  and  with  no  certain  knowledge  yet 
of  differences  in  pathogeny. 

Complications.  In  all  forms  of  infantile  diarrhoea  complica- 
tions are  common.  If  the  diarrhoea  is  at  all  prolonged  there  is 
often  thrush  in  the  mouth,  and  the  tradition  which  still  lingers 
amongst  the  laity  that  this  is  an  occurrence  of  fatal  significance 
probably  arises  from  the  fact  that  thrush  is  specially  liable  to 
occur  in  any  condition  of  extreme  malnutrition,  but  there  is 
no  reason  to  suppose  that  the  prognosis  is  made  either  better 
or  worse  by  the  presence  or  absence  of  thrush,  unless  indeed  the 
stomatitis  which  accompanies  thrush  in  some  cases  be  severe 
enough  to  make  the  infant  unwilling  to  take  food  and  so  increase 
the  difficulty  of  maintaining  the  infant's  strength.  But  it  is  not 
only  in  the  prolonged  cases  of  diarrhoea  with  marasmus  that 
thrush  occurs,  it  is  seen  often  enough  in  transient  gastric  or 
gastro-intestinal  disturbances  in  infancy,  where  the  secretions 
of  the  mouth  are  in  some  way  altered  so  that  the  normal  alka- 
linity is  reduced  or  gives  way  to  the  actual  acidity  which  is 
often  found  with  thrush  and  which  seems  to  favour  the  growth 
of  the  oidium  albicans.  I  have  found  thrush  coating  the 
oesophagus  almost  down  to  the  cardiac  orifice  in  infantile  diar- 
rhoea with  marasmus  ;  and  cases  have  been  recorded  in  which 


INFANTILE  DIARRHOEA  223 

thrush  has  been  demonstrated  on  the  skin  about  the  anus,  so 
that  although  thrush  probably  never  really  traverses  the  intes- 
tinal tract  there  is  some  excuse  for  the  popular  idea  that  the 
'  thrush  has  gone  through  the  child  ',  a  statement  which  usually 
means  nothing  more  than  that  the  anus  has  become  reddened 
and  excoriated  by  irritating  stools. 

Respiratory  complications  are  particularly  common  ;  in  any 
severe  case  of  diarrhoea  if  it  lasts  more  than  a  few  days  bronchitis 
is  apt  to  occur  and  passes  very  easily  and  insidiously  into  a 
broncho-pneumonia.  Such  a  condition  is  sometimes  found  quite 
unexpectedly  at  autopsies  on  cases  of  infantile  diarrhoea.  The 
pulmonary  collapse,  which  is  a  noticeable  feature  in  many  cases 
of  diarrhoea  as  in  other  wasting  diseases  of  infancy  at  autopsy, 
is  seldom  recognizable  during  life. 

Otitis  media  is  to  be  remembered  as  a  complication  of  diar- 
rhoea ;  any  exhausting  disease,  be  it  acute  or  chronic,  seems  to 
bring  with  it  a  special  liability  to  catarrh  of  the  middle-ear  in 
infancy,  sometimes  with  external  discharge,  sometimes  without, 
but  in  either  case  adding  its  own  symptoms  to  those  of  the 
primary  disease.  A  sudden  rise  of  temperature  may  be  due  to 
catarrh  in  the  middle-ear  ;  I  have  often  wondered  whether  the 
head-retraction,  which  is  not  very  rare  in  cases  of  infantile 
diarrhoea  where  there  is  much  exhaustion,  may  not  be  due,  at 
least  in  some  cases,  to  the  same  cause  ;  for  it  is  quite  certain 
that  middle-ear  catarrh  is  responsible  for  marked  head-retraction 
in  some  cases  apart  from  diarrhoea;  the  proof  is  the  disappear- 
ance of  the  head-retraction  after  puncture  of  the  membrana 
tympani.  I  have  several  times  found  pus  in  one  middle-ear  or 
both  after  death  in  cases  of  infantile  diarrhoea  where  there  had 
been  head-retraction  during  life,  but  this,  I  admit,  rather  suggests 
than  proves  a  causal  relation,  for  pus  is  very  commonly  found 
in  the  middle-ear  in  infants  who  have  died  of  any  disease  which 
has  lasted  more  than  a  few  days  whether  there  have  been 
symptoms  of  ear  disease  during  life  or  not.  In  seventy-nine 
consecutive  autopsies  on  infants  who  died  from  any  cause  under 
two  years  of  age,  I  found  pus  in  one  or  both  ears  in  thirty-two. 

Screaming  as  with  pain  in  an  infant  with  diarrhoea  should 
always  suggest  the  possibility  that  the  pain  may  be  in  the  ear 
rather  than  in  the  abdomen. 

Otitis  media,  when  it  occurs  apart  from  diarrhoea,  sometimes 
produces  symptoms  closely  simulating  meningitis ;  it  seems 
quite  possible,  therefore,  that  the  symptoms  seen  in  some  severe 
cases  of  diarrhoea  and  described  as  '  spurious  hydrocephalus  ' 
(the  resemblance  is  to  tuberculous  meningitis,  which  was  formerly 
known  as  '  acute  hydrocephalus ',  not  to  the  chronic  condition 


224          COMMON  DISORDERS  OF  CHILDHOOD 

to  which  the  term  hydrocephalus  is  now  applied)  may  some- 
times be  due  rather  to  some  middle-ear  inflammation  than  to 
any  toxaemia,  as  is  assumed. 

The  cerebral  symptoms  known  as  '  spurious  hydrocephalus  ' 
are  illustrated  by  the  following  case.  Geraldine  W.,  aged  nine 
months,  had  had  diarrhoea  and  vomiting  fourteen  days  ;  she 
was  admitted  to  hospital  about  thirty-six  hours  before  death  ; 
the  infant  lay  on  its  back  quite  apathetic  and  apparently  only 
semi-conscious  ;  the  fontanelle  was  depressed ;  the  eyes  were 
sunken,  rolled  somewhat  upwards,  with  divergent  strabismus  ; 
occasionally  the  infant  gave  a  piercing  scream,  which  was  noted 
as  '  very  like  meningitis  '  ;  the  mother  said  that  there  had  been 
some  rolling  of  the  head  from  side  to  side.  Autopsy  showed 
nothing  abnormal  in  the  brain  or  its  vessels.  There  was  pus 
in  the  left  middle-ear.  The  bowel  showed  enlargement  of 
solitary  follicles  and  five  small  shallow  ulcers  in  the  middle  part 
of  the  ileum ;  all  other  organs  were  normal. 

Charles  D.,  aged  ten  weeks  ;  diarrhoea  began  fourteen  days 
before  death  ;  on  admission,  nine  days  before  death,  the  eyes 
were  sunken,  the  fontanelle  depressed,  there  was  occasional 
divergent  squint ;  the  head  was  rigidly  retracted,  and  there 
was  some  opisthotonos  of  the  dorsal  and  lumbar  spine  ;  the 
limbs  were  rigid,  especially  the  left  arm  ;  there  was  no  optic 
neuritis.  The  head-retraction  continued  with  remissions,  and 
there  was  some  rolling  of  the  head  from  side  to  side  ;  rigidity  of 
the  limbs,  especially  of  the  left  arm,  persisted.  Autopsy  showed 
nothing  abnormal  in  the  brain,  meninges,  or  vessels  ;  the  colon 
showed  extensive  ulceration,  with  very  acute  colitis. 

Cerebral  symptoms  in  infantile  diarrhoea  are  occasionally  due 
to  thrombosis  of  sinuses.  In  my  experience  this  has  been  very 
rare  ;  it  was  found  only  once  in  eighty- two  autopsies  on  infantile 
diarrhoea  at  the  Children's  Hospital,  Great  Ormond  Street  ;  this 
was  in  an  infant  aged  one  year,  who  died  after  severe  gastro- 
enteritis of  3J  weeks'  duration  ;  during  the  illness  some  facial 
paralysis  had  been  noticed  ;  at  autopsy  thrombosis  of  the  longi- 
tudinal sinus  was  found.  Even  when  thrombosis  has  been  found 
there  have  not  always  been  cerebral  symptoms  during  life  ; 
sometimes  convulsions  have  occurred,  but  these  are  not  very 
uncommon  with  infantile  diarrhoea  without  thrombosis  of  sinuses. 
Convulsions  are  always  to  be  regarded  as  a  grave  complication 
of  diarrhoea,  but  they  do  not  by  any  means  necessarily  indicate 
a  fatal  ending ;  they  are  less  serious  when  they  occur  at  the  onset 
of  the  diarrhoea  than  when  they  occur  in  the  stage  of  exhaustion. 


INFANTILE  DIARRHOEA  225 

(Edema,  especially  of  the  extremities,  is  not  an  uncommon 
complication  of  infantile  diarrhoea  ;  it  occurs  usually  when  the 
diarrhoea  has  lasted  long  enough  for  the  infant  to  become  much 
wasted,  and  is  no  doubt  similar  in  its  pathology  to  the  oedema 
which  is  often  seen  with  severe  marasmus  in  infancy  ;  what  this 
pathology  may  be  is  uncertain,  but  it  is  probable  that  some  altered 
state  of  the  blood,  and  perhaps  of  the  walls  of  the  blood-vessels 
together  with  some  feebleness  of  circulation  is  sufficient  cause  for 
the  cedema.  Certainly  it  is  very  rarely  that  oedema  is  due  to 
any  nephritis  in  infantile  diarrhoea  ;  it  is  common  enough  to  find 
a  trace  of  albumen  in  the  urine  in  cases  of  infantile  diarrhoea  ; 
in  some  cases  this  may  be  explained  by  the  presence  of  uric  acid 
granules  in  the  pelvis  of  the  kidney,  for  with  the  concentration  of 
the  urine  during  diarrhoea  these  granules  are  apt  to  be  deposited, 
as  I  have  often  seen  in  the  renal  pelvis.  They  are  associated 
sometimes  with  the  so-called  'uric-acid  infarcts',  i.e.  deposits  of 
uric  acid  in  the  straight  tubules  of  the  kidney,  which  may  be 
not  merely  a  post  mortem  phenomenon  but  an  actual  cause  of 
irritation  during  life. 

Occasionally,  it  is  true,  the  kidney  is  found  to  be  pale  and 
swollen  with  hsemorrhagic  points  under  the  capsule  and  in 
the  cortex,  and  well-marked  nephritic  changes  are  seen  under 
the  microscope,  but  more  often  the  occurrence  of  cedema  or  of 
slight  albuminuria  clinically  is  not  explained  by  any  naked-eye 
change  in  the  kidneys,  and  microscopic  examination  shows  only 
some  granular  appearance  and  feebleness  in  staining  of  the  cells 
of  the  tubules  which  can  hardly  be  taken  as  unequivocal  evidence 
of  nephritis. 

Purpura  is  not  very  uncommon  where  diarrhoea  has  already 
produced  much  wasting  ;  it  is  always  to  be  regarded  as  of  grave 
significance,  but  I  have  several  times  seen  recovery  occur  in  spite 
of  the  presence  of  purpura. 

There  is  another  complication  which,  although  unrecognizable 
during  life,  may  be  of  some  practical  importance,  for  it  may  make 
the  infant  unwilling  to  swallow,  namely,  an  acute  inflammation 
of  the  oesophagus.  It  is  a  rare  occurrence,  but  has  been  observed 
several  times  at  the  Children's  Hospital,  Great  Ormond  Street; 
the  oesophagus,  chiefly  near  the  cardiac  orifice,  shows  deep  con- 
gestion with  haemorrhagic  points  in  the  mucous  membrane.  It 
occurs  apart  from  any  obvious  cause  such  as  the  passage  of  a 
stomach-tube  or  severe  vomiting. 


226  COMMON  DISORDERS  OF  CHILDHOOD 

Treatment 

In  spite  of  all  that  has  been  written  on  the  treatment  of 
infantile  diarrhea,  those  who  have  largest  experience  will  be 
most  ready  to  admit  that  there  are  few  diseases  of  infancy 
in  which  the  choice  of  treatment  is  more  perplexing.  There  is 
no  lack  of  methods  ;  the  difficulty  is  to  decide  what  mode  of 
treatment  is  likely  to  suit  the  particular  case  ;  certain  general 
principles  we  can  lay  down,  and  certain  drugs  and  modes  of 
feeding  can  be  mentioned  as  generally  useful,  but  in  the  individual 
case  drug  after  drug,  and  food  after  food,  has  often  to  be  tried 
before  success  is  obtained.  And  here  I  venture  to  point  out  what 
has  sometimes  seemed  to  me  to  be  a  shortcoming  in  the  treat- 
ment of  severe  infantile  diarrhoea  ;  the  doctor  sees  the  infant 
perhaps  in  the  morning,  gives  his  orders,  and  says  he  will  come 
again  next  day.  Now  in  many  a  case  of  acute '  summer  diarrhoea' 
the  infant  passes  so  rapidhT  from  bad  to  worse  that  if  a  food  or 
drug  which  is  doing  no  good  is  continued  for  several  hours,  the 
chance  of  saving  the  infant's  life  is  lost  ;  it  may  be  necessary  for 
the  doctor  to  see  the  infant  twice  or  even  thrice  in  the  day,  to 
adapt  his  measures  to  the  changing  and  pressing  needs  of  the  infant. 

In  the  so-called  gastro-intestlnal  catarrh  or  simple  diarrhoea,  if 
the  infant  comes  under  treatment  within  a  day  or  two  after  the 
onset  of  the  disorder,  it  is  often  well  to  give  a  mild  purge  to  clear 
out  the  cause  of  the  trouble,  and  for  this  purpose  I  think  nothing 
is  better  than  the  old-fashioned  remedy  castor  oil,  in  a  dose  of 
J  to  1  drachm  for  an  infant  up  to  one  year  old,  for  it  not  only  acts 
as  a  purge,  but  has  a  subsequent  constipating  effect,  which  is 
just  what  is  needed  in  these  cases.  But  often  medical  advice  is 
not  sought  until  the  diarrhoea  has  already  lasted  several  days, 
and  Nature  has  evacuated  the  bowel  so  thoroughly  that  any 
further  purging  would  do  more  harm  than  good.  In  these  cases 
a  combination  of  opium  with  small  doses  of  castor  oil  is  a  very 
effectual  remedy.  And  here  let  me  point  out  the  very  marked 
difference  in  effect  of  castor  oil  according  to  the  dose  given. 
Castor  oil  in  doses  of  5  minims  given,  say,  three  times  daily  to  an 
infant,  has  only  a  constipating  effect,  it  has  no  aperient  action 
whatever  ;  it  is  indeed  almost  as  constipating  as  opium.  For 
infants  under  two  months  old,  it  is  wise  to  use  only  4  minims  for 
this  purpose,  for  at  this  tender  age  5  minims  has  occasionally, 
though  rarely,  an  aperient  effect  ;  at  any  age  up  to  the  end  of 
infancy  (two  years  old)  the  dose  of  5  minims  must  not  be  exceeded 
if  the  castor  oil  is  used  to  constipate  \  any  larger  dose  may  act 


INFANTILE  DIARRHOEA  227 

as  an  aperient ;  a  10-minim  dose  usually  has  this  effect.  A 
useful  mixture  is  the  following  :  R.  Ol.  Ricini  Ct)v,  Spirit. 
Chloroformi  O)j,  Mucilag.  Acacise  O)xv,  Aq.  Anethi  ad  3j  ;  to 
which  for  an  infant  two  months  old,  Tinct.  Camph.  Co.  O)ij  may 
be  added,  at  three  months  Tinct.  Opii  tt)  £,  at  six  months  Tinct. 
Opii  CO  J,  and  at  one  year  Tinct.  Opii  tt)§. 

The  feeding  will  require  some  modification.  If  the  infant  is 
being  hand-fed,  it  will  usually  be  well  to  dilute  the  milk  consider- 
ably, and  the  addition  of  lime-water  or  of  sodium  citrate  to  the 
milk  may  be  useful,  the  former  being  used  in  the  proportion 
of  at  least  1  ounce  to  every  3  ounces,  the  latter  in  the  pro- 
portion of  1  grain  to  every  ounce  of  milk  up  to  4  grains;  both 
these  drugs  have  a  distinctly  constipating  effect  in  addition  to 
their  value  in  assisting  the  digestion  of  milk.  If  the  infant  is  past 
the  age  of  one  year,  a  thin  arrowroot  gruel  made  with  milk  and 
water,  equal  parts,  and  given  only  lukewarm,  makes  a  useful  food. 

In  the  severer  forms  of  diarrhoea,  gastro-enteritis  and  ileocolitis, 
and  even  more  in  the  severest  cases  of  all,  the  so-called  cholera 
infantum,  dietetic  measures  are  of  vital  importance.  First  and 
foremost  in  the  acute  stage  is  the  prohibition  of  all  milk  ;  it  is 
poor  economy  to  temporize  with  various  dilutions  of  milk  in  the 
hope  that  so  nutrition  may  be  maintained  ;  far  less  is  lost  by 
substituting  at  once  some  much  weaker  form  of  nutriment,  which 
may  relieve  the  bowel  from  irritating  residue,  and  so  favour  the 
subsidence  of  the  inflammation.  But  what  is  to  be  given  instead 
of  milk  ?  My  own  bias  as  the  result  of  experience  is  against  all 
modifications  of  milk,  even  the  most  carefully  prepared  whey 
will  sometimes  perpetuate  vomiting  and  diarrhoea  in  these  cases 
if  given  during  this  early  stage  of  the  disorder,  and  peptonized 
milk,  however  much  diluted,  does  only  harm.  The  choice  lies, 
I  think,  between  albumen-water,  barley-water  (or,  better,  rice- 
water),  weak  veal  or  chicken  broth,  ordinary  tea  freshly  infused 
and  made  very  weak,  a  food  much  favoured  for  severe  infantile 
diarrhoea  in  some  parts  of  Germany  as  having  perhaps  some  value. 
I  shall  have  something  to  say  about  this  later  on. 

Broth  is  by  no  means  always  successful ;  sometimes  it  is 
vomited,  and  sometimes  it  excites  diarrhoea  where  albumen- 
wrater  may  be  tolerated  well  ;  but  except  in  the  very  severe  cases 
it  is  worthy  of  trial,  and  an  infant  can  be  kept  on  broth  alone  for 
two  or  three  days  if  necessary  ;  if  the  diarrhoea  is  abating  after 
twenty-four  or  thirty-six  hours,  half  a  teaspoonful  of  milk  sugar 
may  be  added  to  every  3  ounces  of  broth,  and  then  feeds  of  whey 
may  alternate  with  feeds  of  broth. 


228          COMMON  DISORDERS  OF  CHILDHOOD 

Barley-water  is  to  be  used  with  caution  ;  the  starch  which  it 
contains  may  set  up  fermentation  processes  in  the  bowel  which 
may  aggravate  the  diarrhoea ;  sometimes,  however,  it  seems  to 
suit  excellently.  Barley-water  in  these  cases  must  be  made  thin. 

Rice-water  is  perhaps  preferable  to  barley-water  on  account 
of  its  being  less  laxative  ;  I  have  used  it  in  these  severe  diarrhoea 
cases  with  good  result.  (For  method  of  preparation,  see  p.  44.) 

Albumen-water1  is,  I  think,  the  most  useful  food  in  severe  cases, 
for  not  only  is  it  retained  easily,  but  it  seems  to  be  less  irritating 
to  the  bowels  than  either  broth  or  cereal  decoctions.  It  should 
be  remembered,  however,  that  the  white  of  an  egg  is  not  neces- 
sarily sterile  ;  the  utmost  care  should  be  taken  to  procure  fresh 
eggs  for  this  purpose. 

But  there  are  cases  in  which  even  albumen- water  is  vomited;  in 
these  plain  cold  boiled  water  should  be  tried.  The  urgent  need  of 
the  infant  with  severe  diarrhoea  and  vomiting  is  for  fluid  ;  it 
matters  little  whether  it  contains  this  or  that  amount  of  nourish- 
ment, plain  water  will  serve  the  immediate  purpose  at  least  as 
well  as  any  other  fluid. 

The  commonest  fault  in  dealing  with  these  cases  is  to  use  too 
large  feeds.  Many  an  infant  who  vomits  all  that  he  takes,  so  long 
as  two-  or  three-ounce  feeds  are  given  every  hour,  will  retain 
perhaps  a  drachm,  or  it  may  be  2  or  3  drachms,  given  every 
half  hour  ;  it  is  to  be  remembered  that  the  retention  of  the  fluid 
is  not  only  a  gain  in  itself  by  supplying  the  need  of  the  infant,  but 
it  means  that  the  stomach  is  not  irritated  as  it  was  by  the  larger 
feed,  and  so  there  is  more  opportunity  for  subsidence  of  the 
inflammatory  or  catarrhal  condition.  There  can,  I  think,  be  no 
doubt  that,  mutatis  mutandis,  the  same  is  true  of  the  intestine  ; 
where  there  is  no  vomiting  but  severe  diarrhoea  and  the  bowel 
ejects  all  food  rapidly,  it  is  wise  to  use  small  feeds  often,  say  ounce 
feeds  every  hour  or  2  ounces  every  1£  hours  rather  than  three- 
or  four-ounce  feeds  every  two  or  three  hours  ;  it  seems  as  if  the 
smaller  amount  coming  into  the  intestine  at  one  time  excites 
peristalsis  less  than  does  a  larger  amount. 

But  whilst  I  would  insist  upon  the  importance  of  small  feeds 
during  the  very  acute  stage  of  vomiting  and  diarrhoea,  I  would 
also  deprecate  the  prolonged  use  of  very  frequent  feeding.  So 
long  as  only  a  teaspoonful  or  a  dessertspoonful  can  be  retained 
it  is  necessary  to  feed  every  half  hour  or  every  three-quarters  of 

1  To  prepare  a]  bum  en- water,  take  the  white  of  one  fresh  egg,  divide  it  in 
several  directions  with  a  pair  of  clean  scissors,  then  mix  it  with  6  ounces  of  cold 
water  in  a  bottle,  and  shake  vigorously  ;  strain  through  muslin. 


INFANTILE  DIARRHCEA  229 

an  hour,  but  after  four  or  five  hours  an  attempt  should  be  made 
to  increase  the  feed  to  half  an  ounce  every  hour,  and  then  to  6 
drachms  every  1 J  hours,  and  so  on. 

In  cases  where  even  teaspoonful  feeds  are  vomited,  and  some- 
times where  the  stomach  will  just,  but  only  just,  tolerate  these 
small  amounts  of  water  or  albumen-water,  the  best  result  may 
be  obtained  by  stopping  all  attempts  at  feeding  by  mouth  for 
some  hours,  perhaps  four  or  five  hours,  and  in  the  meantime  a 
large  rectal  injection  of  saline  solution  (a  drachm  of  sodium 
chloride  to  the  pint),  5  to  6  ounces  to  an  infant  of  three  months, 
may  be  given  slowly  with  the  idea  of  procuring  absorption  of 
some  of  the  fluid  if  it  is  retained  long  enough,  and  of  washing 
out  the  bowel  if  the  fluid  is  returned. 

If  the  infant  is  very  collapsed,  the  eyes  sunken,  and  the  fon- 
tanelle  depressed,  and  the  vomiting  and  diarrhoea  extremely  severe, 
so  that  it  is  evident  that  there  is  urgent  and  immediate  need  for 
some  absorption  of  fluid,  the  best  procedure  and  the  only  one  which 
will  ensure  the  necessary  absorption  of  fluid,  is  subcutaneous  in- 
fusion. This  is  really  a  very  simple  matter  if  a  funnel,  a  piece  of 
rubber  tubing,  and  an  exploring  needle  of  medium  size  are  available. 

The  barrel  of  an  ordinary  glass  ear  syringe  without  the  piston 
makes  an  excellent  funnel,  being  narrow  enough  to  allow  the 
upper  open  end  to  be  easily  stoppered  with  aseptic  cotton-wool, 
a  precaution  which  should  not  be  neglected,  for  the  fluid  may 
take  nearly  an  hour  to  run  in,  and  during  this  time  serious  con- 
tamination may  occur  if  the  surface  of  the  fluid  is  left  exposed. 
The  needle,  barrel,  and  rubber  tubing  must  be  carefully  sterilized  by 
boiling  water,  the  skin  over  the  lower  ribs  in  the  axilla  is  thoroughly 
cleansed  by  rubbing  first  with  ether,  then  soap  and  water,  and 
then  with  some  antiseptic  solution,  e.g.  1  in  1,000  hydrarg.  pcr- 
chlor.  solution  ;  the  barrel  and  tube  are  then  filled  with  the 
saline  solution,  which  must  be  prepared  with  boiling  water,  and 
cooled  down  to  105°  F.  (if  no  suitable  thermometer  is  available 
the  temperature  can  be  guessed  with  sufficient  accuracy),  and  the 
lower  end  of  the  tube  must  then  be  clamped  or  pinched  to  prevent 
escape  of  the  fluid  whilst  the  needle  is  inserted.  The  skin  over 
the  lower  part  of  the  axilla  is  then  pinched  up  between  the  finger 
and  thumb  of  the  left  hand,  while  with  the  right  hand  the  needle 
is  pushed  through  the  skin  into  the  subcutaneous  tissue,  in  which 
it  should  be  pushed  along  for  about  three-quarters  of  an  inch. 

The  infusion  can  be  done  more  rapidly  a*  d  a  larger  quantity 
can  be  introduced  if  the  tube  from  the  funnel  be  attached  to  a 
Y-shaped  connecting  piece,  so  that  the  fluid  can  pass  by  two 
separate  tubes  and  needles  into  two  different  parts,  e.g.  into  the 
two  axillae  simultaneously. 


230  COMMON  DISORDERS  OF  CHILDHOOD 

The  funnel  must,  of  course,  be  refilled  frequently  so  that  it  does 
not  empty  itself  completely,  and  to  facilitate  the  flow  it  is  often 
necessary  to  push  the  needle  slightly  onwards  into  a  fresh  area  of 
subcutaneous  tissue  from  time  to  time  as  the  tension  becomes 
great,  or  to  move  the  needle  slightly  so  as  to  disengage  the  point 
from  any  fat  or  fibrous  tissue  which  may  be  blocking  the  lumen  ; 
in  this  way  the  fluid  runs  in  slowly,  and  in  about  three-quarters  of 
an  hour  as  much  as  6-8  ounces  may  be  introduced  into  the 
subcutaneous  tissue.  The  large  bulging  swelling  at  the  site  of 
infusion  disappears  completely  in  an  hour  or  two,  and  it  is 
remarkable  how  little  pain  beyond  the  first  prick  of  the  needle 
seems  to  bo  caused  by  infusion.  Various  fluids  have  been  used 
for  infusion.  A  five  per  cent,  solution  of  glucose  which  can  be 
prepared  readily  with  special  sealed  tubes  containing  sufficient 
glucose  to  make  one  pint  (Martindale)  has  the  advantage  that 
it  supplies  nourishment  as  well  as  fluid.  Sea  water  has  been  in 
fashion  recently  and  can  be  obtained  in  sterile  sealed  tubes,  but 
so  far  as  I  have  seen  has  no  advantage  over  ordinary  'normal 
saline  '.  The  most  readily  available  is  this  ordinary  saline  made 
by  adding  one  drachm  of  sodium  chloride  to  the  pint  of  water ; 
of  course  it  is  necessary  that  the  solution  should  be  thoroughly 
sterilized  by  boiling. 

The  effect  of  subcutaneous  infusion  is  generally  very  striking, 
the  eyes  become  less  sunken,  the  fontanelle  less  depressed,  the 
infant  is  less  apathetic,  and  looks  less  distressed  ;  often  he  falls 
into  a  calm  sleep,  which  considerably  assists  recovery  from  the 
previous  exhaustion. 

But  before  infusion  is  done,  if  the  exhaustion  and  collapse 
is  extreme,  it  is  advisable  to  use  some  more  rapid  stimulant  ; 
the  process  of  infusion  must  necessarily  occupy  at  least  half 
an  hour,  and  this  may  be  half  an  hour  too  late  in  the  case  of 
a  collapsed  infant  ;  moreover,  if  infusion  is  done  when  an  infant 
is  already  moribund,  there  may  not  be  sufficient  circulatory 
power  to  ensure  its  rapid  absorption.  In  the  case  of  extreme  ex- 
haustion, therefore,  strychnine  should  be  injected  subcutaneously 
first  ;  very  young  infants  are  particularly  susceptible  to  strych- 
nine, and  I  have  seen  convulsive  symptoms  follow  the  in- 
jection of  one  minim  of  the  B.P.  Liquor  Strychninse  ;  to  an 
infant  under  three  months  half  a  minim  of  this  solution  should 
be  given,  to  an  older  infant  one  minim. 

Here  I  would  dissuade  from  the  subcutaneous  injection  of 
ether  or  brandy  unless  the  infant  is  either  in  articulo  mortis  or 
unconscious  ;  the  effect  of  either  of  these  is  probably  more  rapid 
than  that  of  strychnine,  indeed,  it  is  almost  instantaneous,  but 
it  is  also  more  evanescent  and  therefore  less  valuable,  except  in 


INFANTILE  DIARRHOEA  231 

the  most  extremely  urgent  cases  ;  but  apart  from  their  evanescent 
effect,  both  these  drugs  when  injected  hypodermically  cause 
considerable  pain,  whereas  strychnine,  apart  from  the  mere  prick 
of  the  skin,  causes  none. 

An  excellent  stimulant  in  cases  of  collapse  from  diarrhoea  or 
vomiting  is  the  hot  mustard  bath  (a  tablespoonf  ul  of  mustard  to  a 
gallon  of  water)  at  a  temperature  of  100°-105°.  The  infant  should 
be  undressed  and  supported  on  the  nurse's  hands  in  the  bath,  so 
that  the  whole  body  with  the  exception  of  the  head  is  immersed  ; 
often  I  have  seen  in  the  administering  of  a  mustard  bath  the 
greater  part  of  the  body  uncovered  by  the  water,  so  that  the 
infant  was  being  chilled  by  the  exposure  rather  than  stimulated 
by  warmth.  After  remaining  about  four  minutes  in  the  bath 
the  infant  should  be  quickly  dried  with  a  warm  towel,  wrapped 
in  a  hot  blanket,  and  hot  water-bottles  should  be  placed  outside 
the  blanket.  If  infusion  is  to  be  done  immediately  after  the  hot 
bath,  great  care  must  be  taken  to  keep  the  infant  as  far  as 
possible  warmly  covered,  for  the  dilatation  of  cutaneous  vessels 
makes  even  the  slight  exposure  which  may  be  necessary  during 
infusion  a  possible  depressant. 

The  value  of  alcohol  in  the  early  stage  of  severe  diarrhoea  when 
there  is  extreme  exhaustion  and  collapse,  is,  I  think,  quite 
undeniable  ;  10  or  20  drops  of  brandy  in  a  teaspoonful  of  cold 
water  may  be  retained  when  all  else  is  vomited,  and  this 
amount  of  brandy  acts  as  a  powerful  stimulant  to  an  infant,  the 
small  dose  for  an  infant  under  six  months,  the  large  for  an  infant 
from  six  to  twelve  months  old.  This  dose  can  be  repeated  three 
or  four  times  at  intervals  of  two  hours  or  even  of  an  hour  if  neces- 
sary ;  but  if  it  is  to  be  repeated  after  this  smaller  doses  should  be 
used,  5  minims  for  an  infant  under  three  months,  10  minims  for 
an  older  infant.  It  is  not  only  as  a  stimulant  that  these  small 
doses  of  brandy  are  valuable,  but  also  in  the  prevention  of 
vomiting ;  formerly  I  was  sceptical  of  the  possibility  of,  say,  5 
drops  of  brandy  in  a  three-ounce  feed  having  any  appreciable 
effect ;  I  have  satisfied  myself  that  this  small  dose  has  a  very 
valuable  effect  both  in  preventing  vomiting,  and  also  in  assisting 
the  digestion  of  milk  in  some  cases  of  curd-indigestion  ;  in  this 
way  small  doses  of  brandy  are  sometimes  useful  both  in  the 
acute  stage  of  diarrhoea  and  vomiting,  and  also  a  little  later  when 
an  attempt  is  being  made  to  return  to  milk-feeding.  Having 
said  this  much  in  favour  of  the  use  of  alcohol,  I  must  also  express 
my  conviction  that  great  harm  is  done  by  too  large  doses  of 
alcohol  in  this  disease  ;  I  have  seen  babies  who  were -being  dosed 
with  brandy  every  hour  and  even  oftener  in  amounts  far  exceeding 


232          COMMON  DISORDERS  OF  CHILDHOOD 

those  I  have  mentioned,  with  the  result  that  vomiting  was 
actually  aggravated,  and  sometimes  it  has  seemed  to  me  that  the 
drowsiness  or  the  supposed  delirium  of  the  infant  was  largely  if 
not  entirely  due  to  the  brandy.  If  brandy  is  ordered  for  an 
infant  with  any  disease,  the  exact  dose  and  frequency  should  be 
specified  by  the  doctor,  and  I  think  it  is  very  rarely  that  the 
doses  I  have  mentioned  above  should  be  exceeded,  and  last,  but 
not  least,  the  doctor  should  specify  how  long  the  alcohol  is  to 
be  continued  ;  I  have  known  brandy  and  other  alcoholic  stimu- 
lants continued  for  many  weeks  or  months  simply  because  the 
doctor  had  omitted  to  mention  that  it  should  be  used  only  for 
a  few  days,  and  the  fewer  the  better. 

With  regard  to  choice  of  alcoholic  stimulants  I  doubt  whether 
whisky  has  any  advantage  over  brandy  ;  some,  however,  use  it, 
and  circumstances  may  sometimes  make  it  convenient  to  do  so  ; 
similar  doses  should  be  used. 

Sherry  makes  a  convenient  stimulant  in  the  form  of  sherry 
whey1;  this,  however,  is  usually  not  suitable  in  the  earliest  stage 
if  the  vomiting  and  diarrhoea  are  very  severe  ;  but  later,  when 
both  have  become  less  acute,  sherry  whey  often  makes  a  useful  step 
towards  the  return  to  milk-feeding,  it  seems  to  have  a  carminative 
effect,  so  that  not  only  is  it  retained  itself,  but  other  food  given 
at  alternate  feeds  is  also  retained.  If  necessary,  sherry  whey  can 
be  used  alone  for  a  day  or  two  where  feeds  of  not  more  than 
2  ounces  are  required,  but  as  soon  as  possible  it  should  be  used 
only  as  an  alternate  or  occasional  feed,  the  other  feeds  being  either 
broth,  or  plain  rennet  whey,  or  later,  weak  peptonized  milk  with 
some  lime-water  to  counteract  its  laxative  effect. 

Drugs  must  next  be  considered,  and  I  place  opium  first,  for 
there  is,  I  think,  no  drug  which  is  so  generally  valuable  in  this 
disorder.  This  statement,  however,  needs  qualification,  for  there 
are  cases  in  which  the  administration  of  opium  seems  to  do  harm  : 
when  the  stools  are  extremely  offensive  and  the  diarrhoea  is 
checked  by  opium,  nervous  symptoms  have  sometimes  super- 
vened ;  the  infant  falls  into  a  semi-comatose  condition,  and  symp- 
toms occur  such  as  have  been  described  as  those  of  spurious 
hydrocephalus(vide  p.  224) ;  the  sequence  suggests  that  the  longer 
retention  of  the  faecal  material  in  the  bowel  consequent  upon  the 
administration  of  opium  has  allowed  more  absorption  of  toxic 
material  to  take  place.  This,  however,  is  rare  in  my  experience, 
and  it  is,  I  think,  true  that  there  are  very  few  cases  of  infantile 
diarrhoea  in  which  the  use  of  opium  is  not  beneficial. 

1  For  method  of  making  sherry  whey,  vide  p.  57. 


INFANTILE  DIARRHOEA  233 

As  to  the  form  of  opium,  it  is.  often  more  convenient  to  use  the 
liquid  preparations  than  the  solid,  so  that  it  may  be  given  in 
a  mixture  with  other  drugs  ;  but  in  the  solid  form  as  Pulv. 
Ipecac.  Co.  (Dover's  Powder),  it  is,  I  think,  sometimes  more 
effectual.  For  infants  a  few  weeks  old,  the  Tinct.  Camph.  Co.  in 
doses  of  O)j  during  the  first  month,  and  0)ij  during  the  second 
month,  makes  a  convenient  mode  of  administration  ;  for  older 
infants  at  three  months,  Tinct.  Opii  O)«b  at  six  months  Tinct. 
Opii  O)j,  at  one  year  Tinct.  Opii  0)|  can  be  given  every  three  or 
four  hours.  Dover's  Powder  can  be  given  in  doses  of  J  grain  at 
three  months,  J  grain  at  six  months,  and  J  grain  at  one  year, 
every  six  hours. 

Where  the  vomiting  is  severe  and  the  infant  is  in  a  restless 
semi-delirious  condition  as  sometimes  happens,  the  hypodermic 
injection  of  morphia  in  a  very  minute  dose,  -^  grain  for  an  infant 
three  months  old,  has  a  valuable  effect  in  quieting  the  child  and 
husbanding  his  strength,  apart  from  its  good  effect  both  upon 
the  gastric  and  intestinal  irritability. 

Of  other  drugs  there  are  two  which  are  of  paramount  value  in 
infantile  diarrhoea,  namely,  bismuth  and  minute  doses  of  castor 
oil.  Bismuth  is  particularly  valuable  where  there  is  much 
vomiting  associated  with  the  diarrhoea,  but  to  obtain  good  results 
from  bismuth  it  must  be  given  in  much  larger  doses  than  are 
often  used.  An  infant  a  few  weeks  old  should  have  gr.  v  every 
three  or  four  hours,  and  to  an  infant  of  nine  months  or  more 
10  grains  should  be  given  at  each  dose.  A  useful  prescription  for 
ordinary  use  is  Bismuth  Garb.  gr.  v,  Sod.  Bicarb,  gr.  ijss,  Spirit. 
Chloroformi  tt)  j,  Pulv.  Trag.  Co.  gr.  j,  Aq.  Anethi  ad  3j,  to  which 
Tinct.  Opii  can  be  added  according  to  the  age.  I  do  not  think 
that  anything  is  gained  in  effectiveness  by  administering  the 
bismuth  in  powder  form.  I  sometimes  use  a  formula  such  as 
this  :  Bismuth  Carb.  gr.  iv,  Sod.  Bicarb,  gr.  j,  Pulv.  Cretse 
Aromat.  gr.  j,  or  Bismuth  Carb.  gr.  v,  Pulv.  Ipecac.  Co.  gr.  J,  for 
an  infant  of  three  months,  but  it  is  difficult  to  give  a  sufficient  dose 
in  this  way  without  making  the  powder  inconveniently  bulky,  and 
there  are  many  infants  who  will  spit  out  powders,  whereas  there 
are  few  who  will  not  swallow  a  fluid  medicine  without  hesitation 
when  suffering  with  the  thirst  which  accompanies  diarrhoea  and 
vomiting. 

Castor  oil,  as  I  have  already  said,  when  used  in  doses  not 
exceeding  5  minims  has  no  aperient  action  whatever,  and  has 
a  powerful  effect  in  checking  diarrhoea.  The  mixture  in  use  at 
the  Hospital  for  Sick  Children,  Great  Ormond  Street,  is  R. 


234          COMMON  DISORDERS  OF  CHILDHOOD 

01.  Ricini  O)v,  Mucilag.  Acacise  O)xv,  Aq.  Menth.  Pip.  ad 
3j.  This  should  not  be  given  more  often  than  every  six 
hours,  otherwise  the  purgative  instead  of  the  constipating 
effect  may  be  obtained.  For  cases  in  which  the  lower  part  of 
the  bowel  seems  chiefly  to  be  affected,  as  may  be  shown  by  the 
presence  of  much  mucus  with  or  without  blood,  and  the  slightness 
or  absence  of  vomiting,  these  small  doses  of  castor  oil  are  par- 
ticularly valuable  ;  the  addition  of  Tinct.  Opii,  according  to  the 
age,  makes  it  still  more  effectual.  If  there  is  much  distension  of 

G     * 

the  bowel,  or  the  stools  are  particularly  offensive  or  frothy  as  if 
fermenting,  the  addition  of  Creosot.  O)j  in  each  dose  is  often 
helpful  for  an  infant  over  six  months  of  age,  or  1-3  minims  of 
Liq.  Hydrarg.  Perchlor.,  or  a  minim  of  Glycerin.  Acidi  Carbolici 
may  be  added. 

An  excellent  mode  of  treatment  is  to  give  the  castor  oil  mixture 
as  mentioned  three  times  a  day  without  addition  of  opium,  and 
to  give  also  three  or  four  times  a  day  a  powder  of  Hydr.  cum 
Cret.  gr.  J,  Pulv.  Ipecac.  Co.  gr.  J-J,  according  to  the  age. 

Of  the  value  of  purely  antiseptic  treatment  in  infantile  diar- 
rhoea I  cannot  speak  highly  ;  I  have  seen  cases  in  which  recovery 
occurred  where  only  small  doses  of  grey  powder  (gr.  J-J)  or 
calomel  gr.  -^  had  been  given  three  or  four  times  a  day.  I  have 
seen  the  stools  made  less  offensive  by  the  administration  of  Salol 
(gr.  ii-iij)  every  four  hours;  Glycerine  of  Carbolic  acid  (Cl)i-ij) 
B.  Naphthol  gr.  i-iij,  and  Resorcin  gr.  ii-iv  (which  has  the 
advantage  of  being  soluble  in  water  and  not  unpleasant  in  taste) ; 
all  these  are  occasionally  used,  but  generally  speaking,  I  am  sure 
that  such  methods  are  much  less  effectual  in  checking  diarrhoea 
than  those  I  have  already  mentioned. 

In  the  acute  stage  of  diarrhoea  most  of  the  astringents  are  of 
no  value,  but  when  the  diarrhoea  has  become  chronic  these  are 
often  useful.  Tincture  of  Catechu  Cl)v  with  Tine.  Opii  -J-l  minim, 
according  to  the  age,  in  Mist.  Cretse  3j  may  then  be  successful. 
I  have  found  Tincture  of  Goto  very  effectual  at  this  stage.  It  may 
be  given  either  with  bismuth  or  with  five-minim  doses  of  castor 
oil  in  a  mucilage  emulsion  ;  the  dose  of  the  tincture  of  coto  is 
5  minims  for  a  child  of  one  year. 

Silver  nitrate  also  in  doses  of  TV~J  grain  dissolved  in  distilled 
water  is  sometimes  very  useful,  especially  where  the  presence 
of  much  slime  and  streaks  of  blood,  and  perhaps  tenesmus  and 
prolapse,  make  it  probable  that  the  colon  is  chiefly  affected. 
Tannalbin,  which  has  recently  been  introduced,  is  sometimes 
very  useful  at  this  stage  in  doses  of  5-10  grains  every  four  or 
six  hours  in  a  teaspoonful  of  milk  and  water. 


INFANTILE  DIARRHCEA  235 

Tannigen  in  my  hands  has  proved  quite  ineffective,  but  good 
results  have  been  reported  from  its  use  ;  the  dose  is  2-3  grains 
every  six  hours  for  an  infant  under  six  months. 

At  this  stage  also  a  combination  of  sodium  salicylate  with 
bismuth  is  sometimes  useful ;  Sod.  Salicylate  gr.  i-ij  can  be 
added  to  the  bismuth  mixture  mentioned  above,  or  the 
combination  bismuth  salicylate  can  be  given  in  doses  of  gr.  ij 
to  gr.  iij.  For  infants  under  a  year  old  it  is  safest  to  avoid 
salicylate  altogether,  and  if  used  for  older  children  it  should 
always  be  combined  with  double  as  much  bicarbonate  of  soda 
to  avoid  the  toxic  effects  which  I  have  known  to  prove  very 
nearly  fatal  where  sodium  salicylate  was  being  given  to  an 
infant  in  a  dose  of  about  3  grains  every  two  hours. 

Sometimes  a  mixture  of  Acid  Sulph.  Dil.  Ct)ijss,  Tinct.  Opii  COj-j, 
Syrup  CC)x,  Aq.  Anethi  ad  3j  ter  die,  seems  more  effectual  than 
any  other  astringent. 

Irrigation  of  the  colon  is  of  great  value  under  certain  conditions  ; 
where  the  stools  are  unusually  offensive,  and  there  is  a  tumid 
abdomen,  or  where  from  the  frequent  passage  of  much  mucus 
and  streaks  of  blood,  it  is  clear  that  the  colon  is  greatly  affected. 
I  think  that  irrigation  per  rectum  with  plain  warm  water  or  a 
weak  solution  of  boracic  acid,  or  with  salt  solution,  i.e.  Sodium 
Chloride  3j  to  the  pint,  is  valuable.  The  irrigation  should  be 
done  once  or  twice  in  the  twenty-four  hours  ;  if  the  infant's 
temperature  is  very  high,  the  irrigation  may  be  done  with  fluid 
at  a  temperature  of  70°,  some  even  recommend  60°-65°  F.,  but 
under  the  more  usual  condition  of  feebleness  and  low  or  subnormal 
temperature,  the  fluid  should  be  used  at  a  temperature  of  100°- 
105°  F.  About  6-14  ounces,  according  to  the  size  of  the  infant, 
should  be  allowed  to  run  in  slowly  through  a  funnel  and  soft 
rubber  catheter. 

Rectal  injections  of  4-5  ounces  of  tannic  acid  (gr.  j  to  the  §j) 
and  of  protargol  (gr.  j  to  the  §j)  have  also  been  recommended. 

Where  there  are  frequent  small  stools,  or  tenesmus  occurs, 
showing  irritability  of  the  rectum,  great  benefit  sometimes  results 
from  washing  out  the  bowel  with  normal  saline  solution,  and 
after  this  has  been  returned,  injecting  J-l  oz.  of  a  very  thin 
mucilage  of  starch. 


CHAPTER  XVII 
ON  SO-CALLED  CCELIAC  DISEASE 

THERE  is,  amongst  the  abdominal  diseases  of  early  childhood 
one  which  has  hitherto  received  but  little  recognition,  the  affec- 
tion known  as  '  cceliac  disease  '.  Although  by  no  means  an 
everyday  occurrence,  its  importance  is  out  of  proportion  to  its 
frequency,  for  it  is  very  apt  to  be  mistaken  for  other  and  more 
common  diseases,  especially  tuberculous  peritonitis.  Its  treat- 
ment also  is  worthy  of  study,  for  although  it  is  too  often  an 
intractable  condition,  there  are  certain  definite  lines  of  treat- 
ment upon  which  the  child's  chance  of  recovery  very  largely 
depends. 

This  affection  was  described  by  the  late  Dr.  Gee  l  under  the 
name  of  '  coeliac  disease  '  :  a  vague  term,  inasmuch  as  it  indicates 
nothing  more  than  disease  of  the  bowel.  More  descriptive  is  the 
name  '  recurrent  diarrhoea  ',  but  this  exalts  too  much  a  symptom 
which  is  by  no  means  invariable  ;  nor,  again,  is  '  chronic  colitis  ' 
altogether  satisfactory,  for  although  it  describes  the  pathological 
condition  which  has  been  found  in  some  fatal  cases,  in  others 
no  such  inflammatory  lesion  has  been  demonstrated  ;  moreover, 
there  are  forms  of  '  chronic  colitis  '  which  certainly  do  not  present 
the  clinical  features  of  the  disease  under  consideration.  The  late 
Dr.  Cheadle,  attaching  much  importance  to  the  pallor  of  the 
stools,  included  cases  of  this  disease  in  the  category  of  '  acholia  ' ; 
but  even  in  the  most  typical  cases  the  stools  are  not  always 
white,  and  it  is  evident  that  bile  is  not  necessarily  deficient.  On 
the  whole,  therefore,  it  seems  advisable  at  present  to  retain 
Dr.  Gee's  term  '  cceliac  disease  '. 

Put  briefly,  the  story  of  these  cases  is  usually  as  follows  :  A 
child  of  two  years  or  thereabouts  is  wasting,  the  abdomen  is 
enlarged,  and  though  there  is  no  constant  diarrhoea,  the  bowels 
are  loose.  The  stools  are  large,  pale,  and  offensive,  often  shreddy 
or  full  of  mucus.  The  child,  though  not  emaciated,  has  grown 
thinner  and  flabby,  and  the  association  of  wasting  with  enlarge- 
ment of  the  abdomen  has  raised  in  the  doctor's  mind  the  idea 
of  tuberculous  peritonitis.  As  will  be  seen,  however,  from  a  more 

1  St.  Bartholomew's  Hosp.  Rept.,  1888,  vol.  xxiv,  p.  17. 


CCELIAC  DISEASE  237 

detailed  consideration  of  the  disease,  this  has  special  character- 
istics of  its  own  which  are  usually  sufficient  to  mark  it  off  as 
something  '  sui  generis  '. 

My  description  will  be  based  upon  twenty-four  cases  which 
have  come  under  my  own  observation. 

Etiology.  Cceliac  disease  would  appear  to  be  much  commoner 
in  girls  than  in  boys  ;  of  my  24  cases,  18  were  girls,  6  were  boys. 
It  must  be  mentioned,  however,  that  in  a  recently  published 
series  of  caees,1  which  included  2  boys  who  figure  in  my  own 
statistics,  there  were  7  boys  and  2  girls  ;  so  that,  if  the  two  series 
be  combined,  the  numbers  are  20  girls  and  11  boys. 

There  is  some  difficulty  in  determining  the  age  at  onset,  for 
although  the  affection  may  have  followed  directly  upon  an  acute 
attack  of  diarrhoea,  sometimes  it  seems  to  have  begun  altogether 
insidiously,  so  that  no  exact  date  can  be  assigned.  The  com- 
monest time  of  onset  would  seem  to  be  the  second  year.  The 
earliest  age  in  my  series  was  8  months,  the  latest  3  years  and 
2  months. 

Sometimes,  but  by  no  means  always,  an  acute  diarrhceal  illness 
preceded  the  onset  of  coeliac  disease.  One  might  have  expected, 
in  view  of  the  lesions  found  in  some  cases,  that  this  preceding 
illness  would  have  been  an  ileocolitis  or  colitis,  but  the  history 
in  some  at  least  is  rather  that  of  a  simple  gastro -enteritis,  which 
passed  off  leaving  the  child  apparently  well ;  the  stools,  however, 
remained  somewhat  irregular,  and  gradually  assumed  the  charac- 
teristics of  coeliac  disease. 

In  three  of  my  cases  infantile  scurvy  preceded  or  accompanied 
the  onset  of  the  coeliac  disease.  Larger  figures  would  be  needed 
to  prove  that  this  was  more  than  a  coincidence,  but  it  has  seemed 
to  me  that  children  fed  upon  scurvy-producing  foods  are  par- 
ticularly liable  to  bacterial  infection  in  connexion  with  the  intes- 
tinal tract  ;  thus  I  have  noticed  that  pyelitis,  presumably  due 
to  coli  infection  from  the  intestine,  is  apt  to  occur  in  children 
who  have  been  fed  for  several  months  upon  such  foods,  and  I  have 
elsewhere  pointed  out  that  pyelitis  is  sometimes  a  complication 
of  scurvy.  Moreover,  there  is  a  special  tendency  to  diarrhoea 
in  infantile  scurvy,  which  may  also  indicate  a  diminished  resis- 
tance to  bacterial  infection.  One  might  add  that  the  large 
intestine  •  is  often  directly  involved  in  scurvy,  as  is  shown  by 
the  passage  of  bright  red  blood  in  the  stools.  It  would  seem, 
therefore,  that  as  a  predisposing  cause  there  may  be  a  real 

1  Poynton,  Armstrong,  and  Nabarro.  Proc.  Roy.  Soc.  Med.,  1913,  vol.  vii, 
p.  10. 


238          COMMON  DISORDERS  OF  CHILDHOOD 

connexion  between  the  preceding  scurvy  and  the  occurrence  of 
cceliac  disease,  if  we  may  assume  that  the  latter  is  of  bacterial 
origin. 

At  present  we  have  no  certain  evidence  of  any  specific  micro- 
organism in  this  disease,  but  it  is  tempting  to  believe  that  a 
grouping  of  symptoms  so  constant  in  character  and  consistent 
in  course  is  due  to  one  particular  organism.  Dr.  Nabarro  has 
examined  the  stools  bacteriologically  in  four  cases,  and  in  three 
of  these  he  found  the  dysentery  bacillus  (Flexner),  in  the 
remaining  one  only  Bacillus  coli,  streptococci,  and  pneumo-bacilli. 
It  must  be  left  to  further  and  more  extended  observations,  to 
determine  whether  the  dysentery  bacillus  is  the  specific  cause, 
or  whether  in  different  cases  different  organisms  may  produce 
the  symptoms. 

In  connexion  with  the  bacteriology  of  this  disease,  I  would 
recall  Dr.  Gee's  observation  that  '  sometimes  from  India  English- 
men return  sick  with  the  co3liac  affection  ',  apparently  referring 
to  the  condition  now  known  as  '  sprue '.  In  one  of  the  cases 
under  my  own  observation  the  mother  had  acquired  '  sprue  ' 
whilst  in  India,  and  was  still  bad  with  the  disease  when  her 
child  was  brought  to  me,  at  the  age  of  5|  years,  with  very  typical 
and  severe  cceliac  disease,  which  had  begun  in  India  when  the 
child  was  about  nine  months  old.  In  another  case  possibly  of 
this  nature  a  boy  aged  2  years  had  suffered  with  looseness  of  the 
bowels  seven  months,  the  abdomen  was  large,  but  the  stools, 
though  pale  at  times,  had  more  colour  than  is  usual  in  cceliac 
disease.  His  mother  had  '  sprue  '  when  pregnant  with  this  child. 
There  are  many  points  of  similarity  between  the  '  sprue '  of 
adults  and  the  cceliac  disease  of  children.  Both  are  characterized 
by  wasting  with  looseness  of  the  bowels,  and  pale,  slimy,  or 
shreddy  stools.  Both  show  the  same  prolonged  course  extend- 
ing over  years,  and  the  same  resistance  to  treatment.  In 
'  sprue ',  liberation  of  the  mouth  has  been  described  as  a  fre- 
quent symptom.  I  cannot  say  that  it  is  frequent  in  coeliac 
disease,  but  I  have  known  it  to  occur. 

I  would  not  assert  that  the  two  affections  are  identical,  but 
the  clinical  resemblances  are  worth  bearing  in  mind,  as  bacterio- 
logical research  on  the  one  may  possibly  throw  light  on  the 
other.  At  present  neither  can  claim  a  specific  organism,  though 
in  both  the  dysentery  bacillus  is  thought  to  play  a  part. 

The  uncertainty  as  to  the  etiology  of  coeliac  disease  is  increased 
by  the  scantiness  of  observation  on  its  morbid  anatomy.  Thicken- 
ing of  the  mucosa  of  both  large  and  small  intestine  has  been 
recorded  with  enlargement  of  solitary  follicles  and  Peyer's 


CGELIAC  DISEASE  239 

patches,  but  no  ulceration.  The  mesenteric  glands  have  been 
found  swollen  and  the  liver  fatty.1 

Symptoms.  The  first  and  most  characteristic  symptom  of 
cceliac  disease  is  chronic  looseness  of  the  bowels.  There  is  no 
watery  diarrhoea,  nor  indeed  any  constant  frequency  of  action, 
for  the  bowels  may  not  be  opened  more  than  once  or  twice  daily, 
but  there  is  a  tendency  to  periodic  increases  of  frequency,  when 
the  bowels  will  be  opened  perhaps  four  or  five  times  a  day  for 
two  or  three  days  ;  but  even  then  the  stool  is  only  rather  looser 
or  contains  more  mucous  ;  it  rarely  becomes  watery. 

Perhaps  the  most  characteristic  feature  of  the  stool  is  its 
colour,  which  is  pale,  greyish,  like  oatmeal,  or  even  actually 
white  ;  in  some  cases,  however,  it  is  pale  yellow,  or  even  dark 
brown,  and  the  colour  varies  from  day  to  day.  The  stool  is 
almost  always  unformed,  and  of  porridgy  consistence ;  there  is 
considerable  excess  of  mucus,  and  therewith  may  be  seen  numerous 
grey  shreds  or  flakes  of  what  looks  like  thin  membrane,  but  proves, 
on  microscopic  examination,  to  be  mucoid  material  containing 
leucocytes  and  oval  or  elongated  cells.  Occasionally  the  stools 
contain  streaks  of  blood,  but  this  is  exceptional. 

With  this  unhealthy  condition  of  the  stools,  there  is  more  or 
less  enlargement  of  the  abdomen,  usually  not  of  any  extreme 
degree,  but  sufficient  to  attract  the  mother's  attention.  The 
abdomen  is  seldom  tense,  and  there  is  usually  no  peristalsis  of 
particular  coils  of  intestine  to  be  seen.  On  palpation  there  is 
no  localized  resistance,  no  sense  of  infiltration  or  doughiness, 
such  as  characterizes  tuberculous  peritonitis,  nor  is  there  any 
tenderness.  Occasionally  slight  colicky  pain  is  present,  a 
symptom  common  to  most  intestinal  disorders  of  childhood 
where  there  is  much  mucus  in  the  stools. 

Vomiting  is  not  a  common  symptom,  but  it  occurred  in  some 
cases,  especially  in  the  early  stage  of  the  disease. 

Thirst  is  quite  a  noticeable  symptom,  and  the  appetite  is  usually 
large,  or  perhaps,  rather,  one  should  say  that  the  child  is  con- 
stantly hungry,  as  well  it  may  be,  for  any  attempt  to  satisfy  its 
appetite  results  in  frequent  and  bad  stools  and  a  corresponding 
rapid  loss  of  weight,  so  that  the  child  is  necessarily  kept  upon 
a  meagre  and  unsatisfying  dietary. 

Perhaps  no  feature  is  more  striking  in  cceliac  disease  than  the 
rapid  fluctuations  in  weight ;  a  very  slight  error  in  a  most  care- 
fully regulated  diet  will  result  in  a  loss  of  as  much  as  Jib.  in 
forty-eight  hours,  whilst  an  improvement  in  the  colour  and  con- 

1  Proc.  Roy.  Soc.  Med.,  loc.  cit. 


240  COMMON  DISORDERS  OF  CHILDHOOD 

sistency  of  the  stool  for  a  few  days  may  be  associated  with  a  gain 
of  a  pound  or  more,  which,  in  turn,  is  as  rapidly  lost ;  and  so,  with 
disappointing  fluctuations,  the  net  result  may  be  little  or  no 
gain  after  a  year  or  more  of  constant  rigid  care  and  dieting. 

The  wasting  which  results  from  this  disease  is,  at  first  at  any 
rate,  rather  a  passive  than  an  active  failure.  The  child  grows 
older,  but  does  not  grow  heavier  ;  the  limbs  are  flabby  and  thin, 
although  the  face,  as  Dr.  Gee  pointed  out,  may  still  look  round 
and  full  ;  but  if  the  disease  progresses  unchecked  there  is  apt  to 
be  more  active  wasting,  for  with  the  erratic  fluctuation  of  weight, 
the  losses  on  the  whole  predominate  over  the  gains. 

A  prominent  feature  of  cceliac  disease  is  weakness  ;  it  is  so 
marked  that  walking  and  even  standing  may  be  delayed  long  past 
the  usual  age.  In  some  cases  standing  is  still  impossible  at  2| 
or  3  years  old  ;  one  child  was  only  beginning  to  walk  at6J  years. 

The  child  is  usually  peevish  and  fretful,  and  as  it  grows  older, 
reaching  the  age  of  five  or  six  years,  shows  a  quaint  precocity 
which  is  rather  apparent  than  real,  for  whilst  the  physical  growth 
is  remarkably  hindered,  so  that  the  child  of  six  or  seven  years 
looks  barely  three  years  old,  its  mental  development  is  in  some 
respects  in  advance  of  its  years,  owing  to  the  constant  associa- 
tion with  adults  which  results  from  inability  to  share  in  normal 
nursery  life. 

The  remarkable  hindrance  of  growth  is  one  of  the  most  serious 
results  of  this  disease  ;  a  girl  agedGJ  years  measured  36J  inches, 
the  height  of  a  child  aged  3J  years  ;  another  at  six  years  measured 
37 1  inches. 

The  weight  similarly  is  far  below  the  normal  ;  a  girl  who  at 
6  years  measured  39 J  inches  in  height  weighed  30  Ib.  13  oz., 
the  weight  of  a  child  of  2|  years  ;  another  at  5|  years  weighed 
21  Ib.,  which  is  barely  the  weight  of  an  infant  aged  12  months. 

This  delay  of  development  has  been  described  as  '  infantilism  ', 
a  term  which,  I  think,  has  been  considerably  misused.  We  hear 
of  '  intestinal  infantilism  ',  '  renal  infantilism  ',  &c.,  as  if  the 
'  infantilism  '  constituted  a  disease  in  itself,  whereas  arrest  of 
development,  greater  or  less  in  degree,  is  merely  a  symptom 
produced  by  many  different  causes  and  common  to  many  different 
diseases.  If  the  term  '  infantilism  '  is  to  be  retained  at  all,  it 
should  surely  be  used  only  for  conditions  in  which  the  charac- 
teristics of  adolescerce,  the  sexual  changes  of  puberty,  fail  to 
appear,  but  this  is  not  so  in  some  of  the  diseases  where  '  infan- 
tilism '  is  said  to  occur,  and  I  know  of  no  evidence  that  it  is  so 
in  '  creliac  disease  '. 


CCELIAC  DISEASE  241 

In  spite  of  the  interference  with  weight  and  growth,  teething 
is  usually  not  delayed  ;  a  curious  fact  when  one  considers  how 
greatly  dentition  is  delayed  by  rachitic  disturbance  of  nutrition. 

The  temperature  in  coaliac  disease  is  usually  normal. 

The  liver  and  spleen  show  no  enlargement.  In  long-standing 
cases  there  is  more  or  less  anaemia,  and  this  may  reach  a  severe 
degree. 

I  have  occasionally  seen  itching  papules  ('  lichen  urticatus  ') 
on  the  limbs,  an  association  which  one  might  expect  to  be  more 
frequent  than  it  is  when  one  considers  how  commonly  lichen 
urticatus  is  seen  with  intestinal  disturbances  in  childhood. 

Prognosis.  When  once  the  diagnosis  of  coeliac  disease  is 
certain,  it  is  well  to  explain  to  the  parents  that  there  is  no 
question  of  cure  in  a  few  weeks  or  even  months,  and  that  they 
may  consider  it  a  happy  result  if,  after  a  year  or  two  of  tedious 
dieting  and  treatment  with  varying  success  and  failure,  the 
child  slowly  regains  its  health. 

There  is  undoubtedly  risk  to  life.  It  is  difficult  to  give  actual 
figures,  for,  owing  to  the  chronic  character  of  the  disease,  these 
cases  are  apt  to  pass  out  of  observation,  or  rather,  as  the  parents 
become  discontented  with  the  slowness  of  progress,  they  drift 
from  one  doctor  to  another  ;  it  seems  probable,  however,  that 
few  survive  beyond  childhood  :  if  increasing  debility  and  exhaus- 
tion from  the  disease  do  not  prove  fatal,  sooner  or  later  the  child 
is  liable  to  fall  a  victim  to  some  complication  or  intercurrent 
disease.  I  have  known  several  cases  die  thus,  rather  from  the 
indirect  than  the  direct  effects  of  the  disease. 

On  the  other  hand,  I  would  particularly  insist — and  in  so 
tedious  a  disease  one  can  hardly  insist  too  strongly — upon  the 
possibility  of  a  complete  recovery.  I  have  seen  cases  where 
after  four  or  five  years  of  rigorous  dieting,  and  long  arrest  of 
growth,  the  child  has  at  last  struggled  back  to  health  and  normal 
conditions  of  nutrition. 

Complications.  I  have  already  mentioned  anaemia  amongst 
the  symptoms  of  the  disease.  In  some  cases,  it  becomes  very 
profound,  and  then,  as  in  anaemia  from  other  causes,  purpura 
may  appear.  But  apart  from  anaemia  there  seems  to  be  a 
liability  in  coaliac  disease  to  purpura,  usually  of  mild  degree,  and 
affecting  only  the  skin,  not  the  mucus  membranes.  Dropsy 
also  is  not  uncommon,  and  varies  in  degree  from  slight  puffiness 
of  the  hands  and  feet  to  a  general  dropsy  associated  even  with 
ascites.  I  would  particularly  draw  attention  to  this  occurrence 
of  fluid  in  the  abdomen,  which  may  be  associated  with  only  very 
•  R 


242  COMMON  DISORDERS  OF  CHILDHOOD 

slight  oedema  of  the  extremities.  It  is  apt  to  be  taken  as  evidence 
of  tuberculous  peritonitis.  The  occurrence  of  dropsy  in  these 
cases  is  not  easy  to  explain  ;  it  is  not  necessarily  associated  with 
any  severe  degree  of  anaemia.  One  might  compare  it  with  the 
curious  cases  of  dropsy  without  albuminuria,  in  which  a  promi- 
nent association  is  the  offensive  unhealthy  character  of  the  stools. 

In  4  out  of  my  24  cases,  one  aged  7  years,  and  the  others  aged 
25  months,  15  months,  and  18  months  respectively,  tetany 
occurred  associated  with  facial  and  other  nerve  irritability.  In 
the  series  1  of  nine  cases  mentioned  above,  one  case  also  is  noted 
as  having  had  tetany  at  the  age  of  eighteen  months,  but  in  this 
child  there  was  also  rickets,  which  was  absent  in  two  out  of 
the  four  in  my  own  series.  This  association  is  interesting  in 
relation  to  the  occurrence  of  tetany  with  chronic  dilatation 
of  the  colon,  and  to  the  fact  that  occasionally  apart  from  any 
such  disease,  irrigation  of  the  bowel,  where  the  stools  are  un- 
healthy, is  followed,  as  I  have  seen,  by  tetany.  It  seems  a 
reasonable  inference  that  absorption  of  some  toxic  material 
from  the  colon  is  capable  of  producing  tetany,  and  that  this  is 
the  explanation  of  its  occurrence  in  coeliac  disease. 

As  in  most  chronic  exhausting  diseases,  bronchitis  and  broncho- 
pneumonia  may  supervene  and  prove  fatal. 

A  complication  which  is  specially  to  be  remembered  where 
diet  is  so  restricted,  as  it  necessarily  is  in  this  affection,  is  scurvy  ; 
two  out  of  my  twenty-four  cases  developed  scurvy,  one  at  about 
six  years  of  age,  and  the  other  at  4J  years.  In  both,  the  gradual 
onset  of  pains  in  the  limbs  was  at  first  very  puzzling,  and  one, 
seen  by  a  surgeon  who  had  not  followed  the  dieting  of  the  child, 
was  mistaken  for  a  condition  needing  surgical  treatment. 

In  one  of  my  cases  a  very  remarkable  complication  occurred, 
namely,  so-called  late  rickets.  After  the  child  had  been  dieted 
four  years  for  coeliac  disease,  and  had  gradually  improved,  she 
began,  at  the  age  of  eight  years,  to  show  rapid  bending  of  the 
bones  of  the  legs,  so  that  they  became  severely  distorted.  The 
cause  of  this  very  rare  condition  of  softening  of  the  bones,  which 
probably  bears  no  relation  to  true  rickets,  but  should  rather  be 
classified  as  osteomalacia,  has  never  been  determined  ;  its  occur- 
rence in  this  case  suggests  either  a  dietetic  origin,  or  nutritional 
disturbance  by  toxic  absorption  from  the  bowel. 

Treatment.  Diet.  Dieting  is  by  far  the  most  essential  part 
of  treatment  in  this  disease,  and  it  is  necessary  to  lay  down  very 
exact  rules  as  to  what  may  and  what  may  not  be  given.  Unfor- 
1  Poynton,  Armstrong,  and  Nabarro,  loc.  cit. 


CCELIAC  DISEASE  243 

tunately,  the  menu  which  is  permissible  is  extremely  meagre, 
and  experience  shows  that  the  slightest  departure  from  it  is 
likely  to  be  attended  with  ill  results.  First  and  foremost  in 
importance  is  the  prohibition  of  all  fresh  cow's  milk.  I  lay  great 
stress  upon  this  point,  for  one  has  often  found  that  the  mother 
has  been  specially  advised  to  '  give  the  child  nothing  but  milk  '. 
No  surer  method  could  be  adopted  for  perpetuating  the  trouble, 
and  the  omission  of  all  fresh  milk  is  generally  sufficient  alone  to 
cause  improvement  in  the  character  of  the  stools,  and  therewith 
more  or  less  gain  in  general  well-being. 

Why  exactly  fresh  cow's  milk  should  be  so  harmful  in  these 
cases  is  not  clear,  but  possibly  it  may  be  explained  by  the  success 
which  sometimes  follows  the  use  of  the  fat-free  diet  to  which  I 
shall  refer  later. 

Whilst,  however,  fresh  cow's  milk  is  to  be  entirely  forbidden, 
the  same  ruling  does  not  apply  to  dried  milk.  There  are  various 
preparations  of  dried  milk  on  the  market,  and  some  of  these  are 
made  to  contain  a  very  low  proportion  of  fat  ;  these  are  invalu- 
able as  a  substitute  for  fresh  milk  in  coeliac  disease  ;  indeed, 
many  a  case  which  has  been  unable  to  tolerate  the  smallest  quantity 
of  fresh  milk  without  increased  looseness  of  bowels  and  rapid 
loss  of  weight,  has  done  well  on  dried  milk  as  the  main  article 
of  diet  for  several  years.  Naturally,  where  very  little  else  can 
be  allowed,  the  child  is  apt  to  grow  weary  of  the  dried  milk : 
when  this  is  so,  the  addition  of  a  very  small  quantity  of  tea,  or 
of  cocoa,  may  get  over  the  difficulty  for  a  time.  I  have  found 
a  preparation  of  cocoa  mixed  with  acorn  ('  acorn  cocoa  ')  suit 
well  in  some  of  these  cases. 

The  dried  milk  should  be  used  not  only  for  drinking,  but  also 
in  the  preparation  of  any  foods  that  are  allowed,  such  as  custard 
or  milk  pudding,  or  milk  jelly. 

If  dried  milk  does  not  suit,  or  is  refused,  by  far  the  best  alter- 
native is  asses'  milk,  on  which  I  have  known  great  improvement 
to  take  place.  It  has  also  the  important  advantage  that  it  is 
not  liable  to  produce  scurvy  as  dried  milk  is.  This,  however, 
is  a  resource  open  only  to  the  wealthy,  especially  if,  as  is  usual 
in  this  disease,  it  has  to  be  continued  for  a  long  time. 

For  people  of  ordinary  means,  the  most  practicable  alternative, 
if  dried  milk  fails  or  is  refused,  is  a  condensed  milk.  I  have 
found  the  '  humanoid  milk  '  prepared  by  the  Aylesbury  Dairy 
Company  useful  in  these  cases,  but  usually  a  condensed  milk 
is  less  successful  than  the  dried  preparations.  It  might  have 
been  thought  that  whey,  being  deprived  of  nearly  all  fat,  would 

R2 


244  COMMON  DISORDERS  OF  CHILDHOOD 

suit  these  cases  well,  but  although  it  is  sometimes  tolerated, 
it  is  less  satisfactory  usually  than  the  substitutes  already 
mentioned. 

Bread  is  usually  to  be  avoided  altogether,  and  a  substitute 
must  be  found  in  some  kind  of  biscuit  or  rusk.  The  biscuits 
which  are  made  of  dried  milk  with  a  very  small  addition  of 
starch,  such  as  '  Nurso  Biscuits  '  or  '  Malac  Biscuits  ',  have 
proved  particularly  useful.  I  have  also  given  '  Mellin's  Biscuits  ' 
in  several  cases  without  harm. 

Broths  and  jellies  are  allowable  ;  red  gravy  in  small  quantity 
from  underdone  meat  seems  to  suit  these  cases  better  than  raw 
meat  juice  ;  pounded  chicken  and  boiled  brains  are  also  per- 
missible for  the  older  children.  Farinaceous  pudding  must  be 
used  with  caution,  if  at  all  ;  Revalenta  is  more  suitable,  but  its 
taste  is  disliked  by  some  children. 

In  spite  of  its  high  fat  content,  yolk  of  egg  is  sometimes 
tolerated  well,  and  then  makes  a  very  important  addition  to  the 
diet.  When  this  is  so,  custard  made,  as  already  suggested,  with 
the  dried  milk,  can  also  be  given. 

Fruit  and  vegetables  are  usually  to  be  avoided  altogether,  as 
they  tend  to  aggravate  the  symptoms,  but  their  omission  con- 
stitutes a  danger  in  another  direction,  for  the  restricted  diet, 
particularly  the  absence  of  fresh  milk,  entails  considerable  risk 
of  scurvy.  I  am  not  speaking  now  of  the  scurvy  which  occa- 
sionally accompanies  or  precedes  the  onset  of  cceliac  disease,  but 
of  its  occurrence  after  months  of  dietetic  treatment,  as  has  hap- 
pened more  than  once  in  my  own  experience.  Fortunately, 
although  fruit  and  vegetables  are  ill  tolerated,  many  of  the 
children  with  cocliac  disease  can  take  two  or  three  teaspoonfuls 
of  grape  juice  twice  daily  without  making  the  stools  more  loose, 
and  in  this  way  scurvy  may  be  avoided. 

Out  of  the  foods  already  mentioned,  a  diet  which  is  passable 
enough  for  a  time  can  be  constructed,  but,  as  might  be  expected, 
the  monotony  of  it  soon  palls  on  the  child,  and  it  is  difficult  to 
satisfy  the  child's  constant  craving  for  something  new. 

More  monotonous  still,  but  at  times  undoubtedly  useful,  is  the 
fat-free  diet,  which  includes  rusks,  Robb's  biscuits,  jellies, 
chicken  or  veal  broth,  potato,  Revalenta,  rice  boiled  in  water, 
pounded  chicken  or  fish,  barley  water  or  weak  tea  with  sugar. 

It  must  not  be  supposed  that  all  these  foods  can  be  tolerated 
by  every  child  with  cceliac  disease,  but  experience  shows  that 
the  range  of  choice  usually  lies  within  these  limits. 

I  would  only  add  that  owing  to  the  unsatisfying  nature  of  the 


CGELIAC  DISEASE  245 

diet,  it  is  usually  necessary  to  feed  at  shorter  intervals  than  a 
healthy  child  requires. 

Drugs.  Of  drugs,  the  most  useful  are  the  astringents  and 
antiseptics,  and  I  know  of  no  mixture  which  suits  better  than 
the  one  I  have  mentioned  elsewhere  of  salol  with  castor  oil,  viz., 
Salol.  gr.  iss,  01.  Ricini  O)  v,  Spirit.  Chloroformi  O)  i,  Mucilag. 
Acaciae  CO  xv,  Aq.  Anethi  ad  3  i  ter  die.  In  many  cases,  after 
trial  of  various  drugs,  it  has  been  so  evident  that  this  gave  the 
best  result,  that  the  parents  have  asked  that  this  mixture  might 
be  repeated,  and  in  some  cases  it  was  given  almost  continuously 
for  months,  and  even  years,  as  the  child  seemed  unable  to  do 
without  it. 

Occasionally,  when  the  stools  were  particularly  loose  and 
slimy,  I  have  found  Silver  Nitrate  valuable  in  doses  of  one- 
sixth  of  a  grain.  It  may  be  prescribed  thus  :  Argenti  Nitratis 
gr.  &,  Glycerini  O)  v,  Aq.  Distillat.  ad  3  i  ter  die.  Given  for 
a  week  or  two,  it  sometimes  improves  the  character  of  the  stool. 
Tannalbin,  of  which  at  least  8  grains  ter  die  should  be  given  to 
a  child  of  two  or  three  years,  is  also  useful.  Bismuth  I  have  found 
of  very  little  value  in  this  disease. 

With  wasting  as  a  prominent  symptom,  there  is  a  temptation 
in  cceliac  disease  to  give  malt  or  cod  liver  oil,  but,  as  a  rule,  not 
only  does  no  gain  in  nutrition  result,  but  there  is  considerable 
risk  of  aggravating  the  looseness  of  the  bowels  and  producing 
further  loss  of  weight. 

On  the  assumption  that  some  defect  of  pancreatic  secretion 
underlies  cceliac  disease,  a  view  put  forward  by  the  late  Dr. 
Cheadle  and  others,  various  pancreatic  extracts  have  been  tried. 
I  can  only  say  that  in  my  experience  such  drugs  as  Liquor  Pan- 
creaticus,  Trypsogen,  '  Pankreon  ',  &c.,  have  had  very  little, 
if  any,  effect,  certainly  none  comparable  to  the  effect  of  the 
castor-oil  mixture.  The  pale  colour  or  whiteness  of  the  stools 
has  suggested  an  attempt  to  supply  biliary  constituents  in  the 
form  of  drugs  :  in  one  of  my  cases  Holadin,  in  another  Oxgall 
was  administered,  but  no  good  resulted.  In  one  case  I  gave 
Radium  water  in  large  quantity  by  mouth  for  several  weeks,  but 
without  the  slightest  advantage. 

Lastly  must  be  mentioned  the  Vaccine  treatment,  which  was 
suggested  by  the  finding  of  the  dysentery  bacillus  in  the  stools. 
Dr.  Nabarro  prepared  and  administered  autogenous  vaccines  for 
me  in  some  cases,  with  temporary  improvement  in  the  weight, 
but  with  no  constant  success. 


CHAPTER  XVIII 
BILIOUS  ATTACKS  SO  CALLED,  IN  CHILDREN 

'  MY  child  is  subject  to  bilious  attacks.'  One  hears  this  com- 
plaint so  often  that,  although  the  term  '  bilious  attack  '  belongs 
rather  to  popular  than  to  scientific  phraseology,  we  shall  do  well 
to  consider  what  is  its  real  significance.  And  indeed  it  is  a  com- 
plaint which  always  calls  for  a  very  careful  consideration,  for 
while  in  some  cases  it  refers  merely  to  passing  digestive  disturb- 
ances, there  are  others  in  which  it  serves  as  a  cloak  for  much 
more  serious  conditions.  Herein  lies  the  danger  of  a  vague  term 
like  this  ;  it  has  a  misleading  sound  of  innocence  which  may 
inspire  an  altogether  unjustified  feeling  of  security. 

Now  what  are  the  symptoms  to  which  parents  give  this  name 
'  bilious  attack  '  ?  As  a  rule  the  child  has  attacks  of  vomiting, 
perhaps  being  sick  only  once  or  twice,  perhaps  many  times,  and 
these  bouts  recur  at  intervals  of  weeks  or  months.  With  the 
vomiting  there  is  perhaps  some  abdominal  pain,  and,  it  may  be, 
some  headache  and  a  rise  of  temperature  :  the  tongue  is  furred, 
the  bowels  are  costive.  After  a  few  hours  or  a  day  or  longer  the 
symptoms  subside,  and  the  parents  say,  'It  was  only  a  bilious 
attack  '. 

Appendicitis.  There  is  one  disease  which  should  always  be  in 
the  medical  man's  mind,  when  he  is  told  that  a  child  has  'bilious 
attacks  ',  and  I  shall  mention  it  first  and  foremost,  not  because 
it  is  the  disease  which  is  most  often  called  by  this  name,  but 
because  it  is  so  dangerous  if  unrecognized,  namely,  appendicitis. 

A  surgeon  once  told  me  that  he'  thought  '  bilious  attacks  '  in 
children  nearly  always  meant  appendicitis.  His  opinion  was  the 
result  of  a  large  experience  of  the  cases  of  this  kind  which  come 
under  a  surgeon's  notice  ;  the  physician  sees  many  in  which  the 
attacks  have  other  significance,  but  my  own  experience  has 
convinced  me  that  slight  attacks  of  appendicitis  are  not  uncom- 
monly supposed  to  be  '  bilious  attacks  ',  and  consequently  made 
light  of,  until  a  more  severe  attack  occurs,  and  a  child's  life  is 
sacrificed,which  might  have  been  saved  if  only  a  careful  examina- 
tion of  the  abdomen  had  been  made  during  the  supposed  '  bilious 
attacks  '.  We  are  all  familiar  with  the  classical  symptoms  of 
appendicitis,  the  pain  in  the  right  iliac  fossa,  the  constipation 


248  COMMON  DISORDERS  OF  CHILDHOOD 

and  vomiting,  the  pain  often  on  micturition,  the  high  tempera- 
ture, the  tenderness  especially  at  a  spot  two-thirds  of  the  dis- 
tance from  the  anterior  superior  spine  to  the  umbilicus  (Mac- 
Burney's  spot),  the  dullness  on  percussion,  and  the  infiltration 
and  resistance  in  the  pelvis  on  rectal  examination  ;  but  I  want 
to  emphasize  here  the  slightness  of  the  symptoms  in  many 
attacks.  A  girl,  aged  eight  years,  had  had  attacks  of  slight 
pain  in  the  abdomen  four  or  five  times  in  the  past  year, 
with  some  constipation ;  there  had  been  little  or  no  vomiting, 
and  the  attacks  were  regarded  as  so  trivial  as  hardly  to  call  for 
attention.  Then  another  occurred  which  was  supposed  to  be 
'  one  of  her  bilious  attacks  ',  but  this  time  there  was  severe  pain 
and  vomiting  ;  within  a  few  hours  general  peritonitis  supervened, 
and  in  spite  of  operation  and  removal  of  an  inflamed  appendix  the 
child  died. 

In  another  case  a  girl,  aged  nine  years,  had  been  '  subject  to 
liver  attacks  '  for  four  years  ;  there  was  vomiting  and  some 
slight  pain  in  the  abdomen,  but  the  attacks  were  so  slight  that 
the  mother  had  been  told  by  her  doctor  '  just  to  give  the  child 
a  dose  of  calomel  whenever  an  attack  occurred  ' ;  then  a  more 
severe  attack  than  usual  occurred  ;  at  first  it  was  called,  as 
before,  a  '  bilious  attack  ',  but  it  soon  became  evident  that  it 
was  serious.  I  saw  the  child  a  few  days  after  the  onset  of  this 
attack  ;  there  was  then  evident  appendicitis,  the  child's  con- 
dition appeared  desperate,  and  immediate  operation  seemed  to 
give  the  only  chance  ;  laparotomy  showed  not  only  a  perforated 
appendix  but  an  encapsuled  abscess  with  dense  fibrous  mat- 
ting which  must  have  been  the  result  of  previous  attacks  of 
appendicitis. 

In  the  majority  of  cases  appendicitis  in  childhood  is  a  disease 
of  the  school  age,  but  it  occurs  even  in  infancy  occasionally.  In 
a  boy  whom  I  saw  at  the  age  of  2  years  and  4  months  with  appen- 
dicitis and  general  peritonitis,  which  proved  fatal,  there  had  been 
a  supposed  '  bilious  attack  ',  which  was  almost  certainly  an  attack 
of  appendicitis,  at  the  age  of  19  months.  In  three  other  infants, 
all  boys,  aged  respectively  19  months,  16  months,  and  14  months, 
I  have  seen  very  acute  appendicitis,  which  at  operation  revealed 
m  two  cases  a  gangrenous  appendix,  and  in  the  third  case  also 
the  appendix  was  very  acutely  inflamed.  With  operation  all 
three  cases  made  a  good  recovery,  but  in  all  of  them  the  diagnosis 
was  less  easy  than  it  usually  is  in  older  children.  Appendicitis 
m  the  infant  is  very  apt  to  be  mistaken  for  simple  digestive  dis- 
turbance ;  it  is  only  by  carefully  observing  the  greater  rigidity 


BILIOUS  ATTACKS  249 

of  the  abdomen  on  the  right  side  than  on  the  left,  and  by  watching 
for  evidence  of  local  tenderness  on  pressure  in  the  right  iliac 
region,  that  the  distinction  can  be  made,  and  this  may  require 
no  small  amount  of  tact  and  resourcefulness  when  the  infant 
cries  seemingly  just  as  much  when  he  is  touched  in  one  part  as 
in  another,  or  even  when  he  is  disturbed  at  all.  There  are  times 
when  it  may  be  advisable  to  use  an  anaesthetic,  but,  both  in 
infants  and  in  older  children,  I  feel  sure,  from  experience,  that 
an  anaesthetic,  so  far  from  being  always  a  help,  is  sometimes 
a  hindrance  to  diagnosis,  for  whilst  in  some  cases  there  is  a  local 
thickening  which  it  may  be  very  difficult  to  feel  until  the  muscles 
are  relaxed  by  an  anaesthetic,  in  others,  especially  the  most  acute 
cases,  there  is  no  such  thickening,  and  the  anaesthetic  only  serves 
to  obliterate  the  rigidity  and  tenderness  which  give  the  best 
indication  of  the  diagnosis.  A  warm  hand  and  a  light  touch  will 
often  obtain  information  which  even  an  anaesthetic  will  not  give. 

Let  me  emphasize  the  risk  of  overlooking  appendicitis  by 
referring  to  the  slightness  of  symptoms  in  some  cases.  In  a 
child,  whose  appendix  when  removed  showed  considerable  inflam- 
mation and  liberation  of  its  wall,  there  had  been  no  vomiting  and 
the  temperature  had  not  been  above  100°  F.  ;  in  some  children 
tenderness  and  increase  of  resistance  on  palpation  in  the  right 
iliac  fossa  are  the  only  distinctive  features  of  an  attack  of  appendi- 
citis, which  otherwise  might  pass  for  any  of  the  other  much  less 
serious  conditions,  which  are  described  by  parents  as  '  bilious 
attacks  '.  A  history  of  bilious  attacks  always  calls  for  careful 
examination  of  the  abdomen,  if  possible  during  the  attack,  for 
it  may  be  impossible  to  detect  anything  abnormal  locally  during 
the  intervals  between  these  slight  manifestations,  and  if  the  child 
is  seen  first  during  an  interval,  the  parents  should  be  advised  to 
let  the  doctor  examine  the  child  when  an  attack  occurs  ;  many 
a  child's  life  which  has  been  sacrificed  to  appendicitis  would 
have  been  saved  if  this  precaution  had  been  adopted. 

Digestive  Disturbance,  'Gastric  Catarrh '.  I  pass  now  from 
this  most  serious  significance  of  a  'bilious  attack'  to  the  most 
ordinary  and  perhaps  least  serious.  In  some  children  indi- 
gestion takes  the  form  of  an  attack  of  vomiting,  the  temperature 
rises  to  101°  or  102°  ;  the  tongue  is  furred,  and  there  may  be 
some  'stomach-ache'  or  epigastric  pain,  but  there  is  no  tender- 
ness in  the  right  iliac  fossa.  There  are  children — usually, 
I  think,  very  excitable  nervous  children — who  get  such  attacks 
every  few  weeks  ;  they  have  usually  shown  some  evidence  of 
feeble  digestion  at  other  times.  Such  a  case  is  the  following. 


250          COMMON  DISORDERS  OF  CHILDHOOD 

Rose  R.,  aged  9f|  years,  was  said  to  have  had  two  '  bilious  attacks  ' ;  in  each 
vomiting  persisted  for  about  thirty-six  hours  ;  in  one  there  was  some  pain  in 
the  epigastrium :  the  child  had  been  under  observation  for  pain  in  the 
abdomen  and  flushing  of  the  face  after  meals.  Care  in  diet  and  a  mixture  of 
rhubarb  and  soda  prevented  any  recurrence  of  the  attacks  so  long  as  she  was 
under  observation. 

Sometimes  there  is  no  vomiting,  the  child  simply  becomes 
sallow  and  seems  languid,  the  breath  is  offensive,  and  there 
is  some  heidache,  the  stools  are  costive  and  pale,  the  tem- 
perature is  raised  ;  a  smart  purge  sets  the  child  right  in  a 
few  hours. 

Arthur  D.,  aged  3|,  was  said  to  have  frequent  '  bilious  attacks  ',  in  which  he 
became  dark  under  the  eyes ;  there  was  no  jaundice,  but  the  sclerotics  lost  their 
clearness  and  were  said  to  look  sallow:  sometimes  there  was  more  or  less 
vomiting  in  the  attack,  but  sometimes  there  was  none  ;  the  stools  were  white, 
and  the  appetite  very  poor. 

It  would  be  easy  to  multiply  illustrations  of  such  attacks,  but 
it  is  unnecessary,  they  are  familiar  to  every  medical  man.  The 
pale  colour  of  the  stools  which  so  often  accompanies  this  con- 
dition suggests  some  deficiency  of  bile  secretion,  and  there  are 
those  who  talk  glibly  enough  about  '  liver  attacks  ',  and  '  chill 
on  the  liver  ',  but  I  think  it  is  a  pity  to  use  terms  which  imply 
more  than  we  know  :  it  is  possible,  perhaps  even  probable,  there 
may  be  some  disturbance  of  the  function  of  the  liver  in  these 
attacks,  but  if  so  it  is  probably  secondary  to  disturbance  of 
digestion,  or  to  deficient  elimination  from  the  bowel  owing  to 
constipation.  Certainly  dyspepsia  or  chronic  constipation  is  the 
only  disorder  that  can  be  affirmed  with  any  certainty  in  the  large 
majority  of  cases,  and  the  successful  treatment  is  the  correction 
of  dyspepsia  or  constipation  or  of  both.  It  would  be  out  of  place 
to  enter  on  any  full  description  of  the  treatment  of  either  of  these 
disorders  here  ;  I  will  only  say  that  in  the  dyspepsia  of  childhood 
carbo-hydrates,  that  is  to  say ,  the  starchy  and  saccharine  elements 
of  food,  but  especially  the  former,  are  by  far  the  commonest  cause 
of  indigestion.  This  is  a  point  worth  remembering  in  the  treat- 
ment of  these  so-called  'bilious  attacks',  when  they  are  really 
manifestations  of  dyspepsia  ;  the  amount  of  farinaceous  food  is 
to  be  regulated  ;  for  instance,  the  child  is  not  to  make  a  breakfast 
of  a  large  bowl  of  porridge  followed  by  several  pieces  of  bread- 
and-butter  ;  the  porridge  is  better  omitted,  an  egg  or  a  little 
fat  bacon,  or  some  fish,  with  a  little  bread-and-butter,  is  a  better 
breakfast  ;  and  again  at  dinner  some  blanc-mange  or  junket  or 
custard  may  take  the  place  of  any  cereal  milk-puddings  ;  fruits 
also,  apparently  on  account  of  their  indigestible  residue  of  fibres 
and  seeds,  are  common  causes  of  indigestion  in  childhood  and 
may  require  strict  limitation. 


BILIOUS  ATTACKS  251 

With  the  same  purpose  of  preventing  starch  dyspepsia  the 
administration  of  malt  is  valuable  in  these  cases,  and  its  diastasic 
action  may  be  increased  by  the  addition  of  some  pancreatic 
extract  ;  there  are  several  excellent  preparations  in  the  market 
which  fulfil  these  intentions,  such  as  Bynopancreatin  (Allen  & 
Hanbury's),  Mai  tine  with  Pepsin  and  Pancreatin  (Mai  tine  Manu- 
facturing Co.).  A  teaspoonful  of  any  of  these  given  immediately 
after  meals  has  a  very  marked  effect  in  aiding  digestion. 

At  the  same  time  it  is  often  advisable  to  give  a  rhubarb  and 
soda  mixture  just  before  meals  ;  in  some  cases  this  alone,  if 
given  for  several  weeks,  is  sufficient  to  prevent  any  recurrence 
of  the  attacks,  or  at  least  to  reduce  their  frequency. 

In  most  of  these  cases  there  is  more  or  less  chronic  constipa- 
tion, and  if  this  is  so  it  is  not  sufficient  to  treat  any  indigestion 
which  may  be  present ;  regular  and  sufficient  action  of  the  bowels 
must  be  ensured.  In  these  cases  I  think  the  best  method  is  to 
use  one  of  the  combinations  of  cascara  with  malt,  which  are  now 
made  by  several  chemists,  and  to  give  this  after  each  meal  in 
sufficient  doses  to  keep  the  bowels  regular  ;  or  a  dose  of  fluid 
magnesia  or  some  apenta  water  may  be  given  regularly  every 
morning  :  whatever  laxative  is  used  it  must  be  given  regularly 
for  many  weeks  or  months  so  as  to  establish  in  the  bowels  a  regular 
habit  of  action.  With  such  treatment  there  are  very  few  cases 
of  this  kind  which  cannot  be  freed  altogether  from  the  '  bilious 
attacks  '.  If  the  child  comes  under  treatment  during  an  attack 
it  is  best  to  give  a  dose  of  calomel  at  once,  one  grain  for  a  child 
under  three,  1J  grains  for  a  child  between  three  and  six  years, 
and  2  grains  for  an  older  child  ;  after  this  a  bismuth  and  soda 
mixture,  containing  10  grains  of  the  carbonate  of  bismuth  and 
10  grains  of  sodium  bicarbonate  should  be  given  every  four 
hours. 

Cyclic  vomiting.  There  is  another  disorder  which  very 
commonly  goes  by  the  name  of  '  bilious  attacks  ',  the  con- 
dition first  described  by  Dr.  Gee  as  '  fitful  or  recurrent  vomiting ', 
and  now  often  called  cyclic  or  periodic  vomiting.  This  disorder 
seems  to  be  almost,  if  not  quite,  peculiar  to  childhood.  It  is 
characterized  by  sudden  onset  of  vomiting  without  apparent 
cause,  the  child  is  often  very  drowsy,  there  is  sometimes  head- 
ache, and  sometimes,  but  not  always,  a  rise  of  temperature 
which  may  be  102°  or  more.  I  have  noted  in  several  cases  pain 
in  the  epigastrium,  the  bowels  are  costive,  the  vomiting  is  usually 
severe,  even  teaspoonful  doses  of  water  may  be  vomited,  and  the 
vomit  is  sometimes  coloured  bright  green  with  bile,  and  in  a  severe 


252  COMMON  DISORDERS  OF  CHILDHOOD 

case  may  even  be  tinged  with  blood.  During  the  attack  the 
child  is  often  drowsy  and  apathetic  ;  sometimes  restless,  waving 
the  arms  about  and  unable  to  sleep.  Thirst  is  often  distressing, 
and  in  a  bad  attack  the  lips  are  dry  and  covered  with  sordes. 
After  one  to  three  days  usually  the  vomiting  subsides,  and  the 
child  recovers  its  ordinary  health  within  a  few  days  ;  but  the 
attacks  are  occasionally  much  longer  ;  I  have  twice  known  the 
attack  to  last  fourteen  days,  and,  as  may  be  supposed,  the  degree 
of  exhaustion  may  then  become  very  serious. 

I  have  never  myself  seen  an  attack  prove  fatal,  but  in  one 
of  my  cases  life  seemed  to  be  in  danger  from  the  severity 
of  the  exhaustion.  Dr.  Crozer  Griffiths,  however,  mentions 
two  fatal  cases  writhin  his  OWTL  experience,  and  there  was  in 
the  Children's  Hospital,  Great  Ormond  Street,  under  the  care  of 
Dr.  Lees,  a  girl  aged  4}i  years,  who  was  admitted  with  a  history 
of  recurrent  attacks  of  vomiting ;  for  the  fourth  and  fifth  of  these 
the  child  was  taken  into  hospital,  and  the  fifth  proved  fatal. 
The  child,  whose  breath  smelt  of  acetone  and  whose  urine  showed 
acetone  and  diacetic  acid,  vomited  severely  and  fell  into  a  coma- 
tose condition  with  gasping  respiration  like  the  '  air  hunger  of 
diabetes  '  ;  after  some  terminal  convulsions  she  died,  and  the 
post  mortem  revealed  some  fatty  change  in  the  liver  and  kidneys, 
but  otherwise  nothing  except  some  oedema  of  the  lungs. 

This  case  was  recorded  by  Dr.  Langmead,1  who  has  also  put 
on  record  two  other  fatal  cases  in  girls  aged  respectively  4  and 
^H  years;  in  both  there  was  found  some  fatty  change  in  the 
liver. 

Of  fifty  cases,  which  I  supposed  to  be  of  this  nature,  twenty- 
four  were  boys  and  twenty-six  were  girls  :  in  one  family  two 
children  were  subject  to  severe  attacks  of  cyclic  vomiting,  and 
an  elder  brother  had  had  attacks  probably  of  the  same  nature  ; 
in  another  family  two  sisters  were  affected.  In  thirfcy-four  out 
of  the  fifty  cases  the  attacks  began  during  the  first  five  years  of 
life,  in  six  the  attacks  began  before  the  end  of  the  first  year,  one 
just  under  the  age  of  three  months  and  one  during  the  second 
week  of  life.  The  frequency  of  the  attacks  varied  from  three  in 
two  years  to  once  a  fortnight. 

The  association  of  this  disorder  with  a  nervous  temperament  is, 
I  think,  a  fact  which  cannot  be  ignored  in  considering  its  etiology. 
The  children  affected  are  nearly  always  unduly  excitable,  nervous 
children,  or  show  more  definite  nervous  symptoms,  such  as 
habit  spasm  or  somnambulism ;  in  two  cases  the  attacks  of 

1  Brit.  Med.  Journ.,  Feb.  5,  1905;  ibid.,  Sept.  28,  1907. 


BILIOUS  ATTACKS  253 

vomiting  were  sometimes  associated  with  convulsions.  Dr.  Gee 
noted  a  history  of  migraine  in  one  or  other  of  the  parents  in  some 
of  his  cases,  and  my  own  notes  show  a  similar  occurrence  in  at 
least  four  of  the  series  (in  a  fifth  case  there  had  been  '  sick- 
headaches  '  in  the  mother).  Like  migraine,  the  attack  of  cyclic 
vomiting  is  sometimes  preceded  by  premonitory  nervous  symp- 
toms :  in  one  of  my  cases  a  boy,  10J  years  old,  was  said  to 
become  very  excited  and  to  have  headache  just  before  the  attack 
began  ;  in  another  a  girl,  aged  11|  years,  was  said  to  be  specially 
irritable  for  two  days  before  the  onset  of  each  attack  ;  in  others 
more  general  warnings  were  noticed,  in  sallowness  of  complexion, 
lassitude,  and  dark  colour  under  the  eyes. 

It  seems  probable  that  these  cases  are  quite  distinct  from  the 
recurring  attacks  of  vomiting  and  malaise  which  I  have  already 
described  as  associated  with  dyspepsia  and  chronic  constipation, 
but  I  think  we  must  remember  that  no  proof  of  this  has  yet  been 
brought  forward :  for  aught  we  can  prove  to  the  contrary,  the 
difference  may  be  merely  one  of  degree  not  of  kind  ;  certainly 
differentiation  at  present  is  little  more  than  an  arbitrary  distinc- 
tion between  mild  cases,  in  which  we  think  we  can  recognize 
sufficient  cause  for  the  attacks,  and  those  more  severe  cases  in 
which  there  seems  to  be  no  adequate  cause.  Both  may  be  and 
probably  are  due  to  some  auto-intoxication. 

Within  the  past  few  years  it  has  been  observed  that  acetone 
and  diacetic  acid  can  be  detected  in  the  urine,  and  sometimes 
the  smell  of  acetone,  a  sweetish  apple-like  odour,  in  the  breath 
in  these  cases  of  cyclic  vomiting.  At  first  it  was  supposed  that 
this  feature  indicated  some  special  form  of  auto-intoxication 
which  differentiated  them  from  cases  of  recurring  vomiting  due 
to  other  causes  ;  this,  however,  has  proved  fallacious,  for  with 
severe  vomiting  due  to  any  cause  it  is  not  uncommon  to  find 
acetonuria,  and  occasionally  the  acetone  smell  of  the  breath. 
There  is,  however,  some  ground  for  supposing  that  the  acetonuria, 
or  rather  the  acetonaemia  which  presumably  underlies  it  in  these 
cases,  does  bear  a  direct  causal  relation  to  the  vomiting,  and  is  not 
a  result  or  coincidence :  acetonsemia  implies  a  diminished  alkalinity 
of  the  blood,  an  acidosis  as  it  has  been  called,  and  Dr.  Edsall  of 
Philadelphia,  arguing  that  if  this  were  the  cause  of  the  symptoms, 
the  disorder  should  be  amenable  to  treatment  by  the  administra- 
tion of  alkali,  suggested  the  use  of  large  doses  of  bicarbonate  of 
soda  in  the  treatment  of  this  disorder.  To  the  excellent  results  of 
this  treatment  I  can  testify :  it  seems  to  act  almost  as  a  specific 
in  the  prevention  of  attacks,  and  I  think  undoubtedly  curtails 


254  COMMON  DISORDERS  OF  CHILDHOOD 

attacks  if  given  during  the  first  few  hours  after  the  onset.  If  it 
can  be  retained,  a  solution  of  bicarbonate  of  soda  (15  grains  in 
2  drachms  of  water,  with  five  or  ten  drops  of  brandy)  should  be 
given  every  hour  until  six  doses  have  been  given,  and  then  every 
two  hours.  If  this  is  not  retained  (and  it  should  not  be  assumed 
that  it  will  not  be  retained  because  all  else  is  vomited,  for  some- 
times the  alkaline  solution  is  kept  down  where  other  fluids  have 
been  rejected  at  once)  then  the  bicarbonate  of  soda  must  be 
given  per  rectum,  2  drachms  may  be  injected  in  half  a  pint  of 
water. 

Small  doses  of  morphia  injected  subcutaneously  have  been 
found  useful  in  some  cases,  •$-$  grain  for  a  child  aged  two  years, 
2*0  grain  for  a  child  aged  three  to  four  years,  aV  grain  at  six  years, 
j'o  grain  at  ten  years. 

The  ordinary  treatment  of  vomiting  in  other  conditions,  such 
as  bismuth,  hydrocyanic  acid,  tincture  of  iodine,  and  so  forth, 
seems  to  have  little  effect  in  these  attacks  ;  usually  no  food  is 
retained  for  several  hours,  and  then  only  watery  fluid,  broth, 
whey,  or  perhaps  only  soda-water  in  small  quantities.  If  the 
inability  to  retain  food  persists  beyond  twenty-four  hours  it  will 
be  wise  to  give  nutrient  enemata  of  peptonized  milk  ;  3  ounces 
may  be  given  every  six  hours,  being  allowed  to  run  in  slowly  from 
a  funnel,  through  a  soft  tube,  which  should  be  introduced  quite 
4  to  6  inches.  Where  exhaustion  is  extreme  it  may  be  necessary 
to  administer  saline  infusion  subcutaneously. 

I  have  thought  that  as  a  matter  of  experience  glucose  is  of 
value  in  the  severe  attacks  of  cyclic  vomiting,  and  recently  on 
theoretical  grounds  this  form  of  sugar  has  been  recommended  l 
for  the  treatment  of  these  cases.  I  have  given  it  usually  as 
a  rectal  injection,  using  a  five  or  ten  per  cent,  solution.  I  have 
also  used  it  by  mouth,  when  it  could  be  retained,  in  doses  of  one 
or  two  drachms  of  the  ten  per  cent,  solution  at  short  intervals. 
It  can  also  be  used  for  subcutaneous  infusion  (vide  p.  230). 

The  preventive  treatment  of  this  recurrent  vomiting  is  most 
satisfactory  since  the  introduction  of  the  sodium  bicarbonate 
treatment.  A  dose  of  10  grains  of  the  sodium  bicarbonate  is  to 
be  given  three  tknes  a  day,  and  the  mother  can  be  instructed  to 
give  the  medicine  more  often  if  an  attack  threatens,  and  to  give 
it  every  hour  if  vomiting  begins.  The  result  of  this  treatment  in 
the  prevention  of  these  attacks  has  been  most  gratifying  in  my 
experience.  Before  the  introduction  of  this  method  I  had  been 
in  the  habit  of  ordering  liq.  arsenicalis  for  them,  and  I  think 
1  Mellanby,  Lancet,  July  1911,  p.  11. 


BILIOUS  ATTACKS  255 

with  benefit,  but  I  do  not  think  it  is  so  effectual  as  the  sodium 
bicarbonate. 

I  have  mentioned  the  occurrence  of  high  temperature  in  some 
of  these  attacks  of  cyclic  vomiting,  and  I  have  pointed  out 
that  the  symptoms  vary  considerably  in  severity  :  now  I  wish 
to  refer  to  a  disorder  which  I  believe  to  be  very  closely  allied  to 
this  so-called  cyclic  vomiting,  and  its  mention  here  will  not  be 
out  of  place,  for  it  is  sometimes  called  '  bilious  attack  '  by  the 
parents,  namely,  recurrent  pyrexia.  I  am  not  aware  that  this 
term  is  in  general  use,  but  it  seems  to  me  a  good  one  for  the 
disorder  to  which  I  apply  it,  especially  if  the  relation  to  recurrent 
vomiting  is  as  close  as  I  imagine.  Some  children  are  subject  to 
bouts  of  fever  lasting  sometimes  two  or  three  days,  sometimes 
a  week  or  more,  without  any  apparent  cause.  The  onset  is 
sudden,  but  there  are  often  vague  premonitory  symptoms  like 
those  preceding  recurrent  vomiting  ;  there  is  usually  some  head- 
ache and  the  stools  are  often  pale  and  almost  always  constipated. 
After  two  or  three  days  or  longer  the  temperature,  which  has 
been  almost  continuously  102°  to  104°,  sometimes  even  105°, 
falls  within  twenty-four  or  thirty-six  hours  to  normal,  and  the 
child  quickly  recovers  his  normal  health.  Now  in  some  cases 
these  attacks  are  sometimes  associated  with  vomiting,  some- 
times not  ;  when  vomiting  is  present  the  attacks  may  so  closely 
resemble  those  of  recurrent  or  'cyclic'  vomiting  as  to  suggest 
that  the  two  conditions  of  recurrent  pyrexia  without  vomiting 
and  recurrent  vomiting  with  pyrexia  are  interchangeable.  I  do 
not  assert  that  this  is  so,  but  I  think  it  is  worthy  to  be  con- 
sidered whether  this  recurrent  pyrexia,  which  has  been  described 
as  '  carbo-hydrate  pyrexia  '  and  'food  fever',  may  not  be  the 
manifestation  of  some  auto-intoxication,  allied  to,  if  not  identical 
with,  that  which  produces  recurrent  vomiting. 

Migraine.  The  occurrence  of  headache  is  an  accompaniment 
which  might  be  expected  in  the  febrile  condition  which  I  have 
already  mentioned  as  passing  for  '  bilious  attacks  ' ;  but  there 
is  another  condition  which  I  must  now  mention  in  which  the 
headache  is,  so  to  speak,  a  more  integral  part  of  the  disorder, 
namely  migraine. 

This  is  not  uncommonly  spoken  of  as  '  a  bilious  attack  ',  and 
though  in  my  experience  not  very  frequent  in  childhood,  occurs 
in  its  most  typical  form  occasionally  during  the  later  half  of 
childhood  between  five  and  twelve  years  of  age.  Sir  William 
Gowers  notes  a  point  in  which  the  migraine  of  children  differs 
from  that  of  the  adult,  namely,  in  a  tendency  to  pyrexia  with 


256  COMMON  DISORDERS  OF  CHILDHOOD 

the  attack.  He  quotes  in  illustration  the  case  of  a  child  who, 
from  the  age  of  two  years,  had  attacks  of  severe  pain  on  one  side 
of  the  head  associated  with  a  temperature  of  102°  to  103°  :  after 
vomiting  the  child  fell  asleep  and  woke  up  well.  The  headache 
of  migraine  is  not  necessarily  a  hemicrania,  there  are  not  neces- 
sarily any  visual  changes,  the  vomiting  may  be  repeated  several 
times,  though  usually  the  child  vomits  only  once  or  twice  in  each 
attack  ;  so  that  it  is  easy  to  see  how  with  headache,  vomiting, 
and  rise  of  temperature,  it  is  sometimes  very  difficult  to  say 
whether  the  so-called  '  bilious  attacks  '  are  really  the  result  of 
some  dyspepsia  or  of  constipation,  whether  they  are  short  attacks 
of  the  so-called  cyclic  vomiting,  or  whether  they  are  migraine. 
And,  indeed,  these  conditions  may  be  very  close  akin.  I  have 
already  mentioned  the  occurrence  of  migraine  in  the  parents  of 
children  who  suffer  with  recurrent  vomiting,  and  Dr.  Rachford 
of  Cincinnati  has  observed  an  additional  relation  of  great 
interest,  namely,  the  replacement  of  cyclic  vomiting  by  attacks 
of  migraine  when  the  patient  reached  adult  life  ;  this  he  observed 
in  four  cases. 

In  the  treatment  of  these  attacks  of  migraine  in  children, 
regular  action  of  the  bowels  and  good  digestion  must  be  ensured 
if  prevention  of  the  attacks  is  to  be  successful.  I  would  lay  great 
stress  upon  this  point,  for  I  think  there  is  a  tendency  to  rely 
too  much  upon  sedative  drugs  in  the  prophylaxis  of  migraine  : 
the  regular  administration  of  some  laxative,  for  instance  one 
of  the  preparations  of  cascara  and  malt,  or  of  some  fluid 
magnesia,  may  be  the  most  successful  line  to  adopt  if  at  the 
same  time  the  diet  is  regulated,  especially  in  the  direction  of 
preventing  over-eating  and  the  bolting  of  food  with  deficient 
mastication.  The  children  who  suffer  with  these  attacks  are 
usually  at  the  school  age,  and  in  those  who  attend  our  city 
schools,  the  hurrying  off  to  school  after  a  rapid  breakfast, 
very  likely  without  waiting  to  relieve  the  bowels  for  fear 
of  being  late  at  school,  and  the  hurried  and  sometimes  quite 
unsuitable  midday  meal  at  school,  perchance  of  sandwiches  or 
even  some  pastry  or  a  roll  and  butter,  may  be  a  fruitful  source 
of  chronic  constipation,  dyspepsia,  and  so-called  'bilious  attacks', 
whether  migranous  or  otherwise.  In  some  schools  also  the 
atmosphere  of  the  class-rooms,  especially  in  the  winter,  when 
windows  are  apt  to  be  closed  and  ventilation  very  deficient,  is 
a  sufficient  determining  cause  of  migraine.  If  the  attacks  recur 
frequently,  I  think  that  phenazone  given  twice  or  three  times  a  day 
regularly  in  a  mixture  of  rhubarb  and  soda  is  likely  to  be  useful, 


BILIOUS  ATTACKS  257 

and  to  this  1  or  2  minims  of  liq.  arsenicalis,  according  to  the  age, 
may  be  added.  In  the  attacks  phenazone  or  phenacetin  with 
caffeine  citrate  gives  perhaps  the  speediest  relief  to  the  headache  ; 
but  often,  and  I  speak  from  the  iullness  of  personal  experience 
in  boyhood,  nothing  seems  to  give  relief  until  vomiting  has 
occurred  and  sleep  has  followed. 

Renal  vomiting.  Lastly,  there  are  more  remote  possibilities 
which  must  be  borne  in  mind  as  possible  sources  of  a  supposed 
'  bilious  attack '.  Walter  F.,  aged  six  years,  was  stated  to  have  had 
'  bilious  attacks '  for  the  last  three  years.  Every  three  or  four  weeks 
he  had  an  attack  of  vomiting  usually  lasting  only  a  few  hours,  but 
occasionally  lasting  several  days  ;  in  a  recent  attack  he  had  been 
sick  for  ten  days,  not  able  to  keep  down  even  a  drop  of  water  ; 
he  was  feverish  during  this  time,  constipated,  and  had  some 
pain  in  his  abdomen.  The  pain  in  the  abdomen  was  always  on 
the  left  side,  and  on  palpating  the  abdomen  in  the  routine  of 
examination  one  found  a  rounded  smooth  tumour  almost  the 
size  of  a  man's  fist  in  the  left  lumbar  region,  overlaid  by  bowel, 
which  could  be  rolled  under  the  finger  over  the  underlying 
tumour.  He  was  admitted  into  the  children's  ward  at  King's 
College  Hospital,  where  he  seemed  quite  well  except  for  the 
presence  of  the  tumour,  and  after  a  few  days  the  tumour  suddenly 
disappeared  completely.  The  amount  of  urine  passed  on  that 
day  was  about  4  to  5  ounces  in  excess  of  what  he  had  passed  on 
other  days.  The  tumour  did  not  reappear  while  he  was  in 
hospital ;  so  after  remaining  there  for  about  a  fortnight  he  was 
sent  home.  After  a  short  time  he  reappeared  with  a  history  that 
another  attack  of  vomiting  had  begun  five  days  previously,  he 
had  had  some  pain  on  the  left  side  of  the  abdomen,  and  the 
vomiting  had  been  very  continuous.  On  palpation  the  tumour 
was  now  to  be  felt  as  previously,  but  not  so  large.  He  was  re- 
admitted and  the  tumour  increased  slowly  in  size,  but  the  boy 
had  no  pain  and  no  vomiting  and  seemed  well ;  eight  days  after 
admission  the  tumour  completely  disappeared  again,  and  as 
before  it  was  noticed  that  he  had  been  passing  about  this  time 
a  larger  quantity  of  urine  than  usual. 

It  seemed  clear  that  there  was  a  hydronephrosis,  and  my 
colleague,  Mr.  Carless,  operated  and  found  a  dilated  pelvis  with 
a  valvular  kink  of  the  ureter  at  its  entry  into  the  pelvis  :  for 
this  he  did  a  plastic  operation,  with  excellent  result.  Here,  then, 
was  a  case  of  hydronephrosis  which  gave  rise  to  bouts  of 
vomiting  with  some  abdominal  pain,  wrhich  were  described  as 
'  bilious  attacks  '. 

STILL 


258          COMMON  DISORDERS  OF  CHILDHOOD 

A  girl  of  seven  years  was  brought  for  '  bilious  attacks ',  which 
had  recurred  for  two  years  :  she  was  feverish  and  vomited  in  the 
attacks,  which  lasted  one  to  three  days.  I  saw  her  in  an  attack 
which  had  lasted  five  days  with  severe  vomiting  ;  she  could  keep 
down  nothing  except  soda-water  :  the  temperature  was  103° 
to  104°  ;  there  was  some  acetone  in  the  urine,  which  was  acid. 
So  far  the  case  might  have  passed  for  one  of  recurrent  vomiting, 
but  on  examining  the  urine  further  it  was  found  to  contain  many 
pus  corpuscles,  and  on  palpation  there  was  tenderness  over  the 
right  kidney.  There  was  evident  pyelitis,  and  it  seemed  probable 
that  there  might  be  a  renal  calculus.  I  lost  sight  of  the  case 
before  the  diagnosis  had  been  cleared  up,  but  these  facts  are 
sufficient  to  illustrate  my  subject — pyelitis  producing  a  so-called 
'  bilious  attack '. 

The  last  case  I  will  mention  of  renal  sources  for  such  attacks 
was  an  instructive  one,  for  it  gave  rise  to  a  diagnosis  of  '  cyclic 
vomiting  '.  Leslie  S.,  aged  ten  years,  had  had  attacks  of  vomit- 
ing lasting  one  to  two  days,  every  two  or  three  weeks  for  eleven 
months  ;  in  the  attacks  there  was  no  headache,  but  he  had  some 
pain  in  the  right  hypochondrium  on  which  no  stress  was  laid, 
lie  was  treated  with  bicarbonate  of  soda  for  about  eighteen 
months,  which  seemed  to  diminish  the  frequency  of  the  attacks, 
and  I  had  no  doubt  whatever  that  it  was  a  case  of  cyclic 
vomiting  until  a  severe  attack  occurred  with  great  pain  in  the 
abdomen  followed  by  sharp  pain  in  the  urethra,  and  the  boy 
came  to  the  hospital  showing  with  great  satisfaction  a  renal 
calculus  the  size  and  shape  of  a  date-stone  which  he  had  passed 
with  his  urine. 

Meningitis.  There  is  one  more  condition  which  must  be 
mentioned  here,  for  it  comes  so  often  in  the  guise  of  an  innocent 
'stomach  attack',  or,  as  the  parents  say,  a  'bilious  attack', 
namely,  tuberculous  meningitis.  Face  to  face  with  a  case  of  vomit- 
ing, headache  and  constipation,  who  shall  say  during  the  first  day 
or  two  whether  the  symptoms  are  simply  the  result  of  some 
gastric  catarrh,  or  whether  the  attack  is  a  first  bout  of  cyclic 
vomiting,  or  the  first  indication  of  a  fatal  meningitis  ?  I  have 
notes  of  cases  in  which  mistakes  were  made  owing  to  complaint 
of  pain  in  the  abdomen  during  the  early  stage  of  tuberculous 
meningitis  ;  I  know  not  what  the  explanation  of  this  may  be,  hard 
scybala,  the  result  of  the  constipation,  may  account  for  it,  or 
possibly  the  tuberculous  mesenteric  glands  which  are  so  often 
present  may  be  causing  pain ;  but  any  way  the  fact  is  worthy  of 
note,  for  it  should  put  us  on  our  guard  against  tuberculous  men- 


BILIOUS  ATTACKS  259 

ingitis,  even  where  complaint  of  abdominal  pains  seems  to 
localize  the  trouble  to  the  abdomen.  An  additional  caution 
I  would  give  is  this  :  headache  is  occasionally  absent  or  extremely 
slight  in  the  early  stages  of  tuberculous  meningitis,  although 
vomiting  and  constipation  may  be  very  marked.  For  instance, 
George  B'.,  aged  two  years  and  ten  months,  the  child  of  a  doctor, 
had  vomited  twice  within  two  days,  ten  days  before  I  saw  him  ; 
about  a  week  later  he  vomited  again  two  or  three  times  within 
two  days,  the  bowels  were  costive,  but  there  was  no  headache 
nor  pain  anywhere  apparently ;  the  attack  was  regarded  as  due  to 
some  digestive  disturbance.  Four  days  later  there  was  squint,  wit  h 
optic  neuritis  and  other  signs  pointing  to  tuberculous  meningitis, 
of  which  the  child  died  a  few  days  later.  I  have  seen  cases  in 
which  the  child  repeatedly  declared  that  there  was  no  headache, 
although  the  course  of  the  illness  and  subsequent  autopsy  proved 
that  there  was  tuberculous  meningitis.  Of  course,  both  abdominal 
pains  and  absence  of  headache  are  quite  unusual  in  this  disease, 
but  I  mention  them  to  emphasize  my  point,  that  it  is  only  too 
easy  to  mistake  the  early  symptoms  for  some  slight  gastric  dis- 
turbance, or,  as  the  parents  call  it,  '  a  bilious  attack,'  more 
especially  when  our  wishes  are  all  in  favour  of  the  trivial  ailment. 
The  conclusion  of  the  whole  matter  is  this,  that  the  parent's 
tale  of  a  '  bilious  attack '  •  needs  careful  sifting  :  it  may  mean 
the  most  innocent  of  digestive  upsets,  it  may  on  the  other 
hand  mean  cyclic  vomiting,  or  serious  diseases  such  as  I  have 
mentioned. 


3  2 


CHAPTER   XIX 
FEVER  OF  OBSCURE  CAUSATION 

I  PROPOSE  in  this  chapter  to  consider  a  problem  which  must 
be  only  too  familiar  to  most  medical  men,  the  child  with  fever 
for  which  we  can  find  no  explanation.  One  of  the  most  striking 
features  of  infancy  and  early  childhood  is  nervous  instability, 
and  this  may  show  itself,  not  only  in  what  we  commonly  recognize 
as  nervous  disorder,  for  instance,  the  tendency  to  convulsions 
upon  provocation  which  would  have  no  such  effect  in  later  life, 
but  also  in  irregularity  of  almost  every  function  in  the  body  : 
how  irregular,  for  instance,  the  respiration  of  an  infant  is  apt  to 
be,  how  easily  the  rhythm  of  the  diaphragm  is  disturbed,  so  that 
hiccough  occurs  many  times  a  day  during  the  first  few  months  of 
life  ;  how  easily  the  cardiac  rate  and  sometimes  the  rhythm  is 
disturbed  in  a  child,  and  how  erratic  is  the  secretion  of  urine  in 
early  life,  giving  rise  to  scares  of  suppression  or  retention,  when 
there  is  really  nothing  amiss  ;  even  the  co-ordination  of  the  gastric 
movements  is  so  easily  disturbed  that  the  pylorus  may  contract 
when  it  should  dilate,  and  the  result  may  be  troublesome  vomit- 
ing, and  hypertrophy  of  the  stomach.  The  nervous  control  of  all 
these  functions  only  becomes  stereotyped,  so  to  speak,  as  the 
child  grows  older  ;  with  increasing  years  comes  increasing  steadi- 
ness of  function. 

So  it  is  with  the  temperature,  in  the  regulation  of  which,  as 
we  all  know,  the  nervous  system  plays  an  important  part  :  in  the 
infant  the  temperature  rises  on  the  most  trivial  cause  ;  it  may 
ho  lumpy  faeces  in  the  intestine,  it  may  be  a  slight  coryza.  I  have 
seen  cases  where  even  some  irritation  of  the  skin  seemed  sufficient 
cause  ;  as  the  child  grows  older,  similarly  but  less  often,  consti- 
pation, some  slight  deviation  from  a  customary  diet,  or  even 
some  unwonted  excitement  may  be  sufficient  cause  for  a  rise 
of  temperature. 

The  next  point  that  I  wish  to  lay  stress  upon  is  this  :  that  the 
degree  of  nervous  instability  and  therewith  the  tendency  to 
pyrexia,  varies  in  different  children.  One  child  will  get  a  tem- 
perature of  101°  with  simple  constipation,  where  another  child 
at  the  same  age  will  get  no  rise  of  temperature  at  all:  moreover. 


FEVER  OF  OBSCURE  CAUSATION  261 

this  instability  of  temperature  lasts  to  a  much  later  age  in  some 
children  than  in  others  ;  one  will  have  lost  it  at  four  years  old, 
another  will  show  it  at  ten  years  :  there  are,  indeed,  cases  on 
record  which  show  that  occasionally  it  persists  even  into  adult 
life.  Further,  any  cause  which  produces  fever  in  the  stable  child 
is  likely  to  cause  a  much  higher  temperature  in  the  child  with 
this  instability.  This  peculiar  tendency  to  fever  is  seen  chiefly 
in  the  children  of  neurotic  parents,  or  in  families  with  some 
neuropathic  taint,  and  generally  the  child  whose  temperature  is 
easily  disturbed  is  recognizable  as  in  other  ways  a  nervous  or 
excitable  child. 

In  his  knowledge  of  the  tendencies  of  a  particular  family  and 
of  the  behaviour  of  the  temperature  in  previous  disturbances  in 
the  particular  child,  the  family  doctor  has  a  piece  of  information 
which  is  not  to  be  despised,  and  which  is  included  in  that 
mysterious  '  knowing  their  constitution '  to  which  the  laity  very 
rightly  attach  much  importance. 

But  whilst  it  is  important  to  realize  this  peculiarity  of  early 
life  and  its  accentuation  in  the  children  of  certain  families,  it  is 
easy  in  a  particular  case  to  be  led  astray  by  these  seductive 
generalisms,  and  I  think  that  we  shall  do  well  to  lay  it  down  as 
a  rule  that  nervous  instability  is  to  be  regarded  rather  as  a  con- 
tributing or  modifying  factor,  than  as  the  '  fons  et  origo  '  in  any 
given  case  of  obscure  fever  in  a  child. 

Recurrent  pyrexia.  Turning  now  from  the  general  to  the 
particular,  I  wish  to  consider  first  a  group  of  cases  which  must 
be  familiar  to  most  medical  men,  cases  which  I  would  label 
'  recurrent  pyrexia  '.  The  history  is  this  :  that  at  intervals  of 
weeks  or  months,  perhaps  five  or  six  times  a  year,  the  child, 
usually,  I  fancy,  a  boy  at  any  age  up  to  ten  or  twelve  years 
old,  seems  out  of  sorts,  languid,  sometimes  markedly  drowsy, 
and  feverish,  his  temperature  is  found  to  be  raised,  perhaps  102° 
or  103°,  sometimes  105°,  in  one  of  my  cases  106-2°.  The  onset 
of  the  fever  is  generally  quite  acute  :  in  one  of  my  cases  the 
temperature  was  stated  to  have  risen  from  normal  to  103° 
within  an  hour.  The  fever  usually  subsides  within  three  or 
four  days,  but  its  duration  is  variable  ;  it  may  last  only  twenty- 
four  hours  ;  occasionally  it  lasts  a  week  or  ten  days  with  slight 
remissions.  During  the  attack  the  bowels  are  generally  costive 
and  the  stools  pale.  In  some  cases  there  is  more  or  less  vomit- 
ing. There  is  no  pain  usually  ;  occasionally  the  child  complains 
of  slight  headache.  Physical  signs  there  are  none  whatever, 
as  a  rule,  though  occasionally  a  few  rales  in  the  chest  may  raise 


262 


COMMON  DISORDERS  OF  CHILDHOOD 


1 

o3 

.a 

83 

"c 
o 

a 


3 


o  o 


£  W 

<~  -^ 


o  .2 


£  g 
62 


FEVER  OF  OBSCURE  CAUSATION  263 

suspicions  of  some  commencing  acute  pulmonary  attack,  which, 
however,  fails  to  appear. 

Chart  I  shows  the  temperature  in  four  such  attacks  in  a  boy 
aged  two  years  and  one  month  :  these  all  occurred  within  twelve 
months  ;  he  was  a  bad  sleeper,  often  started  up  in  his  sleep  and 
cried  out,  his  bowels  were  sometimes  costive,  and  after  the 
febrile  attacks  he  passed  '  slime '  in  his  stools  ;  but  there  were 
no  other  symptoms  associated  with  the  fever  beyond  the  usual 
accompaniments  of  any  feverish  condition, — the  pulse  became 
quick,  160  per  minute  on  some  occasions,  and  his  respirations  as 
much  as  52  per  minute. 

Seeing  these  cases  as  the  consultant  generally  does  after 
several  attacks  have  already  occurred,  he  has  an  easier  task  in 
recognizing  their  nature  than  has  the  family  doctor  who  is  called 
in  at  the  first  attack,  when  a  diagnosis  is  impossible,  or  at  best 
can  only  be  a  matter  of  conjecture.  Judging  from  the  histories 
given  to  me,  I  feel  sure  these  cases  give  much  trouble  in  diagnosis, 
even  when  the  attacks  have  recurred  several  times.  '  Influenza  ' 
they  are  called  until  the  most  implicit  confidence  is  shaken  by  an 
influenza  which  recurs  once  every  two  or  three  months,  or  even 
oftener,  for  several  years.  In  the  case  of  one  boy  who  had  had 
about  four  attacks  each  year  from  infancy  until  he  was  nearly 
eleven  years  old,  various  doctors  had  seen  him  in  various  attacks  : 
one  had  diagnosed  influenza,  another  pneumonia,  and  another 
peritonitis,  and  another  had  seen  him  in  an  unusually  prolonged 
attack,  and  had,  very  prudently,  treated  him  as  a  typhoid, 
although  the  mother's  experience  of  her  son's  attacks  made  her 
very  positive  that  the  fever  was  not  typhoid,  and  she  proved  to 
be  right. 

The  association  of  constipation  with  fever  and  perhaps  vomit- 
ing has  raised  the  question  of  appendicitis  in  some  of  the  attacks, 
but  the  absence  of  abdominal  pains  and  tenderness,  and  of  any 
resistance  on  palpation  in  the  right  iliac  fossa  has  negatived  this  ; 
then  again  the  drowsiness  which  may  be  a  marked  feature,  and 
its  association  with  constipation  and  perhaps  vomiting,  has 
raised  fears  of  meningitis,  a  possibility  which  may  be  difficult  to 
exclude,  although  the  history  of  similar  previous  attacks  is  opposed 
to  it,  and  the  subsequent  speedy  recovery  clears  up  the  doubt. 
The  term  'bilious  attacks'  is  sometimes  applied  to  these  bouts 
of  pyrexia,  undesirably,  I  think,  because  it  is  applied  to  several 
entirely  different  conditions,  and  is  often  the  cloak  which  con- 
ceals such  a  serious  disease  as  appendicitis. 

The  significance  of  these  attacks  is  by  no  means  clear.     I  doubt 


264  COMMON  DISORDERS  OF  CHILDHOOD 

if  they  have  the  same  significance  in  all  cases,  but  certainly  some 
of  the  symptoms  seem  to  point  to  a  gastro -intestinal  origin  : 
the  costiveness  of  the  bowels,  the  pallor  of  the  stools,  the  vomiting 
in  some  cases,  the  striking  value  of  calomel  in  stopping  the 
attacks,  and  the  apparent  influence  of  diet  all  seem  to  point  this 
way  ;  in  one  case  the  mother  told  me  that  she  could  always 
recognize  when  attacks  were  coming  by  the  passage  of  much 
mucus  in  the  stools,  in  another  case  mucus  was  passed  in  the 
stools  just  after  the  attacks,  in  a  third  the  onset  of  the  attack 
was  usually  preceded  by  hiccough.  Simple  constipation  is  not, 
I  think,  sufficient  to  account  for  the  attacks  ;  indeed,  in  some 
cases  the  bowels  are  open  thoroughly  though  the  pyrexia  con- 
tinues; there  wTould  seem  rather  to  be  some  auto-intoxication 
from  the  bowel,  but  how  this  arises  there  is  not  sufficient  evidence 
to  show.  Whatever  may  be  the  determining  cause,  one  thing, 
I  think,  is  clear — and  herein  lies  the  application  of  my  opening 
generalisms— these  attacks  of  recurrent  pyrexia  occur  chiefly  in 
children  of  nervous  excitable  tendency,  a  point  to  be  remembered 
in  their  management. 

The  outlook  in  these  cases  is  good  :  the  tendency  to  the  attacks 
becomes  less  as  the  child  grows  older  ;  they  recur  sometimes  for 
several  years,  but  I  should  say  rarely  later  than  ten  or  eleven 
years  old.  I  have  never  seen  any  serious  mischief  resulting  from 
them,  even  when  the  temperature  reached  105°  or  106°. 

Now  what  is  to  be  done  for  them  ?  When  the  attack  has  come, 
the  child  is  languid  and  out  of  sorts,  and  no  doubt  bed  is  the  best 
place  for  him,  and  until  the  bowel  lias  been  cleared  out,  the 
lightest  of  food,  broth  or  diluted  milk,  will  be  sufficient  ;  a  dose 
of  calomel  will  hasten  the  disappearance  of  the  fever,  but  can 
anything  be  done  to  prevent  another  attack  ? 

The  value  of  special  dieting  in  some  of  these  cases  of  recurrent 
pyrexia  was  pointed  out  by  the  late  Dr.  Eustace  Smith,1  who 
applied  the  term  '  Food  Fever  '  to  the  attacks.  The  efficiency 
of  the  regimen  laid  dowrn  by  him  is  illustrated  by  a  case  recorded 
by  Dr.  Davy,2  of  Exeter.  From  the  age  of  2£  up  to  11  years,  his 
patient,  a  boy,  had  frequent  attacks  like  those  I  have  described. 
The  boy  eventually  lost  them  entirely  after  careful  dieting,  the 
chief  point  in  which  was  the  exclusion  of  starchy  puddings,  jam, 
marmalade,  fruit  raw  and  cooked,  potato,  turnips,  carrots,  sweet 
cakes,  and  oatmeal  porridge.  He  referred  to  other  cases  cured 

1  Brit.  Med.  Journ.,  Feb.  10,  1906. 

2  Fever  in  children  caused  by  indigestion  of  certain  kinds  of  carbo-hydrate 
food.     Lancet,  Sept.  24,  1904. 


FEVER  OF  OBSCURE  CAUSATION  265 

by  similar  care  in  diet.  My  own  experience  would  not  justify 
me  in  attaching  a  specific  value  to  the  dieting,  but  I  think  that 
it  is  worthy  of  trial,  and  in  some  cases  does  good  ;  I  have  gener- 
ally dieted  these  cases  upon  similar  lines,  and  given  a  mixture 
of  arsenic  and  citrate  of  potash,  the  arsenic  being  of  value  in 
reducing  the  nervous  excitability  of  these  children. 

There  is  a  group  of  cases  which  ought  perhaps  to  be  mentioned 
here,  inasmuch  as  it  resembles  those  described  above  in  the  recur- 
rence of  seemingly  unexplained  fever,  beginning  suddenly  and 
lasting  several  days,  with  a  temperature  rising  sometimes  even 
to  105°.  The  point  of  difference  is  the  presence,  as  shown  on 
careful  inquiry,  of  some  unhealthy  condition  of  the  throat.  This 
may  have  attracted  little  if  any  notice,  but  when  once  attention 
is  drawn  to  it,  perhaps  by  the  child's  complaining  of  slight  sore 
throat,  or  by  a  little  pufnness  of  glands  at  the  angle  of  the  jaw 
in  one  of  the  attacks,  it  is  found  to  occur  on  each  occasion,  and 
is  evidently  the  underlying  cause.  It  would  seem  that  there  is 
a  recurring  infection  of  the  nasopharynx,  but  there  is  sometimes 
a  perplexing  association,  namely,  an  unhealthy  condition  of  the 
stool,  which  contains  much  mucus  and  is  extremely  offensive. 
Whether  the  throat  or  the  bowel  disorder  is  to  be  regarded  as 
primary  is  not  clear,  but  it  seems  most  probable  that  the  naso- 
pharyngeal  infection  comes  first,  and  that  the  swallowing  of 
infected  mucus  is  responsible  for  the  bowel  disturbance  ;  a 
sequence  which,  I  think,  is  by  no  means  uncommon  in  the  throat 
affections  of  childhood. 

Prolonged  slight  fever.  The  next  group  of  cases  to  which 
I  would  draw  attention  is  one  in  which,  for  weeks  or  months, 
the  child  has  a  slight  evening  rise  of  temperature  to  100°  or 
thereabouts,  or,  as  less  commonly  happens,  a  continuous  slight 
elevation  of  the  temperature  ;  in  either  case  the  rise  of  tempera- 
ture may  persist  for  many  months,  without  signs  or  symptoms  to 
explain  it.  Most  of  the  children  I  have  seen  with  this  condition 
have  been  children  in  the  first  half  of  childhood,  that  is,  under 
the  age  of  six  years.  The  child  has  looked  perfectly  well,  and 
seemed  so  in  every  way,  except,  perhaps,  that  the  weight  has 
not  increased  as  it  should  ;  but,  like  those  with  recurrent  pyrexia, 
they  are  almost  always  markedly  nervous  children,  and  usually 
children  of  neurotic  parentage. 

Such  a  temperature  is  shown  in  Chart  II.  The  patient  was 
a  boy  aged  5  years,  the  elder  of  two  brothers,  both  of  extremely 
nervous  temperament,  both  subject  to  night -terrors,  and  the 
elder  one  to  habit-spasm  also.  Both  children  successively 
showed  in  early  childhood  for  many  months  a  rise  of  temperature 


266 


COMMON  DISORDERS  OF  CHILDHOOD 


to  100°  or  100-2°  at  night  ;  the  morning  temperature  in  both 
cases  was  seldom  below  99°.  The  father,  a  medical  man,  was 
anxious  lest  tuberculosis  should  underlie  this  slight  fever,  but 
there  was  never  any  sign  to  suggest  tuberculosis  ;  at  times  the 
temperature  would  keep  within  a  perfectly  normal  range  for 
a  week  or  two,  then  it  would  fluctuate  at  the  higher  level  again 
for  several  weeks  without  any  apparent  alteration  in  the  health 
of  the  child.  After  many  months  the  temperature  became 
normal  in  both  children,  both,  apart  from  their  nervous  tempera- 
ment, remained  perfectly  healthy,  and  lapse  of  several  years  has 
brought  to  light  no  evidence  of  organic  disease  in  either. 


March. 


April. 


FIG.  12.     Chart  II.     Prolonged  slight  fever  in  nervous  child  without 
apparent  cause. 

I  had  under  my  care  a  girl,  aged  9J  years,  whose  temperature 
for  many  months  was  exactly  similar  to  that  shown  above  :  it 
was  usually  about  100°  at  night.  The  child  showed  no  symptoms 
except  that  she  was  morbidly  nervous,  and  during  part  of  the 
time  that  the  rise  of  temperature  persisted,  she  suffered  with 
a  habit-spasm  consisting  of  a  lateral  twitch  of  the  head.  In  this 
particular  case  the  slight  elevation  of  the  temperature  was  dis- 
covered almost  accidentally  ;  the  habit-spasm  was  mistaken  for 
chorea,  and  the  temperature  was  taken  as  a  precaution  in  watch- 
ing for  evidence  of  rheumatism  ;  when  it  was  found  to  be  above 
normal  it  was  taken  daily,  and  showed  the  slight  evening  eleva- 
tion, on  account  of  which  I  was  consulted.  I  suspect  that  many 
such  temperatures  go  undetected  ;  I  have  noticed  that  in  my 
own  experience  they  have  occurred  much  more  often  in  the-  chil- 


FEVER  OF  OBSCURE  CAUSATION 


267 


dren  of  medical  men  than  in  those  of  other  people,  which  prob- 
ably indicates  a  more  frequent  resort  to  the  thermometer  in 
doctors'  families,  and  so  more  ready  discovery  of  such  abnor- 
malities. 


It  is  at  least  tempting  to  consider  the  temperature  in  such 
a  case  as  purely  neurotic  ;  it  is  clear  from  the  occurrence  of 
habit-spasm  that  there  was  a  morbid  instability  of  the  nervous 


268  COMMON  DISORDERS  OF  CHILDHOOD 

system,  what  more  natural  than  that  the  thermotaxic  function 
of  the  brain  should  also  be  unstable  ?  That  these  slight  daily 
rises  of  temperature  over  prolonged  periods  without  apparent 
cause  may  be  of  no  sinister  significance  I  can  assert  from  having 
had  a  considerable  number  of  such  cases  under  observation  at 
intervals  for  several  years.  This  particular  child  was  said  to  be 
quite  healthy  when  I  heard  of  her  four  years  later  ;  the  daily  rise 
of  temperature  ceased  after  some  months. 

The  temperature  in  a  similar  case  is  shown  in  Chart  III  from 
a  girl  aged  3 J  years  who  had  suffered  at  various  times  with  vomit- 
ing and  pale  stools  and  other  symptoms  of  indigestion.  She  was 
said  to  be  an  extremely  nervous,  excitable  child.  Careful  exami- 
nation failed  to  show  any  other  cause  for  the  fever,  which  persisted 
for  six  months. 

I  have  notes  of  many  similar  cases,  and  if  I  were  to  sum  up 
my  impression  of  them  as  a  whole,  it  would  be  this  :  that  the 
nervous  temperament  plays  a  very  large  part  in  determining  the 
fever;  but  that  in  a  majority  of  the  cases  the  exciting  cause  is  in 
the  gastrointestinal  tract.  In  several  of  the  cases  under  my 
observation,  there  has  been  some  chronic  difficulty  of  digestion  ; 
the  child  has  shown  more  or  less  of  the  usual  symptoms  of  chronic 
indigestion  which  I  have  described  in  a  previous  chapter.  In 
some  cases  it  has  seemed  to  me  that  without  producing  any 
obvious  symptom  of  indigestion,  the  feeding  was  excessive,  and 
a  reduction  of  the  large  quantity  of  milk  or  other  food  taken, 
and  an  increased  allowance  of  exercise  where  it  had  been  restricted 
because  tuberculosis  was  suspected,  have  been  followed  by  sub- 
sidence of  the  temperature. 

A  clinical  feature  which  may  perhaps  point  in  the  same  direc- 
tion is  the  occurrence  in  some  of  these  children  of  bouts  of  much 
higher  fever  at  intervals  of  several  weeks  or  months,  resembling 
the  '  recurrent  pyrexia  '  which  I  have  already  described  as  being 
probably  related  to  faulty  digestion  of  certain  foods.  It  is  easy 
to  talk  glibly  of  auto-intoxication,  it  is  difficult  to  prove  it  ; 
nevertheless  I  think  there  is  much  to  be  said  for  the  view  that 
this  prolonged  slight  fever,  as  well  as  the  recurrent  attacks  of 
severe  fever,  may  be  due  to  an  auto-intoxication  from  the  alimen- 
tary tract  ;  in  the  one  case  the  absorption  may  be  conceived  as 
occurring  daily  in  small  doses  over  long  periods  ;  in  the  other 
case  the  child  absorbs  a  much  larger  dose  at  long  intervals  ;  in 
both  cases  the  effect  of  the  toxic  material  in  producing  fever  is 
determined  by  the  nervous  instability  of  the  child. 

It  may  be  said  that  if  this  were  so  it  should  be  easily  proved 


FEVER  OF  OBSCURE  CAUSATION 


269 


W)  < 


^H      O 

o3  J4 

O    +3 


. 
'§•2 


II 


«0         10          «*         Kl          OJ         — 


S 


".  2 
a, 


270  COMMON  DISORDERS  OF  CHILDHOOD 

by  the  effect  of  dieting.  I  have  already  pointed  out  that  dietetic 
measures  sometimes  seem  to  have  a  marked  effect,  but  I  must 
add  that  there  are  many  more  cases  in  which  they  seem  to  have 
none  ;  yet  knowing  how  protracted  digestive  difficulty  often  is 
in  childhood  in  spite  of  most  careful  dieting,  I  do  not  think  that 
the  failure  of  such  measures  to  stop  the  fever  necessarily  disproves 
an  intestinal  origin. 

However  this  may  be,  these  cases  always  present  a  difficult 
problem  ;  one  may  feel  almost  confident  that  the  yards  of  chart 
which  are  exhibited  by  an  anxious  parent,  showing  a  regular 
evening  rise  to  about  100°  or  1004°,  have  no  serious  significance 
and  depend  on  nothing  worse  than  some  slight  disturbance  of 
function,  perhaps  digestive,  in  a  nervous  child  ;  and  yet  one 
hesitates  to  be  too  positive,  for  there  are  always  present  to  one's 
mind  possibilities  of  more  serious  disease. 

I  have  long  believed  what  the  chart  shown  on  p.  269  seems 
to  demonstrate,  that  a  latent  catarrh  in  the  middle-ear,  without 
pain  and  without  external  discharge,  is  capable  of  producing 
slight  daily  rise  of  temperature  for  many  weeks  or  months.  It 
is  difficult  perhaps  to  differentiate  in  these  cases  between  the 
part  played  by  the  naso-pharyngeal  catarrh,  with  or  without 
adenoids,  which  is  so  often  associated  Yvith  middle-ear  disorder, 
and  that  played  by  the  middle-ear  affection  itself  ;  but  in  the 
case  from  which  Chart  IV  was  taken  there  seemed  to  be  no  reason 
to  doubt  that  the  temperature  was  due  to  the  ear. 

The  patient  was  a  girl  aged  8  months  ;  on  March  13  she 
began  to  ail;  next  day  the  temperature  rose  to  103°  and  the 
child  was  sick,  the  bowels  were  costive,  the  fontanelle  was  unduly 
full  ;  meningitis  was  feared,  but  no  definite  diagnosis  could  be 
made,  although  the  temperature  continued  to  rise  daily  to  101°- 
102°.  On  March  21  the  mystery  of  the  temperature  was  solved 
by  a  discharge  from  one  ear,  although  the  membranes  had  been 
examined  and  no  sign  of  otitis  had  been  detected.  The  drum  of 
the  other  ear  was  then  incised,  and  a  little  pus  escaped.  After 
two  or  three  weeks  all  discharge  from  the  ears  ceased,  the  child 
seemed  perfectly  well  in  every  way,  but  for  ten  months  the 
temperature  rose  almost  every  day  to  100°-101  °.  After  this  the 
record  of  the  temperature  was  discontinued,  for  the  child  was  in 
excellent  health.  But  when  the  thermometer  was  used  again, 
about  the  end  of  the  child's  second  year,  the  irregularity  of  the 
temperature  was  found  to  continue.  Gradually  it  settled  down, 
and  when  I  heard  of  the  child  some  years  later  she  was  quite 
healthy.  The  chart  shows  a  few  weeks  of  the  temperature 
about  2|  months  after  the  otitis  media. 


FEVER  OF  OBSCURE  CAUSATION 


271 


QCSJ 

CO 


o 


8  g    5   §  *8 


I 


g  a 

r^        ° 


to  ^ 

I  S 


H 


272  COMMON  DISORDERS  OF  CHILDHOOD 

I  have  seen  several  cases  in  which  slight  daily  rise  of  tempera- 
ture for  many  weeks  or  months  was  associated  with  obvious 
naso-pharyngeal  catarrh,  or  had  first  been  detected  when  the 
child  had  a  slight  sore  throat  ;  the  initial  trouble  had  passed  off, 
leaving  the  irregularity  of  temperature,  which  probably  would 
never  have  been  noticed  had  it  not  been  for  the  sore  throat  at 
onset.  In  some  of  these  cases  there  has  been  a  complaint  of 
transient  pain  in  the  ear  at  some  time,  which,  although  it  was  not 
followed  by  any  evidence  of  acute  otitis  media,  strongly  sug- 
gested that  there  was  a  slight  catarrh  in  the  middle-ear,  sufficient 
perhaps  to  explain  the  daily  elevation  of  temperature. 

In  almost  all  these  cases  of  prolonged  fever  the  disquieting 
thought  arises,  Is  there  tubercle  lurking  somewhere  ?  No  doubt 
many  such  a  case  finds  its  explanation  in  the  old  tubercular  focus, 
which  perhaps  is  only  discovered  in  the  post-mortem  room  years 
after  the  obscure  ailment  of  childhood  has  been  completely  for- 
gotten. Careful  and  repeated  examination  of  the  child,  includ- 
ing perhaps  the  use  of  X-rays,  is  the  only  means  of  excluding 
this  possibility,  and  even  so  we  cannot  arrive  at  certainty. 

I  remember  a  boy  who  came  under  my  care  at  the  age  of  about 
(>  years,  a  highly  nervous  boy  with  a  stutter,  whose  temperature 
for  months  showed  a  daily  slight  rise  for  which  no  explanation 
could  be  found  ;  he  was  seen  by  several  medical  men,  and  one 
of  them  seemed  for  the  time  to  have  hit  upon  the  explanation 
of  the  fever  :  he  forbade  milk,  whereupon  for  a  few  days,  but 
only  for  a  few  days,  the  temperature  remained  normal  ;  the 
intestinal  origin  of  the  trouble  seemed  the  more  probable  as  the 
boy  suffered  at  various  times  with  obvious  symptoms  of  indi- 
gestion. I  examined  him  thoroughly  on  many  occasions  without 
detecting  any  other  disease,  except  that  at  one  time  I  discerned, 
I  thought,  vague  signs  of  enlargement  of  mediastinal  glands  ; 
after  a  time  some  glands  became  palpable  in  the  abdomen,  and 
for  many  months  the  enlargement  of  mesenteric  glands  remained 
evident.  With  long  residence  at  the  seaside  the  boy  recovered, 
but  it  seemed  clear  that  in  this  case  there  was  tuberculosis. 

The  type  of  fever  which  commonly  results  from  a  caseous 
gland  in  the  abdomen  is  well  shown  in  the  accompanying  chart 
(Fig.  15,  Chart  V)  from  a  boy  aged  7J  years.  During  an  attack 
of  \\  hooping  cough  at  the  age  of  six  years  it  was  discovered  that 
his  temperature  was  usually  about  99°  in  the  morning  and  100° 
at  night.  At  first  the  whooping  cough  seemed  a  sufficient  expla- 
nation, but  after  the  cessation  of  the  whooping  cough  the  tem- 
perature continued  as  before,  and  a  few  months  later  some  pains 


FEVER  OF  OBSCURE  CAUSATION 


273 


S 


3      I      3      I 


to 

§ 
I 


STILL 


274  COMMON  DISORDERS  OP  CHILDHOOD 

in  the  abdomen  drew  attention  to  a  palpable  gland  about  the 
size  of  a  walnut  just  to  right  of  the  umbilicus  :  it  was  hard,  and 
slightly  tender  on  pressure.  The  slight  elevation  of  temperature 
continued  unaltered  for  more  than  a  year,  during  which  time 
also  the  gland  remained  palpable  and  hard,  although  the  boy 
improved  steadily  in  his  general  condition. 

There  is  another  cause  for  prolonged  slight  fever  which  is 
familiar  to  every  one  who  sees  much  of  acute  rheumatism  in 
children.  The  raised  temperature  is  usually  a  sequel  of  active 
rheumatism  in  heart  or  joints. 

Chart  VI,  taken  from  a  case  of  acute  rheumatism  in  a  girl 
aged  6  years,  illustrates  this  residual  fever  of  rheumatism.  The 
child  was  admitted  to  hospital  on  October  2  with  acute  pain  and 
tenderness  in  the  joints.  Under  salicylates  the  pain  disappeared 
completely  in  about  three  days,  but  a  systolic  bruit  appeared 
at  the  apex  of  the  heart,  and  proved  persistent.  Apart  from  this 
the  child  seemed  perfectly  well,  but  for  several  weeks  the  tem- 
perature showed  the  slight  elevation  which  is  seen  in  the  chart, 
and  this  continued  in  spite  of  free  administration  of  salicylates. 

Treatment.  I  am  not  considering  now  the  treatment  of  cases 
ia  which  there  is  some  organic  disease  underlying  the  fever  ; 
these,  of  course,  require  such  measures  as  are  called  for  by  the 
particular  disease  :  sea  air  and  cod-liver  oil  for  tubercle,  salicylate 
for  rheumatism,  and  so  on  ;  but  in  the  cases  where  no  such 
explanation  is  forthcoming,  and  we  are  driven  to  conclude  that 
the  temperature  is  due  to  functional  disturbance  only,  what 
should  be  done  ?  I  have  seen  a  great  variety  of  methods  of 
treatment  tried,  and  I  must  say,  with  remarkably  little  effect  ; 
antipyretics  usually  have  no  effect  whatever,  or  if  they  lower 
the  temperature  for  a  day  or  two,  it  rises  again  directly  they  are 
discontinued.  I  have  tried,  or  seen  tried,  all  sorts  of  antipyretics  ; 
I  know  of  none  that  is  of  any  permanent  benefit  in  these  cases  ; 
quinine,  given  in  a  dose  of  2  grains  once  a  day  to  a  child  about 
5  or  6  years  old,  has  seemed  to  have  some  effect  in  reducing 
the  temperature.  I  am  much  more  inclined  to  use  such  measures 
as  will  ensure  as  far  as  possible  a  healthy  condition  in  the  intestinal 
tract  :  keeping  the  bowels  working  regularly,  and  especially 
adjusting  the  diet  so  as  to  eliminate  those  foods  which  one  knows 
from  experience  are  most  apt  to  cause  intestinal  irritation  in 
children  (see  Chapter  on  Indigestion). 

I  have  tried  creosote  on  the  principle  of  intestinal  antisepsis, 
but  with  no  definite  success,  and,  as  in  other  conditions,  one  has 
had  to  discontinue  it  before  long  on  account  of  its  interference 


FEVER  OF  OBSCURE  CAUSATION  275 

with  appetite.  In  view  of  the  nervous  excitability  of  these 
children,  small  doses  of  arsenic  may  be  useful  given  with  potas- 
sium citrate,  which  often  seems  to  do  good  where  there  is  mucous 
catarrh  in  the  intestine,  or  with  an  ordinary  stomachic  mixture 
of  bicarbonate  of  soda  with  spirit  of  chloroform.  The  possibility 
that  there  may  be  some  latent  catarrh  in  the  middle-ear,  or  an 
unhealthy  condition  of  the  naso-pharynx  must  specially  be  borne 
in  mind  in  the  treatment  of  these  cases.  I  am  fond  of  a  nasal 
spray  for  such  cases,  half  a  drachm  of  oil  of  eucalyptus  in  an  ounce 
of  paroleine  makes  a  useful  spray ;  or  an  alkaline  lotion  of  Bicar- 
bonate of  Soda  gr.  v,  Sod.  Chloride  gr.  iv,  Borax  gr.  x,  Glycerin 
3j,  Aq.  ad  ^j,  may  be  sniffed  up  the  nostrils  and  spat  out  through 
the  mouth  twice  a  day  ;  half  an  ounce  of  this  to  be  placed  in 
a  little  two-ounce  medicine  tumbler,  which  is  filled  nearly  to  the 
brim  with  warm  water ;  the  child  is  directed  to  try  to  drink  it 
through  his  nose,  and  spit  it  out  through  his  mouth  ;  this  is 
managed  well  by  some  children  about  7  or  8  years  old ;  for 
younger  children  the  spray  is  easier,  and  is  not  dreaded  as  is 
syringing.  Possibly  politzerising  may  be  advisable  when  there 
has  been  complaint  of  pain  in  the  ear. 

A  question  which  has  to  be  faced  is  the  advisability  or  other- 
wise of  keeping  the  child  in  bed.  In  some  cases  the  temperature 
is  certainly  higher  when  the  child  gets  up,  but  I  have  known 
exactly  the  reverse.  In  one  case  it  seemed  clear  that  the  fever 
was  kept  up  by  too  much  recumbency  with  a  liberal  diet,  for  it 
was  reduced  at-  once  and  kept  down  by  allowing  more  exercise 
and  curtailing  the  excessive  feeding.  Probably  the  wisest  plan 
is  to  decide  this  question  by  experiment,  and  not  to  be  guided 
only  by  the  temperature  but  also  by  the  general  condition  of  the 
child  ;  if  getting  up  while  the  temperature  is  raised  leads  to 
complaint  of  feeling  tired,  of  headache,  or  of  general  unfitness, 
no  doubt  it  is  better  to  keep  the  child  in  bed  or  let  the  child  rise 
late  and  go  to  bed  early  ;  but,  as  a  rule,  I  think  these  cases  can 
be  allowed  up  without  harm  ;  and  sometimes  I  have  advised 
disregard  of  the  temperature  altogether  and  taking  the  children 
to  the  seaside  ;  this  may  be  specially  advisable  where  there  is 
reason  to  believe  that  the  irregularity  of  temperature  arises  from 
some  catarrh  in  the  naso-pharynx  or  ear,  a  condition  which  is 
very  apt  to  be  perpetuated  by  a  cold,  ft  ggy  atmosphere  such  as 
that  of  London  in  the  winter. 

High  fever  due  to  latent  otitis  media.  It  is,  I  think,  not 
sufficiently  recognized  that  very  high  fever  may  be  produced  in 
a  child  by  acute  inflammation  of  the  middle-ear  without  any 

T2 


276 


COMMON  DISORDERS  OF  CHILDHOOD 


symptom  beyond  the  temperature  to  suggest  ear  mischief,  and 
particularly  without  pain  ;  a  purulent  discharge  may  be  the  first 
indication  of  the  cause  of  the  fever.  I  have  repeatedly  seen 
this  happen  where  the  suggestion  of  otitis  media  had  been  met 
at  once  with  the  objection,  '  But  there  has  been  no  pain.'  It 
is  worth  remembering  that  the  absence  of  pain  by  no  means 
disproves  the  presence  of  acute  suppurative  otitis  media  ;  in  an 
infant  it  is  often  difficult  to  be  sure  whether  there  is  pain  or 
whether  his  crying  is  due  only  to  the  fretfulness  of  illness,  and 
even  if  the  cry  seems  to  indicate  pain  it  may  still  be  difficult  to 
know  whether  it  is  in  the  ear  or  in  some  other  part ;  but  whether 


18      19     20     21     22    23    24 


FIG.  17.    Chart,  VTf.  Fever  due  to  acute  otitis  media.    Boy  aged  15  months; 
no  pain  or  tenderness ;  fever  unexplained  until  discharge  from  ear. 

we  can  bo  sure  of  pain  or  tenderness  over  the  ear  or  not,  the 
possibility  of  car  mischief  as  a  source  of  fever  is  to  be  borne  in 
mind. 

The  following  case,  from  which  Chart  VII  is  taken,  illustrates 
the  difficulty  of  diagnosis  in  these  cases. 

A  boy,  aged  15  months,  had  been  sick  on  August  28  and 
feverish.  After  a  dose  of  castor  oil  he  improved  but  soon  became 
feverish  again  ;  he  was  under  the  care  of  Dr.  Cyril  Cheatle,  with 
whom  I  saw  the  boy  on  September  13.  There  was  some  enlarge- 
ment of  glands  at  the  angles  of  the  jaw  on  both  sides,  but  with 
no  definite  tenderness  ;  the  tonsils  were  considerably  enlarged, 


FEVER  OF  OBSCURE  CAUSATION  277 

but  there  was  no  sign  of  recent  inflammation.  There  was  no 
tenderness  on  pressure  over  or  behind  the  ears.  The  possibility 
of  otitis  media  was  suggested,  but  no  positive  diagnosis  could  be 
made.  On  September  18  I  heard  that  the  child  had  improved 
considerably  in  general  condition,  being  brighter  and  sleeping 
well,  but  the  fever  remained  a  puzzle.  On  September  19  a  puru- 
lent discharge  appeared  from  the  left  ear  and  the  temperature 
became  normal.  Throughout  the  fever  the  child  appeared  to 
have  had  no  pain  in  spite  of  the  acute  otitis  media. 

In  older  children  who  can  describe  their  own  symptoms,  the 
certainty  of  absence  of  pain  in  the  ear  does  not  exclude  this 
source  of  fever  ;  for  instance,  I  had  in  my  ward  a  very  intelligent 
little  girl  aged  5  years  who  had  been  convalescent  from  pneu- 
monia, and  whose  temperature  had  been  normal  for  several  days, 
then  the  temperature  suddenly  rose  to  103-6°  without  any 
apparent  reason  ;  within  a  few  hours  a  discharge  appeared  from 
the  left  ear,  and  the  temperature  became  normal  the  same  day  ; 
the  child  stated  that  she  had  had  no  pain  whatever. 

One  might  think  that  the  diagnosis  could  be  settled  easily 
enough  by  examining  the  ear  ;  I  have  no  doubt  that  it  could  be 
in  some  cases,  but  I  am  satisfied  that  the  aural  speculum  even  in 
the  hands  of  expert  observers  may  fail  to  discover  the  cause  of 
the  temperature  in  such  cases.  I  have  more  than  once  had  the 
ears  examined  by  an  aural  expert,  who  has  found  no  evidence  of 
otitis  media,  and  within  twenty-four  hours  after  the  examination 
there  has  been  profuse  discharge  from  the  ear.  It  would  seem, 
therefore,  that  the  absence  of  visible  alteration  in  the  membrana 
tympani  does  not  necessarily  exclude  otitis  media  as  a  cause  of 
fever. 

Acute  primary  pyelitis.  In  infants  especially,  but  occasionally 
also  at  any  period  of  childhood,  there  is  another  source  of  high 
fever  which  is  very  apt  to  be  overlooked,  namely,  acute  primary 
pyelitis.  I  shall  not  enter  into  any  detailed  account  of  this  disease 
here,  as  I  shall  describe  it  fully  in  a  later  chapter  (chap.  xl). 

Briefly  stated  the  clinical  picture  is  this  :  a  female  child  acutely 
ill  and  in  considerable  distress,  although  with  no  definite  evidence 
of  localized  tenderness  or  pain  anywhere,  is  found  to  have  a  high 
temperature,  perhaps  105°  or  even  higher,  and  nothing  whatever 
to  explain  the  fever  until  the  urine  is  examined.  The  onset  is 
sudden,  and  often  there  has  been  some  shivering  or  an  attack  of 
blueness  and  collapse  during  the  first  day  or  two  of  the  illness. 

In  the  case  from  which  Chart  VIII is  taken,  a  female  infant,  aged  14  months, 
whom  I  saw  with  Dr.  Owen  Lankester,  the  illness  began  on  September  5; 


278          COMMON  DISORDERS  OF  CHILDHOOD 

the  child  had  been  quite  well  up  to  that  day,  but  whilst  being  dressed  in  the 
morning  '  she  went  blue,  and  seemed  cold  and  faint '  ;  the  temperature  was 
found  to  be  104° ;  but  nothing  was  found  to  explain  it.  During  this  early 
stage  of  the  illness,  the  nurse  noticed  once  or  twice  that  the  child's  *  chin 
worked  as  if  with  shivering '.  The  fever  continued,  but  beyond  some  fullness 
of  the  abdomen,  and  fretfulness  of  the  child,  no  symptoms  were  found  and 
the  condition  remained  a  puzzle  until  the  child,  who  had  been  taken  ill  while 
away  at  the  seaside,  was  brought  home  on  September  21,  and  placed  under 
Dr.  Lankester's  care ;  the  urine  was  then  obtained  and  found  to  be  acid, 
with  sufficient  pus  to  make  it  just  turbid,  it  had  the  peculiar  heavy  odour 
which  is  noticeable  when  the  urine  is  infected  with  Bacillus  coli,  and  a  bacillus 
was  found  in  it  which  appeared  to  be  this  micro-organism.  On  September  24, 
treatment  with  potassium  citrate  was  begun,  the  temperature  became  lower, 
and  after  a  few  irregular  rises,  remained  normal.  Urotropin  seemed  to  improve 
the  condition  of  the  urine  in  this  case,  but  the  potassium  citrate,  for  which 
it  was  substituted  for  some  days,  had  more  effect  in  reducing  the  temperature. 

The  fever  is  continuous  and  lasts  for  many  days  unless  the  cause 
is  recognized  and  properly  treated  ;  recognition  is  only  possible 
if  the  urine  be  carefully  examined,  and  hence  it  is  that  the  fever 
is  so  often  unexplained.  It  is  not  always  easy  to  obtain  the  urine 
of  an  infant  for  examination  at  once,  especially  if  the  infant  be 
a  girl,  as  is  almost  always  the  case  in  this  disease ;  but  a  trained 
nurse,  if  the  importance  of  the  urinary  examination  is  realized, 
will  usually  succeed  in  obtaining  a  specimen.  It  should  be  pointed 
out  that  even  a  few  drops  of  urine  are  sufficient  for  the  examina- 
tion, for  it  is  microscopic  not  macroscopic  examination  which  is 
necessary. 

As  might  be  expected  with  a  very  high  temperature,  nervous 
symptoms  may  be  prominent,  so  that  these  cases  of  acute  pyelitis 
are  often  mistaken  for  cases  of  meningitis.  There  are  many 
infants  who  with  any  considerable  rise  of  temperature  readily 
develop  slight  twitching  of  the  face  and  eyes,  or  limbs,  which  may 
pass  into  general  convulsions  with  loss  of  consciousness,  but  with 
acute  pyelitis  the  nervous  symptoms  are  occasionally  so  severe 
as  to  simulate  gross  cerebral  disease  very  closely.  An  infant, 
Marjory  S.,  aged  Hi  months,  whose  temperature  is  shown  in 
Chart  IX,  had  been  ailing  on  September  14,  when  the  bowels 
were  costive  ;  on  September  16  the  temperature  was  found  to  be 
raised  and  fever  continued  as  shown  in  the  adjoining  chart.  On 
September  17  and  18  the  child  was  drowsy  and  twitching  slightly ; 
vomiting  occurred  once  on  September  17,  but  it  was  only  after  a 
calomel  powder.  I  saw  the  child  in  consultation  on  September  20 ; 
the  child  had  fallen  into  a  semi-comatose  condition  that  day, 
she  took  no  notice  of  my  hand  passing  close  to  her  eyes  ;  there 
was  thought  to  be  a  very  slight  internal  squint  of  the  left  eye, 


FEVER  OF  OBSCURE  CAUSATION 


279 


S    M 

I! 


1! 

'345 


*  S 
^^ 

-2  .a 


)0 
ll 


II 


280 


COMMON  DISORDERS  OF  CHILDHOOD 


the  neck  was  slightly  stiff,  and  there  was  a  question  whether  the 
left  leg  was  moved  quite  as  well  as  the  right ;  whilst  being 
observed  the  child  gave  a  short  cry  and  threw  its  body  into 
a  position  of  opisthotonos.  The  child  was  evidently  extremely 
ill,  and  the  advisability  of  lumbar  puncture  was  discussed  as 
a  diagnosis  of  tuberculous  meningitis  had  been  suggested.  But 
there  was  much  against  this  view  :  the  onset  had  been  too 
sudden,  the  temperature  was  too  high,  and  the  child's  stuporous 
semi-convulsive  condition  made  it  difficult  to  be  sure  whether 


Fia.  19.  Chart  IX.  Acute  primary  pyelitis  in  infancy,  showing  prolonged 
high  temperature  which  was  associated  with  nervous  symptoms  clue  to  pyelitis 
in  a  femak  infant  aged  11£  months. 

the  nervous  symptoms,  which  were  all  ill-marked,  really  indicated 
any  gross  lesion  of  the  nervous  system  :  the  possibility  of  acute 
pyelitis  was  therefore  suggested,  and  it  was  decided  not  to  do 
lumbar  puncture,  but  to  get  the  urine  as  soon  as  possible.  The 
next  day  I  heard  that  there  was  some  vomiting,  respiration  was 
irregular,  there  was  conjugate  deviation  of  the  eyes  to  the  left, 
the  left  arm  and  leg  showed  some  rigidity,  and  the  doctor  added, 
'  Can't  get  urine,'  and  the  following  day  there  was  thought  to 
be  slight  ptosis  of  the  left  eye  and  a  transient  weakness  of  the 
right  side  of  the  face.  On  September  24  the  urine  was  at  length 
obtained,  and  was  found  to  contain  about  twelve  pus  corpuscles 
per  field  under  a  high  power.  The  child  was  treated  with  potas- 


FEVER  OF  OBSCURE  CAUSATION  281 

slum  citrate,  the  temperature  speedily  fell  to  normal,  and  the 
child  made  a  good  recovery. 

The  importance  of  recognizing  acute  pyelitis  will  be  appreciated 
by  those  who  have  seen  the  effect  of  treatment.  It  is  a  con- 
dition which,  when  undiagnosed,  drags  on  for  days  and  weeks  with 
high  fever  and  severe  constitutional  disturbance.  It  is  a  grave 
danger  to  the  child,  for  life  may  be  sacrificed  through  failure  of 
adoption  of  the  proper  treatment,  whereas  a  timely  recognition 
of  the  disease  and  a  skilful  administration  of  the  requisite  drugs 
is  followed  by  speedy  subsidence  of  the  fever  and  by  complete 
recovery.  There  is  hardly  anything  more  striking  in  the  field  of 
therapeutics  than  the  effect  of  proper  treatment  upon  acute 
pyelitis  in  infancy.  This  will  be  described  in  detail  in 
chapter  XL. 

Dentition,  gastro-intestinal  disturbance,  constipation,  as 
causes  of  fever.  I  have  already  expressed  my  opinion  that  the 
worry  of  dentition  is  sometimes  the  sole  cause  of  fever  in  infants  : 
I  know  only  too  well  that  this  is  dangerous  doctrine,  for  it  is 
liable  to  be  abused  ;  but  none  the  less  it  is,  I  think,  a  fact,  as 
well  proved  by  experience  as  most  scientific  observations  in 
clinical  medicine,  that  in  some  infants  the  temperature  will  rise 
to  102°  or  103°  when  a  tooth  is  nearing  eruption,  and  will  fall 
to  normal  within  a  few  hours  after  the  tooth  is  cut,  and  this 
without  any  other  ascertainable  cause  for  the  fever.  Lancing 
the  gums  is  out  of  fashion  nowadays,  and  probably  deservedly 
so,  for  no  doubt  far  more  mischief  and  pain  was  produced  by 
indiscriminate  gum-lancing  than  was  caused  by  the  dentition 
which  it  was  supposed  to  assist,  but  although  I  have  never 
personally  had  the  courage  of  my  conviction  to  proceed  to 
gum-lancing,  I  strongly  suspect  that  there  are  cases  in  which 
the  fever  could  be  stopped  speedily  by  a  judicious  lancing  of 
the  gum  when  the  tooth  is  at  the  point  of  eruption,  and  unless 
most  of  the  writers  of  half  a  century  ago  were  extremely  bad 
observers,  their  experience  proves  that  this  is  so. 

Since  these  remarks  were  written,  Dr.  Lovett  Morse,1  of  Boston, 
has  recorded  two  cases  which  illustrate  well  the  production  of 
fever  by  teething  and  the  relief  of  symptoms  by  gum-lancing. 
The  first  I  quote  in  Dr.  Morse's  own  words  : 

A  boy,  17  months  old,  began  to  be  fussy  and  a  little  feverish  the  night  of 
April  14.  The  next  evening  the  temperature  was  103°  F.,  the  next  day  100°  F. 
in  the  morning,  and  104-8°  F.  in  the  evening.  On  the  morning  of  the  17th 
the  temperature  was  100-8^  F.,  the  pulse  140,  and  the  respiration  28.  There 

1  Boston  Med.  and  Surg.  Journ.,  July  9,  1908. 


282  COMMON  DISORDERS  OF  CHILDHOOD 

had  been  no  symptoms  beyond  the  fever  except  restlessness  and  sleeplessness. 
Careful  physical  examination,  including  the  ears,  showed  nothing  abnormal 
beyond  marked  swelling  of  the  gums  over  the  first  four  molars.  The  gums 
were  lanced  over  all.  The  temperature  dropped  to  normal  during  the  day 
and  did  not  rise  again.  No  other  treatment  was  given. 

The  other  was  a  girl  of  3  years,  who  had  always  had  some 
disturbance  with  dentition.  Whilst  cutting  one  of  her  second 
molars  she  had  a  temperature  of  100°  to  102-5°  F.  for  twelve 
days  with  no  other  symptom  except  occasional  vomiting.  Beyond 
the  swollen  gam  over  the  tooth  nothing  was  found,  the  Widal 
test  was  negative,  the  urine  normal,  there  were  no  physical  signs. 
Gum-lancing  produced  a  temporary  fall  of  the  temperature,  and 
was  done  several  times  ;  finally  a  large  piece  of  the  gum  over 
the  tooth  was  removed  and  the  tooth  came  through,  the  tempera- 
ture immediately  fell  to  normal  and  remained  so.  With  each  of 
the  other  second  molars  and  in  less  degree  with  the  six-year-old 
molars  there  were  similar  symptoms. 

In  the  absence  of  serious  symptoms,  such  as  convulsions,  it 
has  not  seemed  to  me  necessary  to  resort  to  gum-lancing,  inasmuch 
as  the  fever  does  little  or  no  harm  in  itself,  being  of  quite  short 
duration  ;  moreover,  it  may  be  amenable,  as  other  dentition 
symptoms  often  are,  to  treatment  with  small  doses  of  phenazone, 
to  which  may  be  added  usefully  an  aperient  dose,  a  drachm  or 
more,  of  fluid  magnesia  or  a  grain  of  grey  powder. 

The  presence  of  undigested  food  in  the  intestine  is  enough  to 
raise  the  temperature  considerably  in  some  infants  and  also  in 
some  older  children  :  so  also  is  a  bout  of  constipation  in  the  child 
who  is  not  habituated  to  it.  It  is  in  such  cases  that  a  dose  of 
castor  oil  -J-l  drachm  for  an  infant  and  2-4  drachms  for  an  older 
child,  produces  rapid  improvement  ;  calomel  also  is  good  in 
these  cases,  i-1  grain  at  night  according  to  the  age  of  the  child. 

In  illustration  of  the  production  of  high  fever  by  an  irritant 
in  the  intestine  I  may  mention  here  a  curious  case  which  was 
under  my  care  in  the  Children's  Hospital,  Great  Ormond  Street. 
The  temperature  is  shown  in  Chart  X.  Rose  O.,  aged  3|-,  was 
brought  with  a  history  that  for  three  weeks  she  had  waked  every 
night  screaming  for  about  four  hours,  and  put  her  hands  to 
her  head  as  if  in  pain.  She  was  kept  in  hospital  thirty-eight 
days  and,  as  the  chart  shows,  there  was  a  considerable  rise  of 
temperature  nearly  every  night  ;  the  child  screamed  for  one  to 
three  hours  while  the  temperature  was  raised,  and  usually 
vomited  when  the  temperature  was  at  its  highest.  The  child 
during  the  daytime  was  rather  pale  and  quiet,  otherwise  nothing 


FEVER  OF  OBSCURE  CAUSATION 


283 


284  COMMON  DISORDERS  OF  CHILDHOOD 

abnormal  could  be  found  except  that  on  several  occasions  there 
was  acetone  in  the  urine  ;  the  child  sat  up  and  took  some  interest 
in  her  surroundings.  She  was  seen  by  several  of  my  colleagues 
and  others,  and  various  diagnoses  were  proposed,  mostly  leaning 
to  gross  cerebral  disease  of  some  sort.  Various  lines  of  treatment 
were  tried  without  apparently  the  least  effect  on  the  temperature, 
the  vomiting  became  worse  and  the  child  began  to  look  more  ill. 
On  the  thirty-fifth  day  of  her  stay  in  hospital  the  child's  tem- 
perature became  normal  and  steady,  the  next  day  the  vomiting 
ceased,  and  two  days  later  the  child  passed  a  dead  roundworm 
and  remained  perfectly  well. 

Inflammatory  conditions  in  the  throat.  It  is  a  good  rule 
that  in  every  case  of  unexplained  fever  in  childhood  the  throat 
should  be  examined.  In  infancy  and  early  childhood  there  may  be 
nothing  whatever  to  direct  attention  to  the  throat,  which  may 
nevertheless  show  an  acute  follicular  tonsillitis,  or  patches  of 
diphtheria,  accounting  for  an  acute  onset  of  fever. 

I  have  already  mentioned  the  probable  relation  of  naso- 
pharyngeal  catarrh  to  the  prolonged  slight  fever  which  is  often 
seen  in  nervous  children,  and  I  strongly  suspect  that  recrudes- 
cence of  pharyngeal  catarrh  with  or  without  adenoids  is  respon- 
sible for  some  attacks  of  'recurrent  fever'  in  children  (vide  p.  265). 
I  have  seen  several  cases  which  seemed  to  support  this  view. 

Blood  Diseases.  In  any  case  of  prolonged  fever  without 
apparent  cause,  the  possibility  of  some  blood  disease  must  be 
borne  in  mind.  In  the  early  stage  of  some  of  the  most  severe 
blood  diseases — for  instance,  acute  lymphatic  leukaemia — there 
may  be  no  noticeable  degree  of  anaemia,  and  beyond  some  malaise 
and  the  seemingly  inexplicable  fever  there  may  be  nothing  to 
be  found  until  the  blood  is  examined.  Such  a  case  as  the  follow- 
ing is  likely  to  cause  difficulty  in  diagnosis,  and,  as  actually 
happened,  the  difficulty  may  remain  unsolved  for  weeks  : 

Gerald  Z.,  aged  10  years,  five  months  ago  had  a  septic  adenitis  in  the  left 
axilla.  This  subsided,  and  the  boy  apparently  recovered  completely  within 
a  fortnight,  and  remained  well  until  two  months  ago,  when  urticarial  rash 
occurred,  with  constipation  and  a  temperature  of  103°.  The  rash  passed  off, 
but  the  temperature  continued.  A  consultant  was  called  in,  and  the  con- 
dition was  thought  to  be  '  food  fever  '.  In  spite  of  dieting  the  high  tempera- 
ture continued.  Another  consultant  saw  the  child,  and  whilst  not  approving 
the  dietetic  theory  was  unable  to  find  any  cause  for  the  temperature.  With 
continued  high  fever  the  gums  now  became  swollen  and  ulcerated,  and  a  third 
consultant  suspected  some  scorbutic  affection,  and  fruit  juices  were  given. 
The  fever,  however,  persisted,  being  often  103°,  and  only  falling  to  100°  in 
the  mornings,  and  by  this  time,  after  eight  weeks'  illness,  the  child  was  becom- 
ing wasted  and  markedly  anaemic ;  moreover,  slight  enlargement  of  superficial 


FEVER  OF  OBSCURE  CAUSATION 


285 


glands  in  several  parts  of  the  body  suggested  the  advisability  of  a  blood  count. 
The  red  cells  were  found  to  be  3,312,500  per  cub.  mm.,  and  the  white,  103,300 
per  cub.  mm.  ;  the  differential  count  showed  polymorphonuclears  2-8  per  cent., 
lymphocytes  92-6  per  cent.  The  case  was  in  fact  one  of  acute  lymphatic 
leukaemia. 

\ 
MAY  


FIG.  21.    Chart  XI.  From  a  case  of  acute  leukanaemia  in  a  child  aged  5  years. 


The  temperature  (Chart  XI)  in  the  case  of  a  child  aged  5  years 
and  10  months  would  have  been  hardly  less  puzzling  than  in  the 
case  just  described  had  it  not  been  for  the  prompt  examination 
of  the  blood  made  by  the  doctor  in  charge,  who  found  a  con- 
dition corresponding  with  that  which  has  been  described  as 
acute  leukanaemia. 


CHAPTER  XX 
INTESTINAL  WORMS 

THE  presence  of  threadworms  in  the  intestine  is  a  common 
trouble  in  childhood,  and  often  very  difficult  to  cure.  In  200 
necropsies,  as  far  as  possible  consecutive,  on  children  under  the 
age  of  twelve  years  at  the  Children's  Hospital,  Great  Ormond 
Street,  the  intestine  was  carefully  examined  for  the  presence  of 
threadworms,  and  these  were  found  to  be  present  in  thirty-eight 
cases,  that  is,  in  19  per  cent.  When  only  children  over  the  age 
of  two  years  were  included,  the  percentage  was  much  higher  ; 
in  a  series  of  100  necropsies  on  children  between  the  ages  of  two 
and  twelve  years,  threadworms  were  found  in  thirty-two  cases, 
that  is,  in  32  per  cent. 

The  point,  however,  on  which  I  wish  to  lay  special  stress  is  not 
the  frequency  of  threadworms,  which  is  familiar  enough,  but 
their  situation.  It  is  often  stated  that  the  threadworm  inhabits 
chiefly  the  rectum  and  lower  part  of  the  colon  and  occasionally 
the  csecum,  but  the  fact  that  the  vermiform  appendix  is  a  favourite 
habitat  of  the  threadworm  has  received  but  little  attention. 

In  no  fewer  than  twenty-five  out  of  the  thirty-eight  cases  in 
which  the  oxyuris  vermicularis  was  present  the  worm  was  found 
in  the  appendix  vermiformis  ;  in  other  words,  the  threadworm 
was  found  in  the  appendix  in  two-thirds  of  the  cases. 

Moreover,  the  appendix  is  in  some  cases  the  only  part  in  which 
the  threadworm  is  found  ;  in  six  of  the  thirty-eight  cases  men- 
tioned no  threadworms  were  found  either  in  the  csecum  or 
elsewhere  in  the  large  intestine,  but  in  each  of  these  six  cases 
threadworms  were  found  in  the  appendix,  and  sometimes  at  its 
extreme  tip. 

The  number  of  threadworms  in  the  appendix  is  sometimes 
very  large,  thus  in  one  case  described  below,  111  were  present 
here  ;  and  it  is  noteworthy  that  these  large  numbers  may  be 
found  in  the  appendix,  when  only  very  few  or  none  are  present 
in  the  large  intestine. 

A  further  point  which  may  be  of  significance,  is  the  immature 
character  of  the  worms  found  in  the  vermiform  appendix.  In 
some  cases  only  one  or  two  of  the  worms  found  here  were 


INTESTINAL  WORMS  287 

full  grown,  the  rest  were  extremely  minute,  measuring  1-5  to 
3  mm.  in  length,  and  requiring  the  use  of  a  lens  for  accurate 
counting.  These  minute  worms  had  already  acquired  the 
characteristic  differences  of  sex,  from  which  it  could  be  deter- 
mined that  many,  probably  the  majority,  were  immature  females, 
though  some  certainly  were  males.  It  has  been  stated  by 
Blanchard  l  that  the  embryo  when  first  hatched  measures  in  the 
case  of  the  female  1-7  to  1-97  mm.,  and  in  the  male  1-1  to 
1-8  mm.,  whereas  the  full-grown  female  measures  9  to  12  mm., 
and  the  male  3  to  5  mm.,  in  length.  Many  therefore  of  the 
minute  threadworms  found  in  the  vermiform  appendix  must 
have  been  hatched  quite  recently. 

This  observation  seems  to  throw  considerable  doubt  upon  the 
view  held  by  Leuckart  and  others,  and  now  current  in  the  text- 
books, that  the  oxyuris  vermicularis  never  multiplies  in  the 
intestine  ;  it  is  absolutely  necessary,  they  say,  that  the  ova 
should  be  passed  and  reintroduced  into  the  mouth,  and  so  into 
the  stomach,  in  order  that  they  may  be  hatched  ;  in  other 
words,  every  single  threadworm  passed  from  the  bowel  has 
been  introduced  as  an  ovum  from  without  into  the  alimentary 
tract. 

Were  such  a  view  correct,  it  would  be  difficult  to  understand 
why  threadworms  are  so  rarely  found  in  the  small  intestine. 
The  embryo  is  said  to  go  through  the  earliest  stages  of  growth 
here  after  being  hatched  in  the  stomach,  and  by  the  time  it 
comes  to  the  large  intestine  it  has  reached,  or  almost  reached, 
'maturity.  If  this  be  so,  then  considering  the  enormous  number 
*  of  threadworms  which  are  passed  by  some  children  for  months 
or  even  years,  and  how  variable  must  be  the  rate  of  passage  of 
each  of  these  worms  through  the  small  intestine,  one  would 
surely  expect  that  the  young  threadworms  would  frequently  be 
found  at  necropsies  still  in  the  small  intestine,  whereas,  as 
a  matter  of  fact,  this  very  rarely  happens.  I  have  found  young 
threadworms  once  as  high  as  45  inches  above  the  ileo-csecal 
valve,  and  two  or  three  times  I  have  seen  mature  worms 
either  just  above  the  valve  or  in  the  last  few  inches  of  the 
ileum,  but  such  a  finding  has  been  very  exceptional  in  my 
experience. 

Further,  this  hypothesis  does  not  explain  the  immaturity  in 

some  cases  of  almost  all  the  threadworms  found  in  the  appendix, 

for  even  supposing  that  owing  to  the  variability  of  rate  of  transit 

through  the  small  intestine  the  degree  of  maturity  varies  in  those 

1  Zoologie  Medicate,  Paris,  1889,  i,  p.  713. 


288          COMMON  DISORDERS  OF  CHILDHOOD 

that  have  reached  the  large  intestine,  it  is  nevertheless  hardly 
conceivable  that  a  large  number  of  very  immature  threadworms, 
hardly  larger  than  those  just  hatched,  should  happen  to  con- 
gregate in  the  vermiform  appendix,  whilst  the  great  majority  of 
those  in  the  caecum  are  almost  or  quite  full  grown. 

The  presence,  therefore,  of  numerous  very  young  thread- 
worms in  the  vermiform  appendix,  associated  with  only  a  few 
full-grown  ones,  seems  to  show  that  at  least  in  some  cases  the 
vermiform  appendix  serves  as  a  breeding-place  for  the  oxyuris 
vermicularis.  It  might  be  added  that  although  there  is  experi- 
mental evidence  to  prove  that  the  swallowing  of  the  ova  is 
followed  after  a  few  weeks  by  the  appearance  of  threadworms 
in  the  faeces,  the  proof  that  every  threadworm  that  is  passed 
from  the  bowel  has  been  introduced  in  this  way  is  yet  to  seek. 
According  to  the  accepted  view  we  are  asked  to  believe  that 
a  child  who  for  months,  and  sometimes  years,  passes  scores  of 
threadworms  daily  in  its  stools,  has  introduced  into  its  mouth 
as  an  ovum  every  single  one  of  these  worms.  To  support  this 
theory  it  is  necessary  to  suppose  either  that  the  ova  are  so  widely 
distributed  from  the  faeces  that  they  are  re-introduced  in  various 
articles  of  food,  or  else  that  they  are  introduced  by  the  fingers 
directly  from  the  anus.  Both  these  sources  are  supposed  to 
contribute  to  the  supply. 

But  if  the  ova  were  distributed  in  such  enormous  numbers 
that  one  child  could  swallow  hundreds  or  possibly  thousands  of 
them  in  articles  of  food  it  would  be  difficult  to  see  how  any 
person  in  an  infected  house  could  possibly  escape  being  infected 
also.  It  happens  indeed  not  very  rarely  that  more  than  one 
child  in  a  family  is  suffering  from  threadworms  ;  but  this  does 
not  happen  with  sufficient  constancy  to  justify  the  assumption 
thcat  such  a  source  is  the  usual  or  even  a  common  one. 

If  again  the  fingers  be  the  source,  then  considering  the  number 
and  persistency  of  threadworms  in  the  faeces  one  can  only  suppose 
that  the  number  of  ova  on  the  fingers  must  also  be  very  large 
and  easily  demonstrable.  With  the  object  of  investigating  this 
point  I  selected  five  children  who  were  passing  large  numbers 
of  threadworms  and  gave  orders  to  the  mother  that  the  hands 
were  to  be  left  unwashed  after  the  night's  rest.  The  dirt  on  the 
finger  ends  and  under  the  nails  of  all  the  fingers  was  then  scraped 
off  and  examined  microscopically,  in  three  of  the  cases  on  two 
occasions,  in  two  of  them  once. 

The  result  of  the  examination  was  that  one  solitary  ovum 
was  found  in  the  dirt  under  the  nail  of  one  child  out  of  the  five. 


INTESTINAL  WORMS  289 

Further  investigation  would  of  course  be  necessary  before  one 
could  make  any  definite  statement  on  this  point,  but  this  observa- 
tion so  far  as  it  goes  seems  to  show  that  the  dirt  on  the  fingers 
is  extremely  unlikely  to  supply  ova  in  sufficient  numbers  and 
with  sufficient  constancy  to  keep  up  the  continual  discharge  of 
enormous  numbers  of  threadworms  from  the  bowel.  In  the 
one  ovum  found  under  the  nail  a  fully-formed  embryo  in  the 
tadpole  stage  was  present,  and  one  cannot  doubt  that  if  this  had 
been  swallowed — and  it  is  to  be  remembered  that  even  when 
the  ova  do  happen  to  be  present  on  the  fingers  it  is  by  no  means 
a  certainty  that  they  will  be  swallowed — the  embryo  would  in 
due  time  have  become  a  mature  threadworm  in  the  intestine. 

That  a  certain  number,  possibly  even  a  large  number,  of 
threadworms  are  introduced  as  ova  into  the  mouth  from  one 
or  other  of  the  sources  mentioned  is  not  improbable,  but  the 
observations  which  are  here  recorded  suggest,  I  think,  that  the 
oxyuris  vermicularis  also  multiplies  in  the  intestine  and  that  the 
appendix  vermiformis  is  in  some  cases  its  breeding-ground. 

On  this  view,  the  extreme  obstinacy  of  those  cases  in  which, 
in  spite  of  all  treatment,  threadworms  are  discharged  in  the 
faeces  for  months  or  years  becomes  at  once  intelligible.  The 
difficulty  of  dislodging  threadworms  from  the  tip  of  the  appendix, 
where  they  are  not  uncommonly  found,  is  sufficiently  obvious, 
and  one  can  well  imagine  that  a  few  female  worms  maturing 
here  would  keep  up  a  continual  supply  of  young  threadworms, 
many  of  which  would  gradually  find  their  way  out  into  the 
caecum  and  so  pass  down  with  the  faeces. 

So  many  of  the  ailments  of  childhood  have  been  attributed  to 
'  worms  ',  some  with  good  reason  and  some  with  none,  that  one 
hesitates  to  add  another  to  the  list.  I  wish,  however,  to  draw 
attention  to  a  condition  which  might  almost  have  been  foretold 
in  the  light  of  the  previous  observations  on  the  presence  of  large 
numbers  of  threadworms  in  the  vermiform  appendix. 

A  boy,  aged  nine,  was  admitted  into  the  Hospital  for  Sick  Children  under  the 
care  of  Dr.  Lees  for  acute  rheumatism  and  pericarditis.  Four  weeks  before 
death  he  complained  of  pain  in  the  right  iliac  fossa.  Pericarditis  and  probably 
pleurisy  being  present,  the  boy  was  questioned  carefully  as  to  the  situation 
of  the  pain  in  view  of  the  possibility  of  the  pain  being  from  diaphragmatic 
pleurisy,  and  being  described,  as  so  often  happens  with  children,  with  no 
strict  accuracy.  The  boy,  however,  who  was  very  intelligent,  persisted  in 
localizing  the  pain  definitely  in  the  right  iliac  fossa.  This  part  was,  therefore, 
particularly  examined,  but  no  abnormal  resistance  and  no  tenderness  could 
be  detected.  The  pain  passed  off  without  further  evidence  of  appendicitis. 

Post  mortem  acute  pericarditis  and  pleurisy  were  present.     The  whole  of 

STILL 


290  COMMON  DISORDERS  OF  CHILDHOOD 

the  colon  was  minutely  examined  with  the  naked  eye,  and  the  mucus  in  the 
caecum  scraped  off  with  a  knife  and  examined  microscopically,  but  only  in  the 
latter  situation  were  two  threadworms  present.  The  vermiform  appendix 
appeared  thicker  than  normal,  as  if  swollen,  and  this  was  due  to  actual 
thickening  of  its  wall,  not  to  distension  of  its  lumen.  The  mucus  here  also 
was  examined  microscopically.  In  the  proximal  inch  not  a  single  threadworm 
was  found,  but  in  the  remaining  2|  inches  at  the  distal  end  no  fewer  than 
111  threadworms  were  counted,  nearly  all  of  which  were  very  small  onee, 
many  of  them  measuring  scarcely  one-sixteenth  of  an  inch  (about  1-5  mm.), 
while  some  of  the  mature  worms  present  contained  large  numbers  of  ova. 

This  case  may,  I  think,  be  taken  as  evidence  that  pain  in  the 
right  iliac  fossa  may  be  associated  with  a  catarrhal  condition  of 
the  appendix  as  a  result  of  threadworms. 

The  discovery  of  this  association  seemed  to  throw  some  light 
on  another  case  which  was  of  very  uncertain  nature. 

A  boy,  aged  nearly  six  years,  was  admitted  to  the  Hospital  for  Sick  Children, 
under  the  care  of  Dr.  Lees,  for  abdominal  pain  and  vomiting.  The  pains  in 
the  abdomen  had  been  present  several  months  ;  the  vomiting  had  only  been 
present  four  days.  The  bowels  were  regular.  The  child  did  not  look  par- 
ticularly ill.  He  complained  of  some  pain  in  the  right  iliac  fossa  ;  the  abdomen 
was  quite  lax.  In  the  right  iliac  fossa  there  was  some  vague  thickening,  the 
nature  of  which  was  uncertain;  it  was  thought  to  be  due  either  to  inflammatory 
adhesions  or  to  enlarged  glands,  but  the  child  allowed  free  palpation  here, 
and  the  presence  of  any  tenderness  was  doubtful  ;  the  hip  was  extended 
freely  ;  the  temperature  was  100-2°.  I  thought  at  the  time  that  the  case 
was  one  of  appendicitis,  but  was  puzzled  by  the  extreme  mildness  of  the 
symptoms.  These  disappeared  in  a  few  days,  and  the  boy  was  discharged 
apparently  well.  Unfortunately,  no  inquiry  was  made  at  that  time  as  to  the 
presence  of  threadworms  in  the  stools.  Within  the  next  few  months  the  boy 
was  found  to  be  passing  large  numbers  of  threadworms  continually,  and  one 
or  two  roundworms  also,  and  on  inquiry  there  was  reason  to  believe  that  he 
had  been  suffering  from  worms  before  his  stay  in  the  hospital.  Frequent 
vomiting,  night  terrors,  and  fits  occurred,  and  the  relation  of  these  symptoms 
to  the  passage  of  threadworms  was  very  striking.  The  mother,  an  intelligent 
observer,  herself  noticed  that  each  time  the  threadworms  diminished  as  the 
result  of  treatment  the  symptoms  diminished,  and  the  boy  was  better  in  every 
way,  only  to  relapse  again  as  the  threadworms  reappeared.  The  threadworms 
persisted  in  spite  of  all  treatment  for  two  years. 

It  seems  probable  that  in  this  case,  as  in  the  preceding,  the 
symptoms  may  have  been  due  to  the  presence  of  threadworms 
in  the  appendix,  which  would  also  account  for  the  obstinacy 
of  the  case  if  the  view  I  have  suggested  be  correct.  That  pain 
in  the  right  iliac  fossa  was  due  to  threadworms  in  the  appendix 
has  seemed  possible  in  other  cases,  but  it  can  only  rarely  happen 
that  actual  evidence  can  be  obtained  as  in  the  first  case  mentioned. 
There  was,  however,  ample  evidence  in  the  series  of  200  cases 
examined  post  mortem  that  the  presence  of  threadworms  may 


INTESTINAL  WORMS  291 

cause  swelling  and  thickening  of  the  vermiform  appendix, 
especially  when  the  worms  are  present  there  in  large  numbers. 
Such  a  condition  was  found  several  times,  and,  indeed,  it  was 
sometimes  possible  to  predict  the  presence  of  threadworms  in 
the  appendix  from  its  swollen  appearance  before  opening  it. 
The  following  cases  may  serve  as  typical  instances. 

W.  M.,  aged  2£  years  ;  empyema,  suppurative  pericarditis,  and  commencing 
peritonitis.  The  vermiform  appendix  had  a  markedly  swollen  and  thickened 
appearance  ;  the  rest  of  the  intestine  appeared  quite  normal.  The  appendix 
was  found  to  contain  twenty-nine  threadworms,  nearly  all  of  these  being  in 
the  distal  inch  ;  of  this  number  only  five  were  full-grown  females  containing 
ova ;  the  rest  were  very  minute,  measuring  from  about  3  mm.  upwards  ;  many 
of  them  were  females,  but  some  were  males.  Only  four  threadworms,  all 
full  grown,  were  found  in  the  large  intestine;  no  young  ones  were  seen  with 
the  naked  eye,  nor  in  portion  of  the  mucus  examined  with  the  microscope. 
One  full-grown  female  was  found  4  inches  above  the  ileo-caecal  valve. 

J.  L.,  aged  3|  years  ;  tuberculous  meningitis.  The  vermiform  appendix 
had  the  typical  swollen  appearance  suggesting  at  once  the  presence  of  thread- 
worms ;  it  was,  therefore,  examined  carefully.  In  the  distal  \  inch,  close  to 
the  tip,  twenty-six  were  found  ;  in  the  rest  of  the  appendix  thirty-three,  or 
forty-three  including  ten  at  the  mouth  of  the  appendix — that  is,  sixty-nine  in 
all.  Most  of  those  in  the  appendix  were  very  young  females.  The  mucus  of 
the  lower  part  of  the  ileum  near  the  ileo-caecal  valve  was  examined  micro- 
scopically, but  showed  no  ova  and  no  embryos.  There  were  numerous  thread- 
worms in  the  colon  and  rectum. 

A.  A.,  aged  4  years  ;  spinal  caries,  tuberculosis.  The  vermiform  appendix 
was  much  swollen — '  nearly  as  thick  as  one's  little  finger'.  The  appearance 
suggested  the  presence  of  threadworms.  The  mucus  from  the  appendix  was 
examined  with  a  low  power  of  the  microscope,  and  showed  forty-three 
threadworms,  chiefly  very  minute  young  females.  There  were  many  thread- 
worms in  the  caecum,  but  only  a  few  in  the  rest  of  the  colon. 

The  colicky  pains  which  are  associated  with  the  presence  of 
threadworms  are  not  limited  to  the  csecal  region,  often  they  are 
vaguely  referred  to  the  lower  part  of  the  abdomen  or  the  um- 
bilical region.  The  occurrence  of  colic  is  not  surprising,  for 
where  there  are  threadworms  there  is  usually  more  or  less  mucous 
catarrh  of  the  intestine  ;  in  some  cases  I  have  found  the  colon 
coated  with  a  thick  layer  of  jelly-like  mucus  ;  no  doubt  the 
intestine  in  its  efforts  to  pass  onward  this  tenacious  material  is 
excited  to  the  excessive  peristaltic  movements  wrhich  are  felt 
as  colic. 

There  is  another  result  of  this  mucous  flux  in  children  with 
threadworms,  namely,  wasting.  Many  a  child  who  is  suffering 
only  with  these  worms  is  brought  to  the  medical  man  for  wasting 
which  perhaps  is  sufficient  to  arouse  fears  of  some  tuberculous 
disease.  If  the  function  of  the  large  intestine,  especially  at  its 

u2 


292          COMMON  DISORDERS  OF  CHILDHOOD 

lower  part,  is  largely  absorptive  as  physiologists  tell  us,  it  is 
natural  enough  that  a  thick  layer  of  viscid  mucus  over  the 
surface  of  the  mucous  membrane  should  interfere  with  nutrition 
by  diminishing  absorption. 

Next  to  the  wasting  and  colicky  pains  which  are  the  most 
frequent  symptoms  of  threadworms,  nervousness  is  probably 
the  commonest  result  of  their  presence.  There  is  nothing 
specially  characteristic  in  the  nervous  symptoms  due  to  thread- 
worms, they  are  just  those  which  a  child  who  is  specially  nervous 
from  any  cause  may  show,  but  the  degree  of  nervous  instability 
is  often  very  striking.  The  child  becomes  unnaturally  timid, 
sleeps  badly,  grinds  his  teeth,  has  night  terrors  and  wakes 
with  a  headache  in  the  morning  or  with  nausea.  I  have  seen 
fidgety,  almost  choreiform  movements,  which  subsided  almost 
completely  when  the  worms  were  expelled;  I  have  also  seen 
habit-spasm  arise  in  association  with  threadworms. 

The  occurrence  of  squint  as  the  result  of  threadworms  is, 
I  think,  a  fact.  I  was  consulted  about  a  girl  of  3J  years,  whom 
I  had  seen  several  times  previously  and  knew  to  have  been 
free  from  squint.  She  had  now  become  extraordinarily  excitable, 
and  within  five  weeks  had  developed  a  very  marked  convergent 
squint,  sometimes  in  one  eye,  sometimes  in  the  other.  No 
explanation  of  the  symptoms  was  forthcoming  until,  a  few  days 
after  I  saw  her.  threadworms  began  to  appear  in  the  stools. 

I  have  mentioned  above  a  case  in  which  fits  occurred  and 
were  markedly  influenced  by  treatment  of  the  threadworms  ; 
I  have  seen  other  cases  in  which  convulsions  seemed  to  be  due 
to  threadworms. 

Enuresis  is  certainly  related  to  the  presence  of  these  worms  in 
some  cases,  possibly  owing  to  direct  irritation  when  they  reach 
the  rectum  as  they  sometimes  do,  especially  at  night,  but  pro- 
bably far  more  often  through  the  general  increase  of-  nervous 
instability  which  worms  somehow  produce  and  which  would 
specially  favour  the  occurrence  of  enuresis. 

There  is  a  popular  idea  that  nose-picking  is  specially  indicative 
of  worms,  but  I  know  of  no  evidence  that  this  is  so  :  the  nervous 
child  is  undoubtedly  more  prone  to  fall  into  abnormal  habits 
or  '  tricks  '  than  other  children,  and  in  this  way  the  child  with 
worms  may  be  rather  more  likely  to  form  such  a  habit  than 
another  child  ;  but  certainly  nose-picking  is  of  no  value  for 
diagnosis. 

Threadworms  sometimes  cause  much  itching  at  the  anus,wThich 
is  very  distressing  to  the  child  at  night — and  not  at  night  only. 


INTESTINAL  WORMS  293 

I  have  seen  numerous  threadworms  wriggling  at  the  anus  of 
a  child  in  the  daytime.  I  have  also  seen  them  in  the  vulva, 
where  they  may  cause  much  irritation. 

It  is  sometimes  thought  that  there  is  a  particular  facies  from 
which  the  presence,  of  worms  can  be  diagnosed  :  it  is  a  pale  face, 
puffy  under  the  eyes.  There  is  no  doubt  of  the  association, 
but  the  same  appearance  is  seen  with  chronic  intestinal  indiges- 
tion, '  mucous  disease,'  which  has  so  many  other  symptoms 
in  common  with  worms  ;  indeed,  I  doubt  if  there  is  any  symptom 
produced  by  threadworms  which  may  not  also  be  produced  by 
intestinal  dyspepsia  with  mucous  catarrh  of  the  intestine  without 
the  presence  of  these  worms. 

Threadworms  when  present  only  in  small  numbers  are  easily 
overlooked  in  the  stool  by  those  who  are  not  familiar  with  their 
appearance  ;  on  the  other  hand,  various  fibres  are  mistaken  for 
worms.  A  child  was  brought  to  me  who  was  said  to  be  passing 
*  hundreds  of  worms  ' ;  I  saw  the  stools,  which  contained  a  very 
large  number  of  fibres  1-1 J  inches  long,  some  whitish,  some 
brown,  but  all  clearly  of  vegetable  origin.  I  was  told  that  no 
fruit  was  being  given,  but  on  pressing  the  question  I  discovered 
that  the  child  ate  bananas  freely,  and  comparison  with  the 
fibres  from  a  banana  showed  that  this  was  the  source  of  the 
supposed  worms.  In  another  case  a  child  was  said  to  be  passing 
many  worms,  and  the  mother  showed  me  white  stemlike  pieces 
J-l  inch  long,  which  proved  to  be  the  stem  of  water-cress,  of 
which  the  child  was  fond. 

Round  worm.  The  round  worm  (ascaris  lumbricoides)  can 
hardly  be  overlooked  or  mistaken,  it  is  very  like  the  ordinary 
earthworm,  both  in  appearance  and  in  size  ;  on  the  average  it 
measures  5  inches  (male)  to  10  inches  (female),  but  I  have  seen 
it  13  inches  long.  It  is  very  much  less  frequent  than  the 
threadworm  in  children  :  and  when  it  is  present  is  seldom 
found  in  large  numbers,  usually  only  three  or  four  and  sometimes 
only  one. 

One  child  was  brought  to  me  who  had  passed  twenty  from 
the  bowel  within  a  fortnight ;  another  boy  of  ten  years  had 
vomited  two  and  passed  twenty-four  per  rectum  within  three 
weeks,  his  sister  had  passed  roundworms  three  months  pre- 
viously ;  cases  have  been  recorded  in  which  many  scores  of 
these  worms  were  passed. 

Several  children  in  a  family  are  liable  to  be  affected  :  in  some 
cases  this  may  mean  direct  transmission  of  the  ova  from  child 
to  child  ;  in  the  following  case  the  intervals  between  the  appear- 


294  COMMON  DISORDERS  OF  CHILDHOOD 

ance  of  the  worm  in  different  children  suggests  rather  coincidence 
or  some  common  source  of  infection. 

Lilian  M.,  aged  three  years,  was  brought  for  roundworms,  of  which  she  had 
passed  altogether  about  two  dozen  within  the  past  twelve  months.  She  had 
frequent  colicky  pains  in  the  abdomen,  and  generally  became  feverish  and  ill 
just  before  passing  the  worm.  One  sister  had  a  round  worm  five  years  ago  ; 
it  crawled  up  into  the  pharynx,  and  she  pulled  it  out  of  her  mouth  without 
vomiting.  Another  sister,  aged  fourteen  years,  complained  when  five  years 
old  of  pain  in  her  nose,  and  some  hours  later  pulled  a  roundworm  out  of  one 
nostril ;  a  younger  sister,  aged  seven  years,  passed  a  roundworm  from  the  bowel 
one  month  ago. 

A  child  aged  1  ,*V  was  brought  to  me  with  a  history  of  having 
coughed  up  a  roundworm  a  few  hours  previously  ;  he  had  passed 
threadworms,  but  never  any  roundworms  by  rectum.  The 
roundworm  shown  to  me  was  below  the  average  size  and  would 
easily  have  slipped  into  the  larynx,  but  I  suspect  that  in  this 
case  it  was  really  coughed  up  from  the  pharynx.  There  are, 
however,  cases  on  record  in  which  these  worms  have  found  their 
way  into  the  air-passages ;  they  have  even  produced  suffocation, 
but  I  have  never  known  any  serious  harm  from  them  myself. 

I  saw  one  child  with  jaundice  associated  with  the  presence  of 
roundworms,  which  suggested  the  possibility  of  a  worm  in  the 
bile-duct,  as  has  happened,  but  there  was  no  means  of  proving 
it,  and  the  jaundice  passed  off  like  an  ordinary  catarrhal  attack. 

In  addition  to  the  colicky  pains  I  have  noted  the  presence  of 
ravenous  appetite  and  of  excessive  thirst  in  children  with  round- 
worms  and  the  cessation  of  these  symptoms  when  the  worms 
were  expelled.  Nervous  disturbances  similar  to  those  seen  with 
threadworms  are  also  seen  with  roundworms  ;  disturbances  of 
sleep  and  general  '  nervousness  '  are  common. 

Occasionally  convulsions  have  been  produced.  Sigaud  l  re- 
corded the  case  of  a  child  aged  six  years,  who  whilst  eating  his 
supper  suddenly  became  unconscious,  the  right  arm  and  leg 
were  paralysed  and  when  consciousness  returned  and  the  ad- 
ministration of  santonin  had  resulted  in  the  passing  of  twenty 
roundworms,  the  paralysis  and  impairment  of  speech  which  had 
accompanied  it  passed  off  in  a  few  days. 

I  have  already  mentioned  the  case  of  a  girl  aged  3-f  years, 
who  had  a  mysterious  fever  for  at  least  five  weeks  with  vomiting 
and  screaming  for  hours  almost  every  night  (the  chart  is  shown 
on  page  283)  ;  the  symptoms  all  subsided  suddenly  with  the 
death  of  a  roundworm  which  was  passed  dead  and  slightly 
shrivelled  two  days  after  the  symptoms  had  ceased. 
1  Oaz.  des  Hopitaux,  June  30,  1904. 


INTESTINAL  WORMS  295 

Trichocephalus  dispar.  Next  to  the  roundworm  the  whip- 
worm  or  trichocephalus  dispar  is  probably  the  commonest  intes- 
tinal parasite  in  children  in  this  country,  and  yet  I  doubt  if  most 
medical  men  have  ever  seen  it.  In  its  white  colour  it  resembles  the 
threadworm,  but  it  differs  altogether  in  its  length  and  shape. 
The  terminal  half -inch  is  nearly  twice  as  thick  as  the  threadworm, 
and  the  rest  of  the  worm  up  to  the  head  consists  of  a  fine  hair-like 
filament  about  1J  inches  long.  I  have  found  this  worm  curled 
up  in  a  spiral  manner  in  the  intestine  with  the  minute  head  fixed 
in  the  mucous  membrane  so  firmly  that  I  have  had  to  pull  to 
detach  it.  I  observed  the  trichocephalus  dispar  in  8  per  cent, 
of  children  examined  post  mortem  at  the  Children's  Hospital, 
and  I  think  invariably  with  threadworms ;  I  have  rarely  found 
more  than  three  or  four  whipworms  and  these  have  been  almost 
always  in  the  caecum. 

I  have  not  seen  a  single  case  myself  in  which  the  worm  was 
detected  in  the  stools  during  life  :  apparently  it  causes  no  symp- 
toms which  can  be  distinguished  from  those  of  the  threadworm 
with  which  it  is  associated. 

Tapeworms  are  so  rare  in  children  in  this  country  that  I  shall 
not  consider  them  in  detail  here.  The  usual  variety  in  this 
country  is  the  tsenia  mediocanellata  (from  beef)  distinguished 
chiefly  by  the  four  suckers  on  its  head  from  the  tsenia  solium 
(from  pork)  whose  head  shows  a  row  of  hooklets.  The  distinction 
is  very  difficult  if  only  the  ripe  proglottides  or  segments  are 
seen,  as  is  usually  the  case ;  fortunately  the  distinction  is  of  no 
practical  importance,  for  the  treatment  is  the  same. 

I  have  seen  tapeworm  at  the  age  of  twelve  months,  but  it  is 
rarely  seen  until  after  the  age  of  three  years.  There  are  no 
characteristic  symptoms  except  the  passage  of  the  segments, 
but  I  have  noted  nervous  symptoms  in  some'cases,  e.g.  Rita  M., 
aged  seven  years,  had  been  passing  segments  of  tapeworm  (which 
proved  to  be  taenia  mediocanellata)  for  two  months ;  she  was 
'very  nervous'  and  lately  had  been  suffering  with  night-terrors. 
I  gave  extract  of  male  fern  CQxl,  and  a  considerable  length  of 
tapeworm  was  passed,  but  not  the  head.  Eleven  and  a  half 
weeks  later,  segments  again  appeared  in  the  stools  and  the  child 
was  brought  with  a  history  that  she  had  again  become  nervous 
and  had  lately  complained  of  pains  in  the  abdomen.  With 
80  minims  of  extract  of  male  fern  the  worm  was  expelled  entire 
with  the  head. 


296          COMMON  DISORDERS  OF  CHILDHOOD 
Treatment 

Threadworms.  The  observations  which  I  have  described 
above  have  a  practical  bearing  on  treatment ;  as  the  ordinary 
habitat  of  the  threadworm  is  the  caecum,  and  it  is  often  in  the 
appendix,  and  sometimes  even  in  the  small  intestine,  any  in- 
jection which  is  only  large  enough  to  reach  the  top  of  the  rectum 
or  the  lower  part  of  the  colon  is  not  likely  to  do  much  good. 
Some  have  even  gone  so  far  as  to  say  that  injections  are  useless, 
on  the  ground  that  it  is  not  possible  to  reach  the  caecum  by 
this  means.  Such  a  statement  is  no  doubt  perfectly  true  if  the 
injection  consist  of  only  3  or  4  ounces  of  fluid.  With  such 
a  quantity  no  part  higher  than  the  descending  colon  is  likely 
to  be  reached.  But  with  larger  quantities — 12  to  18  ounces  or 
more— it  is  quite  possible  to  fill  not  only  the  caecum,  as  is  apparent 
in  the  treatment  of  intussusception  by  injection,  but  also  the 
vermiform  appendix,  if  one  may  judge  from  post  mortem  experi- 
ments in  which  I  have  repeatedly  demonstrated  this.  Injections, 
therefore,  are  of  value,  but  it  is  essential  that  large  quantities  of 
fluid  should  be  used— a  child  of  six  to  twelve  years  will  often 
tolerate  as  much  as  16  to  20  ounces — and  experience  has  shown 
that  large  injections  of  salt  and  water  or  of  infusion  of  quassia 
are  often  effective. 

I  have  occasionally  used  a  decoction  of  garlic  for  injection  : 
three  or  four  roots  of  garlic  are  allowed  to  simmer  in  a  quart  of 
water  for  about  two  hours,  -|-1  pint  of  the  resulting  decoction 
is  used  as  an  enema  and  is  sometimes  very  effectual,  but  I  have 
occasionally  had  complaints  that  the  child  turned  faint  when 
this  was  given.  It  would  be  wise  therefore  to  make  the  decoction 
weaker  by  diluting  it  with  an  equal  quantity  of  water  after  it  is 
prepared. 

Treatment  by  injection  alone,  however,  often  fails,  and  this 
is  easily  intelligible,  for  the  large  intestine  varies  so  much  in 
length,  and  therefore  in  capacity,  in  children  of  about  the  same 
ago,  that  it  is  practically  impossible  to  know  what  amount  of 
fluid  is  required  in  any  given  case.  Thus,  in  one  child,  aged 
fifteen  months,  the  large  intestine  was  28  inches  long,  in  another, 
aged  fifteen  months,  it  was  34  inches,  while  in  another,  aged 
twenty-three  months,  it  was  44 1  inches  long,  and  similar  differ- 
ences were  found  in  older  children. 

Moreover,  as  the  above  observations  have  shown,  thread- 
worms may  be  present,  though  not  very  commonly,  in  the  small 
intestine  ;  and  the  chance  of  reaching  these  by  any  injection  is 


INTESTINAL  WORMS  297 

very  slight,  even  when  they  are  situated,  as  is  usually  the  case, 
only  just  above  the  ileo-caecal  valve.  In  the  post  mortem 
experiments  alluded  to  it  was  found  that  occasionally  the  fluid 
did  pass  up  into  the  small  intestine,  but  it  is  obvious  that  the 
conditions  after  death  are  so  different  from  those  during  life  that 
any  conclusions  drawn  therefrom  must  be  of  very  doubtful  value. 
There  is,  however,  some  evidence  that  this  occasionally  happens 
during  life,  and  in  one  case  where  an  enema  of  olive  oil,  followed 
by  a  large  enema  of  soap  and  water,  was  given  as  an  aperient 
to  a  boy,  aged  4J  years,  twenty-four  hours  before  death,  I  found 
the  oil  as  high  up  as  6  inches  above  the  ileo-csecal  valve.  This, 
however,  is  probably  quite  exceptional,  and  for  practical  purposes 
one  may  say  that  the  small  intestine  cannot  be  reached  by 
injections. 

It  is  necessary,  therefore,  to  give  drugs  by  the  mouth  also, 
and  no  drug  has  proved  more  effectual  in  my  experience  than 
santonin. 

This  drug  is  best  given  in  combination  with  an  aperient 
thus :  Santonin  gr.  ij,  Pulv.  Scammonii  Co.  gr.  ij,  Calomel  gr.  J  ; 
4  grains  of  this  powder  can  be  given  every  alternate  night  to 
a  child  of  about  eight  years  and  3  grains  to  a  child  of  four  years 
(see  below). 

Podophyllin  is  said  to  be  of  value  against  threadworms. 
I  have  used  the  tincture  in  doses  of  1-2  minims  according  to 
the  age  of  the  child  and  have  seen  good  results  apparently  from 
it,  but  even  in  these  small  doses  it  has  the  disadvantage  that 
it  is  apt  to  cause  griping  pains. 

Naphthalin  has  been  recommended;  it  can  be  given  twice 
a  day  in  doses  of  2-3  grains  suspended  in  mucilage,  to  a  child 
of  four  or  five  years;  it  should  be  given  only  for  a  few  days, 
and  every  alternate  night  a  purgative  such  as  calomel  should 
be  administered. 

Liquid  paraffin  has  been  thought  to  be  effectual  in  some  cases, 
and  as  many  children  with  threadworms  are  inclined  to  con- 
stipation paraffin  is  doubly  useful.  It  should  be  given  in  doses 
of  at  least  1-2  drachms  three  times  a  day  half  an  hour  before 
meals. 

In  addition  to  the  use  of  drugs  the  prevention  of  any  possible 
conveyance  of  ova  to  the  mouth  must  be  attempted,  for,  as 
shown  above,  this  is  probably  one  mode  of  keeping  up  the  supply 
of  worms,  and  the  cutting  short  of  finger-nails  and  the  prevention 
—by  mechanical  restraint  if  necessary — of  scratching  the  anus  are 
no  unimportant  adjuncts  to  treatment. 


298  COMMON  DISORDERS  OF  CHILDHOOD 

Roundworms.  If  a  child  can  take  santonin  the  treatment  of 
roundworms  is  simple  enough,  and  they  are  generally  much  more 
speedily  got  rid  of  than  the  threadworms  with  which  they  are 
associated.  But  there  are  many  children  who  are  made  very 
sick  by  the  smallest  dose  of  santonin,  and  occasionally  yellow 
vision  (xanthopsia)  and  reddish-yellow  or  dark  reddish-brown 
urine  and  even  delirium  show  how  profoundly  the  child  is 
affected  by  this  drug. 

In  some  cases  it  may  be  rather  the  purgative  which  is  given 
with  it,  than  the  santonin  itself,  which  causes  the  vomiting  ;  for 
instance,  in  the  powder  which  I  have  mentioned  above,  the 
compound  scammony  powder  or  the  calomel  may  be  responsible  ; 
it  is  not  very  uncommon  for  calomel  alone  to  make  children 
vomit,  and  there  are  children  who  vomit  with  powders  of  any  sort. 
To  these  santonin  can  be  given  in  lozenge  form  as  the  trochisus 
santonin!  (B.P.),  which  contains  one  grain  ;  a  child  of  three 
years  old  can  have  two  of  these  at  night  followed  by  an  aperient 
in  the  morning.  One  of  the  chocolate  '  cocoids  '  (Oppenheimer) 
containing  santonin  grs.  i-ij  with  calomel  gr.  J-j  can  be  ordered 
to  be  given  every  alternate  night  three  or  four  times.  Santonin 
can  also  be  given  with  an  aperient  dose  of  castor  oil  emulsified 
in  mucilage. 

Naphthulin  is  useful  for  roundworms  as  well  as  for  thread- 
worms ;  its  odour,  however,  makes  it  an  unpleasant  drug  to  take. 

Tapeworms.  I  have  generally  used  the  liquid  extract  of  male 
fern  for  tapeworms  in  children  ;  an  aperient  such  as  calomel  or 
castor  oil  is  given  on  the  previous  day  to  ensure  a  free  action 
of  the  bowels  in  the  evening,  and  the  following  morning  at  an 
early  hour  a  draught  of  male  fern  is  given.  To  a  child  of  five 
years  a  drachm  of  the  liquid  extract  should  be  given  ;  as  in  the 
case  mentioned  above,  I  have  used  as  much  as  80  minims  for 
a  child  of  seven  years.  The  drug  may  be  given  in  emulsion 
thus  :  Extract.  Filicis  Maris  liq.  »j,  Spirit.  Chloroform!  Cl)ij, 
Syrup  ,-jij,  Mucilag.  AcaciaB  7,ij,  Aq.  Menth.  Pip.  ad  3].  About 
two  hours  later  a  saline  purgative  such  as  magnesium  sulphate 
30  grains,  half  a  Seidlitz  powder  or  -J-l  ounce  of  castor  oil  should 
be  given. 

I  have  also  used  kamala  with  male  fern,  giving  it  in  the 
manner  described  by  Dr.  Eustace  Smith.  To  a  boy  of  four  years 
a  dose  of  Pulv.  Kamala  gr.  xx,  Extract.  Filicis  Maris  Liquid. 
Cl)xx,  was  given  suspended  in  mucilage  with  water  at  5.30  a.m. 
and  again  at  8  a.m.  This  dose  caused  some  slight  pain  in  the 
abdomen,  and  the  passage  of  a  large  quantity  of  mucus  and 


INTESTINAL  WORMS  299 

7  feet  of  tapeworm,  but  not  the  head.  Usually  no  aperient  is 
necessary  with  this  treatment  as  the  kamala  itself  has  a  purgative 
effect.  Thymol  has  been  used  with  success  ;  but  on  the  only 
occasion  when  I  have  tried  it,  giving  1|  grains  to  a  child  of 
four  years,  it  was  a  failure,  probably  from  insufficiency  of  dose. 


CHAPTER  XXI 
JAUNDICE   IN   CHILDREN 

JAUNDICE  is  a  symptom  which  in  childhood,  as  in  later  life, 
has  a  very  varied  significance  :  I  shall  consider  it  here  chiefly  with 
reference  to  prognosis.  It  is  a  matter  of  importance  to  recognize 
the  different  conditions  under  which  jaundice  may  occur,  for 
while  in  many  cases  it  is  merely  a  symptom  of  some  slight  and 
transient  disorder,  in  others  it  has  the  gravest  possible  significance. 

Icterus  Neoiiatorum.  The  commonest  condition  in  which 
jaundice  occurs  is  that  known  as  icterus  neonatorum.  This 
occurs  in  a  large  proportion,  variously  estimated  at  30  to  80  per 
cent.,  of  all  infants.  It  is  hardly  necessary  for  me  to  describe 
this  condition  ;  the  jaundice  appears  almost  always  within  the 
first  week,  usually  on  the  third  or  fourth  day.  It  is  seen  first  on 
the  trunk  and  face,  then  on  the  limbs  and  conjunctivas  ;  the 
urine  and  faeces  remain  normal  in  the  milder  cases.  The  child's 
health  does  not  suffer  in  any  way,  and  after  four  or  five  days,  or 
at  most  one  or  two  weeks,  the  jaundice  disappears.  Such  is  the 
ordinary  course  of  icterus  neonatorum.  Most  writers  on  the 
subject  mention  two  weeks  as  the  limit  of  duration  in  the  most 
severe  cases,  but  I  should  like  to  draw  attention  to  certain  cases 
in  which,  instead  of  lasting  a  few  days,  the  jaundice  lasts  as  long 
as  two  months  or  even  more,  and  then  passes  off,  leaving  the 
infant  apparently  none  the  worse  for  it. 

A  male  infant  was  brought  to  the  Children's  Hospital  for 
jaundice  at  the  age  of  twenty-nine  days,  with  a  history  that  the 
yellow  colour  had  been  noticed  first  on  the  fourth  day  after 
birth,  and  that,  except  for  occasional  vomiting  and  screaming 
after  food,  the  infant  was  in  good  health.  The  urine  was  said 
to  be  '  very  dark  ',  but  the  stools  were  often  green,  and  once 
at  least  when  I  saw  them  were  of  a  good  yellow  colour.  There 
was  nothing  either  in  the  child  or  in  its  parents  to  suggest  the 
possibility  of  syphilis.  The  infant  was  well  nourished  ;  the  liver 
was  iittle  if  at  all  enlarged,  and  certainly  not  hard  ;  the  spleen 
could  not  bo  felt.  The  jaundice  was  not  very  intense,  but  was 
well  marked  both  on  the  skin  and  conjunctive.  It  persisted  for 
9£  weeks  altogether,  gradually  disappearing,  and  leaving  the 
child  in  apparently  good  health  except  for  some  flatulence. 


JAUNDICE  IN  CHILDREN  301 

A  similar  case  was  the  following  : 

Gilbert  W.  was  admitted  to  King's  College  Hospital,  at  the  age  of  seven 
weeks,  for  jaundice :  this  had  been  present  *  since  birth ' ;  there  had  been  some 
bleeding  from  the  navel  at  three  weeks,  but  not  since.  The  spleen  was  three 
finger- breadths  and  the  liver  about  two  finger- breadths  below  the  costal 
margin  ;  the  child  was  somewhat  wasted,  the  stools  were  yellowish  but  very 
pale ;  the  urine  was  not  obtained  until  the  ninth  day  after  admission,  when 
no  bile  was  detected  in  it. 

The  jaundice  was  still  present  9£  weeks  after  birth,  but  was  then  diminishing 
and  disappeared  within  the  next  few  days.  The  child  was  seen  again  at 
1\  months  old,  when,  except  for  marked  pallor,  he  seemed  healthy ;  the 
spleen  could  not  be  felt  and  the  liver  was  only  just  felt. 

In  this  case  the  family  history  showed  miscarriages  and  still- 
births, thus  :  (1)  lived  fourteen  days  only  ;  (2)  healthy,  aged  six 
years  ;  (3)  miscarriage  ;  (4)  stillborn  ;  (5)  stillbirth  ;  (6)  mis- 
carriage ;  (7)  the  patient.  There  was,  therefore,  at  least  a  possi- 
bility of  syphilis,  and  perhaps  the  enlargement  of  the  spleen  in 
the  patient  pointed  that  way,  but 'there  was  no  other  evidence, 
and  the  complete  recovery  seemed  opposed  to  any  gross  syphilitic 
disease  of  the  liver. 

It  is  impossible  to  say  what  is  the  explanation  of  these  pro- 
longed cases  of  icterus  neonatorum,  but  clinically,  at  any  rate, 
one  may  group  them  provisionally  with  the  commoner  cases  of 
one  or  two  weeks'  duration,  remembering  that  the  nature  even 
of  the  common  condition  is  uncertain.  The  importance  of 
recognizing  the  occurrence  of  these  prolonged  cases  lies  chiefly 
in  the  matter  of  prognosis,  for  when  the  infant  shows  jaundice 
within  a  few  days  after  birth,  and  the  jaundice  persists  more 
than  three  weeks,  one's  tendency  is  to  think  of  syphilitic  hepatitis, 
or  of  congenital  obliteration  of  the  bile-ducts,  in  either  of  which 
conditions  the  prognosis  would  be  extremely  bad  ;  but  bearing 
in  mind  these  unusual  cases  in  which  the  jaundice  passes  off 
after  two  months  or  even  longer  without  ill  effect,  one  must 
examine  such  infants  very  carefully  before  giving  prognosis. 

In  the  first  case  which  I  mentioned  there  were  certain  points 
which  had  to  be  taken  into  account  :  the  jaundice  was  not  the 
intense  yellow  of  the  cases  with  congenital  obliteration  of  ducts  ; 
moreover,  there  was  not  the  enlargement  of  liver  and  spleen, 
nor  the  hardness  of  the  liver  which  characterizes  the  obliterative 
cases  ;  the  apparently  normal  size  of  the  liver  and  spleen  was 
also  opposed  to  a  syphilitic  lesion,  and  the  presence  of  bile  in  the 
stools  showed  that  at  any  rate  there  was  no  complete  obstruction 
of  the  ducts. 

I  felt  by  no  means  certain  of  the  prognosis  in  these  cases,  but 


302  COMMON  DISORDERS  OF  CHILDHOOD 

the  event  showed  that  it  was  altogether  favourable  so  far  as  the 
immediate  future  was  concerned. 

I  say  advisedly  'so  far  as  the  immediate  future  is  concerned', 
for  I  think  more  observation  is  needed  before  we  can  make 
any  general  statement  as  to  the  ultimate  fate  of  such  cases. 
My  own  experience  leads  me  to  regard  them  with  suspicion.  It 
may  be  that  this  unusual  prolongation  of  jaundice,  although  it 
passes  off  apparently  as  innocently  as  in  the  ordinary  cases  of 
short  duration,  has,  nevertheless,  some  sinister  significance. 

A  male  infant,  according  to  the  mother's  statement,  had  been  jaundicedfor 
eight  weeks  after  birth.  When  seen  by  me  at  the  age  of  nineteen  months  he 
was  intensely  anaemic,  the  spleen  was  enormous,  the  liver  not  felt.  The  child 
died  at  the  age  of  twenty-one  months.  The  post  mortem  showed  in  addition 
to  the  enlargement  of  the  spleen  a  very  slight  intercellular  increase  of  fibrous 
tissue  in  the  liver  ;  the  pancreas  was  extraordinarily  hard  and  large,  but 
unfortunately  was  not  examined  microscopically. 

In  this  case  there  was  no  clinical  evidence  of  syphilis  in  the 
child  or  his  family  history. 

The  clinical  aspect  of  the  case  was  that  of  the  so-called  '  splenic 
anaemia  '  of  infants,  a  condition  of  extremely  uncertain  origin, 
but  known  to  be  associated  in  some  cases  with  slight  degrees  of 
proliferation  of  fibrous  tissue  in  the  liver,  and  undoubtedly 
occurring  sometimes  where  there  is  strong  evidence  of  congenital 
syphilis. 

In  this  connexion  I  should  like  to  mention  another  case  in  which 
there  was  a  history  of  prolonged  icterus  neonatorum.  This  wras 
a  boy  who  had  jaundice  lasting  six  weeks  from  the  time  of  birth  ; 
the  jaundice  then  passed  off,  leaving  the  boy  apparently  healthy. 
At  the  age  of  two  years  and  three  months,  however,  jaundice  again 
appeared  ;  it  lasted  several  weeks,  and  ended  fatally.  I  made 
a  microscopical  examination  of  the  liver,  which  showed  advanced 
intercellular  cirrhosis,  which  strongly  suggested  congenital 
syphilis,  although  there  was  no  other  evidence  of  it. 

Even  as  regards  the  immediate  future  of  these  cases  of  pro- 
longed jaundice  in  the  newborn,!  think  we  may  well  be  cautious 
in  prognosis.  I  have  mentioned  cases  in  which  there  was  appar- 
ently permanent  recovery,  but  I  have  also  seen  a  fatal  ending 
where  some  complication  has  supervened  ;  for  instance,  a  male 
infant  who  had  been  jaundiced  '  from  birth  '  came  under  my  care 
at  the  age  of  six  weeks  with  intense  jaundice  and  some  diarrhoea. 
He  rapidly  sank  from  exhaustion  and  was  still  much  jaundiced 
when  lie  died  at  6|  weeks  ;  post  mortem,  there  was  no  cirrhosis 
of  the  liver,  the  bile-ducts  were  normal,  as  we  had  supposed,  for 


JAUNDICE  IN  CHILDREN  303 

there  was  a  trace  of  bile  in  the  stools  ;    the  spleen  was  normal. 
In  this  case  there  was  no  evidence  of  syphilis. 

Even  where  the  jaundice  has  not  been  greatly  prolonged,  I  have 
seen  what  appeared  at  first  sight  to  be  an  innocent  icterus 
neonatorum  end  fatally. 

Ivy  G.  was  brought  to  hospital  at  the  age  of  two  weeks  with  jaundice,  which 
had  been  present  *  since  birth '  ;  the  stools  had  been  green  until  a  few  days 
previously,  when  they  had  become  white;  neither  the  liver  nor  the  spleen 
could  be  felt.  The  child  was  born  at  full  term  ;  had  had  no  snuffles  ;  she 
was  the  fifth  child  ;  there  had  been  no  miscarriages  ;  the  cord  had  separated 
on  the  third  day,  and  the  umbilicus  was  healthy. 

On  the  sixteenth  day  she  vomited  some  blood  and  passed  some  in  the  stools, 
but  no  further  haemorrhage  occurred  from  these  parts.  Two  days  later,  how- 
ever, there  was  some  haemorrhage  from  the  umbilicus,  and  large  subcutaneous 
haemorrhages  appeared  over  the  back  of  the  hands,  and  the  child  became 
convulsed  and  died,  still  deeply  jaundiced,  on  the  nineteenth  day  after  birth. 

Post  mortem  showed  a  layer  of  recent  blood-clot  over  the  vertex  and  base 
of  the  brain.  The  spleen  was  very  slightly  enlarged  and  unduly  soft ;  the 
liver,  beyond  being  rather  soft,  perhaps  slightly  enlarged  and  stained  greenish, 
showed  nothing  abnormal ;  all  other  organs  were  normal.  No  cause  was 
found  for  the  jaundice.  I  examined  the  liver  and  kidney  microscopically; 
only  a  few  of  the  liver  cells  were  fatty,  otherwise  I  could  detect  nothing  abnormal 
in  either  organ. 

Perhaps  this  should  be  regarded  as  an  infective  condition,  or 
perhaps  as  an  instance  of  '  Buhl's  disease  ',  the  so-called  '  fatty 
degeneration  of  the  newborn',  in  which  just  such  symptoms 
are  described  ;  but  the  point  of  practical  importance  which  it 
may  serve  to  emphasize  is  the  need  for  regarding  with  suspicion 
jaundice  which  persists  unusually  long  in  a  newborn  child;  the 
only  point  which  made  one  hesitate  in  prognosis  in  this  case  when 
I  first  saw  it  at  fourteen  days  old,  was  the  intensity  of  the  yellow 
colour  at  this  time  when  the  jaundice  of  icterus  neonatorum  has 
usually  almost,  if  not  entirely,  vanished. 

There  are  rare  cases  in  which  several  successive  children  of 
a  family  succumb  to  a  malignant  type  of  jaundice  within  a  few 
days  of  birth. 

This  family  icterus  gravis  neonatorum  begins  when  the  child 
is  but  a  few  hours  old,  the  jaundice  gradually  deepens,  the  infant 
is  fretful  and  may  seem  to  have  some  abdominal  pain,  he  becomes 
increasingly  drowsy,  and  with  progressive  feebleness  death 
ensues  within  a  week  or  thereabouts. 

The  liver  in  these  cases  is  not  apparently  enlarged,  nor  is  it 
particularly  hard  ;  there  is  no  enlargement  of  the  spleen.  Autopsy 
has  shown  no  gross  lesion  to  account  for  the  condition. 

Two  instances  of  this  family  affection  have  come  under  my 


304  COMMON  DISORDERS  OF  CHILDHOOD 

own  notice  ;  in  one  of  these  three  successive  infants  had  died 
from  this  cause  ;  in  the  other,  four  had  died  including  twcrtwin 
children.  As  many  as  six  deaths  from  this  affection  have  occurred 
in  one  family.  No  cause  is  known,  and  at  present  we  have  no 
effective  treatment  for  the  disease  when  it  has  occurred,  nor  can 
we  prevent  its  occurrence  in  subsequent  infants  of  the  same 
family. 

I  shall  not  enter  into  the  vexed  question  of  the  etiology  of 
icterus  nconatorum  here,  except  to  say  that,  in  my  opinion,  there 
is  little  doubt  that  in  most  of  the  cases,  if  not  in  all,  the  jaundice 
is  not  only  hepatogenous,  but  is  also  obstructive. 

I  do  not  mean  that  there  is  necessarily  any  gross  obstruction 
in  the  larger  bile-ducts  ;  but  when  we  remember  that  the  bile  is 
secreted  at  very  low  pressure,  it  is  easy  to  understand  that  a  very 
slight  increase  in  viscidity  of  the  bile,  especially  in  the  smaller 
ducts,  might  cause  sufficient  obstruction  to  produce  jaundice. 

If  the  bile  secreted  during  the  later  months  of  intra-uteririe 
life  is  particularly  viscid,  one  could  well  understand  that  with  the 
sudden  increase  in  the  secretion  of  bile  which  presumably  occurs 
when  the  child  begins  to  take  food  after  birth,  and  probably  even 
before  food  is  taken,  the  difficulty  of  exit,  owing  to  viscid  bile 
already  in  the  ducts,  may  cause  re-absorption  of  some  of  the 
newly  secreted  bile  into  the  circulation.  And  there  is  some 
evidence  that  the  bile,  both  in  intra-uterine  life  and  in  very  early 
infancy,  is  apt  to  be  very  viscid.  This  I  have  myself  observed  at 
autopsies,  and  the  tendency  to  formation  of  biliary  concretions 
which  seems  to  be  present  in  intra-uterine  life  probably  points 
in  the  same  direction.  In  some  cases  of  icterus  neonatorum 
extreme  viscidity  of  the  bile  has  been  demonstrated  post  mortem. 
In  one  infant  who  died  with  jaundice  at  the  age  of  fourteen  days 
I  found  this  viscidity  marked,  and  in  another  case,  which  died 
at  the  age  of  four  weeks,  when  the  jaundice  was  disappearing,  I 
have  noted  the  contents  of  the  gall-bladder  as  'extremely  viscid'. 
In  an  infant  who  died  at  the  age  of  four  weeks  with  pyaemia 
and  jaundice  I  found  the  bile  so  thick  that  it  could  scarcely 
be  squeezed  through  the  common  duct  with  considerable  force. 

Biliary  concretions  or  calculi  are  extremely  rare,  it  has  even  been 
stated  that  they  never  occur  in  children  ;  but  cases  have  been 
observed,  and  they  appear  to  be  commoner  in  infancy  than  at 
any  other  period  of  childhood.  Of  twenty-three  cases  wrhich  I 
collected,1  including  three  which  came  under  my  own  observa- 
tion, fifteen  were  in  infants,  and  fourteen  of  these  wrere  in  infants 
1  Path.  Soc.  Trans.,  vol.  1,  p.  151. 


JAUNDICE  IN  CHILDREN  305 

under  ten  months  of  age.  In  several  of  these  there  was  intense 
jaundice  at  birth  or  shortly  afterwards,  and  calculi  were  found 
in  the  ducts. 

In  one  of  my  own  cases  minute  calculi  were  found  impacted  in 
the  common  duct  in  an  infant  aged  nine  months,  but  there  had 
been  no  jaundice. 

I  mention  this  very  rare  occurrence  as  indicating  a  tendency 
to  stagnation  of  bile  at  this  age,  and  as  just  worth  remembering 
in  connexion  with  some  of  those  cases  of  icterus  neonatorum 
which  run  an  unusual  course. 

Syphilitic  Jaundice.  Congenital  syphilis,  as  I  have  suggested, 
may  possibly  be  a  factor  in  some  of  the  prolonged  cases  of  jaundice 
in  infants  who  recover,  but  even  temporary  recovery,  with  com- 
plete intermission  of  symptoms,  is  probably  quite  unusual  in 
the  jaundice  of  the  newborn  with  congenital  syphilis. 

The  usual  course  in  syphilitic  infants  is  steadily  downwards  ; 
the  jaundice  is  present  at  birth,  it  persists,  and  may  be  very 
intense.  Haemorrhage  may  occur  in  the  skin  or  from  mucous 
membranes,  and  after  a  few  weeks  the  infant  dies.  The  liver 
shows  only  slight  enlargement,  and  feels  only  slightly  firmer 
than  normal  ;  the  surface  is  smooth  ;  the  change  found  is  an 
interstitial  hepatitis  extending  throughout  the  liver  with  for- 
mation of  fibrous  tissue  between  the  individual  liver  cells,  in 
fact,  an  intercellular  cirrhosis. 

The  presence  of  deep  jaundice  at  birth  is,  I  think,  a  point  of 
some  value  in  distinguishing  these  cases  from  the  simple  icterus 
neonatorum,  but  I  should  not  care  to  lay  any  great  stress  upon 
it,  for  I  have  seen  jaundice  almost  certainly  due  to  syphilis,  and 
ending  fatally,  which  did  not  begin  until  eight  weeks  old. 

Syphilitic  hepatitis,  however,  with  its  resultant  intercellular 
cirrhosis,  is  not  the  only  cause  of  jaundice  which  ends  fatally  in 
congenital  syphilis  ;  some  of  the  cases  of  pyaemic  jaundice  in 
infants  are  indirectly  due  to  syphilis.  Acute  epiphysitis,  which 
is  a  very  early  manifestation  of  congenital  syphilis,  may  become 
suppurative,  owing  to  a  secondary  infection  with  pyogenic  micro- 
organisms ;  in  this  way,  a  pyaemia  may  be  started  which  may 
give  rise  to  pyaemic  jaundice.  In  two,  probably  syphilitic, 
infants  which  I  examined  post-mortem,  this  appeared  to  be  the 
sequence  of  events. 

This  pyaemic  jaundice,  whether  it  is  secondary  to  syphilis, 
or  due  directly  to  umbilical  infection,  almost  invariably  ends 
fatally. 


306  COMMON  DISORDERS  OF  CHILDHOOD 

Congenital  Obliteration  of  Bile-ducts.  There  is  another  group 
of  cases  of  jaundice  in  infancy  in  which  the  prognosis  is  always 
bad  ;  I  mean  those  with  congenital  obliteration  of  the  bile-ducts. 
It  is  by  no  means  always  easy  to  distinguish  these  cases  from 
those  due  to  syphilis,  for  in  both  the  jaundice  may  be  present 
from  birth  ;  it  becomes  very  intense,  and  is  associated  frequently 
with  haemorrhages  ;  the  liver  and  spleen  are  enlarged  and  too 
firm  ;  the  infant  wastes  and  dies. 

One  might  have  expected  that  with  such  a  malformation  of 
the  bile-ducts  jaundice  would  necessarily  have  been  present  at 
birth,  but  in  forty  out  of  the  series  of  fifty  cases  collected  by 
Dr.  John  Thomson  this  point  Avas  specially  mentioned,  and  only 
nine  showed  jaundice  at  birth.  Four  cases  of  this  kind  have 
come  under  my  observation,  and  were  examined  post  mortem. 
None  of  them  had  shown  jaundice  at  birth  ;  in  one  of  them  the 
jaundice  had  not  appeared  until  three  weeks  after  birth,  although 
autopsy  showed  that  the  gall-bladder  and  ducts  were  completely 
absent,  being  represented  only  by  fibrous  tissue. 

In  the  cases  which  I  have  seen,  the  liver  has  seemed  much 
harder  on  clinical  examination  than  in  the  syphilitic  cases,  and 
corresponding  witli  this,  post  mortem,  the  liver  showed  more 
advanced  cirrhosis  than  I  have  found  in  cases  of  congenital 
syphilis.  This  may,  however,  be  due  to  their  longer  duration, 
for  whilst  many  of  the  cases  with  congenital  syphilis  die  within 
a  few  weeks,  the  cases  with  congenital  obliteration  of  ducts  often 
live  as  long  as  four  or  five  months.  Two  of  the  series  mentioned 
above  lived  '  into  the  eighth  month  ',  and  one  of  the  cases  which 
I  examined  post  mortem  died  at  the  age  of  9J  months. 

An  interesting  point  which  I  may  mention  here  is  the  occurrence 
of  severe  jaundice  in  several  infants  of  the  same  family.  This  has 
been  noticed  in  cases  of  congenital  obliteration  of  the  bile-ducts. 
Dr.  J.  Thomson,  in  his  valuable  monograph  on  that  subject, 
mentions  two  instances  in  which  the  malformation  was  found, 
post  mortem,  in  more  than  one  infant  of  the  same  family.  But 
it  is  not  only  with  this  condition  that  several  infants  of  a  family 
may  surfer  with  jaundice.  In  one  autopsy  which  I  made  on  an 
infant  who  died  at  the  age  of  fourteen  days  with  jaundice,  there 
was  nothing  obviously  abnormal  in  the  liver  or  ducts,  nor  was 
there  any  appearance  of  cirrhosis  (unfortunately  no  microscopic 
examination  was  made).  Four  other  children  in  that  family 
were  said  to  have  had  jaundice  lasting  four  to  six  weeks  after 
birth,  but  none  of  them  had  died.  There  was  nothing  in  the 
history  to  suggest  syphilis  in  the  parents  ;  but  some  such  cases 
are  certainly  syphilitic. 


JAUNDICE  IN  CHILDREN  307 

Henoch  records  fatal  jaundice  in  an  infant  whose  mother  had 
syphilis  ;  three  other  children  in  the  family  had  been  jaundiced 
at  birth,  and  had  died  soon  after.  Dr.  Thomson  (loc.  cit.)  also 
refers  to  cases  in  which  several  children  of  one  family  died  with 
jaundice,  perhaps  the  most  notable  being  one  recorded  by  Under- 
wood, in  which  the  first  nine  infants  of  the  family  died  with 
jaundice  under  one  month  old,  and  the  tenth  died,  aged  six  years, 
with  jaundice  also. 

Catarrhal  Jaundice.  In  children  beyond  the  age  of  infancy 
jaundice  is  most  commonly  catarrhal  in  origin.  So  far  as  my 
own  experience  goes  this  catarrhal  jaundice  would  seem  to  be 
most  common  between  the  ages  of  two  and  six  years.  Thirty 
out  of  fifty  cases  fell  within  these  limits.  Almost  always  the 
child  has  been  ailing  for  some  days  before  the  jaundice  appears, 
feeling  languid,  and  sometimes  drowsy.  Often  the  child  is  cross 
and  fretful,  the  appetite  is  bad,  and  almost  invariably  there  is 
something  abnormal  in  the  state  of  the  bowels  ;  in  some  there 
has  been  diarrhoea,  in  others  constipation,  in  others  only  offensive 
stools. 

Vomiting  commonly  precedes  or  accompanies  the  appearance 
of  the  jaundice.  The  urine  quickly  becomes  darkened,  and  the 
faeces  become  pale.  In  many  cases  there  is  pain  in  the  epigastrium 
and  right  hypochondrium,  and  this  may  be  a  marked  symptom. 
In  a  boy  who  was  brought  to  hospital  with  only  slight  jaundice, 
the  pain  in  the  abdomen  was  so  severe  that  I  felt  doubtful  whether 
the  case  was  really  one  of  catarrhal  jaundice  only  ;  the  subse- 
quent course  of  the  case  seemed  to  show  that  it  was  so.  The  liver 
was  also  apparently  very  tender  in  this  boy  and,  as  in  many 
cases  of  catarrhal  jaundice,  could  be  felt  about  1J  inches  below 
the  costal  margin  ;  one  can  sometimes  easily  detect  a  gradual 
diminution  of  the  size  of  the  liver  as  the  jaundice  passes  off. 

The  temperature  in  this  case  was  raised  to  101-6°;  a  slight 
rise  of  temperature  is  not  uncommon  at  the  commencement  of 
the  illness. 

It  is  customary  to  mention  slowness  of  the  pulse  and  itching  of 
the  skin  as  symptoms  of  catarrhal  jaundice,  but  neither  is  common 
in  children.  The  most  marked  slowing  of  the  pulse  which  I  have 
noted  was  in  a  child  of  eleven  and  a  half  years,  in  whom  the  rate 
fell  to  56  per  minute.  Itching  I  do  not  remember  to  have  ob- 
served in  any  case  in  a  child. 

As  a  rule  catarrhal  jaundice  passes  off  in  about  ten  days  or 
a  fortnight,  but  I  have  seen  cases  in  which  it  has  lasted  much 
longer  ;  for  example,  in  one  child  it  lasted  about  seven  weeks,  in 

x2 


308 


COMMON  DISORDERS  OF  CHILDHOOD 


another  it  lasted  twelve  weeks,  so  that  some  caution  is  needed  in 
prognosis. 

In  this  connexion  also  I  should  like  to  draw  attention  to  the 
recurrence  of  jaundice  at  short  intervals  in  some  children.  A  boy, 
aged  8 1  years,  was  brought  to  hospital  with  this  history. 
Two  years  ago  he  had  jaundice  ;  since  then  he  has  had  seven 
or  eight  attacks  of  jaundice.  For  a  short  time  before  each  attack 
he  becomes  very  drowsy,  so  much  so  that  the  mother  says  she 
can  tell  beforehand  when  the  jaundice  is  coming  ;  the  attack  is 
associated  with  vomiting  and  pain  in  the  abdomen.  In  another 
case  an  attack  of  jaundice,  apparently  catarrhal,  lasted  fourteen 
days,  then  the  child  remained  well  for  six  weeks,  after  which 
another  attack  of  jaundice  came  on  and  lasted  a  fortnight. 


FIG.  22.      Seasonal  incidence  of  catarrhal  jaundice  in  children. 

It  is,  of  course,  possible  that  such  cases  in  children  may  occa- 
sionally be  due  to  biliary  calculi,  but,  as  I  have  already  pointed 
out,  these  are  extremely  rare  in  childhood.  I  have  elsewhere 
(loc.  cit.)  recorded  the  case  of  a  boy,  aged  ten  years,  who,  during 
an  attack  of  severe  abdominal  pain  with  vomiting  and  jaundice, 
showed  a  fluctuating  tumour  in  the  position  of  the  gall-bladder. 
He  was  then  under  the  care  of  Sir  Thomas  Barlow,  at  the  Children's 
Hospital.  The  tumour  suddenly  subsided  and  the  jaundice  passed 
off.  I  saw  the  boy  six  years  later,  at  the  age  of  ten  years.  The 
mother  then  stated  that  since  the  original  illness  he  had  suffered 
with  repeated  attacks  of  abdominal  pain,  in  which  he  became  of 
a  '  sallow  colour  '.  It  was  suggested  that  these  were  possibly 


JAUNDICE  IN  CHILDREN  309 

due  to  biliary  colic,  but  in  both  the  cases  mentioned  above  I  was 
inclined  to  regard  the  attacks  as  recurring  catarrhal  jaundice. 

What  may  be  the  cause  of  catarrhal  jaundice  is  at  present 
unknown,  butl  think  there  can  be  little  doubt  that  sometimes  at 
least  it  is  an  infective  condition.  I  have  noticed  at  the  Children's 
Hospital  that  in  some  years  it  seems  to  be  much  more  prevalent 
than  in  others,  and  it  seems  to  have  a  seasonal  incidence,  being 
most  frequent  in  the  autumn  and  winter,  especially  during 
October  and  November,  as  the  accompanying  chart  of  sixty-four 
cases  shows. 

But  the  strongest  evidence  of  its  infective  nature  is  the  occa- 
sional affection  of  several  members  of  a  family  in  succession  ; 
e.g.  I  had  under  my  care  four  children  of  one  family :  Alfred  C. 
was  first  taken  ill  on  February  12,  Wilfred  C.  on  February  14, 
Elsie  C.  on  February  16,  and  Maud  C.  on  February  23  ;  these 
four  were  the  only  children  in  the  family,  the  parents  were  not 
affected.  The  jaundice  in  all  ran  a  benign  course,  the  temperature 
was  taken  only  in  two  of  them  and  was  found  to  be  subnormal ; 
in  each  the  illness  lasted  about  one  or  two  weeks. 

Cirrhosis.  One  must  always  remember  that  there  are  other 
more  serious  causes  of  jaundice  in  children  beyond  the  age  of 
infancy,  and  the  one  which  is  perhaps  most  often  overlooked, 
because  unexpected  in  childhood,  is  cirrhosis.  I  have  already 
referred  (p.  305)  to  the  intercellular  cirrhosis  which  occurs  in 
early  infancy,  usually  where  the  syphilis  is  speedily  fatal,  but 
occasionally  cirrhosis  is  found  in  older  children  associated  with 
unmistakable  evidence  of  syphilis  elsewhere.  In  the  museum 
of  the  Children's  Hospital,  Great  Ormond  Street,  is  the  liver 
of  a  boy,  aged  10  years  and  4  months,  who  had  jaundice  and 
ascites,  with  Hutchinsonian  teeth,  syphilitic  retinitis,  a  sunken 
bridge  of  nose,  and  scarring  round  the  mouth.  The  liver  showed 
extensive  fibrosis  with  much  atrophy  of  liver  cells.  Whether  such 
a  case  should  be  regarded  as  a  late  result  of  the  intercellular 
cirrhosis  of  infancy  in  a  case  which  had  survived  beyond  the 
usual  age,  or  as  the  outcome  of  a  syphilitic  hepatitis  beginning 
in  later  childhood,  is  not  clear,  but  it  seems  probable  that  syphilis 
may  cause  an  acute  hepatitis  in  later  childhood  which  may  lead 
to  cirrhosis. 

A  girl  aged  about  eight  years  was  admitted  into  King's  College  Hospital 
with  severe  jaundice  and  high  fever.  The  child  seemed  very  ill,  the  fever 
continued,  and  I  suspected  that  the  case  might  prove  to  be  one  of  '  Subacute 
Yellow  Atrophy '.  After  about  three  weeks  of  fever,  the  jaundice  was  still  as 
intense  as  ever,  the  child  showed  no  symptoms  of  syphilis,  but  a  Wasbermann 
proved  to  be  distinctly  positive.  The  child  was  then  put  upon  mercury  and 


310  COMMON  DISORDERS  OF  CHILDHOOD 

potassium  iodide,  and  rapidly  improved,  the  jaundice  and  temperature  subsided, 
and  the  child  made  a  complete  recovery. 

Less  rare  than  intercellular  cirrhosis  in  children  beyond  the 
age  of  infancy,  is  the  interlobular  variety,  which  seems  to  have 
no  connexion  with  syphilis.  A  large,  hard,  irregular  liver,  exactly 
like  that  seen  in  adults  with  alcoholic  cirrhosis,  is  occasionally 
found  in  children.  The  surface  is  studded  with  hobnail-like 
bosses  which  are  coarse  enough  to  be  detected  by  palpation  during 
life.  The  jaundice  in  such  cases  is  generally  very  slight  indeed, 
there  may  be  no  jaundice  at  all.  The  striking  feature  of  these 
cases  is  rather  the  great  enlargement  of  the  spleen,  and,  given 
a  child  with  slight  jaundice,  a  very  large  spleen,  and  a  tendency 
to  epistaxis  or  other  hemorrhages,  one  has  sufficient  grounds  for 
suspecting  cirrhosis.  If,  in  addition,  the  liver  can  be  felt — and 
I  would  point  out  that  the  liver  may  not  be  easily  felt  in  these 
cases — its  hardness  and  irregularity  of  surface  may  clinch  the 
diagnosis. 

I  have  seen  at  least  six  cases  of  this  kind,  three  in  girls,  aged 
respectively  six  and  a  half,  seven,  and  eleven  years  ;  the  two 
latter  cases  were  fatal  in  hospital  and  verified  by  autopsy,  the 
other  case  died  at  home  at  the  age  mentioned,  which  was  about 
twelve  months  after  the  first  onset  of  jaundice. 

Three  cases  were  in  boys,  in  one  the  cirrhosis  was  verified  by 
post  mortem  examination  at  the  age  of  5J  years  ;  the  other  two 
\vere  aged  nine  years  and  ten  years  respectively  when  they  first 
came  under  observation  :  one  of  them  was  seen  again  at  the 
age  of  nearly  fifteen  years  with  a  very  large  hard  and  irregular 
livrer,  and  the  spleen  considerably  enlarged. 

The  duration  of  the  disease  in  this  last  case  was,  I  think,  quite 
exceptional  ;  in  most  cases  death  occurs  within  two  or  three 
years  after  the  first  symptoms  have  appeared. 

I  must  mention  that  a  history  of  alcoholism  is  very  rarely  to 
be  obtained  in  these  cases  of  cirrhosis  in  childhood  ;  a  few  of 
them  are  due  to  the  giving  of  beer  and  spirits,  not  necessarily  in 
large  doses,  but  it  seems  likely  that  in  many,  if  not  in  most,  cases 
there  is  no  connexion  whatever  with  alcohol. 

Amongst  the  few  cases  I  have  seen  I  have  failed  on  careful 
inquiry  to  obtain  any  evidence  of  prolonged  or  excessive  use  of 
alcohol  ;  but  the  difficulty  of  excluding  this  cause  is  great  :  a 
mother  may  easily  forget  that  she  gave  her  infant  brandy  in 
what  she  considered  a  suitable  dose,  perhaps  a  teaspoonful  two 
or  three  times  a  day  for  many  weeks  when  it  had  diarrhoea  or 
was  not  thriving  in  infancy.  I  remember  a  child  under  four  years 


JAUNDICE  IN  CHILDREN  311 

of  age  who  cried  for  beer  when  in  hospital ;  it  seemed  likely 
enough  that  she  was  accustomed  to  it  as  a  beverage  ;  but  one 
may  hope  that  the  giving  of  alcoholic  drinks  to  such  young 
children  is  very  rare. 

Dr.  Ernest  Jones 1  points  out  that  experimentally  it  has  been 
proved  that  young  animals  are  more  susceptible  to  the  noxious 
influences  of  alcohol  than  older  ones,  and  this  fact  may  have 
a  bearing  upon  these  cases  of  cirrhosis  in  children  ;  certainly  it 
is  always  wise  in  prescribing  alcohol  as  a  medicine  for  children 
to  use  the  smallest  dose  which  will  produce  the  necessary  stimu- 
lation— and  this  dose  is,  I  think,  much  smaller  than  is  some- 
times supposed.  I  see  half  drachm  or  even  drachm  doses  of 
brandy  given  to  infants  of  twelve  months  where,  judging  from 
my  own  observation,  I  should  consider  10  to  15  minims  a  more 
suitable  dose  ;  but  apart  from  dosage  there  is  another  point  in 
which  care  is  necessary  in  ordering  alcohol  for  children,  namely, 
to  see  that  it  is  stopped  when  no  longer  required.  I  have  myself 
seen  instances  in  which  brandy  had  been  given  for  many  weeks 
after  all  need  had  ceased  because  the  mother  had  received  no 
directions  as  to  stopping  it.  Dr.  Jones  (loc.  cit.)  states  that  in 
some  of  the  cases  of  cirrhosis  in  children  the  disease  was  thought 
to  have  originated  in  this  way. 

Jaundice  with  other  diseases.  Amongst  my  notes  I  find  several 
cases  of  jaundice  occurring  in  children  as  a  complication  of 
various  conditions,  such  as  heart  disease,  pneumonia,  tubercu- 
losis, &c.  It  is  an  important  question  in  connexion  with  such 
cases  whether  the  supervention  of  jaundice  in  any  way  influences 
the  prognosis.  One  of  the  commonest  associations  is  jaundice 
with  heart  disease,  and  so  far  as  my  experience  goes,  this  occurs 
usually  in  the  more  advanced  cases  of  cardiac  disease,  and  I  think 
one's  tendency  is  to  regard  the  supervention  of  jaundice  as  usually 
'  the  beginning  of  the  end  '  ;  but  this  is  certainly  not  always  so. 

I  had  under  observation  a  girl  who  was  in  hospital  at  the  age 
of  9^  years  with  a  very  severe  mitral  incompetence,  a  greatly 
enlarged  heart,  and  probably  adherent  pericardium.  At  that 
time  there  was  considerable  oedema,  jaundice  appeared,  and  one 
might  very  reasonably  have  thought  that  the  case  was  near  its 
end.  She  improved,  however,  and  when  seen  3|  years  later 
was  so  much  better  that  she  could  walk  about  and  enjoy  life  in 
a  quiet  way.  She  lived  until  she  was  about  seventeen. 

I  have  seen  other  similar  cases  in  which,  in  spite  of  temporary 
jaundice,  the  heart  condition  improved  under  treatment,  and 
the  children  were  relieved,  at  any  rate  temporarily. 
1  Bnt.  Journ.  Dis.  Childr,,  Jan.,  1907. 


312  COMMON  DISORDERS  OF  CHILDHOOD 

Both  in  pneumonia  and  tuberculosis  jaundice  is  a  symptom 
of  very  grave  significance. 

There  are  other  rarer  conditions  under  which  jaundice  is  seen 
in  childhood  ;  but  with  these  I  am  not  concerned  here  :  for 
instance,  acute  yellow  atrophy,  a  disease  rare  in  adults,  has  been 
«een  but  only  very  rarely  in  children  ;  I  have  not  met  with  an 
instance  myself. 

Family  acholuric  jaundice  (congenital  family  cholsemia)  is 
another  rare  affection  in  which  jaundice  is  usually  present  from 
birth,  becoming  increased  at  times  and  lasting  throughout  life. 
The  urine  in  these  cases  contains  no  bile  pigment  and  the  stools 
are  of  normal  colour.  The  blood  serum  is  found  to  contain  bile 
and  the  red  cells  are  abnormally  fragile. 

This  condition  seems  to  interfere  but  little  with  the  general 
health  and  is  probably  dependent  upon  some  change  in  the  blood- 
forming  system. 


Treatment 

The  child  writh  congenital  obliteration  of  the  bile-ducts,  or 
with  '  hobnail '  cirrhosis  of  the  liver,  is  beyond  the  reach  of 
curative  treatment ;  we  can  only  treat  any  special  symptom  that 
arises. 

Icterus  neonatorum  is  usually  so  evanescent  a  phenomenon 
that  it  calls  for  no  treatment  beyond — and  I  fancy  this  may  be 
of  importance — keeping  the  infant  warm. 

I  have  often  thought  that  some  of  the  cases  in  which  the 
jaundice  just  after  birth  lasts  for  an  unusually  long  time  may  be 
due  to  some  catarrhal  condition  consequent  upon  chilling  of  the 
newborn  infant  :  he  has  just  come  from  an  environment  where 
the  temperature"was  99°  or  more  ;  he  now  lies  naked,  or  in  the 
sorry  protection  of  a  flimsy  shawl,  in  a  room  with  a  temperature 
of  65°  or  less,  while  he  awaits  the  attentions  of  a  nurse  who  is 
perhaps  none  too  careful  to  avoid  chill  in  washing  him.  If  cold 
has  any  share  in  producing  catarrhal  jaundice,  some  such  origin 
seems  at  least  possible  in  some  of  the  cases  of  jaundice  in  the 
newborn. 

However  this  may  be,  there  is  no  doubt  that  feeble  and  prema- 
ture infants  are  specially  liable  to  icterus  neonatorum,  and  on 
every  ground,  therefore,  these  are  cases  in  which  warmth  is 
desirable.  If  the  jaundice  has  not  disappeared  by  the  end  of  the 
second  week,  it  is,  I  think,  well  to  give  grey  powder.  Hyd.  cum 
Greta  gr.  J,  Sod.  Bicarb,  gr.  j,  may  be  given  three  times  a  day  ; 


JAUNDICE  IN  CHILDREN  313 

and  if  there  is  any  reason  for  suspecting  that  congenital  syphilis 
may  be  present  the  dose  of  hyd.  cum  creta  should  be  increased 
to  half  a  grain,  or  unguentum  hydrargyri,  a  piece  the  size  of 
a  large  pea,  may  be  smeared  over  the  chest  or  back  each  night 
and  left  on  till  morning  covered  with  a  flannel  bandage. 

In  the  treatment  of  the  catarrhal  jaundice  of  older  children,  the 
diet  is  of  first  importance  ;  for  whether  as  cause  or  effect  there  is 
no  doubt  that  gastric  disturbance  is  commonly  associated  with 
it,  and  I  think  that  I  have  seen  recrudescence  of  jaundice  pro- 
duced by  overhaste  in  returning  to  an  ordinary  diet  after  the 
restrictions  which  had  been  practised  during  the  earlier  stages 
of  the  disorder. 

The  lightest  of  food  should  be  given  until  all  jaundice  has 
disappeared  :  at  first  veal  broth  or  chicken  tea,  milk  partially 
peptonized,  or  Benger's  Food  prepared  so  as  to  be  thin,  calves'- 
foot  jelly,  not  for  any  special  nutritive  value,  for  it  contains  but 
little,  but  as  a  change  from  the  weary  monotony  of  milk  foods 
and  broth;  then  if  the  child  is  one  of  those  who,  when  in  health, 
tolerates  eggs  well,  an  egg  may  be  given  very  lightly  boiled  or 
beaten  up  raw  with  the  milk  or  in  the  soup  ;  then  custard,  and 
so  back  to  milk-puddings  and  rusks,  and  if  these  cause  no  relapse 
of  the  jaundice,  bread,  chicken,  fish,  and  gradually  the  ordinary 
diet. 

I  think  such  cases  are  best  kept  in  bed,  but  with  care  to  see 
that  the  child  is  so  clothed  that  while  he  sits  up  and  plays  as 
children  will  in  bed,  he  is  not  exposing  himself  to  cold. 

In  the  way  of  drugs  where  there  has  been  vomiting,  I  have 
usually  ordered  bismuth  carbonate  in  10  grain  doses,  with 
bicarbonate  of  soda  in  a  mucilage  mixture.  Sometimes  I  have 
used  the  ordinary  rhubarb  and  soda  mixture,  such  as  Pulv. 
Rhei  gr.  ij,  Sod.  Bicarb,  gr.  v,  Syrup  Zingiber.  0)xv,  Aq.  Anethi 
ad  3ij  ter  die. 

Recently  I  have  been  using  sodium  salicylate.  To  a  child  of 
six,  Sodium  Salicylate  gr.  v,  Sodium  Bicarb,  gr.  v,  Syrup  tt)xv, 
Aq.  Menth.  Pip.  ad  3ij  ter  die  may  be  given.  In  some  of  the 
cases  in  which  I  have  used  it  the  jaundice  has  disappeared  within 
a  few  days  after  the  administration  was  begun  ;  but  in  a  disorder 
of  such  variable  duration  it  is  difficult  to  assign  to  any  mode  of 
treatment  its  fair  share,  if  any,  in  the  recovery  of  the  patient. 


CHAPTER  XXII 
ENLARGED  TONSILS  AND  ADENOIDS 

IF  in  this  chapter  I  have  undertaken  a  subject  which  might 
seem  to  appertain  rather  to  the  surgeon  or  the  throat  specialist 
than  to  the  physician  my  excuse  must  be  that  the  physician  is 
very  frequently  consulted  with  regard  to  the  naso-pharyngeal 
troubles  of  childhood,  even  though  the  treatment  of  them  may 
pass  into  surgical  hands. 

Troubles  in  this  region  have  so  often  a  close  relation  to  dis- 
turbances of  general  health  and  to  symptoms  remote  from  the 
nose  and  throat,  that  it  is  very  necessary  for  every  medical  man 
not  only  to  realize  that  there  is  such  a  relation,  but  to  define  it  as 
cleurly  as  possible  in  his  own  mind.  I  shall  restrict  my  remarks 
to  two  of  the  commonest,  viz.  enlargement  of  the  tonsils  and 
adenoid  overgrowth,  and  I  have  chosen  these  for  consideration 
because  there  are  in  connexion  with  them  many  points  of  practical 
and  everyday  importance. 

In  one  sense  it  is  a  mistake  to  speak  of  '  adenoids  '  and  '  enlarged 
tonsils  '  as  if  they  Avere  two  different  affections  ;  they  are  really 
both  manifestations  of  one  process,  an  overgrowth  of  normal 
lymphoid  tissue,  and  are  therefore  likely  to  be  associated  together. 
And  here  I  would  point  out  that  lymphatic  gland  tissue  or 
adenoid  tissue  has  a  very  wide  distribution  in  the  body.  In  the 
naso-pharynx  there  are  not  only  the  tonsils  but  patches  of  exactly 
similar  tissue  on  the  wall  of  the  pharynx,  aggregated  in  the  middle 
line  to  form  the  so-called  third  tonsil  or  Luschka's  tonsil,  with 
outlying  small  patches  on  the  lateral  parts  of  the  pharyngeal  wall 
near  the  orifices  of  the  Eustachian  tubes.  At  the  base  of  the 
tongue  there  are  some  small  patches,  and  throughout  the  intestine 
there  are  others  in  the  form  of  solitary  follicles  and  Peyer's  patches, 
whilst  in  the  appendix  there  is  much  lymphoid  tissue,  and  in  early 
life  the  thymus  in  its  cortical  part  consists  of  similar  tissue.  The 
spleen  also  is  largely  a  lymphoid  structure  ;  and  lastly  there  are  the 
lymphatic  glands  proper  all  over  the  body,  the  number  and  wide 
distribution  of  which  are  hardly  realized  until  some  such  disease 
as  lymphadenoma  brings  into  prominence  many  which  in  health 
are  not  appreciable  by  ordinary  examination. 

But  it  is  not  only  the  wide  prevalence  of  lymphatic  or  adenoid 


ENLARGED  TONSILS  AND  ADENOIDS  315 

tissue  in  the  body  which  I  wish  to  emphasize  here,  but  also  the 
curious  variability  of  its  development  in  different  individuals. 
Any  one  who  is  familiar  with  the  post-mortem  room  appearances 
of  childhood  will  know  how  greatly  the  prominence  of  the  solitary 
follicles  and  Peyer's  patches  varies  in  different  cases  without  any 
apparent  reason.  Again,  any  one  who  has  tried  to  determine  the 
average  size  and  weight  of  the  thymus  gland  in  children  of  a  given 
age  will  know  that  the  variations  are  so  .great  that  hardly  two 
individuals  can  be  found  to  agree  as  to  what  constitutes  a  normal 
thymus  in  these  respects.  Again,  examine  clinically  a  score  of 
children  in  succession,  children  of  about  the  same  age  and 
apparently  free  from  any  local  source  of  irritation  which  could 
affect  the  glands,  and  you  will  find  that  the  palpability  of 
the  lymphatic  glands  varies  in  so  striking  a  degree  that  it  is 
very  difficult  to  say  what  size  of  glands,  in  the  groin  or  in  the 
neck  or  axilla,  is  to  be  considered  normal.  So  it  is  with  the 
adenoid  tissue  of  the  naso -pharynx  and  tonsils  ;  in  different 
children  it  varies  largely  in  development  quite  apart  from  any 
variation  of  health. 

I  have  drawn  attention  to  these  points  with  a  practical  purpose  : 
in  the  first  place  I  wish  to  insist  that  the  so-called  '  adenoids  '  are 
not  new  growths  ;  they  are  simply  a  more  or  less  excessive 
development  of  normal  structures  which  are  normally  present 
in  this  situation  in  every  child.  Perhaps  I  ought  to  apologize 
for  mentioning  such  an  elementary  fact  to  medical  men  ;  but 
I  do  so  because  1  have  sometimes  thought  that  medical  men  might 
do  more  to  prevent  the  mischievous  conception  in  the  popular 
mind  of  '  adenoids '  as  new  growths,  which,  being  of  the  nature 
of  '  tumours ',  must  inevitably  require  operation.  Excess  of 
adenoid  tissue  in  the  naso-pharynx  may  be  apparent  within  so 
few  days  after  birth  that  it  seems  probable  that  in  some  cases 
at  least  it  is  congenital,  whilst  in  others  the  differences  of  amount 
are  due  to  variation  in  the  development  of  these  tissues  after 
birth.  Childhood  is  the  age  at  which  the  lymphoid  tissue  is 
specially  abundant,  and  it  must  not  be  forgotten  that  this  tissue 
undergoes  an  involution  during  adolescence,  a  fact  of  no  small 
importance  in  connexion  with  treatment. 

Lastly,  I  will  mention  here  a  point  to  which  I  shall  refer  again 
in  connexion  with  treatment,  that  the  adenoid  tissue  of  the  naso- 
pharynx, and  the  tonsils,  being  part  of  the  general  scheme  of 
adenoid  tissue  in  the  body,  may  share  in  such  a  general  overgrowth 
of  this  tissue  as  is  supposed  to  occur  in  the  '  status  lymphaticus '. 

Symptoms.    Turning  now  to  the  results  of  adenoid  hypertrophy 


316  COMMON  DISORDERS  OF  CHILDHOOD 

and  enlarged  tonsils,  I  suppose  that  the  majority  of  them  are 
directly  or  indirectly  due  to  simple  mechanical  obstruction  to  the 
ingress  of  air  ;  that  some  are  due  to  the  catarrhal  state  which 
seems  to  be  favoured  so  greatly  by  the  presence  of  adenoids  and 
enlarged  tonsils  ;  and  that  a  further  count  against  these  structures 
is  the  possibility  of  their  serving  as  a  portal  of  infection. 

It  is  hardly  necessary  to  catalogue  here  the  results  of  mechanical 
obstruction  which  may  be  due  to  adenoids  ;  the  facies,  with  its 
open  mouth  and  its  '  pinched-in  '  nose,  the  heavy  or  snoring 
breathing,  the  nasal  voice,  the  stooping  shoulders  with  the  head 
poked  forward,  and  the  contracted  so-called  '  funnel-shaped 
chest,  with  its  depressed  lower  end  of  sternum  and  often  transverse 
constriction  below  the  nipples  (Harrison's  sulcus),  or,  as  sometimes 
happens,  a  pigeon  chest ;  all  these  are  only  too  familiar.  Hardly 
less  characteristic  are  the  catarrhal  symptoms — frequent  colds, 
deafness,  at  first  occurring  when  the  child  catches  a  fresh  '  cold  ', 
but  soon  becoming  persistent  ;  otitis  media,  hoarseness  indicating 
a  spread  of  the  catarrhal  condition  to  the  larynx,  cough,  especially 
at  night  socvn  after  going  to  bed  or  in  the  early  morning.  Occa- 
sionally there  is  persistent  catarrh  with  muco-purulent  discharge 
from  the  nostrils  ;  there  may  even  be  some  epistaxis,  and  I  have 
seen  cases  in  which  the  irritation  of  the  pharynx  by  the  catarrh 
.seemed  to  induce  vomiting  sometimes  after  food.  Such  are  the 
more  or  less  direct  results,  mechanical  and  catarrhal,  of  adenoids, 
and  no  one,  I  suppose,  doubts  their  relation  to  the  adenoids  ;  but 
when  \ve  come  to  the  supposed  indirect  results,  there  is  much 
more  room  for  scepticism. 

It  is  natural  enough  that  the  child  whose  air-entry  is  diminished, 
and  whoso  sleep  is  so  disturbed  by  the  difficulty  of  breathing  that 
he  never  has  a  properly  refreshing  sleep,  should  be  pale  and  lacking 
in  vivacity,  may,  indeed,  seem  stupid,  and  suffer  with  headache, 
and  it  is  even  possible  that  the  nervous  system  under  such  con- 
ditions may  become  unduly  irritable,  so  that  the  child  is  pre- 
disposed to  such  affections  as  habit-spasm  or  stuttering,  or  to 
a  combination  of  nervous  with  catarrhal  conditions,  as  in  spas- 
modic croup,  laryngitis  stridulosa,  or  asthma  ;  possibly  even  the 
tendency  to  so  remote  an  affection  as  enuresis  may  be  increased 
by  the  deficient  aeration  and  consequent  irritability  of  the  nervous 
system. 

But  to  suppose,  as  some  have  done,  that  adenoids  can  produce 
nervous  or  any  other  affections  by  some  mysterious  reflex  effect 
apart  from  any  mechanical  obstruction  or  catarrh  is  an  assump- 
tion which  seems  to  me  wholly  unwarranted. 


ENLARGED  TONSILS  AND  ADENOIDS  317 

In  addition  to  the  mechanical  and  catarrhal  results  of  adenoids, 
there  is  another  group  of  consequences,  and  by  no  means  the 
least  important,  namely,  those  connected  with  bacterial  infection. 

Look  at  the  irregularities,  the  pits  and  furrows  on  the  surface 
of  enlarged  tonsils  :  see  the  cheesy  secretion  protruding  from  the 
open  crypts  ;  or  again,  look  at  a  recently  removed  pharyngeal 
tonsil,  the  so-called  '  adenoid  '  mass,  with  its  folded  irregular 
surface  ;  it  is  hardly  surprising  that  in  the  nooks  and  crannies 
of  such  a  structure  bacteria  should  find  a  nidus.  Local  infection 
must  surely  be  favoured  by  this  condition,  and  when  such  an 
infection  as  diphtheria  has  once  taken  hold,  everything  is  against 
the  rapid  disappearance  of  the  bacillus  from  such  a  throat  ;  it  is 
more  than  probable  also  that  under  such  conditions  any  infective 
disease  attacking  the  fauces  or  naso-pharynx  is  likely  to  run 
a  severe  course. 

Research  has  actually  shown  the  tubercle  bacillus  both  in  the 
tonsils  and  in  '  adenoids  ',  and  Drs.  Poynton  and  Paine  have 
obtained  the  coccus  which  they  have  found  in  rheumatic  joints 
and  rheumatic  heart  lesions  from  the  tonsils. 

So  far  I  have  referred  chiefly  to  the  results  of  adenoid 
hypertrophy  ;  now  let  me  say  a  few  words  about  the  results  of 
enlarged  tonsils.  These  similarly  range  themselves  under  the 
three  headings — mechanical,  catarrhal,  and  infective.  In  the 
very  large  majority  of  cases  enlargement  of  the  faucial  tonsils 
is  associated,  as  one  might  expect  from  the  similarity  in  the 
character  of  the  structures,  with  enlargement  of  the  pharyngeal 
tonsil  that  is  '  adenoids ' ;  and  the  resultant  evils  are  for  the  most 
part  only  an  aggravation  of  those  I  have  already  mentioned. 
But  enlargement  of  the  faucial  tonsils  does  introduce  certain 
modifications  into  the  picture  :  the  voice  is  different,  the  catarrhal 
affection  takes  the  form  of  a  recurring  tonsillitis,  a  cold  always 
'  flies  to  the  child's  throat '.  Enlargement  of  the  faucial  tonsils 
adds  also  to  the  infective  risks.  As  already  mentioned,  the  micro- 
coccus  of  rheumatism  has  been  found  in  the  tonsils,  not,  so  far  as 
I  am  aware,  in  adenoids  ;  the  tubercle  bacillus  has  been  found  in 
both,  but  Dr.  Hugh  Walsham,  in  his  work  on  the  channels  of 
tuberculous  infection,  says  that  he  could  not  find  it  after  many 
investigations  on  adenoids,  whereas  it  was  found  repeatedly  in 
enlarged  tonsils. 

In  connexion  with  recurring  tonsillitis  there  is  one  point  which 
calls  for  special  mention,  as  it  is,  I  think,  often  overlooked, 
namely,  the  connexion  between  decayed  teeth  and  these  faucial 
inflammations.  No  one,  I  suppose,  doubts  that  the  recurrence  of 


318  COMMON  DISORDERS  OF  CHILDHOOD 

tonsillitis  depends  upon  fresh  outbreaks  of  infection  in  the 
crevices  and  irregularities  of  the  tonsils,  and  no  doubt  repeated 
attacks  of  inflammation  are  caused  similarly  in  the  adenoid 
tissue  of  the  naso-pharynx  ;  but  how  often  one  sees  children 
who  are  being  assiduously  sprayed  and  painted  and  dosed  in 
the  hope  of  preventing  the  frequent  sore  throats,  whilst  no  one 
pays  any  special  attention  to  several  decayed  and  foul  stumps, 
perchance  with  pus  actually  oozing  from  the  gums,  a  veritable 
hotbed  of  infection. 

There  are  cases  in  which  a  frequently  recurring  acute  inflam- 
mation of  chronically  enlarged  tonsils  is  associated  with  gastro- 
intestinal disturbance,  the  stools  become  offensive,  loose,  and 
slimy,  with  much  mucus.  This  association  is  so  constant  in 
these  particular  cases  that  one  cannot  but  suppose  that  some 
recurring  infection  of  the  throat  leads  to  an  infective  catarrh  of 
the  stomach  or  bowel.  I  have  seen  several  such  cases  and  have 
found  them  most  intractable. 

Treatment.  The  first  principle  that  I  wish  to  lay  down  very 
emphatically  is  this,  the  mere  fact  that  a  child  has  adenoids  or 
enlarged  tonsils  is  not  necessarily  an  indication  for  treatment  of 
any  kind,  much  less  for  surgical  interference  ;  the  one  and  only 
one  criterion  of  the  necessity  of  treatment  is  the  presence  of 
harmful  results  from  them.  I  see  children  in  whom  some  one 
with  an  excess  of  zeal  for  examination,  as  it  seems  to  me,  has 
passed  his  finger  up  into  the  child's  naso-pharynx,  and  finding, 
as  he  thought,  that  the  pharyngeal  tonsil  is  more  easily  felt  than 
normal,  has  announced  that  the  child  has  '  adenoids  '  and  requiies 
an  operation,  although  perhaps  admittedly  they  are  producing 
only  the  slightest  symptoms,  and  these  possibly  of  doubtful 
relation  to  the  adenoids,  and  sometimes,  indeed,  they  are  pro- 
ducing no  symptoms  at  all. 

I  think  that  such  advice  is  wholly  bad  :  but  before  stating  my 
reasons  for  this  view,  let  me,  in  passing,  say  a  word  on  the  digital 
examination  for  adenoids.  Is  it  necessary  to  poke  one's  finger 
into  the  naso-pharynx  to  see  whether  there  are  adenoids  ?  It  is, 
to  put  it  mildly,  an  extremely  uncomfortable  procedure.  To  a 
child  it  is  more  than  uncomfortable,  it  is  terrifying  ;  and  I  know 
only  too  well  from  experience  of  children  who  have  been  examined 
in  this  way  before  they  are  brought  to  me,  that  henceforth  the 
very  sight  of  a  doctor  makes  them  scream  with  fear. 

Now  I  very  much  doubt  whether  adenoids  which  so  far  fail  to 
declare  themselves  by  symptoms  as  to  require  a  digital  examina- 
tion to  determine  whether  there  is  adenoid  hypertrophy  or  not, 


ENLARGED  TONSILS  AND  ADENOIDS  319 

require  any  treatment  whatever  :  always  assuming,  of  course, 
that  the  observer  has  sufficient  experience  to  know  what  the 
symptoms  of  adenoids  are  :  and  therefore  I  would  lay  it  down  as 
a  general  rule  (and  every  rule  has  its  exceptions)  that  there  is  no 
occasion  whatever  to  poke  the  finger  into  the  naso-pharynx  in 
order  to  decide  whether  there  are  '  adenoids '  which  require 
treatment.  Every  child  has  adenoid  tissue  in  the  naso-pharynx  ; 
the  pharyngeal  tonsil  is  a  normal  part  of  our  anatomy  ;  the 
question  whether  it  is  sufficiently  enlarged  to  require  any  treat- 
ment should  be  determined  solely  by  the  symptoms  to  which  it  is 
giving  rise. 

Now  to  return  to  my  previous  point  that  adenoid  tissue, 
whether  that  in  the  naso-pharynx  or  the  faucial  tonsil,  even  when 
distinctly  hypertrophied,  does  not  necessarily  need  removal. 

It  is  to  be  remembered  that  both  the  naso -pharyngeal  and 
faucial  tonsils  undergo  an  involution,  so  to  speak,  after  puberty, 
and  this  even  where  there  have  been  catarrhal  or  inflammatory 
symptoms  which  might  be  thought  to  entail  fibrous  changes  in 
them  ;  no  doubt  the  presence  of  such  fibroid  inflammatory  change 
makes  the  involution  after  puberty  less  than  it  otherwise  wrould 
be  ;  but  I  wish  to  insist  upon  the  fact  that\he  occurrence  of  two 
or  three  attacks  of  tonsillitis,  or  of  repeated  '  colds  '  as  happens 
so  often  with  adenoids,  does  not  preclude  the  possibility  of  con- 
siderable diminution  in  the  size  of  these  structures  after  puberty. 

If,  therefore,  adenoids  or  tonsils  are  producing  no  symptoms 
or  are  associated  with  symptoms  which  are  not  of  serious  gravity, 
for  instance,  merely  with  a  rather  greater  tendency  to  'catch 
cold  '  than  usual,  or  with  the  occurrence  on  one  or  two  occasions 
of  a  tonsillitis,  without  any  affection  of  the  ears  or  other  complica- 
tion, there  is  no  occasion  to  rush  into  operation. 

It  may  be  that  further  enlargement  of  these  structures  may 
occur,  and  produce  symptoms  which  may  make  the  operation 
necessary  ;  but  if  so,  the  harm  of  waiting  until  this  occurs  is  less 
than  the  harm  of  doing  an  unnecessary  operation. 

But,  says  one,  if  you  wait,  surely  there  is  risk  of  ear  affection, 
which  is  perhaps  the  most  serious  of  all  the  direct  evils  from 
adenoids  and  enlarged  tonsils  ?  To  this  I  would  reply  that  one 
of  the  admitted  and  immediate  results  of  the  operation,  an 
occasional  one  it  is  true,  but  nevertheless  an  undoubted  one,  as 
I  can  testify  from  my  own  experience,  is  acute  otitis  media,  set 
up  no  doubt  by  the  inflammatory  reaction  in  the  naso-pharynx 
after  the  operation.  This,  however,  is  one  of  the  lesser  risks. 
The  chief  reason  for  avoiding  the  operation  whenever  possible  is 


320  COMMON-  DISORDERS  OF  CHILDHOOD 

that,  like  other  operations,  it  is  not  free  from  danger  to  life.  I  am 
assured  by  throat  specialists  that  they  have  done  so  many  hundreds 
or  thousands  without  a  single  fatal  result.  This  no  doubt  proves 
that  the  risk  to  life  is  a  small  one  ;  but  it  does  not  alter  the  fact 
that  death  has  resulted.  I  myself  could  mention  one  in  which 
it  occurred  from  haemorrhage,  another  apparently,  from  sepsis, 
two  from  '  death  under  the  anaesthetic  ',  and  another  in  which  it 
appeared  to  be  due  simply  to  shock,  and  I  could  quote  other  cases 
from  my  own  experience  in  which  life  was  all  but  lost  through  this 
operation.  No  doubt  such  accidents  are  rare,  but  the  rarity  is  no 
comfort  to  the  parents  when  they  have  lost  their  child. 

If  it  be  true  that  '  death  under  the  anaesthetic  '  is  to  be  attri- 
buted to  the  so-called  '  status  lymphaticus  ',  ttnd  if  this  status 
lymphaticus  is  evidenced  partly,  as  we  are  told,  by  such  an 
increase  of  lymphoid  tissue  as  is  seen  clinically  in  enlargement  of 
tonsils  and  the  presence  of  '  adenoids  ',  it  follows  that  the  sub- 
jects of  these  affections  are  just  those  on  whom  operation  is  to  be 
avoided  as  far  as  possible. 

Let  us  therefore  realize  that  although  in  comparison  with  some 
operations  that  for  adenoid  overgrowth  and  enlarged  tonsils  is 
a  small  one,  it  is  not  entirely  free  from  danger  to  life  ;  and  there- 
fore unless  the  symptoms  produced  by  adenoids  or  enlarged 
tonsils  entail  grave  harm  to  the  child,  operation  is  not  to  be 
recommended. 

But  what  constitutes  grave  harm  from  adenoid  hypertrophy 
and  enlarged  tonsils  ?  Recurring  earache,  and  still  more,  the 
slightest  degree  of  deafness,  even  if  it  only  recurs  when  the  child 
has  a  cold,  is  one  of  the  strongest  reasons  to  my  mind  for  surgical 
treatment  of  adenoids  and  tonsils  ;  but  I  doubt  whether  one 
attack  of  earache  necessitates  operation  ;  it  is  quite  certain  that 
a  slight  catarrh  in  the  throat  may  cause  earache  which  may  never 
recur. 

In  some  cases  the  chief  harm  resulting  from  adenoid  or  tonsillar 
obstruction  is  general  ill  health  :  the  child  is  pale,  or  of  pasty 
complexion,  partly  no  doubt  owing  to  deficient  aeration  of  the 
blood,  but  partly,  I  think,  from  lack  of  refreshing  sleep,  for  many 
of  these  children  with  marked  adenoid  or  tonsillar  hypertrophy 
sleep  restlessly,  wake  frequently,  and  are  dull  and  heavy-ej^ed, 
perhaps  nervous  and  peevish,  in  consequence.  One  of  the  gratify- 
ing results  of  operation  in  such  cases  is  the  marked  improvement 
in  the  sloop,  and  I  agree  with  parents  who  have  told  me  that  they 
thought  the  improvement  in  the  child's  general  health  was  largely 
due  to  this. 


ENLARGED  TONSILS  AND  ADENOIDS  321 

Another  class  of  cases  which  sometimes  calls  for  operative 
procedure  is  that  in  which  large  tonsils  are  present,  and  there  is 
a  frequent  and  harassing  recurrence  of  acute  tonsillitis  which  can 
only  be  stopped  by  removing  the  tonsils. 

Similarly  there  are  cases  in  which  catarrh  starting  in  the  naso- 
pharynx spreads  to  the  bronchi  repeatedly,  so  that  it  may  be 
necessary  to  remove  adenoids  to  prevent  the  recurrence  of 
bronchitis.  I  have  felt  tempted  to  advise  the  operation  in  some 
cases  of  laryngitis  stridulosa  and  asthma,  where  these  affections 
were  associated  with  adenoids  and  enlarged  tonsils,  but  the 
effectiveness  of  medicinal  treatment  has  deterred  me  unless  there 
were  other  reasons  for  the  operation. 

Another  sufficient  reason  for  operation  is  deformity  of  the 
chest  resulting  from  throat  obstruction ;  the  child  with  a  con- 
stantly open  mouth,  rounded  shoulders,  head  poked  forward, 
narrow  chest,  pigeon  breast  or  depressed  sternum,  is  one  that 
requires  operation. 

The  probability  of  rheumatic  infection  through  the  tonsils  has 
been  mentioned  ;  certainly  it  is  very  common  to  find  enlarged 
tonsils  associated  with  rheumatic  affections.  Whether  rheumatic 
infection  can  be  prevented  by  removal  of  the  enlarged  tonsils 
has  yet  to  be  determined.  I  have  kept  clinical  notes  for  some 
years  of  cases  bearing .  upon  this  point,  but  they  only  prove 
that  the  ordinary  partial  removal  of  tonsils  does  not  prevent 
the  recurrence  of  rheumatism  in  a  child  who  has  previously  had 
rheumatism. 

One  serious  result  to  which  perhaps  not  enough  importance  is 
attached  is  enlargement  of  the  glands  at  the  angle  of  the  jaw. 
Whether  the  tubercle  bacillus  gains  access  to  these  directly 
through  the  pharyngeal  or  faucial  tonsils,  or  comes  to  them  via 
the  blood,  I  think  there  can  be  no  doubt  that  the  lymphatic 
glands,  once  enlarged,  are  particularly  liable  to  become  a  nidus 
for  tubercle  ;  and  therefore,  especially  in  the  child  of  tubercular 
family,  or  of  known  tubercular  tendency,  enlargement  of  the 
gland  from  these  throat  sources  should  raise  the  question  of 
removal  of  adenoids  and  tonsils. 

But  here  caution  is  necessary  ;  the  question  is  often  not  raised 
until  the  glands  are  already  not  only  tuberculous  but  greatly 
enlarged,  more  or  less  evidently  caseous,  and  perhaps  on  the  verge 
of  softening.  It  is  a  difficult  point  to  decide  whether  under  these 
circumstances  immediate  operation  should  be  done  upon  the 
throat,  even  though  the  condition  there  obviously  will  necessitate 
operation  sooner  or  later.  There  is  a  risk  that  by  inducing 

STILL  y 


322  COMMON  DISORDERS  OF  CHILDHOOD 

a  temporary  inflammatory  condition  in  the  throat  the  glands 
may  be  stirred  into  further  activity  and  the  last  chance  of  their 
subsidence  be  extinguished. 

Probably  it  is  best  to  wait  and  send  the  child  to  the  seaside 
under  close  medical  supervision.  If  the  glands  subside,  all  well 
and  good  ;  when  the  subsidence  has  reached  a  considerable 
degree  the  tonsils  and  adenoids  can  be  removed.  If  the  glands 
do  not  subside  they  can  be  removed,  and  after  the  wound  has 
healed  and  the  child  has  been  away  again  to  convalesce,  the 
throat  can  be  dealt  with. 

One  hears  of  cases  in  which  such  troubles  as  night -terrors  and 
cnuresis  have  been  stopped  by  removal  of  adenoids  or  large 
tonsils  ;  I  confess  to  a  certain  amount  of  scepticism  as  to  the 
relation.  I  can  say  positively  that  the  mere  presence  of  adenoids 
or  enlarged  tonsils  does  not  preclude  successful  treatment  of  night- 
terrors  or  enuresis  by  simple  medicinal  measures  ;  I  have  seen  it 
again  and  again.  On  the  other  hand,  I  have  repeatedly  known 
these  operations  to  have  no  effect  whatever  on  enuresis — some- 
times apparently  to  aggravate  it ;  moreover,  in  the  few  instances 
where  I  have  known  the  enuresis  to  stop  immediately  after  the 
operation  it  has  generally  recurred  subsequently. 

Epilepsy,  I  think,  is  never  caused  primarily  by  enlarged  tonsils 
or  adenoid  hypertrophy,  but  it  seems  only  reasonable  to  suppose 
that  the  ill-health  which  is  produced  by  any  marked  degree  of 
naso-pharyngeal  obstruction  may  aggravate  the  tendency  in 
a  child  already  disposed  to  epilepsy,  and  this,  I  think,  is  the  case. 
I  have  seen  a  few  instances  in  which  operation  on  the  throat  under 
these  circumstances  seemed  to  diminish  the  attacks  greatly. 

It  will  be  evident  from  what  I  have  said  that  whilst  the  opera- 
tion for  enlarged  tonsils  and  adenoid  overgrowth  is  never  to  be 
done  unless  there  is  very  grave  reason  for  doing  it,  there  are  many 
cases  in  which  such  reasons  are  present. 

But  even  when  operation  is  necessary  there  is  still  need  for 
careful  consideration  of  the  special  requirements  of  the  individual 
child— there  is  a  time  to  operate  and  a  time  not  to  operate.  The 
child's  condition,  apart  from  its  naso-pharynx,  must  be  taken  into 
account.  It  is  exceedingly  common  in  all  classes,  and  perhaps 
specially  in  these  mouth-breathing  children,  to  find  carious  teeth 
and  foul  stumps  ;  the  dentist  should  deal  with  such,  and  if  possible 
get  the  month  into  a  cleaner  and  healthier  condition  before  any 
operation  on  adenoids  or  tonsils  is  done.  As  I  have  already 
suggested  (p.  ;{J7),  the  mere  removal  of  carious  stumps  and 
removal  of  sepsis  iu  connexion  with  the  gums  and  teeth  may 


ENLARGED  TONSILS  AND  ADENOIDS  323 

do  much  to  prevent  the  recurrence  of  inflammation  in  the  fauces 
and  naso-pharynx. 

Then,  again,  I  often  see  children  who  have  recently  had  an 
attack  of  acute  tonsillitis  ;  the  tonsils  are  greatly  enlarged,  and 
the  question  of  their  removal  is  raised.  It  is,  I  think,  never  wise 
to  recommend  operation  very  soon  after  an  acute  tonsillitis,  for  the 
inflammatory  enlargement  may  gradually  subside  within  three  or 
four  months  to  such  a  degree  that  operation  is  entirely  unnecessary. 

When  a  child  is  in  a  highly  nervous  state,  as  shown,  for  instance, 
by  the  presence  of  habit-spasm,  it  is  better  to  wait  unless  there 
are  any  symptoms  which  make  the  operation  urgently  necessary, 
for  there  is  no  doubt  that  it  entails  a  certain  amount  of  nervous 
shock,  especially  to  the  timid,  nervous  child  ;  I  have  seen  habit- 
spasm  markedly  aggravated  thereby,  and  I  have  known  children 
after  this  operation  to  fall  into  a  state  of  morbid  nervousness, 
from  which  they  did  not  recover  for  many  weeks. 

Another  point  which  should  be  considered  is  the  season  of  the 
year  at  which  the  operation  should  be  done.  Of  course  circum- 
stances may  leave  us  no  choice  of  season,  but  where  choice  is 
possible  I  think  it  is  undoubtedly  safer  to  have  it  done  during 
the  warm  months  than  in  winter,  for  onevof  the  sequelae  of  the 
operation  is  a  bronchitis  apparently  due  to  spread  of  the  inflam- 
matory reaction  from  above  downwards  into  the  air-passages. 

Lastly,  with  regard  to  the  operative  treatment,  I  feel  I  must 
say  a  word  on  the  actual  doing  of  the  operation,  and  perhaps, 
being  a  physician,  and  having,  therefore,  no  active  part  in  the 
operative  treatment,  I  may  speak  with  the  greater  freedom.  I  am 
constantly — I  use  the  word  deliberately — constantly  seeing  chil- 
dren for  conditions,  generally  catarrhal  conditions,  connected  with 
the  throat,  who  are  said  to  have  had  their  tonsils  and  adenoids 
removed.  It  is  obvious,  both  from  the  symptoms  and  from 
examination  of  the  throat,  that  the  removal  has  been  very  incom- 
plete ;  a  certain  amount  both  of  the  pharyngeal  and  of  the  faucial 
tonsils  has  been  removed,  and  the  stump  left  behind  is  perhaps 
even  more  ragged  and  irregular  in  surface  than  the  original  whole 
tonsil  would  have  been,  with  the  result  that  bacteria  are  still 
caught  in  its  crevices,  recurring  catarrh  with  its  attendant 
symptoms  and  complications  still  troubles  the  child,  and  the 
parents  are  grievously  disappointed. 

I  would  lay  stress  upon  the  importance  of  complete  removal  of 
the  adenoids  and  tonsils  by  whatever  method  is  found  to  be  most 
practicable  :  the  results  of  enucleation  seem  to  me  the  most 
satisfactory,  but  I  am  well  aware  that  in  the  hands  of  an  expert 

Y2 


324  COMMON  -DISORDERS  OF  CHILDHOOD 

tonsillotomy  may  be  to  all  intents  and  purposes  tonsillectomy ; 
anyway,  I  feel  sure  the  thing  to  be  aimed  at  is  complete  removal 
of  the  tonsils.  It  is  not  for  me  to  dilate  upon  the  applicability  of 
particular  methods  in  particular  cases  ;  I  feel  sure  that  while  no 
man  will  b3  equally  successful  in  all  cases,  the  success  of  this  or 
that  method  depends  very  largely  upon  the  individual  using  it. 

I  will  even  venture  to  insist  that  the  operation  for  removal  of 
adenoids  and  tonsils  is  not  so  simple  an  operation  that  anybody 
and  everybody  who  happens  to  have  a  surgical  qualification  and 
a  guillotine  can  do  it  as  it  ought  to  be  done  :  it  is  one  which,  if 
done  at  all,  ought  to  be  done  by  the  most  expert  skill  obtainable. 

So  much  for  surgical  treatment.  I  have  said  already  that  the 
mere  presence  of  adenoid  and  tonsillar  hypertrophy  is  not  suffi- 
cient ground  for  operative  interference.  I  have  also  stated  that 
a  mere  slight  tendency  to  iiaso-pharyngeal  catarrh  or  an  occasional 
attack  of  tonsillitis  is  not,  p  r  se,  sufficient  justification  for  opera- 
tion. Is  there  any  good  to  be  gained  from  medical  treatment  ? 

The  slighter  catarrhal  conditions  associated  with  adenoids 
are  undoubtedly  amenable  to  treatment  by  local  applications. 
Children  of  about  eight  years  or  more  will  use  successfully  a  lotion 
to  be  sniffed  up  the  nostrils  night  and  morning  ;  this  method  of 
application  is  less  frightening  to  most  children  than  syringing. 
I  generally  direct  that  a  small  medicine  glass  is  to  be  filled  with 
the  warm  lotion  and  the  child  is  to  '  drink  the  lotion  through  his 
nose  and  spit  it  out  through  his  mouth  '.  A  useful  formula  for  this 
purpose  is  :  sod.  bicarb.,  borax,  sod.  chlorid.  aa  gr.  xv,  glycerin  3j> 
aq.  ad  5]  (K.  C.  H.  Pharmac.),  a  table-spoonful  to  be  used  with 
two  table-spoons  of  warm  water  ;  or  boro-glyceride,  a  teaspoonful 
in  four  ounces  of  water,  may  be  used.  Probably  an  alkaline  lotion 
is  generally  most  useful  as  tending  to  wash  away  mucous  secretion 
most  readily.  Dr.  Eustace  Smith  recommends  dropping  a  few 
drops  of  a  lotion  down  each  nostril  as  the  child  lies  on  his  back, 
and  for  this  purpose  advises  a  1  per  cent,  solution  of  resorcin  in 
'normal  saline',  to  each  ounce  of  which  20  drops  of  tinct.  hama- 
mrlis  may  be  added,  if  the  child  is  subject  to  epistaxis.  For 
those  who  are  not  old  enough  or  are  too  timid  to  use  a  lotion  in 
this  way,  a  very  fine  spray  or  vaporizer  can  be  used  with  one  of 
the  various  apparatuses  sold  for  the  purpose.  The  fine  sprays  in 
which  an  antiseptic,  such  as  oil  of  eucalyptus,  is  mixed  with  an 
oily  base,  such  as  liquid  paraffin,  are  particularly  useful,  as  the 
child  docs  not  feel  the  spray  as  fluid,  and  consequently  is  not 
frightened,  and  the  oily  material  remains  in  contact  with  the 
parts  longer  than  a  watery  solution  would  do. 


ENLARGED  TONSILS  AND  ADENOIDS  325 

Whether  the  tonsils  can  be  diminished  in  size  by  any  local 
application  is  perhaps  open  to  doubt.  It  is  certain  that  they 
sometimes  become  smaller  while  astringents  or  antiseptic  paints 
are  being  applied,  but  it  is  equally  certain  that  tonsils  which  have 
become  swollen  by  some  recent  tonsillitis  may  slowly  decrease  in 
size  without  local  treatment  of  any  sort,  until  after  several 
months  there  may  be  practically  no  enlargement  remaining — 
a  point  to  be  remembered  when  the  question  of  operation  is  being 
considered.  On  the  other  hand,  there  are  enlarged  tonsils  of 
hard  fibrous  appearance,  the  result  of  repeated  inflammation, 
which  are  not  likely  to  diminish  in  size  either  with  or  without 
applications.  None  the  less  I  think  that  where  tonsillar  enlarge- 
ment is  associated  with  a  tendency  to  recurring  tonsillitis,  a  perse- 
vering application  of  some  antiseptic  or  astringent  twice  daily 
for  many  months  reduces  the  liability  to  a  recurrence  of  the 
tonsillitis,  and  in  this  way.  at  least,  favours  the  subsidence  of  the 
enlargement.  A  useful  paint  is  tinct.  hydrastis  3j,  glycerin 
boracis  §ss,  glycerin  ad  gj,  to  be  applied  with  a  camel-hair  brush 
to  the  tonsils  twice  or  thrice  daily ;  the  application  should  be  after 
meals,  so  that  the  paint  may  not  be  carried  away  by  any  food 
or  drink  taken.  Glycerin  and  tannic  acid  is  often  used  similarly. 
A  paint  consisting  of  iodine  gr.  1J,  pot.  iod.  gr.  vi,  menthol  gr.  \, 
glycerin  ad  §j,  is  in  use  at  the  Children's  Hospital,  Great  Ormond 
Street :  a  similar  combination  with  much  larger  doses  is  often 
used,  e.g.,  iodine  gr.  v  and  pot.  iod.  gr.  x  in  the  ounce  of  glycerin. 

In  the  slighter  cases  of  adenoid  and  tonsil  overgrowth  breathing 
exercises  may  have  some  remedial  value,  partly  directly  by  pro- 
ducing a  healthier  condition  of  the  mucous  membrane,  and 
partly  indirectly  by  improving  the  general  health  and  so  reducing 
the  liability  to  catarrh.  But  the  chief  value  of  breathing  exercises 
is  after  removal  of  enlarged  tonsils  and  adenoids  :  too  often  one 
sees  children  losing  in  great  measure  the  benefit  of  the  operation 
because  no  directions  have  been  given  as  to  teaching  the  child  to 
breathe  properly  afterwards,  and  the  child  continues  a  mouth 
breather  when  the  necessity  is  no  longer  present. 

Lastly,  the  climatic  environment  may  have  to  be  considered. 
A  cold,  damp  atmosphere,  and  espacially  the  fogs  which  we  have 
in  London  during  the  winter,  are  potent  factors  in  the  produc- 
tion of  repeated  naso-pharyngeal  catarrh,  whatever  may  be  the 
bacterial  element.  The  ideal  place  of  residence  for  children  with 
the  tendency  to  enlargement  of  faucial  and  pharyngoal  tonsils 
is  one  which  stands  high  and  has  a  porous  soil,  allowing  of  rapid 
drying  after  rain. 


CHAPTER  XXIII 

LARYNGITIS  STBIDULOSA,  AND   OTHER 
AFFECTIONS  KNOWN  AS   'CROUP' 

I  HAVE  placed  at  the  head  of  this  chapter  the  popular  term 
*  Croup  ',  departing  thereby  from  present-day  scientific  nomen- 
clature, and  doing  so  deliberately,  because  this  term  is  still  in 
common  use  by  the  laity  in  describing  a  child's  ailment,  and  is 
sometimes  employed  by  medical  men  with  such  a  varying 
significance  that  it  is  well  we  should  realize  the  several  con- 
ditions to  which  it  may  refer. 

In  former  days  croup  was  a  recognized  scientific  term  ;  in 
the  medical  textbooks  of  less  than  a  century  ago  it  was  regu- 
larly used  to  signify  what  was  supposed  to  be  a  disease  sui 
generis.  In  Underwood's  Treatise  on  the  Diseases  of  Children, 
which  he  dedicated  to  the  Queen  in  1784,  '  The  Croup  or  Acute 
Asthma  '  is  described  very  fully,  and  as  alternative  names  are 
mentioned  *  Asthma  infantum  spasmodicus  '  and  '  Suffocatio 
Stridula  '  ;  like  other  writers  about  that  time,  he  was  evidently 
impressed  with  the  fact  that  whilst  in  some  cases  the  attack  was 
harmless,  in  others  it  was  very  dangerous,  and  he  mentions  two 
stages,  the  earlier  of  which  is  highly  amenable  to  treatment, 
whilst  in  the  later  no  treatment  avails. 

It  is  evident  from  his  description  that  he  did  not  differentiate 
between  conditions  so  widely  different  in  their  etiology  and 
pathology  as  Laryngismus  Stridulus,  Laryngitis  Stridulosa,  and 
Diphtheria.  Restates  that  in  the  only  post  mortem  he  had  seen 
on  a  case  of  croup  there  was  membrane  all  down  the  trachea. 

Fifty  years  later  (in  1836),  when  Sir  Thomas  Watson  was 
lecturing  at  King's  College,  London,  on  '  croup  ',  the  title  of  his 
lecture  was  '  Cynanche  trachealis,  Tracheitis,  or  Croup  '.  He 
laid  stress  on  the  membrane  in  the  trachea  in  cases  of  croup  ; 
he  described  how  certain  places — for  instance,  the  Cow  Gate  and 
Canal  Street  in  Edinburgh — were  infamous  for  croup,  which 
killed  a  large  number  of  children.  Curiously  enough,  however, 
he  regarded  it  as  non-contagious,  although  lie  observed  that  it 
was  endemic  in  certain  places,  and  even  when  describing  two 
children  in  one  family  as  suffering  from  it  on  the  same  night  he 
attributed  it  to  walking  in  a  cold  wind. 


LARYNGITIS  STRIDULOSA  327 

He  considered  a  sudden  onset  at  night,  and  a  remarkable 
tendency  to  recur  as  characteristic  of  the  affection.  Almost 
incidentally  he  referred  to  a  disease  which  he  said  was  much 
more  common  in  France  than  in  this  country,  a  '  diphtheritis ' 
which  resembled  '  croup  '  in  producing  a  membrane,  but  this, 
he  said,  could  not  be  the  same  disease,  for  the  membrane  was 
on  the  fauces  primarily  and  only  secondarily  in  the  trachea. 

On  this  point  it  is  interesting  to  note  that,  according  to  his 
own  statement,  his  opinion  was  not  shared  by  Dr.  Charles  West, 
who,  a  few  years  later,  founded  the  Hospital  for  Sick  Children, 
Great  Ormond  Street.  West  regarded  diphtheritis  and  the 
membranous  croup  as  one  and  the  same  disease. 

I  have  referred  to  Sir  Thomas  Watson  chiefly  because  he 
mentions  what  he  calls  '  a  sort  of  bastard  croup  ',  which,  he 
says,  had  already  been  recognized  by  various  observers  as  a 
distinct  malady.  He  says  that  one  Dr.  Good  bestowed  upon  it 
'  the  somewhat  pedantic  and  cacophonous  title  Laryngismus 
Stridulus  '  ;  he  prefers  to  call  it  '  child-crowing  ',  whilst  others, 
he  says,  have  called  it  '  cerebral  croup  ',  arid  others  again  '  spas- 
modic croup  '  ;  under  these  titles  he  gives  a  good  description  of 
what  we  know  now  as  the  laryngismus  stridulus  associated  with 
rickets. 

West  in  his  Lectures  on  Diseases  of  Children  comes  very  near 
to  making  a  further  differentiation  between  these  conditions 
known  as  croup,  but  failed  owing  to  his  preconceived  idea  that 
in  the  early  stage  of  what  he  calls  '  true  croup  ',  laryngeal,  or 
tracheal  diphtheria,  the  obstructive  dyspnoea  is  due  chiefly  to 
spasm  of  the  larynx,  whilst  later  the  inflammatory  symptoms 
predominated  with  formation  of  membrane.  He  tells  how  some 
observers  had  thought  that  there  was  a  group  of  cases  which 
were  quite  distinct  from  diphtheria,  cases  in  which  a  spasmodic 
laryngitis  was  present,  but  in  which  the  inflammatory  process 
played  a  much  less  prominent  part  than  the  spasm  ;  he  dismisses 
this  view  as  untenable  on  the  ground  that  the  difference  depends 
merely  on  the  idiosyncrasy  of  the  patient,  and  he  mentions  in 
this  connexion  almost  incidentally  the  name  '  Laryngitis  Stridula  ' 
which  had  been  used  by  a  Monsieur  Guersant  in  1835  to  distinguish 
this  spasmodic  condition,  which  we  now  recognize  as  absolutely 
distinct  from  diphtheria  under  the  name  '  Laryngitis  Stridulosa  '. 

This  brings  me  to  our  present  position  as  regards  '  Croup  '  : 
when  we  are  told  by  a  mother  that  her  child  has  the  croup,  what 
may  be  the  significance  of  the  term  ?  For  the  mother  as  for  the 
older  physicians,  croup  is  any  condition  in  which  the  cough 
has  the  ringing,  barking,  almost  brassy  character  of  a  laryngeal 


328  COMMON  DISORDERS  OF  CHILDHOOD 

cough,  or  in  which  there  is  stridor.  There  are  four  common 
conditions  which  are  included  thus  in  the  category  of  '  croup  '  : 
(1)  Diphtheria,  (2)  Simple  Laryngitis,  (3)  Laryngitis  Stridulosa. 
(4)  Laryngismus  Stridulus. 

With  regard  to.  diphtheria  there  is  only  one  point  I  need 
mention  here.  When  the  likeness  between  the  membrane  on 
the  fauces  in  ordinary  faucial  diphtheria  and  the  membrane  in 
the  larynx  and  trachea  in  cases  of  '  croup  '  was  first  observed,  it 
was  held  that  although  the  faucial  membrane  might  extend 
down  the  air-passages  from  above,  there  was  no  such  thing  as 
a  diphtheritic  affection  starting  in  the  larynx  or  trachea,  and  so 
the  latter  occurrence  continued  to  be  regarded  as  distinct  from 
diphtheria.  Undoubtedly  it  is  quite  uncommon  for  diphtheritic 
membrane  to  form  first  or  only  in  the  larynx  or  trachea,  and 
even  up  to  quite  recent  years  it  was  still  disputed  whether  such 
an  occurrence  ever  took  place.  It  seems  certain  now  that  it 
does,  but  perhaps  more  rarely  than  is  supposed,  for  some  of 
the  statistics  on  this  point  are  based  on  post  mortem  examina- 
tion, and  it  must  never  be  forgotten  that  these  tell  us  only 
about  terminal  conditions.  It  is  not  safe  to  conclude  from  post 
mortem  examination  that  because  there  is  only  membrane  in 
the  larynx  or  trachea,  there  has  never  been  any  in  the  fauces  ; 
it  is  clear  from  clinical  evidence  that  the  faucial  inflammation  in 
diphtheria  may  disappear  before  the  laryngeal  appears,  and  it  is 
noteworthy — for  it  is  a  point  of  great  clinical  importance — that 
even  when  there  is  no  faucial  membrane  to  be  seen,  it  may 
be  there  none  the  less,  for  sometimes  at  post  mortem  examina- 
tion membrane  is  to  be  found  only  on  the  upper  or  posterior  sur- 
face of  the  soft  palate  where  it  would  be  invisible  by  ordinary 
inspection  during  life  ;  in  such  cases  there  is  usually,  if  not 
always,  a  nasal  discharge  which  may  help  in  the  diagnosis. 

In  any  child  with  croupy  cough  and  stridor,  even  if  no  mem- 
brane bo  visible  on  the-  fauces,  the  possibility  of  diphtheria  is  to 
be  considered,  the  presence  of  nasal  discharge,  of  albumen  in  the 
urine,  the  history  of  exposure  to  infection,  and  the  finding  of 
diphtheria  bacilli  in  the  swabbing  from  the  fauces,  although  no 
membrane  is  present  there,  may  point  to  diphtheria  of  the  larynx 
or  trachea.  It  must  be  admitted,  however,  that  in  the  absence 
of  membrane  from  the  fauces  it  is  not  uncommon  for  the  swab 
to  prove  negative,  although  subsequent  events  may  prove  that 
there  is  diphtheritic  membrane  in  the  larynx. 

Simple  acute  laryngitis  is  sometimes  the  meaning  of  '  croup  ' ; 
it  is  often  extremely  difficult  to  diagnose  from  diphtheria  ;  in 
fact,  one  has  to  judge  almost  entirely  from  the  absence  of  those 


LARYNGITIS  STRIDULOSA  329 

indications  which  I  have  just  mentioned  as  pointing  to  diphtheria. 
In  infancy  a  simple  laryngitis  causes  much  more  severe  symptoms 
than  are  usual  at  a  later  age  :  the  temperature  may  rise  to  103° 
or  104°  F.,  and  in  addition  to  the  hoarseness  of  the  cry  there 
may  be  definite  stridor  and  paroxysmal  attacks  of  dyspnoea, 
which  are  generally  worse  at  night. 

A  practical  point  to  be  remembered  in  diagnosis  when  a  child 
becomes  hoarse  and  stridulous  with  a  high  temperature,  and  the 
mother  says  her  child  has  '  croup  ',  is  the  occurrence  of  these 
symptoms  as  part  of  the  invasion  of  measles.  I  have  repeatedly 
seen  this  acute  laryngitis  of  measles  mistaken  either  for  ordinary 
catarrhal  laryngitis  or  for  diphtheria,  and  have  seen  tracheotomy 
done  under  the  impression  that  the  child  had  laryngeal  diph- 
theria, whereas  the  appearance  of  the  measles  rash  twenty-four 
hours  later  showed  that  the  symptoms  were  due  to  the  pre- 
measles  laryngitis. 

This  laryngitis  may  be  the  very  first  symptom  of  the  invasion 
of  measles  ;  it  is  sometimes  of  considerable  severity,  but  very 
rarely  calls  for  intubation  or  tracheotomy  ;  the  following  case 
illustrates  the  difficulty  of  diagnosis  in  such  a  case. 

Maud  J.,  aged  five  years,  was  perfectly  well  until  the  evening  of  May  13,  when 
she  was  suddenly  seized  with  intense  dyspnoea  and  loud  croupy  cough  ;  she 
became  blue  and  '  fought  for  breath  '  ;  the  dyspnoea  diminished  after  a  short 
time  ;  on  the  evening  of  May  14,  the  child  was  admitted  to  hospital ;  the 
temperature  was  103°,  there  was  no  definite  coryza  ;  there  was  no  membrane 
to  be  seen  on  the  fauces,  there  was  considerable  inspiratory  stridor,  the  lower 
part  of  the  chest  was  sucked  in  with  inspiration  ;  the  cough  was  of  brassy 
laryngeal  type.  With  a  steam-kettle,  the  breath  became  easier  for  a  few  hours, 
but  soon  became  more  laboured  with  loud  stridor  and  croupy  cough,  and  the 
child  was  restless ;  it  was  thought  that  the  laryngitis  was  diphtheritic ; 
tracheotomy  was  proposed,  but  was  postponed  as  the  breathing  again  improved. 
On  the  morning  of  May  16,  there  was  a  well-marked  measles  rash,  and  the 
laryngitis  was  much  less. 

The  stridor  and  obstruction  to  respiration  in  these  cases 
usually  subsides  as  soon  as  the  rash  appears  ;  it  is  worth  while, 
therefore,  deferring  tracheotomy  as  long  as  possible,  even  if  the 
difficulty  in  breathing  is  severe  ;  and  where  intubation  is  prac- 
ticable it  is  certainly  to  be  preferred  to  tracheotomy.  The 
nature  of  the  laryngitis  in  such  cases  may  be  quite  unrecognizable 
until  the  rash  appears,  but,  since  the  case  I  have  described  above 
occurred,  a  valuable  aid  to  diagnosis  has  been  discovered  in  the 
sign  known  as  '  Koplik's  Spots ',  bluish-white  minute  spots 
which  are  to  be  seen  with  a  good  light  on  the  buccal  mucosa, 
and  sometimes  on  the  inner  surface  of  the  lower  lip  near  the 


330  COMMON'DISORDERS  OF  CHILDHOOD 

angles  of  the  mouth  ;  these  appear  two  days,  and  sometimes 
three  days,  before  the  beginning  of  the  measles  rash,  and  so  may 
be  of  great  assistance  in  determining  the  nature  of  a  doubtful 
laryngitis.  Whilst  referring  to  the  laryngitis  which  precedes 
measles,  I  must  mention  also  the  laryngitis  which  sometimes 
occurs  at  a  later  stage  when  the  rash  is  already  fading.  An 
acute  simple  laryngitis  is  not  very  rare,  but  there  seems  to  be 
some  special  liability  also  to  diphtheria  at  this  time,  so  that 
a  '  croupy  cough  '  after  measles  must  be  regarded  with  suspicion. 
Another  infectious  disease  with  which  laryngitis  is  sometimes 
associated  is  whooping-cough.  During  the  early  catarrhal  stage 
which  precedes  the  appearance  of  the  characteristic  whoop,  the 
larynx  sometimes  shares  in  the  catarrh  of  the  respiratory  tract ; 
I  know  of  no  way  in  which  the  significance  of  the  laryngitis  can 
be  recognized  in  such  cases,  but  to  be  forewarned  of  the  possi- 
bility is,  at  any  rate,  to  be  forearmed  against  surprise. 

Albert  D.,  aged  two  years,  was  brought  to  hospital  with  a  'croupy  cough 
on  September  2  ;  there  was  nothing  abnormal  to  be  seen  in  the  throat ;  the 
eyes  were  rather  suffused,  and  the  onset  of  measles  was  suspected,  but  there 
were  no  '  Koplik's  Spots  '  to  be  seen.  The  temperature  was  103 '2°  ;  the  cough 
was  hoarse  and  laryngeal.  On  September  7  the  child  was  brought  again 
with  obvious  whooping-cough. 

Laryngitis  stridulosa.  Perhaps  more  often  than  to  any  of 
the  foregoing  conditions,  the  term  croup  is  applied  to  a  dis- 
order which  is  peculiar  to  childhood,  and  is  distinctive  on  the 
one  hand  from  diphtheria  and,  on  the  other  hand,  from  simple 
laryngitis,  the  so-called  laryngitis  stridulosa.  This  disorder  is 
sometimes  spoken  of  as  'spasmodic  croup'  or  false  croup;  the 
latter  term  referring  to  the  days  when  true  croup  was  identical 
with  diphtheria. 

Laryngitis  stridulosa  rarely  occurs  in  children  over  the  age 
of  ten  years.  Amongst  twenty-six  consecutive  cases  under  my 
care,  only  one  was  in  his  eleventh  year,  one  in  his  tenth  year, 
and  three  in  their  ninth  year  ;  the  others  were  all  between  the 
ages  of  three  and  eight  years  when  they  were  brought  for  treat- 
ment. The  attacks  date  usually  from  some  time  between  the 
end  of  the  first  year  and  the  end  of  the  fifth  year  of  life  ;  only 
two  of  my  eases  were  said  to  have  had  attacks  before  they  were 
a  ye;ir  old.  It  is  generally  said  that  boys  are  more  liable  to  this 
affection  than  girls;  my  own  figures  show  no  great  preponderance 
of  boys  :  there  were  sixteen  boys  and  ten  girls. 

The  symptoms  in  a  typical  case  are  these  :  the  child  goes  to 
bed  apparently  perfectly  well  ;  some  time  between  10  p.m.  and 


LARYNGITIS  STRIDULOSA  331 

2  a.m.  the  child  wakes  with  a  hard  brassy  cough,  which  in  several 
of  my  cases  was  described  as  being  '  like  a  dog  barking '  ;  at 
the  same  time,  or  immediately  afterwards,  inspiration  is  accom- 
panied with  a  loud  stridor  which  may  be  heard  easily  in  the 
next  room  ;  the  child  is  in  a  state  of  urgent  dyspnoea,  '  fighting 
for  his  breath  ',  with  beads  of  perspiration  standing  on  his  fore- 
head, and  sometimes  with  the  lips  livid  and  blue  ;  he  may  be 
in  a  state  of  terror  at  what  appears  to  be  impending  suffocation  ; 
twice  I  have  been  told  that  the  child  '  felt  as  though  his  throat 
was  closing  '.  After  one  to  two  hours  of  this  distress  the  stridor 
gradually  becomes  less,  the  dyspnoea  subsides,  and  the  child 
falls  asleep  exhausted,  and  wakes  next  morning  quite  well. 
Thus  ends  the  attack  only  to  recur  again  with  exactly  similar 
symptoms  after  an  interval  of  one  to  two  months. 

From  this  typical  course  there  is  some  variation  in  particular 
cases.  Usually  the  child  has  gone  to  bed  perfectly  well,  and 
the  attack  comes  on  with  no  warning  whatever  ;  but  this  is 
not  always  so  :  sometimes  there  are  premonitory  symptoms. 
One  girl  was  noticed  to  be  specially  excitable  before  each  attack ; 
some  showed  slight  hoarseness  or  had  coughed  a  little  during 
the  preceding  evening.  The  time  of  attack  varies  remarkably 
little,  the  onset  is  seldom  earlier  than  10  p.m.  or  later  than 
2  a.m.  It  fell  outside  these  limits  only  in  five  out  of  twenty- 
two  cases  ;  three  of  these  had  attacks  beginning  about  5  a.m., 
one  at  8  a.m.,  and  one  began  an  attack  at  5  p.m.  The  duration 
of  the  attacks  varied  considerably  :  in  a  boy  aged  four  years 
the  attacks  were  said  to  last  sometimes  '  only  a  few  minutes ', 
whilst  at  other  times  they  lasted  much  longer  ;  in  two  cases  the 
child  had  the  symptoms  more  or  less  marked  for  three  days  and 
nights  continuously  ;  in  four  cases  the  child  was  quite  well  all 
the  following  day,  but  had  a  return  of  symptoms  each  night  for 
two  or  three  nights  in  succession.  The  interval  between  attacks 
varies  greatly  in  different  children  :  in  one  case,  for  instance, 
it  was  six  months,  in  another  the  attacks  occurred  once  a  week 
for  three  months  ;  usually  the  interval  is  about  four  to  six  weeks. 

During  the  attack  the  voice  is  sometimes  hoarse,  but  may  be 
quite  clear  in  spite  of  the  loud  stridor.  Examination  of  the 
chest  at  this  time  may  show  some  rales  and  rhonchi ;  in  several 
of  my  cases  there  was  a  slight  bronchial  catarrh  persisting  for 
a  few  days  after  the  attack.  The  temperature  is  probably  normal 
in  most  cases,  and  if  raised  at  all,  the  elevation  is  usually 
slight. 

Etiology.     Cold  is  certainly  one   factor  in  the  causation  of 


332  COMMON 'DISORDERS  OF  CHILDHOOD 

this  disorder.  It  was  noticed  in  several  of  my  cases  that  walking 
against  a  cold  wind  would  induce  an  attack  ;  in  one  case  it  was 
stated  that  the  child  had  the  attacks  only  in  the  winter,  and  in 
another  that  the  attacks  were  limited  to  the  winter  unless  an 
exceptionally  cold  day  occurred  in  the  summer,  when  the  '  croup  ' 
might  occur.  Another  exciting  cause  is  over-eating  :  one  girl 
aged  eight  years  was  said  to  have  these  attacks  whenever  she 
ate  more  freely  than  usual. 

In  addition  to  these  exciting  causes  I  think  there  can  be  little 
doubt  that  there  is  an  underlying  nervous  instability  which 
predisposes  to  this  disorder.  I  have  specially  noted  that  some 
of  my  cases  showed  definite  evidence  of  such  instability  in 
stuttering,  night  terrors,  enuresis,  abnormal  excitability,  and 
general  '  nervousness  ',  and  I  would  lay  considerable  stress  on 
this  element,  for  it  may  be  the  link  connecting  laryngitis  stridu- 
losa  with  asthma,  to  which  I  believe  it  to  be  very  near  akin.  The 
parallel  indeed  between  these  two  disorders  is  so  very  close  that 
it  is  almost  impossible  to  escape  the  conclusion  that  if  the  one  is 
a  respiratory  neurosis,  the  other  is  also  ;  the  sudden  onset  at 
night,  the  fact  that  in  both  disorders  a  cold  wind  or  an  over- 
loaded stomach  seems  equally  capable  of  exciting  an  attack, 
the  striking  effect  of  climate  on  both  disorders,  and  lastly,  as 
I  shall  show,  the  similarity  of  treatment  required,  all  these 
points  suggest  that  asthma  and  laryngitis  stridulosa  are  of  very 
similar  nature.  There  is,  I  think,  further  evidence  of  affinity  in 
the  fact  that  asthma  occasionally  replaces  laryngitis  stridulosa  as 
a  child  grows  older :  in  a  boy  aged  seven  years,  the  history  seemed 
to  show  that  the  asthma  from  which  he  had  suffered  repeatedly 
in  the  past  two  years,  had  replaced  attacks  of  laryngitis  stridulosa, 
which  occurred  at  intervals  from  the  age  of  two  years  up  to  the 
age  of  five  years. 

Like  asthma,  this  laryngeal  spasm  may  be  started  by  any 
catarrh  of  the  respiratory  passage,  and  in  this  way  the  presence 
of  adenoid  overgrowth  in  the  naso-pharynx,  which  is  so  often 
associated  with  a  great  tendency  to  recurring  catarrh  extending 
sometimes  down  into  the  larynx  and  sometimes  into  the  bronchi, 
no  doubt  contributes  to  the  perpetuation  of  the  attacks.  But 
I  have  been  entirely  unable  to  satisfy  myself  that  the  presence 
of  adenoids  is  in  itself  sufficient  cause  for  the  attacks,  and  I  have 
repeatedly  known  removal  of  adenoids  and  the  excision  of 
large  tonsils  in  such  cases  to  fail  completely  to  effect  a  cure. 

Prognosis.  Is  there  any  danger  to  life  in  these  attacks  ? 
Certainly  they  look  alarming  enough,  but  I  know  of  no  fatal 


LARYNGITIS  STRIDULOSA  333 

result,  and  beyond  the  prostration  which  is  sometimes  left  for 
a  day  or  two  after  a  severe  attack,  I  know  of  no  harm  from  them. 
Trousseau  mentions  a  fatal  result  in  three  cases,  but  it  must  be 
remembered  that  in  his  time  the  differentiation  from  diphtheria 
was  less  accurate  than  at  the  present  day. 

The  duration  of  the  disorder  varies  greatly  ;  in  some  children 
after  two  or  three  attacks  within  a  few  months  it  ceases  to 
recur  ;  in  others  it  lasts  for  several  years — for  example,  in  one 
of  my  cases  for  five  years,  in  two  for  seven  years  ;  but  I  have 
never  known  it  to  persist  beyond  the  age  of  eleven  years,  and  it 
rarely  lasts  so  late  as  this. 

Treatment.  To  some  degree  these  attacks  are  preventable,  as 
may  be  gathered  from  what  I  have  said  as  to  their  causation. 
The  child  who  is  prone  to  laryngitis  stridulosa  is  not  to  be  '  taken 
out  in  all  weathers  ' ;  in  particular,  he  is  not  to  be  taken  out  in 
the  teeth  of  a  bitterly  cold  wind.  On  the  other  hand,  I  believe 
that  in  this  disorder,  as  in  asthma,  the  liability  to  attacks  may 
be  increased  by  shielding  the  child  '  like  a  hothouse  plant ' 
from  every  variation  of  temperature  and  from  every  wind  that 
blows  ;  he  should  indeed  live  an  outdoor  life  as  much  as  possible, 
but  with  the  special  precaution  that  he  is  not  exposed  to  cold 
winds  or  to  cold  fog.  The  diet,  too,  will  need  care  ;  any  over- 
loading of  the  stomach  and  overtaxing  of  digestion  is  to  be 
avoided,  as  likely  to  bring  on  an  attack. 

The  drug  treatment  which  I  have  found  most  effectual  is  very 
similar  to  that  used  in  asthma.  Arsenic,  has  a  marked  effect  in 
diminishing  the  frequency  of  the  attacks,  one  minim  of  the  liquor 
arsenicalis  may  be  given  to  a  child  of  three  years,  and  1J-2 
minims  to  a  child  of  seven  years  three  times  a  day  for  three 
weeks,  and  after  an  interval  of  ten  days  or  a  fortnight  the  drug 
may  be  resumed,  and  so  on  for  three  or  four  months.  I  have 
also  used  stramonium  with  arsenic  or  with  potassium  iodide 
when  the  attacks  were  frequent;  5  minims  of  the  tincture  of 
stramonium  with  2  or  3  grains  of  potassium  iodide  and  10  minims 
of  sal  volatile  with  syrup  and  water  make  a  suitable  mixture 
for  a  child  of  six  years. 

When  the  attack  occurs  there  are  several  simple  measures 
which  may  give  relief  :  moistening  the  atmosphere  by  a  steam- 
kettle  has  seemed  to  give  definite  relief  in  some  cases  ;  one 
mother  told  me  that  a  hot  mustard  bath  was  very  successful  for 
these  attacks  in  her  child  aged  eight  years  ;  hot  applications 
such  as  a  sponge  squeezed  out  of  hot  water,  or  a  poultice  or 
fomentation  over  the  larynx  seemed  to  relieve  the  spasm  in 


334  COMMON*  DISORDERS  OF  CHILDHOOD 

others.  In  several  cases  speedy  relief  was  given  by  making  the 
child  vomit  with  drachm  doses  of  ipecacuanha  wine. 

I  should  have  expected  that  suprarenal  extract  which  in  the 
form  of  adrenalin  chloride  has  been  found  to  give  almost  immediate 
relief  in  severe  attacks  of  asthma,  would  prove  useful  also  in  the 
attacks  of  laryngitis  stridulosa,  and  quite  recently  it  has  been 
stated  that  this  is  the  case  ;  1  or  2  drops  of  the  adrenalin 
chloride  solution  (1  in  1,000),  as  prepared  by  Messrs.  Parke, 
Davis  &  Co.,  is  given  by  mouth  in  a  drachm  of  water,  and  is  said 
to  give  ease  very  rapidly. 

The  effect  of  climate  in  this  disorder  is  very  marked,  but  I 
fancy  that,  as  in  asthma,  there  is  no  rhyme  or  reason  by  which 
we  may  foretell  with  any  degree  of  certainty  what  place  is  likely 
to  suit  a  particular  child,  we  can  only  advise  on  general  principles  ; 
seaside  seems  to  suit  most  of  these  cases  better  than  inland,  and 
in  order  to  avoid  cold  and  boisterous  winds  it  is  well  to  choose 
the  warmer  seaside  places,  at  any  rate  those  which  come  in  for 
as  small  a  share  as  possible  of  the  cold  east  winds.  I  have 
noted,  for  instance,  Eastbourne,  Worthing,  and  Penzance  as 
south  coast  resorts  at  which  children  with  this  disorder  remained 
free  from  attacks. 

Laryngisnius  stridulus.  I  have  mentioned  this  condition  as 
one  of  those  sometimes  spoken  of  as  '  croup  '.  It  belongs  more 
properly  to  the  convulsive  disorders,  and  I  shall  describe  it  more 
fully  in  a  later  chapter  ;  but  I  must  refer  to  it  here  partly  because 
of  its  figuring  in  popular  parlance  as  '  croup  ',  and  partly  because 
its  '  pedantic  and  cacophonous  title  '  bears  such  an  unfortunately 
close  resemblance  to  laryngitis  stridulosa,  that  there  is  apt  to 
be  some  confusion  between  them. 

Laryngisnius  stridulus  or  child-crowing  really  bears  little  or 
no  resemblance  to  laryngitis  stridulosa  in  its  symptoms.  It  is 
limited  to  the  first  three  years  of  life  (I  have  seen  it  occa- 
sionally as  late  as  3J  years)  and  consists  in  a  momentary  spasm 
of  tho  glottis,  which  usually  lasts  only  about  five  seconds, 
and  recurs  several  times  a  day,  especially  just  as  the  child 
awakes  from  sleep  or  when  he  begins  to  cry.  Laryngisnius 
stridulus  is  so  closely  associated  with  rickets  that  it  may  almost 
be  regarded  as  one  of  the  manifestations  of  rickets  ;  it  is  asso- 
ciated also  closely  with  convulsions  and  tetany,  and  is  readily 
amenable  to  the  treatment  of  rickets  and  convulsions.  In  all 
these  points  it  differs  entirely  from  laryngitis  stridulosa,  with 
which  indeed  it  could  hardly  be  confused,  except  in  name. 

These  attacks  are  seen  in  rickety  infants  mostly  between  the 


LARYNGEAL  SPASM  335 

ages  of  six  months  and  eighteen  months.  The  mother's  description 
is  that  the  infant c  holds  his  breath  and  goes  black  in  the  face'  and 
then  '  makes  a  funny  noise  '  which  I  find  described  in  my  notes 
as  '  like  a  whoop  '  or  a  *  crowing  noise  '.  This  happens  at  any 
time  of  day,  sometimes  many  times  a  day,  most  commonly 
on  some  extra  inspiratory  effort  as  in  crying  ;  but  at  times 
it  happens  with  no  apparent  reason.  In  addition  to  the  rickets, 
the  infant  with  laryngismus  stridulus  almost  always  shows 
nerve  irritability,  which  is  easily  demonstrated  by  tapping  over 
the  facial  nerve  or  the  musculo-spiral  or  the  anterior  tibial 
(see  Chapter  XLV),  and  in  many  cases  also  some  craniotabes 
and  tetany,  and  a  great  liability  to  convulsions. 

The  attacks  of  laryngeal  spasm  are  not  free  from  danger, 
I  have  known  sudden  fatal  asphyxia  to  result  in  at  least  three 
cases  under  my  own  observation.  They  are,  however,  readily 
amenable  to  treatment  in  most  cases  ;  a  mixture  of  potassium 
bromide  gr.  iij  with  a  drachm  of  cod-liver  oil  emulsion  given 
three  times  a  day  causes  rapid  subsidence  of  the  attacks. 

Other  causes  for  stridor  in  Children 

Lastly,  I  must  point  out  that  there  are  some  rarer  causes  of 
stridor  which  may  have  to  be  considered  in  the  child  who  is  said 
to  have  '  croup  '. 

Laryngeal  spasm  in  the  newborn  has  come  under  my  notice 
several  times,  and  a  most  alarming  disorder  it  is.  The  first  case 
I  saw  was  a  female  infant  aged  six  days  who  had  been  having 
attacks  occasionally  during  the  previous  twelve  hours.  Two 
attempts  to  see  the  throat  brought  on  severe  attacks  :  the  infant 
made  violent  inspiratory  efforts  without  getting  any  air  in, 
became  more  and  more  leaden-coloured,  bloody  froth  appeared 
at  the  mouth,  and  the  child  appeared  to  be  dying  of  asphyxia. 
These  attacks  occurred  sometimes  without  apparent  cause, 
sometimes  when  the  infant  tried  to  take  the  breast ;  nine  such 
attacks  occurred  within  a  few  hours  after  I  saw  the  infant,  and 
she  died  apparently  of  exhaustion  on  the  evening  of  the  same 
day.  Post  mortem  examination  showed  some  congestion  of 
the  pharynx  and  soft  palate,  suggesting  that  there  had  been 
some  degree  of  pharyngitis,  but  there  was  no  exudation  and 
nothing  else  to  account  for  these  attacks. 

Another  case  was  a  boy,  aged  7J  weeks,  who  had  been  subject 
to  sudden  '  crowing  attacks  '  since  birth  ;  two  of  these  had 
been  very  severe,  the  infant  became  cyanosed,  '  unable  to  get 
his  breath  ',  and  seemed  likely  to  die  in  the  attack.  In  this  case 


336  COMMOISf  DISORDERS  OF  CHILDHOOD 

the  attacks  came  on  quite  suddenly  with  no  apparent  cause. 
There  had  been  some  trouble  with  digestion,  and  the  infant  was 
now  put  upon  peptonized  milk,  and  no  further  attacks  of  the 
laryngeal  spasm  occurred. 

Evidently  such  cases  are  very  similar  in  their  pathology 
to  the  laryngismus  stridulus  which  is  seen  with  rickets  in  older 
infants,  but  in  these  younger  cases  there  is  no  suspicion  of 
rickets.  The  late  Dr.  Eustace  Smith  x  drew  attention  to  this 
disorder  of  the  newborn  ;  he  found  in  three  cases  adenoid 
overgrowth  and  post-nasal  catarrh.  In  mild  cases  a  weak 
resorcin  solution  should  be  instilled  into  the  nostrils  several 
times  a  day.  In  the  attack  respiration  must  be  stimulated 
by  sprinkling  the  child's  face  or  chest  with  cold  water  or  hold- 
ing smelling-salts  to  the  nostrils  ;  in  one  attack  I  held  some 
lint  sprinkled  with  ether  to  the  infant's  nostrils,  apparently 
with  good  effect ;  amyl  nitrite  capsules  (1  minim)  might  also  be 
useful  in  such  a  case. 

Congenital  laryngeal  stridor.  In  the  new-born  infant 
there  is  the  curious  disorder  known  as  congenital  laryngeal 
stridor.  Ten  cases  of  this  affection  have  come  under  my  own 
observation,  six  were  girls,  four  were  boys.  The  stridor  was 
noticed  on  the  day  of  birth  in  all  except  one,  in  which  it  was 
first  noticed  on  the  third  day,  perhaps  because  the  infant  was 
feeble  and  breathing  less  vigorously  during  the  first  two 
days. 

The  character  of  the  stridor  is  peculiar.  I  find  that  in  most 
of  my  cases  it  was  compared  to  the  noise  made  by  a  hen  in 
'  clucking  ',  whilst  in  others  it  was  called  *  croaking  ',  or '  crowing '. 
It  is  inspiratory,  and  occurs  with  every  inspiration ;  during  much 
exertion  or  excitement  expiration  also  is  accompanied  by  slight 
stridor  in  some  cases.  I  have  noted  that  in  one  case  it  was 
audible  at  a  distance  of  12  feet,  in  another  that  it  was  '  heard 
easily  23  feet  away  from  the  infant ';  but  it  varies  considerably 
at  different  times  in  the  same  case;  so  long  as  the  infant  is 
lying  quiet  it  may  be  scarcely  audible,  while  directly  the  infant 
is  disturbed  or  excited  and  takes  deeper  respirations  the  crowing 
may  be  loud  with  every  inspiration.  The  stridor  persists  during 
sleep  in  some  cases  ;  in  one  I  have  noted  that  it  was  heard  during 
light  sleep,  but  disappeared  when  the  infant  was  soundly  asleep. 

The  cry  is  normal  ;  there  is  no  hoarseness.  The  infant  is  not 
in  the  least  distressed  by  the  inspiratory  difficulty  ;  there  is  no 
cyanosis,  but  the  obstruction  to  air  entry  is  evident  sometimes 
1  British  Medical  Journal,  July  20,  1907. 


LARYNGITIS  STRIDULOSA  337 

in  the  retraction  of  the  lower  intercostal  spaces,  and  the  sucking 
in  of  the  suprasternal  and  supraclavicular  fossae. 

The  affection  looks  a  far  more  serious  one  than  it  is  ;  as  far 
as  I  know,  only  one  of  the  ten  cases  proved  fatal  (from  broncho- 
pneumonia).  Dr.  John  Thomson,1  to  whose  writings  the  recog- 
nition of  this  disorder  is  mainly  due,  states  that  in  most  cases 
the  stridor  passes  off  before  the  end  of  the  second  year. 

There  is  some  variation  in  this:  in  one  female  infant,  whom 
I  first  saw  at  the  age  of  three  months  with  marked  congenital 
laryngeal  stridor,  the  noise  with  inspiration  was  only  occasionally 
heard  when  the  child  was  eleven  months  old,  and  at  twenty  months 
it  was  not  heard  at  all  during  ordinary  breathing,  but  I  noted  that 
after  the  exertion  of  crying  inspiration  was  still  rather  '  heavy ' ; 
in  a  girl,  whom  I  first  saw  at  9J  months,  the  stridor  had  become 
extremely  slight  at  the  age  of  2J  years,  but  was  still  quite  notice- 
able on  exertion  ;  in  a  third  case,  also  a  girl,  the  stridor  which 
had  been  present  since  birth  was  still  quite  distinct  at  3J  years. 

Allowing  for  this  variation,  we  may  assure  the  parents  that 
in  all  probability  within  two  or  three  years  the  disorder  will 
pass  off  without  causing  any  harm  ;  the  one  danger  is  some 
intercurrent  pulmonary  disease  in  which  these  infants  are  apt  to 
fare  badly,  as  might  be  expected  where  respiration  is  hampered 
not  only  by  pulmonary  disease  but  also  by  laryngeal  obstruc- 
tion. In  the  earliest  observation  on  the  morbid  condition,  by 
Dr.  D.  B.  Lees,2  death  was  due  to  diphtheria  ;  Dr.  Koplik  3  has 
recently  recorded  one  fatal  ending  from  broncho-pneumonia  at 
the  age  of  one  year.  In  both  these  cases,  as  in  some  others 
recorded  by  Dr.  Thomson  and  Dr.  Logan  Turner,4  the  upper 
opening  of  the  larynx  has  shown  in  an  exaggerated  degree  the 
narrowness  of  opening  which  is  peculiar  to  the  infant,  and  cor- 
responding therewith  an  unusual  degree  of  the  normal  infantile 
condition  of  longitudinal  folding  of  the  epiglottis. 

Are  these  peculiarities,  which  are  presumably  the  cause  of 
the  stridor,  a  congenital  deformity  ?  or  are  they  the  result  of 
'  ill  co-ordinated  and  spasmodic  nature  of  the  breathing  ',  as 
Dr.  Thomson  and  Dr.  Turner  have  shown  by  experiment  to  be 
possible  ?  I  have  only  examined  the  larynx  after  death  in 
one  case  myself,  and  I  must  say  that  to  my  mind  a  congenital 
exaggeration  of  the  normal  peculiarities  of  the  infantile  larynx 
seems  ample  explanation  of  the  clinical  features  of  the  disorder  ; 

1  Edinb.  Med.  Journ.,  Sept.,  1892.  *  Pathological  Society  Trans.,  1883. 

•  Archives  of  Pediatrics,  Dec.,  1905.         «  Brit,  Med.  Journ.,  Dec.  1,  1900. 

STILL  Z 


338  COMMON  DISORDERS  OF  CHILDHOOD 

the  occurrence  of  the  stridor  on  the  day  of  birth,  its  continued 
character,  varying  with  the  depth  of  inspiration,  and  its  gradual 
diminution  as  the  laryngeal  aperture  enlarges  with  the  growth 
of  the  child,  all  seem  compatible  with  a  simple  congenital  pecu- 
liarity of  conformation  in  the  larynx.  It  is  likely  enough  that 
the  obstruction  may  set  up  some  degree  of  inspiratory  spasm 
which  may  aggravate  the  deformity  of  the  larynx,  but  it  seems 
to  me  unnecessary  to  suppose  that  the  spasm  is  the  primary 
cause  of  the  condition. 

It  is  well  to  caution  the  parents  that  special  care  is  to  be 
taken  to  prevent  bronchitis  in  these  cases  ;  the  slightest  '  cold  ' 
is  to  be  treated  seriously,  and  if  any  bronchitis  occurs  the  child 
should  be  placed  at  once  under  the  doctor's  care.  If  there  is 
very  severe  bronchitis,  or  broncho-pneumonia  with  great  difficulty 
of  respiration,  I  believe  the  wisest  procedure  may  be  intubation, 
but  this  is  likely  to  be  specially  difficult  owing  to  the  unusual 
narrowness  of  the  laryngeal  opening,  and  should  only  be  attempted 
by  those  who  are  thoroughly  experienced  in  intubation. 

Enlargement  of  mediastinal  glands  is  an  occasional  cause  of 
stridor  in  children.  For  instance,  Catherine  G.,  aged  5J  years, 
was  brought  to  King's  College  Hospital  for  a  '  croupy  cough  ' 
which  had  been  present  about  eight  weeks,  during  which  time 
she  had  also  made  a  crowing  noise  in  breathing.  Examination 
showed  in  addition  to  loud  inspiratory  stridor,  marked  dullness  at 
the  inner  end  of  the  first  and  second  right  spaces,  and  bronchial 
breathing  over  the  greater  part  of  these  two  spaces  in  front, 
whilst  just  above  the  inner  end  of  the  clavicle  an  enlarged  gland 
the  size  of  a  hazel-nut  could  be  felt. 

A  skiagram  showed  that  there  was  some  abnormal  shadow  to 
the  right  of  the  middle  line  at  the  upper  part  of  the  chest,  but 
it  was  not  possible  to  distinguish  whether  this  was  due  to  con- 
solidation of  lung  only,  or  partly  to  enlargement  of  mediastinal 
glands,  as  seemed  most  probable.  Sir  St.  Clair  Thomson,  who 
kindly  saw  the  child  for  me,  thought  there  was  certainly  com- 
pression of  the  trachea  by  something  in  the  mediastinum.  The 
child  was  put  upon  potassium  iodide,  and,  whether  as  a  result 
of  this  or  not,  the  stridor  gradually  disappeared,  so  that  thirteen 
days  after  admission  the  stridor  was  only  very  slight  and  the 
dullness  at  the  right  apex  had  almost  gone,  nor  was  there  any 
bronchial  breathing.  A  month  after  admission  the  stridor  had 
completely  gone  and  the  child  remained  free  from  any  recur- 
rence of  the  respiratory  obstruction  during  the  several  weeks 
she  remained  under  observation. 


LARYNGITIS  STRIDULOSA  339 

In  another  case  a  boy,  aged  2T\,  had  had  difficulty  of  breathing 
with  some  respiratory  stridor  for  about  a  month,  his  voice  was 
perfectly  normal,  there  was  markedly  diminished  air  entry  at  the 
apex  of  the  right  lung  behind  ;  skiagrams  showed  what  were 
thought  to  be  undoubtedly  enlarged  mediastinal  glands  on  the 
right  side  of  the  mediastinum.  He  was  taken  to  the  seaside, 
and  although  for  a  few  days  after  I  saw  him  the  difficulty  in 
breathing  became  extreme  it  soon  diminished  and  gradually 
disappeared  completely  ;  the  boy  seemed  quite  well  when  I 
heard  of  him  nine  months  later. 

These  two  cases  are  interesting  as  showing  that  even  when 
mediastinal  glands  are  already  large  enough  to  cause  compression 
of  the  trachea,  they  may,  nevertheless,  diminish  under  treat- 
ment, and  the  child  may  remain  well,  at  any  rate,  for  months, 
perhaps  for  years. 

Recovery,  however,  from  the  respiratory  obstruction  in  these 
cases  must  not  make  us  too  sanguine,  for  the  fact  that  tuberculosis 
has  occurred  in  the  mediastinal  glands — as  symptoms  running 
this  course  must  always  indicate — points  to  a  diminished  resis- 
tance to  tubercle,  and  therefore  to  the  possibility,  if  not  proba- 
bility, that  at  some  future  date  tuberculosis  will  declare  itself 
in  the  lungs  or  elsewhere. 

Syphilis.  Very  rare  cases  have  been  described  in  which 
stridor  was  due  to  syphilitic  stenosis  of  the  larynx.  I  have  seen 
one  case  of  stridor  due  to  cicatricial  narrowing  of  the  trachea 
from  syphilitic  disease  ;  it  occurred  in  a  boy  at  the  school  age, 
and  was  associated  with  other  evidences  of  severe  syphilis  in 
earlier  life. 

Papilloma  of  the  larynx.  Another  rare  cause  for  stridor, 
though  more  common  in  children  than  in  adults,  is  papilloma 
in  the  larynx. 

The  following  case  shows  how  misleading  the  symptoms  may 
be,  resembling  in  their  sudden  onset  an  acute  laryngitis  or 
diphtheria,  and  also  how  dangerous  the  condition  is. 

Eliza  R.,  aged  3J  years  on  March  4,  began  suddenly  one  night  to  make 
a  stridulous  noise  with  inspiration,  and  at  the  same  time  her  voice  became 
a  hoarse  whisper  ;  these  symptoms  continued,  and  on  April  22,  she  was  brought 
to  me  as  an  out-patient  at  hospital,  seeming  quite  well,  with  no  discomfort, 
but  still  with  marked  stridor  on  inspiration,  and  hoarse  whispering  speech. 
That  same  night  she  was  suddenly  seized  with  suffocative  symptoms  and 
died  within  a  few  minutes.  Post  mortem,  made  by  Dr.  0.  Hildesheim,  showed 
a  large  papillomatous  growth  in  the  larynx. 

In  some  of  these  cases  attacks  of  dyspnoea  recur  many  times 
without  proving  fatal,  but  in  all  the  outlook  is  grave,  and  the 
only  hope  of  recovery  lies  in  operative  treatment. 

z2 


340  COMMON  DISORDERS  OF  CHILDHOOD 

Retro-pharyngeal  abscess  is  another  condition  which  must 
be  borne  in  mind  in  any  case  of  apparent  '  croup  '  in  infancy  or 
childhood. 

As  an  acute  affection,  this  almost  always  occurs  during  the 
first  two  years  of  life,  and  is  then  generally  due  to  some  infective 
process  in  the  fauces  or  adjoining  parts,  causing  suppuration  in 
the  small  lymphatic  glands  which  lie  behind  the  pharynx  over 
the  bodies  of  the  cervical  vertebrae  or  else  in  the  glands  at  the 
side  of  the  neck  from  which  the  suppuration  extends  inwards 
towards  the  middle  line. 

In  later  childhood  a  chronic  retro -pharyngeal  abscess  may 
occur  from  tuberculous  disease  of  the  vertebrae,  but  this  is  much 
less  likely  to  give  rise  to  any  symptoms  which  might  be  mistaken 
for  '  croup  '. 

In  the  case  of  the  acute  infection  the  abscess  is  generally  well 
above  the  level  of  the  larynx,  and  the  symptoms  produced  in 
addition  to  fever  and  constitutional  disturbance  are  difficulty 
of  swallowing  and  some  alteration  of  the  voice  like  that  of  a  child 
with  greatly  swollen  tonsils.  Stridor  is  most  likely  to  occur  when 
the  abscess  is  rather  lower  than  usual,  particularly  when  it  is  about 
the  level  of  the  upper  part  of  the  larynx.  The  inflammation  and 
a>dcma  may  then  extend  to  the  larynx  and  produce  symptoms 
like  those  of  acute  laryngitis,  marked  inspiratory  stridor  with 
recession  of  the  chest  wall,  owing  to  the  difficulty  of  inspiration, 
and  sometimes  repeated  more  acute  suffocative  attacks  in  which 
life  appears  to  be  threatened.  I  have  seen  such  a  condition  exactly 
simulating  a  diphtheritic  laryngitis.  The  diagnosis  is  extremely 
important,  for  if  the  abscess  be  not  recognized  and  opened  it  may 
kill  by  asphyxia,  either  owing  to  the  oedema  of  the  larynx  or 
from  rupture  and  the  sudden  flooding  of  the  air-passages  with 
pus.  Rarely  it  spreads  downward  to  the  mediastinum,  and 
pulmonary  troubles  ensue. 

Foreign  "body.  As  a  possible  cause  of  stridor,  a  foreign  body 
in  the  air  passages  must  be  remembered;  the  following  case 
illustrates  this,  and  shows  also  how  misleadingly  slight  may  be 
the  symptoms  at  the  time  when  the  foreign  body  first  enters  the 
air  passages  : 

Sidney  B.,  aged  10,  had  been  holding  a  hobnail  in  his  mouth,  at  school,  when 
a  boy  suddenly  ran  at  him,  and,  taken  by  surprise,  he  '  swallowed  '  the  hobnail. 
He  only  coughed  slightly  at  the  time,  and  after  going  into  class,  he  thought  he  had 
better  tell  the  teacher.  He  put  up  his  hand  to  attract  the  teacher's  attention, 
but  was  told  to  put  it  down  again  ;  so  he  went  on  with  his  lessons  without 
informing  any  one.  Some  weeks  later  he  was  brought  to  hospital  for  inspira- 
tory stridor,  which  had  been  present  since  the  supposed  swallowing  of  the  nail. 


LARYNGITIS  STRIDULOSA 


341 


The  stridor  was  distinct,  but  not  loud ;  it  could  be  heard  a  yard  from  the 
boy.  X-rays  showed  a  hobnail  with  the  point  upwards  in  the  left  bronchus. 
A  tracheotomy  was  performed,  and  with  the  aid  of  the  X-ray  screen,  my 
colleague,  Mr.  Burghard,  was  able  to  withdraw  the  hobnail  by  a  long  forceps. 
The  boy  made  a  complete  recovery. 

A  foreign  body  in  the  oesophagus  is  also  able  to  produce 
stridor  by  pressure  on  the  adjoining  trachea  : 

David  W.,  aged  4  months,  was  brought  to  me  with  a  marked  stridor,  which 
had  been  present  for  a  week,  and  was  said  to  be  absent  when  the  child  was 
asleep.  I  was  puzzled  by  the  unexplained  commencement  of  stridor  in  an 
infant  at  this  age  and  apparently  in  perfect  health.  Subsequently,  however, 
as  the  child's  breathing  was  embarrassed,  a  skiagram  was  taken,  and  showed 
a  foreign  body,  which  was  thought  to  be  in  the  trachea ;  tracheotomy  gave 
no  relief,  and  a  further  X-ray  showed  that  the  foreign  body  was  still  present 
and  it  was  found  to  be  in  the  oesophagus.  All  efforts,  however,  to  remove  it 
failed,  and  the  child  died.  At  autopsy  a  coin,  nearly  as  large  as  a  halfpenny 
was  found  firmly  impacted  in  the  oesophagus,  about  the  level  of  the  cricoid 
cartilage. 


CHAPTER  XXIV 
ASTHMA  IN  INFANCY  AND  CHILDHOOD 

I  HAVE  chosen  the  title  at  the  head  of  this  chapter  deliberately 
to  emphasize  the  fact  in  primis  that  asthma  is  an  affection  of 
the  earliest  years,  nay,  even  of  the  earliest  months,  of  life.  True 
it  is  but  seldom  recognized  in  infancy,  but  it  is  overlooked  chiefly 
because  its  occurrence  at  this  age  is  not  generally  realized.  Nor  is 
t'.e  recognition  of  asthma  in  early  life  a  matter  of  mere  academic 
interest ;  it  is  a  matter  of  vital  importance,  for  the  emphyse- 
matous  changes  which  asthma  is  so  apt  to  produce  in  the  lung 
at  all  ages,  and  which  may  render  a  child  a  chronic  invalid  before 
he  is  yet  in  his  teens,  are  specially  liable  to  result  wrhen  asthma 
occurs  in  very  early  life,  and  is  not  checked  by  proper  treatment. 

The  early  age  at  which  asthma  begins  is  well  shown  by  the 
following  table,  compiled  from  consecutive  cases  in  my  note- 
books. In  69  out  of  78  the  first  appearance  of  the  asthma  could 
be  dated  with  some  degree  of  accuracy  ;  in  47  out  of  the  69 
the  onset  was  under  the  age  of  three  years  : 

Age  at  onset.  No.  of  cases. 

3  weeks  to  1  year   ........          9 

1-2  years  .......                     .21 

2-3  years .17 

3-4  years  .........          6 

4-5  years  .........          0 

5-6  years 0 

6-7  years 3 

7-8  years  ...                                                                          4 

8-9  years  ...                                                                       2 

9-10  years  ]                                                                1 

10-11  years  ...                                                                       0 

11-12  years .0 

It  is  not  always  easy  from  the  history  to  assign  a  date  to  the 
first  appearance  of  asthma,  especially  when  it  has  begun  in 
infancy,  for  its  nature  has  often  been  unrecognized  at  this  period ; 
the  affection  has  been  regarded  as  a  simple  bronchitis  of  rather 
wheezy  character  until  its  frequent  repetition  at  short  intervals, 
and  the  unusually  sudden  onset  and  perhaps  as  sudden  dis- 
appearance, raise  a  suspicion  that  it  may  be  asthmatic  ;  often 
indeed  it  is  not  until  the  child  grows  older,  possibly  at  five  or 
six  years,  when  the  attacks  have  already  assumed  the  charac- 


ASTHMA  IN  INFANCY  AND  CHILDHOOD         343 

teristic  features  of  the  full-blown  disease,  that  the  nature  of  the 
earlier  attacks  is  recognized.  Almost  all  the  cases  grouped  in 
the  above  table  as  having  begun  under  the  age  of  one  year  were 
instances  of  this  posthumous  diagnosis,  but  if  the  fact  of  the 
occurrence  of  this  immature  asthma  in  infancy  were  borne  in  mind, 
there  is  no  reason  why  the  diagnosis  should  not  be  made  much 
earlier  than  it  usually  is,  for  the  bronchitis  has  certain  features 
which  even  lay  parents  recognize  on  looking  back  as  more  or  less 
closely  resembling  the  more  characteristic  attacks  of  a  later  age  ; 
one  might  add  that  the  resemblance  is  sometimes  more  obvious 
when  the  wheezing  rhonchus  of  the  infantile  asthmatic  bronchitis 
is,  as  it  sometimes  is,  chiefly  expiratory. 

In  one  case  seen  for  typical  paroxysmal  asthma  at  the  age  of 
8J  years,  th»e  mother  was  confident  that  the  first  attack  had 
occurred  at  the  age  of  three  weeks,  and  that  others  of  the  same 
nature  had  occurred  throughout  infancy  ;  in  another  the  first 
attack  was  at  six  weeks  old,  in  another  at  three  months,  and  in 
two  others  at  four  months.  All  these  had  developed  more  charac- 
teristic attacks  of  asthma  as  they  grew  older. 

In  view  of  this  very  early  onset — which  is  probably  commoner 
than  my  statistics  show — it  seems  likely  that  congenital  pre- 
disposition plays  some  part  in  the  causation  of  asthma. 

Sex.  It  is  difficult  to  see  why  asthma  should  be  so  much 
commoner  in  boys  than  in  girls  ;  my  own  figures  show  52  boys 
to  26  girls,  a  proportion  of  2  to  1.  This  sex-incidence  is  interest- 
ing when  compared  with  that  of  laryngitis  stridulosa  (spasmodic 
croup),  which  shows  a  similar  predominance  of  males,  and  which 
has,  as  I  shall  show,  several  points  of  contact  with  paroxysmal 
asthma. 

Predisposing  Causes.  Asthma  and  hay-fever  figure  so  largely 
in  the  family  history  of  the  asthmatic  child  that  one  cannot 
doubt  that  heredity  is  an  important  factor  in  its  etiology.  In 
21  out  of  49  cases  in  which  the  family  history  was  noted  there 
was  asthma  or  hay-fever  in  one  or  more  near  relations  (parents, 
uncles,  aunts,  or  grandparents),  in  6  of  these  21  there  was  asthma 
or  hay-fever  in  mother  or  father.  Such  histories  as  these  are 
common  enough  : 

Gordon  M.,  aged  10  years,  has  had  asthma  since  the  age  of  3|  years ;  his 
maternal  grandfather  and  a  maternal  aunt  had  asthma,  another  maternal 
aunt  had  hay-fever. 

Marjorie  M.,  aged  5  years,  began  to  have  asthma  at  the  age  of  20  months ; 
her  father  has  hay-fever,  a  paternal  aunt  and  also  a  maternal  aunt  had  asthma, 
the  maternal  grandfather  had  gout. 


344  COMMON  -DISORDERS  OF  CHILDHOOD 

Gouty  inheritance  has  been  thought  t-o  play  some  part  in  the 
causation  of  asthma,  but  I  have  not  been  able  to  satisfy  myself 
that  this  is  so.  Out  of  47  cases  only  4  gave  a  family  history 
of  gout. 

Some  have  thought  that  the  gouty  taint  is  evidenced  by  in- 
fantile eczema,  which  appears  with  perhaps  more  than  average 
frequency  in  the  history  of  the  asthmatic  child,  but  this  also  is 
not  shown  very  clearly  by  my  own  figures,  in  which  only  7  out 
of  78  asthmatic  children  had  had  eczema.  In  all  these  cases  the 
eczema  occurred  in  infancy  or  early  childhood,  and  had  preceded 
the  asthma  by  some  months  or  years.  These  statistics  probably 
to  a  slight  degree  understate  the  frequency  of  this  association, 
for  special  inquiry  was  not  made  in  all  cases. 

A  much  more  evident  predisposing  factor  is  nervous  insta- 
bility, showing  sometimes  in  the  family  history,  sometimes  in 
the  child.  I  have  noted  again  and  again  that  the  child  brought 
for  asthma  was  an  unduly  nervous  or  excitable  child ;  in  some 
there  was  stuttering,  in  some  habit-spasm,  one  was  under  treat- 
ment for  hysteria,  one  had  epileptiform  attacks,  one  cyclic 
vomiting,  in  others  headache,  night-terrors,  fainting,  or  head- 
banging  were  noted. 

What  part,  if  any,  is  played  by  enlarged  tonsils  and  adenoids 
in  the  causation  of  asthma  is  an  important  question  ;  there  is 
no  doubt  that  these  are  present  in  some  children  with  asthma, 
but  not,  I  think,  in  larger  proportion  than  is  found  amongst 
children  who  have  no  asthma.  Out  of  71,  3  showed  definite 
enlargement  of  tonsils  with  or  without  '  adenoids  ',  3  showed 
only  adenoid  hypertrophy,  13  had  already  been  operated  upon 
for  more  or  less  enlarged  tonsils  or  '  adenoids  ',  mostly  in  the 
hope  of  curing  the  asthma  thereby.  Only  in  1  out  of  these  13 
cases  had  the  operation  been  of  the  slightest  value,  and  in  this 
one  the  good  effect  was  only  temporary.  It  seems  likely  enough 
that  enlarged  tonsils  and  hypertrophied  adenoid  tissue  encourage 
frequent  outbreaks  of  nasopharyngeal  catarrh,  and  may  thereby 
serve  as  a  starting-point  for  asthma  in  a  child  of  asthmatic 
tendency,  but  the  results  of  operation  do  not  prove  this. 

The  exciting  causes  of  asthma  throw  perhaps  as  much  light 
upon  its  character  as  anything,  for  such  a  motley  group  is  surely 
consistent  with  nothing  but  a  neurosis.  In  one  child  the  smell 
of  tar  always  starts  an  attack,  in  another  the  near  presence  of 
a  cat  or  a  horse,  apparently  by  some  emanation  or  smell,  is  suffi- 
cient cause,  in  two  of  my  cases  violent  laughing  would  produce 
an  attack  ;  sitting  in  a  hot  or  stuffy  room,  walking  against  the 


ASTHMA  IN  INFANCY  AND  CHILDHOOD         345 

wind,  especially  if  it  be  cold  or  easterly,  an  outburst  of  passion, 
over-fatigue,  any  special  excitement,  indigestible  food  and  over- 
eating, all  these  were  amongst  the  causes  assigned. 

In  some  cases  I  have  thought  that  asthma  was  induced  by 
the  fine  dust  or  pollen  carried  by  the  air  from  hay  and  flowers, 
as  apparently  happens  in  the  very  closely  allied  condition  hay- 
fever. 

Almost  as  bizarre  in  its  inconstancy  is  the  causal  relation  of 
climate  to  asthma ;  the  place  which  is  the  salvation  of  one  child 
with  asthma  may  be  the  undoing  of  another,  and  the  same  child 
may  enjoy  complete  freedom  from  attacks  at  a  place  which  is 
but  a  bare  mile  or  even  less  from  one  where  the  asthma  was 
most  severe. 

Relation  to  other  Respiratory  Affections.  It  is  no  uncom- 
mon story  that  the  first  attack  of  asthma  began  soon  after  a 
bout  of  *  congestion  of  the  lungs  ',  or  '  double  pneumonia  ',  or 
'  severe  bronchitis  '.  Is  this  a  coincidence,  or  is  there  some  causal 
connexion  ?  It  is  quite  conceivable  that,  given  a  congenital 
instability  of  the  respiratory  nervous  mechanism,  any  acute  infec- 
tion of  the  lungs  or  air-passages  may  leave  the  respiratory  tract 
in  a  morbidly  sensitive  condition,  so  that  spasm  of  the  bronchi — 
if  that  be  the  essential  change  in  asthma — occurs  on  very  slight 
provocation.  But  such  histories  must  be  received  with  caution  ; 
if  it  has  not  already  been  recognized  that  the  child  is  asthmatic, 
it  is  easy  to  make  much  of  the  catarrhal  symptoms,  which  may 
be  very  marked,  and  to  overlook  the  spasmodic  element,  which 
may  be  much  less  obvious.  Given  a  child,  say  of  two  or  three 
years,  with  rales  and  rhonchi  all  over  the  chest,  and  a  tempera- 
ture of  102°-103°,  it  is  natural  enough  to  diagnose  '  congestion 
of  the  lungs  '  or  acute  bronchitis,  or  to  suspect  some  broncho- 
pneumonia,  although  the  unusually  quick  subsidence  of  the  symp- 
toms may  raise  doubts  in  the  medical  man's  mind  at  the  time, 
and  subsequent  attacks  show  more  and  more  of  the  spasmodic 
symptoms  of  asthma. 

It  is  noteworthy  that  whilst  asthma  is  perhaps  in  the  majority 
of  cases  not  associated  with  any  rise  of  temperature,  it  is  some- 
times accompanied  by  considerable  fever,  and  may  vary  in  this 
respect  in  different  attacks  in  the  same  child,  some  being  febrile, 
some  not.  I  have  thought  that  fever  is  more  often  present  when 
catarrhal  signs  are  a  prominent  feature. 

Probably  more  than  a  chance  antecedent  of  asthma,  though 
much  less  common  than  one  might  have  expected,  is  laryngitis 
stridulosa,  '  spasmodic  croup  '. 


346  COMMON  DISORDERS  OF  CHILDHOOD 

Lillie  K.,  aged  1\\,  suffered  at  the  age  of  2  years  with  attacks  called  '  croup', 
with  barking  and  loud  inspiratory  stridor;  the  attacks  occurred  at  night,  and 
sometimes  on  several  successive  nights.  Since  the  age  of  3  years  the  attacks 
have  altered  in  character ;  she  now  wakes  in  the  night  with  a  choking  dry  cough 
and  much  wheezing,  with  signs  of  bronchitis  ;  her  lungs  are  markedly  emphyse- 
matous. 

Fred  M.,  aged  7  years,  had  attacks  of  '  croup  '  from  the  age  of  2  years  until 
5  years  old  ;  about  10  p.m.  he  awoke,  '  making  a  noise  like  a  dog  barking,' 
and  having  considerable  difficulty  in  breathing ;  the  attack  lasted  several  hours. 
At  5  years  old  he  had  an  operation,  apparently  for  adenoids,  and  a  few  months 
later  had  '  pneumonia  ',  since  then  the  '  croup  '  has  been  replaced  by  attacks 
which  seem  to  be  typical  paroxysmal  asthma,  with  laboured  breathing  and 
orthopnoea  ;  these  begin  suddenly  at  night,  and  have  lasted  as  long  as  three 
days  continuously. 

In  both  these  cases  spasmodic  croup  (laryngitis  stridulosa) 
seemed  to  have  been  replaced  by  asthma  as  the  child  grew  older  ; 
but  there  are  cases  in  \vhich  the  distinction  is  very  difficult  if 
one  has  to  judge  from  history  only  :  both  affections  begin 
suddenly  at  night,  in  both  there  is  difficulty  of  breathing,  so  that 
the  child  '  fights  for  his  breath  ' ;  an  attack  of  asthma  occasion- 
ally begins  with  barking  laryngeal  cough,  like  that  of  *  croup ' ; 
both  affections  are  commonly  without  fever  ;  asthma  sometimes 
ceases  during  the  daytime,  and  returns  at  night,  just  as  laryn- 
gitis stridulosa  does.  Nor  is  it  only  in  their  symptoms  that  these 
two  affections  resemble  one  another;  there  is  a  striking  similarity 
in  the  exciting  causes  :  over-eating,  indigestible  food,  the  excite- 
ment of  a  '  party  ',  over-exertion,  running  or  riding  in  the  teeth 
of  a  cold  wind,  all  this  strange  medley  of  causes,  so  suggestive 
of  a  functional  nervous  affection,  is  common  both  to  laryngitis 
stridulosa  (spasmodic  croup)  and  to  asthma.  Moreover,  there  is 
a  dose  resemblance  in  their  pathology ;  in  both  the  essential 
lesion  is  a  combination  of  spasm  with  catarrh ;  in  croup  a  slight 
laryngeal  catarrh  is  associated  with  much  spasm  of  the  laryngeal 
muscles ;  in  asthma  a  slight  bronchial  catarrh  is  associated  with 
much  spasm  of  the  muscles  of  the  bronchi.  Surely  these  affec- 
tions must  be  close  akin,  if  indeed  they  be  not  pathologically 
identical.  I  have  often  thought  that  the  term  laryngeal  asthma 
would  well  describe  the  relation  of  spasmodic  croup  to  bronchial 
asthma. 

There  is  a  curious  symptom  which  calls  for  mention  here,  not 
only  as  another  link  in  the  relationship  between  spasmodic  croup 
and  asthma,  but  as  having  other  relations  which  bear  upon  the 
subject,  namely  paroxysmal  sneezing. 

It  is  a  not  uncommon  tale  that  at  the  onset  of  a  bout  of  asthma 
the  child  has  a  more  or  less  prolonged  attack  of  sneezing. 


ASTHMA  IN  INFANCY  AND  CHILDHOOD         347 

Henry  H.,  aged  8  &,  has  suffered  with  asthma  for  two  years,  until  recently 
the  attacks  always  began  with  a  bout  of  sneezing  ;  for  instance,  on  one  occasion 
he  sneezed  nineteen  times,  after  which  his  respiration  became  laboured  and 
wheezing,  and  the  asthma  ran  its  ordinary  course. 

Sneezing  is  certainly  not  a  common  symptom  in  spasmodic 
croup,  but  I  have  notes  of  one  case  in  which  the  attacks  of  spas- 
modic croup  in  a  child  three  years  old  began  exactly  similarly 
with  a  bout  of  sneezing. 

Paroxysmal  sneezing  occurs  also  as  an  isolated  symptom,  and 
there  is  much  about  it  then  suggestive  of  asthma. 

Mary  F.,  aged  9|  years,  a  highly  sensitive  child  of  nervous  parentage.  When- 
ever she  was  overtired  would  be  seized  in  the  evening  with  severe  sneezing. 
This  would  sometimes  continue  for  hours,  and  had  lasted  from  5  p.m.  till 
midnight,  so  that  the  child  was  quite  exhausted.  In  some  of  these  attacks  she 
became  feverish.  They  occurred  about  once  in  three  weeks,  were  not  specially 
related  to  the  hay  season,  and  continued  to  recur  for  about  six  months. 

Such  cases  are  no  doubt  close  akin  to,  if  not  identical  with, 
hay-fever,  but  they  lack  the  special  causal  relationship  which 
has  given  to  hay-fever  its  name. 

Between  hay-fever  and  asthma  the  connexion  is  very  close. 
It  is  particularly  noticeable  how  frequently  hay-fever  figures  in 
the  family  history  of  patients  with  asthma,  and  there  are  cases 
in  which  with  the  characteristic  symptoms  of  hay-fever  there 
are  associated  some  of  the  symptoms  of  bronchial  asthma,  e.  g. 

Vivien  D.,  aged  6£|,  last  year,  suffered  with  hay- fever  during  the  early  summer. 
This  year,  in  the  latter  part  of  May,  the  attacks  reappeared  ;  about  5  p.m.  she 
is  seized  with  violent  sneezing,  there  is  running  from  the  nose,  and  the  con- 
junctivae  become  congested.  She  seems  quite  dazed  during  the  attack,  which 
lasts  for  some  hours.  Her  chest  shows  wheezing  rhonchi  all  over  :  and  there  is 
well-marked  emphysema  as  in  a  bronchial  asthma.  This  child's  maternal 
grandfather  and  uncle  both  suffer  from  hay-fever. 

I  have  thought  that  some  children  who  were  subject  to  asthma 
at  all  seasons,  and  who  showed  none  of  the  special  symptoms  of 
hay-fever,  nevertheless  ha,d  the  asthmatic  attacks  more  frequently 
or  more  severely  during  the  hay  season,  when  hay-fever  was 
prevalent. 

Symptoms.  Reference  has  already  been  made  to  the  recurring 
bronchitis,  which  is  usually  the  only  manifestation  of  asthma  in 
infancy;  but  at  a  later  age  also  it  sometimes  takes  this  form. 
Whenever  the  child  '  catches  a  cold  '  it  '  flies  to  his  chest ';  per- 
haps he  becomes  slightly  wheezy  for  a  few  hours ;  perhaps  a  more 
definite  bronchitis  occurs  with  mingled  rale  and  rhonchus,  but 
chiefly  rhonchus,  especially  with  expiration,  and  with  more 


348  COMMON  DISORDERS  OF  CHILDHOOD 

hurry  of  respiration  and  more   tendency  to  wheeze   than  one 
would  expect  with  a  simple  bronchitis. 

The  attacks  mostly  begin  at  night,  and  if  they  begin  in  the  day- 
time or  in  the  evening  they  are  usually  worse  at  night.  Often 
there  is  some  premonitory  symptom,  such  as  sneezing,  or  a 
short  dry  cough,  '  cold  in  the  head  ',  or  some  discomfort  in  the 
epigastrium.  In  one  child,  aged  seven  years,  there  was  always 
intolerable  itching  of  the  nose  at  the  onset. 

The  symptoms  of  asthma  vary  greatly  in  their  severity,  a  point 
to  be  remembered,  for  in  its  mildest  forms  the  asthmatic  nature 
of  this  affection  is  sometimes  overlooked.  In  the  most  charac- 
teristic case  the  child  goes  to  bed  well,  and  wakes  about  2  a.m. 
with  a  short  dry  frequent  cough,  which  is  soon  replaced  by  loud 
wheezing  respiration,  in  which  long  laboured  expiration  pre- 
dominates, the  child  is  unable  to  lie  down,  he  is  '  gasping  for 
air  ',  and  perhaps  begs  to  have  the  windows  opened  ;  the  lips  are 
blue  ;  in  the  worst  cases  the  whole  face  has  a  leaden  cyanotic 
colour,  and  the  child  is  in  a  dull  almost  stuporous  condition,  his 
whole  energies  are  concentrated  on  the  struggle  for  breath.  If 
the  chest  be  examined  at  this  time  it  will  be  found  to  be  hyper- 
resonant,  the  cardiac  and  hepatic  dullness  are  more  or  less 
obliterated  by  pulmonary  resonance,  loud  wheezing,  almost  entirely 
expiratory,  is  heard  all  over  the  lungs,  there  is  little  or  no  rale, 
the  heart  is  beating  tumultuously,  and  its  impulse  may  be  seen 
and  felt  in  the  epigastric  angle.  Often  the  attack  subsides  as 
morning  conies,  but  the  child  is  left  prostrate,  and  sleeps  most 
of  the  day,  and  with  night  all  the  symptoms  return  almost  as 
severely  as  on  the  previous  night. 

Duration  and  Prognosis.  In  the  slighter  cases  the  whole 
attack  may  last  only  an  hour  or  less,  usually  the  respiratory 
distress  which  has  begun  in  the  night  lasts  until  daylight,  and 
some  wheezing  rhonchi  are  to  be  heard  on  auscultation  for  two 
or  three  clays  subsequently  ;  sometimes  there  is  a  recurrence  of 
severe  symptoms  on  two  or  three  successive  nights,  and  some- 
times the  severity  of  the  attack  continues  unabated  for  two  or 
three  days  and  nights  continuously,  after  which  a  wheezing 
bronchitis  may  persist  for  a  week  or  more. 

After  asthma  has  recurred  many  times  the  child  may  be  left 
in  a  persistent  condition  of  chronic  bronchitis,  such  a  state  is 
generally  accompanied  by  more  or  less  emphysema. 

During  any  severe  attack  of  asthma  some  emphysema  is  likely 
to  be  present,  but  until  the  asthma  has  recurred  many  times  and 
become  very  severe,  this  is  only  a  transient  result  of  the  violent 


ASTHMA  IN  INFANCY  AND  CHILDHOOD         349 

expiratory  efforts,  and  when  the  attack  is  over  disappears  within 
a  few  days  or  weeks.  This  is  of  prognostic  importance  only  as  an 
index  of  the  severity  of  the  bronchial  spasm  ;  so  long  as  the 
emphysema  is  recoverable,  in  other  words,  so  long  as  the  lung 
has  not  lost  its  elasticity,  the  asthma  does  not  threaten  life. 

It  is  when  emphysema  has  become  permanent,  not  disappear- 
ing in  the  intervals  between  the  attacks  of  asthma,  that  the 
ultimate  prognosis  becomes  bad. 

The  child  who  has  already  reached  the  stage  of  chronic 
emphysema,  owing  to  the  frequency  and  severity  of  the  attacks 
of  asthma,  may  drag  on  for  years  a  laborious  lethargic  sort  of 
existence,  always  a  little  blue  in  the  lips,  always  short  of  breath 
on  the  slightest  exertion,  and  always  dreading  the  next  attack 
of  asthma  ;  pitiful  cases  are  these,  and  the  more  so  because  such 
a  condition  is  preventable,  if  only  proper  treatment  is  given  in 
the  earliest  stage  of  the  disease.  In  this  condition  a  child  stands 
but  a  poor  chance  when  an  attack  of  acute  bronchitis  or  of 
broncho-pneumonia  supervenes,  as  it  is  likely  to  do  sooner  or 
later.  Fortunately,  there  are  many  cases  which  run  a  much 
more  favourable  course,  especially  where  circumstances  make  it 
possible  to  carry  out  treatment,  and  particularly  climatic  treat- 
ment, with  a  free  hand  from  the  earliest  appearance  of  the  asthma : 
both  the  typical  asthma  and  the  allied  condition  of  paroxysmal 
sneezing  cease  entirely  in  some  children. 

Treatment.  Asthma  is  one  of  those  diseases  in  which,  as  in 
epilepsy  and  migraine,  and  perhaps  nocturnal  enuresis,  there  is 
much  of  pathological  habit,  and  I  doubt  not  that,  in  things 
pathological  as  in  the  affairs  of  life,  '  habit  is  second  nature  ', 
and  the  longer  the  habit  persists  the  more  ingrained  and  the 
more  difficult  of  eradication  it  becomes.  For  another  reason  also 
the  early  recognition  and  proper  treatment  of  asthma  is  of  extreme 
importance.  Each  attack  brings  with  it  the  risk  of  chronic 
emphysema,  and  once  induced  the  emphysema  is  likely  to  form 
a  vicious  circle,  the  special  liability  of  the  emphysematous  lung 
to  bronchial  catarrh  favours  a  fresh  attack  of  asthma,  and 
each  fresh  bout  of  asthma  tends  to  increase  the  emphysema. 
Now,  what  happens  in  most  cases  ?  The  parents  take  the  child 
to  a  doctor,  and,  recognizing,  perhaps,  that  the  condition  is 
asthmatic,  he  prescribes  some  medicine,  lobelia  or  stramonium, 
or  some  such  drug,  to  be  given  when  the  attacks  occur.  Now 
I  venture  to  say  that  this  is  not  the  best  way  to  treat  an  asthma  ; 
the  ideal  to  be  aimed  at  is  prevention,  and  even  though  we  may 
not  succeed  in  preventing  the  attacks  entirely  we  can  usually 


350  COMMOtf  DISORDERS  OF  CHILDHOOD 

make  them  decidedly  less  frequent,  and  also  much  less  severe  ; 
but  this  can  only  be  accomplished  by  continuous  treatment. 
Whatever  drug  is  used  it  must  be  given  regularly  for  months  or 
even  vears.  A  very  effective  mixture  is  potassium  iodide 
gr.  i-iv,  tinct.  stramonii  CD  iss-x,  spirit  ammon.  aromatic  O)iiss-x, 
syrup  CD  xx,  aq.  anethi  ad  ^ii  ter  die.  The  lower  doses  are  suit- 
able for  infants,  for  older  children  larger  doses  will  be  necessary, 
but  it  is  always  wise  to  feel  one's  way  with  these  drugs.  Stra- 
monium particularly  must  be  given  with  the  same  watchful  care 
as  is  necessary  with  belladonna,  for  it  is  liable  to  produce  the 
same  toxic  symptoms,  and  some  children  show  a  marked  idio- 
syncrasy to  it.  Five  minims  of  tinct.  stramonii  was  sufficient  to 
produce  dilated  pupils  with  blurring  of  vision  in  a  boy  of  seven 
years  ;  on  the  other  hand  a  child  of  3J  years  took  ten  minims  of 
tinct.  stramonii  with  great  advantage,  and  without  toxic  results. 
I  am  in  the  habit  of  ordering  this  mixture  to  be  given  continuously, 
except  for  one  week's  intermission  after  every  third  week.  Some- 
times it  is  beneficial  to  alternate  the  course  of  this  stramonium 
mixture  with  courses  of  arsenic  :  each  may  be  given  for  three 
weeks  with  or  without  a  week's  interval  between  the  two  courses. 
This  method  affords  an  opportunity  for  comparing  the  efficiency 
of  these  drugs  in  the  particular  case  :  there  are  asthmatic  children 
who  seem  to  be  greatly  benefited  by  arsenic,  especially,  I  think, 
when  the  asthma  is  only  of  recent  onset,  and  there  is  no  persistent 
bronchial  catarrh  or  emphysema.  Tincture  of  lobelia  (B.  P. 
1885)  or  the  ethereal  tincture  of  lobelia  are  often  used  in  place 
of  stramonium,  but  they  have  no  advantage  so  far  as  I  know. 
Atropine  and  belladonna  are  also  used. 

Nervous  sedatives  are  sometimes  of  value  ;  I  have  known  the 
addition  of  phenazone  to  the  potassium  iodide  and  stramonium 
mixture  to  be  followed  by  great  improvement  :  at  a  year  old 
one  grain  may  be  given,  and  two  grains  thrice  daily  at  eight 
years.  Some  give  larger  doses,  but  phenazone  is  a  drug  which 
occasionally  produces  cardiac  depression,  and  should  be  used  care- 
fully, and  always  in  combination  with  some  cardiac  stimulant. 
Bromides  are  sometimes  a  useful  addition  ;  chloral  also  I  have 
seen  given  continuously  thrice  daily  for  many  months  to  a  boy 
of  seven  years,  with  good  results,  but  it  is  a  drug  which  one  would 
prefer  to  avoid. 

During  an  attack  of  asthma  relief  may  be  given  by  inhalation 
of  the  fumes  of  burning  nitre-paper  (white  blotting-paper  soaked 
in  20  per  cent,  solution  of  potassium  nitrate  and  dried)  or 
of  one  of  the  various  powders  of  stramonium  or  lobelia  and 


ASTHMA  IN  INFANCY  AND  CHILDHOOD         351 

potassium  nitrate,  which  are  sold  for  the  purpose,  e.g.  the 
pulvis  lobeliae  co.  (Martindale).  Ethyl  iodide  is  also  useful 
for  inhalation,  and  is  prepared  in  very  convenient  form  in  cap- 
sules either  alone  or  with  chloroform  (Martindale).  Some  children 
are  more  rapidly  relieved  by  an  emetic,  such  as  a  drachm  of 
vinum  ipecacuanhae,  than  by  anything  else  ;  in  a  very  severe 
case  I  have  seen  very  rapid  relief  by  a  hypodermic  injection  of 
morphia  :  ^th  of  a  grain  can  be  given  to  a  child  of  four  years, 
y^th  of  a  grain  at  six  years. 

But  the  treatment  of  asthma  does  not  consist  merely  in  drug- 
ging ;  it  is  essential  that,  if  possible,  the  exciting  cause  should  be 
discovered  and  removed ;  indeed  there  are  cases  in  which  drugs 
are  of  very  little  if  any  value,  and  the  one  thing  needful  is  to 
remove  the  exciting  cause  of  the  attacks.  This  may  require 
a  minute  investigation,  not  only  of  the  child,  the  state  of  his 
organs  and  their  functions,  but  of  his  home  surroundings  and  his 
whole  regimen. 

I  remember  a  child  in  whom  no  treatment  proved  so  effective 
as  regular  correction  of  his  constipation  by  daily  administration 
of  syrup  of  figs  ;  and  another  in  which  one  of  the  chief  items  of 
treatment  was  the  prevention  of  gluttony.  It  is  poor  policy  to 
dose  a  child  continuously  with  drugs,  if  the  attacks  of  asthma 
are  being  excited  by  idiosyncrasy,  such  as  the  presence  of  a  cat, 
or  by  some  affection  of  the  nose  or  throat.  On  this  last  point 
I  must  say  a  word  :  there  is  no  doubt  that  there  are  cases  of 
asthma  which  are  relieved  greatly,  if  not  stopped  entirely,  by 
correction  of  some  abnormality  in  the  nose,  be  it  a  deflection  of 
the  septum  or  hypertrophy  of  a  turbinated  bone,  or  the  presence 
of  a  polypus,  but  such  cases  are,  I  think,  very  uncommon  ;  and  in 
childhood  the  only  local  condition  for  which  operation  is  likely 
to  be  suggested  as  a  cure  for  asthma  is  enlarged  tonsils  and 
adenoid  hypertrophy.  If  by  removal  of  these  we  could  guarantee 
the  removal  of  the  tendency  to  naso-pharyngeal  catarrh  which 
they  favour,  I  suspect  that  the  operation  would  more  often  do 
good  than  it  does  :  but  it  is  my  experience  that  the  removal  of 
adenoids  and  tonsils — perhaps  owing  to  the  difficulty  of  complete 
removal — leaves  behind  it,  in  a  very  large  proportion  of  cases, 
more  or  less  of  the  tendency  to  naso-pharyngeal  catarrh  for  which 
the  operation  was  done. 

Be  this  as  it  may,  the  removal  of  adenoids  and  tonsils  is  almost 
always  a  woful  failure  as  a  cure  for  asthma.  I  have  already 
mentioned  thirteen  cases  in  which  the  operation  was  done  ;  only 
in  one  single  case  was  there  any  improvement  whatever  in  the 


352  COMMON  DISORDERS  OF  CHILDHOOD 

asthma.  This  was  a  boy  aged  about  9i  years,  who  had  been 
having  attacks  every  2-3  months  ;  after  the  operation  he  re- 
mained entirely  free  from  asthma  for  nearly  eleven  months,  but  at 
the  end  of  this  time  the  attacks  returned  more  frequently  than  ever. 
I  have  left  until  last  the  question  of  climate,  not  that  I  would 
minimize  its  importance,  for  it  is  the  first  and  most  essential 
point  in  the  treatment  of  asthma,  but  because  I  can  say  so  little 
that  is  sufficiently  dogmatic  to  be  helpful.  For  years  I  have 
kept  notes  of  the  places  where  attacks  occurred  and  where  they 
did  not  occur  in  asthmatic  children,  hoping  to  tabulate  from  my 
experience  a  useful  list  of  suitable  and  unsuitable  places.  The 
result  was  only  to  illustrate  the  fickleness  of  the  disease  ;  here 
is  a  child  who  remained  entirely  free  from  attacks  at  Torquay ; 
here  is  another,  seen  the  very  next  day,  who  became  so  bad  at 
Torquay  that  the  parents  were  glad  to  remove  her ;  one  child  found 
relief  at  Worthing,  another  was  particularly  bad  at  Worthing  ;  so 
with  Tunbridge  Wells,  Farnham,  Brighton,  and  many  other  places ; 
in  one  child  a  particular  district  worked  like  a  charm,  apparently 
stopping  the  asthma  as  soon  as  he  went  there,  in  another  the 
same  place  seemed  only  to  aggravate  the  disease.  In  short,  I  can 
only  draw  some  very  general  conclusions  from  my  records  : 

(1)  that  inasmuch  as  there  is  no  certainty  as  to  the  effect  of  any 
particular  climate  on  asthma,  it  is  always  wise  to  recommend  a 
trial  of  a  place  before  deciding  upon  permanent  residence  there, 

(2)  that  sonic  children  with  asthma  do  best  at  the  seaside,  others 
inland  ;  (3)  that  on  the  whole  the  milder  places  seem  to  succeed 
more  often  than  the  colder  and  more  bracing  ;    (4)  that  a  dry 
soil,  such  as  sand  or  gravel,  is  generally  more  suitable  than  a  cold 
or  damp  soil,  such  as  chalk  or  clay  ;    (5)  that  a  hilly  district  is 
more  likely  to  succeed  than  a  flat  one,  and  that  by  choice  the 
residence  should  be  facing  towards  the  warmest  quarter,  generally 
the  south  in  tin's  country,  and  a  few  hundred  feet  up  on  the  slope 
of  a  hill.     With  the  caution  that  most  of  the  places  mentioned 
have  failed  entirely  in  some  cases,  or  even  made  the  child  worse, 
I  will  mention  the  following  as  having  suited  well  some  children 
with    asthma  :— Near   London:    Redhill,    Farnham,    Tunbridge 
Wells,  Sevenoaks,  Norbiton.    Inland  places  distant  from  London  : 
Bath,    Dartmoor,    Malvern.      Sea   coast   places:   Bournemouth, 
Southbourne,  Torquay,  Penzance,  Worthing,  Ryde,  Folkestone, 
Rhyl,  Grange  over  Sands,  Falmouth. 

Most  of  these,  be  it  noted,  are  hilly  places,  and  as  a  rule  the 
asthmatic  child  obtained  benefit  from  living  in  the  higher  parts 
of  these  districts. 


CHAPTER  XXV 
BKONCHITIS 

THERE  is  hardly  a  commoner  complaint  in  childhood  than 
cough  ;  there  is  also  hardly  a  symptom  which  has  a  more  varied 
significance.  It  may  be  the  indication  of  transient  or  permanent 
pulmonary  affection  :  it  may  have  no  connexion  with  the  lungs, 
it  may  depend  entirely  on  naso-pharyngeal  conditions,  or  it 
may  even  be  a  purely  nervous  symptom.  The  medical  man 
must  have  all  these  possibilities  before  him  when  he  has  to  deal 
with  the  child  who  is  brought  to  him  for  a  cough  ;  here  I  shall 
confine  my  remarks  to  bronchitis  as  being  one  of  the  commonest 
of  pulmonary  troubles  in  childhood. 

It  is  no  part  of  my  purpose  here  to  describe  the  ordinary 
symptoms  and  physical  signs  of  bronchitis  or  of  any  other  of  the 
pulmonary  diseases  which  are  common  to  all  ages,  a  descrip- 
tion of  these  may  be  found  in  any  textbook  of  general  medicine  ; 
my  object  is  only  to  describe  those  special  features  which 
characterize  the  occurrence  of  such  affections  in  childhood, 
and  which  are  of  practical  importance. 

Bronchitis  is  common  enough  at  all  periods  of  life,  but  pro- 
bably far  commoner  in  the  first  five  years  of  life  than  at  any 
subsequent  age,  and  this  for  two  reasons  :  firstly,  because  the 
two  specific  fevers  with  which  bronchitis  is  almost  always  asso- 
ciated, namely,  measles  and  whooping-cough,  affect  a  very  large 
proportion  of  children  during  the  first  five  years  of  life;  and 
secondly,  because  there  is  a  special  liability  to  primary  bron- 
chitis during  infancy,  a  liability  which  seems  to  diminish  steadily 
after  the  end  of  the  second  year.  Some  statistics  taken  in  the 
Children's  Out-patient  Department  at  King's  College  Hospital, 
where  children  are  seen  up  to  the  age  of  ten  years,  showed  that 
52  per  cent,  of  the  cases  of  primary  bronchitis  occurred  in  infancy 
(up  to  the  age  of  two  years)  :  and  there  were  nearly  twice  as 
many  cases  in  the  first  year  as  in  the  second  (34  per  cent,  out  of  the 
52  per  cent,  were  under  one  year). 

Upon  what  does  this  special  tendency  to  bronchitis  in  infancy 
depend  ?  There  are  undoubtedly  certain  features  in  which  the 
lung  of  the  infant  differs  in  its  histology  from  that  of  the  adult, 

STILL  A  a 


354  COMMON  DISORDERS  OF  CHILDHOOD 

particularly  in  the  relative  abundance  of  loose  connective  tissue 
in  the  walls  of  the  bronchi  and  alveoli.  It  has  been  suggested 
that  the  blood-vessels  in  this  connective  tissue,  being  but  loosely 
supported,  are  the  more  ready  to  become  dilated.  It  has  been 
stated,  moreover,  that  the  pulmonary  artery  is  relatively  larger 
in  infancy  than  in  later  life,  so  that  the  lungs  at  that  age  are  more 
richly  supplied  with  blood  and  so  more  liable  to  hypersemic 
conditions  than  in  later  life.  I  would  add  that  the  small  size 
of  the  nostrils  in  infancy  and  the  ease  with  which  they  become 
blocked  by  coryza,  is  a  frequent  cause  of  temporary  mouth- 
breathing  in  infancy  ;  and  may  thus  contribute  to  the  frequency 
of  bronchitis. 

However  this  may  be,  there  is  no  doubt  that  the  infant, 
especially  during  the  first  few  months  of  life,  is  very  prone  to 
catarrh,  both  of  the  upper  air  passages  and  of  the  bronchi  :  and 
in  these  days  of  open-air  upbringing  it  is  needful  to  remind  parents 
that  while  dry  warm  open  air  may  be  excellent,  a  cold,  foggy 
atmosphere,  such  as  we  often  have  in  London  in  the  winter  and 
autumn  months,  is  a  common  cause  of  bronchitis. 

A  smoking  fire  in  the  nursery  is  sometimes  the  source  of  trouble ; 
one  of  the  youngest  patients  I  have  seen  with  bronchitis  was  an 
infant  eight  days  old  who  had  an  extremely  severe  attack, 
apparently  due  to  the  smoky  atmosphere  of  its  nursery,  dependent 
on  some  fault  in  the  chimney. 

In  later  infancy  dentition  is,  I  think,  certainly  a  cause  of 
bronchial  catarrh.  How  this  comes  about  I  know  not,  but  of  the 
causal  relation  between  the  eruption  of  teeth  and  transient 
attacks-  of  bronchial  catarrh  I  have  not  the  slightest  doubt. 
The  bronchial  affection  in  these  cases  is  quite  slight,  and  like 
the  corresponding  intestinal  catarrh,  which  is  often  associated 
with  the  eruption  of  a  tooth,  it  lasts  only  three  or  four  days  and 
tends  to  recur  with  fresli  worry  of  dentition. 

Tli is  affection  of  the  bronchial  mucous  membrane  in  one  case 
and  of  the  intestinal  in  another  by  the  same  cause,  namely, 
dentition,  reminds  one  of  the  curious  sympathy  which  apparently 
exists  between  the  respiratory  and  the  alimentary  tract.  There 
are  children  who  are  subject  to  attacks  of  digestive  disturbance, 
in  which  a  furred  tongue,  pale  or  loose  stools,  and  perhaps  some 
nausea  and  vomiting  and  more  or  less  fever  are  associated 
almost  always  with  a  transient  bronchial  catarrh. 

A  similar  connexion  is  seen  in  the  close  relationship  between 
some  attacks  of  asthma  and  gastro-intestinal  irritation  :  it  is 
no  uncommon  story  in  the  case  of  some  asthmatic  children  that 


BRONCHITIS  355 

whenever  they  eat  too  heartily  they  begin  to  wheeze  a  few  hours 
later  and  have  an  attack  of  asthma. 

It  is  also  noteworthy  how  often  the  gastro-intestinal  disorders 
of  infancy,  especially  diarrhoea,  are  associated  with  some  degree 
of  bronchitis. 

After  the  age  of  six  months,  there  comes  into  play  another 
important  factor  in  the  etiology  of  bronchitis,  namely  rickets. 
The  rickety  child  is  prone  to  catarrh  of  the  mucous  membranes, 
particularly  of  the  respiratory  tract ;  but  the  bronchitis  of 
rickets  does  not  depend  entirely  on  constitutional  vice,  it  is 
a  result  in  part  of  the  mechanical  conditions  determined  by 
rickets  :  the  softness  of  the  ribs  and  the  diminished  range  of 
movement  of  the  diaphragm  which  is  a  necessary  sequence  of 
the  eversion  of  the  lower  ribs  in  rickets,  and  also  the  general 
feebleness  of  musculature  in  severe  cases,  all  favour  the  occurrence 
of  pulmonary  collapse  ;  and  atelectasis  or  pulmonary  collapse, 
from  whatever  cause  it  may  arise,  strongly  favours  the  occur- 
rence of  bronchitis.  This  is  a  point  worth  remembering  in  cases 
where  signs  of  bronchitis  remain  localized  in  one  lung  or  in  one 
part  of  a  lung  :  such  a  limitation  of  signs  suggests  the  possibility 
of  tubercle,  but  I  would  emphasize  the  fact  that  even  when 
rales  remain  limited  to  one  lobe  or  to  part  of  a  lobe  (generally 
near  the  base  of  a  lung)  for  several  months,  they  may  still 
indicate  nothing  more  than  a  chronic  bronchial  catarrh  in 
a  portion  of  lung  which  has  been  tied  down  by  adhesions  or  left 
collapsed  by  some  previous  illness,  such  as  whooping-cough,  so 
that  it  has  never  properly  expanded  since. 

I  have  already  referred  to  the  frequency  of  mouth -breathing 
in  infancy  as  one  reason  for  this  special  frequency  of  bronchitis 
at  this  age  :  in  the  infant  the  mouth-breathing  is  often  dependent 
merely  on  slight  coryza,  but  even  at  this  age  adenoids  may  be 
cause  of  mouth-breathing  ;  in  older  children  the  mouth-breath- 
ing, which  is  usually  the  result  of  adenoid  hypertrophy,  is  a  very 
common  cause  of  bronchitis.  I  say  '  cause  ',  but  perhaps  it 
would  be  safer  to  say  that  mouth -breathing  is  associated  with 
bronchitis,  for  it  may  be  that  the  bronchitis  is  due  rather  to 
extension  from  the  nasal  or  naso-pharyngeal  catarrh,  which  is 
so  frequent  where  adenoids  or  enlarged  tonsils  are  present,  than 
to  the  breathing  through  the  mouth,  and  it  is  probable  that 
incomplete  expansion  of  the  lungs  owing  to  naso-pharyngeal 
obstruction  plays  an  important  part  also  in  producing  the 
special  liability  to  bronchitis. 

However  this  may  be,  the  presence  of  adenoid  overgrowth  or 

Aa2 


356  COMMON  blSORDERS  OF  CHILDHOOD 

hypertrophied  tonsils  is  very  commonly  responsible  for  frequent 
attacks  of  bronchitis,  as  is  shown  by  the  cessation  of  the  attacks 
after  removal  of  the  adenoids  and  tonsils. 

It  is  difficult  to  gauge  the  exact  part  taken  by  constitutional 
tendencies  in  the  production  of  bronchitis.  I  have  often  thought 
that  very  fat  babies  were  more  liable  to  bronchitis  than  thinner 
babies.  It  is  quite  certain  that  the  so-called  *  Mongolian ' 
imbeciles  are  extraordinarily  liable  to  bronchitis,  but  in  this 
particular  case,  again,  mouth-breathing  due  to  the  special  small- 
ness  of  the  naso -pharynx  in  these  children  may  be  a  predisposing 
cause. 

The  special  liability  of  children  with  congenital  heart  disease 
to  bronchitis  is  well  known;  no  doubt  it  depends  upon  the 
abnormal  vascular  conditions  in  the  lung,  for  it  is  seen,  I  think, 
only  in  those  cases  in  which  there  is  more  or  less  cyanosis. 

Symptoms.  In  infancy  and  early  childhood,  acute  bronchitis 
is  often  ushered  in  with  considerable  fever,  causing  an  amount 
of  anxiety  which,  as  the  event  shows,  is  quite  unjustified;  for 
instance,  I  saw  recently  the  child  of  a  medical  man,  a  little  boy, 
aged  about  eighteen  months,  whose  temperature  had  been 
raised  for  two  days  to  102°-104°  F.,  respiration  was  rapid, 
and  the  child  was  flushed  with  a  slightly  cyanotic  tinge  ;  there 
were  rales  all  over  the  chest  and  those  at  the  bases  were  fine  and 
rather  sharp  ;  but  there  was  no  dullness  on  percussion.  The 
father  was  confident  that  the  child  had  broncho-pneumonia  ; 
but  about  twenty-four  hours  later,  the  temperature  had  fallen 
to  normal,  the  signs  remained  those  of  bronchitis  only,  and  this 
diagnosis  seemed  to  be  confirmed  by  the  course  of  the  illness. 

In  this  case  I  had  little  doubt  that  the  sharp  character  of  the 
fine  rales  was  due  to  some  collapse  of  the  lungs,  which,  although 
not  sufficient  to  produce  dullness  or  bronchial  breathing,  sufficed 
to  give  this  character  to  the  rales. 

That  tins  does  actually  occur,  I  have  proved  by  comparing 
post  mortem  appearances  with  the  signs  observed  during  life. 
The  readiness  with  which  pulmonary  collapse  occurs,  is  one  of 
the  special  features  of  bronchitis  in  infancy  and  early  childhood. 
Not  only  with  bronchitis  but  with  severe  or  frequent  cough 
from  any  cause,  and  with  any  obstruction  to  air-entry,  such  as 
coryza  in  infancy  or  adenoids  or  large  tonsils  in  early  childhood, 
collapse  of  lungs  occurs  very  readily  and  shows  itself  in  diminished 
air-entry,  sometimes  with  slight  impairment  of  note,  and  with 
occasional  fine  rales. 

This   special    liability   to   collapse    is   to   be   remembered   in 


BRONCHITIS  357 

interpreting  the  physical  signs  at  this  age  ;  it  is  easy  to  mistake 
for  broncho-pneumonia  what  is  nothing  more  than  bronchitis 
with  some  collapse  of  the  lung. 

Another  feature  of  bronchitis  during  the  first  two  or  three 
years  of  life  is  the  remarkable  rapidity  with  which  emphysema 
develops,  if  the  bronchial  affection  is  severe  and  causing  much 
cough  ;  it  would  seem  indeed  that  even  a  few  hours  may  suffice 
for  the  development  of  well-marked  emphysema.  Diminution 
of  cardiac  and  hepatic  dullness,  evidence  of  emphysema,  will 
sometimes  throw  light  upon  the  rapidity  of  respiration  which 
otherwise  might  be  attributed  to  the  more  serious  lesion,  broncho  - 
pneumonic  consolidation.  The  emphysema,  even  when  very 
extensive,  passes  off  quickly  when  the  cough  diminishes;  but 
while  it  is  present  it  undoubtedly  increases  to  some  extent  the 
gravity  of  the  pulmonary  condition. 

This  tendency  to  emphysema  in  early  life  is  very  noticeable 
in  whooping-cough.  Whenever  an  infant  or  young  child  with 
this  disease  is  found  to  be  breathing  rapidly  or  becoming  livid 
and  short  of  breath,  the  likelihood  of  emphysema  is  to  be  remem- 
bered. I  have  frequently  been  consulted  about  children  with 
whooping-cough,  who  had  rapidly  become  worse,  with  blue  lips 
and  dusky  cheeks  and  very  rapid  respiration,  and  therewith 
only  a  few  rales  in  the  chest.  The  medical  attendant,  realizing 
that  the  amount  of  bronchitis  was  not  sufficient  to  account  for 
the  child's  distress,  had  been  puzzled  to  explain  the  severity  of 
the  symptoms. 

In  such  cases  I  have  sometimes  found  the  cardiac  and  liver 
dullness  to  be  completely  obliterated  by  the  emphysematous 
lung  ;  and  this  condition,  associated  no  doubt  with  some  dilata- 
tion of  the  right  side  of  the  heart,  has  been  responsible  for  the 
exacerbation  of  symptoms. 

There  is  another  condition  in  which  emphysema  very  quickly 
becomes  established  in  children,  namely,  asthma  ;  and  the 
child,  like  the  adult,  after  several  'attacks  of  asthma,  is  often 
left  with  chronic  emphysema  and  bronchitis,  which  may  be  very 
intractable,  especially  if  residence  in  a  suitable  climate  is  im- 
practicable. I  mention  this  affection  here  because  it  is  important 
to  recognize  that  bronchitis  even  in  an  infant  is  occasionally  of 
asthmatic  nature  and  amenable  to  the  treatment  of  asthma. 
The  characters  which  suggest  such  an  asthmatic  bronchitis  are 
very  ill-defined  and  may  amount  to  nothing  more  than  sudden- 
ness of  onset  and  a  tendency  to  recurrences.  Sometimes, 
however,  the  respiration  is  decidedly  more  wheezy,  especially 


358  COMMON  DISORDERS  OF  CHILDHOOD 

with  expiration,  than  is  usual  in  simple  bronchitis,  but  even 
then  it  is  not  of  the  noisy  character  which  is  so  familiar  in  the 
typical  paroxysms  of  spasmodic  asthma  which  are  seen  in  later 
childhood. 

Prognosis.  If  only  one  could  be  certain  that  bronchitis  would 
remain  bronchitis,  one  would  feel  but  little  hesitation  in  giving 
a  good  prognosis ;  the  trouble  is  that,  especially  in  infants,  it 
may  at  any  time  extend  to  the  alveoli  and  become  a  broncho- 
pneumonia,  and  it  is  this  possibility  which  should  give  us  pause  ; 
the  younger  the  infant  the  greater  this  risk  appears  to  be. 
Apart  from  the  age  there  is  another  point  which  may  affect 
prognosis,  especially  in  hospital  practice,  namely,  the  presence 
of  rickets.  I  think  there  can  be  no  doubt  that  the  child  with 
active  rickets,  especially  where  there  is  severe  rickety  contraction 
of  the  thorax,  stands  bronchitis  badly  and  is  specially  apt  to 
drift  into  a  broncho-pneumonia. 

In  both  cases,  in  the  very  young  and  in  the  rickety,  this  ten- 
dency to  do  badly  with  bronchitis  probably  depends  largely 
upon  the  feebleness  of  expulsive  respiratory  power,  in  conse- 
quence of  which  secretions  tend  to  accumulate  in  the  tubes, 
and  the  materies  morbi,  instead  of  being  expelled  from  the  tubes, 
is  drawn  into  the  alveoli,  carrying  infection  thither.  It  is  in 
these  cases,  with  feeble  respiratory  muscles  and  soft  ribs,  that 
bronchitis  occurring  several  times  in  infancy  is  apt  to  leave 
behind  it  the  transverse  constriction  of  the  lower  part  of  the 
chest  which  is  called  '  Harrison's  sulcus ',  an  indication  of  the 
collapsed  condition  of  the  bases  of  the  lungs  which  is  both  the 
result  and  the  predisposing  cause  of  bronchitis.  But  even  when 
the  chest  has  become  distorted  in  this  \vay  by  bronchitis  in 
infancy,  the  increasing  muscular  and  respiratory  power  as  the 
child  grows  older  tends  to  expand  the  chest  to  its  normal  shape, 
so  that  the  'Harrison's  sulcus'  rarely  persists  in  later  childhood. 

When  signs  of  bronchitis  persist,  and  even  when  they  remain 
localized  to  one  lung  or  to  the  base  of  one  lung  as  they  some- 
times do,  this  persistence  is  not  in  itself  sufficient  justification 
either  for  a  diagnosis  of  tubercle  or  for  a  gloomy  prognosis. 
I  have  watched  several  such  cases  for  years  without  seeing  any 
harm  come  of  these  conditions  beyond  the  obstinate  cough  and 
occasional  exacerbations  of  the  bronchitis  :  pleural  adhesions 
preventing  full  expansion  of  the  lung,  failure  of  the  lung  to 
re-expand  after  collapse  induced  by  some  previous  attack  of 
bronchitis  or  of  whooping-cough,  these  are  the  conditions  which 
may  lead  to  persistent  and  localized  signs  of  bronchitis. 


BRONCHITIS  359 

In  their  clinical  course  and  in  their  etiology  such  cases  are 
very  similar  to  others  in  which  the  persistent  signs  are  those 
of  localized  consolidation,  namely,  sharp  crackles  with  variable 
tubular  breathing,  bronchophony  and  some  impairment  of  note, 
usually  with  some  local  flattening  of  the  chest  on  the  affected 
side  and  more  or  less  displacement  of  the  heart  towards  that 
side  ;  in  these  cases  also  the  signs  persist  for  years  with  little 
or  no  change  and  with  no  serious  damage  to  the  child's  general 
health  ;  and  in  them  also  the  change  in  the  lung,  which  is  a 
fibrosis  with  some  dilatation  of  bronchi,  is  often  the  sequel  of 
pleurisy  or  of  whooping-cough. 

Treatment 

The  child  who  is  acutely  ill  with  bronchitis  wants  air,  and  for 
this  reason,  if  for  no  other,  it  is  bad  to  have  the  air  in  the  room 
used  up  by  well-meaning  friends  and  relatives  coming  in  to  see 
the  poor  child,  who  already  has  ample  attendance  in  the  mother 
or  the  trained  nurse,  in  addition  perhaps  to 'its  ordinary  nurse. 
If  the  weather  is  warm,  by  all  means  have  the  top  of  the  window 
open,  provided,  of  course,  that  no  draught  from  the  window 
strikes  upon  the  child  ;  but  if  the  weather  is  cold,  and  especially 
if  it  is  foggy,  as  it  often  is  when  bronchitis  occurs,  I  think  the 
less  of  two  evils  is  to  keep  the  windows  closed,  and  secure 
what  ventilation  we  can  by  an  open  door,  for  damp,  foggy  air  is 
specially  prone  to  aggravate  bronchitis. 

I  have  no  liking  for  complete  tents  in  the  treatment  of  bron- 
chitis ;  if  the  room  be  a  draughty  one,  a  half  tent  round  the  head 
of  the  bed  is,  I  think,  sometimes  an  advantage  ;  but  to  exclude 
free  access  of  air  to  the  extent  that  an  ordinary  complete  tent 
does,  is,  I  think,  a  thing  to  be  avoided.  In  some  cases  the  com- 
plete tent  is  necessary,  where  with  deficiency  of  secretion  in  the 
tubes  the  cough  is  dry  and  ineffectual  and  it  is  decided  to  use 
a  steam-kettle  to  moisten  the  air  and  induce  freer  bronchial 
secretion  ;  in  such  cases  a  speedy  effect  from  a  steam-kettle  is 
only  to  be  obtained  by  confining  the  vapour  in  this  way  ;  but 
in  a  small  room  a  tent  is  not  necessary  for  this  purpose,  or 
very  definite  relief  to  the  frequent  ineffectual  cough  may  be 
obtained  by  merely  keeping  a  bronchitis -kettle  boiling  on  the 
fire  so  that  the  steam  passes  into  the  atmosphere  of  the  room. 

The  temperature  of  the  room  is  a  matter  of  practical  impor- 
tance ;  for  an  infant  with  bronchitis  the  temperature  should  be 
kept  as  nearly  as  possible  at  65°  F.  Nowadays,  gas-stoves  are 


360  COMMON*  DISORDERS  OF  CHILDHOOD 

extensively  used  for  warming  bedrooms  ;  for  a  sick-room  I 
think  they  are  almost  wholly  bad;  and  especially  where  the 
illness  is  bronchitis  ;  in  most  cases  a  gas-stove  has  little  or 
none  of  the  valuable  ventilating  effect  of  an  ordinary  fire ;  more- 
over, in  spite  of  special  precautions,  a  gas  fire  of  any  sort  is 
apt  to  make  the  air  of  the  room  very  dry,  a  condition  which 
is  particularly  unsuitable  in  some  stages  of  acute  bronchitis. 

In  the  early  stage  of  acute  bronchitis,  when  there  is  much 
rhonchus  in  the  chest  but  little  rale,  and  there  is  reason  to 
believe  that  the  child's  cough  would  be  freer  and  easier  if  there 
were  more  secretion  in  the  tubes,  the  bronchitis -kettle  used  as 
I  have  described  undoubtedly  gives  much  relief. 

The  addition  of  compound  tincture  of  benzoin  (a  drachm  to 
the  pint)  to  the  water  in  the  kettle,  has,  I  think,  a  real  value 
in  these  cases ;  at  any  rate  I  have  seen  improvement  occur  when 
this  drug  was  added,  where  no  improvement  had  taken  place 
with  the  unmedicated  steam. 

In  the  early  stage,  whilst  the  secretion  in  the  tubes  is  still 
scanty  and  the  adventitious  sounds  are  chiefly  rhonchi,  such 
a  mixture  as  the  following  is  generally  useful  :  Potassii 
Citratis  gr.  ij,  Vin.  Ipecac.  O)ijss,  Spirit.  ^Etheris  Nitrosi  O)ijss, 
Tinct.  Camphorse  Co.  Cl)ijss,  Syrup  Cl)xv,  Aq.  ad  Z>j,  which  may 
be  given  every  three  hours  to  an  infant  a  year  old,  and  double 
this  dose  to  a  child  of  three  years.  For  younger  infants  or  to 
one  who  is  feeble  or  has  a  considerable  degree  of  rickets,  it  will 
be  better  to  omit  the  opiate ;  a  mixture  of  Vin.Ipecac.  CDijss,  Sod. 
Bicarb,  gr.  ijss,  Spirit.  ^Etheris  Nitrosi  CDijss,  Syrup  Cl)xv,  Aq. 
Anethi  ad  ,7>j,  will  be  suitable  at  first. 

Directly  the  cough  has  become  loose,  ammonium  carbonate 
or  squills  should  be  given  to  assist  the  child  in  clearing  the  tubes 
of  the  secretion.  A  useful  mixture  is  Ammon.  Garb.  gr.  J, 
Vin.  Ipecac.  CDijss,  Tinct.  Scillae  Cl)ijss,  Glycerin  0)v,  Spirit. 
Chloroform!  CDj,  Mucilag.  Tragacanth.  O)xxx,  Aq.  ad  5j. 

There  is  a  class  of  cases  to  which  I  have  already  alluded  in 
which  bronchitis  even  in  infancy  is  a  manifestation  of  asthma, 
although  it  may  appear  at  first  in  the  guise  of  a  very  ordinary 
bronchitis.  The  possibility  is  specially  to  be  remembered  where 
the  infant  is  particularly  wheezy  and  there  is  a  history  of 
previous  attacks.  For  these  cases  J-l  grain  of  potassium  iodide 
with  1-1  £  minims  of  tincture  of  stramonium  and  a  minim  or  two 
of  sal  volatile  in  syrup  and  water  three  times  a  day  will  be  the 
proper  treatment  for  an  infant  at  one  year. 

As  the  disease  progresses  the  amount  of  secretion  in  the  tubes 


BRONCHITIS  361 

may  threaten  to  suffocate  the  child,  and  it  is  in  this  stage  that 
emetics  are  usually  recommended.  Perhaps  my  own  experience 
has  been  exceptionally  unfortunate,  but  I  confess  it  has  not 
encouraged  me  in  the  use  of  them.  Some  infants  are  remark- 
ably tolerant  of  emetics,  and  it  is  anything  but  gratifying  to 
wait  in  vain  for  the  return  of  a  large  dose  of  some  depressing 
drug  which  the  infant  shows  no  tendency  to  vomit.  For  an 
infant  J-l  drachm  of  the  vinum  ipecacuanha  will  sometimes 
be  effectual,  but  I  would  rather  trust  to  direct  stimulation  of 
the  pharynx  by  a  feather  or  by  one's  finger  if  necessary  ;  even 
this,  however,  I  have  known  to  fail  in  a  very  young  infant  to 
whom  an  emetic  dose  of  ipecacuanha  had  been  given  without 
producing  vomiting. 

It  is  very  rarely  that  an  emetic  of  any  sort  is  desirable ;  fre- 
quent doses  of  ammonium  carbonate  are  usually  to  be  preferred 
in  those  cases  where  an  excessive  amount  of  fluid  is  accumulating 
in  the  tubes:  to  an  infant  of  a  year,  half  a  grain  of  ammo- 
nium carbonate,  with  2J  minims  of  tincture  of  squills,  may  be 
given  every  two  hours  for  about  twelve  hours,  and  then  every 
four  hours. 

The  great  objection  to  free  dosing  with  ammonium  carbonate 
is  its  tendency  to  set  up  diarrhoea,  which  in  an  infant  may  be  an 
exhausting  complication.  If  there  is  any  tendency  to  looseness 
of  the  bowels  it  will  be  better  to  substitute  a  mixture  of  Tinct. 
Nucis  Vom.  O)j<  Syrup  Scillae  O)x,  Aq.  Anethi  ad  3j,  which 
may  be  given  every  three  or  four  hours  to  an  infant  of  six 
months. 

Alcohol  in  some  form  will  probably  be  advisable  at  this 
stage ;  5  minims  every  three  hours  to  an  infant  of  three  months 
or  younger,  and  10-15  minims  every  three  hours  for  a  child  of 
one  year. 

When  all  the  acute  symptoms  have  passed  off,  but  the  child 
still  has  occasional  cough,  and  occasional  rales  and  rhonchi  are 
to  be  heard  in  the  chest,  I  have  found  cubebs  sometimes  of 
great  use  in  the  form  of  a  mixture  of  Tinct.  Cubebse  tt)v,  Tinct. 
Camph.  Co.  tt)v,  Glycerini  O)v,  Mucilag.  Tragacanth.COv,  Aq.  ad  3j 
ter  die.  This  is  suitable  for  an  infant  of  one  to  two  years  ; 
double  the  dose  can  be  used  for  a  child  of  five  years  or  older. 

In  the  more  chronic  cases  of  bronchitis  when  there  is  little 
secretion,  I  think  that  potassium  iodide  in  doses  of  gr.  i-ij  for  a 
child  of  five  years  is  sometimes  valuable;  and  where  a  chronic 
bronchitis  with  a  good  deal  of  secretion  is  the  manifestation  of 
atelectasis  or  of  some  fibroid  condition  in  the  lung  with  or  without 


362  COMMON' DISORDERS  OF  CHILDHOOD 

evident  bronchiectasis,  I  am  in  the  habit  of  prescribing  a  mixture 
of  Tinct.  Benzoini  Co.  O)ijss,  Creosot.  O)J,  Tinct.  Camph.  Co.  O)v, 
Syrup  Tolut.  O)v,  Mucilag.  Acaciae  O)x,  Aq.  Menth.  Pip.  ad  3j 
ter  die.  This  is  suitable  for  a  child  of  three  years  old  ;  double 
this  dose  may  be  given  to  a  child  of  eight  years. 


CHAPTER  XXVI 
BRONCHO-PNEUMONIA 

BRONCHO-PNEUMONIA  as  a  primary  affection — if  it  may  be 
called  primary  when  it  is  almost  always  an  extension  to  the 
alveoli  of  a  catarrhal  process  which  begins  as  a  simple  bronchitis 
— is  seen  far  more  often  in  infancy  than  at  any  other  period  of 
childhood.  It  is  this  tendency  to  alveolar  involvement  which 
gives  to  the  slightest  bronchial  catarrh  in  infancy  an  importance 
which  would  be  lacking  altogether  in  the  case  of  an  older  child. 
Some  statistics  of  cases  under  my  observation,  including  children 
up  to  ten  years  of  age,  showed  that  84  per  cent,  of  the  cases  of 
primary  broncho-pneumonia  occurred  in  infancy;  that  is,  during 
the  first  two  years  of  life. 

As  a  secondary  condition  broncho-pneumonia  keeps  company 
especially  with  infective  conditions,  particularly  measles,  whoop- 
ing-cough, and  infantile  diarrhoea  ;  but  it  is  very  frequently 
found  in  the  post  mortem  room,  as  a  terminal  affection,  in 
children  who  have  fallen  gradually  into  an  exhausted  or  stuporous 
condition  before  death  from  any  cause.  This  secondary  form  is 
less  limited  to  infancy  than  the  primary,  but  is  very  much 
commoner  in  children  under  four  years  of  age  than  in  older 
children. 

The  signs  and  symptoms  of  broncho-pneumonia  are  familiar 
enough, — the  gradual  onset  with  a  shorter  or  longer  period  of 
bronchitis,  then  the  increase  in  severity  of  the  symptoms,  the 
irregular  fever,  the  restlessness,  the  purplish  lips,  the  rapid 
breathing,  the  working  of  the  alae  nasi,  the  scattered  areas  in 
which  there  are  fine  sharp  rales  with  high-pitched  if  not  definitely 
bronchial  breath-sounds,  nowhere  perhaps  actual  dullness  on 
percussion,  but  here  and  there  a  patch  over  which  the  note  is 
not  quite  so  good  as  elsewhere. 

Sometimes  after  three  or  four  weeks  of  varying  fever,  with 
appearance  of  fresh  patches  of  consolidation  from  time  to  time, 
the  signs  gradually  disappear,  the  temperature  slowly  subsides, 
and  the  child  recovers.  Too  often  the  child  goes  from  bad  to 
worse,  the  areas  of  impaired  note  show  more  definite  dullness, 
the  bronchial  breathing  becomes  more  marked,  the  respiration  is 


364  COMMON  DISORDERS  OF  CHILDHOOD 

rattling,  the  child  passes  from  restlessness  to  somnolence,  and 
within  two  or  three  weeks  after  the  onset  dies  of  exhaustion. 
There  are  other  cases  in  which  after  a  week  or  so  the  signs 
diminish  and  the  child  seems  convalescent,  with  a  normal  tem- 
perature for  three  or  four  days  ;  then  the  temperature  gradually 
rises  again  and  for  a  few  days  continues  very  high  with  only 
slight  daily  remissions,  then  falls  again  within  two  or  three  days 
to  normal,  and  so  with  alternating  periods  of  fever  for  a  week 
or  so  and  then  normal  temperature  for  a  few  days,  the  illness 
drags  on  for  three  or  four  weeks.  Some,  certainly,  I  think  most, 
of  these  cases  of  '  relapsing  broncho-pneumonia '  ultimately 
get  well. 

One  might  imagine  that  nothing  could  be  easier  than  the 
recognition  of  broncho-pneumonia,  but  in  practice  it  is  often 
very  difficult  to  be  sure  whether  we  have  to  do  with  an  acute 
bronchitis,  with  a  broncho-pneumonia,  or  with  a  lobar  pneu- 
monia. 

Simple  bronchitis  in  infants  and  young  children  often  begins 
with  an  amount  of  fever  and  respiratory  hurry  which  may 
easily  suggest  broncho-pneumonia,  and  who  shall  say  where  the 
clinical  line  of  division  comes  ?  In  one  case  the  rales  remain 
medium-sized  or  large,  they  are  not  sharp  or  crackling,  the 
breath-sounds  are  nowhere  high-pitched,  and  after  a  day  or  two 
the  temperature  gradually  falls  and  we  say  the  child  had  bron- 
chitis ;  in  another  the  rales  are  smaller  and  sharper  in  character 
in  some  parts,  and  the  breath-sounds  are  a  little  high-pitched 
but  not  bronchial,  there  is  no  dullness,  perhaps  no  definite  impair- 
ment of  note,  and  we  suppose  the  child  has  broncho-pneumonia  ; 
sometimes  post  mortem  examination  proves  we  are  right,  some- 
times the  suspected  broncho-pneumonia  proves  to  be  nothing 
more  than  some  bronchitis  with  collapse  of  parts  of  the  lung. 
It  is  quite  certain  from  post  mortem  examination  that  the 
only  indication  of  broncho-pneumonia  may  be  a  little  sharpness 
in  the  character  of  the  rales  and  perhaps  a  slightly  higher  pitch 
of  the  breath-sounds  than  over  the  rest  of  the  lung  ;  and  these 
are  subtle  distinctions  upon  which  to  base  a  diagnosis  between 
acute  bronchitis  and  pneumonia,  but  sometimes  they  are  the 
only  ones  available. 

In  the  infant  also  broncho-pneumonia  very  rapidly  becomes 
confluent,  so  that  a  large  part  of  one  lobe  may  be  consolidated, 
and  the  physical  signs  may  resemble  very  closely  those  of  lobar 
pneumonia.  In  such  cases  the  distinction  must  rest  upon  the 
more  gradual  onset,  the  added  signs  of  bronchitis,  the  more 


BRONCHO-PNEUMONIA  365 

irregular  temperature  and  the  subsidence  by  lysis  in  the  broncho- 
pneumonic  affection,  but  there  are  cases  in  which  some  or  all 
of  these  distinctions  fail  :  even  the  temperature  may  not  help 
if  the  case  is  first  seen  two  or  three  days  before  the  fever 
ends,  for  the  pseudo-crisis  of  lobar  pneumonia  simulates  the 
intermittent  or  remittent  fever  of  broncho-pneumonia ;  and 
occasionally  a  lobar  pneumonia  ends  by  lysis.  It  is  true  that 
broncho-pneumonia  usually  affects  both  lungs,  but  it  does  not 
always  do  so,  and,  on  the  other  hand,  lobar  pneumonia  may  occur 
on  both  sides. 

In  infants  also,  I  fancy  more  often  than  in  older  children, 
rales  or  crepitations  are  to  be  heard  in  other  parts  of  the  chest 
when  there  is  undoubted  lobar  pneumonia  in  part  of  one  lung, 
so  that  rales  heard  near  the  area  of  consolidation  or  in  the  other 
lung  would  not  necessarily  indicate  broncho-pneumonia.  The 
distinction  is,  I  believe,  impossible  in  some  cases  during  life, 
and  in  many  it  must  remain  doubtful  until  the  duration  of  the 
disease,  its  termination  by  crisis,  and  perhaps  the  occurrence  of 
pneumococcal  empyema  point  to  the  lobar  form  of  pneumonia. 
Even  in  its  bacteriology  broncho-pneumonia  is  not  always  to 
be  distinguished,  for  whilst  no  doubt  in  the  majority  of  cases  it 
is  due  to  other  micro-organisms  it  is  occasionally  due  to  pneumo- 
coccus,  so  that  the  sequence  of  a  pneumococcal  empyema  does 
not  necessarily  prove  that  the  previous  pneumonia  was  a  lobar 
pneumonia.  It  must,  however,  be  admitted  that  an  empyema 
is  very  rare  with  broncho-pneumonia,  and  the  occurrence  of 
a  pneumococcal  empyema  is,  I  think,  prima  facie  evidence  that 
the  antecedent  pneumonia  was  lobar. 

But  even  when  it  is  clear  from  the  gradual  onset  of  the  pul- 
monary condition  and  from  the  signs  that  there  is  a  broncho- 
pneumonia,  the  possibility  that  it  may  be  secondary  to  whooping- 
cough,  or  may  be  tuberculous,  must  always  be  remembered.  It 
is  a  very  easy  and  very  common  mistake  to  regard  as  a  primary 
broncho-pneumonia  what  is  really  secondary  to  whooping-cough  : 
sometimes  the  primary  catarrh  of  whooping-cough  passes  rapidly 
into  a  broncho-pneumonia  before  any  definite  whoop  has  been 
heard,  and  even  if  the  child  has  already  begun  to  whoop,  the 
whoop  often  disappears  altogether  when  broncho-pneumonia 
supervenes,  so  that  it  is  only  by  inquiring  carefully  into  the 
previous  history — especially  the  paroxysmal  character  of  the 
cough  and  its  association  with  vomiting,  and  perhaps  the  coinci- 
dence of, whooping-cough  in  other  children  in  the  house — that  the 
significance  of  the  broncho-pneumonia  may  be  determined.  The 


366  COMMOtf  DISORDERS  OF  CHILDHOOD 

value  of  the  fraenal  ulcer  in  diagnosis  is  to  be  borne  in  mind  in 
these  cases  ;  this  sign  may  serve  as  evidence  of  the  paroxysmal 
character  of  the  cough,  even  if  the  child  has  not  actually  whooped : 
it  is  present  in  about  one-fourth  of  cases  of  whooping-cough,  and 
is  so  rarely  found  in  any  other  condition,  that  it  may  be  taken 
as  almost  pathognomonic  of  whooping-cough. 

There  is  sometimes  much  difficulty  in  excluding  tubercle, 
especially  where  the  broncho-pneumonia  runs  a  lingering  course. 
With  measles  and  whooping-cough  particularly  one  must  needs 
regard  a  broncho-pneumonia  with  suspicion,  especially  if  it 
persists  for  an  unusually  long  time  ;  again  and  again  post  mortem 
examination  proves  that  what  had  been  thought  to  be  a  simple 
broncho-pneumonia  complicating  these  diseases  is  really  tuber- 
culosis. In  these  cases  where  the  sputum  is  so  seldom  available 
the  Von  Pirquet  reaction  may  assist  diagnosis,  but  it  must  be 
remembered  that  a  negative  result  is  frequent  where  tuberculosis 
is  running  an  acute  course. 

Prognosis.  The  more  I  see  of  broncho-pneumonia  in  infants 
and  young  children  the  more  I  dread  its  occurrence  ;  not  only 
is  its  mortality  high — much  higher  than  that  of  lobar  pneumonia 
— but  it  is  such  a  treacherous  disease  that  one  can  hardly  point 
to  any  particular  condition  or  signs  upon  which  a  prognosis 
may  be  based.  Age  is,  I  think,  the  most  important  element  in 
prognosis  :  Dr.  T.  R.  Whipham  l  has  published  a  very  interesting 
analysis  of  cases  :  the  mortality  in  children  up  to  twelve  years 
was  45-9  per  cent.,  but  in  infancy,  that  is  in  the  first  two  years 
of  life,  the  mortality  was  64-4  per  cent.  ;  Dr.  Voelcker2  found 
a  mortality  of  50  per  cent,  in  the  broncho-pneumonia  of  whoop- 
ing-cough. Even  higher  rates  of  mortality  have  been  recorded, 
but  these  are  sufficient  to  show  that  broncho-pneumonia  is 
always  a  dangerous  disease  in  childhood,  and  especially  in 
infancy. 

I  do  not  think  that  much  information  as  to  outlook  is  to  be 
gathered  from  the  temperature  :  it  is  not  uncommon  to  find 
broncho-pneumonia  at  autopsy  in  an  infant  who  has  died  after 
several  days  of  normal  or  even  subnormal  temperature,  at  the 
end  of  a  chronic  diarrhoea  or  other  exhausting  disease  ;  on  the 
other  hand,  I  have  seen  many  children  get  well  who  had  had 
a  temperature  of  105°  or  even  higher  with  broncho-pneumonia. 

The  extent  of  the  consolidation  of  course  affects  the  prognosis  : 
if  a  large  area  of  one  or  both  lungs  is  involved  the  child's  chance 

1  British  Journal  of  Children's  Diseases,  July,  1908,  p.  284. 

2  Clinical  Journal,  Nov.  5,  1902. 


BRONCHO-PNEUMONIA  367 

of  recovery  is  not  good,  but  a  small  area  of  involvement  is  no 
guarantee  of  recovery,  clinical  signs  are  deceptive,  and  post 
mortem  examination  often  reveals  much  more  extensive  affection 
than  was  suspected  ;  but  on  the  other  hand  I  think  there  are  few 
conditions  in  which  one  may  more  legitimately  hope  until  the 
end,  for  however  extensive  the  consolidation  may  appear  to  be, 
the  child  will  sometimes  struggle  through  successfully. 

I  am  inclined  to  think  that  the  combination  of  severe  diarrhoea 
with  broncho-pneumonia,  whether  the  diarrhoea  is  primary  or 
secondary,  makes  the  prognosis  very  bad. 

Treatment.  Nowadays  it  is  very  necessary  to  point  out  that 
cold  air  may  do  harm  to  the  child  with  broncho-pneumonia  : 
the  doctrine  of  open  air — excellent  when  checked  by  common 
sense  and  experience — has  taken  such  hold  that  one  finds  the 
tenderest  babes  lying  ill  of  broncho-pneumonia  in  a  room  with 
the  windows  wide  open  and  the  thermometer  at  55°,  or  even 
lower.  By  all  means  let  the  child  have  fresh  air,  the  more  the 
better,  and  in  summer  time  or  even  in  winter,  when  there  is 
a  clear  dry  cold,  there  is  no  reason  why  the  windows  should  not 
be  open  if  the  temperature  of  the  room  is  kept  up  to  65°  with 
a  fire  if  necessary  ;  but  when  the  raw,  cold  fogs  of  winter  are 
about  I  would  rather  risk  the  closed  window  and  trust  to  ventila- 
tion through  the  open  door  of  the  room. 

The  important  observations  of  Dr.  C.  B.  Ker1,  at  Edinburgh, 
on  the  treatment  of  the  broncho-pneumonia  of  whooping-cough 
by  open  air  are  sufficient  to  prove  that  traditional  methods  of 
treatment  are  not  necessarily  the  best.  He  placed  even  severe 
cases  of  broncho-pneumonia  out  in  the  open  air  for  seven  hours 
daily  during  the  summer,  and  in  the  winter  treated  them  in 
a  ward  which  was  practically  open  to  the  air  on  two  sides  :  the 
mortality  amongst  these  cases  of  broncho-pneumonia  was  only 
31-5  per  cent.,  whereas  amongst  cases  treated  by  the  usual  indoor 
methods  it  was  66-9  per  cent.  ;  the  chief  centra-indication  to  the 
open-air  treatment  he  considers  to  be  laryngitis  complicating 
the  broncho-pneumonia. 

As  with  bronchitis  (see  p.  359),  I  think  the  complete  tent  is  to 
be  avoided  as  preventing  free  access  of  air,  but  a  half  tent  may 
be  advisable  if  the  room  is  a  draughty  one. 

The  value  of  local  applications  is  difficult  to  prove,  but  I  have 
thought  that  a  hot  application  with  either  a  thin  jacket  poultice 
or  a  hot  turpentine  stupe  is  useful  if — and  it  is  a  big  '  if  '- 
applied  secundum  artem,  by  a  skilful  nurse  ;  if  no  expert  nursing 
1  Scot.  Med.  and  Surg.  Journ.,  Jan.,  1904. 


368  COMMON  DISORDERS  OF  CHILDHOOD 

is  available,  I  think  that  a  hot  fomentation  is  perhaps  the  easiest 
application,  but  whichever  is  used  the  utmost  care  is  necessary 
that  the  application  is  not  hot  enough  to  scald  the  child  ;  it  is 
no  great  rarity  to  see  amongst  the  poorer  classes  children  who 
are  scarred  extensively  on  the  chest  from  severe  burns  due  to 
hot  poultices  or  fomentations  in  infancy.  It  is  horrible  to  think 
of  the  deliberate  infliction  of  such  cruel  torture  upon  a  little 
child  through  the  ignorance  of  a  well-meaning  mother  or  nurse. 

The  drugs  which  are  of  most  service  in  broncho-pneumonia 
are  the  stimulants,  particularly,  Nux  Vomica  and  Ammonium 
Carbonate.  In  the  early  stage  a  mixture  of  Vin.  Ipecac.  Ctyijss, 
Ammonium  Carb.  gr.  J,  Syrup  O)xx,  Aq.  Anethi  ad  3j,  may  be 
given  every  three  hours  to  an  infant  of  three  months,  and  double 
this  dose  to  a  child  of  a  year. 

Belladonna  was  recommended  by  the  late  Dr.  Coutts,  if  with 
the  consolidation  there  is  also  much  bronchitis,  so  that  secretion 
tends  to  accumulate  in  the  tubes,  adding  to  the  difficulty  of  re- 
spiration; the  dose  he  advises  is  J-grain  of  the  Extract  every  three 
or  four  hours,  and  this  dose  is  independent  of  age  ;  it  is  given 
to  an  infant  of  a  few  weeks  or  to  a  child  of  six  or  seven  years. 
As  he  points  out,  it  is  liable  to  produce  toxic  symptoms  such  as 
delirium,  flushing,  &c.,  and  is  therefore  less  applicable  to  private 
practice  than  to  hospital  patients  who  are  under  immediate 
medical  supervision. 

When  the  consolidation  of  the  lung  persists,  as  it  sometimes 
docs,  for  a  long  time,  or  fresh  patches  of  broncho-pneumonia 
keep  appearing  for  two  or  three  weeks,  Potassium  Iodide  is  some- 
times helpful  and  may  be  given  in  the  mixture  of  Ipecacuanha 
and  Ammonium  Carbonate  mentioned  above  ;  J  a  grain  may  be 
given  every  three  hours  to  an  infant  of  6  months  and  1  grain  to 
a  child  of  1-2  years. 

It  is  in  these  prolonged  cases  also  that  vaccine  treatment  has 
sometimes  seemed  to  be  of  considerable  value.  Inasmuch  as 
many  such  cases  are  due  to  pneumococcal  infection,  a  stock 
pncumococcus  vaccine  may  be  used  for  this  purpose,  5-10  millions 
may  be  given  at  a  time  to  an  infant  of  twelve  months,  the  injec- 
tion to  be  repeated  if  necessary  at  the  end  of  four  or  five  days. 
Some  have  punctured  the  consolidated  lung  with  an  exploring 
needle,  and  from  the  drop  of  sanguineous  fluid  withdrawn  in  the 
needle  have  prepared  an  autogenous  vaccine,  whether  of  strepto- 
cocci, staphylococci,  or  pneumococci  ;  but  painful  methods  of 
this  kind  arc  always  to  be  avoided  if  possible  in  the  case  of 
a  child,  and  it  may  be  practicable  by  gently  swabbing  the  pharynx 


BRONCHO-PNEUMONIA  369 

to  excite  a  cough  and  catch  sufficient  sputum  for  the  preparation 
of  a  vaccine. 

If  the  child  shows  signs  of  exhaustion,  Tinct.  Nucis  Vom.O)J, 
Syrup  Scillae  0)v,  Glycerini  tt)v,  Aq.  ad  3j,  may  be  given  every 
three  hours  to  an  infant  of  three  months,  and  double  the  dose  to 
an  infant  of  nine*  months  or  a  year.  For  a  child  of  a  year  old  or 
more  I  think  the  Tincture  of  Digitalis,  or  perhaps  better,  as 
Dr.  Melville  Dunlop l  advises,  Tincture  of  Strophanthus,  in  doses 
of  1-1 J  minims,  is  sometimes  valuable,  where  the  lips  are 
becoming  purple  and  it  is  evident  that  the  right  side  of  the 
heart  is  in  difficulty.  But  as  in  other  conditions,  where  it  is 
necessary  to  increase  the  vigour  of  the  heart-beat  by  these  drugs, 
there  comes  a  stage  when  mischief  may  be  done  by  their  action 
unless  the  circulation  is  first  relieved  by  leeching  or  otherwise. 

I  have  no  doubt  whatever  of  the  great  value  of  leeching  in 
some  cases  of  broncho -pneumonia  where  the  right  heart  is  becoming 
considerably  dilated.  Two,  three,  or  four  leeches,  according  to 
the  age  of  the  child,  should  be  applied  over  the  sternum. 

When  the  cheeks  are  livid,  and  the  lips  blue,  and  the  child  is 
restless  from  dyspnoea,  nothing  gives  so  much  relief  as  tho 
inhalation  of  oxygen  :  in  a  minute  or  two  the  colour  improves 
and  the  child  becomes  more  comfortable  ;  the  easing  of  respira- 
tion means  the  husbanding  of  strength,  and  in  this  way  oxygen 
may  tide  the  child  over  a  time  of  real  danger. 

An  important  point  to  be  remembered  in  the  treatment  of 
broncho-pneumonia  in  early  life  is  the  liability  to  collapse  and 
congestion  if  the  infant  is  kept  lying  in  one  position  for  a  long 
time.  An  adult  or  an  older  child  can  shift  his  position  for  himself, 
but  an  infant  requires  to  be  shifted  from  side  to  side  frequently, 
so  that  he  may  give  free  play  to  each  lung  in  turn. 

Lastly,  with  regard  to  alcohol,  I  think  there  are  very  few  cases 
of  broncho-pneumonia  in  infancy  in  which  alcohol  is  not  advan- 
tageous at  some  period  of  the  disease  ;  in  older  children  also, 
when  the  heart  action  is  becoming  enfeebled  and  the  child  is 
becoming  exhausted,  alcohol  is  most  valuable  ;  but  as  I  have 
said  elsewhere,  it  is  quite  possible  to  overdo  the  alcohol :  a  dose 
of  5  to  15  minims  every  three  hours  for  an  infant  under  a  year 
old,  and  of  15  to  40  minims  for  a  child  one  to  five  years  of  age, 
will  be  sufficient  in  most  cases. 

1  British  Medical  Journal,  August  15,  1908,  p.  368. 


STILL 


CHAPTER  XXVII 
PNEUMONIA 

THE  main  differences  between  lobar  and  lobular  pneumonia 
are  familiar  enough  :  in  the  lobar  variety  there  are  the  sudden 
onset,  the  continuous  and  high  fever,  the  consolidation  limited 
to  one  lobe  or  perhaps  two  lobes  of  one  lung,  whilst  the  other  side 
usually  escapes  altogether,  the  crisis  on  the  seventh  to  the  tenth 
day,  and  the  specific  micro-organism  the  pneumococcus  ;  whereas 
in  the  lobular  or  broncho-pneumonia  there  are  the  gradual  onset, 
often  with  some  bronchitis  at  first,  the  irregular  fever,  the  patchy 
consolidation  often  combined  with  bronchitic  signs,  and  usually 
affecting  both  lungs,  the  termination  of  the  fever  gradually  within 
no  fixed  period,  and,  lastly,  the  variety  of  micro-organisms  \vhich 
may  cause  it. 

It  used  to  be  held  that  if  an  infant  or  a  young  child  developed 
pneumonia  it  was  almost  certain  to  be  a  broncho-pneumonia, 
whereas  in  an  adult  it  was  almost  equally  certain  to  be  a  lobar 
pneumonia.  There  is  some  truth  in  this,  but  more  error.  If  we 
eliminate  secondary  broncho-pneumonia,  that  is  to  say  the 
broncho-pneumonia  which  occurs  as  a  complication  of  other 
diseases,  such  as  measles  and  whooping-cough,  and  consider 
only  that  which  starts  as  an  extension  of  primary  bronchitis, 
perhaps  without  an  antecedent  bronchitis,  the  so-called  primary 
broncho-pneumonia,  it  is,  I  think,  true  that  in  early  infancy,  up 
to  the  age  of  nine  months,  a  primary  pneumonia  is  usually,  but 
not  always,  a  broncho -pneumonia,  but  after  this  age  a  primary 
pneumonia  is  just  as  likely  to  be  lobar  as  it  is  in  the  adult. 

Taking  50  cases  of  lobar  pneumonia  at  random  from  my  note- 
books of  cases  seen  mostly  at  the  Children's  Hospital,  Great 
Orniond  Street,  or  in  the  Children's  Department  at  King's 
College  Hospital,  I  find  that  8  were  under  the  age  of  two  years, 
the  youngest  was  ten  months,  29  were  aged  two  to  five  years, 
13  were  between  five  and  twelve  years  old  ;  but  I  have  notes 
of  lobar  pneumonia  at  the  age  of  three  months,  and  of  one  case 
which  died  with  pneumonia,  empyema,  and  suppurative  menin- 
gitis, from  which  a  pure  growth  of  pneumococcus  was  obtained, 
at  the  age  of  9J  weeks.  I  fancy  that  these  figures  underestimate 
the  relative  frequency  of  lobar  pneumonia  in  the  first  two  years 


PNEUMONIA  371 

of  life.  Dr.  J.  A.  Coutts,1  at  the  Shadwell  Children's  Hospital, 
found  that  50  per  cent,  of  the  cases  of  lobar  pneumonia  were 
under  two  years  of  age,  and  Dr.  Melville  Dunlop,  at  the  Children's 
Hospital  in  Edinburgh,  found  that  45  out  of  147  cases  occurred 
under  the  age  of  two  years.  It  is  evident,  therefore,  that  no 
great  stress  can  be  laid  upon  age  in  the  diagnosis  between  lobar 
and  lobular  pneumonia. 

An  interesting  point  in  regard  to  the  etiology  of  pneumonia 
is  the  possibility  of  conveyance  by  contagion.  I  have  had  several 
cases  under  my  care  in  which  lobar  pneumonia  attacked  two 
members  of  a  family  within  a  few  days.  Two  sisters  were  in  my 
ward  at  King's  College  Hospital,  one  aged  twenty-one  months, 
the  other  aged  five  years,  with  lobar  pneumonia,  which  began 
in  the  former  on  March  22,  in  the  latter  on  March  27  ;  another 
girl,  aged  seven  years,  was  admitted  for  lobar  pneumonia  which 
began  on  May  22  ;  her  father  developed  lobar  pneumonia  on 
May  19  ;  both  had  empyema. 

Such  cases  undoubtedly  suggest  contagion,  but  they  should 
be  compared  with  others,  such  as  these,  in  which  the  onset 
was  simultaneous  :  Gladys  A.,  aged  4|  years,  was  seen  by  me 
for  right  lobar  pneumonia,  which  had  begun  on  December  21  (it 
ended  by  crisis  on  the  28th)  ;  her  brother,  aged  two  years, 
developed  lobar  pneumonia  on  the  same  day.  Charles  J.,  aged 
two  years,  was  in  my  ward  with  pneumonia,  which  began  on 
December  24  (crisis  on  the  ninth  day);  another  child  of  the 
family  developed  pneumonia  also  on  December  24  (crisis  on 
the  third  day).  In  these  cases  the  onset  upon  the  same  day 
makes  it  very  unlikely  that  the  infection  had  spread  from  one 
child  to  the  other  ;  it  suggests  rather  that  both  had  been  ex- 
posed to  some  common  source  of  infection,  which  might  be 
air-borne  or  otherwise,  but  was  not  necessarily  directly  from 
an  infected  person. 

The  point  is  one  of  some  practical  importance  ;  there  are 
other  instances  on  record  like  those  mentioned  above  which  sug- 
gest that  pneumonia  may  occasionally  be  conveyed  from  person 
to  person,  and  in  face  of  such  cases  it  seems  advisable  to  avoid 
close  contact  as  far  as  possible.  Presumably  the  risk  must  be 
lessened  by  large  air  space  and  free  ventilation.  I  have  never 
known  the  disease  to  spread  from  one  child  to  another  in  hos- 
pital, but  when  a  child  has  pneumonia  in  the  comparatively  small 
room  of  a  private  house,  it  is  advisable  to  keep  other  children 
out  of  the  room. 

1  Edinburgh  Medical  Journal,  September,  1902,  p.  210. 
B  b  2 


372  COMMON  DISORDERS  OF  CHILDHOOD 

Symptoms.  The  onset  of  lobar  pneumonia  in  the  child  is 
almost  always  accompanied  by  vomiting  :  it  has  been  said  by 
Dr.  Donkin  that  there  are  two  acute  infective  fevers  in  child- 
hood which  almost  constantly  begin  with  vomiting,  one  is  scarlet 
fever,  the  other  is  lobar  pneumonia.  It  has  also  been  said  that 
vomiting  takes  the  place  of  the  rigor  of  the  adult,  as  convul- 
sions may  upon  occasion.  But  I  am  by  no  means  sure  that 
this  is  so  :  four  out  of  the  fifty  cases  began  with  definite 
'  shivering  ' ;  one  of  these  was  aged  twenty-one  months,  and  in 
his  case  there  was  no  vomiting  ;  the  others  were  respectively 
5,  5J,  and  7  years  old,  and  all  of  them  vomited  as  well  as 
shivered  at  the  onset. 

Vomiting  sometimes  but  rarely  recurs  throughout  the  illness, 
as  in  the  case  whose  temperature  chart  is  shown  below. 

Convulsions  are  quite  exceptional  at  the  onset  of  pneumonia  : 
there  were  none  in  the  series  of  fifty  cases,  but  I  have  noted 
them  occasionally  in  other  cases.  Dr.  Dunlop  noted  them  as  an 
initial  symptom  in  12  out  of  147  cases  ;  my  own  experience 
agrees  with  his  as  to  the  absence  of  serious  import  in  these 
initial  convulsions,  and  the  grave  significance  of  convulsions  at 
a  later  stage. 

A  very  common  feature  at  the  onset  is  drowsiness,  which  may 
very  early  be  replaced  or  accompanied  by  delirium.  Delirium 
is,  I  think,  often  overlooked  in  infants  and  young  children,  for 
in  the  absence  of  speech  it  declares  itself  only  by  an  unnatural, 
restless,  and  vacant  manner,  the  significance  of  which  may  easily 
go  unrecognized  by  those  who  have  no  large  experience  of  the 
ways  of  infants. 

I  have  several  times  been  told  that  the  first  indication  of  the 
illness  was  earache,  a  history  which  may  be  misleading,  for  unless 
the  rapidity  of  respiration  be  noticed,  and  a  careful  examination 
of  the  chest  made,  it  would  be  easy  to  attribute  the  whole  symp- 
toms to  acute  otitis  media.  I  doubt  whether  the '  earache '  in  these 
cases  is  always  genuine  ;  a  child  of  three  or  four  years  is  often 
very  vague  in  the  distinction  between  headache  and  earache, 
and  headache,  sometimes  severe,  is,  as  we  know  from  older 
children,  often  one  of  the  initial  symptoms  of  pneumonia. 

A  common  complaint  at  the  onset  is  pain  in  the  abdomen,  no 
doubt  due  to  diaphragmatic  pleurisy  :  young  children  are  at  all 
times  particularly  vague  in  the  localization  of  pain,  so  that  in 
this  instance,  when  asked  where  it  hurts  them,  they  will  pass 
their  hand  impartially  over  most  of  the  abdomen,  and  if  the 
doctor,  imbued  with  visions  of  appendicitis,  points  to  the  right 


PNEUMONIA  373 

iliac  fossa  and  asks  if  it  hurts  there,  they  will  nod  or  say  '  yes '  in 
the  most  misleading  way.  What  more  natural  than  to  suspect 
'  appendicitis  '  when  a  child  is  seen  with  pain  in  the  abdomen, 
referred  perhaps  to  the  right  side,  with  vomiting,  constipation, 
a  high  temperature,  all  of  sudden  onset,  and  perhaps  on  most 
careful  examination  nothing  abnormal. to  be  detected  in  the 
lungs  ? 

Misleading  cases  are  these  in  which  the  appearance  of  signs 
in  the  lungs  is  delayed,  not  one  day  or  two,  but  possibly,  as 
I  have  seen,  until  the  day  of  crisis.  One  child  I  remember  whom 
I  watched  carefully  for  signs  which  did  not  appear  until  the  day 
of  the  crisis,  when  bronchial  breathing  appeared  at  one  base  and 
quickly  disappeared  again.  It  is  this  delay  of  physical  signs 
which  makes  mistake  so  easy,  especially  where  the  abdominal 
symptoms  are  so  suggestive  of  appendicitis.  The  error  is  not  an 
uncommon  one,  Dr.  Crozer  Griffith1  has  recorded  several  cases 
in  which  the  child  narrowly  escaped  laparotomy,  and  quotes 
Dr.  Morse  as  mentioning  two  instances  in  which  this  operation 
had  actually  been  done  upon  children  with  pneumonia. 

I  have  seen  the  converse  mistake  made  in  a  girl  about  ten 
years  old  whose  high  fever  and  abdominal  pain  was  thought  to 
be  due  to  pneumonia  ;  careful  abdominal  palpation  showed 
a  definite  tumour  in  the  right  iliac  region  and  operation  showed 
appendicitis.  The  rapidity  of  respiration,  which  is  likely  to  be 
out  of  proportion  both  to  the  pulse  rate  and  to  the  fever  in 
pneumonia,  is  I  think  the  most  reliable  criterion,  but  the  tout 
ensemble, — the  flushed  cheeks,  the  bright  eyes,  the  hot,  dry 
burning  skin,  and  above  all  an  extremely  careful  examination 
of  the  chest,  must  determine  the  diagnosis  of  pneumonia. 

And  here  I  would  point  out  that  there  is  one  part  in  which 
signs  of  consolidation  are  very  apt  to  be  overlooked,  to  wit,  the 
extreme  apex  of  the  axilla.  I  have  several  times,  in  doubtful 
cases,  detected  definite  evidence  of  pneumonia  by  pushing  the 
end  of  my  stethoscope  against  the  chest  as  far  up  in  the  axilla 
as  possible,  when  examination  of  the  apex  in  front  showed  no 
'signs  of  consolidation.  This  is  a  more  likely  spot  for  signs  of 
lobar  pneumonia  in  children  than  in  adults,  because  in  early 
years  pneumonia  is  far  more  often  apical  than  in  later  life  :  my 
own  figures  showed  19  apical  cases  (15  right,  4  left)  out  of  50, 
that  is,  38  per  cent.  :  this  proportion  agrees  fairly  closely  with 
that  obtained  by  Dr.  Lovett  Morse,2  of  Boston,  who,  amongst 

1  Journal  of  American  Medical  Association,  August  29,  1903. 
8  Archives  of  Pediatrics,  September,  1904. 


374  COMMON  DISORDERS  OP  CHILDHOOD 

101  cases,  found  31  per  cent,  apical,  17  per  cent,  being  right 
apex,  14  per  cent,  left  apex. 

Dr.  Melville  Dimlop's  figures  showed  34  (23  right,  11  left)  out 
of  147,  i.e.  23  per  cent.  ;  the  late  Dr.  Coutts  stated  that  even 
GO  per  cent.,  which  was  the  proportion  of  apical  cases  in  his  series, 
was  less  than  his  impressions  would  have  led  him  to  expect. 

It  is  clear  that  apical  pneumonia  is  very  common  in  children, 
and  probably  much  commoner  than  in  adults  (Professor  Osier, 
at  the  Montreal  General  Hospital,  found,  amongst  cases  examined 
post  mortem,  only  13  per  cent,  with  pneumonia  limited  to  the 
upper  lobe).  I  think  it  is  also  commoner  in  infants  than  in  older 
children.  I  have  thought  that  these  apical  cases  were  more 
liable  to  profound  nervous  disturbance,  such  as  delirium,  tremor, 
and  apathy,  than  the  basal  cases,  but  my  notes  do  not  confirm 
this,  nor  can  I  satisfy  myself  that  any  practical  guidance  as  to 
prognosis  is  to  be  obtained  from  the  distribution  of  the  pneu- 
monia :  it  is  the  extent,  not  the  localization,  which  matters ;  if 
both  lungs  are  involved  the  danger  to  life  is  much  increased, 
but,  as  I  shall  point  out,  prognosis  is  not  to  be  determined  solely 
by  extent. 

Amongst  the  early  symptoms  I  have  several  times  noted 
a  history  of  '  bringing  up  bright  red  blood  ',  apparently  by 
vomiting,  but  in  some  of  these  cases,  certainly,  and  I  suspect  in 
all  of  them,  there  was  epistaxis,  so  that  the  blood  was  probably 
from  the  nose. 

Herpes  on  the  lips  figures  in  the  pneumonia  of  children  about 
as  frequently  as  in  adults  ;  it  was  present  in  ten  out  of  my  fifty 
cases.  Its  practical  value  is  in  the  distinction  between  lobar 
and  lobular  pneumonia  ;  where  the  physical  signs  leave  the 
diagnosis  doubtful,  herpes  would  point  strongly  to  the  lobar 
variety. 

Tin*  blood  shows  a  marked  increase  of  leucocytes,  which 
average  30,000  to  40,000  per  c.mm.,  with  relative  increase  of 
polymorphonuciear  cells  ;  but  the  range  of  variation  is  consider- 
able. I  have  found  as  few  as  14,000,  and,  in  an  infant  aged 
13  months,  with  pneumonia,  which  ran  an  uncomplicated  course, 
the  blood  on  the  fourth  day  of  the  disease,  two  days  before  the 
crisis,  showed  77,000  per  c.mm.  (polymorphonuciear  82  per 
cent.,  lymphocytes  about  18  per  cent.).  I  mention  this  case  to 
show  that  even  so  high  a  degree  of  leucocytosis  as  this  is  no 
evidence  of  -pus  forming  in  the  pleura  or  elsewhere,  nor  does  it 
necessarily  indicate  a  bad  prognosis. 

The  temperature  in  children  with  lobar  pneumonia  runs  much 


PNEUMONIA 


375 


the  same  course  as  in  adults,  but  I  fancy  that  a  pseudo-crisis, 
that  is  to  say,  a  sudden  fall  of  the  temperature  and  then  another 
rise  before  the  final  crisis,  is  much  commoner  in  children  than  in 
adults.  Such  a  chart  as  the  subjoined  is  common. 

Termination  by  lysis  is  very  rare  in  children  ;  it  occurred  in 
two  out  of  the  fifty  cases. 

Diagnosis.  The  distinction  between  lobar  and  lobular  pneu- 
monia is  no  easy  one  in  some  cases,  for  in  infancy  especially  the 


FIG.  23.  Temperature  chart  of  lobar  pneumonia  in  a  child  aged  20  months, 
showing  pseudo-crisis  at  termination  of  the  attack  ;  also  vomiting  continued 
throughout  the  illness,  an  unusual  feature. 

patches  of  consolidation  in  lobular  pneumonia  very  easily  become 
confluent,  so  that  the  distribution  of  the  signs  may  agree  with 
that  of  lobar  pneumonia  ;  and  even  when  signs  appear  in  the 
other  lung  which  would  suggest  broncho -pneumonia,  there  is 
always  the  possibility  of  a  double  lobar  pneumonia  to  be  con- 
sidered. I  have  sometimes  noticed  in  the  apparently  sound  lung 
in  young  children  a  small  area  of  high-pitched  or  even  definitely 
bronchial  breathing,  perhaps  with  very  slight  impairment  of 


376  COMMON  DISORDERS  OF  CHILDHOOD 

note,  generally  about  the  region  of  the  angle  of  the  scapula.. 
Whether  this  means  an  area  of  collapse  or  whether  there  is  really 
a  patch  of  pneumonia  on  this  side  also  I  know  not,  but  when  the 
signs  in  the  other  lung,  in  which  there  has  been  extensive  lobar 
pneumonia,  have  cleared  up  on  the  occurrence  of  the  crisis  at 
the  usual  time,  this  small  patch  on  the  supposed  sound  side 
has  disappeared  also  :  I  mention  this  only  because  it  might 
suggest  broncho-pneumonia,  but  I  think  it  is  quite  clear  from 
the  course  of  these  cases  that  the  pneumonia  is  lobar. 

Another  feature  which  may  confuse  the  diagnosis  and  which 
I  think  is  commoner  in  infants  and  young  children  than  in  older 
patients,  is  the  occurrence  of  rales  or  crepitations  in  the  parts  of 
the  pneumonic  lung  which  are  not  consolidated,  or  in  the  sup- 
posed sound  lung.  I  have  sometimes  been  in  great  doubt  for 
this  reason,  but  the  diagnosis  of  lobar  pneumonia,  suggested  by 
the  history  of  sudden  onset  and  the  continuous  high  fever,  wras 
confirmed  by  the  termination  in  crisis  at  the  orthodox  time. 

In  its  temperature  lobar  pneumonia  is  simulated  both  by 
typhoid  and  by  acute  miliary  tuberculosis  :  but  the  sudden 
onset  is  usually  distinctive ;  moreover,  lobar  pneumonia  lacks 
the  enlargement  of  the  spleen  which  is  common  to  both  these 
diseases  and  shows  none  of  the  general  bronchitic  signs  which 
are  characteristic  of  acute  miliary  tuberculosis,  nor  of  the  rose 
spots  which  are  associated  with  typhoid  ;  but  whilst  in  theory 
the  distinction  should  be  easy  enough,  in  practice  it  is  sometimes 
exceedingly  difficult. 

I  have  notes  of  more  than  one  case  in  which  physicians  of 
large  experience  were  misled  into  a  diagnosis  of  typhoid  by 
a  pneumonia  in  which  signs  of  consolidation  were  delayed,  and 
in  which  the  delirium,  with  headache  and  drowsiness,  all  seemed 
to  point  to  typhoid.  After  a  few  days  the  occurrence  of  a  crisis 
or  the  development  of  physical  signs  makes  diagnosis  easy  :  we 
c-an  all  be  wise  after  the  event. 

Where  cerebral  symptoms  predominate,  such  as  headache, 
drowsiness,  delirium,  and  even  retraction  of  the  head,  with 
vomiting  and  constipation,  the  condition  sometimes  simulates 
a  cerebro-spinal  meningitis,  and  the  resemblance  is  increased  by 
the  occurrence  of  labial  herpes  in  both  diseases,  although  in 
meningitis  the  herpes  is,  I  think,  more  often  on  other  parts  of 
the  body.  The  rapid  respiration  and,  within  a  few  days  at  most, 
the  signs  of  pulmonary  consolidation  will  point  to  pneumonia ; 
but  it  may  be  advisable  to  assist  diagnosis  by  lumbar  puncture, 
if  further  experience  proves  that  the  early  use  of  Dr.  Flexner's 


PNEUMONIA  377 

serum  is  of  value  in  the  menmgeal  affection  ;  otherwise  there  is 
no  advantage  to  the  child  from  lumbar  puncture,  indeed  there 
may  even  be  risk  :  in  one  case  in  which  lumbar  puncture  was 
done  in  a  doubtful  case  of  this  kind  under  my  care,  death  occurred 
almost  before  the  needle  could  be  withdrawn. 

The  misleading  character  of  some  of  the  symptoms  in  pneu- 
monia, the  earache  suggesting  a  simple  otitis  media,  and  the 
pain  in  the  abdomen  simulating  appendicitis  I  have  already 
mentioned. 

Prognosis.  The  danger  of  lobar  pneumonia  in  childhood  lies 
almost  entirely  in  its  complications  :  and  it  is  in  infancy  especially 
that  the  two  most  serious  complications  occur,  namely,  suppu- 
rative  meningitis  and  suppurative  pericarditis.  Usually  these 
are  associated  with  empyema,  but  the  primary  focus  of  pneumo- 
coccal  infection  is  nearly  always  a  pneumonia.  I  shall  deal  with 
these  and  other  pneumococcal  manifestations  in  a  subsequent 
chapter. 

Here  I  would  only  emphasize  the  need  to  be  ever  on  the  watch 
for  empyema  in  children  with  pneumonia.  At  no  time  is  empyema 
commoner  than  during  the  first  two  years  of  life,  and  it  may  be 
that  by  early  detection  of  this  complication  we  may  save  some 
of  these  infants  not  only  from  suppurative  pericarditis  which 
may  possibly  be  due  to  direct  extension  from  the  pleura  in  some 
cases,  but  also  from  suppurative  meningitis  which  must  be  due 
to  blood  infection,  but  may  nevertheless  be  secondary  to  an 
empyema  rather  than  to  the  original  pneumonia,  as  the  time 
relation  seems  to  prove  in  some  cases.  I  am  no  advocate  for 
using  the  exploring  needle  indiscriminately,  the  highest  skill  is 
shown  in  deciding  correctly  when  it  is  not  necessary  to  explore  : 
but  none  the  less  I  think  that  where  there  is  doubt  much  mischief 
may  be  done  by  delaying  exploration,  for  even  though  the  child 
may  develop  no  further  complication,  the  prolonged  presence 
of  an  empyema  materially  diminishes  the  chance  of  complete 
re-expansion  of  the  compressed  lung. 

Suppurative  meningitis  as  a  cause  of  death  in  pneumonia  is 
very  much  commoner  in  infancy  than  at  any  other  period,  and 
the  onset  of  head-retraction  with  squint  and  perhaps  some 
rigidity  of  limbs  may  be  the  indication  of  its  occurrence.  But 
I  would  point  out  that  there  are  other  causes  for  head-retraction 
in  pneumonia  :  infants  with  respiratory  difficulty  from  any 
cause  not  infrequently  assume  the  position  of  marked  head- 
retraction,  apparently  in  order  to  assist  breathing  by  the  action 
of  the  extraordinary  muscles  of  respiration  ;  in  this  way  head- 


378  COMMON  DISORDERS  OF  CHILDHOOD 

retraction  may  occur  in  pneumonia  without  any  complication. 
Another  cause  of  head-retraction  is  reflex  irritation  from  the 
middle-ear,  and  as  otitis  media  is  a  common  complication  of 
lobar  pneumonia  as  of  most  other  febrile  diseases  in  childhood, 
head-retraction  may  also  be  due  to  this  cause  in  pneumonia. 

Another  complication  which  I  have  known  to  mislead  is 
laryngitis.  I  remember  well  a  little  girl,  aged  about  nine  years, 
whom  I  saw  in  consultation  some  years  ago  for  acute  laryngitis. 
The  case  had  caused  anxiety  because  the  sudden  fever  which 
was  attributed  to  laryngitis  had  continued  high  for  several  days, 
and  because  the  child  seemed  more  ill  than  is  usual  with  simple 
laryngeal  inflammation.  When  I  saw  her  there  was  a  croupy 
cough,  and  it  was  obvious  the  child  had  acute  laryngitis,  but  on 
examining  the  chest  it  was  found  that  there  was  dullness  and 
bronchial  breathing  at  the  left  base  ;  and  it  was  evident  from 
the  signs,  which  had  probably  appeared  late,  that  the  condition 
was  a  lobar  pneumonia. 

I  have  only  twice  seen  malignant  endocarditis  with  pneumo- 
coccal  infection,  once  at  one  year  and  eleven  months,  and  once 
at  three  years,  but  never  with  pneumonia  apart  from  empyema  : 
in  both  the  cases  mentioned  there  was  also  suppurative  meningitis. 

A  thickness  of  the  first  sound,  at  the  apex  of  the  heart,  some- 
times amounting  almost  if  not  quite  to  a  bruit,  is  not  uncommon 
during  pneumonia,  but  this  is  purely  functional  ;  it  is  probably 
caused  in  some  way  by  the  high  temperature,  for  it  is  noticed 
sometimes  in  other  conditions  where  there  is  much  fever. 

I  have  seen  several  cases  in  which  a  suppurative  arthritis  com- 
plicated pneumonia  in  children  when  there  were  other  pneumo- 
coccal  lesions,  especially  empyema,  but-  I  do  not  think  the 
arthritis  is  always  suppurative.  In  one  child,  aged  3J  years, 
the  left  knee  became  painful  and  swollen  with  some  fluid  in  it 
on  the  seventh  day  of  the  pneumonia  ;  under  hot  fomentations 
the  arthritis  disappeared,  but  five  days  later  pus  giving  pure 
growth  of  pneumococci  was  found  in  the  left  pleural  cavity. 

Twice  I  have  seen  acute  nephritis  during  the  acute  stage  of 
lobar  pneumonia  in  boys  aged  respectively  4J  years  and  2  years; 
in  both  cases  there  was  a  large  quantity  of  albumen,  and  many 
casts  were  found  in  the  urine  ;  in  the  latter  there  was  also 
blood  in  the  urine  :  in  neither  was  there  anything  in  the  child's 
appearance  to  suggest  nephritis  ;  both  made  a  good  recovery. 

This  rare  complication  is,  of  course,  quite  distinct  from  the 
slight  albuminuria  which  is  probably  due  to  the  high  temperature 
and  is  common  in  children  with  pneumonia. 


PNEUMONIA  379 

Clearly  there  is  need  for  caution  in  the  prognosis  of  pneumonia 
in  children.  I  have  very  rarely  seen  it  prove  fatal,  except  through 
complications  ;  my  impression  is  that  lobar  pneumonia  is  much 
less  often  fatal  per  se  in  childhood  than  in  adult  life  ;  of  the  fifty 
cases  mentioned  above  only  three  died  of  pneumonia  without 
complication  (in  two  of  them  there  was  slight  pleurisy  also  but 
no  empyema).  One  of  these  three  cases,  however,  shows  that 
in  the  child,  as  in  the  adult,  pneumonia  may  be  malignant  in  its 
severity. 

A  boy,  aged  six  years,  went  to  school  on  July  16  apparently  quite  well  in  the 
morning  and  joined  in  games  at  school ;  at  midday  he  came  home  complaining 
of  headache  and  seemed  drowsy.  He  was  brought  to  King's  College  Hospital 
in  the  afternoon,  his  temperature  was  105°,  but  on  careful  examination  no 
physical  signs  were  detected.  The  temperature  rapidly  rose  to  108-6°,  and  the 
boy  died  the  same  evening  ;  the  whole  illness  had  lasted  less  than  twelve  hours. 
Post  mortem  examination  showed  at  the  base  of  the  left  lung  a  circumscribed 
area  about  2  inches  in  diameter  of  greyish  red,  evidently  quite  recent,  pneu- 
monic consolidation. 

Death  is  far  more  often  due  to  complications,  particularly  to 
empyema  with  suppurative  meningitis,  or  pericarditis  ;  both 
these  occur  chiefly  in  infants.  In  this  way  the  danger  from  lobar 
pneumonia  is  much  greater  in  the  first  two  years  of  life  than 
subsequently,  and  my  impression  is  that  the  risk  from  the 
pneumonia  itself  is  also  greater  in  infancy.  Dr.  Melville  Dunlop's 
figures  showed  a  mortality  of  26-6  per  cent,  in  the  first  two  years 
of  life,  whereas  between  two  and  twelve  years  of  age  it  was  only 
2-9  per  cent. 

In  the  cases  that  do  well  the  duration  of  the  fever  is  seven  or 
eight  days  as  a  rule. 

I  have  always  thought  that  the  crisis  was  apt  to  occur  earlier 
in  the  child  than  in  the  adult,  but  my  own  statistics  do  not  show 
this  ;  only  six  out  of  fifty  had  the  crisis  within  the  first  five 
days  ;  whereas,  according  to  Musser  and  Norris1,  statistics  at 
all  ages,  including  adults,  show  a  proportion  of  25-8  per  cent, 
having  the  crisis  as  early  as  this. 

In  children  as  in  adults  the  crisis  "is  occasionally  delayed  con- 
siderably. I  had  an  infant,  aged  one  year  and  eight  months, 
under  my  care  at  King's  College  Hospital  with  lobar  pneumonia : 
the  crisis  did  not  occur  until  the  fifteenth  day;  the  whole  left 
lung  was  involved,  but  the  right  remained  free  throughout,  and 
no  complication  occurred :  the  temperature  ranged  some  days  at 
105°  to  106°  F.,  but  the  infant  made  a  good  recovery. 

Treatment.  Lobar  pneumonia  is  a  self -limited  disease  :  pos- 
1  Modern  Medicine,  vol.  ii,  p.  588. 


380  COMMON  DISORDERS  OF  CHILDHOOD 

sibly  in  the  days  to  come  we  may.  by  working  along  bacterio- 
logical lines,  arrive  at  some  method  of  curtailing  the  attack,  but  at 
present  I  cannot  satisfy  myself  that  anything  we  can  do  aborts 
the  pneumonia.  I  have  seen  a  crisis  occur  with  rapid  recovery 
under  all  sorts  of  treatment,  and  under  no  treatment  at  all ;  but 
I  am  rather  disposed  to  admire  the  vis  medicatrix  Naturce  than 
to  speak  positively  of  the  termination  of  the  pneumonia  by  thia 
or  that  method  of  treatment.  But  let  me  not  be  misunderstood  ; 
I  do  not  for  one  moment  suggest  that  no  treatment  is  of  value  in 
pneumonia;  on  the  contrary,  I  am  certain  that  symptoms  may 
be  relieved  and  life  saved  by  skilful  treatment. 

In  the  first  place  there  is  the  pain  and  distress  which  often 
accompanies  it ;  some  children  complain  of  pain  in  the  affected 
side  of  the  chest,  others  in  the  abdomen  ;  for  this  and  for  the 
general  distress  caused  by  the  high  fever  I  think  an  ice-bag 
applied  over  the  affected  part  of  the  lung  is  of  great  value,  pro- 
vided always  that  it  is  applied  with  proper  precautions,  in  other 
words,  with  expert  nursing  and  with  medical  supervision  not 
once  but  twice  or  thrice  daily. 

Dr.  Lees  l  has  insisted  upon  the  necessity  of  keeping  the  child's 
feet  warm  during  the  application  of  the  ice-bag  by  wrapping  the 
child's  legs  and  feet  in  hot  flannels  or  by  hot  water-bottle,  and 
says  that  it  may  even  be  desirable  to  apply  warm  fomentations 
to  the  abdomen  ;  if  the  ice-bag  is  used  for  an  infant  or  young 
child  he  would  have  the  temperature  taken  hourly  and  the  ice-bag 
removed  when  the  temperature  falls  to  100°,  and  replaced  when 
it  rises  again  to  102°.  I  have  seen  many  cases  treated  by  this 
method  and  have  not  the  least  doubt  of  its  value  ;  most  children 
like  it  after  the  first  sensation  of  cold  is  past,  and  I  think  it 
husbands  strength  by  calming  the  child  and  keeping  the  tempera- 
ture within  reasonable  limits  ;  it  also  relieves  the  pain. 

In  infants  and  very  young  children  I  have  a  liking  for  warm 
applications  for  the  relief  of  pain  ;  for  I  have  seen  blueness  and 
collapse  from  the  use  of  the  ice-bag :  but  I  have  no  evidence  that 
warm  applications  are  of  any  value  except  for  this  purpose.  For 
the  reduction  of  high  fever,  if  the  ice-bag  is  not  practicable, 
I  think  tepid  sponging  with  water  at  a  temperature  of  75°  to 
80°  is  advisable  if  the  temperature  rises  to  105°  or  higher  ;  if 
the  child  is  very  restless  or  delirious,  or  is  known  to  be  liable  to 
convulsions,  tepid  sponging  may  be  advisable  when  the  tempera- 
ture reaches  104°.  Children  stand  high  temperature  remarkably 
well  as  a  rule,  the  one  exception  is  the  child  who  is  subject  to 
1  Treatment  of  some  Acute  Visceral  Inflammations,  Lond.,  1904. 


PNEUMONIA  381 

convulsions,  and  in  this  case  I  think  that  antipyretic  measures, 
whether  drugs,  or  sponging,  or  cold  packs,  or  ice-bags  to  the  head, 
are  often  advisable  where  the  temperature  might  be  disregarded 
in  other  children. 

At  the  beginning  of  lobar  pneumonia,  when  the  child  is  rest- 
less, with  grunting  respiration  and  in  evident  distress,  Dover's 
Powder,  gr.  j  ter  die  for  a  child  of  two  years,  1J  to  2  grains 
for  a  child  of  five  years,  is  useful,  and  this  can  be  taken  with 
a  mixture  of  Liq.  Ammon.  Acetatis  CC)xl,  Spirit.  ^Etheris 
Nitrosi  O)v,  Syrup  tt)xx,  Aq.  Anethi  ad  3ij  ter  die,  for  a  child  of 
five  years,  or  half  this  quantity  for  an  infant.  The  Dover's 
Powder  should  be  omitted  after  the  first  day  or  two.  From  the 
outset  a  careful  watch  must  be  kept  upon  the  child's  heart  and 
pulse :  if  it  is  evident  from  increase  of  cardiac  dullness  to  the 
right  of  the  sternum  and  from  the  child's  bad  colour  that  the 
right  side  of  the  heart  is  becoming  much  over-distended,  it  may 
be  necessary  to  apply  two  or  three  leeches  over  the  sternum, 
and  to  substitute  for  the  diaphoretic  mixture  a  stimulant  such 
as  Tinct.  Digitalis  Ct)v,  Ammon.  Carb.  gr.  j,  Syrup  Ct)xxx,  Aq. 
Menth.  Pip.  ad  3ij  sextis  horis,  half  this  dose  for  a  child  of  two 
years  or  less. 

Recently  I  have  treated  some  cases  of  lobar  pneumonia  with 
pneumococcus  vaccine  ;  5  to  10  millions  may  be  given  to  an 
infant  of  6-9  months,  and  10  to  15  millions  to  a  child  of  1-5  years 
as  initial  dose.  The  vaccine  is  injected  subcutaneously  and  the 
injection  may  be  repeated  if  necessary  with  a  larger  dose,  say 
5  millions  more,  after  four  days.  I  have  not  been  able  to  satisfy 
myself  that  the  course  of  the  pneumonia  is  appreciably  affected 
by  this  treatment ;  birt  some  observers  have  thought  that  it  did 
good,  and  it  has  been  recommended  especially  where  the  resolu- 
tion of  a  lobar  pneumonia  is  delayed. 

Oxygen  is  valuable  not  only  in  giving  temporary  relief,  which 
it  certainly  does,  when  the  lips  are  becoming  blue  and  the  cheeks 
dusky,  but  also  in  tiding  the  child  over  a  time  of  peril  until 
the  crisis  arrives. 

In  spite  of  all  that  has  been  said  to  the  contrary,  I  think 
that  any  unbiassed  observer  must  admit  that  brandy  is  some- 
times very  valuable  in  the  bad  case  of  pneumonia,  but  it  is 
certainly  not  necessary  in  the  large  majority  of  cases  ;  it  is 
only  when  the  pulse  is  becoming  feeble  or  irregular  and  it  is 
evident  that  the  child  is  becoming  exhausted,  that  brandy  should 
be  given,  and  even  then  I  am  inclined  to  think  that  harm  is 
sometimes  done  by  giving  large  doses.  I  have  seen  cases  in 


382  COMMON*  DISORDERS  OF  CHILDHOOD 

which  it  seemed  to  me  that  vomiting  was  being  caused,  and 
others  in  which  I  think  delirium  was  produced  by  excessive 
dosing  with  brandy  ;  for  a  child  of  two  years  it  is  rarely 
advisable  to  order  more  than  30  minims  of  brandy,  say  every 
three  hours,  and  for  a  child  of  five  years  a  drachm  (not  a  domestic 
teaspoonful)  at  most. 

Judging  only  from  clinical  observation,  I  think  that  where 
the  immediate  danger  is  respiratory  rather  than  cardiac  failure, 
strychnine  given  hypodermically,  or  by  the  mouth  if  the  danger 
is  less  pressing,  is  of  more  value  than  alcohol. 

At  all  stages  of  pneumonia  it  is  very  important  to  keep  the 
bowels  working  freely,  for  which  purpose  calomel  gr.  J-1J, 
according  to  the  age  of  the  child,  is  the  drug  most  useful ;  and 
the  dose  should  be  sufficient  to  produce  a  loose  stool  once  a  day. 

Lastly,  there  are  some  points  which,  although  they  come 
perhaps  under  the  head  of  nursing,  are  worthy  of  the  doctor's 
attention  :  the  child  with  pneumonia  wants  oxygen  even  more 
than  in  health  ;  the  mother,  only  too  anxious  to  do  her  best 
for  the  child,  hearing  that  it  has  '  inflammation  of  the  lungs  ', 
at  once  shuts  every  window  and  door  and,  as  far  as  she  can, 
blocks  every  approach  for  fresh  air  ;  at  the  same  time  she  adds 
to  the  suffering  of  the  fevered  child  by  wrapping  him  up  in 
a  thick  vest,  a  warm  night-dress,  a  woollen  hug-me-tight,  and 
over  all  a  dressing-gown  and  perchance  a  shawl,  and  then  \vonders 
that  the  child  is  unable  to  sleep  !  I  doubt  whether  even  the 
conventional  cotton-wool  pneumonia  jacket  is  always  desirable, 
but  it  has  the  merit  of  being  light — and  whatever  form  of  vest 
is  worn,  it  should  be  loose  and  light  so  as  not  to  hamper  the 
breathing — and  when  this  is  used  a  thin  "flannel  night-dress  over 
it  is  quite  enough  in  the  way  of  clothing  if  the  room  is  kept  at 
62°-64°,  as  it  should  be. 

It  is  well  to  point  out  to  the  parents  also  that  a  sponging  over 
of  the  hands  and  face  with  cold  or  tepid  water  two  or  three  times 
a  day,  if  done  without  disturbing  the  child  much,  not  only  does 
no  harm  but  may  ensure  sleep  ;  and  last,  but  not  least  im- 
portant, that  there  is  no  reason  whatever  why  the  child  should 
be  donied  the  frequent  small  drinks  of  cold  water  for  which  he 
craves. 


CHAPTER  XXVIII 
EMPYEMA 

EMPYEMA,  though  not  one  of  the  commonest  diseases  in  child- 
hood, has  a  special  incidence  upon  the  earliest  years  of  life  ; 
moreover,  there  are  in  connexion  with  it  questions  of  diagnosis 
and  treatment  which  arise  specially  with  regard  to  children, 
so  that  I  need  make  no  excuse  for  considering  it  here. 

In  five  years  (1899-1903)  at  the  Hospital  for  Sick  Children, 
Great  Ormond  Street,  where  children  up  to  the  ago  of  twelve 
years  are  admitted,  there  were  183  cases  of  empyema  (making 
1-7  per  cent,  of  the  total  admissions)  ;  of  these  fifty -four  were 
under  two  years  of  age.  This  high  proportion  of  cases  in  infancy 
(up  to  two  years)  is  borne  out  by  a  series  of  fifty  cases  under 
my  own  observation,  in  which  the  age  incidence  was  as  follows  : 


0-1 

1-2 

2-3 

3-4 

4-5 

5-6 

6-7 

7-8 

8-9 

9-10 

10-11 

11-12 

4 

12 

13 

5 

4 

2 

5 

2 

2 

0 

1 

0 

These  figures  show  that  empyema  is  specially  frequent  in  the 
first  three  years  of  life.  It  occurs  very  early  in  infancy  :  I  have 
seen  it  at  eight  weeks  with  staphylococcus  pyaemia,  and  at  nine 
and  a  half  weeks  with  a  pneumococcal  meningitis.  It  shows 
a  curious  tendency  to  affect  boys  rather  than  girls  :  amongst 
the  183  cases  there  were  112  boys  and  71  girls. 

Empyema  in  children  is,  in  the  very  large  majority  of  cases, 
a  complication  of  pneumonia,  and  with  this  statement  I  will 
couple  another  which  is  of  no  small  practical  importance  :  that 
when  pleural  effusion  occurs  with  pneumonia  in  a  child  it  is 
practically  invariably  purulent.  It  is  hardly  possible,  I  think, 
to  lay  too  much  stress  upon  this  latter  fact ;  I  see  children  with 
signs  of  effusion  at  one  base  after  a  typical  lobar  pneumonia, 
and  the  doctor  hesitating  as  to  the  necessity  for  exploration, 
hoping  that  it  may  be  serum  which  will  disappear  spontaneously : 
a  delusive  hope,  for  if  the  diagnosis  of  lobar  pneumonia  was 
correct,  the  diagnosis  of  empyema  follows  almost  as  a  corollary. 

Let  me  not  be  misunderstood  :   I  know  that  sometimes  if  fluid 


384  COMMON  DISORDERS  OF  CHILDHOOD 

is  drawn  from  the  chest  in  such  cases,  within  a  few  hours  after 
its  first  appearance,  it  is  found  to  be  only  turbid  serum,  but  micro- 
scopic examination  shows  that  there  are  many  pus  cells  and  that 
the  fluid  is  swarming  with  pneumococci,  and  must  be  treated 
as  an  empyema  ;  if  it  is  left  for  a  day  or  two  it  rapidly  becomes 
opaque  like  ordinary  pus, 

It  is  very  necessary,  therefore,  to  inquire  carefully  into  the 
history  of  onset  in  a  case  of  pleural  effusion,  to  ascertain  whether 
there  were  the  sudden  invasion,  the  herpes,  the  vomiting,  the 
temperature,  and  the  physical  signs  of  a  lobar  pneumonia. 

Empyema,  however,  is  not .  invariably  preceded  by  a  lobar 
pneumonia  ;  rarely  it  seems  to  follow  upon  a  broncho-pneumonia. 
I  have  notes  of  cases  in  which  it  occurred  with  the  broncho - 
pneumonia  of  measles,  and  with  that  of  whooping-cough ;  but  in 
some  of  these  cases  also  the  pus  gives  a  pure  culture  of  pneumo- 
coccus,  so  that  we  may  suppose  the  broncho-pneumonia  in  these 
also  to  have  been  of  pneumococcal  origin. 

Certainly  empyema  in  childhood  is  far  more  often  due  to  the 
pneumococcus  than  to  any  other  micro-organism.  Dr.  J.  Graham 
Forbes,  Clinical  Pathologist  to  the  Children's  Hospital,  Great 
Ormond  Street,  found  that  amongst  250  cases  of  empyema  in 
children  under  twelve  years  of  age,  186  (74-4  per  cent.)  were 
due  to  pneumococcus  alone,  21  to  pneumococcus  mixed  with 
streptococcus  or  staphylococcus  pyogenes,  17  (6-8  per  cent.)  to 
streptococcus  alone,  11  to  staphylococcus  pyogenes  aureus  alone, 
5  to  streptococcus  and  staphylococcus  mixed,  1  to  pneumo- 
coccus with  tubercle  bacillus,  1  to  proteus  bacillus,  and  1  to 
bacillus  coli  ;  7  gave  no  growth. 

Amongst  hospital  cases  there  are  many  in  which  the  early 
history  of  the  illness  is  vague  :  the  mother  says  the  child  was 
feverish  and  sick,  had  a  cough  and  breathed  quickly,  was  kept 
in  bed  for  a  week  or  so,  perhaps  was  not  seen  by  a  doctor  at  all ; 
then  the  fever  passed  off,  but  the  child  has  been  wasting  for  many 
weeks  since,  and  by  the  time  the  child  comes  to  hospital,  he  is 
white  and  emaciated,  with  a  hectic  flush  on  the  cheeks,  and 
with  a  dry  harsh  skin,  and  looks  the  picture  of  advanced  tuber- 
culosis. And  indeed  the  diagnosis  may  be  no  easy  one  ;  there 
is  dullness  it  is  true,  but  perhaps  this  is  more  at  the  apex  in  front 
or  in  the  axilla  than  at  the  base  ;  the  breath  sounds  are  diminished 
but  there  may  be  well-marked  bronchial  breathing  over  the  dull 
area  ;  there  are  perhaps  also  a  few  crepitations,  so  that  the 
physical  signs  are  most  misleading. 

I  would  lay  stress  specially  upon  the  frequency  of  well-marked, 


EMPYEMA  385 

perhaps  almost  loud,  bronchial  breathing  over  an  empyema  in 
children.  I  remember  seeing  a  little  girl  about  seven  years  old 
who  was  said  to  be  dying  of  pulmonary  tuberculosis  :  the  child 
was  much  wasted,  and  sat  propped  up  in  a  chair  ;  her  face  was 
grey,  she  breathed  with  evident  difficulty,  and  all  over  the  back 
of  one  lung  there  was  dullness  and  very  marked  resistance  on 
percussion  with  loud  bronchial  breathing  ;  there  was  also  some 
displacement  of  the  heart.  To  my  mind  the  extreme  resistance 
on  percussion  made  fluid  almost  a  certainty,  and  the  history 
showed  that  there  had  probably  been  pneumonia  at  the  onset ; 
the  medical  man  in  charge,  a  most  careful  observer,  had  attached 
so  much  importance  to  the  loud  bronchial  breathing  that  he 
thought  empyema  impossible.  A  large  quantity  of  pus  was 
evacuated,  and  the  child  did  well. 

So  closely  does  the  appearance  of  the  child  with  a  longstanding 
empyema  resemble  that  of  the  tuberculous  child,  that  even 
when  the  empyema  has  been  found,  one  is  sometimes  asked 
whether  it  may  not  be  tuberculous. 

There  is  no  doubt  that  tubercle  and  empyema  occasionally  go 
together  ;  in  fifty  consecutive  post  mortem  examinations  which 
I  made  upon  children  who  had  died  with  empyema,  I  found  six 
who  had  also  pulmonary  tuberculosis,  and  four  who  had  tubercle 
only  in  other  parts  of  the  body,  but  I  very  much  doubt  whether 
in  any  single  one  of  these  cases  the  empyema  could  be  called 
tuberculous ;  in  some  the  association  was  clearly  accidental,  a  pure 
growth  of  pneumococcus  was  obtained  from  the  empyema  ;  in 
one  a  tuberculous  cavity  near  the  surface  of  the  lung  had  burst 
into  the  pleura,  but  even  then  the  empyema  was  probably  rather 
a  septic  infection  from  the  many  micro-organisms  in  the  cavity 
than  due  to  any  tuberculous  affection.  I  think  that  an  empyema 
directly  due  to  tuberculosis  must  be  an  extreme  rarity  in  a  child, 
and  that  when  the  association  of  pulmonary  tuberculosis  with 
empyema  is  observed,  if  there  is  any  causal  relation  at  all  it  is 
usually  an  indirect  one,  the  ordinary  pyogenic  micro-organisms 
which  swarm  in  the  broken  down  tuberculous  focus,  have  gained 
access  to  the  pleura. 

In  early  infancy  an  empyema  and  indeed  an  acute  pleurisy  of 
any  sort  often  produces  profound  constitutional  disturbance 
quite  out  of  proportion  to  the  physical  signs,  so  that  at  this  age 
the  cause  of  the  infant's  sudden  acute  illness  and  almost  mori- 
bund condition  is  sometimes  extremely  obscure,  and  indeed  the 
pleurisy  is  often  discovered  quite  unexpectedly  at  post  mortem 
examination.  At  this  age  also  empyema  is  specially  likely  to 


386  COMMON  DISORDERS  OF  CHILDHOOD 

be  associated  with  pneumococcal  inflammation  of  the  heart  or 
meninges.     The  following  case  illustrated  these  points. 

John  P.,  aged  twelve  weeks,  had  had  a  cough  for  five  days,  and  been  sick 
several  times  since ;  when  brought  to  hospital  he  appeared  moribund,  his  face 
was  pale,  the  lips  ashy  grey  ;  his  temperature  was  101'2°;  the  only  signs  were 
slight  impairment  of  note  at  the  left  base  with  some  diminution  of  breath 
sounds ;  the  signs  were  not  thought  to  indicate  fluid.  The  child  rallied 
slightly  with  mustard  bath,  strychnine,  and  oxygen,  but  died  within  three 
days  after  admission,  when  it  was  found  there  were  4  ounces  of  pus  in  the 
left  pleura,  and  some  consolidation  of  the  left  lower  lobe ;  there  was  also 
suppurative  pericarditis. 

In  connexion  with  the  signs  and  symptoms  of  empyema  there 
are  certain  points  which  are  specially  noteworthy.  I  have 
already  referred  to  the  vagueness  of  onset  in  some  cases,  and  to 
the  wasting  and  the  dryness  of  the  skin  with  empyema  of  long 
standing,  symptoms  which  may  suggest  tuberculosis. 

Another  misleading  symptom  in  some  of  these  longstanding 
cases  is  a  paroxysmal  cough,  which  may  culminate  in  vomiting, 
and  closely  resemble  whooping-cough.  I  have  known  this  mistake 
made  even  when  the  child  was  under  continuous  observation  in 
hospital. 

The  temperature  also  in  a  longstanding  case  of  empyema  may 
mislead,  for  it  is  often  normal,  and  even  when  the  empyema  is 
more  recent  the  temperature  chart  seldom  shows  the  continuously 
high  temperature  which  is  common  with  a  serous  effusion. 
I  would  draw  attention  specially  to  this  difference  between 
serous  and  purulent  effusion,  for  I  often  find  that  the  reverse 
is  expected  ;  the  high  temperature  which  points  to  serum  is 
mistaken  for  an  indication  of  pus. 

I  need  not  consider  the  signs  of  empyema  here  ;  they  are  to 
be  found  in  any  book  on  general  medicine  ;  but  I  will  mention 
two  or  three  points  which  seem  to  me  of  special  importance. 
I  have  already  mentioned  that  bronchial  breathing  may  be  well 
heard  all  over  a  chest  which  nevertheless  contains  an  empyema. 

In  the  child,  even  in  health,  tactile  vocal  fremitus  is  often  not 
to  be  obtained,  or  is  extremely  slight,  so  that  it  is  difficult  to 
derive  much  information  from  it  where  fluid  is  in  question  ; 
when  comparison  with  the  sound  side  shows  that  tactile  vocal 
fremitus  is  absent  only  on  the  affected  side  this  is  strong  evidence 
of  fluid. 

To  an  expert  finger  I  think  the  sense  of  resistance  on  percussion 
over  fluid  will  very  rarely  give  a  false  impression  ;  but  there  is 
one  rare  condition  which  is  almost  peculiar  to  childhood,  which 


EMPYEMA 

gives  exactly  the  same  sense  of  resistance,  and  moreover  may 
produce  just  as  absolute  dullness  and  as  complete  absence  of 
breath  sounds  as  any  pleural  effusion  :  I  refer  to  the  so-called 
cheesy-consolidation  of  the  lung  :  that  form  of  tubercle  in  which 
the  lung  or  a  large  part  of  it  is  converted  into  an  almost  uniform 
mass  of  solid  caseous  material  like  the  section  of  a  firm  caseous 
gland.  I  know  of  no  way  of  distinguishing  between  this  and 
empyema  except  by  the  exploring  needle. 

Skodaic  note  at  the  apex  is  a  sign  to  which  very  great  impor- 
tance may  be  attached  ;  where  this  has  been  present  I  have  not 
hesitated  to  explore  several  times,  when  necessary,  to  find  the 
fluid  which  I  felt  sure  was  present ;  it  is  a  sign  which  very  rarely 
plays  false.  But  no  sign  is  always  to  be  relied  upon  ;  even  dis- 
placement of  viscera  away  from  the  affected  side  does  not  neces- 
sarily mean  fluid.  I  have  seen  several  cases  of  pneumo thorax 
in  little  children,  generally,  I  think,  with  tuberculosis,  and  in 
these  the  heart  is  sometimes  considerably  displaced  ;  again,  if 
the  empyema  be  a  small  and  limited  one  of  old  standing,  the 
contraction  of  the  lung  with  some  fibroid  change  may  cause  the 
heart  to  be  displaced  towards  the  side  with  the  empyema.  Even 
in  the  acute  stage  of  a  pleural  effusion  measurement  often  shows 
that  there  is  some  contraction  of  the  affected  side  ;  I  have 
measured  many  children  to  ascertain  this  point,  and  frequently 
found  that  the  affected  side,  whether  with  serum  or  pus,  was  half 
an  inch  smaller  than  the  sound  side  ;  I  fancy  that  this  means 
that  the  collapse  of  the  lung  is  not  merely  a  mechanical  result 
of  pressure,  it  may  be  out  of  proportion  to  the  amount  of  the 
fluid,  so  that  in  spite  of  the  presence  of  fluid  that  side  of  the 
chest,  so  far  from  being  bulged,  is  contracted. 

In  infants  and  young  children  there  is  confirmation  of  this  in 
the  great  diminution  of  breath  sounds  which  occurs  when  there 
is  recent  pleurisy,  even  though  there  be  no  evidence  of  fluid  at  all. 

Are  there  any  means  by  which  we  may  distinguish  between 
empyema  and  serous  effusion  without  exploration  ?  As  a  rule, 
physical  signs  help  but  little  ;  the  occurrence  of  a  localized 
oedema  of  the  chest  wt-11,  or  a  localized  bulging,  points,  of  course, 
to  empyema,  but  no  one  should  allow  the  question  to  remain 
unsettled  until  this  occurs.  Even  cedema  unless  localized  to  a 
part  of  one  side  of  the  chest  is  no  evidence  of  pus ;  occasionally 
when  a  serous  effusion  occurs  very  rapidly  a  generalized  oedema 
of  the  chest  wall  occurs,  as  I  have  once  or  twice  seen  in 
children. 

Of  far  more  importance  is  the  history :  where  a  definite  lobar 

uc2 


388  COMMON  DISORDERS  OF  CHILDHOOD 

pneumonia  has  preceded  the  effusion,  or  when  there  is  some 
pyaemia  present,  we  can  be  practically  certain  that  it  is  an 
empyema.  If,  on  the  contrary,  the  illness  began  with  pleural 
effusion,  and  especially  if  the  effusion  increase  very  rapidly,  so 
that  within  three  or  four  days  the  signs  of  fluid  have  extended 
almost  up  to  the  apex  of  the  lung,  or  where  a  gradual  onset 
has  been  noticed  with  friction  first,  followed,  after  a  few  days, 
by  effusion,  the  probability  is  strongly  in  favour  of  serum;  and 
in  the  child  a  serous  effusion  almost  invariably  means  tubercle. 

Profuse  sweating  and  diarrhoea  are  certainly  commoner  with 
empyema  than  with  serous  effusion.  As  confirmatory  evidence 
the  blood  count  may  be  of  some  value,  a  high  degree  of  leuco- 
cytosis  is  in  favour  of  empyema,  but  this  is  by  no  means  an 
infallible  guide. 

I  have  kept  till  last  the  mention  of  the  exploring  needle  :  not 
because  I  regard  it  as  least  important — it  is  essential  in  most 
cases  where  the  possibility  of  pleural  effusion  is  in  question — 
but  because,  especially  in  dealing  with  children,  it  should  be  our 
ambition  in  diagnosis  as  well  as  in  treatment  to  avoid  as  far  as 
possible  any  method  which  inflicts  pain  ;  and  one  has  proved 
by  experience  that  there  are  cases — few,  I  admit — in  which  a 
careful  consideration  of  the  history  and  the  course  of  the  illness 
makes  it  possible  to  do  without  exploration  ;  rapid  absorption 
of  the  fluid  in  such  cases  has  proved  that  one  was  correct  in 
supposing  it  to  be  serous. 

If  there  are  no  sufficient  grounds  to  justify  us  in  assuming 
that  only  serous  effusion  is  present  we  must  needs  explore;  and 
here  let  me  point  out  that  exploration  is  not  absolutely  free  from 
danger  ;  it  is  common  enough  for  the  child  to  spit  up  a  small 
quantity  of  blood  just  after  the  puncture,  proving  that  the  lung 
lias  boon  wounded,  but  this  is  usually  of  no  importance  ;  it  has, 
however,  happened  that  severe  bleeding  has  taken  place  from 
the  lung  ;  I  have  also  seen  pneumothorax,  extensive  surgical 
emphysema,  and  haemorrhage  into  the  pericardium,  as  results 
of  exploratory  puncture. 

Certain  practical  details  in  the  matter  of  exploring  are  worthy 
of  mention.  I  shall  assume  that  the  skin  and  the  needle  have 
been  rendered  as  far  as  possible  aseptic,  and  that  the  needle  has 
been  tested  not  merely  by  driving  boiled  water  out  of  the  piston 
through  the  needle  but  by  drawing  it  up  the  needle  into  the 
piston,  which  is  a  far  more  important  test,  as  one  too  often  finds 
that  the  plunger  does  not  fit  accurately  enough  to  draw  fluid 
even  against  the  slight  resistance  of  a  fine  lumen  in  the  needle. 


EMPYEMA  389 

In  infants  and  young  children  the  space,  between  the  ribs  is  so 
small  that  it  is  easy  to  drive  the  needle  against  a  rib  ;  to  avoid 
this  the  child  should  be  made  to  lie  upon  the  sound  side  with 
a  small  pillow  under  that  axilla,  and  the  arm  of  the  affected  side 
should  be  drawn  up  over  the  head  so  as  to  stretch  the  intercostal 
spaces  as  widely  as  possible. 

The  child's  trunk  must,  of  course,  be  steadied  to  prevent  his 
lurching  forward  as  the  needle  enters.  In  older  children  the 
same  posture  may  be  used,  or  if  preferred  the  child  may  be  in 
the  sitting  position  with  the  arm  drawn  forward  and  slightly 
upward. 

I  need  not  describe  here  the  various  causes  of  failure  to  find 
pus  when  it  is  present,  they  are  the  same  in  children  as  in  adults ; 
but  I  will  mention  two  fallacies  which  I  have  noticed  with  special 
frequency  in  my  ward.  Often  the  needle  is  not  inserted  far 
enough  ;  any  one  who  has  seen  the  large  masses  of  shaggy  lymph 
which  come  from  a  pneumococcal  empyema,  and  which  coat 
the  pleura,  can  understand  that  it  may  be  necessary  to  push 
the  needle  in  quite  an  inch  or  more  before  any  pus  can  be  drawn. 
Secondly,  I  have  several  times  been  told  that  the  result  was 
negative  because  no  fluid  had  been  drawn  into  the  barrel  of  the 
syringe,  when  by  driving  down  the  piston  after  the  needle  had 
been  withdrawn  from  the  chest  it  was  found  that  there  was 
a  single  drop  of  fluid  in  the  needle  itself,  and  under  the  microscope 
this  drop  proved  to  be  pus. 

In  every  case  the  fluid  withdrawn  should  be  examined  carefully 
with  naked  eye  and  with  the  microscope,  as  well  as  bacteriologi- 
cally.  I  have  sometimes  been  told  that  the  fluid  was  serous, 
when  careful  examination  even  with  the  naked  eye  showed  that 
it  was  slightly  turbid,  and  microscopic  examination  showed 
a  large  number  of  pus  cells  and  pneumococci,  which  made  it 
evident  that  it  was  not  serum  but  seropus,  and  required  the 
treatment  of  an  empyema.  The  importance  of  examining  the 
fluid  carefully  was  impressed  upon  me  some  years  ago  when  I  had 
explored  a  child's  chest  and  was  about  to  throw  away  the  small 
quantity  of  fluid  in  the  syringe,  having  hastily  concluded  that 
it  was  clear  serum,  when  the  physician  in  charge  of  the  case, 
Dr.  F.  G.  Penrose,  drew  my  attention  to  the  unusually  colourless 
appearance  of  the  fluid ;  microscopic  examination  showed 
hydatid  booklets. 

One  other  point  in  the  fluid  is  worth  noting  :  its  smell ;  twice 
in  the  series  of  fifty  cases  under  my  observation,  I  have  found 
the  pus  stinking  with  an  almost  faecal  odour  where  it  proved  to 


390  COMMON  DISORDERS  OF  CHILDHOOD 

be  secondary  to  an  appendicitis ;  both  cases  made  a  good 
recovery. 

Complications.  Amongst  the  complications  of  empyema,  none 
is  more  important  than  suppurative  pericarditis.  Like  suppura- 
tive  meningitis,  which  is  also  far  more  frequent  in  the  first  three 
years  of  life  than  at  any  other  time,  and  which  is  also  most  often 
associated  with  pneumonia  or  empyema,  suppurative  peri- 
carditis is  usually  fatal,  but  unlike  the  meningeal  affection  it 
offers  a  possibility  of  recovery  if  recognized  and  treated. 

Out  of  31  cases  of  suppurative  pericarditis  which  I  examined 
post  mortem,  20  were  associated  with  empyema.  Dr.  Poynton  l 
found  that  83  out  of  100  cases  of  suppurative  pericarditis  at  the 
Children's  Hospital,  Great  Ormond  Street,  occurred  before  the 
age  of  four  years,  and  about  60  per  cent,  were  associated  with 
empyema  ;  out  of  my  31  cases  (some  of  which  are  included  in 
Dr.  Poynton's  figures)  18  occurred  within  the  first  two  years 
of  life. 

The  recognition  of  this  complication  is  extremely  difficult; 
even  when  it  is  suspected  the  physical  signs  are  so  indefinite 
that  it  needs  a  bold  man  to  advise  opening  the  pericardium  in 
a  child  who  already  looks  desperately  ill,  and  with  no  other 
evidence  perhaps  to  support  the  diagnosis  beyond  the  extreme 
illness  which  does  not  seem  to  be  sufficiently  accounted  for  by  the 
pulmonary  or  pleural  condition.  Nevertheless,  I  think  that  more 
weight  is  sometimes  to  be  attached  to  symptoms  than  to  signs 
in  diagnosing  this  complication  ;  when  a  child  who  has  already 
had  an  empyema  opened  continues  to  look  profoundly  ill,  with 
irregular  fever,  and  especially  with  extreme  pallor  of  face  and 
lividity  of  lips,  hurried  breathing  and  a  rapid  pulse,  suppurative 
pericarditis  should  be  in  question. 

In  some  cases  there  are  sudden  attacks  of  cyanosis.  Dr.  Poyn- 
ton lays  stress  also,  very  rightly  I  think,  on  the  importance  of 
orthopri(i>a  and  syncopal  attacks ;  the  extreme  pallor  and  hurried 
respiration  are  also  striking  symptoms  in  most  cases.  As  to 
signs,  they  arc  of  the  vaguest  :  pericardial  friction  is  almost 
never  present,  and  the  amount  of  pus  is  so  small  in  most  cases 
that  it  does  not  cause  any  considerable  increase  of  the  cardiac 
dullness  ;  usually  it  does  not  exceed  2  ounces,  often  it  is  not 
more  than  1  ounce.  If  there  is  any  increase  of  the  dullness,  its 
extension  upwards  is  specially  significant  ;  more  often  I  think 
information  is  to  be  gained  from  the  heart  sounds  which  some- 
times, but  by  no  means  always,  become  distant  and  muffled. 
1  British  Medical  Journal,  August  15,  1908. 


EMPYEMA  391 

Where  there  is  good  reason  to  suspect  suppurative  pericarditis 
the  diagnosis  must  be  determined  by  the  exploring  needle,  which 
should  be  inserted  in  the  fifth  left  space  close  to  the  sternum  or 
in  the  angle  between  the  xiphoid  and  the  left  costal  cartilages, 
pushing  the  needle  upward  and  backward. 

Suppurative  meningitis  I  found  in  eight  out  of  fifty  fatal  cases 
of  empyema  ;  it  occurs  usually  in  infants,  and  is  fatal  within  a 
few  days  ;  its  presence  may  be  indicated  by  some  squint  or 
slight  head-retraction  or  convulsion,  but  often  it  is  found  quite 
unexpectedly  at  post  mortem  examination. 

Arthritis  was  present  in  two  out  of  the  fifty  cases  ;  in  one  it 
was  certainly  pneumococcal  and  affected  both  hips  and  the 
left  shoulder  in  a  male  infant  aged  ten  months  ;  in  the  other  it 
affected  the  left  hip-joint,  and  was  probably  also  pneumococcal. 

The  peritoneum  shows  suppuration  in  some  cases,  but  this  is 
rarely  recognizable  during  life. 

Prognosis,  Empyema  is  a  much  more  dangerous  disease  in 
a  child  under  two  years  of  age  than  in  an  older  child.  Out  of  the 
series  of  183  cases  mentioned  above,  40  proved  fatal,  that  is  21-8 
per  cent.  ;  but,  as  may  be  seen  from  the  following  figures,  the 
proportion  is  much  higher  in  infancy  : 

Number  of  Cases.          Deaths. 
Dnder  2  years     ....       54     ....     28 
2-12  years  old     ....     129     ....     12 

The  very  heavy  mortality  in  infancy  is  due  partly  to  the 
special  tendency  to  suppurative  pericarditis  and  meningitis  at 
this  age.  In  many  of  the  cases  included  in  these  statistics, 
there  was  generalized  pneumococcal  infection  which  proved 
fatal  ;  it  would  be  difficult  to  say  in  what  proportion  this  was 
secondary  to  the  empyema,  no  doubt  in  some  the  infection  of 
the  serous  membranes  and  meninges  may  have  been  of  the  same 
date,  and  have  resulted  from  a  blood  infection  during  pneumonia, 
so  that  the  fatal  ending  could  hardly  be  attributed  to  the  empyema. 

One  element  in  prognosis  is  the  bacteriology  of  the  empyema  : 
in  infants  the  danger  of  generalization  of  pneumococcal  infection 
makes  an  empyema  due  to  the  pneumococcus  probably  quite  as 
dangerous  as  that  due  to  any  other  micro-organism  ;  but  in  older 
children  where  there  is  much  less  risk  of  suppurative  pericarditis 
or  meningitis,  the  outlook  is,  I  think,  better  with  a  pneumococcal 
empyema  than  with  one  due  to  infection  with  other  pyogenic 
bacteria,  whether  of  single  variety,  such  as  streptococcus,  or  of 
mixed  kinds,  for  instance,  streptococcus  with  bacillus  coli. 

Often  one  can  recognize  with  a  fair  approach  to  accuracy  the 


392  COMMON  DISORDERS  OF  CHILDHOOD 

nature  of  the  infection  from  the  appearance  or  smell  of  the  pus 
when  the  empyema  is  opened  ;  when  large  masses  of  lymph  are 
present,  the  pus  almost  always  contains  pneumococci,  whereas 
with  a  streptococcal  empyema  the  fluid  is  thin,  often  only  seropus 
with  only  a  few  small  shreds  of  lymph  in  it.  Stinking  pus  would 
point  to  infection  with  other  micro-organisms,  probably  the 
bacillus  coli. 

Another  point  which  must  influence  prognosis  is  the  duration  of 
the  empyema  ;  if  pus  has  remained  in  the  chest  for  many  weeks 
the  lung  may  not  re-expand  perfectly  when  the  pus  is  evacuated ; 
and  these  are  the  cases  in  which  there  remains  a  pus-discharging 
cavity  for  many  weeks  or  months — a  sequel  fortunately  much 
less  common  in  the  child  than  in  the  adult ;  these  also  are  the 
cases  in  which  the  open  cavity  is  apt  to  become  infected  with 
some  extraneous  bacteria  so  that  the  discharge  originally  '  sweet ' 
becomes  offensive  in  odour,  and  the  wound  unhealthy  and 
indolent  in  appearance,  and  the  child  does  badly. 

I  have  laid  stress  on  the  unsatisfactory  elements  in  prognosis, 
I  must  refer  now  to  the  brighter  aspects  of  empyema.  Of  children 
over  two  years  of  age  with  empyema,  according  to  my  own 
figures,  fully  90  per  cent,  recover,  and  if  the  empyema  is  opened 
within  a  week  or  two  after  its  occurrence,  the  recovery  is  astonish- 
ingly complete.  Even  the  gap  in  the  rib  where  resection  has 
been  done  is  completely  repaired  within  two  or  three  months, 
and  by  this  time  the  breath  sounds  are  often  so  perfectly  normal 
that  except  for  the  scar  one  would  not  know  that  any  affection  of 
the  lung  had  occurred. 

The  ordinary  pneumococcal  empyema  is,  in  fact,  far  more 
satisfactory  in  its  outlook  than  a  simple  serous  effusion ;  the 
child  who  has  recovered  from  the  empyema  has,  so  to  speak, 
'  a  clean  bill  of  health  '  ;  the  child  who  has  had  a  serous  effusion 
in  the  pleura,  however  completely  all  traces  of  it  have  dis- 
appeared, must  live  the  rest  of  his  life  in  danger  of  tuberculosis, 
which  too  often  declares  itself  in  the  lungs  or  elsewhere  within 
a  very  few  months  or  years  after  its  first  indication  in  the 
pleura. 

Treatment.  The  treatment  of  an  empyema  falls  within  the 
scope  of  the  surgeon  rather  than  of  the  physician  :  but  as  much 
of  the  responsibility  for  the  treatment  usually  rests— and  should 
rest — upon  the  physician,  I  may  perhaps  be  allowed  to  make 
some  general  remarks  upon  it. 

In  the  first  place  I  would  insist  upon  the  importance  of  opening 
the  chest  as  soon  as  possible  in  every  case  of  empyema  ;  it  seems 


EMPYEMA  393 

probable  that  in  some  cases  the  pneumococcal  infection  of  the 
meninges  and  pericardium  to  which  children  are  specially  liable 
is  the  result  of  allowing  pus  or  lymph,  which  is  usually  a  pure 
culture  of  pneumococcus,  to  remain  pent  in  the  pleural  cavity. 
No  doubt,  in  many  cases,  the  pneumococcal  infection  of  the 
pericardium,  meninges,  and  other  parts,  are  only  manifestations 
of  a  general  blood-infection,  to  which  the  empyema  also  is  due  ; 
but  this  is  not  always  so. 

I  had  under  my  care  a  boy  aged  ten  months  ;  I  first  saw  him 
five  weeks  after  an  attack  of  pneumonia,  he  was  ailing  with 
vague  chest  symptoms  which  did  not  suggest  empyema  ;  he 
died  nearly  three  months  after  the  pneumonia  with  suppurative 
meningitis,  and  post  mortem  1  drachm  of  pus  was  found  shut 
up  by  adhesions  in  the  right  pleural  cavity.  The  suppurative 
meningitis  must  have  begun  only  a  few  days  before  death  ;  it 
seemed  clear  that  the  source  of  infection  was  this  small  collection 
of  pus  which  I  had  failed  to  detect  in  the  pleura. 

In  twenty -four  out  of  fifty  fatal  cases  of  empyema  in  children 
whom  I  examined  post  mortem,  there  was  suppuration  in  the 
meninges,  pericardium,  peritoneum,  or  joints  ;  in  thirteen  of 
these  cases  the  empyema  had  not  been  opened  (in  two  of  these 
thirteen  the  child  had  been  explored  with  a  needle  twice  without 
finding  the  pus).  I  do  not  think  that  these  complications  were 
in  all  cases  secondary  to  the  empyema  ;  in  most  cases  probably 
they  occurred  simultaneously  with  the  empyema,  and  were 
part  of  a  general  blood-infection,  but  none  the  less,  the  liability 
to  these  fatal  complications  is  certainly  increased  by  leaving  an 
empyema  unopened,  and  as  we  cannot  tell  at  what  hour  the 
spread  of  infection  may  occur,  the  sooner  the  empyema  is  opened 
the  better. 

But,  says  one — and  this  is  not  an  imaginary  proposal,  I  have 
heard  it  more  than  once — may  we  not  leave  the  pus  alone  in  the 
hope  that  it  may  be  absorbed  ?  There  is  nothing  absurd  in  this 
suggestion  ;  it  is  more  than  probable  that  a  very  small  loculus 
of  pus  may  gradually  dry  up,  so  that  the  pathologist  happening 
to  examine  the  child's  body  a  year  or  two  later  finds  only  a  dry 
washleather-like  patch  of  yellowish  white  material  between  the 
adherent  layers  of  pleura,  and  if  this  were  all  that  remained  it 
would  be  an  excellent  result  :  but,  unfortunately,  it  is  not  all. 
Apart  from  the  risk  of  dissemination  of  the  infection  from  the 
loculus,  however  small,  there  is  a  danger  of  chronic  fibrosis  of 
the  lung  when  an  empyema  is  left  unopened.  The  history  of 
some  of  the  cases  of  fibroid  lung  and  bronchiectasis  in  children 


394  COMMON  DISORDERS  OF  CHILDHOOD 

strongly  suggests  this  origin,  and  in  some  cases  the  post  mortem 
appearances  confirm  it. 

Next  I  would  point  out  that  seropus  is  just  as  dangerous  from 
the  point  of  view  of  secondary  infection  as  thick  pus,  and  there- 
fore it  should  be  treated  by  free  opening  of  the  chest. 

Many  years  ago  aspiration  alone  was  done  in  cases  of 
empyema  at  the  Children's  Hospital,  Great  Ormond  Street,  and 
it  is  said  that  a  certain  number  did  just  as  well  as  with  the 
modern  treatment  of  open  drainage  ;  but  the  risk  of  secondary 
infection  presumably  is  greater  with  this  procedure  than 
with  free  opening,  for  the  large  masses  of  lymph  which  are 
evacuated  by  the  open  method  are  swarming  with  micro- 
organisms, and  the  retention  of  these  in  the  pleura  must 
increase  the  risk.  Nevertheless,  there  are  conditions  in  which 
aspiration  is  useful  and  advisable;  where  the  empyema  appears 
to  be  very  large  in  amount,  and  especially  if  the  child's  con- 
dition is  very  bad  so  that  an  anaesthetic  seems  risky,  I  like 
to  have  the  chest  aspirated  and  about  8  or  10  ounces  drawn 
off  one  day,  so  that  on  the  following  day  or  a  few  hours  later 
the  chest  may  be  opened  with  less  risk  than  would  be  incurred 
if  the  larger  quantity  of  fluid  originally  present  had  been  rapidly 
removed  by  immediate  operation. 

There  are  instances  also  in  which,  owing  to  parents'  refusal 
to  allow  operation,  aspiration  may  be  the  only  course  open  to  us. 

The  choice  of  operation  lies  between  simple  incision  in  the  inter- 
costal space  and  resection  of  a  rib.  Nowadays  the  latter  is  in 
vogue  :  at  some  hospitals  it  is  the  only  method  in  use  ;  and 
undoubtedly  it  has  advantages — it  allows  a  more  thorough 
examination  of  the  empyema  cavity,  which  sometimes  gives 
useful  information,  and  probably  the  opening  is  freer  so  that 
the  masses  of  lymph  escape  more  easily. 

But  I  think  it  should  be  realized  that  resection  of  a  rib  is 
quite  unnecessary  in  many  cases.  I  have  seen  many  cases 
treated  by  simple  incision,  with  excellent  results ;  it  is  an  operation 
which  can  be  performed  more  quickly  even  than  resection  of 
a  rib,  and  this  is  an  important  point  when  we  are  dealing  with 
a  feeble  infant,  or  a  child  who  is  extremely  bad.  In  cases  where 
the  pus  is  thin,  with  few  masses  of  lymph,  so  that  no  large  open- 
ing is  required,  there  is  room  between  the  ribs  for  a  sufficiently 
large  drainage  tube  even  in  an  infant. 

After  the  chest  lias  been  opened  the  temperature  should  fall 
to  normal  if  it  has  been  raised,  and  the  child's  condition  rapidly 
improve  ;  if  the  child  continues  to  look  ill,  and  there  is  some 


EMPYEMA  395 

fever,  one  must  suspect  the  presence  of  pus  elsewhere.  There 
may  be  an  empyema  on  the  other  side,  or  there  may  be  another 
collection  of  pus  separated  by  adhesions  from  the  empyema 
which  has  been  opened  :  or  there  may  be,  as  I  have  found  at 
autopsy,  a  collection  of  pus  in  the  mediastinum. 

If  the  child  looks  acutely  ill,  with  livid  lips  and  hurried  respira- 
tion, after  the  empyema  has  been  relieved,  the  possibility  of 
suppuration  in  the  pericardium  must  be  carefully  considered 
(see  p.  390). 

Sometimes  recovery  is  delayed  by  failure  of  the  wound  to 
heal,  a  sinus  remains  and  discharge  persists.  I  remember  one 
child  in  whom  this  was  explained  by  the  discovery  on  further 
resection  of  a  strip  about  6  inches  long  of  green-protective 
which  had  dropped  into  the  pleural  cavity  from  the  dressings  ; 
a  similar  accident  has  happened  with  the  drainage  tube,  where 
this  was  not  properly  secured  either  by  a  stitch  or  by  a  suitable 
flange.  In  enlarging  the  gap  in  the  rib  after  the  pleura  has  been 
opened  the  piece  cut  off  the  end  of  the  rib  may  fall  into  the 
pleural  cavity  and  cause  a  sinus  to  persist ;  such  mishaps  are 
to  be  avoided  by  proper  care. 

More  difficult  to  prevent  is  the  unhealthy  state  into  which  the 
wound  will  occasionally  fall  when  the  utmost  care  has  been 
taken.  I  suppose  that  in  these  cases  there  has  usually  been 
some  accidental  contamination  from  without,  but  it  seems  quite 
conceivable  that  the  added  infection  may  sometimes  be  from 
within,  and  that  either  from  the  blood  or  from  the  lung  bacteria 
gain  access  to  the  wound  and  flourish  in  the  damaged  tissues, 
especially  if  the  child  is  in  a  feeble  state.  Such  a  condition  may 
call  for  the  use  of  a  vaccine,  and,  if  possible,  an  autogenous 
vaccine,  i.e.  one  prepared  from  cultures  taken  from  the  purulent 
discharge  in  the  particular  case,  should  be  used  in  preference  to 
any  stock  vaccine.  It  may  be  that  a  mixed  vaccine  of  pneumo- 
cocci  with  streptococci  or  staphylococci  or  even  Bacillus  coli  may 
be  found  necessary  after  the  bacteriological  examination  of  the 
discharge.  An  unhealthy  dry  and  glazed  appearance  of  the  wound 
together  with  a  rise  of  temperature  has  sometimes  made  me 
suspect  septic  contamination,  when  the  event  has  proved  that 
those  symtoms  were  due  only  to  the  onset  of  one  of  the  specific 
fevers,  for  instance  measles. 


CHAPTER  XXIX 
TUBERCULOSIS 

THERE  are  few  diseases  so  common  and  so  disastrous  in  their 
results  as  tuberculosis  in  childhood.  The  yearly  sacrifice  of 
childlife  to  tuberculosis  in  this  country  is  nothing  short  of 
appalling  ;  and  it  is  made  only  the  more  distressing  by  the 
certainty  that  some  of  it,  perhaps  much  of  it,  might  be  pre- 
vented if  only  proper  precautions  were  taken. 

It  is  practically  impossible  to  ascertain  the  actual  death  rate 
from  tuberculosis  in  children  ;  the  only  complete  statistics  on 
this  point,  namely,  those  of  the  Registrar-General,  are  rendered 
valueless  by  the  lack  of  post  mortem  verification  in  the  majority 
of  cases.  Some  idea,  however,  of  the  proportion  of  cases  in 
which  death  is  due  to  tuberculosis  can  be  obtained  from  the 
post  mortem  statistics  of  children's  hospitals,  and  a  rough  estimate 
of  the  mortality  from  tuberculosis  amongst  children  can  thus  be 
be  made. 

Amongst  769  autopsies  on  children  under  twelve  years  of  age 
at  the  Hospital  for  Sick  Children,  Great  Ormond  Street,  I  found 
tuberculous  lesions  in  269  cases,  and  in  223  of  these — that  is, 
in  28-9  per  cent. — the  fatal  result  was  directly  due  to  tuber- 
culosis. In  another  series  of  180  autopsies  at  the  same  hospital 
Dr.  Colman  l  found  tuberculosis  in  59  cases,  and  it  was  the  imme- 
diate cause  of  death  in  51 — that  is,  in  28-3  per  cent.  Owing  to  the 
limitation,  by  the  hospital  regulations,  of  the  number  of  infants 
(under  two  years  of  age)  which  may  be  admitted  at  one  time, 
these  figures  perhaps  rather  understate  the  frequency  of  tuber- 
culosis ;  but  the  error  is  probably  not  large,  for  a  very  similar 
proportion  was  found  by  Dr.  Carr 2  at  the  Chelsea  Children's 
Hospital,  where  a  series  of  330  deaths  from  all  causes  showed 
100  cases  with  tuberculous  lesions — that  is,  30-3  per  cent. 

It  would  seem,  therefore,  that  at  any  rate  amongst  hospital 
patients  in  London  nearly  one-third  of  the  child  mortality  is  due 
to  tuberculosis  ;  and  although  such  an  estimate  may  for  various 
reasons  be  too  high  when  applied  to  the  whole  child  mortality 

1  Brit.  Mc.d.  Journ.,  1893,  ii,  p.  740. 
1  Internal.  Mcd.  Mag.,  1893,  p.  498. 


TUBERCULOSIS 


397 


of  this  city,  it  SQems  almost  certain  that  the  average  given  by 
the  Registrar-General's  statistics  is  far  too  low.  During  the 
five  years  1891-5  the  average  number  of  deaths  per  annum  from 
all  causes  amongst  children  up  to  the  age  of  ten  years  in  this 
city  was  36,349  ;  out  of  these  the  average  number  of  children 
certified  each  year  as  having  died  of  tuberculosis  was  3,335.  The 
evidence  of  post  mortem  statistics  makes  it  practically  certain  that 
a  very  much  larger  number  than  this  die  of  tuberculous  disease. 


Fio.  24.    Chart  showing  age-distribution  of  500  consecutive  cases  of 
tuberculosis  in  childhood. 

The  incidence  of  tuberculosis  is  not  the  same  at  all  periods  of 
childhood.  Statistics  show  that  the  special  liability  to  tuber- 
culosis is  much  more  marked  during  the  first  five  years  of  life 
than  during  the  later  years.  A  still  more  striking  fact  is  illus- 
trated by  the  chart  given  above — namely,  the  remarkable  fre- 
quency of  tuberculosis  during  infancy,  especially  in  the  second 
year.  In  500  cases  from  the  post  mortem  records  of  the  Hospital 
for  Sick  Children  no  less  than  130 — that  is,  more  than  25  per 


398  COMMON  DISORDERS  OF  CHILDHOOD 

cent._ occurred  during  the  second  year.  The  chart  illustrates 
also  the  gradual  increase  of  the  liability  to  tuberculosis  during 
the  earlier  months  of  infancy  ;  only  one  case  occurred  below  the 
age  of  three  months  (at  ten  weeks). 

The  significance  of  this  very  marked  age-incidence  is  a  matter 
of  considerable  practical  importance,  for  it  can  hardly  be  doubted 
that  it  bears  some  relation  to  the  mode  of  infection,  and  if 
prophylaxis  is  ever  to  be  successful  it  is  all-important  that  we 
should  determine  what  this  relation  is. 

The  discovery  in  recent  years  that  the  tubercle  bacillus  is 
frequently  present  in  cow's  milk,  as  supplied  commercially,  affords 
at  first  sight  a  very  simple  explanation  of  this  special  incidence 
of  tuberculosis  on  infants  and  young  children.  It  has  been 
proved  experimentally  that  tuberculous  material  given  as  food 
may  produce  tuberculosis  in  guinea-pigs  ;  cow's  milk  frequently 
contains  the  tubercle  bacillus.  The  period  of  infancy  is  the 
period  of  milk-feeding  ;  infants,  therefore,  are  specially  exposed 
to  infection. 

Plausible -as  such  a  theory  may  appear,  more  evidence  is 
required  before  it  can  be  regarded  as  proven  ;  indeed,  the  facts 
of  the  post  mortem  room  are  overwhelmingly  opposed  to  it. 

I  have  elsewhere  discussed  this  subject  at  length,  but  in 
view  of  its  important  bearing  on  the  question  of  prophylaxis, 
I  venture  to  refer  here  to  some  of  my  own  conclusions,  and  to 
compare  with  them  the  entirely  independent  results  obtained  by 
other  observers. 

The  difficulty  of  determining  the  channel  of  tuberculous  in- 
fection in  children  is  greatly  increased  by  the  marked  tendency 
to  generalization  of  tuberculosis  at  this  age.  We  have,  however, 
a  valuable  index  of  its  path  and  duration  in  the  condition  of  the 
lymphatic  glands,  which  in  childhood  show  a  special  susceptibility 
to  the  infection  of  tuberculosis,  so  that  in  many  cases  it  is  possible 
from  a  careful  consideration  of  these  to  determine  with  at  least 
a  high  degree  of  probability  the  primary  channel  of  infection. 

Amongst  269  tuberculous  children  under  twelve  years  of  age 
whom  I  examined  post  mortem,  I  found  it  possible  in  this  way 
to  determine  the  channel  of  infection  with  some  degree  of 
.certainty  in  216  cases  :  in  138 — that  is,  in  63-8  per  cent. — 
infection  appeared  to  have  entered  through  the  lung  ;  in  63 — 
that  is,  in  29-1  per  cent. — primary  infection  was  probably 
through  the  intestine  ;  in  15  it  appeared  to  be  through  the  ear. 
It  would  seem,  therefore,  that  if  the  whole  period  of  infancy 
and  childhood  up  to  the  age  of  twelve  years  be  taken  into  account, 


TUBERCULOSIS  399 

the  view  that  milk  infection  is  chiefly  responsible  for  the  heavy 
incidence  of  tuberculosis  on  childhood  is  untenable. 

But  if  we  take  into  consideration  only  the  period  of  infancy, 
in  which  we  should  expect  the  most  striking  evidence  of  the 
frequency  of  milk  infection,  the  proportion  of  cases  showing 
primary  intestinal  infection,  instead  of  being  larger,  is  actually 
less.  Amongst  100  infants  (up  to  two  years  of  age)  in  whom  the 
primary  channel  of  infection  could  be  ascertained,  65  appeared 
to  be  due  to  pulmonary  infection  ;  only  22  to  intestinal.  The 
comparative  infrequency  of  milk  infection  is  even  more  strongly 
emphasized  by  considering  only  infants  up  to  one  year  old ;  it 
was  possible  to  determine  the  route  of  infection  in  39  out  of  50 
infants  up  to  one  year  old  ;  in  27  out  of  these  39  infection  had 
occurred  through  the  respiratory  tract,*  in  only  5  through  the 
intestine.  (In  the  remaining  7  it  was  through  the  ear.) 

These  observations  are  .confirmed  by  the  statistics  of  other 
observers.  Dr.  Carr,1  in  a  series  of  120  autopsies  on  tuberculous 
children  at  the  Chelsea  Children's  Hospital,  found  primary 
thoracic  infection  in  65-8  per  cent.,  whilst  only  16-7  per  cent, 
showed  evidence  of  primary  abdominal  infection.  Dr.  Guthrie,2  at 
the  Paddington  Green  Children's  Hospital,  in  a  series  of  77  cases, 
found  evidence  of  primary  thoracic  infection  in  42  cases,  whilst 
only  19  appeared  to  have  been  infected  through  the  intestine. 

From  the  records  of  post  mortem  examinations  at  the  Royal 
Hospital  for  Sick  Children,  Edinburgh,  Dr.  Shennan3  collected 
355  cases  of  tuberculosis,  in  331  of  which  he  was  able  to  deter- 
mine the  channel  of  infection  :  in  67-07  per  cent,  this  was 
respiratory,  in  28-1  per  cent,  it  was  alimentary. 

Some  observations  from  America  by  Dr.  Northrup 4  showed 
an  even  higher  proportion  of  cases  with  primary  thoracic  infection 
— namely,  70  per  cent. 

The  above  statistics  show  a  remarkably  close  agreement 
between  the  results  of  entirely  independent  observers,  and  they 
tend,  I  think,  to  disprove  some  of  the  exaggerated  statements 
which  have  been  made  as  to  the  prominence  of  milk  infection 
in  the  causation  of  tuberculosis  in  childhood. 

The  frequency  of  tuberculous  lesions  in  the  mesenteric  glands 
has  been  put  forward  as  evidence  that  infection  is  usually  by 
the  intestine  in  children.  But  even  if  merely  the  relative  fre- 

1  Trans.  Med.  Soc.  Lond.,  1894,  p.  292. 

2  Lancet,  1899,  i,  p.  286. 

3  Edin.  Hosp.  Rep.,  1900. 

«  New  York  Med.  Journ.,  February,  1891. 


400  COMMON  DISORDERS  OF  CHILDHOOD 

quency  of  affection  of  the  mesenteric  glands  were  to  be  con- 
sidered, the  argument  would  fail  entirely  ;  for,  as  will  be  seen 
from  the  figures  given  below,  the  thoracic  glands  are  affected 
far  more  frequently  than  the  abdominal. 

Such  an  argument,  however,  cannot  be  based  on  a  more 
study  of  the  relative  frequency  of  affection  of  the  various  glands 
without  taking  into  account  also  the  apparent  duration  of  the 
process  in  these  glands.  In  many  cases  of  pulmonary  tuber- 
culosis in  childhood  there  are  tuberculous  lesions  in  the  mesen- 
teric glands  as  well  as  in  the  mediastinal,  but  this  is  no  proof 
whatever  that  there  was  primary  infection  through  the  intestine  ; 
indeed,  in  many  such  cases  it  seems  quite  certain  that  the 
primary  infection  was  thoracic,  for  whilst  the  thoracic  glands 
show  evidence  of  longstanding  disease,  and  perhaps  some  old 
calcareous  deposit,  the  lesion  in  the  intestine  and  mesenteric 
glands  appears  to  be  of  quite  recent  date. 

Moreover,  there  is  an  obvious  reason  why  tuberculous  affection 
of  the  mesenteric  glands  should  be  frequently  associated  with 
pulmonary  tuberculosis  in  childhood  :  a  child  under  the  age 
of  five  years  hardly  ever  expectorates  voluntarily  ;  indeed  it  is 
often  difficult  to  teach  even  older  children  to  expectorate. 
Consequently  they  swallow  the  tuberculous  material  coughed 
up  from  the  lungs  and  in  this  way  a  secondary  infection  of  the 
intestine  and  mesenteric  glands  might  well  be  expected. 

It  would  seem,  then,  that  the  special  frequency  of  tuberculosis 
in  the  first  two  years  of  life,  and  to  a  less  degree  in  the  first  five 
years,  is  not  '  due  chiefly  to  infection  through  the  alimentary 
canal  by  milk  from  tuberculous  cows ',  as  has  been  stated. 
The  evidence  of  the  post  mortem  room  shows  that  the  commonest 
channel  of  infection  with  tuberculosis  in  childhood  is  the  lung, 
not  the  intestine  ;  and  so  far  from  there  being  any  special  fre- 
quency of  intestinal  infection  during  the  milk-feeding  period,  it 
would  seem  that  this  mode  of  infection  is  relatively  much  less 
common  in  infancy  and  in  early  childhood  than  it  is  in  older 
children.  My  own  statistics  showed  that  whilst  in  children 
under  five  years  of  age  the  proportion  of  cases  showing  primary 
intestinal  infection  to  those  showing  primary  lung  infection  was 
about  one  to  three  (39  to  115),  in  children  over  the  age  of  five 
years  it  was  exactly  one  to  one. 

The  commonest  mode  of  tuberculous  infection  in  childhood, 
and  especially  in  infancy,  is  therefore  by  inhalation  ;  and  if  it 
be  asked  why  the  liability  to  pulmonary  affection  should  be  so 
much  greater  during  the  first  two  or  three  years  of  life  than  in 


TUBERCULOSIS  401 

the  later  years  of  childhood,  there  is  at  least  a  striking  analogy 
in  the  age-incidence  of  bronchitis  and  pneumonia.  Some  statis- 
tics of  children  (up  to  the  age  of  ten  years)  under  my  care  at 
King's  College  Hospital  showed  that  65  per  cent,  of  the  cases  of 
primary  bronchitis  occurred  during  the  first  three  years  of  life 
and  the  incidence  of  bronchitis  rapidly  diminished  after  the  age 
of  five  years.  Of  cases  of  primary  broncho-pneumonia  under 
the  age  of  five  years— and  it  becomes  quite  infrequent  after  that 
age — 80  per  cent.,  according  to  Holt,  occur  in  the  first  two  years 
of  life.  Lobar  pneumonia  similarly  occurs  far  more  frequently 
under  the  age  of  five  years  than  in  later  childhood. 

There  is,  therefore,  good  reason  for  believing  that  there  is 
some  special  vulnerability  of  the  respiratory  tract  during  the 
first  five  years  of  life,  and  hence,  although  exposure  to  infection 
by  contaminated  air  may  be  shared  equally  by  all  ages,  it  is  in 
infancy  and  early  childhood  that  such  exposure  is  most  often 
followed  by  a  tuberculous  lesion  either  in  the  lung  or  in  the 
lymphatic  glands  about  the  air-passages. 

This  susceptibility  to  pulmonary  infection  must  be  regarded 
as  the  chief  cause  of  the  special  incidence  of  tuberculosis  on 
infancy  and  early  childhood,  and  next  in  importance — but  longo 
intervallo — is  the  liability  of  this  age  to  milk  infection. 

There  is,  however,  a  third  factor  which  is  almost  peculiar  to 
this  age,  namely,  the  frequency  of  ear  infection.  In  my  series 
of  269  tuberculous  children  there  were  fifteen  cases  in  which  it 
seemed  most  probable  that  the  primary  focus  of  infection  was 
the  middle-ear ;  all  these  fifteen  cases  occurred  in  children 
under  the  age  of  five  years,  and  no  less  than  thirteen  of  them 
occurred  within  the  first  two  years  of  life.  The  tubercle  bacillus 
in  these  cases  probably  passes  up  the  Eustachian  tube  from  the 
naso -pharynx,  but  whether  from  the  food  or  from  inhaled  air  it 
would  be  difficult  to  decide  ;  perhaps  inasmuch  as  air  is  con- 
tinually passing  through  the  naso-pharynx,  a  part  which  food- 
carried  bacilli  would  only  reach  indirectly,  it  is  most  likely  that 
the  bacillus  enters  with  the  air. 

It  has  .been  suggested  that  the  tonsil  and  naso-pharyngeal 
adenoid  tissues  are  in  some  cases  the  portals  of  entry  for  tuber- 
culosis :  Dr.  Hugh  Walsham  found  tubercle  of  the  tonsils  in 
20  out  of  34  cases  of  tuberculosis,  chiefly  in  adults.  The  tubercle 
beginning  in  the  tonsil  infects  the  cervical  glands  and  spreading 
downwards  along  the  chain  of  cervical  glands  reaches  the  medias- 
tinal  glands  and  thence  spreads  to  the  lungs. 

Such  is  the  theory,   but  it  must  be  remembered  that  the 


402  COMMON  DISORDERS  OF  CHILDHOOD 

frequency  of  tubercle  in  the  tonsil  is  open  to  exactly  the  same 
interpretation  as  the  tubercle  in  the  intestine.  Every  time 
tuberculous  sputum  is  coughed  up  there  is  a  risk  of  infecting  the 
tonsil,  and  it  is  likely  enough  that  a  secondary  infection  of  the 
tonsil  should  occur  where  there  is  already  disease  in  the  lung. 

Moreover,  there  is  good  reason  for  believing  that  direct  exten- 
sion of  tubercle  from  the  cervical  glands  to  those  in  the  medias- 
tinum if  it  occurs  at  all  is  extremely  rare.  If  this  occurred  one 
would  expect  to  find  from  above  downwards  a  less  and  less 
advanced  stage  of  disease  in  the  glands,  so  that  while  the  glands 
at  the  upper  part  of  the  neck  were  much  enlarged  and  com- 
pletely caseous  those  of  the  lower  part  might  be  smaller  and 
partially  caseous,  whilst  those  in  the  mediastinum  would  show 
perhaps  only  scattered  foci  of  tubercle  and  be  still  less  enlarged. 
So  far  as  the  chain  of  glands  in  the  neck  is  concerned,  post 
mortem  observations  show  that  this  supposition  is  correct,  the 
enlargement  and  caseation  is  progressively  less  from  above 
downwards ;  but  the  condition  of  the  glands  in  the  mediastinum 
entirely  fails  to  accord  with  this  view,  for,  when  they  happen 
to  be  affected  in  such  cases,  where  the  affection  of  the  glands  at 
the  lower  part  of  the  neck  is  extremely  slight,  with  little  or  no 
enlargement  and  only  a  few  grey  points  of  tubercle,  the  glands 
next  below  in  the  mediastinum  show  enlargement  and  caseation 
quite  as  advanced  as  the  topmost  of  the  cervical  glands. 

It  seems,  therefore,  most  natural  to  suppose  that  the 
mediastinal  glands  have  been  infected  in  the  usual  way  through 
the  lung. 

There  is  another  very  strong  reason  for  supposing  that  any 
extension  of  tubercle  directly  from  the  neck  to  the  mediastinum 
must  be  very  exceptional.  The  glandular  affection  in  the 
mediastinum  is  for  some  unknown  reason  much  more  frequent 
and  more  extensive  on  the  right  side  than  on  the  left.  This 
was  pointed  out  by  Dr.  F.  E.  Batten,1  and  my  own  figures 
corroborate  his  observations  :  in  113  out  of  145  cases  I  found 
that  the  mediastinal  glands  showed  more  advanced  tuberculosis 
on  the  right  side  than  on  the  left  ;  only  in  32  was  the  affection 
greater  on  the  left  side,  and,  as  I  shall  point  out,  perforation  of 
the  bronchus  by  a  gland  is  far  commoner  on  the  right  than  on 
the  left. 

If  the  mediastinal  glands  were  commonly  affected  by  extension 
of  tubercle  from   the  cervical    glands  one  would   expect  that 
the  cervical  affection  also  should  be  earlier  and  more  frequent 
1  St.  Bart.  Hosp.  Rep.,  vol.  xxxi 


TUBERCULOSIS  403 

on  the  right  side  than  on  the  left.  Statistics  of  operations 
on  tuberculous  cervical  glands,  kindly  collected  for  me  by 
Dr.  Rowland,  showed  in  100  cases  in  which  one  side  was  chiefly 
affected  51  on  the  right  side,  49  on  the  left ;  in  other  words,  the 
two  sides  of  the  neck  were  almost  equally  affected. 

But,  although  extension  of  tuberculosis  from  the  cervical 
glands  to  the  mediastinum  is  probably  very  rare,  one  can  hardly 
doubt  that  unhealthy  tonsils  and  adenoid  tissue  play  a  part 
in.  the  production  of  glandular  tuberculosis  in  the  neck,  if  only 
by  causing  enlargement  of  the  glands,  and  providing  a  nidus  in 
which  the  tubercle  bacillus  very  readily  gains  a  hold,  but  the 
observations  of  Dr.  Walsham  and  others  make  it  almost  certain 
that  they  sometimes  play  the  more  direct  part  by  transmitting 
the  tubercle  bacillus. 

Apart  from  the  channels  of  infection — and  I  have  considered 
here  only  the  more  frequent,  and  therefore  more  important 
channels — there  are  two  predisposing  causes  which  play  no 
small  part  in  determining  the  heavy  incidence  of  tuberculosis  on 
early  childhood  ;  and  keeping  in  mind  the  paramount  necessity 
for  more  efficient  prophylaxis,  I  wish  to  lay  some  stress  upon 
these  two  potent  factors  in  the  etiology  of  tuberculosis  at  this 
age  :  they  are  measles  and  whooping-cough. 

Again  and  again  one  hears  the  same  tale — that  a  child,  appar- 
ently healthy,  has  had  measles,  and  then,  sometimes  imme- 
diately, sometimes  after  an  interval  of  weeks  or  months,  has 
begun  to  lose  flesh  and  shows  insidious  symptoms  which,  as  the 
event  proves,  are  the  result  of  tuberculosis.  Many  a  case  of 
tuberculosis  follows  directly  on  whooping-cough ;  sometimes  even 
before  the  whoop  has  ceased  the  wasting  and  the  pulmonary 
signs  which  were  thought  to  be  due  simply  to  the  whooping- 
cough  begin  to  assume  a  more  serious  aspect,  and  the  child  dies 
with  tuberculosis. 

This  very  frequent  occurrence  of  tuberculosis  as  a  sequel  of 
measles  and  whooping-cough  no  doubt  contributes  to  the  special 
incidence  of  tuberculosis  on  infancy  and  early  childhood,  for 
nearly  50  per  cent,  of  the  cases  of  whooping-cough  occur  during 
the  first  two  years  of  life,  and  about  80  per  cent,  under  the  age 
of  five  years,  whilst  in  London  at  any  rate  measles  also  occurs 
much  more  often  in  early  childhood  than  in  later  years. 

It  seems  likely  that  the  catarrhal  element  in  these  two  diseases 
is  the  particular  predisposing  cause  of  the  subsequent  tuber- 
culosis, and  one  can  well  imagine  that  the  swollen  condition 
of  the  lymphatic  glands  in  the  mediastinum,  which  is  a  marked 

D  d  2 


404        COMMON'  DISORDERS  OF  CHILDHOOD 

feature  in  some  cases  of  whooping-cough,  and  is  also  a  common 
result  of  the  pulmonary  complications  of  measles,  must  favour 
the  starting  of  a  tuberculous  process  in  them. 

The  prominence  of  glandular  infection  in  the  tuberculosis 
of  childhood  has  already  been  mentioned,  but  it  is  so  im- 
portant a  feature  from  the  clinical  standpoint  that  I  shall 
consider  it  here  again  with  special  reference  to  the  mediastinal 
glands. 

Tuberculosis  of  mediastinal  glands.  One  of  the  commonest 
lesions  found  post  mortem  in  tuberculous  children  is  enlarge- 
ment and  caseation  of  the  mediastinal  lymphatic  glands  ;  in 
many  cases  this  is  quite  out  of  proportion  to  the  tuberculous 
lesion  in  the  lungs,  which  may  be  so  slight  as  to  have 
produced  no  signs  during  life.  In  some  cases  this  affection 
of  the  mediastinal  glands  appears  to  be  the  earliest  gross 
lesion,  for  in  children  who  have  died  of  other  diseases  these 
glands  are  sometimes  found  to  be  caseous  or  calcareous  when  no 
other  tuberculous  lesion  is  found  in  the  body.  It  seems  most 
probable  that  in  nearly  all  such  cases  the  bacillus  has  entered 
through  the  lung,  even  although  no  lesion  may  be  found  there  ; 
but,  however  infection  has  entered,  there  is  no  doubt  that  such 
a  focus  may  directly  infect  the  adjacent  pleura,  lung,  or  bronchus, 
or  it  may  be  the  source  of  infection  through  the  blood-stream  for 
a  tuberculous  meningitis  or  for  some  more  widely  disseminated 
form  of  tuberculosis. 

The  presence  of  calcareous  foci  alone  in  some  cases  proves 
that  even  after  caseation  has  commenced  in  the  mediastinal 
glands  complete  recovery  may  take  place  ;  it  is,  therefore,  of  the 
utmost  practical  importance  that  this  condition  should  be 
detected  as  early  as  possible.  My  own  experience  leads  me  to 
believe  that  with  careful  treatment,  climatic  and  otherwise, 
children  who  come  under  observation  with  wasting,  perhaps 
slight  cough,  and  well-marked  signs  of  enlargement  of  the 
mediastinal  glands,  which  there  is  every  reason  to  regard  as 
tuberculous,  may  make  a  good  recovery  if  only  treatment  is 
begun  sufficiently  early. 

Some  idea  of  the  frequency  of  this  affection  and  also  of  the 
similar  condition  in  the  mesenteric  glands  may  be  obtained 
from  the  following  figures  :  my  own  statistics  showed  that  in 
254  tuberculous  children  in  which  the  condition  of  the  glands 
was  noted,  there  was  caseation  of  the  mediastinal  glands  in 
209 — that  is,  in  81  per  cent. ;  and  caseation  of  the  mesenteric 
glands  in  151— that  is,  in  59  per  cent.  Dr.  Carr's  figures  agree 


TUBERCULOSIS  405 

closely  with  these ;  he  found  caseous  mediastinal  glands  in  80  per 
cent,  and  caseous  mesenteric  glands  in  54  per  cent. 

It  would  seem,  therefore,  that  the  mediastinal  glands  are  more 
often  affected  than  the  mesenteric,  and  it  is  interesting  to  note 
that  when  only  one  or  other  of  these  groups  of  glands  is  affected, 
the  mediastinal  are  those  which  are  more  likely  to  be  affected. 
In  a  series  of  67  such  cases  there  were  45  in  which  the 
mediastinal  alone  showred  caseation,  and  only  22  in  which  the 
mesenteric  alone  were  affected. 

Apart  from  thoir  obvious  bearing  upon  the  question  as  to  the 
most  frequent  channel  of  infection,  these  figures  have  a  practical 
value  in  emphasizing  the  necessity  for  including  in  the  routine 
examination  of  the  chest  in  children  the  examination  for  signs 
of  enlarged  mediastinal  glands.  I  shall  refer  to  the  clinical 
aspect  of  tuberculosis  of  the  mesenteric  glands  in  a  subsequent 
chapter,  here  I  shall  consider  only  the  diagnosis  of  the  mediastinal 
affection. 

Diagnosis  of  tuberculous  mediastinal  glands.  Is  it  possible  to 
recognize  the  presence  of  enlarged  glands  in  the  mediastinum  ? 
I  think  that  from  certain  symptoms  and  signs  it  is  sometimes 
possible  to  diagnose  this  affection  with  at  least  a  high  degree  of 
probability. 

The  symptoms  which  may  point  to  it  are  those  common  to 
tuberculosis  in  other  parts  of  the  body,  an  ailing  condition  with 
loss  of  flesh,  and  some  irregularity  of  temperature.  There  are  also 
certain  characteristic  symptoms  which  if  present  are  of  much 
value  in  diagnosis,  but  they  are  frequently  lacking ;  one  is  a 
curious  clanging  cough  somewhat  paroxysmal  in  character,  so 
that  whilst  partaking  to  some  degree  of  the  brassy  character  of 
the  cough  produced  in  an  adult  by  aortic  aneurism,  it  is  easily 
mistaken  for  whooping-cough,  as  has  sometimes  happened  in 
my  own  experience.  Another  is  inspiratory  stridor  due  pro- 
bably to  pressure  upon  the  trachea  ;  I  have  elsewhere  quoted 
instances  of  this  (p.  338). 

As  a  rule  the  diagnosis  has  to  be  made  from  physical  signs 
which  are  sometimes  sufficiently  characteristic. 

1.  Impairment   of   note  in   the   first   and   second   intercostal 
spaces  close  to  the  sternum :   this  is  of  more  value  if  it  occur 
on  the  right  side,  for  if  it  be  only  on  the  left  it  may  be  normal 
as  there  is  often  quite  a  finger's  breadth  of  impaired  note  adjoin- 
ing the  sternum  in  the  first  left  space  and  still  more  in  the  second, 
presumably  due  to  the  large  vessels  passing  up  from  the  heart. 

2.  Enlargement  of  veins,  usually  most  noticeable  in  the  second 


406  COMMON  DISORDERS  OF  CHILDHOOD 

space  where  one  large  vein  is  seen  passing  inwards  from  just 
below  the  coracoid  process  to  the  inner  end  of  the  space  :  this 
sign  is  of  value  chiefly  when  it  is  limited  to  one  side  of  the  chest ; 
there  are  many  thin-skinned  children  in  whom  a  plexus  of  veins  is 
normally  visible  all  over  the  upper  part  of  the  chest,  no  impor- 
tance can  be  attached  to  this. 

3.  A  bruit  heard  just  below  the  inner  end  of  the  clavicle  on 
extending  the  head  as  fully  as  possible  with  the  child  in  the 
sitting   or   standing  position.      The   late   Dr.    Eus'ace    Smith,1 
who  firs:  described  this  sign,  regarded  the  sound  as  a  venous 
hum,  produced    by  the    bending    back    of    the    head    tilting 
forward  the  lower  end  of  the  trachea  with  its  adjoining  glands, 
which   are   thus   made   to   compress   the   left   innominate    vein. 
I  have  examined  a  large  number  of  children  for  this  sign,  and 
have  often  found  it  in  cases  where  there  was  other  evidence  of 
enlarged   tuberculous  glands   in   the   mediastinum,  and  I  think 
that  taken  in  conjunction  with  the  other  signs  and  symptoms 
it  is  of  real  value  in  the  diagnosis  of  this  condition  ;    but  it  is 
certainly    not    always    present    where    there    are    undoubtedly 
enlarged  and  even  greatly  enlarged  mediastinal  glands.     I  have 
often  heard  it  also  where  there  was  considerable  anaemia  and 
perl  laps  a  bruit  de  diable  in  the  neck  without  anything  to  suggest 
tuberculosis  or  enlargement  of  mediastinal  glands. 

4.  A  marked  deficiency   of  air-entry  into   some  part   of  the 
lung.     This  is  particularly  characteristic  if  it  involves  a  whole 
lobe.     It  is  thought  to  indicate  pressure  upon  one  of  the  bronchi. 

5.  Dullness  about  the  root  of  the  lung  in  the  interscapular 
space.      This    cannot    be    due    directly    to    mediastinal    glands, 
but  points  to  consolidation  of  the  lung  near  its  root  which  is 
particularly  likely  to  happen  when  the  glands  which  lie  in  contact 
with  the  earliest  divisions  of  the  bronchi  are  enlarged,  as  they 
usually  are  where  those  in  the  mediastinum  are  affected. 

6.  Increased  resistance   on  pressure   over   the   manubrium  is 
sometimes    noticeable    where    there    is    much    enlargement    of 
mediastinal  glands.     This  can  be  appreciated  by  steadying  the 
child  by  one  hand  placed  behind  against  his  upper  dorsal  spine 
while  the  fingers  of  the  other  hand  make  an  intermittent  pressure 
upon  the  manubrium.     In  the  healthy  child,  especially  in  the 
earlier  half  of  childhood,  there  is  a  well-marked  normal  resilience, 
and   with   sufficient   tactus   eruditus   one   can   detect   a   distinct 
diminution  or  loss  of  this  resilience  in  some  cases  of  enlarged 
mediastinal  glands. 

1  Lancet,  August  14,  1875. 


TUBERCULOSIS 


407 


7.  Rarely  the  upper  rounded  edge  of  one  of  the  enlarged 
glands  can  be  felt  by  pressing  the  finger  downward  behind  the 
top  of  the  manubrium. 

There  are  cases  in  which  the  enlarged  glands  can  be  demon- 
strated by  the  X-rays,  but  often  the  findings  are  of  doubtful 
significance  for  an  opacity  about  the  root  of  the  lung  might 
equally  well  indicate  some  caseation  in  the  lung  itself,  moreover, 


FIG.  25.     Skiagram  of  child's  chest  showing  opacity  at  root  of  lung  on 
both  sides,  probably  due  to  caseation  of  mediastinal  glands. 

if  the  glands  are  but  slightly  caseous  they  are  not  likely  to 
show  at  all.  In  the  skiagram  reproduced  here,  taken  from 
a  child  about  seven  years  of  age,  the  opacity  about  the  root  of 
the  lung  is  probably  due  to  caseation  of  enlarged  glands  in  this 
position. 

I  have  described  these  indications  of  enlargement  of  medias- 
tinal glands  at  some  length  because  I  have  several  times  seen 
children  with  obscure  symptoms  such  as  prolonged  fever  and 
wasting  which  were  explained,  as  the  event  proved  correctly, 


408  COMMON  DISORDERS  OF  CHILDHOOD 

by  the  detection  of  signs  pointing  to  this  affection.  The  outlook 
is  not  necessarily  a  bad  one  ;  I  have  seen  cases  in  which  the 
subsequent  appearance  of  tuberculosis  in  some  other  part  of 
the  body  confirmed  the  diagnosis  which  had  been  made  pre- 
viously of  tuberculous  glands  in  the  mediastinum,  but  neverthe- 
less the  child  made  what  appeared  to  be  a  complete  recovery 
both  from  the  earlier  and  from  the  later  tuberculous  affection. 

On  the  other  hand,  I  have  seen  the  condition  declare  itself 
by  pointing  of  the  softened  glands.  In  one  girl,  aged  9J  years, 
who  had  been  wasting  for  two  months,  no  physical  signs  had 
been  detected,  but  a  fluctuating  tumour  appeared  in  the  second 
right  space  close  to  the  sternum  ;  my  colleague,  Mr.  Burghard, 
incised  and  evacuated  what  was  evidently  the  remains  of  a 
softened  caseous  gland  which  had  tracked  outwards  from  the 
mediastinum.  In  another  child  an  area  of  softening  appeared 
in  the  middle  of  the  sternum  and  a  caseous  mediastinal  gland 
discharged  itself  through  the  bone. 

Dr.  Voelcker1  and  others  have  recorded  cases  in  which  perfora- 
tion of  a  bronchus  resulted  in  sudden  death  from  asphyxia,  a  part 
of  the  caseous  gland  becoming  lodged  in  the  glottis.  In  doing 
autopsies  at  the  Children's  Hospital  I  have  seen  at  least  four 
cases  in  which  a  gland  ulcerated  into  the  oesophagus,  but  in 
none  of  them  did  this  accident  produce  any  clinical  symptoms. 

It  is  not  only  by  their  local  effects  that  tuberculous  glands  in 
the  thorax  or  abdomen  of  a  child  are  fraught  with  danger  ; 
their  presence  involves  continual  risk  of  an  even  more  serious 
blood-infection.  One  of  the  commonest  endings — and  perhaps 
the  most  distressing — in  the  tuberculosis  of  childhood  is  tuber- 
culous meningitis.  In  238  .children  who  died  with  tuberculosis 
I  found  tubercle  of  the  meninges  in  114  cases — that  is,  in  48-3  per 
cent.,  and  it  was  the  immediate  cause  of  death  in  most  of  these 
cases. 

One  sometimes  hears  of  a  '  primary  tuberculous  meningitis  ', 
but  I  have  never  yet  seen  a  case  in  a  child  where  careful  post 
mortem  examination  failed  to  reveal  some  tuberculous  focus 
elsewhere  which  was  evidently  of  older  standing  than  the  menin- 
gitis ;  and  often,  when  the  rest  of  the  body  seems  to  be  free 
from  tuberculosis,  the  mediastinal  or  mesenteric  glands  show 
some  focus  of  caseation — and  I  fancy  that  an  actually  softened 
area  is  more  mischievous  in  this  respect  than  firm  caseation— 
which  has  probably  been  the  fons  et  origo  of  the  meningeal 
infection. 

1  Practitioner,  June,  1895. 


TUBERCULOSIS  409 

Pulmonary  Tuberculosis.  The  frequency  of  caseation  of  the 
mediastinal  glands  is  to  some  extent  the  cause  of  the  differences 
between  the  pulmonary  tuberculosis  of  children  and  the  phthisis 
of  adults — I  use  these  terms  advisedly  as  accentuating  the  fact 
that  such  differences  exist. 

The  lung  affection  in  childhood  tends  to  be  not  only  a  more 
acute  process,  but  also  more  diffuse  than  in  the  adult.  The 
slowly  progressing  form  of  phthisis  which  is  so  familiar  in  the 
adult,  and  which  for  a  long  time  may  remain  limited  to  its 
starting-point  just  below  the  apex  of  the  lung,  with  cavities 
lined  perhaps  by  a  well-defined  wall  and  traversed  by  trabeculse 
of  fibrous  tissue  or  blood-vessels,  is  quite  unusual  in  childhood. 
It  is  common  in  children  to  find  the .  tuberculous  infection 
spreading  in  from  the  root  of  the  lung  apparently  directly  from 
the  caseous  bronchial  glands,  and  starting  thus  it  tends  to 
affect  the  lower  part  of  the  lung  almost  as  much  as  the  upper. 
Moreover,  it  is  not  a  very  rare  occurrence  in  children  for  one  of 
the  caseous  mediastinal  glands  to  perforate  a  bronchus,  and 
if  this  perforation  occur  beyond  the  first  division  of  the  bronchus 
the  caseous  debris  of  the  gland  may  be  discharged  into  one  lobe 
only  of  the  lung  and  set  up  an  acute  tuberculous  process,  some- 
times with  rapid  cavitation  throughout  the  whole  of  that  lobe, 
while  the  rest  of  the  lung  is  only  slightly  affected. 

The  limitation  of  signs  of  active  tuberculosis  to  one  lobe 
when  there  are  signs  of  enlarged  mediastinal  glands  is  highly 
suggestive  of  ulceration  of  a  caseous  gland  into  a  bronchus  ; 
and  the  more  so  if  the  signs  be  on  the  right  side. 

In  260  tuberculous  children  under  twelve  years  of  age,  in 
whom  the  chest  was  examined  post  mortem,  I  found  perfora- 
tion of  a  bronchus  by  one  of  the  caseous  mediastinal  glands 
in  23  cases.  This  occurs  much  more  frequently  on  the  right 
side  than  on  the  left;  in  21  out  of  these  23  cases  the  perforation 
had  occurred  into  the  right  bronchus. 

But  without  actual  perforation  the  bronchus  may  be  infected 
by  direct  extension  from  an  adjacent  gland,  and  I  have  often 
found  the  mucous  membrane  of  the  bronchus  in  such  cases 
studded  with  grey  or  greyish -yellow  tubercle,  or  already  showing 
superficial  ulceration,  a  source,  no  doubt,  for  extensive  infection 
of  the  lung.  Nor  is  it  only  the  root  of  the  lung  which  may  be 
infected  thus  ;  there  is  a  lymphatic  gland  lying  in  contact  with 
the  right  side  of  the  trachea  just  above  the  bifurcation,  which 
is  very  frequently  found  to  be  caseous.  From  this  gland  the 
caseous  process  sometimes  spreads  directly  to  the  adjacent 
pleura,  and,  after  formation  of  local  adhesions,  spreads  into  the 
right  lung  from  without  inwards,  just  below  its  apex. 


410  COMMON  DISORDERS  OF  CHILDHOOD 

As  I  have  already  said,  it  seems  probable  that  in  the  vast 
majority  of  cases  these  glands  are  primarily  infected  through 
the  lung  with  or  without  the  formation  of  an  actual  focus  ot 
tuberculous  disease  in  the  lung,  but  when  once  the  glands  are 
infected  a  vicious  circle  is  formed,  and  perhaps  to  some  extent 
the  wide  dissemination  of  tubercle  in  the  lung  of  a  child  is  due 


Fir,.  2l>.  Common  type  of  pulmonary  tuberculosis  in  an  infant.  Caseous 
mediastinal  glands  ;  .perforation  of  right  bronchus  (the  opening  is  indicated  by 
the  line  line  A)  ;  caseation  and  cavitation  of  right  upper  lobe.  The  specimen 
shows  also  the  enlarged  and  caseous  right  trachea!  gland  between  the  trachea 
and  the  right  upper  lobe,  and  the  greatly  enlarged  caseous  bifurcation  gland 
between  the  two  bronchi,  and  a  large  caseous  root  gland  imbedded  in  the  root 
of  the  right  lung.  The  left  lung  is  very  little  affected  by  tubercle.  From  an  infant 
aged  nine  months. 

to  the  fact  that  not  only  is  there  the  primary  infection  by 
inhalation,  as  in  the  adult,  but  also  this  re-infection  from  the 
mediastinal  glands. 

Apart  from  this  glandular  infection,  the  early  deposit  of  tubercle 
in  the  lung  of  a  child  shows  the  same  tendency  as  in  the  adult 
to  occur  just  below  the  apices  of  the  upper  and  lower  lobes, 
but  it  tends  to  run  a  more  rapid  course.  The  deposits  of  tubercle 


TUBERCULOSIS 


411 


occur  as  a  few  scattered  grey  tubercles  which  in  parts  are  grouped 
together  in  racemose  fashion  and  in  parts  have  advanced  to 
a  stage  of  caseation  forming  irregular  yellowish  solid  areas, 
in  fact  a  caseous  broncho-pneumonia. 

Cavitation  occurs  by  no  means  rarely — I  found  cavities  in 
60  out  of  212  children  with  pulmonary  tuberculosis — but  it  is  an 


Fio.  27.     Pulmonary  tuberculosis  in  a  child.     Unusual  type,  with  chronic 
cavitation  resembling  the  phthisis  of  adults. 

acute  cavitation,  the  rapid  softening  of  a  caseous  area,  and 
anything  like  the  fibrosis  which  attempts  repair  in  the  adult  is 
completely  lacking,  as  a  rule,  in  the  child .  These  di  fferent  varieties 
of  cavitation  in  a  child's  lung  are  seen  in  Figs.  26  and  27. 

Occasionally  the  caseation  is  diffuse  and  involves  a  large  part 
of  one  lobe,  which  is  thus  converted  into  a  cheesy  mass  with 


412          COMMON  DISORDERS  OF  CHILDHOOD 

little  trace  of  lung-tissue  remaining.  Such  a  condition  is  shown 
in  the  accompanying  illustration  (Fig.  28),  from  a  child  aged 
eighteen  months.  The  clinical  signs  of  this  form  are  sometimes 
most  misleading,  for  the  breath  sounds  may  be  almost  entirely 
abolished  over  the  affected  lobe,  and  the  absolute  dullness  and 
very  marked  resistance  on  percussion  complete  the  likeness  to 


FIG.  28.     Pulmonary  tuberculosis  :  diffuse  caseous  consolidation  in  a  child 
aged  eighteen  months  ;  lower  lobe  almost  completely  caseous. 

pleural  effusion.  I  have  known  exploration  both  by  needle  and 
by  incision  done  in  such  a  case,  where  the  signs  had  exactly 
simulated  those  of  empyema. 

A  variety  of  pulmonary  tubercle  which  is  less  common  than 
those  I  have  mentioned  is  the  general  miliary  tuberculosis 
which  forms  part  of  a  similar  acute  miliary  affection  of  almost 
all  the  organs.  As  is  shown  by  the  photograph  reproduced 


TUBERCULOSIS 


413 


here  (Fig.  29)  the  lung  is  uniformly  and  closely  studded  with 
grey  or  greyish-yellow  tubercles  ;  and  one  might  expect  from 
its  appearance  that  the  signs  would  be  characteristic  enough  to 
make  diagnosis  easy ;  as  a  matter  of  fact,  the  signs  are  usually 
only  those  of  bronchitis,  numerous  rales  all  over  the  chest  which 
as  the  disease  advances  often  become  somewhat  sharp  and  crack- 
ling in  character,  but  even  in  the  most  advanced  stage  of  the 


FIG.  29.    Acute  miliary  tuberculosis  of  the  lung  in  a  child. 

disease  there  is  usually  no  dullness  or  bronchial  breathing.  The 
diagnosis  rests  rather  on  the  associated  symptoms  than  on  the 
physical  signs  ;  the  child  is  acutely  ill,  with  dusky  face  and 
purple  lips,  the  respiration  is  hurried,  the  spleen  is  enlarged  and 
extends  usually  two  or  three  finger-breadths  below  the  costal 
margin,  the  temperature  is  continuously  elevated  like  that  of 
a  patient  with  typhoid  and,  lastly,  the  diagnosis  can  usually  be 
made  certain  in  these  cases  by  examining  the  fundus  oculi. 


414  COMMON  DISORDERS  OF  CHILDHOOD 

Tubercle  of  the  choroid,  which  is  rare  enough  in  other  forms  of 
tubercle,  is  present  in  a  large  majority  of  the  children  with 
general  acute  miliary  tuberculosis. 

In  accordance  with  the  tendency  of  tuberculosis  in  the  child 
to  generalization,  pulmonary  tuberculosis  at  this  age  is  so  often 
part  of  a  more  general  infection  that  the  outlook  in  any  case  is 
necessarily  very  grave.  In  the  acute  miliary  form  there  is  no 
hope  of  recovery,  the  fatal  termination  is  usually  within  six  to 
eight  weeks  after  the  onset ;  but  in  the  other  forms  with  localized 
signs  the  outlook  is  by  no  means  hopeless.  It  is  encouraging  to 
find  evidence  in  the  post  mortem  examination  of  children  who 
have  died  from  other  diseases,  that  even  in  quite  early  life 
complete  healing  of  a  tuberculous  lesion  may  occur  in  the  lung  as 
well  as  in  the  mediastinal  glands.  Of  course  the  earlier  the  condition 
is  recognized  and  treated  the  better  is  the  chance  of  recovery. 

Diagnosis  of  pulmonary  tubercle.  The  diagnosis  of  pulmonary 
tubercle  in  the  child  is  often  a  matter  of  considerable  difficulty : 
a  bronchitis  or  a  pneumonia  which  runs  a  prolonged  course,  as 
happens  so  often  after  measles  or  during  whooping-cough,  raises 
suspicions  of  tuberculosis  which  may  or  may  not  be  correct, 
there  are  crackling  rales  and  high-pitched  breath  sounds  in 
patches,  perhaps  definite  impairment  of  note  and  bronchial 
breathing  at  some  part  of  the  lung,  but  the  child  gradually 
recovers,  and  the  diagnosis  remains  uncertain. 

There  are  two  symptoms  upon  which  an  emphasis  is  often  laid 
which  might  be  quite  justified  in  the  case  of  an  adult,  but  has 
little  justification  with  reference  to  children,  namely  sweating 
and  haemoptysis.  Children  sweat  very  easily,  especially  when 
the  health  is  depressed  :  rickets,  debility  after  any  acute  illness, 
anaemia  from  any  cause,  may  be  ample  explanation  of  profuse 
sweating  at  night ;  the  presence  of  night  sweats  is,  I  think,  of  no 
value  whatever  in  the  diagnosis  of  tubercle  in  children. 

Haemoptysis  is  very  rarely  due  to  pulmonary  tuberculosis  in 
children,  it  usually  means  whooping-cough  or  is  due  to  pul- 
monary congestion  with  advanced  heart  disease,  unless,  as 
sometimes  happens,  it  is  a  spurious  haemoptysis  due  to  bleeding 
from  the  posterior  nares  or  from  the  gums.  Very  rarely  does 
a  child  with  pulmonary  tubercle  cough  up  any  blood;  and 
a  fatal  haemoptysis  from  this  cause  is  an  extreme  rarity  in  child- 
hood :  amongst  the  many  hundreds  of  children  with  pulmonary 
tuberculosis  who  have  been  under  my  observation  I  have  only 
twice  known  death  to  occur  from  haemoptysis ;  once  in  a  child 
about  three  years  of  age  and  once  at  the  age  of  eleven  months. 


TUBERCULOSIS  415 

Until  recently  the  bacteriological  examination  of  the  sputum 
has  generally  been  regarded  as  impracticable  in  children  under 
three  years  of  age,  for  they  swallow  their  expectoration,  and 
even  older  children  usually  do  this  unless  instructed  to  do  other- 
wise ;  but  Dr.  Emmett  Holt 1  has  shown  that  it  is  possible  to 
obtain  sputum  and  to  verify  the  diagnosis  by  its  bacteriological 
examination  even  in  infants.  He  recommends  exciting  a  cough 
by  irritating  the  pharynx  by  a  small  bit  of  muslin  held  in  an 
artery  clamp,  the  secretion  is  coughed  up  into  the  pharynx  and 
caught  on  the  muslin  ;  in  this  way  tubercle  bacilli  were  detected 
in  the  sputum  in  80  per  cent,  of  cases  examined  at  the  Babies' 
Hospital,  New  York,  where  most  of  the  cases  were  under  two 
years  of  age. 

There  is  one  condition  which  must  be  mentioned  here  as 
sometimes  mistaken  for  pulmonary  tuberculosis  in  children, 
namely,  fibroid  lung.  Impairment  of  note  with  tubular  or 
perhaps  cavernous  breathing,  sharp  crackling  rales,  bronchophony 
and  pectoriloquy  are  found  over  a  limited  area,  most  frequently, 
I  think,  at  the  left  base,  just  below  the  angle  of  the  scapula. 
The  rest  of  the  lung  shows  nothing,  but  perhaps,  as  is  common 
in  these  cases,  there  are  a  few  crepitations  to  be  heard  near  the 
base  or  the  root  of  the  other  lung.  So  far  the  signs  would 
accord  well  enough  with  tubercular  consolidation  and  cavita- 
tion,  but  on  further  examination  it  is  found  that  the  heart 
is  displaced  towards  the  affected  side,  and  careful  inspection 
detects  some  slight  flattening  or  contraction  of  the  lower  part 
of  the  chest  on  that  side  ;  and  the  child's  fingers  just  above 
the  nails  are  found  to  be  full,  shiny  and  pigmented  if  there 
be  not  definite  clubbing.  On  inquiry  also  the  mother  states 
that  the  child  expectorates  a  considerable  quantity  of  muco- 
purulent  sputum,  especially  on  awaking  in  the  morning,  and 
perhaps  that  the  breath  and  the  sputum  smell  very  offensive 
at  times.  The  signs  and  symptoms  are  in  fact  those  of  fibroid 
lung  with  bronchiectasis.  In  an  adult  such  a  condition  might 
be  due  to  chronic  tuberculous  affection  of  the  lung,  but  in  a 
child — conformably  with  the  tendency  to  rapid  caseation  which 
I  have  already  mentioned — an  extensive  fibrosis,  such  as  is 
indicated  by  these  signs,  is  very  rarely  due  to  tubercle ;  it  is  the 
result  usually  of  a  simple  broncho-pneumonia  of  prolonged 
duration  at  some  former  time,  especially  that  due  to  whooping- 
cough,  or  of  a  former  pleurisy  with  much  lymph  exudation, 
or  of  a  small  empyema  which  has  been  left  unopened  and  has 
1  Kelynack's  Tuberculosis  in  Infancy  and  Childhood,  p.  99. 


416  COMMON  DISORDERS  OF  CHILDHOOD 

gradually    dried   up.     Occasionally   it   seems    to    be   due   to  a 
chronic  syphilitic  pneumonia. 

Tuberculosis  is  so  rare  as  a  cause  of  fibroid  lung  in  children, 
that  such  signs  as  those  I  have  described  would  be  almost 
enough  to  disprove  the  presence  of  tubercle  ;  but  the  sputum 
is  generally  easily  available  in  these  cases,  so  that  more  positive 
evidence  can  be  obtained. 

Lastlv,  I  must  mention  the  most  recent  methods  of  diagnosis 
by  the  tuberculin  reaction.  These  are  Calmette's  ophthalmic 
reaction  (instillation  of  1  drop  of  a  £  or  1  per  cent,  solution  of 
tuberculin  into  the  eye,  which  in  tuberculous  subjects  should 
show  within  twenty-four  hours  a  definite  congestion  of  the  con- 
junctiva), Von  Pirquet' s  cutaneous  reaction,  and  the  Moro 
cutaneous  reaction  ;  the  opsonic  index  must  also  be  mentioned, 
though,  owing  to  the  elaborate  technique  and  special  experience 
required,  it  is  seldom  available  in  the  ordinary  routine  of  general 
practice. 

As  to  the  ophthalmic  test  there  is  no  doubt  that  in  the  healthy 
eye  it  may  set  up  a  severe  conjunctivitis;  and  I  have  seen  children 
in  whom  two  or  three  weeks  after  it  had  been  applied  a  fresh 
conjunctivitis  appeared  in  the  eye  which  had  been  tested  ;  this 
in  itself  is  not  a  trifling  matter,  but  it  might  be  outweighed  by 
the  value  of  the  test  if  this  were  found  to  be  specially  reliable. 

It  is,  however,  now  quite  clear  that  its  reliability  is  no  greater  than 
that  of  the  other  tuberculin  tests,  and  the  risk  of  causing  serious 
mischief  in  the  eye  is  a  very  real  one,  as  experience  has  proved ; 
the  method  has  already  fallen  into  well-deserved  disrepute. 

The  choice,  therefore,  lies  between  the  Von  Pirquet  and  the 
Moro  reactions,  and,  so  far  as  my  own  experience  goes,  the 
Von  Pirquet  would  appear  to  be  the  more  reliable. 

The  Moro  reaction  is  obtained  by  gently  rubbing  into  a  small 
area  of  .skin  (usually  a  patch  about  two  inches  square  in  the  epi- 
gastric region)  a  specially  prepared  ointment,  containing  tuber- 
culin ;  after  about  twenty-four  hours  this  area  shows  reddening, 
often  with  some  eruption  of  small  papules  if  tuberculosis  be 
present,  whereas  if  this  be  absent  the  skin  remains  normal. 

For  the  Von  Pirquet  reaction  a  fluid  preparation  of  tuber- 
culin is  inoculated  in  exactly  the  same  manner  as  an  ordinary 
vaccination,  except  that  only  one  site,  usually  about  the  size  of 
a  threepenny  piece,  is  inoculated  ;  after  twenty-four  to  thirty- 
six  hours  this  area  becomes  reddened  and  slightly  raised  if 
tubercle  be  present,  whereas  a  control  area  scratched  similarly 
without  application  of  the  tuberculin  shows  no  such  reddening. 


TUBERCULOSIS  417 

The  chief  fault  of  these  reactions  is  their  extreme  delicacy, 
they  are  too  successful,  if  one  may  say  so  ;  they  detect  the 
smallest  trace  of  tubercle,  which  may  be  entirely  latent,  and  may 
have  nothing  whatever  to  do  with  the  symptoms  from  which 
the  child  is  suffering.  A  large  proportion  of  children  past  the 
age  of  infancy  have  at  some  period  become  infected  with  tubercle, 
even  if  it  be  only  in  a  single  lymphatic  gland  in  the  neck  or  the 
mesentery  or  elsewhere,  and  the  likelihood  of  such  latent  tubercle 
is  greater  the  older  the  child  ;  consequently  these  tuberculin 
tests  are  likely  to  give  a  positive  result  in  many  children  who 
show  no  clinical  symptoms  whatever,  and  may  never  show  any, 
of  tuberculous  disease  :  but  in  addition  to  this  positive  fallacy 
there  is  a  negative  failure  also  of  these  tests,  for  the  reaction 
often  does  not  appear  when  the  tuberculosis  is  of  acute  form  or 
is  widely  diffused  and  much  advanced.  The  child  with  tuber- 
culous meningitis,  for  instance,  may  give  a  negative  result  with 
the  tuberculin  test,  so  also  the  child  with  acute  miliary  tuber- 
culosis. Nevertheless  in  infancy  and  early  childhood;  perhaps  up 
to  the  age  of  three  or  four  years,  these  tests  have  some  value,  and 
even  in  later  childhood  a  negative  result  in  some  conditions  may 
carry  weight  in  determining  whether  particular  symptoms  are 
due  to  tubercular  disease.  How  little  value  is  to  be  attached  to 
a  positive  result  in  these  older  children  is  shown  by  the  fact  that 
various  observers  have  found  evidence  of  tubercle  by  this  test  in 
50  to  65  per  cent,  of  all  children  between  the  ages  of  five  and 
fourteen,  although  a  large  proportion  of  them  showed  no  symp- 
toms whatever  to  suggest  tuberculosis. 

Lastly,  the  opsonic  index,  as  I  have  already  mentioned,  is 
but  seldom  available,  and  even  when  it  can  be  obtained,  its 
practical  value  for  diagnosis  is,  I  think,  less  than  that  of  the 
tests  already  mentioned.  It  is  difficult  to  arrive  at  any  certainty 
in  the  interpretation  of  its  variations.  General  rules  can  easily 
be  laid  down,  but  in  the  individual  case  so  much  doubt  attaches 
to  the  significance  of  the  unduly  high  or  unduly  low  or  much 
varying  index,  which  may  possibly  indicate  tuberculosis,  that 
one  is  hardly  justified  in  attaching  much  weight  to  it. 

Treatment 

My  remarks  upon  the  treatment  of  tuberculosis  in  children 
will  be  rather  of  general  application  than  with  reference  to  any 
particular  form  of  the  disease. 

Prevention  is  better  than  cure  :    there  is  no  period  of  life  at 

STILL  E  6 


418  COMMON  DISORDERS  OF  CHILDHOOD 

which  the  liability  to  tuberculosis  is  greater  than  during  child- 
hood, especially  during  the  first  five  years  of  life  :  for  this  reason 
prophylaxis  is  specially  needful  during  this  period  and  particu- 
larly in  the  case  of  the  child  who  comes  of  tuberculous  stock. 
The  two  chief  sources  of  infection  are  the  breathing  of  infected 
air  and  the  drinking  of  infected  cow's  milk. 

In  order  to  avoid  the  risk  of  aerial  infection  it  is  most  important 
that  a  child  should  not  bo  allowed  to  associate  with  persons  who 
have  active  tuberculous  lesions  in  any  part  of  the  body. 

Tuberculous  disease  in  one  part  indicates  a  tendency  to 
tuberculosis  which  may  be  active  although  latent  in  other  parts ; 
the  person  with  tuberculous  bone  disease  or  with  tuberculous 
glands  in  the  neck  may  be  a  source  of  danger  through  incipient 
and  unsuspected  disease  in  the  lung.  In  the  choice  of  domestic 
nurses  and  of  the  child's  companions  this  is  specially  to  be 
borne  in  mind.  I  have  seen  cases  in  which  it  seemed  clear  that 
a  child's  life  was  sacrificed  by  allowing  him  to  stay  even  for  a  few 
weeks  in  a  house  where  there  was  some  person  with  phthisis. 

No  doubt  the  risk  of  such  infection  is  diminished  by  thorough 
ventilation  in  the  house  and  by  keeping  the  child  out  in  the 
open  air  as  much  as  possible  ;  but  whenever  it  is  practicable 
a  child  should  be  kept  altogether  from  association  with  tuber- 
culous persons,  whether  they  be  children  or  adults. 

The  risk  of  infection  from  cow's  milk  is  a  very  real  one;  my 
own  figures  show  that  rare  though  alimentary  infection  may  be 
in  comparison  with  respiratory,  it  probably  accounts  for  nearly 
one-third  of  the  fatal  cases  of  tuberculosis  in  childhood  ;  and 
it  can  hardly  be  doubted  that  the  source  of  the  bacillus  in  these 
cases  is  cow's  milk. 

Sonic  years  ago  I  was  opposed  in  general  to  the  boiling  of  milk 
for  children  :  with  larger  experience  I  have  adopted  different 
views;  I  have  seen  so  many  cases  in  which  there  was  good  reason 
to  suppose  that  unboiled  cow's  milk  was  the  source  of  infection, 
that  1  regard  it  as  always  advisable  to  pasteurize  or  boil  cow's 
milk  for  children  during  the  most  susceptible  period,  the  first 
five  years,  and  longer  if  the  child  has  shown  evidence  of  tuber- 
culous tendencies,  for  instance,  tuberculous  glands  in  the  neck, 
or  lias  a  strong  family  history  of  tuberculosis. 

There  can  be  little  doubt  that  properly  regulated  inspection 
of  cows  and  cowsheds  would  do  much  to  abolish  milk  infection 
altogether ;  until  this  ideal  is  attained  safety  can  be  ensured  only 
by  the  pasteurization  of  milk  or  by  heating  it  nearly  or  quite 
to  the  boiling-point. 


TUBERCULOSIS  419 

*  But,'  says  the  parent,  '  we  have  our  own  cows,  and  they  are 
specially  tested  with  tuberculin  ;  surely  there  is  no  need  to 
pasteurize  or  •  boil  the  milk.'  Even  under  such  conditions 
I  would  not  relax  this  precaution,  for  the  test  is  usually  applied 
only  at  intervals  of  some  months,  and  in  the  cow,  as  in  man, 
tuberculosis  is  sometimes  a  rapid  process ;  the  tuberculin  test 
is  no  guarantee  whatever  that  the  cow  may  not  develop  the 
disease  before  the  next  testing.  No  doubt  affection  of  the 
udder,  which  is  most  likely  to  be  associated  with  tuberculous 
milk,  does  not  occur  as  a  rule  until  the  disease  in  other  parts 
of  the  body  is  somewhat  advanced,  but  there  is  ample  evidence 
that  milk  may  be  infected  where  there  is  only  disease  in  other 
parts.  The  conclusion  of  the  whole  matter  is,  I  think,  that 
under  any  circumstances  cow's  milk  should  be  pasteurized 
or  boiled  for  children  at  least  up  to  the  age  of  five  years,  and 
that  this  practice  is  a  wise  precaution  for  any  period  of  child- 
hood. 

If  for  any  reason  there  is  difficulty  in  giving  cows'  milk  which 
has  undergone  boiling  or  pasteurization — and  there  are  children 
who  will  not  drink  milk  when  it  has  been  treated  in  this  way — 
goats'  milk  makes  an  excellent  substitute;  it  can  be  given 
unboiled  with  exceedingly  little  risk  so  far  as  tubercle  is  con- 
cerned, for  tuberculosis  is  extremely  rare  in  goats. 

The  special  liability  of  children  to  tuberculous  affection  of 
lymphatic  glands  has  a  practical  bearing  upon  the  prophylaxis 
of  tubercle  at  this  age.  A  swollen  lymphatic  gland,  whatever 
be  the  cause  of  the  swelling,  seems  to  furnish  a  nidus  in  which 
tubercle  bacilli  thrive  ;  an  unhealthy  condition  of  the  throat 
with  enlarged  tonsils  and  adenoid  hypertrophy  is  therefore 
a  danger  to  the  child  with  tuberculous  tendencies,  for  the  result- 
ing enlargement  of  glands  at  the  angle  of  the  jaw  makes  them 
specially  liable  to  tuberculous  invasion. 

So  too  with  carious  teeth,  particular  attention  should  be  paid 
to  the  teeth  of  children  who  come  of  tuberculous  family  or  have 
already  shown  manifestations  of  tubercle  themselves,  for  whether 
the  bacillus  enters  through  the  unhealthy  dental  alveolus  or  not, 
the  simple  enlargement  of  glands  due  to  an  unhealthy  condition 
of  the  teeth  and  gums  probably  predisposes  to  tuberculous  disease 
in  these  glands  and  from  them  it  may  spread  elsewhere. 

I  have  referred  above  to  the  frequency  with  which  tuberculosis 
follows  measles  and  whooping-cough,  and  one  can  only  deplore 
the  reckless  way  in  which  children  with  either  of  these  diseases 
are  allowed  to  scatter  infection  broadcast.  There  seems  to  be 

Ee2 


420  COMMON  DISORDERS  OF  CHILDHOOD 

a  current  idea  that,  in  comparison  with  other  specific  fevers, 
these  are  of  little  consequence  ;  but  I  fancy  that  if  it  were 
possible  to  add  on  to  the  direct  mortality  of  these  two  diseases 
the  large  number  of  deaths  from  tuberculosis  which  are  indirectly 
due  to  measles  or  whooping-cough,  we  should  realize  more 
fully  the  danger  of  such  infection.  Certainly  for  children  who 
are  predisposed  to  tuberculosis  by  heredity,  no  unimportant  part 
of  the  prophylaxis  against  tuberculous  disease  is  the  guarding 
against  exposure  to  the  infection  of  measles  or  whooping-cough  ; 
and  probably  much  may  be  done  to  avert  the  onset  of  tuber- 
culosis after  an  attack  of  measles  or  whooping-cough  by  sending 
the  child  away  for  a  time  into  the  pure  air  of  country  or  seaside. 

The  choice  of  climate  for  the  child  with  tuberculous  tendencies, 
or  declared  tuberculous  disease,  is  an  important  matter.  I  think 
it  may  be  said  generally  that  the  tuberculous  child  derives  more 
benefit  from  seaside  than  from  inland  places,  and  that  if  the  seaside 
is  not  available,  high  ground  with  a  sand  or  gravel  soil  is  much 
more  suitable  than  a  low-lying  place.  Children  stand  cold  winds 
badly,  a  bleak  spot  wind-swept  from  north  and  east  is  not 
a  suitable  place  for  the  tuberculous  child  however  high  and  dry 
it  may  be.  Whatever  be  the  place  chosen  it  must  possess  such 
a  climate  as  regards  sunshine,  temperature,  and  rainfall  that 
the  child  can  live  in  the  open  air  the  greater  part  of  the  day, 
and  this  qualification  is  quite  as  important  as  the  particular 
aspect  or  altitude  of  the  place. 

One  more  general  principle  is,  I  think,  worth  notice  before 
mentioning  particular  places,  namely,  that  many  children  seem 
to  do  better  with  a  change  of  climate  after  a  few  months  than 
if  kept  permanently  at  the  place  which  at  first  seemed  to  suit 
admirably. 

Amongst  seaside  places  the  east  coast  resorts,  Cromer, 
Slieringliam,  Felixstowe,  Southwold,  Frinton,  and  Hunstanton, 
are  all  excellent  in  the  heat  of  summer,  but  except  during 
this  hot  season  it  has  seemed  to  me  that  tuberculous  children 
do  better  in  places  where  cold  winds  are  less  prevalent  •  the 
Kent  coast  resorts,  Westgate,  Margate,  and  Broadstairs,  have 
;i  deservedly  high  reputation  for  tuberculous  diseases,  but  some- 
times as  early  as  the  end  of  October  and  usually,  I  think,  about 
the  end  of  December  or  January  these  places  are  too  cold  and 
biting.  Folkestone  and  St.  Leonards  may  be  more  suitable  for 
the  winter  months  if  the  winter  be  not  severe,  but  usually  it  is 
wiser  to  send  the  tuberculous  child  further  west  at  this  time  of 
the  year  ;  Torquay,  Bournemouth,  or  Sidmouth  will  be  suitable 


TUBERCULOSIS  421 

places.  For  those  who  are  unable  to  go  far  from  London, 
Westcliff  near  Southend  offers  a  climate  which  is  sunny  and 
warm  enough  to  allow  the  child  to  be  in  the  open  air  great  part 
of  the  day  even  in  winter. 

For  those  who  prefer  to  take  their  children  inland,  a  residence 
high  up  on  the  slopes  of  the  Cotswold  or  the  Chiltern  Hills  gives 
excellent  results.  Hindhead  or  Tunbridge  Wells  are  also  suit- 
able, and  in  summer  Crowborough  or  the  Surrey  Hills  are 
admirable  for  tuberculous  children.  I  have  referred  chiefly  to 
parts  of  the  suitability  of  which  I  have  personal  knowledge,  many 
other  places  will  occur  to  those  whose  experience  lies  elsewhere  : 
there  are  many  places  on  the  continent  which  have  the  reputation 
of  being  specially  valuable  for  tuberculous  children,  for  instance 
in  France,  Berck-sur-Mer,  which,  according  to  Dr.  Walter  Carr1, 
has  a  climate  resembling  that  of  Margate  or  Broadstairs,  or 
Arcachon,  which  is  said  to  have  a  climate  like  that  of  Bourne- 
mouth ;  while  for  the  winter  months  Cannes  in  the  French 
Riviera  and  Alassio  in  the  Italian,  are  specially  recommended 
for  tuberculous  children. 

Lastly,  I  must  refer  to  the  medicinal  treatment  which,  though 
far  less  important  than  the  climatic,  has  its  value.  There  is 
probably  no  drug  so  generally  useful  for  tuberculous  children 
as  cod- liver  oil,  but  I  think  it  is  often  given  in  too  large  doses  ; 
a  drachm  of  the  oil  is  more  than  some  children  can  tolerate  at 
six  or  seven  years  of  age  and  for  those  who  can  tolerate  it  I  doubt 
whether  there  is  any  advantage  from  giving  larger  doses.  Often 
I  think  a  combination  of  malt  extract  with  cod-liver  oil  is  better 
tolerated  than  the  plain  oil  or  the  ordinary  emulsion  of  cod-liver 
oil ;  and  for  the  child  who  is  sick  or  has  disturbance  of  digestion 
when  given  cod-liver  oil,  malt  extract  alone  or  in  combination 
with  iron  iodide  is  valuable. 

Both  for  the  pulmonary  and  for  the  abdominal  lesions  of 
tubercle,  creosote  has  seemed  to  me  to  be  of  value  ;  in  the 
former  case  it  can  be  given  by  inhalation,  5-10  drops  of  a  mix- 
ture of  equal  parts  of  creosote  and  spirits  of  chloroform  are 
dropped  on  the  sponge  of  a  Yeo's  inhaler  which  the  child  wears 
for  twenty  minutes  several  times  a  day.  Dr.  Lees  recommends 
for  this  purpose  a  formula  of  Acid  Carbol.  7)ii,  Creosote  7,ii,  Tinct. 
lodi  ^i,  Spirit.  ^Etheris  ~,i,  Spirit.  Chloroform  31! .  I  have  not 
found  it  practicable  with  children  to  carry  out  the  almost  con- 
tinuous inhalation  which  he  advises  for  adults,  bub  I  think  that 
even  the  interrupted  treatment  by  this  method,  amounting  to 
1  Practitioner,  July..  1908. 


422  COMMON  DISORDERS  OF  CHILDHOOD 

1J-3  hours  daily,  is  of  real  value.  For  tabes  mesenterica  and 
tuberculous  peritonitis  the  creosote  can  be  given  in  doses  of 
i-l  minim  in  1-2  drachms  of  cod-liver  oil  emulsion  or,  if  the 
bowels  are  loose,  in  an  emulsion  containing  5  minims  of  castor  oil. 

I  have  referred  elsewhere  to  the  value  of  iodoform  in  tuber- 
culous peritonitis. 

The  time  is  not  ripe  yet  to  speak  confidently  of  the  value  of 
tuberculin  in  the  treatment  of  tuberculosis  in  children  :  even  the 
dosage  is  at  present  undetermined,  some  observers  recommend 
doses  of  -g-y^oo  milligramme  or  less  for  an  infant  at  one  year, 
whilst  others  give  TT i^  at  the  same  age ;  Dr.  Clive  Riviere  1 
mentions  ..oiroo  milligramme  at  five  years,  and  ^ouw — TO  thro- 
at one  year.  Using  injections  of  the  new  tuberculin  T.  R.,  I  have 
usually,  in  the  case  of  a  child  of  three  years  or  older,  begun  with 
Touud  milligramme,  and  after  two  or  three  injections  at  inter- 
vals of  five  days,  increased  the  dose  to  about  y^ou*  and  after 
a  similar  interval  to  ^oo  an^  then  to  ^Vo",  anc^  in  some  cases 
to  -j-Jy-y-  milligramme  ;  and  when  using  tuberculin  by  the  mouth 
as  suggested  by  Dr.  Latham,2  I  have  given  S^G-^  milligramme 
in  five  cubic  centimetres  of  horse  serum,  or  in  half  a  wineglassful 
of  warm  milk  to  a  child  of  eight  years  :  the  dose  is  given  two 
hours  before  breakfast,  so  as  to  ensure  an  empty  stomach.  As 
to  the  frequency  of  administration,  whether  it  should  be  every 
three  or  four  days  or  only  once  a  week,  there  is  also  a  difference 
of  opinion,  and  the  necessity  of  determining  this  question  by 
repeated  estimations  of  the  opsonic  index  is  another  moot  point. 

I  have  seen  children  do  well  who  had  had  tuberculin  sub- 
cutaneously,  or  by  mouth,  or  by  rectum,  but  as  in  all  therapeutics 
one  must  be  careful  in  drawing  conclusions  as  to  cause  and 
effect  ;  and  the  more  so  when  as  in  this  case  there  is  much 
discrepancy  between  the  dosage  and  the  results  of  different 
observers. 

Of  the  possibility  of  doing  good  by  such  therapeutic  measures 
as  I  have  described  there  is  no  doubt,  but  the  evidence  of  morbid 
anatomy  and  the  results  of  clincial  experience  seem  to  show  that, 
whilst  we  may  do  much  for  the  tuberculous  child  by  careful 
treatment,  it  is  chiefly  to  a  more  efficient  prophylaxis  that  we 
must  look  for  any  considerable  decrease  in  the  terrible  mortality 
from  tuberculosis  in  childhood. 


1  Kdi/nack's  Tuberculosis  in  Infancy  and  Childhood,  p. 

2  Trans.  Roy.  Soc.  Med.,  vol.  i,  No.  C,  p.  195. 


204. 


CHAPTER  XXX 
ABDOMINAL  TUBERCULOSIS  IN  CHILDREN 

ABDOMINAL  tuberculosis  in  children  may  be  considered  under 
two  heads,  tabes  mesenterica  and  tuberculous  peritonitis. 

Looked  at  purely  from  the  clinician's  standpoint,  neither  of 
these  is  a  very  common  condition,  but  from  the  more  reliable 
estimate  of  the  pathologist  abdominal  tuberculosis  would  seem 
to  be  one  of  the  commonest  of  all  tuberculous  lesions  in  children. 

My  own  statistics  show  that  88-3  per  cent,  of  tuberculous 
children  have  tuberculous  lesions  in  the  abdomen.  Abdominal 
tuberculosis,  therefore,  is  exceedingly  common  in  the  post 
mortem  room,  but  not  so  common  in  the  ward  ;  in  other  words, 
tubercle  is  often  present  in  the  abdomen  without  producing  any 
characteristic  symptoms  during  life.  This  latent  abdominal 
tuberculosis  is  only  too  familiar  to  the  pathologist.  The  body 
of  a  child  who  has  died,  it  may  be  with  symptoms  pointing 
only  to  pulmonary  tuberculosis,  shows  numerous  tubercles  in 
the  spleen,  a  few  in  the  liver,  and  probably  one  or  two  in  the 
kidney,  the  mesenteric  glands  show  caseous  foci,  and  there  may 
be  one  or  two  tuberculous  ulcers  in  the  intestine.  In  spite, 
however,  of  all  these  lesions  in  the  abdomen,  there  has  been 
nothing  during  life  to  suggest  abdominal  tuberculosis. 

Now  such  a  condition  is  of  interest,  it  is  true,  chiefly  to  the 
pathologist,  but  it  has  also  a  clinical  interest,  for  it  emphasizes 
a  very  important  point  in  the  tuberculosis  of  childhood,  namely, 
the  tendency  to  rapid  generalization.  Whatever  may  have  been 
the  clinical  aspect  of  tuberculosis  in  a  child,  whether  death  has 
been  due  to  tuberculous  meningitis  or  to  pulmonary  tuber- 
culosis, or  to  whatever  form  of  the  disease  it  be  due,  tubercle  is 
usually  found  scattered  more  or  less  widely  over  the  body,  and 
there  are  likely  to  be  some  tuberculous  lesions  in  the  abdomen. 
Realizing  this  tendency  to  rapid  generalization,  one  can  realize 
also  the  vital  importance  of  the  early  detection  of  tubercle  in 
children,  for  if  this  disease  is  overlooked  in  the  early  stage  the 
only  chance  of  saving  the  child  may  be  lost  ;  it  is  certain,  both 
from  clinical  experience  and  post  mortem  observation,  that  if 
only  treatment  is  begun  whilst  the  disease  is  still  in  its  early 


424  COMMON  DISORDERS  OF  CHILDHOOD 

stage,  tuberculosis  in  many  of  its  forms  may  be  arrested  even 
in  very  young  children. 

The  frequency  of  abdominal  tuberculosis,  therefore,  although 
it  is  a  matter  chiefly  of  pathological  observation,  has  a  practical 
significance  as  a  manifestation  of  the  tendency  to  rapid  and 
wide  dissemination  of  tubercle  in  a  child. 

Tabes  Mesenterica 

The  term  tabes  mcsenterica  is  not  altogether  satisfactory ;  it 
has  come  to  be  used  in  a  slovenly  way,  sometimes  to  indicate 
almost  any  form  of  abdominal  tuberculosis,  and  sometimes — • 
worse  still — to  indicate  no  tuberculosis  at  all,  but  simply  the 
wasting  of  an  ill-fed  infant. 

Again,  it  is  too  comprehensive  a  term  in  one  sense,  and  too 
narrow  in  another.  If  by  tabes  mesenterica  wTe  mean  any  case 
in  which  there  is  tuberculosis  of  the  mesenteric  glands,  we 
should  have  to  include  under  this  head  nearly  60  per  cent,  of 
the  cases  of  tuberculosis  of  any  sort  or  kind,  although  in  many 
of  them  the  lesion  of  the  mesenteric  glands  is  of  merely  secondary 
importance,  and  the  clinical  aspect  may  have  been  that  of 
pulmonary  tuberculosis  or  tuberculous  meningitis. 

On  the  other  hand,  the  term  is  too  narrow  if  we  restrict  it  to 
the  cases  in  which  there  is  great  enlargement  of  the  mesenteric 
glands,  for  in  this  way  we  create  an  entirely  artificial  distinction 
between  the  case  in  which  the  glands  happen  to  be  the  size 
of  a  walnut  and  the  case  in  which,  although  extensively  caseous, 
they  are  only  slightly  enlarged  ;  and  the  enlargement,  be  it 
observed,  is  not  more  likely  to  be  '  primary  '  in  the  one  case 
than  in  the  other,  so  that  we  cannot  base  any  distinction  of 
'  primary  '  and  '  secondary  '  affection  of  the  mesenteric  glands 
on  their  degree  of  enlargement. 

It  is,  perhaps,  most  satisfactory  to  speak  only  of  '  tuberculosis  of 
the  mesenteric  glands  '  ;  but  it  is  convenient  to  use  the  clinical 
term  '  tabes  mesenterica  '  to  indicate  those  cases  in  which  the 
tuberculous  enlargement  of  the  mesenteric  glands  can  be  detected 
clinically,  and  is  associated  with  wasting,  without  evidence  of 
tuberculous  peritonitis,  and  with  little  or  no  clinical  evidence  of 
tubercle  elsewhere.  In  this  sense  I  shall  use  the  term  tabes 
mesenterica  ;  and  I  may  point  out  at  once  that  this  condition 
is  by  no  means  common.  Tuberculosis  of  the  mesenteric  glands 
is  common  enough— 59  per  cent,  of  tuberculous  children  show 
it — but  cases  in  which  this  is  a  prominent  feature  clinically  are 
quite  uncommon. 


ABDOMINAL  TUBERCULOSIS  425 

Now  what  is  the  history  of  such  a  case  ?  The  child  is  brought 
to  the  medical  man  because  it  has  been  wasting  for  some  weeks 
or  months,  and  has  had  colicky  pains  in  the  abdomen.  The 
pain  is  rarely  severe,  it  is  usually  not  enough  to  make  the  child 
cry.  It  is  colicky  in  character,  and  recurs  in  an  erratic  way 
from  time  to  time.  The  wasting  is  sometimes  considerable, 
and  in  many  cases  the  bowels  have  been  irregular  ;  diarrhoea  has 
been  followed  by  constipation,  and  this  in  turn  by  diarrhoea 
again,  and  so  on.  The  appetite  also  varies  from  day  to  day, 
but  is  more  often  poor  than  excessive.  If  the  temperature  has 
been  taken  frequently,  it  is  found  to  be  irregular  (see  Chart, 
p.  271)  ;  but,  as  a  rule,  in  the  early  stages  the  temperature  has 
not  been  taken,  for  the  onset  is  insidious,  and  the  child  hardly 
looks  ill  enough  to  be  suffering  from  anything  very  serious. 

The  occurrence  in  a  child  of  insidious  wasting  with  colicky 
pain  in  the  abdomen,  especially  if  the  symptoms  have  lasted 
several  weeks,  should  always  arouse  a  suspicion  of  tabes  mesen- 
terica.  But  this  is  not  sufficient  to  establish  a  diagnosis  ;  the 
only  reliable  guide  in  the  diagnosis  of  tabes  mesenterica  is  actually 
to  feel  the  enlarged  mesenteric  glands  ;  and  this  is  not  always 
easy. 

The  place  to  feel  for  them  is  just  to  one  side  of  the  vertebral 
column,  especially  to  the  left  of  the  mid-line  at  or  just  below 
the  level  of  the  umbilicus ;  they  are  also  to  be  felt  not  uncommonly 
in  the  right  iliac  fossa.  Many  children  will  begin  to  cry  at  once 
if  made  to  lie  down  on  a  couch,  or  even  on  their  mother's  lap, 
and  for  this  reason  I  often  find  it  best  to  palpate  the  abdomen 
with  one  hand  as  the  child  sits  on  my  knee  with  the  trunk  bent 
slightly  forwards. 

One  would  think  that  when  the  glands  were  enlarged  to  the 
size  of  a  walnut,  or  even  larger,  they  would  be  easily  felt,  but 
they  are  not,  partly,  perhaps,  because  the  child  often  throws  its 
abdominal  muscles  into  a  state  of  rigidity  directly  one  tries  to 
palpate,  and  partly  because  the  glands  are  movable  to  some 
extent,  and  slip  away  to  one  side  of  the  vertebral  column  and 
rest  on  the  soft  tissues  of  the  lumbar  region,  where  they  are  not 
easy  to  define.  Be  this  as  it  may,  in  many  cases  where  post 
mortem  examination  shows  them  to  be  considerably  enlarged, 
careful  palpation  has  failed  to  detect  them  during  life. 

It  is  not  always  easy  by  a  single  examination  to  distinguish 
between  enlarged  glands  and  solid  faeces,  but  in  some  cases  of 
tabes  mesenterica  there  is  definite  tenderness  over  the  enlarged 
glands,  which  may  help  in  the  diagnosis,  and  faeces  can  some- 


426  COMMON  DISORDERS  OF  CHILDHOOD 

times  be  indented  distinctly  by  the  finger;  but  often  the  dis- 
appearance of  the  masses  after  an  aperient  or  an  enema  is  the 
only  reliable  distinction. 

A  much  greater  difficulty  in  diagnosis  is  caused  by  some  cases 
of  appendicitis  in  which  the  thickened  appendix,  or,  as  sometimes 
happens,  its  distended  terminal  portion,  feels  so  like  a  swollen 
gland  that  the  distinction  may  be  impossible  unless  there  is 
a  history  of  recurrent  acute  symptoms  indicating  appendicitis. - 
In  some  cases  where  exploratory  operation  has  shown  appendi- 
citis there  have  been  no  severe  symptoms  at  any  time,  and 
even  in  retrospect  it  is  difficult  to  see  how  the  diagnosis  from 
tuberculous  glands  could  have  been  made. 

Rectal  examination  may  be  of  value  in  such  cases,  for  the 
diffuse  inflammatory  thickening  of  appendicitis  is  often  appre- 
ciable by  rectal  palpation;  but  for  the  detection  of  mesenteric 
glands  I  have  not  found  rectal  examination  of  much  value,  the 
glands  are  usually  situated  beyond  the  reach  of  the  finger. 

To  sum  up,  the  symptoms  of  tabes  mesenterica  are  :  wasting 
with  colicky  pain,  irregularity  of  the  bowels  and  appetite,  and 
irregular  temperature,  whilst  on  palpation  of  the  abdomen  en- 
larged glands  can  be  felt,  sometimes  forming  a  nodular  mass,  and 
often  slightly  tender  on  pressure. 

There  is,  however,  a  further  important  feature,  which  is  not 
apparent  clinically,  but  which,  nevertheless,  has  a  bearing  upon 
the  treatment  and  prognosis  of  this  condition,  and  may  therefore 
be  mentioned  here,  namely,  ulceration  of  the  intestine. 

Probably  even  in  the  mildest  cases  and  in  the  earliest  stage 
of  tabes  mesenterica,  there  is  some  tuberculous  ulceration  of 
the  bowel  in  nearly  all  cases.  My  own  figures,  taken  from 
examinations  made  whilst  I  was  pathologist  at  the  Children's 
Hospital,  showed  that  out  of  132  cases  with  tuberculous  enlarge- 
ment of  the  mesenteric  glands,  107,  that  is,  over  80  per  cent., 
showed  ulceration  of  the  bowel. 

Ulceration  of  the  intestine  is  not,  of  course,  essential  to  the 
production  of  enlarged  caseous  glands  in  the  mesentery.  It  has 
boon  shown  experimentally  that  when  small  doses  of  tuber- 
culous material  are  given  to  animals  in  their  food,  the  mesenteric 
glands  may  become  caseous  without  ulceration  of  the  bowel  ; 
but  judging  from  post  mortem  evidence  it  seems  probable  that 
the  majority  of  children  who  come  under  observation  with  tabes 
mesenterica  have  some  ulceration  in  the  intestine,  and  this  makes 
the  condition  graver  than  it  would  be  if  we  had  only  to  deal  with 
caseation  of  the  mesenteric  glands.  I  have  seen  cases,  however, 


ABDOMINAL  TUBERCULOSIS        427 

in  which  there  was  complete  scarring  of  the  intestinal  ulcers 
which  had  been  associated  with  caseous  mesenteric  glands,  and  it 
is  not  very  rare  to  find  calcified  mesenteric  glands — evidence  of 
arrested  caseation — in  children. 

The  prognosis,  therefore,  of  tabes  mesenterica,  is  by  no  means 
hopeless.  I  have  seen  many  of  these  cases  improve  so  much 
that  it  seemed  probable  the  disease  was  arrested,  an  event  which 
is  most  likely  where  treatment  is  begun  early,  before  there  are 
signs  of  tubercle  in  the  lung,  and  before  there  is  any  extreme 
wasting.  It  is  to  be  remembered,  however,  that  even  if  tabes 
mesenterica  seems  to  have  recovered  completely,  there  are  still 
possibilities  of  trouble  at  a  later  period.  A  mass  of  caseating 
glands  may  easily  be  the  starting-point  of  a  localized  inflamma- 
tion of  the  peritoneum,  and  without  any  more  general  inflamma- 
tion occurring,  adhesions  may  form  between  the  glands  and 
the  neighbouring  structures.  These  local  adhesions  are  apt  to 
give  rise  to  trouble  long  after  the  tabes  mesenterica  seems  to 
have  quite  recovered. 

A  child,  aged  five  years,  was  brought  to  me  at  King's  College  Hospital  for 
vomiting.  He  was  fairly  well  nourished,  and  walked  up  to  the  hospital  with 
his  mother.  He  had  complained  of  some  pain  in  the  abdomen  and  had  been 
sick  two  or  three  times  in  the  last  forty-eight  hours.  I  examined  the  abdomen 
carefully,  but  could  feel  nothing  abnormal.  There  was,  however,  a  look  of 
illness  about  the  boy's  face  for  which  I  was  unable  to  account,  so  I  sent  the 
boy  into  the  ward  for  observation.  He  continued  vomiting,  and  the  abdomen 
was  opened  by  my  colleague,  Mr.  Burghard,  who  found  a  narrow  fibrous  adhesion 
passing  from  a  dry  caseous  mesenteric  gland  to  the  ascending  colon  ;  under 
this  a  loop  of  ileum  had  slipped  and  become  strangulated. 

In  a  similar  case  in  the  Children's  Hospital,  the  strangulating 
band  passed  from  the  gland  to  the  wall  of  the  abdomen.  In  the 
post  mortem  records  of  that  hospital  there  are  other  cases  in 
which  this  accident  occurred  after  tabes  mesenterica. 

Treatment.  As  to  the  treatment  of  tabes  mesenterica,  by  far 
the  most  important  part  is  the  hygienic  treatment,  particularly  by 
climate.  A  prolonged  stay  at  the  seaside  will  do  far  more  for 
this  disease  than  any  drug,  and  these  patients  do  better  at  the 
seaside  than  in  the  country  inland  (see  p.  420). 

The  diet  to  be  aimed  at  is  such  as  shall  yield  the  maximum 
of  nourishment  with  the  minimum  of  residue,  for,  as  I  have 
already  mentioned,  the  intestine  is  ulcerated  in  most  of  these 
cases.  The  child  should  be  fed  as  far  as  possible  with  eggs, 
custard,  well-cooked  milk-puddings,  and  gravy.  The  eggs  are 
particularly  valuable,  for  they  contain  a  large  percentage  of  fat  in 
the  yolk.  Milk  and  egg  are  to  be  considered  chief  items  in  the 
diet,  and  in  choosing  other  foods,  those  should  be  selected 


428  COMMON  DISORDERS  OF  CHILDHOOD 

which  will  leave  little  residue,  and  are  not  likely  to  give  rise 
to  fermentation  in  the  intestine.  These  children  are  not  to 
be  starved,  they  require  rather  'good  feeding,  and  plenty 

of  it '. 

There  is  one  objection  which  might  be  raised  both  to  milk  and 
eggs,  an  objection  which  has  also  been  raised  to  the  use  of  cod- 
liver  oil  in  this  condition,  and  that  is,  the  blocking  of  the  lacteals 
in  some  of  the  cases  by  caseous  material.  Fat  passes  via  the 
lacteals  from  the  intestine  into  the  lymph  stream,  and  if  this 
passage  is  blocked  it  may  be  useless  to  give  such  food. 


Fin.  .'}().  Tuberculous  mesenteric  glands.  Photograph  shows  the  lymphatics, 
which  pass  from  a  tuberculous  patch  in  the  intestinal  mucosa,  obstructed  and 
distended.  Specimen  from  a  child  aged  11|  years. 


The  photograph  shown  here  will  illustrate  this  point ;  it  is 
a  short  piece  of  small  intestine  attached  to  its  mesentery,  in  which 
is  a  caseous  tuberculous  gland  ;  tuberculous  ulceration  of  the 
bowel  has  occurred,  and  passing  up  from  the  outer  surface  of 
the  bowel  over  the  ulcer  to  the  mesenteric  gland  are  seen  dilated 
lacteals  filled  with  whitish  caseous  material,  perhaps  also  with 
some  fat. 

But  even  in  such  a  case  probably  the  majority  of  the  lacteels 
are  free  from  obstruction,  so  that  the  objection  to  fats  is  perhaps 
more  theoretical  than  practical  ;  at  any  rate  I  think  it  wrill  be 


ABDOMINAL  TUBERCULOSIS        429 

found  that  such  a  diet  as  I  have  mentioned  is  suitable  for  these 
children. 

As  to  drugs,  my  own  belief  is  that  iodide  of  iron  is  particularly 
valuable  in  these  cases.  I  should  be  sorry  to  have  to  explain 
its  good  effect,  but  certainly  in  some  cases  after  its  use  the 
colicky  pain  ceases,  and  there  seems  to  be  general  improvement. 
If  there  is  no  diarrhoea  it  is  well  to  combine  the  iodide  with 
a  malt  extract,  or  with  a  mixture  of  cod-liver  oil  and  malt ;  there 
are  several  such  combinations  of  iron  iodide  on  the  market. 
Another  drug  which  may  be  useful  is  creosote,  which  is  perhaps 
specially  indicated  in  such  a  condition  as  this,  inasmuch  as  not 
only  is  it  an  intestinal  antiseptic,  but  it  seems  to  have  some 
specially  beneficial  influence  on  tuberculous  lesions. 

For  the  diarrhoea  I  have  used  castor  oil  in  small  doses  (ft)v) 
three  times  a  day  ;  it  seems  to  have  a  particularly  soothing 
effect  on  the  mucous  membrane  of  the  lower  part  of  the  intestine, 
and  creosote  (0)J  to  O)j)  may  usefully  be  combined  with  it  and 
opium  if  necessary. 

Sometimes  an  astringent  seems  more  effectual,  a  mixture  of 
Tinct.  Opii  tt)i,  Tinct.  Catechu  0)v,  Spirit.  Choloroformi  O)iJ, 
Mist.  Cretse  ad  3j  may  be  given  to  a  child  of  two  years  three  or 
four  times  a  day  ;  the  Tincture  of  Goto  in  doses  of  5-10  minims, 
or  Tannalbin  gr.  x  given  as  a  powder,  may  be  useful. 

Lastly  I  must  point  out  that  surgery  has  a  place  in  the  treat- 
ment of  tabes  mesenterica.  There  are  cases  like  those  I  have 
mentioned  above  in  which  obstructive  symptoms  necessitate 
operation,  but  there  are  others  in  which  laparotomy  may  be 
advisable  though  it  is  not  imperative.  Such  are  those  in  which 
with  the  palpable  presence  of  enlarged  glands  in  the  abdomen 
there  is  constantly  recurring  colicky  pain.  I  have  seen  excellent 
results  from  laparotomy  and  removal  of  the  affected  glands  in 
these  cases  ;  it  may  not  be  practicable  to  remove  all  the  tuber- 
culous glands,  but  it  maybe  easily  possible  to  remove  those  which 
show  most  enlargement  and  caseation,  and  to  divide  strands  of 
adhesion  which  may  be  accountable  for  the  pain  ;  in  a  boy, 
aged  8J  years,  who  was  under  my  care  for  palpable  enlargement 
of  mesente'ric  glands,  my  colleague  Mr.  Carless  found  a  firm 
fibrous  thread  like  a  cord  of  fine  catgut,  9  inches  long,  passing 
from  one  coil  of  intestine  to  another.  There  was  a  softened 
caseous  mesenteric  gland  in  this  case  without  any  general  peri- 
tonitis and  Mr.  Carless  was  able  to  remove  the  gland  as  well  as 
the  strand  of  adhesion  which  might  at  any  time  have  caused 
acute  strangulation. 


430  COMMON  DISORDERS  OF  CHILDHOOD 

The  operative  treatment  of  tabes  mesenterica  is  on  an  entirely 
different  footing  from  that  of  general  tuberculous  peritonitis  ; 
there  is  no  doubt  of  the  removal  of  a  definite  focus  of  infec- 
tion in  the  former,  whereas  in  the  latter  the  benefit  of  opening 
the  abdomen  is,  except  under  certain  rare  conditions,  quite 
problematical. 

Tuberculous  Peritonitis 

As  I  have  already  said,  a  localized  peritonitis  sometimes  starts 
from  caseous  mesenteric  glands,  and  in  some  cases  it  seems 
likely  that  a  generalized  tuberculous  peritonitis  may  have  a 
similar  origin.  In  the  majority  of  cases,  however,  tubercular 
peritonitis  probably  begins  independently  of  any  tabes  mesen- 
terica ;  indeed  the  mesenteric  glands  are  found  to  be  very  little 
affected  in  some  of  the  cases  of  this  disease  which  come  to  the 
post  mortem  room. 

Tuberculous  peritonitis  may  be  divided  for  practical  purposes 
into  two  varieties,  the  plastic  and  the  ascitic  ;  and  this  division 
is  of  considerable  practical  importance,  as  will  be  seen  when  we 
come  to  consider  treatment. 

The  plastic  variety  is  by  far  the  commoner  ;  in  fact,  speaking 
roughly,  I  should  say  the  proportion  of  plastic  to  ascitic  is 
probably  about  ten  to  one. 

As  to  the  frequency  of  this  particular  form  of  tuberculosis  the 
following  figures  will  give  some  idea.  Out  of  266  children 
who  died  with  tuberculosis  under  twelve  years  of  age,  forty-five 
died  with  tuberculous  peritonitis  ;  so  that  16-8  per  cent.,  of  the 
fatal  cases  of  tuberculosis  were  cases  of  tuberculous  peritonitis. 
Limiting  my  observations  to  children  under  two  years  of  age,  that 
is,  to  infants,  I  found  twelve  cases  of  tuberculous  peritonitis  in 
100  tuberculous  infants. 

This  is  an  interesting  point  in  view  of  the  teaching  in  former 
days  that  tuberculous  peritonitis  is  practically  unknown  in 
infancy.  All  the  cases  which  I  have  included  here  were  such  as 
arc  ordinarily  recognized  as  general  tuberculous  peritonitis,  and 
most  of  them,  if  not  all,  had  been  recognized  as  such  during  life. 
This  occurrence  of  tuberculous  peritonitis  in  infancy  is  even 
more  strikingly  shown  by  the  accompanying  chart  (Fig.  31), 
which  shows  the  age-incidence  in  each  year  of  childhood. 

The  age-incidence  of  tuberculous  peritonitis  as  shown  by  this 
chart — which  includes  only  cases  which  were  verified  by  autopsy 
—corresponds  closely  with  that  of  tuberculosis  in  general ; 
indeed,  the  chart  might  serve  almost  equally  well  to  show  the 


ABDOMINAL  TUBERCULOSIS 


431 


age-incidence  of  tuberculosis  in  childhood.  It  will  be  seen  that 
tuberculous  peritonitis  with  a  fatal  result  is  most  frequent  in 
the  second  year  of  life,  so  that  so  far  from  tuberculous  peri- 
tonitis being  almost  unknown  in  infancy  it  is  actually  commoner 
then — at  any  rate  as  a  fatal  disease — than  at  any  other  period 
of  childhood. 

Trusting  to  one's  impressions,  I  should  have  said  that  tuber- 
culous peritonitis  was  more  frequent  in  boys  than  in  girls,  but 
my  own  statistics  show  that  this  is  not  so  :  in  100  cases  there 
were  48  boys  and  52  girls,  and  in  further  cases  the  proportion 
came  out  very  similar.  Rilliet  and  Barthez,  however,  met  with 


FIG.  31.    Age-incidence  of  tuberculous  peritonitis. 

this  disease  in  53  boys  and  33  girls.  Probably  the  incidence  is 
about  equal  in  the  two  sexes. 

The  symptoms  of  tuberculous  peritonitis  in  its  earliest  stage 
are  very  much  the  same  as  those  of  tabes  mesenterica  ;  but  later 
characteristic  signs  appear  which  can  hardly  be  mistaken. 

The  abdomen  has  a  tumid  appearance,  with  a  '  podgy ', 
doughy  feeling  on  palpation,  as  if  it  were  packed  full  of  some 
softish  material.  In  many  cases  there  is  also  a  transverse  band- 
like  tumour  lying  across  the  epigastrium  ;  this  I  have  several 
times  seen  mistaken  for  the  lower  edge  of  the  liver,  but  with  the 
exercise  of  a  little  care  this  mistake  can  be  avoided,  for  the  tumour 
has  not  only  a  lower  edge,  but  also  a  definite  upper  margin — the 


432  COMMON  DISORDERS  OF  CHILDHOOD 

upper  edge  of  the  thickened  and  caseous  omentum  which  forms 
the  tumour.  This  band-like  and  often  nodular  mass  lies  across 
the  epigastrium,  generally  just  above  the  umbilicus,  and  slopes 
upwards  towards  the  spleen.  In  some  cases  the  edge  of  the  liver 
can  be  denned,  and  is  then  found  to  be  quite  separate  from  the 
tumour.  When  the  abdomen  is  opened  in  these  cases  the  caseous 
omentum  looks  very  like  a  large  pancreas  lying  superficially  just 
below  the  edge  of  the  liver. 

The  appearance  of  the  child  when  the  disease  is  advanced  is 
very  characteristic  :  the  emaciated  limbs  and  the  shrunken  cover- 
ing of  the  chest- wall,  through  which  the  ribs  stand  out  distinct, 
contrast  strangely  with  the  fullness  and  tumidity  of  the  abdomen. 

At  this  stage  there  is  another  sign  which  is  very  characteristic, 
namely,  an  unfolding  of  the  umbilicus,  which  looks  as  if  it  were 
pushed  outwards  from  within  ;  and  in  addition  to  the  unfolding 
there  is  often  induration  and  redness  of  the  skin  extending  out- 
wards about  an  inch  all  round  the  umbilicus.  This  reddening 
and  induration  about  the  umbilicus  is  sometimes  of  value  in 
diagnosis  where  the  general  doughy  resistance  is  not  very  marked. 
For  instance,  in  a  case  in  which  the  enlargement  of  the  abdomen 
had  been  attributed  to  rickets  some  redness  and  induration 
about  the  umbilicus  was  the  first  evidence  of  tuberculous  peri- 
tonitis. 

This  '  pointing  '  at  the  umbilicus  is  not  very  rare,  and  is  one  of 
the  complications  which  must  always  be  watched  for  in  the  course 
of  tuberculous  peritonitis.  An  actual  discharge  of  broken-down 
caseous  material  may  occur,  and  is  not  necessarily  a  matter  for 
alarm ;  indeed,  I  have  several  times  known  cases  to  do  much 
better  after  this  event  than  before  it.  A  case  which  impressed 
this  point  upon  me  was  the  following  :  the  child  was  extremely 
ill  with  advanced  tuberculous  peritonitis  ;  the  umbilicus  was 
reddened  and  shiny,  with  induration  all  round  it,  and  it  was 
obvious  that  the  skin  would  give  way  very  soon.  I  was  inclined 
at  that  time  to  regard  the  prognosis  as  extremely  bad,  and  when 
tho  parents  insisted  on  taking  the  child  away  from  the  hospital 
they  were  strongly  dissuaded  from  doing  so  on  the  ground  that 
ho  might  die  on  the  way  home.  They  took  the  child  away  against 
advice  ;  a  clay  or  two  later  the  skin  over  the  umbilicus  gave 
way,  and  there  was  a  free  discharge  of  caseous  debris  ;  when 
I  hoard  of  the  child,  about  six  weeks  later,  he  was  running  about 
at  homo,  apparently  making  good  progress  towards  recovery. 

A  much  more  serious  accident,  and  one  which  is  usually  speedily 
fatal,  is  perforation  of  the  bowel  before  there  is  much  adhesion. 


ABDOMINAL  TUBERCULOSIS  433 

In  such  a  case  the  symptoms  may  suddenly  change  from  those 
of  tuberculous  peritonitis  to  those  of  acute  septic  peritonitis. 

When  there  is  already  much  adhesion,  perforation  is  not  so 
serious  an  occurrence ;  for  then  a  localized  abscess  forms,  which 
may  track  amongst  the  coils  and  eventually  point  at  the  umbilicus 
or  elsewhere,  and  in  spite  of  a  faecal  discharge  from  the  abscess 
the  child  may  seem  little  the  worse.  Perforation  does  not  always 
take  place  from  the  inside  of  the  bowel  by  rupture  of  the  peri- 
toneum over  a  tuberculous  ulcer.  In  many  cases  a  deposit  of 
caseous  material  between  two  coils  breaks  down  and  discharges 
into  the  neighbouring  bowel,  so  that  the  perforation  occurs  from 
without. 

Ulceration  of  the  bowel  is  present  in  many — about  70  per 
cent. — of  the  cases.  I  found  it  in  fifty-four  out  of  seventy-seven 
cases  where  it  was  possible  to  examine  the  bowel  sufficiently 
thoroughly. 

An  unusual  complication  which  I  have  seen  in  the  early  stage 
of  tuberculous  peritonitis  is  acute  distension  of  the  abdomen, 
a  misleading  symptom,  as  it  suggests  rather  some  acute  septic 
peritonitis  than  a  tuberculous  condition ;  indeed,  the  diagnosis 
in  such  a  case  is  hardly  possible  until  the  gradual  subsidence 
of  the  distension  and  the  increasing  doughy  resistance  of  the 
abdomen  make  the  tuberculous  nature  of  the  peritonitis  clear. 

In  the  ascitic  variety  the  symptoms  are  very  different ;  here 
the  abdomen  is  distended  with  fluid  as  in  other  forms  of  ascites, 
but  it  is  often  quite  impossible  at  first  to  distinguish  ascites  due 
to  tubercle  from  that  due  to  any  other  cause.  If  one  can  have 
the  abdomen  tapped,  and  a  bacteriological  investigation  made, 
it  may  be  possible  to  determine  this  point,  but  in  most  cases  it  is 
necessary  to  wait  some  time,  perhaps  several  weeks,  before  a 
positive  diagnosis  is  possible. 

Under  these  circumstances  it  is  necessary  to  examine  the  child' 
very  carefully  for  evidence  of  tubercle  elsewhere.  In  the  case 
of  a  boy  about  five  years  old  whose  abdomen  was  distended 
with  ascites  of  doubtful  nature  I  had  almost  come  to  the  con- 
clusion that  there  was  nothing  to  throw  any  light  on  the  ascites, 
when  it  occurred  to  me  to  examine  the  testicles  ;  I  found  the 
epididymis  on  one  side  considerably  enlarged  and  hard,  making 
it  practically  certain  that  the  ascites  was  tuberculous. 

These  children  rarely  die  with  ascites.  As  a  rule  the  fluid 
gradually  disappears,  and,  as  adhesions  form,  the  condition 
becomes  that  of  the  ordinary  plastic  form.  Upon  this  point 
I  would  lay  some  stress,  for  I  think  that  in  estimating  the  value 

STILL  F  f 


43  i  COMMON' DISORDERS  OF  CHILDHOOD 

of  operative  treatment  for  tuberculous  peritonitis  some  surgeons 
have  attached  undue  importance  to  the  disappearance  of  ascites 
after  operation.  It  should  be  recognized  that  under  simple 
medical  treatment  tuberculous  ascites  disappears  spontaneously 
in  the  large  majority  of  cases,  and  moreover  that  the  mere  dis- 
appearance of  fluid,  whether  by  incision  or  by  tapping  or  by  less 
active  treatment;  does  not  show  that  the  peritonitis  is  cured,  it 
may  still  run  the  course  of  a  plastic  tuberculous  peritonitis,  and 
it  would  be  premature  to  boast  of  a  cure  until  several  months 
have  passed,  and  until  we  can  be  quite  sure  that  we  have  not 
simply  converted  a  case  of  ascitic  tuberculous  peritonitis  into 
one  of  tho  plastic  variety. 

Prognosis.  The  prognosis  of  tuberculous  ascites  is  good  so 
far  as  the  immediate  present  is  concerned  ;  but  if  the  ascites  is 
gradually  replaced  by  general  matting  and  adhesions,  as  it  is  in 
many  cases,  the  prognosis  does  not  differ  from  that  of  cases 
in  which  the  peritonitis  is  plastic  or  ?,dhesive  from  the  beginning. 

It  is  difficult  to  determine  the  proportion  of  recoveries  from 
tuberculous  peritonitis  amongst  hospital  patients,  for  the  reason 
that  so  many  pass  out  of  observation  after  a  few  weeks  or  months, 
and  their  subsequent  course  is  unknown  ;  but  certainly  many 
cases  leave  the  hospital  greatly  improved,  and  some  apparently 
cured. 

I  say  '  apparently  cured  ',  for  I  would  insist  very  strongly  on 
the  need  for  caution  in  talking  about  '  cure  '  or  '  recovery  '  in  such 
cases. 

A  boy,  aged  about  six  years,  wras  brought  to  me  at  King's 
College  Hospital  when  he  was  four  years  old  for  wasting  and 
pain  in  the  abdomen.  There  was  some  resistance,  and  impair- 
ment of  note  on  percussion  over  the  lower  part  of  the  abdomen, 
and  it  seemed  quite  certain  that  he  had  tuberculous  peritonitis  ; 
the  diagnosis  was  confirmed  by  the  scar  of  an  old  tuberculous 
dactylitis  on  the  right  hand. 

Under  medical  treatment  the  resistance  gradually  disappeared, 
and  tho  abdomen  became  as  supple  as  a  normal  abdomen. 

But  to  call  such  a  case  cured  would  have  been  misleading. 
It  is  true  that  during  the  eighteen  months  he  was  under  observa- 
tion after  his  apparent  recovery,  there  wras  no  return  of  the 
abdominal  symptoms,  unless  some  occasional  colicky  pains  of 
which  he  complained  towards  the  end  of  this  time  indicated 
some  fresh  abdominal  tubercle,  but  more  probably  they  were 
due,  as  they  often  are  in  such  cases,  to  the  old  adhesions  left  by 
the  former  peritonitis  His  tuberculous  peritonitis  may  have 


ABDOMINAL  TUBERCULOSIS         435 

been  cured,  but  his  tuberculosis  was  not  cured.  Eighteen  months 
after  his  recovery  from  the  peritonitis  the  supra-condylar  gland 
in  the  right  arm  caseated  and  broke  down. 

Unless  a  case  has  been  kept  under  observation  for  at  least  a  year 
or  eighteen  months  after  the  supposed  recovery,  it  is  worthless 
as  evidence  of  a  cure  ;  some  at  least  of  the  so-called  '  recoveries  ', 
both  after  surgical  and  medical  treatment,  end  fatally  within 
two  or  three  years  with  other  manifestations  of  tuberculosis  or 
a  recrudescence  of  the  abdominal  disease. 

Unfortunately,  in  many  cases  there  is  not  even  a  temporary 
improvement.  In  a  scries  of  fatal  cases  at  the  Children's  Hospital, 
Great  Ormond  Street,  I  found  that  the  average  duration  was 
about  five  months  ;  the  shortest  was  four  weeks. 

The  outlook  is,  I  think,  less  hopeful  in  the  first  two  years  of  life 
than  in  later  childhood,  but  I  have  known  recovery  which  was 
apparently  complete  to  occur  even  in  infants :  one  was  about  nine 
months  old  when  the  symptoms  appeared  with  the  typical  hard 
infiltration  of  the  omentum ;  six  months  later  the  abdominal  signs 
had  disappeared  and  the  child  was  seemingly  quite  well ;  another 
at  the  age  of  eight  months  had  fluid  in  the  abdomen  with  wasting 
and  fever,  he  had  made  an  apparently  perfect  recovery  when  seen 
six  months  later.  Another  at  the  age  of  eighteen  months  had  the 
usual  signs  of  plastic  peritonitis,  and  three  months  later  a 
discharge  of  caseous  material  from  the  umbilicus,  after  which  she 
steadily  improved,  the  hard  masses  of  infiltration  were  much 
less  and  the  child  seemed  to  be  doing  well  when  last  seen  nearly 
five  months  after  the  discharge  at  the  umbilicus  began. 

Treatment.  The  question  of  the  frequency  of  recovery  with 
various  methods  of  treatment  is  of  great  practical  importance,  for 
in  recent  years  we  have  heard  much  of  the  surgical  treatment  of 
tuberculous  peritonitis,  and  some  have  even  gone  so  far  as  to 
recommend  laparotomy  as  a  routine  treatment  for  this  disease. 

I  imagine  that  no  one  with  a  well-balanced  mind  is  likely  to 
maintain  that  operative  treatment  is  advisable  where  it  is  un- 
necessary ;  experience  has  abundantly  proved  that  some  cases 
of  tuberculous  peritonitis  will  get  well  without  operation,  and 
therefore  that  in  these  at  least  operation  would  have  been 
a  mistake.  But  what  proportion  of  cases  will  recover  without 
operation  ?  The  question  is  a  difficult  one  to  answer,  for  it 
is  difficult  to  trace  a  sufficiently  large  number  of  cases  for 
a  sufficiently  long  period  to  afford  reliable  evidence. 

Dr.  Guthrie   and  Dr.  Sutherland  have  published  statistics  ] 
1  Trans.  Soc.  Study  Dis.  Children,  vol.  iii,  p.  118. 
Ff2 


436  COMMON' DISORDERS  OF  CHILDHOOD 

showing  that  of  41  cases  treated  at  the  Paddington  Green 
Children's  Hospital,  14  underwent  laparotomy  and  7  of  these 
died,  whilst  of  the  remaining  27  treated  medically  only  4  were 
fatal.  Dr.  George  Carpenter  recorded  10  cases  as  recovered 
and  16  as  improved  out  of  54  cases  treated  medically  (19  died 
and  the  result  was  not  known  in  9  cases). 

Without  attempting  to  settle  this  question  by  statistics  I 
will  state  certain  facts  which  seem  to  me  to  have  a  bearing 
upon  it.  As  I  have  already  pointed  out,  the  stage  of  ascites, 
when  it  occurs  at  all  in  tuberculous  peritonitis,  is  an  early  stage  ; 
the  fluid  usually  disappears  spontaneously  and  the  peritonitis 
may  then  subside  or  pass  into  the  plastic  variety.  In  this  early 
stage  of  ascites  tuberculous  peritonitis  is  eminently  amenable 
to  simple  hygienic  treatment  ;  so  far  as  the  mere  presence  of 
ascites  goes  there  is  in  the  majority  of  cases  no  occasion  whatever 
for  laparotomy  or  even  for  tapping,  it  is  only  in  rare  cases  that 
the  mechanical  distension  becomes  such  as  to  require  some 
operative  relief. 

If  it  could  be  shown  that  laparotomy  had  any  specific  influence 
by  so  altering  conditions  in  the  abdominal  cavity  that  the  power 
of  resistance  to  tubercle  was  increased,  the  treatment  of  these 
ascitic  cases  by  incision  would  then  stand  on  a  different  footing  ; 
but  I  know  of  no  clinical  evidence  which  establishes  this. 

There  is  no  doubt  whatever  that  tubercular  ascites  and  miliary 
tubercle  in  the  peritoneum  have  many  times  recovered  after 
laparotomy,  but  there  is  equally  no  doubt  that  recovery  occurs 
in  similar  cases  without  any  operation  where  the  child  is  kept 
lying  down,  carefully  fed,  sent  to  the  country  or  seaside,  and 
kept  much  in  the  open  air  ;  and  it  must  be  remembered  that 
when  operation  is  done  the  child  is  almost  always  placed  under 
just  these  conditions  as  an  adjunct  to  the  surgical  procedure  ; 
and  therefore  one  must  be  cautious  in  concluding  that  the  recovery 
is  due  to  the  operation. 

Next  I  would  point  out  that  the  peritoneum  has  a  marvellous 
power  of  resistance  to  tubercle  ;  and  that  even  where  plastic 
tuberculous  peritonitis  is  present  with  hard  bands  of  infiltration, 
and  forms  masses  which  to  any  one  unfamiliar  with  this  disease 
might  seem  a  hopeless  condition,  recovery  without  any  operative 
interference  is  so  complete  in  some  cases  that  it  would  be  difficult 
for  any  one  seeing  the  child  a  few  years  later  to  believe  that  there 
had  ever  been  peritonitis  of  any  sort. 

One  child  who  came  under  observation  at  7|  years  old,  when 
she  had  large  masses  of  hard  infiltration  in  the  abdomen  and  was 


ABDOMINAL  TUBERCULOSIS  437 

much  wasted,  had  two  years  later  a  discharge  of  broken-down 
caseous  material  from  the  umbilicus ;  she  then  gradually  recovered, 
and  at  the  age  of  11 J  years  was  apparently  in  perfect  health,  fat 
and  jolly,  and  the  abdomen  showed  no  infiltration  on  palpation, 
and  might  easily  have  passed  for  normal  except  for  the  scar  of 
the  former  umbilical  opening. 

I  have  seen  other  similar  cases  in  which  this  plastic  form  of 
peritonitis  subsided  spontaneously  with  or  without  discharge 
from  the  umbilicus,  and  I  mention  this  because  the  possibility 
of  spontaneous  recovery  from  so  advanced  a  stage  of  tuberculous 
peritonitis  emphasizes  the  need  for  caution  in  attributing  good 
results  to  laparotomy.  But  if  the  good  results  of  incision  in 
the  plastic  variety  of  tuberculous  peritonitis  are  doubtful,  the 
bad  results  are  not  open  to  doubt :  the  best  of  surgeons  cannot  be 
sure  of  avoiding  damage  to  the  intestine  when  there  is  such 
general  matting  as  is  usual  in  this  form.  I  have  more  than  once 
seen  a  troublesome  faecal  fistula  as  the  only  result  of  the  operation, 
and  this  fistula  from  operation  is  likely  to  be  larger  and  to  heal 
less  readily  than  the  fistula  which  results  from  Nature's  methcd 
of  evacuation  through  the  umbilicus — the  natural  fistula  is 
sometimes  faecal,  sometimes  not,  but  in  either  case  is  usually 
very  small  and  heals  up  after  a  few  weeks. 

In  my  opinion  laparotomy  is  rarely  if  ever  advisable  in  the 
plastic  form  of  tuberculous  peritonitis  except  for  the  relief  of 
particular  symptoms. 

There  are  cases  in  which  as  a  result  of  the  adhesions  some  part 
of  the  bowel  becomes  strangulated  or  compressed  so  that  symp- 
toms of  more  or  less  acute  obstruction  occur,  with  severe  pain  and 
vomiting ;  under  these  circumstances  obviously  it  is  only  right 
to  attempt  relief  of  the  distress  by  removing  the  band  or  other 
cause  of  obstruction  :  the  operation  is  a  hazardous  one,  for  it 
usually  involves  tearing  asunder  matted  coils  of  bowel  which 
are  probably  thinned  by  ulceration  ;  but  it  is  an  operation  of 
necessity. 

Again,  there  are  cases  in  which,  with  caseous  material  between 
the  coils  of  bowel,  softening  or  perforation  of  bowel  occurs,  but 
the  resulting  abscess  fails  to  point  at  the  umbilicus  and  a  collec- 
tion of  pus  occurs  which  must  be  evacuated  by  incision. 

In  the  medical  treatment  of  this  condition,  climate  stands  first 
and  foremost ;  the  child  should  be  sent  away  to  the  seaside  or 
the  country  as  quickly  as  can  be  managed  and  taken  out  in  some 
sort  of  carriage  in  the  open  air  daily  and  almost  all  day  if  possible. 
A  bracing  atmosphere  suits  these  children  best,  at  any  rate  in  the 


438  COMMON  ^DISORDERS  OF  CHILDHOOD 

summer,  but  cold  is  to  be  avoided  ;  and  a  dry  gravel  soil  is  to 
be  preferred  to  sand  or  clay.  I  need  not  repeat  here  what 
I  have  said  elsewhere  on  the  climatic  and  general  treatment 
of  tubercle  in  children.  Good  feeding  is  essential,  and  must  be 
upon  the  same  lines  as  in  tabes  mesenterica  ;  in  both  conditions 
the  ulceration  of  the  bowel  is  to  be  remembered. 

The  importance  of  recumbency  for  these  cases  of  abdominal 
tubercle  in  children  is  worthy  of  emphasis.  It  is  not  sufficient 
to  take  the  child  to  the  seaside  and  to  feed  it  well,  the  child 
should  be  kept  lying  down  ;  a  long  perambulator  in  which  the 
child  can  lie  should  be  provided,  and  in  this  the  child  should  be 
kept  out  in  the  open  air  the  greater  part  of  the  day. 

The  value  of  recumbency  has  rested  hitherto  solely  on  the  test 
of  experience,  but  recent  studies  of  the  opsonic  index  have  gone 
far  to  supply  more  exact  grounds  for  insisting  upon  rest  in  such 
cases.  Rest  in  bed  combined  with  good  feeding  is  probably 
responsible  for  the  improvement  in  many  cases  admitted  to 
hospital  ;  it  is  remarkable  how  much  children  with  tuberculous 
peritonitis  will  often  improve,  even  in  our  atmosphere  in  London, 
with  these  measures  alone,  but  the  best  results  are  to  be  seen 
where  similar  treatment  can  be  carried  out  in  the  open  air  in 
the  country  or  at  the  seaside. 

Turning  now  to  the  value  of  drugs  for  tuberculous  peritonitis, 
I  would  point  out  that  although  in  my  opinion  drugs  have 
a  very  real  value,  they  must  be  regarded  only  as  an  adjunct  to  the 
far  more  important  remedies,  sea-air  and  recumbency.  lodo- 
form  has,  I  think,  a  distinctly  beneficial  effect,  perhaps  chiefly 
in  the  cases  with  ascites.  I  have  seen  fluid  disappear  very 
quickly  during  the  administration  of  iodoform  by  mouth,  and 
I  have  very  rarely  had  any  difficulty  in  getting  children  to  take 
it  in  the  form  of  an  emulsion  with  cod-liver  oil.  Mr.  Fairweather, 
chief  dispenser  at  King's  College  Hospital,  devised  the  following 
formula,  which  I  have  found  generally  useful  :  Iodoform  gr.  £, 
01.  Morrlmae  Cl)xx,  01.  Caryophylli  O)J,  Tinct.  Lavandulse 
Co.  Cl)v,  Pulv.  Acacia?  gr.  v,  Aq.  ad  3i  ter  die. 

If  the  child  objects  greatly  to  its  taste  it  can  be  used  by  in- 
unction :  years  ago  I  made  some  observations  at  the  suggestion 
of  Dr.  Burney  Yeo  upon  the  absorbability  of  iodoform  through 
the  skin,  and  I  found  that  it  was  absorbed  with  rapidity.  For 
instance,  half  a  drachm  of  the  unguentum  iodoformi  gently 
rubbed  over  the  abdomen  at  9  a.m.  was  easily  detectable  by 
the  presence  of  iodine  in  the  urine  at  11  a.m.,  and  the  drug 
continued  to  be  excreted  in  the  urine  for  at  least  fourteen  hours 


ABDOMINAL  TUBERCULOSIS        439 

after  its  application.  It  is  evident  that  it  may  have  some 
influence  on  the  tuberculous  process  in  the  peritoneum. 
Dr.  Burney  Yeo  has  recommended  the  use  of  equal  parts  of  iodo- 
form  ointment  and  cod-liver  oil  for  inunction  twice  daily.  It 
is  necessary  to  be  watchful  in  the  use  of  iodoform  inunction ; 
a  boy  of  five  years  whom  I  treated  thus  suffered  with  vomiting 
and  irregularity  of  the  pulse  after  a  second  inunction  of  half  a 
drachm  of  the  iodoform  ointment. 

All  treatment  by  inunction  has  the  great  drawback  that  it 
renders  dosage  vague  and  uncertain,  and  therefore  I  prefer 
when  possible  to  treat  by  oral  administration. 

Creosote  is  another  drug  which  I  think  undoubtedly  has  a 
therapeutic  value  in  this,  as  in  some  other  forms  of  tuberculosis  : 
not  only  has  it  a  very  decided  effect  in  correcting  fermentative 
processes  in  the  bowel — and  any  such  condition  is  to  be  com- 
bated in  tuberculous  peritonitis  in  view  of  the  possibly  ulcerated 
condition  of  the  intestinal  mucosa — but  creosote  seems  also  to 
be  in  some  way  antagonistic  to  the  tubercle  bacillus. 

Creosote  can  be  given  conveniently  in  a  cod-liver  oil  emulsion ; 
there  are  several  combinations  of  this  kind  in  the  market,  some 
of  which  disguise  the  unpleasantness  of  creosote  as  far  as  is 
possible.  If  there  is  diarrhoea  the  creosote  is  best  given  in 
a  castor  oil  mixture  with  opium  if  necessary,  thus  :  Creosote 
tt)J,  Ol.  Ricini  0)v,  Spirit.  Chloroformi  CQi,  Mucilag.  Acacise 
<X)xv,  Aq.  Anethi  ad  3i,  to  be  given  thrice  daily  immediately 
after  food. 

In  giving  creosote  to  children  it  must  be  remembered  that  even 
with  the  small  doses  which  are  appropriate  for  them,  such  as 
J-l  minim,  its  administration  continued  for  many  weeks  is  very 
apt  to  cause  loss  of  appetite. 

I  have  also  used  malt  extract  with  iron  iodide,  I  think  with 
advantage.  Urea  has  been  thought  to  exert  some  special 
influence  in  restraining  tuberculous  processes,  and  having  seen 
rapid  recovery  follow  its  use  in  a  case  of  tuberculous  dactylitis, 
I  have  tried  it  also  in  cases  of  tuberculous  peritonitis.  In  one 
of  these  apparently  complete  recovery  followed,  but  other 
drugs  had  been  used  before,  and  may  have  had  a  share  in  pro- 
moting the  recovery  :  I  have  used  it  in  several  advanced  cases 
without  any  perceptible  influence.  The  doses  I  have  used 
have  been  3-5  grains  three  times  a  day,  given  with  some  syrup 
of  tolu  and  water. 

Mercurial  inunction  is  a  very  old  method  of  treatment.  I  have 
used  it  in  many  cases  but  am  not  very  certain  as  to  benefit 


440  COMMON  "DISORDERS  OF  CHILDHOOD 

from  it :  half  a  drachm  of  the  unguentum  hydrargyri,  amounting 
in  more  convenient  terms  to  a  piece  the  size  of  a  large  pea, 
may  be  smeared  over  the  abdomen  every  night  daily  and  covered 
with  a  flannel  binder ;  the  ointment  should  be  thoroughly 
cleaned  off  the  skin  each  morning. 

Lastly — and  I  put  it  last  because  it  is  yet  in  the  stage  of  pro- 
bation— the  use  of  tuberculin  must  be  considered.  Others  perhaps 
who  have  had  larger  experience  of  it  can  speak  with  more  con- 
fidence than  I  of  its  beneficial  effects  in  tuberculous  peritonitis. 
I  have  used  it,  and  seen  it  used,  subcutaneously,  by  mouth, 
and  by  rectum.  In  advanced  cases  it  has  not  seemed  to  me  to 
have  any  effect  which  could  be  appreciated  by  bedside  observa- 
tion; in  an  infant  of  eight  months,  with  a  small  amount  of 
fluid  in  the  abdomen  and  some  fever  and  wasting,  the  parents 
took  the  child  at  my  suggestion  to  Dr.  Latham  for  rectal  injection 
of  tuberculin ;  the  symptoms  and  signs  passed  off  entirely  under 
this  treatment.  If  further  experience  confirms  the  interesting 
observations  of  Dr.  Latham  on  the  value  of  tuberculin  given  by 
mouth  or  rectum,  this  mode  of  administration  would  be  much 
preferable  to  the  subcutaneous  injection  for  children,  who  are  so 
easily  distressed  by  the  slight  pain  of  a  needle-prick. 


CHAPTER  XXXI 
ON  TUBERCULOUS  GLANDS  IN  THE  NECK 

I  SHALL  preface  what  I  have  to  say  on  this  subject  by  some 
general  remarks  on  affections  of  the  lymphatic  glands  in  children. 

In  the  diseases  of  childhood,  the  lymphatic  glands  play  a  more 
prominent  part  than  in  those  of  the  adult.  At  any  age  their 
function  as  filters  for  the  arrest  of  irritating  substances,  bac- 
terial or  otherwise,  passing  along  the  lymph -stream,  must  render 
them  specially  liable  to  morbid  processes,  but  in  childhood  this 
liability  seems  to  be  at  its  height.  As  a  result  of  this  special 
sensitiveness,  enlargement  of  glands  is  particularly  frequent  in 
childhood,  and  the  enlargement  is  generally  to  be  traced  to 
absorption  of  infective  material  from  the  area  which  the  gland 
drains.  I  mention  this  elementary  fact  because  I  think  that  in 
dealing  with  tuberculous  glands  there  is  a  tendency  to  make 
much  of  constitutional  predisposition,  and  to  forget  that,  as  in 
other  infections  of  glands,  the  virus  has  usually  entered  through 
the  area  which  the  gland  drains,  and  that  our  treatment  must 
take  this  into  account. 

The  lymphatic  glands  have  a  further  function  in  the  pro- 
duction of  white  corpuscles,  and  they  may  become  enlarged  as 
part  of  a  widespread  disturbance  of  blood  formation,  as  in 
lymphatic  leukaemia. 

Apart  from  the  causes  of  enlargement  already  mentioned, 
there  are  lymphadenoma  and  lymphosarcoma,  of  which  at 
present  we  know  only  enough  to  surmise  that  they  may  be  due 
to  some  unknown  irritant  or  infection. 

I  have  implied  that  enlargement  of  lymphatic  glands  neces- 
sarily indicates  some  morbid  process,  but  I  would  venture  to 
question  whether  unusual  palpability  is  necessarily  a  sign  of 
disease.  Other  lymphoid  tissues,  the  thymus,  the  spleen,  the 
Peyer's  patches,  and,  I  think,  even  the  tonsils,  and  the  adenoid 
tissue  of  the  naso-pharynx,  vary  in  amount  in  different  children 
at  the  same  age  without  any  apparent  disturbance  of  health ;  it 
seems  therefore  quite  conceivable  that  the  lymphatic  glands  may 
also  vary  in  this  respect,  so  that  without  any  departure  from 


442  COMMON  DISORDERS  OF  CHILDHOOD 

health,  they  may  be  more  palpable  in  one  child  than  in  another. 
Clinical  experience  seems  to  show  that  this  is  so,  and  it  is  worthy 
of  note,  because  unnecessary  alarm  is  sometimes  caused  by  the 
discovery  that  a  child  has  many  lymphatic  glands  felt  more 
easily  than  is  usual. 

But  having  ventured  this  suggestion,  I  must  again  insist  that 
palpable  enlargement  of  glands  should  always  make  us  search 
for  irritation  in  the  area  which  they  drain.  It  is  difficult  to  get 
the  laity  to  realize  this.  We  are  all  familiar  with  the  mother 
who  brings  her  child  to  hospital  for  enlarged  glands  in  the  occi- 
pital region,  and  goes  away  indignant  and  unbelieving  when  it 
is  pointed  out  that  the  one  thing  needful  is  to  rid  the  hair  of 
podiculi  capitis.  The  relation  of  the  enlargement  to  its  source 
is  still  more  apt  to  be  overlooked  where,  as  very  commonly 
happens,  a  child  with  chronic  nasopharyngeal  catarrh  has  pal- 
pable and  sometimes  even  visible  swelling  of  small  lymphatic 
glands  in  the  posterior  triangle  of  the  neck. 

One  might  multiply  instances  to  show  the  special  sensitive- 
ness of  the  glands  in  childhood.  With  any  unhealthy  condition 
of  the  tonsils,  how  much  more  readily  the  glands  just  behind 
the  angle  of  the  jaw  become  swollen  in  the  child,  than  in  the 
adult.  Again,  how  sensitive  an  index  of  catarrh  of  the  middle 
car,  in  a  young  child,  is  the  little  gland  which,  when  swollen, 
becomes  just  palpable  over  the  mastoid  bone.  I  have  instanced 
glands  in  these  parts,  rather  than  elsewhere  in  the  body,  because 
I  want  to  insist  that  there  are  many  sources  of  irritation  and 
infection  for  the  cervical  glands,  and  the  one  great  reason  why 
these  glands  are  so  often  enlarged  is  their  close  relation  to  the 
nasopharyngeal  mucous  membrane,  which,  like  mucous  mem- 
branes in  other  parts  of  the  body,  is  peculiarly  liable  to  morbid 
processes,  catarrhal  or  otherwise,  and,  like  them,  has  an  exten- 
sive lymphatic  drainage.  I  would  specially  emphasize  this  rela- 
tion, because  it  accounts  for  a  very  considerable  majority  of 
the  enlargements  of  cervical  glands,  and  I  might  add  that  a 
large  proportion  of  children,  at  any  rate  in  the  damp  climate 
and  variable  temperatures  of  this  country,  suffer  from  some 
catarrhal  condition  of  the  nasopharyngeal  mucosa,  and  conse- 
quently have  more  or  less  enlargement  of  glands  in  the  neck. 

It  is  perhaps  hardly  realized  how  few  children  there  are  in 
whom  no  glands  can  be  felt  in  the  neck.  With  this  point  in 
view,  I  examined  a  series  of  100  consecutive  cases,  seen  in  private 
practice,  children  in  whom  there  was  no  suspicion  of  tubercle 
in  the  glands  or  elsewhere  (nor  had  any  of  them  nits  in  the  hair). 


TUBERCULOUS  GLANDS  IN  THE  NECK          443 

No  less  than  83  per  cent,  showed  palpable  glands  in  the  neck  ; 
in  69  per  cent,  the  glands  behind  the  angles  of  the  jaw  were 
more  or  less  enlarged. 

I  have  said  enough  to  indicate  that  there  are  many  other 
causes  for  enlargement  of  glands  in  the  neck  besides  tubercle  ; 
nevertheless  it  remains  true,  that  of  all  the  superficial  lymphatic 
glands  in  the  body,  the  most  frequently  affected  by  tubercle 
are  those  in  the  neck  ;  even  in  comparison  with  the  deep  glands, 
this  special  liability  of  the  cervical  is  striking,  for  in  post  mortem 
observations  they  showed  more  or  less  caseation  in  81  per  cent, 
of  tuberculous  children,  the  same  proportion  as  in  the  case  of 
the  mediastinal,  whilst  in  the  mesenteric  glands  the  proportion 
was  59  per  cent. 

The  frequency  of  tuberculosis  in  these  three  groups  is  no 
doubt  due  to  the  fact  that  these  particular  glands  are,  so  to 
speak,  the  outposts  of  defence,  and  therefore  most  exposed  to 
attack  at  parts  where  the  tuberculous  infection  most  commonly 
makes  its  entry,  namely,  the  fauces,  the  lungs,  and  the  intestine. 

It  is  easy  to  understand  on  these  grounds  also  why  certain 
lymphatic  glands  are  very  rarely  affected,  as  they  drain  areas 
comparatively  seldom  attacked  by  tubercle,  e.  g.  the  skin. 
Thus,  the  lymphatic  glands  of  the  groin,  and  of  the  axilla,  as 
also  those  along  the  brachial  artery  and  in  the  popliteal  space, 
and  in  the  back  of  the  neck,  very  rarely  become  tuberculous. 
I  mention  this  because  one  is  not  infrequently  consulted  about 
glands  which  are  unusually  palpable  in  the  back  of  the  neck, 
or  in  the  groin ;  the  parents  have  noticed  them,  and  the  question 
of  tubercle  is  raised.  Remembering  the  rarity  of  tubercle  in 
these  glands,  one  can  almost  always  assure  the  parents  that 
palpability  is  not  due  to  any  tuberculous  enlargement.  On  the 
other  hand,  in  very  rare  cases  some  tuberculous  affection  of  the 
skin  of  the  limbs,  or  scalp,  has  caused  tuberculous  affection 
of  these  glands,  and  I  have  known  operation  necessary  for 
tuberculous  enlargement  of  axillary  glands  where  no  source  could 
be  traced,  and  one  supposed  that  the  infection  might  have  been 
carried  from  some  distant  part  by  the  blood-stream,  a  method 
of  infection  which  is  probably  very  uncommon  in  the  lymphatic 
glands,  to  which  infection  is  usually  conveyed  by  the  lymphatics, 
not  by  the  blood. 

Related  to  this  rarity  of  infection  by  the  blood-stream  is  the 
rarity  of  general  tuberculosis  of  the  superficial  lymphatic  glands, 
a  condition  which  has  only  occasionally  been  observed.  It  is 
common  enough  to  find  in  any  fatal  case  of  tuberculosis  in  a 


444  COMMON  DISORDERS  OP  CHILDHOOD 

child  the  cervical,  mediastinal,  and  mesenteric  glands  all  more 
or  less  infected  with  tubercle,  but  the  glandular  disease  in  these 
cases  is  no  doubt  due  partly  to  infection  by  the  lymph -stream 
from  the  areas  drained  by  these  particular  glands,  and  partly 
to  direct  extension  from  gland  to  gland  ;  such  a  condition  is 
quite  distinct  from  the  general  infection  of  superficial  glands 
which  has  in  rare  instances  simulated  Hodgkin's  Disease.  I 
have  never  met  with  such  a  condition  myself. 

As  I  have  already  mentioned,  tubercle  was  found  at  autopsy 
in  the  glands  of  the  neck  in  81  per  cent,  of  tuberculous  children, 
but  it  must  not  be  supposed  that  the  infection  of  these  glands 
was  primary,  or  even  an  early  event  in  these  cases  ;  on  the  con- 
trary, in  nearly  all  it  was  obvious  from  the  limited  and  early 
character  of  the  tubercular  lesions,  that  they  had  followed  upon 
extensive  tuberculosis  elsewhere.  In  many  cases  small  foci  of 
tubercle  in  the  cervical  glands  were  associated  with  advanced 
pulmonary  tuberculosis,  and  it  seemed  probable  that  the  disease 
in  the  cervical  glands  was  the  result,  not  the  cause,  of  the  lung 
infection.  The  child  coughs  up  tubercular  sputum  from  the  lung 
into  the  nasopharynx,  where  the  constant  presence  of  tubercle 
bacilli  leads,  sooner  or  later,  to  infection  of  glands  through  the 
adenoid  tissue  of  the  pharynx  or  through  the  tonsil.  In  the 
majority  of  these  cases  the  enlargement  of  the  cervical  glands 
had  either  been  so  slight  that  it  had  not  attracted  attention 
during  life,  or  the  evidence  of  advanced  disease  in  other  parts 
had  been  so  pronounced  that  the  enlarged  glands  in  the  neck  were 
regarded  as  of  secondary  importance,  if  not  as  secondary  in  order 
of  infection. 

Very  different  is  the  order  of  events  in  the  common  cases 
where  treatment  is  sought  for  enlargement  of  cervical  glands ; 
these,  it  is  true,  may  be  secondary  to  tuberculosis  in  some  other 
part  of  the  body,  particularly  the  lungs,  but  clinical  experience 
suggests  that  this  is  quite  the  exception.  Extensive  tuber- 
culous disease  in  the  lungs  or  elsewhere  is  commonly  associated 
with  infection  of  the  glands  of  the  n?ck,  but  the  converse  does 
not  hold  good.  Tuberculous  disease  of  the  glands  in  the  neck, 
however  extensive  it  may  be,  is  not  necessarily  nor  indeed  usually 
associated  with  tuberculosis  elsewhere,  so  far  as  can  be  judged 
from  clinical  evidence,  and  experience  shows  that  affection  of 
these  glands  but  seldom  leads  to  tuberculous  disease  in  other 
parts  of  the  body.  This  is  a  point  of  considerable  practical 
importance,  because  the  first  inquiry  of  parents,  when  they 
learn  that  their  child  has  tuberculous  glands  in  the  neck,  is 


TUBERCULOUS  GLANDS  IN  THE  NECK    445 

*  Does  this  mean  that  the  child  has  the  disease  in  other  parts  ?' 
'  Does  it  mean  that  he  will  develop  consumption  ? ' 

Age  at  onset.  In  about  75  per  cent,  of  the  cases  of  tuber- 
culous enlargement  of  glands  in  the  neck  the  disease  begins 
before  the  age  of  7  years  ;  it  is  uncommon  under  the  age  of  18 
months,  and  seldom  begins  after  the  age  of  10  years. 

Etiology.  The  age  incidence  has  an  interest  in  relation  to  the 
source  of  infection.  It  has  recently  been  shown  by  Dr.  A.  P. 
Mitchell  *  that  tuberculosis  of  cervical  glands  in  children  is  due 
to  the  bovine  type  of  bacillus  in  the  large  majority  of  cases 
(65  out  of  72),  and  investigations  2  of  the  milk  supply  have  con- 
firmed the  view  that  in  a  very  large  proportion  of  the  cases  the 
infection  has  been  conveyed  by  unboiled  milk. 

These  observations  explain  the  comparative  infrequency  of 
tuberculosis  of  cervical  glands  in  infants,  for  although  infancy 
is  the  period  of  milk -feeding,  it  is  also  the  time  when  milk  is 
most  often  given  boiled  or  pasteurized.  But  these  remarks  will 
not  apply  to  all  countries ;  if  milk  infection  plays  so  important 
a  part,  the  frequency  of  tuberculosis  of  the  cervical  glands  in 
infancy,  as  at  other  ages,  will  depend  largely  upon  the  prevailing 
usage  of  boiled  or  unboiled  milk  in  the  particular  district  from 
which  the  statistics  are  taken. 

Dr.  Mitchell's  figures,  taken  in  Edinburgh,  show  an  unusually 
high  percentage  of  cases  amongst  infants  aged  1-2  years — 
22  per  cent.  ;  but  this  agrees  with  his  observation  that  84  per 
cent,  of  children  under  2  years  of  age,  in  his  series,  had  been  fed 
since  birth  with  unsterilized  cow's  milk,  whereas  my  own  obser- 
vations are  drawn  from  parts  of  England  where  for  at  least  the 
first  year  of  life  cow's  milk  is  usually  given  pasteurized  or 
boiled. 

It  is  hardly  possible  to  exaggerate  the  importance  of  the  milk 
factor  in  the  etiology  of  tuberculous  glands  in  the  neck.  Dr. 
Mitchell  concluded  that  '  cow's  milk  containing  bovine  tubercle 
bacilli  is  clearly  the  cause  of  90  per  cent,  of  the  cases  of  tuber- 
culous cervical  glands  in  infants  and  children  residing  in  Edin- 
burgh and  district '.  If  only  the  danger  of  tuberculous  milk 
were  fully  recognized,  and  the  enormous  gain  in  safety  from 
boiling  or  pasteurizing  were  appreciated,  we  should  see  less  of 
these  troublesome  cases  of  tuberculous  glands  in  the  neck. 

There  is  a  predisposing  cause  which,  perhaps,  also  has  some 
bearing  on  the  age  incidence.  Any  inflammatory  enlargement 

1  Brit.  Mcd.  Journ.,  Jan.  27,  1914. 

*  Trans.  Internal.  Cong.  Med.,  1913,  Sec.  X,  Pt.  1,  p.  47. 


446  COMMON  DISORDERS  OF  CHILDHOOD 

of  the  lymphatic  glands  renders  them  more  susceptible  to  tuber- 
culous infection,  hence  the  chronic  enlargement  which  is  so 
often  associated  with  enlarged  tonsils  and  adenoids  favours  the 
incidence  of  tubercle,  and  this  is  a  factor  which  is  seldom  in 
evidence  before  the  age  of  2  years. 

Symptoms.  As  a  rule,  the  enlargement  of  the  glands  is  slow 
and  insidious.  The  child  is  paler  than  usual,  and,  without 
seeming  ill,  is  lacking  in  tone  and  vivacity.  The  temperature 
is  not  necessarily  raised  at  all  ;  if  it  is  taken  regularly,  there 
may  be  found  some  slight  elevation,  99°-100°,  at  night,  occa- 
sionally. The  general  nutrition  is  hardly  affected.  The  glands 
at  first  are  rather  felt  than  seen,  and  the  one  to  be  first  affected 
is  most  commonly  that  behind  the  angle  of  the  jaw,  which  drains 
the  tonsil ;  subsequently  the  disease  extends  downwards,  from 
gland  to  gland,  along  the  anterior  edge  of  the  sternomastoid, 
and  sometimes  beneath  the  upper  part  of  the  sternomastoid,  or 
along  its  posterior  edge.  Soon,  the  swollen  glands  become 
visible,  and  there  may  be  some  periadenitis,  causing  matting 
together  of  adjoining  glands.  All  this  may  be,  and  usually  is, 
a  process  of  many  months,  or  even  two  or  three  years,  but  I 
would  particularly  draw  attention  to  the  occasional  acute  onset 
of  tuberculous  glandular  enlargement  ;  sometimes,  in  a  child 
who  has  previously  shown  no  tendency  to  tubercle,  the  glands 
behind  the  angle  of  the  jaw  suddenly  enlarge,  so  that  within 
two  or  three  days  a  bulging  swelling  appears,  which  in  the 
acuteness  of  its  onset  seems  so  unlike  a  tuberculous  condition, 
that  some  septic  infection  from  the  throat  is  suspected.  Never- 
theless, subsequent  events  prove  that  it  is  tuberculous  ;  occa- 
sionally it  passes  forthwith  into  the  stage  of  softening,  and 
tubercle  bacilli  are  found  in  the  caseous  pus,  or  it  subsides  into 
a  chronic  enlargement  which  runs  the  ordinary  course  of  tuber- 
culous glands. 

A  point  which  is  worthy  of  note  in  the  behaviour  of  the  tuber- 
culous gland  is  its  variation  in  size  from  time  to  time  :  for  a  few 
weeks,  perhaps,  it  seems  to  be  growing  smaller,  then  it  increases 
a.irain  for  a  time,  and  then  perhaps  diminishes  again.  Such 
changes  are  very  characteristic  of  the  disease  and  must  carry 
some  weight  in  diagnosis.  I  have  been  assured  by  some  parents 
that  the  glands  varied  in  size  even  during  the  day,  and  several 
have  told  mo  that  the  glands  were  often  larger  in  the  evening. 
No  doubt  these  observations  by  lay  persons  may  be  fallacious, 
but  1  am  not  sure  that  they  are  altogether  incorrect. 

Lastly,  I  would  emphasize  the  rapidity  with  which  a  tuber- 


TUBERCULOUS  GLANDS  IN  THE  NECK          447 

culous  gland  may  undergo  softening  :  sometimes,  within  a  few 
days,  a  gland  which  has  remained  for  months  firm  or  hard, 
suddenly  becomes  larger,  and,  at  the  same  time,  is  found  to  be 
soft  and  fluctuating — an  important  point  to  bear  in  mind  when 
sending  these  children  to  the  country,  perhaps  out  of  reach  of 
proper  surgical  intervention. 

Diagnosis.  The  differentiation  of  tuberculous  from  other 
enlargements  of  cervical  glands  is  by  no  means  easy.  The  size 
has  undoubtedly  some  bearing  upon  diagnosis  ;  tuberculous 
glands  tend  to  enlarge  beyond  the  lesser  degrees  ;  where  there 
is  no  gland  in  the  neck  larger  than  an  ordinary  almond,  a  simple 
irritative  enlargement  is  more  likely  than  where  the  glands  are 
as  large  as  a  walnut,  but,  as  any  one  knows  who  has  seen  tuber- 
culous glands  dissected  out  of  the  neck,  there  are  usually,  in 
addition  to  the  larger  caseous  glands,  many  quite  small,  some 
even  not  larger  than  a  hemp-seed,  with  yellow  points  of  tubercle 
in  them.  In  regard  to  size,  however,  some  distinction  must 
be  made  between  acute  and  chronic  enlargement,  for  a  simple 
septic  adenitis  will  produce  an  acute  swelling  of  a  gland  as  large 
as  any  tuberculous  condition,  but  a  chronic  enlargement  of  the 
same  size  would  point  to  tubercle. 

As  I  have  already  mentioned,  frequent  variations  in  the  size 
of  chronically  enlarged  glands  are  strongly  in  favour  of  tubercle. 

The  distribution  of  the  enlargement  may  throw  some  light  on 
the  problem  ;  a  considerable  unilateral  enlargement  suggests 
tubercle,  but  only  because  any  simple  septic  inflammation  of 
the  fauces  usually  affects  both  sides  of  the  throat,  and  therefore 
is  likely  to  affect  the  glands  on  both  sides. 

A  more  reliable  indication  is  afforded  by  erratic  distribution 
of  enlargement  amongst  the  glands,  as  if  the  morbid  process 
were  much  more  advanced  in  one  gland  than  in  another  ;  for 
instance,  where  in  a  chain  of  glands  moderately  and  for  the  most 
part  evenly  enlarged,  one  is  swollen  altogether  out  of  proportion 
to  the  rest,  the  probability  is  that  it  is  tuberculous. 

The  consistency  of  the  gland  is  also  a  help  ;  hardness  suggests 
tuberculosis  ;  in  its  early  stages,  however,  tuberculosis  produces 
no  more  induration  than  a  simple  inflammatory  enlargement ;  it 
is  only  when  there  is  already  firm  caseous  or  calcareous  change 
or  extensive  fibrosis  that  the  gland  loses  its  normal  feeling  of 
elasticity,  and  becomes  so  hard  that  one  can  feel  fairly  confident 
of  its  tuberculous  nature. 

The  rate  of  enlargement  is  but  a  poor  criterion.  As  a  rule 
tuberculous  enlargement  is  of  slow  and  insidious  onset,  but,  as 


448  COMMON  DISORDERS  OF  CHILDHOOD 

already  mentioned  a  gland  may  swell  up  within  forty-eight  hours 
to  such  an  extent  that  simple  septic  inflammation  is  regarded 
as  almost  certain,  nevertheless  the  glands  have  proved  to  be 
tuberculous. 

I  have  often  thought  that  the  shape  of  an  enlarged  gland  has 
some  bearing  on  diagnosis  ;  a  tuberculous  gland,  especially  when 
the  process  is  chronic,  and  caseation  has  occurred,  tends  to 
become  round  rather  than  oval  ;  a  hard  round  gland  is  most 
likely  to  be  tuberculous. 

It  is  evident  from  the  uncertainty  of  any  of  these  criteria, 
taken  alone,  and  indeed  of  them  all  taken  together,  that  there  is 
often  great  difficulty  in  pronouncing  upon  the  character  of  gland 
enlargement,  particularly  in  distinguishing  between  a  simple 
septic  adenitis  and  a  tuberculous  enlargement.  Lymphadenoma 
is,  next  to  simple  inflammatory  enlargement,  the  affection  of 
glands  which  is  most  likely  to  be  confused  with  tubercle  ;  no 
doubt  the  distinction  is  easy  enough  in  a  pronounced  case, 
the  discrete  character  of  the  glands  and  the  multiple  enlarge- 
ment, affecting  not  only  the  cervical  but  other  superficial 
glands  elsewhere,  and  perhaps  also  some  of  the  deeper  pal- 
pable glands,  are  points  sufficient  for  diagnosis ;  but  in  the 
early  stage,  when  the  lymphadenoma  has  affected  perhaps  only 
two  or  three  glands  on  one  side  of  the  neck — and  I  have 
known  it  to  remain  thus  for  many  weeks — decision  may  be 
impossible  until  either  examination  of  a  removed  gland  or  the 
gradual  generalization  of  the  enlargement  shows  the  nature  of 
the  disease.  Lymphosarcoma  is  much  rarer,  but  I  have  seen 
it  in  the  glands  of  the  neck  at  the  age  of  three  years,  and  have 
known  the  elasticity  of  the  very  vascular  growth  to  simulate 
closely  the  fluctuation  of  a  broken-do\vn  caseous  gland. 

There  is  yet  another  condition  in  which  enlargement  of  glands 
may  raise  the  question  of  tubercle,  namely,  acute  lymphatic 
kuikamiia.  In  its  early  stage,  before  the  pallor  becomes  so 
striking  as  in  itself  to  suggest  a  blood  disease,  there  is  sometimes 
<|iiite  a  noticeable  enlargement  of  the  glands  in  the  neck,  as  well 
as  elsewhere,  but  the  enlargement  does  not  reach  any  great 
degree,  the  glands  are  rather  palpable  than  visible,  or,  at  most, 
arc  just  visible  ;  they  are  markedly  discrete,  and  the  enlarge- 
ment is  general,  so  that  many  glands  which  are  not  commonly 
anYcted  by  tubercle,  such  as  those  in  the  back  of  the  neck,  the 
axilla,  and  groin,  arc  affected.  If  the  possibility  of  leukemia  is 
borne  in  mind,  it  is  of  course  recognized  easily  by  a  blood 
count. 


TUBERCULOUS  GLANDS  IN  THE  NECK    449 

There  is  a  tumour  in  the  neck  which  one  might  think  could 
hardly  be  confused  with  swollen  glands,  but  as  I  have  more  than 
once  known  the  mistake  made,  I  mention  it  here,  namely, 
sternomastoid  haematoma,  which  occurs  in  the  new-born  as 
the  result  of  injury  during  delivery.  The  tumour,  situated 
usually  about  the  junction  of  the  upper  and  middle  third  of  the 
muscle,  is  firm,  or  indeed  quite  hard  ;  it  is  often  the  size  of  a 
small  walnut,  and  so  far  might  pass  as  a  swollen  gland,  but  care- 
ful palpation  shows  that  it  is  in  the  substance  of  the  muscle, 
and  the  history  that  it  has  been  noticed  usually  when  the  infant 
was  only  a  few  weeks  old  would  in  itself  make  any  glandular 
swelling  improbable,  and  puts  tuberculous  enlargement  almost 
out  of  court. 

Prognosis.  The  general  outlook  is  favourable  ;  experience 
shows  that  only  a  small  proportion  of  children  who  come  under 
treatment  for  tuberculous  glands  in  the  neck  have,  or  subse- 
quently develop,  tuberculosis  elsewhere.. 

Granted,  however,  that  infection  of  other  parts  of  the  body, 
directly  or  indirectly  from  tuberculous  glands  in  the  neck,  is 
uncommon,  one  cannot  ignore  the  fact  that  the  tuberculosis  in 
these  glands,  as  in  any  other  part,  points  to  an  unduly  weak 
resistance  to  tubercle,  and  on  this  ground  necessitates  caution 
in  prognosis. 

As  regards  the  glands  themselves,  there  can  be  no  doubt  that 
the  process  may  undergo  arrest  here,  as  elsewhere,  and  the  only 
trace  of  its  occurrence  may  be  some  fibrous  induration  of  the 
gland,  or  perhaps  a  calcareous  focus  where  a  caseous  spot  has 
occurred  ;  but  my  own  experience  has  been  that  the  larger  the 
gland  the  less  likely  is  such  a  result  ;  more  often,  after  persistent 
enlargement  for  several  months,  with  slight  variations  in  size 
from  time  to  time,  the  glands  eventually  soften,  and  surgical 
measures  become  necessary. 

Treatment.  Prophylactic.  Before  discussing  the  treatment, 
I  should  like  to  lay  some  stress  upon  the  prevention  of  tuber- 
culous glands  in  the  neck.  As  already  mentioned,  there  is  very 
strong  evidence  that  in  a  large  majority  of  the  cases  the  disease 
is  due  to  the  use  of  tubercle-infected  milk.  In  some  places 
nearly  20  per  cent,  of  samples  of  milk  have  shown  the  tubercle 
bacillus.  There  is  no  doubt  that  by  boiling  the  milk  this  source 
of  infection  can  be  entirely  avoided. 

Clinical  evidence  seems  to  show  that  any  inflammatory  en- 
largement of  a  gland  renders  it  more  vulnerable  to  tubercle,  and 
therefore  any  source  of  irritation  which  may  cause  enlargement 

STILL  Q.  or 


450  COMMON  DISORDERS  OF  CHILDHOOD 

of  glands  is  specially  to  be  avoided  in  the  child  of  tuberculous 
family,  in  whom  on  this  account  unhealthy  tonsils,  adenoids,  or 
carious  teeth  call  the  more  urgently  for  treatment. 

Curative.  The  remedy  which  has  most  effect  upon  tuber- 
culous glands  in  the  neck  is  sea -air  ;  a  bracing  climate  usually 
does  most  good,  such  as  the  Kent  coast,  Herne  Bay,  Margate, 
Broadstairs,  or  Folkestone  ;  or,  on  the  east  coast,  such  places 
as  Whitby,  Scarborough,  Sheringham,  or  Felixstowe ;  or  the  north 
coast  of  Cornwall  or  Devon.  But  many  such  places  are  less 
suitable  in  the  winter,  and  on  this  account,  as  well  as  for  the 
reason  that  change  of  air  in  itself  seems  to  do  these  cases  good, 
permanent  residence  at  any  particular  part  may  be  less  advis- 
able than  a  change  of  place  with  the  seasons  :  Hastings  or 
Worthing,  or  even  the  milder  seaside  places,  such  as  WestclifT, 
Torquay,  or  Falmouth,  may  be  more  suitable  for  the  winter. 
Mountain  resorts,  for  instance,  in  Switzerland,  have  seemed  to 
me  generally  less  satisfactory  for  these  children,  but  if  inland 
places  are  the  only  ones  available,  high  ground  with  a  bracing 
atmosphere  is  to  be  recommended. 

Here  I  would  add  a  caution  :  in  sending  a  child  away  to  the 
seaside  or  country  for  tuberculous  glands,  it  is  extremely  impor- 
tant to  emphasize  the  necessity  for  frequent  medical  inspection 
whilst  away,  for  the  glands,  sometimes,  very  suddenly  and  rapidly 
soften  and  form  an  abscess,  and  in  this  way  the  opportunity 
for  surgical  intervention  at  the  right  moment  may  be  lost. 

Where  there  is  extensive  glandular  involvement,  complete 
recumbency  for  a  few  weeks  is  a  very  valuable  adjunct  to  the 
climatic  treatment.  The  child  can  be  taken  out  in  an  invalid 
perambulator,  so  that  there  need  be  no  interference  with  the 
open-air  regimen  which  is  essential  for  these  cases. 

Whatever  treatment  is  adopted,  these  cases  require  generous 
feeding,  but  all  the  milk  should  be  given  boiled  or  pasteurized ; 
it  is  illogical  to  be  pouring  tubercle  bacilli  into  the  child  whilst 
we  are  fighting  tuberculosis  in  the  glands.  Cream,  it  must  be 
remembered,  is  nearly,  if  not  quite,  as  dangerous  as  unboiled 
milk  in  conveying  tuberculous  infection,  and  as  it  is  difficult  to 
sterilize  cream  it  is  best  avoided  altogether.  A  useful  substitute 
for  it  is  ordinary  sweetened  condensed  milk,  which  most  children 
enjoy  when  it  is  given  undiluted,  with  stewed  fruit  or  otherwise. 

Dripping  instead  of  butter  is  taken  well  by  many  children, 
and  is  very  suitable. 

As  to  external  applications,  I  am  not  satisfied  that  any  good 
is  obtained  thereby.  Any  rubbing,  however  light,  is  to  be  strictly 


TUBERCULOUS  GLANDS  IN  THE  NECK    451 

forbidden.  Some  observers  have  considered  that  the  application 
of  counter-irritants  such  as  iodine  was  positively  harmful. 

Recently  the  application  of  X-rays  has  been  found  of  value 
in  some  cases,  but  this  method  of  treatment  should  only  be 
carried  out  by  some  one  with  special  knowledge  of  its  use. 

Of  drugs  for  internal  use,  perhaps  the  most  useful  is  Iron  Iodide, 
which  is  best  given  with  malt.  There  are  several  preparations 
of  it  in  the  market,  some  containing  cod-liver  oil  in  addition  to 
the  malt.  For  children  who  dislike  the  ordinary  malt  prepara- 
tions, a  dried  malt  with  Iron  Iodide  (Wander)  can  be  used 
sprinkled  on  bread  and  butter.  An  occasional  course  of  arsenic 
for  two  or  three  weeks  may  also  be  of  value. 

The  late  Dr.  Eustace  Smith  thought  highly  of  a  mixture  of 
Liq.  Ferri  Perchlor.  TT|v,  Liq.  Hyd.  Perchlor.  H\x,  Glycerin  H\xx 
aq.  ad  3  ii,  to  be  given  in  half  a  wineglassful  of  soda-water  three 
times  a  day,  after  meals. 

The  use  of  tuberculin  has  to  be  considered.  I  have  used  it 
in  many  cases,  but  combined  almost  always  with  residence  at  the 
seaside,  so  that  it  was  difficult  to  apportion  the  good  effects,  if 
any.  As  the  sum  of  my  experience,  I  can  say  that  I  have  never 
known  any  direct  harm  to  result  from  the  use  of  tuberculin  in 
these  gland  cases,  and,  on  the  other  hand,  I  have  not  seen  any 
sufficiently  definite  benefit  to  enable  me  to  urge  its  use.  I  said 
direct  harm  because  I  have  several  times  seen  very  unfortunate 
mischief  arise  indirectly  from  this  method  of  treatment ;  parents 
and  doctor  alike,  having  been  led  to  place  confidence  therein, 
have  allowed  surgical  interference  to  be  delayed  until  the  glands 
had  already  broken  down  into  an  abscess,  which  made  any  com- 
plete removal  impossible  and  inflicted  upon  the  child  many 
weeks  or  months  of  tedious  treatment  for  the  healing  of  the 


What  I  have  already  said  about  sources  of  adenitis  as  a  pre- 
disposing cause  of  tubercle  is  to  be  remembered  also  when  the 
glands  have  already  become  tuberculous  ;  an  important  part 
of  treatment  may  be  the  removal  of  tonsils  and  adenoids,  or  of 
carious  teeth,  which  by  keeping  up  a  chronic  adenitis  maintain 
a  favourable  soil  for  the  tuberculous  process. 

This  brings  me  to  the  surgical  aspect  of  treatment,  and  here 
I  must  speak  with  the  caution  which  becomes  a  physician,  but 
none  the  less  there  are  some  points  upon  which  I  shall  venture 
to  be  outspoken.  With  regard  to  the  time  and  manner  of  sur- 
gical intervention,  the  following  seems  to  me  to  be  the  correct 
attitude.  If  after  several  months'  trial  of  sea-air,  there  is  little 


452     COMMON  DISORDERS  OF  CHILDHOOD 

or  no  diminution  in  the  size  of  the  glands,  or  if  after  short  or 
long  stay  at  the  seaside  the  glands  are  becoming  larger,  or  more 
are  becoming  affected,  operation  should  not  be  delayed. 

Operative  measures  should  never  be  postponed  until  the 
glands  have  already  softened.  The  only  operation  which  is  to 
be  advised  is  the  complete  and  thorough  removal  of  all  the 
affected  glands  where  practicable.  This  is  a  much  more  exten- 
sive and  difficult  operation  than  might  be  thought,  for  although 
only  two  or  three  enlarged  glands  may  be  felt,  there  are  almost 
always  many  deeper  ones  also  affected,  which  must  be  dissected 
out  if  the  cure  is  to  be  permanent.  If  operation  is  postponed 
until  the  glands  have  already  softened  into  pus  and  there  is  much 
periadenitis,  complete  removal  may  be  impossible.  When  this 
has  happened,  the  proper  treatment  is  simple  incision  and  evacua- 
tion of  the  pus  by  drainage,  not  by  scraping.  Any  scraping  of 
tuberculous  glands  is  a  dangerous  proceeding,  for  it  entails  a 
risk  of  rubbing  the  tuberculous  material  into  adjoining  lym- 
phatics or  blood-vessels,  and  so  disseminating  the  infection  : 
a  fatal  result  from  tuberculous  meningitis  sometimes  follows 
within  a  few  weeks  of  this  scraping  operation. 

Lastly,  there  is  a  point  upon  which  advice  is  often  asked. 
Is  the  child  with  tuberculous  glands  in  the  neck  dangerous  to 
other  children  ?  In  former  years  I  took  a  light  view  of  the  risk 
of  infection  from  such  cases,  but  I  have  since  seen  several  in- 
stances in  which  there  was  strong  reason  to  believe  that  tuber- 
culosis was  conveyed  by  a  patient  with  tuberculous  glands  in 
the  neck.  The  risk,  no  doubt,  is  greater  where  there  is  an  open 
wound  or  a  discharging  abscess,  but  even  where  there  is  no 
external  opening  it  is  to  be  remembered  that  tuberculous  glands 
are  frequently  associated  v/ith  unhealthy  tonsils  and  adenoids, 
which  in  a  certain  proportion  of  the  cases  have  been  shown  to 
contain  tubercle  bacilli.  It  is  therefore  intelligible  that,  by 
sneezing  or  coughing  or  otherwise,  the  infection  may  be  con- 
veyed by  these  children  to  others.  Close  association,  therefore — 
for  instance,  in  the  schoolroom  or  bedroom — is  to  be  avoided. 
There  will,  of  course,  be  much  less  risk  from  association  out  of 
doors. 


CHAPTER  XXXII 
TUBERCULOUS  MENINGITIS 

SOME  idea  of  the  frequency  of  meningitis  in  childhood  may  be 
gleaned  from  the  following  figures  :  in  the  three  years  1905-8 
there  were  admitted  to  the  Children's  Hospital,  Great  Ormond 
Street,  8,948  children  ;  of  these  174  were  suffering  from  tuber- 
culous, 49  from  cerebro-spinal  or  posterior  basic,  and  17  from 
suppurative  meningitis. 

These  figures  give  also  a  very  fair  idea  of  the  relative  fre- 
quency of  these  three  forms  of  meningitis,  apart  from  the 
special  variations  which  may  be  induced  by  an  epidemic  of  the 
cerebro-spinal  variety. 

I  have  spoken  of  these  three  forms  of  meningitis  as  if  they 
were  the  only  varieties  met  with  in  childhood ;  and  indeed, 
for  practical  purposes  they  are  :  even  amongst  the  many  thou- 
sands of  children  who  pass  through  a  children's  hospital,  it  is 
extremely  rarely  that  any  other  variety  is  seen.  I  have  met  with 
thickening  and  matting  of  the  meninges  in  the  posterior  fossa 
two  or  three  times  in  infants  with  congenital  hydrocephalus, 
where  one  rather  assumed  than  knew  that  the  condition  might 
have  been  due  to  an  intrauterine  meningitis  perhaps  of  syphilitic 
origin.  I  have  also  seen  one  case  in  a  child  of  about  four  years, 
where  there  was  strong  clinical  evidence  of  a  gummatous  menin- 
gitis. It  has  been  thought  that  rheumatism  may  possibly  cause 
a  meningitis,  but  I  know  of  no  satisfactory  evidence  that  it  can. 

When  seeing  children  with  meningitis,  I  have  sometimes 
been  asked  whether  it  might  not  be  influenzal.  It  has  been 
proved  by  bacteriological  evidence  that  meningitis  does  occur 
but  with  extreme  rarity  as  a  result  of  infection  with  the  bacillus 
of  influenza,  but  my  own  experience  has  been  that  the  supposed 
influenzal  meningitis  usually  turns  out  to  be  either  one  of  the 
common  forms  of  meningitis  or  not  meningitis  at  all. 

Tuberculous  meningitis  is  by  far  the  commonest  variety,  so 
I  shall  take  this  as  my  starting-point  in  some  remarks  chiefly 
upon  diagnosis  and  treatment.  There  seems  to  be  no  special 
sex  liability  :  out  of  150  cases  under  my  own  observation 
73  were  girls,  77  were  boys. 


454 


COMMON  DISORDERS  OF  CHILDHOOD 


In  its  age-incidence  tuberculous  meningitis  follows  closely 
the  curve  of  tuberculosis  in  general ;  it  is  so  rare  under  the  age 
of  six  months  that  one  should  always  hesitate  to  make  this 
diagnosis  in  infants  at  this  age  ;  it  is  far  more  frequent  in  the 
second  year  of  life  than  at  any  other  period,  and  though  gradually 
diminishing  in  degree  there  persists,  until  the  end  of  the  fifth 
year,  a  special  tendency  to  this  affection. 

The  adjoining  chart  of  age-incidence  shows  the  contrast  between 
tuberculous  and  posterior  basic  meningitis  in  this  respect, 
a  point  of  some  value  in  diagnosis,  for  it  is  evident  that  under 


6-7  yr* 


•n.    ff-/0yrs     fcll<(r$     IIQyrt 


m 


V 


10 


Fia.  32.     Age-incidence  of  tuberculous  meningitis  (continuous  line)  contrasted 
with  that  of  posterior  basic  meningitis  (dotted  line). 

the  age  of  six  months  meningitis  is  more  likely  to  be  of  the 
posterior  basic  than  of  the  tuberculous  variety. 

One  other  point  I  wish  to  emphasize  in  connexion  with  the 
age-incidence  of  tuberculous  meningitis  ;  namely,  the  very 
special  liability  to  it  during  the  first  five  years  of  life.  If  we  can 
do  anything  in  the  way  of  prophylaxis  against  this  terrible 
disease,  it  is  chiefly  during  these  first  five  years  that  our  pre- 
cautions should  be  taken.  There  are  two  sources  of  tuber- 
culosis which  are  responsible  for  a  certain  number,  perhaps  for 
a  large  proportion,  of  the  deaths  from  this  disease  in  early  child- 
hood :  to  wit,  living  in  close  contact  with  other  persons,  especially 
nurses  or  relatives,  who  are  suffering  with  some  form  of  tubercu- 


TUBERCULOUS  MENINGITIS  455 

losis,  and  the  use  of  unboiled  or  un-pasteurized  cow's  milk.  In 
the  nature  of  things  it  is  impossible  to  produce  scientific  proof  of 
this  causation  in  any  particular  case,  but  none  the  less  I  think 
that  clinical  sequence  when  observed  repeatedly  may  furnish 
at  least  a  strong  presumption  of  cause  and  effect,  and  for  practical 
purposes  may  be  hardly  less  important  than  scientific  proof. 

No  one  doubts  that  there  is  a  risk  of  tuberculous  infection 
from  being  with  those  who  are  tuberculous,  but  in  the  everyday 
care  of  children  this  is  too  apt  to  be  forgotten.  I  have  notes 
of  cases  where  a  father  or  mother  has  developed  pulmonary 
tubercle ;  the  signs  were  but  slight  no  doubt,  a  few  crepitations 
at  one  apex,  hardly  more,  but  no  one  thought  of  the  danger 
to  the  little  child  who  slept  in  the  parent's  bedroom,  and  two  or 
three  months  later  the  child  was  dying  of  tuberculous  meningitis. 
Let  me  quote  a  more  striking  instance :  a  grandfather  had  shown 
signs  of  pulmonary  tuberculosis  and  was  ordered  abroad,  what 
more  natural  than  that  he  should  visit  his  married  son,  and  see 
his  little  grandchild  before  going  ?  He  did  so,  and  stayed  in  his 
son's  house  a  few  weeks  ;  about  two  months  later  I  saw  the 
grandchild  with  tuberculous  meningitis,  of  which  he  died.  In 
the  meantime  the  grandfather  had  gone  abroad,  and  there  taken 
up  his  residence  with  another  married  son,  who  also  had  a  young 
child;  within  a  few  weeks  this  child  also  sickened  with  tuber- 
culous meningitis  and  died. 

Probably  the  risk  is  greatest  where  the  child  is  brought  in 
contact  with  persons  having  the  pulmonary  form  of  tuberculosis, 
but  I  am  not  by  any  means  sure  that  it  is  safe  to  allow  a  young 
child  to  associate  with  persons  who  have  other  forms  of  tubercu- 
losis ;  for  who  shall  say  with  certainty  that  the  lungs  are  entirely 
clear  in  the  child  who  has  extensive  tuberculosis  elsewhere,  say 
in  the  abdomen  or  in  the  cervical  glands  ?  Twice  at  least  I  have 
known  tuberculous  meningitis  to  occur  in  children  who  had  been 
apparently  in  good  heath  until  this  illness,  but  had  .been  living 
recently  in  close  association  with  children  having  tuberculous 
glands  in  the  neck. 

With  regard  to  the  drinking  of  unboiled  milk,  I  think  there  is 
no  reasonable  doubt  that  this  is  one  source  of  tuberculous  infec- 
tion in  general,  and  in  particular  leads  to  tuberculous  meningitis 
via  infection  of  the  mesenteric  glands.  I  have  been  very  much 
impressed  by  cases  in  which  a  child  remained  apparently  in 
perfect  health  upon  scalded  or  boiled  milk,  and  then  a  change 
was  made,  sometimes  because  the  family  had  moved  to  a  district 
in  which  the  milk  was  reported  to  be  specially  reliable,  the  milk 


456  COMMON  DISORDERS  OF  CHILDHOOD 

was  given  unboiled,  and  within  a  month  or  two  the  child  has 
died  of  tuberculous  meningitis.  I  have  noted  this  sequence  suffi- 
ciently often  to  make  me  suspect  very  strongly  that  unboiled 
milk  is  a  real  danger  in  respect  of  tuberculous  meningitis. 

Parents  often  inquire  whether  a  blow  or  a  fall  on  the  head 
can  have  caused  the  meningitis  :  certainly  the  sequence  some- 
times suggests  that  there  may  be  some  connexion  ;  and  it  is 
reasonable  to  suppose  that  a  severe  blow  on  the  head  may  lower 
the  resistance  of  the  meninges  and  so  allow  the  tuberculous 
infection  already  present  in  other  parts  of  the  body  to  invade 
this  part,  but  we  have  no  proof  of  this  connexion,  and  considering 
the  many  tumbles  and  knocks  to  which  little  children  are 
liable,  one  must  be  careful  in  accepting  a  causal  relation  where 
there  may  be  nothing  more  than  coincidence. 

The  causal  relation  of  mental  strain,  for  instance,  of  school 
work,  seems  to  me  still  more  doubtful,  but  even  this  I  would  not 
pooh-pooh  altogether,  for  we  know  very  little  about  the  psychical 
influences  which  may  determine  resistance  to  infection,  and  if 
a  parallel  were  required  I  would  point  out  that  the  strain  of 
school  work  may  almost  certainly  determine  the  incidence  of 
chorea,  notwithstanding  the  evidence  which  accumulates  that 
chorea  depends  upon  a  specific  infection. 

Symptoms.  In  its  most  familiar  form  tuberculous  menin- 
gitis is  usually  the  first  indication  of  tuberculous  infection, 
and  in  this  sense  the  term  'primary'  has  been  applied  to  it,  to 
distinguish  it  from  the  meningitis  which  arises  cither  in  the 
course  of  some  longstanding  and  extensive  tuberculous  affection, 
for  instance,  tuberculous  peritonitis,  or  as  part  of  a  general  acute 
miliary  tuberculosis  ;  in  either  of  these  cases  its  course  is  apt 
to  be  somewhat  different  from  that  seen  in  the  so-called '  primary  ' 
form,  the  cerebral  symptoms  are  of  shorter  duration,  and,  indeed, 
may  not  become  evident  until  a  few  days  before  death. 

But  from  the  pathological  standpoint  it  may  be  doubted 
whether  tuberculous  meningitis  is  ever  really  primary  ;  even 
though  no  symptoms  or  signs  have  been  detected  during  life 
to  raise  suspicion  of  tubercle  elsewhere,  there  is  almost,  if  not 
quite  invariably,  a  caseous  focus  to  be  found  by  sufficiently 
careful  examination  in  some  other  part  of  the  body,  usually 
in  the  mediastinal  or  mesenteric  glands. 

This  point  has  its  clinical  bearing :  in  the  early  stage  when  the 
diagnosis  of  tuberculous  meningitis  is  in  question,  the  detection 
of  enlarged  glands  in  the  abdomen  may  confirm  our  suspicions, 
and  at  a  later  stage  when,  although  it  is  evident  that  there  is 


TUBERCULOUS  MENINGITIS  457 

some  form  of  meningitis  present,  it  is  still  doubtful  whether 
the  infant  is  suffering  with  tuberculous  or  with  posterior  basic 
meningitis,  I  have  sometimes  obtained  valuable  guidance  by 
detecting  hard  and  enlarged  glands  on  careful  abdominal 
palpation. 

It  is  in  these  cases  of  so-called  primary  tuberculous  meningitis 
that  the  insidiousness  of  onset  so  often  makes  diagnosis  difficult 
at  first,  nay,  I  think,  impossible  often  for  a  week  or  more.  Let 
it  be  remembered  that  tuberculous  meningitis  does  not  pick 
out  for  its  victims  always,  or  even  usually,  the  sickly  and  ill- 
nourished  :  too  often  it  is  the  rosy-cheeked,  healthy-looking 
child  that  falls  a  prey  to  tuberculous  meningitis.  I  mention 
this  because  often  at  the  early  stage  too  much  stress  is  laid 
on  the  previous  good  health  and  present  good  nutrition  of 
the  child  as  weighing  against  this  diagnosis. 

The  first  indication  of  the  coming  trouble  is  often  for  a  few 
days  nothing  more  than  simple  malaise, — the  child  who  has  been 
bright  and  active  becomes  unnaturally  quiet,  does  not  care  to 
talk,  wants  to  lie  about  ;  and  perhaps,  but  not  necessarily, 
complains  occasionally  of  headache.  I  have  sometimes  thought 
that  a  particularly  characteristic  feature  at  this  earliest  stage 
is  the  way  the  child  brightens  up  for  a  short  time,  perhaps  for 
a  few  minutes,  perhaps  longer,  and  then  wants  to  be  quiet  again. 

Sometimes  a  mental  alteration  is  the  most  noticeable  symptom, 
especially  in  the  older  children  ;  the  previously  good-tempered 
happy  child  becomes  cross  and  peevish.  I  remember  one  girl 
about  ten  years  old,  in  whom  the  first  symptom  to  attract  atten- 
tion was  alteration  of  behaviour  at  school ;  she  had  been  an 
obedient  well-behaved  child,  but  now  became  so  disobedient 
and  troublesome  that  the  teacher  complained,  and  the  parents, 
suspecting  that  there  must  be  something  more  than  naughtiness, 
brought  her  to  hospital,  where  other  evidence  soon  appeared  of 
tuberculous  meningitis. 

In  older  patients  I  have  known  this  early  mental  change  to  be 
mistaken  for  hysteria  :  it  has  also  simulated  acute  mania.  In 
some  children  an  early  symptom  is  slight  mental  confusion,  the 
child  uses  a  wrong  word  occasionally  although  otherwise  quite 
clear  and  rational  ;  or  there  may  be  more  definite  delirium. 
If  the  child  is  already  walking  the  gait  may  become  unsteady, 
perhaps  definitely  tremulous. 

Within  a  few  days  at  the  most,  vomiting  occurs  :  it  is,  I  think, 
the  most  constant  of  the  early  symptoms.  In  its  most  charac- 
teristic form  it  is  independent  of  meals,  and  it  occurs  with  little 


458  COMMON  DISORDERS  OF  CHILDHOOD 

or  no  retching,  the  contents  of  the  stomach  gush  up  without  effort ; 
but  I  should  be  sorry  to  lay  much  stress  upon  these  features, 
the  vomiting  is  often  very  definitely  related  to  food,  and  so  long 
as  the  child  takes  no  food  there  may  be  no  vomiting.  Of  far 
more  importance  is  the  fact  that  it  occurs  with  obstinate  con- 
stipation ;  to  my  mind  this  combination  of  apparently  causeless 
vomiting  with  constipation  in  any  child  over  six  months  of 
age,  especially  if  therewith  there  is  complaint  of  headache,  is 
always  suggestive  of  tuberculous  meningitis. 

The  vomiting  is  seldom  severe,  it  occurs  perhaps  only  once 
or  twice  in  the  twenty-four  hours,  and  seldom  persists  for  more 
than  a  few  days,  though  it  may  reappear  towards  the  end 
of  the  illness.  But  to  this  rule  there  are  exceptions.  I  have  seen 
cases  in  which  there  was  no  vomiting  throughout,  but  this  is 
extremely  rare  ;  much  more  often  vomiting  is  a  marked  feature 
of  the  early  stage  when  the  whole  aspect  of  the  case  may  be 
gastro -intestinal  rather  than  cerebral.  I  suppose  there  is  no 
commoner  mistake  in  the  diagnosis  of  this  disease  than  to  con- 
clude that  the  vomiting  is  due  to  some  error  of  diet  or  to  a 
*  bilious  attack  '. 

In  rare  cases  the  vomiting  is  very  severe,  even  water  cannot 
'be  retained,  and  then  I  have  known  the  condition  mistaken  for 
'cyclic  vomiting  ' ;  or,  again,  the  combination  of  severe  vomiting 
with  obstinate  constipation  has  raised  the  question  of  intestinal 
obstruction.  I  remember  a  case  of  tuberculous  meningitis  which 
was  sent  into  a  surgical  ward  for  operation  for  supposed  acute 
intestinal  obstruction. 

The  subsidence  of  the  vomiting  after  a  few  days  raises  hopes 
which  are  only  too  soon  to  be  destroyed,  for  the  headache  per- 
sists, and  the  child  does  not  recover  his  natural  vivacity.  Head- 
ache is  not  always  severe  ;  sometimes,  indeed,  its  apparent 
slightness  has  thrown  doubt  upon  the  possibility  of  tuberculous 
meningitis.  Both  in  infancy  and  in  early  childhood,  the  only 
evidence  of  headache  may  be  the  putting  of  the  hand  up  to 
the  head  ;  infants  with  headache  sometimes  beat  the  hand  against 
the  head  ;  often  in  young  children  the  presence  of  headache  h^s 
to  be  judged  from  the  pained  knitting  of  the  brows.  It  is  curious 
how  a  young  child  will  say  '  no  '  persistently  if  asked  whether 
his  head  hurts,  although  the  child  may  be  knitting  his  brows 
and  putting  his  hands  up  to  his  head  in  a  way  that  makes  it 
almost  certain  that  there  is  headache.  If  the  fontanelle  is  still 
open  its  unnatural  fullness  and  tension  is  noticeable  usually  very 
early  in  the  disease. 


TUBERCULOUS  MENINGITIS  459 

At  the  same  time  there  is  an  unnatural  drowsiness  which  may 
indeed  be  the  only  recognizable  symptom  if  the  child  is  too  young 
to  talk  :  the  child  likes  to  be  quiet  with  his  eyes  closed,  and 
although  for  some  days  he  will  reply  to  questions  and  occasionally 
bestirs  himself  to  take  a  languid  interest  in  his  toys  or  picture- 
books,  it  is  soon  evident  that  the  drowsiness  is  increasing  from  day 
to  day.  At  this  stage  the  decubitus  becomes  characteristic  :  the 
child  lies  on  his  side  with  his  legs  drawn  up,  knees  and  hips 
flexed,  the  arms  adducted  and  forearms  flexed  and  the  hands 
constantly  picking  at  the  lips,  which  are  becoming  dry  and 
frayed. 

He  objects  to  the  light,  more  by  turning  away  from  it  than 
by  any  verbal  complaint,  and  he  dislikes  being  disturbed  ; 
if  one  pulls  aside  the  bedclothes  which  are  half  covering  his  face, 
he  pulls  them  pettishly  over  him  again,  and  says  peevishly, '  Go 
away  ',  or  '  Leave  me  alone  '.  Some  children  at  this  stage  will 
cry  out  occasionally  either  wdth  a  simple  short  sharp  cry,  or 
with  a  more  definite  complaint,  '  Oh!  my  head!  my  head!' 

The  abdomen  by  this  time  is  beginning  to  have  the  empty 
hollowed-out  appearance  which  at  a  later  stage  becomes  still 
more  striking,  and  I  have  often  noticed  a  visible  peristalsis  of 
coils  of  intestine  as  if  the  nervous  irritation  affected  the  bowels 
with  irregular  and  ineffective  contractions.  Another  indication 
of  nervous  irritation  is  the  so-called  '  tache  cercbrale  '  :  on 
scratching  the  skin  gently  with  one's  finger-nail  there  appears 
within  a  few  seconds  a  bright  red  flush  along  the  line  of  the 
scratch  ;  or  else  a  white  line  of  anaemia  quickly  bordered  and 
then  replaced  by  a  red  flush. 

Usually  it  is  not  until  a  week  or  ten  days  after  the  onset 
of  symptoms  that  motor  disturbance  becomes  evident  in  a 
slight  droop  of  one  eyelid,  or  some  squint,  or,  more  rarely,  some 
paralysis  of  face  or  limbs  ;  the  pupils  at  this  stage  tend  to  be 
contracted.  The  neck  is  often  slightly  stiff,  so  that  the  child 
objects  to  having  it  flexed  ;  but  anything  like  well-marked 
head-retraction  or  opisthotonos  of  the  rest  of  the  spine  is  very 
rare,  and  would  be  prima  facie  evidence  against  tuberculous 
meningitis,  and  in  favour  rather  of  cerebro-spinal  or  posterior 
basic  meningitis. 

A  symptom  which  is  often  noticeable  during  this  middle 
period  of  the  disease  is  a  fine  tremor  of  the  hands  on  movement ; 
this  may  be  made  more  evident  by  raising  the  child  into  the 
semi-recumbent  position.  Another  symptom  which  is  of  value 
in  diagnosis  is  the  tendency  to  a  deep,  sighing  expiration  at 


460  COMMON  DISORDERS  OF  CHILDHOOD 

intervals, perhaps  once  or  twice  in  five  minutes ;  this  is  noticeable 
sometimes  before  other  symptoms  have  become  sufficiently 
pronounced  to  make  the  diagnosis  clear. 

The  pulse,  which  in  the  earliest  stage  of  tuberculous  meningitis 
is  slightly  quickened  and  irregular,  gradually  becomes  slower, 
and  at  the  stage  now  reached,  the  middle  period  or,  as  some 
writers  have  called  it,  the  '  irritative  stage  '  of  the  disease,  it 
becomes  slow,  sometimes  only  sixty  or  even  forty  per  minute, 
of  high  tension,  and  more  markedly  irregular. 

The  urine  shows  as  a  rule  nothing  characteristic  in  this  disease, 
but  in  a  certain  proportion  of  cases,  which  my  colleague,  Dr.  A.  E. 
Garrod,  has  found  to  be  about  30  per  cent.,  sugar  (glucose)  is 
detected  in  the  urine  during  the  few  days  preceding  the  fatal 
termination.  The  amount  of  the  sugar  is  small ;  Dr.  Garrod 
tells  me  seldom  more  than  one  per  cent.  I  have  found  it  in 
several  cases,  and  it  certainly  may  be  present  as  long  as  a  week 
before  death.  Its  value  for  diagnosis  is  not  great  on  account  of 
its  late  appearance,  when  the  symptoms  are  already  pronounced. 

The  temperature  is  often  remarkably  little  affected  ;  at  the 
beginning  of  the  disease  it  may  be  raised  to  100°  or  thereabouts 
at  some  time  of  the  day,  but  after  a  few  days  it  falls  to  normal 
and  remains  so  until  the  last  day  or  two,  when  it  may  become 
subnormal  or  run  up  just  before  death  to  106°-107°  or  even 
higher;  but  in  some  cases  it  is  raised  throughout,  being  always 
a  little  above  normal  and  running  up  daily  to  101°  or  102°. 

I  have  noticed  in  several  cases  attacks  of  collapse,  in  which  the 
child  turned  grey  and  cold,  the  pulse  became  very  feeble,  and 
the  temperature  fell  suddenly  to  normal  or  subnormal  ;  these 
attacks  have  occurred  two  or  three  times  at  intervals  of  a  few 
days  ;  they  have  lasted  perhaps  half  an  hour  or  less.  I  have 
always  supposed  that  they  indicated  some  interference  with  the 
cardiac  centres  in  the  medulla,  either  by  increase  of  pressure  in 
the  ventricles  or  by  tubercular  deposit  about  the  medulla. 

By  degrees  the  drowsiness  passes  into  more  or  less  complete 
coma,  and  the  final  or  '  paralytic  '  stage,  as  it  has  been  called, 
is  reached.  The  pulse  becomes  more  and  more  rapid,  155-200 
or  more  per  minute,  and  its  irregularity  disappears  ;  the  child  no 
longer  lies  curled  up  on  his  side  but  lies  on  his  back,  often  picking 
with  tremulous  hands  at  the  navel,  or  with  the  hands  folded  one 
over  the  other  just  over  the  pubes,with  one  or  more  limbs  rigidly 
extended  and  undergoing  slight  clonic  spasms  from  time  to 
time.  The  pupils  hitherto  contracted  become  dilated,  perhaps 
unequally,  and  muco-pus  tends  to  accumulate  on  the  cornea  ; 


TUBERCULOUS  MENINGITIS  461 

the  face  becomes  deeply  flushed,  often  an  intense  scarlet,  and 
beads  of  perspiration  break  out,  especially  on  the  forehead  ;  the 
respiration  becomes  irregular  or  definitely  of  Cheyne-Stokes 
type  ;  in  a  day  or  two  the  scarlet  flush  upon  the  face  becomes 
more  dusky  and  blue  as  the  respiration  becomes  more  hurried 
and  irregular,  and  soon  the  pulse,  which  has  become  small  and 
uncountable,  fails  altogether  and  the  child  dies. 

Such  is  the  characteristic  course  of  a  tuberculous  meningitis  : 
in  its  middle  and  last  stage  so  obvious  that  a  fool  cannot  err 
therein,  in  its  beginnings  so  deceptive  that  the  most  sagacious 
physician  may  fail  to  recognize  that  anything  serious  is  amiss 
with  the  child. 

Diagnosis.  As  I  have  already  mentioned,  the  combination 
of  constipation  with  vomiting  and  headache  is  the  characteristic 
grouping  of  symptoms  at  the  onset  of  tuberculous  meningitis. 
If  one  of  these  symptoms  is  more  constant  than  another  it  is 
constipation  :  all  three  are  usually  present.  When  a  child  is 
ailing  with  these  symptoms  the  fundus  oculi  should  always  be 
examined,  for  although  in  the  large  majority  of  cases  no  change 
can  be  detected  during  this  early  period,  there  are  cases  in  which 
our  suspicions  are  confirmed  most  unexpectedly  by  the  finding 
of  well-marked  optic  neuritis.  Usually  pronounced  change  is 
to  be  found  only  during  the  last  few  days  of  the  disease,  when  no 
help  is  required  in  diagnosis,  but  often  an  experienced  observer 
can  detect  an  unnatural  fullness  and  darkness  of  the  veins, 
especially  near  the  disc,  soon  after  the  onset  of  symptoms,  which 
may  help  to  confirm  the  diagnosis. 

Tubercle  of  the  choroid  is  almost  never  seen  apart  from 
general  acute  miliary  tuberculosis,  where  tuberculosis  of  the 
meninges  though  almost  invariably  present  is  seldom  the  prime 
cause  of  the  clinical  symptoms,  which  are  mainly  connected  with 
the  pulmonary  condition  ;  but  it  is  well  to  be  on  the  watch  for 
tubercle  of  the  choroid  even  in  cases  where  so-called  '  primary  ' 
tuberculous  meningitis  is  in  question  ;  twice  at  least  amongst 
the  many  scores  of  cases  of  tuberculous  meningitis  which  I 
must  have  examined,  I  have  found  a  solitary  tubercle  in  the 
choroid  at  an  early  stage  when  the  diagnosis  was  still  doubtful. 

I  have  already  mentioned  some  of  the  conditions  for  which 
tuberculous  meningitis  is  often  mistaken  :  teething,  gastric 
disturbance,  '  bilious  attacks,'  an  ordinary  sick-headache,  these 
are  the  innocent  conditions  it  simulates  at  first  ;  then  the 
persistence  of  headache  may  suggest  typhoid,  but  the  points  of 
distinction  are  many  ;  the  patient  with  typhoid  usually  lies  on 


462  COMMON  DISORDERS  OF  CHILDHOOD 

his  back,  not  curled  up  on  his  side  like  the  child  with  tuberculous 
meningitis,  the  fever  in  typhoid  is  usually  higher  and  more  con- 
tinuous, the  fullness  of  the  abdomen,  the  enlargement  of  the  spleen, 
the  presence  of  the  typical  rose  spots,  the  Widal  reaction,  are  all 
foreign  to  tuberculous  meningitis,  in  which  also  careful  observa- 
tion may  detect  some  slight  indication  of  cranial  nerve  paralysis 
which  may  give  the  necessary  clue. 

Where  ear  discharge  has  been  present  before  the  cerebral 
symptoms  began,  it  is  sometimes  extremely  difficult  to  distin- 
guish between  cerebral  abscess  and  tuberculous  meningitis  :  the 
brain  symptoms  usually  turn  out  to  be  due  to  tuberculous 
meningitis  in  these  cases  because  it  is  much  the  commoner 
disease,  but  none  the  less  it  is  necessary  to  be  on  the  watch  for 
symptoms  pointing  to  cerebral  or  cerebellar  abscess.  Pain 
or  tenderness  in  the  head  localized  to  the  side  on  which  there  is 
ear  disease,  an  optic  neuritis  much  more  marked  on  this  side 
than  on  the  other,  and  paralysis  of  cranial  nerves  limited  to  this 
side  :  these  are  some  of  the  points  which  may  serve  for  the 
distinction,  but  the  symptoms  both  of  abscess  and  of  tuberculous 
meningitis  are  extremely  variable  and  it  is  a  very  difficult,  some- 
times, I  believe,  an  impossible  diagnosis.  I  have  seen  cases 
operated  upon,  and,  indeed,  advised  the  operation  myself,  for 
supposed  abscess,  where  post  mortem  examination  has  shown 
it  to  be  tuberculous  meningitis. 

I  have  known  infantile  paralysis  to  simulate  tuberculous 
meningitis  very  closely  even  in  the  occurrence  of  squint,  facial 
paralysis,  and  semi-coma:  but  the  involvement  of  cranial  nerves 
or  nuclei  is  very  rare  in  infantile  paralysis.  The  converse  error 
has  been  made  occasionally  of  mistaking  tuberculous  meningitis 
for  infantile  paralysis,  where,  as  rarely  happens,  the  earliest 
pronounced  symptom  of  the  meningitis  is  paralysis  of  one  or 
more  limbs. 

In  infants,  as  I  have  mentioned  elsewhere  (Chapter  XL), 
the  nervous  symptoms  which  accompany  the  high  fever  of  acute 
pyelitis  are  sometimes  mistaken  for  those  of  tuberculous  menin- 
gitis, which  is  hardly  surprising,  as  drowsiness,  squint,  twitching, 
and  even  stiffness  of  the  neck  may  be  present  with  acute  pyelitis 
(vide  p.  280).  The  sudden  onset,  however,  and  extremely  high 
fever  and  absence  of  fullness  of  the  fontanelle  are  all  unlike 
tuberculous  meningitis ;  moreover,  the  pyelitis  is  obvious  on 
microscopic  examination  of  the  urine. 

Tuberculous  meningitis  has  to  be  distinguished  from  other 
forms  of  meningitis.  Suppurative  meningitis  differs  chiefly  in 


TUBERCULOUS  MENINGITIS  463 

its  rapid  course,  its  whole  duration  is  less  than  a  week,  perhaps 
usually  three  or  four  days  ;  moreover,  it  is  almost  always 
secondary  to  some  obvious  forms  of  infection,  generally  pneumo- 
coccal  such  as  lobar  pneumonia,  or  empyema,  or  to  some 
pyaemic  condition. 

Cerebro -spinal  and  posterior  basic  meningitis  differ  in  the 
suddenness  of  their  onset  :  there  is  no  prodromal  period  of  in- 
definite malaise,  the  child  becomes  at  once  acutely  ill,  often  the 
mother  can  date  the  onset  from  a  particular  hour  on  a  particular 
day  ;  head -retract  ion,  which  is  the  exception  and  even  when 
present  is  generally  very  slight  in  tuberculous  meningitis,  very 
quickly — sometimes  even  on  the  first  day — becomes  a  marked 
and  characteristic  feature  in  the  cerebro -spinal  and  posterior 
basic  varieties  ;  the  temperature  also  tends  to  be  higher  than 
in  tuberculous  meningitis,  from  which  also  in  some  cases  the 
presence  of  a  rash,  herpetic,  purpuric,  or  a  blotchy  purplish 
erythema,  may  make  diagnosis  easy. 

Whether  any  distinction  should  be  drawn  between  cerebro  - 
spinal  and  posterior  basic  meningitis  is  perhaps  still  doubtful. 
As  regards  clinical  symptoms,  I  think  that  the  cases  to  which  the 
term  Posterior  Basic  has  been  applied  are,  as  a  rule,  of  milder 
type  than  those  usually  described  as  'Cerebro -spinal ',  this  group 
also  comprises  chiefly  infants  under  one  year,  whereas  the  more 
severe  cerebro -spinal  disease,  though  it  attacks  infants,  fre- 
quently attacks  also  older  children ;  whether  sporadic  or  epidemic, 
the  cerebro -spinal  variety  is  much  more  frequently  associated 
with  rashes, 'purpuric  or  herpetic,  than  is  posterior  basic  menin- 
gitis. But  these  may  be  merely  differences  of  degree,  and  I 
doubt  whether  there  are  sufficient  clinical  grounds  to  justify  any 
distinction  unless,  as  some  observers  think,  the  diplococcus  of  the 
posterioHba^ic  disease  can  be  distinguished  by  some  of  the  recent 
methods  of  differentiation  from  that  of  cerebro -spinal  meningitis. 

I  have  laid  stress  upon  head -retraction  in  the  diagnosis  of 
tuberculous  meningitis  from  these  other  varieties  ;  but  this 
symptom  indicates  nothing  more  than  the  fact  that  there  is 
much  irritation  in  the  medullary  region,  and  in  the  exceptional 
cases  in  which  tuberculous  meningitis  produces  much  inflamma- 
tion and  matting  in  this  region  I  have  seen  head -retraction  just 
as  marked  as  in  a  cerebro -spinal  or  posterior  basic  meningitis  : 
this,  however,  is  very  rare. 

Nowadays  other  methods  of  diagnosis  are  open  to  us.  Lumbar 
puncture  may  give  information  on  at  least  three  points,  the 
tension  of  the  cerebro -spinal  fluid,  the  number  and  character  of 


464  COMMON  DISORDERS  OF  CHILDHOOD 

the  cells  contained  in  it,  and  the  nature  of  any  bacteria  which 
may  be  present. 

Increase  of  tension  tells  us  little  more  than  that  there  is 
probably  some  organic  disease  of  the  brain  :  increase  in  the 
number  of  cells  present  points  to  inflammatory  mischief ;  if  the 
predominating  cell  is  polymorphonuclear,  the  inflammation 
is  likely  to  be  of  more  acute  variety  than  if  most  of  the  cells 
are  lymphocytes  :  the  particular  micro-organism  causing  the 
inflammation  is  determined  by  the  bacteriological  examination 
of  the  fluid.  At  the  Hospital  for  Sick  Children,  Great  Ormond 
Street,  Dr.  J.  G.  Forbes  l  found  tubercle  bacillus  in  the  cerebro- 
spinal  fluid  in  27  cases  out  of  47  cases  of  tuberculous  meningitis 
in  which  lumbar  puncture  was  done  during  life,  and  in  a  more 
recent  series  he  found  it  in  25  out  of  31  specimens.  The  fine 
lymph  clot  which  usually  forms  if  the  fluid  withdrawn  is  allowed 
to  stand  for  a  short  time,  offers  the  best  chance  for  the  discovery 
of  the  bacillus  by  staining. 

Lumbar  puncture  is  clearly  a  most  valuable  adjunct  to  diagnosis, 
but  it  is  only  one  element  in  diagnosis  ;  there  are  cases  in 
which  clinical  symptoms  give  far  more  reliable  information  than 
does  lumbar  puncture  ;  for  instance,  I  have  notes  of  cases  under 
my  own  care  in  which  a  diagnosis  of  the  variety  of  meningitis, 
based  upon  the  cell  contents  of  the  cerebro-spinal  fluid,  would 
have  been  entirely  wrong,  and  of  other  cases  in  which  sterility 
of  the  cerebro-spinal  fluid  was  reported  when  post  mortem  showed 
either  tuberculous  or  cerebro-spinal  meningitis. 

These  facts  only  emphasize  the  necessity  for  considering 
lumbar  puncture  in  conjunction  with  clinical  symptoms  :  either 
may  mislead  us  if  considered  alone  ;  the  chance  of  error  is  dimin- 
ished by  checking  the  information  from  one  source  by  that  from 
another. 

But  valuable  as  lumbar  puncture  is  where  certainty  of  diag- 
nosis cannot  be  reached  by  consideration  of  symptoms  alone, 
and  where  at  the  same  time  the  patient's  welfare  is  at  stake  for 
want  of  certainty,  there  is  a  large  proportion  of  cases  in  which 
any  experienced  physician  can  make  a  reliable  diagnosis  both 
of  the  presence  and  of  the  variety  of  meningitis  without  having 
recourse  to  lumbar  puncture,  and  where  this  is  so  lumbar  punc- 
ture is  only  to  be  advised  if  it  has  any  therapeutic  value,  as  it 
may  have  in  cerebro-spinal  meningiti3. 

Prognosis.  To  say  that  tuberculous  meningitis  is  invariably 
fatal  would  perhaps  be  too  sweeping  a  statement,  but  certainly 
1  Quarterly  Journal  of  Medicine,  January,  1908,  i,  2,  p.  109. 


TUBERCULOUS  MENINGITIS 


465 


it  does  not  far  exceed  the  truth.  Amongst  at  least  150  cases  of 
tuberculous  meningitis  under  my  own  observation,  I  have  not 
seen  a  single  recovery,  nor  do  I  know  of  any  instance  of  recovery 
amongst  the  large  number  of  cases  admitted  during  recent  years 
with  tuberculous  meningitis  at  the  Children's  Hospital.  I  say 
'during  recent  years',  for  the  record  of  supposed  recoveries  in 
former  days,  when  cerebro- spinal  or  posterior  basic  meningitis 
was  confused  with  the  tuberculous  variety,  are  necessarily 
unreliable.  But  face  to  face  with  the  individual  case  may  we  not 
rather  cling  to  the  possibility  of  recovery  until  death  disproves 
it  ?  for  there  are  instances  on  record  which  strongly  suggest, 
if  they  do  not  prove,  that,  as  with  tubercle  elsewhere,  so  in 
the  meninges,  though  much  more  rarely,  the  process  may  be 
stayed. 

I  once  saw  a  very  remarkable  improvement  in  a  child  who 
had  been  admitted  with  evident  tuberculous  meningitis  ;  optic 
neuritis  was  present,  and  squint,  and  the  child  gradually  fell 
into  a  semi-comatose  condition ;  then  most  unexpectedly  he 
began  to  improve,  consciousness  returned,  and  he  became  so 
well  that  he  sat  up  and  played  with  his  toys  and  talked  and 
seemed  to  be  on  the  road  to  recovery,  but  the  squint  remained, 
and  after  a  few  days  he  again  became  worse  and  died  some  days 
later  of  tuberculous  meningitis. 

A  case  still  more  suggestive  of  the  possibility  of  recovery  was 
recorded  by  the  late  Dr.  H.  Ashby.  A  girl,  aged  6|  years,  who 
had  abscesses  in  her  legs,  developed  headache,  with  staggering 
gait  and  some  delirium  ;  then  she  began  to  squint,  optic  neuritis 
was  present,  she  vomited,  screamed  occasionally,  and  passed  her 
faeces  under  her.  With  treatment  by  ice-bags  to  the  head  and 
bromides  by  mouth  she  gradually  recovered  and  was  discharged 
three  months  later  ;  after  six  months  she  returned  to  hospital 
with  symptoms  of  meningitis  and  died.  Post  mortem  showed 
recent  tuberculous  meningitis  and  much  matting. 

That  recovery  has  actually  occurred  in  some  cases  may  now 
be  taken  for  an  ascertained  fact,  since  the  introduction  of  lumbar 
puncture  has  made  it  possible  to  detect  the  tubercle  bacillus  in 
the  cerebro-spinal  fluid  during  life.  Dr.  A.  E.  Martin1  collected 
20  cases,  which  had  been  recorded  since  1894,  in  which  recovery 
had  occurred  from  symptoms  believed  to  be  those  of  tuberculous 
meningitis,  and  in  several  of  these  lumbar  puncture  had  shown 
tubercle  bacilli  in  the  cerebro-spinal  fluid.  In  some  inoculation 
of  guinea  pigs  with  the  fluid  withdrawn  produced  tuberculosis. 
1  Brain,  Part  II,  1909,  p.  209. 


STILL 


4G6  COMMON 'DISORDERS  OF  CHILDHOOD 

Lastly,  I  must  add  that  Dr.  Nathan  Raw  has  recently  reported 
two  recoveries  of  children  '  with  all  the  classical  symptoms  of 
tuberculous  meningitis  '. 

But  one  has  told  the  parents  that  the  hope  of  recovery,  if  any, 
is  small,  and  the  next  question  is,  how  long  will  the  child  live  ? 
Of  course  there  is  considerable  variation  in  the  duration  of  the 
disease,  but  as  a  useful  generalization  I  think  one  may  say  that 
the  fatal  termination  is  usually  about  twenty-one  days  after  the 
date  upon  which  the  first  definite  symptom  of  illness,  such  as 
vomiting  or  headache,  or  distinct  malaise  was  noticed.  In  the 
individual  case  our  estimate  will  be  determined  also  partly  by 
the  stage  already  reached,  the  bright  flushing  of  the  face  seldom 
fails  to  appear  as  a  warning  before  the  end  approaches,  and 
from  the  first  beginning  of  this  symptom  to  the  end  of  the  disease 
is  usually  about  four  days  at  most.  The  state  of  the  pulse  also 
furnishes  some  indication;  the  slowness  of  the  middle  stage  is, 
almost,  if  not  quite,  invariably  followed  by  a  gradual  increase 
up  to  great  rapidity  during  the  last  few  days  of  life. 

The  differentiation  between  the  three  forms  of  meningitis, 
tuberculous,  suppurative,  and  posterior  basic,  is  of  importance 
in  the  matter  of  prognosis.  As  regards  duration,  it  may  be  said 
roughly  that  they  last  respectively  three  weeks,  three  days,  and 
three  months.  Suppurative  meningitis  is  probably  as  hopeless 
as  tuberculous,  and  its  duration,  so  far  as  can  be  judged  from 
clinical  symptoms,  is  almost  always  less  than  a  week.  Posterior 
basic  and  cerebro-spinal  meningitis,  though  often  fatal,  are  by 
no  means  always  so  ;  about  10  per  cent,  of  the  cases  of  so-called 
posterior  basic  meningitis  in  infancy  recover,  and  recovery  is 
not  uncommon  in  cases  of  cerebro-spinal  meningitis  in  older 
children,  even  when  the  symptoms  are  very  severe. 

Treatment.  It  is  very  doubtful  whether  treatment  can  do 
anything  to  stay  the  course  of  tuberculous  meningitis.  Formerly 
mercurial  inunction  to  the  back  of  the  neck  was  a  common  mode 
of  treatment,  but  I  cannot  say  that  I  have  seen  any  good  from 
it.  The  Unguentum  iodoformi  has  been  used  ;  I  think  I  have 
seen  definite  advantage  from  iodoform  in  tuberculous  peritonitis, 
and  one  can  believe,  therefore,  that  this  drug  may  possibly  be 
helpful  in  tuberculous  meningitis. 

Recently  I  have  used  urotropin,  for  the  experiments  of  Flexner 
have  shown  that  this  drug,  when  administered  by  mouth,  quickly 
appears  in  the  cerebro-spinal  fluid  and  acts  as  an  antiseptic, 
inhibiting  infection  to  some  degree.  It  is  conceivable  that,  given 


TUBERCULOUS  MENINGITIS  467 

in  large  doses  at  the  early  stage  of  tuberculous  meningitis,  it 
may  at  least  assist  any  tendency  towards  recovery,  and  it  is 
clear  from  such  cases  as  I  have  mentioned  above  (p.  465),  that 
even  without  assistance  Nature  makes  a  strong  effort  towards 
spontaneous  recovery  in  some  cases.  In  one  case  in  which 
I  used  urotropin  the  disease  certainly  ran  a  slower  course  than 
usual,  and  in  another  where  the  symptoms  pointed  strongly  to 
tuberculous  meningitis,  the  child,  a  boy  of  4J  years,  had  so  far 
improved  when  I  saw  him  five  and  a  half  weeks  after  the  onset  of 
the  illness  as  to  be  running  about  at  play.  I  had  seen  him  first 
on  the  fourteenth  day  of  the  illness,  and  urotropin  was  given  in 
doses  of  7  grains  every  four  hours,  until  after  about  six  days  the 
occurrence  of  hsematuria,  which  large  doses  of  this  drug  sometimes 
produce,  necessitated  its  cessation. 

To  an  infant  6-12  months  old  3-4  grains  of  urotropin  may  be 
given  every  four  hours,  and  to  a  child  3  years  old  5-6  grains  every 
four  hours ;  but  I  have  given  as  much  as  10  grains  every  2 
hours  to  an  infant  21  months  old  without  ill  effect,  and  probably 
it  is  wise  to  use  large  doses  like  this,  at  ?*ny  rate  for  two  or  three 
days,  after  which,  if  necessary,  the  smaller  doses  mentioned  may 
be  given.  Experiments  seem  to  show  that  large  amounts  of  this 
drug  are  necessary  to  obtain  its  antiseptic  effect  in  the  cerebro- 
spinal  fluid.  The  effect  which  may  necessitate  its  discontinuance 
or  reduction  is,  as  already  mentioned,  hsematuria. 

I  have  used  tuberculin  injections  with  and  without  the  guidance 
of  the  opsonic  index,  but  in  the  few  cases  in  which  I  have  tried 
it,  there  has  not  been  the  least  improvement  so  far  as  I  could 
observe  ;  in  this  the  experience  of  others  seems  to  agree,  but 
recently  Dr.  Nathan  Raw  has  stated  that  out  of  four  cases 
treated  with  tuberculin,  two  recovered  after  four  injections  ; 
the  evidence  of  tuberculous  meningitis  in  these  cases  rested 
only  on  clinical  symptoms,  which,  however,  were  considered  to 
be  quite  typical. 

The  fact  that  in  some  cases  of  tuberculous  meningitis  there  is 
transient  return  of  consciousness  a  few  hours  before  death  when 
blood  pressure  is  falling,  and,  presumably,  intracranial  tension 
is  diminished,  led  me  to  hope  that  lumbar  puncture  might  possibly 
restore  consciousness  for  a  time  in  the  same  way,  but  even  for 
this  purpose  it  proved  useless.  In  one  way  I  have  known  lumbar 
puncture  to  be  of  value  in  the  treatment  of  this  disease ;  it  some- 
times has  a  markedly  quieting  effect  upon  the  clonic  spasm  or 
general  convulsive  restlessness  of  the  late  stage  of  tuberculous 
meningitis,  which  may  be  an  important  matter  where  the  parents 
are  greatly  distressed  thereby. 

ii  h  2 


468  COMMON  DISORDERS  OF  CHILDHOOD 

But  if  we  can  do  nothing  to  ward  off  a  fatal  ending  we  can  at 
least  do  something  to  prevent  suffering.  An  icebag  to  the  head, 
a  quiet  room  and  darkened  windows  will  conduce  to  the  child's 
comfort,  and  if  the  icebag  does  not  relieve  the  headache,  phena- 
zone  gr.  i-iv,  the  smaller  dose  for  an  infant  of  one  year,  the  larger 
for  a  child  of  eight  or  nine  years,  or  phenacetin  gr.  iij-v,  with 
caffein  citrate,  one  grain,  sometimes  relieves  it  definitely,  and 
if  these  fail  and  the  child  is  restless  and  crying  out  frequently 
or  moaning  with  pain,  I  have  seen  marked  relief  from  morphia  ; 
in  the  later  stage  clonic  spasm,  which,  if  not  distressing  to 
the  patient,  may  be  distressing  to  the  parents,  is  sometimes 
diminished  by  bromides  to  which  chloral  may  be  added. 

Sooner  or  later  nasal  or  rectal  feeding  becomes  necessary  as 
coma  becomes  more  profound,  and  at  this  stage  watch  must  be 
kept  upon  the  bladder,  for  the  urine  may  be  retained.  I  have 
sometimes  found  the  bladder  enormously  distended  where  this 
has  been  forgotten.  Throughout  the  illness  it  will  be  necessary 
to  keep  the  bowels  working ;  as  long  as  the  child  will  swallow, 
calomel  is  perhaps  best,  as  likely  to  produce  a  fluid  stool  and  re- 
lieve blood  pressure  to  some  slight  degree,  but  in  the  later  stages, 
and  sometimes  in  the  earlier,  it  may  be  necessary  to  enforce 
action  of  the  bowels  by  glycerine  suppositories  or  enemata. 


CHAPTER  XXXIII 
RHEUMATISM 

RHEUMATISM  is  one  of  the  many  diseases  which  illustrate  the 
considerable  differences  which  may  exist  between  the  manifesta- 
tions of  one  and  the  same  disease  when  it  occurs  in  an  adult  and 
when  it  occurs  in  a  child.  The  conception  of  rheumatism  as 
essentially  a  joint  disease  is  based  on  its  occurrence  in  adolescent 
and  adult  life ;  the  wider  and  almost  certainly  more  accurate 
conception  of  rheumatism  as  a  general  disease,  probably  of 
infective  origin,  is  based  chiefly  on  its  manifestations  in  child- 
hood. 

In  a  child  the  articular  phenomena  of  rheumatism  become 
a  matter  of  merely  secondary  importance  ;  indeed,  judging  from 
clinical  evidence,  one  would  say  that  a  child  may  suffer  severely 
from  rheumatism  who  has  never  had  a  pain  in  its  joints  in  its  life. 
Some  of  the  most  severe  cases  of  endocarditis,  cases  in  which  the 
rheumatic  nature  of  the  lesion  has  been  confirmed  by  the  presence 
of  rheumatic  nodules,  have  not  at  any  time  had  any  joint  pains 
whatever  so  far  as  can  be  ascertained. 

As  is  wrell  known,  the  joint  symptoms  in  a  child  are  often  so 
slight  that  the  parents  take  no  notice  of  them,  beyond  dismissing 
them  from  their  memory  with  the  comforting  assurance  that 
they  are  '  only  growing  pains  ',  so  that  even  with  careful  inquiry 
it  is  often  difficult  to  be  quite  certain  that  some  such  transient 
aches  or  pains  may  not  have  occurred  at  some  previous  date 
and  have  since  been  forgotten.  Allowing,  however,  for  such 
a  fallacy,  one  sees  cases  of  undoubted  rheumatism  in  childhood 
in  which  joint  phenomena  would  seem  to  be  entirely  absent. 

I  venture  to  lay  some  stress  upon  this  point  in  primis,  for  it 
seems  to  me  that  we  must  widen  our  conception  of  rheumatism 
if  we  would  understand  aright  the  relationship  of  those  appar- 
ently disconnected  phenomena  which  make  up  the  rheumatic 
complex  in  childhood. 

To  measure  the  frequency  of  rheumatism  in  childhood  by  the 
number  of  cases  which  come  under  treatment  for  the  articular 
manifestations  is  entirely  to  misunderstand  the  prevalence  of 
this  disease  in  early  life.  Even  if  the  joint  symptoms  alone  were 


470  COMMON  DISORDERS  OF  CHILDHOOD 

to  be  considered,  such  a  method  of  estimation  would  involve 
a  large  fallacy  ;  for  the  joint  symptoms  are  so  slight  in  children 
that  comparatively  few  of  the  cases  in  which  they  occur  come 
under  medical  observation  until  the  presence  of  severe  cardiac 
affection  or  the  more  obtrusive  phenomena  of  chorea  induce 
the  parents  to  seek  medical  advice. 

Moreover,  the  heart  affections  may  apparently  occur  alone  as 
the  earliest  symptom  of  rheumatism  in  children  ;  and  whatever 
view  may  be  held  as  to  the  exact  relation  of  chorea  to  rheuma- 
tism, the  association  of  chorea  with  other  rheumatic  symptoms — 
particularly  the  cardiac  affections  and  rheumatic  nodules — 
where  articular  symptoms  are  absent,  makes  it  necessary  to 
include  in  our  statistics  not  only  the  cases  of  chorea  in  which 
there  has  been  concurrent  or  previous  articular  rheumatism,  but 
also  many  others,  if  we  wish  to  obtain  any  accurate  idea  of  the 
frequency  of  rheumatism  in  childhood. 

The  following  figures  may  serve  to  illustrate  this  point.  Out 
of  383  as  far  as  possible  consecutive  cases  of  chorea  which  came 
under  my  observation,  183  had  concurrent  or  previous  articular 
rheumatism  (pains  in  limbs  or  joints)  with  or  without  heart 
affections  and  nodules  ;  8  had  no  joint  symptoms,  but  had  heart 
disease  and  rheumatic  nodules  ;  2  had  rheumatic  nodules  with- 
out cardiac  bruits  or  joint  symptoms  ;  12  had  systolic  and 
diastolic  apical  bruits ;  3  had  aortic  diastolic  as  well  as  apical 
bruits  ;  and  48  had  only  systolic  apical  bruits,  without  joint 
symptoms  or  nodules. 

At  the  very  lowest  estimate,  therefore  (excluding  cases  writh 
only  systolic  apical  bruits),  54-3  per  cent,  of  cases  which  came 
under  treatment  for  chorea  showed  positive  evidence  of  rheu- 
matism ;  and  it  is  obvious  that  unless  such  cases  are  included 
in  the  statistics  of  rheumatism  the  frequency  of  that  disease  in 
childhood  will  be  considerably  underrated. 

As  a  matter  of  fact  such  cases  too  often  figure  in  statistics 
as  '  chorea  '  only,  and  perhaps  this  accounts  in  part  for  the 
statement  sometimes  made,  that  rheumatism  is  a  disease  of 
adolescent  and  adult  life  rather  than  of  childhood,  whereas  in 
London  at  any  rate  it  is  probably  more  frequent  in  the  later  half 
of  childhood  (six  to  twelve  years  of  age)  than  it  is  in  older  persons. 

In  the  Children's  Out-patient  Department  at  King's  College 
Hospital,  where  only  children  under  ten  years  of  age  are  treated, 
in  1,000  consecutive  cases  there  were  229  children  between  six 
and  ten  years  of  age ;  of  these  229,  13-1  per  cent,  showed  evidence 
of  rheumatism  (3-5  per  cent,  attended  for  joint  symptoms,  the 


RHEUMATISM  471 

rest  were  cases  of  heart  affection  or  of  chorea,  in  which  there  was 
satisfactory  evidence  from  associated  symptoms  or  from  a  history 
of  previous  joint  pains,  that  the  condition  was  rheumatic),  and 
if  children  up  to  the  age  of  twelve  years  were  included,  no  doubt 
the  percentage  would  be  considerably  higher. 

The  frequency  of  rheumatism  amongst  the  in-patients  of  a 
children's  hospital  may  be  seen  from  the  following  figures. 
During  the  years  1897  and  1898,  681  children  between  the  ages 
of  six  and  twelve  years  were  admitted  to  the  medical  wards 
(including  diphtheria  wards)  of  the  Hospital  for  Sick  Children, 
Great  Ormond  Street :  149  were  cases  of  chorea,  63  of  endocarditis, 
and  38  of  articular  rheumatism.  Records  were  lacking  in  29  of 
the  cases  of  chorea,  but  of  the  remaining  120,  67  showed  evidence 
of  rheumatism  (either  previous  articular  rheumatism  or  definite 
endocarditis,  not  including  systolic  apical  bruits  of  possibly 
doubtful  nature)  ;  so  that  out  of  the  681  children,  168  showed 
evidence  of  rheumatism — that  is,  24-7  per  cent. 

Such  figures,  however,  only  take  into  account  those  cases  of 
chorea  in  which  there  is  evidence  of  past  or  present  rheumatism 
in  heart  or  limbs  or  in  the  form  of  rheumatic  nodules  ;  but  it 
may  well  be  that  in  the  light  of  bacteriology  chorea  may  prove, 
in  some  cases  at  least,  to  be  directly  or  indirectly  the  result  of 
rheumatic  infection,  and  therefore  just  as  truly  a  manifestation 
of  rheumatism  as  the  articular  symptoms.  If  this  were  so, 
chorea,  like  the  heart  affections  and  the  rheumatic  nodules, 
might  be  expected  to  precede  the  joint  symptoms  in  some  cases, 
and  might  be  the  first,  or  possibly  the  only,  clinical  manifestation 
of  rheumatism. 

The  recent  investigations  by  Dr.  Poynton  and  Dr.  Paine  into 
the  etiology  of  rheumatism  would  seem  to  point  in  this  direction, 
and  such  a  view  would  well  accord  with  clinical  experience  ;  but 
until  further  evidence  is  forthcoming,  one  can  only  suspect  that 
a  considerable  number  of  the  cases  of  chorea  in  children  without 
other  manifestations  of  rheumatism,  ought  to  be  included  in  our 
statistics  if  we  would  realize  fully  the  widespread  influence  of 
rheumatism  in  childhood. 

Age-incidence.  From  the  figures  given  above,  it  is,  I  think, 
sufficiently  evident  that  rheumatism  is  an  exceedingly  common 
disease  in  the  later  period  of  childhood.  During  early  childhood, 
however,  rheumatic  phenomena  are  much  less  frequent,  and  in 
infancy  rheumatism  is  almost  unknown.  The  age-incidence  is 
shown  in  the  accompanying  chart  (Fig.  33). 

Several  cases  of  supposed  rheumatism  in  infancy,  from  twelve 


472 


COMMON  DISORDERS  OF  CHILDHOOD 


hours  old  and  upwards,  have  been  recorded,  a  few  well  authenti- 
cated, others  of  very  doubtful  nature.  Amongst  1,027  children 
with  articular  or  cardiac  rheumatism  or  with  chorea,  I  have  not 
seen  a  single  case  under  two  years  of  age,  and  I  have  seen  only 
eight  cases  in  which  any  of  these  rheumatic  affections  were  present 
before  the  age  of  three  years. 

The  youngest  was  a  boy  aged  two  years  and  five  months  with 
acute  articular  rheumatism  ;  his  sister  was  said  to  have  had 
her  first  attack  of  articular  rheumatism  at  eighteen  months  ; 
another  case,  first  seen  with  severe  endocarditis  at  2J  years, 
had  had  an  attack  of  acute  articular  rheumatism  a  month  earlier. 
In  one  case  the  first  attack  of  chorea  was  said  to  have  begun 


FIG.  33.    Age-incidence  of  rheumatism  in  childhood. 

when  the  child  was  two  years  old  ;  in  another  articular  rheuma- 
tism was  said  to  have  begun  at  this  age  ;  in  another  there  was 
good  reason  to  suppose  that  articular  rheumatism  occurred  just 
before  the  age  of  two  years,  but  I  did  not  see  the  child  until  he 
was  brought  for  rheumatism  later.  I  had  under  my  care  a  boy 
with  chorea,  endocarditis  and  articular  rheumatism  at  the  age 
of  two  years  and  ten  months,  and  another  boy  in  whom  there  was 
severe  endocarditis,  the  rheumatic  nature  of  which  was  confirmed 
by  the  subsequent  appearance  of  a  large  rheumatic  nodule  on 
one  elbow  at  2^  years. 

Symptoms.  The  symptoms  of  rheumatism  in  childhood,  as 
already  pointed  out,  differ  from  those  in  adults  chiefly  in  the 
much  slighter  character  of  the  joint  manifestations,  and  in  tho 
much  greater  prominence  and  frequency  of  the  heart  affections. 


RHEUMATISM  473 

Reference  has  been  made  above  to  '  pains  in  the  limbs '  as 
evidence  of  rheumatism  in  children,  and  clinical  experience  shows 
that  pains  referred  to  the  limbs,  as  distinguished  from  the  joints, 
may  be  just  as  significant  of  rheumatism  in  children  as  swollen, 
red  and  tender  joints.  This  is  proved  by  the  fact  that  it  is  quite 
common  for  children  \vith  only  such  vague  '  pains  in  the  limbs ', 
for  example,  in  the  calf  or  thigh,  to  show  other  symptoms  of 
'  acute  rheumatism  ',  such  as  endocarditis  and  pericarditis  or 
subcutaneous  nodules  ;  moreover,  definite  swelling  and  tender- 
ness of  the  joints  may  immediately  precede  or  follow  these 
pains  in  the  limbs. 

It  is  perhaps  worthy  of  note  that,  even  where  there  are  only 
such  vague  and  slight  pains,  examination  of  the  joints  may  show 
that  these  are  really  affected.  In  a  child  under  my  care  as  an 
out-patient  at  King's  College  Hospital,  routine  examination 
showed  considerable  effusion  into  one  knee,  where  the  complaint 
of  vague  pains  in  the  limbs  in  a  child  walking  about  with  appar- 
ently no  discomfort  hardly  suggested  the  possibility  of  such 
a  definite  joint  affection. 

The  practical  importance  of  recognizing  the  significance  of 
these  slight  pains  in  the  limbs  in  children — '  growing  pains  '  as 
they  are  too  often  called — can  hardly  be  overrated.  They  may 
be  the  earliest  indication  of  rheumatic  taint,  and  as  such  should 
always  serve  as  a  danger  signal.  To  disregard  them  is  to  favour 
the  onset  of  more  severe  symptoms,  and  it  seems  likely  that 
active  treatment  in  this  early  stage  may  not  only  cause  the  dis- 
appearance of  the  pains  but  may  also  prevent  those  affections  of 
the  heart  which  are  so  distressing  a  feature  in  the  rheumatism 
of  childhood  ;  certainly  these  vague  pains  call  for  the  utmost 
care  in  prophylaxis,  and  a  child  who  has  once  shown  such  symp- 
toms requires  continual  care  as  to  clothing,  climate,  and  the 
prevention  of  exposure  to  cold  and  damp.  The  presence  of  these 
indefinite  pains  in  a  child  makes  it  necessary  also  to  keep  a  care- 
ful watch  on  the  condition  of  the  heart,  for  these  apparently 
trivial  '  growing  pains  '  may  be  associated  with  or  followed  by 
cardiac  disease  as  severe  as  any  that  occurs  with  the  most  acute 
articular  rheumatism. 

In  connexion  with  the  joint  symptoms  I  may  mention  a  point 
to  which  my  attention  was  first  drawn  by  Sir  Thomas  Barlow  : 
the  frequency  of  affection  of  the  hip-joint  in  the  rheumatism 
of  childhood.  This  point  is  worth  remembering  in  its  bearing 
on  diagnosis,  for  it  happens  occasionally  that  rheumatism  in 
children  remains  limited  to  one  joint  for  several  days.  Snob 


474  COMMON  DISORDERS  OF  CHILDHOOD 

monarticular  rheumatism  is  often  extremely  puzzling,  and  when 
it  affects  the  hip-joint  may  easily  suggest  commencing  tuber- 
culous disease,  or  may  lead  to  stranger  errors  owing  to  the  very 
indefinite  localization  of  pain  by  children.  One  child  was  sent 
to  the  Children's  Hospital  for  peri  typhlitis,  another  for  intus- 
susception, and  a  third  had  been  circumcised  on  account  of 
vague  pain  in  the  right  groin,  which  a  few  days  later  was  followed 
by  definite  symptoms  of  rheumatism  elsewhere.  Another  com- 
mon complaint  is  '  pain  at  the  back  of  the  knee  ',  often  with  no 
objective  evidence  of  rheumatism  in  the  knee-joint. 

Another  symptom  which  is  of  importance  because  it  may  be 
the  earliest  manifestation  of  rheumatism  in  a  child,  is  stiff-neck. 
This  may  seem  a  trivial  affection,  but,  like  the  vague  pains  and 
stiffness  in  the  limbs,  it  may  be  followed  or  accompanied  by 
severe  cardiac  rheumatism.  I  have  seen  severe  endocarditis 
associated  with  rheumatic  nodules  in  a  child  who  had  shown  no 
other  evidence  of  rheumatism  but  stiff-neck. 

The  frequency  of  cardiac  affections  is  one  of  the  most  charac- 
teristic features  of  rheumatism  in  childhood.  In  170  as  far  as 
possible  consecutive  cases  with  rheumatic  manifestations,  128  had 
cardiac  bruits,  which  in  93  cases  were  certainly  due  to  endocarditis. 

But  endocarditis  and  pericarditis  are  by  no  means  the  only 
results  of  cardiac  rheumatism,  and  in  children,  probably  to 
a  greater  extent  than  in  adults,  cardiac  dilatation  is  a  frequent 
result  of  rheumatism,  an  important  point  to  which  Dr.  Lees  has 
specially  drawn  attention.  In  some  cases  this  dilatation,  asso- 
ciated with  irregularity  and  rapidity  of  the  heart,  may  be  the 
only  clinical  evidence  of  cardiac  affection  ;  certainly  in  many 
cases  it  is  the  earliest  indication  of  such  affection. 

It  may  not  be  out  of  place  to  mention  here  the  wasting  which 
so  often  accompanies  cardiac  rheumatism  in  childhood,  and 
which  would  seem  to  be  a  more  noticeable  feature  in  children 
than  in  adults.  It  is  no  uncommon  thing  for  a  child  to  be  brought 
for  medical  advice  simply  on  account  of  wasting,  by  a  mother 
who  has  no  suspicion  that  the  child  has  ever  had  rheumatism  or 
has  any  affection  of  the  heart,  although  examination  reveals 
advanced  cardiac  disease,  and  on  inquiry  there  is  a  history  of 
vague  pains  in  the  limbs  for  many  months  past. 

An  important  manifestation  of  rheumatism  in  children  is  the 
rheumatic  nodule.  This  is  to  be  found  most  often  over  the 
olccranon  process  and  the  condyles  of  the  humerus  and  femur 
(Fig.  34),  but  also  over  the  spinous  processes  of  the  vertebrae, 
the  malleoli,  the  ends  of  the  radius  and  ulna,  I  he  knuckles,  and 


RHEUMATISM  475 

sometimes  over  the  occipital  bone,  scapula  and  crest  of  ilium,  less 
often  over  tendon  sheaths  where  these  are  superficial,  for  instance 
at  the  wrist  and  ankle.  On  dissection  the  nodule  is  seen  as 
a  tawny-yellow  deposit,  about  the  size  of  a  millet-seed  or  hemp- 
seed  in  the  meshes  of  loose  connective  tissue;  a  network  of  fine 
vessels  can  be  seen  passing  on  to  the  surface  of  the  deposit,  but 
it  has  no  capsule.  The  histological  character  of  these  nodules 
shows  that  they  are  exactly  analogous  to  the  fibrinous  deposit 
on  the  inflamed  endocardium  or  pericardium,  and  their  associa- 
tion almost  always  with  endocarditis  suggests  that  they  are  due 


FIG.  34.  Rheumatic  nodules.  Photograph  shows  nodules  on  patella,  condylcs 
of  femur  and  head  of  tibia  ;  girl  aged  about  ten  years  with  severe  endocarditis. 

to  the  same  cause,  the  rheumatic  irritant,  whatever  it  may  be. 
This  view  would  agree  with  clinical  experience,  which  shows 
that,  in  children  at  least,  these  nodules  are  almost,  if  not  quite, 
conclusive  evidence  of  rheumatism. 

While  in  adults  rheumatic  nodules  are  rare,  in  children  they  occur 
with  sufficient  frequency  to  make  them  of  considerable  practical 
importance.  In  50  consecutive  cases  of  articular  rheumatism 
in  children  under  twelve  years  of  age,  no  less  than  23  showed 
nodules,  that  is,  nearly  half  the  cases  ;  and  even  including  cases 
of  chorea  (with  or  without  evidence  of  rheumatism)  and  rheu- 
matic heart  disease  without  concurrent  articular  rheumatism, 


476  COMMON  DISORDERS  OF  CHILDHOOD 

I  found  nodules  in  55  out  of  200  as  far  as  possible  consecutive 
cases,  i.e.  in  27-5  per  cent.  But  these  statistics  were  drawn 
from  cases  admitted  to  the  wards  of  the  Hospital  for  Sick  Children, 
and  therefore  apply  only  to  the  more  severe  cases,  and  give 
altogether  too  high  a  percentage  for  the  average  frequency  of 
rheumatic  nodules.  In  the  out-patient  department,  where  the 
slighter  cases  are  included,  the  frequency  of  nodules  in  consecu- 
tive cases  of  chorea  and  cardiac  or  articular  rheumatism  is 
probably  not  above  10  per  cent.  (Some  figures  taken  from  my 
out-patients  gave  9  in  84.) 

The  practical  importance  of  these  nodules  in  children  is  often 
great.  Their  presence  in  itself  is  a  manifestation  of  rheumatism, 
and  may  therefore  determine  the  character  of  other  symptoms, 
such  as  pains  in  the  limbs  or  cardiac  bruits  where  these  are  of 
doubtful  nature.  Whether  these  nodules  are  ever  the  only 
manifestation  of  rheumatism  may  be  doubtful,  certainly  it  is  ex- 
tremely rare  to  find  them  without  other  rheumatic  phenomena; 
but,  as  already  stated,  they  may  occur  with  chorea  without  other 
clinical  evidence  of  rheumatism,  a  point  which  is  worthy  of  note 
in  considering  the  relation  of  chorea  to  rheumatism. 

The  close  association  of  endocarditis  with  these  nodules  has 
also  its  clinical  importance,  for  even  if  no  signs  of  endocarditis 
are  detected,  the  presence  of  nodules  should  always  arouse 
a  watchful  suspicion  as  to  the  condition  of  the  heart.  In  some 
of  the  few  cases  in  which  I  have  seen  rheumatic  nodules  without 
evidence  of  cardiac  affection,  definite  signs  of  endocarditis  have 
appeared  within  a  few  days  or  weeks  after  the  appearance  of  the 
nodules. 

Moreover,  the  presence  of  nodules  in  a  child  has  a  very  impor- 
tant bearing  on  prognosis  ;  their  frequent  association  with  severe 
endocarditis  and  pericarditis  makes  their  significance  extremely 
grave,  even  where  the  prognosis  otherwise  might  seem  by  no 
means  unfavourable.  In  many  such  cases  the  cardiac  disease 
proves  fatal  sooner  or  later  ;  but  its  advance  may  be  slow.  One 
of  the  most  marked  cases  I  have  seen,  with  numerous  large 
nodules  and  endocarditis,  seemed  little  worse  when  seen  three 
years  later,  although  many  nodules  were  still  present.  I  had 
under  observation  a  boy  who  had  several  nodules  and  a  systolic 
apical  bruit  during  an  attack  of  articular  rheumatism  ;  the  bruit 
disappeared  before  he  left  the  hospital,  three  years  later  no 
bruit  was  detected  and  the  boy  seemed  in  good  health  :  in  another 
case  the  heart  was  normal  and  the  child  seemed  perfectly  well 
3 1  years  after  an  attack  of  chorea,  during  which  many  rheumatic 


RHEUMATISM  477 

nodules  had  been  present,  with  a  systolic  bruit  over  the  base  of 
the  heart. 

Amongst  the  symptoms  of  rheumatism  in  children,  as  in  adults, 
must  be  reckoned  sore  throat.  Tonsillitis  so  frequently  occurs 
just  before  the  onset  of  rheumatic  pains  in  children  that  it  is 
difficult  to  escape  the  conclusion  that  it  bears  some  direct  relation, 
possibly  as  medium  of  infection,  to  rheumatism  ;  its  occurrence 
also  is  sometimes  followed  by  an  exacerbation  of  rheumatism. 

The  skin  eruptions  of  rheumatism  have  not  seemed  in  my 
experience  to  be  particularly  frequent  in  children,  but  their 
recognition  is  important. 

The  rheumatic  child  sweats  easily,  and  therefore  is  liable  to 
sweat-rashes,  either  in  the  form  of  tiny,  pin's-head.  clear  vesicles, 
sudamina,  or  as  papules  capped  with  an  opaque  milky-white 
vesicle,  miliaria.  These  are,  however,  not  essentially  rheumatic  : 
they  occur  in  any  condition  with  profuse  perspiration.  Much 
more  characteristic  is  the  pink,  very  slightly  raised  eruption 
known  as  Erythema  marginatum.  The  name  is  derived  from 
the  sharply  defined  edge  of  the  patches,  which  tend  to  be  circular, 
forming  rings  which,  becoming  confluent,  show  an  irregular  or 
gyrate  margin.  In  a  little  girl  under  my  care  this  curious  con- 
tour had  gained  for  her  at  home  the  nickname  of  '  the  map  girl '. 
This  rash  occurs  chiefly  on  the  trunk,  especially  on  the  chest, 
but  also  on  the  limbs,  does  not  itch,  and  shows  a  great  tendency 
to  recur.  Occasionally  the  erythema  takes  the  form  of  papules 
rather  than  patches,  and  it  may  be  associated  with  purpura. 
Apart  from  erythema,  however,  purpura  is  sometimes  a  striking 
feature,  appearing  in  patches  especially  over  one  of  the  swollen 
joints  during  an  attack  of  rheumatism.  Erythema  nodosum 
is  still  regarded  by  some  as  rheumatic,  but  there  is  very  strong 
evidence  from  its  age-incidence,  its  occasional  epidemic  occur- 
rence, and  the  extreme  rarity  of  a  second  attack,  that  it  has  no 
connexion  with  rheumatism. 

There  is  one  result  of  rheumatism  in  adults  which  is  almost 
unknown  in  childhood,  the  so-called  '  cerebral  rheumatism  '  or 
'  rheumatic  hyperpyrexia  '.  One  would  have  expected  that  the 
nervous  instability  which  is  so  noticeable  a  feature  in  rheumatic 
children  would  have  particularly  favoured  such  a  condition,  but 
Dr.  Cheadle  states  that  he  has  never  seen  a  case,  and  says  that 
the  earliest  age  at  which  he  could  find  it  recorded  was  thirteen 
years.  One  case  occurred  at  the  Hospital  for  Sick  Children, 
Great  Ormond  Street,  under  the  care  of  Dr.  Gee  (to  whom  I  am 
indebted  for  permission  to  place  it  on  record),  of  delirium  with 


478          COMMON  DISORDERS  OF  CHILDHOOD 

fatal  hyperpyrexia  (108-4)  in  the  course  of  acute  articular  rheuma- 
tism without  cardiac  affection  or  chorea  in  a  boy  of  6J  years. 

In  seeing  large  numbers  of  rheumatic  children  one  is  struck 
with  the  frequency  of  certain  minor  symptoms  which,  although 
not  usually  described  as  symptoms  of  rheumatism,  seem  to  have 
a  very  close  connexion  therewith  ;  and  I  think  that  the  recog- 
nition of  their  association  is  often  of  considerable  practical  value. 

A  very  common  complaint  in  such  children  is  that  of  '  pain 
in  the  stomach  '  :  in  my  experience  this  has  seemed  to  occur 
most  frequently  in  children  who  wrere  suffering  at  the  time  with 
articular  rheumatism  or  with  occasional  pains  in  the  limbs. 
The  pain  is  usually  referred  to  the  epigastrium,  and  is  sometimes 
sufficiently  severe  to  make  the  child  cry  ;  more  often  it  is  slight 
and  transient,  in  some  cases  it  was  definitely  after  meals,  but 
in  others  it  seemed  to  be  independent  of  them. 

The  association  with  the  limb-  or  joint-pains  suggests  that  the 
'  pains  in  the  stomach  '  may  sometimes  be  in  the  abdominal 
muscles,  but  I  suspect  that  it  is  usually  gastric  in  origin,  and  is 
due  to  a  catarrhal  condition  in  some  wray  dependent  on  the 
rheumatism. 

Another  symptom  which  I  have  noticed  less  often  is  '  pain  in 
the  side  ',  usually  in  the  lower  part  of  one  axilla,  with  nothing 
otherwise  to  suggest  pleurisy,  and  no  sufficiently  severe  cardiac 
affection  to  account  for  it.  This  may  possibly  be  due  to  rheuma- 
tism affecting  the  intercostal  muscles  ;  at  any  rate  it  is  associated 
often  with  other  symptoms  of  rheumatism  in  the  heart  or  joints. 

A  common  trouble  in  rheumatic  children,  and  in  the  children 
of  rheumatic  parents,  is  headache  :  in  some  cases  it  may  be 
dependent  on  some  gastric  catarrh  as  suggested  above,  in  others, 
as  Sir  James  Goodhart  points  out,  it  is  associated  with  anaemia, 
whilst  in  others  it  may  be  part  of  the  neurotic  element  wrhich  is 
so  prominent  in  these  children  ;  but  I  cannot  help  thinking  that 
in  some  cases  it  may  have  a  more  direct  relation  to  the  rheumatic 
poison  whether  bacterial  in  origin  or  not  ;  the  very  frequent 
association  of  headache  with  chorea  perhaps  points  in  the  same 
direction. 

In  our  estimate  of  the  wider  influence  of  rheumatism  in  child- 
hood we  must  take  into  account  not  only  those  symptoms  which 
seem  to  be  direct  manifestations  of  rheumatism,  but  also  those 
more  distantly  related  phenomena  which  in  children  are  so  often 
associated  with  rheumatism  or  rheumatic  heredity. 

To  my  mind  one  of  the  most  striking  features  in  such  children 
is  the  '  nervous  '  temperament  to  which  Goodhart  has  specially 
drawn  attention.  The  rheumatic  child  is  par  excellence  the 


RHEUMATISM  479 

nervous  child.  In  many  cases  this  is  seen  in  an  undue  excita- 
bility— such  children  will  become  almost  uncontrollable  in  their 
excitement  over  games  and  amusements  ;  or,  on  the  other  hand , 
there  may  be  excessive  timidity  ;  in  some  of  the  older  children 
this  is  replaced  by  a  sensitiveness  or  shyness  which  is  almost 
morbid. 

The  frequency  of  rheumatism  in  association  with  night  terrors 
is  another  illustration  cf  this  point.  Sir  James  Goodhart  found 
rheumatic  parentage  in  17  out  of  37  cases,  and  Dr.  Graham 
Little  from  a  study  of  30  cases  concludes  that  'a  prepon- 
derating number  of  cases  are  found  in  rheumatic  subjects  with 
early  heart  disease ' ;  in  my  own  experience  also  the  association 
of  night  terrors  with  rheumatism  has  been  very  frequent,  and 
I  have  elsewhere  pointed  out  a  similar  association  in  cases  of 
day  terrors. 

Somnambulism  is  another  of  the  neuroses  to  which  such 
children  are  subject ;  they  are  also  prone  to  talk  in  their  sleep 
and  to  be  restless  at  night  after  the  least  excitement. 

Habit-spasm  has  also  seemed  to  me  to  be  specially  frequent 
in  rheumatic  children  ;  in  some  cases  it  occurred  concurrently 
with  pains  in  the  joints  or  limbs,  in  others  there  was  a  strong 
family  history  of  rheumatism.  As  a  rule,  the  character  of  the 
movement,  its  limitation  to  a  sudden  blinking  or  a  twitch  of 
the  nose,  or  a  momentary  lateral  rotation  of  the  head,  has  dis- 
tinguished it  from  chorea ;  but  in  some  of  the  cases  with 
more  complicated  movements  their  nature  is  less  certain,  for 
the  association  with  rheumatism  naturally  suggests  the  possi- 
bility of  an  unusually  limited  chorea,  and  I  have  more  than  once 
seen  typical  habit-spasm  occur  in  rheumatic  children  who  were 
said  to  have  had  chorea  at  some  previous  date. 

Another  ailment  which  I  have  several  times  seen  associated 
with  rheumatism  in  children  is  lienteric  diarrhoea.  This  curious 
irritability  of  the  intestine,  which  results  in  a  desire  to  defsecate 
almost  directly  after — sometimes  indeed  before — a  meal  is 
finished,  is  almost  certainly  a  nervous  phenomenon.  In  cases 
under  my  care  this  has  occurred  sometimes  in  children  under 
treatment  for  articular  rheumatism,  sometimes  in  the  children 
of  rheumatic  families.  The  frequent  association  of  such  neuroses 
with  rheumatism  in  children  has  to  be  remembered  in  considering 
the  relation  of  chorea  to  rheumatism,  but  clinical  experience 
suggests,  I  think,  that  chorea  stands  in  a  different  and  more 
direct  relation  to  rheumatism. 

There  io  one  further  phenomenon  which  is  noteworthy  in 
rheumatic  children,  and  which  is  perhaps  worth  mentioning 


480          COMMON  DISORDERS  OF  CHILDHOOD 

here,  although  it  is  necessarily  noticeable  also  in  adults — the 
association  of  red  hair  with  rheumatism  and  rheumatic  heredity. 
The  following  observation  may  serve  to  illustrate  it.  In  four 
days  there  were  amongst  my  out-patients  eleven  children  with 
red  hair.  Of  these,  two  were  attending  with  articular  rheuma- 
tism ;  one  had  occasional  pain  and  swelling  in  the  knees,  his 
mother  had  red  hair  and  frequent  pains  in  the  limbs,  and  her 
brother  and  sister  had  '  rheumatic  fever  '  ;  one  had  '  pains  in 
the  knees '  and  his  mother  had  '  rheumatism  '  ;  three  others 
showed  a  history  of  '  rheumatic  fever  '  in  the  mother  or  father  ; 
one  was  attending  with  chorea  ;  one  had  a  brother  attending 
with  articular  rheumatism  ;  only  two  out  of  the  eleven  shoAved 
no  rheumatism  or  chorea  in  themselves  or  their  families. 

Amongst  80  children  with  red  hair  (including  the  11  already 
mentioned)  24  were  attending  with  definite  manifestations  of 
acute  rheumatism,  articular  or  cardiac  or  chorea ;  6  had  pains 
in  the  limbs  which  were  almost  certainly  rheumatic,  and  of  the 
remaining  50  cases  17  showed  a  family  history  of  acute  rheuma- 
tism (including  chorea)  in  parents  or  brothers  or  sisters  ;  so 
that  there  was  rheumatism  either  in  the  child  or  the  family  in 
47  out  of  80  ;  i.e.  in  58  per  cent. 

I  would  suggest  that  this  colour  of  the  hair  is  only  the  index 
of  some  fine  peculiarity,  perhaps  in  the  chemistry  of  metabolism, 
which  produces  a  soil  favourable  to  rheumatic  infection,  and 
hence  the  association  is  only  noticeable  where  such  infection  is 
rife.  The  colour  of  the  hair  may  seem  but  a  small  point,  but 
it  is  one  of  the  many  little  indications  which  are  sometimes  of 
value  in  leading  to  the  early  detection  of  rheumatism  in  a  child. 

The  importance  of  early  recognition  of  rheumatism  in  children 
will  be  realized  by  those  who  are  familiar  with  the  frequency  of 
heart  disease  in  the  rheumatic  child.  I  suppose  there  are  few 
more  pitiful  conditions  than  that  of  the  child  dying  with  cardiac 
rheumatism,  and  it  is  by  paying  attention  to  '  the  day  of  small 
things  ',  the  apparently  trivial  aches  and  pains,  and  the  various 
associations  which  make  up  the  picture  of  rheumatism  in  child- 
hood, that  we  may  hope,  in  some  cases  at  least,  to  prevent 
those  terrible  results  which  arc  too  often  seen  from  neglected 
rheumatism  in  children. 

Diagnosis.  But  while  it  is  most  important  to  remember 
the  possibility  of  rheumatism  whenever  a  child  complains  of 
'  growing  pains  '  or  stiffness  of  the  limbs,  or  shows  some  definite 
swelling  of  the  joints,  it  must  not  be  forgotten  that  there  are 
many  other  causes  of  joint  affection  and  pains  in  the  limbs  in 
children. 


RHEUMATISM  481 

It  may  be  laid  down  as  a  sound  principle  that  a  diagnosis 
of  rheumatism  in  the  case  of  a  child  under  two  years  of  age  is 
almost  always  a  mistake.  One  condition  which  is  erroneously 
thought  to  be  rheumatism  in  an  infant  is  scurvy  ;  such  a  case 
as  the  following  is  not  very  rare. 

An  infant,  aged  ton  months,  was  sent  to  me  for  *  rheumatism  '  ;  he  had  been 
ailing  six  weeks  with  slight  swelling  and  tenderness  about  one  ankle  ;  salicylates 
had  been  given  with  little  advantage.  Examination  showed  that  the  swelling 
was  not  strictly  over  the  ankle-joint,  but  extended  over  the  lower  end  of  the 
tibia,  which  was  tender,  there  was  no  effusion  in  the  joint  itself;  the  gums 
showed  the  purple  spongy  appearance  of  scurvy ;  under  antiscorbutic  treat- 
ment the  child  was  well  in  a  few  days. 

Another  affection  which  is  sometimes  confused  with  rheuma- 
tism in  infancy  is  acute  epiphysitis,  \vith  which  there  may  be 
suppuration  in  several  joints  ;  the  general  illness  is  more  severe 
and  the  local  symptoms  more  intense  than  is  usual  in  rheuma- 
tism, and  the  occurrence  of  oedema,  and  suppuration  in  one 
or  more  of  the  affected  joints,  mav  settle  the  diagnosis. 

I  have  seen  a  few  cases  under  one  year  of  age  in  which  one 
joint  has  become  swollen  with  evidence  of  slight  effusion  in  it, 
with  some  limitation  of  movement  but  little  or  no  tenderness  ; 
after  continuing  for  several  weeks  the  affection  has  passed  off, 
leaving  the  joint  apparently  normal.  The  course  of  these  cases 
has  been  unlike  articular  rheumatism,  which  does  not  remain 
limited  to  one  joint  for  several  weeks  and  which,  moreover,  is 
usually  accompanied  sooner  or  later  by  other  manifestations  of 
the  disease,  whereas  in  these  there  was  nothing  except  the  one 
swollen  joint,  and  salicylates  appeared  to  have  no  effect. 

In  one  infant,  aged  six  months,  the  right  knee  was  affected 
thus  for  several  weeks  after  summer  diarrhoea ;  no  evidence  of 
syphilis  could  be  obtained  nor  of  tuberculous  disease,  and  com- 
paring this  case  with  others  that  I  have  seen  I  supposed  it  to 
be  an  infective  condition,  but  its  limitation  for  so  long  to  one 
joint  was  quite  unlike  articular  rheumatism. 

Again',  I  have  seen  arthritis  in  early  childhood  associated 
with  a  vulvo-vaginitis,  which  in  children  is  most  often  due  to 
the  gonococcus. 

A  child,  aged  two  years  and  eleven  months,  who  was  in  the  Children' s  Hospital 
under  Dr.  Lees,  had  a  profuse  purulent  discharge  from  the  vagina  four  weeks 
before  admission.  About  a  fortnight  after  the  discharge  began  one  hand 
became  swollen  and  painful,  and  three  days  after  this  the  other  was  affected. 
The  hand  showed  swelling  not  limited  strictly  to  the  wrist,  but  extending 
over  the  dorsum  of  the  hand  and  upwards  slightly  on  the  forearm.  The 
vaginal  discharge  was  treated,  and  the  tenderness  of  the  hands  disappeared 
quickly,  but  the  swelling  remained  for  some  weeks. 

STILL 


482  COMMON  DISORDERS  OF  CHILDHOOD 

Without  a  bacteriological  examination  one  cannot  be  certain, 
but  it  seemed  most  probable  that  this  was  a  case  of  gonorrhceal 
arthritis. 

There  are  cases  also  in  which  a  gonococcal  arthritis  occurs  in 
infancy  without  any  apparent  primary  focus  of  infection  such 
as  an  ophthalmia  or  a  vaginitis ;  it  is  seen  sometimes  in  male 
infants. 

Charles  H.,  aged  seven  weeks,  was  in  King's  College  Hospital  for  diarrhoea 
and  vomiting  :  a  month  after  admission  he  seemed  in  pain,  and  two  days 
later  the  left  ankle  became  swollen  ;  no  other  joint  was  affected.  After  four 
days  it  was  opened  by  Mr.  Carless,  and  about  a  drachm  of  pus  evacuated 
which,  on  bacteriological  examination  by  Dr.  D'Este  Emery,  seemed  to 
contain  a  pure  growth  of  gonococci. 

Dr.  Emmett  Holt 1  has  reported  twenty-six  cases  of  gonor- 
rhooal  arthritis  in  children  under  three  years  of  age.  Dr.  Kim- 
ball  2  has  reported  eight  cases  in  infants  not  more  than  three 
months  old,  and  several  of  these  cases  were  males  with  no  trace 
of  gonorrhceal  infection  elsewhere.  Probably  such  cases  have 
hitherto  been  included  under  the  head  of  acute  arthritis  of 
infants. 

Lastly,  there  are  cases  of  syphilitic  synovitis  in  infancy  asso- 
ciated with  syphilitic  epiphysitis.  Dr.  Melville  Dunlop3  has 
recorded  two  such  cases  in  infants  aged  three  months  and  six 
mouths. 

I  mention  these  various  causes  of  swelling  about  or  in  the 
joints  in  infancy,  not  because  they  are  common,  for  they  are 
all  very  rare,  but  in  order  to  show  that  there  are  several  con- 
ditions to  be  thought  of  before  we  commit  ourselves  to  the 
extremely  unlikely  diagnosis  of  '  rheumatism  '  in  an  infant. 

I  have  considered  the  diagnosis  of  rheumatism  in  children 
past  the  age  of  infancy  in  my  remarks  on  the  various  symptoms  ; 
but  I  will  add  these  further  cautions. 

The  rarity  of  acute  pain  and  tenderness  in  the  rheumatic 
arthritis  of  childhood  should  make  us  cautious  where  such 
manifestations  are  present.  If  a  child  cries  out  with  tenderness 
when  the  limbs  are  touched  the  possibility  of  acute  infective 
osteomyelitis  is  to  be  borne  in  mind,  and  the  history  of  a  sudden 
onset,  perhaps  with  a  rigor  and  a  very  high  temperature  and 
delirium  and  the  extension  of  the  swelling  and  tenderness  beyond 
tho  limits  of  the  joint,  would  point  to  this  affection. 

In  connexion  with  most  of  the  specific  fevers  an  acute  arthritis 
is  occasionally  seen  in  children  ;  it  may  be  of  suppurative 
character  and  the  constitutional  and  the  local  symptoms  are 

1  Med.  Record,  March  25,  1905. 

2  Ibid.,  November  14,  1903. 

3  Edin.  Med.  Journ.,  December,  1904.' 


RHEUMATISM  483 

likely  to  be  more  severe  in  such  conditions  than  in  rheumatism. 

But  I  must  point  out  also  that  in  rare  cases  the  constitutional 
disturbance  with  acute  rheumatism  is  severe,  and  the  joints 
are  swollen  and  tender,  and  I  have  even  seen  oedema  over  a 
joint  with  acute  articular  rheumatism  in  childhood  ;  moreover, 
there  may  be  acute  illness,  high  fever  and  sordes  on  the  lips 
with  nothing  more  than  some  stiffness  of  one  or  more  joints, 
and  until  further  symptoms  appear  the  only  guidance  in  diagnosis 
may  be  the  rapid  improvement  under  salicylate  treatment. 

In  the  child,  as  in  the  adult,  rheumatism  tends  to  flit  from 
joint  to  joint ;  as  I  have  already  mentioned,  it  is  occasionally 
limited  for  a  few  days  to  one  joint,  but  a  monarticular  affection 
lasting  several  days  should  always  raise  suspicion  that  it  may 
not  be  rheumatism  but  may  be  tuberculous  disease  or  some  other 
form  of  infective  arthritis. 

It  seems  excusable  to  mention  here  an  instance  of  a  form  of 
arthritis  which,  though  almost  unknown  in  childhood,  has  been 
recorded  in  a  few  cases,  namely  gout,  which  Sir  Alfred  Garrod 
saw  in  a  child  aged  7  years,  and  Scudamore  in  a  child  aged 
8  years. 

Florrie  P.,  aged  12  years,  at  the  age  of  3\  years  had  her  first  attack  of  goufc 
in  the  right  ankle,  and  since  then,  every  few  months,  has  had  attacks  of  pain 
and  swelling  in  the  metatarso-phalangeal  joint  of  the  great  toe,  which  becomes 
dusky  red,  and  extremely  tender  ;  the  child's  temperature  is  not  raised  above 
100°.  The  attacks  subside  within  forty-eight  hours  on  free  administration  of 
Vinum  Colchici.  The  child's  father  has  had  typical  attacks  of  gout  since  he 
was  a  young  man  ;  his  father  and  grandfather  also  suffered  with  gout. 

Prognosis.  Rheumatism  in  the  child  must  always  be  re- 
garded as  a  serious  condition  on  account  of  the  special  tendency 
in  early  life  to  heart  affection.  If  there  were  only  the  joints 
to  be  considered  rheumatism  would  be  a  disease  of  little  gravity  ; 
it  is  extremely  rarely  that  any  trace  of  the  articular  affection 
remains  permanently.  I  have  seen  one  or  two  children  in  whom 
there  occurred  a  chronic  thickening  about  the  joints  like  that 
described  by  Jaccoud  as  '  rheumatisme  chronique  fibreux  ',  which 
he  attributed  to  repeated  attacks  of  rheumatic  fever  in  young 
adults.  I  have  elsewhere  l  recorded  such  a  case  in  a  boy  aged 
five  years.  But  this  is  so  rare  that  it  hardly  calls  for  con- 
sideration in  giving  prognosis  in  the  rheumatism  of  children. 
The  point  of  greatest  practical  importance  is  to  warn  the  parents 
of  the  liability  to  heart  disease,  and  to  impress  upon  them  the 
extreme  importance  of  prolonged  rest  if  there  is  any  suspicion 
of  impurity  or  irregularity  or  undue  rapidity  of  the  heart  sounds 
suggesting  that  there  may  be  already  some  affection  of  valve  or 
muscle. 

1  Trans.  Roy.  Hed.  Chir.  Soc.,  vol.  Ixxx. 


484  COMMON  DISORDERS  OF  CHILDHOOD 

Treatment.  So  far  as  the  treatment  of  the  joint  affection 
is  concerned  there  is  little  to  be  said.  Under  salicylate  or 
aspirin  the  articular  symptoms  subside  very  quickly  ;  to  a  child 
of  ten  years,  if  the  symptoms  are  severe,  15  grains  of  the  sali- 
cylate can  be  given  every  two  or  three  hours  for  five  or  six  doses 
and  then  less  frequently;  as  a  rule,  a  smaller  dose,  10-12  grains 
is  sufficient ;  if  as  much  as  10  grains  is  used  it  is  wise  to  give 
with  it,  as  Dr.  Lees  has  suggested,  double  as  much  sodium 
bicarbonate,  to  prevent  any  toxic  symptoms  from  the  salicylate. 

It  is  the  fashion  now  to  give  aspirin,  which  may  be  used  in 
doses  of  gr.  5-7  for  a  child  of  six  to  twelve  years.  I  have  not 
been  able  to  satisfy  myself  that  it  offers  any  special  advantage 
over  sodium  salicylate  ;  given  in  large  doses  it  has  the  same 
toxic  effects.  Dr.  Lees  has  recorded  a  case  in  which  a  child 
with  chorea  developed  air-hunger  and  became  comatose  after 
aspirin  had  been  given  in  doses  of  15  grains  three  times  daily 
only  for  seven  doses,  and,  as  he  has  pointed  out  to  me,  it  has 
the  disadvantage  that  it  cannot  be  given  with  alkalies,  as  sodium 
salic}4ate  can.  Dr.  Lees's  valuable  observations  have  shown 
that  bicarbonate  of  soda  in  large  doses  sufficient  to  keep  the 
urine  alkaline  effectually  prevents  the  toxic  symptoms  of  the 
salicylate  group  of  drugs. 

But  how  long  should  the  salicylate  or  aspirin  be  continued  ? 
The  answer  to  this  question  depends  upon  the  view  taken  as  to 
the  action  of  this  drug.  There  are  those  who  deny  to  salicylate 
and  the  allied  drugs  any  beneficial  effect  beyond  the  reduction 
of  temperature  and  the  relief  of  the  joint  symptoms  ;  on  the 
other  hand,  there  has  been  attributed  to  this  drug  a  specific 
effect  as  antagonistic  to  rheumatism  in  all  its  manifestations 
as  mercury  is  to  syphilis. 

It  has  seemed  to  me  probable  that  salicylates  do  more  than 
merely  relieve  the  arthritis  of  rheumatism.  I  have  several  times 
observed  that  after  salicylates  have  been  given  and  the  joint 
symptoms  for  which  the  drug  was  administered  have  passed 
away  and  the  temperature  has  become  normal,  the  discon- 
tinuance of  the  salicylate  has  been  followed  after  a  few  days  by 
a  further  rise  of  temperature  with  no  recurrence  of  joint  symp- 
toms, and  this  fever  has  subsided  upon  further  administration 
of  salicylates. 

If  the  temperature  in  such  cases  may  be  taken  to  indicate 
activity  of  the  rheumatic  infection  in  other  parts  of  the  body 
after  the  joint  symptoms  have  disappeared,  it  would  seem  that 
salicylate  has  some  effect  in  stopping  this  activity.  It  is,  I  think, 
no  evidence  against  the  specific  value  of  salicylate  that  rheumatic 


RHEUMATISM  485 

endocarditis  or  pericarditis  does  not  disappear  under  its  influence, 
it  may  have  a  preventive  value  where  it  has  no  power  to  remove 
the  products  of  inflammation  or  the  mechanical  results  which 
a  very  little  inflammatory  exudation  must  produce  in  the  heart 
valves  ;  and  when  inflammation  has  occurred  the  drug  may  still 
have  a  definite  value  in  preventing  further  inflammation  of 
the  part. 

I  throw  out  these  suggestions  as  some  justification  for  the 
view  that  the  administration  of  salicylates  should  not  be  dis- 
continued when  joint  symptoms  disappear,  nor  even  when  the 
temperature  falls  to  normal,  but  should  be  continued  for  two  or 
three  weeks  after  fever  has  completely  subsided,  and  should 
be  given  during  this  time  in  moderately  large  doses,  e.g.  10  grains 
of  sodium  salicylate  three  or  four  times  daily,  with  double  that 
dose  of  bicarbonate  of  soda  to  a  child  of  eight  years. 

In  the  cases  in  which  the  joint  pains  tend  to  recur  frequently 
in  subacute  form,  I  have  used  iodide,  given  in  doses  of  3-5 
grains.  A  suitable  mixture  is  Potassium  lodid.  gr.  v,  Sod. 
Bicarbonat.  gr.  xv,  Spirit  Ammon.  Aromat.  O)v,  Syrup  0)xxx, 
Aq.  Menth.  Pip.  ad  3ij  ter  die.  Local  applications  are  hardly 
required  in  the  articular  rheumatism  of  childhood  ;  it  is  sufficient 
to  wrap  the  affected  joint  in  some  warm  cotton-wool,  and  to 
prevent  the  pressure  of  bedclothes,  if  necessary,  by  a  cradle. 

It  is  a  difficult  question  in  regard  to  articular  rheumatism 
how  long  the  child  should  be  kept  in  bed.  I  have  long  thought 
that  not  only  is  articular  rheumatism  much  less  frequent  amongst 
the  children  of  the  well-to-do  than  amongst  the  poor,  but  that 
when  the  child  of  well-to-do  parents  does  suffer  with  rheumatism 
it  is  less  often  accompanied  by  heart  disease  than  in  the  children 
of  the  poor.  If  this  is  so,  the  explanation  probably  lies  in  the 
greater  care  taken  by  the  well-to-do  to  prevent  their  children 
being  exposed  to  damp  and  chill,  and  to  secure  rest  in  bed  when 
the  child  is  affected  with  rheumatic  pains.  It  seems  probable 
enough  that  when  the  rheumatic  infection  is  present  in  the 
blood — of  course  it  must  travel  by  the  blood — any  extra  strain 
thrown  upon  the  heart  by  exercise  may  render  the  heart  valves 
more  liable  to  infection,  just  as  we  know  that  other  infective 
conditions  tend  to  occur  in  parts  subject  to  stress  of  work  or 
injury. 

On  these  grounds — speculative,  I  admit,  but  supported,  I  think, 
by  clinical  experience — I  regard  it  as  a  wise  precaution  to  keep 
the  child  who  has  shown  definite  evidence  of  articular  rheuma- 
tism in  bed  for  three  or  four  weeks  after  all  the  pains  have 
disappeared,  even  though  there  be  no  suspicion  of  heart 
affection. 


CHAPTER  XXXIV 
HEART  DISEASE  IN   CHILDREN:    ENDOCARDITIS 

THE  term  heart  disease  covers  many  conditions:  it  includes 
congenital  heart  disease,  malignant  or  infective  endocarditis, 
suppurative  as  well  as  serous  pericarditis,  and,  in  children  as 
well  as  in  adults,  functional  affections  of  the  heart. 

In  this  chapter  only  simple  endocarditis,  or  acquired  valvular 
disease,  will  be  considered.  I  shall  not  attempt  to  give  any 
general  description  of  endocarditis,  such  as  may  be  found  in 
any  general  textbook  of  medicine,  I  wish  rather  to  draw  atten- 
tion to  some  of  the  special  features  of  this  condition  as  it  is  seen 
in  childhood. 

As  regards  its  frequency,  close  upon  10  per  cent,  of  the  children 
between  two  and  twelve  years  of  age  admitted  to  the  Children's 
Hospital,  Great  Ormond  Street,  are  suffering  from  endocarditis  ; 
and  any  one  who  has  visited  the  out-patient  department  of 
a  children's  hospital  in  London  can  hardly  fail  to  have  been 
struck  by  the  large  number  of  children  attending  with  this 
form  of  heart  disease.  It  would  be  difficult  to  draw  any  reliable 
comparison  between  hospital  statistics  and  those  of  private 
practice,  but  I  will  venture  to  say  from  my  own  experience  that 
heart  disease  is  less  common,  probably  much  less  common, 
amongst  the  children  of  the  well-to-do  than  amongst  the  poorer 
classes.  If  this  is  so,  it  suggests  that  this  terrible  disease — to 
my  mind  one  of  the  most  distressing  diseases  of  childhood — is  to 
some  extent  preventable. 

It  seems  to  me  probable  that  one  factor  in  the  causation  of 
the  rheumatism  from  which  heart  disease  usually  results  in 
childhood,  is  exposure  to  cold  and  damp,  and  that  it  is  partly 
on  tliis  account  that  the  children  of  the  poorer  classes  suffer 
much  more  with  rheumatism  in  all  its  manifestations  than  do 
the  children  of  the  well-to-do.  In  making  this  statement  I  do 
not,  of  course,  mean  to  imply  that  any  exposure  whatever  is 
capable  of  producing  rheumatism  in  any  form  unless  the  specific 
infection,  diplococcus  rheumaticus  or  whatever  it  may  be,  is 
present  ;  but  I  do  think  that  in  some  way  exposure  to  cold  and 
damp  favours  this  infection,  just  as  I  see  no  reason  to  doubt 


HEART  DISEASE  :    ENDOCARDITIS  487 

that  a  common  '  cold '  or  '  relaxed  throat ',  albeit  almost  certainly 
infective,  is  often  induced  by  exposure  to  a  cold  draught. 
I  suspect  also  that  house  infection  and  child  to  child  infection 
may  play  a  much  larger  part  in  the  spread  of  rheumatism  than 
we  have  yet  realized,  and  that  housing  conditions  may  in  this 
way  play  a  part  in  determining  the  frequency  of  rheumatic 
affections,  including  heart  disease  and  chorea,  amongst  the 
hospital  class. 

Most  writers  have  pointed  out  the  heavier  incidence  of  endo- 
carditis on  girls  than  on  boys.  Out  of  255  cases  of  endocarditis 
with  or  without  chorea,  140  were  girls,  115  were  boys  ;  but  if 
only  cases  of  endocarditis  without  previous  or  concurrent  chorea 
were  included ,  the  reverse  would  seem  to  be  true  ;  out  of  67  con- 
secutive cases  of  endocarditis  in  which  chorea  had  never  occurred 
40  were  boys,  27  were  girls.  It  would  seem,  indeed,  as  if,  while 
girls  more  often  suffer  with  rheumatism  than  boys,  the  limitation 
of  the  rheumatic  affection  to  heart  and  joints  is  more  common 
in  boys  than  in  girls. 

A  point  of  some  practical  importance  is  the  age  at  which  the 
liability  to  acquired  endocarditis  begins.  I  say  acquired  endo- 
carditis to  distinguish  it  from  the  intra-uterine  endocarditis 
which  I  think  is  more  often  talked  about  as  a  cause  of  congenital 
heart  disease  than  its  frequency  would  justify,  for  it  is,  I  think, 
extremely  rare.  How  soon  after  birth  may  a  child  develop 
endocarditis  ?  The  answer  to  this  question  lies  in  the  etiology 
of  simple  endocarditis  in  children  ;  the  age-incidence  of  endo- 
carditis is  the  age-incidence  of  rheumatism  :  let  it  be  laid  down 
as  a  fundamental  rule  for  guidance  in  diagnosis  that  rheumatism 
under  the  age  of  three  years  is  extremely  rare,  and  that  under 
the  age  of  two  years  it  is  almost  unknown  (see  p.  472). 

The  practical  bearing  of  these  facts  is  upon  the  diagnosis  of 
heart  disease  in  children  under  two  years  of  age.  It  is  evident 
that  if  acquired  endocarditis  in  children  is  due  to  rheumatism, 
the  possibility  of  acquired  endocarditis  in  a  child  under  two 
years  of  age  can  be  almost  entirely  excluded.  There  is,  indeed, 
one  form  of  endocarditis  which  does  occasionally  begin  in  infancy, 
namely,  malignant  endocarditis,  but  it  is  excessively  rare  and 
when  it  does  occur  is  associated  with  an  obvious  source  of  infection. 
I  have  seen  this  in  one  infant  at  seven  months  and  in  another 
at  two  years,  in  both  cases  associated  with  empyema  ;  in  the 
absence  of  any  such  cause  for  malignant  endocarditis,  a  bruit 
in  an  infant  under  two  years  of  age  is  almost  certainly  either 
functional  or  due  to  congenital  heart  disease. 


488  COMMON  DISORDERS  OF  CHILDHOOD 

I  have  already  implied  that  the  chief  cause  of  endocarditis 
in  children  is  rheumatism ;  perhaps  it  would  be  rash  to  say  that 
rheumatism  is  the  only  cause  of  simple  endocarditis  in  childhood, 
but  my  own  experience  very  strongly  suggests  this.  Out  of  150 
cases  in  which  I  investigated  this  point,  142  showed  evidence 
of  rheumatism  either  in  articular  rheumatism,  subcutaneous 
nodules  or  chorea.  Of  the  remaining  eight  cases  one  was  after 
scarlet  fever,  two  were  after  supposed  influenza,  the  rest  could 
not  be  assigned  to  any  particular  cause. 

Scarlet  fever  and  influenza  are  generally  reputed  causes  of 
endocarditis  ;  but  when  one  remembers  how  often  the  vague 
febrile  symptoms  at  the  onset  of  rheumatism  in  children  are 
mistaken  for  *  influenza  ',  and  how  extremely  probable  it  is 
that  the  so-called  scarlatinal  rheumatism  is  in  many  cases  only 
ordinary  acute  rheumatism  to  which  this  particular  fever  pre- 
disposes, it  seems  at  least  possible  that  these  cases  should  be 
included  under  the  head  of  rheumatic  endocarditis.  Even  the 
cases  in  which  the  history  threw  no  light  on  the  cause  of  endo- 
carditis cannot  be  excluded  from  the  category  of  rheumatism, 
for  the  cardiac  manifestation  may  be  the  first  evidence  of 
rheumatism  in  a  child  ;  this  view  is  confirmed  in  the  majority  of 
such  cases  by  the  subsequent  development  of  other  rheumatic 
manifestations. 

Undoubtedly  a  pysemic  condition  in  connexion  with  scarlet 
fever  or  any  other  disease  may  give  rise  to  a  malignant  endo- 
carditis, but  so  far  as  simple  endocarditis  is  concerned,  I  cannot 
affirm  from  my  own  observation  that  it  is  ever  due  in  childhood 
to  any  other  cause  than  acute  rheumatism. 

Symptoms 

One  of  the  features  which  is  particularly  noteworthy  in  the 
heart  disease  of  children  is  the  insidiousness  of  its  onset.  There 
may  be  nothing  to  draw  attention  to  endocarditis  in  a  child 
until  it  is  already  so  advanced  that  breathlessness  or  some  other 
symptom  results,  which  leads  to  examination  of  the  chest  and 
the  unexpected  discovery  of  signs  of  endocarditis.  For  instance, 
Walter  H.,  aged  11 J  years,  was  brought  for  wasting  with  languor 
and  depression  and  some  '  pain  in  the  chest  after  food  '.  Routine 
examination  showed  most  unexpectedly  an  enlarged  and  hyper- 
trophied  heart  with  a  loud  presystolic  bru^t  at  the  apex.  On 
further  inquiry  it  was  found  that  some  time  previously  he  had 
had  an  illness  which  was  called  '  influenza  '  with  stiffness  of 


HEART  DISEASE  :    ENDOCARDITIS  489 

joints,  and  that  for  six  months  past  he  had  been  complaining  of 
'  growing  pains  '. 

A  common  antecedent  of  heart  disease  is  this  complaint  of 
4  growing  pains  ',  which  so  often  represent  acute  articular  rheuma- 
tism in  children.  It  is  very  important  to  remember  that 
these  vague  aches  and  pains  may  be  associated  with  just  as 
severe  endocarditis  as  the  most  acute  attack  of  so-called  '  rheu- 
matic fever  '.  Even  when  the  heart  disease  is  already  advanced, 
the  symptoms  for  which  the  children  are  brought  to  the  medical 
man  are  often  very  misleading.  A  not  uncommon  complaint  is 
wasting.  I  have  several  times  had  children  brought  to  me 
solely  for  this  when  routine  examination  has  shown  that  the 
cause  of  the  wasting  was  heart  disease,  and  generally  inquiry 
has  elicited  some  history  of  *  growing  pains  '  or  other  evidence 
of  rheumatism.  Such  a  case  was  the  following. 

Henry  S.,  aged  seven  years,  was  brought  for  wasting;  no  mention  was  made 
of  any  other  symptom,  but  I  noticed  that  his  cheeks  were  purplish,  and  on 
examining  the  heart  found  it  was  considerably  enlarged ;  there  were  systolic 
and  diastolic  bruits  at  the  apex  ;  there  were  rheumatic  nodules  on  the  elbow 
and  on  one  knee.  On  further  inquiry  it  was  found  that  the  boy  had  occasionally 
had  some  slight  pains  in  his  limbs. 

Wasting  is  a  much  commoner  and  more  marked  feature  of 
heart  disease  in  the  child  than  in  the  adult,  as  might  be  expected, 
for  the  growth  of  the  body  in  childhood  makes  heavy  demands 
upon  nutrition,  and  if  the  circulation  is  impeded  by  heart  disease 
nutrition  will  suffer  more  in  the  growing  child  than  in  the 
adult,  who  requires  only  nourishment  enough  to  maintain  his 
completed  structure. 

Epistaxis  is  sometimes  the  symptom  for  which  the  child  with 
heart  disease  is  brought  ;  it  is  not  uncommon  in  cases  of  severe 
endocarditis  ;  it  was  present  in  10  out  of  150  consecutive  cases 
of  endocarditis. 

Elizabeth  B.,  aged  seven  years,  was  brought  for  nose- bleeding,  which  had 
occurred  at  intervals  of  a  few  weeks  for  two  years  ;  no  other  symptom  was 
mentioned,  but  on  inquiry  it  was  found  that  she  had  had  pains  in  the  ankles 
and  in  the  neck  occasionally  ;  and  the  mother  had  had  rheumatic  fever.  The 
child's  heart  was  found  to  be  enlarged,  there  was  a  loud  systolic  murmur  at 
the  apex,  with  reduplication  of  the  second  sound. 

Tonsillitis  is  the  only  complaint  in  some  cases ;  for  instance  : 

Lilian  B.,  aged  12 £  years,  had  had  repeated  attacks  of  tonsillitis ;  the  mother 
had  no  idea  that  there  was  anything  more  amiss,  but  on  being  specially  asked, 
said  that  the  child  had  occasionally  complained  of  pains  in  her  limbs,  to 
which  no  importance  had  been  attached.  The  area  of  cardiac  dullness  ex- 


490  COMMON  BISORDERS  OF  CHILDHOOD 

tended  about  f-inch  beyond  the  right  margin  of  the  sternum,  and  1  inch 
beyond  the  left  nipple  line,  and  there  was  a  blowing  systolic  bruit  at  the  apex 
conducted  into  the  axilla. 

It  is  the  exception  for  a  child  with  heart  disease  to  be  brought 
for  any  symptom  directly  traceable  to  the  heart  condition  ; 
occasionally,  it  is  true,  the  child  complains  of  shortness  of  breath, 
especially  on  exertion,  or  comes  for  'palpitation',  or  for  prao- 
cordial  pain,  but  much  more  often  the  doctor  is  consulted  not 
for  heart  symptoms,  but  for  growing  pains,  or  more  definite 
joint  rheumatism,  or  for  stiff-neck  or  chorea. 

The  only  way  to  avoid  overlooking  heart  disease  in  children 
is  to  make  a  practice  of  examining  the  chest  thoroughly  in  every 
child,  whatever  may  be  the  reason  for  seeking  medical  advice. 
I  have  many  times  seen  serious  heart  disease  overlooked  by, 
neglect  of  this  routine.  Where  there  have  been  '  growing  pains  ' 
or  chorea,  or  other  manifestations  of  rheumatism,  the  heart 
should  be  examined  repeatedly  ;  disastrous  heart  mischief  might 
be  avoided  if  endocarditis  were  detected  in  its  earliest  stage  and 
the  child  then  kept  at  rest  in  bed  for  two  or  three  months. 

There  are  certain  points  in  the  examination  of  the  heart  to 
which  I  should  like  to  draw  attention.  Too  often  the  only 
point  to  which  importance  is  attached  is  the  presence  or  absence 
of  bruits,  and  their  character  or  extent.  Let  it  be  recognized 
that  a  child  may  have  endocarditis  with  no  bruit  at  all  :  this 
happens  sometimes  at  the  earliest  stage  of  the  affection  ;  a  child 
with  chorea  or  with  swollen  rheumatic  joints  will  sometimes 
show  slight  but  definite  increase  of  cardiac  dullness  with  rapid 
and  perhaps  irregular  action  of  the  heart,  and  possibly  some 
thickness  of  the  first  sound  at  the  apex  ;  after  these  changes 
have  been  noticed  for  several  days  a  definite  systolic  bruit 
becomes  apparent  at  the  apex,  and  gradually  assumes  the 
character  of  well-marked  endocarditis.  Occasionally  I  have 
noticed  in  such  cases  the  presence  of  rheumatic  nodules  on  the 
elbows  or  elsewhere  several  days  before  the  bruit  appeared  ; 
a  fact  which  confirms  the  presence  of  endocarditis,  for  it  is 
well  known  that  there  is  an  extremely  close  association  between 
the  presence  of  these  nodules  and  the  presence  of  inflammation 
of  the  valves. 

Let  it  be  recognized  also  that  a  careful  estimation  of  the  size 
of  the  heart  is  often  just  as  important  as — nay  sometimes  more 
important  than — the  detection  of  the  presence  and  character 
of  a  bruit.  In  the  child's  heart  dilatation  takes  place  very 
easily  and  often  very  rapidly,  it  may  be  the  earliest  evidence 


HEART  DISEASE  :    ENDOCARDITIS  491 

of  heart  affection.  No  doubt  this  special  tendency  to  dilatation 
in  childhood  is  partly  due  to  the  comparative  thinness  of  the 
muscular  wall,  but  it  is  probably  due  also  in  part  to  the  fact 
that  especially  in  children  rheumatic  inflammation  of  the  heart 
tends  to  affect  the  whole  structure  of  the  heart,  muscle  as  well 
as  valve  and  pericardium. 

In  examining  a  child's  heart,  therefore,  it  is  very  necessary 
to  determine  and  note  carefully  the  '  deep  dullness  '.  I  mean 
by  this,  not  merely  the  limits  of  the  heart  where  uncovered  by 
lung,  an  area  which  in  the  healthy  child  extends  laterally  usually 
from  the  left  margin  of  the  sternum  barely  to  the  nipple  line — 
this  tells  us  little  or  nothing  about  the  size  of  the  heart,  it  only 
shows  how  much  is  not  overlapped  by  lungs — but  the  actual 
extent  of  the  heart  which  in  the  healthy  child  extends  at  the 
widest  part  from  about  J-inch  beyond  the  right  margin  of  the 
sternum  to  the  left  nipple  line,  and  sometimes  nearly  J-inch 
further  out. 

The  appreciation  of  the  actual  size  of  the  heart  by  percussion 
requires  considerable  training  of  hand  and  ear.  I  have  thought 
that  mistakes  are  often  made  by  percussing  from  heart  dullness 
towards  lung  resonance  instead  of  vice  versa.  It  is  easier  to 
appreciate  a  very  slight  change  of  note  when  passing  from 
a  completely  resonant  on  to  a  slightly  impaired  note  than  when 
passing  from  the  complete  dullness  of  heart  gradually  on  to  the 
resonant  lung  ;  so  that  if  percussion  is  begun  in  the  axilla  and 
carried  gradually  towards  the  heart  the  slight  change  of  note 
which  indicates  the  edge  of  the  heart  is  more  readily  appreciated. 

The  limit  on  the  right  side  is  more  easily  determined  than  on  the 
left.  Some  years  ago  I  made  experiments  on  the  cadaver,  insert- 
ing long  needles  through  the  limits  ascertained  by  percussion, 
and  I  found  that  I  could  gauge  the  right  margin  so  accurately 
that  the  needle  would  sometimes  graze  the  outermost  edge  of 
the  heart  on  the  right  side,  whereas  on  the  left  there  were  frequent 
errors  of  f-inch  or  even  more.  In  advanced  heart  disease,  and 
where  endocarditis  is  complicated  by  pericarditis,  it  is  the  limit 
of  the  right  side  which  requires  especially  to  be  watched,  for  any 
considerable  dilatation  of  the  right  side  is  quickly  accompanied 
by  symptoms  of  failing  compensation,  puffiness  of  face  and 
lividity,  oedema  of  legs,  shortness  of  breath,  ascites  and  enlarge- 
ment of  liver  ;  and  the  timely  application  of  leeches,  which  may 
be  suggested  by  percussion  before  these  symptoms  are  pronounced, 
is  of  the  greatest  value. 

In  the  earlier  stages  of  endocarditis  there  is  often  dilatation 


492  COMMON  DISORDERS  OF  CHILDHOOD 

of  the  left  side,  apparently  the  result  of  toxic  or  inflammatory 
changes  in  the  heart  muscle  rather  than  of  the  direct  mechanical 
stress  to  which  right  side  dilatation  is  often  due  ;  its  occurrence 
is  an  important  indication  of  the  need  for  prolonged  rest  in  bed. 

Hypertrophy  of  heart  is  usually  of  much  less  importance  as 
far  as  treatment  is  concerned  than  dilatation.  It  is  an  indica- 
tion of  the  struggle  against  pressure  :  hypertrophy  means  more 
or  less  successful  effort  to  resist,  dilatation  means  failure.  In 
the  child  hypertrophy  often  becomes  very  obvious  by  the  bulging 
of  the  prsecordium  which  is  made  possible  by  the  yielding 
character  of  the  chest  wall  in  early  life. 

On  auscultation  there  are  certain  differences  between  the 
signs  in  children  and  in  older  patients.  In  the  child  aortic 
bruits  are  much  less  common  than  in  adults.  In  250  cases  of 
endocarditis  I  found  aortic  bruits  only  in  nine,  and  they  are 
even  more  rare  in  the  earlier  years  of  childhood  than  in  the  four 
or  five  years  preceding  puberty.  When  aortic  bruits  develop,  it 
is  almost  always  in  cases  where  mitral  disease  has  already  been 
present  for  some  weeks  or  months.  If  the  heart  is  already 
labouring  under  the  stress  of  the  mitral  affection,  I  am  always 
glad  to  discover  signs  of  aortic  regurgitation,  for  it  is  my  ex- 
perience that  when  regurgitation  is  sufficient  to  produce  a  bruit 
it  in  some  way  relieves  the  heart,  and  the  child  generally  lives 
longer  than  when  mitral  bruits  alone  are  present. 

I  have  implied  that  aortic  disease  may  be  present  without 
producing  any  bruit.  Post  mortem  evidence  shows  that  although 
aortic  disease  is  so  rarely  recognizable  in  the  child  during  life, 
it  is  quite  commonly  present  in  fatal  cases  :  in  twenty-eight  out 
of  thirty-six  cases  of  endocarditis  the  aortic  valves  were  found 
to  be  affected,  whereas  only  five  of  these  had  shown  any  aortic 
bruit  during  life. 

Aortic  disease  without  mitral  disease  is  an  extreme  rarity,  if 
it  occurs  at  all  in  childhood.  I  think  I  have  twice  seen  children 
in  whom  there  was  a  diastolic  bruit  without  any  bruit  at  the 
apex,  but  it  would  be  quite  unsafe  to  conclude  that  in  such 
cases  there  was  no  mitral  disease  ;  it  is  quite  possible,  I  think 
probable,  that  if  these  cases  had  been  examined  at  the  onset 
of  the  endocarditis,  definite  evidence  of  mitral  disease  would 
have  been  found. 

As  a  rule  aortic  disease  in  a  child  shows  itself  by  systolic  and 
diastolic  bruits,  which,  be  it  noted,  are  not  only  occasionally  but 
usually  heard  better  over  the  middle  part  of  the  sternum,  or  in 
the  left  second  and  third  spaces  close  to  the  sternum,  than  on 


HEART  DISEASE  :    ENDOCARDITIS  493 

the  right  side  ;  occasionally  there  is  only  a  diastolic  bruit  : 
but  so  far  as  my  own  observation  goes,  there  is  never,  or  almost 
never,  a  systolic  aortic  bruit  without  a  diastolic.  This  is  a  point 
of  some  diagnostic  importance  because  congenital  heart  disease 
occasionally  takes  the  form  of  aortic  stenosis,  and  in  this  con- 
dition a  systolic  bruit  alone  may  be  heard  in  the  second  right 
space. 

The  vast  majority  of  cases,  however,  clinically  show  only 
mitral  disease;  this  was  so  in  241  out  of  250  cases.  In  117  of 
these  there  was  only  a  systolic  bruit  at  the  apex,  indicating 
mitral  regurgitation  ;  in  124  there  was  also  a  diastolic  apical  bruit, 
pointing  to  mitral  stenosis. 

I  am  often  told  that  a  child  has  a  'double  murmur'  at  the  apex, 
as  if  this  were  sufficient  description  where  systolic  and  diastolic 
bruits  are  present.  Now  I  wish  to  insist  here  upon  the  impor- 
tance of  differentiation  between  the  different  kinds  of  diastolic 
mitral  bruit.  It  is  quite  true  they  all  point  to  mitral  obstruction 
and  to  this  extent  have  the  same  significance,  but  there  is 
valuable  guidance,  both  for  prognosis  and  treatment,  to  be 
gained  from  more  accurate  timing  of  the  diastolic  bruit.  Perhaps 
I  shall  make  my  point  more  clear  by  describing  what  is  a  common 
history  of  the  heart  sounds  at  the  apex  in  the  child  who  suffers 
with  mitral  obstruction.  The  child  comes  under  observation 
first  with  evidence  only  of  mitral  regurgitation,  a  systolic  bruit 
at  the  apex,  the  second  sound  is  clear  and  well  defined  ;  soon 
a  change  is  noticed,  the  second  sound  ends  off  less  sharply, 
there  is  a  '  tailing  off  '  of  the  second  sound  ;  next  the  tailing 
becomes  an  evident  reduplication  and  the  second  part  of  the 
reduplication  after  a  few  days  has  changed  into  a  short  puff, 
much  shorter  and  less  marked  than  the  systolic  bruit  but  still 
evidently  a  bruit,  and  this  is  the  middiastolic  bruit,  or  as  it 
is  sometimes  well  described,  a  '  foo-ti-foo  '  murmur,  in  which  the 
first  'foo'  representing  the  systolic  bruit  is  more  prolonged 
than  the  second  '  foo  '. 

Now  if  the  child  be  kept  in  bed  at  this  stage,  the  order  of 
events  may  be  reversed,  and  after  a  few  weeks  the  heart  may 
show  only  the  original  systolic  bruit,  but  if  the  child  is  allowed 
to  get  up,  or  further  endocarditis  occurs,  the  middiastolic  changes 
into  a  presystolic  murmur  which  appears  as  a  slight  explosive 
sound  leading  up  to  the  systolic  bruit,  and  is  a  very  different 
sound  from  the  loud  rumbling  presystolic  bruit  which  is  met 
with  in  the  adult. 

Even  now,  if  proper  precaution  is  taken  to  ensure  thorough 


494  COMMON  DISORDERS  OF  CHILDHOOD 

rest  In  bed,  the  order  of  events  may  be  reversed,  the  presystolic 
may  give  place  to  a  middiastolic  and  this  in  turn  gradually 
disappear ;  but  if  treatment  fails,  or  indiscreet  exertion  is 
allowed,  the  time  of  the  bruit  undergoes  a  further  change,  and 
the  presystolic  bruit  is  replaced  by  an  early  diastolic,  which  with 
the  systolic  produces  '  to-and-fro  '  bruits  at  the  apex.  Even 
when  this  most  unsatisfactory  stage  is  reached,  under  favourable 
conditions  the  bruit  will  sometimes  retrace  its  steps,  but  I  think 
very  rarely  beyond  the  presystolic  stage. 

Such  then  are  the  differences  of  time  which  occur  in  the  bruit 
of  mitral  obstruction.  I  have  described  them  thus  at  length 
because  I  am  sure  from  clinical  experience  that  the  recognition 
of  these  differences  affords  valuable  guidance  in  prognosis  and 
treatment  ;  one  would  feel  more  hopeful  of  the  child  with 
systolic  and  middiastolic,  than  of  the  child  with  '  to-and-fro  ' 
bruits  at  the  apex,  and  the  child  with  a  presystolic  bruit  which 
is  still  capable  of  changing  into  a  middiastolic  is  in  a  better 
position  than  the  child  whose  presystolic  bruit  remains 
unalterable. 

When  a  bruit  has  changed  within  a  few  weeks  from  mid- 
diastolic to  presystolic  and  thence  to  early  diastolic,  it  is  evident 
that  the  mischief  is  progressing  and  that  prolonged  rest  is 
necessary  ;  on  the  other  hand,  where  the  course  is  in  the  reverse 
direction,  we  may  judge  from  it  the  progress  of  repair,  and  there- 
from the  time  during  which  rest  must  be  continued. 

I  have  alluded  to  the  difference  in  character  between  the  child's 
ill-marked  presystolic  and  the  loud  '  rumble-and-snap '  which  is 
so  often  heard  in  the  adult.  This  difference  corresponds  with 
the  difference  in  post  mortem  appearance  of  the  affected  mitral 
valve  in  the  child  and  in  the  adult  :  in  the  child  there  is  usually 
little  or  no  appreciable  diminution  of  the  mitral  orifice,  the 
obstruction  is  evidently  due  rather  to  the  slight  stiffening  of 
the  valve  by  inflammatory  infiltration  which  prevents  its  moving 
freely,  whereas  iri  the  adult  there  is  often  an  obvious  contraction 
of  the  lumen,  the  so-called  '  button-hole  mitral '. 

The  difference  probably  is  one  of  duration  ;  if  the  endocarditis 
is  sufficient  in  degree  and  the  child  survives  long  enough, 
he  may  show  a  presystolic  bruit  of  the  adult  type  during  life 
and  similar  '  button-hole  '  change  post  mortem,  but  this  change 
requires,  I  believe,  some  years  for  its  accomplishment.  I  found 
amongst  124  children  with  some  diastolic  bruit  at  the  apex 
only  three  with  the  loud  rumbling  pn  systolic  of  adult  type.  Only 
in  one  of  them  could  the  duration  of  the  mitral  disease  be  deter- 


HEART  DISEASE  :    ENDOCARDITIS  4% 

mined  with  some  degree  of  probability ;  in  this  case  it  had  lasted 
seven  years  before  the  child  first  came  under  observation  with 
the  adult  type  of  presystolic  murmur,  but  it  could  not  be  ascer- 
tained when  the  murmur  first  assumed  this  character.  In 
another  case,  not  included  in  this  series,  which  was  under  my 
care  with  a  bruit  of  this  adult  character  at  the  age  of  ten  years, 
the  boy  had  had  only  the  ordinary  systolic  and  middiastolic 
bruits  when  I  saw  him  four  and  a  quarter  years  previously,  two 
years  after  his  first  attack  of  acute  rheumatism.  This  type  of 
bruit  has,  I  think,  a  favourable  significance  inasmuch  as  it  points 
to  what  one  might  call  a  cicatricial  condition  of  the  valve,  and 
therefore  usually  to  a  quiescent  stage  of  endocarditis ;  certainly 
the  cases  in  which  it  is  present  are  commonly  stationary,  so  far 
as  can  be  judged  from  clinical  evidence,  and  remain  so  for  years. 

In  children,  as  in  adults,  the  supervention  of  a  musical  character 
in  a  bruit  due  to  endocarditis  is  always  of  sinister  omen,  it  gener- 
ally points  to  very  severe  and  generally  progressive  endocarditis, 
and  the  cases  which  show  it  are  apt  to  do  badly  ;  but  this  is  not 
always  so ;  I  have  known  one's  fears  to  be  falsified,  the  musical 
character  has  disappeared  and  the  child  has  done  well. 

And  here  I  should  like  to  draw  attention  to  a  particular  bruit 
which  has  somewhat  of  a  musical  character,  but  is  neither  of 
sinister  omen  nor  does  it  indicate  endocarditis  of  any  sort.  In 
my  own  notebooks  I  am  in  the  habit  of  labelling  it  '  Physio- 
logical bruit ',  but  only  for  want  of  some  better  name.  It  is 
heard  usually  just  below  the  level  of  the  nipple,  and  about  half- 
way between  the  left  margin  of  the  sternum  and  the  vertical 
nipple  line ;  it  is  not  heard  in  the  axilla  nor  behind ;  it  is  systolic, 
and  is  often  so  small  that  only  a  careful  observer  would  detect 
it ;  moreover,  it  is  sometimes  very  variable  in  audibility,  being 
scarcely  noticeable  with  some  beats  and  easily  heard  with 
others  ;  its  characteristic  feature  is  a  twanging  sound,  very 
like  that  made  by  twanging  a  piece  of  tense  string.  This 
bruit  is  found  mostly  in  children  between  the  ages  of  two  and 
six  years  ;  as  a  rule  they  are  brought  for  some  slight  ailment 
such  as  a  cough,  or  some  indigestion,  and  the  bruit  is  dis- 
covered only  in  the  course  of  routine  examination ;  it  does 
not  seem  to  be  due  to  any  anaemia,  at  any  rate  the  majority 
of  children  with  it  show  no  definite  anaemia.  It  persists  some- 
times for  many  months  ;  I  have  noted  it  as  present  in  one  case 
for  two  years.  Whatever  may  be  its  origin,  I  think  it  is  clearly 
functional,  that  is  to  say,  not  due  to  any  organic  disease  of  the 
heart  either  congenital  or  acquired  ;  and  I  mention  it  in  con- 


496  COMMON  DISORDERS  OF  CHILDHOOD 

nexion  with  endocarditis  because  I  have  seen  several  cases  in 
which  it  has  given  rise  not  only  to  groundless  alarm,  but  to 
unnecessary  restrictions,  so  that  the  child  has  been  treated  as 
an  invalid  and  not  allowed  to  walk  about. 

Prognosis.  I  have  already  indicated  some  of  the  grounds 
upon  which  prognosis  is  based.  So  long  as  any  evidences  of  active 
rheumatism  persist  the  child  with  endocarditis  is  in  danger  of 
further  cardiac  mischief  :  the  tendency  to  fresh  attacks  of 
rheumatism,  chorea,  joint  affection,  and  especially  heart  inflamma- 
tion, is  at  its  maximum  during  the  middle  period  of  childhood 
from  about  five  to  ten  years  of  age,  and  therefore  the  earlier  the 
first  attack  of  rheumatic  heart  affection  occurs,  the  greater  is 
the  probability  that  it  will  be  aggravated  by  subsequent  attacks 
of  rheumatism.  As  a  rough  statement,  I  think  it  is  correct  to 
say  that  the  chance  of  survival  of  a  child  with  endocarditis 
steadily  improves  after  the  age  of  eleven  or  twelve  years  has  been 
reached. 

A  very  important  element  in  prognosis  is  the  occurrence  of 
pericarditis.  There  is  no  complication  more  to  be  dreaded  than 
this  ;  out  of  forty-eight  cases  in  which  pericarditis  supervened, 
forty  proved  fatal  within  a  few  weeks  after  the  onset  of  the 
pericarditis.  Even  when  the  child  recovers  from  the  acute 
stage  of  pericarditis,  it  is  almost  always  left  in  a  much  worse 
position  than  before,  the  myocardium  has  been  inflamed  together 
with  the  pericardium,  and  this  with  the  adhesions  of  the  peri- 
cardium has  aggravated  the  dilatation  so  that  the  heart  already 
crippled  by  valvular  disease  is  left  barely  capable  of  compen- 
sation, which  sooner  or  later  fails  altogether. 

The  presence  of  rheumatic  nodules  is  of  great  practical  im- 
portance as  an  index  of  active  rheumatism,  and  therefore  must 
always  make  us  cautious  in  prognosis.  These  nodules  are  asso- 
ciated specially  with  severe  endocarditis  and  in  this  way  make 
the  outlook  bad ;  they  do  not,  however,  make  the  prognosis 
desperate.  I  have  seen  many  cases  with  nodules  make  an  excel- 
lent recovery,  sometimes  even  to  the  extent  of  losing  their  bruits 
altogether. 

Serious  as  endocarditis  must  always  be,  both  in  its  risk  to 
life  and  in  its  tendency,  when  life  is  spared  for  some  years,  to 
render  the  child  more  or  less  a  permanent  invalid,  I  think  it  is 
extremely  important  that  it  should  not  be  regarded  as  a  con- 
dition which  must  necessarily  go  from  bad  to  worse.  There 
is  no  reasonable  doubt  that  in  rheumatic  children  bruits  which 
eventually  disappear  altogether  are  sometimes,  perhaps  usually, 


HEART  DISEASE  :  -  ENDOCARDITIS  497 

due  to  endocarditis.  I  have  known  loud  bruits,  of  whose 
endocarditic  origin  no  one  had  entertained  the  least  doubt,  to 
disappear  after  several  months.  I  have  even  known  a  bruit 
which  was  associated  with  very  severe  acute  pericarditis  in 
a  child  of  nine  years  to  vanish  completely  so  that  there  was 
no  vestige  of  any  heart  disease  to  be  detected  a  few  months 
later.  I  have  followed  up  cases  which  had  been  in  the  Children's 
Hospital  with  endocarditis  and  many  rheumatic  nodules,  and 
have  found  them  years  afterwards  doing  ordinary  work  and 
showing  no  evidence  of  the  former  heart  affection.  No  doubt 
•  such  happy  results  are  unusual,  but  I  suspect  that  they  are  less 
rare  than  is  often  supposed  ;  at  any  rate  they  are- sufficient  to 
encourage  us  in  taking  a  hopeful  view  of  the  child  with  endo- 
carditis, especially  when  this  is  of  recent  origin.  And  even  where 
endocarditis  is  already  advanced  and  causing  severe  symptoms, 
it  is  astonishing  how  much  improvement  will  sometimes  occur. 
I  remember  one  child  who  at  the  age  of  seven  years  had  severe 
mitral  regurgitation  and  great  dilatation  of  the  heart,  with 
general  oedema,  and  a  dropsical  effusion  in  the  pleura,  great 
enlargement  of  the  liver,  and  jaundice.  Her  condition  looked 
absolutely  hopeless  ;  nevertheless  she  slowly  improved  and 
became  so  far  recovered  that  she  was  able  to  go  about  and  to 
learn  dressmaking  and  lived  nine  years  after  her  condition  had 
seemed  so  desperate. 

Treatment 

In  the  treatment  of  heart  disease,  there  is  one  remedy  which 
above  all  others  is  of  supreme  importance  and  supreme  value — 
rest.  No  change  of  air,  no  dieting,  no  drug,  can  compare  with 
this ;  rest  is  the  sine  qua  non  in  heart  disease.  And  yet  how 
difficult  it  is  to  secure !  Here  is  a  little  child  whose  mitral  disease 
is  still  at  a  stage  when  two  or  three  months  of  quiet  rest  in  bed 
may  cause  all  signs  of  heart  disease  to  disappear,  or,  failing  this, 
may  secure  to  the  child  several  years  of  happy  and  useful  life, 
and  yet  the  parents  will  submit  to  almost  anything  rather  than 
keep  their  child  in  bed.  No  doubt  the  child  dislikes  it,  no 
doubt  it  is  difficult  to  keep  a  child  amused  when  he  is  in  bed 
for  weeks,  especially  if,  as  is  only  natural,  the  child  being  an 
invalid  has  been  rather  spoiled  ;  but  the  child's  life  is  at  stake, 
and  it  is  well  to  impress  this  fact  upon  the  parents  that  even 
though  the  child  may  feel  and  look  well,  the  presence  of  endo- 
carditis, however  early  and  slight  it  may  appear,  means  serious 
danger  which  may  be  averted  by  prolonged  rest. 

STILL  K  k 


498  COMMON  EtfSORDERS  OF  CHILDHOOD 

Whilst  I  am  emphasizing  the  importance  of  rest  in  heart  disease, 
I  should  like  to  point  out  also  the  value  of  sleep.  I  suppose 
the  surest  way  of  securing  rest,  and  thereby  diminishing  to  some 
extent  the  heart's  work,  is  by  promoting  sleep  ;  occasionally 
it  may  even  be  necessary  in  a  case  of  heart  disease  to  obtain 
sleep  by  the  use  of  drugs,  but  this  is  rare  and  is  generally  un- 
desirable, for  the  drugs  themselves  may  exercise  a  harmful 
influence  upon  the  heart.  In  the  slighter  cases  and  in  the 
earliest  stage  of  endocarditis  this  requirement  is  usually  easily 
fulfilled;  the  child  can  be  accustomed  to  a  midday  sleep 
if  the  room  be  darkened  and  kept  quiet,  and  the  night  sleep 
should  be  made  as  long  as  possible  ;  but  in  the  more  advanced 
stages,  when  the  child  is  short  of  breath  and  obliged  to  sit 
up  continually,  the  lack  of  sleep  becomes  a  real  difficulty. 
I  know  of  few  more  pathetic  sights  in  a  children's  hospital 
than  the  child  with  severe  heart  disease  sitting  up  at  night 
leaning  forward  with  his  head  resting  upon  his  arms  on  the  bed- 
board,  ever  and  again  waking  with  a  slight  start  and  seeking  to 
find  some  comfort  in  his  uncomfortable  position,  then  leaning 
back  wearily  on  his  high-propped  pillows,  and  so  with  frequent 
changes  but  always  in  the  sitting  position,  getting  a  broken 
sleep.  The  only  satisfactory  treatment  of  the  sleeplessness  in 
such  a  case  is  the  improvement  of  the  cardiac  condition  by  such 
means  as  I  shall  mention,  but  it  is  a  vicious  circle  which  is 
hard  to  break ;  the  lack  of  proper  sleep  makes  the  heart  worse, 
the  cardiac  distress  prevents  sleep  ;  there  are  cases  in  which  we 
are  driven  to  use  some  hypnotic,  it  may  be  10  grains  of  trional, 
or  3  grains  of  ^eronal. 

And  here  I  venture  to  note  what  has  sometimes  struck  me  as 
a  flaw  in  the  treatment  of  a  child  with  severe  heart  disease  : 
a  medicine  is  ordered  to  be  taken  every  three  or  four  hours  and 
the  child's  sleep,  difficult  enough  to  obtain  perhaps,  is  disturbed 
for  the  administration  of  drugs  which  are  of  less  value  to  the 
child  than  unbroken  sleep  would  be. 

It  is  evident  that  a  child  cannot  always  be  kept  in  bed  until 
the  signs  of  heart  disease  disappear,  for  they  may  never  disappear, 
and  sometimes  the  best  ue  can  hope  for  is  to  secure  good  com- 
pensation so  that  the  child  may  live  on  in  comfort  and  in  reason- 
able activity  in  spite  of  damaged  valves.  What  then  are  the 
special  indications  for  rest  in  bed  ?  For  the  sake  of  clearness 
I  will  state  categorically  what  I  conceive  these  indications  to  be. 

1.  First  and  foremost,  recent  or  active  endocarditis.  It  is  not 
always  easy  to  determine  when  endocarditis  is  recent ;  the  more 


HEART  DISEASE  :    ENDOCARDITIS  499 

carefully  the  heart  is  watched  when  chorea,  or  any  other  rheu- 
matic symptom,  is  present  in  a  child,  the  more  often  will  the 
beginnings  of  endocarditis  be  detected.  As  I  have  already  pointed 
out,  there  are  often  indications  of  heart  affection  before  any  bruit 
is  heard  ;  rapidity  and  irregularity  of  heart  with  signs  of  dilata- 
tion may  point  to  commencing  endocarditis.  Where  a  bruit  has 
been  present  for  some  time  the  appearance  of  fresh  bruits, — for 
instance  of  aortic  bruits  where  there  have  hitherto  been  only 
mitral  bruits,  or  a  change  in  character  of  the  bruit,  so  that 
instead  of  a  blowing  sound  it  becomes  musical, — may  indicate 
fresh  endocarditis.  Wherever  there  is  reason  to  believe  that 
this  inflammatory  process  in  the  valves  is  recent  or  active 
we  should  insist  upon  rest  in  bed  for  several  weeks. 

2.  When  rheumatic  nodules  have  recently  appeared  or  are 
still   appearing.     The    association    of   rheumatic    nodules    with 
endocarditis  is  so  close  that  it  is  generally  safe  to  conclude 
that  when  fibrin  is  being  deposited  in  the  subcutaneous  tissue 
in  the  form  of  nodules,  it  is  also  being  deposited  in  the  cardiac 
valves  to  form  the  minute  vegetations  of  endocarditis  ;    and, 
therefore,  the  recent  development  of  rheumatic  nodules  should 
be  taken  as  an  indication  for  rest  in  bed.     I  think  that  as  a 
general  rule   rest  in  bed  should  not  be  discontinued  until  all 
rheumatic  nodules  have  disappeared,  however  slight  the  endo- 
carditis appears,  but  this  is  not  practicable  in  all  cases,  for  in 
rare  instances  these  nodules  will  last  a  year  or  even  longer  ; 
certainly  a  child  should  not  be  allowed  to  get  up  until  at  least 
a  month  after  the  development  of  a  fresh  nodule. 

3.  When  the  heart  with  endocarditis  shows  much  dilatation 
with  little  or  no  hypertrophy.    This  condition  almost  always 
means  that  there  is  active  inflammation  going  on ;   sometimes 
it  points  to  pericarditis  as  well  as  endocarditis  and  in  any  case 
it  calls  for  rest  in  bed. 

4.  Whenever  there  are  symptoms  of  failing  compensation.    Any 
puffiness  or  blueness  of  face,  or  oedema  of  legs  or  enlargement 
of  liver,  or  other  sign  pointing  to  failure  of  the  right  side  of  the 
heart,  necessitates  rest ;    indeed  not  merely  until  these  urgent 
symptoms  have  passed  off  but  for  many  weeks  afterwards  ; 
and  when  once  such  failure  has  occurred,  and  the  child  has  been 
allowed  to  get  up  even  after  many  weeks  resting  in  bed,  he  must 
only  be  allowed  to  be  on  his  feet  for  quite  a  short  time,  say 
half  an  hour  daily  at  first. 

In  connexion  with  this  subject  of  rest  there  is  a  little  point  in 
treatment  which  is  sometimes  overlooked  :   a  child  is  ordered  a 


500  COMMON  DISORDERS  OF  CHILDHOOD 

medicine  or  some  brandy,  to  the  taste  of  which  he  happens  to 
have  a  great  dislike,  and  each  time  it  is  given  there  is  an  out- 
burst of  crying  or  perhaps,  as  I  once  saw  where  brandy  was  being 
administered,  of  struggling  resistance,  which  must  do  harm  far 
beyond  any  good  likely  to  come  from  the  medicine  or  brandy. 
It  is  generally  easy  to  find  some  substitute  which  will  avoid  these 
scenes  ;  but  if  not,  the  sooner  this  source  of  disturbance  is 
stopped  the  better. 

Drugs  have  little  or  no  effect  in  checking  endocarditis,  but  they 
are  of  the  greatest  value  in  combating  symptoms.  One  might 
have  thought  that  salicylate  would  have  a  specific  effect  upon 
rheumatic  inflammation  in  the  heart  as  it  has  in  articular  rheuma- 
tism, but  so  far  as  I  have  been  able  to  judge  from  my  own 
observation,  salicylate  exercises  no  curative  effect  unless  it  be 
of  value  in  preventing  fresh  endocarditis.  I  am  inclined  to  give 
salicylate  freely  if  there  is  any  articular  rheumatism  with  the 
endocarditis,  believing  that  the  disappearance  of  joint  symptoms 
corresponds  with  a  diminished  danger  of  fresh  endocarditis. 

If  there  is  very  little  dilatation  of  the  heart,  there  is  nothing 
to  be  gained  by  cardiac  tonics,  or  stimulants ;  indeed,  it  is  con- 
ceivable that  harm  may  be  done  by  increasing  the  vigour  of 
the  heart-beat,  where  our  object  should  be  to  rest  the  heart  as 
much  as  possible  ;  but  as  a  rule  dilatation  very  quickly  becomes 
considerable  and  it  is  necessary  to  prevent  its  increasing.  For 
this  purpose  I  think  that  if  the  dilatation  is  only  of  moderate 
degree,  and  there  are  no  symptoms  of  failing  compensation, 
nux  vomica  is  preferable  to  digitalis,  for  although  it  has  a  less 
powerful  influence  in  strengthening  the  heart-beat,  it  does  not 
increase  the  peripheral  resistance  as  digitalis  does.  I  very 
often  use  a  combination  of  Tincture  of  Nux  Vomica  COiii-v 
with  Bicarbonate  of  Soda,  which,  as  Dr.  Lees  has  pointed  out, 
may  have  a  value  in  preventing  dilatation. 

In  more  severe  degrees  of  dilatation,  where  there  are  any 
signs  of  failing  compensation,  or  where,  with  compensation 
just  and  only  just  maintained,  the  heart  is  irregular,  the  choice 
of  drugs  lies,  I  think,  between  strophanthus  and  digitalis  ;  and 
of  these  two  strophanthus  has  often  proved  the  more  useful 
in  my  hands  :  no  doubt  this  may  correspond  with  the  fact  that 
strophanthus  does  not  cause  the  peripheral  vessels  to  contract 
so  much  as  digitalis  does.  A  dose  of  2  or  3  minims  of  tincture 
of  strophanthus  with  5  or  6  minims  of  tincture  of  nux  vomica, 
may  be  given  to  a  child  of  ten  years  every  six  hours. 

Digitalis,  in  doses  of  5-10  minims  of  the  tincture,  will  succeed 


HEART  DISEASE  :    ENDOCARDITIS  501 

in  some  of  these  cases  with  failing  compensation,  but  its  use 
calls  for  discrimination.  It  must  be  remembered  that  by  in- 
creasing the  peripheral  resistance  and  augmenting  the  force 
of  the  heart-beat  it  not  only  increases  the  heart's  power  for 
work,  but  it  gives  it  more  work  to  do  ;  and  if  the  muscle  be 
already  so  inflamed  or  degenerate  that  it  is  incapable  of  much 
increase  in  power,  to  give  digitalis  may  be  to  spur  a  tired  horse, 
and  even  though  there  may  be  slight  temporary  improvement, 
the  result  of  the  digitalis  may  be  irretrievable  cardiac  failure. 

Dr.  D.  B.  Lees  has  insisted  upon  a  very  important  practical 
point  in  the  use  of  digitalis  for  those  cases  in  which  there  is  much 
dilatation  of  the  right  side  of  the  heart — and  it  is  worth  remember- 
ing that  in  endocarditis  as  in  pericarditis,  it  is  usually  dilatation 
of  the  right  side  of  the  heart  that  kills — it  is  often  worse  than 
useless  to  give  digitalis  when  the  right  auricle  and  ventricle 
are  greatly  over-distended  ;  the  heart  stimulated  by  digitalis 
makes  a  great  effort  to  empty  its  over-distended  cavities  and 
exhausts  itself  in  the  effort,  with  the  result  that  the  thin-walled 
right  side  dilates  more  than  ever  ;  whereas  if  the  tension  be 
relieved  even  to  a  very  slight  degree  by  the  application  of  three 
or  four  leeches  over  the  sternum  or  liver  before  the  digitalis  is 
given,  the  drug  stimulates  successful  contraction,  and  the 
dilatation  is  diminished. 

There  is  another  condition  in  which  I  have  several  times 
seen  digitalis  do  harm  in  children,  namely,  where  with  endo- 
carditis there  was  great  hypertrophy  of  the  heart.  In  these 
cases  the  child  has  complained  of  sudden  spasms  of  severe  pain 
over  the  prsecordial  region  and  sometimes  radiating  up  to  the 
left  shoulder  ;  the  attacks  have  generally  occurred  only  once 
every  few  days  and  have  lasted  some  seconds.  I  have  found 
the  heart  beating  with  an  extremely  forcible  but  not  rapid  beat, 
and  it  seemed  obvious  that  the  digitalis  had  induced  spasmodic 
contraction  of  anginal  character  ;  the  attacks  have  stopped 
forthwith  when  digitalis  was  omitted  and  morphia  substituted. 

I  have  also  tried  theocin  sodium  acetate,  a  cardiac  stimulant 
which  has  been  recommended  for  cases  in  which  there  is 
oedema  or  ascites  ;  my  experience  of  it  has  been  too  small 
to  afford  a  reliable  estimate  of  its  value,  but  I  cannot  report 
any  striking  success  from  its  use  :  in  a  boy  of  nine  years  6  grains 
of  theocin  sodium  acetate  produced  a  severe  headache  each 
time  it  was  given,  so  that  it  had  to  be  discontinued.  At  a 
later  period  when  this  boy  was  suffering  with  oedema  of  the 
legs,  I  gave  doses  of  1  grain,  and  these  produced  vomiting,  but 


502  COMMON  DISORDERS  OF  CHILDHOOD 

he  had  also  vomited  other  drugs.  I  have  not,  however,  had  these 
ill  results  in  any  other  of  the  few  cases  in  which  I  have  used  this 
drug  ;  and  I  have  known  the  closely  allied  preparation  theocin, 
in  doses  of  1  grain,  to  increase  the  flow  of  urine  appreciably. 

Diuretin  I  have  also  given  to  children  with  cardiac  dropsy 
in  doses  of  5-8  grains,  and  think  it  is  sometimes  of  value. 

Vomiting  is  sometimes  a  troublesome  symptom  of  dilatation 
of  the  right  side  of  the  heart.  In  making  autopsies  on  children 
who  have  died  of  endocarditis  I  have  often  found  the  stomach 
greatly  dilated  and  lying  vertically  instead  of  transversely  ; 
the  dilatation  results  no  doubt  from  the.  catarrh  produced 
by  chronic  venous  congestion,  and  the  position  from  the  dragging 
downwards  of  the  pyloric  end  by  enlargement  of  the  liver. 
I  have  wondered  sometimes  whether  this  unnatural  position  of  the 
stomach  may  not  combine  with  the  catarrh  to  cause  the  vomiting 
in  such  cases.  Vomiting  may  of  course  be  due  to  the  irritant 
effects  of  drugs,  especially  digitalis,  and  it  must  be  remembered 
that  some  children  are  very  apt  to  vomit  anything  they  dislike, 
so  that  it  may  be  the  taste  of  the  medicine  which  is  at  fault. 

The  treatment  is  to  relieve  as  far  as  possible  the  venous  con- 
gestion of  the  stomach  by  relieving  the  over-distension  of  the 
right  heart,  but  this  is  often  just  what  we  cannot  do  ;  our  cardiac 
drugs,  purgation  by  calomel,  even  the  application  of  leeches,  may 
fail,  and  we  are  driven  to  treat  the  symptom  rather  than  its  cause. 
A  mixture  of  bismuthi  carb.  gr.  x  with  sodium  bicarbonate  and 
nux  vomica  may  be  given,  or  counter-irritation  may  be  tried  in  the 
form  of  a  hot  fomentation  or  a  mustard  plaster  over  the  epigastrium . 

Opium  is  very  valuable  in  some  cases  of  heart  disease  in  children, 
but  it  is  no  easy  thing  to  select  the  particular  case  for  which  it 
is  suitable  :  the  features  which  to  my  mind  suggest  that  it  may 
be  serviceable  are  signs  of  much  hypertrophy  combined  with 
tumultuous  action  ;  but  it  is  very  important  to  distinguish  the 
cases  in  which  enlargement  of  heart  is  due  mainly  to  dilatation 
from  those  in  which  hypertrophy  predominates,  for  opium 
may  do  nothing  but  harm  where  there  is  much  dilatation  with 
little  hypertrophy.  The  forms  of  opium  which  I  have  thought 
most  useful  are  Dover's  Powder  in  doses  of  gr.  ij-iij  ter  die  for 
a  child  of  eight  to  ten  years,  and  the  liq.  morphinse  hydro- 
chloratis  2-3  minims  three  times  a  day  or  every  six  hours. 

A  symptom  which  occurs  sometimes  in  cases  of  severe  mitral 
disease  and  which  can  often  be  relieved  at  once  by  drugs,  is 
sudden  attacks  of  severe  dyspnoea  lasting  a  few  minutes,  some- 
times with  a  feeling  of  oppression  over  the  praecordium.  I  have 


HEART  DISEASE  :   ENDOCARDITIS  503 

found  these  to  be  relieved  very  speedily  by  inhalation  of  amyl 
nitrite,  2  minim  capsules  can  be  used.  Atropin  also  relieves 
these  attacks  :  1  minim  may  be  given  by  mouth  or,  if  necessary, 
by  hypodermic  injection.  I  say,  'if  necessary,'  for  in  my  opinion 
hypodermic  medication  is  always  to  be  avoided  if  possible  in 
children,  whatever  the  disease  may  be  ;  for  these  little  people 
are  frightened  by  little  things,  and  the  disturbance  and  crying 
consequent  on  the  momentary  prick  of  a  hypodermic  needle 
can  do  nothing  but  harm  when  the  heart  is  with  difficulty 
struggling  to  do  its  work. 

Amongst  the  measures  which  are  only  to  be  used  when  other 
methods  have  been  tried  in  vain,  is  puncture  of  the  cedematous 
legs  in  several  places  with  a  triangular  surgical  needle.  If  cardiac 
tonics  and  diuretics  and  aperients  have  failed  to  relieve  cardiac 
dropsy,  three  or  four  punctures  into  the  subcutaneous  tissue 
of  each  leg  will  sometimes  produce  very  striking  improvement  : 
not  only  does  the  fluid  drain  away  into  the  absorptive  anti- 
septic wool  which  should  be  placed  round  the  leg  and  changed 
frequently,  but  the  relief  thus  given  to  the  pressure  upon  the 
veins  improves  the  circulation  so  much  that  the  heart  itself  will 
sometimes  recover  at  least  for  a  time  from  its  extreme  dilatation. 
If  the  mattresses  are  arranged  so  that  the  child's  body  is  on  an 
inclined  plane  with  the  legs  sloping  downwards,  the  drainage  is 
assisted ;  and  not  only  does  the  oedema  of  the  legs  disappear  but 
also  that  of  the  scrotum  and  the  fluid  in  the  abdomen,  no  doubt 
owing  to  the  general  improvement  of  circulation. 

The  value  of  leeching  in  connexion  with  digitalis  has  been 
mentioned  already  ;  I  will  only  add  that  the  advisability 
of  leeching  must  be  determined  by  the  evidence  of  right 
heart  failure  and  especially  by  the  signs  of  dilatation  of  the 
right  side  of  the  heart,  not  by  the  colour  of  the  face  or 
lips.  I  have  several  times  hesitated  to  apply  leeches  because 
the  child's  face  was  profoundly  white  and  the  lips  anaemic, 
but  none  the  less  leeching  has  proved  of  greatest  benefit  ;  on 
the  contrary,  blueness  of  lips  and  face,  though  often  present 
where  leeches  are  needed,  is  not  necessarily  an  indication  for 
leeching,  it  is  sometimes  present  where  the  heart  condition  has 
become  chronic  and  stationary. 

Last,  but  not  least,  in  every  case  of  endocarditis  the  importance 
of  keeping  the  bowels  acting  freely  is  to  be  remembered  ; 
purgation  with  2  or  3  grains  of  calomel  may  do  much  to  relieve 
a  labouring  heart,  and  is  certainly  a  valuable  adjunct  to  the 
treatment  of  the  oedema  and  dropsy  in  advanced  heart  disease. 


CHAPTER  XXXV 


RHEUMATIC  PERICARDITIS  IN  CHILDREN 

RHEUMATIC  pericarditis  is  associated  so  inseparably  with  endo- 
carditis in  children  that  it  seems  a  perversion  of  clinical  grouping 
to  consider  them  separately  :  my  only  excuse  for  doing  so  is  con- 
venience. I  have  never  seen  any  case  of  rheumatic  pericarditis 
in  childhood  in  which  there  was  not  also  endocarditis,  and  I  am 
informed  that  in  the  whole  of  the  post  mortem  records,  extending 
over  forty  years  at  the  Children's  Hospital,  Great  Ormond  Street, 
there  is  no  instance  of  such  an  occurrence.  Pericarditis,  how- 
ever, adds  certain  symptoms  and  signs  to  those  already  present 
in  endocarditis  and  moreover  requires  special  treatment,  so  that 
there  is  some  reason  for  giving  it  special  consideration. 

Rheumatism  is,  of  course,  not  the  only  cause  of  pericarditis  in 
children,  there  are  at  least  three  other  varieties  :  suppurative 
pericarditis,  usually  of  pneumococcal  origin  but  sometimes  due 
to  other  pyogenic  micro-organisms,  tubercular  pericarditis,  and 
the  insidious  form  which  occurs  in  the  'chronic  polyarthritis 
with  enlarged  glands  and  spleen'(a  form  of  rheumatoid  arthritis) 
of  childhood  ;  but  all  these  varieties  differ  completely  from  rheu- 
matic pericarditis  in  their  associations,  symptoms,  and  even  in 
the  treatment  they  require ;  they  have,  in  fact,  just  as  little  in 
common  with  the  rheumatic  form  as  pulmonary  tuberculosis 
has  with  lobar  pneumonia. 

I  shall,  therefore,  confine  my  remarks  here  to  the  pericarditis 
of  rheumatism,  which  is  by  far  the  commonest  variety.  I  suspect 
that  the  liability  to  pericarditis  is  greatest  when  the  heart 
is  affected  by  rheumatism  at  an  early  age,  say  under  six  years, 
but  I  have  no  figures  to  show  what  proportion  of  rheumatic 
children  in  each  year  of  life  develop  this  symptom,  and  if  the 
following  table  is  compared  with  the  age-incidence  of  rheuma- 
tism in  general  it  will  be  seen  that  there  is  a  fairly  close 
correspondence  which  seems  to  contradict  my  impression. 

AGE-IXCIDENCE  OF  RHEUMATIC  PERICARDITIS  IN  53  CASES 


Age   .     .     . 
No.  of  cases 

0-1 
0 

1-2 

2-3 

3-4 

2 

4-5 

5-6 

6-7 
12 

7-8 

8-9 
10 

9-10 

10-51 
4 

11-12 
« 

0 

1 

4 

7 

4 

7 

RHEUMATIC  PERICARDITIS  505 

The  sex-incidence  of  rheumatic  pericarditis  is  in  curious  con- 
trast to  that  of  chorea  :  out  of  the  fifty-three  cases  tabulated 
here,  thirty- three  were  boys,  twenty  were  girls  ;  one  might 
suggest  as  a  possible  explanation  of  this  disproportion  the 
greater  physical  activity  in  boys  which  may  determine  the 
affection  of  the  heart,  as  the  emotional  instability  of  girls  seems 
to  determine  the  incidence  of  chorea  ;  but  this  must  needs  be 
mere  speculation. 

The  clinical  picture  of  rheumatic  pericarditis  can  be  summed 
up  in  few  words  :  a  child  with  some  rheumatic  affection,  chorea, 
endocarditis,  or  joint  inflammation,  begins  to  vomit,  is  short  of 
breath,  and  complains  of  pain  over  the  prsecordium.  Examina- 
tion of  the  heart  shows  three  characteristic  symptoms :  dilatation, 
rapid  and  tumultuous  beat,  and  friction. 

The  importance  of  vomiting  as  an  early  symptom  of  pericarditis 
is  worth  remembering ;  whenever  a  child  with  any  manifestation 
of  rheumatism  begins  to  vomit  without  apparent  cause  one 
should  think  of  the  possibility  of  pericarditis,  especially  if  at 
the  same  time  there  is  some  rise  of  temperature. 

The  respiration  is  often  grunting  and  sometimes  associated 
with  a  frequent  dry  cough,  which  may  be  very  distressing  to 
the  child  and  may  do  considerable  harm  by  preventing  sleep.  The 
presence  of  pain  is  curiously  variable,  as  a  rule  there  is  some, 
but  it  is  not  very  rare  for  a  child  to  state  that  he  has  no  pain 
whatever  when  auscultation  reveals  loud  friction  over  the 
prsecordium.  I  suppose  it  is  the  absence  of  pain  in  some  cases 
which  leads  to  pericarditis  being  overlooked.  The  pain  like 
that  of  pleurisy  is  sometimes  referred  to  the  epigastrium  and 
may  thus  be  misleading,  especially  when,  as  occasionally  happens, 
there  is  also  diminution  or  absence  of  the  abdominal  respiratory 
movements  so  that  the  condition  may  simulate,  as  Dr.  Wynter  1 
has  pointed  out,  some  acute  abdominal  affection. 

There  are  two  other  symptoms  which  to  my  mind  often  suggest 
pericarditis  ;  namely,  a  white  pallor  of  the  face  with  ?rey,  livid 
lips,  and  a  marked  restlessness;  these  often  appear  within  a  few 
days  after  the  onset  of  the  pericardial  inflammation.  Occasionally 
the  constitutional  symptoms  are  severe,  there  is  delirium  with 
sordes  on  the  lips,  the  breath  has  a  curious  sweetish  odour, 
and  the  temperature  reaches  103°  or  104°. 

The  signs  of  pericarditis  are  clear  enough  in  some  cases,  the 
friction  may  be  so  gross  as  to  be  palpable,  and  on  auscultation 

1  Proc.  Roy.  Soc.  Med.,  vol.  iv,  Mod.  Sect.  p.  40. 


506  COMMON  DISORDERS  OF  CHILDHOOD 


it  may  be  obvious  all  over  the  praecordium  ;  but  there  are  many 
others  in  which,  especially  at  the  onset,  the  diagnosis  has  to  be 
made  on  less  conclusive  evidence  :  there  may  be  no  friction 


V 

Sternal  Mete* 


NOV.  6 


Nov.  ir. 


Nov.?.- 


\/ 


Nov.26. 


JAN  a? 


A\ 


FIG.  ;>f>.  Tracings  of  cardiac  area,  taken  during  an  attack  of  rheumatic 
pericarditis  in  a  boy  aged  nine  years.  The  tracings  show  the  gradual  increase 
during  the  acute  stage  and  subsequent  diminution  during  convalescence. 

whatever,  and  yet  the  diagnosis  may  be  almost  certain  from 
the  character  of  the  heart-beat  :  it  is  not  only  unduly  rapid  but 
tumultuous,  it  seems  to  plunge  and  rear  like  a  horse  frightened 
beyond  control.  Even  if  friction  is  present,  it  is  sometimes  easy 


RHEUMATIC  PERICARDITIS  507 

to  overlook,  for  not  only  may  it  be  localized  to  a  very  small 
area,  perhaps  the  size  of  a  sixpence,  and  this  at  any  part  of  the 
praecordium  ;  but  it  may  also  amount  to  nothing  more  than 
a  little  scratchiness,  which  seems  rather  a  modification  of  the 
first  and  second  sounds  than  any  additional  sound  ;  and  it  is 
sometimes  so  far  synchronous  with  the  first  and  second  sounds 
that  it  is  almost  impossible  for  a  time  to  say  whether  the  abnor- 
mality is  valvular  bruit  or  pericardial  friction.  I  remember 
a  child  with  'to^and-fro'  sounds  at  the  base  of  the  heart,  who  was 
examined  by  several  physicians.  Some  thought  the  sounds  due  to 
aortic  disease,  some  to  pericarditis ;  I  believe  it  was  only  after  several 
days  that  definite  evidence  of  pericardial  inflammation  appeared. 

Too  little  attention  is  often  paid  to  the  area  of  cardiac  dullness 
in  these  cases.  Percussion  may  give  valuable  confirmatory 
evidence,  for  dilatation  occurs  very  rapidly,  especially  on  the 
right  side  of  the  heart,  with  pericarditis,  and  if  careful  note  of  the 
cardiac  dullness  is  kept  day  by  day  where  pericarditis  is  suspected, 
the  changes  are  often  very  striking,  and  the  rapid  extension  of 
the  dullness  is  a  point  strongly  in  favour  of  pericarditis.  The 
tracings  reproduced  on  p.  506  were  taken  from  a  child  in  my 
ward  at  King's  College  Hospital  with  the  help  of  my  then  house 
physician,  Dr.  A.  E.  Hay  ;  they  show  the  rapid  increase  of 
cardiac  area,  and  its  diminution  as  the  pericarditis  subsided. 
Such  a  record  is  of  practical  value  in  dealing  with  this  affection, 
for  both  prognosis  and  treatment  depend  to  no  small  extent 
upon  the  degree  and  rapidity  of  these  changes. 

It  is  important  to  recognize  the  special  tendency  to  dilatation 
in  pericarditis,  for  the  enormous  size  of  the  cardiac  dullness  is 
often  mistaken  for  the  result  of  pericardial  effusion.  The  larger 
my  experience  becomes  of  rheumatic  heart  disease  in  children, 
the  less  ready  I  am  to  diagnose  pericardial  effusion.  It  is  quite 
certain  from  post  mortem  evidence  that  where  the  cardiac 
area  is  largest,  extending  perhaps  from  the  right  nipple  line 
almost  to  the  middle  of  the  left  axilla,  there,  is  usually  either 
no  fluid  at  all — there  is  only  a  greatly  dilated  heart  with  adherent 
pericardium — or  the  fluid  amounts  at  most  to  1J-2  ounces 
and  evidently,  therefore,  played  only  a  very  minor  part  in  the 
enlargement  which  was  due  chiefly  to  dilatation. 

The  following  case  illustrates  some  of  these  points. 

Victor  C.,  aged  six  years,  had  complained  of  pains  in  his  limbs  on  September  22 
for  the  first  time,  on  the  25th  his  temperature  was  103°,  and  there  was  some 
swelling  of  joints  ;  on  September  30  he  complained  of  some  pain  in  the  chest, 
and  had  a  short  hacking  cough  ;  auscultation  showed  nothing  definitely 


508  COMMON  DISORDERS  OF  CHILDHOOD       , 

abnormal  in  the  heart.  On  October  2  there  was  a  bruit  at  the  apex  and 
well-marked  pericardial  friction.  He  was  admitted  to  hospital  on  October  4 
with  a  temperature  of  101 '6°,  pulse  140,  his  face  very  white,  and  respiration 
rapid  with  frequent  short  cough.  The  area  of  cardiac  dullness  extended  three 
fingers'  breadth  to  the  right  of  the  sternum,  three  fingers'  breadth  outside  the 
left  nipple  line,  and  upwards  to  the  second  rib  ;  there  was  palpable  friction, 
which  was  so  loud  on  auscultation  as  to  mask  any  bruit ;  there  was  some 
epigastric  pulsation. 

The  question  of  pericardial  effusion  was  raised  on  account  of  the  large  size 
of  the  heart  area,  but,  on  the  ground  of  its  extreme  rarity  in  childhood,  it 
was  concluded  that  the  increase-  of  dullness  was  due  to  dilatation. 

On  October  5  the  area  of  cardiac  dullness  was  still  large,  three  and  a  half 
fingers'  breadth  outside  the  right  margin  of  the  sternum  and  four  fingers' 
breadth  outside  the  left  nipple  line,  respiration  was  65,  and  pulse  160  ;  the 
boy  was  delirious,  restless  and  vomiting,  his  colour  was  dusky,  and  the  constant 
cough  very  distressing.  Next  day  he  died  ;  only  four  days  after  the  first 
definite  symptoms  of  pericarditis. 

Post  mortem,  the  heart  was  extremely  dilated  and  covered  with  yellowish 
fibrin;  not  more  than  2  ounces  of  serum  were  present  in  the  pericardium ;  there 
was  recent  endocarditis  of  the  mitral  and  aortic  valves,  and  some  recent 
pleurisy  at  the  base  of  the  left  lung,  which  was  partly  collapsed. 

This  case  shows  how  deadly  a  disease  rheumatism  sometimes 
proves  in  children  :  this  boy  was  well  and  had  never  had  a 
symptom  of  rheumatism  until  September  22  and  he  was  dead 
within  a  fortnight.  It  shows  also  how  quickly  endocarditis 
supervenes  ;  there  was  no  bruit  on  September  30,  and  yet  by 
October  6  there  was  endocarditis  of  the  aortic  as  wrell  as  the 
mitral  valves. 

The  presence  of  pleurisy  at  the  left  base  is  a  common  occurrence 
with  pericarditis,  nor  is  it  always  the  left  base  only  which  is 
affected,  both  pleurae  are  sometimes  inflamed  or  adherent. 
No  doubt  in  some  cases  this  is  secondary  to  some  pneumonia  or 
infarction  of  the  lung,  but  in  others,  as  in  the  case  mentioned 
here,  there  is  no  pneumonia.  Is  this  pleurisy  due  to  some 
secondary  infection  ?  or  is  it,  as  seems  much  more  probable, 
due  to  the  rheumatic  infection  ?  The  point  is  of  practical  in- 
terest because  now  and  then  one  meets  with  an  unexplained, 
apparently  primary,  pleurisy  as  a  clinical  phenomenon  in  a 
rheumatic  child  and  one  is  tempted  to  brush  aside  one's  experience 
that  an  unexplained  simple  pleurisy  in  a  child  usually  means 
tubercle,  and  to  label  the  condition  rheumatic  pleurisy. 

However,  this  is  a  digression  ;  the  fact  remains  that  rheumatic 
pericarditis  is  very  commonly  associated  with  pleurisy,  and  I 
draw  attention  to  the  point  because  I  have  sometimes  wondered 
whether  the  severity  of  the  symptoms  which  we  attribute  entirely 
to  the  pericardial  condition  may  not  be  aggravated  by  pleurisy, 


RHEUMATIC  PERICARDITIS  509 

which,  especially  in  young  children,  is  sometimes  itself  a  cause  of 
severe  symptoms.  I  think  it  is  always  wise  to  watch  the  lungs 
carefully  in  a  child  with  pericarditis,  for  it  may  be  that  our 
fomentations  or  ice-bags  or  counter-irritants  should  be  applied 
to  the  bases  of  the  lungs  no  less  than  to  the  prsecordium. 

Prognosis.  There  is,  I  think,  no  graver  symptom  in  a 
rheumatic  child  than  pericarditis.  In  the  large  majority  of 
cases  it  proves  fatal  within  a  few  weeks,  and  even  if  the  child 
recover  from  the  acute  attack,  too  often  he  is  left  with  a  damaged 
myocardium  and  an  adherent  pericardium,  so  that  he  drags  out 
an  invalid  existence  for  a  few  months  or  perhaps  a  year  or  two 
with  a  heart  which  is  hypertrophied  enough,  but  only  just  enough, 
to  prevent  still  further  dilatation  ;  and  sooner  or  later  some 
slight  excess  of  exertion  or  some  fresh  endocarditis  upsets  the 
balance  of  compensation  and  further  dilatation  ends  in  death. 

Out  of  fifty-three  cases  under  my  own  observation  only  nine 
recovered  to  the  extent  of  having  lost  all  acute  symptoms  when 
they  were  seen  several  weeks  or  months  later.  One  of  these  is 
known  to  be  still  living,  with  a  much  enlarged  heart  and  mitral 
bruits,  three  years  after  the  acute  attack  of  pericarditis.  Of  the 
remaining  forty-three  cases  nine  died  within  a  fortnight  after 
the  onset  of  pericarditis,  four  others  within  a  month,  five  within 
a  few  weeks — but  the  exact  time  could  not  be  ascertained — 
seven  within  about  four  months  ;  the  rest  could  not  be  timed 
exactly  but  died  within  a  few  months,  except  two  cases  which 
died,  I  believe,  one  and  two  years  respectively  after  the  attacks. 

Amongst  all  these  fifty-three  cases  there  was  only  one  that 
made  a  recovery  so  complete  that  the  most  careful  examination 
of  the  child  three  months  after  she  left  the  hospital  failed  to 
detect  the  slightest  indication  of  any  heart  affection  whatever. 
I  have  quoted  this  case  in  full  below. 

In  the  individual  case,  I  think  that  an  important  element  in 
prognosis  is  the  degree  of  dilatation  which  occurs  ;  perhaps 
because  this  is  to  a  large  extent  an  index  of  the  degree  of  myo- 
carditis present.  The  condition  of  the  lungs  must  also  be  taken 
into  account  :  if  there  is  evidence  of  consolidation,  as  there  often 
is  at  one  or  both  bases,  the  strain  upon  the  heart  must  be 
increased  and  the  chance  of  right  heart  failure  greater.  No 
doubt  the  pleurisy  which  complicates  pericarditis  so  often  must 
also  diminish  the  child's  chance  of  recovery.  I  found  recent 
pleurisy  or  adhesions  which  appeared  to  be  of  the  same  date  as 
the  pericarditis  in  twenty-two  out  of  thirty-eight  cases  which 
were  examined  post  mortem. 


510  COMMON  DISORDERS  OF  CHILDHOOD 

Treatment.  If  rest  is  important  in  simple  endocarditis  it  is 
still  more  urgently  needed  where  pericarditis  is  also  present,  for 
here  it  is  certain  that  the  myocardium  also  is  acutely  inflamed, 
and  it  is  only  astonishing  that  muscles  in  such  continual  activity 
can  recover  at  all  from  so  acute  a  process.  And  herein  lies  the 
importance  of  early  diagnosis  ;  the  sooner  the  child  is  put  to 
rest  in  bed  and  kept  as  free  as  possible  from  all  disturbance  and 
excitement  the  better  the  chance  for  the  inflamed  heart  muscle ; 
we  cannot  give  it  absolute  rest,  but  we  can  prevent  the  extra 
activity  of  the  heart  which  even  the  slightest  exertion  on  the 
part  of  the  child  necessitates. 

Here  I  venture  to  draw  attention  to  a  little  point — a  very 
little  point  it  may  seem,  but  not  to  be  disregarded  on  that  account 
if  it  affects  the  child's  welfare — namely,  the  clothing  of  the  child 
who  is  ill  with  acute  pericarditis.  I  have  little  doubt  that  harm 
is  done  by  the  considerable  disturbance  of  the  child  which  is 
sometimes  involved  in  undressing  the  child  when  for  any  reason 
it  is  necessary  to  take  off  the  child's  bed-dress.  If,  every  time 
the  child's  clothes  are  changed  or  taken  off,  the  child  must  sit 
up  and  have  his  arms  dragged  up  over  his  head  to  extricate  him 
from  a  close-fitting  jersey  vest,  or  must  raise  his  weight  off  the 
bed  in  the  effort  to  free  the  lower  parts  from  that  plague  of  the 
sick  child,  a  'combination  pyjama',  the  fluttering,  rapid  heart  is 
goaded  to  still  further  excitement  and  the  risk  of  further  dilata- 
tion is  increased. 

The  ideal  dress  is  that  which  can  be  taken  off  and  put  on  with 
the  least  disturbance  of  the  child.  I  like  for  heart  cases 
a  flannel  vest  which  opens  at  the  side  or  buttons  above  the 
shoulder,  and  over  this  a  flannel  nightshirt  which  reaches  to  the 
knees  and  is  open  from  top  to  bottom  and  is  secured  behind  by 
not  more  than  three  buttons  at  most  :  with  a  bed-dress  like  this 
a  child  can  be  uncovered  for  any  purpose  with  a  minimum  of 
disturbance. 

It  is  well  also  to  explain  to  those  who  have  the  nursing  of  the 
child  that  the  very  least  possible  amount  of  washing  is  to  be 
done  :  a  gentle  sponge-over  for  the  face  and  hands  twice  a  day 
will  be  quite  sufficient  ;  anything  more  thorough  necessarily 
entails  disturbance  of  the  child,  which  is  much  better  avoided. 

It  may  seem  a  contradiction  of  all  this  to  insist  upon  the  para- 
mount importance  of  examining  the  heart  carefully  every  day, 
or  even  twice  daily;  but  if  the  child  is  properly  dressed,  so  that 
the  chest  can  be  with  ease  partially  uncovered,  the  examination 
can  be  made  with  extremely  little  disturbance,  and  the  information 


RHEUMATIC  PERICARDITIS  511 

gained  as  to  the  degree  of  dilatation  and  the  need  for  leeching 
or  for  administering  digitalis  may  be  of  vital  importance  to  the 
child. 

The  decision  as  to  the  right  moment  for  leeching  is  often  of 
vital  importance.  Dilatation  occurs  with  great  rapidity ;  within 
a  couple  of  days  the  already  considerable  enlargement  of  cardiac 
dullness  may  have  increased  still  further  by  half  an  inch  or  more 
in  either  direction,  the  child  has  become  more  breathless  and  livid, 
and  the  one  thing  needful  is  leeching — I  say  leeching  rather  than 
venesection,  which  is  more  disturbing  to  the  child  and  has  no 
advantage  so  far  as  I  know.  Four  or  even  five  leeches  may  be 
applied  over  the  sternum  and  liver.  I  mention  these  places  par- 
ticularly, for  it  is  well  to  avoid  putting  leeches  over  the  prse- 
cordium  to  the  right  or  left  of  the  sternum,  where  the  wounds 
would  interfere  with  examination  of  the  heart  for  the  next  day 
or  two  ;  the  cardiac  dullness  will  still  require  careful  watching, 
for  it  may  be  necessary  to  leech  again. 

Directly  the  leeching  is  completed  digitalis  should  be  given,  but 
usually  not  before.  I  think  digitalis  should  be  regarded  only  as 
a  last  resource  in  acute  pericarditis  ;  if  the  dilatation  is  so  much 
that  leeches  are  required,  digitalis  also  will  usually  be  needful, 
but>  where  dilatation  is  less  extreme,  and  the  symptoms  less 
urgent,  I  think  digitalis  may  do  actual  harm  by  encouraging 
forcible  contractions  of  the  inflamed  cardiac  muscle,  and  also 
increasing  the  peripheral  resistance. 

If  it  is  thought  that  any  such  cardiac  stimulant  should  be 
used  I  prefer  either  nux  vomica  or  strophanthus,  but  I  have 
often  thought  that  at  the  beginning  of  pericarditis,  when  the 
heart  is  most  tumultuous  in  its  action,  a  sedative  in  the  form  of 
opium— I  generally  use  Dover's  Powder,  gr.  ii-iv  ter  die  or  sextis 
horis,  according  to  the  age  and  condition  of  the  child — is  more 
useful  than  any  cardiac  tonic  in  quieting  the  action  of  the  heart, 
and  saving  the  child  from  exhaustion ;  in  some  cases  also  the  dry, 
hacking  cough  is  so  disturbing  to  the  child  that  some  opiate  is 
necessary,  and  for  this  also  the  Dover's  Powder  is  useful,  or,  if 
a  fluid  medicine  is  preferred,  a  mixture  of  Tinct.  Camph.  Co.  Ct)x, 
Syrup.  Scillae  C0x,  Syrup.  Tolut.  O)x,  Aq.  ad  3ij,  may  be  given 
every  three  hours. 

Dr.  D.  B.  Lees  thinks  highly  of  salicylate  in  the  treatment  of 
rheumatic  pericarditis.  In  some  of  the  few  cases  which  have 
recovered  I  have  used  salicylate  or  aspirin,  and  the  only  case 
which  I  have  ever  known  to  make  apparently  a  complete  recovery 
from  pericarditis  was  treated  with  ice-bag  and  aspirin. 


512  COMMON  DISORDERS  OF  CHILDHOOD 


Lucy  0.,  aged  lOy^,  had  sore  throat,  followed  by  swelling  and  pain  in  several 
joints.  She  was  admitted  to  King's  College  Hospital  with  a  temperature  of 
101-8°,  swollen  joints,  and  a  faint  systolic  bruit  at  the  apex  of  the  heart,  which 
was  only  very  slightly  dilated.  Under  salicylate,  the  joint  symptoms  quickly 
disappeared,  but  the  fever  continued,  and  two  days  after  admission  she  looked 
very  ill,  her  face  was  grey,  and  there  was  some  dyspnoea.  The  heart  became 
very  irregular  and  rapid  during  the  next  few  days,  and  the  child  lay  very 
low  in  the  bed,  looking  extremely  white,  but  it  was  not  until  eleven  days  later 
that  pcricardial  friction  was  heard,  and  by  this  time  the  heart  had  dilated 
about  -^-inch  further  to  the  left,  and  a  few  days  later  it  was  dilating  also  to 
the  right.  The  note  became  impaired  at  the  base  of  the  left  lung,  and  the 
breath  sounds  diminished. 

Sodium  salicylate  gr.  x  every  four  hours  had  been  given  at  first  ;  an  ice-bag 
was  kept  constantly  over  the  heart,  and  after  a  few  days  aspirin  gr.  v  tor  die 
was  substituted  for  the  salicylate,  and  continued  for  about  five  weeks.  Peri- 
cardia] friction  continued  very  marked  for  ten  days,  then  disappeared,  and 
within  three  days  the  heart  rate  fell  from  120  to  88.  Rheumatic  nodules 
were  found  on  the  right  olecranon  a  few  days  later. 

The  systolic  murmur  at  the  apex  remained,  but  the  area  of  cardiac  dullness 
diminished  steadily  ;  ten  weeks  after  the  onset  of  the  pericarditis,  the  systolic 
bruit  was  noted  as  'barely  audible',  and  the  area  of  cardiac  dullness  had 
become  normal.  The  child  left  the  hospital,  but  was  kept  under  observation, 
and  a  month  later  the  systolic  bruit  had  completely  disappeared.  When  the 
child  was  last  seen,  nearly  three  months  after  discharge  from  hospital,  there 
was  not  a  trace  of  heart  disease  to  be  detected,  the  area  of  cardiac  dullness 
was  perfectly  normal,  the  sounds  were  perfectly  pure,  and  the  child  looked 
fat  and  well. 

I  quote  this  case  at  length,  because,  although  it  is  unique  in 
my  experience,  it  makes  one  more  hopeful  of  these  cases  and 
encourages  one  to  believe  that  pericarditis  may  be  amenable  to 
therapeutics. 

In  this  case  I  made  use  of  the  ice-bag  :  how  any  external 
application  can  affect  an  inflammation  of  the  pericardium 
I  cannot  explain,  but  none  the  less  I  am  inclined  to  think  that 
it  does.  I  have  used  in  different  cases  poultices,  hot  fomenta- 
tions, blisters,  and  ice-bags,  and  I  have  thought  that  the  subsidence 
of  the  pericarditis  was  hastened  by  them,  but  I  have  no  scientific 
proof  to  offer  of  their  value,  and  in  this  case,  as  in  so  many 
questions  of  treatment,  one  must  needs  trust  to  impression  — 
and  impressions,  as  we  all  know,  are  too  often  fallacious.  On  the 
whole,  if  skilled  nursing  is  available,  I  am  in  favour  of  the  ice-bag  : 
most  children  after  they  have  had  it  a  short  time  like  it  ;  the 
cold  seems  to  ease  pain,  and  I  have  fancied  that  it  hastened  the 
disappearance  of  signs  of  pericarditis. 

It  requires  skilled  careful  adjustment  to  keep  it  in  place,  and 
it  is  advisable  to  place  only  a  single  layer  of  butter-muslin 
between  it  and  the  chest  wall  ;  if  thicker  material  is  used  the 


RHEUMATIC  PERICARDITIS     .  513 

cold  does  not  reach  the  chest  wall  sufficiently.  If  the  child 
greatly  objects  to  the  cold,  I  use  hot  fomentations.  Blisters  to 
do  any  good  must  be  repeated  in  several  places,  and  they  are  then 
apt  to  interfere  with  the  proper  examination  of  the  heart,  which 
is,  I  think,  an  objection  to  them. 

Lastly,  I  would  caution  against  the  indiscreet  use  of  alcohol 
in  acute  pericarditis.  Brandy  or  any  other  alcoholic  stimulant 
quickens  the  action  of  the  heart,  and  it  may  in  this  way  do  harm 
rather  than  good  :  a  much  more  effective  cardiac  tonic  which 
does  not  quicken  the  heart  to  the  same  extent  and  which  is  more 
lasting  in  its  effect  is  strychnine,  and  although  in  special  urgency, 
when  strychnine  is  not  available,  it  may  be  advisable  to  give 
brandy,  I  feel  sure  that  as  a  general  rule  alcohol  is  best  avoided 
in  these  cases.  With  any  of  the  drugs  which  I  have  mentioned 
above,  the  tincture  of  nux  vomica  may  be  an  advisable  addition, 
if  the  heart  shows  indication  of  feebleness. 


STILL 


CHAPTER  XXXVI 
CHOREA 

To  those  who  visit  the  wards  of  a  children's  hospital  chorea 
must  appear  one  of  the  most  frequent  of  diseases  in  the  later 
half  of  childhood.  At  the  Hospital  for  Sick  Children,  Great 
Ormond  Street,  where  children  up  to  the  age  of  twelve  years  are 
admitted,  out  of  5,116  admissions  to  the  medical  wards  383  were 
for  chorea,  that  is,  13-3  per  cent,  of  the  whole  number  of  children 
admitted. 

But  there  is  an  obvious  fallacy  in  these  statistics,  for  children 
with  chorea  are  specially  selected  for  admission  owing  to  the 
urgent  need  for  rest  in  bed,  which  can  with  difficulty  be  secured 
otherwise.  In  the  children's  out-patient  department  at  King's 
College  Hospital,  where  medical  cases  up  to  the  age  of  ten  years 
are  seen  without  selection,  I  found  that  amongst  600  consecutive 
cases  between  the  ages  of  five  and  ten  years  there  were  eighteen 
cases  of  chorea ;  so  that  only  3  per  cent,  of  the  children  brought 
at  this  age  suffered  with  this  disorder.  This  is  a  much  lower  pro- 
portion than  my  impressions  gained  at  the  Children's  Hospital, 
Great  Ormond  Street,  would  have  led  me  to  suppose  ;  but  in  the 
out-patient  department  at  that  hospital  the  physicians  see  only 
selected  cases,  so  that  the  perspective  of  the  actual  frequency 
of  diseases  is  apt  to  become  distorted. 

The  sex  incidence  of  chorea  is  interesting.  As  is  well  knowrn, 
girls  are  much  more  liable  to  this  affection  than  boys  :  my  own 
statistics  showed  in  150  consecutive  cases  108  girls  and  42  boys, 
a  proportion  of  about  2-5  to  1.  This  difference  of  incidence  does 
not  correspond  so  closely  to  the  sex  incidence  of  other  manifesta- 
tions of  rheumatism  as  might  be  expected  ;  in  150  as  far  as 
possible  consecutive  cases  of  rheumatic  arthritis  or  endocarditis, 
with  no  history  of  previous  or  concurrent  chorea,  there  were 
82  girls  and  68  boys.  If  chorea  were  dependent  upon  no  other 
factor  beside  the  invasion  of  the  brain  by  a  special  toxin  or 
a  specific  micro-organism  there  does  not  seem  to  be  any  particular 
reason  why  girls  should  be  so  much  more  often  affected  by 
chorea  than  boys.  It  seems  reasonable  to  suppose  that  there 
may  be  a  psychical  factor  also  in  determining  its  occurrence,  and 


CHOREA  515 

that  the  excitability  of  the  cortex  induced  by  the  micro-organism 
or  toxin  of  rheumatism  is  more  likely  to  produce  chorea  when 
the  cortex  acted  upon  is  that  of  an  unstable  excitable  child, 
hence  the  special  liability  of  the  girl. 

This  view  is  borne  out  by  the  fact  noted  by  some  observers 
that  after  the  age  of  puberty,  when  the  mental  characteristics 
of  the  two  sexes  become  more  distinctly  differentiated,  chorea, 
an  infrequent  disease  at  this  period,  becomes  more  and  more 
exclusively  a  disease  of  females.  The  occurrence  of  chorea  in 
adult  women  chiefly  during  the  specially  emotional  and  unstable 
time  of  pregnancy  seems  to  point  in  the  same  direction. 

This  is  a  matter  of  some  practical  importance,  for  it  may.  have 
a  bearing  upon  the  prevention  of  chorea  in  a  rheumatic  child. 
One  would  expect  that  excitement,  mental  strain,  profound 
emotion,  or  shock  of  any  kind,  might,  by  increasing  the  insta- 
bility of  the  child,  determine  chorea  ;  and  I  think  there  is  clinical 
evidence  that  this  actually  happens.  How  common  it  is  to  obtain 
a  history  such  as  this  :  Miriam  G.,  aged  6J  years,  was  frightened 
one  day  by  a  soldier  who  pretended  to  shoot  her  ;  about  two 
days  later  she  became  chbreic  for  the  first  time.  She  had  two 
subsequent  attacks  without  any  history  of  special  cause,  and 
then  a  fourth  attack  at  the  age  of  9|  years,  which  began  a  few 
days  after  she  had  been  frightened  by  fear  of  punishment  for 
accidentally  breaking  some  china. 

Sometimes  it  is  the  strain  or  the  excitement  of  school  life 
which  determines  it.  I  have  notes  of  cases  in  which  chorea  began 
in  children  who  \vere  working  for  a  school  examination ;  in  one 
case  a  girl  aged  ten  years  had  been  greatly  excited  by  acting 
in  a  school  play  just  before  the  chorea  began.  It  is  difficult 
to  know  how  much  importance  is  to  be  attached  to  such  histories. 
I  have  inquired  into  a  considerable  number  of  cases  of  alleged 
causation  of  chorea  by  fright,  and  have  often  obtained  what 
seemed  to  me  clear  evidence  that  slight  chorea  was  present 
before  the  fright ;  on  the  other  hand,  I  have  met  with  a  sufficient 
number  of  cases  in  wilich  the  sequence  seemed  to  be  genuine 
to  make  me  hesitate  to  disregard  these  histories  altogether. 
In  any  case  emotion  and  excitement  can  only  be  regarded  as 
contributing  factors  if  we  accept  the  view  that  chorea  is  a 
manifestation  of  rheumatism. 

Relation  cf  chorea  to  rheumatism.  For  my  own  part 
I  may  say  -at  once  that  I  regard  chorea  as  just  as  good 
evidence  of  rheumatism  as  a  gumma  is  of  syphilis,  but  I  am 
not  blind  to  the  arguments  which  may  be  advanced  against 

Ll2 


516  COMMON  DISORDERS  OF  CHILDHOOD 

this  view.  The  strongest,  indeed  to  my  mind  the  only  one 
of  any  weight,  is  the  undoubted  occurrence  of  chorea  occa- 
sionally in  children  who  show  no  other  evidence  of  rheu- 
matism either  in  their  personal  or  in  their  family  history.  In 
a  large  proportion  of  these  cases,  as  Dr.  F.  E.  Batten  l  has  shown, 
observation  of  the  child  during  the  next  few  years  after  the 
supposed  non-rheumatic  chorea  gives  clear  evidence  of  rheu- 
matism in  articular  or  cardiac  manifestations.  If  rheumatism 
be,  as  clinical  and  bacteriological  evidence  suggests,  an  infective 
disease  which  is  not  limited  to  joints  but  may  affect  the  heart, 
the  brain,  and  possibly  the  lung  and  the  pleura,  it  would  be  as 
reasonable  to  deny  that  a  tuberculous  meningitis  was  tuberculous 
because  there  was  no  pulmonary  tubercle  as  to  deny  that  the 
brain  affection,  chorea,  is  rheumatic  because  there  is  no  arthritis  ; 
any  one  of  the  various  manifestations  of  rheumatism  may  be  the 
first  to  appear  or  may  be  the  only  one  to  appear,  and  in  this  way 
a  child  may  have  chorea  months  or  years  before  any  other 
symptom  of  rheumatism,  and  possibly  may  never  develop 
any  other  symptom  of  the  disease. 

The  occurrence  of  chorea  after  scarlet  fever,  a  rare  sequence, 
has  been  adduced  as  evidence  of  its  non-rheumatic  nature ;  but 
it  might  equally  well  be  made  an  argument  in  favour  of  it,  for 
it  is,  I  think,  evident  that  the  joint  affection  which  occurs  during 
convalescence  from  scarlet  fever  is  in  a  large  proportion  of 
cases  ordinary  acute  rheumatism.  I  have  watched  several 
of  these  cases  subsequently  for  months  or  years  and  observed 
in  them  the  ordinary  series  of  rheumatic  manifestations,  heart 
disease,  nodules,  chorea,  &c.  In  the  same  way,  where  chorea 
has  occurred  shortly  after  scarlet  fever,  I  have  seen  it  associated 
with  the  other  manifestations  of  ordinary  rheumatism  ;  for 
instance,  James  B.,  aged  seven  years,  developed  scarlet  fever, 
he  had  never  suffered  with  rheumatism  before,  but  whilst  in  the 
fever  hospital  convalescing  from  the  fever  he  developed  '  post- 
scarlatinal  rheumatism  '  during  which  endocarditis  supervened, 
and  about  a  fortnight  after  his  discharge  from  the  fever  hospital 
chorea  began. 

There  is  undoubtedly  a  post-scarlatinal  synovitis  which  is 
pysemic  and  has  no  connexion  with  rheumatism,  but  I  think 
that  apart  from  this  it  is  evident  that  scarlet  fever  in  some  way 
predisposes  to  ordinary  acute  rheumatism  just  as  measles 
predisposes  to  whooping-cough,  and  hence  the  connexion,  so  far 
as  there  is  any,  between  scarlet  fever  and  chorea.  Pregnancy 
1  Lancet,  November  5,  1898. 


CHOREA  517 

chorea  has  also  suggested  a  difficulty  in  accepting  the  rheu- 
matic origin  of  chorea  ;  but  the  clinical  observations  recorded 
by  Dr.  Poynton,  as  well  as  his  bacteriological  investigations  with 
Dr.  Gordon,  suggest  strongly  that  the  chorea  of  pregnancy  is 
also  rheumatic. 

My  own  experience  has  convinced  me  that  a  good  deal  of  the 
confusion  in  this  matter  of  the  etiology  of  chorea  has  arisen 
either  from  loose  usage  of  the  term  chorea  to  cover  any  irregularity 
or  jerkiness  of  movement,  or  else  from  imperfect  differentiation 
between  chorea  and  habit -spasm  and  other  functional  disturbances. 
There  is  no  doubt,  for  instance,  that  curious  irregularities  of 
movement  may  be  imitated  by  neurotic  children,  and  in  this 
way  have  arisen  epidemics  of  strange  movements  such  as 
dancing,  beating  the  arms  against  the  thighs,  and  so  on,  but  in 
these  cases  the  movements  are  more  like  habit-spasm  than 
chorea,  they  are  more  purposive  and  often  more  limited  to  one 
part  of  the  body  than  chorea  usually  is,  and  they  frequently  consist 
only  in  the  repetition  of  one  particular  movement. 

I  suspect  that  out  of  such  epidemics  has  arisen  the  tradition 
of  an  *  imitation  chorea  '.  Amongst  many  hundreds  of  cases 
of  chorea  which  have  been  under  my  own  observation  in  vi  rious 
institutions  I  have  not  seen  a  single  instance  of  the  spread  of 
chorea  from  one  child  to  another  by  imitation  ;  and  this  in  spite 
of  the  absence  of  any  effort  to  screen  off  the  choreic  child  from  the 
observation  of  others.  It  seems  possible  that  the  shock  of 
seeing  a  severe  chorea  might,  like  any  other  profound  emotion, 
determine  the  occurrence  of  chorea  in  a  rheumatic  child,  but  I 
have  never  known  this  to  occur. 

The  difficulty  of  discriminating  in  some  cases  between  chorea 
and  the  various  functional  abnormalities  of  movement  which 
are  met  with  in  children  makes  it,  I  think,  very  necessary  to 
be  cautious  in  drawing  inferences  from  abnormalities  of  move- 
ment in  animals.  I  was  for  a  long  time  desirous  of  seeing 
a  typical  canine  '  chorea  ',  as  the  close  relation  of  this  dis- 
order to  distemper  has  been  advanced  as  an  argument  against 
the  rheumatic  nature  of  children's  chorea.  A  veterinary 
expert,  who  is  a  well-known  authority  on  diseases  of  dogs, 
kindly  brought  me  what  he  considered  to  be  a  typical  example 
of  canine  chorea  :  the  movements  were  entirely  different 
in  character  from  human  chorea,  they  were  the  exact  counter- 
part of  a  well-marked  habit-spasm.  I  am  assured  that  some 
cases  of  the  canine  disease  resemble  the  children's  chorea  more 
closely,  but  considering  how  irregularities  of  movement  dependent 


518  COMMON  DISORDERS  OF  CHILDHOOD 

upon  various  functional  and  organic  diseases  are  mistaken  for 
chorea  even  in  human  beings,  it  seems  to  me  dangerous  to  lay 
much  stress  upon  the  irregularities  of  movement  in  animals  as 
indicating  chorea.  In  the  case  of  dogs,  however,  I  understand 
that  they  suffer  both  with  arthritis  and  endocarditis,  so  that  if 
chorea  does  occur  in  them  it  may  be  rheumatic. 

Lastly,  the  extremely  close  association  of  chorea  with  symptoms 
which  are  admittedly  due  to  rheumatism  bears  testimony  to  its 
rheumatic  nature.  I  have  already  shown  this  by  statistics  in  the 
previous  chapter,  which  I  may  summarize  here  in  tabular  form. 

CHOREA,  380  Cases. 

Previous  or  concurrent  articular  rheumatism  with  or  without 

heart  disease  and  nodules          .          .          .          .          .          .183 

No  articular  rheumatism,  but 

Cardiac  bruits  with  rheumatic  nodules         ....         8 

Rheumatic  nodules  without  cardiac  bruits   ....         2 

Systolic  and  diastolic  apical  bruits        .          .          .          .          .12 

Aortic  diastolic  as  well  as  apical  bruits          ....         3 

Systolic  apical  bruits  on\y    .         .         .         .         .         .         .48 

No  evidence  of  previous  rheumatism  ....     124 

It  may  be  admitted  that  a  systolic  apical  bruit  alone  may 
not  be  evidence  of  endocarditis,  and  therefore  objection  might 
be  taken  to  including  this  group  of  cases  as  evidence  of 
rheumatism  ;  but  even  if  we  exclude  them,  no  less  than  208  out 
of  the  380  cases,  54-3  per  cent.,  are  seen  to  be  rheumatic;  there 
was,  however,  no  reasonable  doubt  that  in  a  large  proportion 
of  cases  where  there  was  only  a  systolic  bruit  this  was  due  to 
endocarditis,  and  probably  the  error  would  be  smaller  if  we 
included  them  in  our  estimate  of  rheumatism  than  if  we  omitted 
them  ;  their  inclusion  would  raise  the  proportion  of  cases 
showing  rheumatism  to  66-8  per  cent. 

But  even  so  we  shall  under-estimate  the  evidence  of  rheuma- 
tism, for  in  some  of  the  cases  where  there  was  no  rheumatic 
manifestation  in  the  choreic  child,  there  was  a  history  of  definite 
acute  rheumatism  in  the  parents  or  in  the  brothers  or  sisters 
of  the  child  ;  which  must  carry  some  weight  in  this  connexion. 
Moreover,  any  calculation  based  only  upon  concurrent  or  previous 
manifestations  of  rheumatism  in  a  choreic  child  must  necessarily 
be  incomplete,  for,  as  I  have  already  said,  and  as  Dr.  Batten's 
observations  have  shown,  in  a  considerable  proportion  of  the 
cases  articular  or  cardiac  rheumatism  occurs  subsequently  to 
the  chorea,  which  may  be  the  first  indication  of  rheumatism. 

Symptoms.  The  symptoms  of  chorea  in  a  well-marked  case  are 
so  familiar  to  every  medical  man  that  I  need  not  give  any  lengthy 


CHOREA  519 

description  here .  Often  the  first  thing  noticed  wrong  by  the  mother 
is  that  the  child  is  always  dropping  things  ;  or  the  unfortunate 
child  is  punished  by  an  ignorant  teacher  at  school  because  she 
'  can't  do  her  sums  ',  I  have  notes  of  several  cases  in  which  this 
has  happened  ;  the  inability  to  do  lessons  is,  I  think,  not  always 
due  to  the  mechanical  difficulty  from  inco-ordination,  it  seems 
probable  that  the  power  of  attention  may  be  actually  diminished 
in  chorea.  In  many  cases  the  child  is  noticed  to  be  '  always 
falling  about ',  as  the  bruises  on  the  shins  too  obviously  testify ,  and 
occasionally  the  mother  has  been  more  struck  by  the  apparent 
mental  change  than  by  anything  else  and  complains  that  the 
child  has  become  '  so  silly  '  lately. 

A  frequent  complaint  in  the  early  stage  of  chorea  is  headache  ; 
as  I  have  pointed  out  elsewhere,  this  is  not  uncommon  in  rheu- 
matic children,  but  its  occurrence  specially  with  chorea  is 
interesting  in  connexion  with  the  observations  of  Dr.  Poynton 
and  Dr.  Holmes J ,  who  found  vascular  engorgement  of  the 
pia  mater  and  underlying  cortex,  with  some  small  round  cell 
infiltration  of  the  pia-arachnoid  in  the  immediate  neighbourhood 
of  the  vessels,  and  here  and  there  thromboses  of  small  vessels 
both  in  the  pia-arachnoid  and  in  the  cortex,  together  with 
degenerative  changes  in  the  cells  of  the  cortex  and  the  presence 
of  diplococci,  resembling  those  found  in  other  rheumatic  lesions, 
in  the  exudation  about  the  vessels. 

Soon  the  chorea  is  obvious  enough  in  the  child's  fatuous 
appearance  and  the  irregular  jerky  gait  with  a  few  hesitating 
steps  and  then  a  hurried  step  or  two,  or  a  sudden  jerking  forwards 
of  one  leg.  Now  and  again  one  or  other  shoulder  is  shrugged 
and  a  hand  is  jerkily  thrown  behind  the  child's  back  ;  the  facial 
muscles,  too,  show  irregular  working,  now  perhaps  a  slight  pout, 
now  a  twitch  of  one  corner  of  the  mouth.  The  monotonous  speech 
with  a  tendency  to  blurt  the  words  out  suddenly,  the  occasional 
'  clucking  '  noise  made  by  the  suction  of  the  tongue  against  the 
palate  as  the  child  opens  the  mouth,  the  hesitancy  in  protruding 
the  tongue  at  request,  and  the  sudden  drawing  of  it  in  again, 
and  last  but  not  least  the  extraordinary  emotionalism  of  the 
child,  so  that  he  bursts  out  crying  or  laughing  on  little  or  no 
provocation,  complete  the  characteristic  picture  of  chorea. 

In  the  limbs  the  inco-ordination  is  often  much  more  marked 

on  one  side  than  on  the  other;  in  rare  instances  careful  observation 

fails  to  detect  any  chorea  on  one  side,  so  that  the  condition  is 

a  true  hemichorea.     If  one  examines  these  cases  more  thoroughly 

1  Lancet,  October  13,  1906. 


520  COMMON  DISORDERS  OF  CHILDHOOD 

it  will  often  be  found  that  the  jerky  irregularity  of  movements 
involves  also  the  muscles  of  the  trunk,  so  that  not  only  is  the 
back  flexed  or  arched  in  an  irregular  purposeless  way,  but  there 
is  also  a  jerky  inco-ordination  of  the  thoracic  and  abdominal 
muscles  so  that  respiration  is  spasmodic  and  irregular.  The 
knee-jerks  also  are  influenced  by  the  general  uncertainty  of 
muscular  action  ;  in  some  cases  they  are  exceedingly  difficult 
to  obtain,  if  indeed  they  are  not  actually  absent,  although  the 
child  does  not  prevent  their  occurrence  by  any  voluntary  or 
involuntary  rigidity.  More  often,  instead  of  a  single  jerk,  a 
double  or  triple  jerk  occurs  ending  in  complete  extension  of  the 
knee,  which  persists  for  a  few  seconds. 

The  heart  action  is  similarly  affected  in  some  cases  so  that 
its  rhythm  has  a  remarkable  irregularity.  I  think  there  can 
be  little  doubt  that  sometimes  this  is  due  to  choreic  irregularity 
in  the  contraction  of  the  heart-muscle,  at  any  rate  the  sounds 
convey  to  one's  mind  something  exactly  similar  to  the  choreic 
movements  of  the  limbs.  It  must,  however,  be  remembered 
that  one  of  the  earliest  indications  of  endocarditis  in  cases  where 
no  chorea  is  present  is  sometimes  irregularity  of  the  heart-beat ; 
moreover,  rheumatism,  like  some  other  infective  conditions  such 
as  influenza  and  diphtheria,  may  very  quickly  produce  changes 
in  the  myocardium,  the  most  obvious  indication  of  which  may 
be  irregularity  of  action;  we  must  be  cautious,  therefore,  in 
attributing  cardiac  arrhythmia  to  chorea. 

If  the  most  frequent  affection  of  the  heart  in  chorea  were 
merely  a  disturbance  of  co-ordination  like  that  in  the  limbs, 
chorea  would  be  a  disease  of  little  or  no  gravity  ;  unfortunately 
the  cardiac  affection  is  much  more  often  inflammatory,  usually 
an  endocarditis,  occasionally  a  pericarditis,  and  herein  lies 
the  great  danger  of  chorea. 

Amongst  250  cases  of  chorea  I  noted  the  presence  of  cardiac 
bruits  in  155  ;  in  114  of  these  there  was  a  systolic  apical  bruit 
alone  which  was  thought  to  be  due  to  mitral  regurgitation ;  in 
30  the  bruit  disappeared  whilst  the  patient  was  still  under 
observation  ;  38  cases  had  a  diastolic  bruit  as  well  as  a  systolic 
at  the  apex  ;  3  had  an  aortic  diastolic  bruit  as  well  as  apical 
bruits.  Five  out  of  the  155  cases  had  also  pericarditis,  and  two 
others  in  which  the  presence  of  bruits  is  not  mentioned  had 
pericarditis. 

I  have  very  little  doubt  that  in  other  cases  beside  the  thirty 
mentioned  the  bruits  would  have  been  found  to  disappear 
ultimately  had  the  child  been  under  observation  for  several 


CHOREA  521 

months,  but  it  would  be  a  great  mistake  to  suppose  that  this 
proved  the  absence  of  endocarditis  ;  on  the  contrary,  it  is, 
I  think,  practically  certain  that  the  complete  disappearance  of 
bruits  due  to  endocarditis  is  not  very  rare  (see  p.  497).  It 
has  often  been  assumed  that  where  there  was  only  a  systolic 
apical  bruit  in  chorea  this  was  likely  to  be  due  to  some  slight 
dilatation  of  the  ventricle  or  to  be  merely  '  hsemic  '  ;  without 
denying  that  either  of  these  causes  may  occasionally  account 
for  a  systolic  apical  bruit  in  chorea,  I  will  say  that  my  own 
clinical  and  pathological  observations  lead  me  to  think  that 
a  systolic  apical  bruit  in  chorea  means  endocarditis  in  the  very 
large  majority  of  cases.  The  subsequent  appearance  of  other 
bruits,  the  evidence  of  cardiac  hypertrophy,  the  association 
with  rheumatic  nodules  in  some  cases,  the  post  mortem  testimony 
to  the  extremely  early  occurrence  of  endocarditis  in  chorea 
(I  found  minute  recent  vegetations  on  the  mitral  valve  in  one 
case  where  death  occurred,  I  believe  from  exhaustion,  on  the 
tenth  day  of  a  first  attack  of  chorea),  all  these  points  taken 
together  with  the  certainty  that  bruits  due  to  endocarditis  may 
disappear,  make  it,  I  think,  probable  that  a  very  large  proportion 
of  the  cases  with  only  an  apical  systolic  bruit  have  endocarditis. 

Prognosis.  Chorea  involves  but  very  small  danger  in  itself ; 
there  are  exceedingly  rare  cases  in  which  it  proves  fatal  by  its 
violence  and  the  consequent  inability  to  sleep  and  the  difficulty  in 
feeding,  but  these  are  mostly  in  adolescents,  not  in  children  under 
the  age  of  twelve  years.  Almost  invariably  if  death  occurs  during 
chorea  it  is  due  to  endocarditis  or  pericarditis,  and  the  danger 
in  chorea  does  not  end  with  the  attack,  for  the  history  of  many 
fatal  cases  of  heart  disease  in  children  shows  that  the  affection 
dates  from  a  chorea  which  may  have  been  months  or  years 
before.  The  serious  significance  of  chorea  lies  almost  entirely 
in  its  connexion  with  rheumatism  ;  its  dangers  are  the  dangers 
of  rheumatism,  and  as  a  manifestation  of  rheumatism  chorea 
is  always  a  serious  disease. 

When  once  a  child  has  had  chorea,  even  though  there  may  have 
been  no  other  rheumatism  with  it,  it  is  quite  certain,  if  the  views 
which  I  have  expressed  above  be  correct,  that  he  has  the  rheu- 
matic taint  and  may  at  any  time  develop  acute  articular 
rheumatism  or  rheumatic  heart  disease.  It  is  very  common 
for  a  child  who  has  had  chorea  to  come  under  treatment  sub- 
sequently for  an  attack  of  acute  articular  rheumatism,  then 
perhaps  another  attack  of  chorea  with  some  endocarditis,  and 
finally  perhaps  an  attack  of  pericarditis  which  ends  the  tale. 


522  COMMON  DISORDERS  OF  CHILDHOOD 

These  risks  are  the  greater  if  the  chorea  occurs  early,  say 
at  five  or  six  years  old,  because  the  tendency  to  acute  rheumatic 
affections  including  endocarditis  seems  to  be  greater  during  the 
middle  period  of  childhood  from  about  five  to  ten  years  of  age 
than  it  is  subsequently.  In  the  prognosis  of  this  affection  it" 
has  also  to  be  remembered  that,  like  the  joint  pains  of  rheumatism, 
chorea  shows  a  marked  tendency  to  recurrence. 

As  regards  the  duration  of  an  attack  of  chorea,  in  50  cases 
in  which  it  was  possible  to  date  the  onset  and  cessation  fairly 
accurately,  the  duration  was  as  follows  :  4-6  weeks,  17  ;  7-9 
weeks,  18  ;  10-12  weeks,  8  ;  13-16  weeks,  4  ;  5-6  months,  3. 
But  these  figures  apply  only  to  those  cases — the  larger  number — 
in  which  the  disease  has  definable  limits  ;  there  are  cases  of 
chorea  in  which  after  the  acute  phase  of  the  disease  has  passed 
off  there  remains  a  slight  choreic  tendency  which  pervades  the 
child's  movements  for  many  months.  In  these  cases  exacerba- 
tions occur  from  time  to  time,  and  so  in  varying  degree  the  chorea 
drags  on  sometimes  even  for  a  year  or  two. 

The  severity  of  chorea  is  no  criterion  of  the  risk  of  heart  affec- 
tion nor  of  the  duration  of  the  attack.  With  regard  to  the  latter 
point  I  have  often  noticed  that  a  violent  attack  of  chorea  has 
ended  in  much  quicker  recovery  than  one  in  which  the  movements 
wore  altogether  slighter. 

It  is  important  to  realize  that  the  slightest  attack  of  chorea 
is  just  as  liable  to  be  accompanied  by  serious  heart  disease  as  the 
most  extreme  chorea  ;  a  fact  which  corroborates  the  view  that 
the  heart  disease  is  not  the  result  of  the  chorea  but  that  both 
are  independent  manifestations  of  a  more  general  disease, 
namely  rheumatism. 

Diagnosis.  The  recognition  of  chorea  appears  at  first  sight 
so  simple  as  to  offer  little  or  no  possibility  of  error  ;  but  my 
own  experience  has  satisfied  me  that  even  with  the  most  careful 
observation  the  diagnosis  is  sometimes  difficult.  I  have  seen 
mistakes  made  and  have  made  them  myself.  There  is,  however, 
no  excuse  for  the  ignorance  or  slovenliness  which  labels  any  and 
every  jerky  irregularity  of  movement  as  'chorea'.  It  should  be 
our  endeavour  always  to  distinguish  clearly  between  the 
various  abnormalities  of  movement  which  result  from  functional 
nervous  disturbance  or  from  some  gross  disease  of  the  nervous 
system  and  the  specific  rheumatic  disease  chorea. 

I  suppose  that  the  commonest  mistake  is  to  confuse  habit- 
spasm  with  chorea,  although  in  most  cases  the  distinction  is 
easy.  Habit-spasm,  which  occurs  mostly  in  the  later  half  of 


CHOREA  523 

childhood,  differs  from  chorea  chiefly  in  consisting  of  the  repeti- 
tion of  one  movement  or  one  particular  series  of  movements,  and 
in  being  limited  as  a  rule  to  one  part  of  the  body ;  for  instance, 
in  one  case  the  movement  is  a  frequent  blinking,  in  another 
it  is  a  shrug  of  one  shoulder,  in  another  a  toss  of  the  head  and 
so  on  ;  the  child  may  have  more  than  one  such  spasm  at  once, 
and  after  a  few  days  or  weeks  he  may  desist  from  one  form 
of  spasm  and  acquire  another,  but  always  for  the  time  being 
he  adheres  to  this  one  particular  movement  or  set  of  movements, 
so  that  the  mother  can  describe  to  the  doctor  exactly  what  move- 
ment the  child  shows,  whereas  in  chorea  the  movements  are 
hardly  the  same  for  two  minutes  together, — one  moment  there  is 
a  'clucking'  noise,  the  next  moment  a  twitching  of  the  fingers, 
then  grimaces,  and  then  perhaps  a  shuffling  of  the  foot  ;  and 
even  when  the  movements  are  limited  to  one  side  of  the  body 
there  is  complete  uncertainty  as  to  the  particular  irregularity 
of  movement  which  will  occur  at  any  moment. 

Habit -spasm  unlike  chorea  has  no  essential  connexion  with 
rheumatism,  and  therefore  where  chorea  is  in  question  a  personal 
or  family  history  of  rheumatism  in  the  child  would  carry  some 
weight  in  diagnosis :  but  it  must  be  remembered  that  the  child 
who  has  rheumatism  or  is  of  rheumatic  parentage  is  especially  apt 
to  be  a  '  nervous  '  child,  and  therefore  just  the  type  of  child 
who  is  liable  to  contract  habit-spasm  ;  moreover,  apart  from 
any  rheumatism  in  the  child,  a  family  history  of  acute  rheumatism 
is  extremely  common  in  some  parts  of  England  :  my  own 
statistics  showed  this  in  25  per  cent,  of  children  who  were  brought 
to  hospital  for  non-rheumatic  affections. 

A  variety  of  habit-spasm  which  I  have  known  to  be  mistaken 
for  chorea  is  '  Tic  Convulsif  ',  in  which  sudden  violent  jerks 
of  one  or  other  limb  occur,  accompanied  sometimes  with  an 
explosive  utterance  of  some  sound  which  may  be  merely  a 
grunt  or  may  be  an  articulate  word.  One  boy  about  ten  years 
of  age  who  came  under  my  observation  with  this  disorder 
would  be  lying  quite  quietly  in  bed  when  suddenly  a  violent 
contraction  of  limb  or  trunk  muscles  would  almost  jerk  him 
out  of  bed.  The  explosive  character  of  the  movements,  and 
the  intervals  of  many  minutes,  perhaps  quarter  of  an  hour  or 
more,  between  the  explosions,  is  very  unlike  chorea.  Never- 
theless in  the  case  I  have  just  mentioned  the  disease  had 
been  called  chorea. 

Next  to  habit -spasm  as  a  cause  of  confusion  in  diagnosis 
J  should  put  that  capricious  fidgetiness  which  is  natural  to 


524  COMMON  DISORDERS  OF  CHILDHOOD 

some  nervous  children  :  Dr.  Warner  has  described  it  as  micro- 
kinesis.  When  one  speaks  to  the  child  with  this  condition  he 
shows  in  a  marked  degree  what  is  often  to  be  noticed  in  the  shy 
child  when  asked  to  recite  before  a  stranger  :  he  raises  one 
shoulder,  bends  his  head  toward  that  side,  fidgets  with  his  fingers, 
stands  first  on  one  foot  then  on  the  other,  screws  his  face  up 
into  a  troubled  smile,  in  fact  manifests  a  general  fidgetiness 
which  is  easily  mistaken  for  a  slight  degree  of  chorea,  as  might 
be  imagined  when  it  is  remembered  that  chorea  itself  has  been 
described  as  an  exaggerated  fidgetiness. 

This  '  microkinesis  '  is  more  noticeable  at  one  time  than 
another,  especially  when  the  child  is  out  of  health  from  any 
cause,  and  of  course  when  the  child  is  made  timid  or  shy  by 
being  watched  by  a  stranger ;  but  it  never  becomes  more  than 
might  simulate  an  extremely  slight  degree  of  chorea,  so  that 
the  history  of  its  being  habitual  to  the  child,  and  the  fact  that 
it  remains  always  extremely  slight,  wrill  generally  distinguish  it 
from  chorea. 

Jerky  inco-ordination  which  may  more  or  less  closely  resemble 
chorea  occurs  sometimes  as  a  functional  neurosis.  I  have  twice 
at  least  seen  the  presence  of  worms  associated  with  choreiform 
movements  which  subsided  rapidly  on  the  expulsion  of  these 
parasites. 

But  in  these  cases,  as  in  almost  every  other  instance  where 
chorea  is  simulated,  any  one  who  has  seen  large  numbers  of 
children  with  the  true  rheumatic  chorea  can  detect  a  certain 
almost  undefinable  difference  in  the  character  of  the  movements ; 
they  are,  if  I  may  so  say,  choreoid  but  not  choreic.  So  too  with 
hysteria,  which  occasionally  shows  itself  in  children  as  some 
perversion  of  movement,  there  is  often  a  purposiveness  about 
the  movements  which  is  lacking  in  chorea,  and  the  child's  general 
behaviour,  his  self-consciousness  and  the  evident  cessation  of 
the  abnormal  movements  when  the  child's  attention  is  distracted, 
may  all  point  to  hysteria,  the  diagnosis  of  which  may  be  con- 
firmed by  the  complete  cessation  of  the  disorder  within  a  day 
or  two,  when  the  child's  environment  is  changed,  for  instance, 
on  admission  to  a  hospital,  or  under  the  usual  treatment  for 
hysteria.  The  following  case  was  of  this  kind. 

Eleanor  F.,  aged  nine  years,  was  brought  to  hospital  on  April  28  for  sudden 
attacks  of  dyspnoea  with  some  discomfort  in  the  epigastrium  ;  these  had 
occurred  only  during  the  past  few  days.  The  child  was  stated  to  have  had 
'  St.  Vitus's  dance '  in  May  and  again  in  November  of  the  previous  year, 
but  had  had  no  other  symptoms  of  rheumatism,  nor  was  there  any  rheumatism 
i;i  the  family. 


CHOREA  525 

She  was  a  spare  child  and  rather  pale,  with  a  self-conscious  appearance  ; 
the  tongue  was  thickly  furred,  the  heart  was  normal. 

A  fortnight  later  she  was  suddenly  seized  one  evening  with  what  the  mother 
called  '  St.  Vitus's  dance ',  and  on  inquiry  the  mother  said  that  these  move- 
ments were  exactly  the  same  as  in  the  previous  attacks  of  supposed  chorea. 

The  movements  seen  were  at  first  sight  somewhat  like  chorea,  but  they 
differed  in  their  more  purposive  character;  for  instance,  the  child,  whilst 
standing  perfectly  quiet,  would  suddenly  clasp  her  hands  together  as  if  washing 
them,  then  she  would  screw  up  her  lips  as  if  pouting,  and  wrinkle  her  nostrils 
with  a  sort  of  risus  sardonicus  ;  occasionally  the  shoulders  were  shrugged, 
but  quite  symmetrically  ;  in  walking,  her  gait  was  natural  when  she  was  not 
noticeably  under  observation,  but  when  attention  was  specially  directed  to 
her,  there  was  a  sudden  ^wem-purposive  shuffle  of  her  feet.  All  these  move- 
ments were  diminished  when  the  child's  attention  was  diverted  from  herself 
by  talking  to  her.  She  was  admitted  as  an  in-patient,  and  with  the  administra- 
tion of  valerian  the  movements  had  entirely  ceased  within  four  days. 

A  few  months  later  the  child  was  brought  to  hospital  again  with  the 
history  that  she  was  seized  with  attacks  of  immoderate  laughter  without  any 
reasonable  cause  ;  these  came  on  particularly  at  mea^  times  ;  they  speedily 
ceased  under  treatment.  In  December  of  the  same  year  the  movements  of 
the  face  and  limbs  began  again  and  were  similar  to  those  seen  in  the  previous 
attack.  The  child  was  admitted  again,  and  the  movements  had  almost  entirely 
ceased  in  three  days,  and  the  child  was  sent  out  quite  well  seven  days  after 
admission. 

A  much  more  serious  disease  which  may  cause  choreiform 
movements  is  cerebral  tumour.  Some  years  ago  there  was 
admitted  to  the  Children's  Hospital  a  child  about  ten  years  of 
age  with  a  general  lack  of  co-ordination  which  was  at  first  un- 
hesitatingly diagnosed  as  chorea  ;  it  was  only  after  the  child  had 
been  under  observation  in  the  ward  that  the  irregularity  of 
movement  was  noticed  to  differ  vaguely  from  chorea,  and 
other  symptoms  occurred  suggesting  the  possibility  of  cerebral 
tumour.  Examination  with  the  ophthalmoscope  showed  well- 
marked  optic  neuritis,  and  after  a  short  time  the  child  died, 
and  post  mortem  examination  showed  a  new  growth  in  the 
central  part  of  the  base  of  the  brain  invading  the  optic  thalamus. 

There  are  two  other  diseases  which  I  must  mention,  not  as 
bearing  any  close  resemblance  to  chorea,  for  indeed  as  a  rule 
there  is  no  risk  of  confusing  them,  but  because  I  have  known 
both  of  them  to  be  mistaken  for  chorea  :  namely,  infantile 
hemiplegia  and  diphtheritic  paralysis.  In  some  cases  of 
infantile  hemiplegia,  seen  a  few  years  after  the  onset,  the  promi- 
nent symptom  is  inco-ordination,  especially  in  the  movements  of 
the  hand,  in  which  also  there  may  be  some  action  of  involuntary 
nature  ;  in  a  pronounced  case  these  symptoms  could  hardly 
be  mistaken  for  chorea,  but  where  they  have  been  very  slight 


526  COMMON  DISORDERS  OF  CHILDHOOD 

I  have  known  even  an  observer  of  large  experience  to  be  deceived. 
The  history  of  its  duration  and  usually  sudden  onset,  and  the 
evidence  of  some  degree  of  spasticity  in  arm  or  leg  and  probably 
some  difference  in  size  of  the  limbs  on  the  two  sides  will  serve 
for  diagnosis. 

Diphtheritic  paralysis  only  rarely  shows  as  its  most  striking 
manifestation  an  inco-ordination  which  has  simulated  chorea  : 
to  remember  the  possibility  of  this  error  is  to  avoid  it,  for  the 
history  and  the  other  symptoms  of  diphtheritic  paralysis  are 
sufficiently  obvious. 

Treatment.  Before  discussing  the  therapeutics  of  chorea  I 
should  like  to  call  attention  to  certain  points  in  the  general 
treatment  of  the  disease.  First  I  wish  to  lay  great  stress  upon 
the  importance  of  complete  rest  in  bed  during  the  first  few  weeks 
of  the  disease.  I  see  children  with  chorea  who  are  being  allowed 
to  get  up  for  two  or  three  hours  in  the  day,  as  if,  provided  the 
child  spent  the  greater  part  of  the  twenty-four  hours  in  bed,  it 
would  do  no  harm  to  allow  him  to  be  up  for  a  short  time. 
This,  I  think,  is  a  mistake.  The  movements  become  worse,  the 
duration  of  the  attack  is  prolonged,  and  I  suspect  that  the 
danger  of  cardiac  affection  is  increased  by  allowing  the  child  to 
get  up.  If  there  is  one  part  of  treatment  which  is  more  im- 
portant than  any  other  in  dealing  with  chorea,  it  is  complete 
rest  in  bed,  and  by  this  I  mean  remaining  in  bed  entirely  and 
for  two  or  three  weeks  at  least. 

I  must  qualify  these  remarks  on  the  value  of  rest  in  bed  by 
adding  that  I  believe  there  comes  a  time  in  chorea  when  not  only 
is  complete  rest  in  bed  unnecessary,  but  it  may  actually  retard 
recovery.  It  is  difficult  to  fix  any  precise  date  at  which  this 
period  begins,  but  it  is  during  the  late  stage  of  the  attack, 
when  the  choreic  movements  after  subsiding  gradually  seem 
to  have  reached  a  stage  in  which  no  further  improvement  occurs 
and  there  remains  a  certain  amount  of  what  one  might  call 
residual  chorea.  At  this  stage  if  the  child  is  allowed  to  get 
up  for  a  few  hours  daily  and  to  amuse  himself  with  toys  and 
games  an  opportunity  is  given  for  the  re-education  of  co-ordina- 
tion in  the  limbs,  whereas  if  the  child  is  kept  in  bed  his  co-ordina- 
tion is  much  more  slowly  regained. 

This  may  seem  simple  and  obvious  enough  when  pointed  out, 
but  I  venture  to  point  it  out  because  I  only  learnt  it  myself  by 
comparing  the  results  of  the  two  lines  of  treatment  in  a  large 
number  of  cases. 

The  question  next  arises  how  far  it  is  necessary  to  isolate  the 


CHOREA  527 

child.  In  hospital  practice  some  physicians  like  to  have  the 
choreic  child  screened  off  from  the  other  patients,  and  in  private 
practice  I  have  seen  chorea  carefully  secluded  in  solitary  quietude. 
In  a  severe  case  this  is  no  doubt  advisable  as  much  perhaps 
for  the  sake  of  the  other  children,  who  are  only  likely  to  be 
shocked  by  the  sensational  contortions  of  a  violent  chorea,  as  for 
the  patient  himself,  who  can  hardly  be  otherwise  than  benefited 
by  absence  of  all  mental  stimulus.  In  the  moderate  degrees  of 
chorea,  any  such  strict  isolation  is  unnecessary  ;  but  even  in 
the  slightest  attack,  freedom  from  everything  which  may  excite 
or  disturb  the  child  is  certainly  to  be  advised. 

I  turn  now  to  the  medicinal  treatment.  Chorea  is  one  of  those 
diseases  in  which  recovery  follows  the  use  of  so  great  a  variety 
of  drugs  that  one  is  tempted  to  wonder  whether  the  child  might 
not  recover  equally  well  with  no  drug  at  all.  One  thing  is  certain, 
that  the  duration  of  chorea  where  no  drugs  are  given  varies 
greatly,  it  may  last  three  weeks,  it  may  last  three  months ;  it 
is  easy  therefore  to  deceive  ourselves  as  to  the  shortening  of  the 
disease  where  this  or  that  method  of  treatment  is  adopted. 

Amongst  the  many  remedies  which  I  have  used  and  seen  used 
for  chorea,  I  think  there  is  none  more  generally  valuable  than 
arsenic.  At  one  time  at  the  Children's  Hospital,  Great  Ormond 
Street,  in  the  three  medical  wards  three  different  methods  of 
treatment  were  in  vogue :  in  one  the  choreic  children  had  rest  in 
bed  with  no  drugs  except  sometimes  cod-liver  oil,  in  another 
drugs  many  and  various  were  tried,  in  the  third  arsenic  was 
given.  I  had  the  opportunity  of  watching  all  these  methods, 
and  I  must  confess  that  there  was  remarkably  little  to  choose 
between  the  results,  but  so  far  as  there  was  any  difference  it 
seemed  to  me  that  arsenic  given  in  large  doses  had  more  definitely 
beneficial  effect  than  any  other  mode  of  treatment.  By  large 
doses  I  mean  an  initial  dose  of  10  or  12  minims  of  the  liquor 
arsenicalis  for  a  child  of  ten  years  old  ;  this  is  continued  for 
four  days  unless  the  child  shows  any  symptom  of  intolerance 
earlier,  it  is  then  reduced  and  -the  reduction  is  repeated  every 
third  day  by  2  minims  until  the  dose  has  been  reduced  to 
2  minims ;  the  whole  course  occupies  about  fourteen  days. 

But  whenever  arsenic  is  used  in  such  large  doses  a  sharp  watch 
must  be  kept  for  symptoms  of  intolerance  ;  usually  vomiting 
is  the  first  indication,  but  I  have  seen  congestion  of  the  con- 
junctiva come  first,  and  I  have  known  a  very  severe  gastritis 
with  local  tenderness  and  severe  vomiting  to  follow  so  quickly 
upon  the  first  retching  as  to  be  almost  the  first  warning  of  trouble, 


528  COMMON  DISORDERS  OF  CHILDHOOD 

The  absence  of  such  symptoms  should  not,  I  think,  tempt  us 
to  prolong  the  large  doses  beyond  the  duration  mentioned  above  ; 
for  I  have  known  peripheral  neuritis  to  result  from  too  pro- 
longed use  of  large  doses  of  this  drug  in  chorea. 

A  much  less  serious  result  of  the  prolonged  use  of  arsenic 
even  in  moderate  doses  (3  or  4  minims)  is  a  brownish  discoloration 
of  the  skin,  especially  of  the  trunk ;  this  I  have  seen  many  times 
in  children  who  had  been  under  treatment  for  chorea  for  many 
weeks  ;  but  when  the  drug  is  discontinued  it  slowly  disappears. 
The  use  of  initial  large  doses,  followed  by  gradual  diminution 
of  the  dose,  has  seemed  to  me  to  be  more  effectual  than  the 
usual  procedure  of  starting  with  a  small  dose  of  2  or  3  minims 
which  is  gradually  increased. 

On  the  ground  that  if  chorea  is  rheumatic  it  should  be  benefited 
by  codium  salicylate,  Dr.  D.  B.  Lees  has  advocated  the  use  of  this 
drug  in  large  doses  ;  certainly  if  it  has  any  good  effect  in  chorea 
it  can  only  be  from  large  doses,  for  experience  has  long  shown 
that  it  is  useless  for  this  purpose  in  small  ones.  Lr.  Lees  • 
recommends  an  initial  dose  of  10  grains  of  sodium  salicylate 
with  20  grains  of  bicarbonate  of  soda  every  two  hours  during 
the  day  and  every  four  hours  during  the  night  for  a  child  of 
six  to  ten  years.  After  two  or  three  days  the  quantities  are  to 
be  increased  to  15  grains  of  the  salicylate  and  30  grains  of  the 
bicarbonate  of  soda. 

It  is  very  important  that  the  sodium  bicarbonate  should 
be  added  in  the  proportion  of  two  to  one  of  the  salicylate,  for 
given  in  this  excess  it  prevents  the  toxic  effects  of  sodium 
salicylate,  which  may  be  very  serious  when  such  large  doses 
are  given.  The  symptoms  of  salicylate  poisoning  are  very  like 
those  of  diabetic  coma,  a  curious  gasping  for  air,  associated  \vith 
a  drowsy  condition  passing  into  coma  ;  in  some  cases  there 
is  also  much  vomiting.  Dr.  Lees  has  recorded  a  fatal  case 
of  such  poisoning  where  sodium  bicarbonate  had  not  been 
given. 

This  method  of  treatment  must  be  regarded  as  upon  trial  at 
present ;  like  the  use  of  large  doses  of  arsenic,  it  may  be  more 
applicable  to  hospital  practice  where  the  patient  is  under  con- 
tinuous skilled  supervision  than  to  private  practice.  I  once 
prescribed  it  to  a  private  patient  with  very  unfortunate  results, 
the  child  was  made  very  sick  and  pale  and  it  had  to  be  discon- 
tinued within  two  days.  I  have  several  times  noticed  pallor 
and  a  generally  '  ill  '  look  produced  in  children  by  large  doses 
1  Acute  Visceral  Inflammations,  p.  291, 


CHOREA  529 

of  salicylate  before  the  value  of  sodium  bicarbonate  as  a  corrective 
was  known,  and  one  has  sometimes  wondered  how  far  diminution 
of  choreic  movements  might  be  due  merely  to  depression  pro- 
duced by  drugs,  just  as  the  depression  caused  by  any  severe 
illness,  be  it  acute  pericarditis,  or  pneumonia,  or  any  other  acute 
disease  supervening,  will  sometimes  cause  the  choreic  movements 
to  diminish  or  disappear  within  a  few  days. 

Aspirin  has  been  recommended  by  some,  but  so  far  as  I  have 
observed  it  has  no  advantage  over  sodium  salicylate,  and  has  the 
disadvantage  of  being  only  slightly  soluble  in  water. 

The  newer  sedative  preparations  have  been  tried  for  chorea, 
such  as  trional,  chloretone,  and  veronal.  Trional  can  be  given 
to  a  child  of  about  eight  years  in  doses  of  5  grains  every  six 
hours  ;  this  can  be  continued  if  necessary  for  ten  or  fourteen 
days.  Chloretone,  to  a  child  of  the  same  age,  can  be  given  in 
doses  of  3  grains  every  six  hours.  Any  of  these  drugs  can  be 
given  as  powders  in  a  tablespoonful  of  milk. 

I  have  seen  cases  in  which  recovery  seemed  to  be  hastened  by 
the  use  of  trional  or  chloretone  ;  the  latter  particularly  has 
undoubtedly  a  quieting  effect  upon  some  cases  of  chorea,  but 
a  dose  of  3  grains  given  every  four  hours  to  a  child  of  seven  or 
eight  years  sometimes  'produces  a  drowsiness  which  makes  it 
necessary  to  stop  the  drug  ;  and  a  further  ill  effect  of  chloretone, 
given  too  freely,  has  been  irregularity  of  the  heart,  with  feeble 
pulse,  and  grey,  almost  livid  colour.  Veronal  I  have  perhaps 
not  used  in  large  enough  doses  to  secure  any  good  from  it, 
and  -I  think  it  is  too  dangerous  a  drug  to  be  of  any  general 
use  for  children.  Phenazone  I  have  sometimes  thought  useful; 
it  may  be  given  in  doses  of  3  or  4  grains  three  times  a  day  to 
a  child  of  ten  years  ;  some  have  used  much  larger  doses,  but 
knowing  how  powerfully  it  depresses  the  heart  in  some  persons, 
I  have  always  avoided  large  doses,  and  even  with  the  smaller 
doses  I  always  give  some  form  of  stimulant,  usually  sal  volatile. 

If  these  drugs  are  useful  there  seems  to  be  no  reason  why  bromides 
should  not  do  good,  but  I  think  it  must  be  the  experience  of  most 
that  bromide  is  very  much  less  valuable  in  chorea  than  might  be 
expected.  I  sometimes  use  it  in  combination  with  small  doses  of 
arsenic,  and  have  thought  that  used  in  this  way  it  was  serviceable. 
Chloral  is  undoubtedly  valuable  in  severe  cases,  especially 
where  there  is  sleeplessness,  but  I  confess  to  a  dislike  to  the  large 
doses  which  have  sometimes  been  used  with  the  intention  and 
result  of  keeping  the  child  in  a  semi-comatose  condition  for 
several  days  ;  a  single  dose  at  night  of  10  or  12  grains  is  as 

STILL  HI  m 


530  COMMON  DISORDERS  OF  CHILDHOOD 

much  as  I  care  to  give  to  a  child  of  eight  or  ten  years,  but  some 
physicians  give  as  much  as  10  grains  every  six  hours  ;  if  the 
dose  is  to  be  repeated  two  or  three  times  a  day,  3-5  grains  is 
a  suitable  dose. 

A  drug  which  I  think  is  undoubtedly  useful  in  some  cases  is 
ergot  ;  I  have  seen  rapid  improvement  follow  the  use  of  this 
drug  in  violent  chorea,  but  like  other  drugs  its  value  is  by  no 
means  constant.  I  have  used  it  in  some  cases  without  the  least 
advantage.  I  have  usually  given  30-40  minims  of  the  liquid 
extract  three  times  a  day,  but  Dr.  Eustace  Smith  1,  who  has 
advocated  this  drug  for  chorea,  recommends  as  much  as  1  or 
even  1|  drachms  every  three  or  four  hours. 

Zinc  sulphate  is  probably  much  less  used  now  than  formerly. 
I  have  used  it  in  doses  of  3  grains  increased  gradually  up  to  10 
or  12  grains  three  times  a  day,  unless  the  child  vomits,  as  often 
happens  before  the  large  dose  is  reached.  But  there  is  extra- 
ordinary tolerance  of  this  drug  as  of  arsenic  by  some  children. 
About  forty  years  ago  at  the  Children's  Hospital,  Great  Ormond 
Street,  zinc  sulphate  was  in  common  use  for  chorea,  and  was 
increased  sometimes  up  to  25  or  even  30  grains  three  times 
a  day  ;  one  girl  aged  nine  years  took  34  grains  three  times  a  day  ; 
these  heroic  doses  do  not  seem  to  have  been  any  more  successful 
than  more  recent  methods. 

Another  drug  which  has  fallen  out  of  use  for  chorea  is  antimony. 
Dr.  Charles  West2  regarded  it  as  one  of  the  most  valuable  remedies 
for  chorea  ;  it  was  given  '  every  four  hours  in  what  would  usually 
be  nauseating  doses  ',  presumably  about  a  sixth  of  a  grain  ;  he 
says  that  it  accomplishes  all  the  good  of  which  it  is  capable 
within  four  or  five  days,  and  he  considers  it  useful  especially  for 
controlling  violent  chorea  in  its  early  stage. 

As  an  addition  to  drugs  or  in  place  of  them,  certain  other 
methods  of  treatment  have  been  found  useful.  The  wet-pack 
is  very  valuable  in  severe  cases  of  chorea.  The  child  is  stripped, 
and  then  wrapped  in  a  sheet  wrung  out  of  warm  water  at 
a  temperature  of  about  105°  F.,  surrounded  with  a  blanket,  and 
outside  this  a  mackintosh  ;  in  this  warm  pack  the  child  can 
remain  for  half  an  hour,  and  if,  as  often  happens,  he  falls  asleep 
in  it,  there  is  no  need  to  disturb  him  ;  let  the  child  lie  thus  for 
about  an  hour,  then  quickly  dry  him  and  put  on  a  warmed 
ilarmel  night-garment,  when  he  will  usually  fall  asleep  quickly 

1  Brit.  Med.  Journ.,  July  18,  1903. 

2  Diseases  of  Infancy  and  Childhood,  5th  ed.,  p.  229. 


CHOREA  531 

again.  This  procedure  may  be  repeated  on  several  successive 
evenings  with  distinct  advantage. 

Massage  has  not  seemed  to  me  of  much  use  in  chorea  ;  cer- 
tainly if  it  disturbs  and  excites  the  child  as  it  sometimes  does,  it  is 
much  better  omitted.  Douching  or  spraying  over  the  spine  with 
cold  water  has  been  used,  and  some  have  thought  that  it  quieted 
the  movements  ;  like  the  massage,  it  may  disturb  rather  than 
calm  the  child,  and  then  is  only  likely  to  do  harm. 

I  have  dealt  with  the  treatment  of  chorea  as  if  it  were  merely 
a  matter  of  reducing  the  irregularity  of  movement  ;  but  in  the 
majority  of  cases  there  is  more  to  be  considered  than  this.  The 
treatment  of  the  heart  disease  which  accompanies  the  chorea 
may  be  a  much  more  important  matter,  and  the  practical 
questions,  How  long  must  the  child  remain  in  bed  ?  When  may 
the  child  return  to  school  ?  Shall  he  be  sent  away  for  change 
of  climate  ?  may  have  to  be  answered  rather  in  view  of  the 
cardiac  condition  than  with  reference  to  the  chorea.  I  have 
already  considered  rest  in  bed  where  there  is  only  chorea,  but 
where  there  has  also  been  a  bruit  I  believe  that  strict  rest  in 
bed  should  be  enforced  for  at  least  two  months,  and  if  there  is 
any  evidence  of  active  endocarditis,  for  instance,  recent  appear- 
ance of  rheumatic  nodules  or  appearance  of  fresh  bruits,  I  would 
continue  the  rest  in  bed  much  longer.  I  have  referred  to 
these  points  in  the  chapter  on  heart  disease. 

As  to  the  date  of  returning  to  school  after  chorea,  when  there 
has  been  no  bruit  and  the  movements  have  completely  dis- 
appeared, I  think  that  an  interval  of  three  months  is  very 
advisable  ;  nothing  seems  to  determine  a  fresh  attack  so  often 
as  the  return  to  school.  I  think  that  where  it  is  practicable 
home-teaching,  at  first  only  for  a  hour  or  two  daily  and  then  for 
longer,  is  much  to  be  preferred.  With  regard  to  change  of 
climate,  whether  country  or  seaside,  I  think  that  it  is  well  to 
impress  upon  the  parents  that  the  one  thing  needful  for  the 
choreic  child  is  rest,  and  that  no  change  of  air  is  of  any  impor- 
tance in  comparison  with  this.  I  am  often  asked  by  parents 
whose  child  has  slight  chorea,  '  Don't  you  think  it  would  do  him 
good  to  go  to  the  seaside  ?  '  It  is  usually  the  greatest  mistake 
to  '  send  away  for  a  change  '  the  child  who  has  chorea,  the 
excitement  of  going  away,  and  the  unrestricted  liberty  of  play 
and  running  about  which  is  almost  sure  to  accompany  the 
change  of  air,  will  do  nothing  but  harm.  Even  when  the  chorea 
is  almost  over  and  there  is  left  only  a  very  slight  degree  of  residual 
chorea,  I  think  there  is  seldom  anything  to  be  gained  from 

Mm  2 


532  COMMON  DISORDERS  OF  CHILDHOOD 

a  visit  to  the  seaside  or  country,  and  if  the  chorea  has  left  behind 
it  a  damaged  heart  more  harm  than  good  is  likely  to  be  done 
by  the  extra  walking  and  running  about  to  which  such  a  visit 
usually  leads. 

It  must,  however,  be  remembered  that  chorea  is  a  manifesta- 
tion of  rheumatism,  and  whatever  the  explanation  may  be 
I  do  not  think  there  can  be  the  least  doubt  that  cold  and  damp 
conduce  to  fresh  attacks  of  rheumatism,  and  on  this  score  it 
may  be  advisable  under  certain  circumstances  to  send  the  child 
who  has  had  chorea  or  any  other  manifestation  of  rheumatism 
away  to  some  climate  and  soil  where  warmth  and  dryness  of 
atmosphere  are  likely  to  be  found. 


CHAPTER  XXXVII 
CONGENITAL  HEART  DISEASE 

CONGENITAL  heart  disease  is  not  a  common  condition  ;  but 
it  comes  under  medical  notice  much  more  commonly  in  child- 
hood than  at  any  other  period,  partly  because  its  symptoms 
attract  notice  usually  in  infancy  or  early  childhood  and  partly 
because  comparatively  few  survive  to  adult  life.  Amongst 
2,792  children  under  ten  years  of  age  in  the  Children's  Out- 
patient Department  of  King's  College  Hospital,  there  were  only 
sixteen  cases  of  congenital  heart  disease.  My  figures  at  the 
Children's  Hospital,  Great  Ormond  Street,  give  no  accurate 
idea  of  the  frequency  of  this  disease,  for  the  cases  seen  by  the 
physicians  are  only  selected  cases.  I  find  that  amongst  approxi- 
mately 18,000  children  I  saw  64  cases  of  this  affection. 

There  seems  to  be  no  special  sex-incidence ;  out  of  100  con- 
secutive cases,  48  were  boys,  52  were  girls. 

I  am  not  concerned  here  with  the  pathology  of  congenital 
heart  disease,  I  shall  deal  rather  with  its  clinical  aspect,  but 
I  may  point  out  that  the  term  congenital  heart  disease  includes 
various  conditions  which  are  not  all  of  similar  origin.  They  fall 
into  three  distinct  groups,  which  I  shall  tabulate  here  in  order 
of  frequency  according  to  post  mortem  findings  in  forty-four 
cases  recorded  in  the  registers  of  the  Children's  Hospital. 

A.  Abnormal  persistence  of  openings  : 

(1)  Patent  septum  ventriculorum       .         .         .     20  cases  (only  lesion  in  4) 

(2)  Patent  ductus  arteriosus      ....       5  cases  (never  alone) 

(3)  Patent  foramen  ovale  (widely  open)     .         .       1  case 

B.  Deformities  of  valves  : 

( 1 )  Pulmonary  stenosis      .....     15  (only  lesion  in  G) 

(2)  Aortic  stenosis  or  fusion  of  valves         .         .12 

(3)  Pulmonary  atresia 3 

(4)  Tricuspid  stenosis        .         .         .         .         .2 

C.  Abnormalities  of  vessels  and  heart  cavities. 

(These  occur  in  large  variety,  but  are  of  little  practical  importance;  some, 
e.  g.  single  ventricle  with  double  auricle,  or  single  ventricle  and  single  auricle, 
are  not  consistent  with  life  for  more  than  a  few  hours  or  days,  and  none  can  be 
differentiated  during  life.  In  the  present  series  of  cases  the  following  were 
noted) : 

(1)  Abnormally  large  pulmonary  artery(probably 

pulmonary  regurgitation)  ..         .         .         .1 

(2)  Abnormally  small  pulmonary  artery      .         .       1 

(3)  Transposition  of  vessels  and  single  ventricle  .       1 


534  COMMON  DISORDERS  OF  CHILDHOOD 

It  will  be  noticed  that  patent  foramen  ovale  is  one  of  the 
rarest  of  malformations  according  to  these  statistics ;  perhaps 
it  is  a  little  more  frequent  than  they  indicate,  for  in  some  of  the 
cases  which  die  in  early  infancy  it  is  difficult  to  say  whether 
patency  of  the  foramen  ovale  should  be  considered  abnormal 
or  not,  the  time  of  complete  closure  of  the  foramen  ovale  is 
normally  very  variable.  However  this  may  be,  it  is  quite 
certain  that  the  normally  patent  foramen  ovale  in  early  infancy 
does  not  produce  any  bruit  whatever,  and  it  is  probable  that 
only  a  very  wide  patency  can  do  so  :  this  is  rare  in  comparison 
with  other  malformations,  so  that  there  is  no  ground  in  post 
mortem  statistics  for  the  assumption  often  made  at  the  bedside 
that  the  bruit  of  congenital  heart  disease  is  likely  to  be  due  to 
patent  foramen  ovale.  I  mention  this  point  because  I  so  often 
hear  the  remark  a  propos  of  a  child  with  congenital  heart  disease, 
'  I  suppose  it  is  a  patent  foramen  ovale,'  as  if  patency  of  the 
foramen  ovale  usually  produced  a  bruit. 

Most  of  these  conditions  are  abnormalities  of  development  ; 
they  can  hardly  be  called  '  disease  '  in  the  ordinary  sense  of 
the  word.  What  the  influence  may  be  which  perverts  develop- 
ment we  cannot  tell  ;  but  some  light  is  thrown  upon  the  problem 
by  the  associations  of  congenital  heart  disease.  It  is  often  only 
one  of  several  abnormalities  in  a  child;  for  instance,  I  have  notes 
of  one  case  in  which  there  was  also  cleft  palate,  of  another  in 
which  the  penis  was  undeveloped  and  the  testicle  undescended, 
another  with  imperf orate  anus,  another  in  which  there  was 
a  double  thumb  on  one  hand,  another  in  which  there  was  con- 
genital syndactyly,  another  with  severe  congenital  talipes,  and 
another  with  microcephaly.  Some  such  congenital  abnormality 
was  associated  with  the  congenital  heart  disease  in  13  per  cent, 
of  my  cases. 

It  is  evident  from  such  cases  that  congenital  heart  disease 
may  be  only  one  expression  of  a  general  tendency  to  faulty 
development. 

Again,  congenital  heart  disease  is  a  recognized  associate  of 
Mongolian  imbecility,  it  is  found  in  about  5  per  cent,  of  such 
cases  ;  and  this  happens  to  be  one  of  the  forms  of  developmental 
imbecility  in  which  there  often  seems  to  be  an  explanation  in 
the  comparatively  advanced  age  of  the  mother  at  the  time  of 
pregnancy,  a  fact  which  suggests  that  congenital  heart  disease, 
like  Mongolian  imbecility,  may  sometimes  be  an  exhaustion 
product.  Some  information  might  be  gained  from  statistics 
of  the  age  of  the  mother  at  the  time  of  the  child's  birth.  I  have 


CONGENITAL  HEART  DISEASE  535 

no  record  of  this,  but  from  their  place  in  the  family  some  of  my 
case's  suggest  the  influence  of  exhaustion,  one  was  a  nineteenth 
pregnancy,  another  a  tenth  pregnancy,  another  a  fourteenth, 
one  eighth,  and  two  sixth. 

In  discucsing  the  etiology  of  mental  deficiency,  I  shall  point 
out  that  there  is  a  liability  for  the  reproductive  function  to  be 
imperfectly  established  in  a  first  pregnancy,  so  that  the  first 
child  suffers  with  congenital  abnormalities,  while  the  later  or 
last  child  shows  them  because  the  reproductive  function  is 
failing.  I  suspect  that  the  same  applies  to  congenital  deformities 
of  the  heart.  I  have  noted  the  place  in  family  of  fifty  cases, 
no  less  than  sixteen  out  of  the  fifty  were  first-born. 

Closely  allied  to  these  factors  in  its  modus  operandi  is  prolonged 
illness  or  any  depressing  influence  which  impairs  the  mother's 
power  of  perfect  reproduction  ;  in  this  way  also  may  be  explained 
the  influence  of  parental  syphilis  which,  without  producing  any 
specific  manifestation  of  syphilis  in  the  child,  sometimes  figures 
in  the  history  of  the  child  with  congenital  heart  disease.  From 
my  own  observations  I  should  say  that  syphilis  is  quite  an 
exceptional  factor  ;  it  appeared  to  be  present  only  in  two  out 
of  the  series  of  100  cases  mentioned  above,  but  I  think  these 
figures  may  slightly  underestimate  its  frequency.  Recent  obser- 
vations of  the  Wassermann  reaction  in  cases  of  congenital  heart 
disease  give  discordant  results  :  Holt 1  in  six  cases  found  no 
positive  reaction  ;  Findlay  and  Robertson 2  found  a  positive 
reaction  in  nine  out  of  eleven  cases,  either  in  parent,  -or  child, 
or  both.  It  is  quite  conceivable  that  the  influence  of  disease 
in  the  mother  may  be  more  direct,  for,  as  Dr.  Ballantyne  has 
pointed  out,  imperfect  development  may  be  the  effect  of  disease 
or  poison  acting  upon  the  embryo,  although  the  same  disease  or 
poison  acting  at  a  later  period  of  intra-uterine  life  would  pro- 
duce entirely  different  effects,  resembling  more  or  less  closely 
those  which  occur  after  birth.  A  poison  which  may  in  this  way 
act  upon  the  embryo  is  alcohol ;  and  I  have  fancied,  but  I  am 
unable  to  produce  evidence,  that  alcoholism  in  the  parents  is 
one  cause  of  congenital  heart  disease. 

As  with  other  congenital  malformations,  it  occasionally  happens 
that  more  than  one  child  is  affected.  I  had  under  my  care  for 
some  time  two  sisters,  who  both  had  congenital  heart  disease, 
which  in  one  of  them  was  associated  with  cleft  palate.  Another 
instance  was  a  boy  who  was  said  to  be  one  of  three  who  had 

1  Amer.  Journ.  Dis.  Child.,  Sept.  1913,  p.  1G7. 
8  Glasgow  Med.  Journ.,  Deo.  1914. 


536  COMMON  DISORDERS  OF  CHILDHOOD 

congenital  heart  disease  out  of  a  family  of  thirteen.  I  did  not 
see  the  other  two  children,  who  died  in  infancy. 

I  have  spoken  so  far  as  if  congenital  heart  disease  were  always 
due  to  faulty  development,  and  I  think  that  post  mortem  evidence 
show^s  that  this  is  not  far  short  of  the  truth,  but  it  must  be 
admitted  that  there  is  a  very  small  residue  in  which  there  is 
disease  exactly  similar  to  that  which  occurs  after  birth,  an 
endocarditis  which  produces  thickening  of  valves.  Dr.  Poynton 
has  recorded  one  case  in  which  the  mother  had  rheumatism 
during  pregnancy  and  the  child  had  a  cardiac  bruit  at  birth, 
which  was  found  when  the  child  died  shortly  afterwards  to 
be  due  to  recent  endocarditis.  Such  a  case  must,  I  think,  be 
excessively  rare. 

I  had  under  my  care  a  boy,  Jack  E.,  aged  ten  years,  with 
a  rough  systolic  bruit  very  localized  in  the  fourth  intercostal 
space  close  to  the  left  edge  of  the  sternum  ;  it  could  only  just 
be  heard  in  the  third  space  and  was  not  heard  elsewhere  ;  he 
was  not  cyanosed  but  occasionally  had  sudden  attacks  of  panting 
for  breath.  The  mother  had  had  rheumatism  with  swollen 
joints  whilst  pregnant  with  this  child.  At  first  sight  the  family 
history  suggests  a  foetal  endocarditis  of  rheumatic  origin,  as  in 
Dr.  Poynton's  case,  but  the  position  of  the  bruit  was,  I  think, 
in  favour  of  patent  septum  ventriculorum,  and  if  this  were  so, 
the  lesion  \vas  presumably  developmental  and  the  history  of 
maternal  rheumatism  a  coincidence. 

I  have  notes  of  an  almost  exactly  similar  case  in  a  girl,  \vhere 
in  spite  of  the  maternal  rheumatism  during  pregnancy  it  seemed 
very  improbable  that  the  child's  heart  condition  \vas  due  to 
foetal  endocarditis.  I  have  many  times  seen  crumpled  and 
deformed  valves  in  examining  post  mortem  children  with  con- 
genital disease  ;  but  the  appearances  are  so  unlike  what  we  are 
familiar  with  in  post-natal  endocarditis,  that  even  granting 
that  the  effects  of  valve-inflammation  in  intra-uterine  life  may 
be  expected  to  differ  from  those  of  post-natal  disease,  I  cannot 
but  regard  it  as  the  merest  assumption  to  say  that  these  have 
been  deformed  by  foetal  endocarditis.  Moreover,  if  the  endo- 
carditis were  rheumatic,  I  think,  judging  from  the  usual  course 
of  rheumatic  endocarditis  in  young  children,  it  is  unlikely  that 
it  should  all  subside  before  birth,  leaving  the  crumpled,  and 
sometimes,  but  not  always,  abnormally  thick  valves  wrhich 
I  have  mentioned.  It  would  be,  moreover,  very  remarkable  if 
rheumatic  endocarditis  occurred  in  intra-uterine  life,  and  yet 
were  almost  unknown,  as  it  is,  to  attack  a  child  in  the  first  year 


CONGENITAL  HEART  DISEASE  537 

of  life.  In  short,  it  appears  to  me  that,  whilst  it  cannot  be 
denied  that  an  acute  endocarditis — possibly  of  rheumatic  origin 
where  infection  occurs  from  a  mother  with  acute  rheumatism — 
does  occasionally,  but  extremely  rarely,  occur  in  the  fcetus,  the 
majority  of  abnormalities  met  with  in  congenital  heart  disease 
are  not  due  to  endocarditis. 

Symptoms.  Amongst  the  symptoms  of  congenital  heart 
disease  I  suppose  there  is  none  that  is  more  striking  than  the 
cyanosis  which  characterizes  it  in  some  cases,  but  I  want  to 
emphasize  the  fact  that  there  is  no  cyanosis  whatever  in  the 
majority  of  cases  of  congenital  heart  disease.  The  name 
'  morbus  cseruleus  '  has  been  responsible  for  many  oversights 
and  errors  in  diagnosis  ;  far  too  much  stress  has  been  laid  upon 
this  cyanosis.  I  have  many  times  seen  cases  of  congenital  heart 
disease  overlooked  all  together  or  mistaken  for  acquired  heart 
disease,  because  there  was  no  blueness  of  lips  or  cheeks,  and 
when  I  have  pointed  out  that  the  bruit  could  only  be  due  to 
the  congenital  affection,  I  have  been  met  with  the  objection, 
'  But  there  is  no  cyanosis,'  as  if  cyanosis  were  a  necessary 
symptom.  I  have  kept  a  record  especially  of  this  point  in 
100  cases ;  only  thirty-four  showed  cyanosis  and  in  many  of 
these  it  was  only  very  slight ;  sixty-six  showed  no  cyanosis. 

In  this  series  the  diagnosis  rested  upon  clinical  evidence, 
except  in  a  few  cases  where  a  post  mortem  was  made  ;  but 
a  series  of  cases  in  which  congenital  malformations  were  dis- 
covered post  mortem  showed  even  more  clearly  that  cyanosis 
is  the  exception  rather  than  the  rule ;  it  was  present  in  thirteen 
out  of  forty-four  cases. 

In  some  cases  cyanosis  becomes  more  obvious  as  the  child 
grows  older.  I  have  even  known  it  to  become  very  marked 
where  there  had  been  none  in  infancy  :  e.g.  Reginald  B.  was 
seen  by  me  at  the  age  of  ten  months,  when  he  had  a  loud  systolic 
bruit  with  a  marked  systolic  thrill  over  the  inner  end  of  the  left 
second  costal  cartilage.  I  particularly  noted  that  he  had  no 
cyanosis  and  no  clubbing  of  fingers.  I  saw  him  again  at  the 
age  of  7 1  years,  when  the  bruit  had  become  so  small  that  it  was 
only  heard  on  careful  auscultation,  but  the  cyanosis  had  become 
so  marked  that  his  face  was  a  livid  leaden  colour  and  his  lips 
a  deep  blue  and  his  fingers  had  become  clubbed  to  an  extreme 
degree. 

In  some  cases  where  there  is  no  cyanosis  while  the  child  is 
'quiet,  a  little  exertion  such  as  running  about  or  crying  makes 
the  lips  distinctly  blue;  in  others  without  any  definite  cyanosis 


538  COMMON  DISORDERS  OF  CHILDHOOD 

the  fingers  and  toes  are  always  slightly  bluish,  more  rarely  a  bright 
scarlet,  as  I  saw  in  one  child  with  an  abnormally  large  pulmonary 
artery  and  patency  of  the  foramen  ovale  at  six  years. 

In  the  most  severe  cyanosis  the  conjunctivse  are  congested, 
and  the  tongue,  as  well  as  the  lips,  is  a  livid  leaden  colour  ;  in 
such  cases  the  venous  congestion  is  very  conspicuous  in  the 
fundus  oculi  on  ophthalmoscopic  examination,  where  the  veins 
are  not  only  extremely  full  and  dark  but  also  show  a  remarkable 
tortuosity. 

Clubbing  of  ringers  is,  generally  speaking,  proportionate  to 
cyanosis  ;  it  is  gradually  produced  by  venous  stagnation,  and 
therefore  is  not  present  in  the  earliest  weeks  of  life  ;  but  it  soon 
becomes  noticeable  when  the  cyanosis  is  pronounced.  In  an 
infant  aged  sixteen  days,  with  intense  cyanosis  there  was  no 
clubbing  ;  in  another  at  the  age  of  ten  weeks  it  was  barely  notice- 
able ;  in  another  at  eight  months  it  was  well  marked. 

Shortness  of  breath  is  almost  always  noticeable,  especially  on 
exertion,  where  there  is  any  cyanosis,  but  it  is  surprising  how 
little  the  shortness  of  breath  sometimes  is  where  the  child  is 
extremely  blue  ;  many  of  these  '  blue  children  '  seem  perfectly 
comfortable  and  easy  in  their  respiration  so  long  as  they  are 
sitting  quietly.  Evidently  there  is  some  compensatory  arrange- 
ment ;  I  suspect  that  this  is  to  be  found  in  the  state  of  the 
blood.  The  ingress  of  blood  to  the  lungs  is  hindered  usually  by 
the  cardiac  malformation,  especially  by  pulmonary  stenosis,  and 
under  ordinary  conditions  of  the  blood  the  number  of  red 
corpuscles  able  to  reach  the  lung  to  take  up  oxygen  at  each 
inspiration  would  be  comparatively  small  ;  but  if  in  a  given 
bulk  of  blood  the  number  of  corpuscles  were  increased,  the 
amount  of  oxygen  which  could  be  taken  up  would  be  greater. 
Some  such  compensatory  purpose  I  imagine  underlies  the 
remarkable  polycythaemia  which  is  to  be  found  in  these  cases 
with  extreme  cyanosis. 

In  a  boy,  George  R.,  aged  four  years,  with  very  marked 
cyanosis  of  lips  and  cheeks  and  clubbing  of  the  ringers  and  toes, 
whose  heart  showed  a  loud  rough  systolic  bruit  all  over  the 
prsecordium  and  over  the  left  back,  with  its  maximum  intensity 
in  the  left  third  intercostal  space,  the  blood  showed  9,280,000 
red  corpuscles  and  white  corpuscles  9,200  per  cubic  millimetre, 
haemoglobin  160  per  cent.,  and  Colour  Index  0-9. 

The  illustration  (Fig.  36)  shows  two  capillary  tubes  which  were 
almost  filled  with  blood  (A)  from  this  boy,  and  (B)  from  a  normal 
person  to  serve  for  comparison.  The  lower  dark  part  is  blood- 


CONGENITAL  HEART  DISEASE 


539 


clot,  the  upper  part  is  clear  serum.     I  am  indebted  to  Dr.  D'Este 
Emery  for  this  preparation,  which  shows  in  a  graphic  way  the 
much  larger  amount  of  blood-clot  due  to  the  excess  of  red  blood 
corpuscles  in  the  cyanotic  case  of  congenital 
heart  disease. 

Interference  with  the  circulation  means  inter- 
ference with  nutrition,  and  dating  as  it  does  from 
birth  it  is  hardly  surprising  that  the  circulatory 
difficulty  of  congenital  heart  disease  is  asso- 
ciated with  various  manifestations  of  poor 
nutrition.  Most  infants  with  congenital  heart 
disease  are  puny  and  small  and  many  remain 
undersized  delicate  children  as  they  grow  older; 
no  doubt  this  malnutrition  is  most  marked  in 
the  cases  in  which  there  is  cyanosis,  but  I  wish 
specially  to  emphasize  the  fact  that  where 
there  is  not  the  leaden  blueness  nor  shortness 
of  breath,  nor  any  other  symptom  specially 
indicating  affection  of  the  heart,  failure  to  thrive 
and  actual  marasmus  may  nevertheless  be  the 
result  of  congenital  heart  disease. 

I  have  frequently  had  infants  brought  to  me 
solely  for  wasting  or  for  not  thriving,  where 
routine  examination  of  the  chest  discovered 
the  presence  of  a  loud  bruit  over  the  heart.  In 
some  of  these  cases  it  had  been  assumed  that 
the  cause  of  the  wasting  was  simply  digestive 
difficulty,  and  food  after  food  had  been  tried 
in  a  vain  endeavour  to  overcome  the  difficulty. 
There  are  times  when  the  recognition  of  con- 
genital heart  disease  as  a  cause  of  marasmus 
may  be  important,  for  it  may  prevent  unneces- 
sary weaning  and  unwise  changes  from  food 
to  food ;  moreover,  it  is  a  satisfaction  to  parents 
as  well  as  to  doctor  to  have  a  definite  explana- 
tion of  the  failure  to  thrive. 

In  cases  with  cyanosis  there  is  often  a  further 
indication  of  the  interference  with  nutrition  in 
the  curious  condition  of  the  skin  and  hair  :  the 
skin  looks  and  feels  abnormally  thin,  trans- 
parent, and  glossy,  the  network  of  veins  shows 
too  conspicuously  through  it,  the  hair  is  remarkably  soft  and  fino 
and  silky. 


A       B 

FIG.  36.  Blood  (A) 
from  congenital 
heart  disease  with 
cyanosis,  showing 
clot  greater  than  in 
(B)  normal  blood. 


540  COMMON  DISORDERS  OF  CHILDHOOD 

Signs.  In  determining  the  presence  of  congenital  heart 
disease  it  is  all -important  to  locate  carefully  the  maximum 
intensity  of  the  bruit.  Mistakes  are  frequently  made  through 
lack  of  care  in  this  respect  :  a  systolic  bruit  is  heard  on  listening 
at  the  apex  in  a  child  of  perhaps  seven  or  eight  years,  and  we  are 
so  accustomed  to  associate  a  bruit  in  this  position  with  mitral 
disease  due  to  rheumatism,  that,  without  more  than  a  per- 
functory auscultation  of  the  rest  of  the  heart,  the  case  is  labelled 
mitral  regurgitation.  Had  we  listened  more  critically  we  should 
have  found  that  the  bruit  was  better  heard  over  the  inner  end  of 
the  fourth  intercostal  space  close  to  the  sternum,  or  perhaps 
was  louder  at  the  inner  end  of  the  second  or  third  left  space  ; 
a  systolic  bruit  alone,  heard  best  in  either  of  these  positions, 
is  almost  always  either  functional  or  due  to  congenital  heart 
disease,  it  is  not  due  to  any  acquired  endocarditis. 

This  is  the  most  distinguishing  feature  of  the  bruit  of  congenital 
heart  disease,  that  even  though  it  may  be  heard  well  all  over 
the  prsecordium,  it  is  heard  loudest  in  a  position  which  would 
be  quite  unusual  for  the  bruit  of  rheumatic  endocarditis. 

The  quality  of  the  bruit  is  not  much  to  be  depended  upon  ; 
a  very  loud  rasping  or  roaring  bruit  at  the  base,  or  over  the 
mid-prsecordium,  usually  suggests  congenital  heart  affection, 
but  bruits  quite  as  harsh  and  loud  at  the  apex  may  be  heard 
with  acquired  heart  disease.  Often  the  bruit  of  congenital 
heart  disease  is  so  small  that  it  is  only  to  be  heard  on  careful 
auscultation. 

The  presence  of  a  thrill,  like  that  of  a  bruit,  is  only  characteristic 
in  so  far  as  it  occurs  in  a  position  which  would  be  unusual  in 
acquired  endocarditis  :  with  ordinary  rheumatic  mitral  disease 
the  thrill  is  usually  very  limited  at  the  apex ;  with  aortic  disease 
there  is  rarely  any  thrill,  and  when  present  it  is  usually  felt  only 
in  the  second  or  third  right  space  ;  therefore  when  a  systolic 
thrill  is  felt  in  the  epigastric  angle,  or  over  the  pulmonary  area, 
it  would  accord  best  with  congenital  affection. 

I  have  spoken  of  the  bruit  of  congenital  heart  disease  as  if  it 
were  a  necessary  sign  :  some  of  the  most  striking  cases,  so  far 
as  facial  diagnosis  is  concerned,  show  no  bruit  at  all.  The  child 
comes  with  intense  cyanosis,  the  lips  almost  black,  the  cheeks 
deep  purple,  the  tongue  livid,  and  the  conjunctival  vessels 
engorged,  his  ringers  are  almost  spoon-like  in  their  clubbing, 
and  one  listens  to  the  heart  expecting  to  hear  a  loud  roaring 
bruit  ;  there  is  no  bruit  whatever,  the  heart  sounds  are  absolutely 
normal.  These  cases  are  rare.  I  met  with  four  in  a  series  of 


CONGENITAL  HEART  DISEASE  541 

1 14  consecutive  cases  of  congenital  heart  disease  :  post  mortem 
examination  has  shown  pulmonary  atresia,  that  is,  complete 
obliteration  of  the  pulmonary  orifice. 

Another  congenital  abnormality  which  is  sometimes  found 
post  mortem  where  there  has  been  no  bruit  is  fusion  of  the  aortic 
valves  so  that  there  are  only  two,  one  of  which  is  much  larger 
than  the  other  ;  if  the  fusion  is  more  general,  making  a  cone- 
shaped  opening,  there  may  be  a  systolic  bruit  in  the  aortic  area  ; 
with  this  malformation  there  is  no  cyanosis,  so  that  if  no  bruit 
is  produced  it  is  not  recognizable  during  life. 

It  might  be  thought  that  the  bruit  of  congenital  heart  disease 
being  due  to  a  malformation  would  undergo  no  change.  I  have 
mentioned  incidentally  in  the  case  of  Reginald  B.  (p.  537)  a  change 
from  a  loud  systolic  bruit  at  ten  months  old  to  a  very  small  one 
at  7  J  years :  in  that  same  case,  a  year  later,  when  acute  tonsillitis 
occurred  and  the  boy  was  acutely  ill,  I  could  hear  no  bruit  what- 
ever after  careful  listening.  I  did  not  see  the  boy  again,  but  it  is 
probable  that  when  the  acute  illness  subsided  the  bruit  might 
have  been  heard  again. 

I  have  noticed  a  similarly  marked  diminution  of  the  bruit 
just  before  death,  no  doubt  a  result  of  the  enfeeblement  of 
the  heart's  action.  In  addition  to  a  bruit  the  heart  sometimes 
shows  definite  dilatation,  but  this  is  much  less  marked  than 
in  rheumatic  endocarditis,  and  I  am  inclined  to  lay  some  stress 
upon  this  disproportion  between  the  loudness  and  extent  of 
the  bruit  and  the  slightness  or  absence  of  cardiac  enlargement 
as  a  point  of  distinction  between  congenital  and  rheumatic 
heart  disease. 

Diagnosis.  The  diagnosis  of  congenital  heart  disease  from 
rheumatic  endocarditis  depends  not  only  on  the  character  of 
the  bruit  but  sometimes  also  on  the  age  of  the  child.  It  is  to  be 
remembered  that  rheumatic  heart  disease  is  practically  unknown 
under  the  age  of  two  years,  and  therefore  can  be  excluded  in  an 
infant.  The  only  cause  for  acquired  endocarditis  in  infancy  is 
pyaemia  or  pneumococcal  infection  producing  an  infective  endo- 
carditis ;  this,  however,  is  extremely  rare,  and  when  it  occurs 
is  associated  almost,  if  not  quite,  invariably  with  an  obvious 
primary  focus,  such  as  empyema  or  suppurative  epiphysitis. 
One  may  say,  therefore,  that  a  bruit  in  infancy  usually  means 
congenital  heart  disease.  I  say  '  usually  '  because  there  are 
cases  which  suggest  that  some  bruits,  even  loud  ones,  heard  in 
infancy,  may  be  of  functional  origin,  and  therefore  we  should 
be  cautious  how  we  conclude  that  a  bruit  is  due  to  congenital 


542  COMMON  DISORDERS  OF  CHILDHOOD 

heart  disease  simply  because  it  is  heard  in  an  infant.    The  follow- 
ing cases  may  illustrate  the  difficulty  of  diagnosis. 

Henry  H.  was  brought  to  hospital  at  the  age  of  eighteen  months  for  wasting 
and  convulsions ;  there  was  a  loud  blowing  systolic  murmur  below  the  nipple 
and  some  added  unusual  sound  of  uncertain  nature ;  no  doubt  was  entertained 
that  there  was  an  organic  heart  affection,  and  the  age  clearly  pointed  to  its 
being  congenital.  Eighteen  months  later  the  boy  came  again  for  some  cough  ; 
he  was  thin  and  pale,  there  was  no  cyanosis,  and  I  think  never  had  been  ; 
there  was  no  trace  of  any  bruit,  there  was  not  even  any  thickness  of  the  heart 
sounds. 

Charles  N.,  the  son  of  a  medical  man,  was  found  at  the  age  of  three  months 
to  have  a  loud  systolic  bruit  over  the  mid-prsecordium ;  there  was  no  cyanosis, 
but  the  boy  was  not  thriving,  and  he  was  seen  by  two  physicians  of  large 
experience,  who  concluded  he  had  congenital  heart  disease.  Four  years  later 
there  was  no  bruit  whatever,  the  first  sound  in  the  pulmonary  area  was  some- 
times rather  thick,  but  sometimes  even  this  was  hardly  noticeable. 

Was  there  a  mistake  in  the  diagnosis  in  these  cases  ?  or  is  it 
conceivable  that  the  contractions  of  the  several  cavities  of  the 
heart  became  so  nicely  adjusted  as  to  diminish  the  flow  of  blood 
over  a  patent  septum  ventriculorum,  or  through  a  narrowed  pul- 
monary orifice,  so  that  although  the  deformity  persisted  the 
bruit  disappeared  ?  I  know  not ;  but  certainly  the  following  case 
suggests  that  error  in  diagnosis  is  at  least  possible  where  a  loud 
bruit  is  present  in  infancy. 

Louisa  K.,  aged  ten  months,  had  always  been  delicate;  she  had  had  diarrhoea 
for  three  weeks,  of  which  she  died.  I  saw  her  during  life  and  found  a  '  whistling 
systolic  bruit  heard  all  over  prsecordium,  loudest  just  to  left  of  lower  end  of 
sternum  and  in  epigastric  notch  :  no  thrill '.  The  lips  were  pale,  and  perhaps 
slightly  livid,  but  otherwise  there  was  no  cyanosis.  I  had  diagnosed  congenital 
heart  disease  without  hesitation,  and  was  much  surprised  when  post  mortem 
examination  showed  no  malformation  of  any  sort  in  the  heart,  the  foramen 
ovale  and  the  ductus  arteriosus  were  closed,  the  valves  were  normal,  the  only 
suggestion  of  an  abnormality  was  a  rather  deep  depression  in  '  the  undefended 
space'  at  the  upper  part  of  the  ventricular  septum  viewed  from  the  left 
ventricle,  but  it  did  not  amount  to  a  sac,  and  one  could  hardly  be  sure  that 
this  would  account  for  a  bruit. 

Iti  later  childhood  certainly  it  is  necessary  to  recognize  the 
occurrence  of  functional  bruits,  particularly  the  twanging  systolic 
bruit,  which  is  usually  best  heard  about  halfway  between  the 
l-3ft  margin  of  the  sternum  and  the  left  nipple  line  in  the  fifth 
space  or  thereabouts.  I  have  described  this  elsewhere  as  the 
'physiological  bruit'.  I  know  not  what  its  significance  maybe, 
but  I  think  it  is  clearly  functional,  and  it  should  not  be  confused 
with  congenital  heart  disease. 

A  point  which  must  carry  some  weight  where  a  bruit  is  present 
of  doubtful  origin  is  the  presence  of  other  congenital  malforma- 


CONGENITAL  HEART  DISEASE  543 

tions,  for  as  I  have  already  mentioned  there  is  a  tendency  for 
congenital  heart  disease  to  be  associated  with  other  congenital 
abnormalities. 

Is  it  possible  to  diagnose  the  particular  malformation  or  lesion 
which  is  present  ?  I  doubt  if  we  can  do  more  than  guess  in  most 
cases,  sometimes  not  even  that,  for  the  varieties  of  malformation 
are  so  many  and  their  combinations  so  various  that  physical  signs 
will  not  suffice  for  their  certain  diagnosis  ;  but  none  the  less 
there  are  indications  by  which  in  some  cases  we  may  form  an 
opinion  as  to  the  particular  deformity,  and,  as  I  have  proved 
by  post  mortem  examination,  correctly. 

In  the  first  place  it  is  to  be  remembered  that  the  commonest 
of  all  malformations  according  to  post  mortem  evidence  is  patent 
septum  ventriculorum,  and  I  think  it  is  highly  probable,  if  we 
may  judge  from  the  rather  shaky  evidence  of  clinical  experience, 
that  this  is  even  more  frequent  in  comparison  with  other  mal- 
formations than  post  mortem  figures  show  ;  in  the  second  place, 
that  pulmonary  stenosis  is  the  next  in  order  of  frequency,  and 
that  it  is  frequently  associated  with  patent  septum  ventriculorum. 
One  or  other  of  these  deformities,  or  both,  will  be  present  in  the 
large  majority  of  cases  in  wrhich  there  are  signs  of  congenital 
heart  disease  ;  the  aortic  abnormalities  which  come  next  in 
order  of  post  mortem  frequency  seldom  produce  any  signs  cr 
symptoms  during  life. 

When  either  pulmonary  stenosis  or  patent  septum  ventri- 
culorum occurs  alone  it  gives  rise  to  a  bruit  which  may  be  heard 
over  a  large  part  or  the  whole  of  the  prsecordium,  but  has  its 
maximum  intensity  in  a  well-defined  area  ;  the  former  in  the 
second  left  space  or  over  the  third  left  costal  cartilage,  close  to 
the  left  edge  of  the  sternum,  the  latter  lower  down  over  the 
fourth  left  space  or  adjoining  costal  cartilages  close  to  the  left 
edge  of  the  sternum. 

There  are  further  points  of  distinction  between  these  two 
deformities  :  pulmonary  stenosis  is  often,  but  not  always, 
associated  with  a  thrill,  its  murmur  is  usually  harsh  and  rough, 
and  it  gives  rise  to  more  or  less  cyanosis  ;  patent  septum  ventri- 
culorum usually  produces  a  small  blowing  bruit,  no  thrill,  and 
does  not  cause  cyanosis. 

Occasionally  there  is  good  ground  for  suspecting  the  combina- 
tion of  both  these  deformities,  where  with  more  or  less  cyanosis 
and  generalized  systolic  bruit  there  are  two  separate  points  of 
maximum  intensity  in  the  areas  I  have  mentioned. 

There  is  at    least   one   other    malformation  which  produces 


544  COMMON  DISORDERS  OF  CHILDHOOD 

a  characteristic  bruit,  namely,  patent  ductus  arteriosus.  The  bruit 
is  peculiar  in  not  being  strictly  systolic  or  diastolic,it  seems  to  run 
partly  or  entirely  through  both  cycles,  only  being  increased  during 
systole  ;  it  is  increased  also  by  inspiration.  It  has  usually  a  well 
localized  point  of  maximum  intensity  about  1  inch  to  the  left  of 
the  left  margin  of  the  sternum  in  the  third  left  intercostal  space. 

The  only  other  congenital  malformation  which  can,  I  think,  be 
surmised  from  clinical  signs  is  aortic  stenosis  due  to  more  or 
less  fusion  of  valves,  which  produces  a  rough  systolic  bruit  in 
the  second  right  space.  It  is  remarkable  how  extremely  rare  is 
congenital  affection  of  the  mitral  valve,  and  corresponding 
therewith  is  the  rarity  of  an  apical  bruit  in  congenital  heart 
disease  ;  a  bruit  is  often,  it  is  true,  to  be  heard  at  the  apex 
when  it  is  heard  over  the  rest  of  the  prsecordium,  but  careful 
auscultation  will  almost  always  show  that  the  maximum  intensity 
of  the  bruit  is  not  at  the  apex,  but  at  a  higher  level  or  much 
nearer  to  the  left  edge  of  the  sternum. 

And  here  I  venture  again  to  insist  upon  the  importance  of 
localizing  carefully  the  point  of  maximum  intensity  of  cardiac 
murmurs.  It  may  be  admitted  that  there  is  little  practical  value 
to  be  attached  at  present  to  our  clinical  diagnosis  of  the  different 
varieties  of  cardiac  malformation.  I  have  given  my  own  observa- 
tions for  what  they  are  worth,  they  are  based  on  a  comparison 
of  clinical  with  post  mortem  findings  ;  but  whether  we  can  dis- 
tinguish the  different  malformations  or  not,  it  is  valuable  to 
know  that  when  a  bruit  has  its  maximum  in  such  and  such 
a  position  it  is  due  to  congenital  heart  disease  and  not  to  any 
rheumatic  endocarditis,  and  this  much  at  least  we  may  learn 
from  careful  localizing  of  the  bruit. 

There  are  rare  instances  in  which  the  most  careful  auscultation 
will  fail  to  differentiate  between  congenital  malformation  and 
rheumatic  endocarditis.  In  such  cases  the  only  criterion  may 
be  the  age  at  which  the  bruit  was  first  noticed,  e.g.  John  M., 
aged  nine  years,  was  brought  to  me  at  the  Children's  Hospital, 
Great  Ormond  Street,  for  enuresis.  He  had  dark  auburn  hair 
of  the  colour  which  to  my  mind  is  always  suggestive  of  rheuma- 
tism. On  auscultation  I  found  a  soft  blowing  systolic  bruit,  best 
heard  at  the  apex  just  below  and  under  the  left  nipple  ;  it  could 
be  traced  inwards  as  far  as  the  left  margin  of  the  sternum  ;  it  was 
not  heard  above  the  level  of  the  nipple.  It  might  well  have 
passed  for  the  ordinary  bruit  of  mitral  regurgitation  due  to 
rheumatic  endocarditis,  but  I  found  that  I  had  seen  the  boy  at 
King's  College  Hospital  at  the  age  of  six  weeks,  and  that  the 


CONGENITAL  HEART  DISEASE  545 

bruit  was  present  at  that  time,  so  that  there  could  be  no  doubt 
it  was  congenital. 

Such  cases  are,  in  my  experience,  very  exceptional. 

Prognosis.  Congenital  heart  disease  considerably  diminishes 
a  child's  chance  of  long  life  ;  it  is  difficult  to  ascertain  what 
proportion  reach  adult  years,  but  it  is  quite  certain  that  it  is 
a  very  small  one.  Of  the  series  of  44  fatal  cases  mentioned  above, 
41  were  under  five  years  of  age,  and  as  these  figures  were  taken 
from  the  Children's  Hospital,  Great  Ormond  Street,  at  which 
children  are  admitted  up  to  the  age  of  twelve,  it  seems  probable 
that  the  majority  die  under  the  age  of  five  years.  Out  of  100  con- 
secutive cases  under  clinical  observation  for  a  longer  or  shorter 
time,  77  were  under  five  years  of  age,  8  were  surviving  at  the  age 
of  five  to  six,  7  at  seven  years,  1  at  eight  years,  5  at  nine  years, 
2  at  eleven  years.  One  of  those  who  had  reached  six  years  and 
one  who  had  reached  seven  years,  both  with  deep  cyanosis, 
already  showed  symptoms  of  cardiac  failure,  so  that  they  probably 
did  not  live  much  longer,  but  the  rest  passed  out  of  observation 
without  any  indication  of  speedy  death. 

I  think  that  as  a  general  rule  the  prognosis  is  bad  in  direct 
proportion  to  the  cyanosis.  I  am  well  aware  that  some  cases 
with  most  severe  cyanosis  survive  even  to  adult  life,  but  I  think 
that  the  tendency  to  respiratory  complications,  especially  bron- 
chitis and  broncho-pneumonia,  and  to  gradual  failure  of  the  right 
side  of  the  heart,  is  decidedly  greater  in  these  cases  than  in  those 
in  which  there  is  little  or  no  cyanosis.  The  cyanotic  cases  seem 
also  to  be  specially  prone  to  certain  attacks  in  infancy,  which 
I  am  inclined  to  regard  as  anginoid.  I  have  seen  them  in  several 
instances.  The  usual  history  is  that  two  or  three  times  a  day, 
usually  just  after  a  meal,  the  infant  suddenly  becomes  intensely 
distressed,  as  if  in  acute  pain,  fighting  for  its  breath,  and  turning 
more  and  more  deeply  cyanotic  ;  after  a  minute  or  two  the 
attack  passes  off,  leaving  the  child  pale  and  collapsed. 

I  do  not  think  that  I  have  ever  known  an  infant  to  die  in  one  of 
these  attacks,  but  death  has  usually  occurred  within  a  few  weeks 
or  months.  I  imagine  that  the  accumulation  of  gas  or  food  in  the 
stomach  presses  on  the  diaphragm  and  so  hampers  the  already 
labouring  right  heart,  and  that  a  sudden  spasmodic  effort  of  the 
over-distended  right  side  occurs  and  produces  these  anginoid 
symptoms. 

Occasionally  without  any  evidence  of  pain  attacks  of  urgent 
dyspnoea  occur,  which  may  even  lead  to  convulsions. 

There  is  a  great  tendency  to  bronchitis  and  broncho-pneumonia, 
STILL  N  n 


546  COMMON  DISORDERS  OF  CHILDHOOD 

and  the  risk  from  them  is  always  grave,  for  they  throw  additional 
strain  upon  the  right  side  of  the  heart,  which  is  usually  already 
scarcely  able  to  cope  with  the  strain  thrown  upon  it  by  the 
abnormal  cardiac  condition.  I  have  specially  noticed  how  badly 
cases  of  congenital  heart  disease  with  any  degree  of  cyanosis  stand 
whooping-cough ;  the  cardiac  dullness  gradually  extends  further  to 
the  right,  and  I  have  seen  oedema  supervene  with  symptoms  very 
like  those  of  failing  compensation  in  rheumatic  heart  disease. 

With  or  without  cyanosis  the  infant  with  congenital  heart 
disease  tends  to  be  puny  and  feeble,  and  like  all  such  ill- 
nourished  infants  falls  an  easy  prey  to  any  acute  illness,  for 
instance,  to  gastro-enteritis.  Occasionally  without  any  apparent 
cause  death  comes  quite  suddenly.  I  have  known  this  to  happen 
where  there  was  no  trace  of  cyanosis  ;  one  infant  who  died  thus 
I  had  seen  on  the  previous  day,  when  I  had  specially  remarked 
upon  the  child's  healthy  appearance  and  good  colour. 

Lastly,  I  must  mention  the  possibility  of  endocarditis  attack- 
ing a  congenitally  malformed  heart.  I  have  known  this  to 
happen  ;  it  is,  of  course,  a  mere  coincidence,  and  only  happens 
when  the  child  is  old  enough  to  be  liable  to  rheumatism,  or  has 
some  infective  condition  which  might  cause  malignant  endo- 
carditis ;  but  the  possibility  is  worth  remembering,  for  when 
it  does  occur  it  may  lead  to  most  perplexing  physical  signs. 

Treatment.  One  might  suppose  that  congenital  heart  disease 
was  beyond  the  range  of  treatment  ;  but  the  function  of  the 
medical  man  is  not  merely  to  prescribe  drugs,  it  is  to  advise  on 
all  that  concerns  health,  and  in  the  case  of  congenital  heart 
disease  there  are  many  points  upon  which  he  may  be  called  to 
advise.  In  the  first  place,  whilst  the  parents  are  to  be  warned 
of  the  precarious  tenure  of  life  in  these  cases,  they  are  also  to  be 
encouraged  in  the  hope  that  with  care  the  child's  life  may  be 
prolonged  for  years,  perhaps  to  adult  life.  The  more  painstaking 
and  intelligent  the  care  devoted  to  these  children,  the  longer  they 
are  likely  to  live.  I  have  seen  children  in  well-to-do  families  live 
on  for  years  with  congenital  heart  disease  which  would  probably 
have  ended  fatally  at  a  much  earlier  date  had  the  child  been  born 
in  circumstances  where  time  and  money  could  not  be  spent  so 
freely  on  its  care. 

From  infancy  upwards  these  children  require  most  careful 
protection  from  cold  :  an  indiscreet  outing  in  the  perambulator 
on  a  cold,  damp,  foggy  day  may  be  the  beginning  of  the  end  ; 
exposure  to  a  sharp  east  wind  may  start  a  bronchial  catarrh. 
Even  apart  from  the  risk  of  bronchitis  the  child  with  congenital 


CONGENITAL  HEART  DISEASE  547 

heart  disease  stands  exposure  and  chill  badly.  I  have  more  than 
once  been  told  that  these  children  turned  very  blue  or  went  pale 
when  bathed,  and  I  think  that  when  this  happens  it  is  wise  to  forbid 
bathing  and  allow  only  a  small  part  of  the  body  to  be  sponged 
each  day.  The  clothing  is  to  be  warm :  the  underclothing  should 
be  flannel,  and  the  arms  and  legs  are  to  be  warmly  covered. 

It  is  important  to  secure  the  most  easily  digestible  diet  in 
infancy,  not  only  on  account  of  the  special  tendency  to  mal- 
nutrition and  marasmus  with  congenital  heart  disease,  but  also 
because  there  is  a  risk  of  the  sudden  anginoid  attacks,  to  which 
I  have  alluded,  if  any  flatulence  accumulates  in  the  stomach. 
The  value  of  breast-feeding  is  to  be  insisted  upon,  and  if  the 
mother's  milk  fail,  it  may  be  advisable  to  use  a  wet-nurse  ;  other- 
wise I  have  found  peptonized  milk  most  useful  in  these  cases. 

As  the  child  grows  older  the  question  of  education  will  arise, 
and  it  is,  I  think,  clear  that  school  is  wholly  unadvi sable  ;  the 
likelihood  of  careless  exposure  to  damp  and  cold  and  of  physical 
over-exertion  is  too  great  to  be  risked,  no  child  can  be  trusted 
to  take  care  of  himself  in  these  respects  ;  the  child  with  congenital 
heart  disease  should  be  educated  at  home. 

It  is  particularly  important  that  the  child  with  congenital 
heart  disease  should  be  trained  from  earliest  years  to  lie  down, 
and,  if  possible,  sleep,  for  an  hour  or  so  at  midday.  Such  a  habit 
formed  in  infancy  can  be  continued  throughout  the  greater  part 
of  childhood,  and  is  an  asset  of  no  small  importance  when  the 
balance  of  compensation  is  being  maintained  with  difficulty  by 
a  heart  in  which  congenital  deformity  throws  an  unnatural  strain 
upon  the  weaker  portions  of  the  heart  muscle. 

The  slightest  '  cold  '  or  '  cough  '  is  never  to  be  disregarded  in 
these  children  :  a  little  timely  care,  confinement  to  one  room 
for  a  day  or  two,  the  use  of  a  counter-irritant  to  the  chest,  the 
early  administration  of  some  saline  expectorant  and  of  an 
aperient,  may  save  from  the  bronchitis  which  is  so  dangerous 
in  the  congenital  heart  affection. 

But  there  are  times  when  drugs  are  useful  and  necessary.  In 
the  anginoid  attacks  which  I  have  described  in  infants,  inhalation 
of  amyl  nitrite  should  be  given  ;  1  minim  capsules  can  be 
obtained  and  the  mother  may  keep  these  handy  for  use  when 
required.  Carminatives  are,  I  think,  of  value  to  prevent  these 
attacks  ;  a  mixture  of  Sodium  Bicarb,  gr.  ij,  Tinct.  Carminativa 
(B.P.C.)  tt)j,  Spirit.  Chloroformi  O)j,  Glycer.  O)v,  Aq.  Anethi  ad  3j, 
immediately  after  food,  may  be  given  three  or  four  times  a  day. 

For  the  symptoms  of  failing  compensation,  which  sooner  or 

N  n  2 


548  COMMON  DISORDERS  OF  CHILDHOOD 

later  appear  in  some  of  the  cases  with  over-distended  right  heart, 
the  treatment  must  be  upon  the  lines  laid  down  in  the  chapter 
on  rheumatic  heart  disease  :  leeching,  followed  by  digitalis  and 
nux  vomica,  will  improve  the  child  for  a  time  ;  but  usually  the 
relief  is  only  temporary,  as  the  cause  must  necessarily  remain 
unalterable.  The  time  at  which  such  symptoms  may  supervene 
is  very  variable  ;  in  one  case  it  was  at  twenty  months,  in  another 
at  six  vears,  in  another  at  seven  and  a  half. 


CHAPTER  XXXVIII 
NEPHRITIS  IN  CHILDREN 

NEPHRITIS  is  not  specially  a  disease  of  children,  but  it  is  not 
uncommon  in  childhood,  and  when  it  occurs  at  this  age  often 
raises  questions  of  prognosis  and  sometimes  of  diagnosis  which 
re.fer  specially  to  this  particular  period  of  life. 

There  is  no  age  at  which  nephritis  may  not  occur  ;  amongst 
100  cases  in  children  under  the  age  of  fourteen  years  who  were 
under  my  own  observation  one  was  an  infant  of  eight  weeks 
who  had  first  shown  symptoms  of  nephritis  at  six  weeks ; 
another  had  shown  dropsy  at  the  age  of  five  days  and  died  at 
ab\>ut  nine  weeks  ;  post  mortem  showed  acute  nephritis.  The 
late  Dr.  Ashby  recorded  a  case  of  nephritis,  in  which  dropsy 
appeared  on  the  second  day  after  birth  and  the  infant  died  with 
uraemia  a  few  weeks  later. 

Even  chronic  interstitial  nephritis,  rare  as  it  is  at  any  period 
of  childhood,  has  occurred  as  early  as  the  fifth  year  (Guthrie). 
Four  of  my  100  cases  were  probably  of  this  variety. 

There  seems  to  be  no  special  sex -incidence,  52  were  girls, 
48  were  boys.  Probably  the  commonest  cause  of  nephritis  in 
children  is  scarlet  fever,  but  nowadays,  owing  to  the  transference 
of  most  cases  of  this  disease  at  an  early  stage  to  the  fever 
hospitals,  the  physician  at  a  general  hospital  is  not  likely  to  see 
many  cases  of  nephritis  due  to  this  cause  unless  the  renal  affection 
persists  after  the  patient  is  discharged  from  the  fever  hospital. 
My  own  figures  show  that  such  persistence  is  probably  excep- 
tional ;  amongst  the  100  cases  of  nephritis  only  22  were  probably 
due  to  scarlet  fever  ;  most  of  these  scarlatinal  cases  were  seen 
in  the  chronic  stage.  This  infrequency  of  chronic  or  subacute 
cases  of  scarlatinal  nephritis  amongst  the  children  seen  at  general 
hospitals  is  confirmed  by  the  statistics  of  the  fever  hospitals, 
which  show  that  the  majority  of  cases  with  nephritis  recover 
entirely  from  their  renal  symptoms  before  leaving  the  hospital. 

Apart  from  scarlet  fever  there  are  many  causes  for  nephritis 
in  children,  but  my  own  experience  has  been  that  in  the  majority 
of  these  non-scarlatinal  cases  the  disease  begins  without  any 
assignable  cause.  Possibly  cold  and  exposure  may  play  some 
part  in  determining  the  oncct  of  this  unexplained  nephritis,  but 


550  COMMON  DISORDERS  OF  CHILDHOOD 

it  seems  more  probable  that  the  essential  cause  is  bacterial. 
This,  however,  has  not  been  demonstrated,  and  at  present  we 
can  only  recognize  that  there  is  a  large  group  of  cases  in  which 
the  nephritis  of  childhood  is  apparently  primary  and  '  idiopathic ' 
in  the  sense  that  we  do  not  know  its  cause. 

Almost  all  the  specific  fevers  are  occasionally  complicated  by 
nephritis.  Henoch  states  that  he  saw  three  cases  of  nephritis 
beginning  during  measles  ;  amongst  my  cases  there  were  only 
two  in  which  the  close  time  relation  made  it  probable  that  the 
nephritis  was  due  to  measles,  but  in  one  of  these  there  was  also 
whooping-cough,  which  is  an  occasional  cause  of  nephritis. 
Amongst  a  very  large  number  of  children  with  whooping-cough 
I  have  only  once  seen  nephritis  as  a  complication,  unless  the 
case  just  mentioned  was  to  be  regarded  as  due  to  this  cause. 

Varicella  seemed  to  be  the  cause  of  nephritis  in  a  girl  aged 
5 1  years  who.  about  a  week  after  the  rash  appeared,  became 
cedematous  with  much  albuminuria  and  blood  in  the  urine'. 
Henoch  recorded  three  cases  in  which  the  nephritis  began  eight 
to  fourteen  days  after  varicella. 

Mumps  I  have  once  known  to  be  followed  by  nephritis.  I 
have  not  seen  any  case  after  rothem. 

Influenza  was  followed  immediately  by  acute  nephritis  in 
a  girl  of  thirteen  years  :  three  other  persons  in  the  house  had 
had  influenza  within  a  few  days  before  this  child  contracted  it  ; 
none  of  these,  however,  had  nephritis. 

I  saw  with  Dr.  Gundlach,  of  Clapton,  a  girl  aged  13J  years, 
who  within  four  days  after  the  onset  of  a  severe  follicular 
tonsillitis  developed  a  very  acute  nephritis  which  proved  fatal 
in  a  few  days  ;  there  was  nothing  to  suggest  either  scarlet  fever 
or  diphtheria. 

Diphtheria,  though  it  very  commonly  causes  albuminuria,  has 
rarely  been  a  cause  of  nephritis  in  my  experience,  only  one  out 
of  the  100  cases  was  due  to  it. 

Twice  I  have  seen  lobar  pneumonia  complicated  by  acute 
nephritis  (p.  378). 

Congenital  syphilis  is  a  recognized  cause  of  acute  nephritis, 
especially  in  early  infancy  ;  four  cases  have  been  under  my 
care,  the  youngest  was  aged  six  \veeks,  the  oldest  a  girl  of  nine 
years. 

There  was  one  case  in  my  series  that  raised  the  question 
whether  acute  rheumatism  may  not  be  an  occasional  cause  of 
nephritis.  It  was  a  girl  aged  six  years,  who  was  under  treatment 
for  chorea  and  was  found  unexpectedly  to  have  albumen  and 
blood  with  granular  and  epithelial  casts  in  the  urine  ;  she  had 


NEPHRITIS  651 

a  systolic  bruit  at  the  apex,  but  the  cardiac  condition  was  not 
such  as  to  cause  even  slight  albuminuria.  The  association  may 
have  been  a  coincidence,  but  in  view  of  the  strong  evidence  that 
rheumatism  is  an  infective  disease  it  would  be  quite  in  accor- 
dance with  what  we  know  of  other  infective  conditions  that  the 
kidney  should  sometimes  be  affected. 

Amongst  the  few  cases  of  malaria  in  childhood  which  have 
come  under  my  notice  none  have  had  nephritis,  but  Moncorvo, 
of  Rio,  recorded  eleven  cases  of  acute  nephritis  from  this  cause 
in  children,  and  Henoch  mentions  one  in  a  child  of  six  years. 

There  are  two  other  causes  which  though  rare  are  worthy  of 
mention  because  the  likelihood  of  nephritis  constitutes  the  chief 
danger  of  the  disease,  the  one  is  glandular  fever,  the  other  is 
Henoch's  purpura.  The  former  has  been  in  my  experience  an 
extremely  rare  condition,  but  out  of  three  cases  which  I  took 
to  be  glandular  fever,  with  pyrexia,  swollen  glands  in  the  neck 
and  nothing  abnormal  in  the  throat,  two  developed  nephritis 
about  ten  days  after  the  onset  of  the  illness.  The  nephritis 
which  complicates  Henoch's  purpura  has  been  a  very  severe 
hoemorrhagic  form  in  the  few  cases  which  I  have  seen. 

Symptoms  and  diagnosis.  In  the  primary  cases  of  nephritis 
the  onset  is  usually  quite  sudden ;  the  child  who  has  been  in 
perfect  health  up  to  that  time,  has  a  headache  one  day,  is 
drowsy  and  perhaps  vomits  and  has  some  looseness  of  the 
bowels,  within  a  few  hours  the  face  is  noticed  to  be  swollen  and 
the  urine  is  found  to  contain  blood  with  a  large  quantity  of 
albumen  and  some  casts.  In  the  nephritis  which  is  secondary  to 
one  of  the  specific  fevers  the  development  of  symptoms  is  often 
more  gradual. 

Usually  in  the  acute  stage  there  is  little  risk  of  overlooking 
a  nephritis  :  the  puffy  face  and  general  oedema  suggest  examina- 
tion of  the  urine,  which  confirms  the  diagnosis  ;  but  this  is  not 
always  so :  there  are  cases  in  which  the  facies  of  the  child  does 
not  give  the  least  suggestion  of  nephritis,  although  the  urine 
contains  a  large  amount  of  albumen  and  blood.  There  seems 
to  be  no  very  close  correspondence  between  the  amount  of  dropsy 
and  the  amount  of  albumen  in  the  urine.  I  had  under  my  care 
a  boy  of  seven  years  who,  for  several  weeks  after  an  attack  of 
nephritis,  became  very  cedematous  when  allowed  to  get  up, 
although  the  amount  of  albumen  at  that  time  was  only  a  slight  trace. 

When  the  acute  stage  is  over  and  the  albumen  has  diminished  to 
a  very  small  amount  there  is  often  nothing  in  the  appearance  of 
the  child  to  suggest  the  presence  of  nephritis,  and  if  the  child 
is  first  seen  at  this  stage  the  necessity  for  examination  of  the 


552  COMMON  DISORDERS  OF  CHILDHOOD 

urine  is  not  so  apparent  and  the  renal  condition  may  easily  be 
overlooked. 

I  had  under  my  care  for  some  years  a  child  who  at  the  age  of  2£  years  had 
general  dropsy  with  albuminuria,  haematuria,  and  casts  ;  at  the  age  of  6 
years  she  was  the  picture  of  health,  fat  and  rosy-cheeked.  But  every  now 
and  then  she  was  brought  to  me  for  severe  headaches,  which  recurred  for 
a  few  days,  and  called  for  the  free  use  of  some  saline  aperient.  I  do  not  think 
it  would  have  occurred  to  any  one  from  the  child's  appearance  that  these 
attacks  were  related  to  any  nephritis,  but  examination  of  the  urine  showed 
at  all  times  albumen,  though  sometimes  only  in  very  small  quantity  ;  and 
I  had  no  doubt  that  the  headaches  were  of  renal  origin. 

Even  examination  of  the  urine  may  mislead  in  this  chronic 
stage,  for  there  are  sometimes  intervals  of  hours  or  days  in  which 
the  urine  is  entirely  free  from  albumen. 

A  boy  of  9.y  years  was  under  my  observation  for  nearly  three  years  after 
an  attack  of  acute  nephritis.  At  times  his  face  was  slightly  puffy,  but  usually 
there  was  nothing  in  his  appearance  to  suggest  nephritis.  His  urine  on  some 
days  contained  no  albumen  and,  indeed,  appeared  to  be  normal  in  every  way, 
so  that  a  single  examination  might  have  led  to  the  conclusion  that  there  was 
no  nephritis  ;  but  repeated  examination  showed  that  albumen  was  seldom 
absent  for  more  than  a  few  days,  and  at  intervals  of  a  few  months  or  weeks 
it  increased  to  a  large  amount,  blood  and  casts  reappeared  in  the  urine,  and 
the  boy  quickly  became  acutely  ill  with  more  or  less  dropsy. 

This  temporary  absence  of  albuminuria  is  even  more  liable 
to  mislead  in  the  rare  cases  of  primary  chronic  interstitial 
nephritis  in  children,  for  here  there  may  be  nothing  in  the  pre- 
vious history  to  suggest  any  kidney  affection,  and  the  very  rarity 
of  sucli  a  condition  in  children  may  put  us  off  our  guard.  In 
a  boy  aged  eleven  years  who  was  brought  for  severe  headache, 
vomiting,  and  giddiness,  a  diagnosis  of  cerebral  tumour  seemed 
reasonable  after  the  urine  had  been  examined  and  showed  no 
albumen  ;  but  repeated  examination  showed  that  there  was 
often  a  very  small  amount  of  albumen  in  the  urine,  and  examina- 
tion of  the  eyes  showed  albuminuric  retinitis.  In  another  case, 
a  girl  aged  7J  years,  the  absence  of  albumen  or  its  extremely 
small  amount,  led  to  a  diagnosis  of  '  anajmia  and  debility  ', 
until  with  repeated  examinations  it  was  found  that  a  small 
amount  of  albumen  was  frequently  present,  and  that  in  this 
child  also  there  was  albuminuric  retinitis.  It  is  but  seldom, 
however,  that  any  assistance  in  the  diagnosis  of  nephritis  can 
be  obtained  from  examination  of  the  fundus  oculi  in  children. 
Albuminuric  retinitis  indeed  is  generally  considered  to  be  an  ex- 
treme rarity  in  childhood,  although  so  far  as  my  own  experience 
goes  it  would  seem  to  be  rather  the  rule  than  the  exception  in 
the  primary  chronic  interstitial  variety  of  nephritis  ;  four  such 


NEPHRITIS  553 

cases  have  come  under  my  observation  and  all  four  showed 
albuminuric  retinitis.  In  one  other  case,  a  boy  of  9J  years,  who 
died  five  months  after  the  onset  of  what  appeared  to  be  an 
acute  (non-scarlatinal)  nephritis,  there  was  retinal  haemorrhage 
and  some  swelling  of  the  retina  ;  autopsy  showed  that  the 
nephritis  was  of  the  '  large  white  kidney  '  variety. 

Whilst  puffiness  of  the  face  in  a  child  should  always  suggest 
the  advisability  of  testing  the  urine,  it  is  a  common  symptom 
of  other  conditions  beside  nephritis.  In  chronic  intestinal 
indigestion,  the  disorder  which  Dr.  Eustace  Smith  described  as 
1  mucous  disease  ',  there  is  often  noticeable  puffiness  of  the 
lower  eyelids  ;  a  similar  appearance  is  seen  with  cyclic  albu- 
minuria  and  a  more  general  puffiness  of  the  face  with  heart 
disease  and  whooping-cough. 

The  puffy  face  of  whooping-cough  is  generally  explained  at 
once  by  the  history  of  paroxysmal  cough  ;  it  is  only  where  it 
is  associated  with  hsematuria  or  albuminuria  that  doubt  may 
arise. 

A  girl  of  4£  years,  after  coughing  much  for  ten  days,  began  to  whoop 
violently  ;  four  days  later  when  I  saw  her  the  eyelids  were  puffy  and  I  was 
told  that  the  urine  had  been  bright  red  for  two  days  ;  but  the  colour  varied 
much  at  each  micturition — sometimes  the  urine  was  almost  clear.  I  examined 
the  urine  and  found  it  dark  reddish-brown,  sp.  gr.  1010,  with  some  oxalates 
and  other  crystals,  some  small  round  granular  cells,  and  a  few  doubtful  casts, 
some  granular  and  some  hyaline  with  blood-corpuscles  ;  two  days  later  there 
was  no  blood  in  the  urine  and  no  albumen  ;  it  was,  in  fact,  perfectly  normal. 
There  was  no  oedema,  except  in  the  face,  at  any  time. 

Here  the  sudden  onset  and  rapidly  transient  character  of 
the  urinary  disturbance  together  with  its  variation  from  hour 
to  hour,  showed  that  it  was  due  merely  to  a  passive  venous 
congestion,  differing  in  no  way  from  the  venous  engorgement 
which  gives  rise  to  the  oedema  in  the  eyelids  or  to  epistaxis  when 
the  paroxysms  of  whooping  are  severe.  And  one  may  suppose 
that  just  as  casts  may  be  present  in  the  urine  of  patients  in  whom 
heart  disease  and  failing  compensation  are  causing  venous 
engorgement  of  the  kidney,  so  also  in  whooping-cough  casts 
may  be  present  in  the  urine  when  the  congestion  is  sufficiently 
frequent  or  severe. 

I  have  twice  seen  in  infants  a  few  months  old  a  general 
dropsy  which  has  appeared  without  apparent  cause  and  exactly 
resembled  the  dropsy  of  acute  nephritis,  but  the  urine  therewith 
showed  no  albumen,  and  its  only  peculiarity  was  an  extremely 
low  specific  gravity  (1001-1004),  an  almost  complete  absence 
of  colour  and  a  scarcely  appreciable  percentage  of  urea  ;  the 
kidneys  in  a  case  which  I  examined  post  mortem  showed  no 


554  COMMON  DISORDERS  OF  CHILDHOOD 

evidence  of  nephritis,  but  were  rather  unusually  small  for  the 
age.  This  condition  is  of  course  distinct  from  the  oedema  which 
is  sometimes  seen  in  puny  infants  just  after  birth,  the  so-called 
*  oedema  neonatorum  ',  and  is  probably  also  entirely  different 
in  its  etiology  from  the  much  less  uncommon  cases  of  more  or 
less  general  oedema  in  late  infancy  or  early  childhood,  where 
there  is  advanced  marasmus  dependent  upon  some  chronic 
gastro -intestinal  disorder.  The  urine  in  these  cases  also  is 
free  from  albumen. 

Occasionally  older  children  develop  a  general  oedema  as  if 
they  had  acute  nephritis  when  the  urine  proves  to  be  entirely 
free  from  albumen. 

A  boy  aged  eleven  years  was  brought  to  me  with  a  history  that  for  one  week 
his  face  had  been  puffy,  and  for  four  days  his  legs  had  been  swollen.  He 
showed  no  physical  signs  except  the  general  oedema  and  evidence  of  some 
fluid  in  the  abdomen.  He  looked  exactly  like  a  case  of  acute  nephritis,  and 
I  expected  to  find  the  urine  loaded  with  albumen  :  it  contained  not  a  trace 
of  albumen,  and  except  that  the  boy  was  passing  an  abnormally  small  amount 
for  his  age,  there  were  no  urinary  symptoms ;  his  stools  were  very  offensive, 
but  otherwise  there  was  nothing  beyond  the  dropsy  to  be  found. 

Of  some  value,  I  think,  as  confirmatory  evidence  of  nephritis 
in  children,  is  the  character  of  the  aortic  second  sound  which  by 
its  accentuation  may  indicate  increased  arterial  resistance  quite 
early  in  the  disease,  although  the  pulse  tension  is  not  appreci- 
ably raised — and,  indeed,  except  in  the  rare  cases  of  chronic 
interstitial  nephritis,  it  is  but  seldom  that  an  increase  of  pulse 
tension  is  sufficiently  definite  in  children  to  be  of  any  practical 
value  in  diagnosis. 

In  the  chronic  cases,  also,  signs  of  cardiac  hypertrophy  are 
usually  present,  and  in  the  absence  of  any  evidence  of  valvular 
disease  may  confirm  the  diagnosis  of  nephritis.  Amongst 
rny  notes  I  find  records  of  enlarged  cardiac  dullness  in  many 
of  the  subacute  cases  in  which  oedema  was  still  present,  and  in 
some  of  these  the  enlargement  was  apparently  the  result  of 
hypertrophy  ;  but  the  frequency  of  cardiac  dilatation  in  the 
nephritis  of  children  must  also  be  remembered  and  no  doubt 
accounts  not  only  for  the  increased  cardiac  area  in  some  cases, 
but  also  for  the  presence  of  a  systolic  apical  bruit  which  was 
found  in  five  out  of  my  100  cases. 

Prognosis.  Passing  now  to  the  consideration  of  prognosis, 
I  would  emphasize  first  the  need  for  caution  in  regarding  any 
child  who  has  shown  symptoms  of  nephritis — and  I  am  referring 
now  specially  to  non-scarlatinal  nephritis — as  cured.  When  the 
oedema  has  all  gone,  and  the  albumen  has  diminished  to  a  bare 


NEPHRITIS  555 

trace,  and  then  been  absent  altogether  for  a  few  days,  one  is 
tempted  to  pronounce  the  child  '  cured ' ;  so  he  may  be  of  his  acute 
symptoms  but  not  necessarily,  perhaps  not  even  usually,  of  his 
disease.  If  these  children  are  carefully  watched  it  will  be  found 
in  many  cases  that  from  time  to  time  a  cloud  of  albumen  re- 
appears in  the  urine  and  that  this  cloud,  although  on  most  days 
it  may  be  only  just  perceptible  with  most  careful  testing,  increases 
occasionally  to  a  considerable  quantity,  perhaps  as  the  result  of 
some  slight  exposure  to  cold.  To  say  that  the  nephritis  is  cured 
in  such  a  case  is  surely  a  mistake,  however  well  the  child  may 
look,  and  however  infinitesimal  the  trace  of  albumen  may  be  ; 
certainly  not  only  may  the  albumen  increase  from  time  to  time, 
but  at  any  time  the  child  may  show  a  return  of  all  the  symptoms 
of  an  acute  nephritis.  I  have  already  referred  to  children  who 
have  been  under  my  care  as  out-patients  three  years  or  more 
with  this  latent  nephritis,  if  I  may  so  call  it  ;  and  looking  back 
over  my  series  of  cases,  I  am  inclined  to  think  that  this  is  no 
uncommon  result  of  an  acute  nephritis  in  children,  if  indeed 
it  be  not  the  minority  of  cases  which  ever  make  a  complete 
recovery. 

But  here  I  would  draw  a  sharp  distinction  between  scar- 
latinal and  non-scarlatinal  nephritis  in  children.  I  mentioned 
above  that  only  twenty-two  out  of  my  hundred  consecutive 
cases  of  nephritis  in  children  were  scarlatinal  in  origin,  and  when 
this  small  proportion  is  compared  with  the  well-known  fact  that 
the  commonest  cause  of  nephritis  in  children  is  scarlet  fever, 
it  is  obvious  that  of  the  large  number  of  children  with  scarlatinal 
nephritis  in  the  fever  hospitals  the  majority  must  either  die  or  be 
cured,  for  only  a  very  small  number  reappear  with  albuminuria 
subsequently  at  other  hospitals.  Happily  statistics  show  that 
a  very  large  majority  of  the  cases  of  scarlatinal  nephritis  are 
entirely  cured  before  leaving  the  fever  hospital,  and  it  would 
seem  that  the  prognosis  of  scarlatinal  nephritis  in  children,  apart 
from  the  risks  during  the  acute  stage,  is  altogether  more  favour- 
able than  that  of  the  non-scarlatinal  affection  ;  it  is  indeed 
quite  exceptional  to  meet  with  a  prolonged  albuminuria  lasting 
for  years  as  a  result  of  the  scarlatinal  form,  whereas  such  a  course 
is  quite  common  in  the  non-scarlatinal  cases. 

This  will  be  seen  most  clearly  from  actual  figures,  and  for  the 
purpose  of  comparison  I  shall  avail  myself  of  statistics  taken 
from  a  fever  hospital  by  Dr.  Gcodall ;  these,  it  should  be  stated, 
include  adults  as  well  as  children,  whereas  my  own  much  smaller 
figures  include  children  only. 


556  COMMON  DISORDERS  OF  CHILDHOOD 

Out  of  281  cases  of  scarlatinal  nephritis  54  per  cent,  had 
completely  lost  their  albuminuria  within  four  weeks  after  the 
onset  of  the  renal  affection  ;  not  more  than  24  per  cent.,  probably 
only  19  per  cent.,  showed  albumen  persisting  more  than  six 
weeks.  Contrast  with  these  statistics  my  own  figures  of  non- 
scarlatinal  nephritis  as  shown  in  the  following  table  (which 
includes  fatal  cases  and  the  four  cases  of  chronic  interstitial 
nephritis  mentioned  above). 

Duration  of  Nephritis.  Number  of  Cases. 

1 7  days 1  (fatal) 

3-4  weeks       ,..,.,  4  (two  fatal) 

1-3  months     .....  11  (one  fatal) 

3-0  months 14  (four  fatal) 

G-12  months 7  (two  fatal) 

1-2  years C  (two  fatal) 

2-3  years 4 

3-4  years 1 

4-5  years         .....  2 

Probably  several  years    ...  1  (fatal) 

Total  number  of  cases          .         .51 

The  duration  of  the  albuminuria  stated  in  this  titble  refers  to 
the  period  already  reached  when  the  child  died  or  passed  out  of 
observation ;  in  many  cases,  no  doubt,  it  lasted  very  much  longer. 
It  was  only  in  the  fatal  cases  and  in  two  or  three  which  recovered 
that  the  total  duration  of  albuminuria  could  be  ascertained. 

It  is  evident  even  from  these  small  figures  that  anything 
comparable  to  the  rapid  recovery  in  three  or  four  weeks  which 
occurs  in  about  half  the  cases  of  scarlatinal  nephritis  is  quite 
exceptional  in  the  non-scarlatinal  nephritis  of  children;  indeed, 
amongst  my  own  series  of  non-scarlatinal  cases,  37  out  of  51, 
that  is,  fully  73  per  cent.,  lasted  more  than  three  months. 
Whilst,  however,  the  non-scarlatinal  cases  of  nephritis  in  child- 
hood tend  to  run  a  much  more  prolonged  course,  and  in  this 
respect  have  a  worse  prognosis  than  those  of  scarlatinal  origin, 
they  have  at  any  rate  the  advantage  that  a  fatal  ending  rarely 
occurs  as  speedily  as  in  scarlatinal  nephritis.  To  quote  the 
authority  already  mentioned,  in  the  281  cases  of  scarlatinal 
nephritis  there  were  13  deaths,  and  no  less  than  7  of  these 
occurred  within  fourteen  days  after  the  onset.  In  my  51  cases 
of  non-scarlatinal  nephritis  there  were  13  deaths  ;  none  of  these 
occurred  earlier  than  the  seventeenth  day,  and  only  3  within 
four  weeks  after  the  onset,  as  will  be  seen  from  the  following 
table : 


NEPHRITIS  557 

Age  of  Child  at  death.  Duration  of  Nephritis. 

H  years  ......  17  days 

2J  months  .         .         .         .         .  *     .       3  weeks 

If  years 4  weeks 

6£  years 3  months 

3  years 4  months 

3£  years 4  months 

9J  years 5  months 

41  years 6  months 

2|  years .7  months 

9|  years 10  months 

7  years 13  months 

12  years 20  months 

9  years  ......  at  least  2  years 

Whilst,  however,  the  fatal  ending  would  seem  to  be  much 
longer  delayed  in  the  non-scarlatinal  nephritis  of  children  than 
in  the  scarlatinal  affection,  the  heavy  proportion  of  deaths  in 
this  series,  13  out  of  51,  is  noteworthy  as  contrasting  with  the 
much  lower  death  rate  in  the  fever  hospital  cases,  13  out  of  281. 

Moreover,  most  of  the  children  who  passed  out  of  my  observa- 
tion still  had  albuminuria,  and  as  experience  shows  were  likely 
therefore  to  have  exacerbations  of  nephritis  sooner  or  later ;  it 
would  seem,  in  fact,  that  the  ultimate  prognosis  in  cases  of  non- 
scarlatinal  nephritis  in  children  is  very  much  less  hopeful  than 
in  the  scarlatinal  cases.  Undoubtedly  a  small  proportion 
recover  completely,  and  a  much  larger  number  lose  all  symptoms 
of  nephritis  except  the  albuminuria;  but  these  latter  cases, 
although,  as  I  have  said,  they  may  live  in  fair  health  for  months 
or  years,  live  continually  on  the  edge  of  a  precipice  :  they  have 
damaged  kidneys  and  at  any  time  a  fresh  outbreak  of  renal 
inflammation  may  occur  and  prove  fatal.  The  approach  of 
danger  in  such  cases  is  almost  always  indicated  by  the  reappear- 
ance of  oedema,  and  at  the  same  time  the  urine  shows  a  great 
increase  of  albumen  and  perhaps  blood  and  casts.  But  a  child 
may  have  several  relapses  of  this  description  lasting  days  or  weeks 
and  yet  survive  for  several  months  or  years,  but  in  each  relapse 
there  is  danger  to  life  and  the  sources  of  danger  are  several. 

In  at  least  seven  out  of  the  thirteen  fatal  cases  mentioned 
above,  there  were  symptoms  of  uraemia  shortly  before  death 
(intractable  vomiting,  convulsions,  delirium  or  coma),  but  in 
some  of  these  children  there  were  other  complications  which  no 
doubt  contributed  to  the  fatal  result.  Of  extremely  sinister 
significance  is  the  erysipelatoid  rash  which  is  sometimes  seen  in 
cases  with  much  general  oedema.  The  rash  is  generally  asso- 
ciated with  much  local  tenderness  and  some  pyrexia  ;  it  was 


558  COMMON  DISORDERS  OF  CHILDHOOD 

seen  in  four  out  of  thirteen  cases,  and  in  each  case  was  followed 
by  death  within  two  or  three  weeks  at  most.  Any  considerable 
rise  of  temperature  is  also  of  unfavourable  omen,  even  if  no 
obvious  cause  for  it  can  be  found  ;  in  the  majority  of  the  fatal 
cases  pyrexia  (102°  or  103°)  occurs  for  several  days  before 
death.  In  some  of  the  children  under  my  observation  good 
reason  for  this  temperature  was  found  post  mortem  in  a  very 
acute  peritonitis,  five  out  of  the  thirteen  cases  showed  seropus 
or  serum  with  flakes  of  lymph  floating  in  it  in  the  peritoneal 
cavity. 

In  none  of  these  cases  had  the  peritonitis  been  suspected  before 
death,  but  the  pyrexia  which  accompanied  it  and  the  presence 
in  one  or  two  cases  of  considerable  tenderness  over  the  abdomen 
might  have  suggested  this  complication,  and  such  a  combination 
of  symptoms  in  a  child  with  much  oedema  and  a  large  quantity 
of  albumen  in  the  urine — the  conditions  under  which  this  com- 
plication seems  most  likely  to  occur — would  make  the  prognosis 
extremely  bad. 

A  very  marked  diminution  in  the  average  quantity  of  urine 
passed  daily  is  sometimes  the  precursor  of  a  fatal  ending,  but 
it  is  only  when  the  quantity  passed  is  really  very  small  for  the 
age  that  any  prognostic  significance  can  be  attached  to  it.  It 
may  not  be  out  of  place  here  to  mention  that  the  average  quantity 
of  urine  passed  daily  by  a  healthy  child  is  much  lower  than  is 
often  supposed,  and  curious  errors  have  arisen  through  ignorance 
of  the  normal  average  (see  p.  562). 

In  the  very  rare  cases  of  chronic  interstitial  nephritis  to  which 
I  have  referred  the  prognosis  is  probably  invariably  bad.  The 
question  '  How  long  ? '  however,  is  not  easy  to  answer,  for  the 
disease  may  be  so  insidious  that  although  the  child  is  ailing  no 
medical  advice  is  sought  until  the  onset  of  the  chronic  ursemic 
symptoms  which  are  usual  in  these  cases ;  and  even  then,  although 
as  in  one  of  the  four  children  mentioned  here  death  may  occur 
in  seven  weeks,  a  fatal  result  may  be  postponed  for  several  months 
(in  one  of  these  cases  for  eighteen  months).  Probably  one  would 
bo  rig] it  in  saying  that  very  few  of  these  children  witli  chronic 
interstitial  nephritis  live  more  than  two  years  after  the  first 
symptoms  appear.  In  giving  prognosis  in  any  case  of  chronic 
interstitial  nephritis  in  a  child  it  is  well  to  remember  the  possi- 
bility of  cerebral  ha?morrhage,  which  has  been  the  cause  of  death 
in  some  recorded  cases.  One  of  the  four  cases  included  in  my 
series  died  suddenly  with  110  premonitory  increase  of  the  chronic 
uraemic  symptoms  which  she  had  shown  for  several  months  ; 
the  immediate  cause  of  death  was  not  determined. 


NEPHRITIS  559 

The  termination  of  these  cases,  however,  is  most  often  by 
uraemia  with  convulsions  and  coma. 

Lastly,  in  any  case  of  prolonged  nephritis  in  a  child  the  prog- 
nosis will  depend  largely  on  the  possibilities  of  environment,  the 
care  which  is  likely  to  be  taken  with  the  clothing  to  see  that 
the  child  is  warmly  clad,  the  avoidance  of  exposure  to  damp 
and  chill,  and  in  some  cases  on  the  possibility  of  residence  in 
a  suitable  climate. 

Treatment.  The  treatment  of  nephritis  in  children  is  upon  the 
same  lines  as  in  adults.  In  the  acute  stage  the  most  important 
part  of  treatment  is  to  promote  sweating  and  watery  evacuation 
of  the  bowels.  No  measure  has  seemed  to  me  more  generally 
useful  than  hot-packs,  and  if  directly  the  child  is  put  into  the 
pack  2  or  3  ounces  of  milk  diluted  with  about  6  ounces  of  hot 
water  be  given  with  20-60  drops  of  brandy,  or  perhaps  still  better 
with  the  same  quantity  of  rum  or  gin,  according  to  the  age, 
a  diaphoretic  effect  is  usually  obtained,  which  can  be  prolonged 
when  the  child  is  taken  out  of  the  pack  after  about  an  hour  by 
wrapping  him  in  two  or  three  layers  of  dry  hot  blankets  with 
hot-water  bottles  beside  him. 

In  severe  cases  where  ursemic  symptoms  are  present  in  the  acute 
stage  of  the  disease  it  may  be  necessary  to  repeat  the  packs  several 
times  a  day  to  ensure  a  sufficient  action  of  the  skin.  I  have  used 
hot-packs  continuously  for  eight  or  ten  hours,  changing  them 
every  hour  where  there  was  difficulty  in  inducing  perspiration. 

If  suitable  apparatus  is  available  a  hot-air  bath  makes  some 
children  sweat  more  than  the  hot-pack.  Where  electric  light  is 
available,  a  radiant  heat  bath  can  be  improvised  by  fixing  electric 
lamps  inside  a  bed-cradle  which  is  placed  over  the  child  and  covered 
with  blankets.  Care  must  be  taken  that  neither  the  child  nor  the 
bed-clothes  are  burnt  by  the  lamps.  Whatever  method  is  used  it 
is  necessary  to  keep  a  sharp  watch  upon  the  child  while  he  is  in  the 
pack,  for  some  children  show  feebleness  of  pulse  from  these  appli- 
cations of  heat. 

Diaphoretic  drugs  often  fail  altogether  in  severe  cases  unless 
repeated  very  frequently.  Pot.  Nitrat.  gr.  v,  Spirit,  ^theris 
Nitrosi  O)v,  Spirit.  Junipori  O)v,  Syrup.  3j,  Infus.  Scoparii 
ad  388,  may  be  given  every  two  hours  until  six  or  eight  doses 
have  been  given  to  a  child  of  eight  years  ;  and  by  combining 
such  drug  treatment  with  the  use  of  hot-packs  or  the  hot-air 
bath  diaphoresis  may  be  increased. 

In  the  less  severe  cases  the  hot-pack  once  daily  or  on  alternate 
days  will  be  sufficient,  and  in  the  interval  hot  poultices  or  hot 
fomentations  may  be  applied  over  the  lumbar  region.  I  have 
several  times  tried  dry-cupping,  which  can  be  done  with  very 


560  COMMON  DISORDERS  OF  CHILDHOOD 

little  disturbance  even  to  the  youngest  child  ;  I  have  thought 
that  it  was  of  some  value. 

A  dose  of  pulv.  jalapae  co.  gr.  xxx  or  gr.  xl  for  a  child  of 
eight  years  can  be  given  every  alternate  night  for  the  first  week 
of  the  disease  and  then  an  early  morning  dose  of  Mag.  Sulph. 
gr.  xx,  Sod.  Sulph.  gr.  x,  Syrup  O)xxx,  Aq.  Menth.  Pip.  ad  5ij, 
may  be  substituted  ;  the  dose  of  the  sulphates  to  be  regulated 
by  the  effect  produced.  It  is  extremely  important  to  keep  the 
bowels  active,  and  when  there  is  much  oedema,  good  may  be  done 
by  keeping  the  stools  loose  and  diarrhceal  for  a  few  days.  The 
saline  aperients  sometimes  produce  sickness,  after  they  have  been 
used  for  some  weeks,  and  it  is  necessary  to  find  some  more  agree- 
able aperient.  '  Phenolphthalein '  in  doses  of  gr.  j-iij,  given  in  the 
early  morning  on  an  empty  stomach,  may  be  successful,  but  I  have 
sometimes  found  the  most  satisfactory  result  from  'Tamar  Indien', 
which  children  take  very  readily.  J-l  Tamar  is  given  at  night. 

Throughout  this  early  stage  of  the  disease  one  of  the  dangers 
to  be  guarded  against  in  the  child  is  cardiac  dilatation  and  failure  : 
weakness  and  rapidity  of  the  heart,  or  increase  of  the  cardiac 
dullness,  may  make  it  necessary  to  use  strophanthus  or  digitalis  ; 
probably  the  former  is  the  better  in  these  cases. 

When  the  initial  severity  of  symptoms  has  passed  off  and  there 
remains  still  considerable  oedema,  diuretics  may  be  of  value  ; 
sometimes  diuretin,  given  in  doses  of  5  or  6  grains  in  some  syrup 
and  water,  three  times  a  day  for  children  of  six  to  twelve  years, 
increases  the  flow  of  urine  ;  or  potassium  acetate,  5  to  10  grains, 
may  be  added  to  the  diaphoretic  mixture  mentioned  above. 

I  have  also  used  the  tinctura  apocyni  in  doses  of  5  to  7J  minims 
for  children  of  about  eight  years.  Solution  of  Adrenalin  (1  in 
1000)  given  by  mouth  in  doses  of  1-2  minims  in  distilled  water, 
three  or  four  times  daily,  sometimes  has  a  marked  diuretic  effect, 
which,  however,  passes  off  in  a  few  days  but  may,  nevertheless, 
give  valuable  temporary  relief. 

The  so-called  '  Imperial  drink  '  makes  an  excellent  diuretic 
which  children  will  often  take  readily.  The  formula  in  use  at 
King's  College  Hospital  is  Acid  Potassium  Tartrate,  1  ounce  ; 
Tartaric  Acid,  1  ounce  ;  Oil  of  Lemon,  12  minims  ;  Refined  Sugar, 
16  ounces  ;  Boiling  Water,  1  gallon.  Of  this  solution  the  child 
may  drink  half  a  tumblerful  or  more  two  or  three  times  daily. 

Later,  when  there  is  only  slight  oedema  and  the  child  is  in 
a  stationary  condition  with  much  pallor,  I  think  there  is  nothing 
better  than  the  old-fashioned  mixture  of  ferrous  sulphate  with 
magnesium  sulphate,  which  may  be  given  with  advantage  for 
several  months.  I  have  frequently  noticed  that  the  children 
whose  urine  continues  to  show  a  slight  trace  of  albumen  for 


NEPHRITIS  561 

many  months  or  years  after  an  acute  attack  of  nephritis  are 
decidedly  the  better  for  this  mixture,  and  if  they  leave  it  off 
for  a  few  weeks  they  are  apt  to  come  complaining  of  headaches 
apparently  due  to  the  renal  condition. 

The  time  at  which  the  child  may  first  be  allowed  to  get  up  is 
not  easy  to  fix  ;  but  there  is,  I  think,  evidence  that  being  '  up 
and  about '  throws  a  strain  upon  renal  excretion  which  is  to  be 
remembered  where  there  is  a  damaged  kidney.  The  so-called 
cyclic  albuminuria  occurs  usually  only  during  the  hours  of  being 
up  ;  it  has  been  shown  that  in  some  healthy  people  strained 
position  of  the  body  will  produce  albuminuria  ;  in  some  cases  of 
nephritis  during  convalescence  albumen  is  found  to  be  present 
only  when  the  patient  gets  up  ;  and,  lastly,  there  are  cases  such 
as  one  I  have  mentioned  above  in  which  oedema  recurs  directly 
the  patient  gets  up.  It  is  a  good  error,  therefore,  to  keep  the 
child  in  bed  for  a  longer  time  than  might  seem  necessary  if  we 
were  to  judge  only  from  the  child's  general  condition  after  an 
attack  of  nephritis  ;  probably  by  so  doing  we  may  give  the  renal 
tissues  a  better  chance  of  complete  recovery. 

Diet,  I  think,  is  often  needlessly  severe  in  cases  of  nephritis 
which  arc  past  the  initial  acute  stage  ;  no  doubt  in  the  most 
acute  period  it  is  advisable  to  avoid  a  highly  nitrogenous  diet, 
and  the  child  will  do  best  with  milk  diluted  with  barley-water, 
thin  Benger's  Food  and  farinaceous  diet. 

But  after  a  few  weeks,  when  the  child  has  reached  a  chronic 
condition,  even  though  there  be  some  oedema  remaining,  such 
things  as  fish,  bacon,  chicken,  or  eggs,  may  be  given,  though  it 
will  be  wise  to  keep  measurements  of  the  amount  of  urine  excreted 
and  of  the  albumen  and  urea,  and  to  be  guided  in  diet  by  the 
results.  My  experience  has  been  that,  as  a  rule,  the  child  is  no 
whit  the  worse  for  having  such  food,  even  in  the  sub-acute  stage, 
whilst  in  cases  where  a  trace  of  albumen  persists  for  months 
after  the  acute  attack  I  think  that  a  little  red  meat  also  may 
be  allowed  once  a  day. 

When  the  child  has  reached  this  chronic  stage  of  slight  albu- 
minuria, with  no  other  symptoms,  the  question  of  climate  will 
arise,  for  there  is  no  doubt  that  residence  in  a  warm  climate 
considerably  increases  the  chance  of  escape  from  exacerbations 
of  nephritis,  if  not  the  chance  of  complete  recovery.  On  our 
south  coast,  Falmouth,  Torquay,  or  Sidmouth,  or  any  of  the  places 
on  the  south  coast  of  Cornwall,  are  suitable  places  for  these 
children,  while  for  those  who  like  to  take  their  children  further 
afield,  the  French  Riviera  or  the  Canary  Islands  offer  choice  of 
localities. 

STILL  O  O 


CHAPTER  XXXIX 
SOME  URINARY  DISORDERS  IN  CHILDHOOD 

IT  is  sometimes  of  importance  to  know  how  much  urine  a  child 
should  pass  daily.  As  an  easy  method  of  remembering  the 
average  quantities,  I  think  that  the  formula  which  I  worked  out 
some  years  ago  is  sufficiently  accurate,  but  it  applies  only  to 
children  from  four  years  old  and  upwards,  namely,  age  in  years 
multiplied  by  2-5  ;  the  resulting  figure  represents  the  quantity 
of  urine  in  ounces. 

In  younger  children  and  infants  the  amount  of  urine  is  larger  on 
account  of  the  fluid  character  of  their  diet  ;  during  the  first  year 
it  is  about  12  ounces  a  day,  and  during  the  second  year  about 
10  ounces.  But  at  all  ages  it  is  subject  to  considerable  fluctua- 
tion, e.g.  a  boy,  aged  5J  years,  whose  average  for  nine  days  was 
13-5  ounces,  passed  one  day  21  ounces  and  another  day  6  ounces, 
and  n  child  of  three  years,  whose  average  for  nine  days  was 
9-2  ounces,  passed  one  day  15J  and  another  day  4J  ounces. 

This  fluctuation  in  quantity  is,  I  think,  much  more  marked  in 
infancy  and  early  childhood  than  in  older  children,  say  at  eight 
years  or  more  ;  it  is  no  doubt  one  manifestation  of  that  insta- 
bility of  function  which  is  one  of  the  characteristics  of  early 
childhood.  I  mention  this  point  because  it  has  a  practical 
bearing  upon  a  not  very  uncommon  occurrence  in  children 
during  the  first  half  of  childhood,  namely,  suppression  of  urine 
for  many  hours  without  any  apparent  cause.  When  a  mother 
says  that  her  child  has  passed  no  urine  for  more  than  twelve 
hours  this  docs  not  necessarily  mean  that  the  child's  bladder 
is  full. 

A  catheter  should  never  be  passed  where  there  is  this  com- 
plaint without  first  ascertaining  by  percussion  whether  the 
bladder  is  much  distended  :  usually  the  failure  to  pass  urine  is 
not  due  to  any  retention,  the  urine  has  not  been  secreted  and  the 
bladder  contains  so  little  that  the  child  has  no  desire  to  micturate. 
Most  of  the  cases  I  have  seen  with  this  condition  have  been 
children  about  two  or  three  years  old  ;  one  girl  at  3J  years 
passed  no  urine  for  18 J  hours,  and  then  passed  no  more  than 
her  usual  amount.  A  boy  of  throe  years  went  22  hours  without 


SOME  URINARY  DISORDERS  563 

passing  urine  ;  an  older  child,  a  girl  of  twelve  years  in  good 
health,  was  brought  to  hospital  because  she  had  passed  no  urine 
for  21J  hours,  the  bladder  was  not  distended,  but  after  drinking 
some  warm  milk  she  emptied  her  bladder,  which  contained  only 
2J  ounces  of  urine. 

There  is  usually  nothing  to  account  for  the  suppression  of 
urine  in  these. cases  ;  the  urine  which  is  passed  after  the  period 
of  suppression  is  not  even  highly  coloured  in  some  of  the  cases, 
and  there  are  no  symptoms.  The  phenomenon  is  purely  a  physio- 
logical variation,  and  as  such  calls  for  no  special  treatment  ; 
indeed  it  would  hardly  call  for  mention  were  it  not  that  there  is 
a  chance  that  those  who  are  unfamiliar  with  it  might  think 
that  a  catheter  was  necessary.  Catheterization,  always  to  be 
avoided  in  a  child  if  possible,  is  not  only  unnecessary  but  useless 
in  these  cases,  the  small  amount  of  urine  which  is  secreted  will 
be  passed  in  due  time -without  any  interference. 

Albuminuria.  The  presence  of  a  small  and  transient  trace  of 
albumen  in  the  urine  is  not  a  rare  occurrence  in  children  who 
are  out  of  health  from  any  cause,  particularly  when  they  are 
suffering  from  any  gastro-intestinal  disturbance. 

Observations  of  the  urine  from  a  series  of  forty  sick  children, 
amongst  whom  there  were  none  suffering  from  nephritis,  diph- 
theria, heart  disease,  or  any  of  the  diseases  ordinarily  recognized 
as  producing  albuminuria,  showed  that  within  fourteen  days 
no  less  than  twenty-five  had  shown  a  transient  trace  of  albumen 
in  the  urine  on  one  or  more  occasions  ;  several  of  this  series 
were  under  the  age  of  two  years,  and  I  have  the  impression  that 
an  evanescent  albuminuria  is  much  commoner  in  the  urine  of 
infants  and  very  young  children  than  in  older  ones. 

Where  there  is  nothing  more  to  be  detected  in  the  urine  than 
a  slight  trace  of  albumen,  a  single  examination  is  clearly  not 
sufficient  to  show  whether  there  is  any  importance  to  be  attached 
to  it. 

Cyclic  albuminuria.  It  is  a  good  rule  always  to  examine  two 
specimens,  an  early  morning  and  a  mid-day  one,  for  in  some  of 
the  children  whose  urine  shows  a  trace  of  albumen  at  midday, 
cyclic  albuminuria  is  present.  This  condition  is  probably  com- 
moner in  childhood  than  has  been  supposed.  It  is  generally 
said  to  be  commoner  in  boys  than  girls,  but  of  ten  consecutive 
cases  from  my  books  eight  were  girls.  They  were  all  between 
seven  and  thirteen  years  of  age.  They  are  mostly  children  over 
six  years  of  age  in  whom  the  condition  is  found.  The  urine  just 
after  rising  in  the  morning  is  free  from  albumen,  but  two  or 

o  02 


564  COMMON  DISORDERS  OF  CHILDHOOD. 

three  hours  later  a  definite  but  usually  very  slight  cloud  of 
albumen  is  present  on  boiling. 

In  testing  for  albumen  I  think  that  boiling  the  upper  part  of 
the  contents  of  a  test  tube  three  parts  full,  and  then  adding  acetic 
acid,  is  much  more  reliable  than  the  nitric  acid  test,  with  which 
I  have  frequently  known  small  amounts  of  albumen  overlooked 
which  were  easily  recognized  with  the  simple  boiling. 

The  symptoms  for  which  the  children  with  cyclic  albuminuria 
are  brought  to  the  medical  man  are  usually  of  the  vaguest.  The 
child  has  usually  been  noticed  to  be  slightly  puffy  under  the  eyes, 
like  a  child  with  worms  or  chronic  indigestion  ;  he  is  pale  and 
without  being  ill  is  seldom  quite  well  ;  he  is  nervous,  complains 
of  headaches,  occasionally  perhaps  of  nausea,  and  in  many  cases 
has  pains  in  the  abdomen  ;  in  two  of  the  cases  mentioned  the 
child  was  said  to  turn  faint  occasionally.  I  have  seen  cyclic 
albuminuria  in  association  with  enuresis  and  nervous  (lienteric) 
diarrhoea. 

In  at  least  three  of  this  small  series  the  urine  showed  calcium 
oxalate  crystals  ;  an  occasional  hyaline  or  granular  cast  has 
been  found  by  some  observers  in  the  urine  of  patients  with  this 
disorder  ;  in  two  of  these  ten  cases  a  stray  cast  was  found  by 
centrifugalizing  on  one  or  two  occasions. 

The  occasional  presence  of  one  or  two  casts  in  the  urine  in 
these  cases  does  not  apparently  indicate  any  nephritis  ;  but  it 
should  make  us  careful  in  diagnosis,  for  after  a  definite  acute 
nephritis,  when  the  albumen  has  diminished  almost  to  the  vanish- 
ing point,  there  is  sometimes  a  period  during  which  the  albumen 
is  present  only  in  the  middle  of  the  day,  not  in  the  early  morning. 
I  have  mentioned  the  time  relation,  but  no  doubt  the  albumen 
in  these  cases,  as  in  most  cases  of  cyclic  albuminuria,  does  not 
depend  really  upon  the  time  of  day,  but  on  the  erect  posture  or 
on  muscular  activity. 

Another  possible  fallacy  is  the  contamination  of  urine  by 
vaginal  discharge,  which  is  probably  more  likely  when  the  child 
has  been  walking  about  than  when  she  has  only  just  risen  from  bed. 

Beyond  the  slight  symptoms  I  have  mentioned,  cyclic  albu- 
minuria seems  to  have  no  ill  effect  ;  the  child  suffers  little  incon- 
venience from  his  slight  symptoms,  and  sooner  or  later  drifts 
away  from  medical  observation,  so  that  it  is  difficult  to  follow 
out  the  course  of  the  disorder,  but  I  have  kept  several  cases 
under  frequent  observation  for  two  and  three  years,  and  have 
seen  no  further  harm  come  of  this  disorder.  I  have  known  it  to 
pass  off  entirely  soon  after  puberty. 


SOME  URINARY  DISORDERS  565 

Treatment  seems  to  have  little  or  no  effect.  I  have  tried 
calcium  lactate,  of  which  5  or  6  grains  can  be  given  three  times 
a  day  to  a  child  of  eight  or  nine  years  ;  in  one  case  the  child  was 
said  to  be  much  better  in  general  health  while  taking  it,  but  I 
could  not  satisfy  myself  that  the  amount  of  albumen  was  less. 
There  is  little  to  be  done  beyond  the  treatment  of  particular 
symptoms  as  they  arise.  There  is,  I  think,  no  need  to  treat  the 
child  as  an  invalid  or  as  specially  liable  to  nephritis. 

Where  there  are  calcium  oxalate  crystals  in  the  urine  it  is  wise  to 
prohibit  foods  known  to  favour  oxaluria,  such  as  tomatoes  and 
asparagus,  but  especially  rhubarb,  which  in  some  healthy  children 
will  produce  hsematuria  or  albuminuria.  A  small  plateful  of 
stewed  rhubarb  given  to  a  healthy  girl,  aged  four  years,  at 
12.30  noon  produced  red  urine  full  of  blood  corpuscles  and 
calcium  oxalate  crystals  at  3  a.m.  the  next  morning.  There  is, 
however,  marked  idiosyncrasy  in  this,  for  another  child  who 
took  treble  this  quantity  of  stewed  rhubarb  in  twelve  hours 
showed  oxaluria  but  no  haematuria. 

Uric  Acid.  An  occasional  cause  of  albuminuria  in  children  is 
the  presence  of  uric  acid  crystals  in  the  urine.  Infants  often  pass 
a  considerable  quantity  of  this  'cayenne  pepper'  deposit.  Many 
children  in  the  earlier  half  of  childhood  pass  urine  which  is  very 
acid  and  after  standing  a  short  time  deposits  uric  acid ;  a  much 
smaller  number  pass  the  uric  acid  crystals  already  formed. 

It  is  noticeable  in  these  cases  that  the  child  is  pale  and  fretful, 
complains  of  feeling  tired,  has  perhaps  some  nausea,  and  generally 
is  *  below  par  '.  I  find  that  in  most  cases  the  doctor  has  directed 
that  little  or  no  red  meat  shall  be  given,  and  the  parents  having 
an  idea  that  anything  in  the  nature  of  meat  is  likely  to  produce 
this  trouble  have  carried  his  directions  even  further,  and  the 
child  is  living  largely  upon  a  starchy  carbo-hydrate  diet.  I  very 
much  doubt  whether  there  is  wisdom  in  this  ;  it  has  seemed  to  me 
that  some  of  these  children  who  pass  very  acid  urine  with  uric 
acid  in  it  are  suffering  not  from  excess  of  proteid  but  from  excess 
of  carbo-hydrate  in  the  diet,  and  that  what  is  needed  is  reduction 
of  this  element.  The  child  who  begins  the  day  with  porridge 
and  toast  and  then  has  a  meal  consisting  chiefly  of  potato  and 
farinaceous  pudding,  and,  later,  bread-and-butter  and  cake  with 
an  occasional  interlude  of  the  indigestible  apple  or  banana, 
may  be  better  for  the  substitution  of  bacon,  egg,  or  fish  for 
breakfast,  and  of  broth,  boiled  brains,  fish,  sweetbread,  or  chicken 
for  dinner  ;  and  of  custard  or  junket  or  jelly  in  place  of  the 
farinaceous  pudding. 


566  COMMON  DISORDERS  OF  CHILDHOOD 

Free  drinking  of  water  and  the  administration  of  potassium 
citrate  is  advisable  ;  malt  and  pancreatin  may  also  do  good. 

Haematuria.  There  are  some  causes  of  hsematuria  which  may 
be  mentioned  here  as  concerning  chiefly  infancy  and  childhood. 

When  an  infant  under  the  age  of  one  year  shows  blood  in  the 
urine  the  probable  cause  is  infantile  scurvy.  Hsematuria  is  some- 
times the  only  symptom  of  this  disease,  and  the  diagnosis  has 
then  to  be  made  from  the  history  of  scorbutic  feeding  and  the 
rapid  disappearance  of  the  blood  when  fresh  fruit  juice  or  potato 
is  given  ;  usually,  however,  there  are  other  characteristic  symp- 
toms of  scurvy. 

New  growth  in  the  kidney  is  commonest  in  infancy  and  early 
childhood,  but  it  is  seldom  seen  in  the  first  year  ;  haematuria  is 
not  a  constant  symptom. 

Tubercle  of  the  kidney  must  be  reckoned  amongst  the  causes 
of  hsematuria  in  children,  and  the  appearance  of  blood  in  the 
urine,  perhaps  even  in  sufficient  quantity  to  redden  it,  may  be 
the  first  indication  of  this  affection  of  the  kidney.  Sooner  or 
later,  however,  the  blood  in  these  cases  is  likely  to  be  associated 
with  more  or  less  pus,  and  this  is  perhaps  of  more  serious  signifi- 
cance than  the  hsematuria,  which  is  more  likely  to  occur  in  the 
early  stage  of  the  disease,  and  is  certainly  not  always  the  pre- 
cursor of  any  progressive  tuberculosis ;  I  have  seen  several  such 
cases  do  well,  and  am  by  no  means  inclined  to  resort  to  surgery 
even  if  one  could  be  sure  that  the  affection  was  unilateral. 

Whooping-cough  sometimes  produces  profuse  haematuria  when 
the  paroxysms  are  violent  ;  the  bleeding  is  no  doubt  due  to 
rupture  of  small  vessels,  and  after  a  day  or  two  the  blood  ceases 
to  appear  in  the  urine.  I  have  occasionally  seen  nephritis  in 
children  with  haematuria  as  the  only  prominent  symptom  :  the 
child  has  shown  no  trace  of  dropsy,  but  was  brought  because  the 
urine  was  red.  There  are  other  causes  of  hsematuria  which  are 
common  to  adults  as  well  as  children  ;  children  occasionally 
suffer  with  renal  calculus.  In  countries  where  bilharziosis  is 
prevalent  children  are  subject  to  hsematuria  from  this  cause. 
A  boy,  aged  about  nine  years,  was  brought  to  me  at  King's 
College  Hospital  with  hsematuria,  for  which  no  explanation 
could  be  found  until  it  was  discovered  that  he  had  lived  in  South 
Africa,  and  microscopic  examination  showed  the  ova  of  bilharzia 
in  the  urine. 

Children  seem  to  suffer  occasionally  with  an  unexplained 
bleeding  from  the  kidney  like  the  bleeding  from  the  nose  to  which 
many  children  are  liable  ;  this  '  renal  epistaxis  '  passes  off  after 


SOME  URINARY  DISORDERS  567 

a  few  days,  leaving  no  trace  behind  it,  and  nothing  further  occurs 
to  explain  it. 

Lastly,  it  must  be  remembered  that  a  red  urine,  or  a  brown 
one,  does  not  always  mean  hsematuria,  it  may  be  the  result  of 
haemoglobinuria,  as  can  be  determined  by  the  absence  of  blood 
corpuscles,  or  their  extreme  scarcity  in  proportion  to  the  colour 
of  the  urine.  This  disorder,  in  the  few  cases  which  I  have  seen, 
as  in  several  which  have  been  recorded  by  others,  has  been 
associated  with  congenital  syphilis. 

Abnormal  Colour.  Apart  from  abnormalities  of  colour  due 
to  peculiarities  of  metabolism,  such  as  the  rare  congenital  con- 
dition alkaptonuria,  in  which  the  urine  becomes  a  dark  blackish 
colour  after  it  is  passed,  so  that  it  stains  the  diapers,  there  are 
curious  pigmentations  of  the  urine  which  are  specially  liable  to 
occur  in  childhood  owing  to  the  eating  of  coloured  sweets. 

A  yellowish  pink  fluorescent  appearance  of  the  urine,  very 
like  that  of  a  solution  of  eosin  is  produced  by  the  eating  of  pink 
lozenges  and  various  aniline  coloured  substances  may  thus  be 
responsible  for  curious  tints  in  the  urine.  Recently  I  had  under 
observation  a  little  girl  passing  bright  green  urine,  which  on 
examination  appeared  to  be  due  to  aniline  dye,  and  was,  no 
doubt,  explained  by  the  colour  of  her  dress,  which  was  exactly 
the  same,  and  which  she  probably  sucked.  In  one  instance1 
a  boy,  in  order  to  evade  school,  soaked  a  piece  of  turkey-red 
cloth  in  his  urine,  and  pretended  that  he  was  passing  blood. 
1  Clin.  Soc.  Trans.,  vol.  xxix,  p.  174. 


CHAPTER  XL 
PYELITIS  IN  INFANCY  AND  CHILDHOOD 

ACUTE  pyelitis  is  hardly  one  of  the  common  diseases  of  child- 
hood, but  it  is  more  frequent,  especially  in  infancy,  than  is  gener- 
ally known.  Admirable  descriptions  of  this  disease  have  been 
published  by  Dr.  Holt,  of  New  York,1  and  Dr.  John  Thomson,  of 
Edinburgh.2  Its  recognition  is  usually  a  very  simple  matter, 
and  yet  it  is  overlooked  again  and  again  simply  because  the 
possibility  of  its  occurrence  is  forgotten  and  the  urine  of  an 
infant  is  so  seldom  examined.  Unrecognized,  acute  pyelitis  in 
infancy  giyes  rise  to  prolonged  fever  of  most  severe  degree,  with 
profound  constitutional  disturbance,  which  may  end  in  death  ; 
recognized  and  treated  with  appropriate  drugs  it  often  subsides 
in  a  few  days,  and  even  if  symptoms  persist  for  a  while  they 
quickly  become  less  severe,  and  generally  yield  to  treatment 
before  long.  The  recognition  of  pyelitis  is  therefore  a  matter  of 
urgent  practical  importance,  and  as  a  preliminary  to  a  study  of 
its  diagnosis  and  treatment  I  shall  sketch  in  outline  the  clinical 
picture  of  the  disease  as  it  commonly  presents  itself. 

A  female  infant  under  the  age  of  twelve  months,  and  appa- 
rently in  perfect  health,  is  suddenly  taken  ill — so  suddenly  indeed 
that  the  mother  can  often  tell  the  exact  hour  at  which  the  illness 
began — the  child  seems  hot,  so  the  temperature  is  taken  and  ifi 
found  to  be  103°.  From  this  time,  day  after  day,  the  tempera- 
ture ranges  from  101°  to  105°,  the  infant  is  fretful  and  miserable, 
crying  out  suddenly  at  times  as  if  in  pain,  or  perhaps  drowsy 
and  inclined  to  twitch  slightly  in  the  fingers  and  eyelids.  Either 
at  the  moment  of  onset  or  perhaps  later  the  infant  has  been 
noticed  to  turn  blue  and  cold,  or  has  actually  shivered.  Vomit- 
ing is  either  absent  or  occurs  only  occasionally.  The  stools, 
though  perhaps  not  loose  or  costive,  are  nevertheless  not  quite 
as  they  should  be,  and  on  inquiry  there  has  been  some  unhealthi- 
ness  of  the  stools  or  perhaps  constipation  several  days  before  the 
illness  began.  There  has  been  nothing  to  call  the  mother's 

1  Holt,  Archives  of  Pediatrics,  Nov.  1894. 

2  Thomson,  Scot.  Med.  and  Surg.  Journ.,  July  1902,  and  Quart.  Journ.  Med., 
April  1910,  p.  251. 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        569 

attention  to  any  abnormality  of  the  urine,  nor  is  there  any  evidence 
of  pain  anywhere. 

Careful  examination  fails  to  reveal  signs  of  any  sort ;  possibly 
the  abdomen  is  a  little  full,  and  there  seems  to  be  some  vague 
discomfort  on  palpation,  but  there  is  nothing  more. 

The  infant  is  obviously  acutely  ill,  but  no  explanation  of  the 
high  fever  and  profound  constitutional  disturbance  is  forth- 
coming until  the  urine  is  examined,  when  pus  and  bacteria  are 
found. 

Such,  in  brief,  is  the  clinical  picture  of  acute  pyelitis,  which 

1  shall  now  describe  in  more  detail. 

Sex.  Pyelitis  is  almost  but  not  quite  exclusively  an  affection 
of  females.  Of  28  infants  under  one  year  who  have  come  under 
my  own  observation  with  this  disease  only  3  were  boys,  and 
amongst  14  older  children  there  were  no  boys.  Why  this  pre- 
dominance of  girls  ?  It  is  at  least  consistent  with  the  view  that 
the  infection  of  the  urinary  tract  travels  up  from  below,  the 
vulva  is  soiled  with  faces  and  the  bacteria  pass  through  the 
bladder  and  ureter  to  the  kidney. 

Age.  The  age-incidence  also  would  fit  in  with  this  theory. 
Out  of  42  cases  28  were  under  the  age  of  twelve  months  when 
the  pyelitis  began  (the  youngest,  a  girl,  was  ten  weeks  old),  and 

2  others  were  under  two  years.     Of  the  remaining  12,  4  were 
between  two  and  four  years  old,  and  8  were  under  ten  years. 

The  disease  is  evidently  much  commoner  in  infants  than  in 
older  children,  and  the  soiling  of  the  vulva  with  faeces  would 
occur  most  easily  during  this  age  of  diapers. 

One  might  further  point  out  that  the  bowels  have  often  boen 
loose  before  the  onset  of  pyelitis,  or,  if  there  has  been  no  diar- 
rhoea, the  stools  have  been  unhealthy  in  some  way,  green  or 
curdy  or  offensive,  sometimes  only  constipated. 

In  harmony  with  all  these  facts  the  Bacillus  coli  is  found  to 
be  the  exciting  cause  in  the  large  majority  of  cases  of  pyelitis 
(only  rarely  is  the  Proteus  bacillus  or  some  other  micro-organism 
found),  and  it  seems  reasonable  to  suppose  that  the  infection 
comes  from  the  bowel. 

It  is  possible,  however,  that  the  route  from  the  bowel  to  the 
kidney  may  vary,  and  that  in  some  cases  it  is  via  the  blood,  and 
in  some  even  directly  by  contact ;  at  any  rate  it  must  be  remem- 
bered that  pyelitis  does  sometimes  occur  in  boys,  and  that  it 
sometimes  shows  symptoms  very  suggestive  of  a  blood  infection. 

Symptoms.  A  striking  feature  in  most  cases  is  the  abruptness 
of  the  onset.  In  one  case  the  infant  was  being  dressed  one 


570  COMMON  DISORDERS  OF  CHILDHOOD 

morning,  apparently  quite  well,  when  she  suddenly  c  went  blue, 
and  seemed  cold  and  faint ',  from  that  time  the  child  was  acutely 
ill  with  high  fever  ;  in  another  the  infant  had  gone  out  seemingly 
in  perfect  health  in  her  perambulator,  when  she  suddenly  became 
acutely  ill,  and  was  thought  to  have  a  convulsion  ;  she  was 
brought  home  and  found  to  have  a  temperature  of  104°,  which 
was  explained  only  when  the  urine  was  examined  four  days  later. 
I  say  '  thought  to  have  a  convulsion  ',  because  I  think  it  is  quite 
clear,  on  careful  inquiry,  that  in  some  cases  the  supposed  con- 
vulsion is  really  an  attack  of  quite  a  different  character,  some- 
times a  genuine  rigor,  sometimes  an  attack  in  which  the  infant 
goes  cold  and  blue,  but  does  not  actually  shiver. 

Dr.  Thomson  has  laid  stress  upon  the  occurrence  of  shivering 
or  rigor  in  the  infant  as  an  early  symptom.  Rigors  are  so  ex- 
tremely rare  in  infancy  and  early  childhood  from  any  cause 
that  their  occurrence  with  this  pyelitis  may  be  of  considerable 
diagnostic  value.  I  cannot,  however,  affirm  from  my  own 
experience  that  they  occur  in  a  majority  of  the  cases.  I  have 
made  special  inquiries  upon  this  point  in  most  of  the  cases  under 
my  own  observation,  and  in  some  could  obtain  no  history  of 
shivering.  This,  of  course,  does  not  prove  that  rigors  had  not 
occurred,  for  they  would  easily  be  overlooked  in  an  infant,  but 
it  does  prove  that  the  failure  to  obtain  a  history  of  shivering 
does  not  weigh  much  against  the  possibility  of  pyelitis  as  the 
cause  of  fever.  It  is  often  said  that  a  convulsion  takes  the  place 
in  infancy  of  the  rigor  of  the  adult,  but  I  have  not  observed  in 
this  pyelitis  of  infancy  any  special  tendency  to  convulsions  at 
the  onset  in  those  cases  in  which  a  rigor  did  not  occur,  nor  do 
I  think  that  a  convulsion  is  the  only  counterpart  of  a  rigor  ; 
I  suspect  that  vomiting  in  early  childhood  sometimes  takes 
the  place  of  the  rigor  of  the  adult,  for  instance,  at  the  onset  of 
lobar  pneumonia. 

However  this  may  be,  I  would  point  out  that  without  any 
actual  shivering  it  frequently  happens  that  several  times  during 
the  course  of  acute  pyelitis,  especially  at  its  onset,  an  infant 
suddenly  turns  blue  arid  cold,  and  seems  collapsed.  These  attacks 
occur  in  such  a  large  proportion  of  the  cases  that  to  my  mind 
the  combination  of  an  otherwise  unexplained  fever  in  an  infant 
with  attacks  of  blueness  and  collapse  is  always  highly  suggestive 
of  acute  pyelitis. 

Of  course,  not  every  supposed  convulsion  in  acute  pyelitis  is 
of  the  same  nature  as  these  attacks  which  I  have  described  ; 
genuine  clonic  convulsions  do  occasionally  occur  at  the  onset 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        571 

or  during  the  course  of  the  disease,  but  they  are  quite  exceptional — 
only  3  out  of  28  infants  had  convulsions. 

To  any  one  who  has  seen  the  condition  many  times,  the  appear- 
ance and  manner  of  the  infant  is  often  enough  to  suggest  the 
diagnosis  ;  the  extreme  misery  and  restlessness  is  very  striking, 
unless  indeed,  owing  to  the  severity  of  the  infection,  the  infant 
has  already  fallen  into  a  drowsy,  almost  comatose  state  ;  the 
complexion  is  pale  and  earthy,  the  skin  is  hot  and  dry  ;  when 
with  such  a  condition  I  am  informed  by  the  doctor  that  nothing 
has  been  found  to  account  for  the  high  fever,  I  always  suspect 
that  pus  will  be  found  in  the  urine. 

But  perhaps  it  is  not  quite  correct  to  say  that  nothing  is 
found,  for  in  some  cases  the  abdomen  is  a  little  fuller  than  normal 
and  the  infant  seems  to  be  discomforted  more  than  is  natural  by 
gentle  palpation.  It  is  difficult  to  be  sure  of  this,  for  the  infant 
is  so  fretful  that  any  examination  is  resented  ;  but  I  am  the  more 
inclined  to  think  that  this  observation,  made  in  several  cases,  is 
correct,  because  in  older  children  I  have  sometimes  found  quite 
definite  tenderness  over  the  front  of  the  abdomen  with  pyelitis, 
so  that  the  condition  has  even  simulated  appendicitis. 

There  are  cases  in  which  pyelitis  assumes  the  guise  of  acute 
cerebral  disease  :  the  child  is  drowsy  or  even  semi-coxatose, 
there  is  muco-pus  on  the  cornea,  the  neck  is  stiff,  the  head  per- 
haps definitely  though  slightly  retracted,  there  may  even  be 
a  squint  and  some  slight  convulsive  twitching  of  the  limbs  ; 
what  wonder  if  the  case  is  mistaken,  as  it  so  often  is,  for  one  of 
meningitis  ? 

The  temperature  in  acute  pyelitis  is  profoundly  puzzling  so 
long  as  the  condition  remains  unrecognized  ;  day  after  day  it  is 
103°  and  104°,  and  often  reaches  105°  several  times,  nor  does 
the  fever  show  any  sign  of  abating  usually  for  several  weeks 
unless  the  cause  is  recognized  and  the  proper  treatment  given. 
With  the  requisite  drugs  the  temperature  falls  generally  within 
two  or  three  days  to  a  much  lower  level,  if  not  to  normal,  but  it 
is  very  apt  to  rise  again  after  a  few  days,  for  reasons  which 
1  shall  consider  later. 

The  chart  shown  here  (Fig.  37),  from  a  girl  aged  44  months,  is 
a  very  characteristic  example  of  the  prolonged  and  severe  fever 
caused  by  acute  pyelitis,  when  this  is  unrecognized  and  conse- 
quently is  not  treated  with  suitable  drugs. 

In  striking  contrast  with  this  is  the  chart  (Fig.  38)  from  an 
infant  of  the  same  age  in  whom  treatment  of  the  pyelitis  was 
begun  on  the  fourth  day  of  the  disease. 


572 


COMMON  DISORDERS  OF  CHILDHOOD 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        573 

The  one  essential,  of  course,  in  the  diagnosis  of  this  disease  is 
the  examination  of  the  urine,  and  this  is  the  one  point  which 
has  not  been  examined  in  most  cases.  '  It  is  a  baby,'  says  the 
doctor,  '  so  one  can't  get  the  urine.'  I  have  been  told  this  again 
and  again,  and  I  will  venture  to  say  that  in  no  single  one  of  these 
cases  have  I  failed  to  obtain  the  urine  within  a  few  hours — often 
indeed  it  was  forthcoming  within  a  few  minutes — after  explain- 
ing to  the  nurse  the  extreme  importance  of  having  it. 

It  is  necessary  to  point  out  that  the  object  of  examination  is  to 
ascertain  whether  pus  corpuscles  are  present,  and  therefore  the 
urine  must  be  obtained  by  some  other  method  than  by  catching 
in  absorbent  wool  or  any  other  absorbent  material  which  would 


FIG.  38.  Chart  from  a  case  of  acute  pyelitis  in  a  girl  aged  4}  months; 
treatment  with  potassium  citrate  begun  on  fourth  day  of  disease  (chart  begins 
on  second  day  of  illness). 

strain  off  the  pus  cells,  so  that  the  urine  squeezed  out  would 
be  useless  for  the  purpose.  A  simple  plan  is  to  let  the  infant  lie 
for  a  few  hours  on  waterproof  mackintosh  until  some  urine  is 
passed  ;  a  little  arrangement  of  the  mackintosh  will  usually 
secure  that  the  urine  shaU  collect  in  sufficient  quantity  for  the 
purpose.  A  few  drops  will  suffice,  as  it  is  microscopic  examina- 
tion only  which  is  necessary  to  the  diagnosis. 

Several  times  I  have  been  told  that  the  urine  had  been 
examined  and  that  it  was  '  clear  and  acid,  with  no  albu- 
men ',  although  the  aspect  of  the  case  was  that  of  pyelitis,  and 
further  examination  showed  pus  and  albumen  in  the  urine. 
Mistake  is  easy  enough  :  more  than  once  after  I  have  suggested 
that  the  case  was  one  of  pyelitis  the  doctor  has  produced  the 


574  COMMON  DISORDERS  OF  CHILDHOOD 

infant's  urine  in  a  chamber-pot  of  white  china,  and  remarked, 
4  See,  it  is  perfectly  clear  !  '  whereas  directly  it  was  poured  into 
a  clear  glass  bottle  it  was  obvious  that  the  urine  was  slightly 
turbid. 

Again,  the  doctor  says  there  cannot  be  pus,  for  he  found  no 
albumen  ;  on  inquiry  I  find  that  he  used  the  nitric  acid  test, 
and  on  using  the  boiling  test,  with  subsequent  addition  of  a  few 
drops  of  acetic  (being  careful  to  fill  the  test-tube  three  parts  full 
and  to  boil  only  the  upper  half-inch  so  that  the  slightest  tur- 
bidity may  be  seen  by  contrast),  one  is  able  to  show  that  there  is 
albumen,  albeit  extremely  little,  corresponding  to  the  very  small 
amount  of  pus  found  in  many  of  these  cases.  The  use  of  the 
nitric  acid  test  is  a  very  common  cause  for  overlooking  small 
traces  of  albumen  in  urine. 

Again,  even  when  the  urine  has  been  found  to  contain  a  trace 
of  albumen,  there  has  been  so  little  cloudiness  of  the  unboiled 
specimen,  and  such  an  apparent  absence  of  deposit,  that  the 
doctor  has  not  thought  it  necessary  to  examine  it  microscopic- 
ally. It  must  be  remembered  that  the  amount  of  pus  is  generally 
microscopic  in  pyelitis,  often  only  six  or  even  fewer  pus-cells  are 
to  be  seen  in  a  field  (under  a  one-sixth  objective)  when  the  shaken- 
up  urine  is  examined,  and  this  even  when  the  symptoms  are 
most  severe.  Here  I  would  emphasize  the  advantage  of  examin- 
ing the  shaken-up  urine  rather  than  urine  which  has  been  allowed 
to  stand,  or  has  been  centrifugalized.  The  examination  of  a 
deposit  gives  no  idea  whatever  of  the  relative  amount  of  pus 
which  is  present  ;  the  deposit  obtained  by  standing  or  centri- 
fugal ization  from  a  urine  which  would  show  8  cells  to  the  field 
in  the  fresh  or  shakeii-up  specimen,  does  not  differ  from  one 
which  would  show  30  cells,  so  that  a  valuable  standard  of  com- 
parison is  lost.  This  principle  applies  not  only  to  pyelitis  but 
also  to  other  urinary  conditions,  such  as  nephritis  and  hsematuria. 
The  centrifuge  is  often  rather  a  hindrance  than  a  help ;  we  want 
to  know  not  only  that  there  are  casts  or  blood-cells,  but  how 
many. 

The  urine  of  pyelitis  before  treatment  is  acid,  usually  very 
acid,  and  commonly  shows  (under  one-sixth  objective)  an  average 
of  about  6-30  pus-cells  per  field,  and  here  and  there  a  group  of 
perhaps  10  or  12  stuck  together ;  usually,  but  not  always, 
bacilli  can  be  seen  either  singly  or  in  clumps,  and  in  the  large 
majority  of  cases  prove  to  be  Bacillus  coli. 

Hitherto  I  have  referred  only  to  pyelitis  in  its  acute  stage. 
I  want  to  draw  attention  also  to  the  extremely  misleading  cases 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        575 

in  which  the  diagnosis  has  to  be  made  after  the  disease  has 
become  chronic.  These  come  to  the  doctor  under  the  guise  of 
marasmus  ;  a  miserable  fretful  infant  is  brought  solely  for 
wasting;  at  first  sight  there  seems  to  be  enough  to  account 
for  the  condition,  the  infant  takes  food  badly,  and  the  stools 
are  unhealthy,  and  no  one  has  doubted  but  that  the  trouble  was 
simply  digestive.  The  extraordinary  fretfulness  and  misery, 
however,  of  the  child  may  suggest  something  more,  and  inquiry 
elicits  the  fact  that  there  was  some  febrile  illness,  it  may  be 
months  ago,  or  perhaps  there  has  been  a  good  deal  of  irregular 
fever,  which  has  been  attributed  to  teething,  influenza,  or  what 
not  —  in  one  such  case  I  was  assured  that  the  infant  had  had 
tubercular  meningitis,  a  mistake  evidently  due  to  the  nervous 
manifestations  of  acute  pyelitis,  as  examination  of  the  urine 
showed.  In  older  children  also  aColi  pyelitis,  when  it  has  become 
chronic,  may  show  itself  as  a  wasting  disease.  A  girl,  9  years 
old,  was  brought  to  me  for  supposed  phthisis  ;  she  was  much 
wasted,  and,  with  phthisis  in  mind,  it  was  easy  to  imagine  little 
differences  between  parts  of  the  lungs  on  percussion  and  ausculta- 
tion ;  but  the  temperature  chart  was  unlike  it  ;  there  were  bouts 
of  fever  alternating  with  longer  periods  of  normal  temperature, 
and  the  child  was  more  cachectic  than  her  very  doubtful  pul- 
monary signs  would  warrant  ;  examination  of  the  urine  showed 
large  numbers  of  pus-cells  and  Coli-form  bacilli. 

Acute  pyelitis,  as  I  have  already  pointed  out,  is  much  less 
common  in  older  children  than  in  infants,  but  it  is  important  to 
remember  that  it  does  occur,  for  it  is  easily  overlooked  ;  not  only 
are  there  the  same  fallacies  in  the  examination  of  the  urine,  but 
the  symptoms  are  apt  to  be  much  less  severe,  the  temperature 
is  lower,  and  there  is  less  constitutional  disturbance.  In  the 
older  as  in  the  younger  children  there  is  rarely  any  local  symp- 
tom or  disturbance  of  micturition  to  call  attention  to  the  urine  ; 
the  child  is  feverish,  complains  of  headache,  perhaps  has  a  rigor 
or  is  sick,  and  sometimes  there  is  definite  pain  in  the  abdomen, 
which  may  suggest  appendicitis,  as  in  the  following 


Lily  S.,  aged  8|  years,  was  admitted  to  hospital  for  pain  in  the  right  side 
of  the  abdomen  and  high  temperature.  These  symptoms  had  begun  suddenly 
on  March  14.  When  admitted,  on  March  17,  she  was  very  drowsy,  with  some 
headache  and  marked  rigidity  of  the  right  side  of  the  abdomen.  Appendicitis 
was  suspected,  but  examination  of  the  urine  showed  this  to  be  acid  with  many 
pus-cells  and  Coli-form  bacilli.  Under  potassium  citrate  treatment  the  fever 
rapidly  subsided,  and  all  rigidity  and  pain  had  almost  disappeared  by  March  20, 
when  the  child  suddenly  became  bad  again,  with  much  abdominal  pain  and 
rigidity,  which,  however,  were  now  on  the  left  side  of  the  abdomen.  Potassium 


576  COMMON  DISORDERS  OF  CHILDHOOD 

citrate,  22|  grains  '  every  two  hours  when  awake '  quickly  relieved  these 
symptoms  ;  and  the  child  made  an  apparently  complete  recovery.  But  on 
April  23  there  was  still  '  an  occasional  stray  pus-corpuscle '  in  the  urine,  and 
a'ter  remaining  apparently  quite  well  till  August  3  the  child  again  complained 
of  pain  in  the  abdomen,  and  was  found  to  have  fresh  pyclitis,  which  again 
subsided  under  treatment. 

This  case  seems  to  show  that  pyelitis  may  remain  limited  to 
one  kidney,  at  any  rate  for  a  time,  and  that  recurrence  of  fever 
and  other  symptoms  when  the  child  seems  on  the  road  to  recovery, 
may  indicate  infection  of  the  previously  sound  kidney.  It  illus- 
trates also  the  liability  to  a  subsequent  attack  of  pyelitis  if 
treatment  has  not  rendered  the  urine  entirely  free  from  pus  and 
bacteria. 

Diagnosis.  It  is  an  interesting  speculation  how  these  cases 
were  labelled  in  days  gone  by  :  one  cannot  doubt  that  Infantile 
Remittent  Fever,  Dentition,  remarkable  recoveries  from  sup- 
posed Tuberculous  Meningitis,  and  many  another  equally  wrong 
diagnosis  served  to  cover  the  acute  pyelitis  of  infants.  I  have 
kept  a  record  of  some  of  the  diagnoses  which  had  been  made  in 
cases  which  I  have  seen.  '  Tuberculous  meningitis  '  was  the  most 
frequent,  and  indeed  some  of  the  nervous  symptoms  of  pyelitis 
are  scarcely  distinguishable  from  those  of  meningitis,  but  the  very 
high  fever  and  acute  onset  are  quite  unlike  tuberculous  meningitis, 
and  would  better  fit  in  with  cerebro-spinal,  which  had  been  sus- 
pected in  some  of  the  cases.  The  prolonged  fever  without  physical 
signs  had  given  rise  to  a  diagnosis  of  '  Typhoid  '  in  several,  but 
again  the  acute  onset  should  have  raised  a  doubt  as  to  the  possi- 
bility of  this  diagnosis.  The  sudden,  onset  and  sharp  fever  had 
been  attributed  to  a  latent  '  Pneumonia  '  in  some,  whilst  '  In- 
fluenza ',  '  Gastro-enteritis  '  or  '  Dentition '  was  thought  to 
explain  the  symptoms  in  ethers. 

These  mistakes  can  only  arise  if  the  urine  is  not  properly 
examined  ;  there  are  other  questions  of  diagnosis  which  are  less 
simple.  A  girl  with  some  fever  and  headache  is  found  to  have 
pus  in  the  urine,  but  she  has  some  vulvo-vaginitis— is  there 
pyelitis  or  is  the  pus  merely  an  accidental  contamination  from 
the  vulva  ?  The  presence  of  bacilli  in  the  freshly  passed  urine 
may  help  us,  for  vulval  discharges  are  almost  always  due  to  cocci 
of  some  sort,  not  to  bacilli ;  but  it  may  sometimes  be  necessary 
to  obtain  a  catheter  specimen  (a  thing  always  to  be  avoided  in  the 
case  of  children  if  possible).  Usually  the  effect  of  alkalinization 
of  the  urine  will  be  the  most  satisfactory  solution  of  the  problem. 

There  are  cases  in  which  the  distinction  between  Tuberculous 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        577 

pyelitis  and  Coli  pyelitis  is  by  no  means  easy  by  ordinary  clinical 
methods,  especially  when  the  pyelitis  has  become  chronic  ;  the. 
tuberculous  affection  is  not  likely  to  show  the  sudden  acute 
onset  and  severe  constitutional  symptoms  of  the  Coli  disease,  and 
blood  is  often  present  in  tuberculous  urine,  whereas  it  is  very 
rarely  found  in  the  urine  of  Coli  pyelitis.  A  bacteriological  in- 
vestigation of  the  urine  may  be  necessary. 

A  secondary  pyelitis  may  occur  with  congenital  dilatation  of 
the  pelvis  of  the  kidney,  and  may  easily  be  mistaken  for  the 
acute  primary  pyelitis  of  infancy. 

Jessie  P.,  aged  5  months,  had  been  vomiting  for  7  weeks  and  wasting.  The 
child,  on  admission,  was  very  collapsed,  and  temperature  fell  to  97-4°.  The 
urine  was  acid,  showed  about  15  pus-cells  per  field,  and  gave  a  pure  growth  of 
Bacillus  coli.  The  child  rallied  from  its  collapse,  and  3  days  later  the  tem- 
perature was  101-2°,  and  subsequently  103-4°.  Potassium  citrate  caused  no 
improvement,  although  the  urine  became  alkaline.  The  child  died  13  days 
after  admission.  Post-mortem  showed  the  right  ureter  greatly  enlarged  and 
tortuous,  measuring  8  inches  long,  whereas  the  left  was  only  4  inches.  The 
pelvis  of  the  right  kidney  was  somewhat  dilated,  and  there  were  a  few  small 
abscesses  in  the  cortex.  The  left  kidney  looked  dark  and  congested,  but 
otherwise  normal.  There  was  also  some  broncho-pneumonia. 

No  doubt  in  such  a  case  the  absence  of  any  acute  onset,  and 
perhaps  the  low  range  of  temperature,  might  suggest  the  possi- 
bility of  dilated  pelvis,  but  in  the  absence  of  any  palpable  enlarge- 
ment the  nature  of  the  pyelitis  could  hardly  be  diagnosed. 

It  is  difficult  to  account  for  the,  apparent  absence  of  cystitis 
in  most  cases  of  Coli  pyelitis  ;  one  would  have  thought  the  bladder 
must  inevitably  have  been  affected,  nevertheless  it  is  but  rarely 
that  straining  or  discomfort  in  micturition  or  frequent  desire  to 
pass  water  is  present,  indicating  some  irritation  of  the  bladder. 
I  mention  this  here  because  it  is  well  to  remember  that  such 
symptoms  do  sometimes  occur  where  the  course  of  the  case 
otherwise  seems  to  point  to  Coli  pyelitis,  and  where,  moreover, 
the  effective  treatment  is  that  of  pyelitis. 

Prognosis.  To  any  one  who  is  not  familiar  with  the  course  of 
the  disease,  the  condition  of  the  infant  stricken  with  acute  pyelitis 
may  seem  wellnigh  hopeless,  but  experience  shows  that  the  out- 
look is  generally  good.  Amongst  42  cases,  including  28  under 
twelve  months  old,  only  4  were  fatal  (three  under  six  months  old, 
and  one  in  the  second  year). 

Examination  of  the  urine  months  after  the  acute  attack  shows 
that  a  trace  of  pus  sometimes  persists  in  spite  of  energetic 
treatment  with  alkalies  during  the  acute  stage.  I  suspect 
that  this  indicates  insufficient  dosage  or  too  short  duration 

STILL  i> 


578 


COMMON  DISORDERS  OF  CHILDHOOD 


of  treatment ;  in  such  cases  there  is  occasionally,  though  rarely, 
a  recurrence  of  acute  symptoms  after  months  of  apparent  good 
health.  As  a  rule,  with  efficient  treatment,  recovery  is  not  only 
rapid  but  complete  :  sometimes,  as  in  the  case  from  which  the 
chart  shown  below  (Fig.  39)  is  taken,  the  subsidence  of  the  fever 
resembles  in  its  rapidity  the  crisis  of  a  pneumonia. 

DEC.  JAN. 


Fie.  39.     Acute  Pyelitis.     Chart  fr  ra  a  girl,  aged  7  month?,  shoeing  sudden 
subsidence  of  fever  after  treatment  with  potassium  eitrate. 

Morbid  Anatomy.  In  three  cases  which  I  have  examined  post 
mortem,  the  same  characteristic  changes  in  the  kidney  were 
found  in  all.  No  gross  change  could  be  detected  in  the  pelvis, 
but  spreading  up  from  the  pelvis  into  the  pyramids  were  yellow 
streaks  seen  on  section  running  upwards  towards  the  cortex 
parallel  to  the  straight  tubules.  This  purulent  infiltration  wag 
seen  also  in  the  cortex  as  small  irregular  yellow  patches,  some 
oi  which  could  be  seen  bulging  slightly  on  the  surface  of  £he 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        579 

kidney  beneath  the  capsule.  In  some  parts  this  infiltration  could 
be  seen  to  be  surrounded  by  a  narrow  zone  of  inflammatory 
hypersemia. 

This  invasion  of  the  pyramids  and  cortex  may  of  course  occur 
only  in  fatal  cases,  while  in  those  that  recover  the  inflammation 
may  be  limited  to  the  pelvis. 

Treatment.  The  treatment  of  acute  pyeljtis  is  in  most  cases 
as  satisfactory  as  it  is  simple  since  Dr.  J .  Thomson  first  emphasized 
the  importance  of  alkalinization  of  the  urine.  In  most  cases  this 
has  almost  the  virtue  of  a  specific :  the  improvement  in  the  infant's 
condition  is  almost  as  rapid  as  the  relief  of  scurvy  by  potato- 
cream. 

The  drug  which  is  most  generally  convenient  for  this  purpose 
is  potassium  citrate,  but  its  virtue  depends  entirely  upon  proper 
frequency  and  dosage  :  it  is  useless  unless  sufficient  is  given  to 
render  the  urine  alkaline,  and  its  effect  is  only  transitory  unless 
the  alkalinity  is  maintained  night  and  day  continuously  for  at 
least  a  week  or  ten  days.  As  a  preliminary  dose  5  grains  of  the 
potassium  citrate  is  to  be  given  every  two  hours  by  day  and 
every  three  hours  by  niglit  ;  this  dose  will  do  for  any  age  in  the 
first  year  of  life.  Strict  injunctions  must  be  given  to  the  nurse 
that  the  urine  shall  be  obtained  as  often  as  possible,  and  tested 
immediately  after  it  is  passed  with  litmus  paper.  The  only  gauge 
of  the  efficiency  of  the  dosage  is  the  reaction  of  the  urine  ;  so 
long  as  this  remains  acid  the  fever  and  general  symptoms  are 
likely  to  persist.  The  charts  shown  in  Figs.  40  and  41  show  the 
speedy  effect  of  this  treatment  with  potassium  citrate. 

It  is  surprising  what  large  doses  are  necessa^  in  many  cases 
to  keep  the  urine  alkaline,  8  or  10  grains  every  two  hours  may  be 
only  just  sufficient  in  the  case  of  an  infant,  and  a  child  of  three 
years  may  require  20  grains  or  even  more  every  two  hours. 

It  is  necessary,  however,  to  point  out  that  the  use  of  potassium 
citrate  has  its  limitations  ;  I  have  noticed  repeatedly  that  large 
doses,  e.g.  10  grains  or  more  every  two  hours  for  an  infant  of 
six  or  eight  months,  are  apt  to  disturb  digestion  and  to  set  up 
diarrhoea,  which  is  a  troublesome  complication  ;  where  this  has 
happened,  I  have  sometimes  found  that  bicarbonate  of  soda  or 
potassium,  in  doses  of  5-10  grains  every  two  or  three  hours,  has 
been  successful  in  maintaining  the  alkalinity  already  induced  by 
the  potassium  citrate,  and  the  bicarbonate  has  not  had  the  ill 
effects  of  this  drug. 

How  long  the  potassium  citrate  should  be  continued  is  a  very 
important  question.  Again  and  again  I  have  seen  symptoms 


530 


COMMON  DISORDERS  OF  CHILDHOOD 


.  40.     Acute  Pyolitis.     Chart  from  a  boy  aged  4}  months. 


OCT. 


FIG.  41.     Acute  Pyelitis.     Chart  from  a  girl,  aged  5'  months,  showing  effect 
of  treatment  with  potassium  citrate. 


PYELITIS  IN  INFANCY  AND  CHILDHOOD        581 

recur  where  the  drug  was  not  continued  long  enough  with  regu- 
larity. 

When  the  temperature  falls,  as  it  usually  does  after  two  or 
three  days  of  this  treatment,  there  is  a  great  temptation  to  reduce 
the  dose  or  frequency  of  the  potassium  citrate,  and  the  mother 
is  only  too  ready  to  give  up  disturbing  the  infant  at  night  for 
medicine,  which  now  seems  unnecessary.  But  the  result  is 
grievous  disappointment,  the  temperature  quickly  rises  again, 
and  the  child  seems  as  bad  as  ever  until  the  urine  has  again  been 
rendered  alkaline.  I  wrould  lay  it  down  as  a  general  rule  that 
the  potassium  should  be  continued  at  the  efficient  dose,  i.e.  that 
which  renders  the  urine  alkaline,  every  two  hours  by  day  and 
every  three  hours  by  night,  for  at  least  ten  days  after  the  tempera- 
ture has  become  normal. 

I  have  referred  hitherto  to  the  temperature  as  if  it  were  the 
only  symptom  which  is  to  serve  as  guide  in  determining  the 
duration  of  treatment.  But  there  is  another  direction  in  which 
careful  watch  should  be  kept  ;  every  day  or  two  the  number 
of  pus  cells  in  the  urine  should  be  counted  ;  only  in  this  way 
can  we  obtain  any  clear  idea  of  the  degree  to  which  the  pyelitis 
is  subsiding.  This  is  easily  done  with  quite  sufficient  accuracy 
for  practical  purposes  by  examining  a  drop  of  the  shaken-up 
urine  under  a  sixth  objective,  and  taking  the  average  of  the 
number  of  cells  counted  in  half  a  dozen  fields. 

Usually  the  diminution  in  the  number  of  cells  is  quite  appreci- 
able after  two  or  three  days,  and  often  it  is  possible  to  observe 
also  a  decrease  in  the  number  of  bacteria  present  (the  Bacillus  coll 
is  readily  seen  with  a  sixth  objective).  No  doubt  the  most 
scientific  method  of  determining  the  proper  time  to  discontinue 
the  alkali  treatment  would  be  repeated  bacteriological  culture 
from  the  urine,  but  this  is  seldom  practicable  ;  in  the  disappear- 
ance of  the  pus -cells  we  have  a  more  easily  ascertainable  criterion, 
which  is  at  least  as  important  as  the  temperature,  and  by  dis- 
regarding which  we  may,  I  think,  lay  the  seeds  of  future  trouble. 
As  already  mentioned,  a  few  pus-cells  can  sometimes  be  found 
in  the  urine  months  after  the  temperature  has  become  normal, 
and  in  such  cases  a  recurrence  of  all  the  acute  symptoms  may 
occur  ;  it  seems  possible  that  by  having  regard  not  only  to  the 
temperature  but  also  to  the  disappearance  of  the  pus-cells  before 
discontinuing  the  alkali  we  might  prevent  this  misfortune. 

After  laying  so  much  stress  upon  the  alkali  treatment  and  its 
success,  I  must  needs  add  that  there  are  cases  in  which  the 
alkalies  fail.  I  have  not  been  able  to  formulate  any  rule  whereby 


582  COMMON  DISORDERS  OF  CHILDHOOD 

one  could  tell  when  this  was  likely  to  happen ;  it  undoubtedly 
occurs  sometimes  when  the  pyelitis  is  due  to  some  organism  other 
than  the  Bacillus  coli,  e.g.  the  Proteus  bacillus,  but  it  also  occurs 
with  the  Bacillus  coli,  though  very  rarely.  When  this  is  so,  uro- 
tropine  occasionally  does  good;  1J  grains  may  be  given  every 
four  hours  to  an  infant  six  months  old,  and  2J  grains  at  twelve 
months.  Another  drug  which  is  certainly  useful  is  salol,  1  grain 
every  four  hours  at  six  months  of  age  ;  this  sometimes  makes 
a  useful  adjunct  also  to  the  alkali  treatment,  where  the  unhealthy 
condition  of  the  stool  threatens  further  Coli  infection. 

In  the  most  severe  cases  with  profound  toxaemia,  where  the 
temperature  is  very  high,  and  nervous  symptoms  are  prominent, 
anti-colon  bacillus  serum  is  worthy  of  trial.  I  have  known  it 
cause  remarkable  improvement.  It  is  given  subcutaneously  in 
doses  of  5-7  c.c.  for  an  infant  under  six  months  of  age. 

In  obstinate  cases — and  there  are  some  in  which  in  spite  of  all 
drugs  the  pyuria  and  irregular  temperature  persist — I  have  several 
times  resorted  to  vaccine  treatment  ;  this  should  be  carried  out 
if  possible  with  an  autogenous  vaccine,  i.  e.  one  made  from  the 
child's  own  urine.  As  initial  dose  5  millions  may  be  given  sub- 
cutaneously to  an  infant  six  months  old,  and  a  week  later  8  or 
10  millions,  which  may  be  increased  after  another  week  to  15 
or  20  millions  :  to  a  child  of  3J  years  I  have  given  as  many  as 
100  millions. 

Whatever  treatment  is  used  stimulants  are  often  necessary, 
especially  in  the  acute  stage,  when  large  doses  of  potassium 
citrate  are  being  given,  as  whether  from  this  drug  as  some  have 
thought,  or  from  the  disease,  the  child  is  often  much  depressed, 
and  10  or  15  minims  of  brandy  every  four  hours  may  be  an  essen- 
tial part  of  the  treatment. 

If  any  tendency  to  convulsions  shows  itself,  phenazone 
•|-1  grain  at  6-12  months  should  be  given  with  2  or  3  grains 
of  sodium  bromide,  in  a  mixture  separate  from  the  potassium 
citrate,  so  as  not  to  interfere  with  the  frequent  administration  of 
the  latter, 


CHAPTER  XLI 
MENTALLY  DEFICIENT  CHILDREN 

MOST  medical  men  are  confronted  from  time  to  time  with  cases 
of  mental  deficiency  in  children,  and  most  of  us  know  only  too 
well  how  difficult  to  answer  are  some  of  the  questions  put  to  us 
by  the  parents :  Will  the  child  talk  ?  Will  he  learn  to  walk  ? 
Has  his  mental  condition  resulted  from  a  fall  ?  If  other  children 
are  born,  is  there  any  likelihood  that  they  too  may  be  imbecile  ? 
Has  the  fact  that  the  parents  are  first  cousins  any  bearing  on  the 
condition  ?  These  are  only  some  of  the  many  questions  which 
the  doctor  is  expected  to  answer. 

I  have  kept  notes  for  several  years  past  of  all  the  mentally 
defective  children  who  have  come  under  my  own  observation  in 
hospital  and  in  private  practice,  and  I  shall  base  some  rather 
scattered  remarks  on  this  subject  upon  this  series  of  350  cases. 
As  will  be  seen,  I  have  not  been  able  to  investigate  every  case 
with  reference  to  all  the  questions  in  which  I  was  interested. 

Imbecility  seems  to  be  as  common  in  one  sex  as  in  the  other  : 
my  own  figures  show  174  boys  and  176  girls.  Many  statistics 
have  been  published  on  this  point,  some  show  a  slight  prepon- 
derance of  boys,  others  a  slight  preponderance  of  girls  ;  the 
conclusion  would  seem  to  be  that  there  is  no  special  sex-incidence. 

The  recognition  of  mental  deficiency  in  infancy  is  not  always 
easy.  I  find  from  my  notes  that  in  most  cases  the  parents  have 
not  suspected  that  there  was  anything  serious  amiss  until  the 
tenth  to  the  fourteenth  month,  when  the  failure  of  the  infant  to 
sit  up  drew  attention  to  the  abnormal  condition  ;  but  the  medical 
man  can  often  recognize  the  deficiency  earlier  than  this.  In  one 
group  of  cases,  those  known  as  Mongols,  the  facies  within  a  few 
days  after  birth  is  so  striking  and  so  characteristic  that  the 
mental  deficiency  which  is  associated  with  this  particular  abnor- 
mality can  be  foreseen  even  at  this  age  ;  this,  however,  is  the  only 
variety  of  imbecility  in  which  a  diagnosis  is  possible  during  the 
first  week  or  two  of  life. 

It  might  be  supposed  that  cretinism,  which  has  such  charac- 
teristic features  at  a  later  age,  would  be  recognizable  at  birth  or 
very  soon  afterwards  ;  this,  however,  is  not  so.  It  seems  probable 


584  COMMON  DISORDERS  OF  CHILDHOOD 

that  a  newborn  infant  has  received  from  the  maternal  circulation 
a  supply  of  thyroid  secretion  sufficient  to  prevent  any  signs  of 
thyroid  insufficiency  from  appearing  for  many  weeks  after  birth  ; 
it  is  only  after  this  has  been  used  up  that  the  absence  of  thyroid 
secretion  becomes  evident  in  the  appearance  of  cretinism.  How- 
ever this  may  be,  it  is  certain  that  cretinism  is  very  rarely  recog- 
nized, and  probably  is  seldom  recognizable,  until  the  sixth  or 
seventh  month  ;  the  earliest  age  at  which  I  have  seen  it  myself 
was  at  seven  months  ;  Dr.  Koplik,  of  New  York,  has  observed 
it  as  early  as  four  and  five  weeks  after  birth.  Formerly  the  name 
'  foetal  cretinism  '  was  given  to  the  condition  now  known  as 
achondroplasia,  which  is  of  entirely  different  pathology  and  is 
not  associated  with  mental  defect. 

The  abnormality  of  the  thyroid  from  which  cretinism  results 
is  no  doubt  usually  congenital,  but  it  may  be  doubted  whether 
the  symptoms  of  cretinism  are  ever  congenital.  The  date  of 
recognition  of  this  form  of  imbecility  has  a  special  practical 
importance,  for  the  degree  of  physical  and  mental  development 
which  is  attainable,  albeit  always  somewhat  short  of  the  normal, 
is  certainly  greater  when  treatment  with  thyroid  is  begun  very 
early. 

Amongst  other  forms  of  imbecility  one  of  the  earliest  recognized 
is  microcephaly,  partly  perhaps  because  the  contrast  between 
the  small  cranium  and  the  relatively  large  face  attracts  notice, 
and  partly  because  the  more  severe  degrees  of  microcephaly  are 
usually  associated  with  extreme  fatuity  of  mind  ;  as  might  be 
expected,  the  more  complete  the  fatuity  the  earlier  the  mental 
deficiency  becomes  recognizable. 

Symptoms.  There  are  certain  points  which  should  suggest 
imbecility  in  an  infant,  apart  from  the  peculiarities  of  facies  which 
characterize  the  Mongol  and  the  cretin.  The  most  important 
of  these  is  failure  to  acquire  certain  powers  at  the  proper  age. 
Most  infants,  when  held  in  the  sitting  posture,  hold  the  head  up 
quite  steadily  at  the  age  of  four  months  ;  if  an  infant  in  good 
physical  health  fails  to  do  this  at  the  age  of  six  months  there  is 
ground  for  suspecting  some  mental  deficiency.  Most  infants  dis- 
tinguish their  mother  or  nurse  from  a  stranger  quite  definitely  at 
the  age  of  six  months,  often  considerably  earlier  (at  3J  or  four 
months)  ;  failure  to  do  so  at  the  age  of  nine  months  would 
indicate  mental  deficiency  unless  there  were  some  gross  defect 
of  sight. 

A  healthy  infant  should  be  able  to  sit  up  without  support  at 
the  age  of  nine  months  ;  if  an  infant  without  rickets  or  other 


MENTALLY  DEFICIENT  CHILDREN  585 

physical  disease  is  unable  to  sit  up  alone  at  twelve  months, 
mental  deficiency  is  probable.  The  age  of  learning  to  walk  varies 
very  considerably  in  health,  but  I  think  it  may  be  said  that  if 
a  child  is  free  from  rickets  and  other  physical  disease,  and  makes 
no  attempt  to  walk  at  the  age  of  eighteen  months,  mental 
deficiency  is  at  least  probable. 

The  date  of  speech  development  is  even  more  variable  in 
health  ;  it  may  be  very  imperfect  or  even  absent  altogether  for 
as  much  as  two  or  even  three  years,  without  any  deficiency  of 
intellect,  but  as  a  general  rule  a  child  should  be  attempting  to 
say  single  words  at  twelve  months,  and  any  considerable  delay 
beyond  this  age  may,  when  associated  with  such  other  evidences 
as  I  have  mentioned,  point  to  mental  defect. 

Far  more  characteristic  than  mere  delay  in  speech  develop- 
ment is  the  habit  which  some  imbeciles  show  as  early  as  the  end 
of  the  first  year  of  making  meaningless  uncouth  sounds,  some- 
times shrill  sudden  cries,  sometimes  a  drawling,  senseless  sound, 
accompanied  with  a  fatuous  smile,  without  apparent  aim  or 
object  :  these  sounds  are  very  different  from  the  pleasant  cooing 
and  lalling  of  the  normal  infant,  which,  though  inarticulate,  are 
not  meaningless  ;  they  convey  the  idea  of  a  purposive  expression 
of  pleasure  and  contentment. 

Unnatural  movements  are  often  a  symptom  of  mental  disorder. 
I  have  noticed  a  tendency  in  some  imbecile  infants  to  deflect  the 
eyes  without  reason  to  one  side  ;  in  others  the  normal  co-ordina- 
tion of  the  limbs  is  not  acquired,  the  arms  and  legs  are  flung  about 
in  a  clumsy,  purposeless  way  at  the  age  of  nine  or  ten  months, 
when  an  infant  should  be  beginning  to  use  its  limbs  in  a  definitely 
purposive  manner,  particularly  in  grasping  at  objects.  At  four 
months  old  some  normal  infants  will  grasp  at  an  object  with 
definite  purpose  to  reach  it,  though  the  aim  is  usually  very 
inaccurate  at  this  age  ;  at  six  months  the  grasp  is  sometimes 
perfectly  accurate,  though  the  infant  is  apt  to  grasp  with  fingers 
only,  not  using  the  thumb.  If  an  infant  fails  to  grasp  at  objects, 
particularly  at  its  feeding-bottle,  when  it  is  nine  months  old, 
mental  deficiency  is  highly  probable,  and  similar  failure  at  twelve 
months  old  makes  mental  deficiency  almost  certain,  provided  of 
course  that  there  is  no  defect  of  sight. 

A  curious  symptom  of  mental  deficiency,  and  one  which  is  apt 
to  be  puzzling  in  early  infancy,  when  there  may  be  nothing 
otherwise  to  suggest  imbecility,  is  frequent  causeless  crying  and 
screaming.  I  must  confess  that,  as  a  rule,  one  has  only  recognized 
the  significance  of  this  in  retrospect.  The  mother  has  brought 


586  COMMON  DISORDERS  OF  CHILDHOOD 

her  infant  to  me  at  the  age  of  two  or  three  years  or  thereabouts, 
with  obvious  signs  of  idiocy,  and  has  volunteered  the  statement 
that  the  child  as  an  infant  was  always  screaming,  without  any 
apparent  cause  ;  but  sometimes  I  have  heard  this  complaint,  and 
heard  the  crying  too,  when  an  infant  has  come  to  me  with  signs 
suggestive  of  mental  deficiency  in  early  infancy,  and  in  such  cases 
this  symptom  has  contributed  to  the  diagnosis. 

Of  course  crying  and  screaming  are  common  enough  in  infancy, 
with  little  or  no  ascertainable  cause,  and  he  would  be  a  rash 
person  who  would  attach  any  weight  to  this  symptom  by  itself, 
but  in  some  of  those  cases  where  the  most  careful  investigation 
of  all  the  ordinary  causes  fails  to  show  any  reason  for  the  constant 
crying,  the  possibility  of  mental  deficiency  is  to  be  kept  in  mind. 
I  use  this  expression  advisedly  :  it  would  be  worse  than  folly 
even  to  hint  at  such  a  possibility  to  the  parents  until  other  much 
stronger  evidence  has  appeared. 

Exactly  the  reverse  is  the  story  in  some  cases.  l  My  baby  is 
so  good,  it  never  cries  ' ;  the  imbecile  infant  is  often  abnormally 
placid.  I  am  not  referring  now  to  the  stolid  placidity  which 
characterizes  the  cretin,  the  '  chretien  '  or  '  Christian  '  disposition 
to  which  some  have  traced  the  term  '  cretin  '.  Perception  would 
seem  to  be  so  dull  in  many  varieties  of  idiocy  that  the  ordinary 
stimuli  fail  to  produce  the  usual  result,  and  the  mother  mistakes 
for  '  goodness  '  what  is  merely  dullness. 

In  later  infancy  and  in  early  childhood  the  tendency  to  rhyth  • 
mic  movements  which  is  so  often  to  be  seen  in  older  imbecile 
children  becomes  noticeable.  The  child  will  sit  rocking  the 
trunk  to  and  fro  with  only  slight  pauses  for  hours  together,  or 
turning  the  head  slowly  from  side  to  side  as  in  negation  ;  and 
sometimes  such  movements  are  accompanied  with  a  crooning 
sound.  These  rhythmic  movements  in  young  children  are  not 
necessarily  indicative  of  imbecility,  they  are  seen  in  children  who 
are  in  nowise  mentally  deficient,  but,  as  I  have  pointed  out  else- 
where, they  are  even  then  apt  to  be  associated  with  some  eccen- 
tricity or  oddness  of  temperament. 

Akin  to  these  movements  is  another  curious  habit  of  some 
imbeciles,  the  passing  slowly  to  and  fro  of  the  outspread  fingers 
in  front  of  the  eyes  ;  this  is  done  in  such  a  position  usually  that 
the  fingers  are  between  the  face  and  the  window  or  other  source 
of  light.  The  children  who  do  this  have,  I  think,  always  some  con- 
siderable defect  of  vision,  and  the  explanation  which  Mr.  Donald 
Gunn,  formerly  ophthalmic  surgeon  at  the  Children's  Hospital, 
Great  Ormond  Street,  has  suggested  to  me  seems  a  reasonable 


MENTALLY  DEFICIENT  CHILDREN  587 

one  :  the  child  being  unable,  owing  to  its  defective  sight,  to  see 
and  take  pleasure  in  the   complex  details  of  its  surroundings, 
derives  pleasure  from  the  simple  alternation  of  light  and  dark- 
ness produced  by  the  fingers  ;   perhaps  also  in  part  from  the 
feeling  that  he  controls  this  phenomenon  himself. 

Classification.     Various  attempts  have  been  made  to  classify 
imbeciles,  and  I  know  of  no  scheme  that  is  wholly  satisfactory. 
Even  such  a  rudimentary  distinction  as  congenital  or  acquired  is 
impossible  in  many  cases.     A  common  history  is  such  as  this : 
Amy  W.,  aged  ten  months,  the  child  of  first  cousins,  had  many 
convulsions  from  the  age  of  three  days  until  the  age  of  three 
months  ;    she  has  had  none  since,  but  now  at  the  age  of  ten 
months  it  is  clear  that  she  is  idiotic.    Who  shall  say  whether  the 
idiocy  has  resulted  from  the  convulsions  or  whether  the   con- 
vulsions were  only  a  symptom  of  a  congenitally  ill-developed 
brain  ?      I  suppose  there  can  be  no  doubt  that  in  the  large 
majority  of  cases  imbecility  is  due  to  developmental  disorders 
during  intra-uterine  life,  but  there  is  a  small  residue  of  cases  in 
which  it  is  undoubtedly  due  to  causes  acting  after  birth,  and 
it  is  at  least  possible  that  it  may  be  due  in  some  cases  to  causes 
acting  during  birth. 

For  practical  purposes  I  think  a  classification  based  as  far  as 
possible  upon  etiology  is  the  most  useful,  and  for  this  reason  it 
seems  well  to  adopt  some  such  grouping  as  that  proposed  by 
Dr.   W.   W.   Ireland,   without   attempting   any   strictly   logical 
classification.      One    may    recognize    the    following    groups    as 
developmental  imbecility. 

Varieties.  Number  out  of  the  total  350. 

Genetous        .........       177 

Mongolian      .........         77 

Microcephalic          ........         22 

Cretin  10 

Hydrocephalic  (sometimes  acquired)       ....  1 

Spastic  (sometimes  acquired)  .....         26 

The  following  may  be  classified  as  acquired  imbecility  : 

Varieties.  Number  out  of  the  total  350. 

Eclamptic         .         . 10 

Epileptic .20 

Inflammatory  .....-••         1 

Syphilitic  mental  degeneration  (general  paralysis)    .         .         4 
Amaurotic  family  idiocy  .....••         0 

Traumatic 2 

Hypertrophic  .         .         .  .         .         •         •         •         0 

It  will  be  seen  that  if  we  omit  the  hydrocephalic  and  spastic 


588  COMMON  DISORDERS  OF  CHILDHOOD 

cases,  most  of  which  should  probably  be  regarded  as  develop- 
mental, no  less  than  288  out  of  the  350  cases  were  developmental, 
and  I  suspect  that  these  figures  understate  the  proportion,  for 
cases  classified  as  eclamptic  or  epileptic  are  open  to  much  uncer- 
tainty as  to  the  acquired  or  developmental  character  of  the 
mental  defect. 

The  above  grouping  calls  for  some  explanation. 

The  term  Genetous  does  not  mean  merely  congenital — micro- 
cephalic  idiocy  is  congenital,  but  it  is  not  genetous  in  the  sense 
here  intended.  Dr.  Ireland  devised  it  for  the  grouping  together 
of  the  residue  of  cases  which  cannot  be  classified  in  a  precise  way 
on  pathological  grounds.  I  have  followed  him  in  this  except 
that  I  have  regarded  the  Mongols  as  a  separate  group  on  account 
of  their  well-defined  clinical  characteristics. 

It  will  be  seen  that  about  half  the  cases  of  imbecility  are  of  the 
genetous  variety:  simple  developmental  imbecility  it  might  be 
called,  for  all  we  can  say  of  the  child  is  that  he  is  born  idiotic 
owing  to  some  unexplained  failure  in  the  development  of  the 
brain.  There  is  nothing  distinctive  in  the  appearance  or  con- 
formation of  imbeciles  of  this  group  ;  great  stress  has  been  laid 
on  the  frequent  occurrence  in  them  of  the  so-called  '  stigmata 
of  degeneration',  the  high,  narrow  or  V-shaped  palate,  the  ill- 
formed  external  ears,  abnormalities  in  shape  or  size  of  the  skull, 
and  congenital  malformations  of  all  kinds. 

Undoubtedly  these  are  of  some  value  as  confirmatory  evidence 
where  there  are  indications  of  mental  deficiency  ;  but  it  would 
be  very  unwise  to  lay  any  great  stress  upon  them,  for  they  are 
frequently  met  with  in  association  with  perfectly  normal  intellect. 

Microcephalic  idiocy  is  merely  a  clinical  grouping,  and  even 
as  such  is  ill-defined  :  as  the  name  implies,  extreme  smallness 
of  the  cranium  is  its  distinguishing  feature,  and  in  a  well-marked 
case  the  type  is  obvious  enough,  the  small  cranium  contrasts 
strangely  with  the  relatively  large  face  below  it,  reminding  one 
of  a  pear  with  the  narrower  end  above  ;  but  what  degree  of 
smallness  of  the  head  constitutes  microcephaly  ?  More  than 
half  the  cases  of  imbecility,  including  all  varieties,  have  the  head 
below  the  normal  size,  but  very  few  of  these  would  be  classified 
as  microcephalic.  In  a  consecutive  series  of  100  imbeciles 
I.  found  that  in  69  the  maximum  circumference  of  the  head  was 
below  the  normal  average  for  the  age  ;  in  43  of  these  the  head  was 
not  less  than  an  inch  below  the  normal ;  only  in  1 1  was  the 
circumference  above  the  normal. 

I  find  in  my  own  notes  that  I  have  usually  classified  a  case 


MENTALLY  DEFICIENT  CHILDREN  589 

as  microcephalic  when  the  maximum  circumference  was  2  inches 
or  more  below  the  normal  average  ;  but  the  measurement  alone 
is  not,  I  think,  sufficient.  I  have  seen  children  whose  head 
must  have  been  fully  2  inches  below  the  normal  average  in 
circumference,  but  it  was  not  out  of  proportion  to  the  face  or 
to  the  rest  of  their  physical  development,  and  the  child's  mental 
condition  was  perfectly  normal ;  it  is  the  disproportion  between 
the  size  of  the  cranium  and  the  size  of  the  face  which  should 
distinguish  the  microcephalic  imbecile.  The  vault  of  the  cranium 
is  arrested  in  its  growth,  whilst  the  other  parts  of  the  skull 
continue  to  enlarge ;  consequently,  as  the  child  grows  older,  the 
forehead  comes  to  slope  backwards  in  a  characteristic  manner. 

Even  when  such  disproportion  is  present  the  degree  of  in- 
telligence does  not  always  correspond  to  the  size  of  the  cranium. 
My  colleague,  Dr.  Thursfield,  showed  me  a  girl  aged  4}§  who  was 
attending  school  and  whose  intelligence  seemed  to  be  almost 
normal  (I  thought  she  was  a  little  too  babyish  for  her  age)  ;  the 
cranium  measured  only  15  J  inches  (4  inches  below  the  normal  !) 
in  circumference  and  was  strikingly  small  in  proportion  to  the 
face,  so  that  the  child  had  the  typical  appearance  of  micro- 
cephaly. 

Some  degree  of  spasticity  of  the  limbs  is  not  infrequent  with 
microcephalic  imbecility.  I  noted  this  association  in  five  out 
of  twenty-one  cases. 

To  classify  an  imbecile  as  microcephalic  is  merely  to  describe 
the  appearance  of  the  patient,  it  tells  us  nothing  of  etiology  or 
pathology,  for  there  are  many  different  causes  which  may  lead 
to  this  arrest  in  growth  of  the  brain,  and  even  the  gross  changes 
are  by  no  means  always  the  same  in  the  brain  of  the  microcephalic 
idiot.  In  some  cases  the  arrest  of  development  affects  the  whole 
brain  uniformly,  in  other  cases  the  arrest  seems  to  affect  only 
parts  of  the  brain ;  for  instance,  in  one  case  I  found  the  occipital 
lobes  normal  on  macroscopic  examination,  whereas  the  parietal 
lobes  were  so  rudimentary  as  to  be  only  just  definable  and  the 
convolutions  of  the  frontal  region  were  extremely  minute. 
In  some  cases  the  only  abnormality  found  has  been  an  unduly 
small  brain  with  the  convolutions  much  less  complex  than 
normal,  in  others  there  is  obvious  sclerosis  of  all  or  part  of  the 
convolutions.  Sometimes  in  spite  of  the  small  size  of  the  head 
hydrocephalus  has  been  found  in  the  microcephalic  brain. 

Nor  if  we  turn  to  etiology  has  microcephaly  any  more  distinc- 
tive a  significance.  I  have  seen  well-marked  microcephaly 
associated  with  congenital  syphilis,  and  the  late  Dr.  Ash  by 


590  COMMON  DISORDERS  OF  CHILDHOOD 

recorded  a  case  in  which  post  mortem  examination  of  a  syphilitic 
infant  with  microcephaly  showed  some  endarteritis  narrowing 
the  lumen  of  the  vessels ;  but  probably  only  a  very  small  minority 
of  cases  of  microcephalic  imbecility  are  due  to  syphilis.  I  had 
under  my  observation  twin  sisters,  both  microcephalic  and 
both  spastic  ;  there  was  no  evidence  of  syphilis.  Dr.  Ireland 
quotes  a  record  of  four  microcephalic  idiots  in  one  family  and 
of  five  in  another. 

In  most  cases  of  microcephaly  the  fontanelles  close  very  early. 
I  have  found  the  anterior  fontanelle  in  such  a  case  completely 
closed  at  the  age  of  six  months,  but  it  is  clear  that  this  is 
not  the  cause  of  the  arrested  development  of  the  brain,  for 
I  have  found  the  fontanelle  still  open  at  the  age  of  two  years 
and  five  months  in  a  case  of  microcephalic  idiocy.  It  is  but 
a  few  years  since  operations  were  done  for  the  relief  of  this 
form  of  idiocy  by  removing  a  coronal  strip  of  bone  from 
the  vault  of  the  cranium  with  the  idea  of  allowing  the  brain 
freedom  to  expand  :  the  operation  was  based  on  erroneous 
pathology.  The  hindrance  to  the  development  of  the  brain  lies 
not  in  any  mechanical  restriction  by  too  early  closure  of  sutures, 
but  in  some  fault  of  intra-uterine  origin,  in  some  cases  perhaps 
an  interference  with  the  blood-supply  to  the  developing  brain, 
in  other  cases  perhaps  the  influence  of  some  poison  carried  in 
the  maternal  blood  to  the  growing  structures  of  the  embryo 
or  foetus. 

Hydrocephalic  idiocy  requires  no  explanation.  In  some 
cases  it  is  found  where  the  hydrocephalus  is  of  congenital  origin, 
and  presumably  the  impairment  of  mental  function  also  dates 
from  birth  ;  in  other  cases  the  hydrocephalus  has  been  acquired, 
usually  as  the  result  of  cerebro-spinal  or  posterior  basic  meningitis, 
and  the  child  previously  intelligent  has  become  mentally  defective 
from  the  pressure  of  the  ventricular  distension  upon  the  cortex. 
It  is,  however,  surprising  how  seldom  mental  deficiency  results 
from  this  cause ;  even  with  enormous  hydrocephalus  where 
post  mortem  shows  extreme  thinning  of  the  cortex,  the  mental 
function  is  sometimes  injured  very  little  if  at  all. 

Spastic  or  paralytic  idiocy  is  the  condition  which  is  so  often 
associated  with  the  cerebral  palsies  of  childhood  ;  and  with  no 
form  more  often  than  with  spastic  diplcgia.  Both  spastic 
diplegia  and  spastic  paraplegia  are  usually  of  congenital  origin, 
so  that  the  mental  deficiency  in  such  cases  must  be  considered 
as  belonging  to  the  developmental  group,  but  in  the  more 
common  form  of  spastic  cerebral  palsy,  infantile  hemiplegia,  the 


MENTALLY  DEFICIENT  CHILDREN  591 

condition  is  usually  of  post-natal  origin,  and  the  accompanying 
mental  deficiency  will  then  fall  into  the  group  of  acquired 
mental  defects.  In  this  latter  variety  of  spastic  palsy,  especially 
when  it  is  of  post-natal  origin,  the  mental  defect  is  seldom  very 
marked,  the  child  is  apt  to  be  too  facile,  too  easily  pleased  and 
too  ready  to  make  friends  with  strangers,  but  any  degree  of 
mental  defect  which  would  be  described  as  idiocy  is  quite  the 
exception,  whereas  in  spastic  diplegia  the  mental  affection  is 
usually  considerable,  amounting  sometimes  even  to  complete 
fatuity. 

With  spastic  paraplegia  the  degree  of  mental  defect  is  less 
as  a  rule  than  with  spastic*  diplegia,  but  more  than  with  infantile 
hemiplegia. 

I  have  already  mentioned  that  microcephaly  is  often  associated 
with  some  degree  of  spasticity.  It  would  seem  indeed  as  if  the 
pathological  process  which  arrests  the  development  of  the  brain 
in  the  microcephalic  idiot  is  in  some  cases  very  similar  to,  if  not 
identical  with,  that  which  occurs  in  the  spastic  paralysis  of  child- 
hood in  which  the  cranium  is  usually  below  the  normal  size,  and 
the  naked-eye  appearances  of  the  brain  are  similar,  sclerosis  and 
shrinking  of  convolutions  being  prominent  changes  in  both 
conditions. 

Eclamptic  and  epileptic  idiocy.  Turning  now  to  the 
varieties  of  acquired  imbecility,  I  have  adopted  Ireland's  distinc- 
tion between  eclamptic  and  epileptic  imbecility  :  meaning  by 
eclamptic  that  imbecility  which  may  be  produced  by  a  severe 
bout  of  convulsions,  and  by  epileptic  the  idiocy  which  results 
from  chronic  recurring  epilepsy  :  in  the  former  case  the  mind  is 
wrecked  by  a  single  storm,  in  the  latter  it  degenerates  owing 
to  a  series  of  shocks. 

I  have  already  referred  to  the  extreme  difficulty  which  there 
is  in  determining  whether  idiocy  is  the  result  of  either  of  these 
two  causes,  or  is  merely  an  associated  symptom  of  some  con- 
genital abnormality  of  brain.  Probably  in  many  cases  where 
imbecility  in  a  child  is  attributed  to  either  of  these  causes,  the 
abnormal  condition  of  the  brain  was  really  developmental  and 
therefore  congenital. 

Amongst  my  own  notes  I  can  find  very  few  instances  with 
satisfactory  proof  that  idiocy  resulted  from  a  bout  of  con- 
vulsions ;  to  prove  such  a  connexion  it  would  be  necessary  to  have 
clear  evidence  that  the  child  was  mentally  normal  before  the 
convulsions,  and  this  is  just  what  it  is  most  difficult  to  ascertain. 
The  cases  I  have  grouped  as  eclamptic  were  only  possibly  of  this 


592  COMMON  DISORDERS  OF  CHILDHOOD 

nature  ;  several  had  had  many  convulsions  during  the  first  few 
weeks  of  infancy,  e.  g.  Fred  M.,  aged  two  years,  was  much 
asphyxiated  at  birth  and  had  convulsions  from  birth  till  four 
months  old  ;  since  then  there  have  been  no  more  convulsions, 
the  child  is  now  a  fatuous  idiot.  In  these  cases  with  convulsions 
during  the  first  few  months  after  birth  it  cannot  be  denied  that 
the  mental  deficiency  may  have  resulted  from  the  convulsions, 
but  it  is  impossible  to  prove. 

In  the  following  case  there  was  some  evidence  that  the  child 
had  had  some  intelligence  before  the  convulsive  attack. 

Ernest  T.,  aged  2|  years,  had  begun  to  stand  at  nine  months  and  to  talk 
at  twelve  months  old  ;  he  was,  however,  only  using  single  words  at  the  age 
of  2£  years,  and  had  never  acquired  clean  habits,  when  a  severe  convulsion 
occurred  which  lasted  four  hours,  and  was  followed  by  much  screaming  for 
a  fortnight.  Since  this  time  he  has  been  completely  idiotic,  making  meaning- 
less noises  and  taking  very  little  notice. 

A  more  convincing  case  is  one  which  I  have  described  else- 
where (p.  660)  in  which  the  child  had  learnt  to  walk  and  talk 
at  the  usual  age,  and  had  seemed  perfectly  bright  and  intelligent 
up  to  two  years  and  eleven  months,  when  a  bout  of  convulsions 
followed  by  others  occurred,  and  the  child  became-idio'.ic. 

In  estimating  the  part  played  by  convulsions  or  by  epilepsy 
in  the  causation  of  idiocy,  it  must  be  remembered  that  these  are 
common  in  cases  where  it  is  quite  certain  that  the  child  was 
mentally  defective  before  they  began.  Out  of  239  imbeciles 
I  found  that  101  had  had  convulsions  or  epileptic  attacks  at 
some  time  or  other,  mostly  in  infancy  ;  but  only  in  30  of  these 
101  cases  did  it  seem  likely  that  the  mental  defect  might  be  the 
result  either  of  the  convulsions  or  of  the  epilepsy. 

Epilepsy  is  much  more  often  productive  of  mental  defect 
when  it  occurs  in  infancy  than  when  it  occurs  in  later  childhood  ; 
and  I  fancy  from  my  own  observation  that  petit  mal  in  an 
infant  is  of  more  gloomy  prognosis  in  this  respect  than  major 
attacks.  The  infant  who  has  sudden  attacks  of  momentary  loss 
of  consciousness,  with  the  head  falling  forward  on  the  chest, 
or  with  a  momentary  spasmodic  flexion  of  the  trunk,  almost 
always  becomes  more  or  less  mentally  defective.  Such  attacks 
are,  I  think,  certainly  precipitated  by  the  worry  of  dentition 
in  infants  predisposed  to  epilepsy,  and  they  sometimes  cease  when 
dentition  ceases  ;  but  the  mental  ruin  is  irreparable  ;  the  child 
may  become  decidedly  brighter  when  the  attacks  cease,  but  I  have 
never  seen  restoration  to  normal  intelligence. 

Inflammatory   idiocy,   that    is,   idiocy  depending    upon   en- 


MENTALLY  DEFICIENT  CHILDREN  593 

cephalitis  or  meningo-encephalitis,  is  a  condition  of  post-natal 
onset.  In  some  cases  it  is  probably  identical  in  its  pathology 
with  those  cases  of  infantile  hemiplegia  in  which  as  the  result 
of  some  infection  an  acute  polioencephalitis  occurs  affecting 
the  motor  area.  If  this  process  be  more  extensive,  there  will 
be  not  only  spastic  hemiplegia  but  also  mental  deficiency,  as 
sometimes  happens  ;  but  if  the  encephalitis  be  confined  to  other 
parts  of  the  cortex,  the  mental  functions  may  be  affected  alone. 
It  is  noteworthy  that  just  as  infantile  hemiplegia  sometimes 
occurs  directly  after  one  of  the  specific  fevers,  so  imbecility 
occasionally  comes  on  after  measles  or  some  other  specific  fever, 
and  is  perhaps  in  such  cases  due  to  encephalitis.  I  have  very 
little  doubt  that  such  an  encephalitis  occurred  in  the  following 
case. 

A  boy  aged  If  years,  a  bright  healthy  child,  was  seized  with  convulsions 
whilst  out  in  his  perambulator  ;  the  temperature  was  raised,  and  a  few  hours 
later  reached  105° ;  in  spite  of  vigorous  treatment  with  ice-bags,  bromide, 
chloral,  &c.,  the  child  remained  for  more  than  a  week  in  a  semi-comatose, 
convulsive  condition,  with  some  general  rigidity  and  occasional  clonic  spasms  ; 
lumbar  puncture  gave  no  information  ;  after  several  weeks  the  rigidity  passed 
off,  the  knee-jerks  were  normal,  and  the  plantar  response  was  flexion ;  the  child 
began  to  take  some  notice  of  surroundings,  but  there  was  very  little  return  of 
intelligence;  the  child  remained  completely  idiotic,  and  when  seen  again 
four  years  later  could  not  have  been  distinguished  from  a  genetous  idiot. 

Traumatisxn  is  probably  invoked  as  an  explanation  of  mental 
deficiency  far  more  often  than  the  facts  would  justify,  but  rare 
though  they  may  be,  cases  do  occur  in  which  a  blow  upon  the 
head  results  in  mental  defect. 

Cecil  A.,  aged  2T11?  years,  fell  off  his  chair  twelve  months  before  admission 
to  the  hospital,  and  struck  the  back  of  his  head  against  the  fender.  From 
that  time  he  gradually  lost  the  power  of  speech  and  walking,  which  he  had 
previously  acquired,  and  ten  months  later  he  began  to  have  '  twitchings  ' 
with  tenderness  over  the  back  of  the  head  and  much  excitability.  During 
the  six  weeks  preceding  admission  he  had  fits  with  increasing  frequency  until 
about  thirty  occurred  per  diem.  He  now  seemed  dull,  with  evident  mental 
deterioration,  he  was  quite  conscious,  but  took  no  interest  in  his  surroundings ; 
his  temperature  for  three  weeks  after  admission  was  raised  and  irregular, 
then  it  became  normal  for  nearly  three  weeks,  rising  again  to  103°  and  104° 
for  a  week  before  death.  During  the  last  few  weeks  of  life  the  child  became 
rigid  and  apparently  blind,  and  there  was  frequent  vomiting.  The  f undus  oculi 
was  normal.  Post  mortem  examination  showed  all  over  the  occipital  and 
parietal  regions  of  both  sides  extensive  thrombosis  of  veins,  which  were  hard 
like  whipcord  and  pale;  the  thrombosis  was  evidently  not  of  recent  occurrence, 
but  it  was  uncertain  whether  it  could  have  occurred  so  long  as  fourteen 
months  before  death,  the  date  of  the  fall.  There  was  no  gross  meningitis, 
the  pia  mater  on  the  vertex  and  under  surface  of  the  frontal  lobe  was  slightly 

STILI,  Q  q 


594  COMMON  DISORDERS  OF  CHILDHOOD 

more  opaque  than  normal,  the  convolutions  were  markedly  wasted,  so  that 
the  sulci  gaped  between  them,  the  superficial  part  seemed  unusually  soft, 
while  the  deeper  part  felt  much  harder  than  normal,  and  was  evidently 
sclerosed  ;  the  only  part  of  the  brain  which  seemed  normal  was  the  cerebellum, 
which  looked  unusually  large  by  contrast  with  the  small,  wasted  cerebrum. 

Syphilitic  mental  degeneration.  Acquired  imbecility,  or 
more  properly  speaking  mental  degeneration,  as  a  result  of 
congenital  syphilis  is  now  considered  identical  in  some  cases, 
if  not  in  all,  with  general  paralysis  of  the  insane,  and  is  described 
as  juvenile  general  paralysis.  I  confess  I  do  not  altogether  like 
the  term  'general  paralysis '  applied  to  these  cases, for  it  has  come 
to  suggest  a  chronic  affection,  whereas,  as  I  shall  show,  a  similar 
pathological  change  may  occur  as  an  acute  disease  in  children. 
I  have  notes  of  seven  such  cases  which  ran  the  ordinary  chronic 
course  :  four  girls  aged  respectively  four,  four  and  a  half,  nine,  and 
about  eight  years,  and  three  boys,  two  aged  seven  years,  and  one 
aged  ten  years  at  the  time  of  the  onset,  all  showing  well-marked 
evidence  of  congenital  syphilis.  The  history  in  these  cases 
is  this  :  usually  after  the  age  of  five  years,  at  some  time  in  the 
later  half  of  childhood,  the  child  becomes  dull  and  slow,  then 
perhaps  complains  of  headache,  and  begins  to  lose  his  memory, 
the  speech  also  becomes  slow  and  thick,  and  epileptiform  attacks, 
if  not  the  earliest  symptom,  are  likely  to  occur  at  some  period  of 
the  disease,  the  legs  gradually  become  weak  and  the  gait  un- 
certain, the  pupils  may  be  unequal  ;  in  two  of  my  cases  the  sight 
was  impaired  from  optic  atrophy  associated  with  choroiditis. 
The  knee-jerks  in  some  cases  are  much  increased.  Sooner  or 
later  some  rigidity  of  limbs  appears,  the  child  becomes  more 
and  more  demented,  is  unable  even  to  sit  up  and  lies  in  bed 
becoming  gradually  emaciated,  and  usually  within  three  or  four 
years  after  the  onset  dies  of  exhaustion. 

The  brain  in  these  cases  shows  opacity  and  slight  thickening 
of  the  pia  mater,  sometimes  adhesions  of  the  dura  mater,  some 
sclerosis  and  atrophy  of  the  convolutions  and  often  some 
dilatation  of  the  ventricles  ;  there  is  apparently  a  meningo- 
encephalitis. 

In  the  seven  cases  to  which  I  have  referred,  the  affection  ran 
a  chronic  course,  only  one  was  under  observation  until  death 
at  the  end  of  two  years,  in  the  others  the  affection  had  already 
lasted  periods  varying  from  six  months  to  two  years.  But 
I  doubt  if  the  disease  is  always  of  such  long  duration.  I  have 
seen  one  case  in  which  exactly  similar  pathological  changes 
were  found  after  seven  weeks'  illness,  and  another  in  which 


MENTALLY  DEFICIENT  CHILDREN  595 

the  symptoms  were  of  only  thirteen  days'  duration.     I  shall 
quote  the  description  I  have  given  elsewhere  1. 

A  boy  aged  twelve  months,  who  had  had  snuffles  at  the  age  of  five  weeks, 
with  severe  thrush  and  subsequently  some  rash  about  the  buttocks,  and  whose 
eyes  showed  choroido-retinitis  and  opacities  of  the  vitreous,  was  admitted  to 
hospital  for  convulsions  with  rigidity  and  wasting ;  he  died  after  seven  weeks' 
illness.  I  found  the  dura  mater  adherent  to  the  pia  mater  chiefly  at  the 
vertex,  with  small  haemorrhages  on  the  inner  side  of  the  dura,  which  was 
much  thickened  ;  the  pia  was  slightly  thickened,  especially  in  the  neighbour- 
hood of  the  blood-vessels  on  the  surface  of  the  brain  ;  the  convolutions  showed 
a  dirty  yellowish  coloration  and  were  hard  and  in  places  shrunken ;  the  cere- 
bellum was  normal. 

Wilfred  S.,  aged  ten  years  and  eleven  months,  was  born  with  pemphigus, 
the  details  of  his  infancy  otherwise  were  unknown.  Later  he  had  interstitial 
keratitis.  Ten  days  before  admission  to  hospital  under  the  care  of  Dr.  Lees 
he  had  severe  frontal  headache  and  vomited,  some  days  later  he  had  a  fit 
and  another  on  the  day  of  admission.  He  died  three  days  after  coming  into 
the  hospital. 

The  pia  mater  was  thickened,  grey,  fibrous,  and  opaque  over  the  left  side 
of  the  vertex  of  the  brain  and  also  about  the  quadrate  space  and  the  sylvian 
fissures  at  the  base ;  there  was  some  sclerosis  and  wasting  of  one  convolution 
in  the  right  frontal  region.  The  pia  mater  down  the  posterior  surface  of  the 
cord  was  somewhat  thickened.  There  was  no  exudation  of  lymph ;  in  fact, 
none  of  the  ordinary  appearances  of  acute  meningitis. 

I  quote  these  two  cases  to  show  that  the  clinical  course  of  the 
disorder  known  as  'general  paralysis  '  may  be  very  acute.  No 
doubt  the  pathological  process  may  be,  as  in  the  former  of  the 
two  cases  just  mentioned,  of  much  longer  duration  than  the 
clinical  symptoms  ;  it  is  only  in  those  that  last  longer  that 
the  dementia  becomes  a  prominent  symptom.  Dr.  Ashby 
reported  a  case  in  which  complete  idiocy  resulted  from  meningo- 
encephalitis  in  a  syphilitic  infant ;  the  disease  began  with  convul- 
sions at  eight  months  old  and  ended  fatally  after  lasting  six  months. 

With  regard  to  the  two  remaining  groups  of  acquired  imbecility 
I  shall  say  very  little,  for  they  are  extremely  rare. 

Hyper-trophic  idiocy.  Under  the  name  of  hypertrophic 
imbecility  have  been  recorded  cases  in  which  the  child  has 
been  normal  until  a  year  or  two  old,  when  he  has  begun  to  suffer 
with  headache  and  has  become  progressively  duller,  and  has  died 
usually  before  puberty.  In  other  cases  the  course  has  been 
similar  except  that  the  child  has  always  had  a  large  head  and 
been  backward  ;  on  post  mortem  examination  the  brain  has 
been  found  exceptionally  large  and  heavy  with  no  hydrocephalus 
but  with  increase  of  neuroglia.  I  have  seen  several  imbeciles 
with  heads  considerably  above  the  normal  size,  cases  which  I 
1  Power  and  Murphy,  System  of  Syphilis,  i,  p.  324. 
Qq2 


596  COMMON  DISORDERS  OF  CHILDHOOD 

thought  might  be  of  the  hypertrophic  variety  ;  but  I  have 
satisfied  myself  from  clinical  and  pathological  observation  that 
it  is  not  possible  to  exclude  the  presence  of  hydrocephalus 
merely  from  the  shape  of  the  head,  so  that  without  post 
mortem  examination  the  diagnosis  of  this  variety  cannot  be 
made  with  any  certainty. 

Amaurotic  family  idiocy  I  have  only  twice  seen.  One  case 
was  that  of  a  Jewish  infant  who  was  one  of  a  family  of  twelve 
children,  of  whom  four  others  had  died  with  this  disease.  The 
infant,  whom  I  saw  with  Dr.  J.  M.  Twentyman,  had  been  healthy 
for  several  months  after  birth  and  then  had  gradually  become 
more  and  more  dull  and  fatuous,  and  then  rigid  in  its  limbs ;  the 
eyes  showed  the  characteristic  cherry-red  spot  in  the  macular 
region  of  the  fundus.  The  infant  died  when  it  was  two  years  old. 

The  second  was-  also  in  a  Jewish  child,  a  girl,  who  at  the  age 
of  four  months  was  noticed  to  be  weak  in  the  back.  This  weak- 
ness increased  slowly,  and  sight  seemed  to  be  lost.  Some  spas- 
ticity  had  appeared  by  the  time  the  child  was  eighteen  months 
old.  The  typical  cherry-red  spot  was  easily  seen  at  the  macula 
lutea  in  both  eyes.  The  child's  mental  condition  seemed  to  be 
already  completely  fatuous  by  the  time  she  was  eleven  months 
old.  She  was  the  first  child  of  the  family. 

The  course  of  this  disease  is  invariably  progressive  towards 
a  fatal  end  at  about  two  years  of  age.  Its  morbid  anatomy 
has  been  investigated  carefully  by  several  observers,  but  beyond 
the  fact  of  degenerative  changes  in  the  brain,  nothing  has  been 
found  to  explain  its  origin  ;  its  limitation  almost  exclusively 
to  the  Jewish  race,  and  its  occurrence  in  several  children  of 
a  family,  but  only  in  one  generation,  are  very  remarkable. 

Causes  of  Mental  Deficiency 

Apart  from  the  possible  causes  of  mental  defect  which  I  have 
already  mentioned  in  connexion  with  particular  types  of  im- 
becility, there  are  some  more  general  causes  which  are  worthy  of 
consideration. 

Alcoholism  in  either  parent  is,  I  believe,  a  potent  cause  of 
mental  deficiency  in  their  offspring.  It  is  difficult,  however, 
to  prove  the  connexion  by  any  statistics.  I  inquired  carefully 
from  the  mothers  in  fifty  cases ;  in  fourteen  of  these  the  father 
was  said  to  be  drunk  more  or  less  frequently  ;  the  complete 
absence  of  intemperance  in  the  mother  is  no  doubt  unreliable 
as  she  was  the  person  questioned.  Tredgold  l  obtained  a  history 
of  alcoholism  *  in  the  antecedents  '  in  46-5  per  cent,  of  his  150 
cases,  but  noted  a  point  which  is  probably  of  importance,  that 
1  Archives  of  N enrol.,  vol.  ii,  p.  328. 


MENTALLY  DEFICIENT  CHILDREN  597 

there  was  also  in  most  of  these  cases  a  family  history  of  insanity 
or  other  neuropathic  taint.  Some  of  my  cases  showed  parental 
alcoholism  with  no  other  evidence  of  neuropathic  inheritance. 

There  is  experimental  evidence 1  that  alcohol  in  the  mother's 
blood  not  only  reaches  the  fcetal  circulation,  but  may  cause 
malformations  in  the  foetus  ;  one  may  conjecture  that  if  alcohol 
can  modify  the  gross  physical  structure  it  must  still  more  readily 
cause  the  fine  changes  in  the  brain  which  are  sufficient  to  cause 
mental  defect. 

The  influence  of  paternal  alcoholism  is  not  capable  of  explana- 
tion, but  as  the  finest  peculiarities  of  feature  can  be  transmitted 
from  the  father  to  the  child,  it  seems  likely  enough  that  any 
toxic  condition  in  him  may  affect  the  development  of  the  child. 

Syphilis  plays,  I  think,  a  larger  part  in  the  production  of 
idiocy  than  has  been  supposed.  Amongst  my  350  cases  of  mental 
deficiency,  there  were  13  cases  of  undoubted  congenital  syphilis 
and  4  others  were  children  of  probably  syphilitic  parents  ;  so 
that  syphilis  was  a  possible  factor  in  the  causation  of  mental 
deficiency  in  nearly  6  per  cent,  of  the  cases.  The  results  of  the 
Wassermann  test  have  been  so  widely  different  in  the  hands  of 
different  observers,  that  it  is  difficult  to  know  what  value  to 
attach  to  them  :  Dean  found  15  per  cent,  positive  ;  Findlay  and 
Robertson  found  59  per  cent,  positive.2  To  state  the  pro- 
portion of  cases  of  mental  defect  showing  congenital  syphilis, 
however,  is  only  to  compare  the  frequency  of  syphilis  with  that 
of  other  causes  of  idiocy  ;  it  is  at  least  as  important  to  ascertain 
the  frequency  of  mental  defect  in  congenital  syphilis.  Out 
of  142  consecutive  cases  of  congenital  syphilis  I  found  10  showing 
either  congenital  idiocy  or  subsequent  mental  degeneration, 
a  proportion  of  7  per  cent. 

The  congenital  mental  defect  produced  by  syphilis  is  not 
always  of  one  type  :  amongst  the  syphilitic  cases  mentioned, 
most  were. '  genetous  ',  but  two  were  Mongols,  one  was  paralytic, 
one  was  microcephalic. 

The  occasional  association  of  parental  syphilis  with  Mongolian 
imbecility  in  the  offspring,  and  the  still  more  rare  occurrence  of 
actual  evidence  of  syphilis  in  the  Mongol  imbecile  himself,  are 
interesting  as  throwing  some  light  upon  the  relation  of  syphilis 
to  imbecility.  It  is  quite  certain  that  in  the  large  majority  of  cases 
Mongolian  imbecility  occurs  where  there  is  no  reason  whatever 
to  suspect  syphilis  either  in  parent  or  child,  and  the  small,  too 
simply  convoluted  brain  suggests  simply  a  hypoplasia  of  brain 
as  if  Nature  had  lacked  the  energy  to  make  a  brain  of  the 
usual  size  and  complexity.  And,  indeed,  this  suggestion  may 
1  Vide  Ballantyne's  Ante-natal  Pathology  :  The  Foetus,  pp.  273,  274. 
*  Glasgow  Med.  Journ.,  Dec.  1914. 


$ 

598  COMMON  DISORDERS  OF  CHILDHOOD 

• 

be  nearer  the  truth  than  its  unteehnical  form  would  imply,  for 
it  is  well  known  that  this  particular  type  of  imbecility  occurs 
usually  in  children  who  are  born  when  the  mother  is  already 
approaching  or  past  the  age  of  forty  years,  and  is  therefore  nearing 
the  end  of  her  reproductive  period ;  the  Mongolian  imbecile  is  an 
exhaustion  product. 

It  seems  probable,  therefore,  that  syphilis,  when  it  occurs  in 
such  cases,  acts  not  by  producing  any  specific  syphilitic  disease 
in  the  child  or  in  its  brain,  but  by  impairing  the  mother's  power 
of  reproduction,  just  as  advancing  age  or  even  the  strain  of 
domestic  anxiety  may  do.  The  influence  may  thus  be  indirect. 
In  some  cases,  however,  it  is  certainly  direct.  As  Dr.  Ballantyne  l 
has  pointed  out,  a  poison  acting  upon  the  growing  structures  in 
a  very  early  stage  of  intra-uterine  life  tends  to  cause  malforma- 
tions or  abnormalities  of  development  :  the  same  poison  acting 
upon  the  fully  or  almost  fully  developed  structure  will  produce 
diseases  like  those  of  post-natal  life.  I  have  already  referred  to 
a  case  in  which  microcephaly  in  a  syphilitic  infant  was  associated 
with  narrowing  of  the  blood-vessels  by  syphilitic  endarteritis. 

In  some  cases  of  imbecility  with  syphilis  the  occurrence  of 
actual  syphilitic  disease  of  the  nervous  system  at  some  period  of 
i rit ra -uterine  life  is,  I  think,  suggested  by  examination  of  the 
fundus,  which  often  shows  syphilitic  choroiditis  ;  and  this  in 
some  infants  is  almost  certainly  of  intra-uterine  origin. 

And  here  let  me  emphasize  the  importance  of  ophthalmoscopic 
examination  in  determining  the  cause  of  mental  defect.  I  have 
notes  of  cases  in  which  one  might  have  puzzled  in  vain  over 
the  problem  had  not  examination  of  the  eyes  revealed  a  retino- 
choroiditis,  which  in  a  young  child  may  probably  be  taken 
as  proof  positive  of  syphilis.  Opacities  in  the  vitreous,  and 
remains  of  former  iritis,  may  point  in  the  same  direction.  I  have 
already  mentioned  the  red  cherry-tinted  discoloration  of  the 
macula  lutea  which  is  to  be  seen  in  amaurotic  family  idiocy. 
I  have  once  or  twice  found  coloboma  of  the  choroid  in  imbeciles, 
which  was  at  any  rate  interesting  as  indicating  that  the  mental 
condition  was  also  due  to  developmental  defect,  and  could  not  be 
referred  to  any  asphyxia  at  birth  or  to  any  of  the  causes  of 
acquired  mental  defect. 

Asphyxia.  That  asphyxia  at  birth  can  produce  mental 
deficiency  I  have  little  doubt,  but  it  is  impossible  to  prove. 
Out  of  1.33  cases  in  which  I  investigated  this  point  25  had 
suffered  with  asphyxia  at  birth. 

It  seems  that  in  some  of  these  cases  the  mental  defect  is  due 
to  ha3morrhage  damaging  the  brain  substance,  just  as  paralysis 
1  Ante-natal  Pathology:  The  Embryo,  chap.  i. 


MENTALLY  DEFICIENT  CHILDREN  599 

may  be  due  to  haemorrhage  from  venous  congestion,  for  instance, 
in  whooping-cough.  If  this  were  so  one  would  expect  that  in 
some  cases  paralysis  might  be  associated  with  the  mental  defect 
due  to  this  cause  ;  and  this  does  happen.  There  was  spastic 
paralysis  of  limbs  in  three  of  the  twenty-five  cases  mentioned, 
and  in  two  out  of  these  three  cases  it  was  specially  noticed  that 
the  asphyxia  had  been  very  severe. 

But  without  haemorrhage  it  seems  quite  likely  that  prolonged 
non-aeration  of  the  blood  may  have  a  toxic  effect  upon  the  cells 
of  the  brain,  and  at  this  early  age  may  so  affect  their  function 
that  idiocy  results. 

Instrumental  labour.  The  relation  of  asphyxia  in  the  new- 
born to  idiocy  is  closely  connected  with  another  possible  factor 
at  the  time  of  birth,  namely,  instrumental  labour.  It  is  natural 
enough  that  a  mother  seeing  her  infant's  head  deeply  indented 
and  perhaps  severely  lacerated  by  forceps  should  attribute  any 
subsequent  defect  to  injury  from  this  source  ;  but  is  there  any 
evidence  to  support  this  view  ?  It  is  clear  that  certain  forms  of 
imbecility  cannot  possibly  be  due  to  this  cause,  for  instance, 
Mongolism,  cretinism,  hydrocephalic  idiocy,  traumatic  idiocy 
due  to  post-natal  traumatism,amaurotic  imbecility ,  and  syphilitic 
mental  degeneration  ;  but  in  the  genetous,  paralytic,  and 
microcephalic  varieties,  and  in  that  very  doubtful  group  of  the 
cases  in  which  convulsions  or  epilepsy  may  be  the  cause  or  may 
be  the  manifestation  of  the  abnormal  brain  condition,  instru- 
mental labour  might  conceivably  be  the  cause. 

If  it  could  be  shown  that  instrumental  labours  were  much 
more  frequent  in  these  varieties  of  idiocy  than  in  cases  of  normal 
intelligence,  this  would  at  least  be  strongly  suggestive  ;  and 
my  own  figures  show — I  must  say  contrary  to  my  own  pre- 
conceived idea — that  instrumental  labour  figures  with  such 
remarkable  frequency  in  the  history  of  imbeciles  of  these  classes, 
that  the  possibility  of  mere  coincidence  is,  I  think,  quite  excluded. 
I  investigated  136  cases  (including  98  genetous,  13  spastic  or 
paralytic,  10  microcephalic,  8  epileptic,  and  7  eclamptic)  :  no 
less  than  28  out  of  the  136,  that  is  20-5  per  cent.,  were  instrumental 
labours  (21  out  of  the  98  genetous,  4  of  the  13  spastic,  1  micro- 
cephalic,  1  eclamptic  and  1  epileptic). 

The  significance  of  these  figures  is  seen  on  comparison  with 
statistics  of  children  of  normal  intelligence.  At  the  Children's 
Hospital,  Great  Ormond  Street,  excluding  all  cases  of  mental 
deficiency  and  cerebral  palsy,  I  found  that  in  100  consecutive  cases 
there  were  only  3  instrumental  labours,  whilst  amongst  cases 
in  the  Maternity  Department  of  King's  College  Hospital,  amongst 
1.214  children  born,  only  2-2  per  cent,  were  delivered  by  forceps. 


J 

600  COMMON  DISORDERS  OF  CHILDHOOD 

Amongst  the  well-to-do  the  proportion  of  cases  of  instrumental 
delivery  of  children  of  normal  intelligence  would  probably  be 
much  higher  than  this  ;  so  that  in  comparing  idiots  with  normal 
children  with  reference  to  the  effect  of  instrumental  labour, 
it  is  very  necessary  to  compare  children  of  the  same  social  class  ; 
in  the  statistics  on  this  point,  therefore,  I  have  included  only 
cases  seen  in  hospital  practice.  Although  these  figures  go  a  long 
way  to  prove  that  instrumental  labour  is  a  much  more  important 
factor  in  the  production  of  imbecility  than  has  been  supposed 
by  some  observers,  it  must  not  be  assumed  that  traumatism  is 
necessarily  the  modus  operandi  of  the  instrumental  delivery 
in  producing  mental  defect.  It  must  be  remembered  that  the 
labour  which  necessitates  the  use  of  forceps  is  also  one  which  is 
likely  to  result  in  more  or  less  severe  asphyxia,  and  this  rather 
than  traumatism  may  be  the  cause  of  the  mental  condition  ; 
in  nine  out  of  the  twenty-eight  cases  of  instrumental  labour 
there  was  also  more  or  less  severe  asphyxia. 

Consanguinity  of  parents  is  popularly  supposed  to  be  a  potent 
cause  of  idiocy  in  the  offspring.  I  recently  read  in  a  lay  journal 
that  all  children  of  first  cousins  were  idiots  !  Dr.  Tredgold  J 
says  in  regard  to  the  marriage  of  first  cousins,  '  as  a  cause  of 
idiocy  I  do  not  think  this  need  be  seriously  thought  of.'  Probably 
the  truth  is  somewhere  between  these  extremes.  It  is  likely  that 
marriage  of  first  cousins  has  some  influence  in  producing  abnor- 
malities of  one  kind  or  another  in  their  offspring.  My  colleague, 
Dr.  A.  E.  Garrod 2,  has  pointed  out  that  in  cases  of  alkaptcnuria 
the  proportion  of  families  showing  first-cousinship  of  parents 
is  nearly  50  per  cent.  (8  out  of  17  families).  He  quotes  also 
Ascoleo  as  finding  that  in  5  out  of  24  families  in  which  albinos 
occurred  the  parents  were  first  cousins. 

It  may  be  that  consanguinity  of  marriage  only  increases  the 
chance  of  reproducing  abnormalities  which  have  already  been 
present  in  previous  generations  of  the  family,  and  that  when  the 
offspring  of  first  cousins  are  congenitally  imbecile  this  is  merely 
due  to  neuropathic  heredity  in  the  sense  that  consanguineous 
marriage  increases  the  chance  that  a  neuropathic  taint,  like  any 
other  abnormality,  may  reappear  in  the  offspring  :  a  view  which 
would  be  in  accordance  with  Mendel's  law  of  heredity. 

This  view,  however,  would  not  in  any  way  diminish  the  risk 
of  consanguineous  marriage ;  indeed,  considering  the  large  pro- 
portion of  families  in  which  there  is  neuropathic  taint  of  one 
sort  or  another,  it  would  rather  tend  to  emphasize  the  risk  of 
first-cousin  marriages. 

1  Archives  of  Neural.,  vol.  ii.  2  Croonian  Lectures,  Lancet,  July  4,  1908. 


MENTALLY  DEFICIENT  CHILDREN  601 

To  estimate  the  influence  of  consanguinity  we  must  either 
take  a  large  number  of  first-cousin  marriages  and  ascertain  the 
proportion  of  these  which  resulted  in  idiocy,  and  then  compare 
with  these  figures  similar  statistics  in  the  case  of  non-related 
parents,  or  we  may  adopt  the  less  satisfactory  but  more  feasible 
method  of  comparing  the  proportion  of  consanguineous  marriages 
amongst  the  parents  of  idiots  with  the  proportion  amongst  the 
parents  of  families  in  which  there  is  no  idiocy.  It  is  useless  merely 
to  quote  the  proportion  of  cases  of  idiocy  in  which  there  was 
consanguinity  of  parents,  .with  no  standard  of  comparison,  for 
even  if  it  were  assumed  that  the  consanguinity  was  causal,  this 
proportion  would  only  tell  us  how  frequent  consanguinity  is  in 
comparison  with  other  causes  of  idiocy  ;  it  wrould  tell  us  nothing 
whatever  about  the  degree  of  risk  of  idiocy  from  consanguineous 
marriage. 

Dr.  Karl  Pearson's  statistics1  taken  from  observations  collected 
by  Dr.  Garrod,  at  the  Children's  Hospital,  Great  Ormond  Street, 
showed  that  amongst  families  of  the  hospital  class,  that  is,  the 
poorer  class,  there  were  in  700  families  only  0-86  per  cent,  marriages 
of  first  cousins.  Taking  figures  exclusively  from  the  same  class, 
indeed  most  of  them  from  the  same  hospital,  I  found  that 
amongst  166  idiots  the  family  history  showed  seven  first-cousin 
marriages,  that  is,  4-2  per  cent.  If  this  disproportion  is  con- 
firmed by  larger  statistics,  it  can  hardly  be  doubted  that 
first-cousin  marriages  do  play  a  part  in  the  production  of  idiocy. 

I  must  point  out  that  it  is  very  necessary  in  comparing  statis- 
tics on  this  point  to  compare  only  those  which  are  taken  from 
families  in  the  same  social  class,  for  it  is  well  ascertained  that 
first-cousin  marriages  are  considerably  more  frequent  amongst 
the  well-to-do  than  amongst  the  poorer  classes.  It  may  be 
suggested  that  on  this  account  idiocy  should  be  relatively 
commoner  amongst  the  well-to-do  than  amongst  the  poor.  No 
statistics  are  available  on  this  point,  but  it  must  be  remembered 
that  other  factors  such  as  alcoholism  and  syphilis  are  probably 
much  commoner  amongst  the  poor  than  amongst  the  well-to-do, 
and  this  would  tend  to  counterbalance  the  affect  of  consan- 
guinity on  the  relative  frequency  of  idiocy  in  the  two  classes. 

Place  in  family.  There  is  a  factor  in  the  production  of 
imbecility  which  has  attracted  but  little  notice  except  in  the 
cases  of  Mongolism,  namely,  place  in  family.  It  is  well  known 
that  Mongolian  imbecility  occurs  with  much  greater  frequency 
in  children  born  when  the  mother  is  approaching  the  age  of  the 
1  Brit.  Med.  Journ.,  1908,  i,  p.  1395. 


602  COMMON  DISORDERS  OF  CHILDHOOD 

menopause  than  at  an  earlier  age,  and  therefore  this  type  of 
imbecility  is  usually  seen  in  a  child  who  comes  late,  if  not  last, 
in  a  family  :  but  it  is  at  least  as  remarkable  that  in  other  types 
of  imbecility  it  is  the  first  child  of  a  family  who  is  specially 
liable  to  be  affected  :  no  less  than  80  out  of  177  consecutive 
imbeciles  (excluding  all  Mongols)  were  first-born  children.  (In 
these  figures  I  have  been  careful  to  describe  as  first-born  only 
children  who  were  the  result  of  first  pregnancies  ;  I  have  not 
called  a  child  first-born  if  it  was  preceded  by  a  miscarriage.) 

An  explanation  which  suggests  itself  at  once  for  this  special 
incidence  on  the  first-born  is  the  greater  frequency  of  difficult 
labour  and  also  of  asphyxia  in  the  first-born  than  in  later  children ; 
but  my  own  series  of  cases  shows  that  although  in  some  of  the 
first-born  labour  had  been  instrumental  and  in  some  there  had 
been  asphyxia,  in  most  of  them  there  was  no  history  of  either 
difficult  labour  or  asphyxia.  This  explanation  is  also  made  the 
less  probable  by  the  fact  that  some  abnormalities  of  development 
which  are  more  liable  to  occur  in  the  first  pregnancy  than  in 
the  later  ones  could  hardly  be  related  to  any  influence  acting 
at  the  time  of  birth  only  ;  a  striking  illustration  of  this  is  so- 
called  congenital  hypertrophy  of  the  pylorus  which,  whether  it 
be  due  to  abnormality  of  nervous  system  or  to  primary  abnor- 
mality of  muscular  development  in  the  pylorus,  affects  first-born 
children  with  remarkable  frequency  (nearly  half  the  cases). 

The  fact  that  first  children  and  late  or  last  children  are 
specially  apt  to  be  affected  by  abnormalities  of  development, 
mental  and  otherwise,  seems  most  naturally  explained  by  sup- 
posing that  in  the  one  cr.se  the  reproductive  function  in  the 
mother  has  not  yet  become  fully  established,  while  in  the  other 
it  is  already  failing.  The  fault  in  these  cases  seems  to  be  one 
of  maternal  reproductive  function,  not  necessarily  of  general 
health  or  strength  ;  the  mother  whose  first  child  is  imbecile 
is  not  usually  a  very  young  mother  nor  one  whose  health  is 
delicate.  I  inquired  into  the  age  of  the  mother  in  sixty -nine  of 
the  first -born  imbeciles ;  only  five  of  these  were  under  the  age 
of  twenty  years,  including  two  just  under  the  age  of  nineteen, 
when  the  child  was  born ;  most  of  them  were  between  twenty 
and  thirty. 

Nor  is  the  mother  whose  late-born  child  is  a  Mongol  neces- 
sarily in  any  way  unhealthy.  The  mothers  of  Mongols  are 
commonly  healthy  women,  their  failure  is,  so  to  speak,  merely 
physiological  ;  the  reproductive  power  is  flagging  before  it 
ceases  altogether.  It  is  probable  in  both  cases  that  any  cause 


MENTALLY  DEFICIENT  CHILDREN  603 

which  tends  to  exhaust  a  mother's  general  vigour  will  increase 
the  likelihood  of  imperfect  reproduction  :  it  would  be  difficult 
to  offer  any  scientific  proof  of  this,  but  I  am  strongly  inclined 
to  think  from  my  own  clinical  observation  that  great  stress  of 
domestic  anxiety,  no  less  than  exhaustive  illness,  in  the  mother 
before  or  during  early  months  of  pregnancy  may  result  in 
imbecility  in  the  offspring. 

Relative  age  of  parents.  Great  disparity  in  the  age  of 
the  parents  is  a  point  to  which  the  laity  attribute  considerable 
importance  in  the  production  of  imbecility  as  well  as  of  other 
defects  in  the  offspring.  Does  the  fact  that  the  father  is  much 
older  than  the  mother  in  any  way  prejudice  the  child's  health  ? 
I  can  give  little  more  than  impressions  by  ,way  of  answer  to 
this  question.  Certainly  in  comparison  with  other  causes  of 
imbecility  it  must  be  a  very  infrequent  cause  if  it  is  one  at  all. 
I  investigated  the  relative  age  of  the  parents  in  217  cases.  In 
130  the  difference  of  age  was  not  more  than  five  years  (in  85  the 
father  was  the  older,  in  45  the  mother),  in  36  the  age  of  the 
parents  was  equal  ;  in  32  cases  there  was  a  difference  of  five  to 
nine  years  ;  in  one  case  the  mother  was  eleven  years  older 
than  the  father  ;  in  13  the  father  was  older  than  the  mother 
by  ten  to  fourteen  years,  in  one  case  by  twenty-six  years.  But 
these  figures  do  not  show  what  proportion  of  marriages  between 
persons  of  very  unequal  age  results  in  imbecile  offspring  ;  this 
proportion  I  have  been  unable  to  ascertain,  but  it  must  be 
known  before  we  can  judge  whether  such  marriages  have  any 
real  influence  in  producing  imbecility  of  offspring. 

My  impression  is  that  where  the  father  is  much,  e.g.  twenty 
years,  older  than  the  mother  the  children  are  very  apt  to  be 
weaklings  in  physical  constitution,  and  I  should  expect  therefore 
that  disparity  of  age  in  parents  might  cause  also  defect  of  cerebral 
development  ;  but  I  know  of  no  proof  that  this  is  so. 

I  have  discussed  the  various  possible  factors  in  the  causation 
of  imbecility  at  some  length  because  parents  whose  children  are 
mentally  defective  are  generally  anxious  to  know  the  cause. 
The  scientific  mind  is  less  ready  to  assign  causes  than  is  the 
mind  untrained  in  science,  but  none  the  less  it  is  well  that  we 
should  know  how  much,  or  rather  how  little,  it  is  possible  to 
determine  with  reference  to  this  point. 

Family  incidence.  There  is  another  very  practical  question 
which  is  closely  related  to  etiology,  and  which  I  have  many 
times  been  asked  by  the  parents  of  an  imbecile  child :  if  after 
the  birth  of  the  imbecile  child  they  have  other  children,  is  it 


' 

604  COMMON  DISORDERS  OF  CHILDHOOD 

• 

likely  that  any  of  these  will  also  be  imbecile  ?  I  think  it  may 
be  said  without  hesitation  that  with  certain  exceptions  to  be 
mentioned  below,  the  risk  is  so  extremely  small  as  to  be  a  neg- 
ligible one.  I  have  notes  of  seventy  families  in  which  an  imbecile 
child  had  younger  brothers  or  sisters  :  only  in  a  single  instance 
was  one  of  these  younger  children  also  an  imbecile.  In  one 
other  family  there  were  two  imbeciles,  both  genetous,  but  these 
were  twin  children  (the  father  was  alcoholic). 

It  might  be  supposed  that  in  the  case  of  Mongolism  particu- 
larly the  exhaustion  of  the  mother  would  be  still  more  likely 
to  produce  Mongolism  in  a  subsequent  child,  but  although 
I  have  notes  of  several  cases  in  which  a  Mongol  was  last  but 
one  of  a  large  family,  I  have  not  seen  any  instance  in  which 
there  were  two  Mongols  in  a  family. 

The  exceptions  to  this  generalism  are  amaurotic  family  idiocy 
and  epidemic  cretinism  ;  the  former  of  these  is  almost  certain 
to  occur  in  several  children  of  a  family,  the  latter  is  commonly 
seen  in  several  members  of  a  family  when  cretinism  is  endemic, 
but  not  in  this  country. 

Prognosis.  I  know  of  no  more  difficult  question  in  prognosis 
to  answer  with  kindness  and  tact  and  withal  with  honesty, 
than  the  anxious,  almost  imploring  question  of  a  mother  who  is 
trying  to  persuade  herself,  against  the  evidence  of  her  own 
senses,  that  her  child  is  not  an  imbecile,  when  it  is  patent  to  the 
doctor  and  perhaps  to  every  one  except  the  parents  that  the 
child  is  an  imbecile  :  '  Will  he  grow  out  of  his  backwardness  ?  ' 

Or,  perhaps  worse  still,  the  parents  have  not  even  suspected 
the  possibility  of  imbecility,  and  the  child  of  twelve  or  fifteen 
months  is  brought  only  because  he  cannot  sit  up,  and  this  has 
been  attributed  to  his  back  being  weak  ! 

What  is  the  medical  man  to  say  ?  The  knowledge  that  their 
child  is  an  imbecile  comes  as  a  terrible  shock  to  the  parents  : 
i-t  means  the  hopeless  and  irreparable  ruin  of  some  of  their  most 
cherished  hopes,  and  therefore  a  medical  man  may  well  consider 
carefully  how  he  may  cause  as  little  distress  as  possible.  In 
the  first  place  the  choice  of  words  is  not  a  matter  of  indifference  ; 
the  terms  idiot  and  imbecile  are  usually  to  be  avoided  altogether, 
parents  are  much  less  distressed  to  be  told  that  their  child  '  will 
always  be  backward '  or  '  mentally  defective '  than  to  hear 
that  he  will  '  always  be  an  imbecile  '. 

When  the  parents  are  aware  of  the  child's  mental  deficiency, 
the  point  upon  which  they  usually  expect  an  opinion  from  the 
medical  man  is  the  degree  of  mental  development  wrhich  the 


MENTALLY  DEFICIENT  CHILDREN  605 

child  may  be  expected  to  attain.  Such  questions  as  the  follow- 
ing arise  directly  mental  deficiency  is  detected  and  therefore 
almost  always  before  the  child  is  three  years  of  age  :  Will  he 
walk  ?  will  he  talk  ?  will  he  be  able  to  take  an  ordinary  place 
in  society  ?  will  he  be  able  to  earn  his  own  living  ? 

Obviously  each  individual  case  must  be  judged  on  its  own 
merits  ;  for  instance,  the  outlook  is  far  worse  in  every  respect 
in  the  drivelling  fatuous  idiot  who  takes  no  notice  at  all  than 
in  the  child  who  recognizes  its  parents  and  toys  and  pictures 
and  takes  an  interest  in  its  surroundings,  albeit  in  a  somewhat 
silly  manner  ;  but  I  shall  venture  to  state  certain  generalisms 
which  may,  I  think,  be  of  value  in  this  connexion. 

Almost  all  feeble-minded  children  of  whatever  degree  of  imbe- 
cility make  some  progress  in  mental  development  during  the 
first  few  years  of  life  ;  very  few  mentally  deficient  children  fail 
to  walk,  though  walking  may  not  be  acquired  until  the  child  is 
four  years  old  or  more.  In  the  very  large  majority  of  men- 
tally deficient  children,  speech  is  acquired  sooner  or  later,  though 
it  may  always  be  very  imperfect;  most  imbeciles,  even  when 
speech  is  not  acquired  till  three  or  four  years  old  or  later,  can 
be  taught  to  be  clean  in  their  habits,  and  learn  to  make  some 
sign  when  they  want  to  pass  urine  or  faeces.  There  is  no  like- 
lihood that  the  child  whose  mental  deficiency  is  recognizable 
in  the  first  two  or  three  years  of  life  will  be  able  to  take  an 
ordinary  place  in  society,  or  to  earn  his  own  living. 

While  the  child  is  yet  in  its  earliest  years,  it  is  only  right  to 
comfort  the  parents  with  the  assurance  that  there  will  almost 
certainly  be  some  progress  in  mental  development  within  the 
next  few  years  ;  the  extent  of  this  progress  cannot  be  foreseen, 
it  will  certainly  fall  short  of  the  normal,  but  it  is  sometimes 
considerably  more  than  the  child's  appearance  might  lead  one 
to  expect. 

As  to  the  acquirement  of  the  power  of  walking,  I  think  it 
may  safely  be  said  that  unless  the  child  is  extremely  fatuous 
it  will  almost  certainly  learn  to  walk,  though  this  may  not  be 
accomplished  until  the  child  is  five  or  even  six  years  old. 

Dr.  Caldecott  kindly  made  some  investigations  for  me  at 
Earlswood  Asylum  upon  this  point,  and  ascertained  that  out  of 
443  cases  only  four  failed  altogether  to  walk,  and  fourteen  could 
walk  only  with  assistance  ;  so  that  only  4-06  per  cent,  failed  to 
attain  full  power  of  walking. 

The  acquirement  of  speech  is  more  doubtful.  Dr.  Caldecott 
has  investigated  this  point  also,  and  furnished  me  with  statistics 


606  COMMON  DISORDERS  OF  CHILDHOOD 

% 

showing  that  out  of  442  imbeciles,  355  could  talk  intelligibly; 
87,  that  is,  19-6  per  cent.,  failed  to  acquire  speech.  Fully  four- 
fifths  therefore  of  imbeciles  may  be  expected  to  talk. 

One  is  sometimes  asked  another  question  in  prognosis  :  will 
the  child  live  ?  Generally  speaking  the  chance  of  survival  of 
a  mentally  defective  child  is,  I  think,  smaller  than  that  of  normal 
children  ;  the  feeble-minded  child  offers  but  feeble  resistance 
when  attacked  by  disease  ;  he  is,  I  think,  specially  prone  to 
succumb  to  pulmonary  disease,  such  as  bronchitis  or  broncho- 
pneumonia  or  tubercle.  In  one  variety  of  imbecility,  Mongolism, 
it  is  probable  that  a  large  proportion  of  the  cases  die  during  the 
first  five  years  of  life  from  pulmonary  disease,  and  although 
I  am  unable  to  put  forward  any  statistics  illustrating  this  point, 
I  should  say  that  amongst  other  forms  of  imbecility  also  the 
mortality  under  the  age  of  five  years  is  probably  considerably 
higher  than  that  amongst  normal  children. 

In  mentally  defective  children  at  a  later  age  the  mortality  in 
institutions  (Earlswood  and  Royal  Albert  Asylum)  has  been 
shown  by  Dr.  Shuttleworth  to  be  about  nine  times  as  great  as 
the  average  mortality  amongst  normal  children;  his  figures, 
quoted  by  Dr.  Ireland,  show  the  deaths  per  thousand  to  be  as 
follows. 

Age.  Imbeciles.  Normal  Children. 

5-10  years          .          .          .     50-1      .          .          .     6-10  per  thousand 

10-15  years      .    .          .          .     33-9     .          .          .     3-35  per  thousand 

Dr.  Caldecott  found  that  at  Earlswood  Asylum,  amongst 
1,000  consecutive  deaths,  39-2  per  cent,  were  due  to  tuber- 
culosis (30-5  per  cent,  to  pulmonary  tuberculosis,  only  1-1  per 
cent,  to  tuberculous  meningitis) ;  next  to  tubercle  epilepsy  was 
the  commonest  cause  of  death,  12-4  per  cent,  being  due  to 
exhaustion  from  this  cause,  whilst  4-9  per  cent,  died  in  the 
status  epilepticus  ;  pneumonia,  lobar  or  lobular,  accounted  for 
10-4  per  cent,  of  the  deaths.  These  three  diseases,  tubercle, 
epilepsy  and  pneumonia  were  by  far  the  most  frequent  causes 
of  death.  These  figures,  however,  no  doubt  underrate  the 
mortality  from  tubercle  and  pulmonary  disease  among  the 
mentally  deficient  ;  for  at  Earlswood  Asylum  patients  under 
the  age  of  six  years  are  not  eligible  for  admission,  except  by 
payment,  and  consequently  the  number  of  patients  under  this 
age  is  comparatively  small ;  it  is  well  known  that  the  mortality 
from  both  these  causes  amongst  children  of  normal  intelligence 
is  much  higher  under  the  age  of  five  years  than  over  ;  and 
therefore,  if,  as  Dr.  Caldecott's  figures  show,  there  is  a  special 


MENTALLY  DEFICIENT  CHILDREN  607 

tendency  to  tubercle  in  the  mentally  deficient,  this  would 
probably  be  even  more  marked  amongst  younger  children. 

Certain  it  is  that  mental  deficiency  does  not  preclude  the 
possibility  of  long  life;  in  Dr.  Caldecott's  statistics  there  were 
several  imbeciles  who  had  attained  the  age  of  sixty  and  some 
who  had  reached  their  three-score  years  and  ten.  Amongst 
1,000  deaths,  243  occurred  at  or  after  the  age  of  twenty-five 
years,  and  11  of  these  were  over  the  age  of  sixty-five. 

The  figures  for  imbeciles,  it  must  be  remembered,  apply  to  the 
inmates  of  institutions  where  great  numbers  are  living  together, 
and  where  on  this  account  there  may  be  certain  disadvantages 
which  may  tend  to  increase  the  mortality,  but  the  general  con- 
clusion from  them  that  the  probability  of  reaching  adult  life  is 
much  less  in  these  than  in  normal  children  is,  I  think,  applicable 
to  mentally  defective  children  under  any  condition  of  environment. 

Treatment.  Drugs  play  but  a  small  part  in  the  treatment  of 
mental  deficiency,  save  in  cretinism,  where  thyroid,  administered 
either  as  the  fresh  gland  or  as  a  dried  preparation  or  extract 
of  it,  restores  the  cretinous  child  almost  to  a  normal  condition 
of  mind  and  body.  I  say  'almost'  because  even  with  the  best 
results  the  intellect  is,  I  think,  always  more  or  less  below  the 
normal,  though  I  have  seen  instances  in  which  the  child  would 
easily  have  passed  for  normal  in  ordinary  conversation  ;  one 
female  cretin,  for  instance,  at  the  age  of  9|  years  was  able  to 
attend  an  ordinary  school  and  at  the  end  of  the  term  was  six- 
teenth in  a  class  of  thirty-one  girls,  but  she  was  in  a  class  two 
below  that  in  which  she  should  have  been  at  her  age.  She 
would  have  been  quite  capable  of  earning  her  own  living  in  such 
an  occupation  as  housework. 

The  earlier  the  administration  of  thyroid  is  begun  the  greater 
the  intellectual  development  is  likely  to  be.  Some  care,  how- 
ever, is  needed  in  the  administration  of  thyroid  ;  too  large 
doses  have  resulted  in  fatal  syncope  in  an  infant  ;  and  apart 
from  this  rare  disaster  other  symptoms  will  sometimes  show 
that  the  dose  is  excessive  :  one  of  the  first  indications  that  the 
drug  is  taking  effect  should  be  a  gradual  decrease  in  the  weight, 
owing  to  the  disappearance  of  the  excessive  subcutaneous  fat, 
but  if  the  dose  is  too  large  this  decrease  takes  place  unduly 
rapidly  and  therewith  the  infant  looks  pale  and  ill,  the  pulse 
becomes  rapid  and  perhaps  irregular,  and  the  temperature 
shows  irregular  elevation. 

A  further  caution  which  applies  only  to  cases  in  which  the 
child  is  already  beginning  to  walk  when  the  thyroid  treatment 


608  COMMON  DISORDERS  OF  CHILDHOOD 

• 

is  begun,  the  child  should  be  allowed  to  be  on  its  feet  only  very 
little,  for  owing  to  the  rapid  growth  in  length  of  the  bones, 
under  the  thyroid  treatment,  bending  is  apt  to  occur  under  the 
weight  of  the  child's  body,  and  one  difference  between  the 
pictures  '  before  '  and  '  after  '  treatment,  may  be  the  presence  of 
bandy-legs  in  the  latter. 

For  an  infant  of  about  six  months,  a  dose  of  I  -grain  of 
Thyroid  Extract  (Burroughs,  Wellcome  &  Co.)  twice,  and 
then  three  times  a  day  will  be  sufficient  at  first,  increased 
gradually  to  J-grain  ter  die  at  a  year  old  ;  or  the  Thyroideum 
Siccum  (British  Pharmacop.)  gr.  ^  may  be  given  and  increased 
to  gr.  T\j  or  gr.  J  ter  die  at  one  year,  the  dose  can  then  be  increased 
gradually  up  to  gr.  1-J  or  2  grains  of  the  extract,  or  gr.  J  of  the 
thyroideum  siccum  and  given  twice  a  day  instead  of  three 
times.  It  is  noteworthy  that  any  increase  of  dose  beyond 
a  certain  limit,  which  seems  to  vary  in  different  cases,  produces 
no  corresponding  improvement  :  this  limit  must  be  ascertained 
by  experience. 

For  the  maintenance  of  the  improved  condition  I  have  found 
1 J  to  2  grains  twice  a  day  of  Burroughs,  Wellcome  &  Co.  Thyroid 
Extract  (Tabloids)  to  be  sufficient  for  children  from  about  four 
years  old  onwards. 

There  is  another  class  of  drugs  which  are  of  value  in  the 
treatment  of  a  certain  type  of  mental  deficiency,  namely,  the 
sedatives  such  as  bromide,  chloral,  and  phenazone.  In  some 
cases  of  mental  deficiency  associated  with  epilepsy,  especially 
in  the  cases  of  petit  mal  in  infancy  where  the  child  is  becoming 
duller  and  duller  in  intellect  with  the  frequent  recurrence  of  the 
epileptic  attacks,  I  have  seen  very  obvious  improvement  in  the 
mental  condition  when  the  frequency  of  the  attacks  was  reduced 
by  the  use  of  one  or  other  of  these  drugs.  Moreover,  the  adminis- 
tration of  sedatives  is  specially  called  for  at  this  period  when, 
as  I  have  satisfied  myself  by  my  own  observations,  the  irritation 
of  dentition,  however  it  may  do  it,  does  undoubtedly  determine 
the  occurrence  of  epileptic  attacks. 

On  the  other  hand  it  is  a  mistake  to  give  large  doses  of  bromide 
to  these  children,  for  the  drug  may  not  only  interfere  with  the 
child's  general  health,  making  it  look  pale  and  miserable,  but 
may  produce  the  very  condition  we  are  trying  to  avoid,  namely, 
dullness  of  intellect.  A  combination  of  phenazone  with  the 
bromide  often  makes  it  possible  to  get  good  results  from  a  much 
smaller  dose  of  the  bromide  than  would  otherwise  be  required  ; 
the  phenazone  does  not  aflect  the  child's  general  health  or 


MENTALLY  DEFICIENT  CHILDREN  609 

brightness  in  the  same  injurious  way  as  the  bromide  ;  to  a  child 
a  year  old,  a  mixture  of  Sodium  Bromide  gr.  ij,  Phenazon  gr.  j, 
Spirit.  Chloroformi  O)j,  Glycerin  O)x,  Aq.  Anethi  ad  3j,  may  be 
given  twice  or  thrice  a  day. 

It  is  advisable  in  some  cases  to  continue  such  a  mixture  as 
this  throughout  the  teething  period  if  the  fits  tend  to  recur 
frequently,  say  at  intervals  of  a  fortnight  or  less.  But  the  treat- 
ment of  mental  deficiency  in  children  is  usually  a  matter  of 
management  and  training  rather  than  of  drugging.  When 
a  mentally  defective  child  is  brought  to  a  medical  man  his  part 
is  to  encourage  patience  and  perseverance  with  the  hope  that 
even  if  the  child  can  *  never  be  quite  like  other  children  ',  never- 
theless he  may,  and  if  a  very  young  child,  almost  certainly  will, 
make  some  progress  in  mental  development,  provided  proper 
efforts  are  made  to  cultivate  his  mental  faculties. 

In  this  task  a  patient  and  tactful  nurse  is  essential  during  the 
first  few  years  of  the  child's  life — one  who  is  quick  to  see  what 
arouses  the  child's  interest,  and  to  use  this  object,  picture, 
toy-animal,  or  whatever  it  may  be,  to  stimulate  and  train  the 
child's  power  of  attention,  for  therein  lies  one  of  the  most 
important  factors  in  mental  progress.  If  a  mentally  defective 
child  can  be  taught  to  give  his  attention  to  an  object  even  for 
a  few  moments,  there  is  hope  of  further  attainment ;  attention 
like  other  mental  processes  can  be  cultivated,  and  the  nurse 
should  make  persistent  efforts  to  engage  the  child's  interest, 
and  so  to  increase  his  capacity  for  attention. 

Such  training  may  be  made  profitable  in  other  ways.  The 
simple  turning  over  of  the  leaves  of  a  picture  book,  or  the  holding 
of  a  doll  is  valuable  in  teaching  the  finer  movements  of  the 
hands,  especially  of  the  thumbs  which  are  usually  so  difficult 
for  imbecile  children  ;  thus  little  by  little  more  complex  pro- 
cesses of  mental  and  physical  activity  can  be  taught.  By 
frequent  naming  of  the  picture  or  toy  in  the  simplest  manner, 
as  'pussy'  or  'dolly',  or  sometimes  better  by  imitating  the 
sound  made  by  an  animal  which  is  shown  in  picture  or  toy, 
the  child  will  come  to  associate  what  he  sees  or  hears  with  certain 
sounds  or  names,  and  will  sooner  or  later  begin  to  repeat  them 
himself  and  so  gradually  acquire  speech. 

The  speech  of  the  mentally  defective  is  seldom  distinct,  often 
scarcely  intelligible  ;  but  in  no  respect  is  the  value  of  careful 
and  patient  training  more  evident  than  in  the  improvement  of 
speech  which  can  be  attained  in  these  children,  especially  in 
those  whose  mental  deficiency  is  of  minor  degree. 

STILL  B  r 


610  COMMON  DISORDERS  OF  CHILDHOOD 

Another  point  to  which  I  must  refer  in  connexion  with  the 
infantile  period  of  an  imbecile's  life,  is  the  teaching  of  cleanly 
habits.  It  is  remarkable  how  even  with  severe  degrees  of  mental 
deficiency  infants  of  a  year  or  eighteen  months  will  learn  to  make 
some  sign  such  as  a  grunt  or  a  particular  cry  to  indicate  their 
desire  to  defsecate  ;  cleanliness  in  regard  to  micturition  is  often 
not  acquired  until  later.  Training  in  these  cleanly  habits  depends 
upon  the  carefulness  of  the  nurse  in  attending  at  once  to  the 
child's  indications  of  his  need ;  if  the  child  discovers  that  a  grunt 
brings  quickly  the  attention  he  needs,  he  will  soon  acquire  the 
habit  of  grunting  for  this  purpose.  Many  imbeciles  who  do  not 
acquire  any  speech  until  they  are  four  years  old  or  more,  have 
become  accustomed  to  make  their  needs  known  in  some  such 
way,  or  by  pointing  to  the  chamber-utensil  when  they  were  less 
than  two  years  old. 

As  the  child  grows  older  other  methods  of  training  can  be 
used.  The  love  of  music,  which  is  so  common  in  the  mentally 
defective,  can  be  used  to  improve  their  speech  and  gait, 
class  singing  and  musical  drill  are  used  with  excellent  results 
for  this  purpose  in  some  of  the  schools  for  such  children. 
Manual  occupations  of  more  or  less  simple  kind  maybe  employed, 
progressing  from  the  simple  fitting  of  pegs  or  bricks  of  different 
shapes  into  corresponding  holes  in  a  board,  or  threading  beads, 
up  to  complex  processes  such  as  paper  mat-work,  or  basket- 
making  ;  it  is  astonishing  how  skilful  some  of  these  children 
become. 

When  the  child  is  six  or  seven  years  old  the  advisability  of 
sending  him  to  some  institution  or  asylum  has  to  be  considered  ; 
this  question  will  arise  chiefly  where  the  severer  degrees  of 
imbecility  make  education  in  a  day  school  for  '  backward  ' 
children  impracticable.  I  think  any  one  who  has  seen  the 
working  of  many  of  these  institutions  wrill  agree  that  although 
it  may  be  hard  for  the  parents  to  part  with  their  child,  in  no 
other  way  as  a  rule  can  the  feeble-minded  child  obtain  such 
expert  care  and  teaching  :  the  value  of  the  institution  environ- 
ment, with  its  special  adaptations  to  the  capacity  of  the  children, 
lies  not  in  any  intrinsic  value  of  this  or  that  simple  work  or 
occupation  which  the  child  may  learn,  but  in  the  fact  that 
participation  in  routine  with  other  children  of  like  capacities 
is  in  itself  a  source  of  happiness  ;  and  that  even  the  simplest 
accomplishment  learnt  gives  a  pride  and  joy  to  these  children 
which  makes  one  feel  that  it  is  only  right  to  put  them  where 
their  capacity  for  such  enjoyment  will  be  increased  to  the  utmost. 


CHAPTER  XLII 
MONGOLIAN  IMBECILITY 

MONGOLIAN  imbecility  has  such  well-defined  characteristics, 
both  physical  and  mental,  which  distinguish  it  from  other  forms 
of  imbecility  that  it  is  worthy  of  separate  consideration,  especially 
as  it  is  by  no  means  an  uncommon  condition. 

My  own  statistics  taken  as  far  as  possible  from  consecutive 
cases  showed  77  Mongols  amongst  350  imbeciles.  This  propor- 
tion (22  per  cent.)  may  be  higher  than  larger  figures  would 
warrant.  Dr.  Shuttleworth  considers  that  Mongols  constitute 
'  perhaps  nearly  5  per  cent.'  of  all  mentally  deficient  children.  My 
observations  were  taken  for  the  most  part  at  the  Great  Ormond 
Street  and  King's  College  Hospitals,  and  it  is  probable  that  amongst 
imbeciles  seen  at  a  hospital  the  proportion  of  Mongols  is  much 
larger  than  in  asylums,  for  the  Mongol  has  less  chance  than 
most  imbeciles  of  other  types  of  surviving  to  the  age  when 
admission  to  an  asylum  is  practicable. 

The  most  striking  point  about  the  Mongolian  imbecile  is  the 
facies,  and  the  characteristics  of  this  will  be  best  illustrated  by  the 
photographs  here  given  (Figs.  42  and  43).  The  downward  slant  of 
the  palpebral  fissures  towards  the  nose  at  once  attracts  attention, 
and  it  is  this  peculiarity  present  normally  in  the  Mongolian 
races  of  mankind  which  has  given  to  this  particular  type  of 
imbecility  its  name.  The  mother  of  a  Mongol  imbecile  under 
my  care  stated  that  the  neighbours  called  her  child  '  the  Chinese 
baby  '.  The  face  as  a  whole  is  rounded  and  somexvhat  '  squat  '  ; 
the  bridge  of  the  nose  is  much  flattened  and  appears  unduly 
broad,  an  appearance  which  is  increased  by  the  very  marked 
epicanthic  fold  which  is  usually  present.  Owing  to  the  flattening 
of  the  nasal  bridge  the  nose  looks  small  and  retrousse.  The 
cheeks,  especially  in  children  beyond  the  age  of  infancy,  are 
usually  very  high-coloured.  The  tongue  is  broad,  and  in  the 
worst  cases  tends  to  loll  out  of  the  mouth.  In  infants  it  often 
presents  no  abnormal  appearance  otherwise,  but  in  later  child- 
hood the  tongue  has  a  very  remarkable  and  characteristic 
appearance,  probably  due  to  hypertrophy  of  the  papillae.  In 
some  cases  the  surface  looks  like  velvet  with  very  coarse  pile; 


J 

612  COMMON  DISORDERS  OF  CHILDHOOD 

% 

in  others,  where  the  condition  is  more  marked,  it  has  an  almost 
mammillated  appearance,  and  the  whole  dorsum  of  the  tongue 
is  divided  up  by  branching  fissures  into  irregular  areas.  In  the 
child  mentioned  above  the  mother  herself  had  noticed  this,  and 
said  the  tongue  looked  '  as  if  scored  all  over  •'. 


Fir..  42.  Mongol  imbecile.  Photograph  of  case  under  Dr.  R.  Hutchison 
showing  typical  slanting  palpcbral  fissures,  depressed  bridge  of  nose,  and 
protruding  tongue. 

Dr.  John  Thomson  has  made  the  interesting  suggestion  that 
these  curious  appearances  of  the  tongue  may  be  induced  by  the 
habit  which  many  Mongols  show  of  sucking  the  tongue. 

The  palate  is  often  high  and  narrow,  but  by  no  means  always  ; 
a  perfectly  normal  palate  is  sometimes  found. 

One  of  the  most  noticeable  characteristics  of  these  imbeciles 


MONGOLIAN  IMBECILITY 


013 


is  the  brachy cephalic  condition  of  the  skull.  The  head  in  almost 
all  the  cases  I  have  measured  has  been  below  the  average  in 
its  maximum  circumference,  and  in  many  it  has  been  obvious 
that  the  contraction  was  mainly  in  the  antero-posterior  diameter. 
Taking  the  maximum  circumference  of  the  head  in  eight 
Mongols,  and  comparing  these  with  the  average  maximum 


Fia.  43.    Mongol  imbecile. 


circumference  at  the  same  age,  in  a  series  of  children  of  normal 
intelligence,  the  following  results  were  obtained. 


Age. 

4  months 

13  „ 

14  „ 
17       „ 
22       „ 

3J  years 


Circumference  in 

Mongols. 
.     14f  inches     . 


.     17* 


Circumference  in  normal 
children. 
15-5    inches 
.     18 
.     18-2 
.     18-4 
-    .     18-5 
.     19-2 
.     19-5 
20-25 


In  addition  to  the  small  size  of  the  head  the  shape  is  also  peculiar  ; 


614  COMMON  DISORDERS  OF  CHILDHOOD 

% 

the  occipital  region  tends  to  be  flattened  so  that  the  back  of  the 
head  loses  its  rounded  contour. 

The  eyes  frequently  show  some  strabismus,  but  more  commonly, 
in  my  experience,  in  older  children  than  in  infants.  The  squint 
is  probably  due  in  most  cases  to  errors  of  refraction,  which  are 
exceedingly  common  in  all  forms  of  imbecility  and  idiocy.  I 
have  also  met  with  nystagmus  occasionally  in  Mongolian  imbeciles. 

Cataract  is  more  frequent  in  these  children  than  has  been 
generally  recognized.  Mr.  A.  W.  Ormond  x  found  some  form  of 
lens  opacity  in  59-5  per  cent.  (25  out  of  42  cases).  The  opacities 
were  usually  of  the  dot  variety,  and  sometimes  so  faint  that 
they  required  careful  search  to  detect  them.  In  some,  however, 
they  were  more  extensive,  and  I  have  seen  cases  in  which  there 
was  a  large  cataract  easily  recognizable,  even  without  dilatation 
of  the  pupil.  These  more  fully  developed  opacities  are,  accord- 
ing to  Mr.  Ormond,  of  the  lamellar  variety.  Blepharitis  is 
extremely  common ;  indeed,  the  majority  of  Mongols  show  more 
or  less  soreness  of  the  eyelids  from  time  to  time. 

In  several  of  the  cases  under  my  care  the  ears  have  been 
abnormally  small,  although  not  otherwise  misshapen.  The  hair 
is  normal  in  amount,  and  there  seems  to  be  no  special  tendency 
to  any  particular  colour,  points  in  which  this  condition  differs 
from  cretinism. 

The  trunk  and  limbs  are  well  formed  and  well  proportioned. 
These  children  are  usually  well  nourished,  and  often  tend  to 
obesity.  The  stature  is  below  the  average,  but  not  to  any 
such  degree  as  is  seen  in  the  dwarfing  of  cretins.  The  following 
measurements  of  children  at  various  ages  (the  first  four  from 
the  same  case)  show  the  shortness  of  the  Mongol  imbecile  in 
comparison  with  the  normal. 

Age.  Height  of  Mongol.                 Height  of  normal  child. 

-A  years  .          .  29 1  inches  .          .          .33  inches 

2r£     „  ...  31         „  ...     35      ,. 

3T92      „  .  32!       „  .          .          .     36      „ 

4-r35-     „  ...  33         „  ...     38      „ 

li\     „  .  27J      „                                   28|    » 

li6*     „  ...  28        „  ...     31      „ 

4T92     „  ...  33f      „  .         .         .     39      „ 

9r°5      „  .  47!      „                              •     51!    „ 

The  hands  are  short,  and  the  relative  shortness  both  of  the 
little  finger  and  the  thumb  is  very  noticeable.  Special  attention 
has  been  drawn  to  this  shortness  of  the  little  finger  in  association 
with  a  curving  towards  the  ring  finger  as  a  diagnostic  point 
between  Mongolian  and  cretinoid  imbecility,  and,  also,  to  the 
1  Ophthalm.  Soc.  Trans.,  vol.  xxxii,  1912,  p.  69. 


MONGOLIAN  IMBECILITY  615 

fact  that  although  the  hand  is  short  in  both  these  conditions, 
the  fingers  in  the  Mongol  are  tapering,  whereas  in  the  cretin 
they  tend  to  be  square  at  the  tip. 

The  hands  and  feet  are  often  blue  and  cold  ;  the  circulation 
is  sluggish,  as  is  common  in  other  forms  of  imbecility. 

The  great  toe  sometimes  shows  a  curiously  wide  separation 
from  the  adjoining  toe. 

In  many  of  these  Mongols,  especially  in  infancy,  respiration 
is  accompanied  by  a  snorting,  snuffling  sound,  partly,  no  doubt, 
on  account  of  the  smallness  of  the  naso-pharyngeal  space,  the 
result  of  the  antero-posterior  shortening  of  the  base  of  the 
skull,  and  partly  on  account  of  the  tendency  to  catarrh  of  the 
nasal  and  respiratory  passages,  which  is  so  common  in  these 
cases,  but  it  seems  likely  that  this  respiratory  obstruction  is 
increased  in  some  cases  by  a  further  anatomical  peculiarity — 
the  projection  backwards  of  the  vomer  into  the  naso-pharynx — 
which  is  described  below. 

During  infancy  many  of  these  imbeciles  when  they  are  pleased 
make  a  long  respiratory  crowing  sound,  an  exaggeration  of  the 
crow  of  pleasure  which  a  healthy  infant  makes.  It  resembles 
the  crow  of  a  severe  laryngismus  stridulus,  except  that  the 
Mongol  makes  it  voluntarily  and  as  a  sign  of  pleasure. 

Some  other  curious  habits  are  particularly  common  in  this 
form  of  imbecility.  The  eyes  are  often  rolled  upwards  momen- 
tarily so  that,  except  for  the  lower  edge  of  the  cornea,  only  'the 
whites  of  the  eyes  '  are  visible  ;  or  the  eyes  are  turned  suddenly 
in  an  extreme  lateral  direction  as  if  the  child  \vere  '  looking  out 
of  the  corners  of  its  eyes  '  in  a  sly  way.  At  two  or  three  years 
old  the  child  will  still  hold  up  its  hands  with  outspread  fingers 
in  front  of  its  face  and  talk  to  them  with  unintelligible  sounds. 

In  all  respects  these  children  are  backward  in  development. 
Dentition  begins  late  and  is  apt  to  be  irregular  ;  in  one  case 
there  were  nx>  teeth  at  fourteen  months  ;  in  another  only  one 
tooth,  and  that  a  molar,  at  seventeen  months  ;  in  a  third  no 
teeth  until  two  years,  when  one  of  the  molars  appeared.  The 
fontanelle  closes  late  ;  thus  in  one  case  it  was  still  open  at  four 
and  three-quarter  years,  in  another  it  closed  at  three  and  a  half 
years.  In  the  latter  case  walking  was  first  acquired  at  two 
years  and  five  months,  and  at  that  age  the  only  attempts  at 
talking  were  vague  sounds  interpreted  by  the  mother  as  '  gee- 
gee  '  and  '  dad-da  ',  and  even  at  the  age  of  four  years  he  could 
say  only  a  very  small  number  of  simple  words  and  a  few  short 
sentences,  such  as  '  drop  of  tea '.  Another  child  made  no 


616  COMMON  DISORDERS  OF  CHILDHOOD 

attempt  to  talk  at  three  years  old,  but  at  five  and  a  half  years  she 
could  say  a  few  words  such  as  'mamma',  'up',  'go',  but  no 
sentences,  and  at  the  age  of  five  and  a  half  years  she  still  made 
no  attempt  to  walk.  The  '  Chinese  baby  '  mentioned  above  only 
began  to  talk  when  she  was  over  three  and  a  half  years  old,  at 
which  age  she  also  began  to  feed  herself  ;  she  could  not  stand 
until  she  was  two  and  a  half  years  old. 

The  voice  in  these  cases  is  characteristically  deep  and  gruff. 
The  mental  condition  is  usually  rather  backward  than  imbecile, 
if  I  may  draw  such  a  distinction.  These  children  take  con- 
siderable interest  in  their  surroundings  and  soon  learn  to  dis- 
tinguish their  parents  or  nurses  from  strangers  ;  they  are  also 
affectionate  and  sometimes  jealous  of  attention  paid  to  others  ; 
one  boy  at  the  age  of  two  and  a  quarter  years  would  attempt 
to  hit  his  baby  brother  on  the  head  if  the  mother  nursed  the- 
baby  instead  of  himself,  and  another  child  at  the  age  of  four 
years  would  attempt  to  push  away  any  such  interloper.  In 
general,  however,  they  are  not  spiteful  and  are  sometimes  quite 
lovable  children.  They  are  usually  stolid  and  obstinate,  quick 
at  mimicry,  but  slow  to  learn  where  any  process  of  reasoning  is 
required.  At  three  or  four  years  old  they  will  take  interest  in 
pictures,  and  enjoy  scribbling  with  a  pencil,  and  later  some 
of  the  highest  grade  Mongols  can  be  taught  to  read  simple  words 
and  even  to  write  after  a  fashion. 

The  Mongol  at  ten  years  old  is  like  a  child  of  five,  but  often 
rather  like  a  precocious  than  a  dull  one.  He  may,  indeed, 
be  the  enfant  terrible  in  the  smart  things  he  says,  and  in  his 
keen  observation  of  people's  foibles  and  peculiarities.  I  have 
known  a  Mongol  boy  at  nine  years  to  be  quicker  in  repartee 
than  many  normal  children  ;  but  though  the  sen.se  of  humour 
is  prominent,  it  is  such  as  one  expects  in  a  younger  child. 

As  in  other  forms  of  imbecility  there  is  often  a  marked  fond- 
ness for  music,  and  some  of  these  children  can  hum  a  tune  fairly 
correctry  at  about  four  years  old.  Many  Mongols  can  be  taught 
to  be  clean  in  their  habits  quite  early,  if  proper  attention  is  paid 
to  the  grunt  or  other  sign  which  they  make  when  they  require 
to  micturate  or  defalcate  ;  the  '  Chinese  baby  '  made  a  grunting 
sound  before  defsecation  at  one  year,  so  that  it  was  possible 
to  leave  off  napkins  at  that  age,  but  this,  I  fancy,  is  rather  excep- 
tional. Another  case  had  made  no  sign  whatever  of  his  needs 
in  this  respect  up  to  the  age  of  four  years,  but  a  few  months 
later  he  always  went  of  his  own  accord  to  the  chamber  when  he 
required  attention. 


MONGOLIAN  IMBECILITY  G17 

The  morbid  anatomy  shows  little  to  account  for  the  condition. 
The  brain  has  usually  been  below  the  normal  weight ;  for  instance, 
in  a  Mongol  aged  twenty-two  months  I  found  that  the  brain 
weighed  31 J  ounces  instead  of  33|  ounces,  the  normal  average 
for  that  age.  But  otherwise  there  is  nothing  remarkable  in  the 
naked -eye  appearance  of  the  brain,  the  convolutions  are  well 
formed  and  of  normal  consistence.  I  noted  in  one  case  a  curious 
projection  backwards  of  the  vomer  into  the  naso-pharynx. 
Instead  of  projecting  backwards  only  just  beyond  the  posterior 
nares,  as  the  vomer  does  in  the  normal  infant,  it  extended  back- 
wards almost  to  the  posterior  wall  of  the  pharynx,  so  that  it 
could  be  felt  by  digital  examination  from  the  mouth,  as  a  partial 
septum  in  the  naso-pharynx,  with  its  edge  sloping  upwards  and 
backwards  from  the  posterior  nares  to  the  roof  of  the  pharynx. 
In  another  case  under  my  care  at  the  Hospital  for  Sick  Children, 
Mr.  Stansfield  Collier  examined  the  naso-pharynx  at  my  request 
during  life,  and  found  the  same  condition.  He  tells  me  that  he  has 
found  it  in  other  Mongolian  imbocilcs  ;  it  is,  however,  certainly 
only  an  occasional  occurrence. 

This  projection  backwards  of  the  vomer  when  present  no 
doubt  accounts  partly  for  the  obstructed  respiration,  for  it  is 
evident  that  the  very  small  naso-pharyngeal  space  is  thus  made 
still  smaller,  and  when  the  mucous  membrane  over  the  vomer 
is  in  a  swollen  and  catarrhal  condition,  as  part  of  the  frequent 
'  colds  '  to  which  these  children  are  subject,  the  available  space 
must  be  diminished  still  further.  It  is  evident  that  a  very  small 
quantity  of  adenoid  overgrowth  would  be  sufficient  to  obstruct 
breathing  in  these  cases. 

The  thyroid  gland  is  found  to  be  normal. 

Etiology.  A  large  proportion  of  Mongol  imbeciles  are  the 
offspring  of  women  who  have  already  borne  many  children.  Out 
of  73  cases  in  which  I  noted  this  point  : 

9  were     .          .          .1st  children. 
7     „  .          .     2nd  children. 

25  .,  .  .  .  3rd,  4th,  or  5th  children. 
18  ...  .  .  6th,  7th,  or  8th  children. 
14  „.  .  .  9th-13th  children. 

(The  place  in  family  in  these  figures  was  calculated  by  counting  pregnancies, 
not  only  live-born  children.) 

When  it  is  remembered  that  there  are  comparatively  few 
families  in  which  there  are  six  to  thirteen  children,  the  large 
proportion  of  Mongols  who  were  late  children  of  large  families 
becomes  the  more  striking,  as  evidence  that  this  form  of  im- 
becility is  an  exhaustion  product.  But  is  it  the  number  of  preced- 


618  COMMON  DISORDERS  OF  CHILDHOOD 

% 

ing  children  or  is  it  the  age  of  the  mother  which  determines  this 
incidence  upon  the  late-born  child  of  a  family  ?  This  is  not  an 
easy  question  to  determine,  but  there  is  some  evidence  that  the 
age  of  the  mother  is  of  more  importance  than  the  place  in  family. 
In  53  cases  I  noted  the  age  of  the  mother  at  the  birth  of  the 
Mongol  child  ;  it  was  as  follows  : 

Years  of  the  mother's  age.  A'o.  of  Cases. 

18 1 

20-29  inclusive          ....       0 
30-32        ,.  ....       2 

33-35        „  ....       8 

30-39        „  ....     20 

40-45         „  ....     14 

40-50        „  ....       2 

It  will  be  seen  that  30  out  of  53,  that  is  67-8  per  cent.,  were  the 
offspring  of  women  between  thirty-six  and  fifty  years  of  age. 

If  the  advanced  age  of  the  mother  be  the  chief  factor  we  should 
expect  to  find  that  this  applied  equally  when  a  Mongol  imbecile 
was  the  first  or  second  child  in  a  family.  I  can  only  offer  a  small 
series  of  observations  on  this  point  :  out  of  six  Mongols  who  were 
second  children  five  were  born  of  mothers  between  36  and  40 
years  old.  But  in  the  case  of  first-born  Mongols  this  factor  is  by 
no  means  evident  :  the  ages  of  the  mothers  in  seven  cases  were 
respectively  18,  23,  25,  28,  32,  33,  and  34  years. 

This  contrast  between  the  ages  of  the  mothers  of  first-born 
and  second-born  Mongols  suggests  that  there  is  some  other  special 
influence  determining  the  occurrence  of  this  condition  in  the 
first-born:  as  I  have  shown  elsewhere,  there  arc  facts  which  seem 
to  indicate  that  the  power  of  perfect  reproduction  is  often  not 
fully  established  in  the  first  pregnancy,  so  that  various  congenital 
abnormalities  tend  to  occur  specially  in  first  children  ;  in  this 
way  Mongolism  may  be  due  to  immaturity  of  reproductive  power, 
although  it  is  more  often  due  to  exhaustion  of  this  power. 

Whether  the  Mongol  is  bom  early  or  late  in  a  family  it  is  note- 
worthy that  any  child  born  subsequently  is  almost  always  men- 
tally sound,  a  fact  which  is  difficult  of  explanation. 

There  are  no  doubt  other  causes  besides  mere  age  which  may 
render  a  woman's  reproductive  power  imperfect ;  her  vigour  may 
be  diminished  by  the  strain  of  repeated  child-bearing,  but  it 
may  also  be  affected  by  disease,  for  instance,  by  syphilis  or 
tubercle.  If  syphilis  ever  has  any  share  in  the  causation  of 
Mongolian  imbecility  it  is  probably  only  in  this  indirect  way, 
it  impairs  the  mother's  vigour  and  therewith  her  power  of  perfect 
reproduction.  Tuberculosis  similarly  may  have  an  indirect 


MONGOLIAN  IMBECILITY  619 

effect ;  a  family  history  of  phthisis  is  very  common,  and  tuber- 
culosis is  the  cause  of  death  in  many  Mongol  imbeciles,  but  there 
is  no  reason  for  supposing  that  tubercle  has  any  specific  influence 
in  producing  this  condition.  I  have  seen  cases  in  which  it  seemed 
likely  that  the  worry  of  a  great  domestic  anxiety  had  contributed 
to  this  exhaustion  imbecility. 

Diagnosis.  The  diagnosis  of  Mongolian  imbecility  is  easy 
after  a  typical  case  has  once  been  seen.  The  two  conditions 
which  are  most  often  confused  with  it  have  been,  in  my  expe- 
rience, cretinism  and  congenital  syphilis. 

The  points  of  distinction  from  cretinism  are  :  (1)  the  facies, 
the  obliquity  of  the  palpebral  fissures,  the  high-coloured  cheeks, 
the  round  squat  face  ;  all  these  distinguish  the  Mongol  from  the 
cretin,  whose  puffy  eyelids,  sallow  earthy  complexion,  thick  lips, 
large  mouth,  and  splayed  out  nostrils  are  so  characteristic  ; 
(2)  the  skull  in  the  Mongol  is  brachycephalic  and  usually  small, 
in  the  cretin  dolichocephalic  and  often  large  ;  (3)  the  hair  and 
skin  ;  in  the  cretin  the  dry  harsh  skin,  and  the  scanty,  coarse, 
and  often  sandy-coloured  hair  contrast  with  the  skin  of  the 
Mongol,  which  in  the  earlier  years  of  childhood  is  normally 
soft,  while  the  hair  is  abundant  ;  (4)  the  hands  ;  the  short 
stumpy  hands  are  common  to  both,  but  in  the  Mongol  there  is 
also  a  disproportionate  shortness  of  little  finger  and  thumb,  with 
curving  of  the  former  towards  the  ring  finger,  and  the  tapering 
tips  of  the  fingers  contrast  with  the  square  ends  of  the  cretin's 
fingers;  (5)  first  appearance  of  symptoms;  while  the  Mongol 
shows  the  characteristic  appearances  from  birth,  there  is  usually 
nothing  to  attract  notice  in  cretinism  until  some  months  after 
birth. 

The  confusion  with  syphilis  arises  almost  always  from  the 
presence  of  snuffling  with  marked  depression  of  the  bridge  of 
the  nose,  two  characteristic  features  of  Mongolian  imbecility 
which  are  not  in  themselves  evidence  of  syphilis.  The  presence 
of  the  other  characteristics  of  Mongolian  imbecility,  the  history, 
and  the  absence  of  other  syphilitic  symptoms  will  generally 
suffice  for  the  diagnosis  from  syphilis,  and  in  some  cases  careful 
observation  shows  that  the  noisy  respiration  is  not  altogether 
like  the  snuffling  of  congenital  syphilis  ;  it  has  with  it  a  snorting 
character  which  is  common  in  other  forms  of  idiocy,  especially 
with  contracted  skull,  as  in  severe  microcephaly. 

In  the  diagnosis  of  Mongolian  imbecility  in  infancy  and  early 
childhood  it  is  well  to  remember  that  a  facies  somewhat  resem- 
bling that  of  Mongols  is  occasionally  met  with  in  people  of 


J 

620  COMMON  DISORDERS  OF  CHILDHOOD 

• 

perfectly  normal  intelligence,  but  in  some  of  these  cases  certainly, 
perhaps  in  most  of  them,  there  are  obvious  points  of  difference, 
and  in  addition  the  characteristic  shape  of  the  skull  and  of  the 
hands  may  be  lacking.  But  this  resemblance  at  least  suggests 
caution  in  prognosis  in  any  case  of  supposed  Mongolian  imbecility 
in  infancy  ;  and  in  conjunction  with  the  special  symptoms  of 
this  particular  form  of  imbecility  it  is  necessary  to  take  into  con- 
sideration the  presence  of  the  general  symptoms  of  mental 
deficiency. 

Prognosis.  Prognosis  in  these  cases  can  be  given  at  an  early 
age  rather  more  definitely  than  in  some  forms  of  imbecility  and 
idiocy,  for  on  the  whole  Mongol  imbeciles  resemble  one  another 
almost  as  closely  in  their  course  as  they  do  in  their  facies.  As 
to  life,  the  prognosis  is  bad.  A  large  proportion  of  these  children 
die  within  the  first  few  years  of  life;  it  is  the  exception  for  them 
to  reach  adult  years.  There  seems  to  be  a  very  marked  ten- 
dency to  respiratory  disease.  Bronchitis  and  broncho-pneumonia 
are  the  causes  of  death  in  many  of  those  who  die  in  infancy  or 
in  early  childhood,  while  those  who  live  on  to  later  childhood  or 
to  adult  life  succumb,  probably  in  the  majority  of  cases,  to  pul- 
monary tuberculosis.  Dr.  A.  E.  Garrod  1  has  drawn  attention 
to  the  occurrence  of  congenital  heart  disease  in  this  form  of 
imbecility.  It  was  present  in  three  out  of  my  series  of  seventy- 
soven  cases,  and  I  have  known  this  to  be  the  cause  of  early 
death.  Short,  however,  of  fatal  disease  these  children  are  very 
prone  to  recurring  attacks  of  bronchitis  ;  nasal  catarrh  is  a 
frequent  trouble,  and  the  eyelids  become  red  and  sore  with 
repeated  attacks  of  blepharitis. 

As  to  the  mental  condition,  if  the  case  is  seen  in  infancy, 
a  rough  estimate  of  the  possibilities  of  development  can  be  given 
from  the  general  experience  of  such  cases.  So  far  as  concerns  the 
immediate  future,  the  child  will  be  backward  in  every  respect, 
but  he  will  learn  to  walk  and  talk,  and  will  take  an  interest  in 
toys  and  simple  games  and  picture-books. 

The  possibility  of  teaching  him  any  useful  occupation  can  hardly 
be  foreseen,  but  for  the  comfort  of  the  parents  it  may  be  said  that 
some  of  these  children  can  be  taught  simple  reading  and  writing 
and  may  learn  some  simple  work  such  as  gardening  or  farm  work. 
Dr.  Shuttleworth  mentions  the  case  of  a  girl  who  was  not  only 
taught  to  read  and  write  but  could  also  do  laundry  work  and 
cookery,  and  I  have  known  a  Mongol  girl,  at  thirteen  years,  to 
be  capable  of  ordinary  simple  housework.  But  there  is  no  chanco 
1  Trans.  Clin.  Soc.  Lond.,  1S98. 


MONGOLIAN  IMBECILITY  621 

of  the  Mongol  imbecile  ever  being  -able  to  earn  a  livelihood  or  to 
look  after  himself  altogether  ;  he  can  only  do  simple  work,  and 
that  only  under  more  or  less  supervision.  Nevertheless,  it  is  no 
small  gain  if  he  can  learn  to  do  anything  that  is  useful,  for  it  gives 
him  a  purpose  in  life  and  is  a  source  of  pride  and  pleasure. 

No  drug  treatment  has  been  of  any  avail.  The  administration 
of  thyroid  gland  in  particular  has  been  in  my  experience,  as  in 
that  of  others,  absolutely  useless,  except  to  reduce  excessive  fat. 
Various  other  organic  preparations  have  been  tried  without 
success. 

Nevertheless,  much  can  be  done  to  make  the  lives  of  these 
children  happier  by  such  simple  instruction  and  amusement  as 
is  provided  in  our  large  institutions  for  the  feeble-minded,  and 
for  the  poorer  classes  it  is  probably  wisest  to  send  the  Mongol 
at  the  age  of  five  to  seven  years  to  some  such  institution,  in  order 
that  he  may  have  such  teaching  and  occupation  as  is  specially 
adapted  to  his  individual  case,  and  this  can  hardly  be  obtained 
elsewhere. 

Where  it  is  possible  by  home  teaching  or  by  the  special  advan- 
tages of  private  '  homes  ',  to  avoid  sending  the  child  into  crowded 
institution  life,  it  is  probably  better  to  do  so;  for  apparently 
the  crowding  together  of  such  children,  with  their  special  tendency 
to  tuberculous  infection,  increases  the  risk  of  tuberculosis. 

Wherever  these  Mongol  imbeciles  are  kept,  the  special  tendency 
to  catarrhal  complications  makes  constant  medical  supervision 
necessary. 


CHAPTER  XLIII 
NERVOUS  CHILDREN 

IF  any  apology  were  needed  for  the  use  of  a  somewhat  un- 
scientific title  I  should  say  that  there  is  no  technical  term  which 
so  well  expresses  the  condition  which  I  wish  to  emphasize  here 
as  the  homely  word  '  nervousness  '.  Vague  as  the  term  may 
sound  it  represents  a  very  definite  type  of  temperament  which 
is  by  no  means  uncommon  in  children,  and  the  recognition  of 
which  is  a  matter  of  no  small  importance  ;  indeed,  it  were  much 
to  be  desired,  in  the  interests  of  the  children,  that  parents  and 
school  teachers,  as  \vell  as  medical  men,  were  more  fully  aware 
of  its  practical  bearings. 

The  manifestations  of  this  nervous  temperament  in  children 
are  extremely  varied,  not  only  in  kind  but  also  in  degree  ;  at  one 
end  of  the  scale  there  is  the  simply  timid  or  excitable  child,  at  the 
other  end  is  the  child  who  shows  hysterical  symptoms  as  severe 
as  any  that  occur  in  adults. 

It  is  chiefly  with  the  minor  and  commoner  manifestations  that 
I  propose  to  deal  in  this  chapter,  for  it  is  these  which  appear 
to  me  to  be  most  often  neglected  or  perhaps  misunderstood. 

And,  first,  I  would  point  out  that  the  nervous  temperament 
may  be  evident  at  a  very  early  age  ;  at  three  and  a  half  or  four 
years  a  child  will  often  show  well-marked  evidence  of  its  nervous 
tendencies.  I  have  seen  even  severe  hysterical  phenomena  at 
so  early  an  age  as  four  years. 

But  I  suspect  that  even  in  the  first  few  months  of  life  an  undue 
excitability  of  the  nervous  system  may  show  itself  in  a  tendency 
to  start  at  any  slight  noise,  and  certainly  the  infant  who,  apart 
from  any  disturbing  cause  in  digestion  or  dentition  or  general 
health,  has  always  been  a  '  bad  sleeper  ',  sleeping  little  and 
waking  easily,  is  apt  to  turn  out  a  nervous  child  at  a  later  age. 
The  occurrence  also  of  convulsions  in  infancy  upon  a  very  slight 
occasion  and  apart  from  the  influence  of  rickets,  foreshadows, 
I  think,  in  some  cases  a  nervous  temperament  in  later  years. 

Perhaps  one  of  the  commonest  features  of  the  nervous  child 
is  an  abnormal  degree  of  excitability.  Nervous  instability  is  to 
some  extent  normal  in  childhood,  and  the  excitability  which  is 


NERVOUS  CHILDREN  623 

one  of  its  expressions  is  therefore  to  some  extent  normal  also, 
and  the  stolid  child  may  be  as  abnormal  in  one  direction  as  the 
over-excitable  child  is  in  the  other.  It  would  be  difficult  to 
define  in  words  the  limit  between  normal  and  abnormal  excita- 
bility in  childhood,  bat  in  practice  it  is  often  very  obvious  when 
the  limit  is  passed.  To  take  a  well-marked  instance,  a  bright 
intelligent  boy,  aged  eight  years,  was  brought  to  me  with  the 
history  that  amongst  other  symptoms  of  the  nervous  tempera- 
ment he  was  so  excited  by  music  that  the  singing  of  Stainer's 
'Amen'  at  church  would  rouse  him  to  a  state  of  excitement  in 
which  he  was,  so  the  mother  said,  '  almost  past  control  '. 

A  frequent  complaint  with  reference  to  these  children  is  that 
they  become  unduly  excited  in  their  games  ;  and  I  have  been  told 
sometimes  by  parents  that  they  were  afraid  to  send  their  child 
to  a  children's  party  for  fear  of  the  after-results  ;  such  children 
will  become  wildly  excited  at  the  time,  with  the  result  that 
subsequently  they  are  pale  and  exhausted,  and  in  many  cases 
sleep  is  disturbed,  the  child  talks  in  his  sleep  and  keeps  turning 
restlessly  from  side  to  side. 

Closely  related  to  the  excitability  of  these  children  is  what 
I  may  call  their  impressionability.  An  extreme  instance  of  this 
came  under  my  observation  in  a  boy  about  seven  years  old,  who, 
after  overhearing  a  conversation  in  which  a  vivid  description 
was  given  of  a  girl  with  melancholia,  for  several  days  refused  to 
answer  questions,  took  no  interest  in  games,  and  avoided  all  com- 
panionship ;  with  judicious  neglect  the  condition  passed  off  after 
several  days.  This  was  a  quick,  intelligent  boy,  who  suffered 
much  with  headaches,  walked  in  his  sleep,  and  was  of  a  very 
excitable  temperament.  The  same  boy  when  listening  to  a 
pathetic  story  would  be  so  deeply  affected  that  he  would  burst 
into  tears.  A  striking  instance  of  this  feature  in  the  nervous 
child  is  that  recorded  by  Charcot,  in  which  a  girl  of  about 
thirteen  years  after  being  taken  to  a  spiritualistic  seance  was 
seized  with  hysterical  convulsions. 

In  some  cases  sensitiveness  is  extreme  ;  a  girl,  aged  nine  and 
a  half  years,  was  brought  to  me  because  she  was  low-spirited 
and  extraordinarily  timid;  the  child's  sensitiveness  was  dis- 
tressing, she  seemed  unable  to  look  one  in  the  face,  and  started 
nervously  wrhen  she  found  one  was  looking  at  her. 

Some  children  similarly  will  blush  whenever  one  looks  at  them 
or  speaks  to  them  ;  others  will  begin  to  cry  and  display  an 
emotionalism  only  less  in  degree  than  the  child  with  chorea. 

Timidity  in  some  of  these  cases  is  very  striking;  one  little  girl, 


624  COMMON  DISORDERS  OF  CHILDHOOD 

aged  three  and  a  half  years,  whilst  out  driving  with  her  mother 
in  a  brougham  would  scream  in  terror  if  the  carriage  jolted  over 
a  rough  piece  of  road,  and  whilst  travelling  in  a  train  would  be 
terrified  if  the  train  went  under  a  bridge  ;  she  was  brought  to 
me  again  at  a  later  period  with  habit-spasm,  and  showed  other 
evidences  of  the  nervous  temperament.  Another  little  girl, 
aged  six  years,  was  said  to  be  '  terribly  nervous  '  ;  she  was  so 
timid  that  she  shook  and  trembled  if  there  was  a  knock  at  the 
door.  She  suffered  much  from  headache  and  talked  in  her  sleep 
about  her  school  lessons. 

Disorders  of  sleep  are  specially  common  in  these  children  ; 
one  child  will  suffer  from  insomnia,  another  is  simply  restless 
and  sleeps  fitfully,  and  others  will  have  night  terrors  or  walk 
in  their  sleep. 

Insomnia  is  by  no  means  an  uncommon  complaint  in  children, 
and  is  often  very  difficult  to  remedy.  Its  occurrence  does  not,  of 
course,  necessarily  mean  that  a  child  is  unduly  nervous  ;  in 
some  cases  it  means  digestive  disturbance,  particularly  flatulent 
dyspepsia  ;  in  others  it  means  obstructed  respiration,  not  neces- 
sarily of  very  marked  degree,  from  adenoids  or  enlarged  tonsils  ; 
in  others,  again,  it  is  the  result  of  some  fault  in  the  child's  sur- 
roundings, too  little  or  too  much  bedclothing,  or  a  noisy  room 
or  too  much  light  in  the  room  ;  but  apart  from  all  such  causes 
there  are  many  cases  in  which  the  child  lies  awake  quietly  for 
hours,  and  nothing  abnormal  can  be  found  except  that  the  child 
is  one  of  markedly  nervous  temperament,  a  fact  which  is  worth 
recognizing,  for  not  only  does  it  give  us  the  comfortable  feeling 
that  we  know  something,  however  vague,  about  the  cause  of  the 
trouble — a  thing  which  parents  always  crave  to  know  from  the 
doctor — but  it  gives  also  some  practical  guidance.  The  child's 
daily  life  must  be  so  arranged  that  all  excitement  and  mental 
exertion,  particularly  the  strain  of  lessons,  is  to  be  reduced  to 
a  minimum ;  and  if  the  insomnia  still  persists  it  may  yield  only, 
as  do  so  many  other  nervous  irregularities,  to  change  of  scenery 
and  air. 

A  boy  of  seven  years  was  brought  to  me  with  the  following 
history  :  he  was  fond  of  school,  and  the  examinations  were  just 
past.  For  the  last  five  or  six  weeks  his  sleep  had  been  disturbed  ; 
he  lay  awake  for  about  three  hours  before  falling  asleep,  and  then 
cried  out  in  his  sleep  about  his  school.  The  mother  said  he  was 
'  a  very  excitable  child  ',  and  worried  much  over  school,  some- 
times crying  over  his  home  lessons.  I  advised  keeping  him  away 
from  school  altogether  for  a  time,  and  about  three  weeks  later 


NERVOUS  CHILDREN  G25 

I  heard  that  he  was  sleeping  well  and  had  entirely  ceased  to  talk 
in  his  sleep. 

The  pressure  of  school  examinations  is  certainly  in  some  cases 
the  exciting  cause  of  these  disorders.  I  remember  one  girl  who  at 
such  times  repeatedly  walked  in  her  sleep,  to  the  great  uneasiness 
of  her  parents  ;  and  in  a  boy,  aged  six  years,  the  somnambulism 
was  specially  noticed  to  have  begun  since  he  first  went  to  school, 
since  which  date  he  had  also  suffered  frequently  from  headaches. 

Night  terrors  are  common  in  such  children.  For  instance, 
a  little  girl,  aged  four  years,  was  said  to  be  '  very  nervous  ',  and 
was  afraid  to  be  left  alone  in  the  bedroom  ;  even  the  ticking  of 
ft  clock  frightened  her,  so  that  it  had  to  be  stopped.  She  talked 
in  her  sleep,  and  lately,  soon  after  falling  asleep,  she  had  started 
up  in  bed,  seemingly  in  fright,  talking  of  'guys  and  clowns' ;  she 
failed  at  such  times  to  recognize  her  mother,  and  when  awakened 
had  some  difficulty  in  going  to  sleep  again.  Sometimes  several 
of  these  attacks  occurred  in  one  night. 

The  much  rarer  phenomenon,  to  which  the  name  of  '  day 
terrors  '  has  been  given,  usually  occurs  in  children  of  nervous 
temperament.  I  have  recorded  some  of  these  cases  elsewhere,1 
but  I  may  refer  to  one  of  them  here  as  illustrating  this  point. 
A  boy,  aged  three  years,  for  the  last  six  weeks  has  had  sudden 
attacks  of  screaming  with  fright,  often  many  times  a  day  ; 
whilst  sitting  quietly  with  the  rest  of  the  family,  or  busy  at  his 
play,  he  will  suddenly  begin  to  scream,  turn  pale,  and  look 
strange  about  his  eyes  ;  he  rushes  to  his  mother  and  hides 
his  face  in  her  lap,  saying  that  he  is  frightened.  Sometimes  he 
says  that  *  somebody  is  coming  after  him  '  ;  but  he  cannot 
describe  his  imaginary  pursuer.  The  attack  lasts  from  two  to 
three  minutes.  He  has  had  night  terrors  with  visual  hallucina- 
tions for  some  weeks  past,  and  is  '  a  very  excitable  child  '. 
He  is  easily  frightened  by  trivial  things  ;  for  example,  on  crossing 
a  railway  bridge  a  few  days  ago  he  saw  the  smoke  of  a  train 
and  screamed  with  fright.  He  is  quick  and  intelligent,  perhaps 
precocious  ;  he  is  shy,  but  when  this  is  overcome  he  talks  in 
the  rapid  eager  fashion  of  an  excitable  child. 

The  speech  of  these  children  often  shows  evidence  of  their 
nervous  instability,  not  only  in  its  eager  hurry,  but  also  in  some 
degree  of  stuttering.  The  stuttering  in  some  of  these  cases 
seems  to  be  simply  a  failure  of  speech  co-ordination  to  keep  pace 
with  the  child's  haste  to  express  his  ideas,  an  occurrence  which  is 
quite  common  and  natural  in  very  young  children  whilst  they  are 
1  Lancet,  February,  1900. 

STILL  g  „ 


626  COMMON  DISORDERS  OF  CHILDHOOD 

learning  to  talk.  We  are  all  familiar  with  the  momentary 
difficulty  of  the  little  one  whose  words  seem  to  tumble  over  one 
another  in  the  eagerness  of  his  talk,  but  in  an  older  child  the 
momentary  stutter  is  often  significant  of  a  lack  of  nervous 
control  which  should  have  been  acquired  by  this  time.  In 
other  cases — and  these  are  the  more  troublesome — the  stuttering 
seems  to  be  due  to  a  disturbance,  perhaps  an  actual  inhibition 
of  co-ordination  in  the  mechanism  of  speech,  owing  to  the  child's 
sensitiveness  or  timidity  ;  a  result  exactly  analogous  to  the 
disturbances  of  movement, — for  instance,  tremor  or  loss  of  power 
in  the  limbs,  which  may  occur  as  the  result  of  emotion. 

The  nervous  temperament  of  a  child  is  often  very  apparent  on 
auscultation  of  the  heart.  In  examining  large  numbers  of  children 
one  is  struck  by  the  fact  that  while  in  the  majority,  unless  the 
child  cries  or  shows  obvious  signs  of  being  frightened,  there  is 
no  great  quickening  of  the  heart  beat  or  other  alteration  in 
its  character,  in  certain  children  the  effect  of  examination 
is  not  only  great  rapidity  of  the  heart  beat  but  also  a  charac- 
teristic rhythm,  the  beat  becomes  sudden  and  short.  This 
quick  staccato  or  slapping  beat  is,  I  think,  a  sure  sign  of  the 
nervous  temperament,  but  it  is  present  only  in  a  minority  of 
nervous  children.  A  girl,  aged  ten  years,  who  was  brought 
for  some  nasal  catarrh,  showed  no  sign  of  being  frightened  or 
excited,  but  I  noticed  that  her  heart  rate  was  144  per  minute, 
and  the  beat  was  of  the  sudden  slapping  character  which  I 
have  described.  I  noted  it  as  evidence  of  a  nervous  tem- 
perament, and  this  was  confirmed  a  few  days  later  by  the 
appearance  of  a  definite  habit-spasm,  a  frequent  upward  toss 
of  the  head. 

Less  characteristic  than  this  nervous  staccato  rhythm,  is 
irregularity  of  the  heart  beat.  In  some  nervous  children  this 
phenomenon  is  very  noticeable  when  the  child  is  first  examined 
by  a  stranger.  Both  alterations  may  occur  at  the  same  time, 
the  beat  becoming  not  only  irregular  but  quick  and  slapping. 
It  is  important  to  bear  this  possible  cause  for  cardiac  arrhythmia 
in  mind,  otherwise  quite  unnecessary  anxiety  may  be  raised. 

The  nervous  child  shows  his  instability  also  in  his  temperature; 
a  trivial  ailment,  a  little  constipation  or  a  slight  bronchial 
catarrh,  which  in  another  child  would  scarcely  cause  a  devia- 
tion from  the  normal,  will  send  up  the  temperature  several 
degrees  in  these  children  ;  indeed,  it  may  not  require  even  an 
ailment  to  do  this,  an  evening  at  the  pantomime  or  the  excite- 
ment of  a  tea-party  may  be  quite  sufficient  to  raise  the  tempera- 


NERVOUS  CHILDREN  627 

ture  to  101°  or  102°.  It  is  in  these  children  also  that  there 
occurs  a  more  alarming  and  puzzling  pyrexia.  In  some  cases 
this  takes  the  form  of  an  evening  rise  to  about  100°  for  many 
weeks  or  even  months  without  any  apparent  cause — and,  what 
is  more  important,  without  any  injurious  influence  on  the  child's 
health  ;  in  other  cases  there  are  recurrent  bouts  of  more  severe 
fever  every  few  weeks  or  months.  I  have  considered  fevers 
of  these  kinds  more  fully  in  a  previous  chapter  (Chapter  XIX  ). 

Habit-spasm  is  a  very  common  occurrence  in  nervous  children. 
In  one  child  there  is  a  sudden  twitch  of  some  of  the  facial  muscles, 
in  another  a  shrug  of  one  shoulder,  in  a  third  an  oft-repeated 
apparently  involuntary  sniff,  and  with  such  spasms  there  are 
often  other  manifestations  of  the  nervous  temperament.  A  boy, 
aged  eleven  and  three-quarter  years,  was  brought  to  me  for 
a  sudden  twitch  of  both  eyelids  and  of  the  angle  of  the  mouth  ; 
this  had  been  present  six  months.  He  was  a  studious  boy, 
forward  in  his  school  work  ;  spent  most  of  his  leisure  time  in 
reading,  and  was  more  fond  of  books  than  of  play.  He  had  a  shy 
manner,  and  seemed  unable  to  look  one  straight  in  the  face  ; 
he  talked  much  in  his  sleep  at  night.  Another  boy,  aged  nine 
and  a  half  years,  with  twitching  of  the  right  ala  nasi,  and  an 
occasional  contraction  of  the  frontalis  and  of  the  orbicularis 
palpebrarum  muscles,  was  said  to  be  '  a  very  excitable  child  '  ; 
he  dreamed  much,  frequently  cried  out  in  his  sleep,  and  had 
had  definite  night  terrors  a  few  months  previously  ;  he  had  also 
had  occasional  nocturnal  enuresis.  He  was  a  spare  child,  very 
bright  and  intelligent,  talked  in  a  rapid  excited  way  and  gave 
one  the  general  impression  of  being,  as  the  mother  stated,  an 
excitable  child. 

The  occurrence  of  nocturnal  enuresis  in  such  nervous  children 
is  by  no  means  uncommon,  and  perhaps  this  relationship  has  not 
been  sufficiently  recognized. 

The  restless  condition  of  the  higher  centres  in  these  children 
during  sleep  is  evident  in  the  dreams  and  night  terrors  to  which 
they  are  so  liable,  and  it  may  be  that  a  similar  restlessness  in 
the  lower  centres  manifests  itself  in  nocturnal  enuresis. 

Probably  closely  allied  to  this  enuresis  is  the  so-called  '  lien- 
teric  diarrhoea  ',  the  'diarrhee  nerveuse  '  of  Trousseau,  which  is 
specially  associated  with  this  particular  temperament.  A  boy, 
aged  ten  years,  for  two  years  had  been  obliged  to  leave  the 
room  directly  after  each  meal,  and  sometimes  before  the  meal 
was  finished,  to  relieve  the  bowels.  He  was  an  emotional  boy 
and  easily  cried  if  spoken  to  roughly  ;  he  talked  much  in  his 

SS2 


628  COMMON  DISORDERS  OF  CHILDHOOD 

sleep  ;  his  brother  suffered  with  night  terrors.  A  girl,  aged 
seven  years,  was  brought  to  me  with  the  history  that  for  three 
months  the  taking  of  a  meal  was  often  followed  almost  im- 
mediately by  an  action  of  the  bowels  ;  the  slightest  excitement 
had  the  same  result.  7or  two  months  there  had  also  been  enuresis 
at  night.  She  was  '  a  highly  nervous  child  ',  and  suffered  with 
headaches  from  time  to  time. 

Faecal  incontinence,  a  disorder  chiefly  of  boys  between  the  ages 
of  six  and  nine  years,  is  another  manifestation  of  this  nervous 
temperament.  I  have  seen  it  associated  with  habit-spasm, 
insomnia,  enuresis,  stuttering,  night  terrors,  and  occasionally 
with  the  nervous  diarrhoea  which  I  have  just  mentioned.  Some- 
times the  nervous  character  of  this  disorder  is  seen  in  its  relation 
to  school  pressure,  and  complete  holiday  from  lessons  may  be 
a  necessary  adjunct  to  drug  treatment. 

The  frequency  of  headaches  in  nervous  children  is  very 
noticeable,  and  perhaps  more  so  in  those  who  have  reached 
the  school  age  than  in  the  younger  ones.  A  little  over-exertion, 
the  excitement  of  an  entertainment,  the  slightest  pressure  of 
school  work,  may  be  sufficient  cause  for  a  headache.  Some  of 
these  headaches  are  undoubtedly  of  the  nature  of  migraine,  but 
others — and  I  fancy  the  majority — arc  of  different  character, 
and  almost  defy  pathological  classification;  some  of  them  are 
probably  related  more  or  less  closely  to  the  rheumatism  which 
is  so  common  a  feature  in  the  personal  or  family  history  of  these 
nervous  children. 

The  connexion  between  rheumatism  and  the  nervous  tempera- 
ment in  childhood  is  very  close,  and  rheumatism  in  the  parents 
would  seem  to  be  almost  as  important  a  factor  in  the  production 
of  this  temperament  as  rheumatism  in  the  child.  But  there 
are  other  factors  which  enter  into  its  causation,  and  foremost 
among  them  is  neurotic  heredity.  In  many  cases  the  mother 
or  father  shows  evidence  of  the  nervous  temperament,  or  it  may 
be  hysteria,  epilepsy,  or  insanity.  Some  of  the  nervous  children 
under  my  observation  have  been  the  offspring  of  drunken  parents  ; 
in  others,  again,  '  great  wits,'  '  to  madness  near  allied,'  have 
figured  in  the  family  history. 

But  nervous  instability  in  children  is  not  always  congenital, 
often  the  history  is  that  the  child  has  become  nervous  only 
during  the  past  few  weeks  or  months.  In  such  cases  the  presence 
of  worms  in  the  intestine  may  be  the  cause  of  the  trouble.  So 
marked  is  the  effect  of  worms  in  producing  nervous  symptoms 
such  as  I  have  described,  that  it  has  been  suggested  that  they 


NERVOUS  CHILDREN  629 

may  produce  some  toxin  which  acts  specially  upon  the  nervous 
system ;  experiments,  however,  have  given  contradictory  results, 
and  I  am  the  less  inclined  to  attribute  the  nervousness  to  any 
specific  effect  of  the  worms,  because  I  have  often  observed  that  the 
passage  of  much  mucus  in  the  stools,  as  in  the  condition  which 
Dr.  Eustace  Smith  has  called  'mucous  disease',  is  associated 
with  an  exactly  similar  nervous  condition.  It  seems  probable, 
therefore,  that  any  chronic  irritation  of  the  intestine,  whether 
by  digestive  disorder  or  by  parasites,  may  cause  general  nervous 
instability  ;  certainly  in  many  of  these  cases  where  a  child  is 
said  to  have  become  nervous  recently  strict  regulation  of  the 
diet,  most  often,  perhaps,  curtailment  of  starch  and  sugar,  is  an 
important  part  of  treatment. 

Treatment.  The  management  of  the  nervous  child  calls  for 
no  small  amount  of  tact  and  common  sense  on  the  part  alike  of 
parents,  nurses,  and  teachers,  and  a  volume  might  be  written 
on  the  bringing-up  of  such  children  ;  but  here  one  can  only 
touch  on  some  of  the  more  important  points  on  which  the  medical 
man  is  sometimes  consulted. 

A  weighty  matter  in  the  care  of  these  children  is  the  choice 
of  the  nurses  and  teachers  to  whom  they  are  to  be  entrusted. 
The  combination  of  sympathy  and  discretion  which  is  needed 
in  dealing  with  the  nervous  child  is  not  easily  to  be  found,  but 
it  is  very  important  for  the  welfare  of  the  child.  By  sympathy 
I  mean  not  only  a  love  of  children  but  also  that  readiness  to 
divine  the  workings  of  a  child's  mind,  and  to  see  things  from 
a  child's  standpoint,  which  is  perhaps  a  natural  gift  rather  than 
an  acquired  ability.  The  need  for  a  wise  discretion  is  urgent 
and  continual  in  dealing  with  these  children,  and  if  this  discre- 
tion be  important  in  nurses  and  teachers  it  is  even  more  important 
in  the  parents  themselves. 

As  I  have  already  pointed  out,  the  nervous  temperament 
manifests  itself  at  a  very  early  age,  and  the  special  care  which 
is  needed  in  the  management  of  these  children  must  begin  in 
the  nursery.  The  lines  of  this  special  care  are  indicated  to 
some  extent  by  the  traits  which  I  have  described  above  as 
characterizing  the  nervous  child ;  some  of  these  traits  are 
to  be  regarded  rather  as  danger-signals  than  as  dangers  in 
themselves,  and  most  of  them  indicate  sufficiently  clearly  the 
sources  of  harm  which  are  to  be  avoided.  The  sensitiveness,  the 
impressionability  of  these  children  must  be  specially  borne  in 
mind  from  the  first.  Listen  to  some  of  the  hallucinations  and 
delusions  in  their  night  terrors,  and  it  is  evident  that  these  are 


630  COMMON  DISORDERS  OF  CHILDHOOD 

bub  the  echo  of  the  unwholesome  fiction  with  which  they 
have  been  entertained  in  their  waking  hours. 

Look  at  some  of  the  picture-books  which  are  in  vogue 
for  nursery  use.  See  the  impossible  but  fearful  ogre  whose 
special  delight  is  to  devour  small  children,  or  the  mysterious 
and  awful  witch  who  hovers  round  the  bed  at  night,  apparently 
for  the  express  purpose  of  carrying  off  juvenile  offenders  against 
nursery  law.  Is  it  any  wonder  that  the  child  fears  the  dark 
when  it  is  peopled  with  such  appalling  imagery  ?  It  is  difficult 
for  us  to  conceive  of  the  unquestioning  realism  of  early  child- 
hood, but  of  the  harm  done  to  a  nervous  child  by.  filling 
its  imagination — and  these  nervous  children  are  par  excellence 
the  imaginative  children — with  the  terrible  and  the  unlovely 
there  can,  I  think,  be  no  doubt.  I  \vould  protest  against  the 
thrilling  ghost  story  and  other  harrowing  tales  for  the  nervous 
child  ;  perhaps  I  may  be  forgiven  for  illustrating  my  point  by 
a  quotation  from  that  '  Uncommercial  Traveller  '  whose  powers 
of  observation  were  so  often  used  in  the  interests  of  the  little 
people  that  he  loved.  After  narrating  the  gruesome  tale  of 
Captain  Murderer,  one  of  '  Nurse's  Stories  ',  wherewith  that 
typical  domestic  was  wont  to  entertain  her  youthful  charge, 
he  continues,  '  The  young  woman  who  brought  me  acquainted 
with  Captain  Murderer  had  a  fiendish  enjoyment  of  my  terrors, 
and  used  to  begin,  I  remember — as  a  sort  of  introductory  over- 
ture— by  clawing  the  air  with  both  hands  and  uttering  a  long 
hollow  groan.  So  acutely  did  I  suffer  from  this  ceremony,  in 
combination  with  this  infernal  Captain,  that  I  sometimes  used 
to  plead  I  thought  I  was  hardly  strong  enough  and  old  enough 
to  hear  the  story  again  just  yet.  But  she  never  spared  me 
one  word  of  it,  and,  indeed,  commended  the  awful  chalice  to 
my  lips  as  the  only  preservative  known  to  science  against 
"  The  Black  Cat  ", — a  weird  and  glaring-eyed  supernatural  Tom, 
who  was  reputed  to  prowl  about  the  world  at  night  sucking  the 
breath  of  infancy,  and  who  was  endowed  with  a  special  thirst 
(as  I  was  given  to  understand)  for  mine.' 

But  it  is  not  only  in  this  direction  that  books  may  be  harm- 
ful ;  some  of  these  nervous  children  are  children  of  unusually 
studious  habit  ;  they  will  devote  to  reading  all  the  time  which 
should  be  spent  in  bodily  recreation,  and  show  a  disinclination 
for  games  which  is  unhealthy  and  to  be  discouraged.  When 
I  am  told  that  a  little  girl  aged  eight  years  does  not  care  to 
join  in  games,  but  enjoys  reading  Longfellow  and  Milton,  I 
am  not  surprised  to  find  that  the  child  has  a  troublesome 


NERVOUS  CHILDREN  631 

habit-spasm,  and,  as  I  find  in  my  notes  of  the  case,  is  '  very 
excitable '. 

If  the  evil  effects  of  sensational  fiction,  whether  in  books, 
pictures,  or  entertainments,  is  great,  the  effects  of  fright  on 
the  timid  child  are  still  more  serious.  Not  only  functional 
neuroses  of  longer  or  shorter  duration  but  also  syncopal  attacks, 
convulsions,  and  even  idiocy  have  been  traced  to  fright  in  such 
children,  and  I  would  plead  for  these  timid  children  that  their 
fears  be  respected.  The  mixture  of  cowardice  and  ignorance 
which  can  even  threaten  to  shut  one  of  these  nervous  children 
or,  indeed,  any  child  in  a  dark  room  as  a  punishment,  is  nothing 
short  of  contemptible  ;  and  when  one  hears  nurses  or  parents 
playing  upon  the  fears  of  a  child  to  enforce  obedience  by  threats 
or  feints  of  highly  improbable  but  none  the  less  terrifying 
punishments,  one  feels  that  such  people  are  wholly  unfit  to  be 
entrusted  with  the  care  of  any  child,  much  less  of  a  nervous 
child. 

The  nervous  child  is  to  be  treated  gently ;  his  nervous  texture, 
if  I  may  use  so  vague  a  term,  is  more  delicate  and  requires  more 
careful  handling  than  that  of  a  coarser  fibred  child.  It  is  a  great 
mistake  to  attempt  to  '  harden  '  such  a  child  by  exposing  him 
purposely  to  that  which  he  fears ;  the  shrinking,  timid  child  is 
not  to  be  made  *  manly  '  by  a  course  of  exposure  to  the  ridicule 
or  bullying  which  he  will  almost  certainly  meet  with  at  any  large 
school ;  nor  will  the  nervous  and  sensitive  child  be  any  way 
the  better  for  that  foolish  proceeding  which  some  parents  call 
'  knocking  it  out  of  him ' ;  on  the  contrary,  the  nervous  condition 
may  easily  be  aggravated,  and  what  was  first  an  unimportant  and 
almost  natural  characteristic  of  the  child  may  take  the  form  of 
some  functional  neurosis  which  may  be  very  difficult  to  cure. 

Perhaps  one  of  the  most  important  points  in  the  management 
of  these  children — and  even  for  the  medical  man  the  treatment 
of  the  nervous  child  is  largely  a  question  of  management  rather 
than  a  dose  of  medicine  three  times  a  day — is  the  matter  of  school- 
ing. I  have  touched  incidentally  upon  some  of  the  common 
results  of  school  pressure  on  these  children,  and  my  own  expe- 
rience has  more  and  more  convinced  me  that  to  the  nervous  child 
schooling  must  be  given  in  small  doses  well  diluted. 

Long  school  hours  are  bad  in  every  way  ;  for  many  a  nervous 
child  of  seven  or  eight  years  one  to  two  hours'  schooling  in  the 
morning,  or  even  less,  may  be  as  much  as  can  be  advantageously 
given,  and  there  are  those  for  whom  school  must  be  forbidden 
altogether  for  a  time.  Public  schools  have  seemed  in  my 


632  COMMON  DISORDERS  OF  CHILDHOOD 

experience  to  be  wholly  unsuitable  for  such  children.  I  have 
seen  nervous  symptoms  seriously  increased  by  the  methods  of 
education  adopted  in  these  schools.  It  is  useless,  and  worse 
than  useless,  to  attempt  wholesale  methods  in  the  education  of 
nervous  children  ;  they  must  be  dealt  with  individually.  Even 
the  very  subjects  of  study  require  selection  and  adaptation  for 
the  individual  child.  For  one  child  '  sums  '  are  not  merely 
the  bane  of  his  existence,  but  may  and  do  cause  a  mental 
strain,  the  result  of  which  may  be  sufficiently  obvious  when  some 
neurosis  develops  ;  to  another  '  spelling  '  is  a  bugbear  ;  and  to 
a  third  '  music  '  may  be  prejudicial.  For  the  younger  children 
with  this  nervous  temperament  I  believe  that  the  Froebel  system 
is  the  proper  and  best  method  of  education,  while  for  the  older 
ones  home  teaching  by  a  governess  or  tutor  is  often  to  be  pre- 
ferred to  any  school  instruction.  In  one  respect  Froebel  did 
not  follow  the  practice  of  his  great  forerunner,  Pestalozzi. 
'  Although  Pestalozzi,'  says  one  of  his  pupils,  '  objected  on 
principle  to  corporal  punishment,  he  gave  us  every  now  and  then 
boxes  on  the  ear  right  and  left.'  And  this  is  a  point  of  impor- 
tance. In  the  training  of  the  nervous  child  corporal  punishment 
of  any  kind  must  be  absolutely  forbidden  ;  the  effect  of  such 
punishment  may  indeed  be  disastrous.  In  one  case,  for  instance, 
it  was  followed  almost  immediately  by  hysterical  convulsions, 
and  there  can  be  little  doubt  that  such  affections  as  habit-spasm, 
which  are  just  those  for  which  the  child  is  punished  by  an 
ignorant  parent  or  school  teacher,  may  be  seriously  aggravated 
in  this  way. 

The  value  of  physical  training  for  these  children  is  great. 
I  believe  that  disciplined  exercise,  say  in  a  wrell-regulated  gymna- 
sium or  in  the  form  of  Swedish  drill  or  even  in  dancing,  accustoms 
not  only  the  motor  centres  but  also  the  higher  centres  to  that 
ready  and  well-ordered  control  which  is  so  often  lacking  in 
the  nervous  child.  To  obtain  the  full  value  of  such  training, 
however,  the  exercises  or  drill  must  not  be  an  event  of  once  or 
twice  a  week  only,  as  in  some  schools,  but  should  be  part  of  the 
daily  routine  and,  moreover,  must  be  carried  out  with  accuracy 
and  care.  In  visiting  schools,  both  private  and  public,  I  have 
been  disappointed  to  see  how  much  of  the  value  of  such  physical 
training  is  lost  by  the  slovenly  and  perfunctory  way  in  which 
the  children  are  too  often  allowed  to  perform  the  exercises. 

As  I  have  already  said,  there  are  children  for  whom  schooling 
must  be  prohibited  altogether  for  a  time  ;  and  I  \vould  add 
that  there  is  many  a  nervous  child  for  whom  a  few  months  of 


NERVOUS  CHILDREN  633 

freedom  to  run  wild  in  the  country,  or  at  the  seaside,  will  be 
of  far  greater  and  more  lasting  value  than  the  most  intimate 
knowledge  of  multiplication  tables,  or  even  the  more  subtly 
instilled  wisdom  of  Gift  I  in  the  Kindergarten. 

I  have  made  no  mention  hitherto  of  drugs,  for  these  play 
quite  a  subordinate  part  in  the  treatment  of  this  condition ;  but 
drugs  have  their  place,  and  there  are  times  when  the  administra- 
tion of  bromide  or  a  course  of  arsenic  may  be  the  best  possible 
thing  for  the  child 

Lastly,  it  must  be  pointed  out  that  there  is  no  rule  of  thumb 
by  which  we  may  be  guided  in  the  treatment  of  the  nervous 
child  ;  each  case  requires  to  be  weighed  carefully,  not  only 
in  regard  to  its  particular  symptoms,  their  kind  and  degree, 
but  also  as  to  practical  possibilities,  in  the  way  of  modifying 
environment,  or  directing  education  in  its  widest  senso. 


CHAPTER  XLIV 
HABIT-SPASM 

AMONGST  the  many  functional  nervous  disordeis  to  which 
children  aie  subject,  one  of  the  commonest  is  habit-spasm. 
This  name  has  been  given  to  certain  oft-repeated  and  seemingly 
purposeless  movements  which  most  commonly  affect  the  face 
or  head  and  which,  although  they  may  change  in  character  from 
time  to  time,  are  for  varying  periods  persistent  in  kind,  whether 
the  movement  be  a  simple  twitch  of  one  muscle  or  a  more  com- 
plicated action  of  several  muscles.  The  term  '  tic  '  is  sometimes 
applied  to  this  disorder,  but  lacks  the  descriptive  merit  of  'habit- 
spasm  ',  which  I  shall  therefore  use.  Trivial  as  the  movements 
may  be,  their  frequent  repetition  is  most  worrying  and  distressing 
to  parents,  and  so  the  child  is  brought  sooner  or  later  to  the 
medical  man,  and  I  will  venture  to  say  that  there  are  few  dis- 
orders of  childhood  out  of  which  the  medical  attendant  is  likely 
to  gain  less  credit  than  these  cases  ;  they  look  so  easy  and  they 
are  so  difficult  to  cure.  But  if  there  is  no  drug  which  acts  as 
a  specific  for  habit-spasm  there  are  many  details  in  the  manage- 
ment of  these  children  upon  which  we  may  give  valuable  advice, 
and  the  value  of  our  directions  is  likely  to  be  in  direct  proportion 
to  our  appreciation  of  the  relations  and  significance  of  habit- 
spasm. 

The  most  frequent  form  of  habit-spasm  is  a  rapid  blinking  of 
the  eyes  or  a  more  forcible  closure  of  the  eyelids,  described  by 
the  parents  as  '  screwing  up  the  eyes  '  ;  this  movement,  in  the 
slighter  or  more  forcible  degree,  was  present  in  47  out  of  100 
consecutive  cases  under  my  care  ;  sometimes  it  was  the  only 
spasm  present  throughout  the  affection,  but  more  often  it  was 
the  first  to  appear  and  was  subsequently  replaced  or  accom- 
panied by  some  other  form  of  spasm.  Much  less  common  is 
a  movement  of  the  eye  itself  :  in  5  per  cent,  of  the  cases  the 
child  had  a  habit  of  suddenly  turning  the  eyes  upwards,  and  still 
more  rarely  there  was  a  sudden  lateral  deviation  or  a  rolling 
movement  of  the  eyes. 

Next  in  frequency  to  the  sudden  blinking  or  closure  of  the 


HABIT-SPASM  635 

eyes  which  I  have  mentioned  are  various  movements  of  the 
face,  perhaps  most  often  a  twitch  of  the  nose,  which  may  be 
twisted  to  one  side,  or  a  sudden  drawing  up  of  one  angle  of 
the  mouth,  or  the  twitching  may  affect  the  forehead,  causing 
a  sudden  frown  or  an  elevation  of  the  eyebrows.  Grouping 
together  these  various  facial  contortions,  I  noted  one  or  other  of 
them  in  48  per  cent,  of  the  cases.  A  common  spasm  is  a  sudden 
antero-posterior  jerk  of  the  head,  a  rapid  affirmative  nod  ;  some- 
times it  is  a  sudden  lateral  rotation  as  in  negation,  or  the  head 
is  rotated  always  towards  one  shoulder  only,  or  it  may  be 
momentarily  thro wn  upwards.  Some  such  head- jerk  was  present 
in  30  per  cent,  of  my  series.  The  limbs  are  less  often  affected, 
but  the  upper  limb  more  frequently  than  the  lower.  The  upper 
limb  was  affected  in  22  per  cent.,  the  lower  in  9  per  cent.  In 
the  upper  extremity  the  commonest  movement  is  a  sudden 
elevation  of  one  or  both  shoulders  ;  this  was  present  in  several 
of  my  series,  but  all  sorts  of  curious  movements  are  seen.  For 
instance,  a  girl  aged  eleven  years  and  four  months  developed 
a  habit  of  frequently  nipping  the  end  of  the  mid-finger  against 
the  end  of  the  thumb  first  in  one  hand  and  then  in  the  other,  as 
if  snapping  her  fingers  ;  this  continued  at  frequent  intervals 
all  day  for  three  weeks,  then  it  ceased  and  was  replaced  by 
a  habit  of  suddenly  jerking  her  head  upwards.  Another  child, 
a  girl,  began  at  the  age  of  eight  years  and  ten  months  to  strike 
herself  frequently  on  the  chest  with  her  hand  at  home  and 
at  school,  but  soon  this  stopped  and  she  began  to  blink  frequently, 
and  later  developed  a  sudden  antero-posterior  jerk  of  her 
head  ;  another  girl  who,  at  the  age  of  6J  years,  had  begun 
to  blink  and  then  had  developed  an  antero-posterior  jerk  of  the 
head,  began  at  eight  years  to  abduct  her  arms  suddenly  and 
beat  them  against  her  thighs  like  a  bird  flapping  its  wings. 
Another  girl,  nearly  twelve  years  old,  made  frequent  sudden 
clawing  movements  with  her  hands. 

In  the  lower  limbs  equally  curious  movements  occur.  A 
boy  of  eight  years  would  at  frequent  intervals  '  paw  the  ground 
like  a  horse  '  whilst  out  walking  ;  the  affection  had  begun  with 
blinking  of  the  eyes  two  months  earlier  ;  then  this  ceased  and 
he  acquired  a  habit  of  frequent  grunting  and  at  another  time 
a  sudden  head-jerk.  A  girl  about  ten  years  old  who  eighteen 
months  earlier  had  begun  to  interpolate  a  curious  sound  between 
every  few  words  in  speaking,  and  a  little  later  had  changed  this 
habit  for  a  frequent  clearing  of  the  throat,  was  now  said  to 
jerk  one  leg  forward  quite  suddenly  at  short  intervals  when 


J 

636  COMMON  DISORDERS  OF  CHILDHOOD 

walking.  A  girl  aged  6J  years,  who  was  brought  first  for 
blinking,  and  when  this  ceased  for  continual  'hawking',  had  now 
begun  to  pause  suddenly  in  walking  and  turn  one  foot  over 
on  its  outer  side  and  then  the  other  foot  similarly.  Another 
girl,  aged  8J  years,  had  a  curious  habit  of  raising  herself  suddenly 
on  her  toes  whenever  she  began  to  speak. 

Trunk  movements  are  more  uncommon  ;  a  child  to  whom  I 
have  already  referred  as  flipping  her  fingers  was  brought  a  year 
later  for  a  sudden  bending  of  her  trunk  to  one  side,  a  sort  of 
pleurosthotonos,  but  quite  momentary  ;  it  occurred  usually 
whilst  out  walking.  A  boy,  aged  seven  years,  showed  a  sudden 
twitch  of  the  facial  muscles,  drawing  his  mouth  over  to  the  right 
side,  and  at  the  same  time  his  whole  trunk  was  jerked  slightly 
forward. 

A  common  form  of  habit-spasm  is  the  frequent  repetition 
of  some  particular  sound,  which  may  be  like  that  made  in 
'  clearing  the  throat  '  or  a  more  obvious  '  hem  ',  or  may  be  of 
more  articulate  character,  resembling  some  syllable  or  word 
which  the  child  utters  in  season  and  out  of  season  in  the  most 
inopportune  manner  ;  rarely  the  sound  is  much  more  like  one 
of  the  involuntary  sounds  produced  by  healthy  persons,  such 
as  hiccough  or  a  gurgling  sound  in  the  throat.  One  or  other 
of  these  varieties  was  present  in  14  out  of  my  100  cases.  As 
examples  of  these  I  may  mention  a  girl,  aged  9J  years, 
who  first  showed  a  rapid  affirmative  jerk  of  the  head  which 
recurred  sometimes  twice  in  a  minute ;  she  made  also  at 
short  intervals  a  slight  grunting  sound  and  for  a  time  had 
occasional  momentary  adductor  spasm  of  the  arms  ;  these  habits 
disappeared  almost  entirely  after  a  month's  stay  in  the  country, 
but  about  two  years  later  she  was  brought  again  for  a  return  of 
the  antero-posterior  jerks  of  the  head  and  a  very  frequent 
inspiratory  sniff.  A  boy,  aged  eleven  years  and  four  months, 
who  began  with  a  frequently  repeated  'ahem',  and  then  passed 
from  one  habit-spasm  to  another,  has  now  begun  to  roll  his  eyes 
up  frequently  and  twitch  his  face,  and  at  the  same  time  makes 
a  sudden  hissing  noise  between  his  teeth  at  short  intervals.  A 
girl,  aged  eight  years,  who  attended  first  for  blinking  and,  when 
this  stopped,  for  a  sudden  shrug  of  the  shoulders,  uttered  a  sound 
like  'pistol'  at  irregular  intervals  in  the  most  irrelevant  manner. 

Such  are  the  irregularities  which  are  grouped  together  as 
*  habit-spasm  ',  but,  as  will  have  been  noticed,  the  term  '  spasm' 
hardly  seems  equally  applicable  to  all  ;  the  jerk  of  the  head, 
almost  like  the  result  of  an  electric  shock  in  its  suddenness, 


HABIT-SPASM  637 

seems  much  more  appropriately  termed  spasm  than  docs  such 
a  movement  as  flapping  the  arms  against  the  thighs  or  the  even 
more  quasi-purposive  movements  which  sometimes  alternate  with 
a  simple  spasm  ;  twice  I  have  seen  a  simple  twitch  of  face 
or  nose  replaced  by  a  frequent  sudden  licking  of  upper  or  lower 
lip,  so  that  the  lip  became  reddened  and  sore,  and  one  child  who 
attended  for  years  with  first  one  habit-spasm  and  then  another 
had  at  one  time  a  troublesome  habit  of  licking  with  her  tongue 
objects  which  happened  to  be  near  her,  but  this,  like  the  rest 
of  her  curious  habits,  passed  away  soon,  only  to  be  replaced  by 
some  other. 

To  this  account  of  the  individual  movements  I  would  add  that, 
whilst  in  most  cases  the  movement  occurs  singly,  whether  the 
child  shows  only  one  or  more  of  the  different  forms — I  mean,  for 
instance,  that  a  sudden  jerk  of  the  head  and  perhaps  a  grunting 
noise  recur  at  irregular  intervals  of  a  few  seconds  or  minutes — 
yet  in  some  cases  I  have  seen  the  particular  spasm  to  occur  in 
a  series  of  perhaps  six  or  eight  repetitions  in  rapid  succession, 
after  which  the  child  would  show  no  spasm  for  several  minutes, 
when  another  series  would  occur.  There  is  in  these  cases,  as  it 
were,  a  grouped  habit-spasm,  a  sort  of  habit  clonus.  Another 
feature  of  the  disorder,  which  I  have  illustrated  incidentally  in 
this  description  of  the  movements,  is  the  limitation  of  the  spasm 
to  different  parts  at  different  times,  sometimes  to  one  part  only  ; 
in  one  child  there  is  only  blinking,  in  another  blinking  and 
a  twitch  of  the  nose,  in  a  third,  perhaps,  an  added  shrug  of  the 
shoulders  ;  the  particular  spasm  is  defined  and  settled  ;  there 
is  none  of  that  complete  uncertainty  as  to  the  whereabouts  of 
the  next  jerk  which  is  so  characteristic  of  chorea,  where  the 
movements  vary  continually  from  moment  to  moment.  Yet 
a  further  peculiarity,  which  I  have  also  mentioned  incidentally, 
is  the  striking  tendency  to  change  after  a  varying  period  of 
days,  weeks,  or  months,  from  one  form  of  habit-spasm  to  another  ; 
as  one  mother  said  to  me  of  her  child,  who  attended  at  hospital 
with  habit-spasm  for  eight  years,  '  as  fast  as  she  gets  rid  of  one 
movement  she  seems  to  get  another '. 

A  remarkable  feature  of  habit-spasm,  and  one  upon  which  I 
would  lay  some  stress,  for  it  may  be  of  some  weight  in  diagnosis, 
is  its  diminution  or  cessation  in  many  cases  so  long  as  the 
child  is  conscious  of  being  specially  under  observation  ;  some- 
times, indeed,  the  medical  attendant  has  to  rely  entirely  upon 
history  in  his  diagnosis  ;  for  the  movements  may  cease  directly 
the  child  is  conscious  that  he  is  being  watched  by  the  medical 


638  COMMON  DISORDERS  OF  CHILDHOOD 

man,  but  directly  this  inhibitory  effect  of  observation  is  removed 
— as  it  may  be  by  letting  the  child  sit  quietly  aside  whilst  the 
mother  is  being  questioned — the  habit-spasm  becomes  evident. 

So  far  I  have  spoken  chiefly  of  the  movements  which  are  the 
characteristic  feature  of  habit -spasm,  movements  which  vary 
from  a  simple  twitch  of  one  muscle  up  to  a  complex  co-ordinated 
movement  such  as  pausing  in  walking  to  turn  each  foot  over 
on  its  side  ;  I  have  mentioned  also  the  occurrence  of  apparently 
involuntary  utterance  of  sounds  which  similarly  vary  from 
a  simple  grunt  up  to  a  complex  articulate  utterance,  as  in  the 
case  where  '  pistol '  was  the  repeated  sound.  But  there  is  yet 
another  manifestation  of  the  disorder,  which  has  been  described 
by  some  writers  under  a  separate  heading  as  '  psychical  tic  '  ; 
the  child  in  some  cases,  and  these  generally  with  very  marked, 
sometimes  almost  violent  affection  of  movement,  shows  curious 
psychical  disorder  ;  a  girl,  aged  eight  years,  whose  earliest 
symptom  had  been  simple  blinking  of  the  eyes,  which  was  re- 
placed a  little  later  by  shrugging  of  the  shoulders,  subsequently 
was  brought  to  me  with  a  complaint  that  she  had  begun  to 
utter  foul  language,  apparently  without  any  reason  or  even 
seeming  to  be  aware  what  she  was  saying.  Another  child, 
a  boy  aged  10  J  years,  who  had  begun  with  a  simple  noise  like 
clearing  the  throat  at  short  intervals  and  then  had  developed 
the  habit  of  frequent  frowning  and  an  upward  jerk  of  the  head, 
was  brought  to  me  two  years  later  with  delusions  of  '  microbes 
on  his  hands  ',  so  that  it  was  difficult  to  get  him  to  take  his 
food.  Such  cases  undoubtedly  represent  the  more  severe  and 
intractable  degrees  of  the  disorder,  but  I  have  specially  men- 
tioned the  early  symptoms  in  these  two  instances  to  show  that 
they  differ  in  no  way  from  many  another  case  of  habit-spasm 
in  which  there  is  less  evidence  of  psychical  disturbance,  and 
I  say  '  less  evidence  '  advisedly,  for  although  but  few  cases 
show  such  pronounced  disturbance  as  I  have  described,  there 
are  many  more  in  which  extreme  excitability,  great  passionate- 
ness,  or  a  morbid  waywardness  shows  evidence  of  psychical 
disturbance.  To  this  point  I  shall  refer  again  ;  here  I  would 
only  deprecate  the  specializing  of  any  such  group  of  cases,  as  if 
'  psychical  tic  '  were  some  affection  quite  distinct  from  the  mild 
case  of  habit-spasm  which  shows  only  blinking  of  the  eyes. 
Similarly  every  gradation  may  be  observed  in  one  and  the  same 
child,  from  a  simple  twitch  of  the  eyelids  or  nose  up  to  the  violent 
and  sudden  jerk  which  has  been  described — with  no  sufficient 
ground,  as  it  seems  to  me — under  a  separate  heading,  as  if 


HABIT-SPASM 


639 


quite  distinct  from  the  slighter  degree  of  spasm,  as  <  tic  con- 
vulsif  '. 

Etiology.  Turning  now  to  the  etiology  of  habit-spasm,  one 
might  have  expected  that,  being  a  functional  neurosis,  it  would 
be  much  commoner  in  girls  than  in  boys.  My  own"  figures, 
however,  showed  53  girls  to  47  boys  ;  the  excess  of  girls  affected', 
therefore,  is  only  slight.  I  would  point  out  that  the  same 
holds  good  of  hysteria  in  childhood,  where  the  proportion 
according  to  my  own  figures  is  1-5  to  1,  a  proportion  which 
contrasts  with  the  10  to  1  which  is  stated  to  be  the  relative 
frequency  in  adult  life.  The  sexes  are  less  sharply  differentiated, 


Ya    of 
C&»e* 

. 

<*-ro 

10-11 

II  '-U 

W 

r 

\ 

16 

T 

/ 

S, 

1+ 

2 

v 

f 

*\ 

if 

I 

^ 

5 

1O 

i 

T 

\ 

Q 

/ 

^ 

A 

\ 

6 

to^ 

\ 

r 

1 

\ 

/ 

5 

z 

I 

1 

o 

I 

FIG.  44.     Age-incidence  of  habit-spasm.      Chart  showing  age  at  onset 
in  100  case?. 

so  far  as  concerns  the  tendency  to  functional  nervous  disorders, 
in  childhood  than  in  later  life.  With  these  proportions  I  would 
specially  contrast  the  sex -incidence  of  chorea,  where  the  propor- 
tion of  females  to  males  has  been  shown  to  be  approximately 
2-5  to  1.  The  age-incidence  of  habit-spasm  is  of  some  interest, 
as  it  has  been  suggested  that  it  bears  some  relation,  which 
I  shall  mention  later,  to  the  cause  of  the  disorder.  It  is  shown 
in  the  accompany  ing  chart,  in  which  the  age  at  onset  is  recorded 
in  100  consecutive  cases  under  my  care. 

The  one  fact  which  stands  out  pre-eminent  in  the  history  of 
children  with  habit-spasm  is  nervous  instability,  and  this  is 
well  seen  in  the  various  disorders  with  which  habit-spasm  keeps 


640  COMMON  DISORDERS  OF  CHILDHOOD 

company.  A  boy  aged  llf  years,  who  was  brought  for  a  fre- 
quently-occurring shrug  of  both  shoulders,  was  said  to  be  a  very 
timid  child,  often  suffered  with  headaches,  was  very  restless,  and 
talked  much  in  his  sleep  ;  the  shrugging  of  the  shoulders  was 
noticed  to  be  worse  when  he  came  home  from  school.  Another 
boy,  aged  seven  years,  who  was  brought  for  twitching  of  the 
face  and  jerking  of  the  body  forward,  and  later  for  some  blinking, 
was  said  to  be  '  very  nervous  ',  talked  much  in  his  sleep,  had  had 
enurcsis,  and  the  habit-spasm  was  more  whenever  ho  became 
excited.  Another  child,  a  girl  aged  6J  years,  who  attended  for 
many  months  with  various  habit-spasms,  had  recently  walked  in 
her  sleep  ;  at  the  onset  of  the  habit-spasm  she  had  begun  to 
suffer  with  enuresis,  and  a  little  later  was  said  to  be  'so  dread- 
fully nervous,  she  cries  if  you  speak  to  her'. 

There  is  no  need  to  multiply  examples  of  this  sort,  but  to 
sum  up  the  associated  manifestations  in  my  series  of  cases 
they  were  as  follows  :  in  a  large  proportion  of  the  cases  the 
child  was  said  to  be  extremely  nervous  and  excitable  ;  in  some 
cases  the  child  was  extremely  irritable  or  passionate  and  difficult 
to  control.  Disturbances  of  sleep  were  very  common,  the  sleep 
was  often  noticed  to  be  restless,  and  in  20  per  cent,  there  were 
more  definite  disorders  of  sleep  ;  the  child  talked  or  walked 
in  its  sleep,  had  night  terrors,  or  suffered  with  troublesome 
insomnia.  Headaches  were  common  and  enuresis  was  noted 
in  10  per  cent,  of  my  cases.  That  peculiar  form  of  looseness  of 
the  bowels  which  occurs  immediately  after  each  meal,  '  nervous 
diarrhoea  '  as  it  has  been  called,  was  noted  in  two  cases.  Stutter- 
ing occurred  in  two  cases,  and  I  have  noted  in  three  cases  a  vaso- 
motor  instability  showing  itself  in  extraordinarily  ready  flushing 
or  extreme  liability  to  urticaria.  Convulsions  had  occurred  in 
infancy  or  early  childhood  in  7  per  cent,  of  the  cases — an  occur- 
rence which,  as  Dr.  J.  A.  Coutts  pointed  out,  often  foreshadows 
nervous  instability  in  later  years.  To  this  description  of  the 
accompaniments  of  habit-spasm  in  children  I  would  add  one 
more  which,  though  not  a  disorder,  is  like  the  '  genius  which 
is  near  allied  to  madness  ',  a  common  association  of  nervous 
tendencies — I  mean  quick  intelligence.  Most  of  these  children 
are  sharp,  responsive,  '  quick  in  the  up-take.'  Often  I  have 
been  told  that  they  are  '  always  reading  '  or  '  mad  on  school  ' 
(I  quote  the  mother's  words).  The  child  with  habit-spasm  is  to 
be  found  at  the  top  of  the  class  and  not  uncommonly  in  a  class 
above  his  age.  As  a  further  point  in  connexion  with  their 
nervous  temperament  I  would  note  that  these  children  are 


HABIT-SPASM  641 

almost  never  the  'fat,  sleek-headed,  such  as  sleep  o'  nights', 
they  are  nearer  akin  to  the  lean  Cassius — they  are  spare  of 
build. 

With  all  these  indications  of  the  nervous  tendency  I  would 
class  the  perhaps  more  than  average  frequency  of  rheumatism 
in  the  family  history  of  these  children ;  in  14  out  of  the  100, 
the  mother  or  father  had  had  rheumatic  fever  ;  in  three  others 
a  sister  or  brother  ;  in  seven  others  one  of  the  grandparents  ; 
in  seven  others  an  uncle  or  aunt  had  had  rheumatic  fever  ;  in 
six  others  the  child  himself  had  had  pains  in  the  joints,  possibly 
or  probably  rheumatic.  These  figures  perhaps  understate  the 
frequency  of  such  a  history,  for  I  have  counted  only  histories  of 
definite  rheumatism,  omitting  cases  in  which  there  was  '  rheu- 
matism '  of  uncertain  nature.  The  nervous  temperament  of 
the  rheumatic  child  and  the  child  of  rheumatic  parentage  is 
a  very  real  clinical  fact,  whatever  the  pathological  explanation 
may  be,  and  it  is  in  this  respect,  no  doubt,  that  rheumatism 
may  play  some  part  in  predisposing  to  habit-spasm.  As  might 
be  expected,  a  family  history  of  neurosis  is  very  common  in 
these  cases,  but  I  have  only  occasionally  seen  habit-spasm  in 
either  of  the  parents. 

Given  the  nervous  tendency,  there  are  still  other  factors  in 
many  cases  determining  the  onset,  or  it  may  be  the  return  of 
the  habit-spasm  ;  and  first  I  should  place  local  irritation,  not 
because  of  its  frequency — for  in  my  own  experience  it  has  only 
been  in  the  minority  of  cases  that  any  such  could  be  detected — 
but  because  its  detection  may  be  of  much  practical  importance 
in  treatment.  The  local  irritation  may  be  so  slight  that  the  child 
is  barely,  if  at  all,  conscious  of  it,  and  yet  the  removal  of  the 
irritant,  if  it  be  removable,  certainly  diminishes  or  stops  the 
habit -spasm  in  many  cases.  The  age-incidence  suggests  one 
possible  source  of  irritation,  the  onset  of  habit-spasm  corresponds 
in  so  many  cases  with  the  onset  of  the  second  dentition,  a  process 
which  in  some  children  produces  appreciable  local  worry  and 
might  be  expected,  like  the  teething  of  the  infant,  to  produce 
reflex  disturbance.  I  have  seen  several  cases  also  in  which 
caries  of  the  teeth  seemed  to  be  an  exciting  cause  of  habit-spasm, 
and  dental  treatment  has  caused  a  rapid  improvement.  I  am 
satisfied  also  that  in  some  cases  the  blinking  which  is  so  commonly 
an  early  manifestation  of  habit-spasm  is  started  by  a  local  cause, 
sometimes  by  a  slight  follicular  conjunctivitis,  so  that  when  the  lid, 
especially  the  lower,  is  everted  its  inner  surf  ace  is  seen  to  be  unduly 
red  and  granular,  sometimes  and  perhaps  more  often  by  some 

STILL  T  t 


642  COMMON  DISORDERS  OF  CHILDHOOD 

error  of  refraction  which,  so  my  ophthalmic  colleague,  Mr.  L.  V. 
Cargill,  tells  me,  is  most  commonly  hypermetropic  astigmatism. 
Similarly  in  the  nose  I  have  seen  inflammation  of  the  mucous 
membrane  on  the  septum  associated  with  a  constantly  recurring 
screwing  up  of  the  nose,  and  I  doubt  not  that  sometimes  the 
'  clearing  of  the  throat '  which  becomes  a  habit  and  is  replaced 
subsequently  by  other  entirely  different  habits,  may  be  started 
by  some  temporary  naso-pharyngeal  catarrh  or  by  the  more 
chronic  catarrh  which  is  so  often  associated  with  adenoids. 

This  leads  me  to  raise  another  point  which  may  emphasize 
the  necessity  for  early  detection  of  these  local  sources  of  irrita- 
tion— I  mention  it  as  a  suggestion  rather  than  as  an  assertion. 
It  has  seemed  to  me  that  habit-spasm  once  induced  by  a  local 
irritation  begets  habit-spasm  elsewhere,  so  that  a  child  who 
owing  to  some  error  of  refraction  has  acquired  the  blinking 
habit  may  soon  develop  a  twitching  of  the  nose,  and  then, 
perhaps,  lose  both  of  these  spasms  and  develop  a  shrug  of  one 
shoulder  or  a  jerk  of  the  head. 

It  seems  likely  that  more  remote  irritation  may  occasionally 
set  up  habit-spasm.  I  have  noted  particularly  the  presence  of 
worms  in  several  of  my  series  of  cases,  but  one  must  remem- 
ber that  worms  are  exceedingly  common  in  children  without 
habit-spasm  and,  moreover,  even  if  worms  do  play  any  part 
in  the  production  of  habit-spasm,  it  may  be  rather  indirectly 
by  increasing  the  general  nervous  instability  of  the  child  than 
by  any  more  immediate  effect  of  the  irritation. 

Other  factors  which  play  no  small  part  in  the  causation  of 
habit-spasm  in  children  are  mental  strain  and  mental  shock. 
There  can  be  no  doubt  that  the  present  system  of  compulsory 
education,  enforced  as  it  too  often  is  by  the  bullying  ignorance 
of  attendance  officers  and  attendance  committees,  involves 
a  degree  of  mental  strain  which  is  harmful  to  many  a  nervous 
child.  And  let  it"  be  understood  that  in  the  influence  of  school 
there  is  to  be  considered  not  merely  the  strain  of  acquiring  know- 
ledge— this,  indeed,  may  be  but  trivial,  particularly  for  some 
of  these  children  who  suffer  from  habit-spasm,  for  they  are  often 
particularly  quick  at  learning — but  also  the  strain  of  excitement 
in  competition,  the  dread  of  failure  and  punishment — a  very 
real  strain  with  some  of  these  nervous  children — and  in  some 
cases  also  the  continual  dread  of  that  most  thoughtless  of 
torturers,  the  schoolboy  who  finds  his  delight  in  teasing  or 
terrifying  a  timid  boy.  Amongst  the  well-to-do  all  these  diffi- 
culties can  be  avoided  by  home  education,  where  the  nervous 


HABIT-SPASM  643 

child  has,  perhaps,  his  hour  or  two  hours  of  lessons,  and  not  only 
the  hours  but  the  subjects  and  the  methods  of  education  can 
be  adapted,  as  they  should  be,  to  the  requirements  of  the 
individual  child  :  to  attempt,  as  the  modern  tendency  is,  to 
adapt  the  child  to  its  education  may  be  an  inevitable  procedure 
in  wholesale  education,  but  it  is  none  the  less  unsatisfactory, 
and  particularly  unsatisfactory  in  dealing  with  such  children  as 
these  with  habit-spasm.  The  effect  of  school  on  habit-spasm 
is  sometimes  very  striking,  the  spasm  diminishes  when  the  child 
is  kept  away  from  school,  and  increases  markedly  or  returns 
directly  schooling  is  commenced  again  ;  there  is  sometimes 
other  evidence  of  the  nervous  strain  of  school  at  the  same  time 
in  the  appearance  or  increase  of  sleep-walking,  night  terrors,  or 
headaches  when  the  child  returns  to  school.  It  may  be  also 
that  in  this  relation  to  school  life,  especially  to  the  earliest  years 
of  schooling,  lies  the  explanation  of  the  very  striking  age-incidence 
of  this  disorder,  as  shown  in  the  chart  on  p.  639. 

Excitement  of  any  kind  contributes  to  the  production  of 
habit-spasm.  I  have  repeatedly  known  the  good  effects  of 
treatment  undone  by  some  exciting  experience  :  the  sensational 
doings  of  Bluebeard  at  the  theatre  made  one  child  who  was 
under  my  care  much  worse,  and  in  another  the  newly-conferred 
dignity  of  trousers  increased  the  habit-spasm  considerably. 
More  potent  still  is  fright  or  mental  shock  of  any  sort  :  a  boy,  aged 
seven  years,  who  had  been  improving,  became  much  worse  after 
being  knocked  down  by  a  bicycle  ;  another  boy,  aged  eight  years, 
whom  I  have  already  mentioned  as  '  pawing  the  ground  like 
a  horse  ',  became  worse  after  pinching  his  finger  in  the  door  of 
a  railway  carriage.  Similarly — and  this  is  a  point  worth  remem- 
bering— the  mental  shock  of  a  surgical  operation  sometimes 
originates  or  increases  habit-spasm.  In  the  case  of  a  boy,  aged 
nine  years  and  four  months,  the  habit-spasm  began  directly  after 
circumcision,  and  after  various  forms  of  habit-spasm  had  appeared 
for  many  months  he  gradually  improved  ;  the  teeth,  however, 
were  very  carious,  and  five  were  extracted,  with  the  result  that 
his  habit-spasm  again  became  bad  ;  in  another  the  habit-spasm 
seemed  to  have  been  started  by  the  operation  for  removal  of 
tonsils  and  adenoids.  Lastly,  I  would  mention  exhaustion  as 
a  factor  which  at  any  rate  aggravates  if  it  does  not  start  habit- 
spasm.  I  have  purposely  avoided  particularizing  as  to  the  kind 
of  exhaustion,  for  I  doubt  if  it  be  possible  to  separate  physical 
exhaustion  altogether  from  nervous  exhaustion.  In  several 
cases  I  have  been  told  that  the  habit-spasm  was  always  worse 

Tt2 


J 
644  COMMON  DISORDERS  OF  CHILDHOOD 

when  the  child  was  tired ;  in  others  it  was  definitely  worse  in 
the  evening,  or  when  the  child  was  allowed  to  stay  up  later 
than  usual. 

If  I  might  throw  out  yet  another  suggestion  for  consideration 
it  would  be  in  the  form  of  a  question  :  May  not  habit-spasm  arise 
in  the  involuntary  perpetuation  of  what  began  as  a  voluntary 
movement  ?  I  suspect  that  in  some  of  the  cases  of  local  irritation 
to  which  I  have  referred  the  child  began  by  screwing  up  its  eyes 
or  twitching  the  nose  voluntarily,  and  as  a  result  of  frequent 
repetition  the  movement  changed  from  the  voluntary  into  the 
involuntary.  It  has  even  seemed  to  me  possible  that  such 
a  natural  movement  as  a  toss  of  the  head  to  one  side,  which  began 
in  the  effort  to  throw  back  the  irritating  curl  which  will  fall  over 
the  face,  may  sooner  or  later,  in  a  nervous  child,  pass  into  the 
involuntary  jerk  of  a  habit-spasm  ;  in  the  same  way  I  believe 
that  I  have  seen  wilful  imitation  of  a  parent's  habit-spasm  pass 
into  an  involuntary  facial  twitch  in  the  child. 

Diagnosis.  The  diagnosis  of  habit-spasm  is  usually  simple 
enough,  but  it  is  sometimes  mistaken  for  chorea.  The  points  of 
distinction  are  these  :  habit-spasm  is  a  repetition  of  one  move- 
ment or  of  one  set  of  movements,  chorea  shows  movements 
varying  quite  irregularly  from  minute  to  minute  ;  habit-spasm 
is  generally  diminished  or  temporarily  abolished  altogether  by 
observation,  whereas  chorea  is  usually  exaggerated  by  observa- 
tion (in  either  case,  however,  the  reverse  sometimes  occurs)  ; 
habit-spasm  is  usually  much  more  limited  in  distribution  than 
chorea  ;  a  twitch  persistently  limited  to  the  face  or  head  would 
be  almost  unknown  in  chorea,  whereas  it  is  a  common  form  of 
habit-spasm.  But  I  am  quite  sure  that  there  are  cases  in  which 
the  diagnosis  is  extremely  difficult  ;  indeed,  when  I  collected 
from  my  notes  a  series  of  cases  of  habit-spasm  for  this  chapter, 
I  found  myself  obliged  to  omit  several  cases  which  I  had  headed 
*  ?  Chorea  ?  Habit-spasm  '  ;  and  the  difficulty  arises  in  two  ways, 
the  movements  of  habit-spasm — e.g.  in  the  shoulders  and  arms — 
may  approximate  in  character  and  extent  to  those  of  a  limited 
and  slight  chorea ;  and  whilst  habit-spasm  may  be  in  some  cases 
more  extensive  in  distribution  than  usual,  chorea,  as  we  all  know, 
is  sometimes  so  slight  that  it  is  only  detected  by  a  shrug  of  one 
shoulder  or  a  twitch  of  one  hand. 

And  there  is  a  further  difficulty,  as  Dr.  F.  Warner  pointed  out : 
the  nervous  child  often  shows  fidgety  movements,  very  like 
chorea,  especially  under  observation,  and  this  '  microkinesis  ' 
as  it  has  been  called,  is  not  uncommon  in  children  with  habit- 


HABIT-SPASM  645 

spasm.  Imagine,  now,  a  child  with  this  fidgetiness  of  his  limbs 
brought  with  a  complaint  that  he  twitches  his  shoulders  ;  there 
is  perhaps  a  shrug  of  the  shoulder  and  in  addition  there  is  a 
general  fidgetiness  which  might  pass  for  a  slight  chorea  :  it  may 
be  no  easy  matter  to  decide  offhand  whether  the  shrugging  of 
the  shoulder  is  chorcic  or  is  due  to  habit-spasm.  In  such 
cases  repeated,  and  perhaps  prolonged,  observation  may  be 
necessary  before  a  diagnosis  can  be  made.  Even  the  presence  of 
rheumatism  is  not  conclusive  evidence  in  favour  of  chorea.  I  have 
already  pointed  out  that  a  family  history  of  acute  rheumatism 
is  not  uncommon  in  cases  of  habit-spasm  ;  more  importance 
is,  I  think,  to  be  attached  to  acute  rheumatism  in  the  patient, 
though  even  this  is  not  conclusive,  for  some  of  my  cases  had 
apparently  had  definite  articular  rheumatism,  though  none  had 
heart  disease. 

Treatment.  I  have  discussed  etiology  at  some  length  because 
therein  lies  the  key  to  the  management  of  these  cases  of  habit- 
spasm,  but  I  must  refer  to  some  of  these  points  again.  First, 
I  would  emphasize  the  importance  of  the  diagnosis  between 
chorea  and  habit-spasm  in  regard  to  treatment.  By  far  the  most 
important  part  of  treatment  in  chorea  is  rest  in  bed  ;  the  child 
with  habit-spasm,  on  the  contrary,  does  not  require  to  be  kept 
in  bed  at  all  :  a  good  scamper  at  the  seaside,  or  the  varied  interests 
of  farm-life  or  country,  will  do  more  to  get  rid  of  the  habit-spasm 
than  anything  else.  I  doubt  if  there  is  any  treatment  so  effectual 
as  a  change  to  seaside  or  country  for  these  children,  generally 
marked  improvement  at  least  is  obtained  in  this  way,  but  unfortu- 
nately it  is  not  always  permanent,  and  even  if  the  habit-spasm 
has  ceased  altogether  it  is  apt  to  return  when  the  child  goes  back 
to  town  or  to  school.  Of  the  influence  of  school  I  have  already 
spoken  ;  it  may  certainly  be  taken  as  a  general  rule  that  school 
should  be  forbidden  and  for  a  time  no  lessons  should  be  allowed 
at  all.  But  as  the  habit-spasm  diminishes,  an  hour  or  two  daily 
of  home  teaching  by  a  governess  or  tutor  may  be  begun  tenta- 
tively. Not  only  the  duration  of  lessons  but  also  the  choice  of 
subjects  may  have  to  be  restricted  ;  one  subject  or  another  may 
be  particularly  difficult  to  a  particular  child  ;  to  one  '  sums  '  are 
a  bewildering  misery,  to  another  '  spelling  '  is  no  better  ;  and  in 
all  such  cases  those  subjects  should  be  left  in  abeyance  for  a  time  ; 
the  worry  of  them  is  undoubtedly  prejudicial  to  these  nervous 
children  and  will  perpetuate  such  a  condition  as  habit-spasm. 
Obviously  education  is  no  small  difficulty  in  a  disorder  like  this, 
which  may  continue  with  intermissions  for  several  years,  and 


646  COMMON  DISORDERS  OF  CHILDHOOD 

whilst  the  well-to-do  can  get  over  the  difficulty  to  some  extent 
by  such  restriction  of  lessons  as  I  have  described,  the  poor  have 
no  such  opportunity  ;  half-time  attendance  is  resented  or  abso- 
lutely refused  by  school  authorities,  and  the  only  alternative  is 
to  keep  the  child  away  from  school  altogether  for  a  much  longer 
period  than  would  be  necessary  if  more  ideal  methods  of  educa- 
tion were  practicable. 

Having  said  so  much  about  the  necessity  of  avoiding  school, 
I  should  like  to  qualify  this  by  saying  that  in  exceptional  cases 
school,  so  far  from  being  injurious,  seems  to  have  a  quieting 
influence  upon  the  habit-spasm.  One  may  suppose  this  to  occur 
when  the  home  influences  are  such  as  to  encourage  neurotic 
tendencies  ;  in  any  case,  it  is  \vorth  bearing  in  mind  as  a  justifica- 
tion for  trying  the  effect  of  school  for  a  time. 

Another  practical  question  asked  by  parents  is  this  :  Should 
the  child  be  scolded  or  punished  for  his  '  tricks  '  ?  I  have  made 
notes  on  the  effect  of  scolding  in  some  of  my  cases  ;  in  none  was 
it  said  to  have  done  any  good,  in  some  it  was  said  definitely  to 
have  made  the  child  worse.  The  necessity  for  avoidance  of  all 
forms  of  excitement  and  fatigue  follows  from  what  I  have  said 
of  etiology,  and  in  this  connexion  I  must  mention  in  particular 
the  bad  influence  of  late  hours  on  such  cases.  The  need  for 
removing  sources  of  local  irritation  has  already  been  suggested. 
The  eyes  and  the  teeth  are  the  parts  most  often  requiring  atten- 
tion ;  worms  also  should  be  treated.  As  I  have  mentioned  the 
possibility  of  a  naso-pharyngeal  catarrh  occasionally  starting 
the  '  hem  '  which  constitutes  one  form  of  habit-spasm,  let  me 
say  a  word  against  the  indiscriminate  removal  of  adenoids  in  such 
cases.  The  nervous  disturbance  caused  by  the  fright  of  the 
operation  or  the  anaesthetic  has  made  some  cases  of  habit-spasm  so 
much  worse  that  I  am  satisfied  that  only  in  cases  of  necessity 
and  after  other  means  have  been  exhausted  should  operation  be 
done. 

The  drug  treatment  of  habit-spasm  does  not  offer  any  large 
field  for  selection.  I  have  found  most  useful  a  mixture  of 
arsenic  with  bromide  :  liquor  arsenicalis,  2  or  3  minims  with 
potassium  bromide,  5  to  10  grains,  three  times  a  day.  This 
may  be  continued  three  or  four  weeks — the  dose  of  arsenic 
to  be  reduced  if  any  toxic  symptoms  arise— and  then  after  an 
intermission  of  about  a  fortnight  repeated  again  for  three  or  four 
weeks.  Another  drug  which  has  seemed  to  me  of  value  in  some 
cases  is  ergot  ;  from  J  to  1  drachm  of  the  fluid  extract  can  be 
given  with  4  or  5  minims  of  tincture  of  nux  vomica  three  times 


HABIT-SPASM  G47 

daily.  I  have  also  tried  valerian  with  distinct  advantage.  In 
a  bad  case  which  some  would  have  described  as  '  tic  convulsif ' 
I  tried  electricity,  first  faradism  and  then  galvanism,  with  some 
temporary  improvement,  but  not  enough  to  justify  strong 
recommendation.  General  massage  I  have  known  to  cause 
decided  diminution  of  the  habit-spasm  hi  a  severe  case,  but 
massage  is  always  to  be  used  with  caution  in  the  functional 
nervous  disorders  of  children,  for  whilst  in  some  it  acts  as  a 
sedative,  in  others  it  has  only  a  disturbing  and  exciting  effect 
and  is  therefore  harmful.  Lastly,  for  an  intractable  case  simple 
change  of  environment,  especially  living  amongst  strangers  for 
a  time,  will  sometimes  do  more  than  any  drug  .treatment. 


CHAPTER  XLV 
CONVULSIVE   DISORDERS  IN   INFANCY 

THE  subject  which  I  propose  to  consider  in  this  chapter  is 
convulsive  disorders  in  infancy  ;  and  I  use  the  term  '  convulsive 
disorders '  advisedly,  to  comprehend  not  only  the  different 
grades,  if  I  may.  so  say,  of  general  convulsion,  but  also  certain 
local  affections  which,  although  not  usually  considered  under 
this  head,  a^e  nevertheless  convulsive  in  character.  A  proper 
appreciation  of  the  relation  between  these  various  convulsive 
manifestations  has  a  very  practical  value  both  in  prognosis  and 
in  treatment,  the  two  points  which  I  wish  specially  to  consider. 

As  our  starting-point  we  may  take  what  is  ordinarily  recognized 
as  an  infantile  convulsion.  I  need  hardly  describe  such  an  attack, 
every  medical  man  is  familiar  with  it  :  an  infant  suddenly 
becomes  livid  about  the  lips  and  about  the  alee  nasi  ;  its  eyes  are 
fixed  in  a  vacant  stare,  consciousness  is  lost,  the  limbs  stiffen  for 
a  moment,  and  then  face,  arms,  and  legs  twitch  irregularly,  and 
the  eyes  perhaps  show  a  nystagmoid  jerking  to  one  side  or  the 
other,  or  perhaps  a  transient  squint  ;  at  the  same  time  the 
fontanelle  is  bulged,  and  the  child  becomes  more  and  more  livid. 
Gradually  twitching  and  rigidity  subside,  consciousness  is  re- 
gained, and  the  child  lies  back  pale  and  exhausted.  Such  an 
attack  may  occur  as  an  isolated  manifestation,  to  recur  perhaps 
after  weeks  or  months,  perhaps  never  ;  but,  on  the  other  hand, 
it  may  form  part  of  a  series  of  convulsive  attacks,  bet\veen  which 
the  infant  may  not  even  regain  consciousness,  and  is,  in  fact,  in 
a  condition  exactly  resembling  the  status  epilepticus  of  the  adult. 

The  seriousness  of  such  attacks  as  these  no  one  is  likely  to 
overlook,  but  there  are  other  minor  manifestations  which  I  ven- 
ture to  think  are  often  overlooked,  or,  if  not  overlooked,  regarded 
too  lightly  by  the  medical  man.  Those  who  have  attended  the 
out-patient  department  of  a  children's  hospital  must  have  heard 
mothers  talk  of  '  the  inward  convulsions', — a  vague  complaint, 
I  admit,  but  one  to  which  the  mother  attaches  no  little  impor- 
tance. Now  I  shall  put  in  a  plea  for  these  '  inward  convulsions' ; 
I  would  strongly  advise  medical  men  never  to  disregard  such 
a  complaint  from  a  mother  ;  the  symptoms  to  which  she  refers 


CONVULSIVE  DISORDERS  IN  INFANCY  649 

may  bo  the  first  sign  of  coming  danger,  and  may  give  a  valuable 
indication  for  the  prevention  which  is  better  than  cure. 

As  I  have  said,  it  is  a  vague  complaint,  and  the  symptoms 
which  the  mother  includes  under  this  term  are  not  the  same  in 
all  cases.  In  one  case  the  child  screams,  goes  a  little  livid  around 
the  mouth,  and  then  perhaps  turns  its  eyes  upwards,  and  at  the 
same  time  turns  its  thumbs  in  strongly  towards  its  palms.  In 
another  there  is  a  momentary  twitch,  extremely  fine  it  may  be, 
of  the  forearm  or  of  one  leg,  or  perhaps  only  of  the  fingers,  with 
no  apparent  loss  of  consciousness,  and,  indeed,  with  so  little 
disturbance  that  only  a  careful  observer  would  notice  that 
anything  unusual  had  occurred.  In  a  third  there  will  be  a  sudden 
start  of  the  whole  body  as  if  from  an  electric  shock,  so  momentary 
that  if  it  occurs  during  sleep,  as  it  sometimes  does,  it  scarcely 
disturbs  the  infant,  who  perhaps  cries  slightly  after  it,  but  is 
soon  sleeping  quietly  again.  Trivial  as  these  symptoms  may 
appear  in  themselves,  there  can  be  no  doubt  that  they  are  just 
as  truly  convulsive  as  the  major  attacks  which  we  call  infantile 
convulsions  ;  they  stand,  indeed,  in  much  the  same  relation  to 
these  major  manifestations  as  petit  mal  does  to  major  epilepsy, 
and  at  any  moment  they  may  run  on  into  the  more  general 
convulsion. 

Sometimes,  however,  the  mother's  phrase  is  less  accurate, 
and  she  applies  it  to  the  paroxysmal  screaming  of  an  infant  with 
flatulence  and  colic  ;  unless,  indeed,  she  dignifies  that  condition 
by  another  term  from  the  maternal  vocabulary,  '  the  screaming 
convulsions,'  which  may  have  no  justification  in  pathology,  but 
may  serve  to  remind  us  that  the  same  colic  which  gives  rise  to 
the  paroxysms  of  screaming  may  also  give  rise  to  actual  con- 
vulsions. 

Here  I  shall  mention  an  occurrence  which  I  think  is  not  suffi- 
ciently generally  recognized,  namely,  that  a  child  may  literally 
*  cry  himself  into  a  fit '. 

I  have  several  times  had  children  brought  to  me  because  when 
they  cried  they  '  went  black  in  the  face  ',  and  the  parents  were 
terrified  lest  any  harm  should  come  of  it.  Now  any  one  who  is 
not  familiar  with  such  cases  might  easily  pooh-pooh  the  attacks 
and  say,  as  I  have  known  said,  that  they  were  merely  the  tan- 
trums of  a  spoilt  child  and  required  only  firm  discipline.  It  may 
be  perfectly  true  that  the  child  is  a  spoilt  child,  and  that  the 
crying  is  due  to  mere  passion  because  the  child  cannot  have  its 
own  way,  but  the  '  going  black  in  the  face  '  is  none  the  less  an 
indication  of  real  and  very  serious  danger  ;  what  starts  as  a  mere 


650  COMMON  DISORDERS  OF  CHILDHOOD 

bout  of  crying  ends  "in  a  spasmodic  closure  of  the  glottis 
during  the  violent  inspiration  of  crying,  the  child  becomes 
more  and  more  cyanosed,  and,  as  I  have  seen  happen  in  some 
cases,  passes  into  a  state  of  complete  unconsciousness  or  into 
a  general  convulsion. 

Such  a  case  was  the  following  : 

Percy  P.,  aged  three  years,  had  been  subject  to  convulsions  at  intervals 
since  early  infancy  ;  but  now  the  attacks  were  said  to  come  on  when  he  cried 
from  any  cause,  for  instance,  when  he  could  not  get  his  own  way  or  happened 
to  fall  or  hurt  himself ;  sometimes  he  passed  urine  in  the  attacks.  Such  was 
the  account  given  to  me,  and,  rather  sceptical  of  the  mother's  tale,  I  proceeded 
to  examine  the  child,  who  was  apparently  healthy  in  every  respect.  The 
child  objected  to  being  examined  and  began  crying  passionately,  he  went 
bluer  and  bluer  and  then  a  livid  leaden  colour,  and  lost  consciousness.  Gradually 
he  revived  ;  and  I  then  attempted  unwisely  to  look  in  his  mouth,  which  again 
started  an  outburst  of  crying,  and  the  child  again  became  unconscious  and 
was  undoubtedly  in  imminent  danger  of  his  life. 

In  another  boy,  aged  about  two  years,  who  was  under  my  care  and  who 
had  also  been  subject  to  convulsions  in  early  infancy,  definite  convulsions 
occurred  whenever  he  cried  violently  ;  the  attacks  began  in  an  exactly  similar 
way  to  that  just  mentioned  ;  he  was  a  self-willed  child  and  in  a  paroxysm 
of  passionate  crying  would  hold  his  breath,  become  livid,  and  pass  into  com- 
plete unconsciousness  with  some  twitching  or  rigidity  ;  after  the  attacks  ke 
was  pale  and  listless,  and  there  was  no  doubt  that  they  interfered  considerably 
with  his  general  health. 

Such  cases  are  quite  distinct  from  laryngismus  stridulus,  which 
I  shall  mention  subsequently  ;  they  have  no  connexion  with 
rickets  nor  with  any  of  the  special  associations  of  laryngismus 
stridulus.  The  children  who  thus  '  cry  themselves  into  a  fit ' 
have  usually  shown  other  evidence  of  a  convulsive  tendency ;  and 
in  the  two  cases  I  have  just  mentioned  it  was  clear  that  this 
tendency  was  not  due  to  rickets,  for  it  had  been  present  since 
a  few  weeks  after  birth. 

AVhatever  the  exact  pathology  of  these  attacks  may  be,  it  is 
evident  that  a  state  of  partial  asphyxia  is  induced,  and  any  one 
who  has  seen  the  very  similar  manifestations  of  a  severe  attack 
of  laryngismus  stridulus,  or  the  attacks  of  laryngeal  spasm 
which  I  have  described  elsewhere  (p.  335),  in  the  newborn,  will 
realize  that  this  '  going  black  in  the  face  with  crying '  may  indi- 
cate a  condition  fraught  with  real  danger. 

In  all  these  conditions,  whether  the  convulsive  manifestation 
be  of  the  major  or  of  the  minor  variety,  there  is  a  common  basis 
in  an  abnormal  nervous  instability,  and  on  this  I  would  lay  some 
stress,  for  it  forms  a  link  between  these  and  the  other  convulsive 
conditions  to  which  I  shall  refer.  It  would  seem  that  this  nervous 


CONVULSIVE  DISORDERS  IN  INFANCY          651 

instability  may  be  congenital  or  acquired  ;  in  one  case  an  infant 
shows  a  tendency  to  convulsions  almost  from  the  day  of  its  birth, 
in  another  it  is  only  in  later  infancy,  when  rickets  has  had  time 
to  develop,  that  a  convulsive  tendency  appears.  This  difference 
may  be  of  some  prognostic  significance  ;  at  any  rate,  I  strongly 
suspect  that  the  infant  who  suffers  repeatedly  with  convulsions 
under  the  age  of  six  months  is  more  likely  to  show  evidence  of 
nervous  instability,  in  convulsions  or  otherwise,  in  later  years 
than  is  the  infant  who  only  develops  its  convulsive  attacks  under 
stress  of  rickets  ;  though,  of  course,  it  must  be  understood  that 
the  child  who  has  already  shown  the  congenital  tendency  will 
be  specially  prone  to  show  its  nervous  instability  even  more 
markedly  when  the  influence  of  rickets  is  superadded.  Certain 
it  is  that  there  are  children  who  from  earliest  infancy  show 
a  nervous  instability  which  remains  for  years,  and  may  manifest 
itself  in  convulsions  at  the  onset  of  every  acute  illness  which 
befalls  the  child.  I  would  not  recommend  any  medical  man  to 
prophesy  in  such  a  case,  but  I  remember  one  case  in  which  the 
family  doctor  gained  no  little  credit  from  having  foretold  such  an 
occurrence  ;  he  had  seen  the  child  at  the  age  of  three  months, 
when  it  had  had  repeated  convulsions,  arid  recognizing  the 
unstable  nervous  equilibrium  of  the  child,  he  told  the  mother 
that  if  ever  the  child  had  an  acute  illness  it  would  probably  begin 
with  a  convulsion.  Two  years  later,  when  I  saw  the  child,  it 
had  just  begun  an  acute  bronchitis  with  a  temperature  of  103-8° 
and  a  convulsion. 

There  can,  I  think,  be  little  doubt  that  in  certain  cases  also 
infantile  convulsions  foreshadow  other  manifestations  of  nervous 
instability  which  appear  in  later  childhood  ;  for  instance,  a  boy 
of  ten  years  had  convulsions  from  early  infancy  up  to  the  age  of 
three  years ;  since  then  he  has  suffered  with  night  terrors,  and 
occasionally  walks  in  his  sleep  ;  he  is  extremely  '  nervous  ',  and 
after  any  little  excitement  suffers  with  insomnia.  In  another 
child  convulsions  occurred  occasionally  up  to  the  age  of  3 \  years, 
and  at  the  age  of  six  years  he  came  to  the  out-patient  clinic, 
with  a  marked  habit-spasm,  twitching  of  the  facial  muscles,  and 
blinking  of  the  eyes.  Another  child  who  had  suffered  with  con- 
vulsions in  infancy  came  under  my  care  for  hysterical  dyspnoea 
at  the  age  of  twelve  years. 

Of  course  we  must  be  careful  in  tracing  any  relation  between 
conditions  so  common  as  infantile  convulsions  on  the  one  hand, 
and  habit-spasm,  night  terrors,  or  the  various  neuroses  of  child- 
hood on  the  other,  but  the  sequence  is  at  any  rate  sufficiently 


652  COMMON  DISORDERS  OF  CHILDHOOD 

frequent  to  justify  the  suspicion  that  both  arc  dependent  on  one 
underlying  cause,  a  congenital  nervous  instability,  and  to  this 
extent  the  earlier  manifestations  may  foreshadow  the  later. 
Dr.  Coutts,1  in  an  interesting  paper  on  this  subject,  has  pointed 
out  that  infantile  convulsions  are  often  followed  by  neuroses, 
not  only  in  childhood  but  also  in  later  life. 

But  when  we  come  to  consider  the  convulsive  conditions  which 
are  associated  with  rickets  it  is  evident  that  here  we  have  to  do 
with  an  acquired  morbid  state  ;  it  is  only  after  the  development 
of  the  rickets  that  the  convulsive  tendency  appears,  and  it  passes 
off  as  the  rickety  condition  improves.  And  in  this  connexion 
I  should  like  to  draw  attention  to  an  interesting  point,  namely, 
that  the  nervous  symptoms  of  rickets  are  not  necessarily  pro- 
portionate to  the  bony  changes  present  ;  one  child  with  extreme 
rickety  deformity  of  skull,  thorax,  and  limbs  will  show  no  ten- 
dency to  convulsive  manifestations,  whilst  another  with  com- 
paratively slight  rickety  change  in  the  bones  will  suffer  from 
almost  all  the  possible  nervous  symptoms  of  rickets.  It  would 
seem  indeed  that,  as  has  been  noticed  in  many  other  diseases,  the 
stress  of  rickets  may  fall  upon  different  tissues  in  different 
children,  and  I  have  seen  cases  which  strikingly  suggest  that  in 
certain  families,  as  wrell  as  in  certain  individuals,  there  is,  if  I  may 
so  say,  a  tissue  proclivity,  which  determines  the  incidence  of 
rickets  on  certain  tissues.  However  this  may  be,  I  would  empha- 
size the  fact  that  with  slight  evidence  of  rickets  in  the  bones  there 
may  be  marked  nervous  symptoms,  and  vice  versa,  with  severe 
bony  change  there  may  be  little  or  no  nervous  disorder. 

The  acquired  nervous  instability  of  rickets  may  manifest  itself 
in  local  as  well  as  in  general  symptoms,  and  I  wish  to  lay  stress 
particularly  on  these  local  manifestations,  for  a  proper  apprecia- 
tion of  their  significance  has  a  very  practical  value. 

Laryngismus  stridulus.  Laryngismus  stridulus  is  one  of 
these  ;  it  is  a  common  condition  in  the  out-patient  room  of 
a  children's  hospital  ;  a  rickety  infant,  on  being  awakened  from 
sleep,  or  perhaps  more  often  still  when  he  begins  to  cry,  suddenly 
seems  to  hold  his  breath,  his  chest  is  fixed,  his  face  becomes  more 
and  more  cyanoscd,  his  features  are  contorted  as  if  in  terror,  and 
just  as  asphyxia  seems  imminent  inspiration  occurs  with  a  long- 
drawn  crowing  sound  very  like  the  whoop  of  pertussis.  Now 
what  has  happened  ?  Sonic  slight  stimulus,  perhaps  a  deeper 
inspiration  than  usual  bringing  cold  air  in  contact  with  the 
glottis,  has  started  a  spasmodic  or  convulsive  closure  of  the 
1  Trans.  Internal.  Med.  Congress,  1887. 


CONVULSIVE  DISORDERS  IN  INFANCY  653 

glottis,— a  tonic  convulsion,  in  fact,  of  that  particular  part. 
The  close  relation  of  such  attacks  to  general  convulsions  is  seen 

in  the  history  of  many  of  these  cases  :   in  a  large  proportion 

35  out  of  73  cases,  i.e.  47-9  per  cent.— general  convulsions  have 
occurred  within  a  few  weeks  before  or  after  the  first  appearance 
of  laryngismus  stridulus.  The  attack  itself  may  end  in  a  general 
convulsion,  but  this  may  be  a  result  rather  of  the  extreme 
cyanosis  than  of  an  extension  of  the  convulsive  phenomena. 

Laryngismus  stridulus  is  closely  connected  with  rickets  :  the 
bone  manifestations  of  rickets  were  found  in  63  (94  per  cent.) 
out  of  67  cases  of  laryngismus  stridulus.  Us  onset  is  almost 
exclusively  between  the  ages  of  four  months  and  eighteen  months. 
In  73  cases  under  my  own  observation  the  age  at  onset  was  as 
follows  : 

Age  at  onset.  A7o.  of  Cases. 

Birth  to  4  months 0 

4-6  months       .         .         .         .         .         .         .19 

6-12  months 41 

12-18  months LO 

20  months 1 

3-4  years 2 

The  age-incidence  would  harmonize  well  with  rickets  as  the 
chief  factor  in  the  causation  of  this  disorder  :  six  to  eighteen 
months  is  the  age  at  which  the  morbid  changes  of  rickets  are 
most  active,  and  a  tendency  to  convulsive  disorders  is  one  of  the 
dominant  features  of  rickets.  But  although  it  is,  I  think,  clear 
that  rickets  plays  a  very  large  part  in  the  production  of  laryn- 
gismus stridulus,  there  are  probably  other  factors,  for  unlike  most 
of  the  manifestations  of  rickets  which  occur  at  no  special  season 
of  the  year,  laryngismus  stridulus  has  a  very  striking  seasonal 
variation,  as  the  accompanying  chart  (Fig.  45)  shows. 

One  might  suggest  that  during  the  winter  months  an  infant 
is  likely  to  be  kept  indoors  much  more  than  in  summer  weather 
and  the  unwholesome  atmosphere  of  stuffy  rooms  may  aggravate 
the  nervous  instability  of  rickets,  but  beyond  this  mere  specula- 
tion I  have  no  explanation  to  offer  of  this  seasonal  incidence. 

I  would  call  attention,  however,  to  the  similarity  between  this 
chart  and  the  seasonal  chart  of  spasmus  nutans  (p.  771),  another 
functional  nervous  disorder  of  infancy. 

A  very  remarkable  association  with  laryngismus  stridulus  is 
craniotabes  :  twenty-one  out  of  fifty-five  cases  showed  this 
affection  of  the  skull.  Statistics  of  a  series  of  cases  of  craniotabes 
show  even  more  strikingly  how  close  is  the  connexion  between 


654 


COMMON  DISORDERS  OF  CHILDHOOD 


craniotabes  and  laryngismus  stridulus  :  seventeen  out  of  twenty- 
two  cases  of  craniotabes  had  laryngismus  stridulus.  I  have 
considered  the  significance  of  craniotabes  elsewhere  (p.  96), 
I  only  mention  it  here  because  its  association  with  laryngismus 
stridulus  is  so  close  that  it  sometimes  affords  valuable  confirma- 
tion of  diagnosis  when  we  have  to  judge  of  the  presence  of 
laryngismus  stridulus  from  a  mother's  account  without  seeing 
one  of  the  attacks. 


FIG.  45.     Chart  showing  seasonal  incidence  of  laryngismus  stridulus. 


There  are  two  other  nervous  manifestations  which  are  com- 
monly associated  with  this  laryngeal  spasm,  namely,  facial 
irritability  and  tctany. 

Facial  irritability.  As  an  indication  of  a  convulsive  tendency 
in  rickety  children  '  facial  irritability  '  is,  I  think,  of  considerable 
practical  value,  and  has  not  received  the  attention  which  it 
deserves.  It  is  seen  most  often  in  association  with  laryngismus 
stridulus,  but  it  occurs  also  apart  from  this  and  occasionally  even 
apart  from  rickets.  Out  of  seventy-one  cases  of  laryngismus 
stridulus,  in  which  I  noted  this  point,  fifty-seven  showed  this 
facial  irritability  and  three  showed  a  similar  excitability  of  the 
nerves  only  in  the  limbs.  The  name  '  facial  irritability  '  is 
unsatisfactory,  for  the  sign  to  which  it  refers  is  usually  present 
in  the  limbs  as  well  as  in  the  face, — it  was  so  in  the  majority  of  the 
fifty-seven  cases  just  mentioned — and,  as  I  have  stated,  I  have 
found  it  occasionally  in  the  limbs  when  it  could  not  be  obtained 
in  the  face  ;  it  would  be  better  to  speak  of  it  as  '  nerve  irrita- 


CONVULSIVE  DISORDERS  IN  INFANCY  655 

bility '.  A  gentle  tap  with  the  tip  of  the  finger  over  the  motor 
branches  of  a  nerve  produces  a  twitch  in  the  corresponding 
muscle  ;  perhaps  the  easiest  place  to  demonstrate  this  is  on  the 
face,  a  tap  on  the  facial  nerve,  where  it  emerges  on  the  face  just 
in  front  of  the  ear,  produces  a  twitch  of  the  orbicularis  palpe- 
brarum  and  sometimes  of  several  of  the  neighbouring  muscles  ; 
similarly  a  tap  over  the  lower  branches  of  the  facial  nerve,  just 
below  and  external  to  the  angle  of  the  mouth,  produces  a  twitch 
at  the  inner  canthus  of  the  eye  and  sometimes  of  the  muscles  of 
the  nose  on  that  side.  Similarly  an  extensor  jerk  of  the  wrist 
is  produced  by  tapping  over  the  musculo-spiral  nerve  where  it 
turns  round  the  outer  side  of  the  humerus,  and  e version  of  the 
foot,  so  that  the  outer  edge  is  jerked  upwards,  by  tapping 
over  the  external  popliteal  nerve  where  it  turns  round  the  outer 
side  of  the  fibula.  This  nerve  irritability  is  often  very  valuable 
as  a  danger  signal  :  so  long  as  a  child  shows  this  sign  it  is  in 
danger  of  general  convulsions.  I  am  inclined  to  go  further,  and 
say  that  the  degree  of  risk  can  be  judged  to  a  certain  extent  from 
the  degree  of  the  nerve  irritability  ;  where  many  of  the  facial 
muscles  are  thrown  into  twitchings  by  each  tap  or  by  mere 
stroking  over  the  facial  nerve,  there  would  seem  to  be  a  greater 
liability  to  general  convulsions  than  in  those  cases  where  the 
response  is  only  slight  or  limited  to  a  single  muscle,  usually  the 
orbicularis  palpebrarum. 

Not  only  is  this  sign  thus  a  useful  indication  of  danger,  and  of 
the  need  for  prophylaxis,  but  it  may  also  guide  us  to  some  extent 
in  the  course  of  treatment,  for  it  is  often  very  noticeable  that  the 
diminution  or  cessation,  under  the  influence  of  bromides,  of 
convulsions  which  are  dependent  on  rickets,  occurs  pari  passu 
with  diminution  or  disappearance  of  nerve  or  facial  irritability. 
The  effect  of  the  drag  on  this  symptom  may  indeed  be  taken  as  the 
outward  and  visible  sign  of  the  effectiveness  of  our  treatment  on 
the  tendency  to  general  convulsions,  and  may  in  this  way  serve 
as  a  gauge  of  the  necessity  for  continuing  or  increasing  our  anti- 
convulsive  measures.  This  nerve  irritability  is  rarely  found 
apart  from  rickets,  and  is  usually  associated  also  with  laryngismus 
stridulus,  and  with  another  convulsive  disorder  which  is  also 
localized  in  its  distribution,  namely,  tetany  ;  it  is,  however, 
occasionally  seen  in  infants  who  show  a  tendency  to  general 
convulsions  during  the  first  two  or  three  months  of  life,  when 
rickets  is  rare  ;  I  have  seen  it  also  in  later  childhood  with  epilepsy. 

Tetany.  The  relation  of  tetany  to  general  convulsions  is  very 
close  ;  in  a  considerable  proportion  of  the  cases  it  is  preceded  or 


656 


COMMON  DISORDERS  OF  CHILDHOOD 


followed  by  convulsions,  which  may  also  supervene  at  any  time 
whilst  the  tetany  spasm  is  still  present  in  the  limbs. 

The  tetany  position  of  the  hands  and  feet  is  so  familiar  that 
it  hardly  needs  description  here.  The  thumb  is  drawn  in  across 
the  palm  so  that  its  tip  is  between  the  ring-  and  middle-finger  ; 
the  metacarpo-phalangeal  joints  are  semiflexed  and  the  phalan- 
geal  joints  fully  extended,  so  that  the  hand  assumes  the  position 
shown  in  the  illustration.  The  wrist  and  elbows  are  usually  kept 


FIG.  46.  Tetany.  Showing  characteristic  position  of  hands.  The  fore- 
finger of  the  right  hand  shows  over-extension  of  the  phalangeal  joints,  which 
is  common  in  severe  cases.  In  the  left  foot  the  tetany  position,  the  crowding 
together  and  pointing  of  the  toes,  is  just  visible. 

semiflexed.  The  feet  are  often  similarly  affected,  the  toes  are 
crowded  together,  and  often  the  anlde  is  extended.  Very  rarely 
spasm  of  some  of  the  muscles  of  the  trunk  has  been  recorded  ; 
I  have  not  seen  such  an  affection  myself. 

In  some  children  tetany  evidently  produces  no  pain,  for  the 
child  will  play  unconcernedly  with  his  toys,  scooping  them  about 
the  table  when  he  is  unable  to  grasp  them  owring  to  the  spasm  of 
his  hands  :  pain  seems  to  occur  just  as  the  spasm  comes  on, 
and  in  cases  where  the  tetany  position  is  intermittent  and  lasts. 


CONVULSIVE  DISORDERS  IN  INFANCY          657 

only  for  intervals  of  a  few  minutes,  as  it  sometimes  does,  the 
child  may  cry  out  as  it  comes  on,  but  where  it  is  continuous, 
as  it  often  is,  for  hours  or  days,  it  seems  to  be  painless  after 
its  onset. 

With  the  tetany  spasm  there  is  sometimes  well-marked  osderaa 
of  the  hands  and  feet,  and  this  may  extend  a  little  way  up  the 


FIG.  47. 


Tetany.     Showing  spasmodic  flexion  of  the  wrist  with  the 
tetany  position  of  the  fingers. 


limbs.  I  have  known  tetany  to  be  mistaken  for  acute  nephritis 
on  account  of  this  oedema,  and  the  mistake  might  seem  to  be 
confirmed  if  the  urine  were  examined,  for  some  albuminuria — 
usually,  however,  quite  a  slight  cloud—  is  also  a  common  feature 
of  tetany.  It  seems  likely  that  the  oedema  is  purely  mechanical, 
being  produced  by  slight  obstruction  of  the  venous  flow  in  the 
limbs  owing  to  the  spasmodic  contraction  of  the  muscles.  The 


STILL 


uu 


658  COMMON  DISORDERS  OF  CHILDHOOD 

% 

albuminuria  is  probably  a  manifestation  of  the  toxaemia  which 
seems  to  be  the  exciting  cause  of  tetany. 

Tetany  in  children  is  almost  always  associated  with  rickets 
and  is  evidently  comparable  to  the  other  convulsive  manifesta- 
tions with  which  it  often  keeps  company,  laryngismus  stridulus, 
facial  irritability  and  convulsions  ;  but  there  is  also  associated 
very  closely  with  tetany  in  almost  all  instances  some  definite 
gastro-intestinal  disturbance;  usually  there  has  been  diarrhoea 
either  shortly  before  or  at  the  time  of  the  onset  of  the  spasm, 
sometimes  the  stools  without  being  loose  have  been  green  and 
extraordinarily  offensive. 

This  association  is  so  constant  that  one  can  hardly  doubt  that 
the  bowel  condition  plays  an  important  part  in  the  production 
of  tetany,  and  probably  also  of  the  albuminuria  which  goes  with 
tetany,  for,  as  I  have  pointed  out  elsewhere,  apart  from  tetany 
diarrhoea  in  infants  is  often  associated  with  slight  albuminuria. 

The  causal  relation  of  gastro-intestinal  disturbance  to  tetany 
receives  further  confirmation  from  the  occurrence  of  tetany  with 
so-called  cceliac  disease,  and  also  with  chronic  dilatation  of  the 
colon,  and  sometimes  after  irrigation  of  the  bowel  (see  p.  242). 

Tetany  is  not  always  the  obvious  condition  I  have  described, 
in  which  the  characteristic  position  of  the  hands  and  feet  is 
present  spontaneously;  there  is  a  latent  tetany  which  is  only 
to  be  detected  by  a  special  method  which  I  shall  illustrate  by 
the  record  of  an  actual  case. 

A  rickety  infant,  aged  nineteen  months,  had  laryngismus  stridulus  nine  weeks 
ago  ;  three  weeks  ago  the  infant  had  general  convulsions  ;  it  has  now  very 
marked  facial  irritability,  and  although  there  is  no  apparent  trace  of  tetany 
in  the  hands  or  feet,  the  effect  of  compressing  the  arm  by  encircling  it  just 
below  the  insertion  of  the  deltoid  muscle  with  one's  forefinger  and  thumb,  so 
as  to  compress  the  brachial  vessels  and  nerves,  is  to  produce  in  about  thirty 
seconds  the  characteristic  tonic  spasm  of  tetany  in  the  hand. 

This  artificial  method  of  exciting  the  tetany  spasm  is  known 
as  '  Trousseau's  sign  '  ;  and,  as  in  this  case,  the  presence  of  this 
sign  is  almost  always  associated  with  those  other  convulsive 
manifestations  to  which  I  have  already  referred,  and  is  there- 
fore an  indication  of  danger. 

This  latent  tetany  clearly  differs  from  the  ordinary  variety  only 
in  the  degree  of  tendency  to  spasm  ;  for  when  spontaneous 
tetany  has  recently  passed  off  it  is  often  possible  to  reproduce 
it  by  Trousseau's  method  :  the  child  with  latent  tetany  is,  so  to 
speak,  on  the  verge  of  spontaneous  tetany. 

I  find  amongst  my  notes  55  cases  of  tetany,  of  which  25  were 
of  the  spontaneous  variety,  and  30  of  the  latent  ;  13  of  the  former 
were  associated  with  laryngismus  stridulus,  and  29  of  the  latter. 


CONVULSIVE  DISORDERS  IN  INFANCY          659 

The  close  connexion  with  convulsions  is  seen  in  the  fact  that 
28  out  of  my  55  cases  had  convulsions  either  shortly  before  or 
during  the  tetany,  and  this  convulsive  tendency  is  confirmed 
in  most  cases  of  tetany  by  the  presence  of  facial — or,  as  I  would 
prefer  to  say,  nerve — irritability.  It  is  in  this  tendency  to  con- 
vulsion that  the  chief  danger  of  this  disorder  lies,  whether  the 
tetany  be  spontaneous  or  only  produced  by  Trousseau's  method  ; 
and  this  brings  me  to  the  question  of  prognosis. 

Prognosis.  What  is  the  immediate  risk  entailed  by  an 
infantile  convulsion,  and  what  are  the  more  remote  risks  ? 

In  estimating  the  danger  to  life  the  first  point  to  be  taken  into 
account  is  the  age  of  the  infant  ;  there  can  be  no  doubt  that 
the  danger  is  much  greater  during  the  first  year  of  life  than 
subsequently.  It  has  been  calculated  that  89-5  per  cent,  of 
the  deaths  from  convulsions  occur  in  infants  under  a  year  ; 
and  this  high  proportion  is  not,  I  think,  altogether  due  to  the 
fact  that  convulsions  are  commoner  at  this  period  than  in  older 
children,  for  it  seems  probable  that  there  is  no  such  dispropor- 
tion between  the  frequency  of  convulsions  in  the  first  year 
and  in  the  second  as  to  account  for  this  percentage  of  mortality 
in  the  earlier  period.  The  following  statistics  are  quoted  by 
Lewis  (Keating's  Encyclopced.}  from  Jamieson,  who  found  that 
out  of  365  fatal  cases  of  convulsions  in  children  under  five  years 
of  age,  236  occurred  within  the  first  twelve  months,  and  out  of 
this  number  165  occurred  under  the  age  of  six  months. 

Age.  Number  of  deaths. 

0-1  year 230 

1-2  years 73 

2-3     „ 32 

3-4     „ 13 

4-5     „ 11 

On  the  whole,  it  would  seem  also  that  the  earlier  the  date  of 
convulsions  in  the  first  year  the  greater  the  danger  to  life. 

In  considering  the  immediate  prognosis,  naturally  the  severity 
of  the  convulsion,  and  its  duration,  must  be  taken  into  account  ; 
such  a  condition  as  I  have  already  mentioned  as  comparable  to 
the  status  epilepticus  of  adults  is  fraught  with  much  more 
serious  risk  to  life  than  the  slight  twitching  with  little  or  no 
loss  of  consciousness  which  occurs  in  many  infants.  At  the 
same  time  one  must  always  remember  that  even  when  they 
occur  within  a  few  days  after  birth,  convulsions  of  extreme 
severity  may  end  in  perfect  recovery,  and  that  a  fatal  result 
is  very  exceptional.  As  long  ago  as  1789  it  was  pointed  out 

UU2 


660  COMMON  DISORDERS  OF  CHILDHOOD 

by  Underwood  l  that  '  children  are  much  oftener  supposed  to 
die  of  convulsions  than  they  really  do,  for  though  a  convulsion 
frequently  closes  the  scene,  it  has  generally  arisen  from  the 
great  irritability  of  their  nerves,  and  violence  of  the  disease 
under  which  they  have  laboured  '. 

But  apart  from  the  risk  to  life  there  are  other  very  serious 
risks  from  infantile  convulsions  which  must  be  considered. 
There  can,  I  think,  be  no  doubt  that  in  a  certain  number  of 
cases,  probably  an  extremely  small  proportion  of  the  whole 
number  of  infants  who  have  convulsions,  a  severe  attack  of 
convulsion  results  in  permanent  impairment  of  intellect.  Take, 
for  instance,  such  a  case  as  the  following.  A  boy,  aged  5J  years, 
had  been  in  apparently  perfect  health,  up  to  the  ago  of  six 
months,  then  he  had  thirty  convulsions  in  two  days  ;  since 
then  he  has  only  had  convulsions  on  two  occasions,  once  at 
the  age  of  twelve  months,  and  again  at  3|  years  ;  but  he  is  a 
boisterous,  noisy  idiot,  he  only  learnt  to  walk  at  four  years, 
and  is  dirty  in  his  habits.  His  head  is  of  normal  size,  his  palate 
is  high.  Labour  was  natural  and  easy,  and  there  was  no  diffi- 
culty in  establishing  respiration  ;  there  is,  in  fact,  no  apparent 
cause  for  idiocy  apart  from  the  severe  convulsions. 

It  is,  of  course,  extremely  difficult  to  prove  a  causal  relation 
in  any  such  case,  but  it  seemed  even  more  apparent  in  the 
following.  A  girl,  aged  8J  years,  had  learnt  to  walk  and  talk 
at  the  usual  age,  and  seemed  perfectly  healthy  up  to  the  age  of 
two  years  and  eleven  months  ;  then  she  had  ten  convulsions 
in  one  day,  and  subsequently  often  eight  or  nine  a  day.  Since 
the  onset  of  these  attacks  she  has  ceased  to  talk,  and  has  become 
imbecile  ;  her  tongue  lolls  out,  and  she  takes  little  notice  of  her 
surroundings. 

Happily  such  a  result  would  seem  to  be  extremely  rare,  but 
when  it  occurs  it  is  probably  more  often  from  convulsions  in 
very  early  infancy  than  from  those  occurring  later.  It  is  to  be 
remembered,  however,  that  while  infantile  convulsions  are  pro- 
bably only  a  rare  cause  of  idiocy,  they  are  particularly  common 
in  association  therewith.  Statistics  from  100  consecutive  cases 
of  idiocy  or  imbecility  under  my  own  care  showed  that  infantile 
convulsions  occurred  in  at  least  22  per  cent,  of  idiots  ;  and  if 
one  included  convulsions  occurring  after  the  age  of  two  years 
(the  end  of  infancy),  the  proportion  would  be  28  per  cent., 
but  out  of  these  100  cases  there  were  probably  not  more  than 
three  in  which  there  was  any  likelihood  that  the  convulsions 
1  Treatise  on  Diseases  of  Children,  p.  82. 


CONVULSIVE  DISORDERS  IN  INFANCY          661 

were  the  cause  of  the  idiocy.  Whilst,  therefore,  the  risk  of 
idiocy  resulting  from  convulsions  would  appear  to  be  small, 
we  must  remember  that  convulsions,  if  not  the  cause,  may  at 
any  rate  be  the  first  indication  of  anything  abnormal  in  an 
infant  who  is  subsequently  found  to  be  an  idiot. 

But  apart  from  idiocy  there  are  other  abnormal  mental  con- 
ditions which  are  probably  in  some  cases  the  result  of  infantile 
convulsions.  I  have  already  mentioned  that  neuroses  in  older 
children  may  be  a  later  manifestation  of  that  same  nervous 
instability  which  allowed  the  occurrence  of  convulsions  in 
infancy  ;  but  it  seems  almost  certain  that  occasionally  infantile 
convulsions  are  the  cause  of  mental  abnormalities  with  which 
there  is  little  or  no  impairment  of  intellectual  power.  Some  of 
these  infants  who  have  had  a  severe  attack  of  convulsions  grow 
up  eccentric  even  in  their  childhood,  odd  children  with  curious 
habits,  hardly  imbecile  in  the  slightest  degree,  and  yet  '  not  like 
other  children  '.  Then,  again,  it  seems  almost  certain,  as  I  have 
pointed  out  elsewhere,1  that  a  severe  bout  of  convulsions  in 
infancy  may  cause  an  arrest  of  moral  development,  with  the 
result  that  the  child  from  its  earliest  years  is  passionate,  spiteful, 
or  perhaps  an  incorrigible  liar  or  thief. 

Fortunately  all  these  mental  disturbances  are  rare  in  com- 
parison with  the  frequency  of  convulsions,  and  so  far  as  I  have 
seen,  they  would  seem  to  result  almost  exclusively  from  very 
severe  or  prolonged  attacks  of  convulsion  ;  but  they  are  worth 
remembering  in  all  cases,  and  must  '  give  us  pause  '  when  we 
are  asked,  will  the  child's  mind  be  affected  ? 

It  is  not  only  the  higher  functions  of  the  brain,  however, 
which  may  suffer  permanent  damage,  but  also  the  motor 
functions.  Some  of  the  cerebral  palsies  of  children,  particularly 
the  so-called  '  infantile  hemiplegia  ',  may  be  the  direct  result 
of  a  severe  convulsion.  Whether  the  intense  venous  congestion 
during  the  attack  causes  some  haemorrhage  on  the  surface  or 
into  the  substance  of  the  brain,  or  whether  this  venous  con- 
gestion so  profoundly  modifies  the  cells  of  the  cortex  that  their 
function  is  henceforth  impaired,  may  be  uncertain,  but  of  the 
clinical  sequence  there  can  be  no  doubt.  Here  again,  however, 
prognosis  must  be  wary  ;  there  are  cases  in  which  a  complete 
hemiplegia,  differing  in  no  way  from  the  initial  stage  of  an 
ordinary  permanent  infantile  hemiplegia,  results  from  a  severe 
infantile  convulsion,  and,  after  lasting  for  several  hours,  gradually 
disappears  completely.  In  one  infant,  aged  nineteen  months, 
1  Goulstonian  Lectures,  Lancet,  1902. 


662  COMMON  DISORDERS  OF  CHILDHOOD 

who  was  under  my  care  at  King's  College  Hospital,  the  left  side 
was  paralysed  for  four  hours  after  a  convulsion.  In  another, 
paralysis,  also  of  the  left  side,  remained  for  three  hours  only. 
In  both  these  cases  the  paralytic  affection  was  merely  transitory, 
but  had  they  been  seen  during  the  paralysis  there  would  have 
been  nothing  to  distinguish  them  from  cases  of  infantile  hemi- 
plegia  beginning  with  a  convulsion  ;  and  it  is  to  be  remembered 
that  fully  50  per  cent,  of  cases  of  permanent  infantile  hemiplegia 
begin  with  a  convulsion,  although  perhaps  only  a  very  small 
proportion  of  these  have  been  caused  by  the  convulsion. 

Blindness  lasting  for  several  days  or  weeks  has  been  observed 
after  convulsions.  Mr.  Sidney  Stephenson  and  the  late  Dr. 
Henry  Ashby  have  recorded  such  cases  :  out  of  eleven  cases 
under  three  years  of  age,  including  their  own  and  those  reported 
by  others,  ten  had  completely  recovered  sight,  only  one  seemed 
likely  to  be  permanently  blind  :  in  some  of  these  cases,  however, 
the  convulsions  were  only  a  symptom  of  gross  disease  of  the 
brain,  for  the  child  was  left  with  permanent  spastic  paralysis. 

There  are  other  results  which,  although  less  serious,  have 
some  practical  importance.  In  the  later  months  of  infancy, 
when  speech  is  in  process  of  development,  a  convulsion  may 
result  in  stuttering,  and  if  we  regard  stuttering  as  a  disturbance 
of  co-ordination  we  might  almost  have  expected  that  a  con- 
vulsion might  produce  it.  Squinting  also  is  undoubtedly  in  some 
cases  a  direct  sequel  and  result  of  such  an  attack,  whether  the 
squint  be  temporary,  as  it  is  in  some  cases,  or  permanent,  as 
it  is  in  others  ;  and  this  fact  of  the  occurrence  of  squint,  apart 
from  more  serious  results,  is  worthy  of  note,  for  the  question  of 
commencing  meningitis  is  so  often  raised  by  convulsions,  and 
may  be  extremely  difficult  to  determine.  Take,  for  instance, 
the  following  case. 

An  infant  three  months  old  had  been  restless  and  sleeping  badly  for  five 
days,  and  then  had  eight  convulsions  within  a  few  hours.  Two  days  later 
the  doctor  noticed  slight  retraction  of  the  head,  and  the  infant  became  much 
flushed  at  times.  The  bowels  were  very  costive  ;  there  was  no  vomiting. 
On  the  ninth  day  of  the  illness  more  convulsions  occurred,  the  infant  was 
apathetic,  there  was  a  squint,  and  the  fontanelle  was  bulged.  At  this  stage 
I  saw  the  infant,  and  found  it  as  described,  drowsy,  and  with  very  marked 
bulging  fontanelle,  but  with  no  definite  squint,  although  this  was  said  to  have 
been  present  earlier  in  the  day.  There  was  no  paralysis  anywhere,  but  there 
was  an  occasional  momentary  twitch  of  the  hand.  There  was  no  stiffness  of 
the  neck  at  that  time  ;  the  abdomen  was  natural.  On  the  whole,  the  balance 
of  evidence  seemed  to  be  against  meningitis,  and  this  opinion  was  confirmed 
by  a  steady  convalescence  under  chloral  and  bromide. 

Another  point  which  must  be  considered  in  prognosis  is  the 


CONVULSIVE  DISORDERS  IN  INFANCY          663 

relation  of  infantile  convulsions  to  later  epilepsy.  When  a  child 
of  two  and  a  half  or  three  years  is  brought  with  a  history  of 
convulsions  from  early  infancy  it  is  no  easy  matter  to  say 
whether  the  present  attacks  are  to  be  regarded  as  epileptic  or 
not  ;  and,  indeed,  who  shall  decide  where  the  line  is  to  be  drawn  ? 

There  are  cases  in  which  convulsive  attacks  occur  at  intervals 
from  early  infancy  onwards  to  the  end  of  childhood  and  into 
adult  life  ;  but,  so  far  as  my  own  experience  goes,  I  should 
say  that  out  of  the  enormous  number  of  infants  who  have 
convulsions  an  extremely  small  proportion  become  epileptic, 
at  any  rate  before  the  age  of  puberty.  This,  be  it  observed, 
docs  not  necessarily  contravene  the  fact  that  of  cases  of  epilepsy 
in  later  life  a  considerable  proportion,  about  12  per  cent, 
according  to  Gowers,  or  40  per  cent,  according  to  Osier,  have 
begun  during  the  first  three  years  of  life  as  infantile  con- 
vulsions. 

Even  when  infantile  convulsions  have  persisted  beyond  the 
end  of  the  second  year  they  usually  cease  before  the  end  of  the 
fourth  year,  and  often  before  the  end  of  the  third  year. 

But  without  any  direct  continuity  it  seems  likely  enough  that, 
like  the  neuroses  to  which  I  have  already  referred,  epilepsy  also 
should  be  an  occasional  manifestation  in  later  life  of  the  nervous 
instability  which  conduced  to  convulsions  in  infancy. 

With  regard  to  the  prognosis  of  the  local  convulsive  con- 
ditions to  which  I  have  referred,  it  will  be  gathered  from  what 
has  been  already  said  that  the  chief  risk  both  of  laryngismus 
stridulus  and  of  tetany  lies  in  the  tendency  to  general  convul- 
sions which  these  local  affections  indicate  ;  but  the  former  at 
any  rate  has  also  a  danger  of  its  own,  namely,  the  possibility  of 
asphyxia  during  the  closure  of  the  glottis  by  the  convulsive 
spasm  ;  and  although  no  doubt  this  is  a  more  likely  occurrence 
where  the  attacks  are  severe,  I  would  strongly  advise  the  medical 
man  never  to  say  that  a  case  with  apparently  mild  laryngismus 
stridulus  is  free  from  risk,  for  at  any  moment  a  more  severe 
attack  may  occur  and  end  fatally.  I  have  seen  such  an  un- 
expected ending  more  than  once,  and  have  had  occasion  to 
regret  the  favourable  opinion  which  I  had  formed.  I  remember 
in  particular  an  infant  of  seven  months  who  had  what  appeared 
to  be  quite  a  slight  degree  of  laryngismus  stridulus  ;  it  was 
well  nourished,  with  only  a  moderate  degree  of  rickets,  and  some 
facial  irritability.  It  was  attending  as  an  out-patient,  and  one 
day  on  its  way  home  in  the  tram-car  it  was  suddenly  seized  with 
an  attack  of  laryngismus  stridulus  ;  the  parents  rushed  with  it 


' 

664  COMMON  DISORDERS  OF  CHILDHOOD 

to  a  doctor's  house  wfiich  they  were  passing,  but  the  child  was 
dead  by  the  time  they  reached  there. 

Tetany  per  se  involves  practically  no  risk  to  life,  although  in 
very  rare  instances  affection  of  the  respiratory  muscles  by  the 
tetany  spasm  has  ended  fatally.  But  such  affection  of  the 
respiratory  muscles  must,  I  think,  be  an  extreme  rarity  ;  amongst 
a  very  considerable  number  of  cases  of  tetany  in  infancy  and 
early  childhood  which  have  come  under  my  notice  I  have  never 
seen  such  an  occurrence. 

In  all  these  conditions,  however,  the  risk  of  general  convulsions 
is  a  very  real  one,  and  I  come  now  to  the  consideration  of  their 
treatment. 

Treatment.  There  are  few  of  the  exigencies  of  childhood 
which  are  more  alarming  and  distressing  to  parents  than  con- 
vulsions in  a  child,  and  it  is  necessary  in  most  cases  to  adopt 
some  active  treatment  immediately,  almost  as  much  for  the 
parents'  sake  as  for  the  child's. 

The  traditional  warm  bath  has,  at  any  rate,  the  merit  that 
it  is  almost  always  available  ;  and  if  it  does  no  good,  it  is  at 
any  rate  not  likely  to  do  any  harm.  The  water  should  be  at 
a  temperature  of  100°-105°  F.,  and  the  child  should  be  kept  in  it, 
immersed  to  the  neck,  for  about  five  minutes.  In  some  cases 
this  seems  to  have  a  quieting  effect,  and  perhaps  the  benefit  is 
increased  by  placing  a  cold  or  iced  water  compress  over  the 
child's  head. 

Far  more  effectual  than  the  bath  is  the  administration  by 
rectum  of  bromide  or  of  chloral  ;  and  here  I  would  insist  upon 
the  greater  effectiveness  of  chloral,  and  its  value  in  any  case 
of  prolonged  or  frequently  repeated  convulsions.  I  have  some- 
times seen  a  small  dose  of  chloral  put  a  stop  to  the  convulsions 
which  had  continued  in  spite  of  large  doses  of  bromide. 

But  whether  bromide  or  chloral  is  used,  the  drug  will  often 
require  to  be  given  with  a  free  hand  ;  and  especially  in  dealing 
with  the  serious  condition  which  I  have  compared  with  the 
status  epilepticus  of  the  adult,  heroic  doses  may  be  necessary. 

Even  very  young  infants  take  chloral  well  in  small  doses. 
I  saw  with  Dr.  Key,  of  Southsca,  an  infant  fifteen  days  old  who 
had  been  in  convulsions  at  short  intervals  for  twelve  hours. 
Potassium  bromide  had  been  given  by  the  mouth  in  doses  of 
3J  grains,  which  for  the  last  three  hours  had  been  repeated  hourly; 
some  diminution  of  the  convulsions  had  occurred,  but  there 
were  still  frequent  twi tellings  of  the  limbs.  Chloral  gr.  J  was 
then  ordered  immediately,  and  to  be  repeated  alternating  with 


CONVULSIVE  DISORDERS  IN  INFANCY          665 

the  bromide  every  three  hours  ;  and  no  further  convulsions 
occurred.  By  the  rectum  a  grain  dose  of  chloral  might  have 
been  given  to  an  infant  at  this  early  age,  and  if  necessary  might 
have  been  repeated  in  two  hours'  time  ;  whilst  for  an  infant  three 
months  old  2  grains  might  be  given  by  rectum  at  intervals  of 
three  hours  if  necessary.  At  the  age  of  twelve  months  2J  grains 
may  be  given  by  the  mouth,  or  double  that  dose  by  rectum 
if  the  case  is  urgent,  but  probably  in  most  cases  a  dose  of  1  grain 
by  mouth  repeated  every  three  hours  will  be  sufficient. 

It  should  be  borne  in  mind  in  using  chloral  for  infants  and 
young  children,  that  when  given  by  mouth  it  sometimes  causes 
gastro-intestinal  irritation,  with  consequent  vomiting  or  loose- 
ness of  the  bowels  ;  and  for  this  reason  it  is  more  suitable  as  an 
occasional  resource  than  for  continued  daily  administration. 

A  drug  which  is  sometimes  of  value,  both  for  recurring  infantile 
convulsions  and  for  frequent  epilepsy  in  children,  is  urethane  ; 
I  have  known  this  to  be  successful  where  bromide,  phenazone 
and  chloral  had  all  failed  :  to  an  infant  of  nine  months  I  have 
given  If  grains  three  times  a  day,  but  I  have  known  a  smaller 
dose  than  this  to  succeed,  for  instance,  to  a  child  of  nineteen 
months  I  gave  1  grain  three  times  a  day,  and  there  was  complete 
cessation  of  the  convulsions  which  had  been  occurring  for  seven 
weeks,  sometimes  as  many  as  twenty  or  thirty  times  a  day  : 
in  this  case  5  grains  of  sodium  bromide  three  times  a  day  had 
had  little  or  no  effect  :  within  thirty-six  hours  after  the  urethane 
was  begun  the  convulsions  stopped,  and  when  my  last  note 
was  made  thirteen  days  later  there  had  been  no  recurrence. 
To  older  children,  say  at  six  or  ten  years,  I  have  given  3-8  grains 
three  times  a  day. 

Morphia  has  been  recommended,  and  I  have  seen  it  do  good 
in  these  cases  ;  as  much  as  a  forty-eighth  of  a  grain  may  be  given 
hypodermically  to  an  infant  six  months  old.  I  have,  indeed, 
given  more  than  this,  but  I  would  advise  rather  to  begin  with 
less,  and  always  to  feel  one's  way  carefully  in  the  use  of  morphia 
hypodermically  for  infants  ;  a  sixtieth  or  even  a  hundredth  of 
a  grain  may  be  quite  sufficient.  It  is  better  to  err  on  the  side 
of  safety. 

Amyl  nitrite  has  sometimes  done  good  ;  it  may  be  given  by 
inhalation  from  capsules  containing  1  minim. 

If  these  measures  fail  the  inhalation  of  chloroform  is  often  of 
value,  although  prolonged  administration  may  be  necessary. 
Other  remedies  which  have  had  their  advocates  are  lancing  of 
the  gums  where  these  are  swollen  and  tense,  the  application 


666  COMMON  DISORDERS  OF  CHILDHOOD 

of  one  or  more  leeches*  behind  the  ears,  and  the  administration 
of  oxygen.  Lumbar  puncture  has  also  been  recommended. 

More  satisfactory  than  any  remedial  measures  is  the  prophy- 
laxis of  convulsions.  As  I  have  already  pointed  out,  there  are 
several  little  indications,  such  as  the  presence  of  '  facial  irrita- 
tion ',  or  of  those  slight  manifestations  which  the  mother  calls 
1  the  inward  convulsions  ',  which  may  apprise  us  of  the  tendency 
to  the  more  serious  general  attack,  and  in  such  circumstances 
much  may  be  done  in  the  way  of  prevention. 

Perhaps  the  commonest  exciting  cause  of  a  convulsion  is 
constipation.  I  select  this  out  of  many  exciting  causes  which 
may  call  for  treatment,  because  I  feel  sure  that,  especially  in  the 
convulsions  which  occur  during  the  first  few  months  of  infancy, 
constipation  is  so  often  the  determining  cause  that  regulation 
of  the  bowels  should  be  our  first  thought  in  prophylactic  mea- 
sures. In  rickety  infants  the  administration  of  cod-liver  oil 
has  a  very  striking  effect  in  reducing  the  nervous  instability, 
and  this  effect  is  noticeable  before  there  is  any  amelioration 
of  the  osseous  changes.  When  there  is  marked  facial  irritability, 
or  where  convulsions  have  already  occurred,  I  usually  order 
1  or  2  grains  of  bromide  with  an  emulsion  of  cod-liver  oil,  and 
the  rapid  disappearance  of  the  convulsive  tendency  therewith 
is  often  very  noticeable. 

I  am  fond  of  phenazone  for  infants  or  young  children  who 
show  a  tendency  to  convulsive  attacks  of  any  sort  :  this  drug 
seems  to  me  to  be  much  less  depressing  to  the  general  health 
than  bromide,  its  prolonged  use  does  not  produce  the  pale, 
unwholesome  look  and  general  depression  and  dullness  which 
bromide  does  :  there  are  also  cases  in  which  bromides,  even  in 
small  doses,  very  quickly  produce  a  bromide  rash,  sometimes  an 
acneiform  eruption  looking  almost  like  small  pustules  and  occur- 
ring mostly  on  the  limbs,  sometimes  a  warty  patch  like  fungating 
granulation  tissue,  which,  if  it  occur  on  the  face  and  be  followed 
by  keloid,  as  has  happened,  may  be  a  lifelong  disfigurement. 
If  the  nature  of  the  eruption  is  quickly  recognized  it  slowly 
passes  off  after  the  bromide  is  discontinued,  but  I  must  point 
out  that  the  first  appearance  of  a  bromide  rash  may  be  several 
days  after  the  administration  of  the  drug  has  ceased.  It  is 
obviously  desirable  to  avoid  such  eruptions  if  possible,  and  by 
using  phenazone  we  may  enable  the  child  to  do  without  bromide 
altogether,  or  if  these  two  drugs  are  used  in  combination  we 
may  use  a  much  smaller  dose  of  the  bromide  than  would  other- 
wise be  required. 


CONVULSIVE  DISORDERS  IN  INFANCY          667 

With  regard  to  the  treatment  of  laryngismus  stridulus,  it  has 
been  held  by  some  that  the  rational  treatment  of  this  disorder 
is  to  give  '  tone  '  to  the  nervous  system  by  cold  douches  to  the 
back,  by  fresh  air,  and  by  good  hygiene  in  general,  and  that  the 
administration  of  bromides  is  unnecessary.  But  whilst  I  would 
not  for  a  moment  dispute  the  value  of  such  hygienic  measures, 
I  would  insist  upon  the  very  real  risk  of  sudden  death  during  the 
convulsive  spasm  of  the  larynx,  and  on  this  ground  it  is  certainly 
advisable  to  give  bromide  in  laryngismus  stridulus,  combining 
this  drug  with  Ol.  Morrhuse,  and,  of  course,  not  neglecting  the 
hygienic  treatment.  There  can,  I  think,  be  no  doubt  that  the 
attacks  are  rapidly  diminished,  both  in  frequency  and  in  severity, 
by  the  administration  of  bromides,  or  of  such  sedatives  as  chloral 
or  phcnazone,  and  in  so  risky  a  disease  we  cannot  afford  to 
adopt  any  line  of  treatment  which  means  a  slower,  if  not  less 
sure,  cessation  of  the  attacks. 

During  the  spasm  of  laryngismus  stridulus  a  hot  sponge 
applied  over  the  larynx,  or  cold  water  splashed  over  the  chest 
or  face,  may  shorten  the  attack.  In  one  fatal  case,  in  which 
I  happened  to  be  at  the  bedside  when  the  attack  occurred,  the 
spasm  was  so  prolonged  and  the  closure  of  glottis  so  complete, 
that  I  believe  nothing  short  of  tracheotomy  could  have  saved 
life  ;  but  who  would  not  hesitate — perchance,  as  in  this  case, 
hesitate  a  few  seconds  too  long — to  adopt  such  treatment  for 
a  condition  which  his  experience  tells  him  is  usually  quite  tran- 
sient ?  The  treatment  of  tetany  involves  not  only  the  pro- 
phylaxis of  general  convulsions  on  the  lines  which  I  have  already 
indicated,  but  particularly  careful  attention  to  the  state  of  the 
bowels  ;  the  very  striking  relation  of  tetany  to  a  preceding 
diarrhoea  or  some  abnormal  character  of  the  stools  strongly 
suggests  that  the  toxic  influence,  whatever  it  may  be,  which 
results  in  tetany,  arises  usually  from  the  gastro-intestinal  tract, 
and  that  our  therapeutic  measures  must  deal  with  this.  As  in 
laryngismus  stridulus,  the  use  of  bromides  is  not  only  of  value  in 
relieving  the  local  spasm,  but  has  the  advantage  also  of  reducing 
the  risk  of  supervention  of  general  convulsions. 


CHAPTER  XLVI 
EPILEPSY  IN  INFANCY  AND  CHILDHOOD 

EPILEPSY  is  a  disease  of  all  ages,  but  its  beginnings  often  date 
trom  childhood,  sometimes  from  infancy.  According  to  Sir 
William  Gowers,  one-eighth  of  all  cases  commence  during  the 
first  three  years  of  life,  but  the  most  frequent  age  of  onset  is 
from  fourteen  to  sixteen  years. 

Every  medical  man  is  only  too  familiar  with  these  distressing 
cases,  but  when  the  disease  occurs  in  childhood  he  is  confronted 
with  an  anxious  parent,  and  must  needs  answer  questions  as  to 
regime  and  prognosis  which  have  special  aspects  in  the  case  of 
the  child.  Even  as  to  diagnosis  problems  will  arise  which  are 
peculiar  to  infancy  and  childhood.  Is  the  attack  a  simple  infan- 
tile convulsion  ?  Or,  if  the  child  be  at  the  school  age,  is  the 
attack  merely  the  reflex  result  of  some  dietetic  vagary  or  of  the 
indiscretions  of  a  children's  party  ?  Is  it  an  isolated  occurrence 
which  may  never  be  repeated,  or  is  it  the  precursor  of  an  epilepsy 
which  will  blight  the  child's  prospects  for  life  ? 

There  are  many  such  points,  with  reference  to  which  experience 
of  epilepsy  as  seen  in  the  adult  will  help  but  little  in  the  case  of 
the  child.  It  is  only  by  studying  the  disease  as  it  affects  infants 
and  children  that  we  can  hope  to  appreciate  the  peculiar  features 
and  to  solve  the  special  problems  which  it  presents  at  this  age. 

Sex.  There  seems  to  be  no  special  liability  of  either  sex. 
Boys  and  girls  are  equally  affected.  Of  100  consecutive  cases 
from  my  notebooks,  50  were  boys  and  50  girls. 

Age.  It  is  not  always  easy  to  be  sure  from  the  history  at  what 
age  epilepsy  first  occurred,  for  often  there  have  been  convulsive 
attacks  in  infancy,  which  may  or  may  not  have  been  of  this 
nature  ;  sometimes  the  persistent  recurrence  of  the  attacks,  as 
the  child  grows  older,  seems  to  justify  the  assumption  that  they 
were  from  the  beginning  epileptic  ;  sometimes  there  have  been 
only  two  or  three  attacks  in  infancy,  which  were  thought  to  be 
ordinary  infantile  convulsions,  then,  after  an  interval  of  months 
or  years,  attacks  have  begun  which  run  the  course  of  epilepsy  ; 
who  shall  say  whether  the  earlier  attacks  in  such  a  case  were 
really  the  first  manifestations  of  epilepsy  ?  There  are  indeed 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       669 

no  valid  distinctions  between  the  symptoms  of  an  ordinary 
infantile  convulsion  and  an  attack  of  major  epilepsy,  the  dis- 
tinction between  the  two  affections,  so  far  as  there  is  any,  lies 
in  the  course,  not  in  the  symptoms  ;  the  one  being  dependent 
upon  a  nervous  instability  which  in  greater  or  less  degree  is 
a  physiological  feature  of  early  life,  tends  to  subside  as  the  child 
grows  older  ;  the  other  being  due  to  some  morbid  erethism  of  the 
brain  which  is  independent  of  age,  is  likely  to  persist  for  years, 
if  not  for  life. 

There  are,  however,  cases  in  which  even  in  infancy  it  is  possible 
to  be  quite  sure  of  the  epileptic  character  of  the  attacks.  I  refer 
to  those  in  which  there  are  symptoms  of  petit  mal.  The  infant 
who  suddenly  jerks  the  head  forward  on  to  the  sternum  and 
then  for  a  moment  looks  dazed,  or  who  shows  a  sudden  flexion  of 
the  trunk  with  rigid  extension  of  the  arms  and  momentary  loss 
of  consciousness,  is  undoubtedly  epileptic. 

In  a  certain  number  of  cases  the  doubt  must  remain,  and  with 
this  reservation  the  following  statistics  give  some  idea  of  the  fre- 
quency with  which  the  epilepsy  of  childhood  dates  from  infancy. 
In  42  per  cent,  of  children  with  epilepsy — and  my  figures  in  this 
chapter  include  only  children  under  twelve  years  of  age — the 
attacks  began  during  the  first  two  years  of  life.  In  at  least 
28  per  cent,  the  infantile  attacks  merged  directly  into  the  epilepsy 
of  later  childhood,  and  in  the  majority  of  cases  in  which  this 
happened  the  attacks  during  infancy  could  not  have  been  dis- 
tinguished from  ordinary  infantile  convulsions. 

It  is  hardly  necessary  to  point  out  that  the  statement  that 
epilepsy  is  frequently  a  sequel  of  convulsive  attacks  in  infancy 
does  not  by  any  means  involve  the  entirely  distinct  proposition 
that  infantile  convulsions  commonly  lead  to  epilepsy  ;  the  con- 
trary indeed  is  the  fact.  An  extremely  small  proportion  of  the 
children  who  have  infantile  convulsions  ever  become  epileptic. 

The  age  at  onset  is  shown  in  the  following  statistics  of  100  cases  : 
Age  at  onset.  No.  of  cases. 

Birth  to  2  years .42 


2-3  years 
3-4  years 
4-5  years 
5-6  years 
6-7  years 
7-8  years 
8-9  years 
9-10  years 
10-1 1  years 
11- 12  years 


18 
5 
5 
5 

(i 


670  COMMON  DISORDERS  OF  CHILDHOOD 

It  is  evident  that  the  majority  of  cases  begin  during  the  first 
three  years  of  life,  and  that  there  is  no  period  of  special  liability 
during  the  rest  of  childhood  unless  the  very  slightly  increased 
frequency  of  onset  during  the  seventh  and  eighth  years  can  be 
taken  as  an  indication  that  the  second  dentition  is  an  exciting 
cause  of  epilepsy,  as  has  been  affirmed  by  some  observers. 

Etiology.  Any  full  description  of  the  etiology  of  epilepsy 
would  be  out  of  place  here.  There  are  some  causes,  however, 
which  are  peculiar  to  childhood  and  there  are  others  upon  which 
the  study  of  epilepsy  at  this  age  has  some  special  bearing. 

In  children  one  seems  to  see  more  clearly  than  in  the  adult 
how  largely  epilepsy  is  an  inborn  vice.  The  exciting  cause  is  but 
the  spark  that  fires  the  train.  The  necessary  antecedent  is  the 
congenital  tendency,  for  which  in  a  large  proportion  of  the  cases 
heredity  is  responsible  ;  not  necessarily  the  inheritance  of  an 
epileptic  strain,  but  often  only  of  a  neuropathic  taint,  which  in 
the  child's  parents  or  near  relatives  may  have  shown  itself  as 
insanity,  or  alcoholism,  or  in  less  pronounced  degree  as  asthma, 
migraine,  or  neurosis  of  one  kind  or  another.  The  inborn  ten- 
dency of  the  child  seems  to  be  shown  by  the  early  occurrence  of 
the  attacks  in  many  cases.  A  considerable  proportion  occur 
within  the  first  three  months  of  life,  some  even  within  the  first 
few  days.  The  epileptic  in  fact  is,  in  the  majority  of  cases,  an 
epileptic  from  birth,  albeit  the  first  manifestations  of  his  morbid 
tendency  may  be  delayed  for  months  or  years. 

Life  has  its  periods  of  special  danger,  when  the  flashpoint  of 
nervous  explosion  is  at  its  lowest,  periods  which  may  be  passed 
in  safety  by  the  person  of  average  stability,  but  which,  to  the 
victim  of  neuropathic  inheritance  are  likely  to  be  a  time  of 
catastrophe.  That  these  correspond  with  periods  of  special 
activity  of  physiological  development  is  surely  more  than  a 
coincidence.  In  the  adult  no  one  will  deny  that  the  periods 
of  active  functional  change,  the  time  of  pregnancy,  and  the 
age  of  the  climacteric,  to  which  perhaps  there  corresponds  a 
certain  age  in  the  male  also,  are  periods  of  special  stress  when 
such  affections  as  epilepsy  and  insanity  are  only  too  likely  to 
make  their  appearance.  Surely  there  is  nothing  unreasonable 
in  supposing  that  the  time  of  the  first  dentition,  perhaps  also  of 
the  second  dentition,  and  the  age  of  puberty,  may  also  be  critical 
periods  for  the  child  of  neuropathic  tendency.  As  a  matter  of 
observation,  I  am  satisfied  that  undoubted  epileptic  attacks 
sometimes  recur  with  great  frequency  throughout  the  period  of 
dentition,  and  then  either  become  very  infrequent  or  entirely 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       671 

cease  when  the  last  tooth  has  made  its  appearance.  In  such 
cases,  sooner  or  later,  the  attacks  are  likely  to  return,  but  their 
temporary  cessation  corresponds  so  exactly  with  the  end  of 
dentition  that  it  seems  to  me  impossible  to  doubt  the  connexion. 

With  regard  to  the  second  dentition  the  association  is  less 
striking,  but  the  slight  increase  in  the  frequency  of  onset  during 
the  time  when  the  second  dentition  first  becomes  active,  namely, 
between  the  ages  of  six  and  eight  years,  is  probably  more  than 
a  mere  accident  of  statistics.  As  I  have  elsewhere  (p.  641)  men- 
tioned, habit-spasm  shows  an  increased  frequency  of  onset 
between  the  ages  of  six  and  eight  years  ;  acquired  enuresis  also 
might  be  instanced  as  another  nervous  disorder,  the  onset  of 
which  is  specially  incident  to  this  period. 

Puberty  is  by  common  consent  acknowledged  as  one  of  the 
periods  at  which  the  first  manifestations  of  epilepsy  are  most 
likely  to  occur. 

One  is  apt  to  think  of  epilepsy  as  distinguishable  from  other 
convulsive  conditions,  particularly  the  convulsions  of  infancy 
and  the  much  rarer  reflex  convulsions  of  later  childhood,  by  the 
apparent  causelessness  of  its  outbreaks,  but  this  is  by  no  means 
an  infallible  guide.  At  all  periods  of  infancy  and  childhood 
genuine  epileptic  attacks  may  be  excited  by  some  ascertainable 
irritation,  be  it  the  presence  of  Avorms  in  the  bowel,  the  retention 
of  hard  scybala  in  the  colon,  an  indigestible  meal,  or  some  unusual 
excitement.  Nevertheless,  in  a  general  way  it  is  true  that  the 
epileptic  attack  is  traceable  but  seldom  to  any  definite  exciting 
cause. 

Whether  the  presence  of  adenoid  hypertrophy  or  enlarged 
tonsils  is  ever  sufficient  to  cause  epilepsy  is  in  my  opinion  very 
doubtful.  I  have  known  the  attacks  to  cease  for  a  time  after 
removal  of  the  naso-pharyngeal  obstruction,  but  as  a  rule  the 
operation  has  not  the  slightest  beneficial  effect  upon  epilepsy. 
Nor  again  am  I  convinced  that  the  worry  of  an  adherent  prepuce 
is  any  but  an  extremely  rare  exciting  cause  of  the  attacks. 

Among  the  less  recognized  causes  of  epilepsy  in  childhood 
congenital  syphilis  must  be  included.  Its  modus  operandi  is  not 
obvious,  for  there  is  no  evidence  in  such  cases  usually  of  any 
organic  lesion  affecting  the  brain,  and,  apart  from  any  other 
symptoms  of  syphilis  which  may  be  present,  the  epilepsy  runs 
the  same  course  as  in  non-syphilitic  children.  In  a  case  which 
showed  for  many  months  symptoms  of  ordinary  petit  mal,  the 
subsequent  localized  character  of  the  attacks  led  to  trephining 
and  the  discovery  of  syphilitic  meningitis.  In  the  category  of 


1 
672  COMMON  DISORDERS  OF  CHILDHOOD 

syphilis  have  also  to  be  reckoned  a  small  proportion  of  the  cases 
in  which  epilepsy  is  associated  with  cerebral  palsy  dependent 
upon  organic  lesions,  to  wit,  infantile  hemiplegia,  spastic  diplegia, 
and  paraplegia,  with  all  of  which  epilepsy  is  a  frequent  concomi- 
tant. These  cases,  however,  I  have  not  included  in  the  statistics 
given  above,  which  refer  only  to  so-called  idiopathic  epilepsy. 

Some  have  attributed  to  masturbation  a  part  in  the  production 
of  epilepsy.  I  must  have  been  consulted  about  a  large  number 
of  children  for  masturbation,  but  only  in  one  single  case  have 
I  known  this  to  be  an  exciting  cause  of  epilepsy,  and  I  am  strongly 
of  opinion  that,  apart  from  a  pre-existing  tendency  to  epilepsy, 
this  habit  has  no  such  risk  attaching  to  it. 

Symptoms.  In  infancy,  as  in  later  childhood,  epilepsy  may  be 
of  the  minor  or  the  major  variety.  The  latter  is  more  likely  to 
cause  doubt  in  diagnosis  in  the  infant  than  in  the  older  child. 
In  children  past  the  age  of  infancy  the  major  attack  presents 
features  like  those  in  the  adult.  The  child,  with  or  without 
a  sudden  cry,  falls  to  the  ground  unconscious  ;  there  is  increasing 
cyanosis,  with  rigidity  which  is  soon  replaced  by  clonic  spasms  of 
the  limbs,  face,  and  trunk,  perhaps  with  frothing  of  the  mouth 
and  jerky  grunting  respiration  as  the  spasm  of  the  respiratory 
muscles  allows,  until  the  paroxysm  seems  to  exhaust  itself  and 
the  child  lies  pale  and  flaccid,  dazed,  or  drowsy,  as  consciousness 
slowly  returns.  In  the  infant  an  attack  exactly  similar,  except 
of  course  for  the  falling  which  the  recumbent  position  at  that  age 
prevents,  commonly  passes  for  an  ordinary  infantile  convulsion, 
until  its  persistent  recurrence  and  the  absence  of  any  of  the  usual 
causes  of  infantile  convulsions  raise  the  suspicion  that  it  may  be 
epileptic.  There  is  no  difference  of  symptoms  whereby  we  may 
distinguish  between  the  two. 

Very  different  is  the  case  when  symptoms  of  petit  mal  occur  in 
an  infant.  Perhaps  the  commonest  manifestation  of  this  variety  of 
epilepsy  in  infancy  is  a  sudden  jerk  of  the  head  forward.  With 
this  flexion  of  the  neck  there  is  often  associated  a  sudden  rigid 
extension  of  the  upper  limbs,  with  the  hands  clenched  and  the 
arms  slightly  adducted.  The  attack  is  almost  instantaneous,  and 
at  first  the  jerk  of  the  head  may  be  so  slight  as  hardly  to  attract 
the  parent's  attention.  Sometimes  the  petit  mal  takes  the  form 
of  a  momentary  slight  '  start '  which  seems  to  affect  the  whole 
body,  and  is  perhaps  associated  with  a  barely  perceptible  quiver- 
ing of  the  eyelids.  In  comparison  with  the  distressing  spectacle 
of  the  major  attack,  or  an  ordinary  infantile  convulsion,  these 
momentary  spasms  may  appear  but  a  trivial  matter  ;  nevertheless 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       673 

it  is  of  the  utmost  importance  that  their  real  significance  should 
be  recognized.  Such  symptoms  should  be  regarded  without 
hesitation  as  epileptic,  for  experience  shows  that  they  continue 
into  later  childhood,  and  in  many  cases  are  replaced  by  or 
alternate  with  attacks  of  major  epilepsy. 

In  older  children  petit  mal  manifests  itself  in  various  ways. 
Often  the  child  stops  suddenly  in  his  play  or  in  the  act  of  eating, 
looks  vacant  for  a  moment,  and  then  proceeds  as  if  nothing  had 
happened  ;  or  perhaps  in  the  midst  of  talking  he  suddenly  turns 
pale,  shows  a  momentary  upturning  or  quivering  of  the  eyes  and 
becomes  confused  in  his  speech,  but  quickly  finds  his  words  again, 
and  the  attack  is  over.  I  have  seen  several  cases  in  which  the 
only  symptom  was  a  momentary  trance-like  condition  with  fixed 
gaze,  so  that,  if  walking  across  a  road,  the  child  suddenly  stopped, 
stood  still  for  a  few  seconds,  and  then  went  on  its  way  as  though 
nothing  had  happened.  A  dangerous  form  of  the  disease  in  these 
days  of  motors  !  Sometimes  the  attacks  were  described  as 
a  sudden  '  dreaminess ' ;  the  child  took  no  notice  of  a  question, 
and  then  seemed  startled  when  one  spoke  to  him.  It  is  not 
uncommon  for  attacks  of  petit  mal  to  terminate  in  a  deep  audible 
sigh. 

Both  after  minor  and  major  epilepsy  there  sometimes  occur  in 
children,  as  in  adults,  automatic  actions.  A  child  of  three  under 
my  care  for  severe  attacks  of  major  epilepsy  invariably  pulled 
himself  up  by  the  sides  of  his  cot  when  the  attack  was  over,  and 
groped  his  way  round  it  in  an  uncertain,  fumbling  way,  quite 
unconscious  of  his  surroundings,  until,  after  three  or  four  minutes, 
he  regained  full  consciousness  and  seemed  surprised  at  the 
position  in  which  he  found  himself. 

The  danger  of  this  epileptic  automatism  was  well  illustrated 
by  the  following  case  : — 

Henri  D.,  aged  12|  years.  Had  suffered  with  convulsions  at  2  years  old, 
and  on  several  occasions  up  to  the  age  of  5  years.  These  then  ceased,  and  he 
seemed  healthy  until  at  the  age  of  9  years  he  became  liable  to  curious  attacks, 
consisting  of  sudden  lapses  into  a  condition  resembling  somnambulism.  During 
the  attack  the  boy  always  fumbled  with  the  sleeves  of  his  coat,  as  if  trying  to 
pull  them  down,  and  he  would  often  walk  forward,  and  if  he  came  to  a  wall  or 
other  object  against  which  he  could  support  himself  would  lean  against  it  until 
full  consciousness  returned.  On  one  occasion  an  attack  occurred  when  the 
boy  was  approaching  the  bank  of  a  river  :  he  walked  straight  on  into  the  river 
and  stood  in  the  water  fumbling  as  usual  with  his  coat-sleeves ;  his  father, 
who  was  near,  called  to  him,  and  the  boy  came  out,  still  unconscious  of  his 
surroundings;  after  walking  a  few  steps  he  recovered  consciousness,  seemed 
confused,  and  asked  why  his  clothes  were  so  wet. 

STILL  x  x 


$ 
674  COMMON  DISORDERS  OF  CHILDHOOD 

In  addition  to  these  categories  of  major  and  minor  epilepsy, 
there  is  another  which  often  passes  unrecognized  for  a  time,  the 
so-called  '  epilepsie  larvee  ',  or  '  masked  epilepsy  '.  I  have  seen 
several  cases  in  which  the  chief  symptom  was  a  sudden  pain  in 
the  navel  or  epigastrium,  e.  g.  :— 

William  B.,  aged  10|,  since  the  age  of  9  months  has  had  sudden  attacks  of 
pain  in  the  epigastrium  ;  this  lasts  a  few  seconds,  during  which  there  is  sudden 
pallor,  succeeded  by  flushing,  after  which  the  boy  becomes  pale  and  asks  to  lie 
down  and  goes  to  sleep  for  a  long  time.  This  occurs  several  times  a  day.  With 
large  doses  of  bromide  these  attacks  were  greatly  reduced  in  number  and  some- 
times checked  altogether  for  several  weeks. 

A  sudden  loss  oi  speech  is  sometimes  the  only  evidence  of 
masked  epilepsy,  as  in  the  following  case  : — 

Mary  A.,  aged  10J  years,  is  subject  to  curious  attacks  of  difficulty  of  breathing 
which  come  on  just  as  she  is  going  to  sleep.  She  gets  out  of  bed  making  violent 
respiratory  efforts,  but  there  is  no  cyanosis,  and  she  is  able  to  come  downstairs 
to  her  mother.  This  respiratory  difficulty  passes  off  after  two  or  three  minutes, 
leaving  a  numbness  of  the  lips  with  difficulty  in  producing  consonants  or  with 
complete  loss  of  speech  for  a  few  minutes.  The  child  is  conscious,  and  has  even 
tried  to  write  what  she  was  unable  to  say.  The  whole  attack  lasts  only  a  few 
minutes.  It  has  only  once  been  associated  with  convulsive  movements  of  the 
face.  Under  bromide  there  was  great  diminution  of  the  attacks. 

In  another  case  the  child,  a  girl  of  9J  years,  just  after  falling 
asleep  at  night,  woke  unable  to  speak.  Her  tongue  '  wobbled 
about '  and  saliva  '  dribbled  '  from  her  mouth,  but  she  understood 
what  was  said  to  her,  and  was  sufficiently  conscious  to  feel  for 
her  pocket-handkerchief  on  account  of  the  '  drivelling  '.  The 
attack  lasted  about  two  minutes  and  recurred  about  once  a 
fortnight. 

Sleepiness  is  sometimes  the  chief  manifestation  of  a  masked 
epilepsy.  Both  major  and  minor  attacks  are  often  followed 
by  more  or  less  drowsiness  or  prolonged  sleep,  but  the  attacks  to 
which  I  refer  consist  of  little  else,  for  instance  : — 

George  G.,  aged  5^,  had  what  was  supposed  to  be  an  ordinary  infantile  con- 
vulsion at  14  months.  More  recently  he  had  shown  a  curious  tendency  to  fall 
asleep  at  odd  times,  without  warning.  At  any  hour  of  the  day  he  would  sit 
down  and  go  to  sleep  for  several  minutes.  The  nature  of  these  attacks  was  not 
apparent  until  eventually  the  sleepiness  began  to  be  associated  with  epileptic 
twitching. 

Still  more  pronounced  was  the  somnolence  in  the  following 
case  : — 

David  A.,  aged  9|  years,  at  the  age  of  9|-  was  found  one  morning  in  bed 
so  deeply  asleep  that  even  with  strong  smelling-salts  he  could  not  be  roused  for 
nearly  four  hours.  On  one  occasion,  in  order  to  wake  him,  he  was  placed  in 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       675 

a  bath,  but  although  he  was  able  to  stand  in  it  he  remained  in  a  state  of  stupor, 
and  when  he  woke  two  hours  later  knew  nothing  about  what  had  taken  place 
and  complained  of  some  headache.  There  was  nothing  to  indicate  that  these 
lapses  into  profound  stupor  were  preceded  by  any  epileptic  convulsion.  There 
was  no  history  of  involuntary  defaecation  or  micturition  during  the  attack. 
On  the  whole,  it  was  thought  that  the  attacks  probably  represented  a  masked 
epilepsy,  and  this  was  confirmed  by  the  subsequent  history,  for  ordinary  attacks 
of  major  epilepsy  followed,  which  persisted  for  two  years  and  then  ceased  under 
treatment. 

The  relation  of  epilepsy  to  sleep  is  very  remarkable  :  there  is 
in  many  cases  a  special  liability  to  attacks  just  as  the  patient  is 
falling  asleep  and  also  just  before  awaking.  I  have  notes  of  cases 
in  which  the  fits  were  limited  to  these  times.  I  would  compare 
with  this  the  behaviour  of  some  cases  of  enuresis,  and  also  of 
night  terrors,  both  of  which  tend  to  occur  during  this  intermediate 
state  between  sleeping  and  waking.  One  may  suppose  that  the 
lower  activities  of  the  brain  are  still  sensitive  to  stimuli  after 
the  higher  controlling  functions  have  become  dormant,  and 
that  the  abnormal  erethism  of  the  epileptic  brain  is  therefore 
still  less  in  check  when  sleep  is  just  beginning  or  just  ending. 

The  manifestations  of  epilepsy  are  often  curiously  localized, 
although  the  subsequent  course  of  the  disease  shows  that  it  is  of 
the  idiopathic  variety  rather  than  a  symptom  of  some  gross  lesion 
of  the  brain ;  thus  the  epileptic  movements  may  be  limited  at  first 
to  one  side,  or  even  to  one  limb,  although  subsequent  manifesta- 
tions are  of  the  ordinary  general  distribution.  Sometimes  these 
localized  outbreaks  leave  behind  them  a  temporary  weakness  of 
the  affected  limb  or  side  which  may  last  some  hours.  I  have 
elsewhere  (p.  661)  mentioned  a  similar  occurrence  in  connexion 
with  ordinary  infantile  convulsions,  and,  as  in  that  case,  it  is 
important  to  realize  that  such  weakness  does  occur  as  a  tem- 
porary phenomenon,  and  does  not  necessarily  point  to  any 
permanent  cerebral  palsy  or  organic  lesion. 

Various  subjective  symptoms  may  be  the  only  manifestation  of 
epilepsy  in  childhood.  For  instance,  in  one  child,  aged  7J  years, 
there  were  frequent  sudden  sensations  of  falling  replaced  at  times 
by  definite  attacks  of  major  epilepsy.  In  another,  the  child,  aged 
4J  years,  complained  of  the  sensation  of  falling  backwards,  and 
seemed  much  frightened  by  it,  although  she  never  actually  fell. 
This  child  had  suffered  with  an  ordinary  epileptic  fit.  In  another 
the  sensation  was  one  of  giddiness.  Such  subjective  symptoms 
may  form  an  aura  before  an  ordinary  attack  of  major  epilepsy,  but 
the  cases  to  which  I  am  now  referring  show,  in  some  at  least  of  their 
attacks,  no  manifestation  beyond  these  subjective  symptoms. 

XX2 


076  COMMON  DISORDERS  OF  CHILDHOOD 

An  aura,  in  my  experience,  is  not  very  common  in  children. 
I  have  seen  several  cases  in  which  the  child  complained  of  some 
pain  in  the  abdomen,  usually  at  the  navel,  just  before  the  attack 
begins.  In  some  instances  nausea  immediately  preceded  the  onset, 
and  the  child  would  run  to  his  mother  saying  that  an  attack  was 
coming.  I  have  seen  cases  in  which  the  attack  was  preceded  for 
some  hours,  or  even  for  a  day  or  two,  by  extraordinary  perverse- 
ness  and  fractiousness,  which  were  quite  unnatural  to  the  child 
at  other  times. 

This  brings  me  to  the  mental  condition  of  the  epileptic 
child.  There  is  no  more  serious  aspect  of  epilepsy  in  child- 
hood than  its  effect  upon  the  mind.  The  result  depends 
almost  entirely  upon  the  age  at  which  the  epilepsy  begins,  but 
the  variety  of  epilepsy  is  also  a  consideration.  To  the  lay  mind 
the  major  attack  very  naturally  suggests  more  danger  to  the 
intellect  than  the  slight  hardly-noticed  quiver  of  the  eyelids  or 
jerk  of  the  head  which  may  be  the  only  manifestation  of  petit 
mal.  But  these  latter  attacks,  beginning  under  the  age  of  one 
year,  are  almost  invariably  followed  by  idiocy,  and  the  earlier 
they  begin  the  more  profound  is  the  degree  of  the  idiocy  ; 
whereas  major  attacks,  indistinguishable  at  the  time  from 
ordinary  infantile  convulsions,  though  their  subsequent  per- 
sistence may  show  them  to  have  been  epileptic,  are  much  less 
likely  to  interfere  with  the  development  of  the  intellect  in  any 
great  degree.  Beginning  a  little  later,  during  the  second  or  third 
year  of  life,  epilepsy  rather  modifies  the  development  of  the 
intellect  than  arrests  it,  and  it  is  in  children  who  have  been 
first  affected  at  this  age  that  one  sees  the  mental  peculiarities 
so  characteristic  of  many  epileptic  children.  The  child  seems  to 
lose  that  subtle  restraint  which  goes  with  the  higher  degrees  of 
intellectual  refinement.  There  is  a  lack  of  normal  shyness  and 
modesty.  The  child  talks  to  strangers  too  readily  and  with  too 
easy  a  familiarity  ;  at  the  same  time,  he  is  abnormally  impatient 
of  control,  flies  into  a  passion  on  the  slightest  thwarting,  and 
strikes  out  petulantly  at  his  mother  if  she  expostulates  with 
him.  The  power  of  concentration  is  diminished  and  the  child's 
attention  wanders  too  easily  ;  nevertheless  there  is  no  gross 
impairment  of  intelligence,  and  the  child  passes  for  a  normal  child 
albeit  wayward  and  capricious. 

Diagnosis.  To  the  distinction  between  epilepsy  and  infantile 
convulsions  I  have  already  referred  :  there  are  several  disorders 
which  must  be  remembered  as  simulating  epilepsy  in  childhood. 
'  Fainting  attacks  '  are  a  common  cloak  for  epilepsy.  In  children, 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD        677 

before  the  beginning  of  the  second  dentition,  fainting  is  extremely 
uncommon,  but  in  later  childhood,  especially  as  puberty  ap- 
proaches, it  is  by  no  means  rare.  It  is  often  no  easy  matter 
to  distinguish  between  fainting  and  epilepsy  from  a  mother's 
description  ;  especially  when  she  is  naturally  anxious  to  obtain 
a  verdict  in  favour  of  the  less  serious  affection.  Inquiry  may 
elicit  the  fact  that  there  was  some  rigidity  during  the  attack,  or 
that  there  was  twitching.  Either  of  these,  however  slight  in 
degree,  would  be  conclusive  against  fainting. 

Children  are  not  exempt  from  hysteria,  and  I  have  seen 
hysterical  attacks  resembling  severe  major  epilepsy  in  a  girl  about 
9  years,  who  frequently  fell  to  the  ground  kicking  and  struggling 
violently  ;  she  showed  no  loss  of  consciousness,  and  the  purposive 
character  of  her  movements  and  the  deliberate  manner  of  her 
falling  left  no  doubt  as  to  the  hysterical  nature  of  the  fit. 

It  must  be  remembered  also  that  malingering  is  not  unknown 
in  childhood,  and  I  have  seen  deliberate  mimicry  of  an  epileptic 
attack  by  a  child  aged  3  years,  who  had  suffered  with  genuine 
and  severe  epilepsy.  The  child,  finding  himself  under  observation, 
would  suddenly  hold  up  the  right  arm  and  screw  up  the  left  side 
of  his  face,  and  then  laugh  at  the  onlooker. 

A  habit  which  may  be  mistaken  for  epilepsy  is  masturbation. 
I  have  on  several  occasions  been  consulted  for  supposed  epilepsy 
in  such  cases.  The  stiffening  of  the  legs,  the  clenching  of  the  hands, 
and  the  reddening  of  the  face,  followed  by  pallor  and  exhaustion, 
make  up  a  picture  not  unlike  epilepsy,  but  there  is  no  loss  of 
consciousness,  and  careful  observation  shows  that  the  movement 
is  purposive  and  is  directed  to  the  excitement  of  a  sexual  orgasm. 
This  habit  of  masturbation,  as  I  have  elsewhere  pointed  out 
(p.  743),  occurs  frequently  in  infancy,  especially  in  girls,  and  the 
suspicion  of  masturbation  may  be  confirmed  by  the  finding  of 
some  soreness  of  the  vulva,  which  frequently  accompanies  this 
habit.  I  know  of  no  evidence  that  this  orgasm  ever  passes  into 
an  epileptic  attack,  unless  the  child  is  already  the  subject  of 
epilepsy.  When  this  is  so,  the  act  of  masturbation  may  occasion- 
ally be  the  exciting  cause  of  an  attack  of  epilepsy,  as  I  have 
known  happen  in  one  case,  where  actual  loss  of  consciousness  with 
epileptic  symptoms  followed  directly  upon  some  of  the  bouts  of 
masturbation,  though  not  upon  all. 

The  possibility  of  organic  cerebral  disease  as  the  cause  of 
epileptiform  attacks  must  always  be  borne  in  mind.  Both  at  the 
onset  and  in  the  later  stages  of  the  cerebral  palsies  of  childhood 
such  attacks  are  common  (see  pp.  702;  709),  and  tumours,  and  even 


I 

678  COMMON  DISORDERS  OF  CHILDHOOD 

meningitis,  may  first  manifest  themselves  by  an  epileptiform 
attack. 

Prognosis.  There  are  few  diseases  in  which  it  is  more  difficult 
to  give  a  forecast  with  any  confidence  than  in  epilepsy  :  but  this 
point  I  would  specially  urge, — do  not  be  too  gloomy  in  prognosis. 
Parents  and  doctors  alike  are  too  apt  to  think  that '  once  epileptic, 
alwavs  epileptic  '  is  the  inevitable  fate  of  the  child  who  has  showrn 
any  evidence  of  this  disorder.  Undoubtedly  there  are  many 
cases  in  which  such  a  view  is  correct,  but  happily  there  are  also 
many  in  which  it  would  be  cruelly  wrong,  and  it  is  in  childhood 
particularly  that  a  hopeful  prognosis  is  most  likely  to  be  justified. 
The  favourable  prognosis  of  epilepsy  at  this  age  was  noticed  even 
in  ancient  times.  '  They  who  are  troubled  with  the  falling  sick- 
ness before  they  attain  the  age  of  fourteen  may  be  freed  from  it.' 
So  wrote  Hippocrates  (I  quote  from  Sprengell's  translation),  and 
his  observation  was,  I  think,  sound.  I  could  quote  many  cases 
in  which,  even  after  epileptic  attacks  had  recurred  for  several 
years  during  the  middle  period  of  childhood — I  mean  from  about 
five  to  ten  years  of  age — they  then  ceased  for  years,  and  appa- 
rently, as  is  shown  by  the  histories  of  adults  who  had  suffered 
with  the  disease  in  childhood,  in  some  have  never  returned. 

The  frequency  of  attacks  is  no  guide  in  prognosis  ;  often 
indeed  the  child  who  is  having  a  dozen  or  more  attacks  of  major 
epilepsy  every  day  proves  much  more  amenable  to  treatment 
than  one  who  is  only  having  one  attack  every  few  weeks  or 
months.  To  the  uncertainty  of  the  effects  of  treatment,  w^hich 
must  make  us  wary  in  any  case  of  giving  prognosis  before  a 
thorough  administration  of  drugs  has  been  tried,  there  must  be 
added  another  element  of  uncertainty  which  may  baulk  our 
most  careful  calculations.  Epilepsy,  like  enuresis,  is  a  disorder 
which  sometimes  apparently  without  rhyme  or  reason,  after  we 
have  wellnigh  exhausted  the  pharmacopoeia  with  little  or  no 
effect,  suddenly  ceases  spontaneously.  If  I  had  to  single  out  one 
variety  of  epilepsy  as  of  less  hopeful  prognosis  than  another,  it 
would  be  petit  mal.  At  all  periods  of  childhood  I  think  this  is 
generally  less  amenable  to  treatment  than  the  major  variety  ; 
and  in  infancy  certainly  it  is  of  far  more  sinister  significance  than 
the  major  attacks,  from  another  aspect,  namely  the  effect  upon 
the  mind. 

I  have  already  described  the  mental  changes  which  are  likely 
to  result  from  epilepsy  occurring  in  infancy  or  early  childhood ; 
here  I  will  only  repeat  that  petit  mal  in  the  infant  leads  almost, 
if  not  quite,  invariably  to  idiocy.  The  older  the  child  at  the 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       G79 

time  of  onset  of  the  epilepsy  the  less  the  danger  of  mental 
deterioration. 

It  is  remarkable  how  little  effect  is  produced  upon  the  mental 
powers  by  epilepsy  in  children,  even  when  it  recurs  many  times 
daity,  provided  that  it  has  begun  later  than  the  end  of  the  third 
year.  With  a  very  frequent  recurrence  of  attacks,  even  in  late 
childhood,  there  may  be  temporary  dullness  and  slowness  of 
mental  response,  but  this  disappears  as  the  attacks  become  less 
frequent  :  with  a  condition  of  '  status  epilepticus  '  in  late  child- 
hood I  have  occasionally  known  delusions  and  mental  confusion 
to  occur,  but  even  these  clear  away  within  a  few  days  after  the 
bout  of  epilepsy  has  subsided.  It  would  seem  indeed,  as  one 
might  expect,  that  it  is  during  the  earlier  stages  of  mental  develop- 
ment, when  the  processes  of  reason  are  only  just  being  acquired, 
that  epilepsy  is  most  disastrous  to  the  intellect. 

Treatment.  There  are  certain  general  points  which  seem  to  me 
worth  bearing  in  mind  in  connexion  with  the  treatment  of  this 
disease.  First,  that  as  in  many  other  nervous  disorders,  morbid 
habit  probably  plays  no  small  part  in  epilepsy.  '  Principiis  obsta ' 
is  a  good  precept  in  the  treatment  of  any  disease  ;  it  is  specially 
applicable  to  this  one,  for  it  seems  likely  that  by  preventing 
the  attacks  in  childhood  we  may  prevent  the  acquirement  by  the 
brain  of  the  epileptic  habit,  which  unchecked  would  become  in 
later  years  an  ingrained  vice  and  render  the  patient  a  lifelong 
epileptic. 

If  this  be  so,  it  is  surely  important  that  treatment  should  be 
continuous  over  a  long  period.  I  am  convinced  that  when 
bromides  or  any  other  drugs  arrest  the  fits  they  should  not  be 
discontinued  until  many  months  have  elapsed  since  the  last 
attack  ;  the  longer  we  can  arrest  the  outbreaks  the  more  the 
chance  of  accustoming  the  brain  to  a  better  habit. 

Secondly,  that  even  if  we  cannot  arrest  the  attacks  altogether 
we  may  be  able  to  lengthen  the  intervals  between  them  :  and 
this  is  especially  of  importance  in  infancy,  when  a  diminution 
of  the  number  of  attacks  may  mean  a  less  degree  of  permanent 
mental  impairment. 

Thirdly,  that  whilst  in  the  majority  of  cases  of  epilepsy  no 
exciting  cause  is  found,  it  is  never  right  to  assume  that  this  is  so 
without  investigation,  for  there  are  those  in  which  a  mere  off-hand 
prescription  of  bromide  or  any  other  sedatives  would  be  thoroughly 
bad  treatment,  where  faults  of  digestion  or  local  irritation,  or  the 
daily  regimen,  particularly  as  to  diet,  may  be  responsible,  in  part 
at  least,  for  the  attacks. 


I 
680  COMMON  DISORDERS  OF  CHILDHOOD 

To  deal  with  this  last  point  first  :  the  epileptic  child  should 
live  a  life  as  free  as  possible  from  excitement  and  emotional  dis- 
turbances ;  a  children's  party,  a  severe  scolding,  a  sudden  fright — 
any  such  cause  may  determine  an  attack. 

If  there  is  much  nasopharyngeal  obstruction  by  adenoid  hyper- 
trophy or  enlarged  tonsils,  it  may  be  wise  to  have  them  removed, 
but  it  should  be  explained  to  the  parents  that  only  very  rarely 
has  such  an  operation  any  beneficial  effect  upon  the  epilepsy. 
I  have  known  severe  and  frequent  fits  to  cease  on  removal  of  the 
obstruction,  but  as  a  rule  the  epilepsy  has  not  been  checked  even 
temporarily. 

In  every  case  care  should  be  taken  that  the  bowels  are  acting 
regularly  and  well,  and  that  any  digestive  disorder  is  set  right ; 
and  in  this  connexion  it  must  be  remembered  that  defective  teeth 
are  a  very  common  cause  of  indigestion  in  infancy,  and  cases  are 
on  record  in  which  the  irritation  of  carious  teeth  has  seemed  itself 
to  have  caused  epilepsy  in  children  ;  both  West  and  Tomes 
mention  such. 

Apart  from  dietary  to  ensure  good  digestion,  certain  special 
diets  have  seemed  to  be  of  value  in  some  cases,  namely  the  purin- 
free  diet  and  the  salt-free  diet.1  The  purin-free  diet  consists  of 
milk,  eggs,  butter,  cheese,  rice,  macaroni,  tapioca,  white  bread, 
cabbage,  lettuce,  cauliflower,  sugar,  and  fruit.  The  salt-free  diet 
consists  of  milk,  fresh  butter,  eggs,  fruit,  white  bread  made 
without  salt — or  made  with  sodium  bromide  instead  of  sodium 
chloride — weak  tea,  coffee  or  cocoa,  and  sugar. 

I  have  seen  cases  in  which  a  purin-free  diet  certainly  seemed 
to  do  good  ;  but  I  have  seen  others  in  which  a  diet  the  very 
reverse  in  character  seemed  more  successful,  and  I  have  seen 
many  more  in  which  diet  did  not  seem  to  have  the  slightest 
effect  upon  the  epilepsy.  As  this  is  so,  I  am  accustomed  to 
regard  the  special  dietetic  treatment  of  epilepsy  as  so  uncer- 
tain and  so  entirely  empirical,  that  I  always  reserve  it  for  cases 
in  which  the  much  more  reliable  drug  treatment  has  failed, 
which,  moreover,  is  far  less  irksome  to  the  child  and  his  parents 
than  the  restricted  choice  of  these  special  foods. 

Turning  now  to  the  drug  treatment  of  epilepsy  in  children, 
I  know  of  nothing  more  generally  useful  than  the  bromides,  and 
I  must  say  a  word  upon  the  reluctance  which  both  the  profession 
and  the  laity  often  show  to  the  prolonged  and  thorough  adminis- 
tration of  bromide  for  this  disease.  '  Surely,'  says  the  mother, 
'  it  is  so  dulling.'  It  is  perfectly  true  that  some  children  are  made 
1  Aldrcn  Turner,  Practitioner,  1906,  p.  545. 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD       681 

temporarily  not  only  dull  and  sleepy,  but  miserable  and  peevish, 
if  very  large  doses  of  bromide  are  given,  but  the  quantity  which 
can  be  tolerated  without  this  effect  varies  in  different  cases,  and 
in  the  vast  majority  of  them  the  dose  required  to  control  the 
epilepsy  is  not  sufficient  to  cause  any  mental  dullness  ;  in  any 
case  the  dose  should  be  pushed  up,  if  necessary,  until  dullness  is 
apparent,  and  if  any  occurs,  the  bromide  can  be  replaced  in  part 
and  reinforced  by  other  drugs  which  I  shall  mention. 

Nor  is  the  objection  that  bromide  makes  the  child  look  '  seedy  ' 
one  which  can  be  urged  as  any  general  reason  for  not  using  it. 
It  is  astonishing  what  large  doses  children  will  often  take  for 
many  months  not  only  without  looking  ill,  but  with  marked 
improvement  of  their  general  health,  owing  to  the  cessation  of 
the  epilepsy.  Many  children  of  9  or  10  years  will  take  25  or 
30  grains  three  times  daily  for  months  and  months  with  nothing 
but  advantage.  On  the  other  hand,  there  are  cases  in  which 
the  child  becomes  very  pale  and  heavy-eyed,  and  looks,  as  the 
saying  is,  '  seedy,'  whilst  taking  much  smaller  doses,  e.  g.  10  or 
15  grains  at  9  years  thrice  daily.  For  such  the  drug  must 
generally  be  given  in  much  smaller  doses,  combined  with  some 
other  drug  of  value  for  this  disease. 

As  I  mentioned  in  the  preceding  chapter,  there  are  cases  in  which 
even  in  small  doses  bromide  causes  an  eruption  on  the  skin  ;  in 
these  some  other  drug  must  be  substituted  altogether. 

The  doses  of  bromide  must  be  determined  by  experiment  in 
the  individual  case.  It  often  happens  that  with  a  moderate  dose 
of  bromide  the  attacks  become  less  frequent,  but  when  they  do 
occur  they  are  more  severe  ;  where  this  is  so  the  bromide  should 
not  be  stopped,  but  should  be  pushed  until  the  attacks  are  more 
completely  controlled,  as  is  generally  possible. 

Infants,  I  think,  stand  prolonged  administration  of  large  doses 
of  bromide  less  well  than  older  children,  and  for  this  reason  it  is 
advisable  to  supplement  this  drug  with  phenazone.  An  infant 
of  six  months  with  petit  mal  may  take  a  mixture  of  Sodium 
bromide  gr.  ijss,  Phenazone  gr.  ss,  Spirit  chloroform  COJss,  Gly- 
cerine O)  v,  Aq.  anethi  ad  3j  ter  die,  and  at  one  year  the  dose  of 
phenazone  may  be  increased  to  1  grain  and  the  bromide,  if  neces- 
sary, to  4  or  5  grains ;  but  one  would  not  hesitate  to  try  a  watchful 
administration  of  larger  doses  of  bromide  if  these  failed  to  check 
the  attacks,  for  the  stakes  are  high ;  it  is  the  child's  intelligence 
we  are  trying  to  save. 

In  these  infantile  cases  especially,  chloral  is  often  more  effectual 
than  bromide,  but  owing  to  its  disturbing  effect  upon  digestion, 


* 
682  COMMON  DISORDERS  OF  CHILDHOOD 

its  prolonged  use  is  generally  to  be  avoided.  It  is  particularly 
suitable  as  a  temporary  measure  when  the  attacks  happen  to 
be  specially  severe  or  frequent,  and  at  any  time  it  may  be  useful 
to  add  a  small  dose  of  chloral  to  a  bromide  mixture,  so  that  it 
may  not  be  necessary  to  give  a  large  dose  of  either.  To  an  infant 
of  six  months  J  grain  of  chloral  with  1-1 J  grains  of  sodium 
bromide  may  be  given  ;  whilst  a  child  of  18  months  or  2  years 
may  take  1-1 J  grains  of  chloral  three  times  a  day,  for  weeks  if 
necessary  ;  but  this  drug  should  be  discontinued  or  diminished 
as  soon  as  possible. 

For  older  children  the  addition  of  digitalis  to  a  bromide  mixture 
is  sometimes  of  undoubted  value.  Such  a  mixture  as  the  following 
has  been  very  successful  for  children  of  7  or  8  years.  R  Sod. 
bromide  gr.  v,  Pot.  bromide  gr.  v,  Ammon.  bromide  gr.  v,  Tinct. 
digitalis  a)  iii,  Syrup,  5  j,  Aq.  menth.  pip.  ad  3  ss  ter  die.  It  has 
been  supposed  that  by  mixing  the  three  bromides  a  more  sedative 
effect  is  obtained  than  from  a  similar  dose  of  any  one  bromide. 
I  am  not  clear  that  this  is  so,  but  I  have  seen  excellent  results 
from  such  a  mixture,  as  I  have  also  from  the  use  of  strontium 
bromide.  Borax  is  sometimes  distinctly  beneficial  as  an  addition 
to  a  bromide  mixture  :  2|-  grains  may  be  given  thrice  daily  at 
one  year  and  5  or  6  grains  at  six  years. 

Another  bromide  preparation  which  is  worthy  of  trial  for 
children  past  the  age  of  infancy  is  bromocarpin,  which  to  a  child 
of  three  years  may  be  given  in  doses  of  20-30  minims  thrice  daily, 
and  to  a  child  of  six  years  in  doses  of  half  to  one  drachm  thrice 
daily. 

When  there  seems  to  be  a  special  liability  to  the  acneiform  or 
warty  eruption  which  sometimes  comes  from  bromides,  bromipin 
may  be  given  by  rectum  :  I  have  used  1-2  drachms  of  the  weaker 
10  per  cent,  solution  for  rectal  injection  twice  daily  at  the  age  of 
eighteen  months.  Usually,  however,  in  such  cases  it  is  best  to 
discard  bromides  altogether,  and  a  valuable  substitute  is  urethane, 
of  which  1-1 J  grains  may  be  given  thrice  daily  to  an  infant  a  year 
old,  and  3-5  grains  to  a  child  of  six  years.  This  drug  dissolves 
readily  in  water  and  has  but  little  taste,  so  that  it  is  easy  to 
administer.  In  some  cases  urethane  is  more  effectual  than 
bromide,  and  epilepsy  which  has  seemed  intractable  has  yielded 
to  it  ;  but  like  most  other  drugs  it  will  often  fail,  and  sometimes 
in  cases  where  bromide  proves  successful. 

In  one  child,  who  was  not  benefited  by  bromide,  thyroid  seemed 
to  check  the  epilepsy  to  a  marked  degree  ;  but  this  must,  I  think, 
be  exceptional,  for  in  other  cases  it  had  no  good  effect  whatever. 


EPILEPSY  IN  INFANCY  AND  CHILDHOOD        683 

In  older  children,  as  in  infants,  chloral  is  sometimes  more 
effectual  than  bromide,  and  may  be  given  alone  or  in  com- 
bination with  bromide ;  3  grains  may  be  given  thrice  daily  to 
a  child  of  six  years,  whilst  a  child  of  ten  years  may  take  4  grains, 
increased  if  necessary  to  5  grains.  It  is  well,  however,  to  dis- 
continue chloral  as  soon  as  possible  and  always  to  give  the 
smallest  dose  which  is  effectual. 

In  the  rare  cases  in  which  a  child  passes  rapidly  from  one  fit 
to  another,  remaining  in  the  status  epilepticus  for  hours — a  very 
rare  occurrence,  I  think,  in  childhood,  but  one  which  I  have  seen 
in  two  or  three  instances — it  may  be  necessary  to  give  this  drug 
by  rectum,  and  for  this  purpose  it  must  be  given  with  a  free  hand. 
15  grains  may  be  given  by  rectum  to  a  child  of  five  years,  whilst 
as  much  as  20  grains  may  be  necessary  for  a  child  of  ten  years. 
The  prolonged  administration  of  chloroform  is  the  most  effective 
treatment  if  chloral  fails  to  control  the  fits. 


CHAPTER  XLV1I 
INFANTILE  PARALYSIS 

OF  all  forms  of  paralysis  in  childhood  infantile  paralysis  or 
acute  anterior  poliomyelitis  is  the  most  frequent.  And  yet, 
familiar  though  this  disease  may  be,  it  is  constantly  raising 
difficult  practical  questions  for  the  clinician,  whilst  for  the 
pathologist  it  has  remained  until  quite  recently  an  entirely 
unsolved  riddle  so  far  as  its  cause  is  concerned. 

It  may  now  be  taken  as  proved  by  the  researches  of  Flexner 
and  others  that  infantile  paralysis,  at  any  rate  in  its  epidemic 
form,  is  an  infective  disease,  but  there  are  still  many  points  which 
require  elucidation.  The  nature  of  the  virus  itself  is  still  un- 
certain, and  though  it  may  be  assumed  that  the  ordinary  sporadic 
disease,  with  which  we  are  all  familiar,  is  infective  and  probably 
due  to  the  same  infection  as  the  epidemic  variety,  yet  we  must 
keep  an  open  mind  until  more  evidence  is  available  ;  for,  as  I 
shall  point  out,  the  clinical  course  and  the  apparent  exciting 
causes  of  some  of  the  sporadic  cases  at  least  suggest  the  possi- 
bility that  similar  pathological  changes  may  be  due  to  dissimilar 
causes. 

The  consideration  of  its  clinical  features  has  important  bear- 
ings upon  the  pathological  obscurities  of  this  disease,  and  as 
a  clear  mental  picture  of  the  morbid  anatomy  of  infantile  para- 
lysis is  essential  to  the  proper  understanding  of  the  questions  at 
issue  I  shall  describe  briefly  at  the  outset  the  main  facts  of  its 
morbid  anatomy  as  far  as  they  are  known.  It  may  be  taken 
for  granted  now  that  the  clinical  phenomena — the  paralysis,  the 
muscular  wasting,  the  arrested  growth,  and  the  coldness  and 
blueness  in  the  affected  limbs — are  all  due  to  a  primary  lesion 
in  the  spinal  cord,  with  the  reservation  that  in  certain  cases 
peripheral  nerve  lesions  may  be  associated  with  the  spinal 
lesion,  and  that  possibly  in  rare  cases  a  clinical  picture  hardly, 
if  at  all,  distinguishable  from  that  of  poliomyelitis  may  result 
from  a  primary  peripheral  nerve  affection.  To  the  spinal  cord 
we  must  look  for  the  characteristic  changes,  and  it  is  little  use 
seeking  to  determine  the  character  of  the  initial  lesion  or  its 
cause  from  the  changes  found  in  the  spinal  cord  months  after 
the  onset  of  the  disease  :  the  shrinkage  of  the  anterior  horns, 


INFANTILE  PARALYSIS  685 

the  disappearance  or  degenerated  state  of  nerve-cells  in  the 
anterior  cornua,  the  diminished  size  of  the  anterior  roots,  the 
ascending  degeneration  which  may  occur,  these  tell  us  little 
or  nothing  of  the  beginning  of  the  disease.  It  is  from  the 
examination  of  cases  which  have  died  during  the  first  few  days 
of  the  disease  that  we  may  hope,  sooner  or  later,  to  determine 
its  cause  ;  at  present  but  few  such  early  examinations  have 
been  recorded.  My  colleague,  Dr.  Batten,  has  recorded  a  care- 
fully studied  case  which  died  thirteen  days  after  the  onset,  and 
I  quote  his  description  of  the  changes  found. 

*  The  vessels  in  the  grey  matter  are  thrombosed  and  sur- 
rounded by  perivascular  exudation  ;  there  are  scattered  haemor- 
rhages throughout  the  grey  matter  and  exudation  of  small  cells. 
The  congestion  is  almost  limited  to  the  ventral  portion  of  the  cord.' 

In  addition  to  these  changes  in  the  substance  of  the  cord, 
there  occur  more  or  less  increase  of  vascularity  and  small  cell 
infiltration  of  the  spinal  meninges. 

Now,  upon  the  interpretation  of  these  early  changes  there  exists 
considerable  doubt.  Is  the  thrombosis  ever  the  primary  lesion,  or 
is  there  always  first  an  inflammation  of  which  the  thrombosis  is 
merely  a  part  ?  In  either  case  is  the  primary  lesion  necessarily 
the  result  of  invasion  by  some  micro-organism  ?  and  if  so,  is  the 
infection  one  peculiar  to  this  disease  ?  or,  on  the  other  hand, 
may  the  lesion  result  from  many  different  causes,  infective  and 
otherwise  ?  These  are  the  questions  raised  by  the  morbid 
anatomy  of  infantile  paralysis,  and  if  it  be  not  possible  to  give 
a  definite  answer  to  any  of  them,  yet  we  may  at  least  obtain 
some  hints  towards  their  solution  from  a  consideration  of  the 
clinical  facts  of  the  disease. 

Boys  would  seem  to  be  rather  more  liable  than  girls.  My 
own  figures  show  in  100  cases  57  boys  to  43  girls. 

The  age-incidence  is  of  some  interest ;  it  is  shown  in  the  accom- 
panying chart  (Fig.. 48)  of  100  cases  amongst  children  under  twelve 
years  of  age.  The  disease  may  occur  even  in  adults,  but  it 
usually  begins  before  the  end  of  the  third  year,  and  is  far  more 
frequent  during  the  second  year  of  life  than  at  any  other  period. 
Out  of  100  cases  in  which  I  have  noted  this  point,  84  began 
within  the  first  three  years  of  life,  and  there  is  a  very  striking 
maximum  incidence  in  the  second  year  ;  38  began  between 
the  ages  of  one  and  two  years,  whereas  only  20  began  in  the 
first  year  of  life.  The  earliest  age  of  onset  among  my  cases 
was  the  seventh  week.  I  draw  attention  to  the  special  incidence 
upon  the  second  year  of  life  because  it  contrasts  with  the  age- 


COMMON  DISORDERS  OF  CHILDHOOD 


incidence  of  infantile  hemiplegia  which  has  its  onset  most  often 
in  the  first  year. 

With  reference  to  the  age-incidence  I  would  point  out  also, 
but  without  laying  any  great  stress  upon  the  fact,  that  such 
undoubtedly  infective  diseases  as  suppurative,  posterior  basic 
or  cerebro-spinal,  and  tubercular  meningitis  have  their  maximum 
incidence  during  the  first  three  years  of  life,  so  that  it  might  be 


-3  |  3-4    I  4-5  |  5-6  |  6-7  {  7-8   |  8-9  |  9-1O    10-11      11-12 


FIG.  48. 


Age-incidence  of  infantile  paralysis, 
in  100  cases. 


Chart  shows  age  at  onset 


suggested  that  the  central  nervous  system  is  specially  liable  to 
infective  disease  at  this  period  (see  p.  707;. 

More  important  is  the  seasonal  incidence  which  is  shown  in  the 
chart  below  (Fig.  49).  In  71  out  of  100  sporadic  cases  in  which  the 
month  of  onset  could  be  determined,  the  disease  began  between  the 
beginning  of  June  and  the  end  of  September;  and  in  50  out  of 
the  100  cases  the  onset  was  either  in  August  or  September. 
This  incidence  during  a  particular  season  strongly  suggests 


INFANTILE  PARALYSIS 


687 


an  infective  character  ;  but  undue  stress  must  not  be  laid  upon 
it,  for  it  must  be  remembered  that  diseases  which  I  suppose 
no  one  imagines  to  be  infective  have  sometimes  a  very  striking 
seasonal  incidence — for  example,  spasmus  nutans  ;  and  it  is 
quite  possible  that  light,  temperature,  and  barometric  pressure 
may  influence  the  seasonal  incidence  of  a  disease  apart  from 
any  infective  agent. 


JO 

28 

46 


2£ 


JS3L|*L 


o*T. 


Pec. 


V  / 


FIG.  49. 


Seasonal  incidence  of  infantile  paralysis. 
of  onset  in  100  cases. 


Chart  shows  month 


A  further  point  which  harmonizes  with  the  infective  origin 
of  infantile  paralysis  is  the  relation  of  this  disease  to  specific 
fevers  ;  amongst  my  notes  of  100  cases  there  are  7  in  which 
the  paralysis  supervened  during  the  acute  stage  of  a  specific 
fever  or  during  convalescence  therefrom  :  (1)  fourteen  days 
after  the  appearance  of  measles  rash  ;  (2)  four  weeks  after 
measles  ;  (3)  eight  days  after  onset  of  scarlet  fever  ;  (4)  while 
in  hospital  convalescing  from  scarlet  fever  ;  (5)  during  typhoid  ; 


688  COMMON  DISORDERS  OF  CHILDHOOD 

(6)  during  whooping-cough  ;    (7)  eight  days  after  vaccination, 
paralysis   of  vaccinated  arm.     The  tendency  for   one  specific 
fever  to  follow  another  is  often  apparent  in  children,  who  within 
a  few  months  will  pass  through  two  or  three  specific  fevers,  and 
is,  I  think,  a  reasonable  ground  for  assuming  that  if  any  particular 
disease  tends  to  follow  specially  upon  specific  fevers  the  disease 
in  question  is  likely  itself  to  be  of  specific  infective  nature. 
But  there  is  another  possible  explanation  ;    thrombosis  may 
certainly  result  from  typhoid  fever,  and  it  seems  likely  enough 
that  after  other  acute  illnesses  degenerative  changes  in  vessel 
walls  and  feeble  circulation,  perhaps  with  dilatation  of  the  heart, 
may  favour  the  occurrence  of  thrombosis  apart  from  any  specific 
infection  peculiar  to  infantile  paralysis  ;  on  this  view  the  relation 
to  specific  fevers  might  be  held  to  support  the  idea  of  a  primary 
thrombosis  as  the  cause  of  the  spinal  cord  condition.     It  is 
noteworthy  that  infantile  paralysis  follows  directly,  not  only 
the  specific  fevers,  but  also  acute  diarrhoea  ;    in  three  of  my 
cases    acute   diarrhoea   was   followed   after   twenty-four   hours 
duration  by  infantile  paralysis,  and  in  another  case  paralysis 
was  found  after  the  child  had  been  ill  three  weeks  with  diarrhoea. 
A  primary  vascular  lesion  would  accord  also  well  with  the  cases 
in  which  traumatism  has  seemed  to  be  the  determining  factor. 
Parents  are  apt  enough  to  attribute  illnesses  to  blows  and  falls, 
the  occurrence  of  which  just  before  the  illness  may  be  a  mere 
coincidence;    but  it  is  as  easy  to  attach  too  little  importance 
to  them  as  too  much,  and  even  if  a  disease  be  undoubtedly  of 
infective  character  it  may  still  be  true  that  a  blow  or  fall  may 
produce  either  at  the  part  struck  a  locus  minoris  resistentice, 
or  by  its  generally  depressing  effect  a  general  vulnerability  of 
tissues.     For  instance,  a  boy,  aged  five  and  a  half  years,  went 
to  school  apparently  well  ;    whilst  there  he   was   hit  a   severe 
blow  in  the  back  by  another  boy;  in  the  afternoon  shortly  after 
the  blow  he  fell  whenever  he  tried  to  walk  :    both  legs  were 
paralysed  ;     the  right  recovered  gradually,   the  left  remained 
paralysed.     In  two  other  cases  the  onset  of  infantile  paralysis 
was  three  days  after  a  fall  downstairs,  but  in  both  the  onset 
was   accompanied   by  fever    and    in    one    by   vomiting,    as   is 
common  in  cases  where  there  is  no  history  of  traumatism. 

The  strongest  argument  in  favour  of  an  infective  origin,  apart 
from  experimental  evidence,  is  the  occurrence  of  epidemics  of  in- 
fantile paralysis — a  resum^  of  thirty-five  epidemics  has  recently 
been  collected  by  Drs.  Holt  and  Bartlett,1  and  Dr.  F.  E.  Batten  2 

1  A  met:  Journ.  Med.  Sci.,  May,  1908. 

2  Proc.  Roij.  Soc.  Med.  (Epidem.  Sect.),  June,  1911. 


INFANTILE  PARALYSIS  689 

has  collected  information  as  to  similar  outbreaks  in  Great  Britain 
— a  fact  which  seems  also  strongly  to  support  the  view  that  the 
disease  is  due  to  some  specific  infection.  Whilst,  however,  I  draw 
attention  to  this  almost  conclusive  proof  of  an  infective  origin, 
I  would  point  out  that  in  most  of  these  epidemics  there  have  been 
certain  features  very  unlike  those  we  are  familiar  with  in  the 
ordinary  sporadic  infantile  paralysis.  In  the  first  place,  the  mor- 
tality has  been  widely  different  from  that  of  the  sporadic  disease, 
which  is  very  rarely  fatal.  In  the  epidemic  recorded  by  Caverley 
at  Rutland,  Vermont,  U.S.A.,  there  were  eighteen  deaths  out  of 
126  cases — i.  e.,  nearly  15  per  cent.  Again,  in  an  epidemic  in  France 
there  were  three  deaths  among  13  cases.  Moreover,  it  is  remark- 
able that  in  some  of  these  epidemics  some  cases  have  shown  symp- 
toms so  like  cerebro-spinal  meningitis  that  great  doubt  has  arisen 
as  to  their  nature,  and  in  a  recent  epidemic  in  Australia  one 
view 'regarded  the  epidemic  as  including  two  distinct  diseases — 
acute  anterior  poliomyelitis  and  cerebro-spinal  meningitis.  In  the 
Rutland  epidemic  horses,  dogs,  and  fowls  were  affected,  and  in 
a  horse  the  necropsy  showed  that  there  was  definite  meningitis. 
In  some  of  the  epidemics  some  of  the  cases  have  resembled  rather 
a  polyneuritis,  and  this  also  has  been  demonstrated  at  autopsy. 
Lastly,  I  would  point  out  that  complete  recovery,  which  is  so 
rare  in  ordinary  sporadic  infantile  paralysis,  has  been  quite  a 
common  occurrence  in  some  of  the  epidemics.  Caverley  reported 
fifty  complete  recoveries  in  126  cases ;  Altmann,  in  an  Australian 
epidemic,  reported  four  complete  recoveries  in  18  cases. 

I  mention  these  facts,  not  to  throw  any  doubt  upon  the  occur- 
rence of  epidemic  anterior  poliomyelitis,  but  only  to  suggest  that 
until,  by  the  more  exact  methods  of  experimental  medicine  the 
specificity  of  infantile  paralysis  in  all  varieties  of  its  occurrence  has 
been  proved,  the  exact  relationship  of  the  recorded  epidemics  to  the 
sporadic  disease  which  we  call  infantile  paralysis  remains  uncertain. 

The  brilliant  work  of  Flexner  and  his  colleagues  at  the  Rocke- 
feller Institute  has  proved  that  at  least  in  the  epidemic  form  of 
the  disease  there  is  a  specific  infection ;  ar.d  his  results  are  so  im- 
portant that  I  cannot  do  better  than  summarize  them  here.  An 
emulsion  was  made  of  the  spinal  cord  from  children  who  had  died 
during  the  acute  stage  of  epidemic  anterior  poliomyelitis  ;  this  was 
injected  into  the  brains  of  monkeys  through  a  trephine  hole,  and 
it  was  found  that  after  a  period  of  about  6-10  days  paralysis  of 
limbs  appeared  and  autopsy  showed  changes  in  the  spinal  cord 
of  the  monkeys  exactly  similar  to  those  found  in  children.  (As 
the  incubation  period  may  prove  to  be  of  practical  importance  in 

STILL  y  y 


690  COMMON  DISORDERS  OF  CHILDHOOD 

preventing  the  spread  of  this  disease  it  should  be  mentioned  here 
that  Dr.  Batten,  from  his  study  of  epidemics,  concludes  that  in 
human  beings  this  period  is  shorter,  not  exceeding  four  days.) 

The  spinal  cord  from  these  monkeys  was  in  turn  emulsified  and 
injected  into  other  monkeys,  who  also  developed  paralysis  after 
a  few  days  and  showed  the  characteristic  changes  of  acute 
anterior  poliomyelitis  in  the  spinal  cord.  In  passing  the  disease 
from  monkey  to  monkey  it  was  found  that  transmission  was 
possible  not  only  by  intra-cerebral  inoculation,  but  also  by 
injecting  the  emulsion  into  the  peritoneal  cavity  or  into  veins  or 
into  nerves.  Further  experiments  showed  that  transmission  was 
possible  also  by  subcutaneous  inoculation,  and  by  bringing  the 
virus  into  contact  with  the  scarified  mucosa  of  the  nasopharynx. 
The  exact  nature  of  the  virus  remains,  however,  unknown. 
Flexiier,  after  examination  of  the  nervous  tissues  and  of  the 
cerebro-spinal  fluid  from  children  and  from  monkeys,  was  entirely 
unable  to  find  any  micro-organisms  having  the  ordinary  characters 
of  bacteria  or  protozoal  parasites,  and  even  found  that  after 
admixture  of  the  comminuted  spinal  cord  with  glycerine  for 
seven  days,  a  procedure  which  in  the  case  of  the  virus  of  vaccinia 
destroys  any  admixture  of  bacteria  without  destroying  the 
specific  virus,  the  spinal  cord  still  retained  its  power  of  producing 
acute  anterior  poliomyelitis  when  injected  into  monkeys.  It 
seems,  therefore,  clear  that  the  infecting  agent  is  not  an  ordinary 
bacterium. 

A  filtrate  of  the  cord,  which  was  made  into  a  fine  emulsion  and 
passed  through  a  Berkefeld  filter,  so  that  a  clear,  bacteriologically 
sterile  filtrate  resulted,  was  still  capable  of  transmitting  the 
disease.  It  was  thought,  therefore,  that  the  infecting  agent  of 
epidemic  poliomyelitis  belonged  to  the  class  of  the  minute  viruses 
which,  like  those  of  rabies  and  vaccinia,  are  capable  of  passing 
through  fine  filters  and  which  have  not  hitherto  been  discoverable 
with  certainty  by  any  microscopic  examination. 

More  recently,  however,  by  prolonged  culture  of  pieces  of 
cerebral  cortex  in  human  ascitic  fluid,  to  which  has  been  added 
a  fragment  of  sterile  fresh  kidney  from  a  rabbit,  Noguchi  has 
been  able  to  cultivate,  after  about  five  days,  certain  very  minute 
globoid  bodies,  in  chains,  pairs,  and  small  masses,  which  produce 
in  inoculated  monkeys  the  characteristic  lesions  of  poliomyelitis. 
Flexner  and  Noguchi  *  consider  that  this  organism  fulfils  the 
requirements  of  a  specific  virus. 

As  to  the  method  of  conveyance  of  acute  anterior  poliomyelitis 
to  human  beings,  no  conclusive  evidence  is  yet  available,  but 

1  Journ.  Experiment.  Med.,  vol.  xviii,  4,  1913,  p.  401. 


INFANTILE  PARALYSIS  691 

certain  facts  discovered  by  Flexner  are  at  least  suggestive 
and  may  prove  to  be  of  extreme  practical  importance.  The 
virus,  as  already  mentioned,  can  be  inoculated  in  monkeys  by 
simple  application  to  the  scarified  mucous  membrane  ;  it  has 
also  been  obtained  from  the  nasal  mucous  membrane  of  monkeys 
after  they  had  developed  the  disease  from  inoculation  in  other 
parts.  Levaditi  and  Pastia  have  also  shown  its  presence  in  the 
tonsils  and  pharyngeal  mucosa.  It  seems,  therefore,  at  least  con- 
ceivable that  one  portal  of  entry  in  children  is  the  nasopharynx, 
including  the  tonsils.  Lastly,  Flexner  has  shown  that  if  the 
common  house  fly  is  allowed  to  feed  upon  the  fresh  spinal  cord 
from  monkeys  which  have  been  recently  paralysed  by  infection 
with  acute  anterior  poliomyelitis,  and  is  then  killed  and  emulsi- 
fied, the  bacterium-free  filtrate  from  these  flies  is  capable  of 
transmitting  the  disease  to  monkeys. 

An  extremely  important  observation  is  that  made  by  Osgood 
and  Lucas,  quoted  by  Flexner,  that  the  virus  can  survive  in  the 
nasal  mucosa  for  nearly  six  months,  so  that  long  after  the  acute 
stage  of  the  disease  has  passed  a  monkey  can  still  act  as  '  carrier  ' 
of  infection.  Flexner  and  Clark  themselves  have  observed  per- 
sistence of  the  virus  in  the  nasal  and  pharyngeal  mucosa  four 
weeks  after  the  onset  of  the  paralysis.  Clearly,  if  these  facts  hold 
good  for  human  beings  as  well  as  for  monkeys,  they  may  have  an 
extremely  important  bearing  upon  the  prevention  of  this  disease. 

I  have  quoted  these  experiments  at  some  length  because,  what- 
ever future  observations  may  bring  forth  with  regard  to  the 
relation  between  epidemic  anterior  poliomyelitis  and  the  ordinary 
sporadic  instances  of  the  disease,  it  is  clear  that  the  epidemics  are 
due  to  a  specific  infection,  and  until  the  contrary  be  proved,  it  is,  in 
my  opinion,  only  right  that  we  should  assume  that  the  sporadic 
disease  also  is  infective,  and,  moreover,  that  it  is  possibly  con- 
tagious, and  we  should  take  precautions  accordingly. 

Onset  and  symptoms.  The  clinical  course  of  infantile 
paralysis  gives  but  conflicting  evidence  on  the  problems  of  its 
pathology.  Most  striking,  to  my  mind,  are  the  remarkable 
differences  in  the  mode  of  onset,  which  may  be  classified  in  three 
groups : 

(1)  An  acute  illness,  more  or  less  severe,  lasting  a  few  days, 
with  pyrexia  and  drowsiness,  and  perhaps  with  vomiting,  head- 
ache, constipation,  and  some  pain  in  the  back  or  limbs,  is  found 
to  have  left  the  child  paralysed  in  one  or  more  limbs  :  e.g.  Alice 
S.,  aged  eighteen  months,  on  October  9  was  restless  and  seemed 
vaguely  ill  ;  on  October  10  she  vomited  three  times  and  was 
feverish  ;  October  11  she  seemed  less  ill,  but  on  October  12  she 

yy2 


692  COMMON  DISORDERS  OF  CHILDHOOD 

was  noticed  to  be  unable  to  move  her  limbs  or  head,  and  as  she 
improved  she  remained  paralysed  in  the  left  arm  and  leg. 

This  is  the  commonest  mode  of  onset  and  would  fit  in  well 
with  the  idea  of  an  infective  disease. 

(2)  An  insidious  onset  which  perhaps  cannot  be  dated  at  all ; 
the  first  thing  noticed  is  weakness,  and  this  perhaps  only  when 
there  is  already  considerable  wasting  :    e.  g.  Charles  H.,  aged 
two  and  a  half  years,  came  with  flaccid  paralysis  of  the  left  leg. 
The  onset  was  entirely  unnoticed,  and  it  was  only  when  he 
should  have  walked  at  sixteen  months  that  the  weakness  of  his 
left  leg  attracted  attention.    In  some  of  these  cases  one  is  assured 
the  weakness  has  come  on  gradually,  but  it  seems  likely  that  it  is 
the   wasting   rather   than   the   weakness   which   has   gradually 
increased  and  has  given  rise  to  this  statement. 

(3)  Sudden,    perhaps   instantaneous    onset:    e.g.  Violet  S., 
aged  two  years  and  four  months,  was  running  about  at  play  ; 
she  fell  down,  and  on  being  picked  up  was  found  to  be  paralysed 
in  the  right  leg.    I  have  seen  another  case  with  exactly  similar 
history,   where   a  little  girl  running  across  a  room  suddenly 
dropped  down  and  was  found  to  be  paralysed  in  the  legs.     In 
both  these  cases  the  subsequent  condition  seen  by  me  was  that 
of  typical  infantile  paralysis.     Such  cases  suggest  very  strongly 
the   occurrence  of  some  vascular  lesion,  obstruction  or  hsemor- 
rhage.    In  this  group,  perhaps,  should  be  included  the  not  un- 
common cases  of  which  the  following  is  an  instance  :  Willie  S., 
aged  three  years,  went  to  bed  apparently  perfectly  well  ;    in  the 
morning  he  was  found  to  be  paralysed  in  the  right  leg,  though 
otherwise  showing  no  sign  of  illness  ;    the  paralysis  remained 
permanent. 

In  connexion  with  the  onset  of  the  disease  I  would  draw 
attention  specially  to  the  evidence  of  widespread  disturbance 
which  is  noticeable  in  some  cases  at  this  stage.  Not  only  is 
there  fever  with  malaise,  but  in  9  out  of  100  cases  I  have  noted 
convulsions  at  the  onset  ;  a  boy,  aged  four  and  a  half  years, 
whose  illness  had  begun  with  a  convulsion,  followed  by 
vomiting,  headache,  and  drowsiness,  fell  into  a  semi-comatose 
condition,  his  face  became  paralysed  on  the  left  side,  he  passed 
his  urine  and  faeces  under  him,  and  after  a  few  days  lost  power 
in  the  left  shoulder  muscles  and  the  right  leg.  All  these  symp- 
toms disappeared  within  three  weeks  from  the  onset,  except  the 
paralysis  of  the  right  leg,  which  persisted  with  wasting  of 
muscles  and  '  reaction  of  degeneration  '. 

In  such  a  case  it  seems  evident  that  there  is  something  more 
than  a  mere  local  affection  of  the  spinal  cord,  thrombotic  or  other- 
wise ;  there  is  a  profound  constitutional  disturbance  suggestive 


INFANTILE  PARALYSIS  693 

of  some  acute  infective  disorder.  The  facial  palsy  in  this  case 
was  of  interest  as  showing  that  parts  at  least  as  high  as  the  pons 
may  be  affected.  My  colleague,  Dr.  F.  E.  Batten,  has  published 
a  case  in  which  microscopic  examination  proved  that  the  facial 
paralysis  was  the  result  of  congestion  which  '  had  destroyed  the 
nucleus  of  the  seventh  nerve  ' ;  and  if  the  disease  may  produce 
inflammation  of  the  grey  matter  at  this  level  there  seems  to  be 
no  reason  why  it  should  not  produce  it  also  in  the  grey  matter 
of  the  cortex.  On  this  view  the  polio-encephalitis  which  is 
supposed  by  some  to  be  the  usual  primary  lesion  in  '  infantile 
hemiplegia  '  may  be  of  a  nature  identical  with  the  poliomyelitis 
which  is  the  usual  lesion  in  '  infantile  paralysis  '. 

Similarly,  '  infantile  paralysis  affecting  the  brain  '  may  be 
the  explanation  of  the  widely  spread  polio-encephalitis  which 
probably  underlies  some  of  those  cases  in  which,  after  a  sudden 
onset  of  convulsions  with  loss  of  consciousness  and  pyrexia,  a 
child  is  left  idiotic  with  general  spasticity.  But  until  we  have 
bacteriological  evidence  by  which  we  may  test  the  identity  of  such 
conditions  it  would  be.  premature  to  state  that  these  cortical 
lesions  are  etiologically  identical  with  infantile  paralysis. 

It  seems  clear  that  for  some  reason  the  part  of  the  spinal  cord 
remote  from  the  brain  is  affected  most  often  and  most  severely. 
My  own  figures  showed  in  100  cases  : 

Left  lower  limb  paralysed  in     .         .         .         .32 

Right  lower  limb 23 

Both  lower  limbs 10 

Both  lower  and  both  upper  limbs      ...  6 

Both  lower  and  right  upper  limb      ...  2 

Both  lower  and  left  upper  limb         ...  1 

Right  lower  and  right  upper  limb     ...  1 

Right  lower  and  left  upper  limb       ...  2 

Left  lower  and  right  upper  limb       ...  1 

Left  lower  and  left  upper  limb          ...  1 

Both  upper  limbs 2 

Left  upper  limb 5 

Right  upper  limb .8 

It  will  be  seen  that  the  lower  limbs,  one  or  both,  were  the  only 
part  affected  in  71  out  of  100  cases  ;  that  the  lower  limbs  were 
affected  together  with  the  upper  in  14  cases,  and  that  the  upper 
limbs  alone  were  affected  only  in  15  cases. 

These  figures  refer  to  the  permanent  paralyses,  but  it  must  be 
remembered  that  during  the  few  days  or  weeks  following  the 
onset  of  the  disease  there  is  often  much  more  extensive  paralysis, 
which  clears  up,  leaving,  it  may  be,  only  one  limb  or  one  group 
of  muscles  affected. 

I  have  not  referred  in  these  figures  to  paralysis  of  trunk  muscles, 


$ 

694  COMMON  DISORDERS  OF  CHILDHOOD 

which,  though  much  lees  common  than  that  of  limbs,  is  sometimes 
a  marked  feature  ;  twice,  at  least,  I  have  seen  the  diaphragm 
paralysed,  and  cases  have  been  recorded  in  which  the  muscles 
of  the  abdominal  wall  have  been  paralysed  on  one  side  or  both, 
so  that  the  abdomen  was  puffed  out  in  an  extraordinary  manner 
when  the  child  cried  or  coughed.  The  spinal  muscles  were 
affected  in  several  of  my  cases,  giving  rise  to  more  or  less  lateral 
curvature  ;  the  following  case  illustrated  both  the  extensive 
recovery  from  initial  paralysis  and  the  persistence  of  trunk 
affection.  Winifred  P.,  at  the  age  of  eighteen  months,  became 
feverish  and  ailing  one  day  in  August  ;  after  three  days  it  was 
found  that  she  was  weak  in  all  her  limbs,  but  especially  in  the 
right  leg  and  left  arm.  After  a  few  weeks  the  limbs  had  gradually 
recovered  completely,  but  months  afterwards  there  was  severe 
lateral  curvature  left  as  a  result  of  affection  of  spinal  muscles. 

The  results  of  infantile  paralysis  are  not  limited  to  the  loss 
of  muscular  power  ;  in  many  cases  there  arise  gradually  secondary 
deformities  which  add  in  no  small  degree  to  the  disability  already 
present  ;  such  deformities,  which  include  several  varieties  of 
talipes,  claw-hand,  &c.,  are  dependent  chiefly  on  unopposed 
action  of  the  unparalysed  muscles,  but  partly,  for  instance 
in  talipes  valgus,  on  stretching  of  ligaments  owing  to  absence  of 
muscular  support. 

It  is  sometimes  stated  that  there  is  no  affection  of  sensation 
in  infantile  paralysis,  and  this  no  doubt  is  true  for  the  disease 
in  its  chronic  stage,  but  at  the  onset  I  have  often  found  marked 
tenderness  in  the  affected  limbs,  so  that  the  child  cries  whenever 
the  limbs  are  touched  ;  in  some  cases  also  there  is  pain  in  the 
affected  limbs  at  this  stage.  Diminution  of  sensation  is  much 
rarer  than  tenderness  ;  it  has  been  observed  during  the  first 
few  days  of  the  disease. 

As  in  a  case  I  have  quoted,  incontinence  of  urine  and  faeces, 
or  retention  of  urine,  sometimes  occurs  at  the  onset,  but  although 
these  irregularities  may  indicate  affection  of  the  sphincters  in 
some  cases,  they  are  probably  more  often  due  to  the  negligence 
in  these  matters  which  is  common  in  children  with  any  acute 
illness  or  disablement  ;  I  have  never  known  any  sphincter 
affection  to  persist  more  than  a  fortnight  after  the  onset. 

The  tendon-jerks  are  rapidly  lost  in  the  affected  limbs,  but 
I  would  point  out  that  this  loss  depends  entirely  upon  the 
distribution  of  the  paralysis  ;  there  may  be  extensive  paralysis 
in  the  legs  with  no  loss  of  knee-jerk,  so  long  as  part  of  the 
quadriceps  extensor,  particularly  the  vastus  internus,  is  intact. 
Out  of  sixty-four  cases  in  which  the  lower  limb  was  affected  I 


INFANTILE  PARALYSIS  695 

have  noted  that  the  knee-jerk  was  present  in  the  paralysed  leg 
in  no  less  than  twenty-four  cases.  The  plantar  reflex  has  shown 
extensor  response  in  some  of  my  cases,  signifying  probably, 
not  interruption  of  pyramidal  tracts,  but  simply  weakness  of 
flexor  muscles  so  that  the  unparalysed  extensors  predominate. 

Diagnosis.  When  the  limb  is  already  wasted,  cold  and 
blue,  with  loss  of  tendon-jerks  and  with  flaccid  paralysis,  the 
diagnosis  is  usually  easy  enough,  but  at  the  onset  a  diagnosis 
may  be  impossible  for  several  days,  and  the  febrile  illness,  with 
tenderness  or  pains  in  limbs  and  back,  has  been  mistaken, 
naturally  enough,  for  all  sorts  of  febrile  ailments  ;  acute  rheuma- 
tism it  was  supposed  to  be  in  a  little  girl,  who,  with  some  fever, 
complained  of  tenderness  about  one  shoulder  and  inability  to  move 
it ;  and  this,  perhaps,  is  one  of  the  commonest  errors.  Influenza 
the  illness  was  called  in  another  case,  while  in  the  case  mentioned 
above  (p.  692)  where  facial  paralysis  was  associated  with  stupor 
and  fever  before  the  paralysis  of  limbs  appeared,  a  confident  diag- 
nosis of  meningitis  was  made.  Even  when  extensive  paralysis  of 
limbs  is  evident,  it  must  be  remembered  that  there  are  other  con- 
ditions beside  anterior  poliomyelitis  which  occasionally  cause 
such  symptoms  in  children.  I  have  seen  acute  myelitis  paralyse 
all  four  limbs  in  a  child  of  six  years,  but  the  occurrence  of 
anaesthesia,  with  retention  of  urine,  cystitis,  and  a  tendency  to 
bed-sores,  all  pointed  to  this  diffuse  inflammation  of  the  cord. 
Neuritis  also  may  hardly  be  distinguishable  from  poliomyelitis, 
unless  the  occurrence  of  prolonged  tenderness  and  much  pain  in 
the  limbs  may  be  taken  as  indicating  peripheral  nerve-lesion 
rather  than  affection  of  spinal  cord,  but  in  some  of  the  epidemics 
of  supposed  infantile  paralysis  neuritis  was  found  to  be  associated 
with  the  cord-lesion,  and  it  may  be  that  the  specific  materies 
morbi,  if  such  there  be,  of  infantile  paralysis  can  act  upon  nerves 
or  spinal  cord  indifferently  ;  certainly  there  are  cases  in  which 
pain  and  tenderness,  associated  with  very  extensive  paralysis 
and  a  very  slow  recovery  in  almost  all  the  affected  parts  after 
many  weeks  or  months,  strongly  suggest  a  polyneuritis  rather 
than  a  spinal  cord  lesion,  but  the  distinction  may  be  impossible. 

Prognosis.  There  are  few  diseases  which  within  so  few  hours 
or  days  may  so  completely  mar  a  life  by  permanent  and  hopeless 
crippling  as  does  infantile  paralysis.  And  yet,  disastrous  though 
its  results  may  be,  it  is  a  disease  which,  at  any  rate  in  its  ordinary 
sporadic  form,  very  rarely  endangers  life.  When  infantile  para- 
lysis kills  it  is  almost  always  during  the  first  week  or  two  of 
the  disease,  and  death  is  due  to  paralysis  of  respiratory  muscles 
from  affection  of  the  upper  part  of  the  cord,  particularly  of 


696  COMMON  DISORDERS  OF  CHILDHOOD 

that  part  of  the  cerwcal  cord  which  supplies  the  diaphragm. 
But  it  is  possible  that  more  deaths  may  be  due  to  this  disease 
than  are  commonly  attributed  to  it  ;  for  if  it  affects  the  cervical 
cord  there  seems  to  be  no  reason  why  it  should  not  affect  the 
medulla,  and  it  may  be  that  some  of  the  sudden  and  unexplained 
deaths  in  children  may  be  due  to  infantile  paralysis  affecting 
the  medulla,  and  so  damaging  the  respiratory  and  cardiac 
centres  that  death  occurs  before  any  paralysis  of  limbs  has 
appeared. 

Does  complete  recovery  ever  occur  in  infantile  paralysis  ? 
It  is  usual  for  some  of  the  limbs  or  muscles  originally  paralysed 
to  recover  completely  within  a  few  days  or  weeks  after  the  onset, 
and  if  the  lesion  in  the  cord  may  thus  subside  in  one  part  without 
permanently  damaging  its  functions  there  seems  to  be  no  a  priori 
improbability  that  all  the  parts  affected  may  sometimes  recover. 
There  is  evidence,  as  already  mentioned,  that  this  has  happened 
in  some  of  the  epidemic  cases,  but  naturally  it  is  difficult  to  prove 
any  sporadic  instance.  A  child  was  brought  to  the  Children's 
Hospital  with  infantile  paralysis  of  one  limb  ;  it  was  stated  that 
another  child  in  the  family  had  become  paralysed  similarly 
within  ten  days  after  the  onset  in  this  child,  but  had  completely 
recovered. 

The  possibility  of  complete  recovery  is  strongly  suggested 
also  by  the  not  uncommon  cases  in  which  the  weakness  left 
some  months  after  the  disease  is  so  slight  that  it  might  be  over- 
looked were  it  not  for  the  wasting  and  shortening  of  the  limb, 
which  is  more  evident  than  the  weakness. 

If  complete  recovery  occurs  it  is  certainly  to  be  looked  for 
only  in  the  first  few  weeks  after  the  onset  ;  later,  the  only 
question  is  as  to  the  degree  of  improvement  possible.  And  here 
I  would  give  two  pieces  of  advice  :  (1)  Not  to  take  too  gloomy 
a  view  because  the  paralysis,  say  three  months  after  the  onset, 
is  extensive  in  distribution  and  the  muscles  flabby  and  wasted. 
No  doubt  a  complete  loss  of  reaction  to  faradism  and  galvanism 
makes  it  improbable  that  the  muscle  will  recover,  and  a '  reaction 
of  degeneration  '  is  only  less  discouraging,  but  I  would  strongly 
advise  the  medical  man  not  to  base  his  prognosis  merely  on 
electrical  reactions.  The  origin  of  nerve-supply  of  a  muscle  ex- 
tends probably  through  two  or  three  segments  of  the  spinal  cord, 
and  it  is  always  possible  that,  though  the  main  sources  may  be 
irreparably  damaged,  some  may  be  so  little  affected  that  some 
small  portion  of  the  muscle  may  retain  its  function  and,  by 
compensatory  overgrowth,  restore  to  some  extent  the  lost  power. 
Moreover,  where  some  muscles  have  escaped  the  child  gradually 


INFANTILE  PARALYSIS 


697 


learns  to  adapt  its  remaining  powers  to  the  altered  mechanical 
conditions.  The  power  of  walking  may  thus  improve  steadily  for 
years,  not  because  there  is  any  real  recovery  in  affected  muscles, 
but  because  the  child  learns  to  use  to  the  best  advantage  those 
which  remain,  and  the  extra  work  thrown  upon  these  muscles, 
or  surviving  portions  of  muscles,  increases  them  in  size  and  power. 
(2)  Not  to  take  too  bright  a  view  because  the  paralysis  is  very 
slight  and  limited  in  extent.  It  is  a  striking  feature  in  some 
cases  of  infantile  paralysis  that  the  arrest  of  growth  in  the  bones 
of  the  limb  may  be  altogether  out  of  proportion  to  the  paralysis. 
A  boy  who,  at  the  age  of  3|  years,  had  infantile  paralysis  in 
the  left  leg,  had  so  little  weakness  at  the  age  of  ten  years  that 
all  movements  seemed  to  be  good,  but,  nevertheless,  he  limped 
badly  in  walking,  for  the  affected  leg  was  2  inches  shorter  than 
the  other. 

Treatment.  It  is  clear  that  in  some  cases,  at  least,  if  not  in  all, 
infantile  paralysis  is  an  infective  disease,  and  there  is  some 
evidence  that,  at  any  rate  in  its  epidemic  form,  it  may  not  only 
spread  by  direct  contagion  from  person  to  person,  but  may  also 
be  conveyed  indirectly  by  a  healthy  person  who  has  recently 
been  in  contact  with  a  child  who  has  just  developed  the  disease. 

Experience,  however,  shows  that  in  the  sporadic  cases  such 
infection  must  be  extremely  rare,  if  it  occurs  at  all,  and,  there- 
fore, it  hardly  seems  necessary  to  enforce  any  rigorous  isolation. 
Inasmuch,  however,  as  the  possibility  of  contagion  exists,  it 
would  seem  at  least  wise  to  exclude  children  from  the  sick  room 
of  the  child  who  has  recently  become  affected  with  anterior 
poliomyelitis,  so  long  as  there  is  any  fever,  or,  if  practicable,  for 
at  least  a  fortnight  from  the  onset  of  the  disease. 

In  view  of  the  ascertained  infectiousness  of  the  nasal  secretion 
in  monkeys  after  inoculation  with  this  disease,  it  would  also  be 
a  wise  precaution  to  spray  the  nostrils  with  some  antiseptic  such 
as  eucalyptus  during  the  first  two  or  three  weeks  after  the  onset. 

Admittedly  such  precautions  rest  at  present  upon  no  very  solid 
basis  of  clinical  evidence,  but  they  have  the  merit  of  simplicity 
and  seem  worth  the  little  trouble  they  may  give  if  perchance 
thereby  the  spread  of  so  serious  an  infection  may  be  prevented. 

When  acute  anterior  poliomyelitis  has  been  recognized  within 
a  few  days  of  its  onset,  urotropin  is  the  drug  which  seems  likely 
to  have  most  value.  It  has  been  found  by  Flexner  and  Clark 
that  in  monkeys  the  administration  of  urotropin  in  large  doses 
by  mouth  is  speedily  followed  by  its  appearance  in  the  cerebro- 
spinal  fluid,  where  it  exercises  an  appreciable  effect  in  lengthening 
the  incubation  period  of  the  inoculated  disease,  and  can  even 


698*          COMMON  DISORDERS  OF  CHILDHOOD 

entirely  prevent  paral^is.  To  obtain  these  effects,  however,  the 
urotropiii  was  given  before  the  animal  was  infected  ;  it  remains 
to  be  seen  whether  this  drug  can  diminish  or  prevent  the  occur- 
rence of  paralysis  when  administered  to  children  who  have  already 
become  infected  with  the  disease. 

I  know  of  no  observations  upon  the  amount  of  urotropin  which 
it  is  safe  to  administer  to  a  child.  I  have  given  as  much  as 
10  grains  every  2  hours  until  24  doses  had  been  given  to  a  child 
21  months  old,  but  in  a  case  where  a  dose  of  7  grains  was  given 
every  4  hours  to  a  boy  of  about  7  years  for  several  days,  Dr.  P. 
Vosper  tells  me  that  haematuria  occurred  which  ceased  soon 
after  the  drug  was  stopped.  I  have  seen  other  cases  in  which 
ha3maturia  resulted  from  large  doses  of  this  drug.  Certainly  in 
so  serious  a  disease  as  infantile  paralysis  it  is  advisable  to  give 
this  drug  as  freely  as  is  consistent  with  safety  during  the  first  few 
days  after  the  earliest  appearance  of  paralysis,  or  indeed  before 
this,  if  there  is  any  ground  for  suspecting  that  the  illness  may  be 
the  preliminary  stage  of  acute  poliomyelitis  (for  instance,  in  the 
case  of  a  child  who  is  suffering  with  acute  fever  of  obscure  origin 
in  a  neighbourhood  where  cases  of  infantile  paralysis  have 
recently  occurred). 

It  is  very  doubtful  whether  any  other  treatment  has  any 
beneficial  effect  during  the  acute  stage  of  the  disease.  It  is 
conceivable  that  in  the  first  few  days  after  its  onset  good  may  be 
done  by  measures  directed  to  reducing  the  hypera3mia  of  the 
spinal  cord,  particularly  by  application  of  ice-bags  over  the 
affected  portion  or  by  vigorous  counter-irritation,  e.g.  with 
mustard  plasters.  I  have  used  and  seen  used  various  measures 
of  this  kind,  but  as  some  of  the  initial  paralysis  almost  always 
recovers  whether  any  local  treatment  has  been  used  or  not, 
it  is  difficult  to  determine  whether  the  amount  of  residual 
and  permanent  paralysis  is  influenced  by  such  applications. 
I  have  also  used  ergot  internally.  A  child  of  eighteen  months 
will  take  10  minims  of  the  liquid  extract,  and  a  child  of  five 
will  take  30  minims  three  or  four  times  a  day  ;  aconite  and 
eserine  have  also  been  used  ;  but  here  also  the  treatment  rests 
on  theory,  not  on  demonstrable  results.  Examination  has 
shown  that  in  the  affected  portion  of  the  cord  some  inflammatory 
exudation  persists  for  several  weeks.  It  seems  reasonable,  there- 
fore, to  give  iodides  for  a  considerable  period,  perhaps  two  or 
three  months,  in  the  hope  of  promoting  absorption  and  so  relieving 
the  pressure  which  no  doubt  hinders  repair. 

Apart  from  these  measures  of  theoretical  utility  can  we  influence 


INFANTILE  PARALYSIS  699 

the  condition  in  the  spinal  cord  ?  One  would  fancy,  to  hear  the 
extravagant  claims  which  have  been  made  sometimes  for  electrical 
treatment  or  massage  of  the  paralysed  limbs,  that  such  treatment 
had  some  influence  upon  the  seat  of  the  disease  ;  but  surely  one 
might  as  well  water  the  branches  of  a  dead  tree  in  the  hope  of 
reviving  its  root  as  stimulate  the  muscles  with  the  idea  of  restoring 
the  destroyed  cells  in  the  spinal  cord.  What  we  can  do — and  the 
only  thing  we  can  do  by  such  treatment — is  to  promote  the 
nutrition  of  those  muscles  or  parts  of  muscles  whose  nerve- 
supply  has  escaped  destruction,  and  so  to  raise  their  working 
capacity  to  its  utmost.  There  is  no  doubt  that  just  as  the  athlete 
by  continual  use  of  one  muscle  or  set  of  muscles  increases  it  both 
in  size  and  power,  so  by  frequently  repeated  stimulation,  whether 
by  electricity  or  by  specially  adapted  exercises,  and  by  flushing 
the  muscle  with  blood,  as  is  done  by  massage,  we  can  increase 
both  in  size  and  power  those  muscles  or  parts  of  muscles  whose 
representation  in  the  cord  has  not  been  destroyed.  With  this 
purpose  electricity,  massage,  and  carefully  planned  exercises  are 
all  of  value  after  the  first  two  months  of  the  disease,  but  I  doubt 
whether  electricity  has  so  great  a  superiority  over  massage  as  to 
commend  its  use  for  those  children  who  never  seem  to  lose  their 
dread  of  it,  and  to  whom  its  daily  application  means  daily  misery. 
But  no  treatment  is  of  much  avail  which  is  riot  capable  of  home 
application,  for  it  requires  to  be  used,  not  once  or  twice  a  week, 
but  twice  or  thrice  daily,  and  this  is  seldom  practicable  unless 
the  parents  or  nurse  can  carry  it  out  themselves.  While  I  am 
convinced  that  in  expert  hands  the  application  of  galvanism  is 
of  considerable  value,  I  am  not  at  all  sure  that  its  random 
application  by  mother  or  nurse  does  much  good,  and  as  they 
can  be  taught  to  carry  out  efficient  massage  with  excellent 
results,  I  am  inclined  to  recommend  massage  as  the  more 
generally  useful  treatment.  Not  less  valuable  than  either 
electricity  or  massage  are  carefully  adapted  exercises  for  cases 
in  which  a  limb  is  only  partially  disabled  ;  but  they  must  be 
planned  with  care  and  discretion,  for  it  is  obviously  possible  to 
do  harm  rather  than  good  by  encouraging  the  unbalanced  action 
of  muscles  which  are  already  tending  to  cause  deformity  by 
their  unopposed  power  of  contraction.  Where  any  voluntary 
contraction  of  a  weakened  muscle  is  possible,  or  where  by  extra 
development  of  unparalysed  muscles  some  compensatory  advan- 
tage may  be  gained,  the  surest  method  of  increasing  power  in 
these  muscles  is  by  exercising  them  frequently. 

I  have  said  nothing  of  the  surgical  measures  which  are  occa- 


I 

700  COMMON  DISORDERS  OF  CHILDHOOD 

sionally  advisable  in  infantile  paralysis, — tenotomy,  fixation  of 
joints  by  '  arthrodesis  ',  and  the  recent  methods  of  tendon-graft- 
ing ;  each  has  proved  its  value  in  particular  cases,  but  their 
consideration  does  not  fall  within  my  province.  On  one  matter, 
however,  which  is  perhaps  more  surgical  than  medical,  I  venture 
to  speak.  Is  it  wise  to  encase  a  child's  leg  in  a  rigid  apparatus 
which  effectually  prevents  any  exercise  of  the  very  muscles  which 
being  weak  require  to  be  used  ?  I  am  well  aware  that  there  is 
a  Chary bdis  as  well  as  a  Scylla  to  be  avoided,  and  that  some 
deformities — e.g.  talipes  valgus  or  genu  valgum — may  be  aggra- 
vated in  some  cases  by  walking  without  artificial  support  ;  but 
none  the  less  I  think  that  sometimes  a  very  simple  support, 
perhaps  even  a  flat-foot  pad  or  some  stiffening  in  the  side  of  the 
boot,  assisting  but  little  the  action  of  the  weakened  muscles, 
might  give  the  limb  a  better  chance  of  improvement  than  does 
the  elaborate  and  cumbersome  instrument  which  has  been  worn. 
Certainly  if  such  apparatus  must  be  used,  it  should  be  left  off 
for  some  hours  daily  when  the  child  is  not  walking,  and  in  these 
intervals  the  muscles  should  be  improved  by  massage  and 
exercise.  Lastly,  I  would  point  out  that  while  in  all  cases  there 
conies  a  time  when  no  further  improvement  is  possible,  this  may 
not  be  until  two  or  three  years  or  even  more  have  elapsed  since 
the  onset  ;.  recovery  from  paralysis  there  is  probably  little  or 
none  after  the  first  few  months  of  the  disease  ;  but  improvement, 
in  the  sense  of  increased  ability  to  perform  certain  actions,  there 
certainly  is  for  much  longer,  and  this,  as  I  have  said,  depends 
upon  extra  development  of  the  muscles  or  parts  of  muscles  which 
have  escaped. 


CHAPTER  XLVIII 
THE   CEREBRAL  PALSIES  OP  CHILDHOOD 

THE  relative  frequency  of  the  various  forms  of  cerebral  palsy 
in  childhood  is  probably  fairly  shown  by  the  following  statistics 
of  100  consecutive  cases  under  my  own  observation  :  51  were 
infant  hemiplegia,  26  were  spastic  paraplegia,  22  were  spastic 
diplegia,  1  was  spastic  monoplegia. 

As  to  sex  my  owrn  figures  show  in  all  forms  a  predominance  of 
boys  :  of  the  100  cases,  61  were  boys,  39  were  girls  ;  the  incidence 
in  the  different  forms  was  as  follows  : 

Boys.  Girls. 

Infantile  hemiplegia        .          .          .     32     .  .          .19 

Spastic  paraplegia  .          .  14     .  .          .12 

Spastic  diplegia      .          .          .  14     .  .          .8 

Spastic  monoplegia          .          .  1  .0 

Infantile  hemiplegia  differs  from  the  paraplegic  and  diplegic 
forms  of  cerebral  palsy  in  being  usually  of  post-natal  origin  ;  but 
there  are  many  cases  in  which  no  dc,te  of  onset  can  be  assigned, 
the  weakness  and  spasticity  were  only  noticed  when  the  infant 
became  old  enough  for  its  defective  movements  to  attract  atten- 
tion ;  in  some  of  this  latter  group  of  cases  there  seems  to  be  no 
more  reason  for  assuming  the  condition  to  be  of  post-natal  origin 
than  there  is  for  assuming  under  similar  circumstances  that 
a  case  of  spastic  diplegia  or  paraplegia  is  of  congenital  origin. 
This  point  was  investigated  in  49  of  my  cases  of  infantile  hemi- 
plegia, in  33  of  these  a  more  or  less  definite  time  of  onset  was 
assigned,  in  16  the  date  of  onset  was  entirely  unknown,  the  weak- 
ness was  discovered,  so  to  speak,  accidentally  when  the  infant 
was  some  months  old. 

The  age  at  onset  in  the  thirty-three  cases  is  shown  in  the 
following  table  : 

INFANTILE  HEMIPLEGIA. 
Age  at  onset.  Number  of  Oases. 

Congenital 2 

Under  6  months 4 

6  months  to  1  year 4 

1-1^  years 6 

l£-2  years 6 

2-3  years 6 

3-4  years 4 

6  years      .  1 


702  COMMON  DISORDERS  OF  CHILDHOOD 

Of  the  sixteen  case§  with  no  definite  date  of  onset,  one  was 
known  to  have  been  paralysed  before  it  was  three  months  old, 
the  remaining  fifteen  were  first  discovered  to  be  abnormal  about 
the  end  of  the  first  year  or  a  little  later,  when  the  child's  back- 
wardness, especially  in  walking,  drew  attention  to  the  hemi- 
plegia.  In  eight  of  these  cases  convulsions  had  occurred  at  some 
period  of  infancy,  and  may  have  marked  the  onset  of  the  palsy, 
although  it  was  not  noticed  at  the  time,  but  in  the  remaining 
eight  cases  there  had  never  been  a  convulsion,  and  except  in  one 
case,  in  which  some  acute  febrile  illness  had  occurred  sit  the  age 
of  five  months,  there  seemed  to  be  no  ground  whatever  for  assum- 
ing that  the  paralysis  was  of  post-natal  origin.  Out  of  forty-nine 
cases,  therefore,  two  were  certainly  congenital,  and  at  least  seven 
others  were  possibly,  if  not  probably,  congenital. 

I  lay  stress  on  this  point,  for  some  writers  have  drawn  a  sharp 
distinction  between  infantile  hemiplegia,  on  the  one  hand,  as 
an  acquired  palsy,  and  spastic  diplegia  and  paraplegia,  on  the 
other  hand,  as  congenital  or  birth  palsies.  It  is  at  least  possible 
that  a  much  larger  proportion  than  is  usually  supposed  of  the 
cases  of  infantile  hemiplegia  may  be  congenital. 

Relation  to  convulsions.  The  number  of  cases  lacking 
evidence  of  post-natal  onset  would  be  even  larger  if  the 
convulsions  in  the  cases  where  the  paralytic  condition  is  of 
doubtful  date  were  to  be  considered  as  the  result  of  antecedent 
damage  or  disease  in  the  brain,  rather  than  as  marking,  if  not 
causing  the  onset  of  the  paralysis.  Whilst,  however,  it  seems 
unjustifiable  to  assume  that  the  paralysis  dates  from  the  con- 
vulsions in  an  infant  who  is  discovered  several  months  after 
their  occurrence  to  be  hemiplegic,  I  think  that  the  congenital 
origin  of  the  palsy  in  such  cases  is  certainly  made  more  doubtful 
by  the  history  of  convulsions  ;  for  it  is  an  undoubted  fact  that 
of  the  cases  which  become  paralysed  at  some  definite  date 
a  large  proportion  (22  of  32  cases  in  my  series)  begin  with 
convulsions. 

The  exact  relation  of  these  initial  convulsions  to  the  hemi- 
plegia is  uncertain  ;  it  is  generally  held  that  both  the  convulsions 
and  the  paralysis  are  the  result  of  some  vascular  cerebral  lesion, 
inflammatory  or  otherwise,  but  I  am  by  no  means  inclined  to 
accept  this  view  for  all  cases.  Often  there  is  a  history  that  months 
before  the  onset  of  the  palsy  the  child  had  suffered  once  or 
several  times  with  convulsions,  which  differed  in  no  way  from 
ordinary  infantile  convulsions,  and,  like  the  majority  of  these, 
left  no  trace  whatever  of  their  occurrence  ;  then  the  child  had 


CEREBRAL  PALSIES  703 

an  unusually  severe  attack  of  convulsions  and  was  left  paralysed 
on  one  side  ;   for  example : 

Henry  E.  had  had  occasional  infantile  convulsions  since  the  age  of  two 
months  ;  at  the  age  of  fourteen  months  he  had  a  severe  bout  of  convulsions, 
lasting  twenty-four  hours,  which  left  him  with  permanent  hemiplegia. 

With  such  a  case  may  be  compared  the  occasional  occurrence 
of  temporary  hemiplegia  after  an  infantile  convulsion;  sometimes 
the  hemiplegia  lasts  a  few  hours,  sometimes  a  few  days;  for 
instance : 

Florence  P.,  aged  two  years,  had  had  three  convulsions  two  months  pre- 
viously which  appeared  to  be  ordinary  infantile  convulsions  and  left  no  ill 
effects,  but  now,  after  another  convulsion,  the  left  arm  and  leg  were  found 
to  be  paralysed  ;  the  paralysis  remained  very  marked  for  three  hours  after 
the  convulsion  and  then  passed  off  so  completely  that  four  days  later  no  effect 
whatever  of  the  convulsion  was  to  be  found. 

Had  the  paralysis  remained  permanent  in  this  case  we  should 
have  called  it  infantile  hemiplegia. 

If  it  be  asked  how  an  infantile  convulsion  could  cause  hemi- 
plegia, one  might  answer  that  in  severe  convulsions  there  is 
venous  congestion,  which  may  well  originate  some  vascular 
lesion  in  the  brain,  just  as  a  severe  paroxysm  of  whooping-cough 
undoubtedly  sometimes  does,  and  it  may  well  be  that  with 
rupture  or  thrombosis  affecting  only  very  minute  vessels  a  tran- 
sient paralysis  occurs,  whereas  with  more  extensive  haemorrhage 
or  thrombosis  a  permanent  paralysis  results. 

It  is  allowed  that  a  severe  attack  of  convulsions  may  leave 
a  child  idiotic  ;  and  if  the  occurrence  of  such  an  '  eclamptic 
idiocy  '  be  admitted — and  my  own  observations  lead  me  to  think 
that  although  quite  exceptional,  imbecility  as  a  result  of  infantile 
convulsions  does  occur — then  it  seems  only  reasonable  to  suppose 
that  the  storm  which  wrecks  the  mental  function  in  one  case 
may  wreck  the  motor  function  in  another. 

Asphyxia.  That  intense  venous  congestion  may  damage  the 
brain  permanently  is  shown,  I  think,  by  the  occurrence  of  idiocy 
after  severe  asphyxia  at  birth.  I  have  seen  so  many  cases  in 
which  this  sequence  occurred  that  I  have  no  doubt  in  my  own 
mind  of  the  causal  relation  of  asphyxia  to  idiocy :  if  this  be  so, 
one  would  expect  that  motor  disturbance  might  result  from  the 
same  cause.  I  have  noted  this  point  specially  in  nineteen  cases  of 
infantile  hemiplegia  ;  four  of  these  gave  a  history  of  instrumental 
birth,  but  only  one  was  said  to  have  had  severe  asphyxia  at  birth  ; 
this  child  had  convulsions  for  twenty-four  hours  after  birth,  but 
had  no  more  up  to  the  time  when  I  first  saw  him  at  the  age  of 


704*          COMMON  DISORDERS  OF  CHILDHOOD 

three  years.  It  was  noticed  only  when  he  began  to  crawl  that 
there  was  weakness  of  the  left  side  ;  no  date  of  onset  was  assigned 
for  the  hemiplegia,  which  seems  most  naturally  referred  to 
asphyxia  or  to  the  convulsions  immediately  following  the 
asphyxia.  The  possibility  of  traumatism  from  the  use  of  forceps 
cannot  be  excluded  in  such  a  case,  but  damage  to  the  brain  from 
forceps  is  probably  much  less  frequent  than  damage  from  asphyxia. 

It  might  be  expected  that  with  so  general  a  condition  as 
asphyxia  any  damage  to  the  brain  would  be  more  likely  to  be 
diffuse  than  locaHzed  ;  and  that,  therefore,  such  a  cause  would 
figure  more  largely  in  cases  of  generalized  motor  and  mental 
impairment  such  as  occurs  in  spastic  diplegia,  than  in  the  cases 
of  infantile  hemiplegia.  My  own  figures  are  too  small  to  carry 
much  weight,  but  so  far  as  they  go  they  show  that  this  is  so. 
In  17  cases  of  spastic  diplegia  and  13  cases  of  spastic  paraplegia 
in  which  I  have  noted  this  point,  11  were  known  to  have  suffered 
with  more  or  less  asphyxia  ;  and  in  6  of  these  the  asphyxia  was 
known  to  have  been  severe  :  the  asphyxia  occurred  in  7  cases 
of  spastic  diplegia,  in  4  cases  of  spastic  paraplegia.  On  similar 
grounds  it  might  be  expected  that  convulsions  would  also  be 
followed  by  generalized  affection  rather  than  hemiplegia  ;  some- 
times this  is  so,  but  a  localized  lesion  seems  to  be  commoner  as 
a  result  of  convulsions. 

Premature  birth.  The  frequency  of  premature  birth  was 
particularly  noticeable  in  my  series  of  cases  of  spastic  para- 
plegia, of  whom  at  least  11  out  of  25  were  premature.  A 
large  proportion  also  were  firstborn  children — 9  out  of  21 
cases  of  spastic  paraplegia,  and  5  out  of  22  cases  of  spastic 
diplegia  ;  both  these  affections  would  seem  to  occur  much 
more  often  in  the  earlier  children  than  in  those  born  later 
in  a  large  family,  therein  contrasting  with  such  a  condition 
as  Mongolian  imbecility,  in  which  the  later  or  last  children 
of  large  families  are  specially  apt  to  suffer.  The  incidence  on 
firstborn  children  seems  to  support  the  view  that  birth  injuries, 
whether  from  traumatism  or  asphyxia,  are  a  factor  in  cerebral 
palsies  ;  it  is,  however,  noteworthy  that  several  of  the  firstborn 
children  were  also  premature,  and  no  doubt  on  this  account  less 
likely  to  have  met  with  injury  from  difficult  labour  ;  but  prema- 
ture labour  does  not  necessarily  mean  easy  birth,  two  at  least 
of  the  premature  infants  were  delivered  instrumentally,  and  two 
others  were  known  to  have  suffered  with  asphyxia  at  birth. 

Relation  to  syphilis.  Amongst  the  various  causes  to  which 
the  cerebral  palsies  of  childhood  have  been  attributed,  con- 


CEREBRAL  PALSIES  705 

siderable  stress  has  been  laid  upon  syphilis.  The  practical 
difficulties  in  determining  whether  the  parents  have  had  syphilis 
are  so  great  that  I  am  unable  to  offer  any  reliable  statistics 
on  this  point,  but  so  far  as  inherited  syphilis  in  the  child 
is  concerned  my  own  figures  show  that  this  plays  but  a 
small  part.  Of  51  cases  of  infantile  hemiplegia  none  showed 
evidence  of  syphilis,  but  in  2  the  relation  of  miscarriages 
to  the  birth  of  the  infant  raised  a  suspicion  of  syphilis  in  the 
mother.  Of  26  cases  of  spastic  paraplegia  only  1  showed  un- 
doubted congenital  syphilis,  but  another  showed  Parrot's  nodes 
on  the  skull,  which  some  would  consider  evidence  of  syphilis, 
and  in  2  others  a  history  of  miscarriages  suggested  maternal 
syphilis.  Of  22  cases  of  spastic  diplegia  1  showed  evidence  of 
congenital  syphilis.  Ophthalmoscopic  examination  was  made  in 
many  of  these  cases  but  not  in  all ;  in  2  of  the  cases  mentioned 
patches  of  choroiditis  were  the  only  evidence  of  syphilis  ;  and  as 
fundus  changes  may  be  the  only  evidence  it  is  possible  that  the 
proportion  of  cases  showing  syphilis  may  be  slightly  greater  than 
appears  from  these  figures,  but  certainly  it  is  not  high.  Wasser- 
mann  tests  by  various  observers  have  confirmed  these  conclusions, 
but  one  series  1  showed  a  positive  reaction  in  13  out  of  33  cases 
of  spastic  diplegia. 

Folio-encephalitis.  The  mode  of  onset  in  some  cases  of 
cerebral  palsy  beginning  after  birth,  with  a  short  period  of 
malaise  and  pyrexia  preceding  the  appearance  of  convulsions  and 
paralysis,  has  suggested  the  possibility  of  some  infective  cause, 
and  the  nature  of  the  lesion — in  many  cases  apparently  an 
encephalitis  either  of  recent  or  remote  date — has  suggested  that 
the  disease  is  identical  in  its  pathology  with  infantile  paralysis 
(acute  anterior  poliomyelitis).  A  further  point  which  might  be 
urged  in  favour  of  this  identity  is  the  age-incidence, which  is  very 
similar  in  these  two  conditions. 

About  90  per  cent,  of  cases  of  acute  anterior  poliomyelitis 
begin  under  three  years  of  age,  and  50  per  cent,  during  the  second 
year  of  life,  while  of  cases  of  infantile  hemiplegia  beginning  after 
birth,  about  80  per  cent,  begin  within  the  first  three  years  of  life, 
and  about  40  per  cent,  in  the  second  year.  Moreover,  in  both 
conditions  the  paralysis  is  apt  to  occur  during  or  shortly  after 
one  or  other  of  the  specific  fevers.  With  regard  to  infantile 
hemiplegia  it  has  been  stated  that  this  association  is  noticeable 
in  about  one-third  of  the  cases  ( J.  Taylor) ;  but  my  own  series  of 
fifty-one  cases  showed  it  only  in  five— a  proportion  which  corre- 
sponds remarkably  closely  with  that  observed  in  acute  anterior 
1  Glasgow  Med.  Journ.,  Dec.  1914. 

STILL  Z  Z 


706  COMMON  DISORDERS  OF  CHILDHOOD 

poliomyelitis,  in  whioli,  according  to  my  own  figures,  about 
10  per  cent,  of  cases  occur  during  or  shortly  after  one  of  the 
specific  fevers.  The  five  cases  were  : 

1.  Fourteen   days   after   measles   convulsions   occurred,   with 
loss  of  consciousness  for  three  days  ;   the  child  was  found  to  be 
paralysed  on  the  left  side. 

2.  During  diphtheritic   paralysis  the  child  became  paralysed 
suddenly  on  the  right  side  without  convulsions. 

3.  Convulsions  occurred  seven  weeks  after  measles  ;  left  hemi- 
plegia  remained  after  the  convulsions. 

4.  During  a  paroxysm  of  whooping-cough  a  convulsion  occurred 
and  the  child  remained  paralysed  on  the  right  side. 

5.  During  convalescence  from  scarlet  fever,  a  boy,  aged  3ff , 
who  had  suffered  with  convulsions  occasionally  since  two  years 
old,  had  a  convulsion  which  left  permanent  hemiplegia. 

It  is  well  known  that  one  specific  fever  is  often  followed  after  a 
short  interval  by  another ;  it  seems,  in  fact,  as  if  one  infection  pre- 
disposed to  another,  so  that  sometimes  a  child  will  pass  through 
two,  tli roe,  or  even  four  specific  fevers  within  a  few  months  ; 
there  may  even  be  a  special  affinity  between  particular  infections,  as 
is  seen  in  the  frequency  with  which  whooping-cough  follows  after 
measles,  or  acute  rheumatism  after  scarlet  fever.  The  tendency 
of  infantile  hemiplegia  and  also  of  acute  anterior  poliomyelitis  to 
occur  during  or  just  after  specific  fevers  gives  therefore  some 
support  to  the  view  that  both  are  due  to  some  specific  infection  ; 
and  as  already  pointed  out,  there  are  reasons  for  suspecting  that 
both  may  be  due  to  the  same  specific  infection. 

Plausible  as  such  a  theory  may  appear,  there  is  much  that 
might  be  urged  against  it.  The  facts  with  regard  to  the  associa- 
tion of  infantile  hemiplegia  with  specific  fevers  are  susceptible 
of  other  interpretations.  Cardiac  dilatation,  enfeeblement  of 
cardiac  action,  degenerative  changes  in  vessel  walls,  are  all 
recognized  results  of  specific  fevers,  and  might  well  favour  the 
occurrence  of  embolism  or  thrombosis.  In  the  case  mentioned, 
where  hemiplegia  occurred  during  diphtheritic  paralysis,  I  found 
subsequently  localized  softening  in  the  internal  capsule,  a  con- 
dition almost  certainly  the  result  of  embolism  or  thrombosis  ; 
and  again  in  cases  where  hemiplegia  occurs  during  whooping- 
cough  the  lesion  is  explained  most  naturally  as  the  result  of 
venous  congestion,  perhaps  with  hemorrhage,  as  has  been  found 
in  some  cases  at  autopsy. 

Further,  for  two  of  the  points  which  form  perhaps  the  strongest 
arguments  in  favour  of  the  specific  nature  of  acute  anterior 
poliomyelitis,  there  is  no  parallel  in  infantile  hemiplegia  :  these 


CEREBRAL  PALSIES 


707 


two  points  are  seasonal  incidence  and  epidemic  occurrence. 
About  60  per  cent,  of  the  cases  of  acute  anterior  poliomyelitis 
in  this  country  begin  during  the  months  July,  August,  and 
September  (see  chart,  p.  687) ;  infantile  hemiplegia,  when  its  onset 
can  be  dated,  appears  to  begin  with  almost  equal  frequency  at 
any  time  of  the  year,  as  is  shown  by  the  following  table  of  20  con- 
secutive cases  in  which  the  month  of  onset  could  be  ascertained: 


Jan. 

Feb. 
4 

Mar. 

Apr. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

2 

Nov.    Dec. 

zti 

0 

Q 

2 

2 

1 

4 

0 

1 

Acute  anterior  poliomyelitis  has  several  times  occurred  in 
epidemics  ;  if  infantile  hemiplegia  be  due  to  the  same  specific 
infection  it  might  be  expected  that  it  would  at  least  occur  with 
special  frequency  when  such  an,  epidemic  was  rife.  I  have  never 
myself  observed  any  special  prevalence  of  infantile  hemiplegia 
when  acute  anterior  poliomyelitis  has  seemed  to  be  specially 
prevalent  in  London.  Dr.  James  Taylor  has  mentioned  an 
instance  in  which  one  of  two  children  in  a  family  developed 
infantile  paralysis  at  the  same  time  that  the  other  developed 
infantile  hemiplegia,  but  such  an  occurrence  is  very  rare. 

It  is  particularly  noteworthy  that  in  the  experimental  produc- 
tion of  acute  anterior  poliomyelitis  in  monkeys  the  intra-cerebral 
inoculation  of  the  virus  does  not  result  in  a  spastic  paralysis  of 
cerebral  type,  but  in  a  flaccid  spinal  paralysis  with  the  lesions 
of  acute  anterior  poliomyelitis. 

It  is  evident,  therefore,  that  even  under  conditions  which 
would  seem  specially  to  favour  the  occurrence  of  a  cerebral 
paralysis  the  virus  of  acute  anterior  poliomyelitis  maintains  its 
affinity  for  the  spinal  cord,  and  does  not  produce  a  spastic 
paralysis  such  as  is  seen  clinically  in  infantile  hemiplegia. 

This  limitation  of  the  effects  of  the  virus  of  acute  anterior  polio- 
myelitis to  the  cord  under  artificial  conditions  which  would  seem 
specially  to  favour  the  occurrence  of  cerebral  paralysis,  hardly 
gives  support  to  the  view  that  infantile  hemiplegia  is  commonly 
caused  by  this  particular  virus. 

Whilst,  therefore,  the  cerebral  lesion  in  some  cases  of  infantile 
hemiplegia  appears  to  be  similar  to  the  cord  lesion  of  acute 
anterior  poliomyelitis,  the  evidence  of  any  specific  infection  in  the 
cerebral  cases  seems  to  be  much  less  conclusive  than  in  the  spinal 
cord  affection,  and  until  bacteriological  investigation  shall  have 
furnished  us  with  more  exact  knowledge  of  the  pathogeny  of 
these  two  conditions,  there  seems  to  be  no  sufficient  ground  for 


708  COMMON  DISORDERS  OF  CHILDHOOD 

regarding  infantile  heimiplegia  as  having  any  nearer  kinship  to 
infantile  paralysis  (acute  anterior  poliomyelitis)  than  an  occasional 
resemblance  in  its  morbid  anatomy. 

Symptoms.  The  characteristic  features  which  are  common 
to  all  the  cerebral  palsies  are  weakness  and  spasticity  of  the 
affected  limbs,  with  retention  and  exaggeration  of  tendon-jerks. 
I  need  not  describe  these  symptoms  in  detail,  the  names  of  the 
several  varieties  of  palsy  sufficiently  indicate  the  distribution  of 
the  spastic  paralysis  ;  but  I  should  like  to  point  out  some  features 
which  are  of  importance  in  diagnosis.  The  weakness  is  usually 
very  much  less  than  the  spasticity,  and  both  are  so  slight  in  some 
cases  that  the  cause  of  the  child's  slight  talipes  equinovarus,  or 
of  his  easily  stumbling  in  walking,  may  be  overlooked  altogether 
until  careful  examination  shows  that  there  is  a  little  clumsiness 
also  in  the  grasp  of  the  hand,  or  that  the  knee-jerk  is  unduly 
brisk,  and  that  the  plantar  reflex  is  of  extensor  type. 

In  all  forms  of  cerebral  palsy  where  the  legs  are  affected  there 
is  a  tendency  specially  to  spastic  adduction  of  the  thighs  and 
pointing  of  the  toes,  with  inturning  of  the  foot,  so  that  the 
position  assumed  is  like  that  of  talipes  equinovarus,  but  the 
spasm  is  intermittent,  coming  on  chiefly  when  the  child  attempts 
to  stand  or  walk,  so  that  the  position  of  the  feet  has  not  the  fixity 
of  a  congenital  talipes  equinovarus,  or  of  that  due  to  contraction 
of  muscles  after  infantile  paralysis. 

There  are  also  cases  in  which  the  loss  of  co-ordination  is  the 
most  marked  feature,  and  the  child  is  brought  with  what  at  first 
sight  may  be  mistaken  for  a  chorea.  This  applies  especially  to 
cases  of  infantile  hemiplegia,  in  which  within  a  few  years  after 
the  onset  there  are  sometimes  involuntary  movements  of  the 
affected  limbs,  but  much  more  often  in  the  upper  limb  than  in 
the  lower.  In  some  there  is  an  involuntary  slow  'squirming' 
movement  of  the  hand  which  is  known  as  athelosis  ;  in  others 
there  is  only  an  occasional  fidgety  movement  very  like  that  of 
chorea,  and  in  others  a  coarse  tremor  or  jactitation  only  upon 
attempting  voluntary  movement. 

The  face  is  curiously  little  affected  by  the  cerebral  palsies  ; 
in  most  cases  of  infantile  hemiplegia  the  difference  between  the 
two  sides  of  the  face  is  barely  noticeable  a  few  years  after  the 
onset,  although  it  has  been  quite  definite  at  first. 

In  these  hemiplegic  cases  also  the  leg  recovers  to  a  much 
greater  extent  than  the  arm,  which  indeed  tends  rather  to 
become  more  incapacitated  through  spastic  clenching  of  the 
hand  and  flexion  of  the  wrist  as  the  child  grows  older  :  there  is 
often  only  slight  limping  on  the  affected  side  when  the  hand  of 


CEREBRAL  PALSIES  709 

that  side  is  almost  completely  useless  through  spasticity  or  athe- 
toid  movements. 

This  tendency  to  recovery  in  the  face  and  legs  in  infantile 
hemiplegia  makes  it  easy  in  some  cases  to  mistake  the  condition 
for  a  monoplegia  affecting  the  arm,  but  as  the  figures  given  above 
show,  a  true  monoplegia  is  so  rare,  that  we  should  always  examine 
the  other  limbs  and  the  face  very  carefully  before  concluding 
that  any  case  was  primarily  a  monoplegia. 

Almost  more  important  than  the  paralytic  symptoms  are  the 
mental  disturbances  which  are  so  often  associated  with  the 
cerebral  palsies  of  childhood  :  the  child  with  spastic  diplegia  is 
almost  always  more  or  less  imbecile  ;  there  is  also  usually  a  con- 
siderable degree  of  mental  weakness  with  spastic  paraplegia. 

With  infantile  hemiplegia  the  intellect  may  escape  damage 
altogether,  but  many  cases  show  a  slight  degree  of  impairment. 
If  the  onset  was  under  eighteen  months,  they  are  backward  in 
acquiring  speech  and  walking,  and  in  any  case  they  are  backward 
at  school,  their  attention  is  easily  distracted,  they  are  '  facile ', 
laugh  too  easily,  and  make  friends  with  strangers  too  readily, 
and  in  general  give  the  impression  of  being  '  weak  '  mentally, 
without  any  such  deficiency  as  could  be  called  '  imbecility  *. 

The  moral  control  also  is  apt  to  suffer  :  some  of  these  cases 
of  infantile  hemiplegia,  which  otherwise  might  pass  for  mentally 
normal,  are  unnaturally  passionate,  spiteful,  and  seem  to  lack 
sense  of  right  and  wrong,  to  a  degree  which  can  only  be  regarded 
as  morbid.  A  large  proportion  of  cases  of  infantile  hemiplegia 
develop  epileptiform  attacks  sooner  or  later,  whether  the  palsy 
began  with  a  convulsion  or  not  ;  in  the  majority  of  cases  I  think 
this  complication  appears  before  puberty. 

Diagnosis.  The  condition  for  which  the  cerebral  palsies  are 
most  likely  to  be  mistaken  in  infancy  and  early  childhood 
is  infantile  paralysis.  The  chief  points  of  distinction  are  the 
flaccidity  of  the  limbs  in  the  spinal  cord  affection  contrasting 
with  the  more  or  less  spasticity  in  the  cerebral  palsies,  the  affection 
of  a  group  of  muscles  rather  than  the  whole  limb  in  infantile 
paralysis,  the  loss  of  tendon- jerks  in  the  former,  their  exaggera- 
tion in  the  latter,  in  which  also  Babinsky's  sign  (extensor  plantar 
reflex)  is  present  if  the  legs  are  affected. 

But  there  are  cases  in  which  mistake  is  easy,  for  the  spasticity 
is  sometimes  very  slight  with  cerebral  palsy  ;  and  the  action  of 
unopposed  muscles  or  the  contraction  of  paralysed  muscles  in 
infantile  paralysis  may  simulate  the  deformities  of  spastic  para- 
lysis, but,  as  I  have  mentioned,  the  contraction  in  the  latter 


710  COMMON  DISORDERS  OF  CHILDHOOD 

comes  on  chiefly  when  the  muscles  are  in  use  ;  it  may  be  absent 
at  other  times,  whereas  that  of  infantile  palsy  is  permanent. 

The  distribution  sometimes  helps  in  diagnosis ;  facial  weakness 
associated  with  paralysis  of  the  arm  or  leg  of  that  side  points  to  the 
cerebral  affection ;  but  the  face  has  often  recovered  completely 
so  that  it  gives  no  assistance,  and  the  affection  of  both  the  arm 
and  leg  of  one  side  is  not  very  rare  with  the  spinal  cord  paralysis- 

In  any  case  of  hemiplegia,  whether  of  sudden  or  of  gradual 
onset,  in  a  child,  the  possibility  of  some  progressive  form  of 
cerebral  disease  is  to  be  remembered,  such  as  tumour,  cerebral 
abscess,  and  even  meningitis,  for  occasionally  tuberculous  menin- 
gitis begins  with  a  sudden  onset  of  hemiplegia. 

On  the  other  hand,  as  I  have  mentioned,  a  hemiplegia  following 
convulsions  may  be  transitory,  and,  after  a  few  hours  or  days, 
disappear  completely. 

Prognosis.  There  is  no  likelihood  of  complete  recovery ;  there 
are  very  slight  cases  of  cerebral  palsy  in  which  the  affection  of 
the  limbs  is  so  slight  that  after  a  few  years  the  condition  is  only 
just  noticeable,  but  in  the  majority  of  cases  spasticity,  especially 
in  the  arms,  tends  rather  to  increase  than  to  diminish. 

Where  there  is  paraplegia  or  diplegia,  if  the  mental  condition 
is  not  very  bad,  there  is  a  good  prospect  that  the  child  will 
learn  to  walk,  probably  at  a  very  late  age  ;  even  where  at  two 
or  three  years  of  age  the  adduction  of  the  legs  is  so  much  that 
the  feet  cross  one  another  directly  the  child  attempts  to  stand, 
walking  is  usually  acquired  eventually. 

In  the  hemiplegic  cases  the  chief  trouble  is  the  tendency  to 
spacticity  in  the  forearm  and  hand  ;  the  elbow  is  flexed  and 
drawn  in  to  the  side  of  the  chest,  the  wrist  is  strongly  flexed  and 
the  finger  clenched  over  the  thumb,  which  is  drawn  into  the  palm 
of  the  hand. 

If  the  child  is  seen  in  infancy  or  shortly  afterwards,  the  likeli- 
hood of  some  mental  affection  is  to  be  remembered,  but  in  the 
hemiplegic  cases  one  may  fairly  comfort  the  parents  with  the 
assurance  that  if  there  is  any  mental  alteration  it  will  probably  be 
slight.  The  probability  of  epileptiform  attacks  occurring  sooner 
or  later  must  also  make  prognosis  guarded. 

Treatment.  The  most  important  item  in  treatment  is  the 
prevention  of  spastic  contraction.  Even  when  contraction  has 
become  so  marked  that  the  hand  is  almost  useless,  I  have  seen 
great  improvement  from  long-continued  perseverance  in  passive 
movements,  but  I  think  there  is  no  doubt  that  some  of  the 
most  troublesome  deformities  produced  by  the  spasticity  of 


CEREBRAL  PALSIES  711 

cerebral  palsy  might  be  prevented,  or  at  any  rate  minimized,  by 
the  use  of  passive  movements  in  the  early  stage  of  the  affection. 

There  is  no  need  for  massage  in  these  cases ;  indeed,  it  hardly 
seems  logical  to  apply  massage  to  muscles  which  are  already 
doing  more  than  is  desired,  and  it  is  not  likely  that  any  massage 
applied  to  those  muscles  which  are  being  overcome  by  the 
stronger  ones  in  these  cerebral  palsies  can  so  stimulate  them  as 
to  counterbalance  the  tendency  to  spastic  contraction.  On  the 
other  hand,  passive  movements  regularly  and  frequently  applied 
so  as  to  overcome  by  force  the  spastic  deformity,  are,  as  ex- 
perience shows,  of  decided  value  ;  they  are  most  applicable  to 
the  forearm  and  hand,  where  slow  pressure  directed  to  abducting 
the  thumb,  and  extending  the  fingers,  wrist,  and  elbow,  will  over- 
come the  usual  deformities 

These  passive  movements,  each  done  slowly  several  times  in 
succession,  should  be  repeated  three  or  four  times  daily,  and  if 
there  is  already  considerable  contracture,  which  from  neglect  has 
become  continuous,  it  may  be  necessary  for  a  few  weeks  to  wear 
a  splint  so  arranged  as  to  prevent  the  deformities  in  the  intervals 
between  the  passive  movements. 

With  such  measures  I  have  seen  decided  improvement,  but  it 
is  only  by  patient  perseverance  that  the  deformity  can  be  pre- 
vented from  recurring  ;  and  this  entails  considerable  patience  on 
the  part  of  the  parents  until  the  child  is  old  enough  to  realize  the 
importance  of  the  movements,  and  to  do  them  for  himself  with 
the  sound  hand,  as  some  children  can  with  infantile  hemiplegia. 

At  the  same  time,  it  is  important  to  make  the  child  use  the 
affected  arm  and  hand  as  much  as  possible,  and  toys  and  games 
should  be  selected  with  this  object  in  view.  The  lower  limbs  are 
to  be  treated  on  similar  lines,  and  by  simple  dancing  and  drilling 
in  the  milder  cases  the  gait  may  be  improved. 

At  a  later  stage  it  is  often  necessary  to  have  some  special  form 
of  apparatus  to  prevent  the  tendency  to  the  equinovarus  position, 
and  considerable  improvement  is  to  be  obtained  in  some  cases 
by  operative  measures. 

Drugs  have  little  place  in  the  treatment  of  the  cerebral  palsies  ; 
when  I  have  seen  them  in  the  early  stage  I  have  generally  given 
potassium  iodide,  but  I  admit  only  with  vague  ideas  of  possible 
absorption  of  inflammatory  exudation  in  any  encephalitis  which 
may  be  present. 

The  epileptiform  attacks  are  usually  more  intractable  than 
epilepsy  apart  from  cerebral  palsy  ;  but  bromides,  phenazone, 
borax,  or  urethane  may  at  least  diminish  their  frequency. 


CHAPTER  XLIX 
HYDROCEPHALUS 

HYDROCEPHALUS,  in  the  ordinary  clinical  sense  of  the  term, 
with  which  alone  I  am  concerned  here,  is  an  enlargement  of  the 
head  produced  by  excess  of  fluid  within  the  ventricles  of  the 
brain. 

It  is  necessary  to  make  this  clear  at  the  outset,  for  the  patholo- 
gist sometimes  talks  of  the  moderate  dilatation  of  the  ventricles  in 
tuberculous  meningitis  as  '  hydrocephalus  ',  but  clinically  such  a 
case  is  not  one  of  hydrocephalus,  and  nothing  but  confusion  results 
from  terming  such  cases,  as  the  older  clinicians  of  half  a  century 
ago  did,  '  acute  hydrocephalus  '  ;  nor,  again,  am  I  acquainted 
with  any  condition  which  justifies  the  term  '  external  hydro- 
cephalus '.  It  is  perfectly  true  that  there  are  cases  in  which,  as 
a  result  either  of  operation  or  of  accident,  there  occurs  a  perforation 
of  the  thinned  cortex  over  the  dilated  ventricles  of  the  ordinary 
'chronic  internal  hydrocephalus',  and  in  this  way  a  secondary 
collection  of  fluid  collects  in  the  subdural  space  ;  but  this  is 
only  a  secondary  result  of  hydrocephalus,  and  much  less  is  the 
term  external  hydrocephalus  applicable  to  those  cases  in  which 
shrinkage  of  the  brain,  such  as  occurs  in  some  idiots  with  cortical 
sclerosis  and  sometimes  in  children  who  are  extremely  wasted, 
results  in  an  outpouring  of  compensatory  fluid  over  the  surface 
of  the  brain. 

Sir  W.  Gowers  refers  to  a  congenital  condition  in  which  excess 
of  fluid  occurs  in  the  subdural  space  and  produces  progressive 
enlargement  of  the  head,  without  abnormal  distension  of  the 
ventricles.  Such  a  condition  must  be  extremely  rare. 

Hydrocephalus,  in  the  sense  which  I  have  indicated,  an  enlarge- 
ment of  the  head  from  fluid  distension  of  the  ventricles,  is  a 
disease  arising  exclusively  in  infancy  and  early  childhood. 

When  the  fontanelles  are  closed  and  the  sutures  firmly  united, 
such  a  condition  cannot  arise  unless,  as  is  said  to  have  happened 
in  extremely  rare  cases,  the  cranial  bones  become  greatly  thinned 
along  the  sutures,  so  that  these  yield.  The  hydrocephalic  enlarge- 
ment of  the  head,  which  is  occasionally  seen  in  an  older  child 
or  in  an  adult,  almost  invariably  dates  from  infancy  ;  such  cases 


HYDROCEPHALUS  713 

are  rare  only  because  the  child  with  hydrocephalus  so  rarely 
survives. 

Out  of  51  consecutive  cases  under  my  own  observation,  only 
one  began  after  the  end  of  the  first  year  (at  fifteen  months),  and 
8  between  the  age  of  six  months  and  one  year.  Thirty-two  out 
of  the  51  showed  the  hydrocephalus  at  birth  or  within  the  first 
three  months  of  life. 

Hydrocephalus  is  usually  classified  as  (1)  congenital,  (2) 
acquired  ;  but  this  distinction  has  very  little  practical  impor- 
tance. It  is  necessary,  however,  to  point  out  that  the  term 
'  congenital ',  as  applied  to  this  affection,  may  be  used  to  refer 
to  the  origin  or  to  the  date  of  its  appearance,  for  although  in 
some  cases  hydrocephalus  is  noticeable  at  the  time  of  birth, 
in  many  where  post-mortem  examination  has  proved  that  the 
cause  was  antenatal  the  enlargement  of  the  head  has  not  been 
noticed  until  the  child  was  4-10  weeks  old.  In  28  at  least  out 
of  the  51  consecutive  cases  mentioned  above,  the  hydrocephalus 
was  apparently  of  congenital  origin,  and  in  15  of  these  28  the 
large  size  of  the  head  had  been  noticed  at  birth. 

It  would  seem,  therefore,  that  fully  half  the  cases  of  hydro- 
cephalus are  of  the  congenital  variety. 

Morbid  Anatomy.  To  understand  properly  the  important 
questions  which  arise  with  regard  to  the  prognosis  and  treat- 
ment of  hydrocephalus,  it  is  essential  that  one  should  be  per- 
fectly clear  as  to  its  anatomy,  particularly  as  to  the  path  of 
the  cerebro-spinal  fluid,  which  is  shown  in  the  accompanying 
diagram  (Fig.  50).  The  cerebro-spinal  fluid,  in  passing  from 
the  two  lateral  ventricles  above  to  the  theca  or  reservoir  which 
surrounds  the  spinal  cord  below,  has  to  pass  by  the  lateral 
foramina  of  Munro  into  the  median  3rd  ventricle,  thence  by 
the  narrow  iter  into  the  4th  ventricle,  which  lies  between  the 
medulla  and  cerebellum  ;  the  4th  ventricle  is  closed  in  below 
by  an  extremely  thin  transparent  reflection  of  pia  arach- 
noid, which  passes  from  the  inferior  surface  of  the  cerebellum 
to  the  medulla  ;  in  this  reflection  there  are  three  openings  for  the 
passage  of  the  cerebro-spinal  fluid,  a  median  one— the  foramen 
of  Majendie — and  two  smaller  openings,  one  on  each  side — the 
foramina  of  Luschka — which  adjoin  the  roots  of  the  vagus 
nerves.  Hydrocephalus,  at  least  in  a  large  majority  of  the  cases, 
is  purely  a  mechanical  condition,  and  is  due  to  obstruction  at 
some  part  of  this  path. 

In  congenital  cases  the  iter,  as  a  result  of  abnormal  develop- 
ment, may  be  partly  or  entirely  absent,  or  its  lumen  may  be 


714 


COMMON  DISORDERS  OF  CHILDHOOD 


extremely  narrowed;  or  there  may  be  some  deformity  of  the 
cerebellum,  for  instance,  its  lobes  may  be  elongated  posteriorly, 
and  hang  down  into  the  foramen  magnum  of  the  skull,  packing 
this  so  tightly  that  there  is  no  passage  for  the  cerebro -spinal 
fluid  ;  or  there  may  be  cystic  malformation  of  the  cerebellum, 
causing  it  to  bulge  into  and  obstruct  the  ventricles  ;  or,  again, 
there  may  be  adhesions  between  the  cerebellum  and  medulla, 
perhaps  as  the  result  of  some  intra-uterine  meningitis,  so  that 
there  is  no  exit  below  from  the  4th  ventricle.  All  these  con- 
ditions I  have  myself  found  in  congenital  cases  of  hydrocephalus. 


FORAMEN   OF 
MAJENDIZ. 


ONE  OF  THE  LATERAL 
FORAMINA   OF   LUSCHKA, 


Fin.  50.     Diagram  to  show  path  of  the  ccrebro-spinal  fluid  from  the  ventricles 
of  the  brain  to  the  theca  of  the  spinal  cord. 

In  acquired  cases  the  commonest  cause  is  posterior  basic 
meningitis,  whereby  the  pia  arachnoid  reflection  from  the  cere- 
bellum to  the  medulla  becomes  greatly  thickened,  and  the 
foramen  of  Majendie  and  two  foramina  of  Luschka  are  obliterated 
by  inflammatory  material.  In  no  less  than  11  out  of  17  cases 
in  which  the  condition  was  acquired  the  hydrocephalus  was  the 
sequel  of  posterior  basic  meningitis.  Very  much  less  commonly, 
tumour,  generally  a  cerebellar  tumour,  by  pressure  upon  or 
bulging  into  the  4th  ventricle,  acts  as  the  obstructing  cause. 


HYDROCEPHALUS  715 

The  iter  or  the  3rd  ventricle  also  occasionally  becomes  blocked 
by  a  tumour. 

I  have  spoken  so  far  as  if  the  only  cause  of  hydrocephalus 
were  obstruction  of  the  passage  of  the  cerebro-spinal  fluid.  I  am 
quite  aware  that  there  are  cases  in  which  no  obstruction 
can  be  demonstrated.  These  are  difficult  to  explain,  but  to 
my  mind  the  failure  to  find  obstruction  is  not  convincing  proof 
that  they  are  not  due  to  obstruction.  The  ordinary  methods  of 
removing  the  brain  at  autopsy  destroy  the  relation  of  parts  at 
the  base  of  the  skull,  and  it  is  quite  conceivable  that  a  slight 
abnormality  in  the  packing,  so  to  speak,  might  cause  obstructive 
pressure.  The  exact  arrangement  of  the  posterior  reflection  of 
pia  arachnoid  is  usually  not  seen  at  all  when  the  brain  is  removed 
in  the  ordinary  way,  and  any  abnormality  of  the  foramina  here, 
or  any  slight  adhesions  between  the  cerebellum  or  medulla,  would 
easily  be  overlooked. 

On  the  ground  that  the  choroid  plexuses  play  an  important 
part  in  the  production  of  the  cerebro-spinal  fluid,  it  has  been 
supposed  that  some  abnormality  of  their  function,  whether  from 
inflammatory  change  or  not,  may  lead  to  hydrocephalus  where 
there  is  no  obstruction  ;  we  may,  in  fact,  suppose  that  there  is 
a  loss  of  balance  between  secretion  and  absorption,  the  cerebro- 
spinal  fluid  is  produced  more  rapidly  than  it  can  be  carried  off, 
and  hydrocephalus  results.  This  view  rests  merely  on  con- 
jecture and  is  necessarily  incapable  of  proof.  Nor  is  there, 
I  think,  any  good  ground  for  supposing,  as  some  have  done, 
that  lack  of  support  for  the  brain  may  lead  to  dilatation  of  the 
ventricles.  It  is  undoubtedly  true  that  there  are  curious  cases 
in  which  a  congenital  defect  of  ossification  of  the  cranium,  so 
that  a  large  part  of  the  skull  remains  membranous  much  longer 
than  it  should,  is  sometimes  associated  with  hydrocephalus.  But 
there  are  exactly  similar  cases  in  which  the  defect  of  ossification 
is  not  associated  with  hydrocephalus,  so  that  lack  of  support  in 
these,  at  any  rate,  has  not  led  to  dilatation  of  the  ventricles. 

These  cases  of  congenital  defect  of  ossification  with  hydro- 
cephalus should  rather  be  regarded  as  illustrations  of  the  ten- 
dency to  association  of  congenital  deformities.  This  is  very 
noticeable  with  hydrocephalus,  and  may  be  of  value  in  deciding 
whether  the  hydrocephalus  is  of  congenital  origin.  Amongst 
36  congenital  cases  of  which  I  have  notes,  10  showed  congenital 
abnormalities  ;  there  was  spina  bifida  in  4,  congenital  heart  disease 
in  2,  supernumerary  finger  in  1,  a  Meckel's  diverticulum  in  1, 
talipes  varus  in  1,  and  Mongolian  imbecility  in  1. 


716 


COMMON  DISORDERS  OF  CHILDHOOD 


A  factor  which  seems  to  play  some  part  in  the  causation  both 
of  congenital  and  acquired  hydrocephalus  is  congenital  syphilis. 
Amongst  51  consecutive  cases  I  noted  undoubted  syphilis  in  three, 
probable  syphilis  in  one,  and  the  sister  of  another  case  had  inter- 
stitial keratitis.  In  one  of  these  syphilitic  cases  the  hydrocephalus 
was  not  noticed  until  the  age  of  nine  months,  in  another  at  three 
months,  in  another  at  birth.  How  syphilis  causes  hydrocephalus 
is  not  very  clear.  Possibly  the  matting  of  the  cerebellum  on  to 
the  medulla  and  the  thickening  of  the  pia  arachnoid  reflection 
here  which  is  found  in  some  congenital  cases  is  the  result  of 
syphilitic  meningitis  of  intra-uterine  origin  ;  in  some  cases  it 
may  be  that  syphilis  acts  only  indirectly,  the  disease  in  the 
mother  predisposing  to  malformation  in  the  offspring. 

In  one  case  I  have  known  hydrocephalus  follow  after  a  fall 
upon  the  head  at  one  year  old,  an  occurrence  which  suggests  some 
inflammatory  adhesions  resulting  from  the  accident. 

Symptoms.  Most  of  the  symptoms  of  hydrocephalus  are 
sufficiently  obvious  at  a  glance,  the  enormous  rounded  head 
contrasting  with  the  small  and  often  delicate -featured  face,  the 
abnormally  high  forehead,  the  downward  rotation  of  the  eyes,  so 
that  the  white  sclerotic  is  seen  above  the  cornea  and  the  pupil 
is  half  covered  by  the  lower  eyelid,  the  presence  of  nystagmus 
in  some  cases  and  more  often  of  divergent  squint.  Several  of 
these  characteristics  are  seen  in  the  adjoining  illustration  (Fig.  51). 
Not  only  is  the  union  of  sutures  and  f  ontanelles  delayed  so  that  the 
anterior  fontanelle  at  three  or  four  years  (in  one  of  my  cases  at 
7J  years)  is  still  open,  and  at  six  months  measures  perhaps  six 
inches  instead  of  one  inch  transversely,  and  extends  forwards  to 
the  bridge  of  the  nose  and  backwards  to  the  posterior  fontanelle, 
which  I  have  known  to  be  still  open  at  two  years,  but  there  is 
also  interference  with  the  ossification  of  the  bones,  so  that  they 
remain  thin  and  papery,  and  the  intracranial  pressure  may  even 
cause  absorption  of  the  bone  so  that  gaps  somewhat  like  patches 
of  cranio-tabes  appear.  The  bulging  of  the  fontanelle,  which  is 
often  very  striking,  forms  a  reliable  index  of  the  degree  of  intra- 
cranial tension,  and  in  this  way  may  be  of  practical  importance, 
as  I  shall  show  when  discussing  treatment.  The  scalp  is  stretched 
by  the  distension  of  the  cranium,  so  that  the  hair  appears  sparse 
and  thin,  and  the  distended  veins  show  unduly  through  the  thin 
skin.  I  have  seen  several  cases  in  which  the  distension  was  so 
great,  and  the  thinning  of  the  cortex,  skull,  and  scalp  so  con- 
siderable that  the  head  was  actually  translucent— a  bright  light 
showed  red  through  the  enlarged  head. 


HYDROCEPHALUS  717 

The  shape  of  the  head  in  hydrocephalus  is  generally  stated  to 
be  round,  in  contrast  to  the  square  head  of  rickets  ;  but  occasion- 
ally the  hydrocephalic  head,  though  enlarged  in  all  directions, 
is  dolichocephalic— that  is,  elongated  in  the  antero -posterior  direc- 


FIG.  51.  Hydrocephalus,  showing  high  forehead  and  downward  rotation  of 
the  eyes,  which  in  this  case  was  so  extreme  that  the  pupils  were  completely 
covered  by  the  lower  eyelids,,  and  the  infant  had  learnt  to  pull  down  the  eye- 
lids in  order  to  see.  From  a  case  under  the  care  of  Dr.  F.  E.  Batten. 

tion  ;  in  some  cases,  also,  the  increase  in  the  vertical  dimension 
is  the  most  striking  change,  as  the  photograph  (Fig.  51)  shows. 
No  doubt  these  differences  depend  upon  slight  differences  in  the 
resistance  offered  to  expansion  in  the  various  directions,  and  the 
effect  of  an  artificial  increase  of  resistance  is  sometimes  shown 


718  COMMON  DISORDERS  OF  CHILDHOOD 

by  the  asymmetry  of  .the  head  where  the  hydrocephalic  infant 
has  been  habitually  carried  on  one  arm  with  its  head  pressed 
against  the  nurse's  breast,  or  habitually  lies  on  one  side  ;  in  such 
cases  the  side  of  the  head  which  is  not  subjected  to  the  pressure 
expands  more  than  the  other. 

The  enlargement  of  the  head  in  hydrocephalus  is  often  enormous, 
but  to  appreciate  the  degree  it  is  obviously  necessary  to  bear  in 
mind  the  normal  measurement  for  the  age.  The  most  generally 
useful  is  the  maximum  circumference,  which  has  already  been 
given  (see  p.  4),  for  the  various  ages  in  the  healthy  child:  the 
normal  average  at  birth  is  13  inches,  at  one  year  18  inches,  and 
at  seven  years  20  inches.  With  hydrocephalus  the  circumference 
is  often  as  much  as  20  inches  at  three  months,  22  inches  at  one 
year,  and  24  inches  at  five  years.  The  largest  I  have  seen,  a 
congenital  hydrocephalus,  measured  38J  inches  at  the  age  of 
nine  weeks.  I  have  seen  other  congenital  cases  in  which  the 
circumference  was  26-28  inches  at  one  year  old.  The  greatest 
degrees  of  enlargement  are  seen  as  a  rule  in  those  cases  where 
the  hydrocephalus  is  of  congenital  origin.  The  rate  of  increase 
during  the  first  six  months  is  commonly  about  a  quarter  of  an 
inch  a  week,  very  rarely  it  is  as  much  as  |-1  inch  per  week, 
but  after  this  the  rate  of  enlargement  gradually  diminishes, 
no  doubt  owing  to  the  greater  resistance  offered  by  the  harden- 
ing of  the  skull  bones.  The  increase  in  the  second  year  is  often 
at  the  rate  of  about  J  inch  in  three  months,  and  in  the  third 
year  about  an  inch  in  twelve  months.  In  favourable  cases  the 
rate  slowly  diminishes  until  perhaps  at  five  or  six  years  the 
fontanelle  and  sutures  are  closed,  and  the  rate  of  increase  is 
little  more  than  the  normal  for  the  age. 

The  downward  rotation  of  the  eyes  is  so  early  a  symptom  of 
hydrocephalus  that  it  is  difficult  to  suppose  that  it  can  be  due 
to  any  direct  pressure,  in  some  cases  it  is  so  marked  that  the 
pupil  is  almost  covered  by  the  lower  lid  ;  in  the  case  shown  in 
the  photograph  the  infant  had  learnt  to  draw  down  the  lower 
lid  in  order  to  see.  I  have  seen  one  case  in  which  some  proptosis 
of  the  eyes  occurred,  but  this  is  very  rare. 

Some  defect  of  vision  is  present  in  many  cases  ;  blindness  of 
central  origin,  lasting  a  year  or  more,  is  a  not  uncommon  result 
of  posterior  basic  meningitis,  apart  from  hydrocephalus,  so  that 
it  is  found  where  hydrocephalus  has  resulted  from  this  form  of 
meningitis.  More  or  less  defect  of  vision,  however,  may  arise 
from  various  changes  in  the  fundus  oculi. 

Ophthalmoscopic    examination   is    always    worth    making    in 


HYDROCEPHALUS  719 

cases  of  hydrocephalus.  Optic  neuritis  is  almost  never  seen 
with  congenital  hydrocephalus  (a  curious  fact  throwing  doubt 
upon  the  part  played  by  pressure  in  the  causation  of  optic 
neuritis) ;  its  presence  almost  always  points  to  cerebral  tumour 
as  the  cause  of  the  hydrocephalus.  Choroidal  changes  are  found 
in  some  cases  ;  sometimes  symmetrical  patches  of  choroidal 
atrophy  suggestive  of  a  congenital  abnormality :  sometimes 
a  choroiditis  or  choroido-retinitis  pointing  to  congenital  syphilis. 
The  general  symptoms  produced  by  hydrocephalus  are  often 
remarkably  slight.  The  child  may  be  quite  well  and  happy,  and 
even  while  the  head  is  steadily  and  rapidly  enlarging  there  is 
usually  no  evidence  of  headache.  The  mental  condition  during 
infancy  may  seem  unimpaired,  but  if  the  child  survives  it  usually 
becomes  evident  that  there  is  some  mental  alteration  ;  he  is  too 
facile,  too  easily  pleased,  talks  at  six  or  seven  years  in  a  babyish 
way,  like  a  child  of  two  or  three.  When  one  considers  how 
greatly  the  cortex  must  be  compressed  it  is  remarkable  that 
the  mental  change  is  usually  so  slight.  One  might  have  thought 
that  reduction  of  the  cortex  to  a  thickness  of  5  millimetres  or 
even  less  would  involve  complete  loss,  or  at  any  rate  extreme 
perversion,  of  function. 

Sitting  is  delayed,  as  the  child  is  unable  to  support  the  weight 
of  the  head.  Walking  is  always  acquired  very  late.  One  child 
could  not  stand  at  7J,  another  could  just  walk,  with  assistance, 
at  four  years,  another  at  five  years.  The  difficulty  in  walking  is, 
dependent  partly,  no  doubt,  on  the  enormous  weight  of  the  head  ; 
in  one  child  I  found  the  head  weighed  four-fifths  of  the  total 
body  weight  ;  but  there  is  also  in  many  cases,  both  of  congenital 
and  of  acquired  hydrocephalus,  some  spasticity  of  the  limbs, 
especially  of  the  legs,  with  pointing  of  the  toes,  which  interferes 
with  walking  and  makes  the  gait  awkward.  In  such  cases  the 
knee-jerks  are  usually  increased,  but  ankleclonus  is  hardly  ever 
present.  Occasionally  there  is  evidence  of  more  localized  damage  : 
in  one  case  with  congenital  hydrocephalus  the  right  arm  and 
leg  were  spastic,  as  in  an  infantile  hemiplegia. 

Where  the  affection  is  due  to  a  tumour,  paralysis  or  spasticity 
corresponding  to  the  position  of  tumour  may  be  present,  and 
throw  light  upon  the  cause  of  the  hydrocephalus.  Convulsions 
occur  almost  as  frequently  with  congenital  hydrocephalus  as 
with  the  acquired  form,  but  they  are  less  frequent  than  one 
might  expect — they  occur  in  about  a  third  of  the  cases. 

Diagnosis.  There  is  very  rarely  any  difficulty  in  the  diagnosis 
of  hydrocephalus  ;  the  only  doubt  which  is  likely  to  arise  is  in 


720  COMMON  DISORDERS  OF  CHILDHOOD 

the  case  of  rachitic  enlargement  of  the  head.  The  rickety  head, 
with  its  flat  top,  its  square  shape,  its  much  slighter  degree  of 
enlargement,  and  the  associated  evidence  of  rickets  elsewhere, 
sounds  easy  enough  of  recognition,  and  no  doubt  it  is  so  as 
a  rule,  but  there  are  cases  of  slight  enlargement  of  the  head  in 
which,  though  the  evidence  of  rickets  is  indubitable,  the  possi- 
bility of  some  degree  of  hydrocephalus  also  is  by  no  means  easy 
of  exclusion  ;  nevertheless  I  know  of  no  connexion  whatever 
between  rickets  and  hydrocephalus  (see  p.  95),  and  unless 
the  history  showed  evidence  that  the  supposed  hydrocephalus 
was  either  congenital  or  was  due  to  one  of  the  usual  causes  of 
acquired  hydrocephalus,  the  presumption  would  certainly  be 
against  the  existence  of  hydrocephalus.  The  very  rare  con- 
dition known  as  '  hypertrophy  of  the  brain  '  in  which  enlargement 
of  the  head,  with  overgrowth  of  the  neuroglial  elements  of  the 
brain,  is  associated  with  mental  defect,  might  be  confused  with 
hydrocephalus,  but  there  is  none  of  the  rapid  enlargement  of  the 
head  which  occurs  with  hydrocephalus. 

It  is  not  always  easy  to  distinguish  between  a  congenital  and 
an  acquired  hydrocephalus  ;  it  must  be  remembered  that  pos- 
terior basic  meningitis,  the  usual  cause  of  acquired  hydrocephalus, 
though  it  most  commonly  occurs  between  6  months  and  12 
months  of  age,  sometimes  occurs  at  10  or  12  weeks  old  :  and 
cerebral  tumour  occasionally  begins  before  the  age  of  3  months, 
as  the  following  case  may  show  : 

Mabel  A.  was  seen  at  5  months  old  for  hydrocephalus;  the  head  then 
measured  19  inches  in  circumference,  there  was  no  optic  neuritis,  there  was 
some  vertical  nystagmus,  and  the  right  hand  was  slightly  spastic.  The  enlarge- 
ment of  the  head  was  first  noticed  when  the  infant  was  2  months  old.  Having 
regard  to  this  onset  at  8  weeks,  I  had  no  doubt  whatever  that  the  case  was 
one  of  congenital  hydrocephalus.  It  passed  out  of  my  care,  and  I  heard 
subsequently  that  the  child  died  at  the  age  of  3  years.  A  post-mortem 
examination  showed  that  the  hydrocephalus  was  due  to  a  new  growth  in  the 
optic  thalamus,  bulging  into  and  almost  filling  the  3rd  ventricle. 

Prognosis.  Hydrocephalus  is  an  extremely  fatal  condition : 
very  few  cases  survive  beyond  the  end  of  the  third  year.  Death 
results  from  gradual  exhaustion,  with  coma  and  convulsions, 
but  complications  are  apt  to  occur,  the  tense  skin  over  the 
enlarged  head  easily  develops  a  bed-sore  by  pressure  0:1  the 
pillow,  and  the  sores  becoming  septic  may  lead  to  pyaemia  or  to 
suppurative  meningitis.  A  similar  end  may  result  from  the 
giving  way  of  the  skin  over  a  spina  bifida  associated  with  the 
hydrocephalus. 

But  it  is  very  necessary,  in  view  of  the  problems  of  treatment, 


HYDROCEPHALUS  721 

to  emphasize  the  favourable  possibilities  of  hydrocephalus.  It 
is  not  inevitably  a  fatal  condition  ;  there  are  cases  in  which  the 
abnormally  rapid  enlargement  after  continuing  for  two  or  three 
years  gradually  ceases  spontaneously,  and  the  child  lives  on  for 
several  years,  weakened,  it  is  true,  in  intellect,  but  perhaps  only 
to  an  extremely  slight  degree,  leading  a  happy  and  comfortable 
existence,  and  generally  a  bright  lovable  child,  -though  perhaps 
somewhat  quick  tempered,  and  inclined  to  be  passionate. 

The  following  cases  may  illustrate  such  favourable  excep- 
tions : — 

Alice  R.  had  been  hydrocephalic  at  least  since  six  months  of  age,  probably 
earlier ;  the  condition  was  apparently  of  congenital  origin.  When  she  was  first 
seen,  at  2J  years,  the  head  measured  22^  inches,  there  was  divergent  squint 
and  she  could  only  just  stand  with  assistance  ;  after  this  the  head  ceased  to 
enlarge  at  an  abnormally  rapid  rate  :  at  0  years  the  head  was  23]  inches 
and  she  talked  brightly,  and  could  walk,  but  with  difficulty.  At  9  years 
she  goes  to  school,  can  write  her  name  fairly  well,  and  reads  words  of  one 
syllable,  and  answers  questions  quite  brightly  and  intelligently,  but  she  is 
just  a  little  babyish  in  her  manner. 

Boy,  aged  19  years,  looks  as  if  he  were  13  years.  At  3  months  old  had 
posterior  basic  meningitis,  followed  by  hydrocephalus,  which  steadily 
increased  for  about  two  years ;  then  the  abnormal  enlargement  ceased  spon- 
taneously. The  boy's  head  is  obviously  too  large,  but  the  disproportion  is 
not  so  striking  as  it  would  be  with  similar  enlargement  in  a  younger  child. 
The  head  measures  24|  inches.  He  is  somewhat  childish  in  his  ways,  but  talks 
quite  sensibly,  and  is  intelligent  enoughto  be  entrusted  with  bringing  hisyounger 
brother,  aged  8  years,  to  hospital. 

In  which  cases  spontaneous  cure  is  possible  we  cannot  tell ; 
it  is  quite  clear,  as  these  two  cases  may  serve  to  show,  that 
congenital  as  well  as  acquired  hydrocephalus  is  capable  of 
spontaneous  arrest  ;  but  I  know  of  no  way  in  which  we  can 
determine  in  any  particular  case  whether  this  is  likely  to  occur ; 
it  is  not  even  clear  how  the  arrest  is  brought  about  when  it 
does  occur.  It  is  conceivable  that,  if  the  obstruction  is  a  partial 
one,  when  the  intracranial  pressure  reaches  a  certain  degree  the 
secretion  is  so  retarded  that  a  balance  is  struck  between  secretion 
and  absorption ;  it  is  also  possible  that  with  a  sufficient  pressure 
the  partially  obstructed  passage  may  be  forced,  so  to  speak,  and 
the  fluid  then  leaks  through  in  sufficient  quantity  to  prevent 
further  accumulation. 

This  latter  view  would  be  consistent  with  the  clinical  fact  that 
a  gradual  diminution  in  the  bulging  and  tension  of  the  anterior 
fontanelle  is  one  of  the  favourable  signs  which  precede  arrest  of 
the  hydrocephalic  enlargement.  Another  phenomenon  which  is 
of  good  augury  is  diminution  in  the  size  of  the  fontanelle  ;  this 

STILL  3  A 


722  COMMON  DISORDERS  OF  CHILDHOOD 

almost  always  coincide*  with  diminution  in  the  rate  of  enlarge- 
ment of  the  head,  and  if  the  fontanelle  approaches  actual  closure, 
the  hydrocephalus  is  almost  certainly  becoming  stationary. 

One  point  upon  which  some  comfort  may  be  given  to  the 
parents  is  the  disproportion  of  the  head  to  the  body  ;  this  is  so 
striking  in  infancy  and  early  childhood  that  they  are  distressed 
at  the  thought  of  the  child's  appearance  if  he  should  survive ; 
the  disproportion,  however,  becomes  less  and  less  marked  as  the 
child  grows  older,  when  the  body  continues  to  develop  after  the 
hydrocephalus  is  arrested. 

Treatment.  It  is  clear  that  the  scope  for  drugs  is  extremely 
limited  in  the  treatment  of  hydrocephalus  ;  in  the  congenital 
cases,  if  the  trouble  be  not,  as  it  may  be,  due  to  some  malforma- 
tion blocking  the  path  of  the  cerebral  fluid,  the  only  cause  which 
might  conceivably  be  removable  by  drugs  is  syphilis,  and  even 
this  is  little  likely  to  respond  to  the  usual  treatment,  for  in  the 
rare  cases  where  it  is  not  merely  an  indirect  factor,  predisposing 
to  malformation,  it  has  probably  produced  fibrous  adhesions 
which  no  mercury  or  iodide  can  remove. 

In  the  acquired  cases  there  is,  it  is  true,  the  possibility,  in  the 
early  stages  of  a  hydrocephalus,  that  some  inflammatory  exuda- 
tion blocking  the  foramina  in  the  pia  arachnoid  between  the 
cerebellum  and  medulla  may  still  be  capable  of  absorption.  The 
process  may  then  possibly  be  hastened  by  the  administration  of 
iodides  and  mercury,  especially  where  the  exudation,  instead  of 
being  due,  as  it  nearly  always  is,  to  the  diplococcus  intracellularis 
of  posterior  basic  meningitis,  is  due  to  syphilis.  In  the  rare 
event  also  of  its  being  due  to  a  tumour,  drugs  may  have  some 
value.  But  these  possibilities  are  the  exception  :  in  most  cases, 
as  post-mortem  evidence  sho\vs,  there  is  obstruction  by  fibrous 
adhesions.  The  question,  therefore,  which  has  to  be  determined 
is  whether  operation  should  or  should  not  be  done.  On  that 
point  certain  general  considerations  should  be  borne  in  mind  : 
hydrocephalus  is  not  an  inevitably  fatal  condition,  spontaneous 
arrest  occurs  in  about  one  in  ten  cases,  according  to  my  own 
figures;  whatever  method  of  operation  is  adopted,  it  is  very 
seldom  that  any  good  results  ;  often  a  fatal  ending  occurs  within 
forty-eight  hours,  and  even  if  no  ill  effects  follow  the  operation, 
the  intracranial  tension  is  seldom  relieved  for  more  than  a  day 
or  two  at  most. 

On  the  other  hand,  it  must  be  stated  that  operation  has  in 
very  rare  instances  been  followed  by  cessation  of  further  hydro- 
cephalic  enlargement  ;  and  therefore  where  the  increase  in  size 


HYDROCEPHALUS  723 

of  the  head  is  very  rapid  and  persistent,  and  the  intracranial 
tension  is  great,  it  may  be  justifiable  to  give  the  child  the  very 
small  chance  which  operation  affords. 

The  simplest  operation  is  tapping,  and  there  are  two  situations 
in  which  this  has  been  done  :  (1)  through  the  lateral  angle  of  the 
anterior  fontanelle  ;  (2)  in  the  lumbar  region  of  the  spinal  canal. 
The  latter,  lumbar  puncture,  is  rarely  if  ever  advisable,  for 
although  there  are  cases  in  which  there  is  free  communication 
between  the  spinal  canal  and  the  dilated  ventricles  of  the  brain, 
these  are  extremely  rare  ;  almost  always  there  is  some  obstruc- 
tion at  or  above  the  level  of  the  medulla,  so  that  lumbar  puncture 
can  have  no  effect  whatever  upon  the  hydrocephalus. 

Tapping  through  the  lateral  angle  of  the  fontanelle  is  a  much 
more  reliable  method  of  removing  fluid  from  the  lateral  ventricles, 
and  if  the  hydrocephalic  brain  were  merely  a  closed  tank  with  no 
inlet,  no  doubt  this  would  be  an  efficient  procedure  ;  but,  as  it  is, 
experience  shows  that  the  brain  fills  up  again  within  a  day  or  two 
after  the  removal  of  the  fluid.  This  might  be  expected,  seeing  that 
the  fault  in  nearly  all  cases  is  not  an  abnormality  of  secretion 
which  might  conceivably  be  influenced  by  removing  a  little  of 
the  fluid,  as  seems  to  happen  in  some  cases  of  pleural  effusion, 
but  is  a  purely  mechanical  accumulation  of  normally  secreted 
fluid,  owing  to  obstruction  of  outlet.  Even  as  a  temporary 
palliative  this  tapping  of  the  ventricles  very  rarely  does  any 
good  ;  as  a  rule  it  affords  no  relief  to  any  symptoms  such  as  con- 
vulsions or  rigidity,  it  may  indeed  produce  them.  If,  however, 
it  is  decided  to  adopt  this  procedure,  care  must  of  course  be  taken 
that  strict  asepsis  is  observed,  and  only  just  enough  general 
anaesthetic  should  be  given  to  prevent  the  child  from  feeling  the 
punctur-e.  A  fine  trocar  and  cannula  should  be  used,  pushed  in 
-  at  right  angles  to  the  surface  of  the  scalp  at  the  lateral  angle  of 
the  anterior  fontanelle.  The  pulse  must  be  watched  carefully, 
for  after  a  few  ounces  of  the  fluid  have  been  removed  (and  it 
should  be  allowed  only  to  trickle  out  slowly)  the  pube  is  apt  to 
become  feeble,  the  child's  colour  may  turn  bad,  and  it  would 
be  dangerous  to  continue  the  drainage.  I  have  had  quantities 
varying  from  4  to  7  ounces  removed  at  a  time,  but  with  drainage 
to  this  amount  have  seen  symptoms  of  collapse.  Usually  there 
is  some  leakage  through  the  puncture  afterwards,  so  that  careful 
aseptic  dressing  is  necessary. 

Far  more  rational  is  the  operation  of  subdural  drainage  devised 
by  Sir  Watson  Cheyne  and  Dr.  Sutherland.  This  attempts  to 
establish  permanent  drainage  by  creating  an  artificial  route  by 

3  A  2 


724  COMMON  DISORDERS  OF  CHILDHOOD 

which  the  cerebro-spinai  fluid  can  pass  out  of  the  ventricles 
into  the  lymphatic  system.  The  pacchionian  bodies  which  lie 
along  the  longitudinal  sinus  serve  as  lymphatics,  which  pass  on 
fluid  from  the  subdural  space  into  the  blood-stream,  and  if  the 
fluid  could  be  brought  into  contact  with  these  by  allowing  it  to 
pass  out  of  the  ventricles  into  the  subdural  space,  it  should  be 
absorbed.  To  accomplish  this  an  opening  in  the  skull  is  made 
and  a  rectangular  tube  is  inserted  so  that  one  arm  passes  through 
the  cortex  and  projects  into  the  ventricle  while  the  other  arm  lies  on 
the  surface  of  the  brain  in  the  subdural  space.  The  tube  is  sutured 
at  its  angle  to  the  adjoining  dura  mater  to  keep  it  in  position, 
and  the  wound  is  then  closed.  Very  fine  metal  tubes  have  been 
left  thus  as  a  permanent  internal  drain,  but  decalcified  bone  tubes 
have  also  been  used. 

In  theory  this  operation  leaver  nothing  to  be  desired,  in 
practice  it  is  only  rarely  successful.  The  procedure  is  less  simple 
than  it  sounds  :  the  tube  may  become  blocked  passing  through 
the  cortex  or  subsequently  :  the  thinned  cortex  is  very  apt  to 
tear,  so  that  instead  of  trickling  through  the  tube  the  fluid  comes 
out  with  a  big  gush,  and  the  child's  life  is  endangered  thereby. 
Even  when  the  operation  has  been  completed  with  apparent 
success,  hyperpyrexia  and  death  have  followed  in  several  cases 
within  the  next  forty-eight  hours.  Twice  at  least  I  have  seen 
arrest  of  hydrocephalus  after  subdural  drainage,  and  I  must 
have  seen  at  least  ten  or  a  dozen  in  which  it  not  only  failed,  but 
apparently  hastened  death  ;  nevertheless,  there  can,  I  think,  be 
no  doubt  that  subdural  drainage  is  an  operation  which  offers 
some  hope  of  permanent  benefit  to  the  child. 

A  much  simpler  procedure,  based  on  the  same  physiological 
principles,  namely,  the  establishing  of  a  communication  between 
the  intraventricular  cavities  and  the  subdural  space,  so  that  the 
fluid  may  be  drained  off  via  the  pacchionian  bodies,  has  been 
tried  with  success  in  some  cases.  It  consists  in  puncturing  the 
corpus  callosum.  This  is  done  by  passing  a  trocar  and  cannula 
through  the  anterior  fontanelle  at  a  spot  about  half  an  inch 
from  the  middle  line,  so  as  to  avoid  the  longitudinal  sinus  ;  when 
the  cranial  cavity  has  been  reached  the  trocar  is  withdrawn, 
and  a  long  blunt,  probe-like  rod  is  passed  down  through  the 
cannula  until  it  is  felt  to  penetrate  the  tense  corpus  callosum. 
A  few  drops  of  cerebro-spinal  fluid  may  then  escape  through 
the  cannula,  showing  that  an  opening  has  been  made  into  the 
ventricle  :  the  rod  and  cannula  are  then  withdrawn.  A  general 
anaesthetic  is  of  course  necessary.  The  pressure  of  the  fluid  in 


HYPROCEPHALUS  725 

the  distended  ventricles  should  suffice  to  keep  the  puncture  in 
the  corpus  callosum  patent  whilst  the  fluid  slowly  passes  into 
the  subdural  space,  so  that,  in  theory  at  any  rate,  a  permanent 
drainage  is  established.  My  colleague,  Dr.  Theodore  Thompson, 
adopted  this  procedure  in  a  case  under  his  care  with  excellent 
result. 

Obviously  operation  is  never  to  be  recommended  lightly  for 
hydrocephalus  :  careful  measurements  of  the  maximum  circum- 
ference of  the  head  should  be  taken  and  recorded  every  week 
for  several  weeks,  and  only  when  the  rate  of  increase  and  its 
persistence  make  all  hope^of  spontaneous  recovery  remote  should 
the  question  of  operation  be  mooted.  The  exact  time  when  this 
point  is  reached  must  vary  in  different  cases,  but  it  is  certainly 
later  in  those  of  comparatively  slow  increase  than  in  those  where 
this  is  more  rapid  (vide  p.  718).  It  mast  be  remembered,  how- 
ever, that  surgery  has  little  chance  of  success  when  operation 
is  delayed  until  the  cortex  is  thinned  to  an  extreme  degree,  and 
the  brain  is  a  mere  thin- walled  sac  of  fluid  ;  and  even  if  life 
were  prolonged  by  the  operation  at  that  stage,  the  mental 
condition  is  likely  to  have  been  permanently  damaged. 

By  whatever  method  the  fluid  is  removed  from  the  ventricles 
it  is  wise  to  apply  a  firm  bandage  around  the  head  directly  after- 
wards, to  give  some  support  to  the  flaccid  brain. 

A  point  to  be  remembered,  also,  is  the  great  liability  of  the 
hydrocephalic  child  to  pressure-sores  on  the  scalp,  where  the 
head  rests  upon  the  pillow.  This  is  due  partly  to  the  tight 
stretching  of  the  scalp  over  the  distended  cranium  and  partly  to 
the  fact  that  the  child  in  such  cases  is  often  unable  to  lift  or 
even  to  turn  the  heavy  hydrocephalic  head. 

To  prevent  this  very  serious  complication — serious  because  of 
the  risk  of  pyaemic  infection  from  it — it  is  important  to  keep  the 
scalp  thoroughly  dry,  for  which  purpose  a  dusting  powder  of 
borated  talc  may  be  ordered ;  the  position  of  the  child's  head 
should  be  frequently  changed,  and  if  there  is  the  slightest  ten- 
dency to  a  pressure-sore  a  ring  pad  of  wool  and  silk  should  be 
arranged  so  as  to  keep  the  irritated  part  off  the  pillow. 


CHAPTER  L 
ENURESIS  AND  FJECAL  INCONTINENCE 

AMONGST  the  functional  disorders  of  childhood,  one  of  the 
commonest  is  enuresis,  and  I  suppose  there  is  hardly  any  which 
causes  more  petty  trouble  and  annoyance  to  parents  and  shame- 
faced misery  to  a  sensitive  child  than  this,  at  first  sight,  trivial 
complaint.  Moreover,  though  so  much  has  been  written  on 
enuresis  and  its  treatment,  it  remains  a  bugbear  to  the  medical 
man,  who  knows  only  too  well  that,  though  fortune  may  some- 
times favour  him,  reputation  is  more  often  lost  than  won  in  the 
treatment  of  this  disorder. 

In  many  cases  enuresis  can  hardly  be  said  to  have  an  onset  ; 
the  child  has  never  fully  acquired  that  higher  control  of  the 
reflex  act  of  micturition  which  should  come  about  the  end  of  the 
first  year  of  life. 

Micturition  in  the  newborn  infant,  as  in  the  foetus  in  utero, 
is  purely  a  reflex  function  ;  the  higher  centres  in  the  brain  only 
gradually  gain  control  of  the  function  so  that  it  becomes  subject 
to  the  will.  The  contraction  of  the  bladder  and  the  relaxation 
of  its  sphincter  are  dependent  upon  centres  in  the  lumbar  cord, 
and  for  stimulation  of  this  centre  under  ordinary  conditions  a  cer- 
tain moderate  degree  of  distension  of  the  bladder  is  requisite.  It 
seems  clear  from  the  character  of  the  incontinence  in  different 
cases  that  the  defect  in  the  nervous  control  is  not  the  same  in  all 
cases.  In  some  it  would  seem  that  the  chief  fault  is  an  undue 
excitability  of  this  lumbar  centre,  so  that  the  accumulation 
of  only  a  very  small  quantity  of  urine  in  the  bladder  suffices  to 
stimulate  the  centre  to  such  a  degree  that  the  cerebral  control 
is  insufficient  to  prevent  micturition.  These  are  the  cases  in 
which  incontinence  is  associated  with  great  frequency  of  micturi- 
tion, or  pollakiuria,  as  it  has  been  called.  In  other  cases  the 
lumbar  centre  shows  no  undue  excitability,  but  the  control  by 
the  higher  centres  is  unduly  weak,  so  that  although  it  may 
suffice  as  long  as  these  are  actively  exerting  their  control,  yet 
directly  the  higher  centres  become  less  watchful,  so  to  speak, 
the  spinal  centre  works  uncontrolled.  These  are  the  common 
cases  in  which  incontinence  occurs  only  during  sleep,  or  perhaps 


ENURESIS  AND  F^CAL  INCONTINENCE         727 

also  in  waking  hours  if  the  child  happens  to  be  absorbed  in  his 
play  or  other  occupation. 

But  the  whole  explanation  of  enuresis  is  no  simple  matter. 
I  have  sometimes  wondered  whether  there  may  not  be  an  afferent 
rather  than  an  efferent  or  central  failure  of  the  nervous  mechan- 
ism in  some  cases  :  it  seems  clear  from  the  accounts  of  some 
of  the  older  children  that  sometimes  when  enuresis  occurs  in 
waking  hours  there  is  no  consciousness  of  the  act  until  the  child 
discovers  it  from  the  wetness  of  the  underclothing.  Then,  again, 
what  is  the  meaning  of  that  curious  and  not  very  rare  occurrence, 
that  a  child  after  voiding  his  urine  voluntarily  into  a  chamber, 
will  sometimes  within  five  minutes  pass  water  involuntarily  into 
his  clothes  ;  or,  as  I  am  sometimes  told,  a  child  asks  for  the 
chamber  but  is  unable  to  pass  any  urine,  and  yet  almost  directly 
afterwards  passes  urine  involuntarily  ?  Such  cases  suggest  a 
defect  of  co-ordination  like  that  of  the  stutterer  who  becomes 
absolutely  speechless  in  his  struggle  to  get  a  word  out,  and  finally 
blurts  it  out  with  uncontrollable  force.  Again,  there  are  cases 
in  which  the  trouble  seems  to  be  something  more  than  a  mere 
disorder  of  the  control  of  micturition,  for  not  only  is  there 
frequency  of  micturition  and  enuresis,  but  the  amount  of  urine  is 
above  the  normal,  and  the  child  complains  of  thirst — symptoms 
reminding  us  that  the  secretion  of  urine  as  well  as  its  retention 
in  the  bladder  is  under  nervous  control,  and  that  both  may  be 
disordered  at  the  same  time. 

The  controlling  function  of  the  higher  centres,  like  other 
functions  of  the  brain — for"  instance,  speech — is  acquired  more 
slowly  by  some  children  than  by  others.  Control  during  waking 
hours  is  usually  acquired  before  control  during  sleep.  Occa- 
sionally an  infant  can  be  trained  to  be  clean  in  his  habits  while 
awake  before  he  is  a  year  old,  but  control  during  sleep  is  seldom 
acquired  until  the  child  is  at  least  eighteen  months  old,  and 
is  usually  imperfect  and  dependent  upon  very  constant  care 
on  the  part  of  the  nurse  until  the  age  of  two  years.  The  per- 
sistence of  bed-wetting,  and  even  more  of  incontinence  when  the 
child  is  awake,  after  the  age  of  2  5  years,  in  spite  of  careful 
training,  may  be  regarded  as  abnormal  and  described  as 
enuresis. 

Boys  and  girls  seem  to  be  equally  subject  to  this  disorder; 
of  200  cases  under  my  own  care  102  were  boys,  98  were  girls. 
Enuresis  is  a  persistence  of  the  infantile  condition  as  fre- 
quently as  it  is  an  acquired  disorder  ;  in  142  cases  in  which 
this  point  was  noted  the  incontinence  dated  from  birth  in  67 


728          COMMON  DISORDERS  OF  CHILDHOOD 

cases,  and  was  said  to^have  begun  at  some  time  after  infancy 
in  75  cases. 

Where  enuresis  is  an  acquired  disorder  it  very  rarely  begins 
later  than  the  end  of  the  ninth  year.  In  60  per  cent,  of  these 
cases  the  onset  is  between  the  ages  of  five  and  eight  years — 
that  is  to  say,  about  the  time  when  the  second  dentition 
begins,  a  period  in  which  children  would  appear  to  be  par- 
ticularly liable  to  certain  functional  nervous  disorders,  if  we 
may  judge  from  the  similar  age-incidence  of  stuttering  and 
habit-spasm. 

As  control  during  sleep  is  acquired  later  than  control  during 
waking  hours  so  it  is  the  earlier  lost  ;  and,  as  might  be  expected, 
it  is  very  rare  to  find  enuresis  during  waking  hours  if  there  is 
not  also  enuresis  during  sleep  ;  this  occurred  only  in  4  per  cent, 
of  my  cases,  whereas  the  reverse  condition  of  incontinence  during 
sleep  without  enuresis  when  the  child  is  awake  is  the  commonest 
occurrence  ;  it  was  noted  in  52  per  cent.  In  44  per  cent,  the 
enuresis  was  botli  when  the  child  was  asleep  and  when  he  was 
awake.  I  have  referred  to  sleeping  and  waking  rather  than  to 
night  and  day,  for  the  diurnal  enuresis  in  some  cases  is  only 
when  the  child  happens  to  fall  asleep  in  the  daytime  ;  and  this 
is  a  point  of  some  interest  in  regard  to  the  etiology  of  nocturnal 
incontinence,  for  some  writers  have  laid  stress  on  the  concentra- 
tion and  acidity  of  the  urine  during  the  fasting  hours  of  sleep 
as  accounting  for  the  incontinence  at  night;  whereas  the  fact 
that  some  children,  when  they  fall  asleep  in  the  daytime,  even 
for  half  an  hour,  suffer  with  enuresis,  seems  to  show  that,  at 
any  rate  in  these  cases,  it  is  the  lessening  of  cerebral  control 
by  sleep  rather  than  any  special  character  of  the  urine  which 
causes  the  incontinence  to  occur  specially  in  the  night. 

When  there  is  enuresis  at  night  only  there  is  sometimes 
exaggerated  frequency  of  micturition  by  day,  and  this  frequency 
of  micturition,  evidently  indicating  some  undue  excitability  of 
the  spinal  centres,  is  not  very  uncommon  in  children  apart 
from  enuresis  altogether.  I  wish  to  lay  some  stress  on  this 
pollakiuria  occurring  without  incontinence  ;  for  its  near  relation- 
ship to  enuresis  does  not  seem  to  be  generally  recognized.  There 
are,  of  course,  cases  in  which  some  irritating  quality  in  the  urine, 
such  as  the  presence  of  uric  acid  granules,  or  oxalates,  or  bacterial 
contamination,  are  sufficient  cause  for  frequent  micturition, 
but  the  cases  to  which  I  refer  are  those  in  which  the  urine  is 
perfectly  normal,  and  it  seems  clear  that  the  condition  is  purely 
a  nervous  one  ;  moreover,  it  is  amenable  to  exactly  the  same 


ENURESIS  AND  F^CAL  INCONTINENCE          729 

sedative  treatment  as  ordinary  enuresis,  particularly  to  bella- 
donna and  its  allies. 

Diseases,  like  men,  are  often  known  by  the  company  they 
keep,  and  the  nervous  character  of  enuresis  is  more  than  hinted 
at  by  many  of  its  clinical  associations.  I  suppose  that  quite  the 
commonest  association  is  the  presence  of  threadworms  in  the 
child  with  enuresis.  How  often  one  hears  that  the  child  who 
has  recently  begun  to  wet  the  bed  has  been  going  thin  lately, 
and  has  become  '  so  nervous  ',  and  worms  have  been  found  in 
the  stools  !  But  what  is  the  connexion  between  threadworms 
and  enuresis  ?  At  first  sight  the  traditional  explanation  that 
the  local  irritation  in  the  rectum  causes  the  involuntary  emptying 
of  the  bladder  seems  likely  enough  ;  but  I  think  this  is  certainly 
not  the  whole  explanation.  One  of  the  results  of  the  presence 
of  threadworms  is  a  general  increase  of  nervous  instability,  an 
increase  which  is  often  so  striking  that  some  have  even  suspected 
that  it  may  be  due  to  some  special  poison  produced  by  these 
worms.  It  is  evident  from  other  associations  that  nervous 
instability,  however  produced,  is  a  potent  factor  in  the  causa- 
tion of  enuresis,  and  it  is  probable,  therefore,  that  the  effect  of 
worms  is  due,  at  least  in  part,  to  their  general  influence  upon  the 
nervous  system. 

Certainly,  whether  they  have  worms  or  not,  the  children  who 
suffer  with  enuresis  are  commonly  the  nervous  children.  They 
are  unduly  excitable  or  excessively  timid  ;  they  suffer  with 
1  nervous  '  headaches  easily  ;  often  they  have  night  terrors  ; 
occasionally  they  walk  in  their  sleep.  Several  times  I  have 
seen  enuresis  with  habit-spasm  of  face  or  limbs.  I  have  also 
seen  it  associated  with  that  curious  nervous  disorder  which 
is  perhaps  best  known  as  '  nervous  diarrhoea  ',  the  condition 
in  which  each  meal  causes  forthwith  an  urgent  desire  to  dc- 
fsecate,  although  the  stools  may  not  be  loose  at  all.  Incontinence 
of  fseces  also,  a  disorder  which  perhaps  even  more  constantly 
than  enuresis  is  linked  with  nervous  instability,  is  occasionally 
associated  with  enuresis.  Stuttering  is  another  nervous  disorder 
which  sometimes  keeps  company  with  enuresis — a  fact  which 
lends  support  to  the  idea  that  a  similar  defect  of  co-ordination 
may  occasionally  underlie  enuresis.  I  have  also  noted  occa- 
sionally a  history  of  convulsions  at  some  former  period  in  these 
children,  an  occurrence  which  probably  foreshadows,  in  some 
cases,  a  tendency  to  nervous  instability. 

Another  association  which  may  be  more  than  a  coincidence 
is  the  occurrence  of  enuresis  in  rheumatic  children  :  the  rheu- 


730  COMMON  DISORDERS  OF  CHILDHOOD 

matic  child  is  peculiarly  apt  to  be  a  nervous  child,  and  herein 
may  be  the  connexion  with  enuresis  ;  certainly  I  have  noted 
this  association  sufficiently  frequently  (11  times  in  the  200  cases 
mentioned)  to  make  me  always  watchful  for  rheumatism  in 
the  child  with  enuresis.  This  point  was  impressed  upon  me 
some  years  ago  by  the  case  of  a  boy  aged  seven  years, 
who  was  brought  for  enuresis.  I  found  nothing  else  abnormal 
and  treated  the  boy,  not  very  successfully,  for  several  months, 
when  he  made  some  complaint  which  made  me  re-examine  his 
chest,  and  I  found  to  my  surprise  that  quite  insidiously  he  had 
developed  well-marked  mitral  disease,  which  was  soon  accom- 
panied by  other  evidence  of  rheumatism. 

Fright  is  occasionally  the  starting-point  of  enuresis,  as  it  is 
apt  to  be  of  other  functional  nervous  disorders  in  children  : 
a  boy  aged  4|  years,  bitten  by  another  boy,  seemed  much 
frightened,  became  extremely  timid,  and  complained  of  head- 
aches, a  week  later  he  began  wetting  the  bed,  and  a  few  weeks 
later  developed  a  habit-spasm. 

In  a  few  cases  I  have  been  told  that  a  boy  with  enuresis  was 
given  to  masturbation,  and  it  seems  likely  there  may  be  some 
connexion  between  this  and  enuresis,  if  not  by  any  local  effect, 
certainly  by  the  increased  nervous  irritability  which  so  often 
accompanies  masturbation,  and  partly  by  the  impairment  of 
general  health  which  sometimes  results  therefrom. 

The  general  health  of  a  child  often  plays  a  large  part  in  the 
production  of  enuresis.  Control  may  be  perfect  so  long  as  the 
child  is  in  good  health,  but  directly  any  upset  occurs,  perhaps 
a  slight  failure  in  digestion  or  a  *  cold  ',  he  begins  to  wet  the 
bed  ;  it  is  by  no  means  uncommon  for  the  onset  of  enuresis  to 
date  from  some  acute  illness  ;  I  have  noted  its  onset  after  most 
of  the  specific  fevers. 

I  have  emphasized  the  close  relationship  between  enuresis 
and  many  of  the  common  nervous  disorders  of  children  in  order 
to  bring  into  prominence  the  fact  that  incontinence  of  urine  in 
children  is  often,  perhaps  usually,  not  merely  a  local  disorder  ; 
it  is  a  manifestation  of  general  nervous  instability,  either  tem- 
porary or  permanent. 

Nevertheless  local  causes  may  play  some  part  in  its  production. 
It  is  obvious  that  if  the  nervous  mechanism  is  barely  sufficient 
to  control  micturition  when  the  stimulus  is  only  of  normal 
degree,  it  is  likely  to  fail  if  the  stimulus  be  increased,  as  it  may 
be,  by  some  irritating  quality  of  the  urine.  It  is  customary  to 
make  much  of  excessive  acidity  of  the  urine  as  a  cause  of  enuresis. 


ENURESIS  AND  F^CAL  INCONTINENCE         731 

Now,  without  disputing  the  occasional  part  played  by  such 
acidity,  I  venture  to  think  that  it  is  a  very  exceptional  cause, 
and  that  excessive  acidity  is  often  asserted  where  there  is  no 
evidence  whatever  that  the  acidity  found  is  anything  more  than 
a  transient  occurrence,  which  could  not  account  for  the  persistent 
enuresis.  The  passage  of  uric  acid  sand  or  of  oxalates  no  doubt 
plays  a  part  occasionally  ;  but,  again,  I  doubt  whether  much 
stress  can  be  laid  on  these  unless  they  are  almost  of  daily  occur- 
rence. Sometimes  quite  unexpectedly  pyuria  will  be  found  with 
enuresis,  indicating  some  cystitis  which  may  be  the  cause  of  the 
incontinence,  but  this  order  of  sequence  must  not  be  assumed  too 
hastily.  I  have  little  doubt  that  in  girls  the  cystitis  is  sometimes 
not  the  cause,  but  the  result,  of  the  enuresis  ;  it  has  seemed  clear 
that  enuresis  was  present  long  before  the  cystitis,  and  the  under- 
clothing constantly  foul  with  decomposing  urine  has  been  a 
source  of  infection  up\vards  through  the  urethra.  Frequent 
change  of  underclothing  has  proved  beneficial  both  in  the  treat- 
ment of  the  cystitis  and  in  the  prevention  of  its  recurrence. 

Dr.  H.  Thursfield l  has  pointed  out  that  sometimes  without  any 
evidence  of  cystitis  bacteria  swarm  in  the  urine  in  cases  of 
enuresis — a  point  of  practical  importance  if  the  treatment  with 
urotropin,  which  he  recommends,  proves  to  be  successful. 

In  the  examination  of  the  urine  there  are  other  possibilities 
to  be  borne  in  mind,  rare  though  they  may  be.  Twice  I  have 
had  boys  brought  to  me  with  enuresis  when  the  urine  showed 
abundant  sugar  and  the  disease  proved  to  be  diabetes  mellitus. 
In  another  case,  where  the  enuresis  was  associated  with  great 
thirst  and  polyuria,  the  condition  proved  to  be  diabetes  insipidus 
(in  a  boy,  aged  three  years,  passing  about  8  pints  of  urine  per 
diem  with  a  specific  gravity  of  1,000).  The  enuresis  in  the  latter 
disease  seems  to  show  that  failure  of  control  of  the  bladder  may 
be  due  rather  to  the  rapid  filling  of  the  bladder  than  to  any 
irritating  quality  in  the  urine  ;  and  in  some  children  without 
any  morbid  excess  of  urine  it  seems  evident  that  so  long  as  the 
bladder  fills  but  slowly  the  urine  can  be  retained  perfectly, 
whereas  when  the  bladder  fills  more  quickly  it  becomes  intolerant 
and  enuresis  occurs.  For  this  reason,  many  children  are  more 
or  less  free  from  enuresis  in  hot  weather  in  spite  of  the  concen- 
tration of  the  urine  which  occurs  then,  whereas  in  cold  weather, 
when  the  skin  is  excreting  less  and  the  kidneys  more,  the  enuresis 
returns  or  becomes  worse. 

Prognosis.     The  outlook  in  enuresis  is  usually  good  ;    it  is 

1  Clin.  Journ..  October  11,  1905. 


732  COMMON  DISORDERS  OF  CHILDHOOD 

a  disorder  which  is  .very  prone  to  relapse,  but  it  rarely  persists 
even  as  late  as  puberty,  and  extremely  rarely  into  adult  life, 
and  even  then  I  have  known  it  to  cease  on  marriage.  Incon- 
tinence by  day  generally  responds  to  treatment  much  more 
readily  than  nocturnal  incontinence,  and  I  have  thought  that 
the  cases  with  much  frequency  of  micturition,  with  or  without 
enuresis,  are  usually  favourable  cases  for  treatment.  But  each 
case  is  a  law  unto  itself  ;  sometimes  after  resisting  treatment 
for  many  weeks  the  enuresis  will  suddenly  cease  without  apparent 
cause — perhaps  after  all  treatment  has  been  abandoned.  In 
some  cases  a  few  doses  of  belladonna  will  effect  a  permanent 
cure,  while  in  others,  apparently  no  worse,  no  drug  of  any  sort 
seems  to  have  the  least  effect.  We  may  well  be  cautious, 
therefore,  in  our  praise  of  this  or  that  mode  of  treatment,  and 
must  not  too  readily  take  credit  for  recoveries  which  may  be 
nothing  more  than  'Fortune's  testimonials'. 

Treatment.  It  is  undoubtedly  true  that  Nature,  left  to  herself, 
gradually  works  a  cure  in  many  cases  of  enuresis,  and  probably 
would  do  so  in  many  more  if  no  effort  were  made  to  cure  them 
otherwise.  But  this  seems  to  me  no  justification  for  shirking  the 
risk  of  failure  in  treatment,  and  assuring  the  parents  that  there 
is  no  need  to  adopt  any  medical  treatment,  for  the  child  *  will 
grow  out  of  it '.  Such  a  course  means  months  or  years  of  trouble 
and  expense  to  parents,  and  of  discomfort  and  misery  to  the  child 
— often  quite  unnecessarily ;  and  it  seems  only  right,  therefore, 
that  a  thorough  course  of  treatment  should  be  tried  in  every 
case  before  such  a  policy  of  despair  is  adopted. 

Failure  in  treatment  is  too  often  due  to  half-hearted  measures 
—a  bottle  or  two  of  medicine  has  been  given  in  a  desultory  way 
from  time  to  time,  but  no  settled  course  of  treatment  has  been 
thoroughly  tried.  Often  the  fault  lies  rather  with  the  parents 
than  with  the  doctor  ;  they  will  not  give  the  opportunity  for  a 
course  of  treatment,  which  must  necessarily  extend  over  several 
weeks — perhaps  over  two  or  three  months  ;  and  unless  this 
is  clearly  understood  at  the  outset  the  result  is  likely  to  be  only 
disappointment  for  all  concerned. 

Before  deciding  on  the  mode  of  treatment  the  urine  will 
have  to  be  examined,  and  I  must  confess  that  my  own  experience 
has  been  that,  although  occasionally  some  abnormality  may 
be  found  in  the  urine,  in  the  vast  majority  of  cases  the  urine 
is  perfectly  normal  and  gives  no  guidance  whatever.  Occasionally 
a  concentrated  acid  urine  may  call  for  the  use  of  potassium 
citrate  ;  the  presence  of  uric  acid  crystals  may  be  met  by  cutting 


ENURESIS  AND  F^CAL  INCONTINENCE         733 

down  the  carbo-hydrates  as  far  as  practicable — a  measure  which 
I  believe  to  be  more  useful  in  such  cases  than  cutting  off  meat 
and  other  nitrogenous  food,  as  is  usually  done  ;  or  again,  the 
presence  of  pus  or  bacteria  in  the  urine  may  indicate  the  need 
for  urotropin,  which  can  be  given  to  a  child  of  about  five  years 
in  doses  of  4  to  5  grains  three  times  a  day. 

Far  more  often  an  important  indication  for  treatment  is 
found  in  the  presence  of  threadworms,  and  I  think  it  is  often 
wise  even  when  their  presence  is  denied  to  give  one  dose  of 
santonin  gr.  i-ij  with  calomel  gr.  j-ij  according  to  the  age  to 
make  this  point  certain,  for  there  is  little  chance  of  stopping 
enuresis  whilst  worms  are  present. 

In  the  majority  of  cases,  however,  no  exciting  cause  offers 
itself  for  treatment,  and  then  nothing  is  more  generally  useful 
than  the  time-honoured  belladonna.  But  to  obtain  the  best 
results  from  belladonna  it  must  be  given  on  a  definite  plan,  and 
for  a  period  of  several  weeks.  The  random  bottle  of  belladonna 
is  responsible  for  much  discredit  in  the  treatment  of  enuresis. 
The  parents  should  be  given  to  understand  at  the  outset  that  the 
drug  is  a  potent  one,  and  that  the  child  must  be  seen  at  intervals 
of  a  few  days  by  the  doctor  in  order  that  the  dosage  may  be 
carefully  increased  as  the  child  is  able  to  tolerate  it.  If  this 
is  clearly  understood  there  is  some  hope  of  doing  good  with 
belladonna. 

Many  failures  are  due  to  the  use  of  doses  which  are  far  too 
small.  I  have  seen  cases  given  up  as  incurable  in  which  no  more 
than  5  minims  of  the  tincture  three  times  a  day  had  been  tried. 
Children  usually  tolerate  belladonna  well,  and  at  any  period 
beyond  infancy  5  minims  of  the  tincture  should  only  be  con- 
sidered as  an  initial  dose.  If  the  parents  are  intelligent  and  are 
forewarned  of  the  possible  toxic  symptoms,  it  is  usually  safe 
to  begin  with  10  minims  for  a  child  over  five  years  of  age.  The 
dose  should  be  increased  by  2J  minims  every  fifth  or  sixth  day 
until  either  the  enuresis  is  stopped  or  the  limit  of  tolerance  is 
reached. 

If  the  enuresis  is  controlled,  say  by  17  \  minims  three  times 
a  day,  it  is  well  to  '  make  assurance  doubly  sure  '  by  pushing 
the  dose  slightly  further  by  an  additional  2J  minims,  if  tolerance 
allows.  The  dose  should  be  maintained  at  this  level,  just  beyond 
the  minimum  efficient  dose,  for  a  fortnight,  and  then  reduced 
by  decreases  of  2J  minims  once  a  week  and  so  gradually 
discontinued. 

A  word  of  caution  with  regard  to  belladonna  :    children,  like 


734  COMMON  DISORDERS  OF  CHILDHOOD 

adults,  have  their  idiosyncrasies  to  drugs,  and  while  some  will 
tolerate  30  minims  of  the  tincture  of  belladonna  three  times  a 
day,  I  have  occasionally  met  with  marked  intolerance  even  of 
so  small  a  dose  as  5  minims.  Another  caution  which  applies 
especially  to  such  a  drug  as  this  :  see  that  the  dose  is  measured 
with  a  medicine  glass,  not  with  a  spoon  ;  the  domestic  teaspoon 
will  often  hold  2  drachms,  sometimes  as  much  as  3  drachms. 
Nor  is  even  a  medicine  glass  necessarily  reliable  if  it  be  one 
of  the  cheap  measures  which  are  often  used.  I  found  in  one 
case  that  a  drachm  dose  measured  by  a  cheap  medicine  glass 
was  actually  2  drachms,  and  smaller  errors  were  found  to  be 
quite  common. 

There  are  many  cases  in  which,  after  the  belladonna  has  been 
pushed  up  to  17 J  or  20  minims  with  decided  diminution  of  the 
enuresis,  the  disorder  is  still  not  completely  controlled,  and  yet 
any  further  increase  of  the  belladonna  produces  toxic  symptoms 
which  are  sufficient  at  any  rate  to  alarm  the  parents.  Under 
these  circumstances  a  useful  procedure  is  to  keep  the  belladonna 
at  the  topmost  dose  which  is  well  tolerated,  and  to  combine 
with  it  tincture  of  lycopodium,  12J  minims  at  first,  with  increases 
of  2J  minims  as  may  be  required.  A  child  will  usually  take 
20  minims  of  this  drug  without  ill  effect,  sometimes  more,  and 
certainly  in  some  cases  with  most  gratifying  result. 

The  liquor  atropinse  has  been  recommended  by  some  as  more 
effectual  than  the  tincture  of  belladonna,  but  it  must  be  remem- 
bered that  in  respect  of  alkaloids  1  minim  of  the  liquor  atropinse 
is  equivalent  to  28  minims  of  the  tincture  of  belladonna  ;  and 
I  suspect  that  the  supposed  greater  efficacy  of  the  atropine  solu- 
tion is  due  to  the  fact  that  a  stronger  dose  is  used  rather  than 
to  any  intrinsic  difference  between  the  two  drugs.  It  is,  however, 
possible  that  some  difference  in  the  action  of  these  two  drugs 
may  exist,  if  the  tincture  of  belladonna  contains,  as  is  said, 
hyoscyamine  and  little  or  no  atropine.  I  have  used  the  liquor 
atropinse  and  seen  good  results  from  it,  using  it  in  increasing 
doses,  and  commencing  with  J  minim  ;  but  toxic  results  are  apt 
to  occur  when  1  minim  is  reached  ;  and  on  the  whole  it  has 
seemed  to  me  less  convenient  for  manipulation  of  the  dosage 
than  the  belladonna  tincture,  without  any  compensatory  advan- 
tage. With  either  drug  the  occurrence  of  dryness  of  the  throat, 
which  children  sometimes  describe  as  '  sore  throat ',  or  much 
flushing,  or  complaint  of  dimness  of  vision,  and  even  more,  any 
indication  of  delirium,  make  it  advisable  to  reduce  the  dose 
just  sufficiently  to  avoid  these  symptoms. 


ENURESIS  AND  F^CAL  INCONTINENCE         735 

As  an  addition  to  the  belladonna  and  lycopodium,  whether 
these  are  used  together  or  separately,  mix  vomica  is  undoubtedly 
helpful ;  some,  indeed,  use  nux  vomica  alone  and  find  it  effectual. 
The  tincture  of  nux  vomica  should  be  used  in  large  doses,  for 
instance,  6  minims  for  a  child  aged  five  years.  Occasionally 
potassium  bromide  or  phenazone  will  succeed  where  belladonna 
has  failed  ;  I  have  tried  in  vain  to  find  any  feature  in  the  case 
which  might  indicate  when  these  are  likely  to  be  useful ;  one 
might  have  thought  that  a  high  degree  of  '  nervousness '  would  be 
an  indication,  but  this  apparently  forms  no  reliable  gauge,  and 
success  may  be  obtained  with  them  where  least  expected.  Another 
drug,  which  will  sometimes  succeed  where  belladonna  fails,  is 
the  fluid  extract  of  rhus  aromatica.  The  dosage  is  much  the 
same  as  that  of  the  tincture  of  belladonna.  Ten  minims  three 
times  a  day  may  be  given  to  a  child  aged  five  years,  and  the 
dose  can  be  increased  gradually  up  to  20  or  25  minims,  but  1 
have  known  it  to  produce  sickness  when  a  15-mimm  dose  was 
reached.  Like  belladonna  this  drug  will  sometimes  stop  enuresis 
almost  at  once,  in  other  cases  it  fails  completely.  In  a  boy 
aged  seven  years,  to  whom  I  had  given  tincture  of  belladonna 
in  doses  gradually  increased  up  to  20  minims  three  times  a  day 
without  success,  the  fluid  extract  of  rhus  aromatica,  12  minims 
three  times  a  day,  stopped  the  enuresis  at  once.  In  a  girl  aged 
seven  years,  who  had  had  enuresis  three  weeks,  the  enuresis 
ceased  permanently  after  a  week's  treatment  with  fluid  extract 
of  rhus  aromatica,  20  minims  three  times  a  day. 

Excellent  results  also  have  followed  the  use  of  ergot  in  some 
cases  which  I  had  found  most  intractable  with  other  drugs. 
To  a  child  aged  five  years,  20  minims  of  the  liquid  extract  can 
be  given  three  times  a  day,  and  for  an  older  child  30  minims 
is  a  suitable  dose.  I  usually  combine  nux  vomica  with  it. 

At  one  time  I  used  the  liquid  extract  of  salix  nigra  extensively, 
having  found  it  useful  in  cases  of  masturbation,  and  arguing 
that  it  might,  therefore,  have  some  sedative  effect  on  the  spinal 
centres  which  would  be  of  value  in  enuresis  ;  the  results,  how- 
ever, did  not  justify  my  hopes. 

Turning  now  from  the  drug  treatment  to  other  measures, 
I  shall  utter  a  word  of  protest  against  certain  procedures  which 
have  been  advocated  in  recent  years.  We  are  told  that  good 
results  have  followed  the  application  of  silver  nitrate  to  the 
urethra  or  to  the  neck  of  the  bladder  ;  that  a  course  of  massage 
of  the  sphincter  of  the  bladder  by  a  finger  in  the  rectum  has  also 
done  good  ;  that  injection  of  various  fluids  into  the  sacral 


736  COMMON  DISORDERS  OF  CHILDHOOD 

portion  of  the  spinaj  canal,  or  even  into  the  tissues  outside 
the  canal,  has  cured  this  disorder. 

I  do  not  doubt  the  sequence,  but  I  do  doubt  very  gravely  the 
desirability  of  any  such  measures,  some  of  which  not  only  savour 
of  quackery,  but  involve  a  totally  unnecessary  infliction  of 
distress  and  pain.  It  is  clear  that  in  enuresis,  as  in  other  func- 
tional nervous  disorders,  there  is  a  large  psychical  element, 
and  as  these  disorders  may  sometimes  be  induced,  so  also  they 
may  sometimes  be  stopped,  by  any  profound  psychical  im- 
pression ;  hence  enuresis  will  sometimes  cease  after  any  surgical 
operation,  just  as  it  will  cease  sometimes  after  smart  corporal 
punishment.  The  latter  mode  of  treatment  is  generally  con- 
demned, and  rightly  so,  for  even  if  it  were  often  successful — it 
is  as  likely  to  do  harm  as  good — it  would  still  be  liable  to  serious 
abuse,  and,  as  every  one  knows,  has  led  to  gross  cruelty.  The 
manipulative  and  surgical  procedures  to  which  I  have  alluded 
are  certainly  quite  unnecessary  in  the  vast  majority  of  cases, 
and  if  the  disorder  be  so  obstinate  that  it  is  advisable  to  try 
the  effect  of  psychical  impression,  a  much  less  objectionable 
method  is  the  application  of  the  galvanic  current,  one  pole 
over  the  sacrum  and  one  over  the  pubes,  a  mode  of  treatment 
which  is  not  only  free  from  danger,  but  is  also  said  to  be  effectual 
in  some  cases. 

In  this  connexion  I  must  mention  two  operations  which  are 
sometimes  recommended  as  if  they  were  almost  specific  in  the 
treatment  of  enuresis,  namely,  removal  of  adenoids  and  circum- 
cision. It  seems  likely  enough  that  the  child  wrhose  health  is 
being  impaired  by  chronic  starvation  of  air,  through  naso- 
pharyngeal  obstruction,  may  have  not  only  his  general  health, 
but  also  his  nervous  stability,  and  therewith  his  control  of 
micturition,  improved  by  removal  of  adenoids.  But  even  this 
I  cannot  affirm  from  my  own  experience,  and  I  suspect  that  when 
cessation  of  enuresis  follows  removal  of  adenoids,  it  may  be  due 
simply  to  psychical  impression,  and  that  any  other  operation 
would  have  done  equally  well.  I  have  known  most  intractable 
enuresis  stop  the  very  night  after  removal  of  adenoids,  but 
within  a  few  weeks  it  was  as  bad  as  ever  again — surely  an  instance 
of  profound  psychical  impression.  Again  and  again  I  have 
known  adenoids  removed  without  the  least  effect  on  enuresis. 
I  have  sometimes,  as  a  matter  of  interest,  treated  enuresis  by 
drugs  with  success  before  adenoids  were  removed,  in  order 
to  demonstrate  the  curability  of  the  disorder  apart  from  any 
operation  on  adenoids.  Circumcision  similarly  has  usually  no 


ENURESIS  AND  FAECAL  INCONTINENCE         737 

beneficial  effect  whatever  on  enuresis.  I  have  even  known 
enuresis  apparently  started  by  circumcision,  and  I  have  known 
it  to  become  worse  after  circumcision  ;  but  I  doubt  not  that 
the  boy  who  is  cured  by  the  pain  or  nervous  shock  of  corporal 
punishment  might  be  cured  equally  well — or  rather,  equally 
badly — by  the  psychical  impression  produced  by  circum- 
cision. 

Lastly,  I  ^must  refer  to  the  general  management  of  these 
cases.  It  is,  I  think,  seldom  necessary  to  restrict  greatly  the 
amount  of  fluid  which  the  child  may  take  in  the  forenoon,  but 
during  the  latter  half  of  the  day  it  should  be  limited,  especially 
at  the  last  meal,  and  after  this  none  should  be  allowed.  Tea  and 
coffee  are  to  be  forbidden  altogether,  partly  on  account  of  their 
diuretic  effect  and  partly  because  of  their  exciting  effect  upon 
the  nervous  system.  In  most  cases  I  do  not  think  there  is 
much  to  be  gained  by  any  rigorous  dieting,  but  where  there  is — 
as  is  so  exceedingly  common — difficulty  in  digesting  carbo- 
hydrates, or  a  condition  of  intestinal  catarrh,  such  as  Dr.  Eustace 
Smith  has  called  '  mucous  disease  ',  I  am  satisfied  that  the 
reduction  of  starch  and  sugar,  and  especially  the  exclusion  of 
potato  and  raw  fruit,  are  decidedly  helpful.  I  have  known 
enuresis  to  stop  at  once  when  green  vegetables  and  fruit  were 
stopped  altogether  and  potato  reduced  to  an  extremely  small 
amount  ;  possibly  the  presence  of  triple  phosphates  in  the 
urine,  where  the  reaction  is  neutral  or  alkaline,  from  fixed 
alkali  not  from  ammoniacal  decomposition,  may  be  an  indication 
for  this  line  of  treatment. 

The  effect  of  school  on  these  children  is  worth  considering. 
Schooling,  if  it  entails  worry  and  mental  strain,  seems  to  per- 
petuate the  enuresis  in  some  cases.  Boarding-school  has  seemed 
to  me  most  unsuitable  for  them  on  every  ground  :  if  the  child's 
weakness  is  cause  of  ridicule  at  a  school,  whether  from  teachers 
or  school-fellows,  the  sooner  the  child  is  removed  from  that 
school  the  better.  In  hospital  practice  one  hears  too  often  that 
a  child  has  asked  the  teacher  for  permission  to  leave  the  room 
and  has  been  refused,  and  consequently  has  wetted  his  clothes. 
In  such  a  case  it  is  not  the  child  but  the  teacher  who  ought  to 
be  ashamed  of  himself,  and  parents  should  be  advised  to  take 
steps  to  prevent  ill-treatment  of  this  kind. 


STILL  3  B 


738  COMMON  DISORDERS  OF  CHILDHOOD 

Incontinence  of  Faeces 

Incontinence  of  faeces,  that  is,  apart  from  organic  nervous 
disease  and  mental  deficiency,  is  much  less  common  than  incon- 
tinence of  urine,  but  is  near  akin  to  it,  and  sometimes  associated 
with  it.  So  far  as  my  own  experience  goes,  boys  would  seem  to 
be  much  more  liable  to  it  than  girls  ;  out  of  20  consecutive 
cases  16  were  boys,  only  4  were  girls.  Like  enuresis  it  may  be 
a  persistence  of  the  infantile  lack  of  voluntary  control,  or  may 
be  an  acquired  disorder  ;  in  13  out  of  19  cases,  in  which  I  ascer- 
tained this  point,  the  incontinence  was  acquired,  and  in  9  of 
these  the  onset  was  between  the  ages  of  six  and  nine  years. 
It  was  associated  with  enuresis  in  13  out  of  the  20  cases  ;  but 
even  when  this  is  so  the  faecal  incontinence  is  usually  by  day 
onty,  whereas  the  enuresis,  if  it  be  not  both  in  day  and  night, 
is  in  the  night  only. 

In  the  etiology  of  faecal  incontinence  nervous  instability 
plays  at  least  as  large  a  part  as  in  enuresis  ;  almost  all  the 
children  with  this  disorder  are  highly  '  nervous  '  children,  and 
often  show  other  manifestations  of  their  nervous  temperament, 
such  as  night  terrors,  insomnia,  stuttering,  habit-spasm,  and 
I  have  seen  it,  like  enuresis,  associated  with  rheumatism. 

But,  as  in  urinary  incontinence,  there  is  often  a  local  exciting 
cause  in  some  abnormal  condition  of  the  intestinal  contents  ; 
the  stools,  without  being  actually  diarrhoeal,  are  abnormally 
offensive,  or  slimy,  or  perhaps  fermenting  ;  the  bowels,  in  some 
cases,  are  open  two  or  three  times  a  day,  and  most  often  are 
inclined  to  be  loose,  but  there  may  be  no  looseness  whatever. 
The  bowels  in  some  of  my  cases  were  only  open  once  a  day,  and 
sometimes  the  stools  were  of  constipated  character. 

I  have  mentioned  the  frequency  of  micturition  which  sometimes 
accompanies,  and  sometimes  occurs  altogether  apart  from 
enuresis.  It  has  seemed  to  me  that  there  is  a  very  similar 
condition  related  to  faecal  continence,  namely,  the  so-called 
'  nervous  diarrhoea  '  or  '  lienteric  diarrhoea  ' — misleading  names, 
for  the  stools  are  not  necessarily  loose  at  all ;  the  only  charac- 
teristic feature  is  urgency  of  defaecation  directly  a  meal  is  taken  ; 
the  presence  of  food  in  the  intestine  seems  to  excite  an  expulsive 
effort  at  once,  just  as  the  presence  of  a  very  small  quantity  of 
urine  in  the  bladder  excites  micturition  in  the  cases  of  so-called 
'  pollakiuria  '. 

This  nervous  disorder  of  the  bowels,  though  usually  found 
apart  from  incontinence  of  any  sort,  is  associated  in  some  cases 


ENURESIS  AND  KECAL  INCONTINENCE         739 

with  faecal,  and  in  others  with  urinary,  incontinence  ;  moreover, 
its  affinity  for  both  these  disorders  is  suggested  by  its  frequent 
association  with  those  manifestations  of  nervous  temperament 
which  I  have  mentioned  as  frequent  with  urinary  and  faecal 
incontinence.  It  is  readily  amenable  also  to  the  same  treatment 
as  is  required  for  incontinence  of  faeces. 

This  incontinence  is  much  more  easily  checked  than  is  enuresis  ; 
indeed,  in  the  majority  of  cases,  even  when  it  has  been  present 
for  weeks,  a  few  days'  treatment  will  set  it  right.  There  is, 
however,  a  tendency  to  relapses,  which  may  occur  more  than  once 
after  several  months  of  perfect  control. 

Treatment.  The  most  effectual  treatment,  in  my  experience, 
is  the  administration  of  Dover's  Powder,  in  doses  of  1J  to  3  gr. 
three  times  a  day,  according  to  the  age  of  the  child,  and  a  mixture 
of  belladonna  with  potassium  bromide,  to  which  arsenic  and  nux 
vomica  may  usefully  be  added  in  some  cases.  At  the  same  time 
all  food  likely  to  irritate  the  bowel,  especially  fruit,  fresh  or 
dried,  must  be  prohibited  ;  and  all  drink  should  be  given  either 
cold  or  only  just  warm.  The  injection  of  drugs  into  the  tissues 
about  the  rectum,  as  has  been  done,  seems  to  me  to  be  an  entirely 
unnecessary  infliction  of  pain. 


3B2 


CHAPTER  LI 
DISORDERS  OP  SPEECH 

FOR  the  better  understanding  of  the  disorders  of  speech 
which  are  met  with  in  childhood  I  shall  mention  first  some 
facts  in  connexion  with  the  development  of  speech. 

The  first  indication  of  speech  is  the  lalling  which  a  normal 
infant  begins  at  about  four  months  old.  That  this  is  a  real 
attempt  at  imitation  of  speech  is,  I  think,  shown  by  the  fact 
that  the  easiest  way  to  induce  an  exhibition  of  this  baby-prattle 
is  to  talk  to  the  infant.  The  sounds  which  are  made  in  this 
earliest  infant-speech  are  labial  sounds  :  lul-lul-lul  or  bub-bub- 
bub  or  mum-mum-mum  :  while  at  a  later  period  other  sounds 
are  formed,  such  as  goo-goo,  de-de,  da-da  at  eight  or  nine 
months  old. 

After  a  few  weeks  there  is  added  to  this  simple  repetition  of 
a  syllable  some  inflection  of  voice,  which  marks  a  further  stage 
in  the  approach  to  actual  words.  At  the  age  of  six  or  seven 
months  the  child  begins  to  associate  persons  with  names  ;  I  mean 
that  it  understands  which  is  Mamma  and  which  is  Dadda  when 
these  words  are  used  :  and  I  have  been  assured  confidently  by 
a  mother  that  her  infant  actually  said  '  Mamma  '  between  the 
ages  of  five  and  six  months  ;  but  if  so  this  is  certainly  quite 
exceptional.  More  often  at  the  age  of  nine  or  ten  months  the 
child  is  still  in  the  stage  of  lalling,  but  as  I  have  said  is  forming 
guttural  and  dental  sounds  as  well  as  the  labials. 

Between  ten  months  and  twelve  months  many  infants  begin 
to  say  such  simple  words  as  '  Mamma  ',  '  Dadda',  with  evident 
understanding  of  their  application,  and  by  fourteen  months  an 
infant  should  be  saying  many  simple  words,  such  as  '  up  '  and 
'go',  easily.  About  the  age  of  eighteen  months  an  infant 
should  form  simple  sentences,  such  as  '  Baby  go  tata  '. 

The  normal  development  of  speech  depends  upon  several 
factors.  There  must  be  not  only  the  speech  centre  presiding 
over  the  motor  mechanism  of  speech,  but  also  the  auditory 
centre  with  all  that  appertains  to  the  perception  of  sound,  the 
perfect  hearing  and  interpreting  of  which  constitutes  the  basis 
of  speech  ;  the  visual-perceptive  centre  must  play  its  part : 


DISORDERS  OF  SPEECH  741 

moreover,  there  must  be  adequate  connexions  between  these 
centres,  and  above  and  over  all,  utilizing  and  co-ordinating 
them  must  be  that  function  which  we  recognize  as  intellect. 

Most  of  the  disorders  of  speech  can  readily  be  referred  to 
failure  in  one  or  other  of  these  contributing  functions  :  failure 
which,  nevertheless,  is  seldom  an  insuperable  bar  to  the  acquisi- 
tion of  speech,  for  Nature  has  so  carefully  safeguarded  the  all- 
important  means  of  communication  which  distinguishes  Homo 
Sapiens  from  the  lower  animals,  that  where  hearing  is  absent, 
speech  can  still  be  taught  by  employing  visual  and  tactile  sensa- 
tion to  educate  the  mechanism  of  speech,  and  even  where  sight 
and  hearing  are  both  absent  it  is  still  possible  by  tactile  sensation 
alone  to  cultivate  the  power  of  speech,  as  was  proved  by  the 
famous  case  of  Laura  Bridgman,  the  blind  and  deaf  child. 

In  the  few  remarks  which  I  shall  make  here  upon  the  disorders 
of  speech  I  shall  refer  first  to  certain  anomalies  in  its  develop- 
ment, and  then  pass  on  to  mention  some  of  the  acquired  disorders 
of  speech  in  children. 

Absence  of  speech.  Children  are  often  brought  to  the 
medical  man  because  at  the  age  of  two  years  or  more  they 
have  not  begun  to  talk.  What  are  the  possibilities  which  must 
be  considered  ? 

1.  Simple  delay  of  development.  Let  it  be  remembered 
that  the  time  of  first  talking,  like  the  time  of  eruption  of  teeth 
or  of  learning  to  walk,  has  normally  a  considerable  range  of 
variation,  some  infants  will  say  words  fairly  distinctly  at  ten 
months,  others  equally  intelligent  and  healthy  will  say  nothing 
until  the  age  of  eighteen  months,  or  even  several  months  later. 
In  some  cases  this  appears  to  be  due  to  what  one  might  term 
physiological  laziness,  or  perhaps  to  the  absence  of  what  the 
Germans  expressively  term  the  '  Sprechlust ',  the  instinctive 
desire  to  talk. 

The  child  shows  a  quick  understanding  perhaps  of  what  he 
hears,  but  when  he  wants  to  draw  attention  to  an  object  or  to 
ask  for  anything,  instead  of  attempting  to  name  it  he  makes  an 
inarticulate  grunting  noise  and  points  to  the  object,  and  perhaps 
at  the  same  time  pulls  his  nurse  or  mother  towards  it,  or 
describes  what  he  wants  by  a  kind  of  dumb  show.  Such 
children,  even  when  they  have  begun  to  say  a  few  words,  will 
often  continue  for  many  months  to  make  use  of  the  inarti- 
culate grunts  and  pointing  or  dumb  show,  whenever  they  can 
thus  avoid  the  use  of  words,  and  sometimes  if  they  are  shown 
that  their  wish  will  not  be  obtained  until  the  required  word  is 


742  COMMON  DISORDERS  OF  CHILDHOOD 

used  they  will  promjtfly  articulate  the  word  distinctly  and  as 
quickly  relapse  into  grunts  and  pointing  if  they  think  they  can 
get  what  they  want  without  the  trouble-  of  speaking.  I  have 
several  times  noticed  this  delay  in  the  development  of  speech 
to  occur  in  families,  e.g. 

A  girl,  aged  2|  years,  would  never  talk  unless  obliged  to  do  so  by  failing 
otherwise  to  get  her  desire,  she  preferred  to  make  a  noise  like  '  um  ',  '  um', 
and  point  to  the  object  to  which  she  wished  to  draw  attention.  She  was 
a  bright  intelligent  child,  and  about  two  years  later  talked  as  freely  and  well 
as  any  ordinary  child.  Her  .brother,  about  four  years  younger,  and,  therefore, 
born  too  long  afterwards  to  have  been  influenced  by  her  example,  showed 
an  exactly  similar  unwillingness  to  talk  ;  at  the  age  of  two  years  he  would 
never  use  an  articulate  word  if  he  could  avoid  it. 

Another  type  of  simple  delay  is  that  in  which  there  is  no 
attempt  at  speech  until  long  past  the  usual  age,  perhaps  not 
until  two  or  three  years  old  and  then  quite  suddenly,  so  that 
the  day  or  even  the  hour  can  be  fixed,  the  child  begins  to  talk 
almost  fluently.  Mr.  Edmund  Gosse,  in  his  recent  volume 
Father  and  Son,  writes,  '  I  was  slow  to  speak.  I  used  to  be 
told  that  having  met  all  invitations  to  repeat  such  words  as 
"  Papa  "  and  "  Mamma  "  with  gravity  and  indifference,  I  one 
day  drew  towards  me  a  volume  and  said  'book'  with  startling 
distinctness.' 

A  more  striking  example  of  the  sudden  acquisition  of  speech 
at  a  later  age  has  been  recorded  by  Dr.  Bastian1.  I  quote  it 
in  full  : 

The  patient  was  the  son  of  a  leading  barrister,  he  was  then  twelve  years 
old  and  had  been  subject  to  fits  at  intervals.  The  first  fits  occurred  in  infancy 
when  the  patient  was  about  nine  months  old.  Towards  the  end  of  the  second 
year  these  fits  seemed  to  have  ceased,  and  the  child  appeared  sufficiently 
intelligent,  to  be  well,  in  fact,  in  all  respects  except  that  he  did  not  talk. 
When  nearly  five  years  old,  the  little  fellow  had  not  spoken  a  single  word, 
and  about  this  time  two  eminent  physicians  were  consulted  in  regard  to  his 
'dumbness'.  But  before  the  expiration  of  twelve  months,  as  his  mother 
reports  on  the  occasion  of  an  accident  happening  to  one  of  his  favourite  toys, 
he  suddenly  exclaimed  '  What  a  pity ! '  though  he  had  never  previously  spoken 
a  single  word.  The  same  words  could  not  be  repeated  nor  were  others  spoken, 
notwithstanding  all  entreaties,  for  a  period  of  two  weeks.  Thereafter  the  boy 
progressed  rapidly  and  speedily  became  most  loquacious. 

As  another  instance  which,  although  not  illustrating  the  sudden 
acquisition  of  speech,  may  serve  to  prevent  pessimism  in  prog- 
nosis in  cases  of  delayed  speech  development,  I  may  quote  the 
history  of  a  girl  whom  I  first  saw  when  she  was  under  the  care 
of  my  colleague,  Dr.  Voelcker  (he  has  recorded  the  case  fully  in 
1  Aphasia  and  other  Speech  Defects,  p.  5,  Lond.,  1898. 


DISORDERS  OF  SPEECH  743 

the  Transactions  of  the  Clinical  Society,  vol.  xxxiii),  she  was  then 
aged  seven  years  and  did  not  talk  at  all,  beyond  saying  '  Eh » 
and  imitating  a  few  simple  sounds  such  as  '  bee  ',  '  baa',  *  bye' 
and  4  gee  '. 

She  had  had  convulsions  up  to  the  age  of  three  years,  but 
not  since  ;  she  had  learnt  to  walk  at  twelve  months.  I  saw 
this  child  again  at  the  age  of  fourteen  years,  her  speech  was  then 
perfectly  fluent  and  showed  nothing  abnormal  and  the  girl 
seemed  of  average  intelligence. 

2.  Defective  intellect  causing  delay  of  speech  development. 
Judging  from  my  hospital  experience  I  should  say  that  the 
commonest  cause  of  delay  of  speech  development  beyond  the 
end  of  the  second  year  is  mental  deficiency.     Almost  all  im- 
beciles and   mentally  defective  children  are  late   in  acquiring 
speech,  often  making  no  attempt  to  talk  at  four  or  five  years 
old,  and  when  they  do  speak  the  articulation  is  usually  very 
imperfect.     But  in  these  cases  also  it  is  seldom  necessary  to  give 
a  gloomy  prognosis  as  to  the  ultimate  acquirement  of  speech  : 
the  large  majority  of  mentally  defective  children,  almost  all 
indeed  except  the  most  fatuous  of  idiots,  learn  to  talk  eventu- 
ally, and  it  is  remarkable  how  much  their  articulation  can  be 
cultivated  by  patient  and  skilful  teaching. 

I  have  elsewhere  quoted  figures  furnished  to  me  by  Dr.  Calde- 
cott,  of  Earlswood  Asylum,  showing  that  out  of  442  imbeciles 
only  87 — that  is  19-6  per  cent.,  failed  ultimately  to  acquire  speech. 

Dr.  Shuttleworth's  figures  at  the  Royal  Albert  Asylum, 
Lancaster,  showed  complete  absence  of  speech  only  in  13  out 
of  589  imbeciles,  but  95  others  made  only  slight  attempts  or 
a  few  articulate  sounds,  so  that  altogether  108,  that  is  18-3  per 
cent.,  could  hardly  be  said  to  talk. 

3.  Deaf-mutism.     Next  to  deficiency  of  intellect,  I  should  say 
that  deafness  is  the  commonest  cause  of  inability  to  talk,  and 
the  deafness  may  have  been  acquired  or  it  may  be  congenital. 
Rather  over  50  per  cent,  of  the  cases  of  deaf -mutism  are  due  to 
acquired  deafness. 

It  is  noteworthy  that  the  deafness  which  causes  failure  of 
speech  development  is  not  necessarily  complete.  I  have  seen 
cases  in  which  it  was  quite  clear  that  the  child  heard  sounds 
if  they  were  particularly  loud  or  of  a  particular  character,  but 
did  not  hear  voice  sounds  with  sufficient  distinctness  to  imitate 
them,  and  consequently  did  not  learn  to  talk.  In  this  connexion 
I  should  like  to  point  out  also  what  I  think  is  not  generally 
recognized,  that  imperfect  speech,  for  instance,  clipping  the 


COMMON  DISORDERS  OF  CHILDHOOD 

ends  of  words  so  as  to  say  '  Ca  '  for  cat,  and  £  do  '  for  doll,  is 
sometimes  due  to  imperfect  hearing  :  speech  is  normally  acquired 
by  imitating  the  sounds  heard  in  the  speech  of  others,  arid  if 
the  child  catches  these  sounds  only  imperfectly  it  is  natural 
enough  that  he  should  reproduce  them  imperfectly. 

Otitis  media  is  so  common  in  infancy  that  it  is  only  remarkable 
that  deafness  is  not  more  frequent  than  it  is  :  any  acute  illness, 
but  especially,  any  catarrhal  condition  of  the  naso-pharynx, 
may  lead  to  otitis  media  ;  all  the  specific  fevers,  especially 
measles  and  scarlet  fever,  are  at  times  complicated  by  it.  But 
an  acquired  deafness  is  not  always  due  to  ear  disease,  there  are 
cases  in  which  deafness  and  consequent  mutism  are  the  result 
of  posterior  basic  meningitis  :  the  deafness  is  then  probably 
of  central  origin  like  the  blindness  which  is  left  by  this  disease  ; 
but  unlike  the  blindness,  which  usually  disappears  after  several 
months,  the  deafness  remains  permanent  and  complete. 

Posterior  basic  meningitis  is  most  frequent  in  the  first  year 
of  life  and  therefore  before  speech  has  been  acquired,  but  if  it 
occur  in  the  second  year  of  life  when  the  child  has  already 
begun  to  talk,  the  limited  vocabulary  which  has  already  been 
acquired  is  usually  lost  and  the  child  remains  dumb  unless 
taught  by  special  methods.  Such  a  case  was  the  following  : 

Lily  H.,  aged  four  years,  was  a  healthy  child  and  was  talking  well  at  the  age 
of  two  and  a  half  years,  when  she  became  acutely  ill  one  day  with  vomiting  and 
screaming,  and  next  day  had  marked  retraction  of  the  head  and  some  general 
opisthotonos,  which  lasted  for  four  weeks  with  frequent  vomiting;  during  this 
time  sight  was  lost  and  she  ceased  to  talk.  There  was  apparently  no  ear- 
affection. 

Eighteen  months  later,  there  was  no  evidence  of  hydrocephalus,  the  child 
seemed  perfectly  intelligent,  sight  had  completely  recovered,  but  the  child  was 
a  deaf  mute,  hearing  wtas  entirely  lost. 

Congenital  deafness  is  responsible  for  absence  of  speech 
development  in  the  remaining  portion  .of  this  group.  The 
deafness  is  dependent  sometimes  on  congenital  abnormalities 
of  the  internal  ear,  more  often  probably  upon  abnormalities 
of  the  auditory  centre  in  the  brain.  Deaf-mutism  from  this 
cause  shows  a  remarkable  tendency  to  run  in  families  :  there 
was  in  the  Children's  Hospital,  Great  Ormond  Street,  a  boy 
who  was  a  congenital  deaf-mute  ;  he  was  one  of  a  family  of 
eight  children  ;  five  boys  and  three  girls  :  four  of  the  boys, 
and  one  of  the  girls  were  deaf-mutes. 

Congenital  word-deafness.  This  curious  condition  is  presum- 
ably allied  in  its  pathology  to  the  cases  of  congenital  deaf- 
mutism  but  differs  in  the  site  of  the  abnormality.  The  auditory 


DISORDERS  OF  SPEECH  745 

centre  would  seem  to  be  normal  but  there  is  no  adequate  con- 
nexion between  this  and  the  part  of  the  brain  which  should 
interpret  what  is  heard ;  the  child  hears  speech  but  it  conveys  ho 
meaning,  so  that  the  child  pays  no  special  heed  to  it,  and  there- 
fore is  easily  mistaken  for  a  deaf  child.  Moreover,  as  words 
mean  nothing  to  him,  he  naturally  makes  little  or  no  effort  to 
imitate  them,  and  so  does  not  learn  to  talk. 

The  child  with  congenital  word-deafness  often  appears  abso- 
lutely blank  when  spoken  to,  indeed  might  be  '  stone-deaf ' 
for  all  the  notice  he  takes,  but  let  a  clock  strike  or  a  musical- 
box  play  and  at  once  it  is  evident  that  the  child  hears  and  takes 
interest  :  moreover,  it  is  clear  in  some  of  these  cases  from  the 
child's  general  behaviour  that  he  is  perfectly  intelligent,  or  at 
any  rate  nothing  more  than  a  little  backward  in  other  respects. 
Moreover,  if  patient  effort  has  been  made  to  associate  certain 
sounds  with  certain  things  that  he  can  see,  the  child  may  be 
able  to  name  an  object  in  a  picture,  although  he  may  fail  to 
understand  the  same  word  when  mentioned  apart  from  the 
picture  :  for  instance,  if  one  points  to  a  dog  in  a  picture  the 
child  if  he  has  been  taught  will  say  '  dog  ',  but  if  one  asks  him 
without  the  picture  before  him,  '  Where  is  the  dog  ? '  the  word 
may  convey  nothing  to  him. 

The  child  can  repeat  words  which  he  hears  spoken  but  does 
so  mechanically,  without  understanding  them.  Medical  inspec- 
tion of  school  children  has  made  it  evident  that  this  condition 
is  less  rare  than  was  supposed  ;  children  suffering  with  it  were 
formerly  mistaken  for  mentally  deficient  or  for  deaf  children. 
The  following  cases  were  of  this  kind  : 

Victor  M.,  aged  6r\  years,  brought  to  hospital  because  he  is 
unable  to  talk  ;  he  has  had  earache  at  some  time,  but  it  is  not 
known  that  he  has  ever  had  any  otorrhcea :  nothing  abnormal  can 
be  detected  in  the  ears.  The  boy  is  a  first  child,  he  has  never  had 
convulsions.  He  looks  and  seems  in  every  way  perfectly  intelli- 
gent ;  he  is  fond  of  drawing  things  from  sight.  If  shown 
certain  things,  for  instance,  bread  on  the  table,  he  can  name  the 
article;  and  he  evidently  understands  simple  orders,  for  instance, 
'  Shut  the  door  '  ;  but  he  watches  his  mother's  face  carefully 
when  she  speaks  and  evidently  gathers  her  meaning  partly  from 
the  movements  of  her  lips. 

His  hearing  may  be  defective  but  he  certainly  hears,  and 
apparently  hears  ordinary  speech  well.  He  does  not  speak  at 
all  except  to  name  things  which  he  can  see,  or  to  repeat  a  few 
words  said  to  him,  after  he  has  watched  the  face  of  the  speaker. 


746  COMMON  DISORDERS  OF  CHILDHOOD 

Catherine  B.,  aged  4|  years,  had  never  talked:  she  had  some 
otorrhoea  at  two  years  old,  but  before  this  had  made  no  attempt 
to  talk,  only  imitating  sounds  made  by  animals.  When  she 
was  brought  to  me  at  4J  years  she  was  an  unusually  well-grown 
child,  looking  as  if  about  seven  years  old :  she  appeared  to  be 
perfectly  healthy,  and  looked  quite  intelligent. 

She  would  have  passed  for  a  normal  child,  until  one  spoke 
to  her,  when  her  manner  at  first  sight  suggested  complete  deaf- 
ness. I  have  noted  that  she  '  took  absolutely  no  notice  of  the 
sound  of  my  voice,  in  fact  might  have  been  stone-deaf,  dumb, 
and  blind,  for  all  the  notice  she  took  of  anything  said 
to  her  '. 

She  showed  no  sign  of  shyness,  but  simply  appeared  absolutely 
vacant  when  questioned  or  addressed  :  I  tried  to  coax  her  to 
talk  but  her  face  remained  completely  expressionless.  I  was 
beginning  to  think  that,  in  spite  of  the  mother's  statement  that 
she  could  hear,  she  must  really  be  deaf,  when  I  showed  her 
a  doll  which  made  a  long-drawn  but  not  very  loud  squeaking 
sound,  this  caught  her  attention  and  with  scarcely  a  movement 
of  the  muscles  of  her  face  she  imitated  the  sound. 

Her  mother  then  quietly  hummed  a  tune  to  her  and  the  child, 
still  with  a  remarkable  lack  of  expression  on  her  face,  began 
humming  the  tune  in  unison  with  her  mother,  and  when  her 
hand  was  moved  to  beat  time,  she  continued  spontaneously 
beating  time  quite  correctly.  Her  cry  was  curiously  monotonous, 
like  the  speech  of  a  deaf  person.  It  was,  I  think,  clear  that  the 
child's  hearing  was  little  if  at  all  defective  ;  and  that  the 
condition  was  really  one  of  congenital  word-deafness. 

Dr.  C.  J.  Thomas1  has  recorded  four  very  typical  examples  of 
congenital  word-deafness,  all  in  boys.  I  shall  quote  his  descrip- 
tion of  one,  at  the  age  of  9-|  years,  as  it  exemplifies  the  condition 
well. 

'  Healthy  boy  who  would  pass  for  intelligent  on  inspection.  He  under- 
stands no  questions  put  to  him,  but  if  allowed  to  watch  the  lips  will  give  his 
name  when  asked,  his  articulation  being  clear  and  good. 

Hearing  :  hears  all  notes  blown  softly  upon  the  mouth-organ,  responding 
each  time  by  raising  the  hand.  Hears  a  bell  softly  struck  at  a  distance  of 
30  feet.  Repeats  all  simple  sounds,  "  ah,"  "  oo,"  &c.,  softly  spoken  to  him, 
and  will  imitate  many  words  without  understanding  them  in  the  least. 

Sight  :    V  =  G  9. 

Vocabulary  :  has  learnt  to  name  most  of  the  objects  surrounding  him, 
"  book,"  "keys,"  "chair,"  "table,"  &c.,  he  calls  his  chin  his  mouth,  and 
calls  the  mouth-organ  a  "  blow  ". 

General :  recognizes  letters  and  can  give  the  sound  of  the  majority.  Drawing 
1  Internat.  Mag.  School  Hyg.,  1905. 


DISORDERS  OF  SPEECH  747 

very  good,  imitates  well.     He  plays  naturally  and  intelligently  with  the  other 
children  and  is  quite  able  to  take  his  own  part  with  them.' 

Voluntary  absence  of  speech.  There  are  certain  children 
of  abnormal  mental  condition  who  might  easily  pass  for  deaf 
and  dumb  unless  their  history  were  obtainable  from  those  who 
are  constantly  with  them.  When  a  stranger  speaks  to  them 
they  will  take  absolutely  no  notice,  neither  coaxing  nor  scolding 
elicits  a  word  from  them,  and  yet  they  show  no  sign  of  shyness 
or  timidity  :  their  face  betrays  no  consciousness  that  any  one 
is  speaking  to  them. 

The  child  can  talk,  for  the  parents  say  that  he  will  speak  to 
them  at  home,  but  with  strangers  he  is  obstinately  dumb. 
A  boy  was  brought  to  me  at  the  age  of.  eleven  years,  with 
a  history  that  he  had  had  convulsions  from  time  to  time  until 
he  was  seven  years  old,  and  did  not  learn  to  talk  until  he  was 
six.  He  was  a  very  unruly  child  and  very  passionate,  dull, 
but  not  by  any  means  imbecile. 

He  had  a  habit  of  wandering  away  from  home  by  himself, 
with  the  result  that  he  was  frequently  lost,  and  being  found 
by  the  police  in  various  parts  of  London,  apparently  homeless, 
was  taken  to  the  nearest  police-station,  where  no  information 
whatever  could  be  obtained  about  him,  as  the  boy  appeared 
unable  to  talk. 

The  boy  was  brought  to  me  for  this  trouble,  and  I  endeavoured 
to  get  him  to  talk,  but  in  vain,  his  face  showed  no  consciousness 
whatever  that  any  one  was  looking  at  him  or  speaking  to  him. 
After  about  twenty  minutes  of  fruitless  effort,  I  gave  up  the 
attempt  :  a  few  minutes  later,  as  the  boy  \vent  out  of  the  room 
with  his  mother,  he  turned  and  said  in  the  most  natural  way, 
'  Good-morning  '.  I  have  seen  other  cases  very  similar,  the 
unwillingness  to  talk  is  not,  I  think,  due  to  any  contumacy  or 
bravado  :  these  children  are,  so  far  as  my  experience  goes,  always 
mentally  abnormal,  they  are  usually  backward,  sometimes  to 
a  considerable  degree,  and  like  the  boy  I  have  mentioned 
passionate  or  eccentric  children. 

Loss  of  speech.  I  have  already  pointed  out  that  the  child 
who  becomes  deaf  within  a  few  months  after  the  acquisition  of 
speech  is  likely  to  lose  the  words  he  has  learnt,  and  to  remain 
a  deaf-mute  until  taught  by  special  methods.  There  are  con- 
ditions in  which  speech  is  temporarily  lost ;  a  severe  fright  has 
occasionally  abolished  speech  for  a  time.  Buckland  l  tells  of 
a  boy  aged  nine,  who  was  seized  in  Ratcliff  Highway  by  a  tiger 
1  Curiosities  of  Natural  History,  vol.  iii,  p.  249.. 


748  COMMON  DISORDERS  OF  CHILDHOOD 

which  had  escaped  frpm  Jamrach's  Store ;  the  boy  was  rescued 
with  no  further  injury  than  a  bite,  apparently  slight,  in  one 
shoulder,  he  was  so  frightened,  however,  that  he  spoke  not 
a  word  for  four  hours. 

Kussmaul  mentions  the  case  of  a  boy,  twelve  years  old,  who 
was  unable  to  speak  for  nine  days  after  a  fright. 

In  chorea  speech  is  sometimes  completely  abolished  for  several 
weeks ;  a  girl  under  the  care  of  Dr.  Lees  in  the  Children's  Hospital 
was  unable  to  speak  for  eight  months,  although  the  choreic 
movements  during  the  greater  part  of  this  time  \vere  by  no 
means  violent. 

I  have  also  seen  absence  of  speech  for  a  week  or  more  in 
a  child  convalescent  from  typhoid. 

It  is  seldom  that  a  child  becomes  aphasic  from  gross  lesions 
in  the  brain:  in  a  boy,  aged  eleven,  writh  chorea  and  infective 
endocarditis  speech  was  suddenly  lost  when  left  hemiplegia, 
probably  of  embolic  origin,  occurred  ;  not  a  word  was  spoken 
until  the  twentieth  day  after  the  onset  of  the  hemiplegia,  he 
then  gradually  recovered  normal  speech. 

Faulty  Speech 

The  speech  of  children  is  often  faulty  in  production:  the 
faults  may  be  classified  under  two  general  headings  (1)  Stuttering ; 
and  (2),  what  I  shall  call  for  lack  of  a  better  term,  Defective 
articulation.  German  writers  distinguish  these  as  Stuttering 
and  Stammering,  but  in  England  the  term  stammering  is  so 
generally  used  as  synonymous  with  stuttering  that  it  seems 
almost  too  late  to  apply  it  to  faults  entirely  distinct  from  stutter- 
ing, such  as  lisping,  and  failure  to  pronounce  certain  sounds, 
for  example,  th,  r,  and  s  :  the  terms  dyslalia  and  paralalia, 
though  somewhat  pedantic,  convey  well  the  distinction  between 
stuttering  and  defective  articulation. 

1.  Stuttering  (dyslalia)  is  a  defect  of  co-ordination.  Articula- 
tion involves  a  highly  complex  series  of  movements,  involving  the 
muscles  of  the  tongue,  the  jaw,  the  palate,  and,  not  least  impor- 
tant, the  muscles  of  respiration  ;  the  perfect  co-ordination  of 
these  movements  is  only  gradually  acquired,  and  hence  occasional 
stuttering  is  so  common  in  children  of  two  or  three  years,  whilst 
they  are  learning  to  talk,  as  to  be  almost  a  normal  feature  at 
this  age. 

How  often  one  notices  that  a  little  child  will  articulate  quite 
regularly  and  smoothly  so  long  as  he  talks  slowly,  but  directly 
he  becomes  eager  and  excited  his  co-ordination  fails,  he  stumbles 


DISORDERS  OF  SPEECH  749 

in  his  speech  !  Stuttering  at  this  age  is  indeed  exactly  analogous 
to  the  stumbling  in  walking  which  is  so  common,  not  only  in  the 
child  who  is  learning  to  walk,  but  also  during  the  first  two  or 
three  years  of  life,  when  the  child  attempts  to  walk  fast  or  to  run. 
Both  in  walking  and  in  speech  the  failure  of  co-ordination  and 
the  tendency  to  stumble  is  specially  noticeable  when  the  child 
hurries  and  also  when  he  is  tired. 

I  draw  attention  to  these  everyday  facts  of  early  childhood 
because,  as  I  shall  point  out,  they  throw  some  light  upon  the 
occurrence  and  treatment  of  stuttering  in  older  children.  It  is 
also  necessary  to  point  out  the  innocence  of  occasional  stuttering 
during  th,e  first  two  or  three  years  of  life,  because  parents  are  apt 
to  mistake  it  for  the  more  serious  disorder  which  is  met  with  in 
older  children  and  to  be  unnecessarily  anxious  about  it. 

Occasionally,  it  is  true,  co-ordination  is  never  fully  acquired, 
what  is  innocent  and  natural  in  earliest  childhood  persists 
as  the  much  more  serious  inconvenience  of  later  life  :  but  as 
a  rule  this  stuttering  of  the  first  two  or  three  years  passes  off 
after  a  few  months,  leaving  no  tendency  to  this  fault  of  speech. 

The  stuttering  of  older  children  as  a  rule  begins  about  the 
middle  period  of  childhood,  often  about  the  commencement  of 
the  second  dentition,  i.e.  at  six  or  seven  years  old.  Boys  are 
very  much  more  liable  to  stutter  than  girls  :  out  of  forty  con- 
secutive cases  brought  to  me  for  this  disorder  twenty-nine 
were  boys. 

Stuttering  is  associated  in  a  large  proportion  of  cases  with 
other  evidence  of  nervous  instability  or  defective  nervous  control : 
amongst  the  forty  cases  I  have  mentioned  five  suffered  with 
habit-spasm,  six  others  had  enuresis,  four  (including  one  of 
those  who  had  enuresis)  had  epilepsy,  one  had  asthma  and 
occasional  incontinence  of  faeces,  one  had  had  rheumatism  with 
chorea  three  times,  seven  others  talked  or  walked  in  their  sleep 
or  had  night  terrors  ;  in  several  other  cases  the  child  was  said 
to  show  great  nervousness  or  excitability. 

The  basis  of  stuttering  is  defective  nervous  control  :  or  that 
ill-defined  but  very  real  entity,  the  nervous  temperament ;  the 
determining  cause  may  be  some  depressing  illness,  or  a  shock 
of  any  kind,  perhaps  even  the  irritation  of  threadworms.  I  have 
noted  the  onset  of  stuttering  after  specific  fevers,  particularly 
scarlet  fever,  diphtheria,  and  whooping-cough.  I  have  notes 
of  two  cases  in  which  it  began  just  after  a  fright  :  one  of  these 
was  a  boy  whom  I  first  saw  at  eleven  years  old  for  stuttering 
and  enuresis.  A  few  years  previously  he  had  been  lost  for 


750  COMMON  DISORDERS  OF  CHILDHOOD 

a  whole  day  and  wag  taken  to  a  police-station  by  the  police, 
from  this  time  the  stuttering  began.  In  another  case  it  began 
after  a  fall  downstairs. 

Knowing  how  very  easily  nervous  children  contract  morbid 
habits,  I  can  quite  believe  that  stuttering  may  originate  in  some 
cases  by  imitation,  perhaps  even  by  wilful  imitation.  I  have 
seen  cases  in  which  one  or  other  of  the  parents  stuttered  as 
badly  as  the  child  about  whom  I  was  consulted.  One  little  boy, 
aged  six  years,  was  brought  to  me  with  the  history  that  he  had 
amused  himself  a  short  time  previously  by  mimicking  the  stutter- 
ing of  a  playfellow  who  lived  next  door,  and  had  quickly  fallen 
into  the  habit  of  stuttering  in  earnest.  The  boy  was  a  highly 
nervous  child  who  talked  in  his  sleep  and  suffered  also  with 
habit-spasm. 

In  almost  all  the  cases  I  have  mentioned  the  child  was  rather 
above  the  average  in  intelligence  :  the  child  who  stutters  is 
usually  the  quick-witted,  thoughtful,  sensitive  child.  Charles 
Lamb  was  writ  down  '  an  inveterate  stutterer  ',  but  as  he  says 
of  himself,  'his  conceptions  rose  kindlier  than  his  utterance', 
and  it  was  Charles  Kingsley  who  wrote  of  his  difficulty  in  speech, 
'  that  fearful  curse  of  stammering  which  has  been  my  misery 
since  my  childhood  ' . 

In  some  children  the  stuttering  is  only  noticeable  wrhen  the 
general  health  is  poor,  in  most  the  difficulty  is  aggravated  when- 
ever the  child  is  tired,  for  instance,  at  the  end  of  long  school 
hours. 

Stuttering  takes  various  forms  :  in  some  cases  it  consists  in 
prolongation  or  repetition  of  the  first  consonant ;  for  instance, 
one  child,  when  asked  how  old  she  was,  said  '  F-f-f-f-five  ',  the 
'  f  '  sound  was  simply  prolonged  :  in  others  it  is  repetition  of 
the  first  syllable,  for  instance,  a  boy  called  '  Benny  '  told  me 
his  name  was  '  Ben-ben-ben-ben-benny '.  Much  more  rarely 
it  is  the  last  syllable  of  a  word  which  is  repeated. 

Another  variety  consists  in  a  spasmodic  indrawing  of  breath, 
which  for  a  moment  prevents  the  beginning  of  a  sentence  ; 
another  is  spasm  of  the  muscles  of  articulation,  so  that  there 
is  complete  speechlessness  for  several  seconds.  With  any  of 
these  varieties  there  are  often  associated  spasmodic  movements 
of  the  face,  in  severe  cases  also  of  the  head  and  limbs. 

All  these  faults  occur  chiefly  at  the  beginning  of  a  sentence, 
or  over  those  words  upon  which  the  main  emphasis  should  fall, 
and  certain  sounds  are  more  difficult  than  others,  perhaps  parti- 
cularly the  explosive  sounds  '  p ',  'b',  't',  'd',  hard  'g',  and 


DISORDERS  OF  SPEECH  751 

'k'  ;  though  none  are  entirely  free  from  the  difficulty,  and  even 
the  vowel  sounds  which  usually  give  no  trouble  may  be  a 
stumbling-block  to  the  severe  case. 

Stutterers  are  usually  free  from  stuttering  in  singing,  and  also 
in  some  cases  in  reading  aloud  poetry  or  rhyme.  In  whispering 
also  there  is  no  stutter  except  in  severe  cases. 

Treatment  of  stuttering.  The  presence  of  stuttering  as  a 
transient  phenomenon  in  early  childhood  during  the  normal 
development  of  speech,  shows  that  the  co-ordination  necessary 
to  perfect  articulation  is  only  gradually  acquired,  it  has  in  fact 
to  be  learnt.  And  one  may  assume  that  what  is  possible  in  the 
earliest  years  of  life  is  possible  also  for  the  stutterer  in  later  years, 
he  can  with  perseverance  acquire  the  necessary  co-ordination. 

But  in  order  to  do  this  he  must  learn  to  accustom  not  only 
the  muscles  of  articulation  but  also  those  of  respiration  to 
orderly  action.  For  this  purpose  regular  breathing  exercises  are 
of  value,  but  they  must  be  done  daily  and  preferably  twice  a  day 
to  be  of  real  help.  Next  the  child  should  practise  daily  reading 
aloud  and  singing  :  the  latter  particularly  may  be  useful  as  an 
introduction  to  the  more  difficult  exercise  of  reading  aloud  ; 
and  for  the  reading  or  reciting,  nursery  rhymes  or  simple  poems 
should  come  first,  as  the  rhyme  assists  co-ordination  ;  and  so 
gradually  the  child  may  reach  ordinary  prose. 

But  whatever  exercises  are  used  care  must  be  taken  that 
faulty  speech  is  not  allowed  to  go  unheeded  :  if  the  child  stutters 
he  should  be  asked  to  say  the  word,  or  read  the  sentence  again. 
Often  it  will  be  found  that  by  taking  a  deep  inspiration  before 
beginning  a  sentence  a  child  can  avoid  stuttering  altogether. 

Before  all  else  there  are  two  rules  to  which  the  stutterer  must 
pay  attention  if  he  is  to  be  cured  :  Speak  slowly  :  speak  quietly. 

But  the  treatment  of  stuttering  consists  not  only  in  the 
education  of  speech  ;  it  involves  also  in  many  cases  attention 
to  the  general  health.  It  is  very  noticeable  in  some  children 
that  they  stutter  only  when  they  are  '  run  down  '  :  and  it  may 
be  more  necessary  to  advise  a  stay  at  the  seaside  or  a  course  of 
arsenic  and  nux  vomica  than  to  give  directions  for  the  training 
of  speech.  There  can,  I  think,  be  no  doubt  that  the  presence 
of  worms  in  some  way  enhances  nervous  instability,  and  a  few 
doses  of  santonin  may  be  a  necessary  part  of  the  treatment  of 
stuttering.  The  effect  of  fatigue  is  also  to  be  remembered, 
both  physical  and  mental  exertion  must  be  limited. 

Defective  articulation  (paralalia),  the  fault  which  Ger- 
mans would  describe  as  stammering  in  contradistinction  to 


752*          COMMON  DISORDERS  OF  CHILDHOOD 

stuttering,  is  a  normal  occurrence  during  the  development  of 
speech.  It  consists  essentially  in  the  substitution  of  an  easy 
sound  for  one  which  the  child  finds  more  difficult.  This  only 
adds  to  the  charm  of  baby  talk  :  it  is  pretty  enough  to  hear 
the  little  one  talk  of  *  doin'  in  de  tain  wif  muvver  ',  but  in  an 
older  child  such  faulty  speech  is  a  serious  drawback. 

By  the  age  of  about  four  years  these  natural  imperfections  of 
baby  talk  should  have  disappeared,  and  their  persistence  after 
this  age  must  usually  be  regarded  as  abnormal. 

Amongst  mentally  defective  children  a  very  large  proportion 
show  some  defect  of  articulation  ;  most  commonly,  I  think,  a 
simple  slurring  of  word-endings,  e.  g.  the  child  says  '  ca  '  for  '  cat ', 
'  do  '  for  '  dog  ',  and  so  on  ;  but  very  usually  in  association 
with  other  faults,  for  instance,  the  child  substitutes  '  d  '  for 
'  th  ',  says  '  da  '  for  '  that  ',  or  omits  consonants  almost  entirely, 
saying  '  ah-ah  '  for  *  father  '. 

Amongst  children  of  normal  intelligence  various  faults  are 
met  with  ;  two  of  the  most  familiar  are  lisping,  the  substitution 
of  '  th  '  for  '  s  '  (sigmatismus  interdentalis),  and  the  use  of  '  w  ' 
in  place  of  '  r  '  ;  so  that  the  child  says,  '  wound  the  wugged  wock 
the  wagged  wascal  wan  '  :  but  other  faults  are  hardly  less 
common,  omission  of  consonants  both  in  the  middle  and  at  the 
end  of  words,  or  substitution  of  sounds  which  seem  to  follow 
no  particular  rule  :  for  instance,  a  highly  intelligent  boy  of 
six  years  used  the  sound  '  pf  '  to  replace  many  other  sounds  ; 
for  '  blackbird  '  he  said  '  pfaf-bir  ',  for  *  goat  '  '  pfo  ',  for  '  cock- 
a-doodle-doo  '  he  said  '  pfof-a-boo-boo  '.  A  '  mouse-trap  '  wras 
'pfar-ta'. 

A  girl,  aged  5J  years,  used  a  '  y  '  sound  chiefly  ;  '  ladder  '  was 
'yadder',  and  'house'  was  'youse',  and  so  on:  her  brother,  aged 
4|  years,  omitted  all  consonants  except  at  the  beginning  of 
words,  he  even  managed  to  get  through  '  rhododendron  '  without 
a  single  consonant  except  the  initial  one,  it  was  '  Ro-o-ee-ah  '  ! 

I  have  seen  a  few  cases  in  which  this  omission  and  substitution 
of  sounds  was  carried  so  far  that  speech  was  entirely  unintelligible, 
and  might  have  passed  for  some  barbarian  language  ;  the  child 
spoke  with  fluency  and  with  obvious  intelligence,  a  nursery 
rhyme  was  only  recognizable  by  the  rhythm,  but  it  was  clear 
the  child  had  understood  and  learnt  from  the  normal  speech  of 
his  parents  :  such  cases  have  been  described  as  '  Idioglossia  '. 

They  differ  in  no  respect  except  in  degree  from  other  cases  of 
defective  articulation  or  '  paralalia  ',  in  which  only  certain  sounds 
are  at  fault  :  moreover,  like  these,  the  fault  may  be  rectified 


DISORDERS  OF  SPEECH  753 

by  training  ;  for  instance,  I  saw  a  girl,  Alice  C.,  aged  6T2^,  whose 
language  was  entirely  unintelligible,  with  the  exception  of  the 
word  '  Daddy  '  ;  for  '  Daddy,  come  and  play  with  me  ',  she  said 
'  Daddy,  tar-tar  tay  te  tee  '  :  for  '  Rosie  Griffiths  '  she  said 
'  Essie  Disser  '  ;  for  '  pencil ',  *  Tan-too  '  ;  she  understood 
apparently  perfectly  well  what  was  said  to  her.  I  saw  the  child 
again  when  she  was  nearly  thirteen  years  old,  she  had  been  to 
school  and  her  speech  had  gradually  become  almost  completely 
normal. 

Many  of  the  children  who  show  one  or  other  of  these  various 
defects  of  speech  are  of  perfectly  normal  intelligence,  but  I  think 
it  must  be  admitted  that  the  presence  of  such  faults  in  a  child 
of  six  or  seven  years  or  more  should  make  one  cautious  in 
prognosis,  for  such  children  are  apt  to  be  more  or  less  back- 
ward in  mental  development  ;  and  in  this  respect  are  less 
satisfactory  than  the  stutterer,  who  is  usually  fully  up  to,  if  not 
above,  the  average  intelligence. 

Treatment.  The  first  essential  in  the  correction  as  in  the 
prevention  of  defective  articulation  is  good  example.  It  is  as 
true  of  speech  as  it  is  of  morals  that  '  evil  communications 
corrupt  good  manners  '  :  a  child  cannot  be  expected  to  be  clear 
and  accurate  in  articulation  if  his  exemplar  is  a  nurse  or  a  parent 
who  lisps  or  has  some  other  fault  of  speech.  And  here  I  would 
emphasize  the  need  not  only  for  freedom  from  gross  faults  of 
articulation  in  those  with  whom  the  child  is  in  constant  associa- 
tion, but  also  for  distinct  speech  ;  let  it  be  remembered  that 
every  word  and  syllable  has  to  be  acquired  by  a  child  by  imitation 
of  what  he  hears,  and  it  is  no  wonder  if  his  articulation  is  faulty 
when  those  around  him  are  mumbling  and  indistinct  in  speech. 

Attention  paid  to  the  careful  education  of  a  child's  speech 
during  the  first  four  or  five  years  of  life  would  do  much  to  prevent 
some  of  the  defects  of  articulation  which  are  most  common. 

And  here  I  cannot  refrain  from  mentioning  a  practice  which 
in  my  opinion  is  as  mischievous  as  it  is  foolish,  in  talking  to  little 
children,  namely,  the  use  of  those  very  faults  of  articulation 
which  are  often  so  troublesome  to  correct  as  the  child  grows 
older  ;  a  mother  says  to  her  child,  '  Dood  boy,'  or,  '  Baby  do 
in  de  tain,'  correctly  imitating  the  child's  way  of  talking, 
as  if  the  baby  understood  her  any  the  better  because  she  uses 
incorrect  sounds:  such  a  practice  is  only  likely  to  favour  the 
persistence  of  defective  articulation  in  the  child. 

I  need  hardly  point  out  that  there  is  a  great  difference  between 
the  use  of  the  conventional  terms  of  babydom  such  as  '  puff-puff  ', 

STILL  3  C 


754  COMMON  DISORDERS  OF  CHILDHOOD 

or  '  gee-gee  ',  or  '  bya-bye  ',  and  the  use  of  slovenly  articulation  ; 
there  is  no  harm  in  a  child  learning  to  say  '  puff -puff  ',  but  there 
is  harm  in  encouraging  him  in  his  faulty  way  of  saying  it  as 
'  fuff-fuff  '  ;  the  child  should  be  taught  to  articulate  these  baby 
words  distinctly  and  correctly. 

Faults  of  articulation  can  usually  be  cured  by  careful  training 
if  the  child  is  of  normal  intelligence,  and  even  in  the  mentally 
defective  it  is  surprising  how  great  an  improvement  can  be 
obtained  by  patient  teaching.  The  old  familiar  nursery  rhymes 
are  excellent  for  speech  cultivation  :  the  child  finds  a  pleasure 
in  repeating  them,  and  if  taught  to  say  them  clearly  and  dis- 
tinctly may  profit  more  from  '  Jack  and  Jill '  and  '  See-saw, 
Marjory  Daw  ',  than  from  many  a  more  recondite  study. 


CHAPTER  LII 

SLEEPLESSNESS,   LOSS  OF  APPETITE,  AND  SOME 
OTHER  SYMPTOMS 

IN  tliis  chapter  I  shall  consider  certain  symptoms  which  are 
not  uncommon  in  childhood,  and  which  are  often  puzzling  both 
as  to  significance  and  treatment. 

Insomnia.  How  often  one  hears  the  complaint,  '  My  child 
will  not  sleep  '  !  There  are  infants  who  from  their  birth  are 
1  bad  sleepers  ',  they  sleep  lightly,  waking  on  the  slightest  distur- 
bance, and  often  they  will  lie  awake  without  any  apparent  cause 
so  much  of  the  day  and  night  that  the  mother  almost  believes  her 
own  exaggerated  statement  that  they  *  never  sleep  '. 

In  children  beyond  the  age  of  infancy  also  there  is  the  same 
trouble  ;  some  children  will  lie  awake  for  several  hours  after 
being  put  to  bed,  others  will  fall  asleep  quickly  but  wake  a  few 
hours  later  and  remain  awake  for  two  or  three  hours,  with  the 
result  in  either  case  that  next  day  the  child  is  languid  and  looks 
pale  and  dark  under  the  eyes. 

When  the  trouble  dates  from  earliest  infancy  I  think  it  usually 
indicates  an  abnormal  nervous  excitability  and  foreshadows 
a  nervous  temperament  in  later  years,  certainly  some  of  the 
children  who  suffer  with  insomnia  at  a  later  age,  say  six  or  seven 
years,  have  always  been  more  or  less  troubled  in  this  way,  and 
were  babies  who  slept  very  little.  In  many  of  these  older  children 
careful  investigation  fails  to  detect  anything  to  account  for  the 
insomnia,  beyond  the  fact,  which  is  generally  sufficiently  obvious 
in  such  cases,  that  the  child  is  of  nervous  excitable  temperament. 

A  very  common  cause  of  sleeplessness  in  infants  is  dentition. 
Whether  the  local  worry  prevents  sleep,  or  whether  the  general 
increase  of  nervous  excitability  which  undoubtedly  accompanies 
dentition  in  some  infants  makes  them  wakeful,  I  know  not  ; 
probably  both  factors  play  their  part,  certainly  in  some  cases 
there  is  evidence  that,  as  the  mother  says,  the  infant  is  *  feeling 
his  teeth',  for  he  frequently  'pulls  at  his  gums  '  and  crams  his 
fingers  into  his  mouth  in  a  way  that  clearly  means  discomfort. 

Both  in  infants  and  in  older  children  sleeplessness  is  sometimes 

3C2 


756  COMMON  DISORDERS  OF  CHILDHOOD 

dependent  upon  indigestion :  distension  of  the  stomach  or 
intestines  with  flatulence  is,  I  think,  a  common  cause,  perhaps 
by  interfering  with  the  movements  of  the  diaphragm  and  making 
respiration  less  comfortable  than  it  should  be. 

Obstructed  respiration,  as  every  one  knows  from  experience 
with  a  common  'cold',  makes  sleep  difficult  :  in  infants  even 
more  readily  than  in  older  children,  owing  to  the  smallness  of 
the  parts,  coryza  or  adenoids  will  prevent  nasal  respiration  and 
interrupt  sleep  ;  the  infant  drops  off  to  sleep,  but  after  a  short 
time  is  awakened  by  the  difficulty  of  breathing,  he  cries  pettishly 
for  a  few  minutes,  then  falls  asleep  again,  only  to  be  disturbed 
soon  by  the  recurring  difficulty  of  nasal  respiration.  In  older 
children  large  tonsils  and  adenoids  are  apt  to  prevent  sound 
sleep,  and  the  benefit  of  operation  in  some  of  these  cases  is, 
I  think,  due  in  part  to  the  sounder  and  more  refreshing  sleep 
which  is  made  possible  by  the  freer  respiration. 

The  value  of  fresh  air  in  promoting  sleep  is  very  noticeable  in 
the  case  of  infants,  who  often  suffer  with  sleeplessness  whenever 
it  becomes  necessary  for  any  reason  to  keep  them  indoors  for 
a  few  days  :  older  children  similarly  may  be  sleepless  for  lack 
of  an  open  window. 

Treatment.  The  medical  man  is  often  at  a  disadvantage  in 
advising  upon  the  treatment  of  insomnia  through  ignorance  of  the 
details  of  the  child's  environment  at  night.  There  are  children — 
those  of  nervous  temperament — whose  sleep  is  disturbed  by 
noises  or  lights  which  would  not  affect  a  less  sensitive  child  in 
the  least  ;  there  are  others  who  do  not  sleep  because  their  bed- 
clothing  is  too  heavy  or  too  light.  A  romping  exciting  game 
just  before  going  to  bed  keeps  some  children  awake  for  hours. 
The  nervous  child  too,  like  the  nervous  adult,  easily  becomes  the 
victim  of  auto-suggestion,  '  they  can't,  because  they  think  they 
can't.'  In  no  disorder  is  the  role  of  habit  more  evident  than  in 
sleeplessness ;  if  this  habit  can  but  be  broken  for  a  few  nights  only, 
the  insomnia  may  be  cured. 

In  every  case  the  diet  must  be  considered  :  it  may  need 
revision  especially  in  the  direction  of  reducing  such  elements 
as  make  for  flatulence,  excess  of  sugar,  barley-water,  starch- 
containing  patent  foods  in  the  case  of  the  infant,  fruit,  potato, 
porridge  and  suchlike,  in  the  case  of  the  older  child.  In  the  latter 
case  also  special  attention  must  be  paid  to  the  last  meal.  I  see 
children  occasionally  of  eight  or  nine  years  who  are  being  allowed 
to  take  as  their  supper  part  of  the  late  dinner  of  their  parents, 
including  soup  or  fish,  milk-pudding  and  fruit.  A  child  should 


SLEEPLESSNESS,  LOSS  OF  APPETITE  757 

have  his  last  substantial  meal  at  4.30  or  5  p.m.,  not  just  before 
going  to  bed,  when  a  big  basin  of  bread  and  milk  or  even  un- 
diluted milk  is  too  much  for  some  children. 

If  sleep  is  difficult  the  milk  at  bedtime  should  be  given  with 
one-third  water,  and  perhaps  a  teacupful  of  Benger's  Food  with 
diluted  milk  may  be  better  than  plain  milk  and  water.  If  the 
child  wishes  for  something  to  eat,  plain  biscuits  or  rusk  are, 
I  think,  better  than  bread  just  before  going  to  bed.  I  am  often 
asked  whether  if  the  child  lies  awake  for  hours  at  night  it  is 
advisable  to  give  food  :  I  think  that  it  is,  and  nowadays,  when 
it  is  possible  to  keep  food  warm  for  hours  by  Thermos  flasks, 
there  is  no  difficulty  in  giving  some  warm  milk  and  water  at  night, 
which  with  a  biscuit  may  help  to  get  the  child  to  sleep  again. 
A  warm  bath  at  night  seems  to  soothe  some  children  and  promote 
sleep. 

Occasionally  I  think  sleeplessness  is  due  simply  to  going  to 
bed  too  early  ;  a  mother  rightly  anxious  that  her  child  of  six 
or  seven  years  should  have  plenty  of  sleep  sends  him  to  bed  at 
6.30  p.m.,  with  the  result,  especially  on  light  summer  evenings, 
that  he  lies  awake  for  two  or  three  hours,  when  if  he  had  been 
kept  up  half  or  three-quarters  of  an  hour  later  he  would  have 
fallen  asleep  easily. 

Children  vary  in  the  amount  of  sleep  which  they  require. 
In  general  a  newborn  infant  should  sleep  about  twenty-one  hours 
out  of  the  twenty-four  ;  at  three  months  an  infant  should  sleep 
about  nineteen  hours  and  at  six  months  sixteen  hours  a  day  ; 
from  one  to  five  years  of  age  a  child  should  sleep  about  fourteen 
hours  a  day  ;  from  five  to  seven  years  about  twelve  hours,  and 
from  seven  to  ten  years  about  eleven  hours.  During  the  rest  of 
childhood  ten  hours  is  sufficient.  In  these  averages  I  have 
included  the  midday  sleep,  which  I  would  have  continued,  if 
possible,  until  a  child  is  seven  years  of  age.  But  there  are 
children  who  not  only  are  incapable  of  but  do  not  require  so 
much  sleep,  and  sometimes  it  is  better  to  allow  a  child  to  stay 
up  a  little  later  than  to  send  him  to  bed  to  lie  awake. 

But  in  spite  of  any  modification  of  the  daily  routine,  some  of 
the  nervous  children  remain  sleepless  for  hours  every  night,  and 
the  medical  man  is  expected  to  supply  sleep  in  a  bottle  of  medicine. 
Under  these  circumstances  it  is  useful  to  point  out  to  the  parents 
that  the  trouble  is  due  in  large  part  to  the  child's  nervous  tem- 
perament, and  that  though  it  would  be  easy  to  drug  the  child 
to  sleep  by  large  doses  of  hypnotics,  such  treatment  is  undesirable, 
the  better  course  is  to  change  the  child's  environment  altogether 


m 
758  COMMON  DISORDERS  OF  CHILDHOOD 

for  a  time  ;  almost  invariably  a  few  days  at  some  country  or 
seaside  place  restores  sleep  to  the  child,  and  after  a  little  while 
a  better  habit  is  induced. 

For  some  of  the  very  excitable  children  a  short  course  of  phena- 
zone  and  arsenic  may  be  useful,  but  rather  as  an  adjuvant  to 
such  measures  as  I  have  mentioned  than  as  sole  therapeutic. 

I  have  occasionally  tried  bromides,  chloral,  and  trional,  but 
they  are  usually  quite  unsuccessful  unless  such  large  doses  are 
used  that  one  would  hesitate  ever  to  recommend  them. 

Anorexia.  Loss  of  appetite  is  common  enough  at  all  ages, 
but  it  is  particularly  puzzling  sometimes  in  childhood,  for  there 
may  be  no  obvious  reason,  and  the  refusal  to  take  food  is  so 
obstinate  that  parents  become  alarmed. 

In  infancy  teething  is  quite  the  commonest  cause  of  loss  of 
appetite ;  many  babies  for  a  week  or  two  before  a  tooth  is  cut 
will  refuse  some  feeds  entirely  and  take  only  a  small  part  of  others, 
and  no  amount  of  coaxing  will  induce  them  to  take  more.  In 
these  cases  the  most  favourable  time  to  get  food  taken  is  often 
when  the  infant  is  half  asleep. 

Children  a  little  past  the  age  of  infancy,  at  about  three  or 
four  years  old,  often  suffer  with  such  complete  anorexia  that 
after  the  child  has  eaten  a  few  mouthfuls  any  further  attempt 
to  eat  is  followed  by  retching  and  actual  vomiting  ;  they  will 
refuse  the  things  for  which  most  children  crave, — cakes,  sweets, 
jam  and  such  things  have  no  charm  for  them  ;  the  child  will 
sit  at  table  without  displaying  the  least  interest  in  the  meal, 
and  if  pressed  to  eat  will  burst  into  tears.  I  have  seen  scolding 
and  coaxing  tried  in  vain,  compulsion  ends  with  vomiting. 

Most  of  the  children  who  show  this  profound  anorexia  are  pale 
and  unwholesome  looking  ;  but  sometimes  there  is  absolutely 
nothing  in  the  child's  appearance  to  suggest  anything  amiss, 
the  child  though  taking  little  food  gets  enough  to  maintain 
nutrition  and  might  pass  for  a  healthy  child.  But  I  think 
that  almost  always  careful  inquiry  will  detect  some  of  the 
vague  symptoms  which  are  associated  with  indigestion  (see 
Chapter  XIII),  and  in  many  cases  the  bowels  are  costive. 

Chronic  constipation  both  in  infants  and  in  older  children, 
but  more  often  I  think  in  the  latter,  is  a  cause  of  lack  of  appetite. 

The  appetite  like  sleep  is  greatly  affected,  especially  in  infants 
and  very  young  children,  by  the  amount  of  fresh  air  taken  ;  if 
from  any  cause  the  child  is  kept  indoors  for  a  few  days  the 
appetite  quickly  flags. 

Treatment.      In  the  treatment  of  anorexia  the  first  thing  is 


SLEEPLESSNESS,  LOSS  OF  APPETITE  759 

to  assure  the  parents  that  in  the  absence  of  any  signs  of  organic 
disease  the  lack  of  appetite  need  cause  no  anxiety.  Both  in 
infants  during  dentition  and  in  children  of  three  or  four  years 
this  trouble  will  last  sometimes  for  many  weeks,  without  any 
serious  harm,  the  child  may  lose  a  little  weight,  but  this  will 
soon  be  regained  when  appetite  returns.  In  the  case  of  the 
teething  infant  it  is  worth  while  to  try  some  phenazone,  gr.  J 
twice  daily  at  six  months,  gr.  i  thrice  daily  for  an  infant  of  one 
year;  and  if  the  bowels  are  not  well  open,  \  grain  of  grey  powder 
with  a  grain  of  bicarbonate  of  soda,  and  if  necessary  a  grain  or  two 
of  compound  rhubarb  powder  should  be  given  three  times  a  day. 

For  the  older  child,  after  a  regular  daily  action  of  the  bowels 
has  been  ensured,  any  of  the  various  preparations  which  contain 
phosphorus  may  be  useful  :  Parrish's  Food,  the  Syrup  Ferri 
Phosph.  Co.  (B.P.C.),  in  doses  of  1  drachm  for  a  child  of  four 
years,  or  Byno-hypophosphites  (Allen  &  Hanbury),  J  drachm 
for  a  child  of  this  age,  or  plain  Malt  Extract  (which  contains 
phosphates),  a  small  tcaspoonful  three  times  a  day,  or  a  mixture 
of  nux  vomica,  2  minims  with  5  minims  of  dilute  phosphoric 
acid  and  glycerine  and  water  ;  any  of  these  given  just  after 
meals  may  help  in  these  cases. 

Children  usually  have  so  great  a  dislike  to  the  vegetable 
bitters,  such  as  gentian,  that  I  have  rarely  prescribed  them,  but 
I  have  known  these  to  be  as  useful  in  children  as  they  are  in 
adults  when  given  with  some  bicarbonate  of  soda  shortly  before 
meals.  A  cold  bath  in  the  morning  in  summer  with  Tidrnan's 
sea-salt,  or  a  warm  bath  in  winter  with  an  almost  cold  douche, 
may  help  to  stimulate  appetite  ;  and  care  must  be  taken  that 
the  child  is  out  in  the  open  air  several  hours  a  day,  but  without 
fatigue  :  these  children  are  often  unfit  for  much  walking,  they 
are  easily  tired  and  look  pale  if  made  to  walk  far,  so  that  their 
outing  should  be  as  much  as  possible  riding  in  perambulator  or 
go-cart  or  carriage. 

Lastly,  I  would  point  out  that  a  child  easily  becomes  the 
malade,  imaginaire,  and  that  anxious  parents  constantly  watching 
the  child  at  table  and  remarking  on  the  smallness  of  his  appetite 
may  be  fostering  the  trouble  they  deplore  ;  there  is  a  sense  of 
distinction  in  being  peculiar,  and  the  child  will  sometimes  eat 
more  when  no  notice  is  taken  of  him  ;  a  meal  in  the  nursery 
with  younger  children  to  distract  attention  may  be  better  taken 
than  a  meal  in  the  dining-room  with  mother. 

Difficulty  in  swallowing.  I  mention  next,  as  being  in  some 
instances  connected  with  anorexia,  certain  cases  in  which  a  child 


COMMON  DISORDERS  OF  CHILDHOOD 

is  said  to  have  difficulty  in  swallowing.  Leaving  out  of  account 
rare  cases  in  which  the  trouble  was  due  to  some  real  cesophageal 
obstruction  or  gross  disease  of  some  sort,  I  find  in  my  notes  sixteen 
cases  in  which  there  was  this  tale.  The  youngest  was  aged 
three  weeks,  the  oldest  ten  years ;  nine  were  between  one  and  two 
years  old  ;  and  the  second  year  of  life  is,  I  think,  the  usual 
age  at  which  this  trouble  occurs.  I  shall  perhaps  make  the 
condition  clear  by  mentioning  actual  cases. 

Wilfred  T.,  aged  one  year  and  five  months,  was  brought  for  '  something 
wrong  in  his  throat' ;  he  had  always  had  difficulty  in  swallowing  fluids;  after 
taking  the  fluid  into  his  mouth,  he  held  it  at  the  back  of  his  mouth  for  some 
time  as  if  unable  to  swallow.  Given  some  water  to  drink  in  my  presence, 
he  took  it  into  his  mouth  and  tilted  his  head  slightly  backwards  with  his 
mouth  widely  open,  so  that  the  fluid  could  be  seen  unswallowed  in  his  throat ; 
in  this  position  he  remained  for  a  few  moments  like  a  person  gargling,  but  he 
made  no  noise  and  then  gradually  he  swallowed  the  fluid. 

Arthur  S.,  aged  one  year  and  three  months,  was  fed  at  the  breast  till  twelve 
months  old,  and  ever  since  birth  had  been  awkward  in  swallowing.  Since 
weaning  there  was  more  difficulty  in  swallowing  fluids,  though  he  took 
sopped  bread  easily.  Given  some  milk  in  my  presence  he  kept  it  at  the 
back  of  his  mouth  like  a  person  gargling  with  his  mouth  open  and  made  six 
or  seven  masticating  movements  as  if  he  were  eating  solids,  then,  after  a  minute 
or  so,  he  swallowed  the  fluid.  There  was  no  abnormality  of  any  sort  to  be 
seen  in  the  throat,  the  palate  moved  well.  The  child  was  apparently  bright 
and  intelligent.  Five  months  later  the  difficulty  had  almost  gone  ;  only  when 
he  took  a  large  mouthful  of  fluid  he  occasionally  went  through  the  same 
performance. 

Charles  A.,  aged  one  year  and  five  months,  was  brought  because  for  the 
last  five  weeks  he  did  not  swallow  solids  properly.  He  was  said  to  keep  them 
in  his  mouth  until  they  were  taken  out ;  he  swallowed  fluids  readily.  I  gave 
him  a  finger  of  bread-and-butter  which  he  took  with  pleasure  :  he  filled  his 
mouth  with  it,  leaving  a  piece  hanging  out  between  his  lips.  He  sat  thus 
quite  unconcerned  for  four  minutes,  making  no  effort  even  to  draw  into  his 
mouth  the  piece  of  bread  which  was  hanging  out.  From  some  movement  in 
the  sublingual  region  I  thought  he  was  gently  sucking  the  mouthful,  but  he 
made  no  attempt  to  swallow  it,  and  at  the  end  of  the  four  minutes  he  quietly 
spat  the  whole  mouthful  out.  A  month  later  the  child  was  swallowing  solids 
almost  normally. 

The  last  case  shows  that  the  difficulty  may  occur  with  solids 
as  well  as  with  fluids.  In  both  cases  I  fancy  the  difficulty  is  due 
simply  to  lack  of  education  :  the  co-ordination  necessary  for 
swallowing  is  less  readily  established  in  some  children  than  in 
others  ;  and  when  the  child  has  been  accustomed  only  to  fluid 
food  the  change  to  solid  food  requires  a  new  effort  of  co-ordination 
which  he  cannot  or  will  not  make.  There  are  many  infants  who 
object  strongly  to  the  first  introduction  of  solids  into  their  diet 


SLEEPLESSNESS,  LOSS  OF  APPETITE  761 

and  will  spit  and  retch  if  solid  food  such  as  sops  or  pudding 
is  forced  upon  them. 

But  it  is,  I  think,  clear  that  the  delay  in  swallowing  is  not 
always  due  merely  to  infantile  caprice,  there  is  in  some  cases 
a  genuine  defect  of  co-ordination  ;  for  in  two  of  my  series,  a  boy 
of  three  years  and  a  girl  of  twenty-one  months,  fluids  were 
occasionally  regurgitated  through  the  nose  when  the  child  drank  ; 
in  neither  case  was  there  anything  to  suggest  paralysis  of  the 
palate. 

The  difficulty  is  noticed  specially  when  the  child  passes  from 
one  method  of  feeding  to  another  ;  a  girl  of  sixteen  months 
swallowed  normally  so  long  as  she  took  food  from  breast  or 
bottle,  but  when  an  attempt  was  made  to  give  fluid  from  a  cup 
she  took  it  into  her  mouth  but  kept  her  mouth  open  so  that  some 
of  the  fluid  ran  out  before  she  swallowed  the  remainder.  She 
was  apparently  a  perfectly  intelligent  child,  but  the  trouble 
first  noticed  at  six  months  still  persisted  when  she  was  eighteen 
months  old. 

Amongst  my  cases  there  were  some  in  which  the  supposed 
difficulty  in  swallowing  was  simply  a  manifestation  of  anorexia, 
it  was  *  a  can't  of  won't '. 

Violet  B.,  aged  6|  years,  was  brought  to  me  for  loss  of  appetite.  She  had 
recently  taken  a  great  dislike  to  food,  and  actually  vomited  at  the  sight  of  it. 
Compelled  to  take  food  into  her  mouth,  she  would  keep  it  there  unswallowcd, 
and  had  kept  it  so  for  two  hours  ;  she  said  she  '  could  not  swallow  it '. 

Kenneth  K.,  aged  4|f  years,  had  no  appetite,  was  occasionally  sick  in 
the  night,  was  a  very  nervous  boy,  and  had  attacks  of  '  recurrent  pyrexia '. 
The  mother  said,  '  he  takes  food  in  his  mouth  and  keeps  it  there,  says  he  can't 
swallow  it.' 

It  is  surprising  how  long  such  children  will  keep  the  food  in 
their  mouths  unswallowed  ;  I  saw  myself  a  large  bolus  of  bread 
in  the  mouth  of  a  boy  aged  2J  years,  three  hours  after  he  had 
taken  it,  according  to  the  mother's  statement. 

As  I  have  indicated,  there  are  cases  in  which  difficulty  of 
swallowing  in  children  is  dependent  upon  more  serious  cause  : 

Esther  W.,  aged  9|  years,  was  brought  to  me  with  a  history  that,  from 
birth  until  the  age  of  three  years  she  had  had  difficulty  in  swallowing  fluids  : 
they  regurgitated  through  the  nostrils.  Her  speech  was  like  the  speech  of 
a  severe  diphtheritic  paralysis;  the  soft  palate  moved  hardly  at  all.  Her 
sister  was  a  cretin. 

In  this  case  there  was  apparently  a  congenital  paresis  of  the 
soft  palate. 

The  condition  known  as  congenital  ataxia,  in  which  there  is 


762*          COMMON  DISORDERS  OF  CHILDHOOD 

some  coarse  ataxy  of  the  limbs,  noticed  generally  about  the  end 
of  the  first  year,  though  no  doubt  present  from  birth,  with 
nystagmus  and  curious  drawling  speech,  is  associated  with  some 
difficulty  of  swallowing  :  a  girl  who  was  under  my  care  with 
this  condition  at  4|  years  had  always  had  difficulty  in  swallowing 
fluids,  she  had  to  drink  slowly  and  in  small  quantities. 

I  have  seen  one  case  in  which  difficulty  of  swallowing  in  a 
child  seemed  to  be  due  to  hysterical  spasm  of  the  oesophagus,  it 
persisted  in  spite  of  the  passing  of  an  cesophageal  bougie,  but 
disappeared  after  one  or  two  applications  of  electricity. 

Knee-elbow  position  in  sleep.  This  symptom  may  be  men- 
tioned here,  not  as  being  in  itself  of  any  importance,  but  because 
it  seems  to  be  an  indication  usually  if  not  always  of  digestive 
disorder.  I  have  noted  it  most  frequently  in  children  from  two 
to  five  years  of  age  ;  the  child  lies  on  his  face  with  the  knees 
drawn  up  upon  the  abdomen,  and  generally  the  forearms  flexed 
and  drawn  in  under  the  chest,  so  that  the  child  rests  in  the  prone 
position  chiefly  upon  his  elbows  and  knees.  In  most  cases  the 
child  who  sleeps  thus  has  a  large  abdomen,  the  result  of  un- 
healthy fermentation  in  the  intestine  from  unsuitable  food, 
especially  excess  of  starch.  Sometimes  there  are  other  indications 
of  digestive  disturbance  in  the  character  of  the  stool,  for  instance, 
excess  of  mucus.  I  have  also  seen  that  curious  perversion  of 
appetite  which  is  known  as  'pica'  associated  with  this  symptom, 
and  pica,  as  I  have  pointed  out  (p.  781),  seems  to  be  due  in  some 
cases  to  faulty  digestion. 

I  fancy  that  the  explanation  of  the  knee-elbow  position  is 
relief  of  pressure  upon  the  diaphragm,  as  when  the  child  lies 
thus  the  pressure  of  the  distended  intestines  falls  chiefly  upon 
the  anterior  abdominal  wall,  which  is  more  yielding  than  the 
posterior,  and  by  its  bulging  takes  more  of  the  pressure  off  the 
diaphragm.  No  doubt  what  begins  as  an  unconscious  effort 
to  relieve  discomfort  may  persist  subsequently  as  simple  habit. 

'  Palling  about/  Under  this  somewhat  untechnical  phraseo- 
logy I  shall  refer  to  a  complaint  often  made  by  parents  with 
regard  to  children  about  three  or  four  years  old,  that  they 
stumble  more  often  than  is  natural  at  that  age  in  walking  and 
running.  There  are  many  causes  which  may  account  for  such 
a  complaint, — a  cerebral  tumour,  or  infantile  hemiplegia,  which 
causes  the  toes  to  be  pointed  so  that  the  child  is  apt  to  trip  in 
walking,  or  the  disorder  known  as  congenital  ataxia,  or  chorea, 
or  diphtheritic  paralysis, — but  in  these  and  the  various  other 
conditions  which  may  interfere  with  walking  there  are  usually 


SLEEPLESSNESS,  LOSS  OF  APPETITE  763 

characteristic  symptoms  which  make  the  cause  of  the  stumbling 
obvious  enough  ;  in  the  cases  to  which  I  refer  there  is  usually 
no  obvious  evidence  of  disease  to  account  for  the  mother's 
complaint.  The  falling  is  not  due  merely  to  unsuccessful  efforts 
in  learning  to  walk,  for  the  child  has  usually  been  able  to  walk 
for  at  least  a  year  or  two,  and  sometimes  the  mother  dates  the 
trouble  definitely  from  a  few  weeks  before  medical  advice  is 
sought,  and  says  that  it  is  increasing  rather  than  diminishing. 

There  are,  I  think,  two  causes  for  this  '  falling  about '.  In 
some  cases  there  is  a  defect  of  co-ordination  precisely  similar 
to  the  stuttering  which  is  so  common  at  this  age.  The  child  of 
three  or  four  years  may  talk  fluently  so  long  as  he  talks  slowly, 
but  if  he  becomes  excited  and  talks  quickly  the  speech  co-ordina- 
tion cannot  keep  pace  with  his  words  and  stuttering  occurs  ; 
moreover,  at  this  age  the  child  who  talks  fluently  when  well  and 
vigorous  is  very  apt  to  stutter  when  health  is  depressed  from  any 
cause.  So  it  is  with  walking,  and  especially  with  running,  the 
co-ordination  recently  acquired  is  sufficient  under  ordinary  circum- 
stances to  prevent  stumbling,  but  if  the  child  becomes  unduly 
nervous  and  excitable  as  children  are  very  apt  to  do  with  diges- 
tive disorders,  with  worms,  or  with  any  slight  disturbance  of 
health,  it  becomes  insufficient  and  action  outruns  co-ordination : 
the  child  in  fact  stutters  in  walking. 

In  another  group  of  cases  there  is  a  more  tangible  cause,  namely, 
laxity  of  ligaments,  which  goes  usually  with  flabbiness  of 
muscle.  These  are  the  children  whose  tibiae  can  be  wabbled 
from  side  to  side,  knocking  loosely  against  the  condyles  of  the 
femur;  the  ligaments  of  other  joints  are  equally  lax,  and  the 
result  is  that  fixation  of  the  joints  in  walking  is  less  sure  than 
it  should  be. 

Such  a  condition  is  familiar  in  rickets,  but  it  is  also  quite 
common  apart  from  any  definite  rickets. 

Treatment.  In  the  last-mentioned  cases  the  legs  should  be 
massaged  twice  daily,  and  a  douche  of  hot  and  cold  water  alter- 
nately may  be  used  over  the  legs  while  the  child  is  in  his  morning 
bath.  The  amount  of  walking  must  be  limited,  for  the  laxity 
of  the  joints  and  lack  of  tone  in  the  muscles  are  apt  to  lead  to 
slight  degrees  of  flat-foot  or  knock-knee  if  the  child  runs  about  too 
much.  Where  the  trouble  appears  to  be  merely  an  insufficiency 
of  co-ordination  as  I  have  suggested,  the  diet  may  need  revising, 
or  santonin  powder  may  be  necessary  for  worms.  In  both 
groups  of  cases  a  tonic  containing  nux  vomioa  will  be  useful. 


CHAPTER  LIII 
HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY 

UNDER  various  names,  such  as  '  spasmus  nutans ',  'head- 
nodding  of  infants',  and  'head-shaking  with  nystagmus',  there 
has  been  described  a  curious  and  somewhat  uncommon  disorder 
which  is  worthy  of  attention,  if  only  on  account  of  the  unneces- 
sary anxiety  which  it  arouses  in  the  minds  of  those  unfamiliar 
with  its  occurrence.  The  earliest  published  record  of  which 
I  am  aware  is  one  by  Ebert  in  1850,  but  it  was  not  until  the  late 
Dr.  W.  B.  Hadden  of  the  Hospital  for  Sick  Children,  Great 
Ormond  Street,  published  his  series  of  observations  in  1890 
that  the  disorder  became  generally  recognized.  Thirty-seven 
cases  of  this  affection  have  come  under  my  own  observation  ; 
twenty- two  of  the  patients  were  boys,  and  fourteen  were  girls 
(the  sex  wras  not  noted  in  one  case)  ;  this  disproportion,  how- 
ever, may  be  accidental,  for  in  a  series  recorded  by  Dr.  J.  Thom- 
son,1 there  were  fifteen  boys  and  twenty  girls.  The  disorder  is 
almost  limited  to  infancy,  i.e.  the  first  two  years  of  life,  although, 
as  I  shall  point  out,  in  rare  cases  it  lasts  beyond  this  limit.  In 
twenty-eight  out  of  thirty-four  cases  in  which  the  age  at  the 
onset  could  be  determined,  the  disorder  began  between  the  ages 
of  five  months  and  twelve  months  ;  of  four  which  began  earlier 
only  one  was  said  to  have  begun  as  early  as  the  age  of  three 
months,  and  two  began  after  the  first  year,  both  before  the  age  of 
fourteen  months. 

Sketched  in  outline  the  clinical  picture  is  somewhat  as  follows  : 
as  the  child  sits  on  his  mother's  lap  there  is,  perhaps,  nothing 
abnormal  to  be  seen  for  a  minute  or  two,  then,  as  the  child  fixes 
his  gaze  on  some  object,  the  head  begins  to  nod  at  the  rate  of 
about  eight  or  ten  nods  within  five  seconds,  after  which  there  is 
a  pause  of  varying  length  ;  and  so,  with  irregular  intervals,  short 
series  of  noddings  occur  more  or  less  frequently  so  long  as  the 
child  is  in  the  sitting  position.  Hardly  less  striking  than  this 
rhythmic  unsteadiness  of  the  head  is  the  curious  way  the  child 
1  International  Contributions  to  Medical  Literature,  Festschrift,  May,  1900. 


HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY     765 

has  of  looking  at  objects  out  of  the  corner  of  his  eyes  with  the 
head  slightly  averted,  and  the  face  turned  slightly  downwards 
as  if  he  were  unaccountably  shy. 

The  other  feature  which  attracts  attention  is  the  exceedingly 
fine  rapid  nystagmus,  which  is  peculiar  in  being  so  much  more 
marked  in  one  eye  than  in  the  other  that  it  may  appear  to  be 
actually  limited  to  one  eye,  a  point  which  the  mother  herself 
has  usually  noticed.  These  three  symptoms,  the  head-nodding, 
the  tendency  to  look  out  of  the  corner  of  the  eyes,  and  the 
nystagmus,  constitute  the  characteristic  features  of  spasmus 
nutans  which  I  shall  now  consider  in  more  detail. 

Symptoms.  The  rhythmic  movement  of  the  head  is  not  neces- 
sarily an  antero-posterior  affirmative  nod  as  the  term  *  head- 
nodding  '  might  seem  to  imply ;  indeed,  so  far  as  my  own  observa- 
tions go,  a  lateral  shake  of  the  head  as  in  negation  would  appear 
to  be  a  commoner  movement.  Sometimes  also  the  movements 
vary,  being  at  one  time  antero-posterior,  at  another  negation, 
whilst  more  rarely  there  is  a  simultaneous  combination  of  the 
lateral  and  antero-posterior  movements,  producing  a  sort  of 
pendulum  movement.  In  twenty-eight  cases  I  have  noted  the 
variety  of  movement  :  fifteen  patients  showed  only  lateral 
rotation  (negation)  ;  eight  showed  only  antero-posterior  nodding  ; 
four  either  of  these  movements  at  different  times  ;  and  one  the 
combined  pendulum  movement. 

The  rate  of  movement  varies  from  60  to  120  nods  per  minute  ; 
the  series  of  nods  lasts  sometimes  only  for  four  or  five  seconds, 
and  sometimes  as  long  as  thirty  seconds.  I  have  noted  in  one 
case  three  bouts  of  nodding  in  six  minutes,  but  they  may  be 
more  frequent,  or  may  occur  much  less  often  ;  there  is  no  regu- 
larity in  the  intervals,  they  depend  largely  on  the  child's  occupa- 
tion. I  have  thought  that  the  nodding  occurs  chiefly  when  the 
child  fixes  his  gaze  upon  an  object  in  a  sort  of  abstraction,  but 
that  the  movements  cease  directly  the  child  is  aroused  to  active 
attention.  In  some  cases  I  have  specially  noted  that  the  move- 
ments could  be  stopped  by  attracting  the  child's  attention. 
Perhaps  there  is  some  variation  in  this  respect,  for  one  mother 
informed  me  that  the  movements  were  specially  noticeable  when 
the  child  was  watching  children  playing  in  the  street,  and  another 
said  that  her  child  showed  the  nodding  chiefly  when  not  interested 
by  anything  in  particular.  The  head  movement  occurs  only 
when  the  child  is  sitting  with  the  head  unsupported  ;  it  ceases, 
therefore,  when  the  child  is  lying  in  a  cot  or  leaning  the  head 
against  the  mother's  arm.  This  is  a  point  upon  which  I  would 


766  COMMON  DISORDERS  OF  CHILDHOOD 

lay  some  emphasis,  for  it  is  of  some  importance  in  diagnosis  ; 
the  condition  might  easily  be  overlooked  if  the  child  is  seen  only 
lying  in  a  cot.  Moreover,  there  is  another  movement,  head- 
rolling,  which  must  be  distinguished  from  the  head  movement  of 
spasmus  nutans,  and  which  occurs  chiefly  when  the  child  is  lying 
down.  The  range  and  vigour  of  the  movements  vary  considerably 
in  different  cases  and  in  the  same  case  at  different  times  ;  in 
some  they  are  so  slight  as  to  be  easily  overlooked,  while  in  others 
they  are  obvious  to  all.  Twice  I  have  seen  the  antero-posterior 
nodding  so  forcible  as  almost  to  shake  the  child's  bonnet  off, 
but  this  is,  I  believe,  quite  exceptional.  But  whether  the  move- 
ments be  slight  or  vigorous,  they  are  obviously  involuntary,  and 
in  this  way  differ  from  the  much  commoner  '  head-rolling',  which 
has  the  appearance  of  a  voluntary  movement. 

I  have  already  alluded  to  the  occurrence  of  head-nodding 
when  the  infant  is  sitting  gazing  at  some  object  in  an  absent- 
minded  sort  of  way.  And  this  leads  me  to  remark  on  the  curious 
tendency  of  these  children  with  spasmus  nutans  to  fall  into  an 
absent-minded  stare,  a  sort  of  '  brown  study '  which  seems 
hardly  natural  for  an  infant.  But  there  is  nothing  whatever  in 
these  moments  of  abstraction  to  suggest  petit  mal.  The  child 
takes  notice  directly  attention  is  drawn  to  sight  or  sound  ;  there 
is  no  change  of  colour,  no  tendency  to  any  epileptiform  mani- 
festation— in  fact,  no  ground  whatever  for  regarding  this  pecu- 
liarity as  due  to  petit  mal.  I  wish  to  lay  great  stress  upon  this 
point,  for  it  has  been  stated  that  children  with  spasmus  nutans 
show  a  special  liability  to  petit  mal.  So  far  as  my  own  observa- 
tions go,  I  have  not  seen  the  least  tendency  to  epilepsy  of  any 
sort.  Very  remarkable  is  the  habit  these  infants  have  of  looking 
out  of  the  corner  of  the  eyes  while  the  face  is  turned  in  the  opposite 
direction  and  slightly  downwards.  So  characteristic  is  this 
when  present — and  I  think  it  is  present  in  many  cases — that  it 
should  at  once  suggest  spasmus  nutans.  The  parents  themselves 
have  often  noticed  it.  In  one  of  my  cases  it  was  the  first  com- 
plaint that  the  infant  had  recently  begun  to  look  out  of  the 
corners  of  his  eyes  '  in  a  funny,  coy  way  ',  which  had  made  the 
father,  a  medical  man,  fear  some  serious  cerebral  disease. 
I  have  no  explanation  to  offer  for  this  curious  symptom.  I  have 
heard  it  suggested  that  it  is  due  to  an  effort  to  obtain  fixation  of 
the  eyes  which  nystagmus  renders  difficult,  but  this  can  hardly  be 
so,  for  I  have  seen  this  sideway  gaze  very  marked  in  two  of  the 
exceptional  cases  where  there  was  no  nystagmus.  '  Gaze ' 
I  say  rather  than  '  glance  ',  for  during  this  action  perhaps  even 


HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY     767 

more  than  at  other  times  the  infant  is  apt  to  stare  fixedly  as  if 
in  one  of  those  '  brown  studies  '  to  which  I  have  referred.  This 
phenomenon  may  be  noticeable  several  times  within  five  or  ten 
minutes. 

The  nystagmus  which  with  the  head  movement  constitutes 
the  chief  feature  of  spasmus  nutans  is  characteristic  and  peculiar 
in  certain  respects,  and  chiefly  in  two  points:  (1)  its  unilateral 
predominance.  It  is  almost  invariably  much  more  marked  in  one 
eye  than  in  the  other — indeed,  in  some  cases  it  appears  to  be 
actually  unilateral.  This  unilateral  predominance,  apart  from 
any  unilateral  lesion  of  the  media  or  fundus,  is,  so  far  as  I  am 
aware,  excessively  rare  apart  from  this  particular  disorder ; 
(2)  its  onset  without  apparent  cause  in  an  infant  a  few  months  old, 
and  its  complete  disappearance  after  a  few  weeks  or  months. 
Such  temporary  nystagmus  in  infancy  without  ocular  lesion  or 
any  evidence  of  gross  cerebral  disease  is  almost  peculiar  to 
spasmus  nutans.  The  nystagmus  differs  also  from  that  due 
to  some  other  conditions  in  being  exceedingly  fine  and  rapid. 
It  may  be  vertical,  horizontal,  or  rotary,  and  Dr.  Thomson  has 
observed  it  to  be  convergent  instead  of  conjugate  in  some  cases. 
I  have  seen  it  associated  with  vertical  nystagmus  of  the  upper 
eyelid,  but  this  is  unusual.  I  have  not  observed  the  rhythmic  con- 
traction of  the  pupil  (hippus)  which  some  writers  have  recorded ; 
Dr.  Thomson  noted  this  in  four  out  of  thirty-five  cases. 

The  onset  of  nystagmus  in  spasmus  nutans  may  precede  the 
head-shaking  by  several  weeks  or  even  months.  In  one  of  my 
cases  it  was  stated  to  have  been  present  three  months  before  the 
head-nodding  began  ;  more  often  the  head  movement  is  the 
first  symptom  that  attracts  attention,  and  the  nystagmus  may 
appear  later.  From  this  variation  in  the  order  of  occurrence  of 
these  symptoms  it  might  be  conjectured  that  cases  would  occur 
in  which  one  or  other  symptom  was  lacking  altogether,  and  there 
can  be  little  doubt  that  not  only  does  the  characteristic  head- 
nodding  occur  sometimes  without  nystagmus  at  any  period  of 
the  disorder,  but  the  nystagmus  may  be  the  only  manifestation  of 
spasmus  nutans,  if  the  affection  may  be  so  called  when  head- 
shaking  is  entirely  absent.  The  evidence  of  this  lies  in  the  occur- 
rence in  infants  of  nystagmus  which  has  the  characteristic 
features  mentioned  above,  and  which  shows  the  same  age -inci- 
dence, seasonal  variation,  and  relation  to  rickets,  and  the  same 
temporary  character,  a  duration  of  weeks  or  months,  as  does 
the  nystagmus  which  is  associated  with  head-nodding.  I  have 
included  in  my  series  of  thirty-seven  cases  three  in  which  was 


768  COMMON  DISORDERS  OF  CHILDHOOD 

shown  this  nystagmu^  alone,  and  two  in  which  was  shown  the 
characteristic  nystagmus,  associated  not  with  head-nodding, 
but  with  the  much  commoner  quasi- voluntary  movement,  head- 
rolling,  an  association  which  is  perhaps  to  be  regarded  as  acci- 
dental. Of  the  thirty-two  cases  with  head-nodding,  twenty-nine 
patients  showed  nystagmus  sooner  or  later  (in  two  of  these  it 
was  extremely  slight  and  perhaps  open  to  doubt)  ;  only  two 
showed  no  nystagmus  at  any  time. 

With  this  description  of  the  symptoms  of  spasmus  nutans 
I  would  mention  the  case  of  an  infant,  aged  five  months,  in 
whom  not  only  were  the  antero -posterior  noddings  of  the  head 
unusually  marked,  but  there  was  also  some  shaking  of  one  arm. 
These  symptoms  had  lasted  for  some  days  when  I  saw  the  child, 
and  I  heard  from  Dr.  C.  W.  Cooke  of  Willesden,  under  whose 
care  the  child  was,  that  they  passed  off  soon  afterwards  without 
leaving  any  ill  effect.  In  one  other  case  I  have  noted  some 
shakiness  of  the  arms,  and  Dr.  Thomson  mentions  this  symptom 
as  present  in  two  cases  in  his  series. 

Etiology.  I  turn  now  to  the  consideration  of  the  etiology  of 
spasmus  nutans.  Rickets  is  present  in  a  large  proportion  of  the 
cases.  In  twenty-four  out  of  thirty-one  cases  in  which  I  have 
noted  this  point  the  patients  showed  some  degree  of  rickets,  but 
only  four  showed  severe  osseous  rickets ;  in  most  it  was  particularly 
noted  that  the  evidence  of  rickets  was  definite  but  slight.  The 
occasional  absence  of  rickets  shows  that  rickets  is  not  an  essential 
factor  ;  moreover,  in  the  rare  cases  in  which  the  disorder  begins 
at  as  early  an  age  as  two  or  three  months,  rickets  is  not  likely 
to  have  been  a  causal  factor  even  if  it  is  found  later.  It  is, 
I  think,  clear  that  spasmus  nutans  does  not  stand  in  so  close  a 
relation  to  rickets  as  do  such  conditions  as  laryngismus  stridulus, 
facial  irritability,  and  tetany — phenomena  which  in  infancy  are 
almost  always  associated  with  well-marked  and  often  severe 
degrees  of  rickets.  It  is,  indeed,  noteworthy  how  seldom  spasmus 
nutans  keeps  company  with  any  of  these  phenomena,  which  are 
so  closely  associated  together  that  the  presence  of  any  one  of 
them  raises  an  expectation  of  the  others  and  which,  like  convul- 
sions, are  well  recognized  as  expressions  of  the  nervous  instability 
of  rickets.  In.  my  own  series  one  patient  showed  facial  irrita- 
bility ;  in  Dr.  Thomson's  series  of  thirty-five  cases  two  showed 
laryngismus  stridulus  with  or  without  facial  irritability,  and 
two  others  showed  facial  irritability  without  laryngismus.  As 
a  predisposing  cause,  however,  rickets  must  be  regarded  as  a 
frequent  factor  in  the  etiology  of  spasmus  nutans. 


HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY     769 

The  relation  of  this  disorder  to  dentition  is  specially  note- 
worthy. The  onset  of  spasmus  nutans  is  most  commonly  be- 
tween five  and  twelve  months  of  age,  the  period  when  the  worry 
of  dentition  begins  ;  the  affection  rarely  persists  after  the  end 
of  the  second  year,  the  end  of  the  first  dentition.  Moreover,  it 
was  evident  in  some  of  my  cases  that  just  before  the  eruption  of 
a  tooth  the  head  movements  and  also  the  nystagmus  were 
increased,  while  they  at  once  became  less  when  the  tooth  was 
through  the  gum.  My  own  opinion  is  entirely  in  agreement  with 
that  of  Henoch,  who  regarded  the  irritation  of  teething  as  a 
possible  cause  of  spasmus  nutans.  I  think,  however,  that  it  is 
quite  likely  that  other  forms  of  peripheral  irritation  may  also 
act  as  exciting  causes,  and  some  support  is  given  to  this  view 
by  the  closely  comparable  phenomenon  to  which  Mr.  W.  T.  Lister 
has  drawn  my  attention,  the  occasional  production  of  temporary 
nystagmus  by  ear-syringing.  Preceding  illness  or  injury  would 
seem  to  have  determined  the  onset  in  some  of  my  cases  ;  in  one 
with  nystagmus  alone  this  began  three  days  after  an  attack  of 
diarrhoea  and  vomiting  ;  in  another  it  began  during  conva- 
lescence from  diphtheria  ;  in  two  others  during  convalescence 
from  infantile  scurvy  ;  in  one  case  head-nodding  began  four 
days  after  an  attack  of  diarrhoaa,  in  two  just  after  bronchitis, 
and  in  one  a  few  hours  after  a  fall  on  the  head.  Its  occurrence 
in  rickety  children  and  after  the  exhaustion  of  various  illnesses 
or  the  shock  of  an  injury,  and  its  very  close  relation  to  dentition 
and  the  exacerbations  just  when  a  tooth  is  in  process  of  eruption, 
all  suggest  that  spasmus  nutans  is  a  functional  disorder  depending 
upon  an  acquired  or  congenital  nervous  instability  with  some 
peripheral  irritation  as  an  exciting  cause. 

The  defective-light  theory.  Of  recent  years  there  has  been 
put  forward  a  theory  which  is  worthy  of  careful  consideration — 
namely,  that  spasmus  nutans  is  due  to  living  in  ill-lighted  dwel- 
lings ;  dimness  of  light,  it  is  supposed,  causes  deficient  fixation 
of  vision,  and,  moreover,  the  infant  throws  his  eyes  into  an 
unnatural  and  strained  position  in  attempting  to  look  towards 
the  window.  To  this  strain  upon  the  ocular  muscles  is  due  the 
nystagmus  ;  the  head  movements  are  secondary  to  the  nystagmus. 
This  is  the  view  put  forward  by  Raudnitz1.  The  arguments 
adduced  in  its  favour  are  :  (1)  the  fact  that  infants  with  spasmus 
nutans  often  live  in  dark  dwellings  ;  (2)  the  rarity  or  non-existence 
of  the  disorder  amongst  the  wealthier  and  consequently  better 
housed  class  ;  (3)  the  onset  of  the  disease  nearly  always  during 
1  Jahrluch  fur  Kinder heilkunde,  Band  xlv,  p.  145. 

STILL  3  D 


770  COMMON  DISORDERS  OF  CHILDHOOD 

the  dark  months  of  the  year  ;  and  (4)  the  analogy  with  miners' 
nystagmus,  with  which  there  are  known  to  be  associated  in 
rare  instances  some  rhythmical  swaying  movements  of  trunk 
and  head. 

Now  I  venture  to  think  that  in  spite  of  the  above  apparently 
strong  arguments  there  are  grave  difficulties  in  accepting  the 
defective-light  theory. 

1.  It    is    quite  certain  that   spasmus  nutans    may  occur  in 
infants  living  in  well-lighted  dwellings.     I  have  inquired  specially 
into  this  point  in  thirty-one  cases  :   in  four  of  these  I  was  able 
to  visit  the  home,  in  the  rest  my  inquiry  was  only  by  careful 
interrogation,  not  by  actual  visiting,  and  is  therefore  less  con- 
vincing than  actual  visitation  would  be.     In  seven  cases  only 
did  the  home  appear  to  be  ill  lighted,  and  in  some  of  these  the 
child  was  hardly  taken  out  of  doors  at  all.     In  twenty-four  out 
of  the  thirty-one  cases,  including  the  four  which  I  visited  myself, 
there  appeared  to  be  no  reason  for  regarding  the  room  in  which 
the  child  chiefly  lived  as  ill  lighted,  and  in  several  cases  it  was 
specially  noted  that  the  rooms  were  light  and  sunny.     But  in 
considering  the  question  of  light,  it  is  obviously  necessary  to 
take  into  account  to  what  extent  the  child  lives  indoors.     Some 
of  my  patients  were  taken  out  daily.     One  of  those  which  I  have 
mentioned  as  living  in  ill-lighted  rooms  was  out  in  the  open  air 
daily  for  three  to  four  hours,  and  in  one  case  it  was  particularly 
stated  that  the  child  was  taken  out  much  every  day  and  '  in  all 
weathers  '. 

2.  The  disorder  is  undoubtedly  seen  chiefly  in  hospital  prac- 
tice, but  I  have  seen  it  in  three  cases  in  private  practice  amongst 
people  in  comfortable  circumstances  and  well  housed,  once  in 
the  infant  of  a  medical  man  \vhose  nursery  was  an  excellently 
lighted  room.     It  must  be  remembered  also  that  rickets,  which 
most  observers  have  regarded  as  a  predisposing  cause,  is  com- 
moner amongst  the  hospital  class  than  amongst  the  well-to-do. 

3.  The  seasonal  incidence  of  the  disease  is,  indeed,  remark- 
able.    In  26  of  my  cases  the  onset  could  be  dated  \vith  some 
degree   of   accuracy  :    January,    7  ;     February,    7  ;    March,    1  ; 
April,  0  ;  May,  0  ;  June,  1  ;   July,  1  ;   August,  0  ;   September,  2  ; 
October,  1  ;   November,  1  ;    and  December,  5.     In  seven  others 
the  date  could  be  determined  with  less  certainty,  thus  :  January, 
1  ;   February,  2  ;   March,  3  ;   and  November,  1.     So  that  out  of 
33  cases  22  began  within  the  three  months  December  to  February. 
Only  two  began  during  the  five  months  April  to  August.     These 
figures  agree  with  those  collected  by  Dr.  Thomson,  and  addition 


HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY     771 

of  his  statistics  to  mine  shows  that  85  per  cent,  of  the  cases  of 
spasmus  nutans  have  their  onset  during  the  five  months  November 
to  March. 

But  the  special  incidence  of  the  disorder  in  these  comparatively 
dark  winter  months  is  not  necessarily  connected  with  deficiency 
of  light,  and  I  would  point  out  that  laryngismus  stridulus,  another 
nervous  disorder  associated  with  rickets,  and  one  which  can 
hardly  be  attributed  to  deficiency  of  light,  has  a  very  similar 
seasonal  incidence  (see  chart,  p.  654);  its  onset  is,  it  is  true, 
rather  more  often  in  March  than  in  January,  but  according  to 
my  own  statistics  no  less  than  80  per  cent,  of  the  cases  have 


Fia.  52.  Seasonal  incidence  of  Spasmus  Nutans.  Chart  showing  the  month 
of  onset  m  110  cases  (statistics  collected  by  Dr.  J.  Thomson  combined  \\ith  the 
author's  series). 

their  onset  during  the  five  months  November  to  March.  It 
would  seem,  therefore,  that  during  this  season  there  is  some 
influence  apart  from  deficiency  of  light  favouring  the  onset  of 
certain  nervous  disorders  in  connexion  with  rickets. 

4.  The  analogy  with  miners'  nystagmus  can  hardly  be  said 
to  support  very  strongly  the  defective-light  theory,  for  it  is  the 
opinion  of  experts  now  that  such  nystagmus  is  due  much  less 
to  the  bad  light  than  to  the  strained  position  of  the  eyes  in  this 
occupation  ;  and  nystagmus  is  known  to  occur  from  a  similar 
cause  in  other  occupations  in  winch  a  strained  position  of  the 
eyes  is  usual,  although  the  work  is  done  in  broad  daylight. 

3D2 


772*         COMMON  DISORDERS  OF  CHILDHOOD 

Moreover,  the  miners'  nystagmus  does  not  show,  so  far  as  I  have 
been  able  to  ascertain,  the  unilateral  predominance  which  is  so 
striking  a  feature  in  the  nystagmus  of  spasmus  nutans. 

Lastly,  this  theory  seems  to  assume  that  the  head  movements 
are  secondary  to  the  nystagmus  ;  whereas  clinical  experience 
shows  that  the  head  movements  often  precede  the  nystagmus, 
and  occasionally  no  nystagmus  appears  at  any  time. 

Prognosis.  Spasmus  nutans  usually  passes  off  after  a  few 
months,  leaving  no  ill  effects ;  occasionally  it  lasts  only  from  two 
to  three  weeks,  more  often  it  lasts  from  three  to  twelve  months ;  it 
rarely  lasts  beyond  the  end  of  the  second  year.  I  have,  however, 
seen  nystagmus  still  present  in  one  case  at  the  age  of  four  years. 

As  already  stated,  I  know  of  no  special  relation  between 
spasmus  nutans  and  epilepsy,  minor  or  major  ;  indeed,  I  have 
not  seen  a  single  case  in  which  the  child  has  developed  epilepsy 
either  during  the  persistence  of,  or  subsequently  to,  spasmus 
nutans.  I  suspect  that  the  tradition  of  such  an  association  has 
arisen  from  the  description  given  by  Ebert  of  cases  of  epilepsy 
with  clonic  jerking  of  the  head  under  the  same  heading  '  Spasmus 
sou  Eclampsia  Nutans  ',  an  unfortunate  confusion  of  disorders 
which  differ  widely  both  in  their  symptoms  and  in  their  course. 
In  one  of  my  cases  a  single  convulsion  occurred  in  the  ten  months 
during  which  spasmus  nutans  lasted,  but  it  appeared  to  be  an 
ordinary  infantile  convulsion  such  as  any  rickety  infant  may 
have,  and  no  others  occurred  during  the  subsequent  period  of 
observation  (five  months). 

I  have  been  asked  several  times  whether  the  disorder  will  leave 
any  injurious  effect  upon  the  intellect  and  I  have  kept  notes  in 
several  cases  of  the  child's  progress  in  walking,  in  talking,  and 
in  intelligence.  I  have  not  found  them  more  backward  than 
other  children,  unless  the  degree  of  rickets  happened  to  delay 
development,  which  it  rarely  did  ;  but  spasmus  nutans,  being 
an  index  of  nervous  instability,  is,  I  think,  likely  to  occur  in 
children  who  will  show  nervous  peculiarities  at  a  later  age. 
(I  am  not  alluding  to  imbecility,  though  there  would  seem  to  be 
some  special  liability  to  this  disorder  in  Mongol  imbeciles  ;  two . 
cases  in  my  series  were  '  Mongols  ',  and  Dr.  Thomson  includes 
two  cases  in  his  series  of  thirty-five  cases,  and  alludes  to  another.) 
In  several  cases  I  have  thought  that  the  child,  long  after  all  trace 
of  the  disorder  had  disappeared,  was  a  hi ghly  nervous  or  eccentric 
child,  without  showing  any  lack  of  intelligence.  One  patient 
was  sent  to  me  subsequently  for  '  spitefulness  and  screaming  ', 
another  at  the  age  of  four  years  because  it  was  *  so  nervous  and 


HEAD-NODDING  WITH  NYSTAGMUS  IN  INFANCY     773 

screamed  at  the  slightest  thing  '.  Another  at  three  years  and 
four  months  for  pica  (dirt  eating).  Apart,  however,  from  this 
possible  foreshadowing  of  later  tendencies  to  neurosis,  it  is 
probably  safe  to  give  an  unqualified  good  prognosis. 

Diagnosis.  Spasmus  nutans  must  be  distinguished  from  a  very 
rare  congenital  condition  of  nystagmus  with  head-nodding.  This 
disorder,  unlike  spasmus  nutans,  is  permanent,  not  transitory. 
In  a  case  under  my  care,  a  boy  aged  seven  years,  apparently 
of  average  intelligence,  showed  head-nodding  very  like  that  of 
spasmus  nutans,  but  the  nystagmus,  which  dated  from  birth, 
was  coarser  and  less  rapid  than  that  usually  seen  in  spasmus 
nutans  and  showed  no  unilateral  predominance.  The  eyes,  as  in 
spasmus  nutans,  showed  nothing  abnormal  apart  from  nystagmus. 

Another  curious  movement  to  be  distinguished  from  spasmus 
nutans  is  the  head-rolling  which  is  seen  in  infancy,  and  some- 
times in  children  just  past  infancy.  It  occurs  chiefly  when 
the  infant  is  lying  down — the  child  rolls  his  head  monotonously 
from  side  to  side  on  the  pillow.  The  movement  appears  to  be 
quite  voluntary,  whereas  that  in  spasmus  nutans  appears  to  be 
involuntary  ;  it  is  not  associated  with  nystagmus. 

Clonic  antero-posterior  jerkings  of  the  head  occasionally  form 
the  chief  manifestation  of  epilepsy,  which  has  then  unfortunately 
been  called  '  eclampsia  nutans  '  and  by  some  writers  '  spasmus 
nutans  '.  The  attacks  consist  of  a  series  of  forcible  noddings  of 
the  head  or  bowing  movements  of  the  whole  trunk.  Dr.  West 
states  that  as  many  as  fifty  or  more  jerks  of  the  head  may  occur 
in  succession.  The  child  at  the  time  has  a  vacant  appear- 
ance, probably  with  more  or  less  complete  loss  of  consciousness. 
Nystagmus,  if  present,  is  only  likely  to  occur  as  part  of  each 
attack,  whereas  in  spasmus  nutans  it  is  to  be  seen  just  as  often 
when  the  head  is  at  rest  as  when  the  nodding  is  present. 
The  head- jerking  may  occur  without  any  spasm  of  the  limbs, 
but  sooner  or  later  more  widespread  spasm  is  likely  to  occur,  so 
that  the  attack  resembles  the  more  ordinary  attacks  of  epilepsy  ; 
but  even  when  the  clonic  spasm  of  the  head  is  the  only  mani- 
festation, the  sudden  onset  of  each  attack,  the  more  jerky 
character  of  the  movement,  the  vacant  appearance  or  loss  of 
consciousness,  and  probable  change  of  colour,  all  make  the  dis- 
tinction from  spasmus  nutans  obvious;  indeed, it  is  probable  that 
whatever  confusion  has  arisen  is  owing  less  to  any  resemblance 
between  the  disorders  than  to  the  unfortunate  use  of  the  term 
'  eclampsia  nutans  '  for  this  form  of  epilepsy,  which  bears  no 
relation  whatever  to  spasmus  nutans. 


I 
774  COMMON  DISORDERS  OF  CHILDHOOD 

Treatment.  The  very  variable  duration  of  this  disorder 
and  its  frequent  fluctuations  in  degree  make  it  difficult  to 
estimate  the  value  of  treatment.  Diminution  both  of  the 
head-nodding  and  of  the  nystagmus  sometimes  follows  the  use 
of  sedative  drugs,  and  I  have  thought  that  phenazone  was  more 
valuable  than  bromide  in  these  cases.  At  six  months  old  half 
a  grain,  and  at  one  year  old  one  grain  of  phenazone  may  be 
given.  In  some  cases  I  have  given  a  combination  of  bromide  with 
cod-liver  oil  apparently  with  good  results. 

The  part  played  by  rickets  in  predisposing  to  spasmus  nutans 
suggests  also  the  advisability  of  inquiring  into  the  feeding 
and  correcting  any  fault  which  may  favour  the  rachitic  tendency. 
I  have  no  doubt  also  that  cold  or  tepid  douches  as  the  infant 
sits  in  a  warm  bath  tend  to  reduce  the  nervous  instability, 
and  that  confinement  in  a  close,  ill- ventilated  room,  whether 
well  or  ill  lighted,  increases  this  instability  and  is  therefore  to 
be  forbidden.  For  this  reason  I  have  urged  the  parents  to  keep 
these  children  out  of  doors  as  much  as  possible,  and  I  suspect 
that  in  the  greater  liability  to  confinement  in  a  stuffy  room 
with  closed  windows  during  the  cold  months  lies  the  explanation 
of  the  seasonal  incidence  of  spasmus  nutans  rather  than  in  any 
deficiency  of  light. 


CHAPTER  LIV 
ON  CERTAIN   MORBID  HABITS  IN  CHILDREN 

THERE  is  no  period  of  life  at  which  habits  are  so  readily  estab- 
lished  as  in  childhood,  but  fortunately — for,  like  rank  weeds, 
bad  habits  grow  faster  than  good — childhood  is  a  plastic  age 
when  the  deep  ruts  of  habit  may  yet  be  smoothed  away,  and 
custom  moulded  to  new  tracks. 

A  troublesome  habit  is  that  of  masturbation,  a  practice  only 
too  common,  as  every  medical  man  knows,  in  boys  at  the  school 
age,  but  common  also  in  girls,  and — a  fact  not  nearly  so  well 
known — by  no  means  rare  in  infancy.  For  some  reason  the 
large  majority  of  children  brought  to  the  medical  man  for  this 
habit  in  the  first  few  years  of  life  are  girls.  I  doubt  whether  it 
is  really  commoner  in  girls  than  in  boys,  possibly  the  mother 
mistakes  for  an  innocent  phenomenon  the  manifestation  of  the 
habit  in  the  boy  ;  but  there  is  one  reason  which  may  account 
for  its  frequency  in  girls,  namely  >  the  great  liability  to  vulval 
irritation  from  lack  of  cleanliness  or  from  actual  vulvo-vaginitis. 
I  am  convinced  from  my  own  observations  that  in  the  large 
majority  of  these  cases  in  girls  the  habit  has  been  started  by 
some  such  local  irritation,  and  what  began  as  a  mere  scratching 
or  rubbing  to  palliate  itching  or  discomfort,  has  ended  in  the 
habit  of  masturbation.  No  doubt  the  child  is  led  thereto  by 
the  discovery  that  the  act  brings  with  it  some  concomitant 
gratification. 

I  find  amongst  my  notes  thirty-nine  cases,  of  whom  thirty- 
one  were  girls  ;  five  of  these  thirty-nine  cases  were  brought  for 
this  habit  when  under  the  age  of  twelve  months,  and  six  in  the 
second  year  ;  the  youngest  was  eight  months  old  when  brought, 
but  several  were  known  to  have  begun  the  habit  earlier  than  this  ; 
two  began  it  at  five  months,  two  at  six  months,  three  at  seven 
months  ;  in  one  girl  whom  I  saw  at  the  age  of  two  and  a  half 
years  for  masturbation  the  mother,  an  intelligent  woman,  was 
quite  certain  that  the  habit  began  during  the  first  week  of  life. 
In  twenty-two  out  of  twenty-five  cases  in  which  I  have  noted 
this  point,  masturbation  began  before  the  age  of  two  years. 
The  manifestations  of  this  habit  are  so  often  unrecognized  by 


776  COMMON  DISORDERS  OF  CHILDHOOD 

medical  men  that  I  shall  quote  the  mother's  description  of  the 
symptoms  in  a  few  cases,  as  far  as  possible  in  her  own  words. 

Elsie  D.,  aged  one  year  and  eleven  months,  was  brought  for 
*  attacks  '  which  began  at  the  age  of  eleven  months  ;  '  she 
throws  her  head  back  and  gets  into  such  a  heat  that  beads  of 
perspiration  stand  on  her  forehead,  at  the  same  time  she  screws 
her  legs  up  and  crosses  her  thighs  and  takes  no  notice  of  anything ; 
after  this  her  face,  which  has  become  very  red,  turns  pale.  This 
occurs  many  times  a  day  if  the  child  is  left  sitting  alone.' 

Irene  W.,  aged  nine  months,  when  sitting  on  her  mother's 
lap  crosses  her  left  thigh  over  the  right  and  '  works  her  body 
about '  ;  whilst  doing  this  she  throws  her  head  back,  flushes 
and  perspires,  and  then  goes  very  pale. 

Annie  W.,  aged  seven  years,  was  said  to  *  wriggle  '  when 
sitting  on  a  chair,  and  at  the  same  time  went  very  red  and  then 
turned  pale  and  seemed  sleepy. 

Mabel  S.,  aged  eighteen  months,  since  the  age  of  six  months 
has  had  a  habit  of  frequently  '  clenching  her  hands  and  wriggling 
till  she  goes  dull  in  the  eyes  '. 

Maud  J.,  aged  two  years,  was  brought  for  attacks  of  '  stiffness 
of  the  legs  '.  Since  she  was  twelve  months  old  she  has  had 
these  '  attacks  '  five  or  six  times  a  day,  always  when  sitting  up, 
never  in  bed  ;  she  crosses  the  thighs  rigidly,  goes  very  red, 
breaks  out  in  a  sweat,  and  then  turns  pale. 

In  other  cases  the  child  was  said  to  '  rise  as  if  trotting  while 
sitting  on  a  chair,  making  a  grunting  noise,  and  turning  pale 
afterwards  ',  or  to  '  sway  herself  backwards  and  forwards  on  her 
chair,  and  then  perspire  very  much  and  go  red  and  then  white ', 
or  again,  the  child  is  said  to  '  stand  and  rub  herself  against  the 
corner  of  a  chair,  making  a  straining  noise  and  then  turning  pale  '. 

In  most  of  these  cases  in  infancy  and  in  early  childhood  the 
habit  is  practised  in  the  day-time,  not  at  night — at  any  rate,  it 
is  not  noticed  at  night  ;  only  in  few  cases  does  the  child  use  her 
hands  to  rub  herself. 

From  the  symptoms  which  I  have  described  it  can  be  under- 
stood that  the  habit  may  easily  be  mistaken  for  some  epileptic 
manifestation.  I  have  twice  at  least  seen  such  cases  in  consulta- 
tion where  a  diagnosis  of  epilepsy  had  been  made.  The  mistake 
is  the  more  natural  when  the  mother  mentions,  as  I  have  noted  in 
several  of  my  cases,  that  the  child  '  fixes  her  eyes '  or  *  stares  ' 
during  the  paroxysm,  and  also  that  she  '  quivers  '  or  '  waves 
her  hands  in  a  sort  of  tremor',  and  that  after  the  attack  the  child 
is  sleepy  01  actually  goes  to  sleep. 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     777 

This  last  symptom  is,  I  think,  occasionally  accountable  for  the 
persistence  of  the  habit ;  the  child  learns  that  sleep  comes  with 
the  exhaustion  from  the  orgasm  and,  by  a  kind  of  auto-suggestion, 
finds  difficulty  in  getting  to  sleep  until  she  has  induced  weariness 
by  masturbation  ;  one  little  girl  who  was  brought  to  me  for  this 
habit  at  about  eight  years  old,  when  reproved,  said,  '  But 
I  can't  go  to  sleep  if  I  don't  do  it,'  and  I  have  no  doubt  that  her 
explanation  was  a  sound  one. 

I  have  noted  in  almost  every  case  that  after  the  orgasm  the 
child  turned  pale  ;  in  some  cases  the  mother  added  that  after 
it  the  child  '  looked  dark  under  the  eyes  ',  and  usually  the  child 
was  '  quite  exhausted  '.  In  several  cases  the  mother  said  that 
the  child  had  become  very  nervous  and  fretful  when  the  habit 
was  most  frequent. 

These  symptoms  indicate  the  harm  that  is  likely  to  come  from 
this  habit  in  early  childhood  ;  the  general  health  is  depressed  to 
some  extent  by  the  repeated  exhaustion,  the  child  becomes  pale, 
lacking  in  vivacity,  and  often  nervous  and  peevish. 

Beyond  this  I  have  seen  no  harm,  unless  I  was  right  in 
suspecting  that  in  one  child  who  had  had  previous  convulsions, 
the  orgasm  of  masturbation  sometimes  passed  directly  into  an 
epileptic  attack ;  but  here,  as  I  think  probable  in  all  such  cases, 
the  tendency  to  epilepsy  was  present  independently  of  the  mastur- 
bation, which  was  only  a  determining  cause  of  particular  attacks. 

No  doubt  in  later  life  the  habit  may  do  serious  harm  by  increas- 
ing sexual  excitability  and  so  predisposing  to  immorality,  and 
herein  I  think  lies  one  important  reason  for  making  every  effort 
to  stop  this  habit  before  it  has  become  firmly  established.  In 
the  meantime  we  can  assure  the  parents  that  the  physical  harm 
from  this  habit  has  been  grossly  exaggerated  by  unscrupulous 
quacks  for  their  own  base  ends,  and  that  there  is  not  the  least 
danger  of  the  child  becoming  idiotic  as  a  result  of  this  practice — 
idiots  are  often  addicted  to  this  habit,  but  it  is  the  result  and 
not  the  cause  of  their  mental  condition. 

I  have  already  referred  to  the  part  played  by  vulval  soreness 
and  irritation  in  producing  this  habit  in  girls  ;  let  me  here  point 
out,  especially  to  those  who  have  the  responsibility  of  decidirg 
whether  a  boy  should  be  circumcised,  that  the  exposure  of  the 
glans^  penis,  especially  of  the  corona,  by  circumcision  seems 
sometimes  to  be  the  exciting  cause  of  masturbation  in  boys. 
No  doubt  an  adherent  prepuce— and  an  unduly  long  or  tight 
prepuce  is  usually  adherent — may  be  and  often  is  a  cause  of 
local  worry,  and  may  thus  induce  this  habit,  but  none  the  less, 


778  COMMON  DISORDERS  OF  CHILDHOOD 

I  think  that  in  many  cases  circumcision  is  done  most  unadvisedly , 
A  boy  is  deprived  of  Nature's  covering  for  the  sensitive  glans, 
which  is  left  exposed  to  the  constant  friction  of  clothes,  so  that 
the  poor  child  is  willy-nilly  kept  in  constant  mindfulness  of  this 
part,  when,  perhaps,  by  merely  separating  the  adhesions  and 
pulling  the  foreskin  back  daily  during  the  first  few  years  of  life 
circumcision  might  have  been  avoided  and  all  this  local  irritation 
prevented.  Even  wrhere  circumcision  is  necessary,  there  is  no 
need  whatever  to  cut  the  foreskin  away  wholesale,  leaving  corona 
and  glans  exposed  ;  nowadays  some  surgeons  have  realized  this, 
and  I  see  boys  with  a  prepuce  left  sufficient  to  cover  the  corona 
and  the  greater  part  of  the  glans,  a  condition  of  things  far  less 
likely  to  favour  the  habit  of  masturbation  than  the  flayed  and 
unprotected  state  which  is  too  often  seen  after  circumcision. 

The  underclothing  of  boys  is  sometimes  calculated  to  increase 
the  irritability  of  these  parts  :  an  undergarment  which  allows 
the  penis  to  be  continually  slipping  in  and  out  through  the 
opening  in  front  is  a  bad  one  ;  many  little  boys  are  clad  in  a 
combination  garment  so  arranged  that  this  is  inevitable  ;  a  little 
care  and  common  sense  can  easily  prevent  this  source  of  irritation. 

Treatment.  One  great  factor  in  the  successful  treatment  of 
this  habit  is  early  recognition.  If  only  masturbation  is  detected 
in  infancy  it  is  seldom  difficult  to  stop,  but  when  it  has  been 
going  on  several  years  there  is  usually  great  difficulty  in  breaking 
the  habit.  It  seems  probable  that  in  a  very  large  proportion  of 
cases  this  habit  begins  in  infancy,  and  as  the  infant  practises  it 
without  concealment  the  failure  or  success  of  treatment  at  this 
age  is  evident.  It  should  be  impressed  upon  parents  that  they 
must  not  be  satisfied  until  it  is  quite  certain  that  the  habit  is 
stopped.  Whether  any  evidence  of  inflammation  is  detected 
in  the  vulva  or  not,  it  is,  I  think,  w^ise  to  insist  upon  the  necessity 
of  sitting  the  child  in  a  warm  bath  for  a  few  minutes  twice  a  day, 
with  the  thighs  well  separated,  and  if  there  is  definite  evidence 
of  local  irritation,  a  calamine  lotion,  such  as  that  in  use  at 
the  Children's  Hospital  (Zinci  Oxidi  gr.  xxx,  Calaminse  Prep. 
gr.  xxx,  Glycerin.  0)xxiv,  Liquor  Calcis  O)xxiv,  Aqua  gj),  may 
be  applied  after  the  bath,  or,  if  there  is  definite  vulvo-vaginitis, 
a  half  per  cent,  solution  of  protargol  should  be  used  locally. 

In  infancy  mechanical  devices  are  more  likely  to  be  successful 
than  at  a  later  age,  when  I  think  they  are  seldom  of  any  permanent 
value.  In  these  earlier  years,  however,  mechanical  restraint  is 
very  rarely  necessary,  for  drugs  are  often  effectual.  I  have 
found  the  liquid  extract  of  salix  nigra  particularly  valuable  in 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     779 

several  of  these  cases,  almost  always  it  reduced  the  frequency  of 
the  habit  considerably,  and  in  some  cases  it  stopped  it  apparently 
altogether.  In  the  case  of  a  girl  of  two  and  a  half  years,  5  minims 
of  the  liquid  extract  given  three  times  a  day  stopped  the  mastur- 
bation in  a  few  days;  in  a  boy  aged  one  year  the  habit  was 
much  diminished  in  frequency  by  2J  minims  given  similarly. 

On  the  other  hand,  an  older  child,  a  boy  of  seven  years,  was 
none  the  better  for  10  minims  of  the  extract  three  times  a  day  ; 
and  I  must  point  out  that  the  drug  produces  unpleasant  symp- 
toms when  given  in  large  doses.  A  dose  of  15  minims  ter  die 
given  to  a  boy  of  nine  years  made  him  feel  giddy  each  time  it 
was  given,  and  a  dose  of  20  minims  given  thrice  daily  to  another 
child  of  nine  years,  gave  her  a  transient  headache  after  each  dose. 

I  have  also  used  belladonna  in  combination  with  bromide 
with  good  effect  :  to  a  child  of  twelve  months  a  mixture  of 
Tinct.  Belladonnse  ft)iv,  Sod.  Bromid.  gr.  ij,  Syrup  Ct)xx,  Aq. 
Anethi  ad  3j,  niay  be  given  three  times  a  day,  and  the  dose  of 
belladonna  may  be  cautiously  increased  if  necessary.  Occasion- 
ally I  have  used  phenazone  with  the  bromide,  but  I  think  it  is 
less  valuable  than  belladonna  in  these  cases. 

Whatever  drug  or  other  treatment  is  used,  it  must  be  impressed 
upon  the  parents  that  at  all  costs  the  habit  must  be  broken,  and 
that  whenever  the  child  attempts  to  do  it,  he  or  she  must  be  stopped 
by  force  if  necessary.  This  will  mean  some  determination  on  the 
part  of  the  parents,  for  infants  will  scream  passionately  when 
interfered  with  during  the  act. 

In  older  children  a  little  judicious  bribery  is  worthy  of  trial, 
the  child  should  be  under  constant  supervision  by  a  trustworthy 
and  tactful  nurse,  and  a  promise  should  be  made  that  a  successful 
avoidance  of  lapses  for  a  stated  interval  shall  secure  some  coveted 
reward.  Some  such  method  is,  in  my  opinion,  far  preferable  to 
punishment,  which  is  only  likely  to  add  cunning  and  deceit  to 
bad  habit. 

Pica:  or  Perverted  Appetite 

Very  curious  is  the  habit  which  has  been  described  as  pica, 
or  dirt-eating  ;  it  is  seen  mostly  in  the  later  half  of  infancy, 
from  one  to  two  years  of  age,  but,  as  Dr.  John  Thomson  has 
pointed  out,  it  begins  sometimes  in  later  childhood,  when  from 
any  cause  the  general  health  fails,  and  the  child  becomes  anaemic. 
Dr.  Thomson1  has  recorded  eleven  cases,  in  nino  of  which  the 
habit  began  before  the  child  was  two  years  old. 
1  Edinburgh  Hospital  Report,  vol.  iii,  p.  81. 


780  COMMON  DISORDERS  OF  CHILDHOOD 

I  have  notes  of  fourteen  cases  which  have  been  under  my  care, 
seven  boys  and  seven  girls  ;  not  including  three  cases  of  hair- 
eating  which  ought  perhaps  to  come  in  a  different  category. 

The  history  of  the  child  with  pica  is  sufficiently  shown  by  the 
following  cases  : 

Ivy  J.,  aged  4J  years,  was  sent  to  me  by  Dr.  H.  M.  Stewart  of  Dulwich, 
since  the  age  of  fifteen  months  she  had  had  a  craving  for  what  her  mother 
described  as  '  rubbish',  she  was  particularly  fond  of  green  stuff,  such  as  raw 
cabbage-leaf  and  potato-peel,  a  fortnight  before  I  saw  her  she  had  pulled 
down  a  clematis  in  a  neighbour's  garden  and  eaten  the  leaves,  she  would  also 
eat  the  wax  faces  of  her  dolls,  had  eaten  five  between  Christmas  and  February, 
and  at  times  had  eaten  sand  and  mortar  and  had  also  eaten  part  of  her  pina- 
fore ;  when  taken  to  consult  a  doctor,  she  was  found  eating  the  papers  in  his 
waiting-room. 

She  was  a  very  passionate  child,  but  apparently  of  normal  intelligence. 
Her  appetite  for  ordinary  food  was  very  poor.  She  had  had  threadworms 
since  the  age  of  two  years. 

The  only  acute  disturbance  which  had  resulted  from  her  morbid  appetite 
was  after  eating  privet  leaves,  when  acute  gastric  symptoms  had  occurred. 

Muriel  J.,  aged  2\\,  at  the  age  of  fourteen  months  began  to  eat  earth,  and 
when  placed  in  her  '  pram  '  to  stop  this  she  sucked  the  mud  off  the  wheels 
and  ate  it ;  she  had  a  great  fondness  for  eating  mortar,  which  she  picked  out 
of  walls  ;  she  had  eaten  the  tops  off  a  dozen  safety  matches,  and  candle-grease 
was  also  a  favourite.  She  ate  the  legs  and  arms  off  all  her  dolls  if  they  were 
made  of  'composition',  so  that  only  china  dolls  could  be  used.  She  had 
a  very  bad  appetite  for  ordinary  food,  and  was  so  passionate  that  the  day 
before  I  saw  her  she  had  thrown  a  scissors  at  her  sister  when  thwarted  of  some 
desire  :  she  had  also  suffered  with  night  terrors. 

She  sometimes  passed  earth  with  her  stools  and  had  also  vomited  earth. 
Her  mother  stated  that  she  herself  had  suffered  at  the  age  of  sixteen  years 
with  a  craving  for  blotting-paper  and  linen,  and  used  to  get  out  of  bed  at  night 
to  eat  towels. 

Grace  D.,  aged  2|  years,  since  the  age  of  eighteen  months  has  been  in  the 
habit  of  eating  mud  and  dirt :  she  will  pick  the  dirt  out  from  between  the 
boards  of  the  floor,  or  mud  off  the  soles  of  boots,  and  eat  it ;  she  will  also  eat 
coals  and  earth,  and  if  prevented  by  force  she  cries.  She  is  a  very  excitable 
child  and  is  quite  unnaturally  timid.  The  mother's  brother  is  insane. 

Stewart  H.,  aged  l^-  years,  was  brought  because  for  the  last  two  months 
he  had  taken  to  eating  mud,  hearth-stone,  bits  of  brick,  soap,  or  '  anything 
he  can  get  hold  of '  :  he  was  particularly  fond  of  the  white  plaster  off  toy 
horses. 

His  appetite  for  normal  food  was  bad:  the  bowels  had  been  constipated, 
and  occasionally  after  eating  such  things  as  those  mentioned  he  retched. 

The  child  was  very  irritable,  and  during  the  persistence  of  the  dirt-eating 
habit  he  had  begun  to  sleep  badly,  talking  in  his  sleep  and  starting  up  in  terror 
at  night :  he  was  intelligent  and  showed  no  signs  of  disease  except  some  rickets. 

Three  months  later  he  was  taken  to  Scotland,  with  the  result  that  his  general 
health  improved  greatly  and  his  appetite  became  good,  and  he  lost  his  craving 
for  unnatural  food  altogether. 

Mud  and  mortar  seem  to  be  special  favourites   with  these 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     781 

children ;  coal,  cinders,  and  gravel  were  also  mentioned  in  some 
of  my  cases.  In  nine  out  of  my  fourteen  cases  the  habit  began 
in  the  second  year  of  life  ;  in  one  only  it  began  in  the  first  year 
(at  eight  months)  ;  in  two  it  began  in  the  fourth  year  ;  in  two 
I  have  not  noted  the  time  of  beginning,  but  in  one  of  these  the 
habit  was  present  at  3^,  and  in  the  other  it  was  known  to  have 
been  present  at  2J  years. 

Now  what  is  the  significance  of  this  curious  perversion  of 
appetite  ?  As  I  have  mentioned,  there  was  nothing  in  any  of 
the  cases  to  which  I  have  referred  to  suggest  any  mental  defi- 
ciency ;  imbeciles  often  show  a  similar  habit  of  dirt-eating,  but 
in  them  it  is  less  strange,  for  it  is  associated  usually  with  an 
extreme  degree  of  mental  deficiency. 

Some  light  is  thrown  upon  the  point  by  the  disorders  with 
which  pica  is  associated.  It  goes,  I  think,  in  the  majority  of 
cases  with  definite  indications  of  the  *  nervous  '  temperament ; 
one  child  I  had  seen  a  few  months  earlier  for  spasmus  nutans, 
another  a  few  months  after  the  pica  ceased  attended  for  enuresis, 
another  subsequently  developed  stuttering  and  somnambulism, 
others,  like  the  cases  I  have  mentioned,  show  an  abnormal 
passionateness  or  excitability. 

No  doubt  these  nervous  symptoms  are  aggravated  by  more 
or  less  digestive  disturbance  set  up  by  the  abnormal  material 
eaten,  but  I  think  that  the  development  of  other  nervous  dis- 
orders in  some  cases  after  the  pica  has  entirely  ceased,  and  the 
family  history  in  others,  go  to  prove  that  the  nervousness  is 
partly  at  least  cause  rather  than  effect. 

Another  association  which  I  think  plays  an  important  part 
in  the  causation  of  this  perverted  appetite  is  digestive 
disorder. 

Again  I  admit  the  difficulty  of  proving  how  much  of  this  is 
cause  and  how  much  effect.  In  almost  all  cases  the  appetite 
for  ordinary  food  is  extremely  poor,  in  fact  it  is  often  this  rather 
than  the  dirt-eating  which  excites  the  mother's  anxiety  :  the 
abdomen  is  usually  large,  the  stools  sometimes  contain  mucus, 
and  the  bowels  are  costive  or  irregular. 

It  is  natural  enough  that  such  symptoms  should  be  induced 
by  the  indigestible  substances  eaten,  but  in  some  cases  it  has 
seemed  to  me  clear  that  there  was  digestive  disturbance  before 
this  habit  began,  and  I  suspect  that  this  is  so  in  the  majority 
of  cases  and  that  the  consequent  discomfort,  hardly  felt  as  such 
perhaps  by  the  child,  plays  some  part  in  exciting  the  habit  of 
dirt-eating  in  a  nervous  child.  Tlu's  is  confirmed,  I  think,  by 


782  COMMON  DISORDERS  OF  CHILDHOOD 

the  effect  of  treatment  :  an  important  part  of  the  treatment  is 
the  improvement  of  digestion. 

Prognosis.  I  have  not  seen  any  serious  harm  come  from 
this  habit,  but  it  is  obvious  that  there  must  always  be  a  risk 
of  acute  gastro-intestinal  disturbance.  The  most  noticeable 
feature  in  my  cases  has  been  the  dull  pallor  of  the  face. 
As  Dr.  Thomson  says,  '  Their  complexion  has  not  the  rosy  tint 
of  healthy  childhood:  it  lacks  clearness  and  is  dull  and  un- 
healthy looking.  They  are  hollow-eyed,  of  ten  with  a  hungry  and 
unhappy  look'.  I  would  add  that  they  are  almost  always  fret- 
ful and  irritable  while  the  habit  is  in  force. 

The  duration  of  the  habit  is  often  months,  or  even  some  years 
if  no  special  measures  are  taken  for  its  cure  :  in  one  of  my  cases 
the  dirt-eating  persisted  from  eight  months  to  two  years  and 
four  months,  when  it  ceased  spontaneously  :  in  another  it  stopped 
when  the  child  was  about  two  years  old  :  in  another  at  two  years 
and  eight  months  :  in  another,  where  it  began  at  fifteen 
months,  it  was  still  troublesome  at  4J  years.  It  usually  yields 
to  treatment,  but  I  have  known  relapse  to  occur. 

Treatment.  The  first  essential  in  treatment  is  to  prevent  the 
child  obtaining  the  dirt,  coal,  mortar,  or  other  injurious  substance 
for  which  it  craves ;  the  second  is  to  improve  its  general  health, 
especially  its  digestion.  For  this  purpose  a  combination  of 
liquid  malt  with  nux  vomica  makes  a  useful  mixture,  and  it 
may  be  advisable  to  give  with  this  or  separately  a  grain  or 
1 J  grains  of  phenazone,  according  to  the  age,  to  allay  the-nervous 
irritability  which  is  one  part  of  the  disorder. 

But  there  is  no  part  of  the  treatment  more  valuable  than 
a  few  weeks  at  a  bracing  seaside  place,  or  if  this  is  not  attainable, 
at  some  high-standing  breezy  inland  country  place.  At  the 
same  time  it  will  be  necessary  to  aid  digestion  by  the  most 
careful  dieting  :  if  the  child  is  living  chiefly  on  milk,  it  may  be 
well  to  add  sodium  citrate  to  it,  or  to  peptonize  it  partially  for 
a  time,  and  care  must  be  taken  that  the  food  is  not  such  as  to 
set  up  fermentation  in  the  bowel,  or  to  keep  up  a  mucous  catarrh 
by  its  irritating  residue  ;  I  need  not  repeat  here  what  I  have 
already  said  elsewhere  on  the  subject  of  feeding  and  indigestion, 
these  cases  of  pica  call  for  careful  adaptation  of  the  diet  to  the 
digestive  capacity  of  the  particular  child. 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     783 


Teeth-grinding 

Teeth-grinding  is  exceedingly  common  in  childhood,  and  is 
sometimes  puzzling  as  to  its  significance.  It  is  seen,  or  rather 
heard,  under  such  diverse  conditions  that  it  will  be  well  to 
mention  first  those  in  which  we  can  be  certain  of  its  exciting 
cause,  and  then  to  consider  those  in  which  its  relation  to 
associated  disorders  is  less  defined. 

Grinding  of  the  teeth  occurs  sometimes  in  the  waking  condition, 
but  far  more  often  during  sleep  :  so  far  as  I  have  observed  in 
children  its  occurrence  during  waking  hours  is  almost,  but  not 
quite,  restricted  to  those  cases  in  which  there  is  either  organic 
disease  of  the  brain  or  imbecility.  I  shall  refer  subsequently 
to  the  rare  cases  in  which  this  is  not  so. 

Teeth-grinding  in  a  marked  and  persistent  form  is  to  be  heard 
in  the  child  with  chronic  meningitis,  especially  with  posterior 
basic  meningitis,  where  it  sometimes  alternates  with  the 
curious  champing  movements  of  the  lower  jaw  to  which  Dr. 
Lees  and  Sir  Thomas  Barlow  have  drawn  attention.  It  is  also 
to  be  heard  sometimes  where  there  is  chronic  hydrocephalus 
from  any  cause,  and  it  is  not  uncommon  in  imbeciles,  where 
it  is  likely  that  there  is  some  structural  abnormality  of  the 
brain. 

In  all  these  conditions  it  may  reasonably  be  assumed  that 
there  is  direct  cortical  irritation. 

Next  there  are  cases  in  which  local  irritation  seems  to  be  the 
cause,  for  instance,  I  have  met  with  it  in  children  who  were 
worried  by  teething,  both  towards  the  end  of  the  first  dentition 
and  during  the  early  stage  of  the  second  dentition.  In  two 
girls,  aged  respectively  about  six  and  eight  years,  the  habit 
began  with  the  approach  of  the  permanent  incisors  and  when 
these  were  cut  rapidly  passed  off.  I  have  seen  it  also  with 
extensive  caries  of  teeth,  and  in  the  absence  of  other  apparent 
reasons  it  seemed  at  least  possible  that  the  dental  irritation  was 
responsible  for  the  habit. 

I  have  noted  teeth-grinding  in  association  with  otorrhcea,  and 
considering  how  definitely  middle-ear  irritation  is  responsible 
for  various  functional  nervous  symptoms  such  as  head-retraction 
and  head-rolling,  I  think  it  is  likely  enough  that  it  may  also 
start  the  habit  of  teeth-grinding. 

But  commoner  than  any  of  these  sources  of  irritation  is  dis- 
turbance in  the  intestines.  There  is  a  popular  notion  that 


784  COMMON  DISORDERS  OF  CHILDHOOD 

teeth -grinding  usually,  means  the  presence  of  worms  in  the 
bowel ;  I  think  it  may  safely  be  affirmed  that  while  this  is  true 
for  some  cases,  in  the  majority  of  children  who  grind  their  teeth 
there  are  no  worms,  but  there  is  chronic  indigestion  ;  they  are 
often  pale  children  with  large  abdomen  and  rather  puffy  about 
the  eyes,  and  they  are  constipated  or  their  stools  are  said  to 
contain  mucus  :  the  child  is  usually  thin  and  said  to  be  wasting 
as  children  with  chronic  indigestion  do ;  moreover,  there  are 
often  associated  with  teeth-grinding  those  other  indications 
of  a  restless  brain  which  are  closely  connected  with  digestive 
disorders,  sleep-talking,  somnambulism,  and  night  terrors. 

I  have  more  than  once  seen  children  with  teeth-grinding 
assume  the  knee-elbow  position  in  sleep,  a  habit  which  I  think 
almost  always  indicates  digestive  disorder,  particularly  chronic 
distension  of  the  abdomen  from  fermentation  and  flatulence  in 
the  stomach  or  bowel. 

There  are  other  associations  which  may  throw  some  light 
upon  the  significance  of  teeth-grinding  even  if  they  have  no 
bearing  upon  its  exciting  cause  :  enuresis  is  common  in  children 
who  grind  their  teeth  during  sleep,  habit-spasm  also  I  have  seen 
with  teeth-grinding.  I  have  known  laryngitis  stridulosa  (spas- 
modic croup),  which  I  take  to  be  a  respiratory  neurosis,  to  occur 
in  the  child  who  was  given  to  teeth-grinding;  and,  lastly,  the 
children  with  this  habit  are  often  notably  excitable,  nervous 
children. 

Now  it  is  always  necessary  to  be  careful  in  attributing  any 
causal  relation  to  such  common  conditions  as  worms  or  indiges- 
tion and,  a  fortiori,  to  physiological  processes  such  as  dentition ; 
association  does  not  prove  a  causal  relation,  we  have  to  reckon 
with  the  possibility  or  probability  of  coincidence  ;  but  none 
the  less  the  cumulative  evidence  of  experience  goes,  I  think,  for 
something,  and  from  the  facts  which  I  have  mentioned  I  think 
we  may  reasonably  surmise  that  teeth-grinding  means  cortical 
irritation,  which  may  be  direct  as  in  the  case  of  posterior  basic 
meningitis  or  may  be  reflex  from  some  peripheral  source,  be  it 
the  teeth  themselves,  the  ear,  or  the  intestine  ;  moreover,  the 
liability  to  this  habit  will  be  the  greater  where  the  cortex  is 
specially  excitable  as  it  is  in  the  child  of  nervous  temperament. 

The  limitation  of  teeth-grinding  as  a  rule  to  the  time  when 
the  child  is  asleep  corresponds  no  doubt  with  the  diminished 
control  by  the  higher  functions  of  the  brain  at  this  time,  and  is 
comparable  to  the  much  greater  frequency  of  enuresis  during 
sleep  than  when  awake  ;  and  one  might  expect  that  if  the 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     785 

nervous  instability  were  much  increased  or  the  stimulus  more 
powerful,  the  teeth-grinding  might  occasionally  occur  like 
enuresis  when  the  child  was  awake.  As  I  have  already  men- 
tioned, this  happens  with  gross  lesions  of  the  brain  and  in  the 
mentally  defective,  but  it  happens  also,  though  very  rarely,  in 
the  child  who  shows  neither  of  these  causes. 

A  boy,  aged  7£  years,  was  brought  to  me  on  account  of  a  very  slight  elevation 
of  the  temperature,  which  for  seven  weeks  had  been  noticed  to  be  up  each  night 
nearly  to  100°.  The  boy  was  said  to  be  a  nervous,  excitable  boy  ;  but  was 
chiefly  remarkable  for  his  intellectual  attainments  ;  he  talked  like  an  intelligent 
boy  of  about  fifteen,  he  read  French  and  English  well,  took  a  keen  interest  in 
the  scientific  nomenclature  of  insects  and  was  regarded  in  fact  as  a  '  prodigy '. 

Whilst  he  was  in  my  consulting-room  and  unoccupied  during  my  talk  with 
his  parents  he  began  grinding  his  teeth  horribly,  and  I  found  that  some  of  his 
teeth  were  worn  down  by  this  habit. 

It  was  noteworthy  in  this  case  that  the  boy  had  been  under 
treatment  recently  for  indigestion,  his  bowels  were  so  costive 
that  he  had  to  take  a  daily  aperient,  and  he  suffered  with  nausea 
frequently.  The  slight  rise  of  temperature  at  night  for  many 
weeks  with  nothing  more  than  slight  digestive  disturbance  is,  as 
I  have  pointed  out  elsewhere  (Chap.  XIX),  a  common  occur- 
rence in  the  nervous  child. 

Here  there  was  clearly  a  combination  of  an  exceptionally 
nervous  temperament  and  active  brain  with  indigestion  and 
constipation  :  and  therein  lay  the  explanation  of  this  unusual 
occurrence  of  teeth-grinding  during  waking  hours  without  mental 
deficiency  or  gross  cerebral  lesion. 

Treatment.  The  treatment  of  teeth-grinding  is  sufficiently  in- 
dicated by  its  causes.  It  is  seldom  necessary  to  give  sedatives  such 
as  bromide  or  phenazone;  the  chief  point  to  be  investigated  where 
imbecility  and  gross  brain-disease  can  be  excluded  and  where 
the  presence  of  worms  has  been  disproved,  is  the  diet  ;  in  most 
cases  this  will  need  careful  revision,  not  only  as  to  the  food  taken, 
but  also  as  to  the  time  of  meals.  Dr.  Bazett,  of  Hcndon,  tells 
me  of  a  girl  of  nearty  fourteen  years  in  whom  troublesome  teeth- 
grinding  ceased  when  the  taking  of  a  substantial  meal  immediately 
before  going  to  bed  was  discontinued  ;  in  some  cases  I  think 
the  source  of  the  trouble  is  fruit,  which  so  often  causes  the  various 
symptoms  of  indigestion  in  children  and,  lastly,  a  regular  action 
of  the  bowels  may  be  the  one  thing  lacking. 


STILL 


786  COMMON  DISORDERS  OF  CHILDHOOD 

Head-rolling  and  head-banging 

There  occur  in  infancy  and  early  childhood  certain  curious 
movements  more  or  less  rhythmic  in  character,  and  sufficiently 
unusual  to  cause  some  anxiety  to  parents  and  to  others  who  are 
unfamiliar  with  them.  It  is  important  that  the  medical  man 
should  be  aware  both  of  their  occurrence  and  of  the  significance 
of  these  movements,  for,  although  in  themselves  they  may  be 
but  of  little  importance,  they  are  sometimes  a  valuable  indication 
of  underlying  conditions. 

It  is  no  uncommon  complaint  that  an  infant  '  keeps  rolling 
his  head  from  side  to  side  '  on  his  pillow,  and  there  may  be 
corroboration  of  the  mother's  statement  in  the  thinness  of  the 
hair  at  the  back  of  the  infant's  head.  As  the  infant  lies  in 
his  cot  he  rolls  his  head  monotonously  from  side  to  side  with 
occasional  pauses  if  his  attention  is  attracted;  the  movement 
may  continue  even  when  the  child  is  asleep,  as  I  have  noted 
in  two  cases,  but  in  both  it  was  only  during  light  sleep  ;  it 
ceases  almost  invariably  when  the  child  is  sitting  up.  This 
head-rolling  occurs  chiefly  in  infants  under  the  age  of  two  years. 
Nineteen  out  of  twenty-nine  cases  under  my  own  observation 
occurred  within  the  first  two  years.  The  oldest  child  I  have 
seen  with  it  was  a  girl  aged  five  years,  who  was  in  hospital  for 
cleft-palate.  The  head-rolling  in  this  case  was  chiefly  during 
light  sleep,  and,  as  usual,  only  when  the  child  was  lying  down, 
but  it  had  the  unusual  feature  that  it  was  accompanied  by 
a  low-pitched  crooning  noise,  a  sort  of  '  auto-lullaby  '. 

The  curious  rolling  of  the  head  is  apt  to  arouse  fears  in  the 
parents'  mind  of  '  something  wrong  with  the  brain  ',  and  even 
to  the  medical  man  it  may  suggest  the  possibility  of  meningitis. 
With  regard  to  this  latter  association,  let  me  say  at  once  that 
head-rolling  very  rarely,  if  ever,  means  meningitis.  What,  then, 
is  its  significance  ? 

A  large  proportion — fifteen  out  of  nineteen  cases  in  which  the 
point  was  noted — showed  more  or  less  rickets  ;  and  in  four  of 
my  twenty-nine  cases  other  nervous  disorders,  usually  associated 
with  rickets  at  this  age — viz.  laryngismus  stridulus  with  facial 
irritability  in  three,  arid  facial  irritability  alone  in  one,  were 
present.  But  rickets  can  hardly  be  an  essential  factor,  for  the 
head-rolling  began  in  one  of  my  cases  of  the  age  of  four  weeks, 
and  in  some  I  have  specially  noted  that  rickets  was  absent. 
Whether  there  be  rickets  or  not,  there  is  usually  another  factor — 
namely,  peripheral  irritation  of  some  sort. 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     787 

It  is  to  this  particular  form  of  peripheral  irritation  that  1 
wish  to  draw  attention  specially  in  connexion  with  these  cases 
of  head-rolling.  In  no  less  than  fifteen  out  of  twenty-nine 
cases — i.e.  in  more  than  half  the  cases — head-rolling  was  asso- 
ciated sooner  or  later  with  evidence  of  middle-ear  irritation. 
It  would  seem  that  head-rolling  may  be  caused  by  middle-ear 
affection  where  there  is  no  other  symptom  suggestive  of  ear 
trouble,  and  long  before  any  discharge  appears  from  the  ear  : 
in  one  case  head-rolling  began  four  weeks,  in  another  five  weeks 
before  ear  discharge  began  ;  while  in  another  two  months 
elapsed  before  the  persistent  head-rolling  was  explained  by 
a  discharge  from  the  ear.  The  movement  in  such  cases  has 
nothing  in  it  to  suggest  pain  ;  indeed,  the  infants  have  usually 
appeared  to  be  entirely  free  from  pain,  except,  perhaps,  for 
a  few  hours  before  otorrhcea  began.  In  some  cases  ear  discharge 
has  preceded  the  onset  of  head-rolling,  and  the  unhealthy  con- 
dition of  the  middle- ear  remaining  after  discharge  has  ceased 
may  still  be  sufficient  to  cause  continuance  of  the  movement. 
This  seemed  to  be  shown  by  one  case  in  which  head-rolling  had 
begun  synchronously  with  otorrhoea,  and  persisted  in  spite 
of  the  cessation  of  the  ear  discharge  ;  after  head-rolling  had 
continued  many  weeks  the  aural  disease  again  became  evident  by 
recurrence  of  discharge,  explaining,  as  it  seemed,  the  persistence 
of  the  movement.  But  middle-ear  catarrh  may  exist  with- 
out perforation  of  the  membrane  at  any  time,  and,  there- 
fore, without  discharge,  and  probably  without  causing  pain  at 
any  time,  certainly  without  causing  any  manifestation  of  pain 
which  can  be  recognized  as  such  in  an  infant  ;  there  can,  I  think, 
be  little  doubt  that  some  cases  of  head-rolling  are  due  to  such 
latent  catarrh  in  the  middle -ear  ;  indeed,  the  existence  of  such 
a  cause  was  proved  at  autopsy  in  some  cases.  In  two  cases  in 
which  death  was  due  to  acute  colitis,  head-rolling  had  been 
specially  noted  during  the  illness,  but  there  was  nothing  else 
to  suggest  ear  disease  during  life  :  autopsy  showed  in  one  case 
pus  in  one  middle-ear,  in  the  other  case  pus  in  both  middle-ears. 
In  a  case  of  tuberculous  meningitis,  where,  during  the  early 
stage  of  the  disease,  there  had  been  head-rolling,  there  was 
nothing  during  life  to  account  for  the  movement,  which  might 
very  naturally  have  been  regarded  as  due  to  the  meningitis,  had 
not  autopsy  shown  pus  in  both  ears,  which,  in  the  light  of  other 
cases  illustrating  the  usual  relation  of  head-rolling  to  middle-ear 
catarrh,  made  it  probable  that  the  head-rolling  here  was  due,  not 
to  the  meningitis,  but  to  the  accompanying  middle-ear  affection. 

3  E  2 


J 

788  COMMON  DISORDERS  OF  CHILDHOOD 

It  may  well  be  that* such  a  latent  middle-ear  catarrh  accounts 
for  many  of  the  cases  of  head-rolling  for  which  there  is  no 
obvious  cause,  and  that  the  proportion  of  cases  due  to  ear  disease 
is  higher  even  than  can  be  demonstrated  from  clinical  or  post 
mortem  evidence.  But  there  is  no  proof  that  head-rolling  is 
due  in  all  cases  to  this  particular  form  of  peripheral  irritation. 
It  seems  likely  enough  that  dentition  is  the  exciting  cause  in 
some  cases.  The  age-incidence,  of  course,  suggests  this  :  twenty- 
one  out  of  twenty-nine  cases  began  between  the  ages  of  five 
months  and  two  years,  and  it  would  be  strange  indeed  if  the 
obvious  irritation  of  tense  gums  were  not  as  efficient  as  the 
much  less  obvious  irritation  of  an  apparently  painless  middle- 
ear  catarrh  in  producing  this  head-rolling.  Such  a  case  as  that 
of  a  boy,  aged  seventeen  months,  in  whom  the  eruption  of  each 
fresh  tooth  was  stated  to  have  aggravated  the  head-rolling,  lends 
support  to  this  view  ;  but  as  in  other  disorders  where  the  causal 
relation  of  dentition  has  been  asserted,  conclusive  evidence  is 
difficult  to  obtain. 


Head-banging 

In  connexion  with  head-rolling  may  be  mentioned  another 
curious  movement,  seen  during  the  first  few  years  of  life,  namely, 
head-banging.  In  some  cases  this  takes  the  form  of  beating 
the  head  with  the  fists  or  with  any  available  implement,  in 
others  the  child  beats  the  head  against  some  hard  object,  often- 
times bending  downwards  deliberately  to  beat  its  head  against 
the  floor,  or  banging  its  head  against  the  side  of  the  cot,  or  against 
a  neighbouring  wall  if  this  happens  to  be  more  convenient. 

I  am  not  referring  now  to  cases  in  which  some  slight  thwarting 
of  a  child's  wishes  is  immediately  followed  by  an  outburst  of 
fury,  in  which  the  child  dashes  himself  down  on  the  floor  and 
bangs  his  head  again  and  again  against  the  floor  ;  such  behaviour 
is  not  very  rare  in  excitable,  unstable  children  during  the  first 
three  or  four  years  of  life,  and  sometimes  indicates  a  morbid 
defect  of  self-control  which  may  show  itself  in  troublesome 
ways  later  on.  The  head-banging  to  which  I  wish  to  draw 
attention  is  something  quite  different  from  this — it  occurs 
without  any  apparent  provocation  from  without,  often  indeed 
when  the  child  is  quite  unaware  that  he  is  being  observed.  It 
is  sometimes  sufficiently  forcible  to  cause  bruising  of  the 
head,  but  usually  the  child  does  himself  no  harm,  although  the 
possibility  of  injury  naturally  distresses  the  parents. 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN     789 

Of  twenty-eight  cases  of  which  I  have  kept  notes  all  were 
under  five  years  of  age,  and  twenty-two  were  between  the  ages 
of  six  months  and  two  years.  Rickets  was  not  more  frequent 
in  these  cases  than  in  any  series  of  children  under  three  years 
of  age  amongst  the  hospital  class  :  nine  out  of  twenty-two 
cases  showed  rickets  associated  with  head-banging,  but  my 
own  statistics  showed  that  44-6  per  cent,  of  children  under 
three  years  of  age  brought  to  hospital  for  disease  of  any  kind 
have  rickets. 

Head-banging  sometimes  occurs  in  a  child  who  at  other  times 
has  shown  head-rolling  ;  a  fact  which  suggests  a  similar  causa- 
tion. My  own  series  showed  that  in  six  out  of  twenty-eight 
cases  head-banging  bore  some  relation  to  oar  disease,  and  that 
like  head-rolling  it  may  precede  by  several  weeks  the  appearance 
of  discharge  from  the  ear,  or  may  be  due  to  a  latent  middle-ear 
catarrh.  It  is  noteworthy,  also,  that  the  banging  in  these 
cases  with  ear  disease  is  usually  not  a  beating  of  the  ear  but  of 
the  frontal  or  occasionally  of  the  occipital  region. 

My  impression,  however,  is  that  head-banging  less  often 
indicates  ear  irritation  than  does  head-rolling,  and  so  far 
as  statistics  on  this  point  are  of  any  value  the  figures  I  have 
mentioned  confirm  this  impression. 

The  fact  that  more  than  three-fourths  of  the  cases  occur 
between  the  ages  of  six  months  and  two  years  makes  it  probable 
that  head-banging,  like  head-rolling,  is  due  to  the  worry  of 
dentition  in  some  cases.  It  seems  possible  also  that  headache, 
from  whatever  cause,  may  sometimes  excite  this  movement, 
but  I  have  never  seen  head-banging  in  association  with  meningitis 
or  cerebral  tumour. 


Body-rocking 

A  less  common  movement  than  those  I  have  already  described 
is  an  antero-posterior  rocking  of  the  trunk.  It  occurs  in  infancy 
and  early  childhood,  but  almost  exclusively  in  the  sitting  position, 
and  therefore  only  in  children  old  enough  to  sit  up,  not  in  infants 
under  nine  months  of  age. 

Usually  it  is  a  simple  swaying  to  and  fro  of  the  trunk  as  the 
child  sits  ;  rarely  it  is  more  complicated,  as  in  a  girl  aged  one 
year  and  nine  months,  in  whom  I  noted  a  combination  of  a  rising 
movement  with  the  antero-posterior,  so. that  the  child  appeared 
to  be  '  rising  '  as  a  rider  does  in  trotting,  and  this  she  did  at  the 
rate  of  four  times  in  ten  seconds,  for  periods  of  ten  or  twelve 


790  COMMON  DISORDERS  OF  CHILDHOOD 

seconds,  when  there  would  be  a  pause,  and  the  movement  was 
then  resumed  after  a  few  seconds.  This  movement  would  con- 
tinue thus  at  short  intervals  for  hours,  and  even  whilst  being 
watched  by  three  doctors  beside  her  bed  the  child  continued  the 
movement  quite  unconcernedly.  In  this  particular  case  the 
movement  ceased  during  sleep,  but  in  two  others  it  occurred 
chiefly  during  sleep,  when  the  child  sat  up  asleep,  rocking  itself 
backwards  and  forwards.  Twice  I  have  noted  in  children 
respectively  of  three  years  and  seven  months,  and  four  years, 
a  less  common  variety  of  body-swaying,  a  slow  side-to-side 
movement  like  that  of  a  metronome  ;  I  counted  the  rate  in  one 
case  and  found  it  twenty-eight  per  minute.  In  one  of  these  the 
rocking  was  chiefly  during  light  sleep,  and  if  the  child  was  roused 
he  would  lie  down  and  substitute  for  the  body  movement  head- 
rolling  such  as  I  have  already  described. 

The  substitution  of  one  curious  movement  for  another  is  not 
uncommon  ;  the  little  girl  who  showed  the  *  rising  '  movement 
exchanged  it  when  she  was  lying  down  for  a  rhythmic  lifting 
of  trunk  and  pelvis.  In  a  boy  aged  eighteen  months  the  to-and- 
fro  rocking  \vas  replaced  at  times  by  a  banging  of  his  head  against 
the  sides  of  his  cot  ;  another  boy,  aged  6J  years,  would  some- 
times substitute  for  his  to-and-fro  rocking  during  sleep  a  rhythmic 
rocking  in  the  knee-elbow  position  with  his  face  buried  in  the 
pillow.  The  boy  at  the  same  time  made  a  monotonous  cooing 
noise,  and  I  have  noted  a  similar  accompaniment  in  another 
case  ;  in  both  apparently,  as  in  the  case  of  head-rolling  with 
this  accompaniment,  a  sort  of  self-soothing  lullaby. 

In  itself  this  body-swaying  is  of  no  importance,  but  as  a  little 
indication  of  a  child's  temperament  and  tendencies  it  is,  I  think, 
worthy  of  notice.  The  children  who  show  this  curious  move- 
ment are  generally  odd  children — not  in  the  least  defective  in 
intellect,  indeed  often  rather  above  the  average  in  this  respect, 
but  children  of  peculiar  temperament,  sometimes  extraordinarily 
reserved,  sometimes  unduly  self-conscious,  sometimes  showing 
some  more  definite  evidence  of  nervous  abnormality,  as  in  the 
boy  aged  6J  years  already  mentioned,  who  was  brought  at  one 
time  for  temporary  fsecal  incontinence,  a  disorder  which  usually 
indicates  a  neuropathic  taint. 

The  formation  of  abnormal  habit,  whether  rhythmic  or  other- 
wise, is  often  an  indication  of  wider  abnormality  in  the  higher 
functions  of  the  brain,  and  it  is  interesting  to  compare  with 
this  body-rocking  of  children  who  show  no  intellectual  defect 
the  very  similar  rocking  which  is  often  seen  in  imbeciles. 


ON  CERTAIN  MORBID  HABITS  IN  CHILDREN      791 

T  must  refer  again  in  this  connexion  to  a  movement  which 
must  be  distinguished  from  the  harmless  body-rocking  to  which 
I  have  referred,  namely,  that  which  sometimes  accompanies 
masturbation  in  the  sitting  position.  I  have  notes  of  several 
such  cases.  For  instance,  a  girl  aged  five  years,  was  brought 
with  the  history  that  she  would  several  times  a  day,  when  she 
thought  herself  not  observed  by  her  mother,  rock  herself  back- 
wards and  forwards  as  she  sat  on  her  chair,  at  the  same  time 
turning  red  in  the  face,  and  perspiring,  and  then  turning  white 
as  if  exhausted.  Inquiry  showed  that  masturbation  occurred 
at  night  also,  and  it  was  evident  from  the  child's  appearance 
that  her  health  was  being  impaired. 

One  must  distinguish  also  from  the  head  movements  men- 
tioned above  the  '  head-nodding  of  infants  '  or  spasmus  nutans, 
which  I  have  considered  in  the  previous  chapter,  where  I  have 
also  mentioned  the  occasional  occurrence  of  head-jerking  as  a 
manifestation  of  epilepsy. 

Treatment 

In  the  treatment  of  the  movements  which  I  have  described, 
the  first  point  to  be  determined  is  the  underlying  cause ; 
it  may  be  possible  to  relieve  a  middle-ear  catarrh,  it  may 
be  advisable  to  give  some  drug,  perhaps  even  in  very  rare 
cases  to  lance  the  gums  to  relieve  the  worry  of  dentition,  but 
often  it  is  impossible  to  find  any  cause,  and  we  are  driven  to 
treat  the  symptoms. 

It  has  seemed  to  me  that  phenazone  in  such  cases  is  some- 
times more  useful  than  bromide,  but  a  combination  of  the  two 
drugs  may  be  still  better.  Only  let  us  be  careful  that  our  treat- 
ment is  not  worse  than  the  disorder  ;  if  the  movement  is  doing 
no  harm,  and  we  can  assure  the  parents  that  its  continuance 
can  have  no  ill-result,  it  may  be  wiser  to  practise  a  wholesome 
abstention  from  drugs  than  to  give  any  of  these  sedatives,  and 
indeed,  it  may  be  that  by  careful  attention  to  the  diet'  and 
hygiene  of  the  child,  particularly  in  the  matter  of  baths  and 
fresh  air,  we  may  do  more  to  reduce  his  abnormal  tendencies 
than  by  many  bottles  of  medicine. 


CHAPTER  LV 
CONGENITAL  SYPHILIS 

THE  frequency  of  syphilis  in  children  no  doubt  varies  con- 
siderably in  different  parts  of  the  world  and  in  different  cities; 
and  this  variation  depends  partly  on  the  frequency  of  acquired 
syphilis  in  the  adult  population,  and  partly  on  the  possibility 
of  securing  thorough  and  effective  treatment  for  the  syphilitic 
adults  in  the  particular  locality.  My  own  statistics  would 
seem  to  show  that  amongst  the  children  who  are  brought  for 
hospital  treatment  in  London  congenital  syphilis  is  not  a  very 
frequent  condition  :  amongst  4,830  consecutive  out-patients 
at  King's  College  Hospital  in  the  children's  department,  where 
only  children  under  the  age  of  ten  years  are  seen  and  where 
fully  a  third  of  the  patients  are  under  two  years  of  age,  there 
were  only  twenty-nine  cases  of  congenital  syphilis,  i.e.  less 
than  1  per  cent.,  or  to  be  more  exact  0-6  per  cent.  These  figures 
include  only  cases  in  which  the  presence  of  syphilis  was  beyond 
dispute  ;  but  even  when  doubtful  cases  are  included  the  pro- 
portion is  not  above  1-5  per  cent. 

.  Such  statistics,  however,  give  very  little  idea  of  the  extent  to 
which  the  inheritance  of  syphilis  damages  the  community ; 
to  estimate  this  it  would  be  necessary  to  have  some  record  of 
the  number  of  children  who  fail  to  reach  live  birth,  or  die  shortly 
after  birth,  as  a  result  of  the  syphilitic  taint.  Some  idea  perhaps 
of  this  early  mortality  amongst  the  children  of  syphilitic  parents 
may  be  gained  from  the  following  figures  in  which  only  those 
still-births,  miscarriages  and  early  deaths  are  included  which 
immediately  preceded  or  followed,  or  formed  part  of  a  series 
immediately  preceding  or  following  the  birth  of  the  patient  in 
whose  family  history  they  occurred  ;  there  were  39  still-births, 
36  miscarriages,  and  25  deaths  attributable  to  congenital  syphilis 
in  the  family  histories  of  87  children  who  were  under  treatment 
for  congenital  syphilis  ;  moreover,  out  of  these  87  children, 
13  died  whilst  under  observation. 

I  shall  not  consider  here  the  much  rarer  condition,  acquired 
syphilis  in  children.  The  infection  of  a  child  after  or  during 
birth  by  contact  with  a  syphilitic  person  who  is  still  in  the 
infective  stage  depends  upon  such  a  combination  of  favouring 


CONGENITAL  SYPHILIS  793 

coincidences  that  it  must  necessarily  be  very  rare,  i  have  only 
seen  two,  or  perhaps  three  cases  myself  in  which  the  possibility 
of  such  acquired  syphilis  could  be  entertained  ;  it  must  be 
seldom,  indeed,  that  such  infection  can  be  absolutely  proved 
by  the  presence  of  a  primary  chancre  on  the  child. 

The  introduction  of  the  Wassermann  test  may  necessitate 
some  revision  of  our  ideas  of  the  frequency  of  syphilis,  but  it 
would  be  premature  to  accept  statistics  based  on  this  test  at 
present,  for  we  have  yet  to  learn  the  fallacies  attaching  to  it, 
and  fallacies  there  must  be,  for  the  results  obtained  are  some- 
times not  only  inconsistent  with  clinical  facts  and  pathological 
findings,  but  actually  contradictory  of  themselves,  as,  for  instance, 
where  a  child  examined  by  different  skilled  observers  showed 
within  the  same  week  first  a  positive  and  then  a  negative 
reaction  apart  from  any  influence  of  treatment.  There  is  no 
doubt  that,  in  conjunction  with  other  evidence  of  the  disease, 
a  positive  reaction  must  carry  considerable  weight,  but  in  view 
of  the  undoubted  fallacies,  dependent  partly  upon  variations  in 
technique  and  partly  upon  other  less  known  factors,  it  is  not 
sufficient  to  base  a  diagnosis  upon  this  test  alone.  On  these 
grounds  one  must  view  with  suspicion  statistics  in  which  children, 
who  admittedly  showed  no  trace  whatever  of  the  disease, 
were  counted  as  syphilitic  solely  on  the  strength  of  a  positive 
Wassermann  reaction.  By  such  methods  some  observers  have 
found  10-30  per  cent.,  or  even  more,  of  children  attending 
hospitals  to  be  suffering  from  syphilis.  On  the  other  hand, 
a  recent  investigation l  amongst  the  newly  born  in  the  East 
End  of  London  showed  a  positive  Wassermann  reaction  only 
in  4  out  of  677  infants,  i.e.  in  0-59  per  cent. ;  a  proportion  which 
agrees  curiously  closely  with  that  determined  solely  on  clinical 
grounds  as  mentioned  above. 

A  distinction  has  been  drawn  between  inherited  and  con- 
genital syphilis.  Some  writers  would  apply  the  term  '  inherited  ' 
only  to  those  cases  in  which  the  syphilis  dates  from  the  time  of 
conception,  whilst  they  would  call  '  congenital '  only  those  in 
which  the  syphilis  was  transmitted  at  some  later  period  of 
intra-uterine  life,  in  other  words,  where  the  mother  became 
infected  during  pregnancy.  No  doubt  such  a  difference  in  the 
date  of  transmission  docs  exist,  but  it  is  more  than  doubtful 
whether  there  exists  any  corresponding  difference  in  the  resulting 
manifestations  of  the  disease,  and  in  the  absence  of  any  special 
clinical  significance  for  these  terms  it  seems  a  pity  to  complicate 
the  subject  by  what  for  all  practical  purposes  is  a  distinction 
without  a  difference,  so  I  shall  speak  indiscriminately  of  'inherited ' 
or  '  congenital '  syphilis. 

-_  T i  n~.,  r,r,f  TJ^orrl  W  Dr   P   Filrlea.  1915. 


794  COMMON  DISORDERS  OF  CHILDHOOD 

Transmission  of  Syphilis  to  Offspring 

Perhaps  one  of  the  most  striking  features  in  the  family  history 
of  syphilitic  children  is  the  frequent  absence  of  any  history  of 
syphilis  in  the  mother. 

In  past  times  various  suggestions  have  been  made  to  account 
for  this  seeming  anomaly.  The  fact  which  is  embodied  in  Colles's 
law  that  a  mother  who  has  shown  no  symptoms  of  syphilis  may 
suckle  her  infant  who  has  congenital  syphilis  without  fear  of 
becoming  infected,  whilst  a  wet  nurse  would  be  infected  by  the 
same  infant,  seems  to  show  that  the  mother  has  somehow  acquired 
immunity.  It  has  been  suggested  (Coutts)  that  this  immunity 
is  derived  from  the  syphilitic  foetus,  which  pari  passu  with  its 
disease  develops  an  antitoxin,  and  imparts  this  to  its  mother  in 
sufficient  quantity  to  confer  immunity  upon  her.  Such  a  view, 
however,  assumes  that  the  father  can  beget  a  syphilitic  child 
without  giving  the  disease  to  the  mother.  So  far  as  clinical  symp- 
toms are  concerned  this  undoubtedly  is  so,  but  in  the  light  of  the 
more  recent  methods  of  investigation  it  would  seem  that  the 
mother  of  a  syphilitic  child,  although  she  may  never  have  shown 
a  single  symptom  of  syphilis,  has  nevertheless  been  infected,  for 
her  blood  gives  a  positive  reaction  with  the  Wassermann  test. 

The  various  modes  of  transmission,  classified  according  as 
symptoms  of  syphilis  are  present  in  one  parent  or  in  both,  might 
be  arranged  in  order  of  frequency  thus:  (1)  father  syphilitic, 
mother  apparently  healthy  ;  (2)  father  and  mother  both  show 
symptoms  of  syphilis  ;  (3)  mother  syphilitic,  father  healthy  ;  and 
(4)  mother  acquired  syphilis  during  pregnancy.  Does  the  mode 
of  transmission  make  any  difference  to  the  disease  in  the  infant, 
either  in  the  character  or  in  the  severity  of  the  symptoms  ?  So 
far  as  my  own  observations  go  there  would  seem  to  be  no  corre- 
sponding difference,  unless  it  be  that  when  the  mother  has 
acquired  syphilis  after  the  time  of  conception  the  infant  is  apt  to 
be  affected  more  severely  than  in  other  cases  ;  but  even  if  this  be 
so — and  I  do  not  feel  at  all  sure  of  it — the  difference  may  depend 
merely  on  the  recency  of  the  disease  in  the  mother. 

And  this  brings  me  to  another  question  :  Does  the  stage  of 
the  disease  in  the  parents  influence  in  any  way  the  character 
of  the  disease  in  the  offspring  ?  At  first  sight  it  appears 
obvious  that  the  later  the  stage. of  the  disease  in  the  parents  the 
less  the  severity  of  the  disease  in  the  child.  How  common  is 
a  record  of  successive  pregnancies  like  this  :  (1)  miscarriage  at 
4J  months;  (2)  miscarriage  at  5J  months;  (3)  eight  months 
child,  lived  two  hours  ;  (4)  boy  with  marked  symptoms 
of  congenital  syphilis  who  survived  ;  and  (5)  apparently 
healthy,  now  aged  five  months.  Or  this,  where  the  mother 


CONGENITAL  SYPHILIS  795 

showed  secondary  symptoms  of  syphilis  during  her  first  preg- 
nancy :  (1)  still-born  ;  (2)  still-born  ;  (3)  lived  four  days  ;  (4) 
lived  19  days  ;  and  (5)  idiot  who  survives  with  choroiditis  and 
other  marked  symptoms  of  syphilis.  Moreover,  it  has  been 
shown  that  in  the  still-born  or  short-lived  infants  of  syphilitic 
parents  there  are  often  severe  syphilitic  lesions  which  certainly 
cannot  be  present  in  the  later  infants  who  survive.  It  is,  of 
course,  possible  that  the  increasing  duration  of  successive  preg- 
nancies and  the  longer  life  of  the  foetus  may  depend  upon 
diminishing  placental  disease — i.e.  the  decreasing  severity  of  the 
syphilis  may  be  in  the  mother  and  in  the  maternal  portion  of  the 
placenta,  not  in  the  foetus  ;  but  in  face  of  the  frequent  occurrence 
of  syphilitic  lesions  in  the  foetus  this  explanation  hardly  seems 
probable  for  all  cases.  It  must  be  admitted,  however,  that 
there  are  certain  facts  which  are  difficult  to  reconcile  with  any 
theory  of  progressive  diminution  in  the  intensity  of  the  trans- 
mitted disease.  The  intensity  of  the  disease  may  be  greater 
in  a  later  than  in  an  earlier  child  ;  occasionally  the  disease  may 
even  be  absent  in  one  child  and  reappear  in  a  later  child.  The 
following  history  illustrates  these  points  :  (1)  twin,  premature, 
both  still-born  ;  (2)  survived,  shows  interstitial  kcratitis  ;  (3)  (4) 
and  (5)  all  miscarriages  ;  (6)  apparently  entirely  free  from 
syphilis;  (7)  and  (8)  still-born.  I  have  no  record  of  the  sub- 
sequent children  until  (14)  a  girl,  who  came  under  my  observa- 
tion at  six  years  and  eight  months  with  haemoglobinuria,  a  con- 
dition which  in  children  is  usually  associated  with  congenital 
syphilis.  Even  more  curious  are  the  cases  in  which  one  of 
a  twin  is  healthy  while  the  other  has  congenital  syphilis.  Several 
such  cases  have  been  recorded.  One  came  under  my  own 
observation,  an  infant  with  severe  and  fatal  syphilis  who  died 
at  the  age  of  seven  months.  His  fellow- twin  was  apparently 
perfectly  healthy. 

Symptoms 

Earliest  appearance  of  symptoms.  According  to  my  own 
statistics  in  nearly  80  per  cent,  of  cases  of  congenital  syphilis 
the  disease  shows  itself  within  two  months  after  birth.  The 
following  table 1  shows  this  : 

DATE  OF  FIKST  APPEARANCE  or,  SYMPTOMS  IN  104  CASES. 

In  first  month 54 

In  second  month    ......••     26 

In  third  month 10 

Between  end  of  third  month  and  end  of  sixth  month 
Between  end  of  sixth  month  and  end  of  twelfth  month   .       3 

One  year  to  eighteen  months 

Eighteen  months  to  two  years 1 

1  Power  and  Murphy,  System  of  Syphilis.     Art.  Congcn.  Syph. 


$     • 
796  COMMON  DISORDERS  OF  CHILDHOOD 

The  practical  importance  of  these  facts  is  appreciated  when 
the  question  arises  whether  a  woman  can  safely  be  engaged  as 
a  wet-nurse  ?  As  I  have  already  mentioned,  a  woman  may 
show  no  symptoms  of  syphilis  although  her  child  is  undoubtedly 
syphilitic.  How  soon  may  we  expect  manifestations  of  the 
disease  in  the  infant  ?  It  is  clear  from  the  above  table  that  even 
at  the  age  of  three  months  there  is  still  a  possibility  that  symp- 
toms may  yet  appear  in  the  infant,  but  the  likelihood  is  then 
small.  Unfortunately  it  is  often  impracticable  in  this  countiy 
to  obtain  a  wet-nurse  whose  infant  is  as  much  as  three  months 
old,  more  often  the  woman  who  desires  employment  in  this 
capacity  wants  to  be  employed  as  soon  after  her  confinement 
as  possible  :  it  may  be  laid  down  as  a  general  rule  in  the  selection 
of  a  wet-nurse  that  it  is  best  to  obtain  one  whose  child  is  not 
younger  than  two  months  old.  As  I  have  pointed  out  elsewhere, 
a  discrepancy  of  one  or  two  months  between  the  age  of  the 
wet-nurse's  child  and  the  foster-child  is  of  little  importance,  and 
certainly  of  far  less  moment  than  the  risk  of  syphilitic  infection. 

Nowadays,  however,  the  Wassermann  test  affords  an  additional 
safeguard  in  this  important  matter  of  the  selection  of  a  wet  nurse. 

I  have  assumed  that  the  fact  of  syphilis  in  the  infant  indicates 
clanger  of  infection  from  the  mother  to  any  healthy  child  she 
may  wet-nurse ;  but,  as  already  pointed  out,  it  is  possible  that 
the  infant  may  inherit  syphilis  though  the  mother  shows  no 
symptoms  of  the  disease  :  admittedly  in  such  cases  her  blood  will 
give  a  positive  reaction  with  the  Wassermann  test,  but  it  is  by  no 
means  certain  that  where  this  is  the  only  evidence  of  the  disease 
in  a  woman  her  milk  can  infect  a  foster-child.  I  know  of  no 
proof  that  it  can,  but  I  also  know  of  no  proof  that  it  cannot : 
a  few  cases  are  on  record  which  prove  that  a  syphilitic  woman 
may  suckle  a  healthy  infant  without  giving  the  disease.  Mr.  Lucas 
has  recently  published  one  such1  but  it  would  require  a  large 
number  of  these  cases  even  to  prove  that  infection  was  the 
exception  ;  judging  from  the  analogy  of  tubercle,  it  is  probable 
that,  rare  though  it  may  be,  infection  may  be  transmitted  through 
the  milk.  Certainly  where  so  much  is  at  stake  it  would  be 
unwise  to  take  the  risk. 

In  the  series  of  cases  tabulated  above  there  happens  to  be 
no  case  illustrating  the  delayed  manifestation  of  congenital 
syphilis  which  is  sometimes  called  syphilis  hereditaria  tarda. 
I  had  under  my  care  a  girl  who  came  under  treatment  at  the  age 
of  7  J  years  for  synovitis  of  both  knee-joints ;  no  symptoms 
of  syphilis  had  been  noticed  until  a  month  previously,  when 
interstitial  keratitis  had  appeared.  In  some  of  these  cases 
no  doubt  earlier  symptoms  have  been  so  slight  that  they  have 


CONGENITAL  SYPHILIS  797 

been  overlooked  or  forgotten,  but  in  others  where  the  child 
has  been  carefully  watched  there  seems  to  have  been  no  symp- 
tom until  the  later  years  of  childhood. 

Rarity  of  manifestations  at  birth.  It  is  customary  to  state 
that  inherited  syphilis  very  rarely  manifests  itself  at  birth  ; 
Diday  even  questioned  whether  symptoms  of  syphilis  were  ever 
present  at  birth.  Undoubtedly  it  is  very  seldom  possible 
to  make  a  positive  diagnosis  so  early,  but  I  suspect  that  symp- 
toms which  are  seen  in  the  light  of  subsequent  events  to  have 
indicated  syphilis  are  present  at  birth  in  a  larger  proportion  of 
cases  than  is  usually  supposed.  Perhaps  the  most  charac- 
teristic is  the  so-called  syphilitic  pemphigus;  this  was  present 
at  birth  in  2  out  of  100  cases  under  my  observation.  Jaundice, 
the  result  of  intercellular  cirrhosis,  is  occasionally  present  at 
birth  ;  snuffling  was  noted  after  careful  inquiry  as  present  on 
the  day  of  birth  in  11  per  cent,  of  my  cases  ;  some  of  the  changes 
in  the  fundus  oculi,  particularly  choroido-retinitis,  are  almost 
certainly  intra-uterine  in  origin,  and  therefore  present  at  birth ; 
enlargement  of  the  liver  and  spleen  are  also  present  at  birth  in 
some  cases. 

A  curious  association  of  congenital  syphilis  may  be  men- 
tioned here,  for  it  is  noticeable  at  birth  in  some  cases,  namely, 
an  unusually  abundant  crop  of  hair,  usually,  I  think,  dark  in 
colour.  This  was  present  in  4  per  cent,  of  my  cases  and  may 
perhaps  be  of  some  value  as  confirmatory  evidence  in  conjunction 
with  other  symptoms  ;  alone  it  certainly  has  no  diagnostic  value. 
Here  also  may  be  mentioned  the  so-called  syphilis  haemorrhagica 
neonatorum,  which,  although  not  observed  actually  at  birth,  has 
usually  appeared  within  a  few  days  after  birth.  Some  observers 
have  thought  that  spontaneous  haemorrhages  in  the  newly-born— 
e.g.  from  the  stomach  or  bowel — are  commonly  due  to  congenital 
syphilis.  I  can  only  say  that  in  my  own  experience  such  an 
association  has  been  exceedingly  rare ;  most  cases  of  melsena 
neonatorum  and  other  haemorrhages  in  the  newly-born  are  not* 
in  syphilitic  families,  and  most  syphilitic  infants  show  no  special 
tendency  to  haemorrhages.  There  can  be  no  doubt  that  the 
association  exists,  I  have  seen  it  myself  more  than  once,  and 
microscopic  change,  particularly  endarteritis  presumably  syphi- 
litic in  origin,  has  been  demonstrated  in  the  small  vessels  in  some 
fatal  cases  of  melsena  neonatorum  ;  but  none  the  less  I  think 
that  the  frequency  of  this  association  has  been  exaggerated 
and  that  it  is  actually  very  rare. 

Order  and  frequency  of  symptoms.      I  shall  consider 
symptoms  of  congenital  syphilis  as  far  as  possible  in  order  of 
occurrence  ;  but  it  will  be  understood  that  while  some  symptoms 


79$  COMMON  DISORDERS  OF  CHILDHOOD 

usually  occur  during  J/he  first  two  or  three  months  of  life,  and 
others  later  in  the  first  or  second  year,  there  is  no  rigid  sequence, 
and  while  it  is  useful  for  practical  purposes  to  know  how  late 
or  how  early  any  particular  symptom  usually  occurs,  considerable 
variation  is  to  be  expected. 

Marasmus.  This  may  be  mentioned  first  not  only  because 
it  is  noticeable  in  greater  or  less  degree  in  a  large  majority 
of  syphilitic  infants,  but  also  because  in  its  gravest  form  it  fre- 
quently dates,  if  not  from  birth,  at  any  rate  from  a  few  days 
after  birth.  It  has  seemed  to  me  that  wasting  occurs  in  two 
different  forms  in  congenital  syphilis  ;  the  first  and  commoner 
is  the  moderate  degree  of  wasting  which  accompanies  almost 
any  illness  in  infancy.  This  is  associated  with  well-marked 
manifestations  of  S3^philis  and  ceases  when  the  accompanying 
symptoms  of  syphilis  subside  ;  it  scarcely  influences  prognosis. 
The  second  is  a  progressive  marasmus  which  often  begins  before 
any  other  manifestations  of  syphilis  have  appeared,  and  which 
continues  even  when  associated  symptoms  of  the  disease  have 
disappeared  completely  under  mercurial  treatment ;  the  wasting 
is  independent  of  any  fault  in  feeding  or  irregularity  of  the 
bowels,  it  may  occur  when  the  infant  is  breast-fed  and  free  from 
vomiting  and  all  other  ordinary  causes  of  marasmus ;  some- 
times, and  herein  lies  the  urgency  of  diagnosis,  it  responds  to 
treatment  with  mercurials,  but  more  often,  I  think,  it  fails  to 
respond  to  any  treatment,  and  day  after  day  the  infant  loses 
weight  and  after  a  few  weeks,  generally  within  three  or  four 
months  after  birth,  he  dies.  In  families  where  there  is  known  to 
be  syphilis  in  the  parents,  either  from  their  own  admission  or 
from  the  occurrence  of  congenital  syphilis  in  previous  children, 
this  grave  form  of  marasmus  may  be  recognized  as  due  to 
syphilis  before  other  manifestations  are  present,  and  in  any 
infant  under  the  cigc  of  three  months  who  wastes  persistently 
in  the  absence  of  the  ordinary  causes  of  marasmus,  the  possibility 
of  congenital  syphilis  should  be  considered,  for,  as  I  have  said, 
although  mercurial  treatment  often  fails  to  arrest  the  wasting 
in  such  cases,  occasionally  it  will  save  the  infant. 

Snuffles.  Snuffling  occurs  almost  always  within  the  first 
three  months,  usually  within  the  first  six  weeks  ;  it  was  present 
in  70  per  cent,  of  my  cases.  The  condition  varies  greatly  in 
degree  from  a  slight  stuffiness  of  the  nose  up  to  a  profuse  dis- 
charge of  pus,  perhaps  blood-stained,  continually  running  from 
the  nose,  so  that  the  infant  cannot  suck  and  is  half  asphyxiated 
if  it  tries  to  close  its  mouth  ;  these  severer  degrees  are,  however, 
quite  rare,  and  corresponding  with  this  rarity  is  the  fact  that 
depression  of  the  bridge  of  the  nose  results  only  in  a  small  minority 


CONGENITAL  SYPHILIS  799 

of  the  cases  which  have  snuffles,  and  even  more  rare  as  a  result 
is  ozsena.  The  depression  of  the  bridge  of  the  nose  may  be 
produced  very  rapidly  ;  in  an  infant  recently  under  my  care 
with  very  severe  snuffles  the  bridge  of  the  nose  had  markedly 
fallen  in  at  the  age  of  twelve  weeks,  so  that  had  the  child  lived 
he  would  have  been  permanently  disfigured.  Vigorous  and  early 
treatment,  with  local  antiseptic  applications  by  syringing,  as 
well  as  internal  mercurialization,  might  do  much  to  prevent  this 
nasal  deformity. 

I  need  hardly  point  out  that  infants,  like  older  people,  are 
subject  to  '  cold  in  the  nose  '  and  snuffling  may  be  due  to  this 
simple  coryza  with  no  taint  whatever  of  syphilis.  Adenoids 
also  are  not  very  rare  even  in  infants  a  few  weeks  old  and  may 
be  associated  with  some  catarrh  causing  snuffling  respiration. 
There  are  also  some  forms  of  idiocy,  particularly  Mongolian 
imbecility  and  microcephaly,  in  which  a  small  naso-pharynx 
with  a  special  tendency  to  catarrh  is  responsible  for  snuffling 
and  snorting  respiration  quite  apart  from  syphilis. 

Skin  eruptions.  These  generally  appear  soon  after  the 
snuffles  and  almost  always  within  the  first  three  months.  They 
are  certainly  very  uncommon  after  the  age  of  six  months  ;  in 
one  of  my  cases  the  rash  appeared  at  eight  months  and  in  another 
at  one  year.  Some  characteristic  eruption  was  present  in  69  per 
cent,  of  my  cases.  I  shall  not  attempt  to  describe  all  the  skin 
affections  which  have  been  observed  in  congenital  syphilis  ;  tlie 
most  characteristic  might  be  grouped  as  follows  : 

1.  Macular,  small  reddish-brown,  '  raw-ham-colourcd '  areas, 
generally  roughly  circular,  but  running  together  into  irregular 
areas,  dry  and  sometimes  finely  desquamating  on  the  surface  ; 
occasionally  these  patches  are  yellowish-brown  or  fawn-coloured 
and  have  a  dry,  glazed  surface.     This  eruption  may  be  present 
on  any  part  of  the  body  but  is  particularly  characteristic  in  its 
tendency  to  affect  the  middle  third  of  the  face,  i.e.  if  the  face 
be  divided  into  three  parts  vertically,  the  middle  portion  including 
the  chin  and  upper  lip,  the  nose,  and  inner  end  of  the  eyebrows, 
is  specially  affected  and  sometimes  the  only  part  affected  by  the 
syphilitic  rash. 

2.  Erythematous,  diffuse  in  distribution  and  occurring  specially 
about  the  perineum  and  down  the  inner  side  of  the  thigh  and  leg 
as  far  as  the  instep  of  the  foot  ;   the  skin  may  be  dry  and  glazed 
and  at  the  edge  of  the  affected  area  there  are  often  outlying  small 
round  patches  of  similar  character. 

3.  Desquamative ;  either  of  the  preceding  is  sometimes  asso- 
ciated with  a  little  fine  branny  desquamation  of  the  affected  areas, 
but  apart  from  these  there  is  a  profuse  desquamation  of  the 


80(5  COMMON  DISORDERS  OF  CHILDHOOD 

palms  and  soles  whiclj,  occurring  in  an  infant  under  the  age  of 
three  months,  is  very  characteristic  of  congenital  syphilis. 

4.  Fissures,  usually  radiating  outwards  from  mucous  surfaces, 
e.  g.  the  mouth  and  anus ;  these  generally  occur  within  the  first 
few  weeks  of  life  and  are  often  deep  enough  to  leave  scars  which 
last  for  the  rest  of  life. 

5.  Bullous,    the    '  syphilitic   pemphigus ',   which,   as  already 
mentioned,  is  present  at  birth  or  within  the  next  few  days. 

6.  Condylomatous  ;     these   moist   warty-looking,   flat-topped 
slightly  raised  patches  usually  of  about  the  size  of  a  threepenny- 
bit  or  smaller  and  situated  in  moist  parts,  for  instance,  about  the 
anus  or  in  the  mouth,  must  be  mentioned  here,  for  although  they 
differ  from  the  other  skin  lesions  of  congenital  syphilis  in  their 
tendency  to  appear  and  reappear  long  after  infancy,  they  are, 
I  think,  most  common  in  the   first  and  second  years  of  life. 
Lastly,  I  would  draw  attention  to  the  frequent  occurrence  in 
syphilitic  infants  of  skin  affections  which  exactly  resemble  such 
ordinary  non-syphilitic  lesions  as  eczema  and  erythema  inter- 
trigo  ;  for  instance,  behind  the  ears  there  is  often  a  very  ordinary 
eczema,  whilst  on  the  face  there  is  a  characteristic  syphilitic  rash 
in  an  infant  who  shows  other  well-marked  evidence  of  the  disease. 
Similarly  a  scborrhceic  condition  of  the  scalp  or  an  ordinary 
erythema  intertrigo  about  the  groins  and  perineum  frequently 
coexists  with  definite  manifestations  cutaneous  or  otherwise  of 
congenital  syphilis. 

Whilst  considering  the  skin  lesions  of  this  disease  I  must 
mention  two  symptoms  which  are  very  characteristic  of  inherited 
syphilis.  I  have  already  referred  to  the  abundant  crop  of  Kair 
which  is  sometimes  a  noticeable  feature  at  birth  in  the  syphilitic  ; 
a  few  months  later  the  opposite  condition  (a  more  frequent  and 
much  more  characteristic  symptom)  is  sometimes  present  (it 
occurred  in  G  per  cent,  of  my  cases) — a  thinning  of  the  hair,  so 
that  it  becomes  sparse  and  scanty,  never  leaving  complete 
baldness  as  in  alopecia  areata,  but  leaving  so  little  hair  that  the 
baldness  at  once  attracts  notice  and  the  more  so  as  it  commonly 
begins  over  the  vertex  and  leaves  for  some  time  a  fringe  of 
thicker  hair  around  the  side  of  the  head  somewhat  after  the  style 
of  a  monk's  tonsure.  The  other  symptom  is  onychia,  seen  usually 
in  early  infancy  and,  I  think,  usually  associated  with  some  cu- 
taneous lesion,  especially  perhaps  with  the  desquamative  lesions  ; 
the  nails  of  the  fingers  and  sometimes  of  the  toes  become  dry 
and  shrivelled  and  discoloured  and  soon  are  shed  altogether, 
leaving  a  small  base  of  newly-formed  nail  which  if  the  infant 
is  under  treatment  with  mercurials  may  speedily  grow  to  a 
perfectly  healthy  nail. 


CONGENITAL  SYPHILIS  801 

Enlargement  of  the  spleen.  Widely  varying  statistics  have 
been  recorded  on  this  point ;  some  have  placed  the  frequency 
as  low  as  10  per  cent.,  some  as  high  as  78  per  cent.  This  variation 
probably  depends  in  part  upon  difference  of  ideas  as  to  what 
is  to  bo  called  enlargement ;  if  easy  palpability  bo  the  standard, 
then  45  per  cent,  of  my  cases  showed  splenic  enlargement,  but 
including  only  cases  in  which  the  enlargement  was  at  least  one  and 
a  half  fingers'  breadth  (about  1  inch)  below  the  costal  margin 
the  proportion  was  22  per  cent.  It  is  quite  clear  that  absence 
of  splenic  enlargement  weighs  very  little  against  the  diagnosis  of 
congenital  syphilis,  and  mere  palpability,  I  think,  is  of  very 
little  value  as  positive  evidence,  for  the  spleen  is  often  to  be  felt 
in  infants  who  are  free  from  all  suspicion  of  syphilis  ;  when, 
however,  the  spleen  extends  an  inch  or  more  below  the  costal 
margin,  especially  in  an  infant  under  the  ago  of  six  months,  it 
has,  I  think,  some  value  as  confirmatory  evidence. 

The  virus  of  syphilis,  the  spirochscte  pallida,  which  must  now  be 
regarded  as  the  specific  organism,  evidently  exerts  some  irritative 
action  on  the  spleen,  for  in  autopsies  on  infants  with  congenital 
syphilis  there  is  frequently  seen  a  recent  capsulitis,  and  in  later 
stages  patches  of  thickening  of  the  capsule  and  some  increase  of 
connective  tissue  in  the  substance  of  the  organ  remain  as  evidence 
of  past  reaction  ;  to  these  changes  apparently  the  enlargement 
is  duo  in  some  cases.  Very  rarely  has  any  gummatous  deposit 
been  found  in  the  spleen  in  children.  I  have  elsewhere  l  recorded 
two  cases  (one  associated  with  lardaceous  disease)  and  collected 
four  other  published  instances.  In  some  cases  the  enlargement 
of  the  spleen  has  been  secondary  to  a  syphilitic  cirrhosis  of 
the  liver. 

Seeing  that  the  peritoneum  over  the  spleen  sometimes  shows 
distinct  inflammatory  change  one  might  expect  that  occasionally 
a  more  general  peritonitis  would  result,  and  this  becomes  more 
probable  when  it  is  admitted,  as  it  is  by  some  writers,  that 
syphilis  may  cause  peritonitis  during  intra-uterine  life.  By 
the  kindness  of  Dr.  A.  E.  Naish  of  Sheffield,  I  had  the  oppor- 
tunity of  examining  the  viscera  of  a  still-born  infant,  whose 
birth,  had  been  hindered  by  foetal  ascites.  The  intestines  were 
found  to  be  matted  together  by  adhesions  ;  the  liver  showed 
intercellular  cirrhosis.  There  was  no  evidence  of  syphilis  in  the 
family  history,  but  the  condition  of  the  liver  made  such  a  cause 
at  least  probable.  Of  syphilis,  however,  as  a  cause  of  acute 
peritonitis  after  birth  very  little  is  known  ;  one  case  probably 
of  this  nature  has  been  described  by  West  2  in  a  syphilitic  infant 

1  Path.  See.  Trans.,  vol.  xlviii. 

2  Diseases  of  Infancy  and  Childhood,  1865,  p.  650. 

STILL  3    F 


8(fe  COMMON  DISORDERS  OF  CHILDHOOD 

whose  abdomen  beca/ne  enlarged  and  extremely  tender  at  the 
age  of  four  weeks  ;  but  the  peritonitis,  if  such  it  was,  gradually 
subsided  and  the  infant  recovered.  In  an  infant,  aged  four  weeks, 
who  was  brought  to  me  with  a  well-marked  syphilitic  rash,  the 
abdomen  became  distended  and  the  child  died  in  about  forty  - 
eight  hours  from  the  onset  of  symptoms  ;  autopsy  showed  a 
very  acute  peritonitis  with  turbid  serum  and  lymph  in  the  pelvis  ; 
in  the  liver  there  was  very  advanced  intercellular  cirrhosis. 
Whether  the  peritonitis  in  this  case  was  solely  due  to  syphilis 
or,  like  the  suppuration  which  sometimes  occurs  in  a  syphilitic 
epiphysitis,  was  due  to  a  superadded  infection  without  any 
apparent  source,  is  uncertain,  but  it  seems  a^-  least  possible  that 
the  association  of  acute  peritonitis  with  syphilis  was  more  than 
a  coincidence. 

Laryngitis  is  one  of  the  most  frequent  of  the  early  symptoms. 
It  was  present  in  14  per  cent,  of  my  cases.  It  occurs  usually 
soon  after  the  onset  of  the  snuffles  or  rash.  A  hoarse  aphonic 
cry  in  an  infant  under  the  age  of  three  months  should  always 
suggest  the  possibility  of  congenital  syphilis.  I  have  twice  had 
the  opportunity  of  examining  the  larynx  in  this  condition  after 
death  :  in  one  case  at  the  age  of  four  months,  where  the  hoarse- 
ness had  been  very  marked  during  life,  the  only  change  detected 
was  slight  thickening  and  roughening  of  the  mucous  membrane 
over  the  arytaenoid  cartilages ;  there  was  no  change  in  the  cords. 
In  the  other  at  the  age  of  eight  weeks  there  was  much  thickening 
of  the  epiglottis  with  some  ulceration  of  the  mucosa  near  its 
base  ;  there  was  extensive  ulceration  of  the  vocal  cords  also, 
chiefly  at  the  anterior  part. 

Epiphysitis  was  present  in  11  per  cent.  Some  observers  have 
found  it  even  more  frequently,  e.  g.  Scherer  found  it  eleven  times 
in  fifty  cases.  The  earliest  onset  in  my  cases  was  at  two  weeks, 
and  six  out  of  eleven  began  during  the  first  three  months  (six 
out  of  Scherer's  eleven  cases  also  began  under  the  age  of  three 
months).  It  is  one  of  the  causes,  if  not  the  only  cause,  of  the 
so-called  '  syphilitic  pseudo-paralysis  '  and  should  always  be 
suspected  when  an  infant  during  the  first  half-year  loses  the 
use  of  one  limb,  especially  the  upper  limb,  without  apparent 
injury.  In  my  own  cases  the  arms  were  affected  alone  in  five, 
and  with  the  legs  in  three,  out  of  eleven  cases. 

The  folio-wing  is  a  typical  example  of  this  affection  : 

Herbert  G.,  aged  two  months,  began  to  scream  fourteen  days  ago  when 
his  arms  were  moved,  and  seemed  to  have  lost  the  use  of  both  arms.  He  has 
had  snuffles  from  birth,  but  has  had  no  rash;  some  thickening  is  felt  about 
the  upper  epiphysis  of  the  left  humerus  and  also  about  the  upper  epiphysis 


CONGENITAL  SYPHILIS  803 

of  the  radius  in  each  forearm  ;  there  is  no  movement  of  the  arms  or  forearms 
the  child  cries  if  they  are  handled.  The  mother  was  treated  ten  months  for 
syphilis  about  three  years  ago  ;  she  then  gave  birth  to  a  child  who  had  snuffles 
severely  and  died  at  five  weeks ;  the  patient  was  the  next  child.  Inunction 
of  mercury  over  the  abdomen  produced  rapid  diminution  of  the  epiphysial 
thickening  and  also  of  tenderness,  and  when  the  infant  was  seen  about  a  week 
after  this  treatment  was  begun,  there  was  already  slight  movement  of  fingers 
and  wrists,  and  a  week  later  there  was  good  movement  of  the  upper  limbs. 

This  syphilitic  epiphysitis  might  be  mistaken  for  infantile 
scurvy,  but  the  latter  disease  rarely  occurs  under  the  age  of  six 
months  and  practically  never  under  four  months.  Infantile 
paralysis  also  hardly  occurs  under  the  age  of  six  months,  and 
rheumatism  can  be  excluded  for  it  is  almost  unknown  in  infancy. 
The  tenderness  and  pain  on  movement  will  usually  suffice  to 
eliminate  a  paralysis  of  cerebral  origin  which,  moreover,  is 
seldom  limited  to  one  limb  as  this  syphilitic  pseudo-paralysis 
usually  is.  The  history  of  onset  some  weeks  after  birth  serves 
to  distinguish  it  from  the  palsy  which  results  from  damage  to  the 
brachial  plexus  during  birth.  The  diagnosis  is  important,  for 
with  mercurial  treatment  the  pseudo-paralysis  disappears  com- 
pletely in  a  week  or  two;  local  treatment  is  seldom  necessary, 
beyond  protection  of  the  flaccid  limb  from  mechanical  injury. 
But  if  the  syphilitic  origin  of  the  condition  is  overlooked,  apart 
from  the  suffering  entailed  to  the  infant,  there  is  a  risk  of  separa- 
tion of  the  epiphysis  and  also  of  suppuration,  which  I  have  seen 
occur  about  the  affected  epiphysis  with  undoubted  syphilis,  per- 
haps from  superadded  pyogenic  infection  of  the  damaged  tissue. 

Dactylitis  is  less  frequent  than  epiphysitis,  if  indeed  it  is  to 
be  distinguished  therefrom ;  some  observers  have  thought  it  was 
an  epiphysitis,  others  have  rather  described  it  as  a  periostitis  or  an 
osteomyelitis.  It  was  present  only  in  2  per  cent,  of  my  cases.  Out 
of  nine  which  I  collected  seven  were  under  one  year,  including  five 
which  occurred  at  four  weeks  ;  none  were  over  two  years  of  age. 

The  fingers  are  more  often  affected  than  the  toes  and  usually 
more  than  one  finger  is  affected.  There  is  a  fusiform  swelling 
usually  of  the  proximal  phalanx.  Dr.  Carpenter  in  his  mono- 
graph on  congenital  syphilis  mentions  affection  of  the  meta- 
carpal  bones  in  one  case,  and  I  have  seen  one  similar  case. 

The  condition  can  hardly  escape  observation,  the  difficulty  is 
to  distinguish  between  syphilitic  and  tuberculous  dactylitis. 
It  has  been  said  that  the  syphilitic  tends  to  be  symmetrical  in 
the  two  hands,  but  this  was  not  apparent  from  the  nine  cases 
I  have  mentioned  nor  do  I  know  of  any  reliable  point  of  distinc- 
tion ;  the  age-incidence  will  sometimes  assist,  for  tubercle  is 

3  F  2 


804  COMMON  DISORDERS  OF  CHILDHOOD 

excessively  rare  under  the  age  of  three  months  and  by  no  means 
common  under  the  age  of  six  months,  whereas  most  of  the 
syphilitic  lesions  of  infancy  including  dactylitis  are  almost  as 
likely  to  occur  under  three  months  of  age  as  later  ;  the  diagnosis 
must  usually  depend  upon  the  presence  of  other  symptoms 
of  syphilis  which  are  seldom  lacking. 

Orchitis,  present  in  five  out  of  sixty-four  males,  i.  e.  in  nearly 
8  per  cent,  of  my  cases,  is  another  symptom  which  in  early 
infancy  is  almost  pathognomonic  of  congenital  syphilis.  The 
testes  are  enlarged  to  two  or  three  times  the  normal  size,  are  very 
hard  and  quite  free  from  tenderness.  The  condition  may  easily 
be  overlooked  unless  specially  sought  ;  its  detection  is  important, 
not  only  as  an  aid  to  diagnosis  but  also  because  early  administra- 
tion of  mercury  may  prevent  loss  of  function  in  these  organs. 
It  differs  from  tuberculous  disease  not  only  in  affecting  the  body 
of  the  testis  first  and  chiefly,  whilst  the  epididymis  is  seldom 
appreciably  affected,  but  also  in  being  more  often  a  bilateral 
affection.  In  three  out  of  my  five  cases  it  began  at  the  age 
of  twelve  weeks,  a  time  at  which  tuberculosis  of  any  sort  and 
especially  of  the  reproductive  organs  is  very  rare.  The  orchitis 
usually  begins  under  the  age  of  five  months. 

Brain  affections  and  indeed  nervous  affections  of  any  sort  are 
usually  stated  to  be  very  uncommon  in  congenital  syphilis. 
According  to  my  own  figures  10  per  cent,  of  children  up  to  the 
age  of  twelve  years  with  this  disease  showed  cerebral  affection 
of  one  kind  or  another,  and  even  if  only  infants  were  included 
the  proportion  seemed  to  be  nearly  as  high. 

Of  fifteen  cases  with  wrell-marked  congenital  syphilis  and  affec- 
tions of  the  brain,  seven  were  cases  of  progressive  mental  degenera- 
tion (i.e.  juvenile  general  paralysis)  commencing  at  about  five 
to  eight  years  of  age  ;  three  were  idiots  from  birth  (one  of  these 
three  was  markedly  microcephalic) ;  one  was  hydrocephalic, 
and  one  hemiplegic.  It  seems  likely  that  even  10  per  cent, 
is  below  the  actual  proportion,  for  I  have  not  included  some 
cases  of  cerebral  palsy  in  which  the  history  suggested  the  likeli- 
hood of  congenital  syphilis  without  sufficient  evidence  to  make 
it  certain.  It  is  recognized  also  that  some  children  with  congenital 
syphilis  become  epileptic  in  the  later  years  of  childhood,  and 
I  would  add  that  it  is  not  uncommon  for  syphilitic  infants  to  die 
with  convulsions  shortly  after  birth.  The  relation  of  syphilis 
to  mental  deficiency  I  have  already  considered  (pp.  594,  597). 

It  has  been  customary  in  textbooks  to  mention  congenital 
syphilis  as  a  cause  of  meningitis  in  infancy  ;  but  if  by  meningitis 
is  meant  a  simple  inflammation  of  the  pia-arachnoid — I  mean 


CONGENITAL  SYPHILIS  805 

as  distinct  from  the  pachymeningitis  with  cortical  sclerosis 
which  is  found  in  cases  of  juvenile  general  paralysis— then 
meningitis  is  certainly  of  extreme  rarity  in  congenital  syphilis. 
There  can  be  little  doubt  that  what  was  formerly  described  as 
a  chronic  basal  meningitis  due  to  syphilis  in  infants  was 
identical  with  the  disease  which  we  now  know  as  posterior 
basic  meningitis  or  cerebro-spinal  meningitis  and  which, 
however  chronic  it  may  be,  is  the  result  of  infection  with 
known  micro-organisms  and  has  no  connexion  with  syphilis, 
although  there  is  of  course  no  reason  why  it  should  not  occur  in 
a  syphilitic  infant.  I  have  never  seen  such  an  association 
myself.  But  apart  from  this  posterior  basic  meningitis  which, 
as  is  now  generally  admitted,  has  nothing  to  do  with  syphilis, 
is  there  any  form  of  lepto-meningitis  (inflammation  of  the  pia- 
arachnoid)  which  can  be  attributed  to  inherited  or  congenital 
syphilis  ?  Cases  have  been  recorded  in  which  syphilitic  infants 
with  microcephaly  have  shown  thickening  and  adhesions  of 
the  pia  mater — sometimes  at  the  vertex,  sometimes  at  the  base — 
evidently  the  result  of  meningitis  during  intra-uterine  life. 
I  have  more  than  once  found  adhesions  and  opaque  thickening 
of  the  pia-arachnoid  about  the  medulla  and  under  surface  of  the 
cerebellum  in  cases  of  congenital  hydroccphalus  where  it  seemed 
clear  that  there  must  have  been  meningitis  before  birth.  In  some 
such  cases  it  seems  certain  that  syphilis  is  the  cause,  in  others 
it  can  only  be  suspected. 

Sir  Thomas  Barlow1  has  recorded  a  case  in  which  old  thicken- 
ing and  calcification  of  the  pia  mater  was  found  with  arteritis 
and  choroiditis  in  a  syphilitic  infant  aged  ten  months.,  but  here 
there  was  no  history  of  definite  meningitic  symptoms  at  any  time 
and  the  date  of  the  inflammation  was  quite  uncertain.  In  a 
syphilitic  boy  aged  10^,  who  died  after  thirteen  days  of  acute 
symptoms,  I  found  a  chronic  inflammation  of  the  pia  mater 
which  was  thick  and  opaque  over  parts  of  the  vertex  and  showed 
some  thickening  with  adhesions  in  the  Sylvian  fissures  and 
between  the  medulla  and  cerebellum  ;  there  was  also  some 
opacity  of  the  membranes  down  the  posterior  surface  of  the  spinal 
cord  ;  this  case  showed  also  some  sclerosis  of  the  cortex  and 
comes  into  the  category  of  juvenile  general  paralysis  (see  p.  595, 
where  I  have  considered  this  case  more  fully). 

Eye  affections.     A  striking  feature  in  all  the  nervous  affec- 
tions of  congenital  syphilis  and  to  a  less  extent  with  other  mani- 
festations of  this  disease  in  children  is  the  frequency  of  syphilitic 
eye  changes  ;   in  at  least  21  per  cent,  of  cases  with  or  without 
1  Path.  Soc.  Trans.,  vol.  xxviii,  p.  287. 


806  COMMON  DISORDERS  OF  CHILDHOOD 

nervous  manifestations  some  syphilitic  eye  affection  was  present ; 
in  12  per  cent,  there  was  choroiditis,  and  these  figures  no  doubt 
understate  the  frequency,  for  the  point  was  not  specially  noted 
in  all  my  series.  With  the  nervous  affections  they  are  much 
more  frequent,  ten  out  of  fifteen  cases  with  cerebral  manifesta- 
tions showed  some  eye  affection  which  in  nine  out  of  the  ten 
was  a  choroiditis  or  choroido-retinitis ;  the  remaining  one 
showed  only  keratitis.  These  statistics,  although  they  deal  only 
with  small  numbers,  may  serve  to  emphasize  the  value  of  ophthal- 
moscopic  examination  in  the  diagnosis  of  gongenital  syphilis. 
In  view  of  the  probable  intra-uterine  onset  of  the  eye  changes 
in  some  cases,  it  seems  likely  that  in  cases  where  from  the  known 
presence  of  syphilis  in  the  parents  or  in  the  other  children 
syphilis  is  suspected  in  an  infant,  examination  of  the  fundus 
oculi  may  be  of  value  in  determining  whether  antisyphilitic 
measures  should  be  adopted  before  other  symptoms  have 
appeared  :  nine  out  of  sixty  syphilitic  infants  in  the  first  year 
of  life  showed  iritis  or  choroiditis. 

A  very  characteristic  affection  is  interstitial  keratitis,  which 
is  often  associated  with  the  Hutchinsonian  type  of  permanent 
teeth,  and  begins  most  often  between  six  and  twelve  years  of 
age.  In  most  cases  it  begins  in  one  eye  several  weeks  before  the 
other  is  affected,  but  I  have  seen  both  affected  within  a  week. 
The  haziness  of  the  cornea,  with  spots  of  opacity  in  its  substance, 
and  the  fine  blood-vessels  ramifying  over  it  and  passing  deeply 
into  the  cornea,  afford  very  positive  evidence  of  syphilis.  Sight 
is  almost  completely  lost  in  some  cases  for  many  weeks  or 
months  owing  to  the  dense  opacity  of  the  cornea;  but  the 
prognosis  is  much  better  than  appearances  would  suggest,  for 
with  free  administration  of  iodide  and  mercury  internally  and  the 
use  of  an  ointment  of  the  yellow  oxide  of  mercury  locally  the 
opacity  gradually  diminishes,  and  if  the  cornea  does  not  become 
quite  clear  as  it  may  do  in  a  mild  case,  it  at  least  becomes 
sufficiently  clear  to  allow  of  good  vision. 

Anaemia  of  a  very  profound  degree  is  sometimes  a  result  of 
congenital  syphilis,  most  often,  I  think,  towards  the  end  of  the 
first  or  in  the  second  year.  This  anaemia  may  occur  after  all 
other  manifestations  of  the  disease  have  disappeared,  so  that  at 
the  time  it  is  the  only  indication  of  syphilis.  This  was  impressed 
upon  me  some  time  ago  by  the  case  of  an  infant  whom  I  had 
treated  for  syphilis  at  the  age  of  five  months;  he  passed  out  of 
my  observation  for  a  time  and  at  the  age  of  about  eighteen 
months  he  was  brought  again  with  profound  ansemia.  I  had 
forgotten  the  previous  symptoms  (syphilitic  epiphysitis  and 


CONGENITAL  SYPHILIS  807 

condylomata)  and  was  in  great  doubt  as  to  the  cause  of  the 
anaemia,  which  was  the  only  symptom  except  some  diffuse 
thickening  of  the  epithelium  of  the  tongue.  The  anaemia  remained 
a  puzzle  until  after  some  months  large  condylomata  appeared 
at  the  anus. 

The  extreme  pallor  of  the  face  with  a  brownish -yellow  tinge, 
especially  about  the  nose  and  cheeks,  is  very  striking,  and  may 
even  in  the  absence  of  other  symptoms  suggest  syphilis,  but  it 
is  certainly  not  pathognomonic.  This  anaemia  of  congenital 
syphilis  is  not  associated  usually  with  any  special  enlargement 
of  the  spleen  beyond  the  moderate  degree  which  is  common  in  this 
disease,  and  herein  lies  one  difference  from  the  so-called  '  splenic 
anaemia  ',  the  relation  of  which  to  congenital  syphilis  is  still 
sub  judice,  and  in  which  enormous  enlargement  of  the  spleen 
is  a  characteristic  symptom.  Examination  of  the  blood  shows 
nothing  to  distinguish  this  profound  anaemia  of  congenital 
syphilis  from  profound  anaemia  secondary  to  other  conditions, 
for  instance,  rickets. 

As  in  the  following  case  there  is  often  a  marked  diminution  of 
haemoglobin,  but  poikilocytosis  is  uncommon  : 

Doris  G.,  aged  2£  years,  was  one  of  a  twin,  and  had  been  preceded  by  two 
miscarriages ;  there  were  marked  Parrot's  nodes,  and  the  yellowish  pallor 
suggested  syphilis.  The  blood  showed  haemoglobin  40  per  cent.,  red  blood 
corpuscles  3,032,000  per  cub.  cm.,  white  corpuscles  15,500  per  cub.  cm.  Differ- 
ential count  of  white  corpuscles  showed  polymorphonuclears  01  per  cent., 
large  mononuclear  2 -5  per  cent.,  small  lymphocytes  32  per  cent.,  large  lympho- 
cytes 3  per  cent.,  eosinophiles  1*5  per  cent. 

Whether  a  study  of  the  blood  will  draw  any  hard-and-fast 
line  between  this  syphilitic  anaemia  and  the  so-called  '  splenic 
anaemia  of  infants  '  is  still  a  moot  point.  Undoubtedly  the 
blood  in  the  latter  group  of  cases  presents  features  which  might 
suggest  a  disease  sui  generis,  but  the  very  close  association 
between  this  '  splenic  anaemia  '  and  congenital  syphilis  and  rickets 
must,  I  think,  make  us  very  cautious  in  accepting  any  such 
view.  The  cafe-au-lait  tint  which  is  sometimes  described  as 
characteristic  of  congenital  syphilis  differs  considerably  from 
the  yellowish  anaemia.  The  predominating  tint  is  brown  rather 
than  yellow,  and  it  is  seen  not  in  well-nourished  infants  as  the 
anaemia  is,  but  almost  always  in  puny,  emaciated  infants  and 
at  an  earlier  age  than  that  at  which  the  anaemia  usually  occurs. 

Parrot's  nodes  and  craniotabes.  The  relation  of  these  to 
congenital  syphilis  has  been  much  disputed.  By  some  they 
have  been  regarded  as  indubitable  evidence  of  syphilis,  by  others 
as  a  product  of  syphilis  and  rickets  combined,  and  by  others  again 


808  COMMON  DISORDERS  OF  CHILDHOOD 

as  due  to  rickets  alone.    If  I  may  simply  state  my  own  opinion, 
formed  as  the  result  of  some  special  observation  on  this  point, 

1  should  say  that  neither  of  these  symptoms  can  be  taken  as 
evidence  of  syphilis  ;    that  both  of  them  are  found  far  more 
often  without  syphilis  than  with  it ;    that  both  of  them  may 
be  produced   by  rickets   alone  ;     but   that   both   of  them   are 
occasionally  found  with  congenital  syphilis  apart  from  rickets. 
Of  100  cases  of  congenital  syphilis  under  my  observation  only 

2  showed  Parrot's  nodes  and  both  these  showed  rickets  also. 
I  think  it  is  quite  possible  that  under  the  name  '  Parrot's  nodes  ' 


FIG.  53.  Parrot's  nodes.  Photograph  of  skull,  showing  characteristic  Parrot's 
nodes.  In  this  case  there  was  roughening  of  the  outer  surface  over  the  bosses, 
which  had  a  honeycomb  appearance :  the  child  had  both  rickets  and  congenital 
syphilis. 

two  conditions  structurally  different  though  resembling  one 
another  clinically  are  confused  together,  one  being  the  result  of 
syphilis  and  the  other  of  rickets  ;  at  any  rate  I  can  affirm  from 
my  own  observation  that  these  bosses  on  the  skull  show  anatomical 
differences  which  seem  to  support  this  view. 

In  some  cases  the  thickening  is  found  to  be  due  to  a  very 
vascular  thickening  of  the  diploe,  while  the  outer  surface  of  the 
thickened  part  remains  normally  smooth;  in  other  cases  there 
is  deposit  of  new  bone  on  the  outside  of  the  skull  which  has 
a  rough  honeycomb  appearance.  The  latter  condition  is  certainly 


CONGENITAL  SYPHILIS  809 

found  in  syphilitic  infants.  I  do  not  know  that  it  is  ever  found 
in  pure  rickets.  In  either  case  the  bossing  is  usually,  but  not 
always,  symmetrical,  affecting  the  parietal  and  frontal  bones 
near  the  anterior  fontanelle,  and  so  producing  the  natiform  or 
hot-cross-bun  skull. 

Craniotabes  has  seemed  to  me  to  be  very  rarely  due  to  syphilis 
(see  p.  97) ;  indeed,  in  examining  the  heads  of  syphilitic  infants 
for  craniotabes  I  have  been  struck  with  the  firmness  of  the 
bones,  which  have  often  seemed  to  become  firm  and  hard  rather 
earlier  than  in  infants  who  showed  no  evidence  of  syphilis  ;  in 
my  own  experience  craniotabes  has  been  associated  most  often 
with  laryngismus  stridulus  and  tetany,  which  are  both  recognized 
as  rachitic  manifestations,  and  in  most  of  these  cases  there  has 
been  no  suspicion  of  syphilis.  There  is  no  doubt  that  congenital 
syphilis  may  cause  extensive  absorption  of  the  bones  of  the 
skull  as  in  the  following  case  : 

Edward  H.,  aged  ten  months,  was  brought  for  a  rash  on  the  face,  buttocks, 
and  head.  He  was  slightly  hoarse,  and  had  condylomata  about  the  anus  ;  the 
fundus  oculi  showed  choroidoretinitis  ;  but  the  remarkable  feature  of  the  case 
was  the  presence  just  in  front  of  the  frontal  eminences  of  two  symmetrical 
gaps,  one  in  each  frontal  bone,  triangular  in  shape — the  base  of  the  triangle 
being  above — and  measuring  about  one  inch  in  the  transverse  line  of  the  fore- 
head, whilst  the  distance  from  base  to  apex  (which  reached  nearly  halfway 
down  the  forehead)  was  also  about  one  inch.  The  bone  appeared  to  be  entirely 
absent  in  these  areas,  and  I  concluded — wrongly,  as  events  proved — that  it  was 
an  unusual  example  of  congenital  defect  of  ossification.  The  child  was  treated 
with  mercury  and  iodide  for  the  other  syphilitic  manifestations,  and  in  the 
course  of  a  few  weeks  it  was  found  that  the  holes  in  the  frontal  bones  had  com- 
pletely disappeared,  being  filled  up  with  hard  thick  bone  with  a  somewhat 
uneven  surface.  No  swelling  of  any  sort  had  been  noticed  over  these  areas 
before  the  absorption  of  the  bone  ;  so  that  it  was  unlikely  that  it  had  been 
preceded  by  any  gummatous  deposit. 

Nephritis.  Less  common  than  any  of  the  affections  already 
mentioned  is  nephritis  as  a  result  of  congenital  syphilis.  Several 
such  cases  have  recently  been  recorded  by  Dr.  Carpenter, 
Dr.  Sutherland,  Dr.  Walker,  and  others.  I  have  had  four 
syphilitic  children  with  nephritis  under  my  observation.  One 
developed  general  oedema  at  the  age  of  six  weeks  and  died  six 
weeks  later ;  the  kidney  showed  acute  nephritis.  Another 
showed  symptoms  of  nephritis  at  the  age  of  three  years  and  three 
months,  became  dropsical  with  ascites  and  died  :  intercellular 
cirrhosis  of  the  liver  was  found  and  an  acute  nephritis  chiefly 
of  interstitial  character. 

A  third  came  under  treatment  at  the  age  of  three  months 
with  'pseudo-paralysis'  of  one  arm,  enlarged  spleen,  anaemia, 


810*          COMMON  DISORDERS  OF  CHILDHOOD 

dropsy,  and  albuminuria.  The  epiphysitis  rapidly  cleared  up 
under  mercury,  but  the  child  died  shortly  afterwards  of  sup- 
purative  meningitis,  and  the  kidney  showed  acute  parenchymatous 
nephritis.  The  fourth  case  was  a  girl  aged  nine  years  who  had  been 
under  the  care  of  Dr.  Thursfield  with  hsematuria  and  interstitial 
keratitis,  the  left  kidney  was  thought  to  be  unduly  palpable  ; 
under  iodide  treatment  the  urine  became  free  from  blood  but 
albuminuria  continued  and  many  casts  were  found  in  the  urine. 

In  five  out  of  ten  cases  in  which  the  character  of  the  nephritis 
has  been  noted,  the  inflammation  was  chiefly  or  entirely  inter- 
stitial :  a  fact  which  has  suggested  that  the  rare  cases  in  which 
chronic  interstitial  nephritis  is  found  in  childhood  may  possibly 
in  some  instances  be  explained  by  congenital  syphilis. 

Teeth.  Passing  now  to  the  symptoms  which  occur  in  later 
childhood  I  must  mention  the  characteristic  changes  in  the 
teeth  which  were  described  by  Sir  Jonathan  Hutchinson.  The 
upper  central  incisors  are  chiefly  affected,  they  are  unduly  small 
and,  partly  in  consequence  of  this,  appear  widely  separated. 
They  are  also  abnormal  in  shape,  the  cutting  edge  is  usually 
narrower  than  the  base  and  its  corners  are  round  instead  of 
sharply  angular ;  most  characteristic  is  the  edge,  which  shows  a 
crescentic  notch,  as  shown  in  the  accompanying  photograph 
(Fig.  54)  of  a  boy  aged  ten,  who  had  also  disseminate  choroiditis. 

Similar  changes  are  present  sometimes  but  in  less  marked 
degree  in  the  lower  central  incisors.  The  first  molars  sometimes 
show  a  characteristic  but  less  obvious  change,  being  small  and 
dome-shaped  owing  to  defective  development  of  the  cusps.  I 
have  not  found  these  dental  changes  to  be  frequent,  but  when 
they  do  occur  they  are  of  great  value  in  the  recognition  of  syphilis 
in  later  childhood. 

Is  the  primary  dentition  affected  in  any  way  by  congenital 
syphilis  ?  It  has  been  stated  positively  that  the  characteristic 
teeth  of  congenital  syphilis  are  seen  only  in  the  permanent 
dentition,  never  in  the  temporary  set.  I  venture  to  think  that 
like  most  rules  this  one  also  has  its  exceptions.  A  male  infant, 
aged  fourteen  months,  was  brought  to  me  at  the  Hospital  for 
Sick  Children,  Great  Ormond  Street,  for  screaming  and  colic. 
His  central  upper  incisors  were  both  of  typical  screwdriver  shape, 
narrower  at  the  edge  than  at  the  base ;  they  showed  at  the  cutting 
edge  a  well-marked  shallow  crescentic  notch,  and  in  addition 
showed  that  undue  separation  from  one  another  which  is  common 
in  syphilitic  teeth.  I  do  not  think  that  a  more  characteristic 
specimen  of  syphilitic  teeth  could  well  be  found ;  there  was  no 


CONGENITAL  SYPHILIS 


811 


other  evidence  of  syphilis  in  the  child,  but  the  family  history  was 
suggestive— (1)  still-born  at  sixth  month  ;  (2)  premature,  eight 
months'  child,  lived  nine  weeks  ;  (3)  seven  months'  child,  deaf 
and  dumb  ;  (4)  patient.  Smale  and  Colycr,  in  their  treatise  on 


FIG.  54.  Notched  upper  incisors  in  congenital  syphilis  (Hutchinsonian  teeth). 
Photograph  shows  characteristic  dwarfing  and  notching  of  the  upper  central 
incisors,  which  are  also  widely  separated  from  the  lateral  incisors  and  especially 
from  each  other.  The  lower  central  incisors  showed  a  much  shallower  notch  at 
their  cutting  edge.  The  boy  had  interstitial  keratitis. 

Diseases  and  Injuries  of  the  Teeth,  refer  to  a  case  recorded  by 
Mr.  Oakley  Coles,1  of  '  peg-shaped  temporary  teeth  which  were 
very  characteristic,  occurring  in  a  child  the  mother  of  whom  had 
long  been  the  subject  of  syphilis  '. 

1  Trans.  Odont.  Soc.,  vol.  ix,  p.  258. 


812  COMMON  DISORDERS  OF  CHILDHOOD 

Apart  from  these  extremely  rare  affections  of  the  milk-teeth, 
it  has  been  thought  that  syphilis  has  some  influence  upon  the 
date  of  appearance  of  the  temporary  teeth,  but  opinions  are 
divided,  some  have  thought  dentition  was  delayed  and  others 
that  it  was  hastened.  In  some  cases  certainly  the  first  teeth 
appear  rather  earlier  than  usual,  and  in  view  of  the  fact,  which 
I  think  is  indisputable,  that  the  skull  is  often  more  firmly  ossified 
than  usual  in  the  early  infancy  of  a  syphilitic  child,  one  would 
rather  expect  that  dentition  would  occur  early.  The  exact  influence 
of  syphilis  in  this  respect  is  difficult  to  determine,  for  syphilis  is 
complicated  in  a  very  large  proportion  of  cases  by  rickets. 

Periostitis.  In  the  limbs  and  joints  during  the  later  half 
of  childhood  from  six  years  of  age  till  puberty  there  are  some- 
times very  characteristic  syphilitic  affections.  A  chronic  perio- 
stitis is  not  very  rare,  especially  in  the  tibia,  affecting  the 
diaphysis,  and  producing  a  thickening  which  gives  the  bone  the 
appearance  of  convexity  forward  and  has  thus  given  rise  to  the 
term  '  sabre  tibia  '. 

In  some  cases  the  bone  is  also  affected,  becoming  inflamed  and 
soft  so  that  it  bends,  but  I  think  this  is  quite  the  exception,  the 
convex  appearance  is  more  often  due  to  periosteal  thickening 
only.  The  periostitis  apparently  causes  but  little  pain  ;  in  some 
of  my  cases  there  have  been  vague  aching  pains  and  there  has 
been  some  slight  tenderness  on  pressure. 

I  have  thought  that  this  condition  was  specially  frequent  with 
the  mental  affections  of  congenital  syphilis;  for  instance,  four 
children  with  syphilitic  mental  degeneration  (juvenile  general 
paralysis)  all  showed  periostitis  of  the  tibia. 

Joint  affections.  Joint-lesions  are  not  very  rare  in  congenital 
syphilis ;  a  symmetrical  synovitis  was  present  in  the  knees  in  three 
of  the  100  cases  mentioned  above,  and  one  of  these  three  showed 
also  symmetrical  synovitis  of  the  ankles.  But  more  obscure  in 
its  pathology  is  a  curious  affection  of  the  joints  which  closely  simu- 
lates osteo-arthritis.  I  have  notes  of  four  such  cases  ;  all  were 
boys  between  the  ages  of  five  and  twelve  years,  and  in  all  there 
was  limitation  of  movement  in  many  joints,  with  some  thickening 
about  the  joints,  which  in  some  certainly  appeared  to  be  due  to 
osteophytic  change  ;  but  there  was  also  some  thickening  of  soft 
tissues,  probably  of  the  capsule  of  the  joint,  and  in  one  case 
at  least  there  were  probably  fibrous  adhesions  in  the  joints. 
There  was  no  enlargement  of  lymphatic  glands,  and  in  three 
of  the  cases  the  spleen  could  not  be  felt.  In  all  the  four  cases 
there  was  some  syphilitic  eye  affection  ;  three  showed  interstitial 


CONGENITAL  SYPHILIS  813 

keratitis  ;  one  showed  patches  of  choroidal  atrophy.  The  joint 
affection  does  not  appear  to  be  continuously  progressive  :  the 
joints  became  affected  successively  during  a  period  extending 
over  several  weeks  or  months,  but  apparently  before  anti- 
syphilitic  treatment  had  been  commenced  they  had  already 
become  quiescent,  leaving  the  movements  of  the  joints  more  or 
less  impaired.  The  thickening  about  the  joints  seemed  to 
diminish  very  slowly,  being  still  noticeable  two  or  three  years 
after  the  onset  of  the  affection. 

Enlargement  of  lymphatic  glands.  A  point  of  some 
practical  importance  is  the  relation  of  enlargement  of  lymphatic 
glands  to  congenital  syphilis.  It  is  not  uncommon  in  children 
with  this  disease  to  find  many  of  the  superficial  glands  slightly 
enlarged  so  that  they  are  easily  palpable,  but  there  is  nothing 
in  such  a  condition  to  differentiate  it  from  similar  palpability  of 
glands  which  is  often  noticeable,  especially  in  poorly  nourished 
children,  without  any  obvious  cause  and  without  any  taint  of 
syphilis  ;  but  there  seems  to  be  no  doubt  that  occasionally  a 
considerable  local  enlargement  of  glands,  which  might  easily 
be  mistaken  for  tubercular  enlargement,  occurs  as  a  result  of 
congenital  syphilis,  and  that  without  any  local  source  of  irri- 
tation. Holt  states  that  in  his  experience  this  adenitis  is  usually 
a  late  manifestation  of  congenital  syphilis.  Hutchinson  l  refers 
to  one  such  case  where  the  cervical  glands  became  greatly  en- 
larged in  a  girl  of  fifteen  years  with  interstitial  keratitis,  and 
the  enlargement  rapidly  subsided  under  treatment  with  potas- 
sium iodide.  In  a  boy  aged  eight  years  who  was  under  treat- 
ment for  several  years  at  the  Hospital  for  Sick  Children,  Great 
Ormond  Street,  for  various  syphilitic  manifestations,  including, 
interstitial  keratitis  and  gummata  in  the  liver,  there  appeared 
at  one  time  considerable  enlargement  of  glands  forming  a  visible 
tumour  in  one  groin  and  palpable  also  in  the  iliac  fossa ;  this  sub- 
sided very  rapidly  on  treatment  with  potassium  iodide  and  mercury 
internally  :  there  was  no  apparent  local  cause  for  the  adenitis. 

Deafness.  Lastly,  and  I  put  it  last  because  it  is  usually  the 
latest  to  appear  of  the  symptoms  of  congenital  syphilis,  there 
is  the  affection  of  the  ears  which  is  specially  characteristic  of  this 
disease,  and  which  is  perhaps  due  to  an  insidious  inflammation 
of  the  internal  ear  :  the  patient  becomes  rapidly  deaf  so  that 
hearing  is  completely  lost  within  a  few  weeks.  This  affection 
belongs  rather  to  adolescence  than  to  childhood  for  it  begins 
usually  after  puberty. 

1  Syphilis,  p.  450. 


814          COMMON  DISORDERS  OF  CHILDHOOD 


Contagion  in  Inherited  Syphilis 

I  turn  now  to  a  very  important  practical  point,  the  con- 
tagiousness of  inherited  syphilis  :  Is  there  any  risk  that  the 
infant  may  give  the  disease  to  any  one  else  ?  I  have  already 
referred  to  Colles's  law,  which  emphasizes  the  extremely  important 
fact  that  a  mother  can  suckle  her  child  who  has  congenital 
syphilis  without  risk  of  infection.  It  is  hardly  possible  to 
exaggerate  the  importance  of  this,  for  the  life  of  a  syphilitic 
infant  often  depends  upon  the  continuance  of  breast-feeding; 
the  special  frequency  of  gastro-intestinal  disorders  and  marasmus 
in  these  infants  makes  it  a  matter  of  vital  importance  that  the 
mothei  should  suckle  her  child  if  possible  for  the  full  nine  months. 
A  few  cases  have  been  recorded  in  which  a  syphilitic  infant  was 
supposed  to  have  infected  the  mother,  but  in  some  of  these  there 
was  a  doubt  whether  the  infant  might  not  have  had  acquired 
syphilis,  and  in  any  case  the  number  is  so  small  that  such  infection 
must  be  excessively  rare  and  the  risk  is  so  infinitesimal  that  it 
can  hardly  be  taken  into  account  when  the  difference  which 
suckling  makes  in  the  chances  of  the  infant's  survival  is  con- 
sidered. But  Colles's  law,  be  it  remembered,  states  also  that 
the  infant  with  inherited  syphilis,  although  he  does  not  infect 
his  mother,  will  infect  a  wet-nurse  ;  and  this  raises  the  broad 
question  as  to  the  contagiousness  of  inherited  syphilis.  On  this 
point  there  is  a  wide  difference  of  opinion.  '  The  lesions  of 
congenital  syphilis,'  says  Diday,  '  differ  from  those  of  ordinary 
syphilis  by  an  infinitely  greater  power  of  contagion.  And  what 
is  at  the  same  time  remarkable  and  deleterious  in  them  is,  that 
they  transmit  this  same  property  to  the  person  who  receives  the 
disease  through  them.'  A  modern  writer  has  even  stated  that 
*  Hundreds  and  thousands  of  cases  of  innocent  syphilis  have  had 
their  origin  in  innocent  babes  '. 

On  the  other  hand,  Dr.  J.  A.  Coutts  in  his  Hunterian  lectures 
on  infantile  syphilis  says,  after  excepting  one  doubtful  case, 
'  I  have  personally  never  known  an  instance  where  syphilis  was 
contracted  from  an  infant  with  the  inherited  complaint,  and  this 
in  spite  of  many  thousands  of  healthy  children  and  adults 
having  been  exposed  to  infection  from  cases  under  my  care.' 
He  mentions  also  that  as  a  result  of  special  inquiry  from  eighteen 
medical  men  connected  with  children's  hospitals  he  could  hear 
of  only  eight  cases  of  supposed  infection  from  children  with 
congenital  syphilis,  and  four  of  these  eight  cases  took  the  form 


CONGENITAL  SYPHILIS  815 

of  exceptions  to  Colles's  law  and  might  therefore  by  some  be 
rejected  as  unreliable.  In  my  own  practice  I  have  not  met 
with  a  single  case  of  infection  from  an  infant  with  inherited 
syphilis.  Dr.  W.  R.  Grove  of  St.  Ives,  Huntingdon,  showed 
me  a  family  in  which  such  infection  apparently  occurred.  I 
shall  quote  the  case  from  his  own  record,1  as  it  is  of  importance 
in  emphasizing  the  possible  danger. 

An  infant  who  had  had  snuffles  a  few  days  after  birth,  and  whose  mother 
was  known  to  have  had  syphilis,  developed  condylomata  at  the  anus  and  some 
sores  in  the  mouth  at  the  age  of  seventeen  months.  About  a  month  later  the 
grandmother,  in  whose  care  the  infant  had  been  left,  developed  two  primary 
sores  of  syphilis,  one  on  the  lower  lip,  the  other  on  the  tonsil,  and  shortly  after- 
wards showed  a  syphilitic  rash.  About  the  same  time  a  daughter  aged  twelve 
years,  and  shortly  afterwards  a  son  aged  seven  years,  developed  a  primary  sore 
on  the  tonsil  followed  very  soon  by  a  syphilitic  rash.  The  baby  had  been  fed 
with  a  spoon  with  which  the  grandmother  and  her  granddaughter  had  tasted 
the  food  from  time  to  time  during  the  feeding  of  the  infant,  and  it  was  supposed 
that  the  grandson  also  had  used  the  spoon  unwashed. 

I  have  heard  of  two  other  cases  in  which  infection  (not  of  the 
mother)  seemed  to  have  occurred,  and  I  am  entirely  in  agreement 
with  Dr.  Coutts's  conclusion,  '  that  inherited  syphilis  is  occa- 
sionally contagious  is  certain,  but  it  is  equally  certain  that  the 
virulence  of  such  contagion  has  been  grossly  and  vastly  over- 
estimated.' 

The  practical  outcome  of  these  observations  is  clear  ;  it  is 
only  right  to  warn  parents  that  such  a  danger  does  exist, 
especially  so  long  as  syphilitic  skin  lesions,  condylomata,  or  other 
specific  affections  of  mucous  membranes  are  present.  Kissing 
of  the  syphilitic  infant  should  be  avoided  altogether,  and  those 
who  must  handle  the  child  should  wash  their  hands  carefully 
after  each  handling  ;  the  filthy  habit  of  moistening  the  '  com- 
forter '  or  '  teat '  in  the  mother's  own  mouth  before  giving  it 
to  the  infant,  objectionable  and  dangerous  as  it  is  in  any  circum- 
stances, becomes  even  more  so  when  children,  following  the 
example  of  their  elders,  do  the  same  for  the  syphilitic  infant. 
A  mother,  whose  little  girl  aged  about  eight  years  was  born  before 
syphilis  appeared  in  the  family,  told  me  that  this  child  frequently 
took  the  teat  from  the  syphilitic  baby's  mouth  and  moistened 
it  afresh  in  her  own.  Such  a  practice  should  certainly  be 
forbidden. 

1  Brit.  Med.  Journ.,  1906,  vol.  i,  p.  1400. 


816  COMMON  DISORDERS  OF  CHILDHOOD 


Treatment 

The  treatment  of  congenital  syphilis  is  simple  enough  so  far 
as  choice  of  drugs  is  concerned  ;  indeed,  if  the  early  manifesta- 
tions only  are  to  be  considered  there  is  no  choice — mercury  is 
the  one  essential.  There  are,  however,  two  points  which  require 
consideration  in  the  use  of  this  drug,  the  mode  of  administration 
and  its  duration. 

The  simplest  and  most  convenient  method  in  the  large  majority 
of  cases  is,  I  think,  to  give  mercury  by  the  mouth  as  grey  powder. 
With  this,  as  with  any  other  form  of  mercury,  the  risk  of  produc- 
ing diarrhoea  in  an  infant  who  is  perhaps  already  puny  and 
wasted,  as  so  many  syphilitic  infants  are,  has  to  be  remembered  ; 
but  it  is,  I  think,  avoided  to  some  extent  by  giving  small  doses 
rather  than  the  large  doses  recommended  by  some  writers. 
Half  a  grain  three  times  a  day  with  a  grain  of  Sod.  Bicarb, 
and  2  grains  of  Pulv.  Greta?  Aromat.  can  usually  be  given  safely 
to  an  infant  a  few  weeks  old  without  causing  diarrhoea,  and  this 
dose  is  quite  sufficient  in  many  cases  to  cause  a  steady  sub- 
sidence of  symptoms.  If  there  is  a  tendency  to  diarrhoea  the 
combination  of  grey  powder  with  J  to  J  grain  of  pulv.  ipecac,  co., 
according  to  the  age  of  the  infant,  may  be  used.  Sometimes, 
where  J-grain  doses  of  the  mercurial  have  been  sufficient  to 
cause  the  symptoms  of  syphilis  to  disappear,  fresh  manifestations 
of  the  disease  have  appeared  subsequently  although  the  infant 
was  still  taking  the  drug  regularly.  In  such  cases  the  dose  may 
be  increased  to  1  grain  three  times  a  day,  or,  as  suggested  below, 
a  combination  of  the  internal  with  the  external  administration 
of  mercury  may  be  more  useful. 

Whether  such  small  doses  of  grey  powder  are  likely  to  affect 
the  teeth  subsequently,  is,  I  think,  very  doubtful  ;  but  the 
possibility  of  such  a  result  is  at  any  rate  a  reason  for  using  the 
smallest  dose  which  is  effectual.  The  risk  of  salivation  or 
of  stomatitis  from  mercury  is  very  small  in  infants  ;  I  have 
known  it  to  occur  only  two  or  three  times  amongst  a  very 
large  number  of  infants  to  whom  mercury  was  given  for  one 
cause  or  another. 

As  an  alternative — and  one  may  be  wanted,  for  there  are 
infants  who  will  vomit  powders  of  any  sort — the  liquor  hydrar- 
gyri  perchloridi  is  sometimes  useful,  and  may  be  given  in  doses 
of  3  to  5  minims  three  or  four  times  a  day  to  an  infant  a  few 
weeks  old,  and  in  doses  of  10  minims  or  even  more  for  an  infant 


CONGENITAL  SYPHILIS  817 

of  six  to  twelve  months.  My  own  experience  of  this  drug  is  that 
it  produces  looseness  of  the  bowels  more  often  than  the  grey 
powder  does,  and  for  this  reason  is  less  satisfactory.  To  prevent 
this  it  may  be  combined  with  small  doses  of  castor  oil,  as  in  the 
following  formula  :  Liq.  Hyd.  Perchlor.  O)v,  01.  Ricini  O)iv, 
Mucilag.  Acaciae  0)xv,  Aq.  Anethi  ad.  3i,  tor  die,  for  an  infant 
two  months  old  ;  and,  if  necessary,  Tinct.  Camphorse  Co.  in 
minute  doses  may  be  added. 

Some  observers  have  recommended  calomel  in  doses  of  T\  to 
J  grain  twice  or  three  times  in  the  twenty-four  hours,  as  a  more 
rapidly  effective  form  of  mercury  than  grey  powder  ;  its  tendency 
to  cause  diarrhoea,  however,  is  greater,  and  will  probably  neces- 
sitate the  use  of  opium  in  some  form. 

Where  rapidity  of  action  is  very  important,  as  in  the  very 
severe  cases  where  an  infant  appears  likely  to  succumb  speedily 
to  the  intensity  of  the  syphilitic  virus,  a  combination  of  internal 
administration  of  grey  powder  with  external  administration  by 
inunction  of  unguentum  hydrargyri  has  seemed  to  me  better 
than  large  or  very  frequent  doses  of  the  drug  internally.  I 
usually  order  a  piece  of  the  ointment  the  size  of  *  the  tip  of 
the  little  finger  ',  or  of  '  an  average  green  pea  ',  which  corre- 
sponds roughly  to  15  grains  ;  this  is  gently  rubbed  over  the 
abdomen  or  the  inside  of  the  arm  or  thigh  each  night,  and 
left  covered  with  a  flannel  bandage  till  the  next  morning, 
when  it  is  thoroughly  washed  off.  The  risk  of  dermatitis  from 
inunction — albeit  a  small  one,  especially  if  the  skin  is  properly 
cleansed  after  the  application,  and  the  area  chosen  is  varied 
from  day  to  day — makes  this  method,  I  think,  less  suitable  as 
a  routine  treatment  than  the  use  of  grey  powder.  As  a  cleaner 
method  of  external  application  warm  baths  containing  about 
10  grains  of  perchloride  of  mercury  in  about  2  gallons  of  water 
have  been  recommended.  I  have  never  used  this  method, 
which  seems  open  to  objection  on  account  of  the  large  quantities 
of  corrosive  sublimate  which  must  be  entrusted  to  unskilled  and 
sometimes  careless  persons.  No  method  of  external  application 
seems  to  allow  of  so  accurate  a  control  of  dosage  as  the  administra- 
tion by  mouth. 

I  shall  make  no  reference  to  the  intramuscular  injections  of 
mercury  and  intravenous  injections  of  iodine  which  have  been 
used  by  some  in  congenital  syphilis,  except  to  state  that  in  my 
opinion  such  methods  are  unnecessary  in  the  syphilis  of  child- 
hood, for  by  the  combination  of  inunction  and  oral  administra- 
tion it  is  easy  to  get  a  child  very  speedily  under  the  influence 


818  COMMON  DISORDERS  OF  CHILDHOOD 

of  mercury  to  any  desired  extent.  Methods  which  involve  pain 
and  risk  of  inflammatory  complications  are  always  to  be  avoided, 
especially  for  children,  if  the  desired  result  can  be  obtained 
otherwise. 

These  objections  apply  equally  to  the  treatment  of  congenital 
syphilis  with  '  606  ',  salvarsan.  At  present  the  number  of  cases 
in  which  this  treatment  has  been  adopted  is  too  small  to  justify 
any  general  conclusions  as  to  its  value  in  the  congenital  form  of 
the  disease.  Cases  have  been  reported  in  which  injection  of  this 
drug  into  the  suckling  mother  was  followed  by  rapid  disappear- 
ance of  symptoms  of  syphilis  in  her  breast-fed  infant.  These 
indirect  methods  of  treatment  through  the  mother  are  always 
highly  unsatisfactory,  as  they  render  it  impossible  to  regulate 
with  any  accuracy  the  dose  received  by  the  infant. 

If  salvarsan  is  to  be  used  at  all  in  congenital  syphilis  it  will 
usually  be  advisable  to  administer  it  directly  to  the  infant,  and 
for  this  purpose  doses  varying  from  J— 1  grain  (0-02-006  grm.) 
have  been  given  :  to  older  children  2-3  grains  may  be  given. 

The  intramuscular  injection  of  salvarsan  into  an  infant  is 
certainly  not  without  danger.  Necrosis  of  the  glutens  muscle 
has  occurred  more  than  once  with  fatal  result  when  the  injection 
has  been  made  in  this  part.  Other  fatal  cases  have  been  recorded, 
and  in  view  of  the  harmful  results  which  have  already  been 
recorded  from  its  use  in  adults,  and  the  now  ascertained  fact 
that  relapses  may  occur  in  spite  of  this  treatment,  it  hardly 
seems  expedient  to  use  so  painful  a  procedure  when  we  have 
already  an  efficient  remedy  in  the  simple  oral  administration  or 
inunction  of  mercury. 

Intravenous  injection  of  neo-salvarsan  has  been  recommended 
as  preferable  to  the  intramuscular  method.  A  sterilized  saline 
solution  containing  f  grain  in  one  drachm  is  injected  slowly  into 
a  vein  in  the  arm  or  in  the  scalp.  The  injection  may  have  to  be 
repeated  several  times  at  intervals  of  about  a  week,  and  the 
close  may  be  increased  up  to  2  or  3  grains.  In  this  way  it  is 
claimed  that  the  Wassermann  reaction  can  be  rendered  negative, 
and  the  symptoms  of  syphilis  rapidly  disappear.  It  is  not 
denied  that  vomiting,  rigors,  cyanosis,  and  even  coma  and 
death  may  result  from  the  intravenous  injection,  but,  apart 
from  such  effects,  the  pain  and  terror  involved  can  only  be 
justified  if  the  beneficial  results  are  not  to  be  obtained  by  any 
less  distressing  method  of  treatment.  Certainly  in  the  large 
majority  of  cases  of  congenital  syphilis  the  simple  treatment 
with  mercury  by  mouth  or  skin  effects  a  cure  without  the 


CONGENITAL  SYPHILIS  819 

slightest  distress  to  the  child.  The  duration  of  treatment  is 
much  longer,  it  is  true,  but  most  parents  would  prefer  this 
inconvenience  to  the  risks  and  suffering  involved  in  the  salvarsan 
or  neo-salvarsan  treatment. 

The  place  of  iodides  in  the  treatment  of  congenital  syphilis 
is  a  question  of  some  importance.  It  is  sometimes  taught  that 
mercury  should  be  given  to  the  infant  and  iodide  to  the  older 
child  in  congenital  syphilis,  on  the  general  ground,  no  doubt,  that 
the  earlier  symptoms  are  usually  of  '  secondary  ',  the  later  of 
'  tertiary  '  character.  The  two  stages,  however,  do  not  neces- 
sarily correspond  with  any  age  limit,  and  there  are  certainly 
many  cases  in  which  potassium  iodide  is  just  as  necessary  for 
an  infant  as  for  an  older  child.  Gummata  are  sometimes  present 
in  early  infancy,  and  some  of  the  bone-lesions,  epiphysitis  and 
periostitis,  are,  I  think,  often  more  successfully  treated  by  a 
combination  of  iodide-treatment  with  mercury  than  with  the 
mercurial  alone.  Potassium  iodide  is  taken  well  by  children, 
and  in  some  of  the  lesions  of  later  childhood  where  there  is  no 
response  to  small  doses,  the  dose  may  be  increased  until  15  or 
20  grains  or  even  more  arc  taken  three  or  four  times  a  day. 

The  duration  of  treatment  with  mercury  is  a  point  on  which 
there  is  some  difference  of  opinion. 

Great  stress  has  been  laid  on  the  injury  to  teeth  which  results 
from  prolonged  administration  of  mercury  during  infancy ; 
it  has  been  recommended  not  to  continue  the  treatment  much 
beyond  the  disappearance  of  symptoms.  But  in  some  cases  this 
might  mean  administration  of  mercury  for  three  or  four  weeks 
only,  and  so  short  a  course  of  treatment  is  certainly  not  sufficient 
to  prevent  a  recurrence  of  symptoms.  I  have  seen  fresh  mani- 
festations of  syphilis  occur  in  an  infant  after  a  very  short  interval 
each  time  the  mercury  was  stopped  in  this  way.  A  regular 
administration  of  mercury  to  the  syphilitic  infant  for  at  least 
twelve  months  and  if  circumstances  allow  for  eighteen  months, 
even  where  all  symptoms  arc  in  abeyance  after  the  first  few 
weeks  of  the  treatment,  seems  to  be  the  most  satisfactory  routine. 

Another  matter  to  which  reference  must  be  made  is  the  feeding 
of  the  syphilitic  infant  ;  and  here  I  should  like  to  insist  again 
upon  the  vital  importance  of  breast-feeding  for  these  infants. 

There  seems  to  be  a  dread  in  the  minds  of  some  medical  men 
that  a  mother  may  be  infected  by  her  own  child  when  the  child 
has  congenital  syphilis  and  the  mother  shows  no  sign  of  the 
disease  ;  and  I  have  sometimes  found  that  a  mother  had  been 
advised  to  stop  suckling  at  once  when  it  was  found  that  the 

3  o2 


820  COMMON  DISORDERS  OF  CHILDHOOD 

child  had  syphilis.  Even  if  it  be  taken  as  proved — and  the 
evidence  is  so  slight  that  it  can  hardly  be  called  proof — that 
exceptions  have  occurred  to  Colles's  law  that  a  mother  cannot 
be  infected  by  her  infant  when  it  has  inherited  syphilis,  these 
exceptions  must  be  so  exceedingly  rare  that  for  practical  purposes 
they  may  safely  be  disregarded.  Moreover,  there  must  be 
weighed  against  such  an  extremely  small  and  doubtful  risk 
the  very  real  and  great  difference  which  breast-feeding  makes 
in  a  syphilitic  infant's  chances  of  survival.  Amongst  the  causes 
of  death  in  congenital  syphilis  during  infancy,  one  of  the  most 
frequent  is  marasmus  :  it  would  almost  seem  as  if  there  were 
some  inherent  difficulty  of  assimilation  in  these  infants  at  birth  ; 
some  of  them  waste  almost  from  the  day  they  are  born,  although 
no  other  evidence  of  syphilis  may  be  apparent  until  wasting  is 
already  advanced  ;  and  the  marasmus  often  occurs  without 
any  obvious  gastro-intestinal  disturbance  in  an  infant  who  is 
properly  fed  at  the  breast.  Apart,  however,  from  this  tendency 
to  marasmus,  there  seems  to  be  a  special  liability  also  to  gastro- 
intestinal disorders  ;  a  large  proportion  of  the  infants  who  come 
under  treatment  for  congenital  syphilis  are  brought,  not  for  anj 
specific  manifestations,  but  for  persistent  digestive  disorder 
in  spite  of  careful  feeding.  It  is  therefore  all-important  that  the 
food  should  be  as  easy  of  assimilation  as  possible,  and  for  this 
reason  no  method  of  artificial  feeding  can  replace  the  mother's 
milk.  To  deprive  the  syphilitic  infant  of  his  mother's  milk  may 
be  to  deprive  him  of  his  chance  of  life.  Suckling,  however,  can  only 
be  done  by  the  mother  :  no  wet-nurse  must  be  allowed  to  suckle 
an  infant  with  congenital  syphilis,  for  however  rare  infection  from 
congenital  syphilis  may  be,  it  seems  clear  that  a  wet-nurse  can 
be,  and  in  several  cases  has  been,  infected  by  suckling  an  infant 
who  had  this  disease. 

Lastly,  I  would  point  out  that  apart  from  the  marasmus  to 
which  I  have  referred,  not  only  infants  but  also  older  children 
with  congenital  syphilis  are  so  often  poorly-nourished,  pale 
and  '  unwholesome-looking  '  even  when  free  from  any  definite 
manifestation  of  the  disease,  that  good  food,  and  perhaps  malt 
and  cod-liver  oil,  sea-air  and  good  hygiene  in  general,  play  no 
unimportant  part  in  the  treatment  of  syphilis  in  children. 


INDEX 


Abdominal  distension,  acute,  in  tuber- 
culous peritonitis,  433. 
Abdominal  distension,  flatulent,  124. 

181. 

Abdominal  pains,  168. 
Abdominal  pains  from  appendicitis, 
173. 

from  constipation,  169. 

from  cyclic  albuminuria,  171. 

from  defective  teeth,  169. 

from  epilepsy,  676. 

from  indigestion,  168,  176. 

from  meningitis,  258. 

from  movable  kidney,  172. 

fr®m  pneumonia,  372. 

from  rheumatism,  478. 

from  threadworms,  169. 

from  tuberculous  glands,  172. 
Abdominal  tuberculosis,  423. 
Abscess,  cerebral,  simulated  by  menin- 
gitis, 462. 

Acetoncemia  in  cyclic  vomiting,  253. 
Acholia,  182,  236. 
Acholuric  jaundice,  312. 
Acidity  of  urine  causing  enurcsis,  730, 

732. 

Acupuncture  for  cardiac  dropsy,  503. 
Acute  anterior  poliomyelitis  (cce  In- 
fantile paralysis),  684. 
Acute  myelitis,  695. 
Acute  pyelitis,  277,  568. 
Adenoids,  314. 

asthma  with,  316;  344. 

bronchitis  with,  355. 

climate  for,  325. 

collapse  of  lung  with,  356. 

conveying  tuberculosis,  401. 

decayed  teeth  with,  318,  322. 

digital  examination  of,  318. 

enuresis,  relation  to,  736. 

infection  through,  317. 

laryngeal  spasm  with,  332. 

medical  treatment  of,  324. 

operation  for,  321,  322. 

otitis  media  with,  316,  319,  320. 

results  of,  316. 

sleeplessness  from,  316,  320,  756. 

snuffling  from,  799. 

symptoms,  315. 

status  lymphaticus  with,  315,  320. 
Adrenalin  in  spasmodic  croup,  334. 


Agar-agar  for  constipation,  213. 
Albinism,  consanguinity  in,  600. 
Albumen-water,  227. 
Albuminuria,  551,  563. 
Albuminuria,  dropsy  without,  553. 
nephritis  without,  552. 
with  diarrhoea,  225. 
with  nephritis,  551. 
with  tetany,  657. 
Albuminuria,  cyclic,  563,  181. 
abdominal  pains  with,  171. 
frequency  of,  563. 
oxalates  with,  565. 
symptoms,  564. 
treatment,  565. 
Albuminuric  retinitis,  552. 
Alcohol,  ill  effects  of,  231,  310. 
in  broncho-pneumonia,  369. 
in  diarrhoea,  231. 
in  pericarditis,  513. 
in  pneumonia,  381. 
Alcoholism  a  cause  of  idiocy,  596. 
causing    congenital    heart   disease, 

535. 

Alkaptonuria,  567. 

Alkaptonuria,  consanguinity  in,  600. 
Alopecia,  syphilitic,  800. 
Amaurotic  idiocy,  596. 
Amyl    nitrite    for    congenital    heart 

disease,  547. 
for  convulsions,  665. 
for  mitral  disease,  503. 
Anaemia,  decayed  teeth  with,  195. 
rheumatism  with,  478. 
rickets  with,  99. 
splenic,  807. 
syphilitic,  806. 

Analysis  of  breast-milk,  21,  24. 
Angeioneurotic  oedema,  186. 
Anginoid  attacks  due  to  digitalis,  501. 
with  congenital  heart  disease,  545, 

547. 
Anorexia,  758. 

carious  teeth  causing,  197. 
causes  of,  758. 
dentition  causing,  8. 
difficulty  in  swallowing  with,  759. 
treatment,  759. 
Antimony  in  chorea,  530. 
Antipyrin  (see  Phcnazono),  529,  608, 
666. 


822 


INDEX 


Antiscorbutic  diet,  120.      • 
Anus,  fissure  of,  203. 

itching  of,  with  threadworms,  292. 

stenosis  of,  204. 
Aortic  disease,  492. 

congenital,  541,  544. 
Aortic  endocarditis,  492. 
Aperients,  210. 

enemata  as,  214. 

suppositories  as,  213. 
Aphasia,  747. 

cerebral  lesions  causing,  748. 

chorea  causing,  748. 

fright  causing,  748. 
Appendicitis,  247. 

colic  from,  173. 

in  infants .  248. 

simulated  by  pneumonia,  373. 

simulated  by  pyelitis,  571. 

simulated  by  recurrent  fever,  263. 

simulated  by  threadworms,  289. 

simulating  '  bilious  attacks  ',  247. 

symptoms,  247. 

tabes  mesenterica  confused  with,426. 

vomiting  with,  248. 
Appendix,  threadworms  in,  286. 
Appetite,  failure  of,  177,  758. 

perverted,  779. 
Arms,  shaking  of,  in  spasmus  nutans, 

768. 
Arsenic  for  chorea,  527. 

for  laryngitis  stridulosa,  333. 

for  nervous  children,  646. 

toxic  effects  of,  527. 
Arthritis,  gonorrhooal,  in  infancy,  482. 

pneumococcal,  378,  391. 

rheumatic,  481. 

suppurative,  with  pneumonia,  378. 

syphilitic,  812. 

with  empyema,  391. 

with  specific  fevers,  482. 

vaginal  discharge,  481. 
Artificial  feeding,  17. 
Ascaris  lumbricoides,  293. 
Ascites,  foetal,  syphilitic,  801. 

tuberculous,  433. 

with  cceliac  disease,  241. 
Aspiration  for  empyema,  394. 
Aspirin  for  chorea,  529. 

for  rheumatism,  484. 

toxic  effect  of,  484. 
Asphyxia,  infantile  hemiplegia  due  to, 
703. 

mental  deficiency  from,  598. 
Asses'  milk,  59. 

composition  of,  59. 

in  marasmus,  147. 
Asthma,  adrenalin  in,  334j 

age-incidence  of,  342. 

climate  for,  352. 

croup,  relation  to,  345. 

digestion,  relation  to,  345. 


Asthma  (continued) — • 

duration,  348. 

eczema  with,  344. 

emphysema  with,  348,  357. 

exciting  causes,  344. 

fever  with,  345. 

hay  fever,  relation  to,  347. 

heredity  in,  344. 

infantile,  342. 

predisposing  causes,  343. 

prognosis,  348. 

sex  in,  343. 

sneezing  in,  347. 

symptoms,  347. 

tonsils  and  adenoids  in,  316,  344. 

treatment,  349. 
Athetosis,  708. 
Atropine,  for  enuresis,  734. 

toxic  symptoms  of,  734. 
Aura,  epileptic,  676. 
Auto-intoxication,  fever  from,  268. 

Bacteriology  of  cceliac  disease,  238. 

of  empyema,  384,  391. 

of  infantile  diarrhoea,  217. 

of  pyelitis,  569. 

Bananas,  fibres  of,  simulate  thread- 
worms, 293. 

indigestible,  169,  187. 
Barley-water,  43. 

advantages  of,  43. 

harm  from,  44. 

starch  in,  43. 
Baths,  hot-air,  in  nephritis,  559; 

in  rickets,  106. 

mercurial,  817. 

mustard,  231. 

Beading  of  ribs  in  rickets,  91,  101. 
Belladonna    for    broncho-pneumonia, 
368. 

for  enuresis,  733. 

toxic  symptoms  of,  733. 
Bile  deficiency  (acholia),  182,  236. 

constipation  from,  203. 
Biliary  colic,  172. 
'  Bilious  attacks  ',  181,  247. 

appendicitis  simulating,  247. 

cyclic  vomiting  called,  251. 

indigestion  causing,  249. 

meningitis  simulating,  258,  458. 

migraine  with,  255. 

renal  vomiting  with,  257. 

treatment,  253,  256. 
Bismuth  in  diarrhoea,  233. 
Bleeding  in  scurvy,  116. 

in  syphilis,  797. 

Blood  disease  causing  fever,  284. 
Blood  in  congenital  heart  disease,  538. 

in  stools,  205. 

in  syphilis,  807. 
Body-rocking,  789. 

treatment    791. 


INDEX 


823 


Boiled  milk,  47,  48. 
causing  scurvy,  120. 
not  a  cause  of  rickets,  102. 
to  avoid  tubercle,  419. 
Bones,  curvature  of,  in  rickets,  93. 
Bowel  irrigation,  213,  235. 
Bowel  ulceration  in  tabes  mescnterica 

426. 

in  tuberculous  peritonitis,  432. 
Brandy  for  infants,  230,  231. 
Bread,  brown,  indigestible,  187,  209. 
Breast-feeding,  17. 

convulsions  rare  with,  17. 
diarrhoea  with,  24. 
flatulence  and  colic  with,  23. 
green  stools  with,  24. 
importance  of,  17,  18. 
indigestion  with,  23,  24,  25. 
intervals  of,  23. 
limitations  of,  17. 

mortality  compared  with  hand-feed- 
ing, 17. 
partial,  23. 
Breast-milk,  18. 
analysis  of,  21,  24. 
compared  with  cow's  milk,  32,  37. 
composition  of,  19,  20. 
deficiency  in  quality,  22. 
deficiency  in  quantity,  22. 
drugs  excreted  in,  26. 
estimation  of,  18. 

excess  in  quality,  24,  25  ;  in  quan- 
tity, 23. 

methods  of  modifying,  22,  25. 
sample  of,  to  obtain,  19. 
Breath,  offensive,  182. 
enlarged  tonsils  with,  182. 
shortness  of,  with  indigestion,  182. 
Bromide  in  convulsions,  664. 
in  epilepsy,  680,  682. 
in  mental  deficiency,  608. 
rashes  from,  666. 
Bronchial  breathing,  with  empyema, 

385. 

Bronchiectasis,  415. 
Bronchitis,  353. 

adenoids  causing,  355. 
age-incidence  of,  353. 
causes  of,  354. 
collapsed  lung  with,  356. 
congenital  heart  disease  with,  356, 

545. 

dentition  causing,  354. 
digestive  disturbance  with,  354. 
emetics  for,  361. 
emphysema  with,  357. 
enlarged  tonsils  with,  355. 
fever  with,  356. 
Mongolism  with,  356. 
mouth-breathing  causing,  355. 
prognosis,  358. 
rickets  causing,  355. 


Bronchitis  (continued)— 

simulating  broncho-pneumonia,  35<J. 

symptoms,  356. 

treatment,  359. 
Broncho-pneumonia,  363. 

age-incidence  of,  363. 

alcohol  in,  369. 

belladonna  in,  368. 

diagnosis  of,  364. 

leeching  in,  369. 

open  air  for,  367. 

poultices  in,  367. 

prognosis,  366. 

relapsing,  364. 

simulating  lobar   pneumonia,   364, 
365. 

temperature  in,  146,  363,  364. 

treatment  of,  367. 

tuberculosis  simulated  by,  365,  366. 

tuberculous,  411. 

vaccine  for,  368. 

with  infantile  diarrhoea,  223. 

with  infantile  marasmus,  146. 

with  whooj ing-cough,  365. 
Bronchus,  foreign  body  in,  340. 

perforation  of,  408. 
Bruit,  disappearance  of  supposed  con- 
genital, 542. 

Eustace  Smith's,  406. 
functional,  in  infancy,  487,  542. 
in  chorea,  518,  520.  " 
Buhl's  disease,  303. 
Bullous  syphilide,  800. 
Butter  added  to  milk,  39. 

Calculus,  renal,  171. 
Calmette's  reaction,  416. 
Carbohydrate,  excess  of,  causing  colic, 
127. 

flatulence  from,  127. 
Cardiac  dilatation,  490. 

with  endocarditis,  490. 

with  nephritis,  554. 
Carious  teeth,  193. 
Caseation  of  lung,  tuberculous,  411. 
Castor  oil  in  constipation,  210. 

in  diarrhoea,  22(i. 
Cataract  in  Mongols,  614. 
Catarrh    of    appendix,    with    thread- 
worms, 290. 

gastric,  249. 

ejastro-intcstinal,  219. 

intestinal,  with  threadworms,  293. 
Catarrhal  jaundice,  treatment  of,  312. 
Cavitation  of  lung,  tuberculous,  411. 
Cerebral  abscess  simulated  by  menin- 
gitis, 462. 
Cerebral  palsies,  701. 

after  specific  fevers,  706. 

age-incidence,  701. 

asphyxia  causing,  703. 

convulsions  with,  702. 


J 
824 


INDEX 


Cerebral  palsies  (continued) — 

diagnosis,  709. 

epilepsy  with,  710. 

massage  in,  711. 

mental  affection  in,  709. 

polio-encephalitis  in,  705. 

premature  birth  in,  704. 

prognosis,  710. 

sex-incidence,  701. 

symptoms,  708. 

syphilis  with,  704. 

treatment,  710. 

varieties,  701. 
Cerebral  rheumatism,  477. 
Cerebral    tumour,    with    choreiform 

movements,  525. 

Cerebro-spinal  fluid  in  meningitis,  4G3. 
Cerebro-spinal    meningitis,    diagnosis 

from  other  forms,  463. 
Cervical  glands,  tuberculosis,  402. 
Chest,  exploration  of,  388. 

measurement  in  plcural  effusion,  387. 

rachitic,  99. 
Chloral,  dose  of,  C64. 

in  asthma,  350. 

in  chorea,  529. 

in  epilepsy,  683. 

value  of,  in  convulsions,  064. 
Chloretone  in  chorea,  529. 
Choleraic  diarrhoea,  221. 
Cholera  infantum,  221. 
Chorea,  514. 

antimony  in,  530. 

arsenic  in,  527. 

bruits  in,  518,  520. 

chloral  in,  529. 

chloretono  in,  529. 

diagnosis,  522. 

duration,  522. 

endocarditis  with,  521. 

frequency  of,  514. 

habit-spasm  mistaken  for,  517,  522. 

headache  with,  519. 

heart  affection  in,  520. 

hysterical,  524. 

imitation,  517. 

isolation  for,  527. 

knee-jerk  in,  520. 

microkinesis  confused  with,  524. 

pregnancy  with,  515. 

prognosis,  521. 

relation  to  rheumatism, 470, 515, 518. 

rest  in  bed,  duration  of,  in,  526,  531. 

salicylates  in,  528. 

scarlet  fever  with,  516. 

school  a  cause  of,  515. 

sex  in,  514. 

speech  lost  in,  748. 

symptoms,  518. 

treatment,  526. 

wet-packs  in,  530. 

zinc  sulphate  in,  530. 


Choreiform  movements,  522. 

with  cerebral  tumour,  525. 

with  hysteria,  525. 

with  infantile  hemiplegia,  525. 

with  worms,  292,  524. 
Choroid,  tubercle  of,  414,  461. 
Choroidal  changes  in  hydrocephalus, 

718. 

Choroido-retinitis,  syphilitic,  806. 
Chronic  fibrous  rheumatism,  483. 
Chronic  interstitial  nephritis,  558. 

prognosis,  558. 

Circumcision    causing    masturbation, 
777. 

for  enuresis,  736. 

harmful  effect  of,  777. 

proper  method  of,  778. 
Cirrhosis,  309. 

in  newborn,  302,  797. 

intercellular,  in  stillborn,  797. 

jaundice  with,  in  newborn,  309. 

with  congenital  syphilis.  305. 

with  obliteration  of  bile-ducts,  306. 
Citrate  of  potassium  in  pyelitis,  579. 

of  soda,  to  reduce  curd,  52. 
Citrated  milk,  52. 

oedema  from,  53. 
Climate  in  nephritis,  561. 

for  enlarged  tonsils  and  adenoids, 
325. 

in  asthma,  352. 

in  spasmodic  croup,  334. 

in  tuberculosis,  420,  437. 
Clubbing    of    fingers,    in    congenital 
heart  disease,  538. 

with  fibroid  lung,  415. 
Cod-liver    oil,    contra-indications    of, 
149. 

in  indigestion,  191. 
Coeliac  disease,  236. 

age  at  onset  in,  237. 

arrest  of  growth  with,  240. 

bacteriology  of,  238. 

complications  of,  241. 

debility  with,  240. 

diet  in,  242. 

drugs  in,  245. 

etiology,  237. 

infantilism  with,  2-10. 

prognosis,  241. 

resemblance  to  '  sprue  ',  238. 

sex -incidence,  237. 

stools  in,  239. 

symptoms,  239. 

treatment,  242. 
Cold,  causing  rheumatism,  473,  485. 

harmful  in  congenital  heart  disease, 
546. 

ill  effects  of,  in  infants,  148. 
Coli  bacillus  in  pyelitis,  278. 
Colic,  biliary,  172. 
Colic,  causes  of-  123. 


INDEX 


825 


Colic  (continued) — 

constipation  causing,  123. 

due  to  carious  teeth,  194. 

faulty  feeding  a  cause  of,  127. 

flatulent,    simulating    intussuscep- 
tion, 124. 

from  carbohydrate,  127. 

in  infants,  123. 

in  older  children,  168. 

stools,  examination  of,  in,  126. 

threadworms  causing,  291. 

treatment  of,  in  infants,  129. 

treatment  of,  in  older  children,  173. 

with  breast-feeding,  23. 
Collapse  in  tuberculous  meningitis,  460. 
Collapsed  lung,  with  adenoids,  356. 

with  bronchitis,  356. 
Colles's  law,  138,  787,  794,  814,  815. 
Colon  irrigation  in  diarrhoea,  235. 

length  of,  at  different  ages,  202. 
Condensed  milk,  62,  70. 

cause  of  rickets,  70. 

composition  of,  70,  71. 

diarrhoea  with,  74,  216. 

dilution  of,  71. 

scurvy  with,  70. 

unsweetened,  72. 

use  of,  62,  71. 
Condylomata,  800. 

Congenital  abnormalities,  association 
of,  534. 

with  congenital  heart  disease,  534. 

with  hydrocephalus,  715,  718. 
Congenital -aortic  disease,  541,  544. 
Congenital  ataxia,  762. 
Congenital  deafness,  744. 
Congenital  defect  of  ossification  with 

hydrocephalus,  715. 
Congenital  family  cholamiia,  312. 
Congenital  heart  disease,  533. 

abnormalities  associated  with,  534. 

alcoholism  causing,  535. 

amyl  nitrite  in,  547. 

anginal  attacks  in,  545,  547. 

aortic,  541,  544. 

blood  in,  538. 

bronchitis  with,  356,  545. 

bruit,  characters  of,  in,  540. 

clubbing  of  fingers  with,  538. 

cold  harmful  in,  546. 

congenital  deformities  with,  534. 

cyanosis  in,  537,  545. 

diagnosis,  541. 

diet  in,  547. 

disappearance  of  bruit  in  supposed, 
542. 

endocarditis  acquired  with,  546. 

endocarditis  causing,  536. 

family  incidence  of,  535. 

frequency  of,  533. 

hair  in,  539. 

marasmus  with,  140,  539. 


Congenital  heart  disease  (continued) — 

Mongol  imbecility  with,  534,  C20. 

ophthalmoscopic    appearances    in, 
538. 

place  in  family  in,  535. 

polycythaemia  in,  538. 

prognosis,  545. 

signs  of,  540. 

simulates   rheumatic   endocarditis, 
544. 

skin  in,  539. 

symptoms,  537. 

syphilis  with,  535. 

thrill  in,  540. 

treatment,  546. 

variability  of  bruit  in,  540. 

varieties  of,  533. 

without  bruit,  540. 
Congenital  hemiplcgia,  701. 
Congenital  hydrocephalus,  713. 
Congenital    hypertrophy    of    pylorus 

(see  Pylorus),  151. 
Congenital  laryngcal  stridor,  336. 

treatment  of,  338. 
Congenital  obliteration  of  bile-ducts, 

306. 

Congenital  palatal  palsy,  761. 
Congenital  syphilis  (see  Syphilis,  con- 
genital), 792. 

treatment,  816. 
Congenital  teeth,  5. 
Congenital  word-deafness,  744. 
Consanguinity,  effect  on  offspring,  600. 

in  albinism,  600. 

in  alkaptonuria,  600. 
Constipation,  201. 

abdominal  pains  from,  169. 

Agar-agar  for,  213. 

anatomical  causes  of,  201. 

anus,  fissure  of,  with,  203. 

castor  oil,  harmful  in,  210. 

causes,  in  infancy,  201. 

colic  from,  123. 

convulsion  from,  205,  666. 

cream  for,  208. 

diet  in,  207,  209. 

drugs  for,  210. 

due  to  deficiency  of  bile,  203. 

enemata  for,  214. 

fruit  treatment  of,  209. 

grey  powder  in,  211. 

headache  with,  205. 

hernia  from,  205. 

indigestion  associated  with, _  192. 

in  tuberculous  meningitis,  458. 

malted  foods  in,  207. 

marasmus  due  to,  204. 

mercury  for,  211. 

petroleum  for,  211,213. 

prolonged,  206. 

results  of,  204. 

screaming  from,  205. 


826 


INDEX 


Constipation  (continued) — 

sugar  for,  208. 

tiredness  with,  205. 

treatment,  206. 

vomiting  with,  204. 

with  pylori  c  hypertrophy,  155. 
Contagion  in  lobar  pneumonia,  371. 

in  syphilis,  815. 
Convulsions,  048. 

amyl  nitrite  for,  6C5. 

blindness  from,  662. 

chloral  for,  664. 

constipation  causing,  205,  666. 

epilepsy,  relation  to,  663,  669. 

facial  irritability  in,  654. 

hemiplegia  with,  662. 

idiocy  caused  by,  660. 

in  breast-fed,  17. 

infantile,  relation  to'  epilepsy,  668. 

in  pneumonia,  372. 

mental  alteration  from,  660. 

moral  defect  from,  661. 

nerve-irritability  in,  654. 

paralysis,  temporary,  from,  661. 

phenazone  for,  666. 

prognosis  of,  659. 

prophylaxis  of,  666. 

pyclitis  causing,  570. 

relation  to  infantile  hemiplegia,  661. 

squint  from,  062. 

stuttering  from,  662. 

tetany  with,  655. 

treatment,  6(14. 

urethane  for,  6('5. 

with  dentition,  10. 

with  diarrhoea,  224. 

with  idiocy,  660. 

with  roundworms,  294. 

with  syphilitic  mental  degeneration, 
595.' 

with  threadworms.  292. 
Coryza,  simple,  snuflling  with,  799. 

syphilitic,  799. 
Coto  in  diarrhoea,  234. 
Cough,  its  significance,  353. 
Cow's  milk,  30,  81. 

a  source  of  tubercle,  419,  445. 

alkalies  added  to,  45. 

boiled,  changes  in,  48. 

boiled,  objections  to,  48. 

compared  with  human  milk,.  32,  37. 

composition  of,  32. 

diluents  of,  42,  44. 

dilution  of,  34,  35. 

dilution  of,  insufficient,  33,  34. 

infection  from,  48. 

laboratory  formulne  of,  45. 

lime-water  added  to,  45. 

modification  of,  accurate  measure- 
ment in,  30,  47. 

peptonization  of,  53. 

percentage-feeding  with,  31. 


Cow's  milk  (continued) — • 

proportions  of  ,at  various  ages,  35, 36. 

proteids  in,  32. 

sodium  citrate  with,  52. 

sterilization  of,  47. 

substitutes  for,  64. 

sugar  added  to,  40. 

tuberculous  infection  from,  47,  398, 

399,  419. 
Craniotabes,  96,  807,  809. 

relation  to  rickets,  96. 

relation  to  syphilis,  97,  809. 

with  laryngismus  stridulus,  98,  653. 
Cream  and  fat  for  infants,  36,  81. 

centrifugal,  38,  82. 

difficulty  of  digesting,  83. 

for  constipation,  208. 

gravity,  37. 

ordinary  shop-sold,  38. 

preservatives  in,  83. 
Creosote,  inhalation  of,  421. 

for  tubercle,  421,  439. 

for  tuberculous  peritonitis,  439. 
Cretinism,  age  when  recognized,  583. 

constipation  in,  203. 

diagnosis  from  Mongolisin,  619. 

stolidity  of,  586. 

thyroid  in,  607. 
Croup,  326. 

asthma,  relation  to,  345. 
Croup,     spasmodic     (see     Laryngitis 

stridulosa),  326. 
Curd,  citrate  of  soda,  to  reduce,  52. 

indigestion,  34,  52. 
Cyanosis  with  congenital  heart  disease, 
537,  545. 

without  bruit,  540. 
Cyclic  albuminuria,  181,  563. 

abdominal  pains  from,  171. 

oxalates  with,  564. 

puiliness  under  eyes  in,  181. 

simulated  by  \  aginal  discharge,  564. 

symptoms,  564. 

treatment,  565. 
Cyclic  vomiting,  251. 

acetomemia  in,  253. 

called  '  bilious  attacks  ',  251. 

drowsiness  with,  251. 

fatal  cases  of,  252. 

nervous  temperament  in,  252. 

relation  to  recurrent  fever,  255. 

treatment,  253. 
Cystitis,  enuresis  with,  731. 

pyelitis  with,  577. 

Dactylitis,  syphilitic,  803. 

tuberculous,  803. 
Damp  causing  rheumatism,  473. 
Deaf-mutism,  743. 

after  meningitis,  744. 

after  otitis  media,  744. 

family  incidence  of,  744. 


INDEX 


827 


Deafness  after  posterior  basic  menin- 
gitis, 744. 

congenital,  744. 

wi.h  congenital  syphilis,  813. 

with  otitis  media,  744. 

word-,  congenital,  16,  744. 
Degeneration,  stigmata  of,  588. 
Delirium  in  infants,  372. 
Dementia,  syphilitic,  594. 
Dental  caries,  treatment  of,  199. 
Dental  decay  in  families,  198. 

prevention  of,  199. 

with  rickets,  198. 
Dentition,  5. 

bronchitis  with,  9,  354. 

congenital  teeth,  5. 

delayed  in  rickets,  90. 

diarrhoea  with,  9. 

disorders  associated  with,  6,  12,  13. 

epilepsy,  relation  to,  070. 

failure  of  appetite  with,  8. 

fever  with,  9,  281. 

head-banging  with,  789. 

head -rolling  with,  8. 

in  Mongolism,  615. 

meningitis  simulated  by,  12. 

nervous  excitability  with,  7,  10. 

permanent,  date  of,  13. 

photophobia  with,  11. 

primary,  date  of,  5. 

primary,  order  of,  6. 

rickets,  effect  on,  5,  90. 

screaming  with,  11. 

second,  13. 

sleeplessness  with,  11,  755. 

stomatitis  with,  10. 

syphilis,  effect  on,  5,  810. 

teeth-grinding  with,  783. 

vomiting  with,  10. 

weight  affected  by,  3,  9. 
Desiccated  milk,  60. 
Development  of  speech,  740. 
Diabetes  insipidus,  enuresis  with,  731. 
Diabetes  mullitus,  enuresis  with,  731. 
Diaphoretics  in  nephritis,  559. 
Diarrhoea,  215. 

albuminuria  with,  2254' 

alcohol  for,  231. 

antiseptics  in,  234. 

astringents  for,  234. 

bacteriology  of,  217. 

baths  in,  231. 

bismuth  in,  233. 

castor  oil  in,  226,  233,' 

causes  of,  216. 

choleraic,  221. 

classification  of,  218. 

complications  of,  222. 

condensed  milk  causing,  74,  216. 

convulsions  with,  224. 

coto  in,  234. 

dentition  causing,  9. 


Diarrhoea  (continued) — 

diet  in,  227. 

glucose  infusions  for,  230. 

hand-feeding  versus  breast-feeding, 
216. 

head-retraction  with,  223. 

hypodermic  injections  in,  229. 

in  breast-fed,  24. 

infantile,  215. 

infective,  218. 

lienteric,   with  faecal  incontinence, 
738. 

lienteric,  with  rheumatism,  479. 

micro-organisms  of,  217. 

mortality,  215. 

mustard  bath  in,  231. 

oedema  with,  225. 

cosophagitis  with,  225. 

opium  in,  233. 

otitis  media  with,  223. 

purpura  with,  225. 

rectal  injections  in,  229,  235. 

rice-water  for,  228. 

screaming  with,  223. 

seasonal  incidence,  216, 

sea  water  for,  230. 

sherry- whey  in,  232. 

silver  nitrate  for,  234. 

simple,  219. 

spurious  hydrocephalus  with,  223. 

strychnine  in,  230. 

subcutaneous  infusion  for,  229. 

symptoms,  220. 

tetany  with,  658. 

thrombosis  of  sinuses  with,  224. 

thrush  with,  222. 

treatment,  226. 

vomiting  with,  220,  221. 
Diet,  after  nine  months,  104. 

antiscorbutic,  120. 

for  uric  acid  in  urine,  565. 

in  diarrhoea,  227. 

in  cceliac  disease,  242. 

in  colic  due  to  indigestion,  173. 

in  congenital  heart  disease,  547. 

in  constipation,  207,  209. 

in  epilepsy,  680. 

in  indigestion,  185. 

in  insomnia,  756. 

in  jaundice,  313. 

in  nephritis,  561. 

in  recurrent  pyrexia,  264. 

in  tabes  mesenterica,  427." 

purin  free,  680. 

salt  free,  680. 

Digitalis,    anginoid   attacks   due   to, 
501. 

harmful  effect  of,  501. 

use  of,  in  endocarditis,  500. 

in  pericarditis,  511. 
Dilatation,  cardiac,  490. 

treatment,  511. 


828 


INDEX 


Dilatation,  cardiac  (continued) — 

with  endocarditis,  490. 

with  pericarditis,  507,  511. 
Diphtheria,  infantile  hemiplegia  after, 
700. 

nephritis  with,  550. 

primary  laryngeal,  327. 

stuttering  after,  749. 
Diphtheritic  palsy  simulating  chorea, 

520. 
Diplegia,  idiocy  with,  590. 

spastic,  701. 
Dirt-eating,  779. 
Diuretin  for  heart  disease,  502. 
Dover'sPowder,dosageforinfants,233. 
Dress  in  infantile  scurvy,  122. 

in  pericarditis,  505. 

in  pneumonia,  382. 

of  marasmic  infants,  149. 
Dried  milk,  00. 

comj  tared  with  fresh,  09. 
Dropsy  caused  by  sodium  citrate,  53. 

with  coeliac  disease,  241. 

with  nephritis,  553. 

without  albuminuria  in  infants,  553. 

in  older  children,  554. 
Drowsiness  in  pneumonia,  372. 

with  cyclic  vomiting,  251. 

with  recurrent  fever,  201. 

with  tuberculous  meningitis,  459. 
Drugs  excreted  in  breast-milk,  20. 
Drvness  of  hair  with  indigestion,  183. 
Dwarfs,  rickety,  93. 
Dyspepsia,  170. 

'intestinal,  219. 

Dyspnoea,    attacks    of,    with    mitral 
disease,  502. 

paroxysmal,    in    congenital    heart 
disease,  545. 

Earache  with  adenoids,  319,  320. 
Ear  disease,  deaf-mutism  from,  744. 

head-rolling  with,  787. 

syphilitic,  813. 

Ear  infection  in  tuberculosis,  401. 
Ear-syringing,  nystagmus  from,  709. 
Eclamptic  idiocy,  591. 
Ee/ema,  syphilide  simulating,  800. 

asthma  wit h,  344. 
Ett'usion,  pleural,  387. 
Eg.u;s,  idiosyncrasy  to,  ISO. 

value  of,  104. 

Eleei  ricity  for  infantile  paralysis,  099. 
Emetics  in  bronchitis,  301. 
Emphysema  with  asthma,  348,  357. 

with  bronchitis.  357. 

with  whooping-cough,  357. 
Empyema,  383. 

aue-ineidence  of,  383. 

arthritis  with,  391. 

aspiration  for,  .'594. 

bacteriology  of,  3S4,  39. l< 


Empyema  (continued) — 

bronchial  breathing  with,  385. 

complications  of,  385,  390. 

diagnosis  from  serous  effusion,  387. 

duration  of,  392. 

incision  for,  394. 

in  early  infancy,  391. 

meningitis  with,  391. 

operation,  choice  of,  for,  394. 

pericarditis  with,  390. 

pneumococcal,  384. 

pneumonia,  relation  to,  383,  384. 

prognosis,  391. 

resection  of  rib  in,  394. 

signs  and  symptoms,  386. 

treatment,  392. 

tubercle  with,  385. 

unopened,  393. 

vaccine  for,  395. 

whooping-cough,  simulated  by,  380. 

with  pneumonia,  377. 
Endocarditis,  480. 

age-incidence  of,  487. 

aortic,  492. 

bruits  in,  490,  492. 

cardiac  dilatation  with,  490. 

cardiac  dullness  in,  491. 

causes  of,  480,  488. 

digitalis  in,  500. 

foetal,  530. 

frequency  of,  480. 

insidious  onset  of,  488. 

irregularity  of  heart  in,  490. 

jaundice  with,  311. 

leeching  in,  503. 

mitral,  493,  494. 

opium  in,  502. 

pericarditis  with,  491,  49G. 

prognosis,  490. 

rest  in,  497. 

rheumatic,  simulated  by  congenital 
heart  disease,  544. 

sex  in,  487. 

sleep,  value  of,  in,  498. 

symptoms,  488. 

treatment,  497. 

vomiting  with,  502. 

wasting  with,  489. 
Enemata,  failure  of,  for  worms,  296. 

in  chronic  constipation,  214. 

small  intestine  reached  by,  290. 
Enucleation  of  tonsils,  323. 
Enuresis,  720. 

acidity  of  urine  causing,  730,  732. 

adenoids  removed  for,  730. 

age  at  onset  of,  14,  727,  728. 

atropine  for,  734. 

belladonna  for,  733. 

bromide  for,  735. 

caused  by  fright,  730. 

circumcision  for,  730. 

cystitis  with,  731. 


INDEX 


829 


Enurcsis  (continued) — 

diabetes  insipidus  with,  731. 

diabetes  mellitus  with,  731. 

diurnal,  728. 

enlarged  tonsils  and  adenoids  with, 
322. 

ergot  for,  735. 

fright  causing,  730. 

habit-spasm  with,  729. 

lycopodium  for,  734. 

masturbation  with,  730. 

nervousness  with,  729. 

prognosis,  731. 

psychical  influence  in,  736. 

punishment  for,  736. 

rheumatism  with,  729. 

rhus  aromatica  for,  735. 

sex  in,  727. 

stuttering  with,  729. 

threadworms  with,  729. 

treatment,  732. 

urine  in,  731. 
Eosinuria,  567. 
Epidemic,  infantile  paralysis,  089. 

jaundice,  309. 
Epilepsy,  668. 

age -incidence  of,  668. 

aura  in,  676. 

automatic  actions  with,  673. 

bromide  in,  680,  682. 

cerebral  palsy  with,  710. 

chloral  for,  683. 

convulsions,  relation  to,  609. 

dentition,  relation  to,  670. 

diagnosis,  676. 

diet  in,  680. 

due  to  carious  teeth,  196. 

enlarged  tonsils  and  adenoids  with, 
671. 

etiology,  670. 

exciting  causes  of,  671. 

head-jerking  in,  672. 

idiocy  with,  592,  676. 

infantile   convulsions,    relation   to, 
669. 

masked,  674. 

masturbation,  relation  to,  672,  677, 
777. 

mental  condition  with,  592,  676. 

minor,  672,  673. 

moral  defect  with,  676. 

onset,  age  of,  669. 

phenazone  for,  681. 

prognosis,  678. 

purin-free  diet  for,  680. 

salt-free  diet  for,  680. 

sex  in,  668. 

sleepiness  in,  674. 

speech,  loss  of,  in,  674. 

subjective  symptoms  in,  675. 

symptoms  of,  672. 

syphilis,  causing,  594,  671. 


Epilepsy  (continued') — • 

treatment,  679. 

urethane  for,  682. 

vasomotor,  180. 
Epileptic  idiocy,  591,  608. 
Epiphysitis,  syphilitic,  802. 

acute,  mistaken  for  rheumatism,  481. 
Epistaxis,  with  adenoids,  316. 

with  heart  disease,  489. 

with  pneumonia,  374. 
Ergot  for  enuresis,  735. 
Erythema  marginatum,  477. 
Erythema  nodosum,  477. 
Erythema,  rheumatic,  477. 
Eustace  Smith's  bruit,  406. 
Eyelids,  puffinoss  of,  181,  553. 
Expectoration  in  tuberculosis,  415. 
Exploration  of  chest,  388. 

Face,  puffiness  of,  553. 
Facial  irritability,  654. 

convulsions  with,  654. 

in  spasmus  nutans,  768. 
Facial  palsy,  with  infantile  paralysis, 
693. 

with  tuberculous  meningitis,  459. 
Facies  in  cretinism,  619. 

in  Mongolian  imbecility,  611. 
Faecal  incontinence,  738. 

age  at  onset,  738. 

lienteric  diarrhoea  and,  738. 

prognosis,  739. 

sex  in,  738. 

treatment,  739. 
Fainting,  677. 
'  Falling-about ',  762. 

treatment,  763. 
Family  acholuric  jaundice,  312. 

icturus  gravis  neonatorum,  303. 

jaundice,  303. 

Family  incidence,  of  congenital  heart 
disease,  535. 

of  disease,  90,  535,  603. 

of  mental  deficiency,  603. 

of  microcephaly,  590. 
Fat,  estimation  of,  in  human  milk,  20. 

excessive,  harm  of,  77. 

in  infant-feeding,  36,  38,  80,  147. 
Fat-deficiency,  36,  39. 

cause  of  rickets,  36,  66. 

in  patent  foods,  67. 

methods  of  rectifying,  36. 
Fats  in  tabes  mesenterica,  428. 
Feeding,  of  infants,  17. 

artificial,  17. 

breast-,  17. 

faults  and  fallacies  in,  76. 

faulty,  a  cause  of  colic,  127. 

faulty,  a  cause  of  flatulence,  127. 

in  second  year,  88,  104. 

intervals  of,  23. 

partial  breast-,  23. 


$ 
830 


INDEX 


Feeding  (continued) — 

'  percentage-feeding  ',31. 
Feeds,  amount  of,  at  different  ages,  79. 

excessive  bulk  of,  77. 

excessive  bulk  of,  causing  maras- 
mus, 78,  135. 
Fever,  260. 

auto-intoxication  causing,  268. 

indigestion  causing,  282. 

in  nervous  children,  260,  265,  623. 

in  pyelitis,  277,  571. 

in  scurvy,  116. 

of  obscure  causation,  260. 

otitis,  latent,  causing,  270,  275. 

prolonged  slight,  265. 

prolonged  with  latent  tubercle,  272. 

recurrent,  attacks  of,  255,  2(51. 

rheumatism  causing  prolonged,  274. 

roundworms  causing,  284. 

throat  affection  with,  284. 

with  bronchitis,  356.  ' 

with  dentition,  9,  281. 
Fevers,  specific,  482. 

followed  by  infantile  palsy,  687. 

followed  by  stuttering,  749. 
Fibroid  lung,  359,  415. 

clubbing  of  fingers  with,  415. 

treatment,  361. 

tuberculous,  rarity  of,  416. 
Firstborn,  congenital  heart  in,  535. 

congenital  pyloric  hypertrophy  in, 
152. 

mental  deficiency  in,  602. 
First  cousins,  marriage  of,  601. 
Fissure  of  anus,  203. 
Flatulence,  123. 

abdomen  distended  with,  177. 

carbohydrate,  excessive,  in,  127. 

causing  hiccoughs,  124. 

causing  sleeplessness,  124. 

faulty  feeding  a  cause  of,  127. 

treatment,  129. 

with  breast -feeding,  23. 
Foetal  endocarditis,  536. 
Fontanelles,  4. 

delayed  closure  of,  4. 

in  Mongol  idiocy,  4. 

lateral,  5. 

measurement  of,  4. 

posterior,  closure  of,  5. 

premature  closure,  in  microcephaly, 

590. 

Food  fever,  26S. 
Foods,  eausing  rickets,  85,  103. 

patent,  63. 

scorbutic,  119. 
Foreign  body,  in  bronchus,  340. 

in  oesophagus,  341. 
Fnenal  ulcer  in  whooping-cough,  366. 
Flight,  aphasia  caused  by,  748. 

enuresis  from,  730. 

speech  lost  after,  748. 


Fright  (continued] — • 

stuttering  caused  by,  749. 
Fruit,  constipation  treated  by,  209. 

indigestion  caused  by,  168,  189,  209. 

proper  time  for,  189. 
Fruit  juice  in  scurvy,  120. 
Functional  bruits,  495. 

in  infancy,  542. 

in  later  childhood,  495. 

Garlic  injection  for  worms,  296. 
Gastric  catarrh,  249. 
Gastritis  from  arsenic,  527. 
Gastro-entcritis,  220. 
Gastrointestinal  catarrh,  219. 
General  paralysis  of  the  insane,  594. 
Genetous  idiocy,  588. 
Glands,  cervical  tuberculous,  321,  402, 
419,  441. 

dental  caries  infecting,  195. 

enlarged,  in  syphilis,  813. 

enlarged  tonsils  infecting,  321. 

mediastinal,  338,  402,  404. 

mesenteric,  424. 

tuberculous,  in  neck.  441. 
Glandular  fever,  nephritis  with,  550. 
Glaxo,  61. 
Glucose  for  diarrhoea,  230. 

for  cyclic  vomiting,  254. 
Glycosuria  in  tuberculous  meningitis, 

460. 
Goat's  milk,  49,  419. 

composition  of,  49. 
Gonorrhceal,  affection  of  joints,  481. 

arthritis,  481. 
Gout,  483. 
Grey  powder,  for  constipation,  211, 

for  syphilis,  816. 

Grinding  of  teeth,  nervous  association 
of,  784. 

treatment,  785. 

with  dentition,  783. 

with  hydrocephalus,  783. 

with  meningitis,  783. 

with  worms,  292,  784. 
Growing  pains,  473,  489. 
Growth,  in  length,  3. 

in  weight,  3. 

stunted  by  rickets,  93. 
Gum  lancing,  281. 
Gumrna  of  spleen,  801. 
Gums  in  scurvy,  113. 

Habit-spasm,  634. 

adenoids  removed  in,  646. 

age-incidence,  14,  639. 

arsenic  for,  646. 

confused  with  chorea,  517,  522. 

delusions  with,  638. 

dental  caries  with,  196,  641. 

diagnosis,  644. 

etiology,  639. 


INDEX 


831 


Habit-spasm  (continued) — 

headaches  with,  640. 

microkinesis  confused  with,  644. 

psychical,  symptoms  with,  638. 

rheumatism  with,  479. 

school,  effect  of,  in,  642. 

sex,  639. 

treatment,  645. 

worms  causing,  642. 
Habits,  morbid,  775. 
Haematuria,  566. 

from  rhubarb,  565. 

from  urotropin,  698. 

in  nephritis,  553. 

in  scurvy,  115. 

tubercle  causing,  466. 

with  whooping-cough,  £53,  566. 
Haemoglobinuria,  567. 

syphilis  with,  795. 
Haemoptysis,  significance  of,  414. 
Haemorrhage,  from  kidneys,  566. 

in  joints,  from  scurvy,  117. 

in  syphilis,  797. 
Hair,  dryness  of,  183. 

in  congenital  heart  disease,  539. 

in  syphilis,  797,  800. 
Hand-feeding,  compared  with  breast- 
feeding, 17. 

dangers  of,  17,  216. 

v.  breast-feeding  in  diarrhoea,  216. 
Harrison's  sulcus,  99. 
Hay  fever,  asthma  related  to,  347. 
Head,  age  of  holding  steady,  16. 

in  mental  deficiency,  4. 

in  Mongolism,  613. 

large,  causes  of,  4. 

measurements  of,  4. 
Headache,  255. 

in  nervous  children,  628: 

migraine,  255. 

with  carious  teeth,  197. 

with  chorea,  519. 

with  constipation,  205. 

with  habit-spasm,  640. 

with  meningitis,  458. 

with  nephritis,  551,  552. 

with  rheumatism,  478. 
Head-banging,  787. 

age-incidence  of,  789. 

dentition  with,  789. 

passionateness  with,  788. 

treatment,  791. 
Head-nodding,  764. 

with  nystagmus,  treatment  of,  774. 

with  dentition,  12. 
Head-retraction,  with  diarrhoea,  223. 

with  meningitis,  463. 

with  otitis  media,  223. 

with  pneumonia,  377. 
Head-rolling,  786. 

age -incidence  of,  786. 

ear  disease  with,  787. 


Head-rolling  (continued) — 

otitis  media  with,  787. 

rickets  with,  786. 

treatment,  791. 

with  dentition,  8. 
Hearing,  development  of,  15. 
Heart  affection,  in  nephritis,  554. 

with  chorea,  520. 

Heart  disease  (see  Endocarditis,  Peri- 
carditis, Congenital  heart  disease), 
474,  4£6,  504,  533. 
Heart  dullness,  determination  of,  491. 

importance  of,  490. 

in  pericarditis,  507. 
Heart  irregularity,  in  endocarditis,  490. 

in  tuberculous  meningitis,  460. 
Hemichorea,  519. 
Hemiplegia,  infantile,  701. 
Hemiplegia,  temporary,  after  convul- 
sions, 662. 

Henoch's  purpura,  nephritis  with,  550. 
Hernia  from  constipation  205. 
Herpes,  with  lobar  pneumonia,  374. 
Hiccough  due  to  flatulence.  124. 
Hip,  rheumatism  in,  473. 
Hot-air  bath,  in  nephritis,  559. 
House-infection,  in  rheumatism,  487. 
Human  milk,  1 9. 

analysis  of.  21,  24. 

compared  with  cow's  milk,  32. 

composition  of,  variable,  46. 

deficiency  in  quality,  22  ;   in  quan- 
tity, 22. 

drugs  excreted  in,  26. 

estimation  of  fat,  20. 

excess,  in  quality,  24  ;   in  quantity, 
23. 

methods  of  modifying,  22,  25. 

sample  of,  to  obtain,  19. 

specific  gravity  of,  19,  20. 
Humanized  milk,  50. 

analyses  of,  50. 

disadvantages  of>  51. 
Humanoid,  73. 

Hurried  meals,  harm  of,  184,  256. 
Hutchinsonian  teeth,  811. 
Hydrocephalic  idiocy,  590. 
Hydrocephalus,  712. 

acquired,  714. 

acute,  712. 

age-incidence  of,  713. 

congenital,  713. 

diagnosis,  719. 

external,  712. 

eye  changes  in,  718. 

internal,  712. 

meningitis  causing,  714. 

mental  condition  in,  719. 

morbid  anatomy  of,  713. 

operation  for,  722,  723. 

ossification,    congenital    defect    of, 
with,  715. 


$ 
832 


INDEX 


Hydrocephalus  (continued)-* 

prognosis,  720. 

size  of  head  in,  718. 

spurious,  223. 

symptoms,  716. 

syphilis  causing,  716,  805. 

teeth-grinding  with,  783. 

treatment,  722. 

tumour  causing,  714. 
Hydronephrosis,    causing    vomiting, 

257. 

Hyperpyrcxia,  rheumatic,  477. 
Hypertrophic  idiocy,  595. 
Hypertrophy  of  heart,  with  endocar- 
ditis, 492,  501. 

with  nephritis,  554. 
Hypertrophy  of  pylorus  (see  Pylorus), 

151. 

Hypnotics,  498,  757. 
Hypodermic  injections,  229. 
Hysteria,  chorea  simulated  by,  524. 

epilepsy  simulated  by,  077. 

spasm  of  oesophagus  in,  7G2. 

Ice-bag,  in  pericarditis,  512. 

in  pneumonia,  380. 
Icterus  neonatorum,  300. 

treatment,  312. 

Idiocy  (see  Mental  deficiency),  583. 
Idioglossia,  752. 
Ileocolitis,  220. 

Imbecility  (see  Mental  deficiency),  583. 
Imbecility,  Mongol,  01 1. 
Imitation,  chorea  from,  517. 

habit-spasm  from,  (544. 

stuttering  from,  750. 
Incontinence,  foxsal,  738. 

infantile  palsy  with,  091. 
Indigestion,  10S,  170. 

a  cause  of  abdominal   pains,    108, 
177. 

appetite  lost  with,  177. 

l)-i lianas  causing,   ]<S9. 

'  bilious  attacks  '  due  to;  249. 

brown  bread  causing,  187,  209. 

carious  teeth  causing,  184,  194. 

cod-liver  oil  in,  191. 

constipation  with,  192. 

diet   in,   J85. 

dry  ness  of  hair  with,  183. 

fever  from,  2S2. 

from  curd,  34,  52. 

fruit  causing,  189,  209. 

knee-elbow  position  with,  702. 

malt  extract  in,  191. 

milk,  excess  of.  causing,  190. 

nervousness  with,  178. 

night-terrors  with,  179. 

palpitation  with,  183. 

pica  with,  781. 

porridge  causing,  188,  209. 

potatoes  causing,  188. 


Indigestion  (continued) — 

shortness  of  breath  with,  182. 

sleeplessness  from,  756. 

symptoms  of,  176. 

teeth -grinding  with,  783. 

tiredness  with,  180. 

treatment,  183. 

vomiting  with,  181. 

wasting  with,  176. 

with  breast-feeding,  23,  24,  25. 
Infant-feeding     (see     Breast-feeding, 
Milk),  17,  30. 

common  faults  in,  76. 
Infantile    diarrhoea    (see    Diarrhoea), 

215. 
Infantile  hemiplegia,  701. 

age  at  onset  in,  701. 

after  diphtheria,  706. 

after  measles,  706. 

after  scarlet  fever,  706. 

asphyxia  causing,  703. 

congenital,  frequency  of,  702. 

convulsion,  relation  to,  702. 

diagnosis,  709. 

mental  condition  in,  709. 

moral  defect  with,  709. 

prognosis,  710. 

seasonal  incidence,  707. 

specific  cause,  706. 

specific  fevers,  followed  by,  705. 

symptoms,  708. 

treatment,  710. 

with  chorciform  movements,  525. 

with  whooping-cough,  700. 
Infantile  paralysis,  084. 

age-incidence  of,  685. 

apparatus  for,  700. 

brain  affected  by,  693. 

cerebral  symptoms  with,  693. 

channel  of  infection,  691. 

complete  recovery  in,  696. 

diagnosis,  695. 

death  from,  695. 

distribution  of,  693. 

electricity  in,  699. 

epidemics  of,  689. 

experimental  production  of,  689. 

facial  palsy  with,  693. 

incontinence  in,  094. 

incubation  period  of,  689- 

infective  origin  of,  084,  689. 
j        massage  in,  699. 

measles  followed  by,  687. 

morbid  anatomy  of,  684. 

neuritis  in,  695. 

onset  of,  691. 

prognosis,  695. 

rheumatism  simulating,  695. 

scurvy  simulating,  112. 

seasonal  incidence,  686. 

sensation  in,  694. 

sex-incidence  of,  685,  687. 


INDEX 


833 


Infantile  paralysis  (continued) — 

specific  fevers  followed  by,  687. 

symptoms,  691. 

tendon  jerks  in,  694. 

traumatism  causing,  688. 

treatment,  697. 

trunk  muscles  in,  693. 

urotropin  for,  697. 

vaccination  followed  by,  688. 

whooping-cough  followed  by,  688. 
Infantile  scurvy  (see  Scurvy),  108. 
Infection,  from  cow's  milk,  48. 

in  tuberculosis,  399,  418. 

mode  of,  in  pyelitis,  569. 

pneumococcal,  371. 
Infective  diarrhoea,  218. 
Inflammatory  idiocy,  592. 
Influenza,  endocarditis  with,  488. 

fever,  recurrent,  simulating,  263. 

meningitis  with,  453. 

nephritis  with,  550. 
Influenzal  meningitis,  453. 
Infusion,  subcutaneous,  229. 
Inhalation  of  creosote,  421. 
Injections,  hypodermic,  229. 

rectal,  in  diarrhoea,  229,  235. 
Insane,  general  paralysis  of,  594. 
Insomnia,  622,  755. 

dentition  causing,  11,  755. 

diet  in,  756. 

from  flatulence,  124. 

in  heart  disease,  498. 

indigestion  causing,  756. 

masturbation  related  to,  777. 

treatment,  756. 

Instrumental     labour,    mental    defi- 
ciency from,  599. 
Interstitial  keratitis,  806. 
Interstitial  nephritis,  chronic,  558. 
Intestinal  dyspepsia,  219. 
Intestinal     strangulation    by     band, 

427. 
Intestinal  worms,  236. 

treatment,  296. 
Intra-uterine  meningitis,  453. 
Intussusception,  relapsing,  126. 

simulated  by  flatulent  colic,  124. 

simulated  by  scurvy,  117. 

spontaneous  reduction  of,  125. 
'  Inward  convulsions  ',  648. 
lodoform  for  tuberculous  peritonitis, 

438. 

Iritis,  syphilitic,  806. 
Irregularity  of  heart,  in  endocarditis, 
490. 

in  tuberculous  meningitis,  460. 
Irrigation,  of  bowel,  213,  235. 

of  colon,  in  diarrhoea,  235. 
Irritability,  facial,  654. 

of  nerve,  654. 
Jaundice,  300. 

catarrhal,  307. 


Jaundice  (continued) — 

cirrhosis  with,  309. 

endocarditis  with,  311. 

epidemic,  309. 

family  congenital,  306,  312. 

family  malignant  in  newborn,  303. 

in  newborn,  300. 

in  newborn,  family  incidence  of,  303. 

pyaemic,  305. 

recurring,  308. 

seasonal  incidence,  309. 

syphilitic,  305,  797. 

treatment,  312. 

with  heart  disease,  311. 

with  pneumonia,  311. 
Jersey  cows'  milk,  80. 
Joints,  affection  of,  in  syphilis,  812. 

in  rheumatism,  470,  473,  474. 

gonorrhceal  affection  of,  481. 

haemorrhage  in,  from  scurvy,  117. 

haemorrhage,  scorbutic,  in,  117. 
Juvenile  general  paralysis,  594. 

Keratitis,  interstitial,  806. 
Kidney,  haemorrhage  from,  566. 

inflammation  of,  549. 

movable,  172. 

stone  in,  171. 

tubercle  of,  566. 

Kidney  disease  causing  vomiting,  257. 
Knee-elbow  position  in  sleep,  762. 
Knee-jerk  in  chorea,  520. 
Koplik's  spots,  329. 

Labour,  instrumental,  causing  mental 

deficiency,  599. 
Lactalbumen,  34. 
Lancing  of  gum,  281. 
Laparotomy    for    tuberculous    peri- 
tonitis, 435. 

Laryngeal  spasm,   adenoids   causing, 
332 

in  the  newborn,  335. 
Laryngeal  stridor,  326,  335. 

congenital,  336. 
Laryngismus  stridulus,  334,  652. 

age -incidence,  653. 

craniotabes,  relation  to,  653. 

diagnosis  from  laryngitis  stridulosa, 
334. 

prognosis,  335. 

seasonal  incidence  of,  653. 

treatment,  335,  667. 
Laryngitis,  acute,  328. 

severity  of  symptoms  in  infancy, 
329. 

stridor  with,  329. 

with  measles,  329. 

with  pneumonia,  378. 

with  whooping-cough,  330. 
Laryngitis  stridulosa,  326,  330. 

asthma  related  to,  332,  345. 


3H 


• 
834 


INDEX 


Laryngitis  stridulosa  (continued) — 

etiology,  331. 

prognosis,  332. 

symptoms,  330. 

treatment  of,  333. 
Laryngitis,  syphilitic,  802. 
Larynx,  papilloma  of,  339. 

roundworms  in,  294. 

stenosis  of  syphi.itio.  339. 
Leeching,  in  broncho- pneumonia,  309. 

in  endocarditis,  503. 

in  pericarditis,  511. 
Length,  of  infant,  3. 

of  colon,  202. 

I  eukannia,  fever  with,  284. 
Lichen  urticatus,  183. 
Lienteric  diarrhoea,  and  foecal  incon- 
tinence, 738. 

in  nervous  children,  738. 

with  rheumatism,  479. 
Lime-water,  44. 

added  to  cow's  milk,  45. 

not  preventive  of  rickets,  45. 
Lisping,  752. 
Lobar    pneumonia    (see    Pneumonia), 

370. 

Lobular    pneumonia    (see    Broncho- 
pneumonia),  303. 
Lumbar  puncture  in  meningitis,  403, 

404. 

Ly co podium  for  enuresis,  734. 
Lymphatic  glands,  in  syphilis,  813. 

tuberculous,  402,  419,  441. 

Malaria,  nephritis  with,  550. 
Malignant  endocarditis,  487. 
Malignant  pneumonia,  379. 
Malingering,  507,  077. 
Malt  extract,  in  indigestion,  191. 

its  uses  in  marasmus,  1-19. 
Malted  foods  for  constipation,  208. 
Marasmus  infantile,  132. 

abiotrophy,  dependent  on,  137. 

abscesses,  superficial,  with,  143. 

after  diarrhoea,  137. 

asses'  milk  in,  147. 

broncho-pneumonia  in,  140. 

bulk  of  food,  excessive,  causing,  135. 

causes  of,  132. 

citrated  milk  in,  144. 

complications  of,  143. 

congenital   heart   disease,    causing 
140,  539. 

constipation  with,  139,  204. 

cream,  excess  of,  causing,  133. 

death  sudden  in,  140. 

family  occurrence  of,  130. 

oedema  with,  144. 

prognosis,  145. 

purpura  in,  145. 

pyelitis  causing,  142,  575. 

syphilis  causing,  l:;s,  70S. 


Marasmus  infantile  (continued) — 
thrush  with,  143. 
thyroid  for,  150. 
treatment  of,  147. 
tuberculosis,  a  rare  cause  of,  1 42. 
warmth,  important  in,  149. 
with  hypertrophy  of  pylorus,  155. 
Massage,  in  cerebral  palsy,  711. 
in  infantile  palsy,  699. 
in  rickets,  107. 
Masturbation,  775. 
age  at  onset,  775. 
body-rocking  with,  791. 
circumcision  causing,  777. 
epilepsy,  relation  to,  072,  677. 
epilepsy  simulated  by,  776. 
epilepsy  with,  777. 
idiocy  with,  777. 
in  infancy,  775. 
pallor  with,  777. 
sleeplessness  causing,  777. 
symptoms,  776. 
treatment,  778. 
vulvo-vaginitis  causing,  775. 
Meals,  hurried,  harm  of,  184,  256. 

intervals  of,  190. 
Measles,    infantile    hemiplcgia    after, 

700. 

infantile  palsy  following,  687. 
Koplik's  spots  in,  329. 
laryngitis  with,  329. 
nephritis  with,  550. 
tubercle  following,  403,  419. 
Measurement,    of    chest,    in    plcural 

effusion,  387. 
of  fontanelle,  4. 
of  head,  4. 
Meat- juice  raw,  54. 
as  antiscorbutic,  120. 
method  of  preparing,  56. 
Mcdiastinal  glands,  enlarged,  diagnosis 

of,  405. 

frequency  of,  404. 
in  tuberculosis,  402,  404. 
perf  oration  of  bronchus  by,  402.  409. 
simulating  whooping-cough,  405. 
stridor  caused  by,  338. 
symptoms  of,  405. 
Medicine  measures,  734. 
Melaena    neonatorum,    syphilis    with, 

797. 

Meningitis,  abdominal  pains  with,  258. 
cere bro -spinal,  453,  463. 
deaf-mutism  after,  744. 
hydrocephalus  following,  714. 
influenzal,  453. 
intra-uterine,  453. 
lumbar  puncture  in,  464. 
simulated  by  acute  pyelitis,  280, 571 . 
simulated  by  dentition,  12. 
simulated  by  infantile  palsy,  C95. 
simulated  by  pneumonia,  376. 


INDEX 


835 


Meningitis  (continued) — 

simulated  by  recurrent  fever,  263. 

simulating  '  bilious  attack  ',  259. 

suppurative,  378,  391. 

syphilitic,  716,  805. 

teeth-grinding  with,  783. 

tuberculous,  453. 

varieties  of,  453. 

with  empyema,  391. 

with  influenza,  453. 

with  pneumonia,  378. 
Meningo-encephalitis,  syphilitic,  595. 
Mental  affection,  in  cerebral  palsy,  709. 

in  tuberculous  meningitis,  457. 

from  convulsions,  660. 
Mental  condition,  in  infantile  hcmi- 
plegia,  709. 

in  rickets,  95. 

in  spasmus  nutans,  772. 

with  epilepsy,  676. 
Mental  deficiency,  583. 

age  when  recognized,  5S3. 

alcoholism  a  cause  of,  596. 

amaurotic,  596. 

asphyxia  causing,  598. 

asylum  treatment  of,  610. 

bromide  in,  608. 

causes  of,  596. 

classification,  587. 

consanguinity  causing,  600. 

deafness  simulated  by,  15. 

eclamptic,  591. 

epileptic,  591,  676. 

family  incidence  of,  603. 

genetous,  588. 

head  in,  4,  588. 

hydrocephalic,  590. 

hypertrophic,  595. 

inflammatory,  592. 

instrumental  labour,  causing,  599. 

long  life  with,  607. 

microcephalic,  588. 

mortality  in,  606. 

place  in  family  a  cause  of,  601. 

prognosis,  604. 

relative  age  of  parents  in,  603. 

rhythmic  movements  in,  586. 

screaming  in,  585. 

sex -incidence,  583. 

spastic,  590. 

speech  in,  585,  609,  743,  751. 

symptoms,  584. 

syphilis  causing  594,  597,  804. 

syphilitic,  594. 

thyroid  in,  608. 

training  in,  609. 

traumatic,  593. 

treatment,  607. 

tuberculosis  with,  606. 
walking,  acquirement  of,  605. 
Mental  degeneration,  epilepsy  with, 
591. 


Mental  degeneration  (continued) — 
syphilitic,  convulsions  with,  595. 
syphilitic,  fundus  oculi  in,  594. 
Mental  development,  14. 
Mercurial  baths,  817. 
Mercury,  dosage  for  syphilis,  816. 

for  constipation,  211. 
Microcephaly,  588. 
etiology  of,  589. 
fontanelle  in,  590. 
morbid  anatomy  of,  589. 
normal  intelligence  with,  589. 
spasticity  with,  589. 
Microkinesis    confused    with    chorea, 

524. 
Micturition,  control  of,  726. 

frequency  of,  728. 
Middiastolic  bruit,  493. 
Migraine,  255. 

treatment  of,  256. 
Miliary  tuberculosis,  acute,  412. 
Milk,  asses',  59. 
in  marasmus,  147. 
boiled,  47,  48. 
causing  scurvy,  48,  120. 
not  cause  of  rickets,  48. 
citrated,  52. 
condensed,  62,  70. 
diarrhoea  with,  74,  216. 
dilution  of,  71. 
rickets  from,  72. 
scurvy  from,  70. 
unsweetened,  72. 
cow's,  30. 
compared  with  human  milk,  32 

37. 

composition  of,  32. 
diluents  of,  44. 
modification  of,  30. 
proteids  in,  32. 
desiccated,  60. 
excess  of,  indigestible,  190. 
human,  19. 

compared  with  cow's  milk,  32. 
composition  of,  19,  20. 
deficiency  of.  22. 
drugs  excreted  in,  26. 
estimation  of  fat  in,  20. 
examination  of,  18. 
methods  of  improving,  22,  25. 
'  nursery,'  79. 
peptonized,  53. 
scurvy,  risk  of,  from,  54. 
tuberculosis  from,  47,  399,  418. 
value  of,  62. 

Milk-sugar,  in  infant-feeding,  40. 
Mitral  disease,  493. 
dyspnoea  with,  502. 
frequency  of,  493. 
Mitral  stenosis,  494. 
Mongol  imbecility,  611. 
age  of  mother  in,  618. 


3  II  2 


9 

836 


INDEX 


Mongol  imbecility  (continued) — 

bronchitis,  tendency  to,  356,  620. 

cataract  in,  614. 

congenital  heart  disease,  with,  534, 
620. 

cretinism,  diagnosed,  from,  619. 

dentition  in,  615. 

diagnosis,  619. 

etiology,  617. 

facies  in,  611. 

fontanelle  in,  4,  615. 

frequency  of,  611. 

head  in,  (513. 

mental  condition  in,  616. 

morbid  anatomy  of,  617. 

nystagmus  with,  614. 

place  in  family  in,  617. 

prognosis,  620. 

recognizable  at  birth,  533. 

snu filing  in,  615. 

spasmus  nutans  with,  772. 

speech  in,  615. 

syphilis  and,  619. 

tongue  in,  611. 

treatment,  621. 
Monoplegia,    spastic,   rarity   of,    701, 

709. 
Moral  defect,  from  convulsions,  661. 

with  epilepsy,  676. 

with  infantile  hemiplegia,  709. 
Morbid  habits,  775. 
Moro  reaction,  416. 
Morphia,  dosage  for  infants,  665. 

dosage  for  older  children,  254. 
Mortality     in     breast-fed     compared 

with  hand-fed,  17. 
Mouth-breathing,  cause  of  bronchitis, 

355. 

Movable  kidney,  172. 
Mucous   catarrh,   with   threadworms, 

293. 

Mucous  disease,  176. 
Muscular  weakness,  in  rickets,  89,  94. 
Mustard  bath,  231. 
Ne  j-salvarsan  injection,  818. 

Nephritis,  549. 

albuminuria,  absent  in,  552. 
causes  of,  549,  550. 
chronic  interstitial,  558. 
climate  in,  561. 
diagnosis,  551. 
diaphoretics  in,  559. 
diet  in,  5(51. 
diphtheria  with,  550. 
dropsy  with,  553. 
duration  of,  556. 
glandular  fever  with,  550. 
heart  affection  in,  554. 
llcnofh's  purpura  with,  550. 
hot-air  baths  in,  559. 
in  infancy,  549. 


.Nephritis  (continued) — 

mortality  of,  556. 

packs  in,  559. 

prognosis,  554. 

retinitis  with,  552. 

sex-incidence,  519. 

symptoms,  551. 

syphilitic,  809. 

treatment,  559. 
Nerve  irritability,  654. 

in  convulsions,  654,  65D. 
Nervous,  bowel,  163. 

children,  622. 

fever  in,  260,  205. 

diarrhoea,  738. 
treatment,  175. 

disorders,  with  stuttering,  749. 

excitability,  7,  10,  622,  626. 
Nervousness,   earliest  indications   of, 
622. 

onurcsis  with,  627,  729. 

habit  spasm  with,  627. 

headaches  with,  628. 

pica  with,  781. 

teeth-grinding  with,  784. 

treatment,  629. 

with  indigestion,  178. 

with  rheumatism,  478. 

with  worms,  292,  294. 
Neuritis,  in  infantile  palsy,  695. 
Neuroses,  following  convulsions,  651 
Newborn,  jaundice  in,  300. 

family  malignant  jaundice  in,  303. 

hemorrhages  in,  797. 

intercellular  cirrhosis  in,  797. 

laryngcal  spasm  in,  335. 
Night-sweats,  414. 
Night-terrors,  625. 

indigestion  causing,   179. 

rheumatism  with,  479. 

worms  causing,  292. 
Nitrite  of  silver,  in  diarrhoea,  234. 
Nitrite  of  amyl,  in  heart  disease,  503, 

547. 

Nodules,  rheumatic,  474,  496. 
Nose-picking,  292. 
'  Nursery  milk,'  79. 
Nystagmus,   acquired   without   head- 
shaking,  768. 

ear-syringing  a  cause  of,  769. 

in  congenital  ataxia,  762. 

in  Mongolism,  614. 

spasmus  nutans  with,  765,  769. 

Obstruction   of  bowel  by  adhesions, 

427. 
(Edema,  angeioneurotic,   186. 

from  citrated  nrlk,  53. 

of  eyelids,  180,  181. 

with  diarrhoea,  225. 

marasmus,  144. 

nephritis,  551. 


INDEX 


837 


(Edema  (continycd)  — 

with  tetany,  657. 

without  albuminuria,  554. 
(Esophageal  spasm,  hysterical,  762. 
(Esophagitis,  with  diarrhoea,  225. 
Offensive  breath,  182. 
Oil  inunction,  150. 
Onychia,  syphilitic,  800. 
Open  air,  in  broncho-pneumonia,  367. 

value  and  dangers  of,  148. 
Ophthalmo-tuberculin  reaction,  410. 
Ophthalmoscopic      appearances,      in 
acute  tuberculosis,  461. 

in  congenital  heart  disease,  538. 

in  hydrocephalus,  718. 

in  nephritis,  552. 

in  syphilitic  mental  degeneration, 
594. 

in  tuberculous  meningitis,  461. 
Opium,  dosage  for  infants,  233. 

in  endocarditis,  502. 

in  pneumonia,  381. 
Opsonic  index,  value  of,  417. 
Optic  atrophy,  with  syphilitic  mental 

degeneration,  594. 
Orchitis,  syphilitic,  804. 
Osteo-arthritis  simulated  by  syphilis, 

819. 
Otitis,  latent,  cause  of  fever,  270,  275. 

adenoids  causing,  316,  319,  320. 

deaf-mutism  after,  744. 

head-retraction  with,  223. 

head-rolling  with,  787. 

with  diarrhoea,  223. 

with  pneumonia,  372. 

with  tuberculous  meningitis,  462. 

without  pain,  270. 
Oxalates,  in  urine,  564. 
Oxyuris  vermicularis,  286. 

treatment,  296. 
Ozsena,  syphilitic,  799. 

Packs,  hot,  in  nephritis,  559. 

wet,  in  chorea,  530. 
Palatal  palsy,  congenital,  761. 
Pallor,  sudden,  with  indigestion,  179. 

with  masturbation,  777. 
Palpitation,  with  indigestion,  183. 
Palsies,  cerebral,  701. 

asphyxia,  causing,  703. 

with  syphilis,  704. 
Palsy,  facial,  with  infantile  paralysis, 

693. 

Pancreatin,  use  of,  174. 
Papilloma  of  larynx,  339. 
Paralalia,  751. 

Paralysis,      diphtheritic,      simulating 
chorea,  526. 

epiphysitis  simulating,  802. 

infantile,  684. 

scurvy  simulating,  112. 

spastic,  701. 


Paralysis  (continued) — 

temporary,  661. 
Paraplegia,  spastic,  701. 

idiocy  with,  590. 

Parents,    consanguinity   of,    affecting 
offspring,  600. 

relative  age  of,  affecting  offspring, 

603. 
Paroxysmal  dyspnoea,   in   congenital 

heart  disease,  545. 
Parrot's  nodes,  807. 
Passionatenes?,head-bangingwith,788. 

with  pica,  781. 
Pasteurization  of  milk,  48. 

to  prevent  tubercle,  418. 
Patent  foods,  in  infant  feeding,  63,  64. 

carbohydrate  excess  in,  65,  68. 

classification  of,  64. 

fat  deficiency  in,  65,  67. 

scurvy  from,  69,  119. 

starch  in,  64. 

varieties  of,  64. 
Patent  foramen  ovale,  534. 
Patent  septum  ventriculum,  543. 
Pemphigus,  syphilitic,  797. 
Peptogenic  milk  powder.  53. 
Peptonization  of  milk,  53. 

disadvantages  of,  54,  62. 

value  of,  62. 
Percentage  composition,  fallacies  of, 

46. 

Percentage  feeding,  31,  46. 
Perforation  of  bronchus  by  medias- 

tinal  glands,  408. 
Pericarditis,  rheumatic,  504. 

age-incidence  of,  504. 

alcohol  in,  513. 

dilatation,  cardiac,  in,  507,  511. 

dress  in,  505. 

heart  dullness  in,  507. 

heart  tracings  in,  506. 

ice-bag  in,  512. 

leeching  in,  511. 

opium  in,  511. 

pleurisy  with,  508. 

prognosis,  509. 

rapidly  fatal,  509. 

sex  in,  505. 

symptoms,  505. 

treatment,  510. 

Pericarditis,  suppurative,  390. 
Peristalsis,  visible,  with  pyloric  hyper- 
trophy, 156. 
Peritonitis,  intra-uterine,  801. 

tuberculous  (see  Tuberculous  peri- 
tonitis), 430. 

syphilitic,  801. 

with  empyema,  391. 
Perverted  appetite,  779. 
Petit  mal  in  infancy,  672. 

simulated  in  spasmus  nutans,  766. 
Petroleum  for  constipation,  211,  213. 


838 


INDEX 


Phcnazono,  for  chorea,  529. 

for  convulsive  disorders,  666. 

for  epilepsy,  681. 

for  spasmus  nutans,  774. 
Photophobia,  with  dentition,  11. 

with  meningitis,  459. 
Phthisis,  see  Pulmonary  tuberculosis, 

408. 

Phthisis,  pyelitis  simulating,  575. 
Pica,  779. 

associations  of,  781. 

nervous  symptoms  with,  781. 

passionateness  with,  781. 

prognosis,  782. 

symptoms,  780. 

treatment,  782. 
Picking  of  nose,  292. 

with  threadworms,  292. 
Pigmentation,  arsenical,  528. 
Piles,  in  infancy,  205. 
Place,  in  family,  535,  603. 

Mongolism  related  to,.  617. 
Pleural  effusion,  measurement  of  chest 

in,  387. 

Pleural  haemorrhage,  in  scurvy,  117. 
Pleurisy,  rheumatic,  508. 
Pneumococcal,  arthritis,  378,  391. 

empyema,  391. 

pericarditis,  391. 
Pneumonia,  lobar,  370. 

age-incidence,  370. 

alcohol  in,  381. 

apical,  374. 

arthritis  in,  378. 

blood  in,' 374. 

broncho-pneumonia  simulating,  364, 
375. 

bruits  in,  378. 

contagion  in,  371. 

convulsions  in,  372. 

diagnosis,  375. 
from  broncho-pneumonia,  370,375. 

dress  in,  382. 

drowsiness  in,  372. 

empyema  with,  377. 

epistaxis  with,  374. 

head-retraction  with,  377. 

herpes  with,  374. 

ice-bag  in,  380. 

leucytosis  in,  374. 

malignant,  379. 

meningitis  with,  377. 

nephritis  in,  378,  550. 

opium  in,  381. 

otitis  media  with,  372. 

prognosis,  377. 

pseudo-crisis,  in,  375. 

simulating  appendicitis,  373. 

simulating  meningitis,  376. 

simulating  typhoid,  376. 

symptoms,  372. 

temperature  in,  374- 


Pneumonia,  lobar  (continued) — • 

treatment,  379. 

vaccine  for,  381. 

vomit  at  onset,  372. 
Pneumonia,    lobular    (see    Broncho- 
pneumonia),  363. 
Polio-encephalitis,  693,  705. 

causing  idiocy,  593. 

cerebral  palsies  with,  705. 
Poliomyelitis  (see  Infantile  paralysis), 

684. 

Pollakiuria,  726,  728. 
Polycythgemia,  with  congenital  heart 

disease,  538. 

Porridge  causing  indigestion,  188,  209. 
Posterior  basic  meningitis,  463. 

age-incidence  of,  454. 

champing  movement  in,  783. 

deaf-mutism  after,  744. 

frequency  of,  453. 

teeth-grinding  in,  783. 
Potassium  citrate  in  pyelitis,  280,  579. 
Potato,  in  indigestion,  188. 

in  scurvy,  121. 
Potato  cream,  121. 
Poultices,  in  broncho-pneumonia,  367. 
Pregnancy,  chorea  in,  515. 
Premature  birth,  cerebral  palsies  with, 

704. 

Presystolic  bruit,  493. 
Primary  dentition,  syphilis  affecting, 

810. 
Prolapse,  of  rectum,  205. 

with  diarrhoea,  221. 
Protargol  for  vulvo-vaginitis,  778. 
Proteid,    deficiency    of,    relation    to 

rickets,  85. 
Proteids  in  cow's  milk,  32. 

curd-forming,  indigestion  from,  52. 

increased  by  using  whey  as  diluent, 
42. 

lactalbumen,  34. 
Pseudo-paralysis  in  scurvy,  112. 

syphilitic,  802. 

Puberty,  relation  to  epilepsy,  671. 
Puffiness  of  eyelids,  in  cyclic  albumin  - 
uria,  181. 

whooping-cough  with,  553. 
Pulmonary  atresia,  541. 
Pulmonary  stenosis,  543. 
Pulmonary  tuberculosis,  408. 

caseation  in,  411. 

cavitation  in,  411. 

diagnosis  of,  414. 

inhalation  for,  421. 

prognosis,  414. 

special  liability  to,  in  infancy,  397. 

varieties  of,  409. 

Pulse  in  tuberculous  meningitis,  460. 
Purin-free  diet,  in  epilepsy,  680. 
Purpura,  Henoch's,  550. 

nephritis  with,  550. 


INDEX 


839 


Purpura  (continued) — 

with  diarrhoea,  2'25. 

with  marasmus,  145. 
Pus  in  urine,  277,  280. 
Pyaemia,  jaundice  with,  305. 
Pyclitis,  568. 

age-incidence  in,  509. 

appendicitis  simulated  by,  571. 

bacteriology  of,  569. 

cause  of  unexplained  fever,  115,  277, 
568,  571. 

chronic,  575. 

collapse  with,  570. 

convulsions  with,  570. 

diagnosis,  576. 

fever  with,  277,  571. 

mode  of  infection,  569. 

morbid  anatomy,  578. 

potassium  citrate  in,  579. 
•prognosis,  577. 

rigors  in,  570. 

scurvy  with,  115. 

sex  in,  569. 

simulating  meningitis,  280,  571. 

stimulants  in,  582. 

symptoms,  569. 

temperature  in,  571. 

treatment,  579. 

urine  in,  573. 

urotropin  for,  582. 

vaccine  for,  582. 
Pylorus,  hypertrophy  of,  151. 

age  of  onset,  152. 

constipation  in,  155. 

diet,  influence  of,  in,  154,  160. 

dietetic  treatment,  160. 

nasal  feeding  for,  162. 

operations  for,  165. 

peristalsis  visible  in,  156. 

place  in  family,  152. 
-    results  of  treatment  in,  160. 

sex,  152. 

stomach-washing  in,  160,  162. 

symptoms,  151. 

treatment,  159. 

tumour  of  pylorus  felt  in,  153. 

vomiting,  characters  of,  154. 

wasting  with,  155. 
Pyrexia,  recurrent,  255,  201. 

diet  in,  264. 

treatment,  264. 

Quinine  for  prolonged  fever,  274. 

Rachitic  chest,  99. 

Raw-meat  juice,  54. 

Rectal  injections  in  diarrhoaa,  229, 235. 

Rec  um,  stenosis  of,  204. 

prolapse  of,  205. 

Recumbency    for    tuberculous    peri- 
tonitis, 438. 
Recurrent  fever,  201. 


Recurrent  fever  (continued)  — 

diet  in,  264. 

drowsiness  with,  261. 

pale  stools  in,  264. 

relation  to  cyclic  vomiting,  255. 

simulated  by  meningitis,  203. 

simulating  appendicitis,  263. 

treatment,  264. 

Recurrent  vomiting  (see  Cyclic  vomit- 
ing), 251. 

Recurring  jaundice,  308. 
Red  hair,  rheumatism  with,  480. 
Relapsing  broncho-pneumonia,  364. 
Renal  calculus,  171. 
Renal  vomiting,  257. 
Resection  of  rib  in  empyema,  394. 
Rest  in  bed,  in  chorea,  526,  531. 

in  heart  disease,  497. 
Retinitis,  albuminuric,  552. 
Retraction  of  head  (see  Head-retrac- 
tion), 223. 
Rheumatic  endocarditis  simulated  by 

congenital  heart  disease,  544. 
Rheumatic  nodules,  474. 
Rheumatism,  469. 

age-incidence,  471. 

anremia  in,  478. 

arthritis  in,  481. 

cardiac  affections  in,  474,  480. 

cerebral,  477. 

chorea,  relation  to,  470,  515,  518. 

chronic  fibrous,  483. 

cold  and  damp,  causing,  473,  485. 

diagnosis,  480. 

endocarditis  with,  474,  476,  480. 

frequency  of,  470. 

growing  pains  in,  473,  489. 

habit-spasm  with,  479. 

headache  with,  478. 

house  infection  in,  487. 

hyperpyrexia  in,  477. 

infantile  palsy  simulates,  695. 

infants  rarely  affected  by,  481. 

in  hip,  473. 

joint  affection  slight  in,  470,  473. 

lienteric  diarrhoea  with,  479. 

nephritis  with,  550. 

nervousness  in,  478. 

night-terrors  with,  479. 

nodules  with,  474. 

pain  in  side  with,  478. 

pericarditis  with,  504. 

pleurisy  with,  508. 

prognosis,  483. 

prolonged  fever  with,  274. 

rashes  in,  477. 

red  hair  with,  480. 

scurvy  confused  with,  110,  431. 

skin  eruptions  in,  477. 

somnambulism  with,  479. 

sore-throat  in,  477. 

stiff-neck  in,  474. 


J 
840 


INDEX 


Rheumatism  (continued)^ 

symptoms,  472. 

tonsillitis  in,  457,  477. 

treatment,  484. 

wasting  with,  474. 
Rheumatism,  scarlatinal,  488. 
Rhubarb,  haematuria  from,  565. 
Rhus  aromatica  for  enuresis,  735. 
Rhythmic  movements,  780,  789. 

in  mental  deficiency,  580,  789. 
Rice-water,  44. 

as  milk  diluent,  44. 

for  diarrhoea,  228. 

preparation  of,  44. 
Rickets,  00,  70,  84. 

abdomen  large  in,  98. 

a  food  disorder,  84,  85,  102. 

age-incidence  of,  88. 

anaemia  with,  99. 

barley-water  causing,  103. 

baths  for,  100. 

beading  of  ribs  in,  91,  101. 

bending  of  bones  in,  93. 

boiled  milk  not  causal  of,  102. 

bronchitis  with,  99,  355. 

carious  teeth  with,  198. 

clavicle,  deformity  in,  93. 

condensed  milk  a  cause  of,  70. 

contributing  causes  of,  87. 

convulsions  with,  053. 

coxa  vara  in,  93. 

deficiency  of  fat,   causing,   30,   GO, 
80,  87,  103. 

deformities  of,  preventable,  93,  94. 

dentition  delayed  by,  101. 

diagnosis  of,  100. 

diarrhoea  with,  99. 

dietetic  causes  of,  85,  103. 

egg,  yolk  of,  for,  104. 

epiphysial  enlargement  in,  92. 

fontanelle  in,  95,  101. 

frequency  of,  84-. 

green-stick  fractures  in,  93. 

growth  stunted  by,  93. 

head  characteristic  in,  95. 

head-sweating  in,  101. 

internal  beads,  formation  of,  92. 

kyphosis  in,  94. 

laryngismus  stridulus  in,  98. 

ligaments  lax  in,  94. 

lime-water  not  preventive  of,  44,  45 
SS,  103. 

massage  in,  107. 

mental  condition  in,  95,  90. 

muscular  symptoms  in,  94. 

nervous  symptoms  in,  90,  107. 

newborn  with,  100. 

pain  in,  90. 

phosphorus  in,  105. 

posterior  beads  in,  92. 

lirevcnt ion  of,  102. 

reeti,  diastasis  of,  in,  98. 


Rickets  (continued) — 

recumbency,  value  of,  in,  94. 

spasmus  nutans  with,  768. 

symptoms,  89. 

syphilis  and,  87,  97. 

teeth  decayed  in,  91,  198. 

tetany  with,  658. 

treatment,  102. 
Rigor,  in  pyelitis,  280,  570. 

rarity  of,  in  infants,  570. 

replaced  by  vomiting,  280,  372. 
Roundworms,  293. 

convulsions  with,  294. 

family  incidence  of,  293. 

fever  with,  284. 

in  larynx,  294. 

treatment,  298. 

vomited,  293. 

Salicylate  of  sodium,  for  jaundice,  313. 

for  chorea,  528. 

for  pericarditis,  511. 

toxic  effects  of,  528. 

use  of,  484. 
Saline  infusion,  in  diarrhoea,  229. 

rectal  injections,  229,  235. 
Salix  nigra  in  masturbation,  778. 
Salvarsan  injection,  818. 
Santonin,  administration  of,  297. 
Scarlatinal  rheumatism,  488. 
Scarlet  fever  with  chorea,  516. 
Scorbutic  foods,   119. 
Screaming,  constipation  causing,  205. 

with  colic,  131. 

with  dentition,  11. 

with  diarrhoea,  223. 

with  mental  deficiency,  585. 
Scurvy,  108. 

age-incidence,  110. 

boiled  milk  causing,  120. 

diagnosis  from  epiphysitis,  110. 

diagnosis  from   infantile   paralysis, 
112. 

diagnosis  from  rheumatism,  1 10, 48 1 . 

dietetic    cause,    not    same    as    of 
rickets,  109. 

dress  in,  122. 

epiphysis  separated  in,  112. 

epiphysitis  simulating,  803. 

Glisson  on,  108. 

gums  in,  113. 

haamaturia  in,  115. 

haemorrhages  in,  116. 

limb  affection  in,  111. 

mode  of  onset  of,  110. 

muscles  in,  112. 

nephritis  in,  115. 

oedema  in,  113. 

onset,  sudden  in,  111. 

orbital  hemorrhage  in,  114. 

palatal  haemorrhage  in,  114. 

patent  foods  causing,  67,  119. 


INDEX 


841 


Scurvy  (continued)  — 

prognosis,  118. 

pyelitis  in,  115. 

traumatism  in,  111. 

treatment,  119. 

urine  in,  114. 

Sea  water  for  diarrhoea,  230. 
Senna  pods  for  constipation,  211. 
Serous  effusion,  387. 
Sherry-whey,  57. 

alcohol,  amount  of,  in,  58. 

in  diarrhoea,  232. 

method  of  preparing,  57. 
Shivering  in  pyelitis,  277. 
Shortness  of  breath  with  indigestion, 

182. 
Sight,  development  of,  14. 

testing  of,  in  infants,  14. 
Silver  nitrate,  in  diarrhoea,  234. 
Sitting,  date  of,  16. 
Skin  eruptions  in  syphilis,  799. 
Skodaic  note,  value  of,  387. 
Skull  in  mentally  defective,  588. 

in  hydrocephalus  defective  ossifica- 
tion of,  715. 

in  Mongolism,  613. 

in  rickets,  95. 

in  syphilis,  97,  808. 
Sleep,    amount   required   at   various 
ages,  757. 

disorders  with  habit-spasm,  640. 
in  nervous  children,  624. 

disturbed  by  adenoids,  316,  756. 

masturbation  inducing,  777. 

mid-day,  757. 

relation  to  epilepsy,  675. 
Sleeplessness,  622,  755. 

from  adenoids,  316,  750. 

from  flatulence,  124. 

with  dentition,  11,  755. 

with  heart  disease,  498. 

with  indigestion,  756. 

treatment,  756. 
Sleepiness  in  epilepsy,  674. 
Small  intestine,  reached  by  enemata, 
296. 

threadworms  in,  287. 
Sneezing,  paroxysmal  in  asthma,  347. 
Snuffles,  with  adenoids,  799. 

with  Mongelism,  615,  798. 

with  syphilis,  798. 

Sodium  citrate,  with  cow's  milk,  52. 
Somnambulism,  rheumatism  with,479. 
Somnolence  in  epilepsy,  674. 
Sore-throat,  rheumatic,  477. 
Spasm,  laryngeal,  in  newborn,  335. 
Spasmodic  croup,  330. 

climate  in,  334. 

etiology,  331. 

prognosis,  332. 

relation  to  asthma,  345. 

treatment,  333. 


Spasmus  nutans,  764. 

age-incidence,  764. 

defective  light  with,  769. 

dentition  causing,  12,  769. 

diagnosis,  773. 

etiology,  768. 

facial  irritability  in,  768. 

miner's  nystagmus  compared  with, 
771. 

nystagmus  in,  767. 

prognosis,  772. 

rickets  related  to,  768. 

seasonal  incidence  of,  770. 

shaking  of  arms  in,  768. 

simulating  '  petit  mal ',  766. 

symptoms,  765. 

treatment,  774. 
Spastic  diplegia,  701. 

idiocy  with,  590. 

syphilis  causing,  705. 
Spastic  monoplegia,  rarity  of,  701,  709. 
Spastic  paralysis,  701. 
Spastic  paraplegia,  701. 

idiocy  with,  590. 

syphilis  causing,  705. 
Specific  fevers,  arthritis  with,  482. 

followed  by  cerebral  palsies,  706. 

followed  by  infantile  paralysis,  688. 

followed  by  stuttering,  749. 

infantile  hemiplegia  with,  705. 
Specific  gravity  of  milk,  19,  20. 
Speech,  16,  740. 

absence  of,  741. 

deaf-mutism,  743. 

defective  articulation,  751. 

defective  intellect,  relation  to,  743. 

defective,  treatment  of,  751,  753. 

development  of,  740. 

disorders  of,  740. 

faulty,  748. 

loss  of,  747. 

loss  of,  from  fright,  747. 

loss  of,  in  epilepsy,  674. 

stuttering,  748,  751. 

voluntary  absence  of,  747. 
Spleen,  syphilitic  enlargement  of,  801 
Splenic  anaemia,  807. 
Sprue,  resemblance  to  cceliac  disease, 

238. 

Spurious  hydrocephalus,  223. 
Sputum,    examinatjon    for    tubercle 
bacillus,  415. 

method  of  obtaining,  415« 
Stammering,  751,  753. 

treatment  of,  753. 
Standing,  date  of,  16. 
Starch,  in  barley-water,  43. 
Status    lymphaticus    with     enlarged 

tonsils  and  adenoids,  315,  320. 
Stenosis,  mitral,  494. 

of  rectum,  204. 
Sterilization  of  cow's  milk,  47. 


* 
842 


INDEX 


Stiff-neck,  474. 

Stomach     peristalsis     with     pyloric 

hypertrophy,  150. 

Stomach-washing,  in    pyloric    hyper- 
trophy, 160,  102. 
risks  of,  165. 
Stomatitis,  with  dentition,  10. 

with  foul  teeth,  195. 
Stone  in  kidney,  171. 
Stools,  blood  in,  205. 

diarrhceal,  220,  221,  222. 
in  cceliac  disease,  239. 
in  infantile  colic,  120. 
pale,  with  recurrent  fever,  204. 
paleness  of,  181,  239. 
Strangulation,  intestinal,  by  band,  427. 

in  tuberculous  peritonitis,  437. 
Stridor,  congenital  laryngeal,  330. 
mediastinal  glands  causing,  338. 
papilloma  of  larynx  with,  339. 
with  acute  laryngitis,  329. 
Strychnine,  for  infants,  230. 
in  broncho-pneumonia,  309. 
in  heart  disease,  500. 
in  pneumonia,  382. 
Subcutaneous  infusion,  229. 
Subperiosteal  ossification  in   scurvy, 

118. 
Sudden    death,    in    congenital    heart 

disease,  540. 
in  marasmus,  140. 
with  infantile  paralysis,  090. 
Sugar,  added  to  cow's  milk,  40. 
effect  on  teeth,  199. 
excess  of,  relation  to  rickets,  85. 
for  constipation,  208. 
in  infant-feeding,  40. 
milk-,  preferable  to  cane-,  41. 
solutions  of,  objections  to,  40. 
Suppositories,  aperient  use  of,  213. 
Suppression  of  urine, physiological, 502. 
Suppurative  meningitis,  378,  391. 
Suppurative  pericarditis,  390. 
Sweating  in  childhood,  414. 
Sweets,  effect  on  teeth,  199. 
Synovitis,  syphilitic,  482,  812. 
Syphilides,  799. 
Syphilis,  congenital,  792. 
acquired,  792. 

age  at  first  appearance  of,  795. 
alopecia  with,  800. 
ana'inia  in,  800. 
at  birth,  797. 
blood  in,  807. 
brain  affection  in,  804. 
breast-feeding  in,  790,  823. 
causing  epilepsy,  671. 
cerebral  palsies  with,  704. 
choroiditis  in,  80(5. 
cirrhosis  with,  305,  3)0,  797. 
Colles's  law  in,  794,  815,  820. 
contagion  in,  815. 


Syphilis  (continued) — 

craniotabes  in,  97,  809. 

dactylitis  in,  803. 

deafness  with,  813. 

depressed  bridges  of  noso  in,  7D9. 

epiphysitis  in,  802. 

eye  affection  in,  805. 

fcetal  ascitcs  with,  801. 

frequency  of,  792. 

general  paralysis  with,  804. 

hair  in,  800.  " 

hsemoglobinuria  in,  795. 

haemorrhages  in,  797.     • 

heart  disease  with,  535. 

Hutchinsonian  teeth  in,  811. 

hydrocephalus  with,  716,  805. 

idiocy  with,  594,  804. 

interstitial  keratitis  in,  806. 

jaundice  with,  305,  797. 

joint  affection  in,  812. 

laryngitis  in,  802. 

late  hereditary,  796. 

lymphatic  glands  in,  813. 

marasmus  in,  138,  798,  820. 

melsena  neonatorum  with,  797. 

meningitis  in,  805. 

milk  infection  in,  79G. 

mortality  from,  792. 

neo-salvarsan  for,  818. 

nephritis  in,  809. 

onychia  in,  800. 

orchitis  in,  804. 

parental  syphilis,  stage  of,  affecting, 
795. 

Parrot's  nodes  in,  807. 

periostitis  in,  812. 

peritonitis  in,  801. 

rickets  with,  87,  97. 

salvarsan  for,  818. 

skin  eruptions  of,  799. 

skull  in,  97,  808. 

snuffles  in,  797,  798. 

spleen  in,  801. 

symptoms,  795. 

tarda,  796. 

teeth  in,  810. 

transmission  of,  794. 

treatment,  816. 

Wassermann  test  for,  793. 
Syphilitic  arthritis,  482,  812. 
Syphilitic  idiocy,  597,  804. 
Syphilitic  mental  degeneration,  80 1. 
Syphilitic  oza?na,  799. 

Tabes  mesenterica,  424. 

appendicitis  confused  with,  420. 
diagnosis,  425. 
diet  in,  427. 
fats  in,  428. 
frequency  of,  424. 
lymphatics  obstructed  in,  428. 
operation  for,  429. 


INDEX 


843 


Tabes  mcsentcrica  (continued) — 

prognosis,  427. 

symptoms,  425. 

treatment,  427. 

ulceration  of  bowel  in,  426. 
Tache  cerebrale,  459. 
Talipes  due  to  cerebral  palsy,  70S. 

due  to  infantile  paralysis,  694. 
Tapeworms,  295,  298. 
Teeth,  carious,  193. 

abdominal  pains  from,  169. 

anaemia  from,  195. 

anorexia  from,  197. 

channel  of  tuberculosis,  419. 

colic  from,  194. 

congenital,  5. 

decayed,  in  rickets,  91. 

epilepsy  from,  196. 

failure  of  appetite  from,  194. 

foul,  causing  stomatitis,  195. 

frequency  of,  193. 

habit-spasm  from,  196. 

headache  from,  197. 

indigestion  caused  by,  184,  194. 

in  rickets,  198. 

second,  13. 

stomatitis  from,  195. 

sugar,  effect  of,  on,  190. 

sweets,  effect  of,  on,  199. 

tuberculosis  from,  195. 

tuberculous  glands  from,  195. 

wasting  from,  194. 
Teeth-grinding,  causes  of,  783. 

indigestion  with,  783. 

nervous  associations  of,  784. 

with  worms,  292,  784. 
Temperature,  irregularity  of,  260. 

with  nervous  instability,  260,  626. 
Testicle,  syphilitic,  804. 

tuberculous,  433. 
Tetany,  655. 

albuminuria  with,  657. 

convulsions  with,  659. 

latent,  658. 

prognosis,  659. 

treatment,  664,  667. 
Theocin,  501. 
Threadworms,  286. 

abdominal  pains  with,  169. 

anal  irritation  with,  292. 

appendix,  catarrhal,  with,  290. 

appendix,  seat  of,  286. 

choreiform  movements  with,  292. 

colicky  pain  with,  291. 

convulsion  with,  292. 

enuresis  with,  292,  729. 

frequency  of,  286. 

in  small  intestine,  287. 

in  vulva,  293. 

itching  at  anus  with,  292. 

life-history  of,  287. 

mucous  catarrh  with,  293. 


Threadworms  (continued)— 

nose- picking  with,  292. 

ova  on  hands,  288. 

simulated  by  vegetable  fibres,  293. 

simulating  appendicitis,  289. 

treatment,  296. 

wasting  with,  291. 
Throat 'affections,  fever  from,  234. 
Thrombosis  of  sinuses,  224. 
Thrush,  222. 

with  marasmus,  143. 
Thyroid,  dosage  of,  608. 

in  cretinism,  607. 

in  marasmus,  149. 

in  mental  deficiency,  608. 

use  of,  608. 
Tiredness,  with  constipation,  205. 

with  indigestion,  180. 
Toast,  often  harmful,  187. 
Tongue  in  Mongolian  imbecility,  611. 
Tonsillitis,  in  rheumatism,  477,  489. 

nephritis  with,  550. 

recurring,  317. 

with  decayed  teeth,  317,  322. 

with  gastric  disturbance,  316. 
Tonsils,  enlarged,  314. 

asthma  with,  344. 

climate  for,  325. 

conveying  tuberculosis,  321,  401. 

effects  of,  317. 

enlarged  glands  with,  321. 

enucleation  of,  323. 

operation  for,  321,  322. 

paints  for,  325. 

pharyngeal,  319. 

rheumatic  infection  from,  321. 

status  lymphaticus  with,  315,  320. 

svmptoms,  315. 

treatment,  318. 
Top-milk,  37. 
Trachea,  foreign  body  in,  340. 

stenosis  of,  339. 
Traumatic  idiocy,  593. 
Traumatism,  causing  infantile  palsy, 
688. 

with  tuberculous  meningitis,  456. 
Trichocephalus  dispar,  295. 
Trousseau's  sign,  658. 
Tubercle   of   choroid,   in   meningitis, 

414,  461. 
Tubercle    bacillus,     examination    of 

sputum  for,  415. 
Tuberculin,  reaction,  416. 

for  tuberculous  glands  in  neck,  451. 

for  tuberculous  meningitis,  467. 

for  tuberculous  peritonitis,  440. 

treatment,  422. 
Tuberculosis,  396. 

abdominal,  423. 

age-incidence  of,  397. 

channels  of  infection  in,  398. 

climatic  treatment,  420. 


844 


INDEX 


Tuberculosis  (continued) — 

cow's  milk,  a  source  of,  419. 

creosote  for,  421,  430. 

ear  infection  in,  401. 

empyema  with,  385. 

from  milk,  399,  419. 

glands,  cervical  in,  402. 

glandular,  402. 

infection,  risk  of,  398,  399,  419. 

inhalation,  infection  by,  400. 

latent,  prolonged  fever  with,  272. 

measles,  followed  by,  403,  419. 

mediastinal  glands  in,  402,  404. 

mental  deficiency  with,  600. 

miliary,  acute,  412. 

milk,  infection  in,  47,  398,  418. 

mortality  from,  390. 

prevention  of,  398,  418. 

pulmonary,  408. 

simulated    by    broncho-pneumonia, 
3<>5,  300. 

tonsils  and  adenoids  conveying,  401. 

tnut ment,  417. 

whooping-cough  followed  by,  403, 

419. 

Tuberculous    glands,    from    decayed 
teeth,  195. 

with  abdominal  pains,  172. 

with  enlarged  tonsils,  321. 
Tuberculous  glands  in  neck,  441. 

age  at  onset,  445. 

diagnosis,  447. 

etiology,  445. 

frequency  of,  443. 

milk  infection  causing,  445. 

operation  for,  451. 

prognosis,  449. 

simple  adenitis,  diagnosis  from,  448. 

symptoms,  44(i. 

treatment,  449. 

tulxTculin  for,  451. 
Tuberculous  mediasthrxl  glands,  404. 

diagnosis  of,  405. 
Tuberculous  meningitis,  408,  453. 

age-incidence,  45  \. 

cerebro-spinal  meningitis  diagnosed 
from,  403. 

collapse  with,  400. 

constipation  in,  453. 

diagnosis,  4(11. 

drowsiness  \vit  h,  459. 

duration  of,  401). 

glyeosura  in,  400. 

infect  ion  can  ;iiiLr,  45f>. 

irregularity  of  heart  in,  400. 

mental  symptoms  with,  457. 

ophthalmoscopic    appearances    in, 

otitis  media  with,  402. 
primary,  so-called,  450. 
prognosis,  404. 
pulse  in,  400. 


Tuberculous  meningitis  (continued) — 

recovery,  possibility  of,  in,  465. 

school  strain  predisposing  to,  456. 

sex  in,  453. 

symptoms,  456. 

temperature  in,  460. 

traumatism  with,  456. 

treatment,  466. 

tuberculin  for,  467. 

urine  in,  460. 

urotropin  for,  466. 

vomiting  in,  457. 
Tuberculous  peritonitis,  430. 

acute  abdominal  distension  in,  433. 

age-incidence,  430,  431. 

ascitic  variety  of,  433. 

bowel  perforation  in,  432. 

climatic  treatment  of,  437. 

creosote  for,  439. 

duration  of,  435. 

feeding  in,  438. 

frequency,  430. 

iodoform  for,  438. 

laparotomy  for,  4G5. 

prognosis  of,  434. 

recumbency  for,  438. 

sex  in,  431. 

surgical  treatment  of,  435. 

symptoms,  431. 

treatment,  435. 

tuberculin  for,  440. 

ulceration  of  bowel  in,  433. 

umbilical  perforation  in,  432. 

urea  for,  439. 
Tumour,    cerebral,    with    chorciform 

movements,  525. 
Twins,  genetous  idiocy  in,  604. 

microccphalic,  590. 

one  syphilitic,  795. 

Typhoid,    meningitis    confused    with, 
401. 

simulated  by  pneumonia,  376. 

Ulcer,  frscnal,  in  whooping-cough,  366. 
Ulceration  of  bowel,  in  tabes  mesen- 
terica,  420. 

in  tuberculous  peritonitis,  433. 
Umbilical  perforation  in  tuberculous 

peritonitis,  432. 
Urea  for  tuberculosis,  439. 
Urcthanc  for  convulsions,  605. 

for  epilepsy,  682. 
Uric  acid,  enurcsis  caused  by,  C99. 

in  urine,  505. 
Urinary  disorders,  502. 
Urine,  acidity  causing  enurcsis,  731. 

abnormal  colour  of,  507. 

aveiage  daily  amounts  of,  562. 

collection  of  infants',  573. 

in  cyclic  albuminuria,  171,  563. 

in  scurvy,  114. 

oxalates  in,  564. 


INDEX 


845 


Urine  (continued) — 

pink,  567. 

pus  in  infants,  280. 

sugar  in,  with  meningitis,  460. 

suppression  of,  physiological,  563. 
Urotrophi,  in  infantile  paralysis,  697. 

in  pyelitis,  582. 

in  tuberculous  meningitis,  466. 

Vaccination,  infantile  palsy  following, 

688. 
Vaccines,  in  pneumonia,  381. 

in  broncho-pneumonia,  368. 

in  emphysema,  395. 
Vaginal  discharge,  arthritis  with,  481. 

masturbation  with,  775. 

simulating  cyclic  albuminuria,  564. 
Varicella  causing  nephritis,  550. 
Vasomotor  epilepsy,  180. 
Vegetable    fibres    simulating    thread- 
worms, 293. 
Vegetables,  difficulty  of  digesting,  168. 

for  children,  188. 
Vomiting  cyclic,  251. 

acetonsemia  in,  253. 

called  '  bilious  attacks  ',  251. 

drowsiness  with,  251. 

relation  to  recurrent  fever,  255. 

treatment,  253. 

Vomiting,  constipation  with,  204. 
-    renal,  257. 
k  replaces  rigor  in  child,  280,  372. 

•  with  appendicitis,  248. 
,with  dentition,  10. 
-with  diarrhoea,  220,  221. 

•  with  heart  disease,  502. 

•  with  indigestion,  181. 
>with  pneumonia,  372. 

-with  pyloric  hypertrophy,  154. 
with  tuberculous  meningitis,  457. 
Von  Pirquet's  reaction,  416. 
Vulva,  threadworms  in,  293. 
Vulvo-vaginitis,     albuminuria     from, 

550. 

arthritis  with,  481. 
masturbation  from,  775. 
pyelitis  simulated  by,  576. 

Walking,  acquirement  of,  in  mental 
deficiency,  605. 

date  of,  16. 

difficulty  in,  762. 

stumbling  in,  762. 

stuttering  in,  763. 
Warmth,  importance  of,  in  marasmus, 

149. 
Wassermann  test,  793. 

in  cerebral  palsies,  705. 

in  congenital  heart  disease,  535. 

in  mental  deficiency,  597. 

in  wet-nurse,  27. 
Wasting,  carious  teeth  causing,  194. 


Wasting  (continued) — 

congenital  heart  disease,  140,  539. 

with  heart  disease,  489. 

with  indigestion,  176. 

with  rheumatism,  474. 

with  threadworms,  29 1 . 
Water  as  diluent  of  cow's  milk,  41. 
Weighing,  importance  of,  2. 
Weight  affected  by  dentition,  3,  9. 
Weights  at  different  ages,  3. 
Wet-nurse,  26,  60. 

health  of,  26. 

management  of,  28,  20. 

selection  of,  26. 

syphilis  in,  27,  820. 
Whey,  42,  55. 

as  diluent  of  milk,  42. 

composition  of,  55. 

sherry,  57. 

tartarated,  56. 
Whip-worms,  295. 
Whiskey  in  diarrhoea,  232. 
White  wine  whey,  57. 

method  of  preparing,  57. 
Whooping-cough,  broncho- pneumonia 
with,  365. 

congenital  heart  disease  with,  546. 

emphysema  with,  357. 

fibrosis  of  lung,  following,  415. 

fraenal  ulcer  in,  366. 

hsematuria  with,  550,  553,  566. 

infantile  hemiplcgia,  with,  706. 

infantile  palsy,  following,  688. 

laryngitis  with,  330. 

nephritis  with,  550. 

puffy  face  with,  553. 

simulated  by  empyema,  386. 

simulated  by  enlarged  mediastinal 
glands,  405. 

stuttering  after,  749. 

tuberculosis  after,  403,  419. 
Word- deaf  ness,  congenital,  744. 
Worms,  choreiform  movements  with, 
524. 

convulsions  with,  292,  294. 

enuresis  with,  292,  729. 

failure  of  enemata  for,  206. 

fever  with,  284. 

garlic  injections  for,  296. 

intestinal,  286. 

nervousness  with,  628. 

round-,  293,  298. 

tape-,  295,  298. 

teeth-grinding  with,  784. 

thread-,  286,  296. 

treatment,  296. 

whip-,  295. 
Wriggling,  in  masturbation,  776. 

Yolk  of  egg,  value  of,  104,  186. 
Zinc  sulphate  in  chorea,  530. 


REPRINTED    1920    IN    ENGLAND 
AT   THE   OXFORD   UNIVERSITY    PRESS 


University  of  Toronto 
library 


DO  NOT 

REMOVE 

THE 

CARD 

FROM 

THIS 

POCKET 


Acme  Library  Card  Pocket 

Under  Pat.  "Ref.  Index  File" 
Made  by  LIBRARY  BUREAU